Development of a program for teaching practical skills in visceral and digestive surgery by simulation.

Up until 2013 in France, practical training for DES/DESC (advanced level) residents in visceral and digestive surgery was not standardized. Since 2017, the third cycle of medical studies has been restructured around three major thematic axes: academic knowledge, and technical and non-technical skills. The curriculum now includes a practical training program by means of simulation outside the operating theater, and it is structured, uniformized and standardized nationwide. Development of this training program is derived from the deliberations of a national consensus panel working under the umbrella of the French college of visceral and digestive surgery, program presenting a training guide to all future surgeons in the specialty. Four consensus conference sessions bringing together an eight-member commission have led to the drafting of a "Resident's manual for practical teaching in visceral and digestive surgery". As a reference document, the manual details in 272 pages the objectives (phase I), the learning resources for each skill (phase II) and, lastly, the means of evaluation for the cornerstone phases as well as the in-depth phases of an advanced degree (DES) in visceral and digestive surgery. As a complement to the manual, we have conducted a review of the structuring and implementation of the program as of November 2017 on a nationwide scale; the conclusions of the review are detailed at the end of this article.

Residency training in robotic surgery: The role of simulation.

Simulation has become increasingly important in surgical teaching in recent years and the French National Authority for Health (HAS) recently underlined the goal and ethical priority: "never the first time on the patient". Simulation programs have been tested and validated for laparotomy and for laparoscopy, but there is not yet a validated program specific for robotic surgery. Due to substantial advances in this new technology, we have developed a program in Nancy dedicated to outside-the-operating room (OR) teaching of robotic surgery using the Da Vinci robot. This teaching is based on a combined program of theoretical teaching (e-learning) and learning of practical skills using virtual simulators (DV-Trainer®, Robotic Mentor®, DVSS®), mechanical simulators (Dome, Applied® abdominal simulators), microsurgery and wet lab using ex vivo animal organs, anesthetized animals, and cadavers. This program also emphasizes team training. The course is intended for residents in surgical training and is integrated into the specialized study diploma (DES) program for Visceral and Digestive Surgery; it also can be used by qualified surgeons who can integrate it with the Inter-University Diploma (DIU) in General Robotic Surgery for basic techniques and also for DIUs in other surgical specialties (digestive and gynecologic surgery) for robotic uses within their specialty. These courses are based on the concept of step-by-step skills acquisition and verification allowing a transition to safe clinical activity.

Innovative appliance for colostomy patients: an interventional prospective pilot study.

BACKGROUND: The control of body waste emptying is a constant research topic in stoma care. The aim of this pilot study was to assess the efficacy and safety of an innovative colostomy appliance. METHODS: An interventional prospective non-comparative pilot study was conducted in seven French centers. The study device is a new type of two-piece appliance including a base plate and a "capsule cap" (CC) composed of a capsule cover and a folded collecting bag. The device gently seals the stoma to provide stoma output control. When the bowel movement pressure increases the patient may control the deployment of the folded bag and collect stools. Patients with left-sided colostomy all using a flat appliance, were enrolled in a 2-week trial. Outcome measures were type of CC removal and peristomal fecal leaks while wearing the device. RESULTS: Of 30 patients (females 66.7%), with left-sided colostomy (permanent 76.7%), 23 (76.7%) completed the 2-week trial. A total of 472 CC changes were analyzed. EFFICACY: of 404 (85.5%) CC changes reported in diaries, 302 (74.8%) were linked with stool and/or gas. In 244 (60.3%) changes, the patient controlled stoma bag deployment and it occurred with bowel emptying 301 (74.5%) times. No leaks around the appliance were observed in 400 (85.3%) changes. SAFETY: no serious adverse event occurred. Peristomal skin was not modified during the trial. CONCLUSIONS: In the short term this new device has provided an increased control over bowel emptying at no risk in half of the trial population suggesting that an alternative approach to bag wearing is achievable.

Mid term functional results following surgical treatment of recto-urinary fistulas postprostate cancer treatment.

