Preoperative nutritional support to tackle morbidity in multivisceral resection for retroperitoneal sarcoma. Early outcomes from a novel nutritional prehabilitation program in a prospective cohort.

OBJECTIVE: Evaluate the feasibility and outcomes of the implementation of a routinely prehabilitation nutritional program (PNP) in retroperitoneal sarcoma (RPS) patients. SUMMARY BACKGROUND DATA: Rate of preoperative malnutrition is scarcely evaluated in RPS patients and the efficacy of a PNP in detecting and reverting malnutrition has not been studied. METHODS: Prospective study in a high-volume reference center for RPS; adult patients with primary or persistent RPS deemed surgically resectable were enrolled in a PNP. RESULTS: 119 patients underwent surgery for RPS at Fondazione IRCCS Istituto Nazionale dei Tumori in Milan, 73 (61.3 %) were enrolled in the PNP while the remaining served as control cohort. 43.8 % (32/73), 28.8 % (21/73), and 27.4 % (20/73) were classified as non-malnourished, moderately malnourished, and severely malnourished at diagnosis, respectively. Preoperative nutritional support was provided to 35 out of 73 patients (47.9 %). Among untreated patients 20 of 38 (52.6 %) experienced a preoperative worsening of their nutritional status, whereas among those in the prehabilitation program 16 of 35 (45.7 %) showed improvement. Surgical complications did not significantly differ between malnourished and non-malnourished patients, potentially due to increased use of diverting stomas in malnourished patients to prevent infectious complications. Reversal of initial malnutrition correlated with better postoperative outcomes, as evidenced by lower rates of severe complications (OR: 0.18, 95%CI 0.04-0.75, p = 0.02) and a lower Comprehensive Complication Index (OR: -0.28, 95%CI -0.51 to -0.06, p = 0.02) in multivariate analysis. CONCLUSIONS: The implementation of a prehabilitation nutritional program brought relevant benefits in terms of postoperative morbidity.

Delayed Gastric Emptying After Multivisceral Resection for Retroperitoneal Sarcoma.

INTRODUCTION: Delayed gastric emptying (DGE) is a common complication in surgery, but incidence and relevance following multivisceral resection are unknown. METHODS: Data from 100 consecutive patients treated for primary retroperitoneal sarcoma (RPS) were analyzed from our institutional prospectively maintained database from January 2019 to April 2020. DGE severity was graded according to the International Study Group of Pancreatic Surgery and classified as primary or secondary to other complications. The primary outcome was incidence and grade of clinically relevant DGE (grades B-C). Secondary outcomes were correlation with patient, tumor, and treatment characteristics, and non-DGE morbidity [Clavien-Dindo (CD) grade ≥ 3]. RESULTS: Forty-two patients developed DGE and 28 had clinically relevant DGE. DGE was primary in 10 patients and secondary in 18 patients; the most common associated complications were: infections (11/18, 61.1%), pancreatic leak (7/18, 38.9%), bleeding (6/18, 33.3%), and bowel leak (6/18, 33.3%). DGE was related to longer length of hospital stay (P < 0.001), ICU admission (P = 0.004), ICU length of stay (P = 0.001), postoperative complications (CD [Formula: see text] 3 in 14/28 in DGE patients vs 11/72 in no-DGE; P = 0.04), and re-operation (P = 0.03). With multivariate analysis, the independent risk factors for DGE were patient comorbidities (OR 1.05; 95% CI 1.01-1.1; P = 0.04) and tumor size (OR 1.05; 95% CI 1.0-1.1; P = 0.02). DISCUSSION: Following multivisceral resection, DGE is a clinically relevant event that can be caused by an underlying complication. Prompt diagnosis and treatment of both DGE and any underlying complications led to full recovery in all cases.

Nutritional Support Indications in Gastroesophageal Cancer Patients: From Perioperative to Palliative Systemic Therapy. A Comprehensive Review of the Last Decade.

Gastric cancer treatments are rapidly evolving, leading to significant survival benefit. Recent evidence provided by clinical trials strongly encouraged the use of perioperative chemotherapy as standard treatment for the localized disease, whereas in the advanced disease setting, molecular characterization has improved patients' selection for tailored therapeutic approaches, including molecular targeted therapy and immunotherapy. The role of nutritional therapy is widely recognized, with oncologic treatment's tolerance and response being better in well-nourished patients. In this review, literature data on strategies or nutritional interventions will be critically examined, with particular regard to different treatment phases (perioperative, metastatic, and palliative settings), with the aim to draw practical indications for an adequate nutritional support of gastric cancer patients and provide an insight on future directions in nutritional strategies. We extensively analyzed the last 10 years of literature, in order to provide evidence that may fit current clinical practice both in terms of nutritional interventions and oncological treatment. Overall, 137 works were selected: 34 Randomized Clinical Trials (RCTs), 12 meta-analysis, 9 reviews, and the most relevant prospective, retrospective and cross-sectional studies in this setting. Eleven ongoing trials have been selected from clinicaltrial.gov as representative of current research. One limitation of our work lies in the heterogeneity of the described studies, in terms of sample size, study procedures, and both nutritional and clinical outcomes. Indeed, to date, there are no specific evidence-based guidelines in this fields, therefore we proposed a clinical algorithm with the aim to indicate an appropriate nutritional strategy for gastric cancer patients.

