[Which management of pregnancy after bariatric surgery?] / Quelle prise en charge de la grossesse après une chirurgie bariatrique ?

Obesity represents a major public health issue and a potential threat for people health. Moreover, the incidence of obesity has been increasing and therefore, the incidence of women with an history of bariatric surgery with a pregnancy desire has been also increased. Although the weight loss after bariatric surgery has positive effects on pregnancy outcomes, these surgical procedures may be associated with adverse outcomes as well, for example micronutrient deficiencies, dumping syndrome, surgical complications such as internal hernias, and obstetrical complications such as small for gestational age as instance. Nevertheless, physician knowledge about pregnancy management after bariatric surgery is currently insufficient and a multidisciplinary approach is therefore mandatory. The aim of this article is to provide to readers general and recent data regarding the management of pregnancy after bariatric surgery.

Evaluation of training of residents and chief-residents in visceral and digestive surgery in France: results of a national survey.

AIM OF THE STUDY: To establish an inventory of the training facilities available to residents and chief-residents in visceral and digestive surgery in France and to assess their satisfaction and their expectations. PARTICIPANTS AND METHODS: An anonymous questionnaire was sent by E-mail in 2011 to all residents and chief-residents in visceral and digestive surgery in France. The questionnaire addressed demographic characteristics, educational resources used and desired, as well as the current medical and university curriculum. The practical and theoretical aspects of training were evaluated. RESULTS: Of 208 residents, 63% responded to the survey (96 residents and 35 chief-residents). Daily practice of surgery and the reading of English-language articles were the two most frequently used teaching resources. Surgical training was judged satisfactory by 41.2% of respondents. In multivariate analysis, only the function of chief-resident (p < 0.001) and authorship as first author of scientific papers (p = 0.041) were associated with a feeling of satisfaction. Surgical training on animals, use of online course materials, and the establishment of a mentoring process during residency were rated favorable by more than 80%. CONCLUSIONS: The majority of residents and chief-residents in visceral and digestive surgery in France believe their training is unsatisfactory. However, this dissatisfaction decreases progressively throughout the training period. Strengthening of companionship through tutoring, better information on existing resources, and improved access to surgical training in animals should enhance satisfaction.

Management of voluminous abdominal incisional hernia.

Incisional hernia is one of the classic complications after abdominal surgery. The chronic, gradual increase in size of some of these hernias is such that the hernia ring widens to a point where there is a loss of substance in the abdominal wall, herniated organs can become incarcerated or strangulated while poor abdominal motility can alter respiratory function. The surgical treatment of small (<5 cm) incisional hernias is safe and straightforward, by either laparotomy or laparoscopy. For large hernias, surgical repair is often difficult. After reintegration of herniated viscera into the abdominal cavity, the abdominal wall defect must be closed anatomically in order to restore the function to the abdominal wall. Prosthetic reinforcement of the abdominal wall is mandatory for long-term successful repair. There are multiple techniques for prosthetic hernia repair, but placement of Dacron mesh in the retromuscular plane is our preference.

Vaccination coverage among medical residents in Paris, France.

Medical residents are particularly exposed to the risk of occupational infection. We aimed to determine the vaccination coverage in residents with an anonymous self-reporting electronic questionnaire. A total of 250 residents took part in this survey. Vaccination rates were particularly high for mandatory vaccinations (diphtheria, tetanus, poliomyelitis, hepatitis B virus and tuberculosis). Regarding recommended vaccinations (influenza, 45.6%; pertussis, 65.2%; measles, 62.8%; varicella, 62.8%), rates were insufficient to prevent hospital epidemics, but higher than those reported in other healthcare workers. Further immunization programmes should target residents, and not only senior healthcare workers, with a critical role for occupational medicine departments.

Post-operative adhesions after digestive surgery: their incidence and prevention: review of the literature.

