ANNIVERSARY ISSUE
REVIEW
The future developments in nutrition C F Donnellan,1 S Lal2
1 Department of Gastroenterology, St James’s University Hospital, Leeds, UK 2 Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, UK
Correspondence to Clare Donnellan, Department of Gastroenterology, Level 4, Bexley Wing, St James’s University Hospital, Leeds, LS9 7TF, UK; [email protected] Received 6 February 2012 Accepted 28 February 2012
Abstract Malnutrition is both a cause and consequence of disease. It is imperative that evidence-based approaches to detect and treat malnutrition are embedded into routine practice; these can range from routine malnutrition screening, the safe and appropriate use of enteral feeding and managing more complex patients with intestinal failure. This article outlines service developments over the next 5 years that may enable all hospitals to achieve optimal standards of care for a malnourished patient and examines the role of developments in clinical nutrition over the next 5–10 years.
Introduction Malnutrition is both a cause and consequence of disease.1 It is therefore imperative that the nutritional status of all patients is considered and, where necessary, optimised. Older patients are at particular risk of nutritional deficiencies,2 and with an ageing population in the West, there is an immediate need for all healthcare organisations to establish care pathways aimed at detecting and treating malnutrition.3 Furthermore, in times of austerity, it is worthwhile reflecting that optimising current, established evidence-based practice may often be more beneficial and cost-effective than reaching for new, and sometimes expensive, strategies that may be difficult to employ in large numbers of patients.4 This article will thus focus initially on the need to optimise current nutritional care services, and will go on to review some changes and developments in clinical nutrition that may be on the horizon. Improvements in nutrition services over the next 5 years Oral and enteral nutrition
Since the publication of guidelines in 2006 by the National Institute of Health and Clinical Excellence (NICE), clear standards have been established for the i28
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safe and effective delivery of nutritional support to adults in the UK.3 All patients should be screened for malnutrition, and the ‘malnutrition universal screening tool’ is a validated means of screening patients in hospitals and in the community.5 It is also recommended that hospitals have a multidisciplinary nutrition support team (NST), with governance overview provided by a nutrition steering committee.3 Simple measures aimed at improving food intake—for example, protected meal times and/or the use of ‘red trays’ to identify and improve the oral intake of malnourished inpatients, or those with feeding difficulties—can be extremely effective,6 but are inadequately used in many hospitals.7 For patients requiring enteral support, the National Patient Safety Agency published clear guidance aimed at avoiding nasogastric tube misplacement in 2005, but 20 deaths and 75 cases of harm have been subsequently reported, leading to a second National Patient Safety Agency alert last year.8 NSTs are effective in improving the safe and appropriate delivery of enteral tube feeding, but only ~40% hospitals have a functioning team in place.9 NSTs are cost-effective by reducing complications associated with malnutrition and with the delivery of nutrition support. Five years ago, NICE predicted that the average PCT could expect to save almost £30 000/year by implementing their guidelines.3 Thus, as standards in nutritional care are established and benchmarked, employing these basic measures throughout all hospitals over the next 5 years will lead to an overall quality improvement in the nutritional care of patients, reduce complications and save important resources. Parenteral nutrition and intestinal failure
Intestinal failure (IF) can be classified into three types.10 Patients with type 1 IF require short-term parenteral nutrition (PN), often owing to ileus after abdominal surgery. This is the commonest type of IF,
ANNIVERSARY ISSUE representing more than 90% of hospital patients identified as needing PN in a recent National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report.11 Furthermore, NSTs can play an important role in guiding the implementation of enhanced recovery after surgery on surgical wards, which has been shown to reduce the metabolic insult to patients undergoing a variety of surgical procedures.12 These systems include early postoperative feeding, and—when successfully used—may reduce the incidence of type 1 IF. However, if a patient currently develops nutritional problems after surgery, then NCEPOD data also suggest that a NST will only be involved in the decision to initiate PN in 52% of cases.11 This can lead to inappropriate use of PN, which, of course, represents a further concern, not least because the NCEPOD report also identified deficiencies of PN monitoring in 54% patients, with metabolic complications relating to PN deemed avoidable in 49%. We predict that as NSTs are established in all acute trusts over the next 5 years, in response to NICE guidelines and the more recent NCEPOD report, the incidence of type 1 IF will reduce as a result of enhanced recovery after surgery. In addition, PN institution will be more appropriate, its delivery safer and associated complications fewer. Type 2 IF occurs in patients with major septic, metabolic and nutritional complications following abdominal surgery, and requires careful multidisciplinary input over prolonged periods. Fortunately, type 2 IF is rare, although the exact incidence is unknown. There are two centres in the UK designated to manage these complex patients (Salford Royal Hospital and St Mark’s Hospital (London)). The commonest causes of type 2 IF are surgical complications and Crohn’s disease10 and the commonest reason why patients with Crohn’s disease develop type 2 IF are multiple ‘unplanned’ laparotomies for intra-abdominal sepsis.13 The latter suggests that the risk of type 2 IF may be reduced by considering if there are alternatives to returning the patient to theatre in the event of postoperative complications; for example, the wider use of radiological drains for postoperative collections, wherever appropriate. The so-called ‘SNAP’ algorithmic approach highlights the importance of optimising a patient’s condition before considering surgery and forms the cornerstone to the management of all patients with type 2 IF.10 Briefly, the approach underlines the importance of identifying and treating any form of sepsis (S), before intestinal function and nutritional status can be restored; that nutritional repletion (N) is vital before considering reconstructive surgery; and that intestinal anatomy (A) must be defined before formulating a definitive management plan (P). This simple approach can lead to successful outcomes in these most difficult patients with type 2 IF.14 Promoting and publicising such a standardised approach to the management of patients with acute IF throughout the surgical community, as outlined in the recent seminal document
