Reform of the 3rd cycle in surgery training.

The main objectives of the reform of the 3rd cycle of medical studies in France that was instituted in 2017 after eight years of preparation, are to train future specialists in a consistent and equitable fashion and to replace the previous time-based qualification by training based on the progressive acquisition of skills. This reform was an opportunity for the 13 different French surgical specialty Colleges involved to share reflections on what a surgeon actually was and to define training in surgical sub-specialties. The current reform is well adapted to these specifications and has fostered training models that are consistent with each other. This article discusses the historical construction of this reform, what will change in the training of future surgeons, as well as some points that warrant caution. The third cycle reform has also triggered a reform of the second cycle, which is expected to come into force for the 2020 academic year. Its objective will be to eliminate the guillotine effect created by the National Classifying Examinations and to allow students to better understand and test their desire and skills for a given specialty. It will be up to these same surgical Colleges to determine how to do this for the sub-specialties of the "surgery" discipline.

Editor's Choice - Ex vivo Renal Artery Repair with Kidney Autotransplantation for Renal Artery Branch Aneurysms: Long-term Results of Sixty-seven Procedures.

OBJECTIVE/BACKGROUND: To evaluate the long-term outcome of renal revascularization by ex vivo renal artery reconstruction and autotransplantation for renal artery branch aneurysms (RABAs). METHODS: Between 1991 and 2015, 67 ex vivo renal artery reconstructions with kidney autotransplantation were performed in 55 adults (mean age 47 years) and 10 children to repair 87 RABAs. The main underlying disease was fibromuscular dysplasia in 34 patients. Other etiologies were systemic congenital disease in eight patients, spontaneous dissecting aneurysms in five, iatrogenic aneurysms in three, atheromatous aneurysms in two and unknown etiology in 13. Median RABA diameter was 20.5 mm. Fifty-three patients (82%) were hypertensive, 60 had normal renal function and no patient was on hemodialysis. Seven patients (11%) were operated on after failure of an endovascular procedure. The mean number of renal artery branches repaired per patient was 3.5 and multiple aneurysms were treated in 14 patients (22%). The hypogastric artery was used in 41 patients, the saphenous vein in 18, the superficial femoral artery in five and a combination of different materials in three. RESULTS: No deaths occurred during the first 30 days. Primary patency at 30 days was 90.8% following to six early thromboses. Three patients (5%) were lost to follow up. No other thrombosis occurred. At 8 years, the primary and primary-assisted patency were 88% and 91%, respectively. Survival was 95% at 9 years. Among the 53 hypertensive patients, two were lost to follow up. At 9 years, 22 (43%) were cured and nine (18%) were improved with a significant reduction of antihypertensive medication (p < .05). The pre-operative modification of the diet in renal disease (MDRD) clearance was 93 ± 29 mL/minute, the immediate post-operative MDRD was 94 ± 33 mL/minute, and at the end of follow up it was 86 ± 26 mL/minute (p > .05). CONCLUSION: Ex vivo renal artery reconstruction for complex RABAs eliminates the risk of rupture, confers a benefit to hypertension, and preserves renal function with a satisfactory long-term patency.

Amplatzer Plug to Occlude the Internal Iliac Artery During Endovascular Aortic Aneurysm Repair: A Large Multicenter Study.

OBJECTIVE: During endovascular repair of abdominal aortic aneurysms (EVAR), in the absence of a distal iliac landing zone, the Amplatzer plug is increasingly being used to replace other internal iliac artery (IIA) embolization techniques. This study aimed at assessing the technical success, complication occurrence, and durability of the Amplatzer plug for IIA embolization. METHOD: From January 1, 2007 to December 31, 2013, all consecutive patients who underwent internal iliac embolization with an Amplatzer plug during EVAR were included in the study. There were 169 patients, (160 men, 9 women, mean 75 ± 9 years), treated by unilateral (158 cases, 93%) or bilateral (11 cases, 7%) embolization of the IIA, performed either separately prior to (65 cases, 38.5%) or during EVAR (104 cases, 61.5%). Follow up CT scan and/or US scan were performed 1 month after treatment and yearly thereafter. The inclusions were done retrospectively but the series was continuous and consecutive. Data were collected and analyzed using acquisition REDCap software. RESULTS: The technical success rate was 97.6%. Failures were device migration (n = 1), navigation failure (n = 2), and release outside the target zone (n = 1). On average, 1.43 plugs were required to achieve the embolization. The average amount of contrast agent for the embolization procedure was 111 ± 51 mL and the radiation dose was 127,777 ± 89,528 mGy/cm(2). The total fluoroscopy time was 854 ± 538 seconds. No re-canalization of the IIA trunk was observed during follow up. Complications were buttock claudication (n = 41, 24.3%), which resolved in 24 cases (58.5%, 24/41) at the first follow up, and intestinal ischemia requiring limited bowel resection in two cases. CONCLUSION: This multicenter study is the largest published to date. It demonstrates the efficacy and reliability of the Amplatzer plug to embolize the IIA during EVAR, with few side effects.

