Search

Aim Postoperative morbidity is high in patients operated on for Crohn's disease (CD) complicated by malnutrition. This study aimed to evaluate the impact of preoperative enteral nutritional support (PENS) on postoperative outcome in patients with CD complicated by malnutrition included in a prospective nationwide cohort. Method Malnutrition was defined as body mass index 10%. Failure of PENS was defined as the requirement for additional preoperative parenteral nutrition to PENS. Univariate analysis of the risk factors for PENS failure was performed. Propensity score matching (PSM) was used to compare the outcomes between 'upfront surgery' and 'PENS' groups. The primary endpoint was the rate of intra-abdominal septic morbidity and/or temporary defunctioning stoma. Results Among 592 patients included, 149 were selected. In the intention-to-treat population including 20 (13.4%) patients with PENS failure after PSM, 78 'upfront surgery' and 71 'PENS'-matched patients were compared, with no significant difference in the primary endpoint. Perforating CD and preoperative intra-abdominal fistula were associated with PENS failure [37.5 vs 16.1% (P = 0.047) and 41.2% vs 16.2% (P = 0.020), respectively]. After exclusion of these 20 patients, PSM was used to compare 45 'upfront surgery' and 51 'PENS'-matched patients, with a significantly decreased rate of intra-abdominal septic complications and/or temporary defunctioning stoma in the PENS group (19.6 vs 42.2%, P = 0.016). Conclusion Preoperative enteral nutritional support is associated with a trend but no conclusive evidence of a reduction in intra-abdominal septic complications and/or requirement for defunctioning stoma. Patients with perforating CD complicated with malnutrition are at risk of PENS failure.

Background Natural orifice transluminal endoscopy surgery (NOTES) gastrojejunal anastomosis (GJA) with duodenal exclusion (DE) could be used as a less invasive alternative to surgical gastric bypass. The aim of this study was to compare the efficacy and safety of both methods for bariatric purpose. Methods This was a prospective, experimental and comparative study on obese living pigs, comparing 4 groups: GJA alone (group 1, G1), GJA + DE (group 2, G2), surgical gastric bypass (group 3, G3), control group (group 4, G4). GJA was endoscopically performed, using NOTES technic and LAMS, while DE was performed surgically for limb length selection. Animals were followed for 3 months. Primary outcome included technical success and weight evolution, while secondary endpoints included the rate of perioperative mortality and morbidity, histological anastomosis analysis and biological analysis. Results Technical success was 100% in each intervention groups. No death related to endoscopic procedures occurred in endoscopic groups, while early mortality (

International audience; BackgroundBladder invasion by colon cancer is rare; however, its management is still controversial. Our objective was to report outcomes and identify risk factors for local recurrence in colon cancer with clinically suspected bladder invasion.MethodsWe conducted a retrospective study in 23 centers in France. All patients who underwent colon surgery with bladder resection (2010–2017) were included. Metastatic and recurrent colon cancers were excluded.ResultsOne hundred and seventeen patients (men = 73) were included. Partial cystectomy occurred in 108 patients (92.3%), with a total cystectomy occurring in 9 patients (7.7%). Neoadjuvant treatment was given to 31 patients (26.5%). Major morbidity was 20.5%. R0 resection rates were 87.2%. Histologically confirmed bladder invasion was present in 47%. Thirty-four patients were pN+, while 60 patients (51.3%) received adjuvant chemotherapy. Mean follow-up was 33.8 months. Three-year overall survival and disease-free survival were 82.9% and 59.5%. Rates of local recurrence and distant recurrence were 14.5% and 18.8%, respectively; the local recurrences (11/17; 65%) were in the bladder, while 4 of these patients had a bladder recurrence despite not having histologically confirmed bladder invasion at the index surgery. The rate of bladder recurrence after histologic bladder invasion was 13% (7/55), while the rate of bladder recurrence without primary bladder invasion was 7% (4/62) (P = .343). Neoadjuvant therapy, type of cystectomy, and adjuvant therapy did not influence local recurrence (P > .445 each). R1 bladder resections, when compared with a R0 bladder resections, were associated with an increased rate of local recurrence (63% vs 10%; P < .0001).ConclusionClinically suspected bladder invasion increases local recurrence even in the absence of histologically confirmed bladder invasion. Only complete resections with R0 margins decrease local recurrence. Careful, detailed postoperative surveillance is required, even without pathologic bladder invasion.

BACKGROUND AND AIMS: Crohn’s disease (CD) frequently affects young women and may require surgery during pregnancy. Data regarding operation for CD in expectant mothers are scare. MATERIALS AND METHODS: This was a retrospective nationwide survey from the GETAID Chirurgie. Any woman with CD undergoing surgery during pregnancy was eligible. RESULTS: A total of 15 cases were collected between 1992 and 2015. Most operations were performed due to penetrating or stricturing complications. Mean gestational age at delivery was 34 weeks, with a mean birth weight of 2507 g. Maternal post-operative complications occurred in two-thirds of cases. Maternal mortality rate was 6.7% and neonatal mortality rate 9.1%. CONCLUSIONS: This is the largest case series of surgery for CD during pregnancy. This operation may have significant morbidity and mortality for mother, fetus, and newborn. Indication needs to be tailored to maternal status, disease severity, and gestational age. Surgery should be managed by experienced gynecologists, physicians, and surgeons. Active CD may be associated with a greater risk to the fetus than the surgical procedure itself.

Resume Jusqu’en 2013, la formation pratique des internes inscrits au DES/DESC de chirurgie viscerale et digestive en France n’etait pas standardisee. Depuis 2017, le troisieme cycle des etudes medicales a ete restructure autour de deux axes : connaissances theoriques et competences techniques et non-techniques. Celui-ci comporte notamment un programme de formation pratique par simulation, hors bloc operatoire, national, structure, uniformise et standardise. Le developpement de ce programme de formation est le fruit d’un travail de consensus national sous l’egide du college francais de chirurgie viscerale et digestive permettant d’offrir un guide de formation a tous les futurs chirurgiens de la specialite. Quatre seances de conference de consensus reunissant une commission de 8 membres ont abouti a la redaction du « Livret de l’Interne pour l’Enseignement Pratique en Chirurgie Viscerale et Digestive ». Ce referentiel detaille en 272 pages les objectifs (phase I), les moyens d’apprentissage de chaque competence (phase II) et enfin les methodes d’evaluation (phase III) pour les phases socles et des phases d’approfondissement du DES de chirurgie viscerale et digestive. En complement de ce livret, nous avons mene une reflexion sur la structuration et la mise en place de ce programme a l’echelle nationale a compter de novembre 2017 qui est detaille a la fin de cet article.