published by the Association of Surgeons of Great Britain and Ireland,15 will hopefully lead to improved outcomes for these patients over the next 5 years. Type 3 IF includes patients who require long-term (home) PN (HPN). This remains rare, with the UK HPN point prevalence reported as 8.4 per million in 2010.9 Crohn’s disease is the major cause of type 3 IF, and it is notable that cancer is a smaller indication for HPN in the UK when compared to healthcare practices elsewhere (eg, USA).16 The reason for this difference is unclear, but it is plausible that the indications for HPN in the UK will change over the next few years, perhaps with an increased prevalence of HPN for patients with active cancer, as has been witnessed in one of the national intestinal failure units (IFUs) in recent years (unpublished observations). There is an increasing trend in the overall number of new registrants on HPN in England,9 and it has also become increasingly clear in recent years that a number of units are managing a few patients on HPN. Plans are in place to establish a network of IF centres in the UK that will all be required to achieve set quality standards in HPN delivery to complement the service offered by the two national centres. These service changes will probably be made over the next 5 years. Clinical developments over the next 5 years Oral/enteral nutrition
Immunonutrition, defined as the use of enhanced feeds with specific anti-inflammatory components (ω-3 fatty acids, arginine, glutamine, RNA), is arguably one of the most exciting of the emerging fields in oral nutrition support. Evidence has emerged of benefit, particularly for patients undergoing gastrointestinal surgery.17 Data may be underpowered to demonstrate a reduction in mortality, but a meta-analysis of 2730 postoperative patients showed significant reductions in overall complications (OR=0.46, 95% CI 0.38 to 0.56) and infections (OR=0.47, 95% CI 0.38 to 0.59), as well as length of hospital stay (OR=−2·26, 95% CI −2·65 to −1·88).17 There remain several unanswered questions, such as the optimal timing of delivery, quantity required (usually >25 kcal/kg/day),18 or whether benefit is limited to patients with malnutrition. However, this is an exciting, and cost-effective19 avenue that will probably be introduced into routine clinical practice in many, if not all, areas of oral nutrition support over the next few years. While there is much work to be done evaluating different types of oral/enteral nutrition formulas such as immunonutrients, perhaps the most important immediate need is to make improvements in the safety of nutrition delivery devices. Percutaneous endoscopic gastrostomy tubes (PEGs) remain a key delivery device for long-term enteral nutrition support and are widely available. However, there remains a lack of understanding among non-gastroenterologists about the risks (personal observations). The largest series of 1041 patients
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ANNIVERSARY ISSUE demonstrated a 30-day mortality of 5.8%.20 Older NCEPOD data from 2004 revealed a similar death rate of 6%, but a strikingly high percentage of patients died within 7 days,21 suggesting inappropriate selection of patients. Recent data suggest C-reactive protein, albumin and age predict mortality22 23 but there are clearly differences between different patient populations— for example, those with progressive neurological disease versus head injury patients, where there may some prospect of recovery. There is a clear immediate need to incorporate this emerging evidence relating to safety, into a validated disease-specific risk score for PEG placement, for ready use in all hospitals. Parenteral nutrition/Intestinal failure
Deaths during the first 2 years of HPN usually relate to the underlying disease.24 HPN-related mortality after this time derives principally from IF-associated liver disease (IFALD)24 25 and from complications related to the use of central catheters.25 HPN still offers patients with type 3 IF the best chance of survival and alternatives such as intestinal transplantation are reserved for patients in whom HPN-related complications are a concern.26 It is undoubtedly true that, as experience relating to transplant techniques and immunosuppressive regimes evolve, survival after small-bowel transplantation will also improve. However, it is equally true that non-transplant strategies aimed at improving the survival of patients with type 3 IF, such as optimising HPN delivery or reducing HPN-associated complications, will evolve in parallel. For example, although central venous catheter (CVC) infection rates as low as 0.39 per 1000 catheter days can be achieved (unpublished observations), CVC infections remain a recurring problem in many centres, both in this country and abroad. An increasing number of IF centres are advocating the use of antimicrobial locks to reduce catheter infection rates; taurolidine lock, for example, has been shown to reduce catheter infection rates by up to 90%27 and an increasing number of centres are using such agents, either in patients with recurrent line infections or even in all patients. However, antimicrobial locks such as taurolidine cannot replace the principal method of minimising CVC infections: strict adherence to catheter care techniques with appropriate patient training, which will no doubt become an audited quality standard required by all IF centres over the next few years. IFALD represents an important indication for smallbowel transplantation in patients dependent on HPN.28 While mildly abnormal liver function is common in patients receiving long-term PN, the incidence of advanced liver disease varies widely.28 IFALD is a multifactorial entity, resulting, for example, from a variety of nutrient excesses and/or deficiencies. Lipid excess, in particular, can be especially hepatotoxic,29 and recent evidence suggests that the use of more sophisticated lipids (eg, medium chain triglyceride/long-chain triglyceride mixtures and monounsaturated fatty acids,