Common hepatic artery as inflow in kidney transplantation.

Kidney transplantation originating from the hepatic artery has not previously been reported. Herein, we report a third kidney transplantation with the common hepatic artery as inflow. A 62-year-old male with chronic renal failure due to polycystic kidney disease was proposed to a third kidney transplantation. CT-scan showed diffuse calcification of the aorto-iliac axis and the splenic artery. The common hepatic artery was the only artery suitable for anastomosis and as such was chosen as the inflow for retransplantation. The operation was performed through a right subcostal laparotomy. A saphenous bypass was interposed between the common hepatic artery and the graft, then the renal vein was anastomosed to the suprarenal inferior vena cava. Duration of warm ischemia was 27 min. Postoperative course was complicated with delayed graft function of 17 days and pulmonary infection. Patient was discharged at day 30. With a follow-up of 40 months, serum creatinine level and eGFR are, respectively, 191 µmol/L and 32 mL/min. Hepato-renal bypass technique can be used in kidney retransplantation when patient anatomy is not compatible with other classical options.

Editor's Choice - ECAR (Endovasculaire ou Chirurgie dans les Anévrysmes aorto-iliaques Rompus): A French Randomized Controlled Trial of Endovascular Versus Open Surgical Repair of Ruptured Aorto-iliac Aneurysms.

OBJECTIVES/BACKGROUND: ECAR (Endovasculaire ou Chirurgie dans les Anévrysmes aorto-iliaques Rompus) is a prospective multicentre randomized controlled trial including consecutive patients with ruptured aorto-iliac aneurysms (rAIA) eligible for treatment by either endovascular (EVAR) or open surgical repair (OSR). Inclusion criteria were hemodynamic stability and computed tomography scan demonstrating aorto-iliac rupture. METHODS: Randomization was done by week, synchronously in all centers. The primary end point was 30 day mortality. Secondary end points were post-operative morbidity, length of stay in the intensive care unit (ICU), amount of blood transfused (units) and 6 month mortality. RESULTS: From January 2008 to January 2013, 107 patients (97 men, 10 women; median age 74.4 years) were enrolled in 14 centers: 56 (52.3%) in the EVAR group and 51 (47.7%) in the OSR group. The groups were similar in terms of age, sex, consciousness, systolic blood pressure, Hardman index, IGSII score, type of rupture, use of endoclamping balloon, and levels of troponin, creatinine, and hemoglobin. Delay to treatment was higher in the EVAR group (2.9 vs. 1.3 hours; p < .005). Mortality at 30 days and 1 year were not different between the groups (18% in the EVAR group vs. 24% in the OSR group at 30 days, and 30% vs. 35%, respectively, at 1 year). Total respiratory support time was lower in the EVAR group than in the OSR group (59.3 hours vs. 180.3 hours; p = .007), as were pulmonary complications (15.4% vs. 41.5%, respectively; p = .050), total blood transfusion (6.8 vs. 10.9, respectively; p = .020), and duration of ICU stay (7 days vs. 11.9 days, respectively; p = .010). CONCLUSION: In this study, EVAR was found to be equal to OSR in terms of 30 day and 1 year mortality. However, EVAR was associated with less severe complications and less consumption of hospital resources than OSR.

Editor's choice--hybrid treatment of thoracic, thoracoabdominal, and abdominal aortic aneurysms: a multicenter retrospective study.

