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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. [ABSTRACT FROM AUTHOR]

The article discusses ideas of suburban houses with hedge borders to create individual rural spaces within a suburban environment, with a focus on suburban lots constructed between 1990 and 2000 in Marne-la-Vallée, outside of Paris, France, and Rennes Métropole, in Western France. Topics include the diversity and design of fences, the floral diversity of hedges, and hedge design practices.

Summary: Goal: Present and analyze the implementation of laparoscopic teaching program at the Surgical School of Paris, introduced in 2008. Materiel and methods: Evaluation of the technical capacities of 43 students in six basic tests after four, one and a half hour training sessions with a pelvic-trainer. Results: The time necessary to perform an intracorporeal knot improved significantly by 56% after four sessions. Overall, 89% of students progressed and mastered the basic skills. Asked about their formation, 74% of the students thought their training in laparoscopy was insufficient. Conclusion: The pelvic-trainer is an accessible and reliable tool for training of young residents in laparoscopy. Use of the pelvic-trainer must be promoted among young residents during their training. [ABSTRACT FROM AUTHOR]

Intestinal invasion by the protozoan parasite Entamoeba histolytica is characterized by remodelling of the extracellular matrix (ECM). The parasite cysteine proteinase A5 (CP-A5) is thought to cooperate with human matrix metalloproteinases (MMPs) involved in ECM degradation. Here, we investigate the role CP-A5 plays in the regulation of MMPs upon mucosal invasion. We use human colon explants to determine whether CP-A5 activates human MMPs. Inhibition of the MMPs' proteolytic activities abolishes remodelling of the fibrillar collagen structure and prevents trophozoite invasion of the mucosa. In the presence of trophozoites, MMPs-1 and -3 are overexpressed and are associated with fibrillar collagen remodelling. In vitro, CP-A5 performs the catalytic cleavage needed to activate pro-MMP-3, which in turn activates pro-MMP-1. Ex vivo, incubation with recombinant CP-A5 was enough to rescue CP-A5-defective trophozoites. Our results suggest that MMP-3 and/or CP-A5 inhibitors may be of value in further studies aiming to treat intestinal amoebiasis.

The extracellular matrix (ECM) and its role in the outcome of infectious diseases have been poorly investigated. In this study, we determined the impact of the collagen fibres architecture on the invasive process of the enteric parasite Entamoeba histolytica. The behaviour of E. histolytica wild-type and silenced for the cysteine protease A5 (CP-A5) were compared on a three-dimensional collagen matrix and within human colon fragments for fibrillar collagen cleavage and migration. The interstitial collagen fibres within the connective tissue of the human colon, visualized by multiphoton and second harmonic generation signals imaging, presented a dense scaffold at the subepithelial level and a loose meshwork within the chorion. To penetrate the tissue, E. histolytica migrated on the dense scaffold that remained intact, reached the crypt of Lieberkhün, migrated along and then disorganized the loose scaffold to escape into the mucosa. Interestingly, in vitro, CP-A5 was not required for collagenase activity and migration through the matrix but was necessary within the tissue environment for collagen meshwork remodelling and subsequent invasion. The data point out that further step of invasion relay with ECM destruction that requires human components induced or activated in the presence of CP-A5., (© 2012 Blackwell Publishing Ltd.)

Amoebiasis (a human intestinal infection affecting 50 million people every year) is caused by the protozoan parasite Entamoeba histolytica. To study the molecular mechanisms underlying human colon invasion by E. histolytica, we have set up an ex vivo human colon model to study the early steps in amoebiasis. Using scanning electron microscopy and histological analyses, we have established that E. histolytica caused the removal of the protective mucus coat during the first two hours of incubation, detached the enterocytes, and then penetrated into the lamina propria by following the crypts of Lieberkühn. Significant cell lysis (determined by the release of lactodehydrogenase) and inflammation (marked by the secretion of pro-inflammatory molecules such as interleukin 1 beta, interferon gamma, interleukin 6, interleukin 8 and tumour necrosis factor) were detected after four hours of incubation. Entamoeba dispar (a closely related non-pathogenic amoeba that also colonizes the human colon) was unable to invade colonic mucosa, lyse cells or induce an inflammatory response. We also examined the behaviour of trophozoites in which genes coding for known virulent factors (such as amoebapores, the Gal/GalNAc lectin and the cysteine protease 5 (CP-A5), which have major roles in cell death, adhesion (to target cells or mucus) and mucus degradation, respectively) were silenced, together with the corresponding tissue responses. Our data revealed that the signalling via the heavy chain Hgl2 or via the light chain Lgl1 of the Gal/GalNAc lectin is not essential to penetrate the human colonic mucosa. In addition, our study demonstrates that E. histolytica silenced for CP-A5 does not penetrate the colonic lamina propria and does not induce the host's pro-inflammatory cytokine secretion.

