Proceedings of the 12th Congress of the Parenteral and Enteral Nutrition Society for Asia (PENSA), Metro-Manila, Philippines, yr 2007

Home (Includes Pictures from Day 1 to Day3) / Day 2: October 19, 2007

Plenary Sessions

Symposia:

1) Symposium 3

2) Symposium: Cancer

3) Breakfast Symposium

4) Lunch Symposium

5) Dinner Symposium

Day 1 | Day 3

Unrestricted Grant

Abstracts

SGA Workshop

Pedia Workshop

 

 

PLENARY SESSIONS (Top)

Maurizio Muscaritoli (Italy)

Chair: Jonathan Asprer (Philippines)

 

SYMPOSIA (Top)

Chair: Thanyadej Nimmanwudipong (Thailand)

Co-Chair: Regina Bagsic (Philippines)

3.1 Early EN in surgical patients: Ryoji Fukushima (Japan) / view abstract

3.2 NS in GI Fistulas: Jianan Ren (China) / view abstract

3.3 Pancreatitis: Rakesh Tandon (India) / view abstract / View lecture in PDF format

 

2.1 Tilakavati Karupaiah (Malaysia) / view abstract

2.2 Winnie Swee (Malaysia) / view abstract

2.3 Edel Navarette (Philippines)

2.4 Cherrilyn Tan (Philippines)

2.5 Anna Dugang (Philippines)

 

LUNCH SYMPOSIUM (sponsored by FRESENIUS KABI) / (top)

a) Special substrates in the ICU: Raymundo Resurreccion (Philippines)

b) TPN using All-In-One: what does it mean and what are the benefits?: Staffan Bark (Sweden) / view lecture in PDF format

c) Glutamine: a life saving therapy in critical illness, but why?: Paul Wischmeyer (USA) / View lecture in PDF format / part 1: Why is gluatmine life-saving? / part 2: Heat shock proteins / part 3: other benefits of glutamine / part 4: negative trials with glutamine

 

UNRESTRICTED GRANT (sponsored by NESTLE PHILIPPINES) (top)

Chair: Jesus Fernando Inciong (Philippines)

a) The central role of the gut in critical illness: Ray Resurreccion (Philippines)

b) Enteral nutrition in critical illness: Reynaldo Sinamban (Philippines)

 

SYMPOSIUM 4: CANCER (top)

Chair: Jonathan Asprer (Philippines)

Co-Chair: Romulo de Villa (Philippines)

4.1 Nutritional status, weight loss, and outcome in cancer: Maurizio Muscaritoli (Italy)

4.2 Dietitian's role in feeding cancer patients: Tilakavati Karupaiah (Malaysia) / view abstract

4.3 Cancer cachexia management: Eduardo Santos (Philippines)

 

SPECIALTY SESSION 3: PEDIATRIC CLINICAL NUTRITION WORKSHOP (top)

Chair: Luisito Llido (Philippines )

Co-Chair: Grace Uy (Philippines)

SS3.1 Screening and Assessment: Mary Jean Guno (Philippines)

SS3.2 ESPGHAN Guidelines: Patrick Ball (New Zealand) / view abstract

SS3.3 Transitional Feeding: Felizardo Gatcheco (Philippines)

SS3.4 Access: Grace Uy (Philippines)

 

DINNER SYMPOSIUM (sponsored by OTSUKA PHILIPPINES) (top)

Branched Chain Amino Acids: Liver Disease and Beyond: Diana Payawal (Philippines)

 

ABSTRACTS (top)

WHAT IS NEW IN PARENTERAL NUTRITION ? (top)
Staffan Bark. MD. PhD.
Associate Professor of Surgery, Karolinska Institute

The history of Parenteral Nutrition (PN) goes back to 1940ies but true Total Parenteral Nutrition (TPN) did not become available until 1962 when the introduction of the fi rst safe fat emulsion, Intralipid, was launched. Glucose for intravenous infusion was shown to be possible to administer already back in the pre-WW II-period and protein hydrolysates was introduced during the war. Big jumps forward regarding improvements in medicine are rarely seen. Small, minimal steps forward are much more common and characteristic for progress in clinical care and sometimes combined with steps backwards. The introduction of NSAIDs is for example a good step forward followed by a slight movement backwards with the Vioxx story. We have seen similar things in clinical nutrition. One of the early fat emulsions that came to the market was a cottonseed based oil that proved to be very toxic. It was developed in USA. The side effects of that emulsion caused a long delay before Intralipid became available for the American patients.

