The Process of Directing Edward Albee\u27s The Goat, or Who is Sylvia

This paper will follow director Shelley Whitehead\u27s process of bringing The Goat, or Who Is Sylvia? by Edward Albee to production at Minnesota State University, Mankato. Within the paper the director discusses her initial concepts and ideas; a historical look at the playwright and play; journals regarding the rehearsal and performance process; a dissection of that process to ascertain success or failure of the ideas set forth in the first chapter; and a final look at how her years at Minnesota State Mankato shaped her as a director. Included in the paper is an Appendix to supplement the paper\u27s findings. Within this document the director looks at the Greek influence that Albee infused within the script and how it could be best used to create an intellectual catharsis for the audience. This catharsis is sought to challenge those watching to seriously think about the issues that stood out to them in the play

2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy.

Bile duct injury (BDI) is a dangerous complication of cholecystectomy, with significant postoperative sequelae for the patient in terms of morbidity, mortality, and long-term quality of life. BDIs have an estimated incidence of 0.4-1.5%, but considering the number of cholecystectomies performed worldwide, mostly by laparoscopy, surgeons must be prepared to manage this surgical challenge. Most BDIs are recognized either during the procedure or in the immediate postoperative period. However, some BDIs may be discovered later during the postoperative period, and this may translate to delayed or inappropriate treatments. Providing a specific diagnosis and a precise description of the BDI will expedite the decision-making process and increase the chance of treatment success. Subsequently, the choice and timing of the appropriate reconstructive strategy have a critical role in long-term prognosis. Currently, a wide spectrum of multidisciplinary interventions with different degrees of invasiveness is indicated for BDI management. These World Society of Emergency Surgery (WSES) guidelines have been produced following an exhaustive review of the current literature and an international expert panel discussion with the aim of providing evidence-based recommendations to facilitate and standardize the detection and management of BDIs during cholecystectomy. In particular, the 2020 WSES guidelines cover the following key aspects: (1) strategies to minimize the risk of BDI during cholecystectomy; (2) BDI rates in general surgery units and review of surgical practice; (3) how to classify, stage, and report BDI once detected; (4) how to manage an intraoperatively detected BDI; (5) indications for antibiotic treatment; (6) indications for clinical, biochemical, and imaging investigations for suspected BDI; and (7) how to manage a postoperatively detected BDI

ERS: A simple scoring system to predict early recurrence after surgical resection for hepatocellular carcinoma.

peer reviewed[en] BACKGROUND: Surgical resection (SR) is a potentially curative treatment of hepatocellular carcinoma (HCC) hampered by high rates of recurrence. New drugs are tested in the adjuvant setting, but standardised risk stratification tools of HCC recurrence are lacking. OBJECTIVES: To develop and validate a simple scoring system to predict 2-year recurrence after SR for HCC. METHODS: 2359 treatment-naïve patients who underwent SR for HCC in 17 centres in Europe and Asia between 2004 and 2017 were divided into a development (DS; n = 1558) and validation set (VS; n = 801) by random sampling of participating centres. The Early Recurrence Score (ERS) was generated using variables associated with 2-year recurrence in the DS and validated in the VS. RESULTS: Variables associated with 2-year recurrence in the DS were (with associated points) alpha-fetoprotein (100: 3), size of largest nodule (≥40 mm: 1), multifocality (yes: 2), satellite nodules (yes: 2), vascular invasion (yes: 1) and surgical margin (positive R1: 2). The sum of points provided a score ranging from 0 to 11, allowing stratification into four levels of 2-year recurrence risk (Wolbers' C-indices 66.8% DS and 68.4% VS), with excellent calibration according to risk categories. Wolber's and Harrell's C-indices apparent values were systematically higher for ERS when compared to Early Recurrence After Surgery for Liver tumour post-operative model to predict time to early recurrence or recurrence-free survival. CONCLUSIONS: ERS is a user-friendly staging system identifying four levels of early recurrence risk after SR and a robust tool to design personalised surveillance strategies and adjuvant therapy trials

