Nutritional management of the patient with pancreatic cancer: from the diagnostic and therapeutic pathway to an integrated hospital-territory approach.

Abstract: Pancreatic cancer is associated to a high risk of malnutrition and neoplastic cachexia even at first diagnosis. Malnutrition is a negative prognostic factor for the outcome of surgery or medical oncology treatments. Despite the good awareness of the problem and the knowledge of the guidelines, the early recognition of malnutrition and its management are still uneven, mainly due to the lack of implementation of standardized and shared protocols and the shortage of dedicated clinical nutritionists and dieticians. An early and appropriate nutritional intervention is mandatory to improve the outcome of patients with pancreatic cancer at any stage of disease. The Mini Nutritional Assessment is useful tool to screen patients malnourished or at risk of malnutrition. The need for the establishment and implementation of an integrated hospital - territorial assistance as well as a home-delivered nutrition service is discussed.

Management of Patients with Gastric or Gastroesophageal Junction Cancer: From Theory to Integrated Clinical Path- ways Implementation in the Real World.

Introduction: Best care of esophagogastric junction and gastric cancer (EGC) requires a complex, timely interaction between members of a multi-disciplinary team (MDT). An integrated clinical pathway (ICP) is necessary to achieve this goal as well as the implementation of its use in daily practice. The objective of this study was to elaborate on an integrated clinical pathway for the multi-disciplinary management of ECG. Authors also put in act an implementation program to improve adherence to guidelines thought an ICP. Method: This prospective work carried out by a multi-institutional MDT in Italy identified expert panel extracted relevant recommendations and/or statements from published papers and guidelines obtaining a set of crucial interventions employed the Estimate-Talk-Estimate method. A flow-chart diagram was elaborated to elicit the process at a glance. The primary outcome measure was the elaboration of an ICP with a high consensus rate also reported as a snapshot diagram and its implementation in daily clinical practice. An accredited certification body agency validated results, and an implementation process was started in several hospitals known to treat ECG. Results: A methodologist aggregated a multi-disciplinary panel of experts from different institutions. The panel elaborated a flow-chart diagram with crucial intervention highlight and connecting lines, as well as outcome measures. An accredited certification body agency validated the entire process, representing the basis for empowerment and implementation among patients and oncological professionals in various hospitals. Conclusion: The multi-disciplinary and multi-institutional expert panel successfully elaborated on a validated ICP for all stages ECG. An in-hospital implementation program has been programmed.

[Mirizzi's syndrome]. / La sindrome di Mirizzi.

Two cases of Mirizzi's syndrome are reported. The syndrome consists of: external compression of the common bile duct due to a benign lesion (Type I)--presence of a cholecystobiliary fistula with impacted stones and partial or total obstruction of the hepatic duct (Type II). Clinical signs are non-specific and suggest at first sight an obstructive jaundice. Ultrasonography shows dilatation of the upper biliary tract with narrowing of the biliary tract below the dilatation. ERCP often proves mandatory for diagnosis. Therapeutical procedures are reported.

[Diverticula of the right colon. The diagnosis and treatment of complications]. / Diverticoli del colon destro. Diagnosi e trattamento delle complicanze.

BACKGROUND: Diverticula are localized in the right colon with a rate of 6.7-14% in Western countries. Two types of diverticula have been described in the right colon, on the basis of etiologic and pathological features: multiple diverticula and solitary diverticulum of the caecum. The most common clinical presentation of the right-sided colonic diverticula is an acute inflammatory complication, which is difficult to distinguish from other causes of right iliac fossa pain. METHODS: A survey of the literature is presented and personal experience relative to 4 cases of acute diverticulitis of the right colon observed over a 10-year period is described. RESULTS: In all the patients the preoperative diagnosis was acute appendicitis. In two cases the poor clinical conditions of the patients were associated with the free perforation of a solitary caecal diverticulum and diffuse faecal peritonitis. A temporary caecostomy was therefore required. In two cases a localized inflammatory mass was found around a perforated solitary diverticulum of the caecum. An ileocaecal resection was performed. CONCLUSIONS: The purpose of this study is to emphasize the epidemiological, etiologic and clinical features of right-sided colonic diverticula, and the diagnostic and therapeutic management of their complications.

[Hemobilia. Etiopathogenic, clinical, and therapeutic considerations]. / Emobilia. Considerazioni eziopatogenetiche, cliniche e terapeutiche.

The authors present a case report of hemobilia resulting from the rupture of a cystic artery pseudoaneurysm into the biliary tract. They analyse the international literature and stress aethiology, pathogenesis, clinical presentation, diagnosis and therapeutic aspects.