Some good steps forward have been seen in clinical nutrition after the war. The introduction of Intralipid was a big jump. Some smaller steps came later like the launch of crystalline amino acid solutions, All-In-One containers, micronutrients as additives, medium chain fatty acids and structured triglycerides. All these things have made clinical nutrition very safe and effective. The research during the latest 2-3 decades has however shown that a good thing can be even better. Steadily improving knowledge about the pathophysiology of various conditions and mechanisms of some key nutrients have put glutamine and omega-3 fi sh oils (EPA and DHA) into focus. During the ESPEN congress a few weeks ago, fi sh oil was a key nutrient frequently mentioned and discussed. New data showed that humans can be “conditioned” by a single intravenous dose of 0.2 g fi sh oil/kg bw and test subjects will thereby signifi cantly sustain a LPS challenge. Fish oil is also reducing rolling and adhesion of neutrophils on endothelium and has a protective effect on the liver by reducing bilirubin and ASAT compared with LCT emulsions. Recent research has demonstrated that EPA and DHA also are acting anti-infl ammatory via resolvins. The liver protective effect is also supported by the increasing experience in small children on TPN in Children’s Hospital in Boston, USA. It started as a “desperate” attempt supported by animal studies to save babies and small children from liver transplantation due to PN associated liver dysfunction. By giving fish oil in a high dose, long term and as “stand-alone” fat emulsion (very off-label) they have converted life threatening liver failures and saved many children from liver transplantation.

Glutamine and its relation to citrulline and arginine is another hot topic. The role of arginine has been discussed extensively during the last few years. Is it benefi cial or harmful in high doses? Arginine is partly considered to be conditionally essential in critical illness. A signifi cant part is synthesized in the kidneys from citrulline derived from glutamine in the liver. Enterally provided glutamine yield more arginine than parenteral glutamine. Clinical studies have also shown the cell protective effect by Heat Shock Proteins following a challenge. This effect is dependent on suffi cient amounts of glutamine.

Metabolic control is a key issue in medical care today and clinical nutrition is more and more becoming an important tool. Lipids as a part of TPN is one way to control blood sugar levels and glutamine has been demonstrated to improve insulin sensitivity. Another important new message is the signifi cance of energy balance for a better outcome. Still not published data shows that bed rest and a hypocaloric diet intake (80% of REE) significantly reduces lean body mass during a 2 weeks study. Earlier studies have clearly shown a relation between negative energy balance and various complications. (top)

 

EARLY ENTERAL NUTRITION AFTER SURGERY FOR THE UPPER GASTROINTESTINAL CANCER PATIENTS (top)
Ryoji Fukushima MD, PhD
Department of Surgery, Teikyo University School of Medicine, Tokyo Japan

Malnutrition is a common and signifi cant problem in patients with upper gastrointestinal cancer. It is well known that perioperative nutritional support is important in reducing postoperative morbidity and mortality. Experimental and clinical investigation reveals that early enteral nutrition after surgery should be preferred to parenteral nutrition. However, surgeons often prefer postoperative parenteral nutrition despite a functioning gastrointestinal tract. According to a survey by the Japanese society for parenteral and enteral nutrition in 2002, almost up to 80% of patients who underwent total gastrectomy received TPN. The reason for the surgeons to prefer parenteral feeding may be the concerns for possible adverse effects of early feeding such as increased risk of anastomotic dehiscence, abdominal distention, diarrhea, or the feeding tube related complications.