i30
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or fish-oil based lipid emulsions) may further attenuate hepatic injury.28 A key challenge over the next few years is to identify patients at risk of developing IFALD at an early stage to facilitate, for example, the early targeted use of these second/third generation lipids, before patients with IF develop end-stage liver disease necessitating multivisceral transplantation. It is hoped that current work into the use of serological or radiological non-invasive markers of liver disease30 in the HPN population will lead to these techniques becoming an integral part of HPN monitoring in the future. Repeated hospital admissions resulting from HPN complications are only one of many factors that damage a patient’s quality of life.31–33 It has been known for some time that patients prefer to be dependent on as few nights of HPN as possible.31 There are a number of evolving treatments, both surgical and medical, aimed at reducing PN requirements; for example, recent work has centred on the use of growth factors to promote intestinal adaptation in the remnant small bowel of patients on HPN. Unfortunately, results for growth hormone and glutamine have been disappointing.34 35 However teduglutide, a long-acting GLP-2 (glucagonlike peptide-2) analogue appears more promising: a recent placebo-controlled randomised, controlled trial of 83 patients with short bowel syndrome demonstrated that teduglutide was efficacious in reducing PN (principally volume) requirements.36 However these effects are temporary if teduglutide is stopped, therefore the long-term safety and cost-effectiveness of this approach needs to be considered. Surgical approaches to lengthen the remnant small bowel and so reduce, or sometimes obviate, PN requirements are well established in children,37 but these techniques have only recently been applied to adults with type 3 IF. There are two principal techniques that can be used to lengthen the remnant small intestine: longitudinal intestinal lengthening and tailoring (LILT or ‘Bianchi’ procedure) and serial transverse enteroplasty. A recent study of 20 adult patients with short-bowel syndrome demonstrated that both of these techniques are technically feasible and can lead to weaning from PN in more than 50% of cases.38 Clearly, the techniques have been evaluated only in a very small number of patients, but experience will now evolve in the UK, as one of the national IFUs has recently begun to offer the option of small-bowel lengthening to adult patients receiving long-term PN. Clinical developments: 10-year horizon It has been long hoped that the use of new treatments, such as biological therapies would lead to a reduced incidence of short bowel syndrome in Crohn’s disease. However, there is no evidence that this has (yet) been realised,9 possibly because short-bowel syndrome is a relatively rare entity itself or because of incomplete data collection. However, it is important to recognise that the data on surgeries in Crohn’s disease collected thus
ANNIVERSARY ISSUE far relate to patients treated with episodic, rather than maintenance biological therapy, which is not current optimal practice.39 40 Nonetheless, we would predict a change in the aetiology of IF over the next decade and beyond, perhaps with a fall in Crohn’s disease and/or, as mentioned earlier, a rise in cancer, or as is beginning to emerge in the USA41 (and in one of the national UK IFUs (unpublished data)), an increasing incidence of IF following complications of bariatric surgery. Once a patient develops type 3 IF, he/she is currently most likely to be placed on HPN in the longterm because of improved survival rates compared to other management options. Although UK experience in small-bowel transplantation lags that of North America, recent 1-year survival rates in the UK are excellent42; however, whether these rates will be maintained in the longer term, over and above the survival rates that will be offered by HPN is, unknown. If survival rates following transplantation improve, and if—as hoped— small-bowel lengthening offers patients an option to reduce PN requirements, then it is likely that patient choice—based principally on quality of life—will determine the treatment of type 3 IF in the future. Another exciting potential development is the artificial gut (Gabe, personal communication). Tissue engineering techniques allow the removal of cells from the small bowel (de-cellularisation), leaving the extracellular matrix. This can then be seeded with the patient’s own cells and then transplanted. Such techniques have already been successful with the trachea43 and warrant exploration in the gut since they avoid the use of toxic immunosuppressive drugs. Whether we will be more likely to be lengthening the ‘native’ gut of, or implanting an artificial gut into, a patient with short bowel syndrome in 10 years’ time is purely speculative. Summary While there are many exciting new developments in clinical nutrition, improvements in the delivery of established, evidence-based services are likely to have the biggest impact on the highest number of patients in the immediate future. Service improvements need to be driven by education and training, starting at undergraduate level, and spanning all specialties within medicine and allied professions. Improving our detection and treatment of malnutrition, both in hospitals and in the community, as gauged by targeted quality standards, will lay the foundation on which evolving clinical developments can be built. Contributors CFD wrote the article
with significant input from SL. Competing interests None. Provenance and peer review Commissioned; internally peer reviewed. References 1. Brotherton A, Simmons N. Malnutrition Matters. BAPEN 2010.