INTRODUCTION: To evaluate the mid term functional results of patients treated for RUF and to determine an optimal treatment strategy to improve their quality of life. Recto-urinary Fistula (RUF) is a rare complication following prostate cancer treatment, and can have a major impact on patients' quality of life. There is a lack of consensus concerning the best approach and different techniques have been proposed: endoscopic, transrectal, perineal and transperitoneal (open, laparoscopic or robotic). MATERIALS AND METHODS: We retrospectively reviewed the charts of patients who underwent RUF repair from January 2001 to December 2010 at our Institute. 16 patients who developed RUF following prostate cancer treatment were included in the study. The fistula had to be confirmed both clinically and by imaging. All patients had follow up consultation every 3 month for the first year and then annually. They were asked to fill questionnaires evaluating functional outcomes. The International Continence Society (ICS) score was used to assess the postoperative urinary continence. Fecal continence was evaluated with the Wexner score and sexual function was assessed with the International Index for erectile function (IIEF-5) score. RESULTS: Eighty-seven percent patients (14/16) in our series developed RUF as a consequence of prostate cancer surgery and 13% (2/16) postbrachytherapy (BT). All patients initially had a diversion colostomy and a supra pubic catheter. 69% (11/16) underwent primary YM repair and 73% (8/11) were successful. 2/3 primary failures were successfully retreated with graciloplasty. Primary gracilis flap interposition (GFI), on 3 non-irradiated patients were successful (100%). Primary GFI postbrachytherapy, no patient had recover urinary and digestive continuity. In total primary GIF was successful in 60% (3/5). Over all long term, success rate with a urinary and digestive continuity and without recurrence of the fistula was 81% (13/16). Mid term functional results were evaluated at mean follow up of 40 months (14-92). 13% (2/16) achieved complete urinary continence, 48% (7/16) required single pad, 25% (4/16) developed major incontinence, 7% (1/16) required urinary diversion and 13% (2/16) developed complete urethral closure post BT requiring permanent suprapubic catheterization. Colostomy was reversed in 93% (15/16) cases. 75% (12/16) achieved complete faecal continence, minor incontinence (wexner score 3-4) was seen in 13% (2/16) and major incontinence (wexner score 14) in 7% (1/16) and 7% (1/16) required a long term colostomy. 19% (3/16) developed colostomy related complications. Only 13% (2/16) achieved adequate erections with the use of intra cavernosal prostaglandin injections. CONCLUSIONS: RUF following prostate cancer treatment is a serious complication with severe repercussion on patients' quality of life. Surgical repair with the York Mason technique or Gracilis Flap interposition is associated with good success rates. If available pediculed gracilis muscle should be used as it offers better success rates. LEVEL OF EVIDENCE: 3.

Robot-assisted adrenalectomy: indications and drawbacks.

Adrenal tumors can vary from a benign adrenocortical adenoma with no hormonal secretion to a secretory adrenocortical malignancy (adrenocortical carcinoma) or a hormone-secreting tumor of the adrenal medulla (pheochromocytoma). Currently, laparoscopic adrenalectomy is regarded as the preferred surgical approach for the management of most adrenal surgical disorders, although there are no prospective randomized trials comparing this technique with open adrenalectomy. However, widespread adoption of robotic technology has positioned robotic adrenalectomy as an option in some medical centers. Speculative advantages associated with the use of the robotic system have rarely been evaluated in clinical settings and cost increase remains an important drawback associated with robotic surgery. This review summarizes current available data regarding robotic transperitoneal adrenalectomy including its indications, advantages, limitations, and comparison with conventional laparoscopic adrenalectomy. We believe that the use of a robotic system seems to be useful especially in more difficult patients with larger tumors, truncal paragangliomas, and bilateral and/or partial adrenalectomies. Overall, we believe that overcosts due to robotic system use could be balanced by hospital stay decrease, patients' referral increase, improved postoperative outcomes in more difficult patients and ergonomics for the surgeon. However, we also believe that the current surgical intuitive business model is counterproductive, because there are no available strong clinical data that could balance overcosts associated with the use of the robotic system.

Prevalence of hepatic lesion types defined by T2-weighted and dynamic gadolinium-enhanced MR imaging in patients with metastasized neuroendocrine tumors.

PURPOSE: Identifying liver metastases from neuroendocrine tumors (NETs) is a pretherapeutic challenge in patients who are candidates for liver resection. The aims of our study are to characterize and determine the frequency of different MRI characteristics of liver metastases caused by NETs in a lesion-by-lesion analysis and to determine the frequency of monomorphous and polymorphous metastases in a patient-by-patient analysis. METHODS: This retrospective study involved 47 patients with liver metastases arising from histologically confirmed NETs. In a lesion-by-lesion analysis, we classified these metastases according to their MRI characteristics as follows: hypervascular lesions with homogeneous or peripheral enhancement, hypovascular lesions, pure cystic lesions, and mixed solid/cystic lesions. In the patient-by-patient analysis, we distinguished patients whose metastases had the same MRI characteristics from patients with mixed lesion characteristics. RESULTS: A total of 376 metastases were analyzed. Of these, 84.3% (n = 317) were hypervascular, with 51.9% showing homogeneous enhancement and 32.4% (n = 122) showing peripheral enhancement. Another 7.4% (n = 28) were hypovascular, 5.3% (n = 20) were pure cystic, and 2.9% (n = 11) were mixed solid/cystic. After excluding three patients with solitary lesions, 40.9% of patients (n = 18) had mixed-type lesions, consisting of hypervascular lesions with either homogeneous or peripheral enhancement in 27.3% of cases (n = 12), while 59.1% of patients (n = 26) had identical lesions. CONCLUSION: Approximately 15% of metastases have atypical MRI characteristics and are either hypovascular or cystic. Metastases with different MRI characteristics coexist in 40% of patients.