In recent years, we have been performing postoperative early enteral feeding to those who underwent esophageal resection, total gastrectomy or pancreatoduodenectomy. A catheter-feeding jejunostomy was placed at the end of surgery. Jejunal feeding was started on the next day of surgery using a peristaltic pump at 15-20 ml/hour. The amount of nutrition given was 250-300 ml/day (1kcal/ ml) on POD 1 and the amount was gradually increased to 900-1250 ml/day on POD 5. Additional fl uids and electrolytes were given intravenously according to clinical requirements. Base on our experience, we would like to show the safety and feasibility of postoperative early enteral nutrition in those who underwent major digestive surgery for cancer. (top)

 

NUTRITIONAL SUPPORT IN GASTROINTESTINAL FISTULAS (top)
Jianan Ren M.D.
Research Institute of General Surgery
Jinling Hospital, Nanjing University, Jiangsu 210002, P. R. of China

Nutritional supports including parenteral and enteral nutrition play a key role in the management of Gastrointestinal fi stula patients. Malnutrition is very common among the patients complicated with gastrointestinal patients because of hypermetabolism induced by stress such as sepsis and injury and intestinal dysfunction. The optimal route of nutritional support is determined by the general strategy of reaching closure of gastrointestinal fi stula. Different large specialist centers have resulted in a variety of different management strategies.

Promoting spontaneous closure of fi stula is the first choice. To reach this purpose, total parenteral nutrition should be given to reduce the fi stula output and somatostatin may be given initially to further reduce the fi stula output. When the fi stula output could be controlled, enteral nutrition could be given and recombinant human growth hormone may be added to promote rapid spontaneous closure of fi stula.

Surgical intervention is need if the fi stula remains open after 2 months. Whenever it is found the fi stula could not close spontaneously and surgery is needed, enteral nutrition should be considered to maintain long term waiting for the surgery. The specifi c techniques for the implementation of enteral feeding include patch patching method, fi stuloclysis as well as the routine nasal gastric or nasal jejunal tube feeding. Enteral nutrition could be given incase of suspect of intestinal barrier damage and bacterial translocation to prevent repeat sepsis. In the perioperative period, total parenteral nutrition (TPN) should be given until the recovery of intestinal function. In selected cases, early defi nitive operation could be performed within two weeks of operation that induce fi stula. In this case, TPN may be given longer then the routine defi nitive surgery.

 

NUTRITION SUPPORT IN ACUTE PANCREATITIS: WHAT IS THE SCORE? (top)
Rakesh K Tandon
Head, Dept of Gastroenterology, Pushpawati Singhania Research Institute for Liver, Renal and Digestive Diseases, New Delhi, India.

Acute pancreatitis is an abdominal emergency that requires immediate attention to provide the patient relief from pain and do aggressive fl uid replacement. Further management depends on the severity of the disease. Those with mild to moderate disease (70-80%) tend to settle down within 3-5 days and are fed orally a gradually advancing diet. The remaining 20-30% suffering from severe acute pancreatitis (SAP) may continue to have systemic infl ammatory response syndrome (SIRS) for several weeks and suffer rapid weight loss and high mortality.1,2 It is this group of patients that requires special nutritional support.3

SIRS in AP is caused initially because of the infl ammation in the pancreas, stimulation of exocrine enzyme secretion as a result of feeding and loss of gut integrity and is greatly responsible for the subsequent course of the disease.3 Whilst factors causing infl ammation, such as a stone in the common bile duct, ethanol ingestion, infection, should be removed, proper nutritional management is required to control the other two factors. To avoid stimulation of the exocrine pancreas, the patients were kept nil orally and given pareneral nutrition (PN) in the past. This approach however, did not show any benefi t in outcome in at least two prospective studies in mild acute pancreatitis.4,5. The major factor that possibly contributed to this poor outcome was the increased intestinal permeability.

Enteral feeding (EN) was thus introduced by placing a nasojejunal tube. That indeed led to a better outcome. Of 6 prospective randomized controlled trials (PRCTs) of EN vs PN in AP randomized within 48 hours, fi ve showed signifi cant impact on clinical outcome.5-10 In these fi ve studies, EN was associated with decreased infectious morbidity, shorter length of hospital stay, less overall complications, reduced duration of the disease process and length of nutritional therapy and faster resolution of SIRS. Futhermore, the cost of therapy was much lower in the EN group7. This should not be surprising as similar experience exists with use of early enteral feeding in critically ill patients. In 15 PRCTs and 2 metaanalyses, early vs delayed feeding in such patients has been shown to reduce infection, length of hospital stay as well as mortality3.