Objective: To assess the ability of clinical or biochemical parameters to predict outcome (survival or non-survival; severe or moderate/no complication) using multiple regression analyses., Design: Prospective, descriptive cohort study with no interventions, Setting: 12 surgical intensive care units of university hospitals and large community hospitals; four medical school research laboratories in eight European countries, Patients: 128 surgical patients with major intra-abdominal surgery admitted for at least two days to an intensive care unit, Main Outcome Measures: Prediction of complications or survival based on analysis of clinical (Multiple Organ Dysfunction Score, Multi-Organ-Failure Score, Acute Physiology and Chronic Health Evaluation II scores) and immunological (plasma levels of endotoxin, endotoxin neutralizing capacity, IL-6, IL-8, cell associated IL-8, Fc-receptor polymorphism, soluble CD-14) parameters, with comparison of predicted and actual outcomes., Results: APACHE II, MODS score, MOF score, platelets, IL-6, IL-8, ENC, cell ass. IL-8 were significantly different between survivors and non-survivors and patients with/without severe complications by univariate analysis. By multivariate analysis only MOF, MODS score, IL-6, platelets, comorbidity predicted complications with a sensitivity of 82% and a specificity of 87%. Multivariate analysis demonstrated that only APACHE II score, plasma IL-8 and complications predicted death (sensitivity 84%; specificity 90%)., Conclusion: Immunological surrogate parameters may predict complications and death of surgical ICU patients. The use of several parameters may add to increase sensitivity and specificity in a prognostic model.

A retrospective review of 56 patients operated upon for tumours of Oddi was performed in order to determine optimal diagnostic and therapeutic procedures. Common presenting symptoms were jaundice (86%) and anemia (21%). Mean size of the tumour was 2.3 cm. Five tumours were benign and 51 were malignant. According to the classification of Martin, five were grade I: 10 grade II; 18 grade III; and 18 grade IV. Forty-seven patients underwent resection of the tumour: three local excisions for small benign tumors, six ampullectomies (followed in three by a Whipples' procedure for recurrence) and 41 Whipples' procedures. The hospital mortality was 5.3%, minor complications appeared in 21%. The overall five years survival was 41%. It was 75% in grade I, 50% in grade II, 40% in grade III and 10% in grade IV. The patients who received ampullectomies were alive with a follow-up of one, two and three years. All patients operated upon for a benign tumour were alive except one who died of cardiac failure. Ultrasonography and duodenoscopy are the most useful tests for the diagnosis of tumours of Oddi. Prognosis depends on the degree of infiltration of the duodenal wall and the presence of positive lymph nodes. Whipples' procedure is best but ampullectomy can be used in elderly or poor risk patients. Malignant tumours of the ampullary region are infrequent and reported to constitute between 0.02 and five percent of all cancers of the digestive tract. With wider application of endoscopic techniques, there has been an increasing interest in this group of tumours during recent years. In the literature tumours of Oddi are usually reported in the group of periampullary tumours, including tumours of the ampulla itself, duodenal wall surrounding the ampulla, the distal part of the common bile duct and head of the pancreas. We have wanted to distinguish specifically the tumours of the ampulla of Vater and have adopted the term tumour of Oddi introduced by Marchal and Hureau.(ABSTRACT TRUNCATED AT 250 WORDS)

We prospectively studied peritonitis secondary to small bowel leakage in 30 critically ill patients, each of whom had complete diversion of intestinal continuity by stoma, fistula, or both. All patients received total parenteral nutrition during implementation of the protocol. The proximal intestinal effluent was collected and recycled into the distal small bowel. During reinfusion of succus entericus, a significant reduction in the output of the proximal stoma was observed (mean 30.2%, p less than 0.001). The reinfusion also significantly reduced the volume from isolated small bowel loops in six patients (32.6%, p less than 0.001). When isotonic dialysate solution was infused into the distal intestine, a lesser though significant reduction in stoma output occurred (mean 20.3%, p less than 0.001). These findings demonstrate a consistent inhibitory effect upon upper gastrointestinal secretions by reinfusion of succus entericus. Clinical benefits of this technique include simplified control of fluid and electrolyte balance in patients with high output stomas and optimal utilization of remaining absorptive capacity for enteral nutrition.

Wound management following laparotomy for postoperative peritonitis and varying degrees of parietal necrosis remains a challenging and controversial problem. Because maintained peritoneal integrity and primary wound closure offer the best opportunity for survival, an original technique involving bilateral incisions to relax skin and rectus fascia is proposed. This technique permits medial myocutaneous advancement and primary tension-free skin closure of midline laparotomy incisions. Sixty-nine patients with severe postoperative peritonitis were treated according from 1980 through 1985. Nine of these patients died of advanced multiple organ failure soon after referral, and eight more died after prolonged treatment. Fourteen patients had one or more reoperations for complications. Only nine wound failures resulted, including five eviscerations and four wound infections followed by progressive dehiscence. The bilateral relaxing incisions healed secondarily without complication. Survivors developed midline wound hernia; ten of the 52 surviving patients have had these repaired. This method of primary closure is safe when performed in conjunction with rigorous surgical care of intraperitoneal infection and may enhance survival. We recommend the technique to surgeons who treat severe postoperative peritonitis and septic necrosis of midline laparotomy wounds.