The place of simulation in the surgical resident curriculum. The pedagogic program of the Nice Medical School Simulation Center.

INTRODUCTION: Surgical training relies on medical school lectures, practical training in patient care and in the operating room including instruction in anatomy and experimental surgery. Training with different techniques of simulators can complete this. Simulator-based training, widely used in North America, can be applied to several aspects of surgical training without any risk for patients: technical skills in both open and laparoscopic surgery, the notion of teamwork and the multidisciplinary management of acute medicosurgical situations. METHOD: We present the curriculum developed in the Simulation Center of the Medical School of Nice Sophia-Antipolis. All residents in training at the Medical School participate in this curriculum. RESULTS: Each medical student is required to pursue theoretical training (familiarization with the operating room check-list), training in patient management using a high fidelity mannequin for various medical and surgical scenarios and training in technical gestures in open and laparoscopic surgery over a 2-year period, followed by an examination to validate all technical aptitudes. This curriculum has been approved and accredited by the prestigious American College of Surgeons, making this the first of its kind in France. CONCLUSION: As such, it should be considered as a model and, in accordance to the wishes of the French Surgical Academy, the first step toward the creation of true schools of surgery.

A new composite model including metabolic syndrome, alanine aminotransferase and cytokeratin-18 for the diagnosis of non-alcoholic steatohepatitis in morbidly obese patients.

BACKGROUND: Non-invasive approaches are useful to differentiate simple steatosis from non-alcoholic steatohepatitis (NASH) in obese and morbidly obese patients. AIM: To develop a new scoring system to diagnose definitive NASH. METHODS: Preoperative clinical and biological data including serum caspase 3-generated cytokeratin-18 fragments (CK18) and surgical liver biopsies were obtained from 464 morbidly obese patients who had undergone bariatric surgery. The cohort was divided into two groups: training group (n = 310) and validation group (n = 154). Definitive NASH was defined according to Kleiner's classification with a Non-alcoholic fatty liver disease Activity Score (NAS) ≥5. RESULTS: Alanine aminotransferase (ALT), CK18 fragments and the presence of metabolic syndrome were independent predictors for discriminating patients with NAS ≥5 in the training group. These three parameters were used to carry out a scoring system for the prediction of NAS ≥5. Whereas serum CK18 fragment alone had an area under the receiver operating characteristic (AUROC) curve = 0.74, AUROC curves of the scoring system were 0.88 and 0.83 in the training group and the validation group, respectively. CONCLUSION: A simple and non-invasive composite model (the Nice Model) including metabolic syndrome, ALT and CK18 fragments is able to predict accurately a non-alcoholic fatty liver disease activity score ≥5 in morbidly obese subjects.

[How the information system can contribute to the implementation of a risk management program in a hospital?]. / Comment le système d'information peut-il aider un programme de gestion des risques en établissement de santé?

Nowadays, information system is recognised as one of the key points of the management strategy. An information system is regarded conceptualised as a mean to link 3 aspects of a firm (structure, organisation rules and staff). Its design and implementation have to meet the objectives of medical and economical evaluation, especially risk management objectives. In order to identify, analyse, reduce and prevent the occurrence of adverse events, and also to measure the efficacy and efficiency of the production of care services, the design of information systems should be based on a process analysis in order to describe and classify all the working practices within the hospital. According to various methodologies (usually top-down analysis), each process can be divided into activities. Each activity (especially each care activity) can be described according to its potential risks and expected results. For care professionals performing a task, the access to official or internal guidelines and the adverse events reporting forms has also to be defined. Putting together all the elements of such a process analysis will contribute to integrate, into daily practice, the management of risks, supported by the information system.

[Adenocarcinoma in Barrett's esophagus. A study of 28 resected cases]. / Adénocarcinome sur endobrachyoesophage. Etude de 28 cas réséqués.