In studies on patients with AP, it is notable that two factors were crucial in determining a favourable outcome with enteral feeding. Firstly, only patients with severe AP benefi tted. One study that enrolled patients with AP of much milder severity (Ranson’s criteria 1.1) early EN failed to show any benefi t 5. Secondly, if the introduction of EN was delayed to 4 full days in patients with SAP the expected benefi t from EN over PN did not occur.11 Delays in initiating EN in SAP lead to prolonged ileus and reduced chances for tolerance. In a prospective nonrandomized study of 102 patients with AP, it has been shown that if feeding could be started within 2 days tolerance to feeding was achieved in 92% of the patients. 12 . If however, the start of enteral feeding got delayed to 5 days or beyond the tolerance rate was reduced to 50% and if delayed to beyond 6 days the tolerance to EN was down to 0%.12 On the other hand, early start of enteral feeding within 48 hours of admission served to maintain gut function and improve tolerance. Fewer problems were encountered with ileus and gastric stasis with this aggressive approach.

Most groups have used naso-jejunal feeding although there are problems with regard to maintenance of the position of the tube and the patency of the tube. There is at least one group of investigators who suggest that naso-gastric feeding may be tolerated by patients with acute pancreatitis as well as naso-jejunal feeding.13 A group of 26 patients with prognostically severe AP were fed by fi ne-bore naso-gastric tube soon after admission. This was shown to be both practical and safe in 22 of the 26 patients. Feeding began within 48 hours of hospital admission starting with 30 ml/hr in most of these patients, increasing gradually within a further 36-48 hours of treatment. Subsequently, a randomized study of naso-gastric versus naso-jejunal feeding in severe AP has shown little difference in terms of c-reactive protein response, pain, analgesic requirement or clinical outcome from these two approaches of early naso-enteric feeding.14 Based on these studies the present trend is strongly in favour of using early naso-enteric feeding. However, judicious use of TPN in certain specifi c situations may still be needed in patients with AP; they include those with gastrointestinal hemorrhage or respiratory failure requiring ventilatory support. Which nutrients to feed and at what rate remain to be determined. Since fats stimulate the exocrine pancreas maximally and carbohydrates minimally, it would appear logical to start with carbohydrates. Small peptides are less stimulating than intact proteins or individual amino acids. Clearly studies need to address these issues. Similarly, the role of glutamine and other immunonutrients remains highly debatable. Addition of probiotics (Lactobacillus plantarum) to enteral feeding has also shown recently some promise of preventing the occurrence of infection in pancreatic necrosis.15

REFERENCES:
1 Blackburn GL. Williams LF, Bistrian BR, et al. New approaches to the management of severe acute pancreatitis. Am J Surg 1976, 131:114 – 124
2 Feller JH, Brown RA, Tousant GPM, and Tompson AG. Changing methods in the treatment of severe pancreatitis. Am J Surg 1974, 124: 196 – 201
3 McClave SA. Nutrition support in acute pancreatitis. Gastroenterology Clinics of North America 2007; 36:65-74.
4 Sax HC, Warner BW, Talamini MA, et al. Early total parenteral nutrition in acute pancreatitis: lack of benefi cial effect. Am J Surg 1987, 153: 117 – 24
5 Mc Clave S A, Snifer H. Owens Negative, et al. Comparison of the safety of early enteral VS parenteral nutrition in mild acute pancreatitis. J Parenter Enter Nutr 1997, 21: 14 – 20.
6 Kalfarentzos F, Kehagis J, Kokkinis K, et al. Enteral nutrition is superior to parenteral nutrition in severe acute pancreatitis: results of a randomized prospective trial. Br J Surg 1997, 84: 1665 – 1669
7 Windsor ACJ, Kanwar S, Li AGK, et al. Compared with parenteral nutrition, enteral feeding attenuates the acute phase response and improve disease severity in acute pancreatitis. Gut 1998, 42: 431 – 435.
8. Olah A, Pardavi G, Belagyi T et al. Early nasojejunal feeding in acute pancreatitis is associated with a lower complication rate. Nutrition 2002; 18: 259-62.
9. Abou-Assi S, Craig K, O’Keefe SJ. Hypocaloric jejunal feeding is better than total parenteral nutrition in acute pancreatitis: results of a randomized comparative study. Am J Gastroenterol 2002; 97: 2255-62.
10. Gupta R, Patel K, Calder PC et al. A randomized clinical trial to assess the effects of total enteral and total parenteral nutritional support on metabolic, infl ammatory and oxidative markers in patients with predictedsevere acute pancreatitis (APACHE II > or =6). Pancreatology 2003; 3: 406-13.
11. Louie BE, Noseworthy T, Hailey D et al. Enteral or parenteral nutrition for severe pancreatitis: a randomized controlled trialand health technology assessment. Can J Surg 2005; 48: 298-306.
12. Cravo M, Camillo ME, Marques A et al. Early tube feedingin acute pancreatitis: a prospective study. Clin Nutri 1989; 8:14.
13. Eatock FC, Brombacher GD, Steven A et al. Naso-gastric feeding in severe acute pancreatitis may be practical and safe. Int J Pancreatol 2000;28: 23 – 9.
14. Eatock FC, Chong PS, Menezes N, Imrie CW, McKay CJ, Carter R. A randomized study of early nasogastric versus naso-jejunal feeding in severe acute pancreatitis. Am J Gastroenterol 2005;100: 432-9.
15. Olah A, Belagyi T, Issekutz A, Gamal ME, Bengmark S. Randomized clinical trial of specifi c lactobacillus and fi bre supplement to early enteral nutrition in patients with acute pancreatitis. Br J Surg 2002; 89: 1163 – 7. (top)