OBJECTIVES: The aim of this study was to assess the results of hybrid techniques for the treatment of thoracic, thoracoabdominal, and abdominal aortic aneurysms based on multicenter results and the various series regarding hybrid procedures reported in the literature. METHODS: The results of 76 hybrid procedures performed in 19 French university hospital centers between November 2001 and October 2011 were collected. There were 50 men and 26 women, mean age 68.2 (35-86) years. All patients were considered at high risk (ASA≥3) for conventional surgery. Aneurysms involved the thoracic, abdominal, and thoracoabdominal aorta in five, 14, and 57 cases respectively. There were 11 emergent repairs. The revascularization of four visceral arteries was performed in 38 cases. Between one and three visceral arteries were revascularized in the other cases. Visceral artery debranching and stent graft deployment were performed in a one-stage procedure in 53 cases and in a two-stage procedure in 23 cases. RESULTS: There were 26 (34.2%) postoperative deaths. Nine of the survivors developed paraplegia, of which one resolved completely. Bowel ischemia occurred in 13 cases (17.1%), and one patient was treated by a superior mesenteric artery bypass. Four patients required long-term hemodialysis. Postoperative computed tomography scan showed a type II endoleak in two patients. CONCLUSIONS: Morbidity and mortality in this study were greater than previously reported. Candidates for hybrid aortic repair should be carefully selected.

Identification of the in vivo elastic properties of common carotid arteries from MRI: a study on subjects with and without atherosclerosis.

The stiffness of the arterial wall, which is modified by many cardiovascular diseases such as atherosclerosis, is known to be an indicator of vulnerability. This work focuses on the in vivo quantification of the stiffness of the common carotid artery (CCA) by applying the Magnitude Based Finite Element Model Updating (MB-FEMU) method to 13 healthy and diseased volunteers aged from 24 to 76 years old. The MB-FEMU method is based on the minimisation of the deviation between the image of a deformed artery and a registered image of this artery deformed by means of a finite elements analysis. Cross sections of the neck of each subject at different times of the cardiac cycle are recorded using a Phase Contrast cine-MRI. Applanation tonometry is then performed to obtain the blood pressure variations in the CCA throughout a heart beat. First, a time averaged elastic modulus of each CCA between diastole and systole is identified and a stiffening of the artery with age and disease is observed. Second, four elastic moduli are identified during a single heart beat for each artery, highlighting the nonlinear mechanical behaviour of the artery. A stiffening of the artery is observed and quantified at systole in comparison to diastole.

Early and late results of ex vivo repair and autotransplantation in solitary kidneys.

INTRODUCTION: Autotransplantation of a solitary kidney provides an excellent opportunity to study the immediate and long-term consequences of intra-operative renal ischaemia. The purpose of this report is to describe a series of nine patients who underwent ex vivo repair and autotransplantation on solitary kidneys. PATIENTS AND METHODS: The series included six females and three males with a mean age of 36 years. Seven of the nine patients were hypertensive (mean number of anti-hypertensive agents: 3). Two patients had chronic renal failure (serum creatinine levels: 192 and 205 µmol l(-1)). All arteries except one with Takayasu disease were affected by dysplastic aneurysm or fibrodysplasia lesion. There was no atherosclerotic lesion. The mean number of renal artery branches repaired was 3.1 per patient. Mean duration of ischaemia was 161 min. RESULTS: Creatinaemia increased in all patients following the procedure. Creatinaemia and clearance returned to preoperative values between the 3rd and 10th postoperative days. One kidney was lost due to renal vein thrombosis. Late findings indicated that renal function was stable and there was no deterioration in the function of the autotransplanted kidneys after a follow-up period of 89 months. Preoperative versus postoperative creatinaemia and clearance levels were respectively 111 vs. 105 µmol l(-1) and 66.9 vs. 62.0 ml min(-1) (ns). During the same time, the mean number of anti-hypertensive agents decreased slightly from 3 to 2.5. CONCLUSION: In this small series of patients who underwent ex vivo repair and autotransplantation on solitary kidneys, intra-operative renal ischaemia had no detrimental effect on renal function.

Incidental visceral and renal artery stenosis in patients undergoing coronary angiography.

