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Resume But de l’etude Un quart des cancers colorectaux se revele avec des metastases hepatiques synchrones. Si une stomie de derivation est realisee lors de la chirurgie rectale, le moment opportun pour retablir la continuite digestive n’est pas etabli. L’objectif de cette etude etait d’evaluer la morbidite de la fermeture de stomie pendant le geste d’hepatectomie secondaire. Patients et methodes Il s’agit d’une etude retrospective cas-temoins mono-centrique incluant des patients ayant beneficie entre 2004 et 2016 d’une fermeture d’ileostomie ou de colostomie par abord direct (groupe FERMETURE) ou ayant une stomie en place (groupe NON RETABLI) au cours d’une hepatectomie pour metastase(s) d’un cancer rectal. Les donnees perioperatoires ont ete recueillies. Le critere de jugement principal etait le comprehensive complication index (CCI). Les criteres de jugement secondaires etaient la mortalite globale, la morbidite hepatique, la duree d’hospitalisation et la fistule digestive. L’analyse statistique etait realisee a l’aide du logiciel SPSS 23.0. Resultats Trente hepatectomies etaient incluses dont 14 dans le groupe FERMETURE (F/H = 11/19, âge = 60 ans). Il n’y avait pas de difference significative du CCI (15 vs 20,8 ; p = 0,6). La survenue de complications etait comparable et concernait 9 (64 %) et 8 (50 %) patients des groupes FERMETURE et NON RETABLI, respectivement (p = 0,48). Il n’y a eu aucune fistule digestive ni mortalite postoperatoire. Conclusion La fermeture de stomie au cours d’une hepatectomie pour metastase(s) d’un cancer rectal n’est pas associee a une sur-morbidite postoperatoire et peut donc etre envisagee.

Background Several randomized controlled trials (RCTs) have demonstrated improved short-term outcomes of totally minimally invasive esophagectomy (TMIE) compared with open esophagectomy (OE); however, to what extent these outcomes can be extrapolated to a national level remains debatable. Objective The aim of this study was to evaluate, on a nationwide basis, the short-term outcomes of TMIE and to analyze these results within the context of previously implemented hybrid minimally invasive esophagectomy (HMIE). Methods All consecutive patients who underwent a curative Ivor Lewis esophagectomy in France between 2017 and 2019 were included in this retrospective cohort study. The primary endpoint was to compare 90-day postoperative mortality (POM) between OE, HMIE, and TMIE, while secondary endpoints were defined as the rate of postoperative complications. A matched and multivariate analysis was adjusted for confounding factors. Results Overall, 2675 patients were included (1003 OE vs. 1498 HMIE vs. 174 TMIE). In every center where TMIE was performed, HMIE had been previously adopted. The matched 90-day POM rate in the TMIE group was significantly lower compared with the OE group (2.3% vs. 6.3%, p = 0.046) but not compared with the HMIE group (2.3% vs. 4.9%, p = 0.156). There was no significant difference between TMIE and OE, or TMIE and HMIE, regarding the 30-day fistula rate (21.8% vs. 17%, p = 0.176; and 21.8% vs. 21.3%, p = 0.88, respectively). TMIE was associated with a reduced rate of pulmonary complications compared with OE (33.9% vs. 44%, p = 0.027) and HMIE (33.9% vs. 42.8%, p = 0.05). Low-volume centers were identified as a negative predictive factor for 90-day POM (odds ratio 1.89, 95% confidence interval 1.3-2.75, p = 0.001). Conclusion TMIE is associated with a lower 90-day POM rate compared with OE and offers reduced rates of pulmonary complications compared with OE and HMIE. After previous adoption of the HMIE technique, TMIE can be safely implemented in high-volume centers nationwide.

National and international guidelines about thyroid surgery seem to be moving more and more towards less radical surgical procedures but everyday practice does not seem to always align with them. We describe for the first time the role of non-surgical parameters in the surgeon's choice for thyroid surgery.The ain of this study was to describe thyroid surgery and to identify the factors leading to either a total or a partial thyroidectomy regardless of the severity of the thyroid disease.National and international guidelines about thyroid surgery seem to be moving more and more toward less radical surgical procedures but everyday practice does not seem to always align with them.We based this nationwide retrospective cohort study on a national database that compiles discharge abstracts for every admission for thyroidectomy to French acute healthcare facilities (PMSI database 2010 to 2019).In this study, 375,810 patients (male: 23%; age = 53 ± 15 years) had a thyroidectomy (partial: 28%) for cancer (17%), hyperthyroidism (16%), nonfunctioning goiter (64%), or other (3%). We noticed a global trend toward more partial thyroidectomy (P0.001) with a significant increase in the proportion of lobectomy in the post-ATA recommendations' period (P0.001) as well as in the "French Levothyrox crisis" period, in which we saw an unexpected rise of adverse events notifications associated with the marketing of a new formula of Levothyrox (P0.001) amid widespread media coverage. In a multivariate analysis, we also identified that complete resection was more frequently performed in centers with a caseload40/year [P0.001, odds ratio (OR) = 1.48], for obese patients (body mass index30 kg/m2; P0.001, OR = 1.42), and according to the indication of surgery (OR benign = 1, OR cancer = 2.25, OR hyperthyroidism = 4.13).We describe for the first time the role of non-surgical parameters in the surgeon's choice for thyroid surgery.