Second-stage robot-assisted biliopancreatic diversion with duodenal switch after sleeve gastrectomy.

Biliopancreatic diversion (BPD) was initially described in 1979 and consisted of a distal gastrectomy with a 250-mL stomach pouch and a distal intestinal bypass with a 50 to 100-cm common channel resulting in malabsorption of dietary fat (Scopinaro et al. Br J Surg. 66(9):618-20, 1979). Later, several modifications (sleeve gastrectomy, pylorus preservation, and duodenal switch) were proposed to improve incidence of postoperative dumping syndrome, diarrhea, and anastomotic ulcerations (Lagacé et al. Obes Surg. 5(4):411-8, 1995). Gagner et al. developed a simplified and reproducible approach for laparoscopic BPD with duodenal switch (BPD-DS) after sleeve gastrectomy (Ren et al. Obes Surg. 10(6): 514-23, 2000). BPD-DS has been considered as one of the most difficult bariatric procedures for its surgical complexity and postoperative metabolic complications management. In this regard, the number of BPD-DS has remained extremely low (<4 %). We hypothesize that robotic approach could facilitate the feasibility of BPD-DS procedure. In this multimedia video (8 min), we present a step-by-step robotic BPD-DS.

Risk Factors for Postoperative Morbidity After Totally Robotic Gastric Bypass in 302 Consecutive Patients.

BACKGROUND: Totally robotic gastric bypass (robotic Roux-en-Y gastric bypass, R-RYGBP) has been adopted in some centers on the basis of large retrospective studies. In view of some data showing higher morbidity and higher costs, some authors have considered that robotic gastric bypass may no longer be justified with the existing system. Although low postoperative complication rates after R-RYGBP have been reported, risk factors for postoperative morbidity have never been evaluated. The goal of this study was to identify risk factors for postoperative morbidity after R-RYGBP. METHODS: A retrospective analysis of a prospectively maintained database was performed and included 302 consecutive patients after R-RYGBP performed between 2007 and 2013. This subset of patients represented 34 % of all gastric bypass procedures performed during this study period. Univariate and multivariate analyses were performed in order to identify risk factors for postoperative overall morbidity (Clavien scores 1-4 versus 0) and major morbidity (Clavien score ≥3 versus 0-1-2). RESULTS: Postoperative morbidity and mortality rates were 24.4 and 0.6 %, respectively. In multivariate analysis, independent risk factors for overall morbidity were American Society of Anesthesiologists (ASA) score ≥3 (odds ratio (OR) 2.0) and previous bariatric surgery (revisional gastric bypass) (OR 2.0). Independent risk factors for major morbidity (Clavien ≥3) were previous bariatric surgery (revisional gastric bypass) (OR 3.7), low preoperative hematocrit level (OR 0.9), and revisional gastric bypass procedure with concomitant gastric banding removal (OR 5.7). CONCLUSIONS: R-RYGBP is prone to increased complications in the setting of a high preoperative ASA score and revisional surgery. This should be taken into consideration by clinicians when evaluating R-RYGBP.

Long-term outcome of robotic-assisted laparoscopic rectopexy for full-thickness rectal prolapse in elderly patients.

AIM: Full-thickness rectal prolapse is common in the elderly, but there are no particular practice guidelines for its surgical management. We evaluated retrospectively the perioperative and long-term clinical results and function in elderly and younger patients with complete rectal prolapse after robotic-assisted laparoscopic rectopexy (RALR). METHOD: Seventy-seven patients who underwent RALR between 2002 and 2010 were divided into Group A (age < 75 years, n = 59) and Group B (age > 75 years, n = 18). Operative time, intra- and postoperative complications, length of hospital stay, short-term and long-term outcomes, recurrence rate and degree of satisfaction were evaluated. RESULTS: There was no significant difference between the groups regarding operation time, conversion, morbidity or length of hospital stay. At a median follow-up of 51.8 (5-115) months, there was no difference in the improvement of faecal incontinence, recurrence and the degree of satisfaction. CONCLUSION: Robotic-assisted laparoscopic rectopexy is safe in patients aged over 75 years and gives similar results to those in patients aged < 75 years.