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.

The aim of this study was to assess recurrence risk factors following ileocolonic resection (ICR) for Crohn disease (CD) in a nationwide cohort study SUMMARY BACKGROUND DATA:: Recurrence rate after ICR for CD can be up to 60%, but its predictive factors have never been evaluated in large prospective cohort studies.From 2013 to 2015, 346 consecutive patients undergoing ICR for CD and a postoperative ileocoloscopy within 6 to 12 months after surgery at 19 academic French centers were included prospectively.Twelve-month postoperative endoscopic (Rutgeerts score ≥i2) and clinical recurrence rates were 57.6% [95% confidence interval (CI), 54.2-61.0] and 11.3% (95% CI, 9-13.6), respectively. A total of 185 patients (54%) had a postoperative CD prophylaxis, comprising thiopurine in 69 (20%), or anti-tumor necrosis factor (TNF) therapy in 93 (27%). In multivariate Cox regression analysis, absence of postoperative smoking {odds ratio [OR] = 0.60 (95% CI, 0.40-0.91); P = 0.016}, postoperative prophylaxis [OR = 0.60 (95% CI, 0.41-0.88); P = 0.009], and penetrating disease behavior [OR = 0.58 (95% CI, 0.39-0.86); P = 0.007] were the only independent predictors of reduced endoscopic recurrence risk. Postoperative prophylaxis [OR 0.31 (95% CI, 0.15-0.66); P = 0.002), and penetrating behavior [OR = 00.36 (95% CI, 0.16-0.81); P = 0.013), were the only independent predictors of reduced clinical recurrence risk. Postoperative anti-TNF therapy was associated with a significant reduction of both 12-month risks of endoscopic (P0.001) and clinical (P = 0.019) recurrences.Absence of postoperative smoking, CD prophylaxis, and penetrating disease behavior could be independent predictors of reduced postoperative recurrence after ICR for CD. Prophylactic anti-TNF therapy reduces both endoscopic and clinical recurrence rates. It suggests that upfront surgery followed by postoperative anti-TNF therapy is probably the best therapeutic approach for complex CD (penetrating disease behavior).

Background Simulation-based care pathway approach (CPA) training is a novel approach in surgical education. The objective of the present study was to determine whether CPA was feasible for training surgical residents and could improve efficiency in patients’ management. A common disease was chosen: acute appendicitis. Methods All five junior residents of our department were trained in CPA: preoperative CPA consisted in virtual patients (VPs) presenting with acute right iliac fossa pain; intraoperative CPA involved a virtual competency-based curriculum for laparoscopic appendectomy (LAPP); finally, post-operative VP were reviewed after LAPP. Thirty-eight patients undergoing appendectomy were prospectively included before (n = 21) and after (n = 17) the training. All demographic and perioperative data were prospectively collected from their medical records, and time taken from admission to management was measured. Results All residents had performed less than 10 LAPP as primary operator. Pre- and intraoperative data were comparable between pretraining and post-training patients. Times to liquid and solid diet were significantly reduced after training [7 h (2–20) vs. 4 (4–6); P = 0.004, and 17 h (4–48) vs. 6 (4–24); P = 0.005] without changing post-operative morbidity [4 (19%) vs. 0 (0); P = 0.11] and length of stay [48 h (30–264) vs. 44 (21–145); P = 0.22]. Conclusions CPA training is feasible in abdominal surgery. In the current study, it improved patients’ management in terms of earlier oral intake.

The laparoscopic approach is widely accepted as the procedure of choice for abdominal surgery. However, laparoscopic liver resection (LLR) has advanced slowly due to the significant learning curve (LC), and only few publications have dealt with advanced training in LLR. Two reviewers conducted systematic research through MEDLINE and EMBASE with combinations of the following keywords: (learning curve OR teaching OR training OR simulation OR education) AND (liver OR hepatic) AND (laparoscopic OR laparoscopy). Robotic-assisted, hand-assisted and hybrid LLRs were excluded. Nineteen studies were retrieved. Overall, the level of evidence was low. Thirteen articles assessed the LC during real-life LLR, and six articles focussed on simulation and training programmes in LLR. The LC in minor LLR comprised 60 cases overall, and 15 cases for standardised left lateral sectionectomy. For major LLR (MLLR), the LC was 50 cases for most studies, but was reported to be 15–20 cases in more recent studies, provided MLLR is performed progressively in selected patients. However, there was heterogeneity in the literature regarding the number of minor LLRs required before MLLR, with 60 minor LLRs reported as the minimum. Six studies showed a potential benefit of simulation and training programmes in this field. The gradual implementation of LLR combined with simulation-based training programmes could reduce the clinical impact of LC. The LC in LLR is a long process, and MLLR should be gradually implemented under the supervision of experienced surgeons. Training outside the operating room may reduce the LC in real-life situations.

To evaluate the performance of an early repeated computed tomography (rCT) in initially non-operated patients with blunt bowel and mesenteric injuries (BBMI). This was a monocentric retrospective observational study from 2009 to 2017 of patients with a BBMI on initial CT (iCT). Patients initially non-operated on were scheduled for a rCT within 48 h. Initial CT and rCT diagnostic performance were compared based on a surgical injury prediction score previously described. For statistical analysis, we used the chi-square analyses for paired data (McNemar test). Eighty-four patients (1.9% of trauma) had suspected BBMI on iCT. Among these patients, 22 (26.2%) were initially operated on, 18 (21.4%) were later operated on, and 44 (52.4%) were not operated on. The therapeutic laparotomy rate was 85%. Thirty-four patients initially non-operated on had a rCT. The absolute value of the CT scan score increased for 15 patients (44.1%). The early rCT diagnostic performance, compared with iCT, showed an increase in sensitivity (from 63.6 to 91.7%), in negative predictive value (from 77.4 to 94.7%), and in AUC (from 0.77 to 0.94). In initially non-operated patients with BBMI lesions, the performance of an early rCT improved the sensitivity of lesion detection requiring surgical repair and the security of patient selection for non-operative treatment. • Selective non-operative treatment for hemodynamically stable patients with blunt bowel and/or mesenteric injuries on CT is developing but remains controversial. • An early repeated CT improved the sensitivity of lesion detection requiring surgical repair and the security of patient selection for conservative treatment.