It has been demonstrated that mortality following pancreatectomy is correlated with surgical volume. However, up until now, no French study has focused on predictive factors to undergo pancreatectomy in low-volume centers. The objective of this study is to analyze the clinical characteristics, socio-economic status and medical density according to surgical volume and to analyze predictive factors for undergoing pancreatectomy in low-volume centers.All patients who underwent pancreatectomy in France from 2012 to 2015 were identified fromthe PMSI database. Hopsitals were classified as low, intermediate and high volume (10, 11-19, ≥20 resections/year, respectively). Clinical and socioeconomic data, travel distance and rurality were assesed to identify factors associated with undergoing pancreatectomy at low-volume hospitals.In overall, 12,333 patients were included. Those who underwent pancreatectomy in low-volume centers were more likely older, had high Charlson comorbidity index (CCI), had low socioeconomic status, and resided in rural locations.distance traveled by patients operated on in low-volume centers was significantly shorter (23 vs. 61km, P0.001). In multivariable analysis, older age (P=0.04), CCI≥4 (P=0.008), short travel distance (P0.001), low socio-economic status (P0.001) and rurality (P0.001) were associated withundergoing pancreatectomy in low-volume centers.Patients continue to undergo pancreatectomy at low-volume hospitals is due not only to clinical parameters, but also to socioeconomic and environmental factors. These factors should be taken into account in process of pancreatic surgery centralization.

BACKGROUND Surgical removal of hyperfunctional parathyroid gland is the definitive treatment for primary hyperparathyroidism (pHPT). Postoperative follow-up shows variability in persistent/recurrent disease rate throughout different centers. OBJECTIVE To evaluate the incidence of redo surgery after targeted parathyroidectomy for pHPT. METHODS We performed a nationwide retrospective cohort study on the "Programme de Medicalisation des Systemes d'Information," the French administrative database that collects information on all healthcare facilities' discharges. We extracted data from 2009 to 2018 for all patients who underwent parathyroidectomy for pHPT between January 2011 to December 2016. The primary outcome was the reoperation rate within 2 years since first surgery. Patients who had a first attempt of surgery within the previous 24 months, familial hyperparathyroidism, multiglandular disease, and renal failure were excluded. Results were adjusted according to sex and the Elixhauser Comorbidity Index. Operative volume thresholds to define high-volume centers were achieved by the Chi-Squared Automatic Interaction Detector method. RESULTS In the study period, 13,247 patients (median age 63, F/M=3.6) had a focused parathyroidectomy by open (88.7%) or endoscopic approach. Need of remedial surgery was 2.8% at 2 years. In multivariate analysis, factors predicting redo surgery were: cardiac history (P=0.008), obesity (P=0.048), endoscopic approach (P=0.005), and low-volume center (P

To compare the incidence and the safety outcomes associated with active stone removal procedure (ASRP) between neurological and non-neurological patients.The present study was conducted using the data issued from the French National Health Data Base. All patients that have been hospitalized to undergo an ASRP between January 1 2012 and December 31 2018 were included and allocated to four neurological groups (multiple sclerosis, spinal dysraphism, paraplegia, tetraplegia) and one non-neurological group. The primary outcome was the rate of patients hospitalized at least once to undergo an ASRP over the study period. The secondary outcomes included the type of ASRP performed, the length of hospital stay, the rates of post-operative UTI, of early re-admission and re-treatments. Multivariate logistic regression was used to estimate odd ratios, the four neurological groups being compared to the non-neurological group.During the study period, 45,745,055 patients were hospitalised, with 151,850 of them presenting with an underlying neurological disease. Among the non-neurological patients, 0.89% underwent an ASRP, while 1.39% neurological patients did. Neurological patients presented with a lower rate of ESWL associated with a higher rate of PCNL, while the length of hospital stay, the rate of post-operative UTI, of early re-admission and of re-treatment were systematically increased (p 0.001), when compared to non-neurological patients, regardless of the type of ASRP considered.The results presented here confirm and clarify the incidence and the safety outcomes associated with ASRP within the neurological population and advocate for the emergence of a dedicated research field focusing on neuro-urolithiasis.

