Surgery In France Research Articles

Education and training of thoracic and cardiovascular surgeons: Academic aspects in France

Over the last 15 years, there have been notable advancements in healthcare services, as well as teaching and organizational aspects, within thoracic and cardiovascular surgery in France. Traditionally, residents would enter a general surgery program before proceeding to a thoracic and cardiovascular surgery fellowship. However, starting from 2017, residents now directly enrol in a six-year thoracic and cardiovascular program, which is divided into three phases: “basic training”, “in-depth development”, and “consolidation”. Theoretical knowledge is taught during regional and national biannual seminars. To improve surgical skills, simulation workshops are organized during these seminars and on dedicated days. Finally, to further diversify their experience, residents benefit from visiting referral centres through a national tour.This article seeks to document the conventional training route for residents specializing in thoracic and cardiovascular surgery in France. We provide an overview of the training structure and methodologies employed in France for these residents, outlining the national framework that oversees their local and day-to-day training activities.

Evaluating the impact and costs of conversional or revisional metabolic bariatric surgery on obstructive sleep apnea: Insights from a French nationwide cohort

BackgroundThis study assesses the effectiveness of 5 main conversional or revisional metabolic bariatric surgery sequences after sleeve gastrectomy, adjustable gastric banding and gastric bypass on reimbursement and cost of continuous positive airway pressure therapy, the first line treatment for obstructive sleep apnea, in France. MethodsThis nationwide observational population-based cohort study analyzed data from the French National Health Insurance database. It included all patients who had undergone primary metabolic bariatric surgery in France between January 1, 2012, and December 31, 2014, and followed until December 31, 2020. The study assessed continuous positive airway pressure therapy reimbursement discontinuation and costs of reimbursed continuous positive airway pressure therapy across 5 different conversional or revisional metabolic bariatric surgery sequences. ResultsDuring follow-up, 6,396 patients underwent the following sequences: sleeve gastrectomy–gastric bypass (n = 2,400), adjustable gastric banding–sleeve gastrectomy (n = 2,277), adjustable gastric banding–gastric bypass (n = 1,173), sleeve gastrectomy–sleeve gastrectomy (n = 546), and gastric bypass–others (n =332), with a rate of obstructive sleep apnea of 15.2%, 12.4%, 15.5% 12.8%, and 9.9% in the year before conversional or revisional metabolic bariatric surgery. The rates of patients who had a discontinuation of continuous positive airway pressure were at 2 and 4 years: 41.1%, 41.9%, 46.4%, 29.3%, and 33.3%; 62.3%, 57.0%, 78.2%; 57.5%, and 44.4%, respectively. At 4 years, the mean annual costs (euros) of obstructive sleep apnea treatment per patient were significantly lower (P < .01) than the costs in the year before conversional or revisional metabolic bariatric surgery for each sequence: 526.9 ± 414.4 vs 257.4 ± 349.7; 368.0 ± 247.5 vs 230.9 ± 288.4; 433.7 ± 326.0 vs 116.8 ± 238.3; 540.7 ± 275.3 vs 248.0 ± 308.4 and 501.2 ± 254.0 vs 281.1 ± 287.0, respectively. ConclusionsOur study underscore the effectiveness of conversional or revisional metabolic bariatric surgery in significantly reducing the need and associated costs of continuous positive airway pressure therapy for patients with obstructive sleep apnea postprimary metabolic bariatric surgery over a 4-year period.

Evolution of minimally invasive liver surgery in France over the last decade.

Despite evidence of benefits on postoperative outcomes, minimally invasive liver surgery (MILS) had a very low diffusion up to 2014, and recent evolution is unknown. Our aim was to analyze the recent diffusion and adoption of MILS and compare the trends in indications, extent of resection, and institutional practice with open liver surgery (OLS). We analyzed the French nationwide, exhaustive cohort of all patients undergoing a liver resection in France between January 1, 2013 and December 31, 2022. Average annual percentage changes (AAPC) in the incidence of MILS and OLS were compared using mixed-effects log-linear regression models. Time trends were analyzed in terms of extent of resection, indication, and institutional practice. MILS represented 25.2% of 74,671 liver resections and year incidence doubled from 16.5% in 2013 to 35.4% in 2022. The highest AAPC were observed among major liver resections [+ 22.2% (19.5; 24.9) per year], primary [+ 10.2% (8.5; 12.0) per year], and secondary malignant tumors [+ 9.9% (8.2; 11.6) per year]. The highest increase in MILS was observed in university hospitals [+ 14.7% (7.7; 22.2) per year] performing 48.8% of MILS and in very high-volume (> 150 procedures/year) hospitals [+ 12.1% (9.0; 15.3) per year] performing 19.7% of MILS. OLS AAPC decreased for all indications and institutions and accelerated over time from -1.8% (-3.9; -0.3) per year in 2013-2018 to -5.9% (-7.9; -3.9) per year in 2018-2022 (p = 0.013). This is the first reported trend reversal between MILS and OLS. MILS has considerably increased at a national scale, crossing the 20% tipping point of adoption rate as defined by the IDEAL framework.

