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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.

Background: Incisional hernias can be associated with pain or discomfort. Surgical repair especially mesh reinforcement, may likewise induce pain. The primary objective was to assess the incidence of pain after hernia repair in patients with and without pre-operative pain or discomfort. The secondary objectives were to determine the preferred mesh type, mesh location and surgical technique in minimizing postoperative pain or discomfort. Materials and methods: A registry-based prospective cohort study was performed, including patients undergoing incisional hernia repair between September 2011 and May 2019. Patients with a minimum follow-up of 3–6 months were included. The incidence of hernia related pain and discomfort was recorded perioperatively. Results: A total of 1312 patients were included. Pre-operatively, 1091 (83%) patients reported pain or discomfort. After hernia repair, 961 (73%) patients did not report pain or discomfort (mean follow-up = 11.1 months). Of the pre-operative asymptomatic patients (n = 221), 44 (20%, moderate or severe pain: n = 14, 32%) reported pain or discomfort after mean follow-up of 10.5 months. Of those patients initially reporting pain or discomfort (n = 1091), 307 (28%, moderate or severe pain: n = 80, 26%) still reported pain or discomfort after a mean follow-up of 11.3 months postoperatively. Conclusion: In symptomatic incisional hernia patients, hernia related complaints may be resolved in the majority of cases undergoing surgical repair. In asymptomatic incisional hernia patients, pain or discomfort may be induced in a considerable number of patients due to surgical repair and one should be aware if this postoperative complication.

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

Resume But Presentation de l’activite de formation a la laparoscopie de l’ecole de chirurgie de Paris, par l’analyse de la mise en place d’un nouveau programme d’entrainement. Materiel et methodes Un nouveau programme d’entrainement progressif a la laparoscopie a ete introduit en 2008 et utilise par 43 etudiants. Les etudiants ont ete evalues sur leurs capacites techniques au cours des quatre seances d’une heure et demie selon six items testant les gestes de base de la laparoscopie sur pelvic-trainer. Resultats Il existait une amelioration significative du temps de realisation d’un nœud intracorporel de 56 % apres quatre seances. Par ailleurs, 89 % des etudiants avaient progresse et maitrisaient la gestuelle de base en laparoscopie et 74 % des etudiants trouvaient leur formation a la laparoscopie insuffisante. Conclusion Le pelvic-trainer est un outil fiable et accessible pour la formation des jeunes internes a la laparoscopie. Son utilisation doit etre promue aupres des jeunes internes en formation.

Resume But de l’etude Realiser une analyse comptable de l’activite d’un service de chirurgie digestive universitaire et savoir quels sejours sont beneficiaires et lesquels sont deficitaires. Patients et methodes Tous les sejours hospitaliers de l’annee 2006 ont ete analyses retrospectivement. Le mode d’entree (programme/urgence), le diagnostic principal du sejour, le libelle du groupe homogene de malade (GHM), l’acte realise et la duree de sejour ont ete etudies. Une estimation des couts et des recettes de chaque hospitalisation a ete effectuee. Resultats Il y a eu 1985 sejours representant 11 000 journees d’hospitalisation, generant 8 M euros de recettes des groupes homogenes de sejour (GHS). Le service etait en deficit de 1,3 M euros. Il y a eu 775 sejours dans le cadre de l’activite programmee, generant 50 % des recettes GHS et seulement 13 % du deficit (178 562 euros). Il y a eu 749 sejours dans le cadre des urgences, qui ont genere 45 % des recettes et ont ete responsables de 82 % du deficit, soit 1,1 M euros. Il y a eu 461 sejours pour l’activite d’endoscopie, generant 5 % des recettes et 5 % du deficit (67 249 euros). Les hospitalisations de moins de deux jours ont fait perdre 122 624 euros, et le non-respect des bornes basses, 42 850 euros. Conclusion L’activite programmee en chirurgie digestive peut etre a l’equilibre, et le respect de la duree de sejour minimale pour gagner le tarif plein du GHM est important. En revanche, la T2A entraine des deficits considerables en ce qui concerne l’activite d’urgence.

Objective The surgical treatment of severe attacks of sigmoid diverticulitis and the indications for prophylactic surgery are currently matters of debate. We have analysed our experience in a university hospital, bringing new information into the discussion. Method All patients admitted to our department between 1995 and 2002 for an attack of sigmoid diverticulitis were reviewed. There were 222 who had had a first attack and these formed the basis of the study. Analysis of short- and long-term outcomes was made. Results Of the 222 patients, 66 underwent an operation during the first admission (mainly Hartmann’s opertation) with no death. Twenty-five patients were operated during a subsequent admission, either for a deterioration of their symptoms or prophylaxis. One hundred and twenty-eight patients were managed conservatively, and were followed up for 5–12 years. Recurrence was observed in 43% of the patients with a trend to a higher incidence in patients under 50 years. Recurrent exacerbating diverticulitis were severe in 13% of cases. Conclusion Complicated diverticulitis can be managed with a low mortality. Hartmann’s operation was proven safe in our experience. The risk of recurrence was higher than observed in many recent studies but few reccurences were severe.