To explore the determinants of postoperative outcomes of adrenal surgery in order to build a proposition for healthcare improvement.Adrenalectomy is the recommended treatment for many benign and malignant adrenal diseases. Postoperative outcomes vary widely in the literature and their determinants remain ill-defined.We based this retrospective cohort study on the "Programme de médicalisation des systèmes d'information" (PMSI), a national database that compiles discharge abstracts for every admission to French acute health care facilities. Diagnoses identified during the admission were coded according to the French adaptation of the 10th edition of the International Classification of Diseases (ICD-10). PMSI abstracts for all patients discharged between January 2012 and December 2017 were extracted. We built an Adrenalectomy-risk score (ARS) from logistic regression and calculated operative volume and ARS thresholds defining high-volume centers and high-risk patients with the CHAID method.During the 6-year period of the study, 9820 patients (age: 55 ± 14; F/M = 1.1) were operated upon for adrenal disease. The global 90-day mortality rate was 1.5% (n = 147). In multivariate analysis, postoperative mortality was independently associated with age ≥75 years [odds ratio (OR): 5.3; P0.001], malignancy (OR: 2.5; P0.001), Charlson score ≥2 (OR: 3.6; P0.001), open procedure (OR: 3.2; P0.001), reoperation (OR: 4.5; P0.001), and low hospital caseload (OR: 1.8; P = 0.010). We determined that a caseload of 32 patients/year was the best threshold to define high-volume centers and 20 ARS points the best threshold to define high-risk patients.High-risk patients should be referred to high-volume centers for adrenal surgery.

Introduction: Clinical pathways represents the sequence of interventions from which the patients benefit during their encounters with health care structures. There are several complex issues which make it difficult to represent these pathways (e.g. high numbers of patients, heterogeneity of variables). Methods: We developed a tool to automate the representation of clinical pathways, from an individual and population points of view, and based on the OMOP CDM. The tool implemented the Sankey diagram in three stages: (i) data extraction, (ii) generation of individual sequence of steps and (iii) aggregation of sequence to obtain the population-level diagram. We tested the tool with three surgery procedures: the total hip replacement, the coronary bypass and the transcatheter aortic valve implantation. Results: The tool provided different ways of visualizing pathways depending on the question asked: a pathway before a surgery, the pathway of deceased patients or the complete pathway with different steps of interest. Discussion: We proposed a tool automating the representation of the clinical pathways, and reducing complexity of visualization. Representations are detailed from an individual and population points of view. It has been tested with three surgical procedures. The tool functionalities will be extended to cover a greater number of use cases.

There is growing evidence that failure to rescue (FTR) is an important factor of postoperative mortality (POM) after rectal cancer surgery and surgical approach modified post-operative outcomes. However, the impact of laparoscopy on FTR after proctectomy for rectal cancer remains unknown. The aim of this study was to compare the rates of postoperative complications and FTR after laparoscopy vs open proctectomy for cancer. All patients who underwent proctectomy for rectal cancer between 2012 and 2016 were included. FTR was defined as the 90-day POM rate among patients with major complications. Outcomes of patients undergoing open or laparoscopic rectal cancer surgery were compared after 1:1 propensity score matching by year of surgery, hospital volume, sex, age, Charlson score, neoadjuvant chemotherapy, tumor localization and type of anastomosis. Overall, 44,536 patients who underwent proctectomy were included, 7043 of whom (15.8%) developed major complications. The rates of major complications, POM and FTR were significantly higher in open compared to laparoscopic procedure (major complications: 19.2% vs 13.7%, p

OBJECTIVES We aimed to analyze the outcomes of interhospital transfer (IHT) patients after pancreatectomy, describe the characteristics of transferring hospitals, and determine the risk factors of transfer and mortality in IHT patients. BACKGROUND Implementation of the centralization process is complex and currently unrealized in France. Alternatively, centralization of patients with postoperative complications to high volume centers could reduce postoperative mortality (POM) and failure to rescue (FTR). METHODS All patients undergoing pancreatectomy for cancer between 2012 and 2018 were included. Hospitals' and patients' characteristics were analyzed to determine predictive factors for transfer and FTR. POM was defined as death occurring during the hospital stay and FTR as POM rate among patients with major complications. RESULTS Overall, 19,938 patients who underwent pancreatectomy were included, 1164 (5.8%) of whom were transferred. IHT patients were mostly originated from low volume hospitals (60.3% vs 39.7%), from facilities without intensive care unit (46.9% vs 22.4%) or interventional radiology (22.8% vs 12.8%). Among IHT patients, 51% underwent reoperation before transfer and 34.9% experienced hemorrhage complications. The POM was 5.2% and varied significantly between transfer and nontransfer patients (13.3% vs 4.7%, P < 0.001). Patients who experienced major complications after pancreatectomy in low volume hospitals had greater odds of being transferred (Odds Ratio (OR) = 2.46, confidence intervals (CI)95%[1.734; 3.516], P < 0.001). Also, transfer (OR = 2.17, CI95%[1.814; 2.709], P < 0.001) and especially transfer after pancreatectomy in low volume centers (OR = 3.76, CI95%[2.83; 5.01], P < 0.001) were associated with increased FTR rates. CONCLUSIONS Transfers after pancreatectomy were associated with high rates of FTR, especially for patients undergoing surgery in low volume hospitals. Local expertise, resources, and volume of hospitals are mandatory to provide appropriate care after pancreatectomy.

