Patient characteristics and clinical outcomes in a specialised intestinal failure unit: An observational cohort study

When Should the Appropriateness of PEG be Questioned?

PURPOSE OF REVIEW

This review aims to analyze the evidence regarding the appropriateness of PEG placement in the following clinical situations: short bowel syndrome, head and neck cancer, dementia and palliative use in malignant bowel obstruction.

RECENT FINDINGS

Percutaneous endoscopic gastrostomy (PEG) tubes are placed for a variety of clinical indications by numerous different specialties. First described in 1980, PEG tubes are now the dominant method of enteral access. Typically, PEG tubes are technically feasible procedures that can come with significant risk for both minor and major complications. Therefore, it is important to perform an in-depth, patient specific risk-benefit analysis when considering insertion. By analyzing the current evidence regarding benefits in these situations, superimposed by the lens of biomedical ethics, we make recommendations that are accessible to any provider who may be a consultant or proceduralist, helping to provide informed care that is in the patient's best interest.

Intestinal failure in Finland: prevalence and characteristics of an adult patient population

OBJECTIVES

Details of intestinal failure in the Finnish adult population are unknown. This study aimed to specify the intestinal failure prevalence and to clinically characterize the patient population in Finland.

METHODS

All Finnish healthcare units with the potential of providing parenteral support received an electronic survey to report whether they had patient(s) aged ≥18 years on long-term (≥120 days) parenteral support due to intestinal failure. Patient details came from patient records. IBM SPSS v.25 was used to analyze descriptive statistics.

RESULTS

Of the 74 patients, 52 were included after confirming parenteral support indication from the records. The adult intestinal failure prevalence for 2017 was 11.7 per million, 95% confidence interval: 8.9-15.3. Most patients were women (69%), and the median age was 62 (45-72) years. Short bowel syndrome was the most frequent intestinal failure mechanism (73%), and surgical complication the most frequent underlying diagnosis (29%). Of patients, 66% represented the clinical classification category parenteral nutrition 1 or parenteral nutrition 2. Median Charlson Comorbidity Index was one (0-2.8); hypertension (37%) and diabetes (23%) were the most frequent comorbidities. Patients received seven (3.5-7) parenteral support infusions weekly, and eight patients (15%) were on fluids and electrolytes only. The median duration of parenteral support was 27.5 (11.3-57.3) months. Ten patients ceased parenteral support during 2017 after a median of 20.0 (9.0-40.3) parenteral support months. Eight weaned off parenteral support, one ran out of catheter sites, and one died.

CONCLUSION

Prevalence and patient characteristics of adult intestinal failure in Finland are similar to those in other Western countries.

Systematic review with meta-analysis: effects of implementing a nutrition support team for in-hospital parenteral nutrition

BACKGROUND

Nutrition support teams (NST) may improve parenteral nutrition (PN) outcomes. No previous systematic review has provided conclusive data on catheter-related infection (CRI) occurrence after NST introduction, nor have previous studies performed meta-analysis or graded the evidence.

AIMS

To systematically evaluate the effects of implementing an NST for hospitalised adults on PN and compare these with standard care.

METHODS

This was a systematic review and meta-analysis, pre-registered in PROSPERO (CRD42020218094). On November 24, 2020, PubMed, Web of science, Scopus, Embase, Cochrane Library, and Clinical Key were searched. Clinical trials and observational studies with a standard care comparator were included. Primary outcome was relative reduction in CRI rate. A random-effects meta-analysis was used to estimate effects, and evidence was rated using Cochrane and GRADE methodologies.

RESULTS

Twenty-seven studies with 8166 patients were included. Across 10 studies, NST introduction reduced the CRI rate (IRR = 0.32, 95% CI: 0.19-0.53) with -8 (95% CI: -12 to -5) episodes per 1000 catheter days compared with standard care. Hypophosphataemia occurred less frequently (IRD = -12%, 95% CI: -24% to -1%) and 30-day mortality decreased (IRD = -6%, 95% CI: -11% to -1%). Inappropriate PN use decreased, both judged by indication (IRD = -18%, 95% CI: -28% to -9%) and duration (IRD = -21%, 95% CI: -33% to -9%). Evidence was rated very low to moderate.

