Benefits of a 14-year surgical site infections active surveillance programme in a French teaching hospital.

BACKGROUND: Surgical site infections (SSIs) are the second most common healthcare-associated infection. Active SSI surveillance can help inform preventative measures and assess the impact of these measures. AIM: We aimed to describe the evolution in trends over 14 years of prospective active SSI surveillance and implementations of SSI prevention measures in a French Teaching Hospital. METHODS: We monitored and included in the study all surgical procedures performed from 2003 to 2016 in eight surgical units. The semi-automated surveillance method consisted of weekly collection of SSI declaration forms (pre-filled with patient and procedure administrative data and microbiology laboratory data), filled-in by surgeons and then monitored by the infection control practitioners. FINDINGS: A total of 181,746 procedures were included in our analysis and 3270 SSIs recorded (global SSI rate 1.8%). The SSI rate decreased significantly from 3.0% in 2003 to 1.1% in 2016. This decrease was mainly in superficial SSIs and high infectious risk procedures. Higher SSI rates were observed for procedures associated with the usual risk factors. During this 14-year period, several evolutions in surgical practices occurred that might have contributed to this decrease. CONCLUSIONS: With an overall decrease in SSI rate throughout the surveillance, our results revealed the benefits of an active and comprehensive hospital SSI surveillance programme for understanding the SSI rate trends, analysing local risk factors and assessing the effectiveness of prevention strategies. These findings also highlighted the importance of the collaboration between surgeons and infection control practitioners.

Transition effects from laparocscopic to robotic surgery skills in small cavities.

Conventional laparoscopic surgery (LS) is being challenged by the ever-increasing use of robotic surgery (RS) to perform reconstructive procedures. The purpose of this study was to assess the acquisition of skills in both techniques and the potential transfer of skills from one technique to the other when restricted spaces are involved. A preclinical randomized crossover study design was implemented. Twelve subjects performed two different reproducible drill procedures: "Thread the Ring" (TR) and "Transfer the Plot" (TP). To assess surgical proficiency in confined workspaces, these exercises were performed with LS and RS technology in a pediatric laparoscopic surgery (PLS) simulator. Each performance was recorded and evaluated by two reviewers using objective structured assessment of technical skills (OSATS). The times to complete the TP and the TR procedure were significantly shorter with RS compared to LS (64 s vs. 319 s; p < 0.0001 for both TP and TR). A significant transfer effect of skills between LS and RS was noted for the TP exercise (p = 0.006). The percentage improvement was greater overall with LS, meaning a higher number of trials were required to adequately master the procedure. This study demonstrated that RS performed significantly better compared to LS on pediatric simulation devices. A transfer effect was identified from LS to RS exclusively. The learning curves showed that progression was definitely longer with LS. These results, indicate that novice surgeons should be encouraged to persist with learning LS, and they support the use of a pediatric robotic simulation device.

Postoperative compensation after neurotomy in Meniere's disease: Retrospective study of 15 cases.

INTRODUCTION: Vestibular neurotomy is a functional surgery for Meniere's disease in the event of medical treatment failure. The aim of the study was to assess the efficacy and complications of vestibular neurotomy, and to address the question of postoperative compensation. MATERIAL AND METHOD: All patients included in this retrospective study underwent a vestibular neurotomy at our center between 2009 and 2016. A preoperative evaluation was performed including MRI, audiometry, and videonystagmography. The functional level of disability was evaluated by the Dizziness Handicap Inventory (DHI) score. In all patients suboccipital retrosigmoid approach was performed. All patients underwent early postoperative vestibular rehabilitation. One month and two years after surgery, we assessed the effectiveness of treatment on dizziness, disability and imbalance. At the time of this study (2 to 8 years), DHI and patients' satisfaction by patient's global impression of change (PGIC) scale were evaluated. RESULTS: Fifteen patients aged between 42 and 74 years of age were included in our study. Postoperative complications occurred in two patients (meningitis and a wound infection). At one month, all patients had a dramatic clinical improvement with decreased vertigo. Two years after surgery, 85% of the patients were cured and had no dizziness or balance disorder. Only one patient experienced bilateralization and only one had a persistent poor compensation. CONCLUSION: Vestibular neurotomy is a very effective treatment in the case of Meniere's disease resistant to medical treatment, with very good functional results and an extremely low failure rate.