A better understanding of pathological features and oncological survival in ypT0 rectal cancer after neoadjuvant chemoradiotherapy is required to improve patient selection criteria for rectal-preserving approach by local excision. Our aim was to define risk of lymph node metastasis and oncological outcomes in ypT0 rectal cancer after chemoradiotherapy and total mesorectal excision.All consecutive patients who underwent total mesorectal excision for a nonmetastatic rectal adenocarcinoma classified ypT0 after neoadjuvant chemoradiotherapy, with or without locoregional lymph node involvement (ypN+ or ypN-), in 14 French academic centers between 2002 and 2015 were included. Data were collected retrospectively. Overall and disease-free survival were explored.Among the 383 ypT0 patients, 6% were ypN+ (23/283). Before chemoradiotherapy, 86% (327/380) were staged cT3-T4 and 41% (156/378) were staged cN+. The risk of ypN+ did not differ between cT3-T4 and cT1-T2 patients (P = .345) or between cN+ and cN- patients (P = .384). After a median follow-up of 61.1 months, we observed 95% confidence interval (92%-97%) of 5-year overall survival and 93% confidence interval (91%-96%) of 5-year disease-free survival. In Cox multivariate analysis, overall survival was altered by intra-abdominal septic complications (hazard ratio = 2.53, confidence interval [1.11-5.78], P = .028). Regarding disease-free survival, ypN+ status and administration of adjuvant chemotherapy were associated with a reduced disease-free survival (P = .001 for both). cT3/T4 staging and cN+ staging did not modify overall survival (P = .332 and P = .450) nor disease-free survival (P = .862 and P = .124).The risk of lymph node metastasis and the oncological survival do not depend on the initial cT or cN staging in cases of ypT0 complete rectal tumor regression.

No specific performance assessment scales have been reported in laparoscopic liver resection. This study aimed at developing an objective scale specific for the assessment of technical skills for wedge resection in anterior segments (WRAS) and left lateral sectionectomy (LLS). A laparoscopic liver skills scale (LLSS) was developed using a hierarchical task analysis. A Delphi method obtained consensus among five international experts on relevant steps that should be included into the LLSS for assessment of operative performances. The consensus was predefined using Cronbach’s alpha > 0.80. A semi-structured review extracted 15 essential subtasks for full laparoscopic WRAS and LLS for evaluation in the Delphi survey. Two rounds of the survey were conducted. Three over 15 subtasks did not reach the predefined level of consensus. Based on the expert’s comments, 13 subtasks were reformulated, 4 subtasks were added, and a revised skills scale was developed. After the 2nd round survey (Cronbach’s alpha 0.84), 19 subtasks were adopted. The LLSS was composed of three main parts: patient positioning and intraoperative preparation (task 1 to 8), the core part of the WRAS and LLS procedure (tasks 9 to 14), and completion of procedure (task 15 to 19). The LLSS was developed for measuring the skill set for the education of safe and secure laparoscopic WRAS and LLS procedures in a dedicated training program. After validation, this scale could be also used as an assessment tool in the operating room and extrapolated as an operative roadmap to other complex procedures.

Cohort studies have recently initiated a paradigm shift in the field of preoperative bowel preparation. Indeed, the adjunction of oral antibiotics (OAB) to mechanical bowel preparation (MBP) is now the gold standard for the American guidelines. However, this strategy is highly controverted.This review was an up-to-date analysis of literature on bowel preparation. We conducted a systematic review for randomized controlled trials (RCTs) and meta-analyses published since 2009. A non-exhaustive overview of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) cohort studies and the international guidelines was also given, and future leads were discussed.The methodology of the ACS NSQIP studies did not allow a strong conclusion in favor of the association MBP+OAB. Besides, guidelines were not univocal, with non-American guidelines promoting no preparation at all. RCTs favored OAB alone: indeed, MBP+OAB showed no benefits in terms of surgical site infection (SSI) except when compared to MBP alone, while OAB alone seemed superior to no preparation. Likewise, the meta-analyses also favored OAB alone in terms of overall SSI and organ space infection. Large RCTs are currently running and may change these conclusions. Finally, microbiota is a future lead for personalized OAB.

AIM To assess short- and long-term outcomes of redo ileal pouch-anal anastomosis (redo-IPAA) for failed IPAA, comparing them with those of successful IPAA. METHOD This was a case-control study. Data were collected retrospectively from prospectively maintained databases from two tertiary care centres. Patients who had a redo-IPAA between 1999 and 2016 were identified and matched (1:2) with patients who had a primary IPAA (p-IPAA), according to diagnosis, age and body mass index. RESULTS Thirty-nine redo-IPAAs (16 transanal and 23 abdominal procedures) were identified, and were matched with 78 p-IPAAs. After a mean follow-up of 56 ± 51 (2.6-190) months, failure rates after transanal and abdominal approaches were 50% and 15%, respectively. Reoperation after the transanal approach was higher than after p-IPAA (69% vs 7%; P

Aim Few studies have been published on erectile function after ileal pouch-anal anastomosis (IPAA) and, unlike in women, male fertility after IPAA has never been assessed. The primary objective was to assess the impact of IPAA on erectile function. The secondary objective was to assess the impact of IPAA on male fertility. Methods All of the male patients who underwent IPAA in two university care centres between 2003 and 2017, aged 70 years or less at the time of operation, were included. Forty-eight per cent of the patients responded to the international index of erectile function, the Jorge-Wexner score and a fertility questionnaire. All demographic and perioperative data were prospectively collected. Fertility results were compared with those of a control group undergoing appendectomy, matched for age at the time of operation, desire for paternity and length of follow-up. Results One hundred and thirty-nine patients were included, among which 46 (33%) presented with erectile dysfunction and 14 (10%) with severe erectile dysfunction. Age older than 50 years (OR 0.27, 95% CI 0.12-0.62, P = 0.002) and rectal dissection performed by open surgery (OR 4.16, 95% CI 1.62-10.65, P = 0.003) were independent risk factors for erectile dysfunction. There was no infertility after IPAA compared with controls: indeed, 23 (16%) IPAA patients presented with pregnancy in their couple versus 27 (22%) controls (P = 0.29), whereas 36 (26%) IPAA patients and 34 (28%) controls (P = 0.80) expressed paternity desire. Conclusion A total laparoscopic approach, including rectal dissection, should be preferred to preserve erectile function. Male fertility is not impaired after IPAA.