INTRODUCTION: Post-operative adhesions after gastrointestinal surgery are responsible for significant morbidity and constitute an important public health problem. The aim of this study was to review the surgical literature to determine the incidence, consequences and the variety of possible countermeasures to prevent adhesion formation. METHODS: A systematic review of English and French language surgical literature published between 1995 and 2009 was performed using the keywords "adhesion" and "surgery". RESULTS: Peritoneal adhesions are reported as the cause of 32% of acute intestinal obstruction and 65-75% of all small bowel obstructions. It is estimated that peritoneal adhesions develop after 93-100% of upper abdominal laparotomies and after 67-93% of lower abdominal laparotomies. Nevertheless, only 15-18% of these adhesions require surgical re-intervention. The need for re-intervention for adhesion-related complications varies depending on the initial type of surgery, the postoperative course and the type of incision. The laparoscopic approach appears to decrease the risk of adhesion formation by 45% and the need for adhesion-related re-intervention to 0.8% after appendectomy and to 2.5% after colorectal surgery. At the present time, only one product consisting of hyaluronic acid applied to a layer of carboxymethylcellulose (Seprafilm(®)) has been shown to significantly reduce the incidence of postoperative adhesion formation; but this product is also associated with a significant increase in the incidence of anastomotic leakage when the membrane is applied in direct contact with the anastomosis. The use of this product has not been shown to decrease the risk of re-intervention for bowel obstruction. CONCLUSIONS: The prevention of postoperative adhesions is an important public health goal, particularly in light of the frequency of this complication. The routine use of anti-adhesion products is not recommended given the lack of studies with a high level of evidence concerning their efficacy and safety of use.

Accidental blood exposures among medical residents in Paris, France.

Accidental blood exposure (ABE) exposes healthcare workers, including medical residents, to the risk of occupational infection. We aimed to determine the characteristics of ABEs in residents with an anonymous self-reporting electronic questionnaire. A total of 350 residents (33% from surgical disciplines) entered this survey. One hundred and eighty-five residents (52%) reported at least one ABE during their residency (median, 2; range, 1-25), 53% of which occurred in operating theatres. Sixty-nine per cent of residents followed the current procedures for local disinfection. ABEs were notified to the hospital administration by 62% of residents, but only 51% of residents were referred to the occupational medicine department. The most frequently reported concerns following ABEs were human immunodeficiency virus (52%) and hepatitis C virus infection (39%). In 74% of cases, the serological status of the index patient was investigated. Only 54% of residents were aware of their hepatitis B surface antibody titres. Medical residents behaved inappropriately in 33% of cases in this survey. Further educational programmes should include residents, and not only senior healthcare workers, in order to improve individual behaviours.

[Internal abdominal hernias]. / Les hernies internes abdominales.

Internal hernias are complete or partial protrusions of one or several viscera or tissues through an intraperitoneal orifice remaining in the abdominal cavity. Whatever the type or anatomical location may be, the seeming banality and lack of specific symptoms contrasts with the seriousness of complications such as strangulation followed by ischemia or intestinal necrosis. Delay in diagnosis can be shortened if these complications are kept in mind at diagnosis and if the imaging studies are illustrative. At the least doubt, surgery will correct the diagnosis and allow adapted treatment.

[Carcinoid tumor from the small bowel]. / Tumeur carcinoïde de l'intestin grêle.

Carcinoid tumors are non-pancreatic digestive neuroendocrine tumors well differentiated. Most of time they are developed from enterochromaffin cells of the digestive tract. Most of them are localized in ileum, rectum, stomach and appendix. Only bronchi are a frequent extra-digestive localization (20 to 25%). Most of these tumors are asymptomatic and discovered incidentally during a laparotomy or secondary to the exploration of a carcinoid syndrome. From a case report and a recent review of literature, diagnosis, histology and treatment of small bowel carcinoid tumors are summarized.

[How to choose a mesh for the treatment of incisional hernias?]. / Comment choisir une prothèse pour le traitement des éventrations abdominales?

The incidence of recurrences after raphy for treatment of incisional hernias has been reported as high as 50%. So, the use of a mesh is recommended for reinforcement of the parietal abdominal wall in the management of incisional hernias. Many types of mesh are presently available with different characteristics. The use of a mesh requires to choose the appropriate material, depending on the site of the implantation and the type of performed surgical procedure.