Emanuele Rinninella

NutriCatt protocol in the Enhanced Recovery After Surgery (ERAS) program for colorectal surgery: The nutritional support improves clinical and cost-effectiveness outcomes

BACKGROUNDnPostoperative complications and length of hospital stay (LOS) are major issues and affect hospital costs. Enhanced Recovery After Surgery (ERAS) protocols are effective in reducing morbidity and LOS after major surgery. We propose a nutritional protocol within ERAS programs in colorectal surgery, starting from preadmission.nnnMETHODSnWe compared the ERASu2009+u2009NutriCatt approach versus the ERAS standard program adopted in our center in the previous months. Complications, LOS, hospital readmission at 30u2009days, and late complications (at 90u2009days) were assessed and compared. A cost-effectiveness analysis was performed.nnnRESULTSnA total of 114 patients were treated according to the ERAS program between April 2015 and January 2016; 105 were enrolled in the ERASu2009+u2009NutriCatt protocol from February to September 2016; Patients characteristics were similar in the two groups, except for American Society of Anesthesiologists score, which was significantly worse in the ERASu2009+u2009NutriCatt cohort; preoperative diagnoses and surgical approaches were similar in the two periods. LOS was significantly inferior in the ERASu2009+u2009NutriCatt protocol (4.9u2009±u20091.7u2009d; 95% confidence interval [CI] 4.60-5.28) compared with the standard ERAS program (6.1u2009±u20093.9u2009d, 95% CI 5.36-6.81) (Pu2009=u20090.006), as were postoperative complications (36, 34.3% versus 55, 48.2%; Pu2009=u20090.03). Complications within 90u2009d were 0 in ERASu2009+u2009NutriCatt and 4 in the ERAS standard cohort. Cost-effectiveness analyses indicated savings in the ERASu2009+u2009NutriCatt protocol.nnnCONCLUSIONSnNutritional care, starting from the preadmission visit, is able to reduce LOS, postoperative and late complications, and costs, in addition to ERAS standard items in colorectal surgery.

Liver Resection versus Radiofrequency Ablation plus Transcatheter Arterial Chemoembolization in Cirrhotic Patients with Solitary Large Hepatocellular Carcinoma

PURPOSEnTo compare liver resection (LR) with single-step, balloon-occluded radiofrequency (RF) ablation plus drug-eluting embolics transarterial chemoembolization in cirrhotic patients with single hepatocellular carcinoma (HCC) ≥ 3 cm.nnnMATERIALS AND METHODSnFrom 2010 to 2014, 25 patients with compensated cirrhosis and single HCC ≥ 3 cm (median size 4.5 cm; range, 3.0-6.8 cm) not suitable for LR or liver transplantation were treated with RF ablation plus transarterial chemoembolization in a prospective observational single-center pilot study; all patients had complete tumor necrosis after treatment. A retrospective control group included 29 patients (median HCC size 4.0 cm; range, 3.0-7.4 cm) who underwent LR. RF ablation plus transarterial chemoembolization group included more patients with severe portal hypertension (65.5% vs 35.0%, Pxa0= .017). Primary endpoints were overall survival (OS) and tumor recurrence (TR) rates.nnnRESULTSnOne death and 1 major complication (4%) were observed in LR group. No major complications were reported in RF ablation plus transarterial chemoembolization group (Pxa0= .463). OS rates at 1 and 3 years were 91.8% and 79.3% in LR group and 89.4% and 48.2% in RF ablation plus transarterial chemoembolization group (Pxa0= 0.117). TR rates at 1 and 3 years were 29.5% and 45.0% in LR group and 42.4% and 76.0% in RF ablation plus transarterial chemoembolization group (Pxa0= .034). Local tumor progression (LTP) rates at 3 years were significantly lower in LR group (21.8% vs 58.1%, Pxa0= .005). Similar results were found in patients with HCC ≤ 5 cm (TR rates 35.4% vs 75.1%, Pxa0= .016; LTP 16.0% vs 55.7%, Pxa0= .013).nnnCONCLUSIONSnLR achieved lower TR and LTP rates than RF ablation plus transarterial chemoembolization, but 3-years OS rates were not statistically different between the 2 groups. RF ablation plus transarterial chemoembolization is an effective treatment option in patients with compensated cirrhosis and solitary HCC ≥ 3 cm unsuitable for LR.

