Intraoperative carcinoid syndrome during small-bowel neuroendocrine tumour surgery

Only few descriptions of intraoperative carcinoid syndrome (ioCS) have been reported. The primary objective of this study was to describe ioCS. A second aim was to identify risk factors of ioCS. We retrospectively analysed patients operated for small-bowel neuroendocrine tumour in our institution between 2007 and 2015, and receiving our preventive local regimen of octreotide continuous administration. ioCS was defined as highly probable in case of rapid (<5 min) arterial blood pressure changes ≥40%, not explained by surgical/anaesthetic management and regressive ≥20% after octreotide bolus injection. Probable cases were ioCS which did not meet all criteria of highly-probable ioCS. Suspected ioCS were detected on the anaesthesia record by an injection of octreotide due to a manifestation which did not meet the criteria for highly-probable or probable ioCS. A total of 81 patients (liver metastases: 59, prior carcinoid syndrome: 49, carcinoid heart disease: 7) were included; 139 ioCS occurred in 45 patients: 45 highly probable, 67 probable and 27 suspected. ioCs was hypertensive (91%) and/or hypotensive (29%). There was no factor, including the use of vasopressors, significantly associated with the occurrence of an ioCS. All surgeries were completed and one patient died from cardiac failure 4 days after surgery. After preoperative octreotide continuous infusion, ioCS were mainly hypertensive. No ioCS risk factors, including vasopressor use, were identified. No intraoperative carcinoid crisis occurred, suggesting the clinical relevance of a standardized octreotide prophylaxis protocol

Impact of organizational factors on surgical performance

Introduction : Dans le contexte actuel où l'efficacité opérationnelle des établissements de santé est cruciale, concilier l'augmentation de la productivité des soins tout en préservant leur qualité est essentiel. En chirurgie, les recherches se concentrent désormais sur les facteurs organisationnels périopératoires. Notre étude visait à estimer l'association entre le taux de rotation des patients dans les lits sur les résultats post-opératoires, identifier dans la littérature les facteurs organisationnels influençant la performance chirurgicale, et évaluer l'influence des perturbations des flux opératoires sur les résultats chirurgicaux. Méthodes : Une étude nationale sur grande bases de données a mesuré l’association entre le taux de rotation des patients dans les lits et la survenue d’évènements indésirables, dans 631 hôpitaux français. Une revue systématique de 76 publications a identifié les déterminants organisationnels entre 2000 et 2019 pouvant influer sur la durée opératoire, la morbi-mortalité et les coûts de prise en charge. Une étude observationnelle prospective a évalué l’influence des retards au programme opératoire et temps d'attente entre opérations sur les résultats de 45 chirurgiens. Résultats : Les hôpitaux à haute rotation présentaient des taux d’évènements indésirables inférieurs pour les patients subissant une chirurgie digestive mineure comparativement aux hôpitaux à faible taux de rotation des lits. Les équipes expérimentées et stables semblaient avoir un effet favorable sur les suites opératoires telles que rapportées dans la littérature. Durant une journée opératoire, les retards opérationnels de plus d’une heure étaient associés à une augmentation des événements indésirables majeurs. Conclusion : Des lacunes importantes persistent dans notre compréhension des déterminants du résultat chirurgical. L’étude approfondie de l'influence des facteurs organisationnels sur la survenue d’évènements indésirables peut fournir des indications précieuses pour améliorer la qualité des soins et la sécurité du patient au bloc opératoire. Une meilleure gestion des flux de patients au bloc et dans les lits hospitaliers représente une piste prometteuse pour fiabiliser le parcours de prise en charge periopératoire du patient.Introduction : In the current context where the operational efficiency of healthcare institutions is crucial, reconciling the increase in care productivity while preserving its quality is essential. In surgery, research is now focusing on perioperative organizational factors. Our study aimed to estimate the association between patient turnover rate in beds and postoperative outcomes, identify organizational factors influencing surgical performance in the literature and assess the influence of disruptions in operative flows on surgical outcomes. Methods : A national study using large databases measured the association between patient turnover rates in beds and the occurrence of adverse events in 631 French hospitals. A systematic review of 76 publications identified organizational determinants between 2000 and 2019 that could influence operative duration, morbidity, and healthcare costs. A prospective observational study evaluated the influence of delays in the operating schedule and waiting times between surgeries on the outcomes of 45 surgeons. Results : Hospitals with high turnover rates had lower rates of adverse events for patients undergoing minor digestive surgery compared to hospitals with low bed turnover rates. Experienced and stable teams appeared to have a favorable effect on postoperative outcomes as reported in the literature. During an operative day, delays of more than one hour were associated with an increase in major adverse events. Conclusion : Significant gaps persist in our understanding of the determinants of surgical outcomes. A thorough study of the influence of organizational factors on the occurrence of adverse events can provide valuable insights to improve the quality of care and patient safety in the operating room. Better management of patient flows in the operating room and hospital beds represents a promising avenue to streamline the perioperative patient care pathway