2. Elia M, Stratton RJ. Geographical inequalities in nutrient status and risk of malnutrition among English people aged 65 y and older. Nutrition 2005;21:1100–6. 3. NICE. Nutrition Support for Adults. Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition (2006) http:// www.nice.org.uk/CG32 (accessed 22 Mar 2012). 4. Woolf SH, Johnson RE. The break-even point: when medical advances are less important than improving the fidelity with which they are delivered. Ann Fam Med 2005;3:545–52. 5. Elia M. The ‘MUST’ report: nutritional screening of adults: a multidisciplinary responsibility. Development and use of the ‘Malnutrition Universal Screening Tool’ (‘MUST’) for adults. A report by the Malnutrition Advisory Group of the British Association for Patenteral and Enteral Nutrition. Redditch: British Association for Parenteral and Enteral Nutrition (BAPEN). http:// www.bapen.org.uk/must_report.html (accessed 22 Mar 2012). 6. Bradley L, Rees C. Reducing nutritional risk in hospital: the red tray. Nurs Stand 2003;17:33–7. 7. Age UK. Still Hungry to Be Heard 2011 www.ageuk.org. uk/Documents/EN-GB/ID9489%20HTBH%20Report%20 28ppA4.pdf?dtrk=true (accessed 22 Mar 2012). 8. NPSA. Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants. NPSA/2011/ PSA002 www.nrls.npsa.nhs.uk/resources/?EntryId45=129640 (accessed 22 Mar 2012). 9. Smith T, Micklewrigh A, Hirst A, et al. A report by the British Artificial Nutrition Survey (BANS), a committee of BAPEN (The British Association for Parenteral and Enteral Nutrition), 2011. 10. Lal S, Teubner A, Shaffer JL. Review article: intestinal failure. Aliment Pharmacol Ther 2006;24:19–31. 11. Stewart JAD, Mason DG, Smith N, et al. A mixed bag. An enquiry into the care of hospital patients receiving parenteral nutrition. National Confidential Enquiry into Patient Outcome and Death. 2010 http://www.ncepod.org.uk/2010pn.htm (accessed 22 Mar 2012). 12. Basse L, Hjort Jakobsen D, Billesbølle P, et al. A clinical pathway to accelerate recovery after colonic resection. Ann Surg 2000;232:51–7. 13. Agwunobi AO, Carlson GL, Anderson ID, et al. Mechanisms of intestinal failure in Crohn’s disease. Dis Colon Rectum 2001;44:1834–7. 14. Kalaiselvan R, Abraham A, Teubner A, et al. Aetiology and outcome of severe acute intestinal failure. Society of Academic and Research Surgery 2012:25. 15. Carlson G, Gardiner K, McKee R, et al. The surgical management of patients with acute intestinal failure. Associations of Surgeons of Great Britain and Ireland 2010. http://www. asgbi.org.uk/en/publications/issues_in_professional_practice.cfm (accessed 22 Mar 2012). 16. Mullady DK, O’Keefe SJ. Treatment of intestinal failure: home parenteral nutrition. Nat Clin Pract Gastroenterol Hepatol 2006;3:492–504. 17. Cerantola Y, Hübner M, Grass F, et al. Immunonutrition in gastrointestinal surgery. Br J Surg 2011;98:37–48. 18. Akbarshahi H, Andersson B, Nordén M, et al. Perioperative nutrition in elective gastrointestinal surgery–potential for improvement? Dig Surg 2008;25:165–74. 19. Braga M, Gianotti L, Vignali A, et al. Preoperative oral arginine and n-3 fatty acid supplementation improves the immunometabolic host response and outcome after colorectal resection for cancer. Surgery 2002;132:805–14. 20. Richter-Schrag HJ, Richter S, Ruthmann O, et al. Risk factors and complications following percutaneous endoscopic
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25.
26. 27.
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29.
30.