Cost-effectiveness of left atrial appendage occlusion during cardiac surgery in France: An economic evaluation based on the LAAOS III study

Objectives Left atrial appendage occlusion during cardiac surgery is a therapeutic option for stroke prevention in patients with atrial fibrillation. The effectiveness and safety of left atrial appendage occlusion have been evaluated in several studies, including the LAAOS-III trial. While these studies have demonstrated efficacy and safety, the long-term economic impact of this surgical technique has not yet been assessed. Here, we aimed to evaluate the cost-effectiveness and cost-utility of left atrial appendage occlusion during cardiac surgery over a long-term time horizon. Methods Our study was based on a model representing an hypothetical cohort with the same characteristics as LAAOS-III trial patients. We modelled the incidence of ischemic strokes and systemic embolisms in each intervention arm: "occlusion" and "no-occlusion," using a one-month cycle length with a 20-year time horizon. Regarding occlusion devices, sutures, staples, or an approved surgical occlusion device (AtriClip™—AtriCure, Ohio, USA) could be used. Results Our model generated an average cost savings of 607 euros per patient and an incremental gain of 0.062 quality-adjusted life years (QALYs), resulting an incremental cost-utility ratio (ICUR) of €-9,775/QALY. The scenario analysis in which occlusion was systematically performed using the AtriClip™ device generated an ICUR of €3,952/QALY gained. Conclusions In the base-case analysis, the strategy proved to be more effective and less costly, confirming left atrial appendage occlusion during cardiac surgery as an economically dominant strategy. The scenario analysis also appeared cost-effective, although it did not result in cost savings. This study provides a new perspective on the assessment of the cost-effectiveness of these techniques.

Average total weight of surgical waste and CO2 carbon footprint of orthopedic surgery in France, estimated on the basis of a representative panel

BackgroundReduction of waste and carbon footprint can be optimized. Awareness of carbon sources and quantification of the waste are two key parameters. To our knowledge, there is no study in France on waste production by the surgical team during the operation in orthopedic surgery, in a global scope. Therefore, we performed an observational investigation aiming to: (1) quantify and characterize the weight of the wastes generated after a panel of orthopedic procedures, (2) calculate the CO2 footprint generated by these wastes and extrapolate the figure at the national scale. HypothesisWaste production is highly variable according to the types of procedures and infectious clinical waste is still a predominant source of waste and CO2 emission. Materials and methodsIt is a comparative and prospective study in which a total of 14 procedures were selected as a representative panel: arthroplasties (hip, knee), spine fusions, arthroscopic procedures (shoulder, knee), nerve release, forefoot osteotomies, trauma procedures. The main outcome was the average total weight of waste for each of the fourteen categories (280 measurements: 140 times 2, at the end of each procedure), expressed in kilograms (kg), and the proportions of infectious clinical waste (ICW) and household wastes (HW), expressed in percentages. Ten measures were prospectively recorded for each type of procedure in a single teaching hospital from January to September 2022. The theoretical carbon footprint generated by the treatment of the wastes was estimated in kilograms of CO2 equivalent (KgEqCO2). The national extrapolation of the carbon footprint was performed by collecting the total number of procedures in France in 2021 using the VisuChir tool. ResultsA total of 937kg of waste were produced for the 140 procedures, amongst which 514kg of ICW (54.8%) and 423kg of HW (45.2%). The overall median waste weight was 5.9kg (Q1: 4.4, Q3: 8.1), ranging from 1.8kg to 18.3kg. The overall median waste weight for HW was 2.8kg (Q1: 2.5, Q3: 3.4), ranging from 1.8kg to 17.8kg. The overall median waste weight for ICW was 3.8kg (Q1: 2.7, Q3: 4.8), ranging from 0.8kg to 7.2kg. The knee surgeries were responsible for the heaviest waste weight; the least waste-productive procedures were the foot and the carpal tunnel release. The median proportions of ICW varied from 39% for the total knee replacements to 72% for the femoral nails. There was a significant inverse correlation between the total waste weight and the proportion of ICW: r=−0.47, p<10−4. The total median estimated carbon footprint was 4.3KgCO2Eq (Q1: 3.1, Q3: 5.8), ranging from 1.59KgCO2Eq (Q1: 1.5, Q3: 1.8) and 7.07KgCO2Eq (Q1: 6.7, Q3: 8.17). The total median estimated carbon footprint was 3.5KgCO2Eq for ICW (Q1: 2.5, Q3: 4.5) and 0.76KgCO2Eq (Q1: 0.54, Q3: 1.3) for HW. The national median estimated carbon footprint was 10.1 million KgEqCO2 in 2021 for orthopedic surgery. ConclusionOur study revealed that in most cases more than half of the wastes were ICW. The total estimated national carbon footprint for orthopedic procedures was 10 million kilograms. The reduction of the ICW constitutes a cornerstone, as they are responsible for more carbon emissions. Level of evidenceIII; prospective comparative observational in vivo study.

