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Abstract:

Careful targeting of radiation therapy for gynecological, gastrointestinal, and genitourinary cancers can reduce the problems with radiation enteritis and the need for specialized nutrition support. However, 5% of patients treated with radiation develop intestinal failure and require parenteral nutrition to survive. The purpose of this study was to observe the complications associated with home parenteral nutrition (HPN) support in patients dependent on HPN because of radiation enteritis. Records were reviewed in this retrospective study for duration of HPN, complications associated with HPN therapy in this subset of patients, and survival. Fifty-four patients met criteria for chart review including 39 women and 15 men. Death related to a complication of HPN was seen in one patient. All other deaths were related to the underlying disease. Thirty-three catheter infection episodes were seen in 23 of the patients yielding a catheter infection rate of 1.56 per 1000 days of HPN with no correlation seen between catheter sepsis and duration of HPN therapy. Five-year survival rates with HPN were calculated by Kaplan-Meier analysis at 64%, which was comparable in most other non-Crohn’s disease patients. The authors conclude that HPN is a viable therapy for intestinal failure in radiation enteritis with no additional risk compared to HPN patients with other conditions.

home care, parenteral nutrition, radiation enteritis, outcomes, five-year survival, retrospective, intestinal failure, cancer

Discussion:

Radiation enteritis has both an acute and short-term effect as well as chronic and long-term adverse effect that may be seen months to years later. Treatment for radiation enteritis may include both surgical and medical strategies. Patients may become dependent on parenteral nutrition for long-term survival. Home-initiation or home-transitioned parenteral nutrition has become an important lifeline for patients with radiation enteritis. 

Methods:

All patients with the diagnosis of radiation enteritis treated with HPN were included in the retrospective review of medical records for duration of therapy, diagnoses, and survival. The mean duration of HPN therapy was 20.4 months with a range of 2-108 months with the majority on HPN for less than 12 months. The most common reasons for HPN requirement was radiation induced mechanical obstruction, radiation strictures, and short bowel syndrome.

Results:

Patients were started on HPN primarily because of the inability to maintain weight and hydration through oral intake alone. At the time of chart review, 17 of 54 were still alive. The prediction for survival was more correlated with underlying disease than with HPN therapy. The survival rate at one year was 76% and at five years was 64% in this group of patients as estimated by Kaplan-Meier analysis. Deaths were related to the underlying cancer with one death attributed to the HPN complication of catheter sepsis. The rate of catheter sepsis was well within expected ranges for other patients on HPN and was not correlated with the duration of HPN therapy.   

While no liver failure occurred, some signs of very mild HPN-induced liver disease were seen in half of the patients. Of the 54 patients reviewed, 19 discontinued HPN therapy and were able to maintain weight and hydration on oral intake alone. Patients who experienced short bowel syndrome were less likely to discontinue HPN than those with problems that could be surgically addressed. In this group of 19 patients eight were found to be still alive. 

Summary of Study 3:

1. Centers for Disease Control and Prevention/ Guidelines for the Prevention of Intravascular Catheter-Related Infections. MMWR 2002;51(No. RR-10):[1-29] http://www.cdc.gov/mmwr/PDF/RR/RR5110.pdf