Evaluate at a national level the postoperative mortality (POM), major morbidity (MM) and failure-to-rescue (FTR) after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) across time and according to hospital-volume.CRS/HIPEC is an effective therapeutic strategy commonly used to treat peritoneal surface malignancies. However, this aggressive approach has the reputation to be associated with a high POM and MM.All patients treated with CRS/HIPEC between 2009 and 2018 in France were identified through a national medical database. Patients and perioperative outcomes were analyzed. A cut-off value of the annual CRS/HIPEC caseload affecting the 90-day POM was calculated using the Chi-squared Automatic Interaction Detector method. A multivariable logistic model was used to identify factors mediating 90-day POM.A total of 7476 CRS/HIPEC were analyzed. Median age was 59 years with a mean Elixhauser comorbidity index of 3.1, both increasing over time (P0.001). Ninety-day POM was 2.6%. MM occurred in 44.2% with a FTR rate of 5.1%. The threshold of CRS/HIPEC number per center per year above which the 90-day POM was significantly reduced was 45 (3.2% vs 1.9%, P = 0.01). High-volume centers had more extended surgery (P0.001) with increased MM (55.8% vs 40.4%, P0.001) but lower FTR (3.1% vs 6.3%, P = 0.001). After multivariate analysis, independent factors associated with 90-day POM were: age70 years (P = 0.002), Elixhauser comorbidity index ≥8 (P = 0.006), lower gastro-intestinal origin, (P0.010), MM (P0.001), and45 procedures/yr (P = 0.002).In France, CRS/HIPEC is a safe procedure with an acceptable 90-day POM that could even be improved through centralization in high-volume centers.

OBJECTIVE To define the cost of pancreatectomies and to identify factors associated with increased hospital costs after pancreatic resection. METHODS All patients undergoing pancreatic surgery in our department between January 2008 and December 2014 were included. All complications occurring during hospitalization or in the 90-day period after discharge were documented. The hospital costs were analyzed and predictive factors of increased hospital costs were determined. RESULTS One hundred and twenty seven patients were identified. Most patients underwent pancreatectomy for malignant tumors (70%). Median hospital costs were 21,392 [15,998-29,667] euros. Age (P=0.011) and preoperative jaundice (P

OBJECTIVE To evaluate the influence of hospital volume on failure-to-rescue (FTR) after pancreatectomy in France. BACKGROUND There are growing evidences that FTR is an important source of postoperative mortality (POM) after pancreatectomy. However, few studies have analyzed the volume-FTR relationship following pancreatic surgery. METHODS All patients undergoing pancreatectomy between 2012 and 2015 were included. FTR is defined as the 90-day POM rate among patients with major complications. According to the spline model, the critical cutoff was 20 resections per year and hospitals were divided into low (

Brexit has been one of the defining features of Theresa May’s premiership. In the summer of 2016, when the EU referendum’s results forced David Cameron out of Downing Street, Theresa May took over as PM with the task of seeing the United Kingdom through the withdrawal process. The first few months of her term in office have proven all the more difficult as the unprecedented nature of Brexit has led to high-profile legal challenges in the courts, especially in R (on the application of Miller) v Secretary of State for leaving the European Union. In the latter, the Supreme Court established that notification of withdrawal from the EU could only be triggered by a vote in Parliament, hereby strengthening Parliament’s role in the Brexit procedure as opposed to the government’s Crown prerogatives. This fight between supporters of the principle of Parliamentary sovereignty, as opposed to the government’s, has encouraged several observers to describe Britain’s current political situation in Civil War-era terms, as “Roundheads versus Cavaliers”. Nevertheless, Brexit’s intricacies have long outgrown this procedural question and have put several aspects of the British Constitution to the test, from the separation of powers to the representative function of MPs. All in all, the use of this Civil War-era metaphor aptly describes the many divisions carved out by Brexit within the UK government, but also within the Conservative party itself.

Introduction Des travaux suggerent que la centralisation de la chirurgie pancreatique est necessaire pour diminuer la mortalite postoperatoire. Elle est cependant complexe. Une alternative serait une centralisation de la prise en charge des complications post-operatoires. L’objectif de cette etude etait d’analyser la mortalite des patients transferes apres pancreatectomie. Methodes Tous les patients de la base nationale PMSI MCO 2012-2018 ayant eu une pancreatectomie pour cancer etaient inclus. Les etablissements etaient caracterises selon leur haut volume operatoire eleve (HV) (≥ 26 resections/an) ou bas volume (BV) ( Resultats Au total, 19 938 patients etaient inclus, dont 1164 (5,8 %) transferes. Le taux de transfert etait plus eleve pour les patients operes en etablissement a BV (6,1 % contre 5,5 %, p Discussion/Conclusion Nos resultats montrent que les patients transferes dans des etablissements a HV ont des taux de mortalite tres eleves malgre leur equipement de soins critiques. Ceci suggere que la centralisation de la complication apres une pancreatectomie n’ameliore pas le devenir des patients.