What Do We Know About the Do-It-Yourself Diets of Patients in Our Care?

This pilot study aimed to investigate dietary changes introduced after being diagnosed with cancer in a sample of 60 consecutive children and adolescents on the basis of a self-report questionnaire. The study showed that 53% of patients changed their diet, usually "to combat the tumor" (in 47% of cases). In 1 in 2 of these cases, the health care staff were not informed about any changes. This study underscores the fact that many patients and families chose to impose dietary changes that are not always discussed with their health care staff and that may risk interfering with the continuity of a patient's treatment. It is essential to have more opportunities to speak with patients and families about this issue.

Nutritional intervention in head and neck cancer patients during chemo-radiotherapy.

OBJECTIVE: Head and neck cancer patients experience unintentional weight loss and malnutrition at diagnosis, during oncologic treatment, and after the end of therapy because of reduction of eating ability. The aim of the present study was to assess nutrition intervention efficacy in maintaining basal nutritional conditions. METHODS: Head and neck cancer patient candidates for chemoradiotherapy and requiring enteral nutrition (EN) support through gastrostomy, according to international guidelines, were included in the study. Nutritional intervention aimed to reach 30 kcal/kg/d, considering both EN and oral intake. Adjustments were made during and after treatment, aiming to maintain stable or improving nutritional indicators. Anthropometry, body composition measured by bioelectrical impedance vector analysis, and oral and EN intake were monitored at baseline (before chemoradiotherapy) and at 1, 3, and 6 mo. RESULTS: A total of 54 patients were evaluated; 35 patients completed follow-up at 6 mo and were included in the analysis. At baseline, mean weight loss in the last 6 mo was 12 ± 7.9%; mean body mass index and phase angle were 20.6 ± 3.9 kg/m2 and 4.8 ± 1.2°. Before chemoradiotherapy 21 patients (60%) were able to eat; the percentage decreased during and after treatment to 34.3% (P = 0.026) at 1 and 3 mo and at 51.4% at 6 mo. From the analysis, a mean daily energy intake of 35 ± 10 kcal/kg was needed to maintain stable body weight and phase angle during and after treatment. CONCLUSION: To preserve body weight and composition, we identified an energy requirement greater than expected both during and after chemoradiotherapy.

Bowel ultrasound imaging in patients with cystic fibrosis: Relationship with clinical symptoms and CFTR genotype.

BACKGROUND: Ultrasound imaging is used to assess bowel abnormalities in gastrointestinal diseases. We aimed to assess the rate of predefined bowel ultrasound signs and their relationship with gastrointestinal symptoms and the cystic fibrosis transmembrane conductance regulator (CFTR) genotype in cystic fibrosis patients in regular follow-up. METHODS: Prospective study of 70 consecutive patients with cystic fibrosis and 45 controls who underwent abdominal ultrasound; pertinent findings were related to gastrointestinal symptoms and, in cystic fibrosis patients, to pancreatic status, malabsorption degree, lipase intake, CFTR genotype (classified as severe or mild against functional class of CFTR mutations). RESULTS: 96% patients showed at least one abnormal bowel ultrasound sign. Most frequent signs were lymph node enlargement (64%), bowel loop dilatation (55%), thick corpuscular intraluminal content (49%), bowel wall hypervascularization (26%), thickened bowel wall (22%) and intussusception (17%). Patients with recurrent abdominal pain showed more bowel wall hypervascularization than patients without recurrent pain (47% vs. 19%, respectively; p = 0.02) and intussusception (58% vs. 17%, respectively; p < 0.01). Genotype was not associated to specific bowel ultrasound signs. Patients with bowel loop intussusception showed greater lipase intake than those without intussusception (8.118 ± 2.083 vs. 5.994 ± 4.187, respectively; p < 0.01). CONCLUSION: Cystic fibrosis patients present a higher rate of bowel ultrasound abnormalities than controls. Bowel ultrasound abnormalities are associated with abdominal symptoms.

The use of a pocket-sized ultrasound device improves physical examination: results of an in- and outpatient cohort study.