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gastrostomy: a case series of 1041 patients. Can J Gastroenterol 2011;25:201–6. Cullinane M, Gray AJG, Hargraves CMK, et al. Scoping our practice. The 2004 report of the National Confidential Enquiry into Patient Outcome and Death 2004. http://www.ncepod.org. uk/2004report/ (accessed 22 Mar 2012). Blomberg J, Lagergren P, Martin L, et al. Albumin and C-reactive protein levels predict short-term mortality after percutaneous endoscopic gastrostomy in a prospective cohort study. Gastrointest Endosc 2011;73:29–36. Leeds J, McAlindon ME, Grant J, et al. Albumin level and patient age predict outcomes in patients referred for gastrostomy insertion: internal and external validation of a gastrostomy score and comparison with artificial neural networks. Gastrointest Endosc 2011;74:1033–9.e1. Pironi L, Joly F, Forbes A, et al. Long-term follow-up of patients on home parenteral nutrition in Europe: implications for intestinal transplantation. Gut 2011;60:17–25. Pironi L, Forbes A, Joly F, et al. Survival of patients identified as candidates for intestinal transplantation: a 3-year prospective follow-up. Gastroenterology 2008;135:61–71. Fishbein TM. Intestinal transplantation. N Engl J Med 2009;361:998–1008. Bisseling TM, Willems MC, Versleijen MW, et al. Taurolidine lock is highly effective in preventing catheter-related bloodstream infections in patients on home parenteral nutrition: a heparin-controlled prospective trial. Clin Nutr 2010;29:464–8. Gabe SM, Culkin A. Abnormal liver function tests in the parenteral nutrition fed patient. Frontline Gastroenterol 2010;1:98–104. Cavicchi M, Beau P, Crenn P, et al. Prevalence of liver disease and contributing factors in patients receiving home parenteral nutrition for permanent intestinal failure. Ann Intern Med 2000;132:525–32. Nguyen D, Talwalkar JA. Noninvasive assessment of liver fibrosis. Hepatology 2011;53:2107–10.
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31. Staun M, Pironi L, Bozzetti F, et al. ESPEN Guidelines on Parenteral Nutrition: home parenteral nutrition (HPN) in adult patients. Clin Nutr 2009;28:467–79. 32. Carlson G, Richards DA. Quality of life assessment and cost effectiveness. In: Nightingale J, ed. Intestinal Failure. Cambridge, Cambridge University Press 2001:447–57. 33. Howard L. Home parenteral nutrition: survival, cost, and quality of life. Gastroenterology 2006;130(Suppl 1):S52–9. 34. Scolapio JS, McGreevy K, Tennyson GS, et al. Effect of glutamine in short-bowel syndrome. Clin Nutr 2001;20: 319–23. 35. Scolapio JS. Short bowel syndrome: recent clinical outcomes with growth hormone. Gastroenterology 2006;130(Suppl 1):S122–6. 36. Jeppesen PB, Gilroy R, Pertkiewicz M, et al. Randomised placebo-controlled trial of teduglutide in reducing parenteral nutrition and/or intravenous fluid requirements in patients with short bowel syndrome. Gut 2011;60:902–14. 37. Bianchi A. Longitudinal intestinal lengthening and tailoring: results in 20 children. J R Soc Med 1997;90:429–32. 38. Yannam GR, Sudan DL, Grant W, et al. Intestinal lengthening in adult patients with short bowel syndrome. J Gastrointest Surg 2010;14:1931–6. 39. Jones DW, Finlayson SR. Trends in surgery for Crohn’s disease in the era of infliximab. Ann Surg 2010;252:307–12. 40. Slattery E, Keegan D, Hyland J, et al. Surgery, Crohn’s disease, and the biological era: has there been an impact? J Clin Gastroenterol 2011;45:691–3. 41. McBride CL, Petersen A, Sudan D, et al. Short bowel syndrome following bariatric surgical procedures. Am J Surg 2006;192:828–32. 42. Middleton SJ. Is intestinal transplantation now an alternative to home parenteral nutrition? Proc Nutr Soc 2007;66:316–20. 43. Jungebluth P, Alici E, Baiguera S, et al. Tracheobronchial transplantation with a stem-cell-seeded bioartificial nanocomposite: a proof-of-concept study. Lancet 2011;378:1997–2004.
REVIEW
The future developments in nutrition C F Donnellan,1 S Lal2
1 Department of Gastroenterology, St James’s University Hospital, Leeds, UK 2 Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, UK
Correspondence to Clare Donnellan, Department of Gastroenterology, Level 4, Bexley Wing, St James’s University Hospital, Leeds, LS9 7TF, UK; [email protected] Received 6 February 2012 Accepted 28 February 2012
Abstract Malnutrition is both a cause and consequence of disease. It is imperative that evidence-based approaches to detect and treat malnutrition are embedded into routine practice; these can range from routine malnutrition screening, the safe and appropriate use of enteral feeding and managing more complex patients with intestinal failure. This article outlines service developments over the next 5 years that may enable all hospitals to achieve optimal standards of care for a malnourished patient and examines the role of developments in clinical nutrition over the next 5–10 years.