Introduction La surrenalectomie est le traitement recommande pour de nombreuses maladies surrenaliennes benignes et malignes. Les resultats postoperatoires varient dans la litterature et leurs determinants restent mal definis. L’objectif est d’explorer les determinants des resultats postoperatoires de la chirurgie surrenalienne. Methodes Etait inclus tout patient de la base nationale PMSI-MCO 2012–2017 comportant un acte de surrenalectomie et presentant un diagnostic de maladie surrenalienne. Le critere principal etait la mortalite a 90 jours. Les criteres secondaires etaient la reintervention et la readmission a 90 jours. Les complications postoperatoires ont ete identifiees. Les comorbidites ont ete examinees selon le score de Charlson. Les autres variables analysees etaient le sexe, l’âge, l’obesite, la voie d’abord, le volume operatoire par etablissement. Une regression logistique a permis de construire un score de risque de mortalite. Des seuils de score et de volume operatoire ont ete determines avec la methode CHAID. Resultats Sur la periode, 9820 patients (âges de 55 ± 14 ans ; F/M = 1,1) ont ete operes pour une maladie surrenalienne. Le taux de mortalite global a 90 jours etait de 1,5 % (n = 147). En analyse multivariee, la mortalite postoperatoire etait independamment associee a l’âge ≥ 75 ans (OR : 5,3 ; p Discussion/Conclusion Un haut volume d’activite diminue le risque de mortalite postoperatoire, particulierement pour les patients a haut risque. Ces patients devraient etre diriges vers des centres de traitement de volume eleve pour une chirurgie surrenalienne.

This study deals with the elaboration and characterization of ZnO/Si type heterojunctions with various rare earths doping between 0,3 to 3,0 at% (Yb, Tb, Eu) of ZnO. Materials engineering based on the know-how of a CIMAP team has demonstrated remarkable light emission properties of such structures related to optical transitions of rare earths and especially following extreme heat treatments (up to 1373 K). These latter have indeed generated new phases with interesting properties. Moreover, the electroluminescence of these structures was explored and it revealed very high intensities upon thermal treatments at 973 K. These annealings gave rise to a configuration favorable to the emission of rare earth ions located more particularly in the space charge area of the heterojunction owing to rare earth diffusion at the ZnO:TR/Si interface. Finally, 65 nm thick multilayer structures consisting of ZnO:Ce, ZnO:Tb and ZnO:Tb,Eu sub-layers with varying thicknesses were tested in electroluminescence to obtain white light emitting diodes. Rare earth excitation mechanisms are discussed., Cette étude porte sur l’élaboration et la caractérisation d’hétérojonctions de type ZnO/Si avec plusieurs dopages en terres rares de 0,3 à 3,0 % atomique (Yb, Tb, Eu) du ZnO. Une ingénierie des matériaux basée sur le savoir-faire d’une équipe du CIMAP a permis de mettre en évidence des propriétés remarquables d’émission lumineuse de telles structures liées aux transitions optiques des terres rares et notamment à la suite de traitements thermiques extrêmes (jusqu’à 1373 K). Ces derniers ont en effet généré de nouvelles phases présentant des propriétés intéressantes. Par ailleurs, L’électroluminescence de ces structures a été explorée et elle a révélé des intensités importantes suite à des traitements thermiques à 973 K. Ces derniers ont donné lieu à une configuration favorable à l’émission des ions terres rares localisées plus particulièrement dans la zone de charge d’espace de l’hétérojonction suite à une diffusion des terres rares à l’interface ZnO:TR/Si. Enfin, des structures multicouches de 65 nm d’épaisseur constituées de sous couches ZnO:Ce, ZnO:Tb et ZnO:Tb,Eu avec des épaisseurs variables ont été testées en électroluminescence afin d’obtenir des diodes blanches. Les mécanismes d’excitation des terres rares sont discutés.

Objective The centralization of complex surgical procedures is associated with better postoperative outcomes. However, little is known about the impact of hospital volume on the outcome after distal pancreatectomy. Methods Using the French national hospital discharge database, we identified all patients having undergone distal pancreatectomy in France between 2012 and 2015. A spline model was applied to determine the caseload cut-off in annual distal pancreatectomy that influenced 90-day postoperative mortality. Results A total of 3314 patients were identified. Use of a spline model did not reveal a cut-off in the annual distal pancreatectomy caseload. By taking the median number of distal pancreatectomy (n = 5) and the third quartile (n = 15), we stratified centers into low, intermediate, and high hospital volume groups. The overall postoperative mortality rate was 3.0% and did not differ significantly between these groups. In a multivariable analysis, age, Charlson comorbidity score, septic complications, hemorrhage, shock, and reoperation were independently associated with a greater overall risk of death. However, hospital volume had no impact on mortality after distal pancreatectomy (odds ratio, 0.954; 95% confidence interval, 0.552-1.651, P = 0.867). Conclusions Hospital volume does not seem to influence mortality after distal pancreatectomy in France, and centralization may not necessarily improve outcomes.