CONCLUSIONS

This study documents the clinical impact of introducing an NST, with moderate-grade evidence for the reduction of CRI occurrence compared with standard care. Further, NST introduction significantly reduced metabolic complications, mortality, and inappropriate PN use.

Experiences with intestinal failure from an intestinal rehabilitation unit in a country without home parenteral nutrition

OBJECTIVE

For the first time, we reported experiences with an intestinal rehabilitation unit (IRU) from a country without home parenteral nutrition (HPN).

METHODS

We included patients with a diagnosis of intestinal failure (IF) since the establishment of our IRU from February 2018 to February 2020. We further report on our protocols for management of enterocutaneous fistulas (ECFs), short-bowel syndrome (SBS), chronic intestinal pseudo-obstruction and motility disorders.

RESULTS

Among a total of 349 patients who have been admitted, 100 patients had IF and were included . Mean (SD) age of patients was 46.3 ± 16.1 years. Most common cause of IF was ECFs (32%), SBS (24%), and SBS + fistula (22%). Most common causes of SBS were mesenteric ischemia (63.3%) and repeated surgery (22.4%). Median (interquartile range [IQR]) duration of parenteral nutrition (PN) for patients was 32 (18-60) days. The most common reconstructive surgery performed was resection and anastomosis (75.4%), followed by serial transverse enteroplasty procedure (10.5%) and closure of ostoma (7%). Patients were hospitalized for a median (IQR) of 33 (17.5-61) days. Most common complications were sepsis (45%), catheter infections (43%), and catheter thrombosis (20%), respectively. At the final follow-up, 61% stopped receiving PN, 23% became candidates for transplantation, and 16% died.

CONCLUSION

Considering that most countries lack facilities for HPN, by establishing IRUs using specific treatment protocols and autologous gastrointestinal reconstruction techniques will provide a means to manage patients with IF, thus decreasing death rates and number of patients who require intestinal transplantations due to IF.

Hypophosphatemia in a Specialized Intestinal Failure Unit: An Observational Cohort Study

BACKGROUND

Patients with intestinal failure (IF) are prone to hypophosphatemia and shifts in magnesium and potassium levels. Although these shifts are often attributed to refeeding syndrome (RFS), the incidence of electrolyte shifts among patients with IF is unknown. We evaluated the occurrence of hypophosphatemia and other electrolyte shifts according to the functional and pathophysiological IF classifications.

METHODS

We consecutively included all patients' first admission to an IF unit from 2013 to 2017. Electrolyte shifts were defined as severe hypophosphatemia <0.6 mmol/L (mM) or any 2 other shifts below reference range, comprising hypomagnesemia <0.75 mM, hypophosphatemia <0.8 mM, or hypokalemia <3.5 mM. Outcomes included length of stay, central line-associated bloodstream infection, and other infections. Mortality was evaluated 6 months after discharge.

RESULTS

Of 236 patients with IF, electrolyte shifts occurred in 99 (42%), and 127 (54%) of these patients received intravenous supplementation with either phosphate, magnesium, or potassium. In patients who started parenteral nutrition, up to 62% of early-onset shifts (<5 days) related to refeeding, and up to 63% of late-onset shifts (≥5 days) could be ascribed to infections. Derangements occurred in 7 (18%) with type 1 IF, 53 (43%) with type 2 IF, and 39 (53%) readmitted patients with type 3 IF. Of 133 patients with IF secondary to short-bowel syndrome, 65 (49%) developed shifts.

CONCLUSION

In patients with IF, electrolyte shifts are frequent but not always due to RFS. Electrolyte shifts are common in patients with type 2 and those readmitted with type 3 IF.