Introduction Malnutrition is both a cause and consequence of disease.1 It is therefore imperative that the nutritional status of all patients is considered and, where necessary, optimised. Older patients are at particular risk of nutritional deficiencies,2 and with an ageing population in the West, there is an immediate need for all healthcare organisations to establish care pathways aimed at detecting and treating malnutrition.3 Furthermore, in times of austerity, it is worthwhile reflecting that optimising current, established evidence-based practice may often be more beneficial and cost-effective than reaching for new, and sometimes expensive, strategies that may be difficult to employ in large numbers of patients.4 This article will thus focus initially on the need to optimise current nutritional care services, and will go on to review some changes and developments in clinical nutrition that may be on the horizon. Improvements in nutrition services over the next 5 years Oral and enteral nutrition
Since the publication of guidelines in 2006 by the National Institute of Health and Clinical Excellence (NICE), clear standards have been established for the i28
Frontline Gastroenterology 2012;3(Supp 1):i28–i32. doi:10.1136/flgastro-2012-100137
safe and effective delivery of nutritional support to adults in the UK.3 All patients should be screened for malnutrition, and the ‘malnutrition universal screening tool’ is a validated means of screening patients in hospitals and in the community.5 It is also recommended that hospitals have a multidisciplinary nutrition support team (NST), with governance overview provided by a nutrition steering committee.3 Simple measures aimed at improving food intake—for example, protected meal times and/or the use of ‘red trays’ to identify and improve the oral intake of malnourished inpatients, or those with feeding difficulties—can be extremely effective,6 but are inadequately used in many hospitals.7 For patients requiring enteral support, the National Patient Safety Agency published clear guidance aimed at avoiding nasogastric tube misplacement in 2005, but 20 deaths and 75 cases of harm have been subsequently reported, leading to a second National Patient Safety Agency alert last year.8 NSTs are effective in improving the safe and appropriate delivery of enteral tube feeding, but only ~40% hospitals have a functioning team in place.9 NSTs are cost-effective by reducing complications associated with malnutrition and with the delivery of nutrition support. Five years ago, NICE predicted that the average PCT could expect to save almost £30 000/year by implementing their guidelines.3 Thus, as standards in nutritional care are established and benchmarked, employing these basic measures throughout all hospitals over the next 5 years will lead to an overall quality improvement in the nutritional care of patients, reduce complications and save important resources. Parenteral nutrition and intestinal failure
Intestinal failure (IF) can be classified into three types.10 Patients with type 1 IF require short-term parenteral nutrition (PN), often owing to ileus after abdominal surgery. This is the commonest type of IF,
ANNIVERSARY ISSUE representing more than 90% of hospital patients identified as needing PN in a recent National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report.11 Furthermore, NSTs can play an important role in guiding the implementation of enhanced recovery after surgery on surgical wards, which has been shown to reduce the metabolic insult to patients undergoing a variety of surgical procedures.12 These systems include early postoperative feeding, and—when successfully used—may reduce the incidence of type 1 IF. However, if a patient currently develops nutritional problems after surgery, then NCEPOD data also suggest that a NST will only be involved in the decision to initiate PN in 52% of cases.11 This can lead to inappropriate use of PN, which, of course, represents a further concern, not least because the NCEPOD report also identified deficiencies of PN monitoring in 54% patients, with metabolic complications relating to PN deemed avoidable in 49%. We predict that as NSTs are established in all acute trusts over the next 5 years, in response to NICE guidelines and the more recent NCEPOD report, the incidence of type 1 IF will reduce as a result of enhanced recovery after surgery. In addition, PN institution will be more appropriate, its delivery safer and associated complications fewer. Type 2 IF occurs in patients with major septic, metabolic and nutritional complications following abdominal surgery, and requires careful multidisciplinary input over prolonged periods. Fortunately, type 2 IF is rare, although the exact incidence is unknown. There are two centres in the UK designated to manage these complex patients (Salford Royal Hospital and St Mark’s Hospital (London)). The commonest causes of type 2 IF are surgical complications and Crohn’s disease10 and the commonest reason why patients with Crohn’s disease develop type 2 IF are multiple ‘unplanned’ laparotomies for intra-abdominal sepsis.13 The latter suggests that the risk of type 2 IF may be reduced by considering if there are alternatives to returning the patient to theatre in the event of postoperative complications; for example, the wider use of radiological drains for postoperative collections, wherever appropriate. The so-called ‘SNAP’ algorithmic approach highlights the importance of optimising a patient’s condition before considering surgery and forms the cornerstone to the management of all patients with type 2 IF.10 Briefly, the approach underlines the importance of identifying and treating any form of sepsis (S), before intestinal function and nutritional status can be restored; that nutritional repletion (N) is vital before considering reconstructive surgery; and that intestinal anatomy (A) must be defined before formulating a definitive management plan (P). This simple approach can lead to successful outcomes in these most difficult patients with type 2 IF.14 Promoting and publicising such a standardised approach to the management of patients with acute IF throughout the surgical community, as outlined in the recent seminal document