OBJECTIVES We aimed to examine whether the improved outcome of a digestive cancer procedure in high-volume hospitals is specific or correlates with that of other digestive cancer procedures, and determine if the discriminant cut-off of hospital volume may influence postoperative mortality (POM) regardless of the procedure. BACKGROUND Performing complex surgeries in tertiary centers is associated with improved outcome. However, the association between POM and hospital volume of nonspecific procedures is unknown. METHODS Patients who underwent colectomy, proctectomy, esophagectomy, gastrectomy, pancreatectomy, and hepatectomy for cancer between 2012 and 2017 were identified in the French nationwide database. Chi-square automatic interaction detector was used to identify the cut-off values of the annual caseload affecting the 90-day POM. A common threshold was estimated by minimization of chi-square distance taking into account the specific mortality of each procedure. RESULTS Overall, 225,752 patients were identified. Hospitals were categorized according to the procedure volume (colectomy: ≥80 cases/yr, proctectomy: ≥35/yr, esophagectomy: ≥41/yr, gastrectomy: ≥16/yr, pancreatectomy: ≥26/yr, and hepatectomy: ≥76/yr). The overall 90-day POM was 5.1% and varied significantly with volume. The benefits of high volume were transferable across procedures. High-volume hospitals for colorectal cancer surgery significantly influenced the risk of death after hepatectomy (P < 0.001) and pancreatectomy (P < 0.001). The common threshold for all procedures that influenced POM was 199 cases/yr (odds ratio 1.29, P < 0.001). CONCLUSION In digestive cancer surgery, the volume-POM relationship of one procedure was associated with the volume of other procedures. Thus, tertiary hospitals should be defined according to the common threshold of different procedures.

It remains to be established whether centralization to high volume centers is essential for all patients undergoing pancreatic surgery. The aims of this study were to identify the optimal cut-off volume to optimize patient outcomes and to determine if patient comorbidity affected the volume-outcome relationship.Patients undergoing pancreatectomy from 2012 to 2015 were retrospectively identified (n = 12 333) in the French nationwide database. The 90-day Post-Operative Mortality (POM) was analyzed according to hospital volume of pancreatectomy (very low:10, Low:10-19, High:20-49 and very high:≥50 resections/year) and Charlson Comorbidity Index (ChCI).The overall POM was 6.9%. The cut-off of 20 pancreatic resections per year was identified as predictor of POM. Compared to high volume centers, POM was significantly higher in low and very low volume centers whatever the ChCl. Regarding surgical procedures, there was a significant decrease in POM with increasing hospital volume only after pancreaticoduodenectomy regardless of the ChCl. On multivariable analysis, low and very low volume centers were independently associated with increased mortality rates.The optimal cut-off of annual caseload was 20 pancreatic resections. POM following pancreaticoduodenectomy is high in low and very low volume centers independently of ChCl, suggesting that this procedure should be centralized.

But Apres chirurgie digestive carcinologique majeure hors CCRC + CHIP, la mortalite postoperatoire (MPO) a 90 jours est de 5,1 %. Le but de notre etude est d’evaluer au niveau national la correlation entre CCRC + CHIP et la MPO. Methodes Tout sejour de patients ≥ 18 ans de la base nationale PMSI 2009–2018 comportant un acte CCAM de CHIP etait inclus. Les caracteristiques des patients, de la chirurgie et la MPO a j90 ont ete etudies. Les seuils d’activite significativement lies a la mortalite etaient determines par methode CHAID. Resultats Notre population de 7476 patients comprenait 63,5 % de femmes, d’un âge moyen de 56,9 ± 11,6 ans et un indice Elixhauser de 3,1 ± 1,4. La carcinose etait primitive (19,1 %) et secondaire d’origine colorectale (46 %), ovarienne (17,6 %), gastrique (6,1 %). Le taux de complications majeures etait de 36,3 % (34,2 % abdominales/8,8 % de fistules). La MPO etait de 1,0 % a j30 et 2,6 % a j90. Sur la periode de l’etude, le seuil d’activite reduisant la MPO etait de 8 procedures/an (5,5 % vs. 2,4 %) ; en s’affranchissant de la courbe d’apprentissage (periode 2015–2018), le seuil est de 45 (3,2 % vs. 1,9 %). Conclusion La CCRC avec CHIP est une procedure controlee et devrait etre centralisee dans des centres haut volume pour ameliorer la PMO.

International audience; BACKGROUND AND AIMS: The potential benefit of the centralization of Bariatric surgery (BS) remains debated. The aim of this study was to evaluate the impact on 90-day mortality of an innovative organization aiming at centralizing the care of severe postoperative complications of BS. STUDY DESIGN: The centralization of care for postoperative complication after BS was implemented by French Authorities in 2013 in the Nord-Pas-de-Calais Region, France. This unique formalized network (OSEAN), coordinated by 1 tertiary referral center, enrolled all regional institutions performing bariatric surgery. Data were extracted from the medico-administrative database providing information on all patients undergoing BS between 2009 and 2016 in OSEAN (n = 22,928) and in Rest of France (n = 288,942). The primary outcome was the evolution of 90-day mortality before and after the implementation of this policy. Rest of France was used as a control group to adjust the results to improvement with time of BS outcomes. RESULTS: The numbers of primary procedure and reoperations increased similarly before and after 2013 within OSEAN and in Rest of France. The 90-day mortality rate became significantly lower within OSEAN than in the rest of France after 2013 (0.03% vs 0.08%, P < 0.01). This difference was confirmed in multivariate analysis after adjustment to the procedure specific mortality (P < 0.04). The reduction of 90-day mortality was most visible for sleeve gastrectomy. CONCLUSION: The implementation of centralized care for early postoperative complications after BS in OSEAN was associated with reduced 90-day mortality. Our results indicate that this reduction was not due to a lower incidence of complications but to the improvement of their management.