Role of an enhanced recovery program in liver transplantation

La transplantation hépatique (TH) est le traitement de référence de la cirrhose et ses complications, à considérer dans son ensemble comme un projet thérapeutique dont le complexe parcours de soins nécessite une mobilisation importante de ressources humaines et financières. Le concept du programme de Récupération Améliorée après Chirurgie (RAC ou Enhanced Recovery After Sugery-ERAS) est un protocole de soins visant à réduire le stress chirurgical, d'améliorer la récupération, de réduire le taux de complications post-opératoires et la durée moyenne de séjour (DMS). L'ensemble de ce travail de recherche repose sur l'hypothèse qu'un protocole de RAC appliqué à la TH pourrait simplifier la prise en charge des malades tout en améliorant les suites post-opératoires et en diminuant la durée de leur récupération fonctionnelle. Une première étude prospective sur un échantillon restreint de malades transplantés hépatiques et bénéficiant d'une prise en charge RAC a montré la sécurité et la faisabilité d'un tel programme avec un taux d'adhésion de 72.9% au protocole, ainsi qu'une réduction significative de 47% de la durée totale d'hospitalisation. Compte tenu de l'absence de critères de jugement (CdJ) de RAC en TH, il a fallu les construire en trois études: les deux premières ont permis de déterminer les CdJ en TH (morbidité, suivi de mortalité, dysfonction du greffon, récupération, durée de séjour), et de RAC en chirurgie hépatique (durée d'hospitalisation, complications, impact économique, durée de récupération fonctionnelle). La dernière étude a permis de définir une liste consensuelle de critères de sortie après transplantation hépatique, définissant la récupération fonctionnelle. L'originalité de cette récupération repose sur le fait qu'elle s'applique au malade et au greffon avec des critères pour chacun. La dernière étape a consisté en la réalisation des recommandations officielles de la RAC en transplantation hépatique, sous l'égide de la société ERAS, sur la base de la littérature existante. Une révision systématique de la littérature (PROSPERO CRD42019132798) et un consensus via 27 experts internationaux issus de 12 centres de greffe, ont permis la rédaction de la première édition des recommandations. Tout au long de ce travail de recherche, il a été mis en évidence que la RAC en TH est faisable et sûre, et que parmi les critères de jugement les plus pertinents, la durée de récupération fonctionnelle était le plus appropriée. La définition des recommandations permettra une diffusion standardisée de l'impact de la RAC en TH, avec la récupération fonctionnelle comme critère de jugement à la cléLiver transplantation (LT) is the reference treatment for cirrhosis and its complications, to be considered as a complex therapeutic project requiring a significant mobilization of human and financial resources. The Enhanced Recovery After Surgery (ERAS) program is a protocol of care aiming at reducing surgical stress, improving recovery, reducing the rate of post-operative complications and the length of hospital stay. All of this research work is based on the hypothesis that an ERAS protocol in LT could simplify the management of patients while improving recovery and reducing the length of their functional recovery. A first prospective study on a small sample of patients undergoing LT with an ERAS program showed the safety and feasibility of such a program with a compliance rate of 72.9% to the protocol, as well as a significant reduction of the hospital stay. Given the absence of endpoints for ERAS in LT, we had to build them with the three following studies: the first two defined the common endpoints in LT (morbidity, mortality, graft dysfunction, recovery , length of stay), and in ERAS and hepatic surgery (length of stay, complications, economic impact, duration of functional recovery). The third study allowed to define a consensual list of discharge criteria after liver transplantation, defining functional recovery. The originality of this recovery is based on the fact that applies to the patient and to the graft with dedicated criteria. The last step consisted in the realization of the official ERAS recommendations in liver transplantation, on the basis of the existing literature. A systematic review of the literature (PROSPERO CRD42019132798) and a consensus via 27 international experts from 12 transplant centers, enabled the drafting of the first edition of the recommendations. Throughout this research, we showed how ERAS in LT feasible and safe, and that among the most relevant endpoints, the duration of functional recovery is the most appropriate. The definition of these recommendations will allow a standardized dissemination of the impact of ERAS in LT, with functional recovery as an endpoin

Etude de l'impact d'un programme de Récupération Amélioré en Transplantation Hépatique