Carmustine wafer implantation for high-grade gliomas: Evidence-based safety efficacy and practical recommendations from the Neuro-oncology Club of the French Society of Neurosurgery.

There is a growing body of evidence that carmustine wafer implantation during surgery is an effective therapeutic adjunct to the standard combined radio-chemotherapy regimen using temozolomide in newly diagnosed and recurrent high-grade glioma patient management with a statistically significant survival benefit demonstrated across several randomized clinical trials, as well as prospective and retrospective studies (grade A recommendation). Compelling clinical data also support the safety of carmustine wafer implantation (grade A recommendation) in these patients and suggest that observed adverse events can be avoided in experienced neurosurgeon hands. Furthermore, carmustine wafer implantation does not seem to impact negatively on the quality of life and the completion of adjuvant oncological treatments (grade C recommendation). Moreover, emerging findings support the potential of high-grade gliomas molecular status, especially the O(6)-Methylguanine-DNA Methyltransferase promoter methylation status, in predicting the efficacy of such a surgical strategy, especially at recurrence (grade B recommendation). Finally, carmustine wafer implantation appears to be cost-effective in high-grade glioma patients when performed by an experienced team and when total or subtotal resection can be achieved. Altogether, these data underline the current need for a new randomized clinical trial to assess the impact of a maximal safe resection with carmustine wafer implantation followed by the standard combined chemoradiation protocol stratified by molecular status in high-grade glioma patients.

Multicolumn spinal cord stimulation for significant low back pain in failed back surgery syndrome: design of a national, multicentre, randomized, controlled health economics trial (ESTIMET Study).

BACKGROUND: Many studies have demonstrated the efficacy of spinal cord stimulation (SCS) for chronic neuropathic radicular pain over recent decades, but despite global favourable outcomes in failed back surgery syndrome (FBSS) with leg pain, the back pain component remains poorly controlled by neurostimulation. Technological and scientific progress has led to the development of new SCS leads, comprising a multicolumn design and a greater number of contacts. The efficacy of multicolumn SCS lead configurations for the treatment of the back pain component of FBSS has recently been suggested by pilot studies. However, a randomized controlled trial must be conducted to confirm the efficacy of new generation multicolumn SCS. Évaluation médico-économique de la STImulation MEdullaire mulTi-colonnes (ESTIMET) is a multicentre, randomized study designed to compare the clinical efficacy and health economics aspects of mono- vs. multicolumn SCS lead programming in FBSS patients with radicular pain and significant back pain. MATERIALS AND METHODS: FBSS patients with a radicular pain VAS score≥50mm, associated with a significant back pain component were recruited in 14 centres in France and implanted with multicolumn SCS. Before the lead implantation procedure, they were 1:1 randomized to monocolumn SCS (group 1) or multicolumn SCS (group 2). Programming was performed using only one column for group 1 and full use of the 3 columns for group 2. Outcome assessment was performed at baseline (pre-implantation), and 1, 3, 6 and 12months post-implantation. The primary outcome measure was a reduction of the severity of low back pain (bVAS reduction≥50%) at the 6-month visit. Additional outcome measures were changes in global pain, leg pain, paraesthesia coverage mapping, functional capacities, quality of life, neuropsychological aspects, patient satisfaction and healthcare resource consumption. TRIAL STATUS: Trial recruitment started in May 2012. As of September 2013, all 14 study centres have been initiated and 112/115 patients have been enrolled. Preliminary results are expected to be published in 2015. TRIAL REGISTRATION: Clinical trial registration information-URL: www.clinicaltrials.gov. Unique identifier NCT01628237.

Intraoperative 3D imaging control during subthalamic Deep Brain Stimulation procedures using O-arm® technology: Experience in 15 patients.