OBJECTIVE To identify the impact of hospital volume according to Charlson Comorbidity Index (ChCI) on postoperative mortality (POM) after rectal cancer surgery. BACKGROUND A volume-outcome relationship has been established in complex surgical procedures. However, little is known regarding the impact of hospital volume on POM according to patients' comorbidities after rectal cancer surgery. METHODS All patients undergoing proctectomy for cancer from 2012 to 2016 were identified in the French nationwide database. Patient condition was assessed on the basis of the validated ChCl and was stratified into 3 groups according to the score (0-2, 3, and ≥4). Chi-square automatic interaction detector (CHAID) was used to identify the cut-off values of the annual proctectomy caseload affecting the 90-day POM. The 90-day POM was analyzed according to hospital volume (low

Cet article vise à entreprendre un état des lieux de l’enseignement en anglais dans les facultés de droit en France en partant de l’exemple des cours dispensés en Licence dans les universités de Rennes 1 et de Lyon 3. Après avoir évoqué les principaux enjeux de l’élaboration de cours d’anglais destinés à de futurs juristes, notamment la place à accorder au contenu disciplinaire, les auteurs présentent les programmes et les modalités d’enseignement dans les deux facultés comparées. Les similitudes observées témoignent d’une conscience croissante de la nécessité d’adapter l’enseignement de la langue aux communautés professionnelles dans lesquelles les étudiants seront amenés à évoluer, conformément à ce que préconisent les spécialistes de l’anglais de spécialité. Cet article montre également que les modalités d’enseignement varient sensiblement d'une faculté à l'autre, ce que les auteurs attribuent au fait que les choix pédagogiques sont étroitement liés au contexte socio-économique propre à chaque université. This article aims to provide a first step towards an overview of English teaching practices in French law faculties, through the comparison of how classes are taught in the universities of Rennes 1 and Lyon 3. After discussing the main issues of English courses for law students, such as the place to be given to the specific disciplinary content, the authors present the syllabi and teaching methods used in the two universities of reference. The similarities observed are a sign of the growing awareness that language teaching ought to be adapted to the professional community in which students will eventually work, in accordance with what most specialists of English for specific purposes advocate. This article also demonstrates that teaching practices vary conspicuously from one university to another, which the authors attribute to the fact that pedagogical choices are closely linked to each university’s own socio-economic context.

This project was established to evaluate the feasibility of black chokeberry (Aronia melanocarpa (Michx.) Ell.) culture on Canadian cut-over peatlands and to define its appropriate production practices. We tested the effects of different fertilizer rates, application methods, and mulches on the vegetative development and berry production of seedlings over a 6-year period (2000 to 2006). Fertilization was essential for survival of the plants. A low fertilizer rate (131 g/plant of 1.7N-4.1P-12K) ensured adequate vegetative development for good establishment. Applying such a rate for 2 consecutive years proved to be more beneficial than a single dose of fertilizer for increasing plant height, crown width, and height growth. However, fruit yield was best when fertilized with the highest dose tested (550 g/plant of 3.4N-8.3P-24.2K). Black plastic mulch had a positive effect on height, width, and growth of the plants. More weeds were observed when the fertilizer was applied to the surface as compared with soil incorporation. However, this study revealed that black chokeberry is tolerant of weeds. Based on these results, black chokeberry is a promising plant for the management of cut-over peatlands for both vegetative growth and fruit production. In Eastern Canada, peatlands are mined for the horticultural properties of peat. When peat mining ends, the natural revegetation of the site is usually slow and scarce (Poulin et al., 2005). Generally, ecological restora- tion of cut-over peatlands follows peat har- vesting with respect to the ''no net loss'' policy for the management of wetlands in North America (Lynch-Stewart, 1992). Plant- ing small fruit plants on cut-over peatlands could be considered a complement to eco- logical restoration (Rochefort et al., 2003) or as a reclamation option. Berry plantations in restoration projects could increase landscape heterogeneity and facilitate the return of typical peatland bird species. As a reclama- tion option, added value could be gained from formerly abandoned sites. Among small fruits native to North Amer- ica, black chokeberry (Aronia melanocarpa) is a promising candidate for use in cut-over peatlands. This species produces black edible fruits, readily eaten by birds, and is known for its low maintenance requirements; slight pruning is required and low occurrence of pests and diseases has been observed (Finn, 1999; McKay, 2001; Richer et al., 1997; Strik et al., 2003). Fruits also have antimutagenic properties resulting from their high antho- cyanin content (Gasiorowski et al., 1997). Black chokeberry is already commercially grown, especially in Europe, where its fruits are used in several juices, alcoholic or ener- gizing drinks, and in food colorant. Very little research on small fruit culture on cut-over peatlands has been done because large-scale industrial peat harvesting is rela- tively recent. The first small fruit plantings on industrial cut-over sites were done in Europe in the mid-1970s (Paal, 1992). Most plantings are found in Estonia, where blueberry (Vac- cinium angustifolium Ait.) and cranberry (V. oxycoccos L.) are also successfully grown on cut-over peatlands (Noormets, 2006; Noormets et al., 2004; Paal, 1992; Paal and Paal, 2002). A few small fruit trials have been done on Canadian cut-over peatlands, but

