[ACACIAS 3: Learning about announcement consultations in the second cycle of medical studies]. / ACACIAS 3 : Apprentissage des consultations d'annonce dans le deuxième cycle d'études médicales.

INTRODUCTION: The second cycle of medical studies is a key time for developing interpersonal skills and the doctor-patient relationship. High-fidelity simulation is an initial learning option that enables learners to confront situations involving empathy. METHODS: This is a feedback report from May 2023 on the implementation of simulation as a training tool for 2nd cycle medical students in the announcement consultation. The training consists of two parts: theoretical teaching via a digital platform with an assessment of theoretical knowledge and a practical part with a simulation session with an actress playing a standardized patient. The acquisition of skills and the reflexivity of learners are assessed by means of a pre- and post-test. RESULTS: Twenty-nine externs took part in this project. Student satisfaction was 96 %. The feedback was very positive, both in terms of the quality of the sessions and the briefings/debriefings. Almost all the students wanted to repeat the experience. The simulation exercise was beneficial for the students in terms of the development (before vs. after) of their skills (verbal, emotional and relational) (1.05±0.25 vs. 1.22±0.19, P=0.047) and appeared to be relevant to the development of reflexivity (3.29±0.72 vs. 3.48±0.9, P=0.134). CONCLUSION: This first published French study demonstrates the feasibility and value of training in announcing a diagnosis, combining teaching via a digital platform and high-fidelity simulation for second cycle medical students.

Alpha-fetoprotein and focal nodular hyperplasia: An unconventional couple.

We report the case of a 36-year-old patient who was initially managed for gynecomastia. The first biological analyses showed a moderately elevated alpha-fetoprotein (AFP) level. After an endocrine etiology was excluded, an abdominal computed tomography scan showed typical focal nodular hyperplasia (FNH) proven by biopsy and showing expression of AFP in FNH cells. After follow-up for 24 months, the serum AFP and liver radiology remained unchanged. The association between an elevated AFP and FNH is rarely described in the medical literature.

An MRI study of typical anatomical variants of the anterior communicating artery complex.

PURPOSE: This magnetic resonance imaging study examined the most frequent anatomical variants of the anterior communicating artery (ACoA) complex of the cerebral arterial circle, and aimed to determine whether they were associated with ACoA complex aneurysm. METHODS: The study enrolled 669 patients. Using three-dimensional time-of-flight magnetic resonance angiography, 617 patients were classified into the following groups based on the anatomical variation in the ACoA complex: no ACoA complex anomaly; ACoA complex aneurysm; and vascular anomaly distant from the cerebral arterial circle. RESULTS: Of the 617 classified subjects, the classical anatomical description applied to 48.73% in the no ACoA complex anomaly group and 37.5% in the ACoA complex aneurysm group. One variant (left anterior cerebral artery segment A1 hypoplasia) was significantly more frequent in the ACoA complex aneurysm group. There was no sex difference in the prevalence of any variant. CONCLUSIONS: Anatomical variants of the ACoA complex of the cerebral arterial circle were found in almost half of the subjects. One variant seemed to be associated with a higher likelihood of an aneurysm, but causality could not be inferred.

Bile Duct Injury During Cholecystectomy: Necessity to Learn How to Do and Interpret Intraoperative Cholangiography.

Introduction: Biliary duct injury (BDI) is a serious complication during cholecystectomy. Perioperative cholangiography (POC) has recently been generating interest in order to prevent BDI. However, the current literature (including randomized controlled trials) cannot conclude whether POC is protective or not against the risk of BDI. The aim of our study was to investigate whether POC could demonstrate earlier BDI and which criteria are required to make that diagnosis. Methods: We performed a retrospective study between 2005 and 2018 in our French tertiary referral center, which included all patients who had presented following BDI during cholecystectomy. Results: Twenty-two patients were included. Nine patients had POC, whereas 13 did not. When executed, POC was interpreted as normal for three patients and abnormal for six. In this latter group, only two cases had a BDI diagnosed intraoperatively. In other cases, the interpretation was not adequate. Conclusion: BDIs are rare but may reduce patients' quality of life. Our study highlights the surgeon's responsibility to learn how to perform and interpret POC in order to diagnose and manage BDIs and potentially avoid catastrophic consequences.