Evolution of laparoscopic liver surgery in France over the last decade

Evolution of laparoscopic liver surgery in France over the last decade

Is female sex a risk factor for mortality after coronary artery revascularization surgery in France?

Is female sex a risk factor for mortality after coronary artery revascularization surgery in France?

Clinical and economic burden of surgical complications during hospitalization for digestive cancer surgery in France.

Surgical complications and particularly infections after digestive cancer surgery remain a major health and economic problem and its burden in France is not well documented. The aim of this study was to analyse recent data regarding surgical complications in patients undergoing major digestive cancer surgery, and to estimate its burden for the French society. Using the 2018 French hospital discharge database and 2017 National CostStudy we studied hospital stays for surgical resection in patients withdigestive cancer. The population was divided into three groups based onpostoperative outcomes: no complications (NC), related infectious complications (RIC) and other complications. The main analysis compared the length and cost per stay between RIC and NC. Forty-Four thousand one hundred and twenty-three stays following a digestive cancer resection were identified. Lower gastro-intestinal cancers were the most prevalent representing 74.8% of stays, the rate of malnutrition was 32.8% and 15.8% of patients presented RIC. Mean (SD) length of stay varied from 11,7 (9.0) days for NC to 25,5 days (19.5) for RIC (p < 0.01). The mean cost per patients' stay (SD) varied from €10 641 (€ 5897) for the NC to €18 720 (€7905) for RIC (p < .01). The risk of RIC after digestive cancer resection remains high (>15%) and was associated with significantly longer length of stay and higher cost per stay. Although important prevention plans have been implemented in recent years, care strategies are still needed to alleviate the burden on patients and the healthcare system.

Mortality and failure-to-rescue major complication trends after lung cancer surgery between 2005 and 2020: a nationwide population-based study

ObjectivesTo estimate the evolution of quality indicators (30-day mortality and failure-to-rescue) inpatients who underwent lung cancer surgery in France over the past 15 years and to study the potential influencing...

Incidence, risk factors, and burden of incisional hernia repair after abdominal surgery in France: a nationwide study

PurposeIncisional hernias are common after laparotomies. The aims of this study were to assess the rate of incisional hernia repair after abdominal surgery, recurrence rate, hospital costs, and risk factors, in France.MethodsThis national, retrospective, longitudinal, observational study was based on the exhaustive hospital discharge database (PMSI). All adult patients (≥ 18 years old) hospitalised for an abdominal surgical procedure between 01-01-2013 and 31-12-2014 and hospitalised for incisional hernia repair within five years were included. Descriptive analyses and cost analyses from the National Health Insurance (NHI) viewpoint (hospital care for the hernia repair) were performed. To identify risk factors for hernia repair a multivariable Cox model and a machine learning analysis were performed.ResultsIn 2013–2014, 710074 patients underwent abdominal surgery, of which 32633 (4.6%) and 5117 (0.7%) had ≥ 1 and ≥ 2 incisional hernia repair(s) within five years, respectively. Mean hospital costs amounted to €4153/hernia repair, representing nearly €67.7 million/year. Some surgical sites exposed patients at high risk of incisional hernia repair: colon and rectum (hazard ratio [HR] 1.2), and other sites on the small bowel and the peritoneum (HR 1.4). Laparotomy procedure and being ≥ 40 years old put patients at high risk of incisional hernia repair even when operated on low-risk sites such as stomach, duodenum, and hepatobiliary.ConclusionThe burden of incisional hernia repair is high and most patients are at risk either due to age ≥ 40 or the surgery site. New approaches to prevent the onset of incisional hernia are warranted.