PURPOSE: The study aimed to examine the association between incidentally discovered mesenteric artery stenosis, renal artery stenosis (RAS) and coronary artery disease in patients undergoing coronary angiography. MATERIALS AND METHODS: We performed a prospective analysis of consecutive patients undergoing routine cardiac catheterisation. Abdominal aortograms in lateral and antero-posterior view were obtained to assess arterial stenosis of the coeliac axis, superior mesenteric artery and renal arteries. Significant arterial stenosis was defined as a narrowing of at least 50% compared with the normal artery. Demographic data and cardiovascular risk factors were analysed. RESULTS: The prevalence of visceral artery stenosis (VAS) was 63/450 (14%) including 48/450 (10.6%) cases of coeliac axis stenosis and 15/450 (3.3%) cases of superior mesenteric artery stenosis. Female sex (p = 0.01), older age (p = 0.03) and the presence of coronary artery disease (p = 0.05) were significant predictors for the presence of VAS in univariate analysis. The determinants for VAS in multivariate analysis were female sex and three-vessel coronary artery disease, while two- and three-vessel coronary artery disease was significant for RAS. CONCLUSION: Screening for VAS and RAS in female patients older than 60 years with more than two diseased coronary segments could have a high diagnostic value.

Fenestrated endovascular grafting: the French multicentre experience.

PURPOSE: This study aims to evaluate the medium-term outcomes following aortic aneurysm repair using fenestrated endografts performed in 16 French academic centres. MATERIALS AND METHODS: A retrospective analysis of prospectively collected data was carried out. This study included all patients treated with fenestrated endografts in France between May 2004 and January 2009. Patients were judged to be at high risk for open surgical repair. Fenestrated endografts were designed using computed tomography (CT) reconstructions performed on three-dimensional (3D) workstations. All patients were evaluated with CT, duplex ultrasound and plain film radiograph at discharge, 6, 12, 18 and 24 months, and annually thereafter. RESULTS: A total of 134 patients (129 males) were treated over the study period. Median age and aneurysm size were 73 years (range 48-91 years) and 56 mm (range 45-91 mm), respectively. A total of 403 visceral vessels were perfused through a fabric fenestration, including 265 renal arteries. One early conversion to open surgery was required. Completion angiography and discharge CT scan showed that 398/403 (99%) and 389/394 (99%) respective target vessels were patent. The 30-day mortality rate was 2% (3/134). Pre-discharge imaging identified 16 (12%) endoleaks: three type I, 12 type II and one type III. After the procedure, transient or permanent dialysis was required in four (3%) and two (1%) patients, respectively. The median duration of follow-up was 15 months (range 2-53 months). No aneurysms ruptured or required open conversion during the follow-up period. Twelve of 131 patients (9%) died during follow-up (actuarial survival at 12 and 24 months: 93% and 86%, respectively). Median time from procedure to death was 15 months. None of these deaths were aneurysm related. Aneurysm sac size decreased by more than 5 mm in 52%, 65.6% and 75% of patients at 1, 2 and 3 years, respectively. Three (4%) patients had sac enlargement within the first year, associated with a persistent endoleak. During follow-up, four renal artery occlusions were detected. A total of 12 procedure-related re-interventions were performed in 12 patients during follow-up, including six to correct endoleaks, and five to correct threatened visceral vessels. CONCLUSIONS: The use of endovascular prostheses with graft material incorporating the visceral arteries is safe and effective in preventing rupture in the medium term. A predictable high mortality rate was depicted during follow-up in this high-risk cohort. Meticulous follow-up to assess sac behaviour and visceral ostia is critical to ensure optimal results.

[After low anterior rectal resection, colonic pull-through with delayed colo-anal anastomosis can avoid the need for a diverting ileostomy]. / Anastomose colo-anale différée sans stomie de dérivation après résection antérieure basse du rectum.

A delayed colo-anal anastomosis has been proposed as a way to avoid diverting stoma after low anterior resection. Surgical and functional results were reviewed in 17 patients operated between 1999 and 2007 using this technique. Complications included one colonic necrosis, two pelvic abscesses and one colovaginal fistula. Results of continence and quality of life scores were satisfactory. Rates of parietal and septic complications are low after delayed colo-anal anastomosis and functional results are good. The use of this technique is particularly effective to avoid diverting ileostomy and for use in patients with a high risk of pouch fistula.

Conversion to open repair after endovascular aneurysm repair: causes and results. A French multicentric study.