We report on a case of migration inside the liver of the distal end of a ventriculoperitoneal shunt catheter in an adult patient. A simple laparotomy permitted the surgical removal with no haemorrhagic complication. We discuss the other cases reported in the literature and we outline the need to perform an abdominal CT scan in patients carrying a VP shunt with digestive symptoms.

For this quarter's digest, Drs Pascal Frileux and Denis Castaing, from Annales de Chirurgie, choose the best from issues eight, nine and ten of 1995. A reciprocal digest written by our European Editor, Colin Johnson, appears in the French journal.

We report on a case of migration inside the liver of the distal end of a ventriculoperitoneal shunt catheter in an adult patient. A simple laparotomy permitted the surgical removal with no haemorrhagic complication. We discuss the other cases reported in the literature and we outline the need to perform an abdominal CT scan in patients carrying a VP shunt with digestive symptoms.

Pinaverium bromide is a specific calcium channel blocker used in the treatment of irritable bowel syndrome (IBS) for its spasmolytic activity. The aim of the present study was to evaluate the effect of orally administered pinaverium bromide on jejunal motility and total and segmental colonic transit time in control subjects. Gastrointestinal studies were performed in 10 healthy volunteers (30 +/- 3 years), before and after a treatment phase of 14 days (150 mg/d). Jejunal motility was measured by prolonged manometry (14 h) and colonic transit time by a multiple ingestion, single marker technique. No significant modification of phase III of the migrating motor complexes was demonstrated. On the contrary, a significant (p < 0.01) but weak decrease of the frequency of contraction was found. Unlike previous studies, no decrease of total or segmental colonic transit time was demonstrated.

The aim of this study was to perform a detailed analysis of income and expense in a department of general surgery in a French hospital under the new system of funding based on a "fee-for-service" principle.All hospital stays of year 2006 were analysed retrospectively. The conditions of admission (elective vs. emergency), the principal diagnosis, and surgical procedures were examined. We determined hospital costs and the reimbursement for every admission.One thousand nine hundred and eighty-five hospitalizations generated an income of 8Meuros with a deficit of 1.3Meuros. The 775 elective admissions generated 50% of the income and 13% of the deficit (178,562euros). Seven hundred and forty-nine emergency admissions generated 45% of the income and 82% of deficit (1.1Meuros). Four hundred and sixty-one admissions for endoscopy generated 5% of the income and 5% of the deficit (67,249euros). Hospital stays of less than two days (the minimum duration of stay for total reimbursement) caused a loss of 122,624euros. Length of hospital stay below the lower limit caused a loss of 42,850euros.Elective surgical activity in digestive surgery can generate a balanced budget provided the length of hospital stay is reduced to the minimum, sometimes to the detriment of patient comfort. Emergency admissions result in a large deficit between cost and reimbursement; this fact may lead hospitals to avoid emergency activity in the future unless appropriate remedial measures are taken.

For this quarter's digest, Dr Pascal Frileux, Editor of Annales de Chirurgie, chooses the best from issues six and seven of 1995. A reciprocal digest written by our European Editor, Mr Colin Johnson, appears in the French journal.

Colonic location of actinomycosis must be distinguished from infected colonic carcinoma and other colonic inflammatory pseudotumors. The diagnosis is often made by histological examination of the tumor. Initial treatment consists in surgery, followed by an antibiotic treatment. We report the case of a 32-year old woman with a right colonic actinomycosis.

In surgical intensive care, the results must be analyzed both in terms of mortality and quality of life; this is particularly important in elderly patients for whom recovery remains uncertain. The aim of this prospective study was to assess the early and late prognosis in elderly patients (aged over 75 years) admitted to a digestive surgical intensive care unit (DSICU) for mortality, quality of life, patient autonomy, and also the predictive factors involved.Over a one-year period, 182 patients were admitted to a tertiary referral DSICU; 30 of these subjects were over 75 years old, and formed the basis of this study. The following data were analyzed: hospital mortality rate; mortality rate at six months, and quality of life at six months (Kamofsky scale). These factors were correlated with the severity of the patient's state at admission and also with the causal disease, circumstances connected with admission, and duration of stay in the DSICU.The hospital mortality rate of patients was 23% (7/30 patients), and the overall mortality rate at six months was 40% (12/30 patients). Of the 12 patients who stayed in the DSICU for more than ten days with a simplified acute physiology score (APS) = 10, not one was alive at six months post-DSICU admission. The 18 remaining patients were still alive at six months, and 72% of them (13/18 patients) had regained their previous post-operative autonomy.These results provide reference data for this patient category. The results concerning long-term survival and the good functional outcome are encouraging. If the prognostic criteria defined in this investigation are confirmed by further studies, they may help in making the sometimes difficult decisions regarding elderly patients hospitalized in a DSICU.

