Cognitive outcomes in patients treated with neuromuscular electrical stimulation after coronary artery bypass grafting

Objective

Mechanisms of neurocognitive injury as post-operative sequelae of coronary artery bypass grafting (CABG) are not understood. The systemic inflammatory response to surgical stress causes skeletal muscle impairment, and this is also worsened by immobility. Since evidence supports a link between muscle vitality and neuroprotection, there is a need to understand the mechanisms by which promotion of muscle activity counteracts the deleterious effects of surgery on long-term cognition.

Methods

We performed a clinical trial to test the hypothesis that adding neuromuscular electrical stimulation (NMES) to standard rehabilitation care in post-CABG patients promotes the maintenance of skeletal muscle strength and the expression of circulating neuroprotective myokines.

Results

We did not find higher serum levels of neuroprotective myokines, except for interleukin-6, nor better long-term cognitive performance in our intervention group. However, a greater increase in functional connectivity at brain magnetic resonance was seen between seed regions within the default mode, frontoparietal, salience, and sensorimotor networks in the NMES group. Regardless of the treatment protocol, patients with a Klotho increase 3 months after hospital discharge compared to baseline Klotho values showed better scores in delayed memory tests.

Significance

We confirm the potential neuroprotective effect of Klotho in a clinical setting and for the first time post-CABG.

ERAS Protocol for Perioperative Care of Patients Treated with Laparoscopic Nonanatomic Liver Resection for Hepatocellular Carcinoma: The ISMETT Experience

Background: Liver resection (LR) remains the best therapeutic option for patients with early-stage hepatocellular carcinoma (HCC) with preserved hepatic function and who are not eligible for liver transplantation. After its inception, the enhanced recovery after surgery (ERAS) protocol was widely used for treating patients with liver cancer, although there are still no clear indications for improving upon it in both open and laparoscopic surgery. Objective: This study aims to describe our institute's experience in the application of the ERAS protocol in a cohort of HCC patients, and to explore possible factors that could have an impact on postoperative outcomes. Materials and Methods: We retrospectively analyzed our experience with LR performed from September 2017 to January 2020 in patients treated with ERAS protocol, focusing on describing impact on postoperative nutrition, analgesic requirements, and length of hospitalization. Demographics, operative factors, and postoperative complications of patients were reviewed. Results: During the study period, 89 HCC patients were eligible for LR, and 75% of patients presented with liver cirrhosis. The most prevalent among etiologic factors was hepatitis C virus infection (53 patients out of 89, 60%), followed by nonalcoholic steatohepatitis (18 patients, 20%). The median age was 70 years. Liver cirrhosis did not have an impact on postoperative course of patients. Patients who underwent laparoscopic surgery and nonanatomic LR experienced low complication rates, shorter length of stay, and shorter time of intravenous analgesic requirements. Conclusions: Continual refinement with ERAS protocol for treating HCC patients based on perioperative counseling and surgical decision-making is crucial to guarantee low complication rates, and reduce patient morbidity and time for recovery.

A comprehensive protocol for physiokinesis therapy and enhanced recovery after surgery in patients undergoing video-assisted thoracoscopic surgery lobectomy

Background

Video-assisted thoracoscopic surgery (VATS) lobectomy has recently been adopted as the gold standard surgical option for the treatment of early stage non-small cell lung cancer. Enhanced recovery after surgery (ERAS) is being progressively adopted in thoracic surgery to improve the postoperative outcomes. Even if the benefits of ERAS are universally accepted, to date a standardized and uniform approach has not been described in the medical literature. The Italian VATS group has recently proposed to include in the VATS lobectomy database a structured protocol for ERAS.

Methods

The ERAS section of the Italian VATS group is proposing a comprehensive ERAS protocol within the VATS lobectomy database, allowing the prospective collection of a dedicated set of data. Separate sections of the protocol are dedicated to different topics of ERAS. This study is specifically dedicated to the section of physiokinesis therapy. The medical literature will be extensively reviewed and a physiotherapy (PT) protocol of ERAS will be presented and discussed. A seta of structured clinical pathways will also be suggested for adoption in the VATS Group database.

Discussion

Pre- and post-operative adoption of an ERAS protocol in patients undergoing VATS lobectomy may promote an improved post-operative course, a shorter hospital stay and an overall more comfortable patients' experience. The mainstays of a physiokinesis therapy ERAS protocol are patients' education, constant physical and respiratory therapy sessions, and adoption of adequate devices. Although many studies have investigated the usefulness of physical and respiratory physiokinesis therapy, a comprehensive ERAS protocol for VATS lobectomy patients has not yet been described. The proposed ERAS platform, adopted by the VATS Group database, will contribute to a prospective data collection and allow a scientific analysis of the results.