There are no specific guidelines for ventral hernia management in Crohn’s disease (CD) patients. We aimed to assess the risk of septic morbidity after mesh repair in CD. This was a retrospective multicentre study comparing CD and non-CD patients undergoing mesh repair for ventral hernia (primary or incisional hernia). Controls were matched 1:1 for the presence of a stoma, history of surgical sepsis, hernia size and Ventral Hernia Working Group (VHWG) score. All demographic, pre-, intra- and postoperative data were retrieved, including long-term data. We included 234 patients, with 114 CD patients. Both groups had comparable VHWG scores (p = 0.12), hernia sizes (p = 0.11), ASA scores ≥ 3 (p = 0.70), body mass index values (p = 0.14), presence of stoma (CD 21.9% vs. controls 15%, p = 0.16), history of sepsis (14% vs. 6.7%, p = 0.23), rates of malnutrition (4.4% vs. 1.7%, p = 0.46), rates of incisional hernia (93% vs. 95%, p = 0.68) and concomitant procedures (18.4% vs. 11.7%, p = 0.12). CD patients carried a higher risk of postoperative septic morbidity (18.4% vs. 5%, p = 0.001), entero-prosthetic fistula (7% vs. 0, p

To determine the risk factors of morbidity after surgery for ileocolonic Crohn disease (CD).The risk factors of morbidity after surgery for CD, particularly the role of anti-TNF therapy, remain controversial and have not been evaluated in a large prospective cohort study.From 2013 to 2015, data on 592 consecutive patients who underwent surgery for CD in 19 French specialty centers were collected prospectively. Possible relationships between anti-TNF and postoperative overall morbidity were tested by univariate and multivariate analyses. Because treatment by anti-TNF is possibly dependent on the characteristics of the patients and disease, a propensity score was calculated and introduced in the analyses using adjustment of the inverse probability of treatment-weighted method.Postoperative mortality, overall and intra-abdominal septic morbidity rates in the entire cohort were 0%, 29.7%, and 8.4%, respectively; 143 (24.1%) patients had received anti-TNF3 months prior to surgery. In the multivariate analysis, anti-TNF3 months prior to surgery was identified as an independent risk factor of the overall postoperative morbidity (odds-ratio [OR] =1.99; confidence interval [CI] 95% = 1.17-3.39, P = 0.011), with preoperative hemoglobin10 g/dL (OR = 4.77; CI 95% = 1.32-17.35, P = 0.017), operative time180 min (OR = 2.71; CI 95% = 1.54-4.78, P0.001) and recurrent CD (OR = 1.99; CI 95% = 1.13-3.36, P = 0.017). After calculating the propensity score and adjustment according to the inverse probability of treatment-weighted method, anti-TNF3 months prior to surgery remained associated with a higher risk of overall (OR = 2.98; CI 95% = 2.04-4.35, P0.0001) and intra-abdominal septic postoperative morbidities (OR = 2.22; CI 95% = 1.22-4.04, P = 0.009).Preoperative anti-TNF therapy is associated with a higher risk of morbidity after surgery for ileocolonic CD. This information should be considered in the surgical management of these patients, particularly with regard to the preoperative preparation and indication of temporary defunctioning stoma.

Summary Background The aim was to determine whether a simulation-based care pathway approach (CPA) curriculum could improve compliance for enhanced recovery programs (ERP), and residents’ participation in laparoscopic colorectal surgery (LCS). Indeed, trainee surgeons have limited access to LCS as primary operator, and ERP have improved patients’ outcomes in colorectal surgery (CS). Methods All residents of our department were trained in a simulation-based CPA: perioperative training consisted in virtual patients built according to guidelines in both ERP and CS, whilst intraoperative training involved a virtual reality simulator curriculum. Twenty consecutive patients undergoing CS were prospectively included before (n = 10) and after (n = 10) the training. All demographic and perioperative data were prospectively collected, including compliance for ERP. Residents’ participation as primary operator in LCS was measured. Results Five residents (PGY 4–7) were enrolled. None had performed LCS as primary operator. Overall satisfaction and usefulness were both rated 4.5/5, usefulness of pre-, post- and intraoperative training was rated 5/5, 4.5/5 and 4/5, respectively. Residents’ participation in LCS significantly improved after the training (0% (0–100) vs. 82.5% (10–100); P = 0.006). Pre- and intraoperative data were comparable between groups. Postoperative morbidity was also comparable. Compliance for ERP improved at Day 2 in post-training patients (3 (30%) vs. 8 (80%); P = 0.035). Length of stay was not modified. Conclusions A simulated CPA curriculum to training in LCS and ERP was correctly implemented. It seemed to improve compliance for ERP, and promoted residents participation as primary operator without adversely altering patients’ outcomes.

Resume Objectif Determiner si une formation en parcours de soin simule (FPSS) ameliore le respect des objectifs rehabilitation amelioree (ORA) et la participation des internes au bloc operatoire en chirurgie colorectale laparoscopique (CCL). Methodes Tous les internes du service ont recu cette FPSS : les entrainements pre- et postoperatoires etaient constitues de patients virtuels scenarises selon les recommandations de rehabilitation amelioree et de chirurgie colorectale (CC) ; l’entrainement peroperatoire etait un programme valide en CCL sur simulateur. Vingt patients admis consecutivement pour CC ont ete inclus prospectivement avant (n = 10) et apres (n = 10) FPSS. Les donnees demographiques, perioperatoires, et le respect des ORA ont ete collectes. La participation des internes en CCL a ete mesuree comme % de temps en tant qu’operateur. Resultats Cinq internes (4e–7e annee) ont ete formes. Aucun n’avait realise de CCL comme operateur. La satisfaction et l’utilite globale de la FPSS etaient de 4,5/5, l’utilite des formations pre-, per- et postoperatoires de 5/5, 4,5/5 et 4/5. La participation des internes en CCL a augmente apres formation (0 % [0–100] vs. 82,5 % [10–100] ; p = 0,006). Les donnees preoperatoires des patients etaient comparables entre les groupes. La morbidite postoperatoire, dont la morbidite majeure (4 [40 %] vs. 1 [10 %] ; p = 0,15) etait egalement inchangee. Le respect des ORA etait meilleur a j2 dans le groupe post-FPSS (3 [30 %] vs. 8 [80 %] ; p = 0,035). La duree d’hospitalisation etait inchangee (p = 0,74). Conclusion La FPSS a permis d’ameliorer le respect des ORA. Elle a aussi augmente la participation des internes comme operateur sans alterer les suites operatoires des patients.