Liver transplantation (LT) is the reference treatment for cirrhosis and its complications, to be considered as a complex therapeutic project requiring a significant mobilization of human and financial resources. The Enhanced Recovery After Surgery (ERAS) program is a protocol of care aiming at reducing surgical stress, improving recovery, reducing the rate of post-operative complications and the length of hospital stay. All of this research work is based on the hypothesis that an ERAS protocol in LT could simplify the management of patients while improving recovery and reducing the length of their functional recovery. A first prospective study on a small sample of patients undergoing LT with an ERAS program showed the safety and feasibility of such a program with a compliance rate of 72.9% to the protocol, as well as a significant reduction of the hospital stay. Given the absence of endpoints for ERAS in LT, we had to build them with the three following studies: the first two defined the common endpoints in LT (morbidity, mortality, graft dysfunction, recovery , length of stay), and in ERAS and hepatic surgery (length of stay, complications, economic impact, duration of functional recovery). The third study allowed to define a consensual list of discharge criteria after liver transplantation, defining functional recovery. The originality of this recovery is based on the fact that applies to the patient and to the graft with dedicated criteria. The last step consisted in the realization of the official ERAS recommendations in liver transplantation, on the basis of the existing literature. A systematic review of the literature (PROSPERO CRD42019132798) and a consensus via 27 international experts from 12 transplant centers, enabled the drafting of the first edition of the recommendations. Throughout this research, we showed how ERAS in LT feasible and safe, and that among the most relevant endpoints, the duration of functional recovery is the most appropriate. The definition of these recommendations will allow a standardized dissemination of the impact of ERAS in LT, with functional recovery as an endpointLa transplantation hépatique (TH) est le traitement de référence de la cirrhose et ses complications, à considérer dans son ensemble comme un projet thérapeutique dont le complexe parcours de soins nécessite une mobilisation importante de ressources humaines et financières. Le concept du programme de Récupération Améliorée après Chirurgie (RAC ou Enhanced Recovery After Sugery-ERAS) est un protocole de soins visant à réduire le stress chirurgical, d'améliorer la récupération, de réduire le taux de complications post-opératoires et la durée moyenne de séjour (DMS). L'ensemble de ce travail de recherche repose sur l'hypothèse qu'un protocole de RAC appliqué à la TH pourrait simplifier la prise en charge des malades tout en améliorant les suites post-opératoires et en diminuant la durée de leur récupération fonctionnelle. Une première étude prospective sur un échantillon restreint de malades transplantés hépatiques et bénéficiant d'une prise en charge RAC a montré la sécurité et la faisabilité d'un tel programme avec un taux d'adhésion de 72.9% au protocole, ainsi qu'une réduction significative de 47% de la durée totale d'hospitalisation. Compte tenu de l'absence de critères de jugement (CdJ) de RAC en TH, il a fallu les construire en trois études: les deux premières ont permis de déterminer les CdJ en TH (morbidité, suivi de mortalité, dysfonction du greffon, récupération, durée de séjour), et de RAC en chirurgie hépatique (durée d'hospitalisation, complications, impact économique, durée de récupération fonctionnelle). La dernière étude a permis de définir une liste consensuelle de critères de sortie après transplantation hépatique, définissant la récupération fonctionnelle. L'originalité de cette récupération repose sur le fait qu'elle s'applique au malade et au greffon avec des critères pour chacun. La dernière étape a consisté en la réalisation des recommandations officielles de la RAC en transplantation hépatique, sous l'égide de la société ERAS, sur la base de la littérature existante. Une révision systématique de la littérature (PROSPERO CRD42019132798) et un consensus via 27 experts internationaux issus de 12 centres de greffe, ont permis la rédaction de la première édition des recommandations. Tout au long de ce travail de recherche, il a été mis en évidence que la RAC en TH est faisable et sûre, et que parmi les critères de jugement les plus pertinents, la durée de récupération fonctionnelle était le plus appropriée. La définition des recommandations permettra une diffusion standardisée de l'impact de la RAC en TH, avec la récupération fonctionnelle comme critère de jugement à la cl

An update on topical haemostatic agents in liver surgery: systematic review and meta analysis

International audienceMortality and morbidity in hepatic surgery are affected by blood loss and transfusion. Topical haemostatic agents (THA) are composed by a matrix and/or fibrin sealants, and their association known as "carrier-bound fibrin sealant" (CBFS): despite widely used for secondary haemostasis, the level of evidence remains low. To realize a meta-analysis on the results of CBFS on haemostasis and postoperative complications. Searches in PubMed, PubMed Central, Cochrane and Google Scholar using keywords: "topical_haemostasis" OR "haemostatic_agents" OR "sealant_patch" OR "fibrin_sealant" OR "collagen_sealant" AND "liver_surgery" OR "hepatic_surgery" OR "liver_transplantation". Randomized clinical trials, large retrospective cohort studies, case control studies evaluating THA on open/laparoscopic liver surgery and transplantation. From 1993 to 2016 were found 22 studies for qualitative synthesis and 13 for quantitative meta-analysis. The time to haemostasis was lower in the CBFS group (mean difference -2.33 min; P = 0.00001). The risk of receiving blood transfusion, developing collections and bile leak was not influenced by the use of CBFS (OR 0.75; P = 0.25), (OR 0.72; P = 0.52), (OR 0.74; P = 0.30) respectively. The use of CBFS in liver surgery significantly reduce the time to haemostasis, but does not decrease transfusion, postoperative collection and bile leak

A methodological review of clinical outcomes reported in liver transplantation trials

International audienceBACKGROUND : Liver Transplantation (LT) is a life-saving treatment for end-stage liver disease, for which various outcomes are measured in randomized clinical trials (RCT). The aim of this methodological review is to evaluate and classify outcomes reported in RCT in LT. METHODS : PubMed and ClinicalTrials.gov were searched in July 2018 for published and ongoing RCTs on LT in the last 5 years. Studies were eligible if focusing on first LT in adult patients, with interventions during the perioperative period. Data extracted concerned LT characteristics, type of intervention, methodological characteristics and outcomes assessed.RESULTS : Of 2685 references, 55 were included with a median of 78 (40-120) patients for published trials and planned to include 117 (55-218) patients for ongoing trials. Morbidity was the most frequently used as primary outcome in 37 published (67%) and 13 ongoing trials (54%). We identified 10 different definitions for graft dysfunction, 9 for recovery outcomes and 12 different time-points for mortality. For published trials, among the 397 outcomes specified in the method section, results were reported for 283 (71%). CONCLUSION : Outcomes reported in LT trials are very heterogeneous. A consensus approach to develop a core outcome set (COS) should be considered allowing for comparisons of results across trials

Hydatid biliocystic fistula-induced cholestasis

International audienc