OBJECTIVE: O-arm(®) now gives us the opportunity not only to perform 2D but also 3D scans during deep brain stimulation (DBS) procedures. We present our experience with the intraoperative use of this device. Our objective was to measure the geometrical accuracy of electrode placement during surgical procedures driven under O-arm(®) control. METHODS: Fifteen patients underwent STN-DBS. For the first 4 patients, 3D scans were performed at the end of the procedure. We calculated the accuracy of electrode positioning, i.e. the distance between final electrode positioning and the planned trajectory. For the next 11 patients, who underwent both intraoperative and final 3D scan, we also calculated the accuracy of the microelectrode positioning. RESULTS: Average stimulation-induced improvement of UPDRS-III score was 52.5±15%. For the first 4 patients, the mean electrode positioning accuracy was 1.46±0.56mm. For the 11 patients who underwent intraoperative 3D scan, the mean microelectrodes positioning accuracy was 1.59±1.1mm. Aberrant positioning was detected in two cases, and was analyzed by fusing 3D scan with preoperative MR images. The definite electrodes positioning accuracy was 1.05±0.54mm. CONCLUSION: Intraoperative 3D scan is feasible, and can help us detect and correct early aberrant trajectories.

Endovascular treatment of middle cerebral artery aneurysms for 120 nonselected patients: a prospective cohort study.

BACKGROUND AND PURPOSE: Multiple technologies have developed the endovascular approach to MCA aneurysms. We assess the safety and the efficacy of a systematic endovascular approach in nonselected patients with MCA aneurysms and determine predictors of treatment outcomes. MATERIALS AND METHODS: We analyzed data collected between January 2007 and January 2012 in a prospective clinical registry. All patients with MCA aneurysms treated by means of the endovascular approach were included. A multivariate analysis was conducted to identify predictors of complications, recanalization, and outcome. RESULTS: A total of 120 patients with 131 MCA aneurysms were included. Seventy-nine patients (65.8%) were treated electively and 41 (34.2%) in the setting of subarachnoid hemorrhage. Thirty-three of 131 aneurysms (25.2%) were treated with simple coiling, 79 aneurysms (60.3%) with balloon-assisted coiling, and 19 aneurysms (14.5%) with stent-assisted coiling. Complications occurred in 13.7% of patients. Stent-assisted coiling was significantly associated with more complications (P = .002; OR: 4.86; 95% CI, 1.60-14.72). At 1 month after treatment, both the permanent morbidity (mRS ≤2) and mortality rates were 3.3%, without any significant difference according to the endovascular techniques. Mean angiographic follow-up was 16.3 months. The rate of recanalization was 15.6% without a statistical difference, according to the technique. Larger aneurysms were a predictor of recanalization (P = .016; OR: 1.183; 95% CI, 1.02-1.36). Retreatment was performed in 10 of 131 aneurysms (7.6%). CONCLUSIONS: Even though stent-assisted coiling significantly increases the risk of procedural complications, endovascular treatment of MCA aneurysms is safe, effective, and provides durable aneurysm closure in nonselected patients.

[Chronic subdural hematoma infected by Campylobacter fetus: case report]. / Infection d'hématome sous-dural chronique à Campylobacter fetus : à propos d'un cas.

We report here a rare case of chronic subdural hematoma infected by Campylobacter fetus in a 86-year-old woman. She was admitted for confusion and disorientation in a context of high fever and diarrhoea. After two surgeries, the evolution was finally good with a combination of antibiotics (amoxicillin and clindamycin). Chronic subdural hematoma is a potential site for bacterial infection. Our case suggests that C. fetus infection should be suspected in elderly patients presenting with fever and enteritis. The frequency of such cases may be underestimated, due to the difficult diagnosis of C. fetus. It is also suspected that C. fetus could play a role in the recurrence of hematoma, because of its vessel tropism.

[Dosimetric stereotactic radiosurgical accident: Study of 33 patients treated for brain metastases]. / Traitement des métastases cérébrales par radiochirurgie stéréotaxique : étude de 33 cas liés à un accident de "surexposition".