STUDY AIM: The aim of this retrospective study was to report a series of 28 patients with adenocarcinoma (ADK) arising in Barrett's esophagus (BE), treated by esophagectomy. PATIENTS AND METHODS: From 1992 to 1998, 28 patients were operated on for ADK in BE. There were 27 men and one woman (mean age: 65 years) classified as ASA I (n = 2), ASA II (n = 15) and ASA III (n = 11). Eighteen patients had a long story of gastro-esophageal reflux disease which required surgical repair in five of them. Dysphagia was the main symptom (n = 19). Surgical procedures included 15 Ivor Lewis operations, nine esophagectomies without thoracotomy and four esophagogastrectomies by the left thoracic approach. RESULTS: Pathological examination of the specimens showed an EBO with adenocarcinoma (n = 27) and a high grade dysplasia (n = 1). Among five patients with a previously known BE, three under endoscopic surveillance had high grade dysplasia (n = 1) and limited T1 tumor (n = 2), while the other two patients without surveillance developed an invasive tumor (T3N1). There were three postoperative deaths (mortality rate: 10%), all arising from pulmonary failure. Median survival was 16.6 months. All patients resumed a normal diet. The actuarial survival rates were 63%, 42% and 15.2% respectively at 1, 2 and 4 years. A multivariate analysis could identify 3 prognostic factors: ASA score previously known BE under surveillance, length of BE. CONCLUSION: Adenocarcinoma arising in BE is very often diagnosed too late. Patients with high risk BE require an endoscopic survey. High grade dysplasia detected in two successive examinations by two different pathologists may require prophylactic esophagectomy, but local endoscopic management presently under evaluation could be efficient in the future.

Video-assisted thoracoscopic treatment of spontaneous pneumothorax: technique and results of one hundred cases.

OBJECTIVE: This article describes the technique and results for an initial series of 100 pneumothoraces treated by video-assisted thoracoscopy. METHODS: From May 1991 to November 1994, 97 patients (78 male and 19 female patients) aged 37.2 +/- 17 years (range 14 to 92 years) underwent video-assisted thoracoscopy for treatment of spontaneous pneumothorax (primary in 75 patients, secondary in 22 patients). RESULTS: The procedure was unilateral in 94 patients and bilateral in three patients (total 100 cases). Pleural bullae were resected with an endoscopic linear stapler; a lung biopsy was performed in the absence of any identifiable lesion. Pleurodesis was achieved by electrocoagulation of the pleura (n = 3), "patch" pleurectomy (n = 3), subtotal pleurectomy (n = 20), or pleural abrasion (n = 74), including conversion to standard thoracotomy in five. One of these five patients had primary pneumothorax and four had secondary pneumothorax. There were no postoperative deaths. A complication developed in 10 patients: five patients with a primary pneumothorax (6.6%) and five with a secondary pneumothorax (27.7%). The mean postoperative hospital stay was 8.25 +/- 3.2 days. Mean follow-up is 30 months (range 7 to 49 months). Pneumothorax recurred in 3% of patients, all of whom were operated on at the start of our experience. Three percent of the patients had chronic postoperative chest pain. CONCLUSIONS: Video-assisted thoracoscopy is a valid alternative to open thoracotomy for the treatment of spontaneous primary pneumothorax. Its role for the management of secondary pneumothorax remains to be defined. In the long term, the efficacy of video-assisted thoracoscopic pleurodesis and surgeon experience should yield the same results as standard operative therapy.

[Para-esophageal hernias. Apropos of 42 cases]. / Les hernies para-oesophagiennes. A propos de 42 observations.

Between 1979 and May 1994, 42 patients (11 males, 31 females, mean age 72.8 +/- 12.4 years) underwent surgery for paraoesophageal hiatal hernia. In 37 cases, clinical signs had been observed for 64 months on the average: digestive (32), respiratory (15), cardiac (9). Nine patients had iron deficiency anaemia. Eighteen patients had a complication (acute obstruction: 10, haemorrhage: 6, perforation: 2, lung infection: 2). In 5 cases, the complication was the inaugural sign. Surgery was performed in a emergency situation in 5 cases and deferred emergency in 12 and surgery was elective in 25. An antireflux procedure was used in 36 cases (Lortat-Jacob (2), Toupet (5), Dor (2), Nissen-Rossetti (27)). Another procedure was also needed in 12 patients. There were no postoperative deaths and complications occurred in 6 patients (14.9%). Outcome was known in 40 patients with a mean follow-up of 40.5 months (range 3 to 140 months). Functional results was very good in 35 patients (87.5%), good in 3 (7.5%) and poor in 2 (5%). The most satisfactory immediate results were obtained for patients who had elective surgery and in those with a deferred emergency. Use of the Nissen-Rossetti procedure did not have any deleterious effect on these results and no long-term inconveniences.