published by the Association of Surgeons of Great Britain and Ireland,15 will hopefully lead to improved outcomes for these patients over the next 5 years. Type 3 IF includes patients who require long-term (home) PN (HPN). This remains rare, with the UK HPN point prevalence reported as 8.4 per million in 2010.9 Crohn’s disease is the major cause of type 3 IF, and it is notable that cancer is a smaller indication for HPN in the UK when compared to healthcare practices elsewhere (eg, USA).16 The reason for this difference is unclear, but it is plausible that the indications for HPN in the UK will change over the next few years, perhaps with an increased prevalence of HPN for patients with active cancer, as has been witnessed in one of the national intestinal failure units (IFUs) in recent years (unpublished observations). There is an increasing trend in the overall number of new registrants on HPN in England,9 and it has also become increasingly clear in recent years that a number of units are managing a few patients on HPN. Plans are in place to establish a network of IF centres in the UK that will all be required to achieve set quality standards in HPN delivery to complement the service offered by the two national centres. These service changes will probably be made over the next 5 years. Clinical developments over the next 5 years Oral/enteral nutrition
Immunonutrition, defined as the use of enhanced feeds with specific anti-inflammatory components (ω-3 fatty acids, arginine, glutamine, RNA), is arguably one of the most exciting of the emerging fields in oral nutrition support. Evidence has emerged of benefit, particularly for patients undergoing gastrointestinal surgery.17 Data may be underpowered to demonstrate a reduction in mortality, but a meta-analysis of 2730 postoperative patients showed significant reductions in overall complications (OR=0.46, 95% CI 0.38 to 0.56) and infections (OR=0.47, 95% CI 0.38 to 0.59), as well as length of hospital stay (OR=−2·26, 95% CI −2·65 to −1·88).17 There remain several unanswered questions, such as the optimal timing of delivery, quantity required (usually >25 kcal/kg/day),18 or whether benefit is limited to patients with malnutrition. However, this is an exciting, and cost-effective19 avenue that will probably be introduced into routine clinical practice in many, if not all, areas of oral nutrition support over the next few years. While there is much work to be done evaluating different types of oral/enteral nutrition formulas such as immunonutrients, perhaps the most important immediate need is to make improvements in the safety of nutrition delivery devices. Percutaneous endoscopic gastrostomy tubes (PEGs) remain a key delivery device for long-term enteral nutrition support and are widely available. However, there remains a lack of understanding among non-gastroenterologists about the risks (personal observations). The largest series of 1041 patients
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ANNIVERSARY ISSUE demonstrated a 30-day mortality of 5.8%.20 Older NCEPOD data from 2004 revealed a similar death rate of 6%, but a strikingly high percentage of patients died within 7 days,21 suggesting inappropriate selection of patients. Recent data suggest C-reactive protein, albumin and age predict mortality22 23 but there are clearly differences between different patient populations— for example, those with progressive neurological disease versus head injury patients, where there may some prospect of recovery. There is a clear immediate need to incorporate this emerging evidence relating to safety, into a validated disease-specific risk score for PEG placement, for ready use in all hospitals. Parenteral nutrition/Intestinal failure
Deaths during the first 2 years of HPN usually relate to the underlying disease.24 HPN-related mortality after this time derives principally from IF-associated liver disease (IFALD)24 25 and from complications related to the use of central catheters.25 HPN still offers patients with type 3 IF the best chance of survival and alternatives such as intestinal transplantation are reserved for patients in whom HPN-related complications are a concern.26 It is undoubtedly true that, as experience relating to transplant techniques and immunosuppressive regimes evolve, survival after small-bowel transplantation will also improve. However, it is equally true that non-transplant strategies aimed at improving the survival of patients with type 3 IF, such as optimising HPN delivery or reducing HPN-associated complications, will evolve in parallel. For example, although central venous catheter (CVC) infection rates as low as 0.39 per 1000 catheter days can be achieved (unpublished observations), CVC infections remain a recurring problem in many centres, both in this country and abroad. An increasing number of IF centres are advocating the use of antimicrobial locks to reduce catheter infection rates; taurolidine lock, for example, has been shown to reduce catheter infection rates by up to 90%27 and an increasing number of centres are using such agents, either in patients with recurrent line infections or even in all patients. However, antimicrobial locks such as taurolidine cannot replace the principal method of minimising CVC infections: strict adherence to catheter care techniques with appropriate patient training, which will no doubt become an audited quality standard required by all IF centres over the next few years. IFALD represents an important indication for smallbowel transplantation in patients dependent on HPN.28 While mildly abnormal liver function is common in patients receiving long-term PN, the incidence of advanced liver disease varies widely.28 IFALD is a multifactorial entity, resulting, for example, from a variety of nutrient excesses and/or deficiencies. Lipid excess, in particular, can be especially hepatotoxic,29 and recent evidence suggests that the use of more sophisticated lipids (eg, medium chain triglyceride/long-chain triglyceride mixtures and monounsaturated fatty acids,