The consequences of a dosimetric radiosurgery accident are not the same as a conventional radiotherapy accident. The objective of this study was to estimate the clinical and radiological outcome of patients treated by radiosurgery for metastasis during the period of the overexposure accident that occurred in the Toulouse Radiosurgery Unit. Between April 2006 and March 2007, 33 patients with 57 metastases were treated in the Toulouse Radiosurgery Unit (Novalis(®), BrainLab). An initial error in the estimation of the scatter factors led to an overexposure to radiation. The median age was 55 years [range, 35-85]. Twenty-one patients (64%) harbored a single metastasis. The primary tumor location was lung (16 cases), kidney (nine cases), breast (four cases), and others (four cases). The mean tumoral volume was 3.2cm(3) [0.04-14.07]. The mean prescribed dose at the isocenter was 20 Gy [range, 10-23], the mean delivered dose was 31.5 Gy [range, 13-52], and the mean overdose was 61.2% [range, 5.6-226.8]. In order to evaluate the consequences of the overdose, three parameters were analyzed: a risk index using dose and volume, the volume of parenchyma that received more than 12 Gy, and the mean dose in a sphere of 20cm(3) surrounding the target volume. Median actuarial survival was 14.1 months, the survival rate was 79.4 % at six months, 59.1% at 12 months, and 27.2% at 24 months. The rate of tumor control was 80.7%. No morbidity was observed. There was no correlation between death and the parameters studied. The survival rates and times observed in our study of the patients treated for brain metastases by radiosurgery and overexposed were among the good results of the international literature. Deaths were not related to the overdose and no side effect was noted. This dosimetric accident has not had worse consequences in this population.

Intraoperative use of the Medtronic O-arm for deep brain stimulation procedures.

The purpose of this study was to analyze the feasibility and utility of 3D imaging to help lead positioning during a deep brain stimulation (DBS) procedure. A bilateral subthalamic DBS procedure was conducted in 2 patients for idiopathic Parkinson's disease. Subthalamic nucleus targeting was based on preoperative stereotactic MRI. We used the Medtronic O-arm to perform 2D-imaging control (frontal and lateral) as well as quick (<30 s) 3D acquisition. This allowed us to check the positioning of micro-macro electrodes and definite electrodes. 3D images were fused with postoperative CT to assess their accuracy, and with preoperative MRI to visualize the anatomical location of the electrodes. 3D imaging is a quick and safe method to ensure perioperative control of lead placement during DBS procedures.

[Method and results of lumbar infusion test in normal pressure hydrocephalus: review of the literature]. / Méthode et résultats du test de perfusion dans l'hydrocéphalie à pression normale : revue de la littérature.

INTRODUCTION: The cerebrospinal (CSF) infusion test is used to analyze the dynamics of CSF circulation. We describe the technique and report test results obtained in subjects with normal pressure hydrocephalus. STATE OF THE ART: The CSF infusion test is based on pressure monitoring during a continuous infusion of saline solution into the CSF space via a lumbar puncture. The main parameters are: intracranial pressure, resistance to CSF outflow (Rout), and compliance of the cranial enclosure estimated by the pressure-volume index. Our review of the recent literature dealing with the results of infusion test in normal pressure hydrocephalus indicates that the positive predictive value is about 80 % for Rout greater than 12 mmHg/ml per minute, i.e. shunt response is observed in 80 % of patients. The information available in the literature for assessing negative predictive value of Rout and usefulness of compliance is limited. PERSPECTIVES AND CONCLUSION: The CSF infusion test may be helpful for the diagnosis of normal pressure hydrocephalus, as supplemental testing when the diagnosis is not certain. We propose a procedure, which includes the infusion test, for identifying shunt-responsive patients.

[Creation of self-assessment tools for on-line continuing medical education. Modelization of a training session]. / Création d'outils d'autoévaluation pour une formation médicale continue en ligne. Modélisation à propos d'une formation.

BACKGROUND: For several years, the sessions of continuing medical education organized within the framework of the Société française de neurochirurgie have been recorded on the "campus de neurochirurgie" website, accessible in a form called in "videostreaming" which structures the training session. PURPOSE: Using modern educational methods, how can we transform the scientific productions of our meetings into effective tools for on-line continuing education? METHODS: The article describes the experience gained while creating self-assessment tools starting from the teaching material transmitted by the person in charge of a continuing medical education session, selected and an example for demonstration. RESULTS: We present the various written tools for self-assessment: multiple-choice test and script concordance test (SC). These SC were based partly on a clinical case with various test formats: units of diagnosis, investigation and therapeutics. In connection with the example chosen, we propose a model for constructing on-line continuing medical education sessions, which could be used by persons in charge of such training sessions in neurosurgery and in other specialties. CONCLUSIONS: With the availability of on-line self-assessment tests round-tables videostreaming, this teaching method can be used to fulfil mandatory continuing medical education requirements.