BACKGROUND: The performance of pocket mobile ultrasound devices (PUDs) is comparable with that of standard ultrasonography, whereas the accuracy of a physical examination is often poor requiring further tests to assess diagnostic hypotheses. Adding the use of PUD to physical examination could lead to an incremental benefit. AIM: We assessed whether the use of PUD in the context of physical examination can reduce the prescription of additional tests when used by physicians in different clinical settings. METHODS: We conducted a cohort impact study in four hospital medical wards, one gastroenterological outpatient clinic, and 90 general practices in the same geographical area. The study involved 135 physicians who used PUD, after a short predefined training course, to examine 1962 consecutive patients with one of 10 diagnostic hypotheses: ascites, pleural effusion, pericardial effusion, urinary retention, urinary stones, gallstones, biliary-duct dilation, splenomegaly, abdominal mass, abdominal aortic aneurysm. According to the physicians' judgment, PUD examination could rule out or in the diagnostic hypothesis or require further testing; the concordance with the final diagnosis was assessed. The main outcome was the proportion of cases in which additional tests were required after PUD. The PUD diagnostic accuracy was assessed in patients submitted to further testing. FINDINGS: The 1962 patients included 37% in-patients, 26% gastroenterology outpatients, 37% from general practices. Further testing after PUD examination was deemed unnecessary in 63%. Only 5% of patients with negative PUD not referred for further testing were classified false negatives with respect to the final diagnosis. In patients undergoing further tests, the sensitivity was 91%, and the specificity 83%. CONCLUSIONS: After a simple and short training course, a PUD examination can be used in addition to a physical examination to improve the answer to ten common clinical questions concerning in- and outpatients, and can reduce the need for further testing.

Nutritional deficiencies in inflammatory bowel disease: therapeutic approaches.

BACKGROUND & AIMS: Malnutrition is common in inflammatory bowel diseases (IBD), mainly in Crohn's disease (CD) because the small bowel is primarily affected. We reviewed the literature to highlight the importance of proper nutrition management. METHODS: A PubMed search was performed for English-language publications from 1999 through 2012. Manuscripts comparing nutritional approaches for IBD patients were selected. RESULTS: We identified 2025 manuscripts: six meta-analyses, 170 clinical-trials, 692 reviews. The study findings are discordant. In adult CD, enteral nutrition plays a supportive role, steroid therapy remaining the first choice treatment. In CD children enteral nutrition may represent the primary therapy. As regards parenteral nutrition, there are no large randomized studies, although mild improvements in morbidity have been described as a result of parenteral nutrition in malnourished surgical IBD patients. Specific micronutrient deficiencies are common in IBD. A number of factors may contribute to micronutrient deficiencies, and these include: dietary restriction, disease activity and surgery. The possible therapeutic roles of omega-3 fatty-acids, probiotics and prebiotics have been studied, but the results are still preliminary. CONCLUSION: Protein-energy malnutrition and micronutrient depletion are clinical concerns in IBD patients. Enteral nutrition, parenteral nutrition and micronutrient supplementation are cornerstone of the multidisciplinary management of IBD patients.

Transient elastography in patients with celiac disease: a noninvasive method to detect liver involvement associated with celiac disease.

BACKGROUND: Liver involvement in celiac disease (CD) is clinically relevant and could require specific treatment in addition to gluten-free diet (GFD). Transient elastography (TE), a noninvasive tool for assessing liver stiffness (LS), has widely been reported as an accurate surrogate marker of liver fibrosis. AIMS: To prospectively identify celiac patients with liver involvement by TE and to assess the effect of GFD. MATERIAL AND METHODS: Ninety-five histologically confirmed CD patients (24 newly diagnosed) were consecutively evaluated by TE and compared with 146 patients with chronic hepatitis C (HCV) and 54 healthy subjects. RESULTS: LS ranged between 2.8 and 6.7 kPa (median 4.9) in healthy subjects, defining 6.9 kPa as the upper reference limit (2 SD above the mean levels). TE was above 6.9 kPa in 10 (10.5%) CD patients. Median TE values resulted significantly higher in CD patients with hypertransaminasemia than those without [6.1 vs. 4.2 kPa (p < 0.01)]. Among the 24 newly diagnosed patients with CD, median TE values declined from 4.4 to 4 kPa, after 6 months of GFD, resulting below 6.9 kPa in 100% of the patients. CONCLUSIONS: A subset of CD patients with hypertransaminasemia showed liver involvement by TE. Accordingly, based on its accuracy in predicting liver fibrosis, TE could be used to identify those CD patients suitable for liver biopsy.

[Transient elastography]. / L'elastografia transiente.

Transient elastography (TE, Fibroscan) is a recent, rapid and highly reproducible technique for measuring liver tissue stiffness. Several studies in patients with chronic liver disease evidenced that it accurately predicts the degree of hepatic fibrosis and that it is particularly accurate in identifying severe fibrosis and cirrhosis. However, in the clinical practice TE provides an answer to a single question (liver elasticity) that could be influenced by several factors, mainly by hepatic fibrosis, but also by necrosis-inflammatory activity and extrahepatic cholestasis.