C-reactive protein is a predictive factor for complications after incisional hernia repair using a biological mesh.

The introduction of biological or absorbable synthetic meshes has provided an alternative to conventional repair for incisional hernia. The ability to predict the development of complications after hernia surgery is important, as it guides surgical planning and patient management. This retrospective study assessed whether the postoperative C-reactive protein (CRP) level can predict complications after incisional hernia repair using biological mesh reinforcement. Patients who underwent incisional hernia repair surgery using biological meshes between February 2009 and February 2015 were screened for study inclusion. Patients included in the study were divided into two groups: those with and without postoperative complications. The two groups were analysed based on sex, surgical operation, length of intensive care unit stay (ICU), complications and mortality. Laboratory values, including white blood cell (WBC) count and CRP levels, were determined preoperatively and up to postoperative day (POD) 10. Postoperative complications requiring further management occurred in 32 of the 60 patients (53.3%). Among 47 patients, the mean CRP and WBC levels were 6.6 mg/L and 9.073 G/L in the group without complications vs. 141.0 mg/L, 16.704 G/L in the group with complications (p < 0.001). Patients with complications also had a longer ICU stay (10.1 vs. 0.6 days, p < 0.0001). A cut-off was 101 mg/L and offered 80.00% sensitivity (IC 61.43% to 92.29) and 95.24% specificity (76.18% to 99.88%) for postoperative complication. The rate of postoperative complications before POD10 was 95% in the group with CRP > 100 mg/L vs. 46% in the group with CRP < 100 mg/L (p = 0.000372). A high postoperative CRP level (> 100 mg/L) up to POD10 may serve as a predictor of postoperative complications in patients undergoing incisional hernia using biological meshes.

Correlations of the rectus abdominis muscle anatomy with anthropometric measurements.

PURPOSE: The anterior abdominal muscle wall has a strong aesthetic connotation, primarily because of the classical anatomical description of the rectus abdominis muscle in the collective consciousness. However, the morphological reality of the general population considerably deviates from this description. Therefore, we investigated the anthropometric characteristics correlated with the anatomy of the rectus abdominis muscle. METHODS: We performed a computed tomography scan anatomical study of recti abdominis muscles in 86 patients with no history of abdominal surgery. We noted the transverse and anteroposterior measurements of the rectus abdominis muscle, the transverse measurement of the linea alba, and the cutaneous and muscular abdominal perimeters. We compared these morphological elements with anthropometric data (sex, age, weight, height, and body mass index [BMI]). RESULTS: BMI was positively correlated with cutaneous abdominal perimeter (r = 0.89, p < 0.001) and muscular abdominal perimeter (r = 0.7, p < 0.001). The correlation of BMI with cutaneous abdominal perimeter was not influenced by sex (r = 0.90 and r = 0.89 in men and women, respectively). The correlation of BMI with muscular abdominal perimeter was greater in men than in women (r = 0.80 vs. r = 0.75). The muscular abdominal perimeter was more strongly correlated with the transverse measurement of the rectus abdominis muscle in men than in women (r = 0.75 vs. r = 0.59). The muscular abdominal perimeter was more strongly correlated with the linea alba in women than in men (r = 0.51 vs. r = 0.31). CONCLUSION: The anatomy of the anterior abdominal wall correlated with anthropometric data, including BMI. Rectus abdominis muscles and linea alba structures differed between men and women.

Implantation of biologic mesh in ventral hernia repair-does it make sense?