[Giant intradiploic infratentorial epidermoid cyst]. / Quiste epidermoide intradiploico infrastentorial gigante.

Epidermoid cysts are benign, uncommon lesions (1% of all intracranial tumors). Their localization is intradiploic in 25% of cases, and exceptionally subtentorial. We report here a rare case of giant intradiploic infratentorial epidermoid cyst. A 74-year old patient presented with recent diplopia and sindrome cerebellar. CT scan and MR imaging revealed a giant osteolytic extradural lesion of the posterior fossa (5.2 cm x 3.8 cm) with a small area of peripheral enhancement after contrast injection. Retrosigmoid suboccipital craniectomy allowed a satisfactory removal of the tumor, followed by an acrylic cranioplasty. The outcome was good. Neuropathological examination confirmed an epidermoid cyst. We review the literature and discuss our case.

Quiste epidermoide intradiploico infratentorial gigante / Giant intradiploic infratentorial epidermoid cyst

Los quistes epidermoides son lesiones congénitas benignas, de lento crecimiento, que representan el 1% de todos los tumores intracraneales. En un 25% tienen una localización intradiploica y excepcionalmente infratentorial. Presentamos un caso clínico poco frecuente de un quiste epidermoide intradiploico gigante infratentorial. El paciente consultó por una diplopia y un síndrome cerebeloso. La tomografía computarizada y la resonancia magnética mostraron una lesión gigante lítica extradural de la fosa posterior de 5,2 cm x 3,8 cm, con realce periférico con el contraste. Utilizamos un abordaje suboccipital retrosigmoideo para realizar una exéresis completa tumoral y una resección incompleta capsular, debido a la adherencia de ésta al seno lateral. La evolución posoperatoria fue favorable. Realizamos una revisión bibliográfica de la literatura y discusión de nuestro caso

Epidermoid cysts are benign, uncommon lesions(1% of all intracranial tumors). Their localization is intradiploic in 25% of cases, and exceptionally subtentorial. We report here a rare case of giant intradiploicinfratentorial epidermoid cyst. A 74-year old patient presented with recent diplopia and sindrome cerebellar. CT scan and MR imaging revealed a giant osteolytic extradural lesion of the posterior fossa (5,2 cm x 3,8 cm)with a small area of peripheral enhancement after contrast injection. Retro sigmoid suboccipital craniectomy allowed a satisfactory removal of the tumor, followed by an acrylic cranioplasty. The outcome was good. Neuropathological examination confirmed an epidermoidcyst. We review the literature and discuss our case

[Less invasive calibration of lumbar canal stenosis. Results with a tubular muscle retraction system used in 35 patients]. / Recalibrage moins invasif des sténoses canalaires lombaires. A propos de 35 patients opérés en utilisant un système tubulaire de rétraction musculaire.