Hypokalemia-induced pseudoischemic electrocardiographic changes and quadriplegia

Hypokalemia is a common biochemical abnormality. Severe hypokalemia can produce cardiac rhythm alterations and neurologic manifestations. Early detection and treatment allow clinician to prevent morbidity and mortality from cardiac arrhythmias and respiratory failure. Here, we describe a case of severe hypokalemia inducing pseudoischemic electrocardiographic (ECG) alterations and quadriplegia, in a patient affected by chronic diarrhea. Electrocardiographic alterations and neurologic manifestations completely disappeared after potassium replacement; however, prolonged potassium supplementation was required to achieve the normalization of plasmatic potassium levels. Consecutive figures show ECG improvement until normalization of ECG findings.

Risk, prevalence, and impact of hospital malnutrition in a Tertiary Care Referral University Hospital: a cross-sectional study

Hospital malnutrition is still underestimated among physicians, even in internal medicine settings. This is a cross-sectional study, aiming to estimate the risk, the prevalence and the impact of malnutrition in an Internal Medicine and Gastroenterology Department of a large Italian hospital (Fondazione Policlinicoxa0Universitario A. Gemellixa0IRCCS, Rome). Patients were evaluated within 72xa0h from admission according to Nutritional Risk Screening-2002 (NRS-2002) and European Society for Clinical Nutrition and Metabolism (ESPEN) Criteria. Anthropometric, laboratory tests and Bioelectrical Impedance Analysis (BIA) derived phase angle were also performed. Length of hospital stay (LOS) and in-hospital mortality were collected. Univariate and multivariate analyses were conducted to correlate nutritional status with LOS and hospital mortality. In 10xa0months, 300 patients were enrolled: male patients were 172 (57.3%); mean age was 63.7 (±u200917.6). At admission, 157 (52.3%) patients were at risk of malnutrition; 116 (38.7%) were malnourished. Malnourished patients had a mean LOS of 11.5 (±u20098.0) days, not-malnourished 9.4 (±u20096.2) days (pu2009<u20090.05). In-hospital mortality did not significantly differ between the two groups. Multivariate analysis shows that both malnutrition (pu2009=u20090.04; 95% CI 0.03–3.41) and phase angle (pu2009=u20090.004; 95% CI −u20091.92 to −u20090.37) independently correlate with LOS. In an Internal Medicine and Gastroenterology Department, over half (52.3%) of the patients were found at risk of malnutrition, and over a third (38.7%) were malnourished at hospital admission. Malnutrition and BIA-derived phase angle are independently associated with LOS. ESPEN Criteria and phase angle could be performed at admission to identify patients deserving specific nutritional support.

Nutritional support in mitochondrial diseases: the state of the art

Mitochondrial diseases are a group of rare multisystem disorders characterized by genetic heterogeneity and pleomorphic clinical manifestations. The clinical burden may be heavy for patients and their caregivers. There are no therapies of proven efficacy until now and a multidisciplinary supportive care is therefore necessary. Since the common pathogenic mechanism is the insufficient energy production by defective mitochondria, nutrition may play a crucial role. However, no guidelines are still available. The article reports the current evidence, highlighting nutrition both as support and as therapy. The estimate of nutritional status, energy needs and nutritional behaviors are firstly discussed. Then, we go in-depth on the scientific rationale and the clinical evidence of the use of anti-oxidants and enzyme-cofactors in the clinical practice. In particular, we analyze the role of Coenzyme Q10, Creatine monohydrate, α-lipoic acid, riboflavin, arginine and citrulline, folinic acid, carnitine, vitamin C, K, and E. Every attempt at nutritional intervention should be made knowing patients disease and focusing on his/her energy and nutrients requirements. For this reason, clinicians expert in mitochondrial medicine and clinical nutritionists should work together to ameliorate care in these fragile patients.