But Identifier l’impact du volume chirurgical et des comorbidites sur la mortalite de la chirurgie pancreatique. Methodes De 2012 a 2015, 12 333 patients operes de resection pancreatique ont ete inclus a partir des bases PMSI. La mortalite a 90 jours a ete comparee au volume chirurgical (tres faible Resultats Le taux de mortalite etait de 6,9 %. La mortalite etait significativement superieure dans les centres a tres faible et faible volume par rapport aux centres a moyen et haut volume (9,1 %, 8,1 % vs 5,8 %, 4,8 % respectivement ; p Conclusions La mortalite apres chirurgie pancreatique est etroitement correlee au volume du centre, independamment des comorbidites des patients.

International audience; Le phénomène Cool Britannia a remis au premier plan l'identité britannique, notamment en s'appuyant sur sa branche musicale, la vague Britpop, et ses groupes phares comme Blur ou Oasis. En reprenant à leur compte le glorieux héritage culturel du Swinging London et des Beatles à travers leurs chansons, ces artistes illustrent une certaine vision de l'identité britannique, grâce à leurs chroniques sociales mettant en scène la nation et son mode de vie (certaines compositions ont, entre autres, pour thème le fameux Sunday Roast ou les programmes de la BBC). Cette représentation de l'identité semble néanmoins plus proche de l'image d'Epinal, d'une part parce qu'elle repose sur un certain nombre de stéréotypes n'ayant plus réellement cours dans la Grande-Bretagne des années 1990, et d'autre part parce qu'elle semble réduire la britannicité à l'anglicité. Or, lorsque Tony Blair prend les commandes du Parti travailliste, il s'appuie sur le phénomène Cool Britannia, notamment en se rapprochant des artistes susnommés, et tente de donner une image rénovée et moderne de l'identité nationale par le biais de son slogan « New Labour, New Britain ». Il est donc légitime de se demander comment Tony Blair a pu se faire le chantre d'une nouvelle identité britannique, jeune et dynamique, tout en s'appuyant sur un phénomène culturel qui semblait donner de celle-ci une vision réductrice.

Owing to their high specific stiffness and strength, Carbon Fiber Reinforced Composites (CFRP) are ideal candidates for the development of lightweight high-performance structures. Within this family, thin-ply composites allow for wider design freedom and present superior mechanical properties as failure is reached at nearly the ultimate strain of the fiber, in contrast with regular composites, due to the delay or suppression of transverse cracking, micro-cracking, and delamination. However, this results in a very brittle failure, and a low translaminar toughness. Thus, thin-plies are not tolerant to stress intensity concentrators, preventing a damage-tolerant design approach, and thus restricting their wider use. Fiber hybridization is a possible route to reach a trade-off between the translaminar toughness and tensile properties in thin-ply composites. The present thesis work focuses on the combination of two different types of carbon fibers, one with a high strain to failure and lower modulus, and the other with a high modulus, and low strain to failure. Various types of fiber hybridization are explored, from an interlayer configuration to interyarn and intrayarns architectures. A thorough experimental analysis was conducted to evaluate the Energy Release Rate in Cross-ply laminates, and the tensile properties in unnotched and open-hole tensile mode for Quasi-iso laminates, and identify hybrid effects, as a function of the low-strain fiber volume fraction, ply-block thickness and symmetry. A novel J-integral implementation to derive the experimental mode I translaminar toughness from experimental displacement fields of Compact Tension (CT) specimens measured by Digital Image Correlation (DIC) was proposed and benchmarked for three different formulations. Results highlighted the large design space opened by hybridization, with a significant change in the damage sequence. The interlayer hybridization yields a substantial positive hybrid effect with respect to the ply-thickness effect. The positive hybrid effect observed for the best-performing arrangements resulted from the presence of secondary damage in asymmetric ply-blocks. In contrast, symmetric ply-blocks were found ineffective as a proper fragmentation of the low-strain plies could not be triggered, due to a lower experimental strain to failure of the high-strain fiber, as compared to the datasheet. Interyarn and intrayarn configurations were then explored as a means to increase fiber dispersion and mitigate the ply-block thickness increase resulting from layer-by-layer hybridization. A similar experimental test campaign was conducted, highlighting the possibility of obtaining a positive hybrid effect through alternative mechanisms as compared to pull-out, such as crack bridging by low-strain tows. A phenomenological study was then conducted to account for the change in translaminar toughness, by quantification of the pull-out length in fracture surfaces, completed by a shear-lag model implemented in a finite element model to propose a method for prediction of these changes as a function of microstructure. Results showed that the pull-out bundle height and width distributions are strongly impacted by the ply thickness in agreement with previous studies. More importantly, quantitative data was gathered about the influence of fiber hybridization and its architecture on the pull-out bundle distribution, leading to identify two distinct dissipative mechanisms.