NUTRITION ASSESSMENT WORKSHOP: SUBJECTIVE GLOBAL ASSESSMENT (top)
Winnie Chee Siew Swee and Tilakavati Karupaiah
Dept of Nutrition & Dietetics, Fac. of Allied Health Sciences,
National University of Malaysia

It is well accepted that hospital malnutrition is a veritable skeleton in the closet. To seriously address this issue, it is the right of every in-patient to receive nutrition screening. Evaluating and monitoring of nutritional status is a continuous quality improvement measure and is therefore an important measure to institute in any hospital. Should nutrition screening then be performed for 100% of hospital admissions? But do we have enough staff, the right staff and enough time to perform 100% screening?

Subjective Global Assessment (SGA), a well established rapid procedure for nutrition assessment, is ideal for the Asian hospital setting. SGA can be subjectively performed by the doctor, nurse or dietitian, or all in multi-disciplinary nutrition support care using minimal resources to screen a patient within a short period of time. The global approach is to combine clinical and physical assessment parameters which are separately rated using a 7-point scoring system. With the overall mean score, it is possible to grade a patient as A [normal/ well-nourished], B [mild to moderate malnutrition] and C [severe malnutrition].

Our Workshop will introduce SGA to the uninitiated, demystify the complexities of SGA and using case situations stimulate participants to perform SGA. Participants will be able to screen and identify patients who are at risk for nutrition-related problems through understanding the application of subjective global assessment and interpreting the SGA scores for rationale in instituting appropriate nutrition support.

 

THE DIETITIAN’s ROLE IN FEEDING CANCER PATIENTS: AN OVERVIEW (top)
Tilakavati Karupaiah
Dept of Nutrition & Dietetics, Faculty of Allied Health Sciences,
National University of Malaysia

The role of the dietitian in feeding the cancer patient is very much related to the involvement of nutrition issues in the spectrum of cancer survival. This spectrum includes patients undergoing treatment and recovery, living after recovery, and, for some, living with advanced cancer. Each of these phases has different needs and challenges with respect to nutritional requirements but the primary
site of the cancer and therapeutic methods infl uence needs. Specifi cally, active cancer treatment such as surgery, radiation therapy, and chemotherapy can change nutritional needs and alter the survivor’s intake and the body’s digestion, absorption, and use of food. Challenges such as achieving energy balance or preventing weight loss is an early goal in medical nutritional therapy. It becomes the most important nutritional goal for survivors at risk for unintentional weight loss in those receiving treatment directed to the alimentary tract. The involvement of the dietitian, therefore, should begin while active treatment is being planned and should focus on the patient’s current nutritional status, nutritional adequacy of the consumed diet and anticipated nutritional problems related to treatment. Assessment and planning for cancer survivors are crucial activities the dietitian performs in determining the rationale for nutrition support. In addition, this patient group and their family are often highly motivated to seek information about
food choices, dietary supplement use, and complementary nutritional therapies to improve their treatment outcomes, quality of life, and survival. This presentation gives an overview of the role of the dietitian plays in providing nutritional care for the cancer patient.