May nutritional status worsen during hospital stay? A sub-group analysis from a cross-sectional study

Hospital malnutrition is a detrimental prognostic factor regarding hospital mortality, complications, and length of stay. However, the role of hospitalization itself on nutritional status has not been fully elucidated. We report the results of a secondary analysis from the dataset of a recent cross-sectional study at Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy. Data from patients evaluated at admission and discharge were collected and compared. One hundred thirty-nine patients were evaluated. Mean length of stay was 13.6 (±u20097.7) days. Patients at risk of malnutrition, according to NRS-2002, were 75 (53.9%), while 63 (45.3%) were malnourished according to ESPEN Criteria. Compared to admission, at discharge, patients reported a significant decrease in Mid-Upper Arm Circumference (MUAC)—from 26.5xa0cm (±u20093.6) to 25.9xa0cm (±u20093.7) (pu2009=u20090.016), a reduction in Phase angle (PhA)—from 4.25° (±u20091.20) to 4.01° (±u20091.15) (pu2009=u20090.005), fat-free mass (FFM)—from 47.5xa0kg (±u20099.19) to 44.9xa0kg (±u20099.4) (pu2009=u20090.03) and fat-free mass index (FFMI)—from 16.9xa0kg/m2 (±u20092.3) to 15.8xa0kg/m2 (±u20092.7) (pu2009=u20090.04). Laboratory data showed a reduction of albumin—from 29.2 (±u20095.7) to 28.0 (±u20095.9) (pu2009=u20090.01) and Onodera’s PNI- from 29.1 (±u20095.6) to 27.6xa0kg (±u20095.6) (pu2009=u20090.039). At the multivariate linear regression analysis, the variables significantly associated with a worsening of PhA at discharge are the PhA value at admission and the diagnosis of malnutrition according to ESPEN Criteria. Hospitalization leads to significative changes in nutritional status. A clinical concern should be raised about the quality of hospital food and meal times and on the need for a clinical nutritionist on the ward.

TACE with degradable starch microspheres (DSM-TACE) as second-line treatment in HCC patients dismissing or ineligible for sorafenib

ObjectivesTo date, there is no approved second-line treatment for patients dismissing sorafenib or ineligible for this treatment, so it would be useful to find an effective alternative treatment option. The aim of our study was to evaluate safety, feasibility and effectiveness of transarterial chemoembolisation with degradable starch microspheres (DSM-TACE) in the treatment of patients with advanced hepatocellular carcinoma (HCC) dismissing or ineligible for multikinase-inhibitor chemotherapy administration (sorafenib) due to unbearable side effects or clinical contraindications.MethodsForty consecutive BCLC stage B or C patients (31 male; age, 70.6 ± 13.6 years), with intermediate or locally advanced HCC dismissing or ineligible for sorafenib administration, who underwent DSM-TACE treatment cycle via lobar approach were prospectively enrolled. Tumour response was evaluated on multidetector computed tomography based on mRECIST criteria. Primary endpoints were safety, tolerance and overall disease control (ODC); secondary endpoints were progression-free survival (PFS) and overall survival (OS).ResultsTechnical success was achieved in all patients. No intra/peri-procedural death/major complications occurred. No signs of liver failure or systemic toxicity were detected. At 1-year follow-up, ODC of 52.5% was registered. PFS was 6.4 months with a median OS of 11.3 months.ConclusionsDSM-TACE is safe and effective as a second-line treatment in HCC patients dismissing or ineligible for sorafenib.Key Points• DSM-TACE is safe and effective as second-line treatment in HCC patients dismissing or ineligible for sorafenib• DSM-TACE allows the temporary occlusion of the smaller arterial vessels, improving overall therapeutic effectiveness by reducing the immediate wash-out of the cytostatic agent• DSM-TACE also decreases the risk of systemic toxicity and post-embolic syndrome

Reverse time-dependent effect of alphafetoprotein and disease control on survival of patients with Barcelona Clinic Liver Cancer stage C hepatocellular carcinoma