Cooperating on digital cultural mediation devices in museums: actors, adjustments and content

International audienceDigital displays, visual projections, virtual reality tablets, etc., can now be found in many exhibitions, from the largest museums to the smallest. This spread of digital cultural mediation devices inside musuems has been analysed by various researchers who have revealed the promotional discourses and the imaginary notions that accompany them. However, few works question the way they are concretely produced. This is the challenge of our paper, which questions, on the one hand, the stability of expectations towards these devices and, on the other hand, the working relationships that are established around their deployment. Our main result shows that the mediation services are not involved from the outset in their design and that negotiations take place between the scientific and mediation services and the service provider. The latter sometimes being confined to the role of technical subcontractor, sometimes being a force for futher propositions.Borne, projection visuelle, tablette en réalité virtuelle (RV), etc., se retrouvent aujourd’hui dans de nombreuses expositions des plus grands musées aux plus petits. Ce déploiement des dispositifs de médiation culturelle numérique in situ a été analysé par différents chercheurs qui ont notamment révélé les discours d’escorte et les imaginaires qui les entourent. Cependant, peu de travaux questionnent la manière dont ils sont concrètement produits. Là est l’enjeu de notre article qui questionne d’une part la stabilité des attentes envers ces dispositifs et d’autre part les relations de travail qui se nouent autour de leur déploiement. Notre résultat principal montre que les services de médiation ne sont pas associés d’emblée à leur conception et que des négociations s’opèrent entre service scientifique, de médiation et prestataire, ces derniers pouvant tantôt être cantonnés à un rôle de sous-traitant technique, tantôt être force de proposition

Influence of operating room organization on surgical performance and patient outcomes: a scoping review protocol

Surgical performance is the result of a complex combination of technological, human and organizational factors, leading to an overall risk of 12% preventable complications. The progress made in perioperative management (anesthesia and resuscitation) has made it possible to make surgical procedures safer and to reduce the vital risk caused by complications. Technical progress in medical devices has also made it possible to reduce complications. However, all these aspects are technical and based on introducing a technology at the service of patients. The surgical intervention and the management around it remain managed by humans with all the individual and organizational factors that can influence patient outcome. Until now, the identification of risk factors for surgical complications has mainly focused on the determinants linked to the patient's comorbidities and the type of surgical procedure proposed. However, postoperative complications are only partially explained by these determinants and depend concomitantly on organizational parameters linked to the operating room environment, which remain not well known today. Indeed, these parameters have been poorly quantified and most of published studies essentially regards qualitative investigations with few statistical association with clinical implications for patient

Laparoscopic Treatment of Gastro-Gastric Fistula After RYGB: Technical Points

International audiencePostoperative abdominal pain after Roux en Y gastric bypass associated with gastro esophageal reflux is difficult to manage. A gastro-gastric fistula can be the etiology and besides pain and weight regain, it can also be revealed by a dilatation of the excluded stomach and duodenum. We present the case of a 45-year-old woman who had a medical history of revisional RYGB after failure of gastric band. She recently complained of recurrent epigastric abdominal pain and biliary GERD. Upper gastro intestinal endoscopy found biliary reflux gastritis. The CT scan with gas expansion and opacification revealed a dilated excluded stomach and duodenum leading to the diagnosis of gastro-gastric fistula. Because of pain and GERD correlated to this radiological finding, we decided to perform an exploratory laparoscopy. The patient was placed in a half-sitting position, surgeon between the legs. A 12-mmHg pneumoperitoneum was made. A 4-port technique was used. The first step consisted of a complete adhesiolysis. The second step consisted in the dissection of the excluded stomach, stuck to the gastric pouch, and revealed two gastro-gastric fistulas treated by stapling. An epiploplasty was performed on the excluded stomach and the staple line of the gastric pouch was invaginated. Postoperative course was uneventful. One year later, she had no more reflux and no more pain. Causes of abdominal pain and GERD after RYGB are difficult to identify. Gastro-gastric fistula is one of them and should be evoked when biliary reflux and abdominal pain appear