OBJECTIVE The aim of this study was to compare the survival of patients with stage II obstructing colon cancer (OCC) who had adjuvant chemotherapy with those who did not. SUMMARY BACKGROUND DATA The need for adjuvant chemotherapy in stage II colon cancer is still debated. METHODS All consecutive patients treated for a stage II OCC in a curative intent (with primary tumor resection) between January 2000 and December 2015 were included in this retrospective, multicenter cohort study which included a propensity score analysis using an odds of treatment weighting (Average Treatment effect on the Treated, ATT). The endpoint was the comparison between the 2 groups for overall survival (OS) and disease-free survival (DFS) according to whether or not patients received adjuvant chemotherapy. RESULTS During the study period, 504 patients underwent a curative colectomy for a stage II OCC. Among these patients, 179 (35.5%) had adjuvant chemotherapy and 325 (64.5%) had no adjuvant treatment. Among the 179 patients who received adjuvant chemotherapy, 108 patients (60%) received oxaliplatin based regimen and 99 patients (55%) completed all scheduled cycles. At multivariate analysis, after weighting by the odds (ATT analysis) and adjustment, adjuvant chemotherapy after resection of a stage II OCC was associated with improvements in OS [hazard ratio (HR) = 0.42 (0.17-0.99), P = 0.0498] and DFS [HR = 0.57 (0.37-0.88), P = 0.0116]. CONCLUSION This study suggests that adjuvant chemotherapy after curative resection of stage II OCC may improve oncological outcomes.

At equal TNM stage, obstructing colon cancer (OCC) is associated with worse prognosis in comparison with uncomplicated cancer. Our aim was to identify prognostic factors of overall (OS) and disease-free survival (DFS) in patients treated for OCC. From 2000 to 2015, 2325 patients were treated for OCC in French surgical centers, members of the French National Surgical Association (AFC). Patients with palliative management were excluded. The main endpoints were OS and DFS. A multivariate analysis, using Cox proportional hazards regression model, was performed to determine independent prognostic factors. The cohort included 2120 patients. The median of follow-up was 13.2 months. In multivariate analysis, age > 75 years, ASA score ≥ 3, ECOG score ≥ 3, right-sided colon cancer, presence of synchronous metastases, anastomotic leakage, and absence of adjuvant chemotherapy were independent OS factors. Age > 75 years, ASA score ≥ 3, right-sided colon cancer, presence of synchronous metastases, and absence of postoperative chemotherapy were independent factors of poor OS after exclusion of patients who died postoperatively. Age ≥ 75 years, ASA score ≥ 3, ECOG score ≥ 3, right-sided colon cancer, lymph node involvement, presence of vascular, lymphatic or perineural invasion, less than 12 harvested lymph nodes, and absence of adjuvant chemotherapy were independent DFS factors. Management of OCC should take into account prognostic factors related to the patient (age, comorbidities), tumor location, and tumor stage. Adjuvant chemotherapy administration plays an important role. For patients undergoing initial defunctionning stoma, neoadjuvant chemotherapy could be an option to improve prognosis.

Purpose. Anastomotic leak is the main complication after low colorectal anastomosis. Defunctioning ileostomy is therefore recommended, which carries its own morbidity. The aim of this study was to assess the technical feasibility, safety, and preliminary efficacy of a vacuum-based intra-colonic diverting device (Colovac) to reduce the impact of anastomotic leak. Methods. This prospective preclinical study was conducted on living swine. The device was surgically inserted transanally, proximal to a colorectal anastomosis, and removed endoscopically at day 14. Then, open surgery was performed to look for deep sepsis and/or anastomotic leak, and the remaining colorectal anastomosis was resected for histopathological analysis. The endpoints were successful insertion and delivery of the device, postoperative morbidity, successful maintaining of the device, and absence of feces spillage and/or abscess in the abdominal cavity. Results. The Colovac was inserted in 22 swine. Stent migration occurred in 7 of the first 8 specimens, leading to natural expulsion of the device. After diet adaptation, a subsequent group of 14 swine was undertaken, of which 13 did not show any sign of migration post-implantation. Disconnection of the suction drain occurred in 1 case, leading to device expulsion on day 10. Colovac retrieval was achieved successfully in 13 cases. The endoscopic assessment of the anchorage site showed limited mucosal injury, whereas histopathological findings revealed mild hyperplasia. One swine died prematurely of postoperative colonic ischemia. Conclusion. This new device appears to be safe in the swine model and may prevent peritonitis or abscess due to colorectal anastomotic leak.

Background and AimsTo compare perioperative characteristics and outcomes between primary ileocolonic resection [PICR] and iterative ileocolic resection [IICR] for Crohn’s disease [CD].MethodsFrom 2013 to 2015, 567 patients undergoing ileocolonic resection were prospectively included in 19 centres of the GETAID chirurgie group. Perioperative characteristics and postoperative results of both groups [431 PICR, 136 IICR] were compared. Uni- and multivariate analyses of the risk factors of overall 30-day postoperative morbidity was carried out in the IICR group.ResultsIICR patients were less likely to be malnourished [27.2% vs 39.9%, p = 0.007], and had more stricturing forms [69.1% vs 54.3%, p = 0.002] and less perforating disease [19.9% vs 39.2%, p < 0.001]. Laparoscopy was less commonly used in IICR [45.6% vs 84.5%, p < 0.01] and was associated with increased conversion rates [27.4% vs 14.6%, p = 0.012]. Overall postoperative morbidity was 36.8% in the IICR group and 26.7% in the PICR group [p = 0.024]. There was no significant difference between IICR and PICR regarding septic intra-abdominal complications, anastomotic leakage [8.8% vs 8.4%] or temporary stoma requirement. IICR patients were more likely to present with non-infectious complications and ileus [11.8% vs 3.7%, p < 0.001]. Uni- and multivariate analyses did not identify specific risk factors of overall postoperative morbidity in the IICR group.ConclusionsSurgery for recurrent CD is associated with a slight increase of non-infectious morbidity [postoperative ileus] that mainly reflects the technical difficulties of these procedures. However, IICR remains a safe therapeutic option in patients with recurrent CD because severe morbidity including anastomotic complications is similar to patients undergoing primary resection.PodcastThis article has an associated podcast which can be accessed at https://academic.oup.com/ecco-jcc/pages/podcast