The authors have retrospectively analysed the drainage fluid of 39 patients undergoing Whipple's operation over a 18-year period. The aim of the study was to assess whether the volume and amylase concentration of the drainage fluid were good criteria of healing of the pancreatico-jejunal anastomosis. The patients have been divided into two groups: Group I (30 patients) with no complications at the pancreatico-jejunostomy--Group II (9 patients) with a pancreatic leak. The analysis of the volume, amylase concentration and amylase index (Log of the amylase concentration x volume) showed that the groups had clearly different profiles: in group I all three criteria were rapidly decreasing, while they remained abnormally high in group II. Those criteria may help the clinician in the monitoring of individual patients; they also may prove useful in prospective studies evaluating new means of prevention of this anastomosis.

Since the first attempts at resection of Klatskin tumours, an increasingly aggressive surgical treatment has been proposed. Results obtained after examination of the specimen have shown that a significant proportion of resections were palliative. Curative resection appears to be difficult to perform selectively.This retrospective study evaluates the results of a surgically-oriented management of hilar bile duct cancers. Thirty-nine patients were operated on in the period 1982-1994. Eighteen resections were carried out, requiring liver resection in 13 cases. Pathology of the specimen showed that the resection had been curative in 14 cases. The remaining 21 patients had surgical palliation, i.e. bypass and/or stenting.In the resection group, there was no death but four patients suffered severe complications. The 1- and 5-year survival rates were 67 and 47 per cent respectively, with a median survival of 26 months. In the palliation group, the mortality rate was 14 per cent and median survival was 7 months.In the absence of evident contraindications, surgical exploration is worthwhile as it allows detection of the cases where curative resection is possible. Curative resection often requires a major hepatectomy, but mortality and morbidity may be kept low, and it offers a real hope of cure.

Carcinoma of the upper third of the extrahepatic bile ducts (Klatskin's tumors) are difficult to manage and there is still no consensus on the best means of diagnosis and therapy. The objective of this general review was to determine the state of the art about the pathology and the available diagnostic and therapeutic options.

Evaluate the surgical approach of curative resection in patients treated for cancer of the hepatic hilus.We made a retrospective analysis of 50 cases collected between 1982 and 1994. Preoperative work-up was progressively centered on ultrasonography and Doppler examinations together with transhepatic cholangiography. Surgery was performed in 39 patients; surgery was not attempted in 11 patients in poor health status or with advanced stage disease.Curative resection was performed in 14 of the 39 operated patients. There were no hospital deaths and mean survival at 5 years was 60%. Median survival was 23 months. A palliative procedure was used in 25 patients with 3 deaths and a 7-month median survival. Transhepatic intubation of the bile ducts was performed in the 11 non-operated patients: there were 3 deaths and median survival was 3 months.A surgical approach, based on a simple preoperative work-up and extensive surgical exploration together with extemporaneous pathology can detect cases in which curative surgery is indicated. Care for operated patients given only palliative treatment is not compromised with this attitude and results are at least as good as those obtained with endoscopic or transhepatic intubation.

Internal fistulas in Crohn's disease join a diseased intestinal segment to a "victim organ" (VO) that is affected by proximity. While the diseased segment is resected, the other can be sutured in selected cases.Seventy-four patients with 100 internal fistulas were retrospectively reviewed to assess the results of this conservative operative approach.Closure of the fistulous defect of the VO was achieved by resection (n = 41) or suture (n = 59). The VO was histologically unaffected by Crohn's disease in 86 cases. One patient died postoperatively. Three patients had postoperative fistulas after suture of the VO. There was no long-term recurrence of an internal fistula.Surgical treatment of internal fistulas can be achieved safely by resection of the source of the fistula and suture repair of the VO when the latter is not affected by active Crohn's disease and when local conditions make it feasible.

Infected pancreatic necrosis, developing in the early stages of severe acute pancreatitis is a diffuse suppurative process and is difficult to eradicate. Pancreatic abscess, on the other hand, is a late appearing and easily drainable localised infection. Our rule of thumb is that the later the operation, the shorter the course of antibiotics. Following an operation for infected pancreatic necrosis we recommend a 5-week course of antibiotics. After drainage of a pancreatic abscess antibiotics are given for at least 10 days.

Internal fistula is a complication of Crohn's disease. Among 589 patients operated upon at Hôpital Saint-Antoine between 1970 and 1992, 17 (2.9%) had entero-vesical fistula. Ileovesical fistulas were twice as frequent as sigmoidovesical fistulas. Typical symptoms were pneumaturia, fecaluria, and recurrent urinary tract infection. Cystoscopy was performed in 8 patients and determined the site of the fistula in each case. The indication for operation was the fistula itself (35%) or another complication of Crohn's disease (65%). Associated lesions were as follows: 6 entero-enteral, 2 ileogenital, 5 enterocutaneous fistulas and 6 intraabdominal abscesses. Resection of the bowel segment responsible for the fistula was performed in every case, with primary anastomosis in 9 cases and enterostomy in 8 cases. The vesical opening was excised and sutured in 10 cases and left open in 7 cases. An urethral catheter was left in place for at least 7 days. There was no postoperative death; one postoperative external vesical fistula healed without reoperation. Seven enterostomies have been closed, one is definitive. There were no late recurrences of vesical fistula.

A case of rectal endometriosis, presenting in the form of acute obstruction, is described. The primary diagnosis was malignancy, but endometriosis was discovered at emergency operation. The diagnosis and management of rectal endometriosis are reviewed.