BACKGROUND: Biological acellular porcine dermis mesh, such as Permacol™, has been used since 2009 to treat abdominal incisional hernias in a septic context. This study investigated the risk factors for incisional hernia recurrence after biological mesh augmentation. RESULTS: Over a period of 6 years from February 2009 to February 2015, 68 patients underwent surgery. The mesh was placed intraperitoneally with closure of the anterior fascia in 27 cases (39.7%). The biological mesh was placed in the retromuscular pre-fascial plane in 1 case (1.5%) and pre-aponeurotic plane in 1 case (1.5%). Closure of the anterior fascia was not achieved in 39 cases, including 20 cases in which the mesh was placed intraperitoneally (intraperitoneal bridging group, 29.4%) and 19 cases in which the mesh was placed between the edges of the fascia (inlay bridging group, 27.9%). There were 37 cases of postoperative surgical site infections (54.4%), and Clavien-Dindo morbidity staging indicated stage I-II and III-IV complications in 19.1% and 44.1% of the cases, respectively. The recurrence rate was 61.8%, and the mortality rate was 0%. The rate of recurrence was significantly lower in the «fascia approximated¼ group (37%), p = 0.001). Univariate analyses of risk factors for procedural failure indicated an increased risk of recurrence in cases of postoperative surgical site infections, complications of Clavien-Dindo grade III or higher, an absent fascial closure in front of the mesh (OR = 8.69), an operating time longer than 180 min, and a VHWG score higher than 2. After logistic regression, the risk factors for recurrence were postoperative infections (OR = 6.2), placement of bridged biological mesh (OR = 22.3), and postoperative morbidity grade III or higher (OR = 16.7). CONCLUSIONS: Patients with postoperative surgical site infections are at an increased risk for recurrence, and bridged mesh placements lack efficacy. Overall, this study challenges the purported advantage of biologics in treating incisional hernia repairs.

What is the ideal indwelling time for metal stents after endoscopic ultrasound-guided gastrojejunostomy? Case report of delayed iatrogenic perforation with a review of the literature.

Several recent studies have described the feasibility, efficacy and safety of the placement of lumen-apposing metal stents (LAMS) for the treatment of gastrointestinal strictures. However, the optimum stent indwelling time is unclear. We reviewed the literature on endoscopic gastroenterostomy (GE) with a focus on the stent indwelling time and we described the first reported case of iatrogenic perforation six months after Axios stent placement. In the literature review (n = 239), the composite technical success rate and clinical success rate were 93.7% and 87.9%, respectively. The mean follow-up period was 191 days, and the mean stent indwelling time was 88 days. Among 13 studies (n = 202), the mean rate of complications was 13.4%. The principal complication was mis-deployment of the stent (4.5%). We report a case report of delayed iatrogenic perforation. A 59-year-old male patient with cystic dystrophy of the duodenum has been followed for several years. He presented with anorexia following duodenal obstruction and underwent endoscopic ultrasound-guided gastrojejunostomy. Six months later, he was referred to our center due to septic shock, and abdominal computed tomography revealed peritonitis secondary to a perforation of the small intestine, opposite the Axios stent. The mean LAMS indwelling time after GE was 88 days. To minimise the rate of adverse events, such as ulceration and mucosal overgrowth, regular abdominal computed tomography and endoscopy can be performed to evaluate the local effect of the stent. When the disease has resolved, the LAMS must be removed as soon as possible.

Managing chemotherapy extravasation in totally implantable central venous access: Use of subcutaneous wash-out technique.

BACKGROUND: Totally implanted venous access is widely used in chemotherapy administration. With over 1 million intravenous chemotherapy infusions given worldwide each day, complications are frequent. Accidental cases of extravasation in the presence of a catheter are rare yet very serious and may require discontinuation of chemotherapy. The aim of this study was to evaluate the feasibility and efficacy of the subcutaneous wash-out technique for chemotherapy extravasation treatment. METHODS: We retrospectively reviewed the medical charts of patients who had received chemotherapy and sustained extravasation in our hospital between October 2013 and October 2016. Subcutaneous wash-out treatments were carried out exclusively, without the application of antidotes or the use of specific antidotes. RESULTS: We documented seven cases of chemotherapy extravasation. Two cases were treated with antidotes and suffered necrosis in the following weeks. The five patients treated using subcutaneous wash-out had no necrosis and had a steady decrease in the inflammatory reaction of the cutaneous and subcutaneous soft tissues. For these five patients, chemotherapy was restarted within 1 month following extravasation. CONCLUSION: This study would argue for the feasibility and effectiveness of subcutaneous wash-out in the treatment of chemotherapy extravasations.

