Conceptual innovation: 4P Medicine and 4P surgery.

The aim of this article is to present the concept of "4P medicine" i.e., medicine that is Personalized, Preventive, Predictive, and Participatory. We will discuss the evolution from cure-focused traditional medicine toward personalized medicine based on genome analysis. This new approach is illustrated by several clinical examples such as prevention of cardiovascular diseases (primary and secondary), prophylactic cancer surgery, targeted therapies, targeted peri-operative care and patient participation in their care. Finally, it will discuss the impact of this development on the health system of the future and the ethical questions raised by this new approach.

Evidence-based evaluation of abdominal drainage in pancreatic surgery.

Pancreatic fistula is the most common and dreaded complication after pancreatic resection, responsible for high morbidity and mortality (2 to 30%). Prophylactic drainage of the operative site is usually put in place to decrease and/or detect postoperative pancreatic fistula (POPF) early. However, this policy is currently debated and the data from the literature are unclear. The goal of this update is to analyze the most recent evidence-based data with regard to prophylactic abdominal drainage after pancreatic resection (pancreatoduodenectomy [PD] or distal pancreatectomy [PD]). This systematic review of the literature between 1990 and 2020 sought to answer the following questions: should drainage of the operative site after pancreatectomy be routine or adapted to the risk of POPF? If a drainage is used, how long should it remain in the abdomen, what criteria should be used to decide to remove it, and what type of drainage should be preferred? Has the introduction of laparoscopy changed our practice? The literature seems to indicate that it is not possible to recommend the omission of routine drainage after pancreatic resection. By contrast, an approach based on the risk of POPF using the fistula risk score seems beneficial. When a drain is placed, early removal (within 5 days) seems feasible based on clinical, laboratory (C-reactive protein, leukocyte count, neutrophile/lymphocyte ratio, dosage and dynamic of amylase in the drains on D1, D3±D5) and radiological findings. This is in line with the development of enhanced recovery programs after pancreatic surgery. Finally, this literature review did not find any specific data relative to mini-invasive pancreatic surgery.

Eco-responsibility in the operating theater: An urgent need for organizational transformation.

Factors associating environmental degradation with human health have shown that air pollution is a source of morbi-mortality throughout the world. Unfortunately, hospitals are themselves "silent polluters". As healthcare professionals, we are the guarantors not only of quality of patient care, but also of proper hospital conduct. The aim of this attempt at clarification is to outline what can be done in the operating theater to reduce the environmental impact of the treatments we administer. Our recommendations will go above and beyond regulatory frameworks and draw upon daily practice concerning waste management, energy consumption, utilization of anesthetic agents and multiple forms of waste. A number of French and international pilot experimentations have been carried out and could strongly contribute to the modification of clinical practices with a societal impact, at a time when ecology has become one of the main preoccupations of our fellow citizens.

The increasing prominence of "non-surgical" articles in surgical literature.

INTRODUCTION: Publications in the surgical field have usually to do with technical skills (TS). However, the field peripheral to surgical procedures, which brings to bear non-technical skills (NTS) has been achieving increasing prominence. The goal of this study is to objectively assess the evolution of the two fields in surgical literature. METHODS: The authors perused all the articles published over a decade in four large-scale surgical journals and assigned them to the following three categories: (1) TS, (2) NTS or (3) miscellaneous. While the "TS group" included all aspects of surgical procedures, the "NTS group" comprised all aspects of non-surgical perioperative management, and the "miscellaneous group" was composed of all elements extraneous to the first two fields. RESULTS: Of the 8775 articles analyzed, 4326 (49%) belonged to the TS group, 2343 (27%) to the NTS group and 2138 (24%) to the miscellaneous group. There was a significant decrease in the proportion of TS publications [61% in 2007, 44% in 2016 (P<0.001)], accompanied by a significant increase in the proportion of NTS publications (16% in 2007, 34% in 2016 (P<0,001)] over the course of the last decade. The trend first appeared in 2009 and has been confirmed and reinforced over the ensuing years. CONCLUSION: The increasing prominence of non-surgical skills represents a major shift in the editorial choices of high impact surgical journals. It highlights the extent to which the surgical community is manifesting increased interest in the perioperative field, which is now drawing almost as much attention as surgical procedure per se.

The concept of prehabilitation: What the surgeon needs to know?

Despite advances in surgical techniques, anesthesia and perioperative care, which became safer and accessible to a higher proportion of high-risk patients, major surgery remains morbid with a lot of patients not recovering their previous capacity. Indeed surgery is a physiological stress and decreases functional capacity in the postoperative period. A "prehabilitation" program should increase functional capacity in anticipation of an upcoming stress. It should occur after the surgical consultation and before surgery, and is based on three components: physical care, nutritional support and psychological support, during 6 to 8 weeks. The aims of prehabilitation are to improve both nutritional status and pre- and postoperative fitness, and to reduce postoperative complications. Prehabilitation demonstrated benefit on postoperative complications in cardiovascular surgery but its benefit in digestive surgery is still unclear with contradictory results. The aim of this review was to summarize results of prehabilitation on the pre- and postoperative period and to determine its possible future in digestive surgery.