BACKGROUND: The purpose of this study was to evaluate retrospectively the indications, surgical technique, and postoperative findings in a series of 35 patients presenting lumbar canal stenosis due to osteoarthritic degeneration who underwent surgery using a tubular system for muscle retraction. METHODS: This retrospective analysis included 35 patients, 28 with lumbar canal stenosis on a single level and seven with stenosis on two levels. On the stress images, 8 of these 35 patients presented stable degenerative spondylolisthesis. The surgical technique consisted in using a tubular system for muscle retraction. This enabled access for magnification and microsurgery of the canal, which was opened via an interlaminal approach. Concentric endocanal treatment was thus achieved without laminectomy. The same surgeon performed these 35 operations. The following variables were noted: patient age, level of canal narrowing, initial symptoms, duration of the operation, postoperative pain, use of analgesics, duration of hospital stay, clinical outcome at one and six months. RESULTS: The postoperative period (mean postoperative stay 2.5 days) was generally uneventful with little pain (mean VAS 0.8). This can be explained by the absence of invasive dissection. Disinsertion of the paravertebral muscles and use of elevators can induce muscle ischemia. The spine is not destabilized since laminectomy is avoided. The six-month outcome showed relief of the initial symptom for 84% of patients. There were two dural breaches with no clinical impact and one patient required revision surgery because of destabilization of a degenerative spondylolisthesis. One other patient also required revision for complementary laminectomy. CONCLUSION: The short-, mid-, and long-term results of spinal canal recalibration using a less invasive approach to lumbar canal stenosis via a tubular system for muscle retraction has provided encouraging results in terms of symptom relief. The early postoperative period is short and uneventful allowing earlier resumption of daily activities. This technique reduces the cost of hospitalization and drugs and is adapted for geriatric patients. The long-term outcome with this technique should be assessed in terms of spinal stability after recalibration.

Platelet-activating factor and human meningiomas.

Meningiomas are common primary intracranial tumours. Platelet-activating factor (PAF) is an inflammatory and angiogenic lipid mediator involved in several types of cancer. The presence of PAF receptor (PAF-R) transcripts, the levels of PAF, the phospholipase A2 activity (PLA2, the enzymatic activity implicated in PAF formation) and the PAF acetylhydrolase activity (AHA, the PAF degrading enzyme) were investigated in 49 human meningiomas. PAF-R transcripts, PAF, PLA2 and AHA were detected in meningiomas. However, their levels did not correlate with biological parameters such as the tumour grade, the presence of associated oedema, necrosis, mitotic index as well as intensity of the neovascularization and chronic inflammatory response. In conclusion, PAF is present in meningiomas where it might act on tumour growth by altering the local angiogenic and/or cytokine networks as previously suggested for human breast and colorectal cancer.

[Subthalamic deep brain stimulation for severe idiopathic Parkinson's disease. Location study of the effective contacts]. / Stimulation sous-thalamique dans la maladie de Parkinson severe. étude de la localisation des contacts effectifs.

The subthalamic nucleus (STN) is the main target of deep brain stimulation (DBS) treatment for severe idiopathic Parkinson's disease. But there is still no clear information on the location of the effective contacts (used during the chronic phase of stimulation). Our aim was to assess the anatomical structures of the subthalamic area (STA) involved during chronic DBS. Ten patients successfully treated were included. The surgical procedure was based on direct STN targeting (stereotactic MRI based) pondered by the acute effects of intraoperative stimulation. We used a formaldehyde-fixed human specimen to compare by matching MRI images obtained at 1.5 Tesla (performed in clinical stereotactic conditions) and at very high field at 4.7 Tesla. This allowed accurate analysis of the anatomy of the STA and retrospective precision of the location of the center of effective contacts which were located within the STN in 4 patients, at the interface between the STN and the ZI and/or FF in 13, at the interface between ZI and FF in 2 and between the STN and the substantia nigra in one. These results were consistent with the literature, revealing the implication of neighboring structures, especially the zona incerta and Forel's Field, in the clinical benefit.

[Venous embolization of dural arterio-venous fistulas. Transcranial approach under neuronavigation]. / Embolisation de fistules artério-veineuses durales par voie veineuse.

OBJECT: Transvenous embolization is an effective treatment for dural arterio-venous fistulas. In the event of dural sinus thrombosis, embolization can be performed by direct puncture via craniectomy. We report our experience with transcranial venous embolization in two patients. METHODS: Two patients underwent transcranial venous embolization of a type-III dural arterio-venous fistula of the transverse sinus. The craniectomy was performed with neuronavigation assistance. RESULTS: The surgical approach consisted in a minimal exposure of the sinus with a drill. Neuronavigation allowed accurate placement of the craniectomy. The endovascular treatment was performed in a second stage, enabling complete and stable occlusion of the fistula in both patients. CONCLUSION: This combined treatment of dural AVFs associating craniectomy and transcranial puncture of the sinus is simple and efficient when retrograde navigation through the internal jugular vein cannot be achieved. Neuronavigation is helpful in accurately positioning the craniectomy.