Identification of risk factors for morbidity and mortality after Hartmann's reversal surgery - a retrospective study from two French centers.

Hartmann's reversal procedures are often fraught with complications or failure to recover. This being a fact, it is often difficult to select patients with the optimal indications for a reversal. The post-recovery morbidity and mortality rates in the literature are heterogeneous between 0.8 and 44%. The identification of predictive risk factors of failure of such interventions would therefore be very useful to help the practitioner in his approach. Given these elements, it was important to us to analyze the practice of two French university hospitals in order to highlight such risk factors and to allow surgeons to select the best therapeutic strategy. We performed a bicentric observational retrospective study between 2010 and 2015 that studied the characteristics of patients who had undergone Hartmann surgery and were subsequently reestablished. The aim of the study was to identify factors influencing morbidity and postoperative mortality of Hartmann's reversal. Primary outcome was complications within the first 90 postoperative days. 240 patients were studied of which 60.4% were men. The mean age was 69.48 years. The median time to reversal was 8 months. 79.17% of patients were operated as emergency cases where the indication was a diverticular complication (39.17%). Seventy patients (29.2%) underwent a reversal and approximately 43% of these had complications within the first 90 postoperative days. The mean age of these seventy patients was 61.3 years old and 65.7% were males. None of them benefited from a reversal in the first three months. We identified some risk factors for morbidity such as pre-operative low albuminemia (p = 0.005) and moderate renal impairment (p = 0.019). However, chronic corticosteroid use (p = 0.004), moderate renal insufficiency (p = 0.014) and coronary artery disease (p = 0.014) seem to favour the development of anastomotic fistula, which is itself, a risk factor for mortality (p = 0.007). Our study highlights an important rate of complications including significant anastomotic fistula after Hartmann's reversal. Precarious nutritional status and cardiovascular comorbidities should clearly lead us to reconsider the surgical indication for continuity restoration.

Long-term survival after surgery of pancreatic primary squamous cell carcinoma: A case report and literature review.

Pancreatic primary squamous cell carcinoma is rarer and no optimal treatment has been validated according to the tumor stage. The surgical resection was the only curative option. The radiotherapy or chemotherapy was performed for the other cases.

Impact of neoadjuvant chemoradiotherapy on postoperative outcomes after esophageal cancer resection: results of a European multicenter study.

OBJECTIVES: To assess the impact of neoadjuvant chemoradiotherapy (NCRT) on anastomotic leakage (AL) and other postoperative outcomes after esophageal cancer (EC) resection. BACKGROUND: Conflicting data have emerged from randomized studies regarding the impact of NCRT on AL. METHODS: Among 2944 consecutive patients operated on for EC between 2000 and 2010 in 30 European centers, patients treated by NCRT after surgery (n=593) were compared with those treated by primary surgery (n=1487). Multivariable analyses and propensity score matching were used to compensate for the differences in some baseline characteristics. RESULTS: Patients in the NCRT group were younger, with a higher prevalence of male sex, malnutrition, advanced tumor stage, squamous cell carcinoma, and surgery after 2005 when compared with the primary surgery group. Postoperative AL rates were 8.8% versus 10.6% (P=0.220), and 90-day postoperative mortality and morbidity rates were 9.3% versus 7.2% (P=0.110) and 33.4% versus 32.1% (P=0.564), respectively. Pulmonary complication rates did not differ between groups (24.6% vs 22.5%; P=0.291), whereas chylothorax (2.5% vs 1.2%; P=0.020), cardiovascular complications (8.6% vs 0.1%; P=0.037), and thromboembolic events (8.6% vs 6.0%; P=0.037) were higher in the NCRT group. After propensity score matching, AL rates were 8.8% versus 11.3% (P=0.228), with more chylothorax (2.5% vs 0.7%; P=0.030) and trend toward more cardiovascular and thromboembolic events in the NCRT group (P=0.069). Predictors of AL were high American Society of Anesthesiologists scores, supracarinal tumoral location, and cervical anastomosis, but not NCRT. CONCLUSIONS: Neoadjuvant chemoradiotherapy does not have an impact on the AL rate after EC resection (NCT 01927016).