The Effect of the COVID-19 Crisis on Vascular Surgery Training in France.

In France, since March 2020, the healthcare system has experienced a significant decrease or even suspension of surgical activity and admissions due to the coronavirus disease 2019 (COVID-19). This activity is essential to the acquisition of technical skills for all trainees enrolled in the Vascular and Endovascular Surgery Training Program either as residents or fellows. The crisis may have affected the training of vascular surgery trainees. We describe the consequences and effects of the COVID-19 crisis on the training of vascular surgery trainees. A cross-sectional study using an anonymous survey of 12 items was sent to all surgeons in training, registered at the French College of Vascular and Endovascular Surgery (CFCVE). Responses were collected between July and November 2021. Fifty-two responses were collected from trainees (residents=48%; fellows=52%), seven of who contracted COVID-19 disease. The crisis affected their scheduled and emergency surgical activities, in 96% and 77%, respectively. Thirty-one percent of responders stopped all activity, for an average of 1.5 months. Eighteen percent of responders were reassigned to other services (emergency department, ICU, vascular access unit, etc...) for an average duration of two months. Sixty-seven percent of responders believe that their level of surgical training was affected due to the crisis. Fifty-six percent of responders do not think they have achieved their training objectives (55% for fellows, 65% for senior vascular surgery residents (4th, 5th, and 6th year), and 92% for junior vascular surgery residents (year 1, 2, and 3), contributing that to the COVID-19 crisis and its effect on the flow of patients during the crisis.Additional training time (> 3 months) and the utilization of simulation training to reduce the gap produced by the COVID-19 crisis were favored in 60% and 73% of cases respectively. The COVID-19 health crisis has affected the training of surgical trainees in vascular and endovascular surgery in France. Endovascular and vascular surgical French students in training are waiting now, for additional educational proposals, allowing them to make up for their lack of practice.

Diffusion of Minimally Invasive Approach for Lung Cancer Surgery in France: A Nationwide, Population-Based Retrospective Cohort Study

Background. The minimally invasive approach (MIA) has gained popularity thanks to its efficacy and safety. Our work consisted of evaluating the diffusion of the MIA in hospitals and the variability of this approach (within and between regions). Methods. All patients who underwent limited resection or lobectomy for lung cancer in France were included from the national hospital administrative database (2013–2020). We described between-hospital differences in the MIA rate over four periods (2013–2014, 2015–2016, 2017–2018, and 2019–2020). The potential influence of the hospital volume, hospital type, and period on the adjusted MIA rate was estimated by a multilevel linear regression. Results. From 2013 to 2020, 77,965 patients underwent a lobectomy or limited resection for lung cancer. The rate of the MIA increased significantly over the four periods (50% in 2019–2020). Variability decreased over time in 7/12 regions. The variables included in the multilevel model were significantly related to the adjusted rate of the MIA. Variability between regions was considerable since 18% of the variance was due to systematic differences between regions. Conclusions. We confirm that the MIA is part of the surgical techniques used on a daily basis for the treatment of lung cancer. However, this technology is mostly used by surgeons in high volume institutions.

Editorial Comment.

