Crossing the Bridge Into the 21st Century
Ezra Steiger, MD
Vice Chairman, Department of General Surgery; Head, Section of Surgical
Nutrition
The Cleveland Clinic Foundation, Cleveland, Ohio
The history of parenteral nutrition can be traced back to the 1600s when Sir Christopher Wren infused ale, wine and opium into the veins of dogs and first reported his experience with that intravenous type of feeding, a little over 300 years ago. The actual first use of an intravenous feeding solution for the treatment of a specific disease process was that of Dr. Latta, when he described his experience with the use of an IV solution and the treatment of cholera in a letter to the Lancet in 1832. His prescription included two drachmas of muriate, two scruples of carbonative soda and 60 ounces of water. This essentially gave the patient a saline solution that was invaluable in treating the great fluid losses associated with cholera and helped to save many lives.
There have been some side-steps along the way in the historical evolution of the
use of parenteral nutrition, including a report in Philadelphia in 1902, about
the use of nutrient enemas. This was two case reports of patients nourished
exclusively by rectum, with a determination of their ability to absorb nitrogen
products.
The modern day era of the history of parenteral nutrition began in 1937, when
Elman and Weiner, in a Journal of The American Medical Association
article reported on their experience with the use of carbohydrates and protein
hydrolysates for intravenous feeding in man. They published a book with
photographs on the benefits of intravenous feeding, but this work became
difficult to apply because of the difficulty in providing the large amounts of
calories and protein required by intravenous feeding through peripheral IV sites
in the hands and arms.
Dr. Harry Vars worked to perfect a technique of intravenous feeding in adult
dogs that he described in the 1940s and 1950s, working out of The Harrison
Department of Surgical Research at The University of Pennsylvania. Dr. Vars'
work in intravenous nutrition became waylaid by the Korean War and the emphasis
of treating shock and blood substitutes. He devoted a lot of his attention to
this area and it wasn't until Dr. Jonathan Rhoads, as Head of the Department of
General Surgery at the Hospital of the University of Pennsylvania re-emphasized
the importance of nutrition, was there further work done in this area. Dr.
Rhoads' work included the use of 5 liters a day of 10 percent dextrose solution
with protein hydrolysates. In that way, sufficient calories along with protein,
could be delivered to patients in need of intravenous nutrition support. The
down-side risk of that program related to the large volumes of fluid that had to
be infused to deliver the nutrients.
Dr. Stanley Dudrick, as a resident in General Surgery, working with Drs. Rhoads
and Vars, perfected a technique of intravenous feeding in beagle puppies that
showed normal growth and development could be achieved working with intravenous
feeding in a growing mammalian system. Dr. Wilmore joined the team and reported
subsequent experience in the use of this technique, not only in dogs, but in
infants or babies who were born with catastrophic gastrointestinal (GI)
conditions that did not allow them to adequately absorb nutrients that they took
in through their GI tract. Dramatic growth and development was noted with the
intravenous feeding and soon this technique became applicable for use in adult
patients with a variety of gastrointestinal tract disease states and
difficulties that did not allow for adequate nutrition.
It was not long afterwards, in the middle to late 1960s, that the use of
intravenous feeding became very popular in many hospitals throughout the country
and was adapted for use in the home setting for patients who had permanent bowel
dysfunction. With this technique, patients could be maintained indefinitely, as
long as they had a central venous access line through which to infuse the
nutrient solutions.
In the beginning days of home parenteral nutrition, the patients would make
their own solutions by adding 10 or more ingredients to the bottles, mixing the
solutions at home in a miniature pharmacy setup and refrigerating and hanging
the bottles that same night. The patients often had to go to their local
hospitals to pick up a truck full of supplies that they would cart home for use
for one month at a time and at the end of that month had to go back to the
hospital to get another truck full of nutrient solutions, additives, and
paraphernalia to make the solutions as well as self administer them. The pumps
that were used to infuse the nutrient solutions were often very big and bulky
and were not mobile at all. There were even some contraptions set up for gravity
delivery of the nutrient solutions and an IV pole that the patient had strapped
to their back to give some mobility to it. This is a far cry from what has
happened subsequently. The modern era of home parenteral nutrition has seen the
introduction of ready-made TPN bags, smaller, portable pumps and systems that
truly can be worn like a vest or backpack so that patients can get their
intravenous feeding while remaining fully mobile.
Where We Are Now
In looking ahead into the 21st Century, the problems of infection, vascular
access, enhanced intestinal adaptation and small bowel transplantation remain in
the forefront. We will be examining specifically the results of the use of oral
rehydration therapies in trying to minimize the use of TPN, and the results of
short bowel syndrome treatment with intestinal transplantation. It is important
in all of this to recognize the contributions that have been made by the Oley
Foundation and the American Society of Parenteral and Enteral Nutrition
(A.S.P.E.N.) that have generated a lot of valuable information.