OBJECTIVE: To evaluate the causes and results of conversion to open repair after aortic aneurysm endovascular treatment (EVAR). DESIGN: Retrospective study of open conversion after EVAR was performed in eight French academic centres. Primary conversion (PC) within 30 days after EVAR and secondary conversions (SC) were analysed separately. RESULT: Between 1997 and 2007, open conversions were performed in 34 patients (most often in high-risk patients): 14 PC and 20 SC. Two main causes of PC were unfavourable iliac artery anatomy and renal artery coverage. In hospital mortality was 21%. SC occurred at a median of 44 months after primary EVAR. Nine were urgent cases for rupture or infection and 11 elective for aneurysm growth, infection or thrombosis. Early mortality was similar after emergent or elective SC (25%). CONCLUSION: Open conversion, and, in particular, PC and urgent SC, was associated with a poor outcome. According to the literature, mortality after elective SC is low but remains high in high-risk patients.

[Incidence, prevalence and risk factors for a first infectious complication on a totally implantable venous-access port]. / Incidence, prévalence et facteurs de risque de survenue d'une première complication infectieuse sur chambres à cathéter implantables.

BACKGROUND: Totally implantable venous-access ports (TIVAP) should present less risk of complications than central venous catheters over a long time period. AIMS: Firstly, the study's objective was to assess the prevalence and incidence of a first infectious complication on a TIVAP and secondly, to assess the risk factors associated with this first infection. METHODS: The authors made a longitudinal historical cohort study of patients with a TIVAP in 2003, in the Dijon University Hospital. RESULTS: Two hundred and nineteen patients (sex-ratio 1.9) were included, with a total follow-up of 92,773 patients-days. Ninety percent of the TIVAP were used for chemotherapy, 5% for antibiotic drug administration, 2% for parenteral nutrition and 3% for other reasons (recurrent blood transfusions, etc.). Overall, 34 (16.3%) out of 209patients presented with at least one infectious complication, with an incidence rate of 0.37infection/1,000patients-days. The 5-year cumulative probability to be free of infectious complication was only 62.8%. In multivariate analysis, only underlying hematological neoplasia (by contrast with solid tumors) was significantly associated to a higher risk of infectious complication. CONCLUSIONS: The infectious risk linked to the use of TIVAP is significant, higher in case of underlying hematological neoplasia and during the first months of use.

Bypass to the perigeniculate collateral arteries: mid-term results.

PURPOSE: The purpose of this report is to present mid-term results of infrainguinal revascularizations using either the highest genicular artery or medial sural artery as the distal anastomosis site. MATERIAL AND METHODS: Between 1996 and 2005, a total of 59 bypass procedures to perigeniculate collateral arteries were performed in 57 patients (14 women, 43 men) with a mean age of 74. Fifty five patients presented with critical ischemia (tissue loss in 28 and rest pain in 27). Four patients presented with intermittent claudication. Mean ankle brachial index was 0.48. The distal anastomosis site was the highest genicular artery in 18 patients, medial sural artery in 37 cases, highest genicular and/or medial sural artery and/or tibial artery in sequential fashion in four cases. The proximal anastomosis was to the common femoral artery in 26 cases and superficial femoral artery in 33. RESULTS: There were two deaths during the immediate postoperative period. Mean follow-up duration was 35 months (range 1-108 months). One patient was lost to follow-up. Six patients required major amputation. At 3 years, primary patency was 65+/-7%, secondary patency was 70+/-7%, limb salvage and survival rate were 90+/-4% and 64+/-7% respectively. CONCLUSION: Bypass to perigeniculate collateral arteries provides acceptable patency and limb salvage rates.

[Iatrogenic biliary injuries during cholecystectomy]. / Lésions iatrogènes des voies biliaires lors des cholécystectomies.