The effect of immune therapy on surgical site infection following Crohn's Disease resection.

BACKGROUND: Patients with Crohn's disease are increasingly receiving antitumour necrosis factor α (anti-TNF-α) therapy. Whether anti-TNF-α therapy increases the risk of postoperative infectious complications in Crohn's disease is a matter of debate. METHODS: This was a retrospective study of three referral centres. The charts of patients who underwent ileocaecal or ileocolonic resection for Crohn's disease between 2000 and 2011 were reviewed. The impact of baseline characteristics and Crohn's disease-related medications on the risk of postoperative intra-abdominal infectious complications was investigated by univariable and multivariable analysis. RESULTS: A total of 217 patients were included in the study. Median age at the time of surgery was 36·8 (range 15-78) years. A postoperative intra-abdominal infection occurred in 24 (11·1 per cent) of 217 patients. No deaths were reported. On univariable analysis, age less than 25 years (P = 0·023), steroid use (P = 0·017), anti-TNF-α therapy (P = 0·043) and anti-TNF-α treatment in combination with steroids (P = 0·004) were associated with an increased risk of postoperative intra-abdominal infectious complications. On multivariable analysis, only anti-TNF-α therapy in combination with steroids significantly increased this risk (odds ratio 8·03, 95 per cent confidence interval 1·93 to 33·43; P = 0·035). CONCLUSION: Combined use of steroids and anti-TNF-α therapy was associated with an increased risk of postoperative intra-abdominal infectious complications.

Long-term outcomes after totally robotic sacrocolpopexy for treatment of pelvic organ prolapse.

PURPOSE: This study evaluated the feasibility, safety, effectiveness, and long-term results of pelvic organ prolapse surgery using the Da Vinci robotic system. METHODS: During a 7-year period, 52 consecutive patients with pelvic organ prolapse underwent robotic-assisted abdominal sacrocolpopexy. Clinical data were retrospectively collected and analyzed. RESULTS: All but two of the procedures were successfully completed robotically (96 %). Median operative time was 190 (range, 75-340) mins. There was no mortality and no specific morbidity due to the robotic approach. Mean hospital stay was 5 days. The median follow-up was 42 months. Five recurrent prolapses (9.6 %) were diagnosed. CONCLUSIONS: Our experience indicates that using the Da-Vinci robotic system is feasible, safe, and effective for the treatment of pelvic organ prolapse with good long-term results.

Gastric electrical stimulation for the treatment of diabetic gastroparesis.

Diabetic gastroparesis is a component of autonomic neuropathy, and is the most common manifestation of gastrointestinal neuropathy. Diabetes is responsible for about one quarter of gastroparesis. The upper gastrointestinal symptoms are often non-specific and dominated by nausea, vomiting, early satiety, fullness, bloating. We also have to look for diabetic gastroparesis in case of metabolic instability, such as postprandial hypoglycaemia. The pathophysiology of diabetic gastroparesis is complex, partly due to a vagus nerve damage, but also to changes in secretion of hormones such as motilin and ghrelin. A decrease in the stem cell factor (SCF), growth factor for cells of Cajal (gastric pacemaker), was found in subjects with diabetic gastroparesis. These abnormalities lead to an excessive relaxation in the corpus, a hypomotility of antrum, a desynchronization antrum-duodenum-pylorus, and finally an abnormal duodenal motility. The treatment of diabetic gastroparesis is based on diabetes control, and split meals by reducing the fiber content and fat from the diet. The antiemetic and prokinetic agents should be tested primarily in people with nausea and vomiting. Finally, after failure of conventional measures, the use of gastric neuromodulation is an effective alternative, with well-defined indications. Introduced in the 1970s, this technology works by applying electrical stimulation continues at the gastric antrum, particularly in patients whose gastric symptoms are refractory to other therapies. Its efficacy has been recently reported in different causes of gastroparesis, especially in diabetes. Gastric emptying based on gastric scintigraphy, gastrointestinal symptoms, biological markers of glycaemic control and quality of life are partly improved, but not normalized. Finally, a heavy nutritional care is sometimes necessary in the most severe forms. The enteral route should be preferred (nasojejunal and jejunostomy if possible efficiency). However, in case of failure especially in patients with small bowel neuropathy, the long-term parenteral nutrition is sometimes required.