LA NUTRIZIONE ARTIFICIALE DOMICILIARE: LUCI E OMBRE

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1 LA NUTRIZIONE ARTIFICIALE DOMICILIARE: LUCI E OMBRE PAOLO COTOGNI SC Terapia del Dolore e Cure Palliative Dipartimento di Anestesia e Rianimazione AOU Città della Salute e della Scienza Università di Torino

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3 Arends J, et al. Clin Nutr. 2017; 36:

4 Arends J, et al. Clin Nutr. 2017; 36:

5 Old Misunderstanding EN VS. PN Cotogni P. Ann Palliat Med. 2016;5(1):

6 Worthington P. et al. JPEN J Parenter Enteral Nutr

7 EN Feasibility When EN is not sufficient or feasible? EN patients may be unable to achieve the target nutritional intake due to: complications of long-term nasoenteric tube placement or PEG tube placement clinical problems: Diarrhea Nausea Vomiting Constipation Aspiration McClave SA, Chang WK. Gastrointest Endosc. 2003;58:739-5 Orrevall Y, et al. Nutrients. 2013;5:267e82.

8 Arends J, et al. Clin Nutr. 2017; 36:

9 Arends J, et al. Clin Nutr. 2017; 36:11-48 HCT = Hematopoietic cell transplantation. 9

10 Nutrition Support during Chemotherapy If patients develop GI toxicity from chemotherapy or radiation therapy, short-term PN is usually better tolerated (and more efficient) than EN to restore the intestinal function and prevent nutritional deterioration. Bozzetti F, et al. Clin Nutr. 2009;28: (ESPEN Guidelines). 10

11 Prevalence of Malnutrition and Current Use of Nutrition Nutrition Support Disease State (n) % of Patients with Nutrition Support % of Malnourished Patients with Nutrition Support % of Non- Malnourished Patients with Nutrition Support % Receiving Oral Supplements % Receiving Enteral Nutrition Volume 38 Number 2 Original Communication % Receiving Parenteral Nutrition Blood (377) Head and Neck (366) Lung (247) Breast (229) Colon/Rectum (191) Esophagus/Stomach (103) Uterus/Ovaries (87) Prostate (72) Pancreas (42) Kidney/Bladder (29) Others (160) TOTAL (1903) Adapted from Hébuterne X, et al. JPEN J Parenter Enteral Nutr 2014;38:

12 Is There a Benefit? PN may contribute to the maintenance or improvement of quality of life (QoL) in advanced cancer patients Bozzetti F, et al. Clin Nutr. 2009;28: (ESPEN Guidelines). 12

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14 Cotogni P, et al., Cancer Medicine; 2017, in press.

15 Catheter-Related Complications in Cancer Patients on Home Parenteral Nutrition: A Prospective Study of Over 51,000 Catheter Days Volume 37 Number 3 Original Communication Infectious Complications Medium-term VADs Long-term VADs PICC Hohn Tunneled Port No of VADs Local Infection, No No./1000 Catheter-Days No./1000 HPN-Days CRBSI, No. 0 a b,c 18 No./1000 Catheter-Days No./1000 HPN-Days Risk Factors for CRBSI, P-value Use During HPN <.001 <.001 <.001 Previous VAD NS <.05 <.05 No Ultrasound-Guidance <.04 NS NS Securement by Suture <.05 NS Infraclavicular Exit Site <.01 Cuff <2 cm from Exit Site <.05 Total CRBSI=catheter-related bloodstream infection; HPN=home parenteral nutrition; NS=not significant; PICC=peripherally inserted central catheter; VAD=venous access device; = not applicable. a P<.01 vs Hohn catheter and tunneled Groshong catheter; b P<.01 vs Hohn catheter; c P<.05 vs tunneled Groshong catheter. Cotogni P, et al. JPEN J Parenter Enteral Nutr. 2013;37:

16 Catheter-Related Complications in Cancer Patients on Home Parenteral Nutrition: A Prospective Study of Over 51,000 Catheter Days Volume 37 Number 3 Original Communication Noninfectious Complications Medium-term VADs Long-term VADs PICC Hohn Tunneled Port No of VADs Venous Thrombosis, No. (%) 0 3 (2.8) (1) Mechanical Complications Risk Factors for Thrombosis, P-value Risk Factors for Dislocation, P-value Catheter Dislocation, No. (%) 5 (7.7) 15 (15) 4 (8.9) 25 (8.6) Rupture of External Tract, No. (%) 2 (3.1) 0 2 (4.4) 4 (1.4) Lumen Occlusion, No. (%) 2 (3.1) 3 (2.8) 0 7 (9.7) 12 (4.1) TOTAL 9 (13.9) 19 (17.8) 6 (13.3) 7 (9.7) 41 (14.1) No./1000 Catheter-Days No./1000 HPN-Days Use During HPN <.01 <.01 <.01 <.01 No Ultrasound Guidance <.001 Left Side Insertion <.001 Use During HPN <.01 <.01 <.01 <.01 Suture <.001 NS Cuff <2 cm from Exit Site <.01 Total PICC=peripherally inserted central catheter; VAD=venous access device; = not applicable. Cotogni P, et al. JPEN J Parenter Enteral Nutr. 2013;37:

17 Catheter-Related Complications in Cancer Patients on Home Parenteral Nutrition: A Prospective Study of Over 51,000 Catheter Days Volume 37 Number 3 Original Communication CONCLUSIONS If accurately managed, HPN can be safely provided for most cancer patients, even in an advanced stage, without expecting a relevant incidence of catheter-related complications Therefore, concerns about the risks should not still have influence on the decision to feed or not a cancer patient when HPN is clinically indicated 12 Cotogni P, et al. JPEN J Parenter Enteral Nutr. 2013;37:

18 Is There an EBM? It would have been ethically unacceptable to have a non-pn control arm So, any prospectively controlled evidence of potential benefit is denied RCT EBM Bozzetti F, et al. Clin Nutr. 2009;28: (ESPEN Guidelines). 18

19 Should This Patient Continue PN or Start PN at Home? 19

20 How to Intervene? Kumpf VJ, Tillman EM. Nutr Clin Pract. 2012;27(6):

21 How to Intervene? Dreesen M, et al. Support Care Cancer. 2013;21:

22 How to Intervene? HAN should be prescribed and regularly monitored using defined protocols shared between oncologists and clinical nutrition specialists.

23 Worthington P. et al. JPEN J Parenter Enteral Nutr How to Intervene?

24 Worthington P. et al. JPEN J Parenter Enteral Nutr How to Intervene?

25 Is There the Indication for HPN in Patients With No Further Treatments? Yes It is not a contraindication for HPN that oncologic treatment has been stopped. Bozzetti F, et al. Clin Nutr. 2009;28: (ESPEN Guidelines). 25

26 of death due to malnutrition Arends J, et al. Clin Nutr. 2017; 36:

27 Daanish Hoda Oncology, Mayo Clinic Rochester Cancer 2005;103: American Cancer Society Hoda D. Cancer 2005;103:

28 Arends J, et al. Clin Nutr. 2017; 36:

29 HPN Is Not Recommended in Patients With: How to predict survival? Cotogni P. Ann Palliat Med. 2016;5(1):42-9.

30 Development and Validation of a Nomogram to Predict Survival in Incurable Cachectic Cancer Patients on Home Parenteral Nutrition Cox modeling based nomogram for predicting 3-, 6-month and median overall survival Adapted from Bozzetti F, et al. Ann Oncol. 2015;26(11):

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32 LA NUTRIZIONE ARTIFICIALE DOMICILIARE: più LUCI che OMBRE