AIM OF THE STUDY: To analyze our experience with biliary injuries during cholecystectomy in order to determine associated risk factors, morbidity, and results after reconstruction. PATIENTS AND METHODS: Review of the series of patients referred to our department for biliary injury during cholecystectomy over a 9-year period. Items regarding the type of lesion, risk factors, management, morbidity, and late results were recorded. RESULTS: Fifteen patients were referred to our department for bile duct injury during cholecystectomy between 1997 and 2005 (14 by laparoscopy and four by laparotomy; nine women and nine men). The main surgical indication was biliary colic (n=8). Three patients were operated on in an emergency setting (for acute cholecystitis). In nine patients the gallbladder wall was inflammatory. Intraoperative cholangiography was performed in nine patients, but revealed just one injury. Lateral injury to the bile duct was the most frequent type of lesion. In nine patients, the injury was detected intraoperatively and a biliary drainage was left in place; five of them had a synchronic repair and three required later reconstruction. Nine patients had a delayed identification of biliary injury; six of them required a biliodigestive anastomosis. Two patients died, three had several episodes of acute cholangitis after reconstruction and two presented incisional hernia. CONCLUSION: An inflammatory environment is the main risk factor for biliary injury during cholecystectomy. Bile duct injury is more frequent with laparoscopic cholecystectomy but can also occur with an open approach. Intraoperative cholangiography does not prevent biliary injuries nor detect them accurately. Biliary drainage can reduce morbidity for intraoperatively detected injuries and may be a sensitive approach for the surgeon with no hepatobiliary experience. Morbidity is increased in patients with delayed identification of the injury.

Analysis of risk factors for skip lymphatic metastasis and their prognostic value in operated N2 non-small-cell lung carcinoma.

BACKGROUND: The aim of this study is to report a series and to analyze risk factors for skip lymphatic metastasis an their prognostic value in operated N2 non-small-cell lung carcinoma. METHODS: From 1997 to 2002, 142 patients classified pN2 were included in the study. Tumours were classified according to the TNM classification. Skips metastases were defined by the cases of N2 disease without lobar and interlobar and hilar lymph node involvement. A skip (+) and a skip (-) group were defined. Characteristics of tumours, ganglionar involvement and survival were analysed in both groups. RESULTS: Forty-two patients fulfilled the criteria for skip metastasis. The average number of mediastinal lymph nodes resected by patient was similar in both groups, whereas more intrapulmonary nodes were dissected in the skip (-) group (4.7 +/- 3 vs 3 +/- 3; p < 0.002). The ratio of involved to resected lymph nodes was 0.47 +/- 0.27 in the skip (-) group vs 0.23 +/- 0.20 in the skip (+) group (p < 0.0001). In the skip (+) group, 85% of the patients presenting with a right upper lobe tumour had involvement of the superior mediastinal lymph nodes against 40% in the skip (-) group. The 5-year survival rate was 48% in the skip (-) group vs 37% in the skip (+) group (p = 0.49). In multivariate analysis, incomplete resection, tumour size, extended resection and pT were significant prognostic factors. CONCLUSIONS: Skip metastasis are frequent in non-small-cell lung cancer and complete dissection of hilar and mediastinal lymph nodes should remain the surgical standard procedure for this disease. However, skip metastasis are not an independent prognostic factor in survival.

[Anisakiasis: an infestation to be known by surgeons]. / Anisakiase: une parasitose que le chirurgien doît connaître.

BACKGROUND: Anisakis infestation is related to the consumption of raw or undercooked fish. It can cause allergic reactions, or abdominal pain when the gastrointestinal tube is involved. Its incidence is rising in Europe. OBJECTIVE: To analyze a group of patients complaining of right iliac fossa pain with ileitis or colitis and establish its relationship with Anisakis spp. infection. PATIENTS AND METHODS: During a 3-months period, 28 patients with abdominal pain were referred to the hospital with a diagnosis of ileitis or colitis by imaging, endoscopy or surgery. Specific serology for Anisakis was performed in all of them. RESULTS: At imaging study, 14 patients had ileitis or colitis, three intestinal obstruction and one acute appendicitis. Fourteen patients were operated on and 7 of them underwent resection; histopathologic diagnosis were eosinophilic ileitis (2 cases) or colitis (3 cases), non specific ileitis (1 case) and Crohn's disease (1 case). Another patient had an endoscopic biopsy that concluded eosinophilic colitis. Anisakis serology was positive in 25 (89%), negative in two and unknown in one. All patients were discharged uneventfully. CONCLUSIONS: Digestive anisakiasis may present as acute abdomen. Surgeons should know and consider this diagnosis in patients with ileitis or colitis, moreover if an antecedent of raw or undercooked fish ingestion is present. A conservative approach is best performed but the clinical picture can require an emergent laparotomy.