No AccessJournal of UrologyAdult Urology16 Jun 2023Editorial CommentThis article comments on the following:Early vs Delayed Transurethral Surgery in Acute Urinary Retention: Does Timing Make a Difference? Timothy J. Burns and Peter J. Gilling Timothy J. BurnsTimothy J. Burns Department of Urology, Tauranga Hospital, Tauranga, New Zealand More articles by this author and Peter J. GillingPeter J. Gilling Department of Urology, Tauranga Hospital, Tauranga, New Zealand University of Auckland, Auckland, New Zealand More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003559.01AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack Citations ShareFacebookLinked InTwitterEmail "Editorial Comment." The Journal of Urology, Publish Ahead of Print, pp. REFERENCES 1. Consequences of SARS-CoV-2 pandemic on urological surgery in France: a nationwide analysis of the healthcare system database. BMJ Open. 2022; 12(11):e066220-e066220. Crossref, Medline, Google Scholar 2. Management of acute urinary retention: a worldwide survey of 6074 men with benign prostatic hyperplasia. BJU Int. 2011; 109(1):88-95. Crossref, Medline, Google Scholar 3. . Early vs delayed transurethral surgery in acute urinary retention: does timing make a difference?J Urol. 2023; 210(3):000-000. Google Scholar Submitted November 11, 2022; accepted May 15, 2023; published 000. © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsRelated articlesJournal of Urology30 May 2023Early vs Delayed Transurethral Surgery in Acute Urinary Retention: Does Timing Make a Difference? Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Timothy J. Burns Department of Urology, Tauranga Hospital, Tauranga, New Zealand More articles by this author Peter J. Gilling Department of Urology, Tauranga Hospital, Tauranga, New Zealand University of Auckland, Auckland, New Zealand More articles by this author Expand All Submitted November 11, 2022; accepted May 15, 2023; published 000. Advertisement PDF downloadLoading ...

Association of Organizational Pathways With the Delay of Emergency Surgery

Delayed admission of patients with surgical emergencies to the operating room occurs frequently and is associated with poor outcomes. In France, where 3 distinct organizational pathways in hospitals exist (a dedicated emergency operating room and team [DET], a dedicated operating room in a central operating theater [DOR], and no dedicated structure or team [NOR]), neither the incidence nor the influence of delayed urgent surgery is known, and no guidelines are available to date. To examine the overall frequency of delayed admission of patients with surgical emergencies to the operating room across the 3 organizational pathways in hospitals in France. This prospective multicenter cohort study was conducted in 10 French tertiary hospitals. All consecutive adult patients admitted for emergency surgery from October 5 to 16, 2020, were included and prospectively monitored. Patients requiring pediatric surgery, obstetrics, interventional radiology, or endoscopic procedures were excluded. Emergency surgery. The main outcome was the global incidence of delayed emergency surgery across 3 predefined organizational pathways: DET, DOR, and NOR. The ratio between the actual time to surgery (observed duration between surgical indication and incision) and the ideal time to surgery (predefined optimal duration between surgical indication and incision according to the Non-Elective Surgery Triage classification) was calculated for each patient. Surgery was considered delayed when this ratio was greater than 1. A total of 1149 patients were included (mean [SD] age, 55 [21] years; 685 [59.9%] males): 649 in the DET group, 320 in the DOR group, and 171 in the NOR group (missing data: n = 5). The global frequency of surgical delay was 32.5% (95% CI, 29.8%-35.3%) and varied across the 3 organizational pathways: DET, 28.4% (95% CI, 24.8%-31.9%); DOR, 32.2% (95% CI, 27.0%-37.4%); and NOR, 49.1% (95% CI, 41.6%-56.7%) (P < .001). The adjusted odds ratio for delay was 1.80 (95% CI, 1.17-2.78) when comparing NOR with DET. In this cohort study, the frequency of delayed emergency surgery in France was 32.5%. Reduced delays were found in organizational pathways that included dedicated theaters and teams. These preliminary results may pave the way for comprehensive large-scale studies, from which results may potentially inform new guidelines for quicker and safer access to emergency surgery.

Impact of robotic access on outcomes after lung cancer surgery in France: Analysis from the Epithor database

