What defines a great surgeon? A survey study confronting perspectives.

Background: The definition of a great surgeon is usually reported by surgeons themselves. The objective of the study was to define a multifaceted definition of a great surgeon, by confronting patients', healthcare workers', and surgeons' perspectives. Study design: An online open-ended questionnaire was created to identify three qualities and three shortcomings defining a great surgeon. Age, gender, and profession of respondents were collected. Responses with a similar meaning were combined into word groups and labeled within four themes: human qualities, technical surgical skills (TSS), non-technical skills (NTS), and knowledge. Multivariate analyses were conducted between themes and respondent characteristics. Results: Four thousand seven hundred and sixty qualities and 4,374 shortcomings were obtained from 1,620 respondents including 385 surgeons, 291 patients, 565 operating theater (OT) health professionals, and 379 non-OT health professionals. The main three qualities were dexterity (54% of respondents), meticulousness (18%), and empathy (18%). There was no significant difference between professional categories for TSS. Compared with surgeons, non-OT health professionals and patients put more emphasis on human qualities (29 vs. 39% and 42%, respectively, p < .001). OT health professionals referred more to NTS than surgeons (35 vs. 22%, p < 0.001). Knowledge was more important for surgeons (19%) than for all other professional categories (p < 0.001). Conclusions: This survey illustrates the multifaceted definition of a great surgeon. Even if dexterity is a major quality, human qualities are of paramount importance. Knowledge seems to be underestimated by non-surgeons, although it essential to understand the disease and preparing the patient and OT team for the procedure.

Five-year Outcomes of Sleeve Gastrectomy: A Prospective Multicenter Study.

BACKGROUND: Sleeve gastrectomy (SG) is the most frequently performed bariatric procedure in the world. Our purpose was to evaluate the percentage of excess weight loss (%EWL), resolution of obesity-related comorbidities after SG, and identify predictive factors of weight loss failure. METHODS: A prospective cohort study of adults who underwent SG during 2014 in 7 Belgian-French centers. Their demographic, preoperative, and postoperative data were prospectively collected and analyzed statistically. RESULTS: Overall, 529 patients underwent SG, with a mean preoperative weight and body mass index (BMI) of 118.9 ± 19.9 kg and 42.9 ± 5.5 kg/m2, respectively. Body mass index significantly decreased to 32.2 kg/m2 at 5 years (P < .001). The mean %EWL was 63.6% at 5 years. A significant reduction in dyslipidemia (28.0%-18.2%), obstructive sleep apnea (OSAS) (34.6%-25.1%), and arterial hypertension (HTN) (30.4%-21.5%) was observed after 5 years, but not for diabetes and gastroesophageal reflux disease (GERD). At multivariate analysis, age >50 years old, BMI >50 kg/m2, and previous laparoscopic adjustable gastric banding (LAGB) remained independent predictors of weight loss failure. CONCLUSIONS: Five years after SG, weight loss was satisfactory; the reduction of comorbidities was significant for dyslipidemia, OSAS, and HTN, but not diabetes and GERD. Age >50 years old, BMI >50 kg/m2, and previous LAGB were independent predictors of weight loss failure.

Ventral hernia repair by totally extraperitoneal approach (VTEP): technique description and feasibility study.

BACKGROUND: The repair of ventral hernias by intra-peritoneal patch (IPOM) involves a risk of pain due to stapling as well as intestinal adhesions. Extraperitoneal placement of the patch without fixation can prevent these drawbacks. Techniques of endoscopic preperitoneal repair were previously described by others. The aim of this article is to describe our technique and to evaluate the feasibility and short-term results. METHODS: The totally endoscopic technique consists of dividing the median aponeurotic structures, while preserving the proper linea alba, to create a unique retro-muscular space, in which the patch is deployed without any fixation. Hundred twelve consecutive patients were operated on for ventral hernias (82 umbilical, 20 epigastric, 10 combined). Perioperative data including duration of operation, technical problems, conversions and complications, as well as postoperative pain, time to resume daily activities and time off work were prospectively assessed. RESULTS: 98 (87.5%) patients were operated in ambulatory surgery, and 14 (12.5%) in overnight stay. The mean sizes of the hernia and the patch were 9 (1-50) cm2 and 225 (50-500) cm2, respectively. The mean operation duration was 75 (30-270) min. The peritoneum was opened in 43 (38.4%) cases and closed by suture in 41 instances. There were 5 (4.5%) conversions to IPOM and 4 (3.6%) complications (1 seroma, 1 urine retention, 1 transitory ileus, and 1 intestinal obstruction) which were reoperated. The mean VAS value of postoperative pain was 2.45 (0-8), pain was scored 0 by 17 (15%) patients. The mean times to resume daily activity and work were 4 (1-15) days and 11.5 (1-30) days, respectively. CONCLUSION: Our results suggest that VTEP is safely feasible by surgeons skilled in laparoscopy, and might contribute to minimize pain, though this must be established by comparative studies.