Prostatic abscesses and severe sepsis due to methicillin-susceptible Staphylococcus aureus producing Panton-Valentine leukocidin.

BACKGROUND: Prostatic abscesses are an uncommon disease usually caused by enterobacteria. They mostly occur in immunodeficient patients. It is thus extremely rare to have a Staphylococcal prostatic abscess in a young immunocompetent patient. CASE PRESENTATION: A 20-year-old patient was treated with ofloxacin for a suspicion of prostatitis. An ultrasonography was performed because of persisting symptoms and showed acute urinary retention and prostatic abscesses. So the empirical antibiotic therapy was modified with ceftriaxone/amikacin. The disease worsened to severe sepsis and the patient was admitted in ICU. CT-scan and MRI confirmed three abscesses with perirectal infiltration and the bacteriological samples (abscesses and blood cultures) were positive to methicillin-susceptible Staphylococcus aureus producing Panton-Valentine leukocidine. The treatment was changed with fosfomycin/ofloxacin which resulted in a general improvement and the regression of the abscesses. CONCLUSION: Staphyloccocus aureus producing Panton-Valentine leukocidin are most commonly responsible for skin and soft tissue infections. To this day, no other case of prostatic abscess due to this strain but susceptible to methicillin has been described.

Obscure bleeding colonic duplication responds to proton pump inhibitor therapy.

We report the case of a 17-year-old male admitted to our academic hospital with massive rectal bleeding. Since childhood he had reported recurrent gastrointestinal bleeding and had two exploratory laparotomies 5 and 2 years previously. An emergency abdominal computed tomography scan, gastroscopy and colonoscopy, performed after hemodynamic stabilization, were considered normal. High-dose intravenous proton pump inhibitor (PPI) therapy was initiated and bleeding stopped spontaneously. Two other massive rectal bleeds occurred 8 h after each cessation of PPI which led to a hemostatic laparotomy after negative gastroscopy and small bowel capsule endoscopy. This showed long tubular duplication of the right colon, with fresh blood in the duplicated colon. Obscure lower gastrointestinal bleeding is a difficult medical situation and potentially life-threatening. The presence of ulcerated ectopic gastric mucosa in the colonic duplication explains the partial efficacy of PPI therapy. Obscure gastrointestinal bleeding responding to empiric anti-acid therapy should probably evoke the diagnosis of bleeding ectopic gastric mucosa such as Meckel's diverticulum or gastrointestinal duplication, and gastroenterologists should be aware of this potential medical situation.

How to successfully implement a robotic pediatric surgery program: lessons learned after 96 procedures.

BACKGROUND: Both our teams were the first to implement pediatric robotic surgery in France. The aim of this study was to define the key points we brought to light so other pediatric teams that want to set up a robotic surgery program will benefit. METHODS: We reviewed the medical records of all children who underwent robotic surgery between Nov 2007 and June 2011 in both departments, including patient data, installation and changes, operative time, hospital stay, intraoperative complications, and postoperative outcome. The department's internal organization, the organization within the hospital complex, and cost were evaluated. RESULTS: A total of 96 procedures were evaluated. There were 38 girls and 56 boys with average age at surgery of 7.6 years (range, 0.7-18 years) and average weight of 26 kg (range, 6-77 kg). Thirty-six patients had general surgery, 57 patients urologic surgery, and 1 thoracic surgery. Overall average operative time was 189 min (range, 70-550 min), and average hospital stay was 6.4 days (range, 2-24 days). The procedures of 3 patients were converted. Median follow-up was 18 months (range, 0.5-43 months). Robotic surgical procedure had an extra cost of 1934 compared to conventional open surgery. CONCLUSIONS: Our experience was similar to the findings described in the literature for feasibility, security, and patient outcomes; we had an overall operative success rate of 97 %. Three main actors are concerned in the implementation of a robotic pediatric surgery program: surgeons and anesthetists, nurses, and the administration. The surgeon is at the starting point with motivation for minimally invasive surgery without laparoscopic constraints. We found that it was possible to implement a long-lasting robotic surgery program with comparable quality of care.