Introduction Postoperative ileus(POI) and anastomotic leakage(AL) are highly associated but the direction of this link is unknown. Indeed, it has traditionally been stated that AL leads to POI(secondary POI). The objective was to statistically determine the best model of link between POI and AL by comparing different Structural Equation Models(SEM). Methods This is a retrospective analysis of a prospective multicentric database from the Francophone Group for Enhanced Recovery after surgery(GRACE) including patients undergoing colorectal resection or Hartmann reversal between 2014 and 2017. The main outcome measure was the occurrence of postoperative ileus defined by the absence of Gastrointestinal (GI)-3 recovery in or after postoperative day 4 and the occurrence of AL. Results Among the 2227 patients included, 223 patients experienced POI (10 %) and 72 patients experienced anastomotic leakage (3.2 %). In all the models, POI was significantly increased in case of male gender, older age, opioids consumption, right colectomy, chronic obstructive bronchopneumopathy disease and performance of a stoma, and reduced by Enhanced Recovery Programs (ERP) compliance ≥ 70 % and intake of Non-Steroidal Anti-Inflammatory Drugs. Open surgery was not significantly associated with POI in all the models. In contrast, the male gender was the only factor increasing AL in the model drawn with ERP risk factors for AL. In all the models, POI was highly associated with AL and statistical analyses advocate for POI leading to AL. Conclusion The findings of the present large study suggest that the more statistically probable model is the one in which POI come first before AL.

Resume Introduction La rehabilitation amelioree apres chirurgie (RAC) aboutit souvent a un retour precoce a domicile. En termes de gestion des risques lies a cette prise en charge une prolongation de la surveillance a domicile est recommandee. La surveillance par SMS est validee en chirurgie ambulatoire pour des interventions dites mineures. L’objectif de cette etude etait d’evaluer la faisabilite d’une surveillance par SMS a domicile apres chirurgie colorectale dans le cadre d’un programme de rehabilitation amelioree. Methodes Il s’agit d’une etude prospective multicentrique, menee dans les CHU de Clermont-Ferrand, Grenoble, Marseille et Lyon Sud entre novembre 2014 et septembre 2015. Tous les patients avaient une chirurgie colorectale dans le cadre d’un programme de RAC. Les patients recevaient des SMS (4 questions simples sur la douleur, le transit, la temperature, et la phlebite) a j1, j3, j5 apres leur sortie. Une alerte automatique etait envoyee par internet au medecin referent et les patients rappeles a chaque reponse anormale ou en cas d’absence de reponse. Resultats Cent onze patients etaient inclus. Les reponses etaient obtenues avec un delai median maximum de 12 (1–422) minutes, 90 % des patients ont repondu a tous les SMS. Parmi les 48 alertes recues, 56 % concernaient des douleurs, 40 % etait dues a une absence de reponse aux SMS. Les alertes ayant amene des soins a l’hopital concernaient 4 % des patients avec 3 re-hospitalisations dont 2 re-interventions non programmees. Le score median de satisfaction des patients (85 % de reponses) etait de 5 sur une echelle de 5. Conclusion Cette etude suggere la possibilite, comme pour la chirurgie ambulatoire, d’utiliser les SMS a domicile dans la surveillance post-hospitalisation des patients dans le cadre d’un programme de rehabilitation amelioree apres chirurgie colorectale.

But de l’etude Il n’existe pas de large etude evaluant les facteurs de risque d’echec de rehabilitation amelioree apres chirurgie (RAAC) chez le sujet âge. Methodes L’objectif primaire etait d’identifier les facteurs de risque d’echec de RAAC (ER) a partir d’une base de donnees prospective multicentrique de patients de plus de 65 ans operes pour une pathologie colorectale. Les objectifs secondaires etaient de comparer les patients de 65–74 ans aux patients de plus de 75 ans, et d’identifier les facteurs de risque de mortalite. Les donnees pre-, per- et postoperatoires etaient colligees. Le respect de moins de 70 % des items de RAAC definissait l’ER. Resultats Parmi 2513 patients > 65 ans, 1038 patients avaient plus de 75 ans (81 ± 5 ans, [75–97]). Les facteurs de risque preoperatoires d’ER etaient l’âge > 75 ans (p Conclusions Il n’existe pas de facteur preoperatoire independant limitant la RAAC chez le sujet âge. En revanche, l’ER a un impact significatif sur la mortalite, notamment l’absence de mobilisation precoce apres 75 ans.

Objectif Rapporter l’experience francaise de la prise en charge chirurgicale des tumeurs retro-rectales (TRR). Methodes Tous les patients operes d’une TRR dans 17 centres francais etaient retrospectivement inclus (2000–2019). Les voies d’abord (anterieure, posterieure et combinee) etaient comparees. Resultats Deux cent trente-six patients (184 femmes, âge moyen 46 ± 17 ans) ont ete inclus. Le diagnostic etait fortuit pour 94 patients (40 %). Les TRR etaient malignes dans 10 % des cas. La chirurgie etait realisee par voie anterieure (n = 65, 27,5), posterieure (n = 161, 68 %) ou combinee (n = 10, 4 %). Les voies d’abord posterieure et combinee etaient associees a des abces de paroi (16 % et 20 % vs 1,5 %, p = 0,008), alors que l’ileus survenait uniquement apres une voie anterieure (8 %, p = 0,001). Apres un suivi median de 12 [1–221] mois, une recidive locale etait observee dans 10 % des cas. Les complications fonctionnelles etaient rares (douleurs chroniques 8 %, dysfonctions urinaires 3 %, sexuelles 2,5 %, incontinence anale 1 %). Le taux de recidive et les complications fonctionnelles etaient similaires selon la voie d’abord. Conclusions Les TRR constituent un challenge chirurgical car majoritairement benignes et potentiellement pourvoyeuses de complications per- et postoperatoires. Il ne semble pas y avoir de superiorite d’une voie d’abord sur l’autre.