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or fish-oil based lipid emulsions) may further attenuate hepatic injury.28 A key challenge over the next few years is to identify patients at risk of developing IFALD at an early stage to facilitate, for example, the early targeted use of these second/third generation lipids, before patients with IF develop end-stage liver disease necessitating multivisceral transplantation. It is hoped that current work into the use of serological or radiological non-invasive markers of liver disease30 in the HPN population will lead to these techniques becoming an integral part of HPN monitoring in the future. Repeated hospital admissions resulting from HPN complications are only one of many factors that damage a patient’s quality of life.31–33 It has been known for some time that patients prefer to be dependent on as few nights of HPN as possible.31 There are a number of evolving treatments, both surgical and medical, aimed at reducing PN requirements; for example, recent work has centred on the use of growth factors to promote intestinal adaptation in the remnant small bowel of patients on HPN. Unfortunately, results for growth hormone and glutamine have been disappointing.34 35 However teduglutide, a long-acting GLP-2 (glucagonlike peptide-2) analogue appears more promising: a recent placebo-controlled randomised, controlled trial of 83 patients with short bowel syndrome demonstrated that teduglutide was efficacious in reducing PN (principally volume) requirements.36 However these effects are temporary if teduglutide is stopped, therefore the long-term safety and cost-effectiveness of this approach needs to be considered. Surgical approaches to lengthen the remnant small bowel and so reduce, or sometimes obviate, PN requirements are well established in children,37 but these techniques have only recently been applied to adults with type 3 IF. There are two principal techniques that can be used to lengthen the remnant small intestine: longitudinal intestinal lengthening and tailoring (LILT or ‘Bianchi’ procedure) and serial transverse enteroplasty. A recent study of 20 adult patients with short-bowel syndrome demonstrated that both of these techniques are technically feasible and can lead to weaning from PN in more than 50% of cases.38 Clearly, the techniques have been evaluated only in a very small number of patients, but experience will now evolve in the UK, as one of the national IFUs has recently begun to offer the option of small-bowel lengthening to adult patients receiving long-term PN. Clinical developments: 10-year horizon It has been long hoped that the use of new treatments, such as biological therapies would lead to a reduced incidence of short bowel syndrome in Crohn’s disease. However, there is no evidence that this has (yet) been realised,9 possibly because short-bowel syndrome is a relatively rare entity itself or because of incomplete data collection. However, it is important to recognise that the data on surgeries in Crohn’s disease collected thus
ANNIVERSARY ISSUE far relate to patients treated with episodic, rather than maintenance biological therapy, which is not current optimal practice.39 40 Nonetheless, we would predict a change in the aetiology of IF over the next decade and beyond, perhaps with a fall in Crohn’s disease and/or, as mentioned earlier, a rise in cancer, or as is beginning to emerge in the USA41 (and in one of the national UK IFUs (unpublished data)), an increasing incidence of IF following complications of bariatric surgery. Once a patient develops type 3 IF, he/she is currently most likely to be placed on HPN in the longterm because of improved survival rates compared to other management options. Although UK experience in small-bowel transplantation lags that of North America, recent 1-year survival rates in the UK are excellent42; however, whether these rates will be maintained in the longer term, over and above the survival rates that will be offered by HPN is, unknown. If survival rates following transplantation improve, and if—as hoped— small-bowel lengthening offers patients an option to reduce PN requirements, then it is likely that patient choice—based principally on quality of life—will determine the treatment of type 3 IF in the future. Another exciting potential development is the artificial gut (Gabe, personal communication). Tissue engineering techniques allow the removal of cells from the small bowel (de-cellularisation), leaving the extracellular matrix. This can then be seeded with the patient’s own cells and then transplanted. Such techniques have already been successful with the trachea43 and warrant exploration in the gut since they avoid the use of toxic immunosuppressive drugs. Whether we will be more likely to be lengthening the ‘native’ gut of, or implanting an artificial gut into, a patient with short bowel syndrome in 10 years’ time is purely speculative. Summary While there are many exciting new developments in clinical nutrition, improvements in the delivery of established, evidence-based services are likely to have the biggest impact on the highest number of patients in the immediate future. Service improvements need to be driven by education and training, starting at undergraduate level, and spanning all specialties within medicine and allied professions. Improving our detection and treatment of malnutrition, both in hospitals and in the community, as gauged by targeted quality standards, will lay the foundation on which evolving clinical developments can be built. Contributors CFD wrote the article
with significant input from SL. Competing interests None. Provenance and peer review Commissioned; internally peer reviewed. References 1. Brotherton A, Simmons N. Malnutrition Matters. BAPEN 2010.
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