1. Home Artificial Nutrition (HPN) in adult patients F. Bozzetti (Milano) B. Messing (Paris) M. Staun (Copenhague) A. Van Gossum (Brussels)

2. HPN in adult Content Indications and Epidemiology Venous access care Metabolic complications: prevention and treatment How to adapt nutritional support? HPN in cancer patients Training and monitoring

3. Home Artificial Nutrition (HPN) in adult patients Indications and Epidemiology A. Van Gossum (Brussels)

4. HPN in adult History (1) 1.HPN was initiated in North America (Shils et al) and in Western Europe (Solassol et al) in the early seventies 2.HPN programs started in specialized centres that rapidly developped a growing experience 3.At the beginning, HPN was exclusively reserved for patients with life-threatening intestinal failure related to benign diseases

5. HPN in adult History (2) 4.In the meantime, the number of HPN centres increased with a high variable number of patients from one to another centre 5.HPN has been progressively used in patients with intestinal failure related to advanced cancer (carcinomatosis) 6.HPN is now worldwide used in industrialized countries. However, legislations and funding are still lacking in many European countries

6. Intestinal failure Definition A condition in which the intestine is unable to process sufficient food to maintain an adequate nutritional state (  parenteral nutrition)

7. The central IV line was considered to be the "artificial gut"

8. HPN Underlying diseases Benign: –Crohn's disease –mesenteric vascular disease –post-surgical, trauma –intestinal pseudo-obstruction –radiation enteritis –miscellaneous: chronic pancreatitis, mucosal atrophy, anorexia nervosa,… Malignant AIDS

9. HPN Causes Short bowel syndrome Digestive fistula Alteration of GI motility Chronic intestinal (pseudo-) obstruction (carcinomatosis) Intractable diarrhea (AIDS) Severe malnutrition

10. Short bowel syndrome Major resection of the small bowel Nutritional and metabolic consequences Diarrhea, fluid and electrolyte abnormalities, malabsorption, weight loss

11. Short bowel syndrome Parenteral nutrition-dependency Cut-off values of SB lengths End-enterostomy (I) 100 cm Jejunocolonic (II) 65 cm Jejunoileocolonic (III) 30 cm Messing B, Transplant Proceedings, 1998

12. Jejuno-sigmoid anastomosis

13. Duodenostomy (Foley sonde)

14. Incidence of HPN from 1 January 97 to 31 December 97 ESPEN-HAN, Clin Nutr 1999, 18, 135

15. HPN in adult Incidence / Prevalence The point prevalence of HPN is estimated to be 6 to 10 times higher in US than in Europe Late available data: –Incidence: 3/10 6 inhabitants/y France (2001-2004) 1.65/10 6 inhabitants/y Spain (2001) –Point prevalence: 12/10 6 inhabitants/y Scotland (2001) 9/10 6 inhabitants/y UK (2001)

16. Point prevalence and new registrations of adults receiving HPN (UK) 1996199719981999200020012002 Point prevalence207250306344400422465 New registrations5884113126134126103 Number of reporting centres 2128292528 34 BANS Registry, 2003

17. Distribution of underlying diseases for HPN patients in Europe (1997; n = 479) ESPEN-HAN, Clin Nutr 1999, 18, 135

18. Indications for HPN in 7 different European countries where reporting was assumed to be more than 80% of patients (1997) ESPEN-HAN, Clin Nutr 1999, 18, 135

19. Outcome at 1 January 1998 for HPN patients enrolled between 1 January 97 and 31 June 97 ESPEN-HAN, Clin Nutr 1999, 18, 135

20. HPN Complications 1. Catheter-related – sepsis – venous thrombosis – occlusion – migration 2. Metabolic liver abnormalities biliary stones metabolic bone disease trace element and/or vitamins deficiencies manganese toxicity renal function impairment 3. Psychological 4. Quality of life 5. Rehabilitation

21. Long-term HPN Complications (n = 228) Hospitalization stays (within 12 previous months): 23 days (0 to 270 d) Reasons for hospitalizations: –underlying diseases (37%) –HPN related (30%) (majority: catheter sepsis) –other (33%) ESPEN-HAN, Clin Nutr 2001, 30, 205

22. Long-term HPN Clinical features n = 228 patients Depression: 17% Opiates use: 8% Analgesics use: 35% Interest for intestinal transplantation: 8% ESPEN-HAN, Clin Nutr 2001, 30, 205

23. Long-term HPN (n = 228) Rehabilitation status Before At HPNevaluation IAble to work full time 50% 35% or looking after home and family unaided IIAble to work part time 14% 33% or looking after home and family with help IIIUnable to work but able 12% 23% to cope with HPN unaided and able to go out occasionally IVHousebound: needs major 24% 9% assistance ESPEN-HAN, Clin Nutr 2001, 30, 205

24. HPN – Indications and Epidemiology Conclusions (1) 1.HPN is worldwide used in industrialized countries 2.In many European countries as well as in US, cancer has become the main indication for HPN 3.For patients with benign diseases, the main indications are short bowel and chronic intestinal motility disorders

25. HPN – Indications and Epidemiology Conclusions (2) 4.The number of HPN centres increased with a variable degree of expertise 5.The prevalence in US is expected to be 10 times higher than in Europe (from 2 to 12/10 6 inhabitants) 6.HPN related complications are quite rare and rehabilitation status is good in the majority of the patients