AIM To characterize the survival of cirrhotic patients with Barcelona Clinic Liver Cancer (BCLC) stage C hepatocellular carcinoma (HCC) and to ascertain the factors predicting the achievement of disease control (DC). METHODS The cirrhotic patients with BCLC stage C HCC evaluated by the Hepatocatt multidisciplinary group were subjected to the investigation. Demographic, clinical and tumor features, along with the best tumor response and overall survival were recorded. RESULTS One hundred and ten BCLC stage C patients were included in the analysis; the median overall survival was 13.4 mo (95%CI: 10.6-17.0). Only alphafetoprotein (AFP) serum level > 200 ng/mL and DC could independently predict survival but in a time dependent manner, the former was significantly associated with increased risk of mortality within the first 6 mo of follow-up (HR = 5.073, 95%CI: 2.159-11.916, P = 0.0002), whereas the latter showed a protective effect against death after one year (HR = 0.110, 95%CI: 0.038-0.314, P < 0.0001). Only patients showing microvascular invasion and/or extrahepatic spread recorded lower chances of achieving DC (OR = 0.263, 95%CI: 0.111-0.622, P = 0.002). CONCLUSION The BCLC stage C HCC includes a wide heterogeneous group of cirrhotic patients suitable for potentially curative treatments. The reverse and time dependent effect of AFP serum level and DC on patients’ survival confers them as useful predictive tools for treatment management and clinical decisions.

Scleroderma and liver disease: a case of an association with primary sclerosing cholangitis

Index. J Rheumatol 1994;21:2286–91. 10. Machado P, Landewe R, Lie E, Kvien TK, Braun J, Baker D, et al. Ankylosing Spondylitis Disease Activity Score (ASDAS): defining cut-off values for disease activity states and improvement scores. Ann Rheum Dis 2011;70:47–53. Anneke F Marsman, Amsterdam Rheumatology and Immunology Centre, location Reade, PO Box 58271, 1040HG Amsterdam, The Netherlands. E-mail a.marsman@reade.nl

Mo2030 Treatment of Portal Vein Tumor Thrombosis (PVTT) Can Impact Survival of Patients With Advanced HCC

Background/Aims: Hepatolithiasis is a well known risk factor of cholangiocarcinoma. Despite advances in diagnostic modalities, diagnosing cholangiocarcinoma in patients with hepatolithiasis still challenging and there are not enough reports on the incidence of cholangiocarcinoma in patient with hepatolithiasis after treatment. We aimed to evaluate the incidence and clinical characteristics of cholangiocarcinoma in patients with hepatolithiasis who underwent liver resection or non-resection. Methods: Among a total of 257 patients who received treatment for hepatolithiasis from 2002 to 2011 at Korea University Anam and Guro Hospital, 236 patients were eligible for analysis; 92 patients underwent liver resection (resection group) and 144 patients did not (non-resection group). The data were retrospectively collected and analyzed. Results: The incidence of cholangiocarcinoma was 6.8% (16/236) during follow-up period (mean 41±41 months). The median tumor occurrence time was 28 (13-111) months. Cholangiocarcinoma occurred 6.5% (6/92) and 6.9% (10/144) in resection and non-resection group respectively (P=0.425). In resection group, cholangiocarcinoma occurred in 3.6% (2/56) of patients with complete stone removal, and in 13.3% (4/ 30) of patients with incomplete stone removal (p=0.591). In non-resection group, cholangiocarcinoma occurred in 5.7% (3/53) of patients with complete stone removal, and in 8.9% (7/79) of patient with incomplete stone removal (p=0.738). When analyzed according to completeness of stone removal regardless of treatment modality, cholangiocarcinoma occurred in 4.6% (5/109) of patients with complete stone removal, and in 10.1% (11/109) of patients with incomplete stone removal (p=0.429). Although the site of stone and tumor occurrence concurred in 10/16 patients (3/6 patients in the resection group, 7/10 patient in the non-resection group), it did not match in 6 patients. On univariate analysis, none of the factors (age, gender, abdominal pain, bile duct stenosis, bile duct dilatation, liver atrophy, residual stone, stone recurrence and liver resection) showed relationship with the incidence of cholangiocarcinoma. Conclusion: There was no difference in the incidence of cholangiocarcinoma according to the treatment modality or completeness of stone removal. Therefore, patients with hepatolithiasis should carefully be followed-up to detect cholangiocarcinoma even after treatment.