Background Acute diverticulitis is a common disease with public health significance. Many studies with a high level of evidence have been published recently on the surgical management of acute diverticulitis. Objective The aim of this systematic review was to define the accurate surgical management of acute diverticulitis. Data sources Medline, Embase, and the Cochrane Library were sources used. Study selection One reviewer conducted a systematic study with combinations of key words for the disease and the surgical procedure. Additional studies were searched in the reference lists of all included articles. The results of the systematic review were submitted to a working group composed of 13 practitioners. All of the conclusions were obtained by full consensus and validated by an external committee. Interventions The interventions assessed were laparoscopic peritoneal lavage, primary resection with anastomosis with or without ileostomy, and the Hartmann procedure, with either a laparoscopic or an open approach. Main outcome measures Morbidity, mortality, long-term stoma rates, and quality of life were measured. Results Seventy-one articles were included. Five guidelines were retrieved, along with 4 meta-analyses, 14 systematic reviews, and 5 randomized controlled trials that generated 8 publications, all with a low risk of bias, except for blinding. Laparoscopic peritoneal lavage showed concerning results of deep abscesses and unplanned reoperations. Studies on Hinchey III/IV diverticulitis showed similar morbidity and mortality. A reduced length of stay with Hartmann procedure compared with primary resection with anastomosis was reported in the short term, and in the long term, more definite stoma along with poorer quality of life was reported with Hartmann procedure. No high-quality data were found to support the laparoscopic approach. Limitations Trials specifically assessing Hinchey IV diverticulitis have not yet been completed. Conclusions High-quality studies showed that laparoscopic peritoneal lavage was associated with an increased morbidity and that Hartmann procedure was associated with poorer long-term outcomes than primary resection with anastomosis with ileostomy, but Hartmann procedure is still acceptable, especially in high-risk patients.

Aim To report the results of surgery for obstructive right colon cancer (ORCC) and to identify risk factors associated with worse outcomes that may help surgeons to choose the best surgical option. Methods This is a retrospective national cohort study, including all patients operated on for ORCC from 2000 to 2015. Those treated with colonic stent or symptomatic treatment were excluded. We described outcomes after surgery for ORCC and performed multivariate analyses for mortality, morbidity and survival. Results Among 776 patients analyzed, 716 (92%) had their primary tumor removed, with primary anastomosis in 582 (82%). The remaining 194 underwent anastomosis with loop ileostomy (n = 21), resection with double-end stoma (n = 113), defunctioning stoma without resection (n = 48) and ileocolic by-pass (n = 12). Postoperative mortality, morbidity and anastomotic leak rates were 10%, 51% and 14%, respectively. In multivariate analysis, age >70, ASA score ≥3 and hemodynamic instability were predictors of postoperative mortality whereas ASA score ≥3, hemodynamic instability and intra-operative complications were predictors of severe morbidity. No factors were correlated with anastomotic leak. After a median follow-up of 26 months, 8% of patients were alive with a permanent stoma. Five-year overall, disease-free and cancer-specific survival was 42%, 42% and 62%, respectively. In multivariate analysis, peritonitis, synchronous metastases and absence of adjuvant chemotherapy were predictors of decreased overall survival. Conclusions Emergency surgery for ORCC is associated with high mortality and morbidity. Two third of patients with ORCC can be managed with resection and primary anastomosis. For high-risk patients, a staged surgical management may be discussed.

Background After ileocecal resection for Crohn's disease, a temporary faecal diversion is indicated in high-risk patients. The impact of a temporary stoma on post-operative morbidity has been poorly assessed so far. The aim was to analyse post-operative morbidity of temporary faecal diversion after ileocecal resection for Crohn's disease. Methods Patients undergoing temporary faecal diversion combined with ileocecal resection were retrospectively included. Patients presenting with complications were compared with patients with an uneventful post-operative course, to identify any predictive factor for morbidity. Results Eighty faecal diversions were performed (43 males, 33.5 (18–75) years), including 63 split stoma (79%) and 17 covering loop ileostomies (21%). Fifty-two patients (65%) presented with a perforating disease. Post-operative complications occurred in 15 patients (19%), 15 days after surgery (1–30). The main complications were intra-abdominal abscess (n = 6), functional renal failure (n = 6), fistula (n = 2) and stomal prolapse (n = 2). Two patients required surgery. Previous bowel resections (60% versus 28%, P = 0.01) were significantly associated with post-operative morbidity. Conclusions Temporary faecal diversion is useful in high-risk patients after ileocecal resection for Crohn's disease. Patients' information about post-operative risks remains an important issue. Risk factors for post-operative morbidity despite faecal diversion are previous bowel resections.

The transition from medical student to surgical intern can be intimidating with consequences for patient safety as demonstrated by the “July” or “August” effect.1,2 Anecdotally, trainees have reported feeling ill-prepared and extremely nervous in their first couple of weeks as a surgical intern. Indeed, the prevalence of psychiatric morbidity and burnout has been shown to rise during the intern year.3 Traditionally, “shadowing” the current intern was used to ease the transition. This is a form of work experience, which may be referred to as a subinternship in the United States, where the incoming student follows the incumbent surgical intern to experience their daily duties. Since 2012, this practice has been made compulsory in the UK. The move was in part a response to the so-called August effect, whereby increased patient mortality was found to be associated with the August changeover and arrival of newly qualified doctors.2 The effect of changeover of junior doctors is referred to as the “July effect” in the United States. A recent review found evidence of increased mortality and reduced efficiency in hospitals owing to the changeover of doctors at the end of the year.1 Easing the transition from medical student to intern could potentially provide clinical benefits for patients in addition to making the experience less fear-inducing for the clinician. During shadowing, the exposure to clinical scenarios is largely based on chance occurrences. Moreover, there is a feeling among the profession that 4 days of shadowing is not enough on its own to protect patients.4 There have been encouraging reports of intensive simulated skills courses targeting medical students to prepare them for the transition to junior surgeon.5–8 Studies in the United States have shown that simulated skills courses or boot camp can increase the confidence of junior surgical interns.6,7,9,10 They have largely been small-scale feasibility studies with self-assessed confidence as the primary outcome and no clinical metrics. Subjects on these courses have in particular found the “hands-on” training sessions to be of most benefit.6 There is also some objective evidence of improvement in both knowledge8,11 and technical skills.12 Although the majority of studies have focused on generic surgical skills, specialty-specific boot camps have also been shown to improve technical skills in first year residents.13 In 2012, Fernandez et al14 reported encouraging results from 4 successive years of a simulation-based surgical boot camp. One of the challenges they highlight is the need for protected teaching time and how to balance this against duty-hour regulations. A proposed solution is to implement this type of training before PGY-1. In fact, as early as 2004, the American Surgical Association Blue Ribbon Committee recommended collaboration between the Division of Education of the American College of Surgeons, the Accreditation Council for Graduate Medical Education, Association of American Medical Colleges, surgical boards, and medical schools to develop a surgical preparation curriculum to assist the transition from medical student to surgery resident.15 Progress has been made in the United States; however, there remains a lack of supporting evidence that these encouraging results can be applied to the training system in the UK. Competence in medical school examinations assesses both cognitive and to some extent practical skills. The focus of these examinations is on testing knowledge and targeted technical or practical skills. However, this does not necessarily provide adequate preparation for the real-world situations that a surgical intern faces. The purpose of this study was to develop, pilot, and evaluate an immersive, intensive, simulated 1-week course that recreates experiences and situations that a surgical doctor is likely to face in their first weeks as a clinician. It aims specifically to prepare final year medical students for the transition into their surgical internship. This project allows the subject to learn and practice in a controlled, simulated environment away from the patient.

