Impact of enhanced recovery program implementation on postoperative outcomes after liver surgery: a monocentric retrospective study

INTRODUCTION

It is still unclear whether enhanced recovery programs (ERPs) reduce postoperative morbidity after liver surgery. This study investigated the effect on liver surgery outcomes of labeling as a reference center for ERP.

MATERIALS AND METHODS

Perioperative data from 75 consecutive patients who underwent hepatectomy in our institution after implementation and labeling of our ERP were retrospectively compared to 75 patients managed before ERP. Length of hospital stay, postoperative complications, and adherence to protocol were examined.

RESULTS

Patient demographics, comorbidities, and intraoperative data were similar in the two groups. Our ERP resulted in shorter length of stay (3 days [1-6] vs. 4 days [2-7.5], p = 0.03) and fewer postoperative complications (24% vs. 45.3%, p = 0.0067). This reduction in postoperative morbidity can be attributed exclusively to a lower rate of minor complications (Clavien-dindo grade < IIIa), and in particular to a lower rate of postoperative ileus, after labeling. (5.3% vs. 25.3%, p = 0.0019). Other medical and surgical complications were not significantly reduced. Adherence to protocol improved after labeling (17 [16-18] vs. 14 [13-16] items, p < 0.001).

CONCLUSIONS

The application of a labeled enhanced recovery program for liver surgery was associated with a significant shortening of hospital stay and a halving of postoperative morbidity, mainly ileus.

[Enhanced recovery after surgery of the elderly in colorectal surgery]

The concept of enhanced recovery in colorectal surgery is a multimodal and multidisciplinary programme aiming at reducing surgical stress through optimization of patient care in the pre-, intra-, and postoperative periods. It allows to reduce postoperative morbidity and the duration of the hospital stay. We describe the case of an elderly patient with multiple comorbidities who was scheduled for a sigmoidectomy in an enhanced rehabilitation programme, and emphasize the interest and specificity of such a rehabilitation protocol for the elderly.

[Prevalence of Candida parapsilosis, C. orthopsilosis and C. metapsilosis in candidemia over a 5-year period at Nantes hospital and in vitro susceptibility to three echinocandins by E-test®]

AIM OF THE STUDY

To determine the prevalence of C. parapsilosis sensu stricto, C. orthopsilosis and C. metapsilosis among candidemia at Nantes University Hospital and to evaluate the in vitro susceptibility of the isolates against three echinocandin drugs (caspofungin, micafungin and anidulafungin).

MATERIAL AND METHODS

Retrospective study (march 2004 to july 2009) of 178 cases of candidemia corresponding to 183 Candida spp. strains identified by means of routine phenotypical methods. Re-identification of C. parapsilosis sensu lato isolates was performed by ITS rDNA sequencing analysis. Minimal inhibitory concentrations (MIC) were determined by E-test(®). All echinocandin non-susceptible isolates (MIC>2 μg/mL) were analyzed for the presence/absence of FKS1 mutations associated with resistance.

RESULTS

During this period, C. parapsilosis sensu lato was responsible for 27 candidemia, ranging at the second most common Candida species after C. albicans (n=99, 54.1%). Neither isolates belong to C. orthopsilosis nor C. metapsilosis. According to the literature, all the isolates displayed high MICs against the three echinocandin drugs. All the isolates displayed both susceptibility (MIC ≤ 2 μg/mL) and a good agreement between MICs read at 24h and 48 h for caspofungin and micafungin (MIC(50)=0.75 μg/mL, MIC(90)=1.5 μg/mL). Surprisingly, whereas most of the strains were susceptible to anidulafungin at 24h (MIC(50)=1 μg/mL, MIC(90)=1.5 μg/mL), 14 (52 %) displayed non-susceptibility, despite the lack of mutation associated with resistance on FKS1, when reading was performed at 48 h (MIC(50)=3 μg/mL, MIC(90)=12 μg/mL).

CONCLUSION

Prevalence of C. orthopsilosis and C. metapsilosis in patients with candidemia is low at Nantes University Hospital. The difficulty encountered with MIC reading by E-test(®) are discussed.

Language and brain: what is up? What is coming up?

The classical aphasiological model of brain/language relationships is nowadays complemented by independent results from functional neuroimaging studies using techniques such as Positron Emission Tomography, functional Magnetic Resonance Imaging, or Event-Related Electro-Encephalography and Magneto-Encephalography mapping. Although brain mapping of language is still hampered by many methodological pitfalls, these methods now appear reliable and provide a renewed description of the temporal spatial dynamics of neural ensembles subserving language functions. Moreover, neuroimaging techniques should also shed a new light on remaining difficult issues such as neural and functional plasticity in developmental or post-lesional contexts.

[Memory: a functional imaging approach]

Functional imaging permits us to tackle in a better way one of the most noble functions of the human brain: memory. First of all, it is a way to validate the wide subdivisions proposed by cognitive psychology and clinical neuropsychology such as short-term memory/long-term memory dissociation, episodic memory/semantic memory dissociation and the distinction among working memory subcomponents. Moreover, functional imaging yields a new perspective on the global physiology of the brain. It makes it possible to propose new relationships that are more or less reciprocal between cerebral structures and cognitive functions and raises new fundamental questions. Thus, its first goal is to answer precise questions in the framework of definite cognitive models and it offers the possibility of elaborating a new modelling conception. Finally, functional imaging is a potential tool for a predictive approach to memory functions in both normal subjects and patients.

Temporal sorting of neural components underlying phonological processing

Event-related haemodynamic responses (EHRs) were recorded in subjects performing phonological tasks to test whether distinguishable temporal involvement of corresponding neural components would show through. A sequence of activation leading from primary auditory cortices to premotor regions emerged in the fast repetition and the phoneme monitoring tasks used. EHRs peaked significantly earlier in Wernicke's area (phonological decoding) than in Broca's area, the left supramarginal gyrus and the precentral gyrus (phonological rehearsal). Moreover, the sensitivity of within cluster temporal gradients to the nature of the tasks indicated either sensory to association cortex synchronization for fast repetition or delayed analysis for phoneme monitoring. These results are consistent with previous findings on working memory and show that fMRI permits temporal tracking of cognitive activations.

ERP mapping in phonological and lexical semantic monitoring tasks: A study complementing previous PET results

Previous PET results identified distinct neural systems involved with phonology (vicinity of the left sylvian fissure) and lexical semantics (left inferior temporal, left superior frontal, bilateral inferior parietal regions). In the time domain, the phonological task was thought to involve serial parsing of pseudo-words, whereas the lexical semantic task would correspond to probabilistic automated access to meaning. Auditory event-related potentials (ERPs) elicited by the same tasks were explored on 32 channels in 12 male volunteers. Subjects had to categorize as target a second element of a pair of pseudo-words or words if a preceding target was detected in the first element. Depending on the absence/presence of target in the first element, a RELEASE condition and a HOLD condition were distinguished. RELEASE and HOLD ERPs split earlier in the semantic task than in the phonological task (300 versus 412 ms after SOT, respectively), although words lasted longer than pseudo-words. Corresponding paired t test maps showed a predominance of differences over left perisylvian regions for the phonological task and posterior bilateral regions for the semantic task. Underlying generators were investigated using BESA (Scherg, 1990) with global task ERPs. Six dipoles-constrained according to PET clusters-brought residual variance down to 0.36%, from 364 to 565 ms after SOT, in both tasks. Relative dipole amplitudes suggested a left-sided functional asymmetry for phonology. These results support the hypothesis of left perisylvian serial processing for phonology contrasting with bihemispheric parallel access for semantics and substantiates BESA for temporally tackling cognitive processes.