 

THE ESPEN/ESPGHAN PAEDIATRIC PN GUIDELINES AND THEIR RELEVANCE TO ASIA (top)
Patrick A. Ball
Professor of Pharmacy, Charles Sturt University, Wagga Wagga NSW, Australia

The pan-European guidelines for pediatric parenteral nutrition were jointly sponsored by the European Society for Paediatric Gastroentereology and Nutrition and the European Society for Parenteral and Enteral Nutrition. The concept arose out of growing concerns that practices varied widely across Europe and that the differences were a consequence of reasons other than scientifi c evidence or the best interests of the child.

Parenteral Nutrition is a therapy which can be life-saving, safe, effective and cost effective when done properly. Further, a number of other therapies such as neonatal surgery, neonatal intensive care, cancer chemotherapy and organ transplantation are severely compromised, and the cost of these therapies may be wasted, if adequate nutrition support is not available to help the patient through the course of treatment. Even if carried out sub-optimally, it is generally better than starving the patient, but it has the risk of severe and expensive complications if carried out badly.

The concept was to produce a document that would provide suffi cient information for someone starting out to put together all the necessary pieces for a service, based upon the best available evidence, or where evidence is lacking, a strong international consensus of a multidisciplinary team of experienced experts.

The process was supported by unconditional fi nancial support from Baxter Healthcare, B.Braun Melsungen, Fresenius-Kabi and the Child Health Foundation of Germany. All members of the team completed a disclosure of potential confl icts of interest.
The process is summarised in the table below. A steering committee was formed, forking groups were identifi ed, a literature review was undertaken, the evidence summarized and circulated for comment. A plenary session was held to develop consensus where evidence was lacking. The guidelines were developed, circulated for consultation and comments, and then published in the Journal of Paediatric Gastroenterology and Nutrition.

The guidelines are divided into the following sections:
1. Introduction
2. Energy.
3. Amino Acids.
4. Lipids.
5. Carbohydrates.
6. Fluid and Electrolytes (Na, Cl and K).
7. Iron, Minerals and Trace Elements.
8. Vitamins.
9. Venous Access.
10. Organisational Aspects of Hospital PN.
11. Home Parenteral Nutrition in Children.
12. Complications.
13. Annex: List of Products.
Each section presents, a review of published evidence, specifi c recommendations with levels of evidence and grade of recommendation, and a comprehensive bibliography.

The guidelines have relevance to Asia in that they currently provide; the strongest evidence or broadest consensus on best practice that is currently available. Like Europe, standards vary widely across the membership of PENSA. For those who appear to be at or beyond the standards set out, the guidelines enable users to benchmark their services with ‘best practice’ across all aspects of nutrition support and ensure they are in line. They also provide an opportunity to protect services and facilities against cut-backs and cost-savings.

For those apparently behind the standards, they provide a target to aim for and justifi cation of the need to aim for these standards. They also provide suffi cient information to allow these services to be built from scratch. For Asia, the guidelines may need adaptation. The number and skill level of allied health professionals available to support a team may vary from country to country, but the guidelines clearly indicate the skills needed and it may be appropriate for some of these skills to be acquired by professionals other than those traditionally used in Europe owing to availability and training level constraints. The guidelines provide a strong basis on the science of admixture stability, and this is important in matters such as generic substitution of solutions and components within a nutrition support service. The evidence is clear that substitution of alternative amino acid mixtures, lipid emulsions, additives etc requires full validation. These cannot be considered interchangeable items of commerce The guidelines are having a profound infl uence on practice across Europe and beyond. 2005

Koletzko, B., Goulet, O., Hunt, J., Krohn, K., Shamir, R. for the Parenteral Nutrition Guidelines Working Group. Guidelines on Paediatric Parenteral Nutrition of the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society for Clinical Nutrition and Metabolism (ESPEN), supported by the European Society of Paediatric Research (ESPR). Journal of Pediatric Gastroenterology and Nutirition 2005:41:S1-S8 (top)