Laparoscopic sleeve gastrectomy for morbid obesity in a Belgian-French prospective multicenter study: outcomes and predictors weight loss failure.

INTRODUCTION: Laparoscopic sleeve gastrectomy (LSG) became the most frequently performed bariatric procedure worldwide, gaining rapidly popularity thanks to its technical simplicity and the relatively good results. The aim of this Belgian-French study was to evaluate postoperative complications, weight loss, and resolution of obesity-related comorbidities after LSG, and identify predictive factors of weight loss failure. PATIENTS AND METHODS: A prospective multicenter study was conducted on all LSG performed during 2014 in 7 centers. Their demographic, preoperative, and postoperative data were prospectively collected and analyzed statistically. RESULTS: Overall 529 patients underwent LSG, with a mean preoperative weight and body mass index (BMI) of 118.9 ± 19.9 kg and 42.9 ± 5.5 kg/m2, respectively. Postoperative mortality was null and early postoperative morbidity was 6%, including 2.5% of gastric leakage. BMI significantly decreased to 31.1 kg/m2 and 30.0 kg/m2 at 1 and 3 years, respectively (p < .001). The mean %EWL was 77.2 and 74.6% at 1 and 3 years. A significant reduction in dyslipidemia (28.0-16.8%), obstructive sleep apnea (OSAS) (34.6-23.3%) and arterial hypertension (HTN) (30.4-20.2%) was observed after 3 years, but it does not concern diabetes and gastroesophageal reflux disease (GERD). At multivariate analysis, age > 50 years old, BMI >50 kg/m2 and previous laparoscopic adjustable gastric banding (LAGB) remained independent predictors of weight loss failure. CONCLUSIONS: LSG for morbid obesity is safe and effective. Satisfactory outcome after 3 years can be achieved regarding %EWL and some comorbidities such as dyslipidemia, OSAS, and HTN, but not diabetes and GERD. Age > 50 years old, BMI > 50 kg/m2 and previous LAGB were independent predictors of weight loss failure.

Sentinel lymph node biopsy or nodal observation in melanoma: a prospective study of patient choices.

BACKGROUND: There is no consensus regarding the therapeutic utility of sentinel lymph node biopsy (SLNB) versus that of nodal observation (NO) in melanoma. OBJECTIVE: To prospectively evaluate a standardized counseling procedure and its effect on patient choices to undergo SLNB or NO. METHODS: In four centers, patients with melanoma eligible for SLNB or NO received a complete counseling procedure that included verbal information from dermatologists and surgeons, a detailed information sheet, and a written consent form. Data collected included patient and tumor characteristics, counseling conditions, and specialties of informing doctors. Factors influencing patients' choices were studied using multivariate analysis. RESULTS: Of 343 consecutive patients, 309 were offered SLNB and NO and received complete verbal and written information from a dermatologist alone (62%) or in association with a surgeon (38%). Approximately half took advice from trusted persons, and half asked for additional time before making a decision; 268 (86.7%) ultimately decided to undergo SLNB. Multivariate analysis showed that older patients, those with a head and neck melanoma, and those informed without a surgeon present were more likely to prefer NO. CONCLUSIONS: This counseling procedure was easily implemented in clinical practice. Patients favored SLNB but were able to understand uncertainties and express preferences.

Anal carcinoma: incidence and effect of cumulative infections.

INTRODUCTION: Human papilloma virus (HPV) causes anal condyloma that is a risk factor for anal carcinoma. The incidence and mechanism of invasive anal carcinoma in patients with anal condyloma are prospectively determined. PATIENTS AND METHODS: From 1993 to 2002, 228 consecutive patients (164 HIV positive) with anal canal condylomas were included in the study, after curing of their lesions. They were asked to attend follow-up visits at 3- or 6-month intervals. We checked for anal co-infection with syphilis, gonococci, viruses (Epstein-Barr virus, cytomegalovirus, herpes simplex, HPV types), and quantified Langerhans' cells (LC) in anal mucosa at baseline and during follow up. We cured and analysed relapsed condylomas during follow up (3-112 months; median 26). Serum HIV loads and CD4 T-lymphocyte counts were determined at each visit and the densities of LC in consecutive specimens from patients with cancers were compared with that for a matched control group (n = 23). RESULTS: Analysis of 199 patients showed high-grade dysplasia (HGD) in 13.6% of patients, more in HIV-positive (16%) than in HIV-negative (6%) patients at baseline. During follow up, 3.5% (7/199; six HIV positive) patients developed invasive carcinoma after 13-108 months and 112 (56%) patients relapsed condylomas. HIV and anal co-infection were identified as independent risk factors (P < 0.01) for HGD and cancer: odd ratio (95% confidence interval) of 9.4 (2.4-37.4) and 3.67 (0.95-14.2), respectively. LC densities in anal mucosa were lower in patients with invasive carcinoma than in controls. CONCLUSION: The risk of invasive carcinoma in HPV-infected patients is increased by HIV and anal co-infection. Decreases in LC numbers in anal mucosa may favour this outcome.