Despite their low occurrence, endoscopic perforations (EPs) are concerning. Some predictive factors have been identified, and EP management is debated, whether non-surgical (medical and/or endoscopic) or surgical. The objective was to elaborate a predictive score for surgical management of EP. All the patients addressed for upper and lower EP, except oesophageal EP, were retrospectively included (2004–2015). Demographic data, endoscopic features (indication, location, type), clinical, biological and radiological presentations of EP were reviewed. Management of EP and outcomes were recorded. A predictive score was constructed by multiple linear regression and a cut-off value for surgical management was identified. Additional subgroup analysis was performed according to the location of EP (upper and lower). Among 41150 endoscopic procedures, 44 patients (22 males, median age = 65 years [22–87]) presenting with EP were included (0.09%). Lower gastrointestinal (GI) endoscopy was mostly performed (66%). EP diagnosis was immediate in 73% of the cases (n = 32). Non-surgical management was efficient in 2/3 cases treated medically alone, and 18/20 cases treated by endoscopy. Surgical management was always successful (n = 24/24). In case of peritonitis, surgery was systematically required, whereas easily required in case of delayed diagnostic of EP. The EP score was based on the presence of previous abdominal surgery, lower GI endoscopy and diagnostic endoscopy. A cut-off EP score of 22.8% for surgery was chosen; it was associated with a specificity and sensitivity of 40 and 100%, respectively. When subgroups were analysed according to EP location, the EP score was still based on the presence of previous abdominal surgery and diagnostic endoscopy. The cut-off was 6.3 and 73.3% for upper (specificity: 73%, sensitivity: 100%) and lower (89 and 45%) locations, respectively. The predictive EP score may avoid inappropriate surgical management, as well as delayed surgery after non-surgical management failure. Forthcoming study should prospectively validate this score.

Background This study investigated whether deliberate practice leads to an increase in surgical quality in virtual reality (VR) laparoscopic cholecystectomies (LC). Previous research has suggested that sustained DP is effective in surgical training. Methods Fourteen residents were randomized into deliberate practice (n = 7) or control training (n = 7). Both groups performed ten sessions of two VR LCs. Each session, the DP group was assigned 30 min of DP activities in between LCs while the control group viewed educational videos or read journal articles. Performance was assessed on speed and dexterity; quality was rated with global (GRS) and procedure-specific (PSRS) rating scales. All participants then performed five porcine LCs. Results Both groups improved over 20 VR LCs in time, dexterity, and global rating scales (all p < 0.05). After 20 LCs, there were no differences in speed or dexterity between groups. The DP group achieved higher quality of VR surgical performance than control for GRS (26 vs. 20, p = 0.001) and PSRS (18 vs. 15, p = 0.001). For VR cases, DP subjects plateaued at GRS = 25 after ten cases and control group at GRS = 20 after five cases. At completion of VR training, 100 % of the DP group reached target quality of performance (GRS ≥ 21) compared with 30 % in the control group. There were no significant differences for improvements in time or dexterity over five porcine LCs. Conclusion This study suggests that DP leads to higher quality performance in VR LC than standard training alone. Standard training may leave individuals in a state of “arrested development” compared with DP.

Both intra- and perioperative care are essential for patients' safety. Training for intraoperative technical skills on simulators and for perioperative care in virtual patients have independently demonstrated educational value, but no training combining these 2 approaches has been designed yet. The aim of this study was to design a pathway approach for training in general surgery. A common disease requiring essential skills was chosen, namely, acute appendicitis.Preoperative care training was created using virtual patients presenting with acute right iliac fossa (RIF) pain. A competency-based curriculum for laparoscopic appendectomy (LAPP) was designed on a virtual reality simulator: Novices (10 LAPP) and experienced surgeons (100 LAPP) were enrolled to perform 2 virtual LAPP for assessment of validity evidence; novices performed 8 further LAPP for analysis of a learning curve. Finally, postoperative virtual patients were reviewed after LAPP.Four preoperative patient scenarios were designed with different presentations of RIF; not all required operative management. Comments were provided through case progression to allow autonomous practice. Ten novices and 10 experienced surgeons were enrolled for intraoperative training. Time taken (median values) of novices versus experienced surgeons (285 vs 259 seconds; P = .026) and performance score (67% vs 99%; P .0001) demonstrated evidence for validity, whereas path length did not (916 vs 673 cm; P = .113). Proficiency benchmark criteria were defined for measures with validity evidence. Two postoperative virtual patients were created with an uneventful or complicated outcome.A virtual care pathway approach has been designed for acute appendicitis, enabling trainees to follow simulated patients from admission to discharge.

Background and Aims: The mastery of manual skills that are indispensable for the performance of surgical tasks is a competence specific to surgery. One way of facilitating this acquisition is to move the training out of the operating room and all of its restrictions. Surgical training out of the operating room, also called simulation, has spread widely in the past decade, especially in laparoscopic and endoscopic surgery. Material and Methods: This review assesses the role of virtual reality (VR) simulators in laparoscopic surgery and their actual impact on technical skills. Results and Conclusions: There is a wealth of simulators, ranging from low- to high-fidelity simulators incorporating haptic feedback. They comprise basic tasks, procedural modules, and full procedures. Virtual reality simulators have shown acceptable fidelity and validity evidence. Moreover, training out of the operating room on virtual reality simulators has demonstrated its positive impact on basic skills during real laparoscopic procedures in patients. The benefit of virtual reality over simple video trainers remains unclear for teaching basic skills. However, virtual reality simulators provide automatic feedback that permitted to design structured competency-based curricula and allow deliberate practice. Finally, advanced procedures and patient-specific models have been designed on virtual reality simulators, and further investigations are still awaited to appraise their educational value.