The measures of home parenteral nutrition therapy outcome were well documented
by Dr. Lyn Howard and her co-workers in the journal Gastroenterology
in 1995. A number of disease states, including Crohn's disease, motility
disorders, radiation enteritis, cancer and AIDS were looked at as far as home
parenteral nutrition therapy outcome. Hospital readmissions occurred about twice
per year, in most of those categories of Crohn's disease, motility disorder and
radiation enteritis and four to five times a year in patients with cancer and
AIDS. The rehabilitation status at the end of one year was very good, including
complete rehabilitation for 60 percent of the Crohn's patients, partial
rehabilitation for 38 percent of the patients and only 2 percent having minimal
rehabilitation. Similarly, in the motility disorder and radiation enteritis
group, complete or partial rehabilitation occurred in more than 80 to 90 percent
of the patients. Rehabilitation rates were a little lower in the cancer patients
and much lower in the AIDS groups of patients. Most patients with Crohn's
disease were able to resume full oral nutrition at the end of one year, whereas
in the motility disorder, radiation enteritis, cancer and AIDS groups, most
patients still needed to be maintained on home parenteral nutrition. The
survival at one year was 96 percent for the Crohn's patients and 87 percent for
the motility disorder and radiation enteritis patients, only 20 percent for the
cancer patients and 10 percent for the patients with AIDS. It is important to
keep in mind that the one year survival is around 90 percent or a little bit
more in the Crohn's patients and for people on home parenteral nutrition therapy
for non-malignant or non-lethal disease entities, so we can compare these result
against the results of subsequent modalities of therapy such as small bowel
transplantation (see chart at end of article).
Rehospitalization for home parenteral nutrition patients occurs in about half
the patients over the number of years that they are on parenteral nutrition.
Most of the rehospitalization was related to their underlying diagnosis, another
large part was related to home parenteral nutrition and a smaller percentage for
other reasons. Of the home parenteral nutrition causes for rehospitalization,
infection or catheter problems accounted for well over two-thirds of those
reasons. The risk factors for recurrent sepsis in home parenteral nutrition
patients was reported by O'Keefe and coworkers in The Journal of Parenteral
and Enteral Nutrition in 1994. They compared their home parenteral nutrition
patients who had no infection versus a group of patients who had frequent
infections. They found that the younger age group of patients, patients with
Crohn's disease, patients with jejunostomies and patients with venous thrombosis
were significantly more likely to get in trouble with sepsis or infection. The
environmental factors felt to be responsible for increased sepsis or recurrent
sepsis in the home, including poor catheter care technique and tobacco smoking,
were also more likely to be associated with patients who had more trouble with
their catheters.
Looking Ahead
Future research for short bowel syndrome includes looking at growth factors to
increase residual gut mass and absorption, improving small bowel transplantation
results and slowing transit time. The Nutritional Restart Center has supplied us
with some valuable information about the use of their special diet
considerations along with glutamine and growth hormone in trying to enhance
intestinal absorption in patients on home parenteral nutrition. In their
treatment reports, growth hormone was given at a dose of 0.1 mg/kg per day and
glutamine was given at a dose of 0.16 gram per kg/day intravenously or 30 grams
per day orally. Generally their diet was high in carbohydrates and low in fat,
provided six feedings daily and contained no simple sugars. Only drinks
containing electrolytes were allowed. Their initial response to treatment showed
that many patients were able to come off TPN and of those patients who were able
to come off TPN, the jejunal ilial length was about 27 centimeters. Those people
who remained on TPN had an average jejunal ilial length of 19 cm. The predictors
of successful outcome, as far as weaning off TPN included body weight, bowel
length and the growth hormone dosage. There was no significant correlation with
age, gender, duration of TPN, or colonic length. The oral rehydration fluid
given to patients in an attempt to enhance absorption of both sodium and water
from the gastrointestinal tract is important for its therapy. There are a number
of oral rehydration solutions that are available and most contain 50 to 90 mEq
per liter of sodium and 20 to 25 mEq per liter of potassium, 45 to 80 mEq per
liter of chloride and 20 to 30 gram per liter of glucose. Most of them have an
osmolality between 240 and 330 mg. (See: "Fluid and Electrolyte Balance: A Must with TPN"
in the March/April 1997 Issue of the LifelineLetter, for more information
about oral rehydration solutions.)
Small bowel transplantation started by Alexis Carrel in 1902, where intestinal
segments were implanted in the necks of dogs. Lilliehei in 1959,
autotransplanted cold preserved small bowel. Seven human intestinal recipients
were recorded in the 1960s, all of whom died. In the 1970s, TPN was emphasized.
In the 1980s rejection or infection led to loss of most grafts. The
International Intestinal Transplant Registry polled 24 programs from 1985
through June of 1995, and reported the results in the Lancet in 1996
(Volume 347, page 1801). Most of the small bowel transplants were a combination
of intestine and liver. Fewer numbers were isolated small bowel, plus or minus
colon, and 16 percent were multivisceral. The patient survival at the end of one
year with small bowel transplant only was 57 percent; small bowel and liver was
44 percent and multivisceral was 41 percent. The use of FK506, however, improved
these early results so that after one year the results of small bowel
transplantation patient survival was up to 83 percent, small bowel and liver
survival was up to 66 percent and multivisceral survival was up to 59 percent.
However, these number still do not measure up to the 90 percent survival for
Crohn's patients on home parenteral nutrition.
To summarize the International Intestinal Transplant Registry through 1995,
there were 170 patients, 51 percent were survivors and 39 percent were able to
come off home TPN. The conclusions of this study were that small bowel
transplantation is a life-saving option for patients who can't be maintained on
TPN and for patients who need massive abdominal evisceration for locally
aggressive tumors. Most patients on TPN do well and transplantation is too risky
for these patients today. Most patients on TPN do well and transplantation is
too risky for these patients today.
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HPN for Benign Conditions* |
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Small Bowel Transplant** |
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Small Bowel & Liver Transplants** |
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Copyright © 1995 The Oley Foundation