IntroductionWe aimed to compare postoperative outcomes after pulmonary resection for lung cancer after open thoracotomy (OT), video-assisted (VATS), and robotic-assisted (RA) thoracic surgery using a propensity score analysis. MethodsFrom 2010 to 2020, 38,423 patients underwent resection for lung cancer. In total, 58.05% (n = 22,306) were operated by thoracotomy, 35.35% (n = 13,581) by VATS, and 6.6% (n = 2536) by RA. A propensity score was used to create balanced groups with weighting. End points were in-hospital mortality, postoperative complications, and length of hospital stay, reported by odds ratios (ORs) and 95% confidence intervals (CIs). ResultsVATS decreased in-hospital mortality compared with OT (OR, 0.64; 95% CI, 0.58-0.79; P < .0001) but not compared with RA (OR, 1.09; 95% CI, 0.77-1.52; P = .61). VATS reduced major postoperative complications compared with OT (OR, 0.83; 95% CI, 0.76-0.92; P < .0001) but not RA (OR, 1.01; 95% CI, 0.84-1.21; P = .17). VATS reduced prolonged air leaks rate compared with OT (OR, 0.9; 95% CI, 0.84-0.98; P = .015) but not RA (OR, 1.02; 95% CI, 0.88-1.18; P = .77). As compared with OT, VATS and RA decreased the incidence of atelectasis (respectively: OR, 0.57; 95% CI, 0.50-0.65; P < .0001 and OR, 0.75; 95% CI, 0.60-0.95; P = .016); the incidence of pneumonia (OR, 0.75; 95% CI, 0.67-0.83; P < .0001 and OR, 0.62; 95% CI, 0.50-0.78; P < .0001); and the number of postoperative arrhythmias (OR, 0.69; 95% CI, 0.61-0.78; P < .0001 and OR, 0.75; 95% CI, 0.59-0.96; P = .024). Both VATS and RA resulted in shorter hospital stays (−1.91 days [−2.24; −1.58]; P < .0001 and −2.73 days [−3.1; −2.36]; P < .0001, respectively). ConclusionsRA appeared to decrease postoperative pulmonary complications as well as VATS compared with OT. VATS decreased postoperative mortality as compared with RA and OT.

Is there variation between hospitals within each region in postoperative mortality for lung cancer surgery in France? A nationwide study from 2013 to 2020.

The practice of thoracic surgery for lung cancer is subject to authorization in France. We evaluated the performance of hospitals using 30-day post-operative mortality as a quality indicator, estimating its distribution within each region and measuring its variability between regions. All data for patients who underwent pulmonary resection for lung cancer in France (2013-2020) were collected from the national hospital administrative database. Thirty-day mortality was defined as any patient who died in hospital (including transferred patients) within the first 30 days after the operation and those who died later during the initial hospitalization. The Standardized Mortality ratio (SMR) was the smoothed, adjusted, hospital-specific mortality rate divided by the expected mortality. To describe the variation in hospital mortality between hospitals in each region, we used different commonly used indicators of variation such as coefficients of variation (CV), interquartile interval or range (IQR), extreme ratio, and systematic component of variance (SCV). In 2013-2020, 87,232 patients underwent lung resection for cancer in France. The number of deaths was 2,537, a rate of 2.91%. The median SMR of 199 hospitals was 0.99 with an IQR of 0.86 to 1.18 and a CV of 0.25. Among the regions that had the most hospitals performing lung resections for cancer, the extreme ratio was >2, which means that the maximum value is twice as high as the minimum value. The SCV between hospitals was >10 for two of these regions, which is considered indicative of very high variation. For the other regions (with few hospitals performing lung resections for cancer), the variation between hospitals was lower. Globally, the variability between regions concerning the SMR was moderate, 6% of the variance was due to differences across regions. On the contrary, the hospital volume was significantly related to the SMR (p = 0.003) with a negative linear trend, whatever the region. This work shows significant differences in the practices of the various hospitals within regions. However, overall, the variability in the 30-day mortality rate between regions was moderate. Our findings raises questions regarding the regionalization of major surgical procedures in France.

Abstract P3-07-06: Comedications at Breast Cancer diagnosis impact overall survival: results from the ADRENALINE (Atlas for DRug and brEast caNcer survivAL INtEraction) study (n=235,368)

Abstract Background: More than half of Breast Cancer (BC) patients take chronically used non-cancer treatments (denoted as comedications) at BC diagnosis. Epidemiological evidence has reported that several non-cancer treatments may modify BC risk, BC recurrence, and overall survival (OS). The ADRENALINE project (Atlas for DRug and brEast caNcer survivAL INtEraction) analyses the impact of the use of each commonly prescribed non-cancer treatment at BC diagnosis on OS using the French social security system data on a comprehensive cohort of French BC patients. Methods: We identified all women diagnosed with an incident BC treated with surgery in France from 2011 to 2017 and affiliated to the general health insurance scheme. Women with concomitant cancer or metastases at diagnosis were discarded from the analyses. Comedication intake was defined as the delivery in pharmacy of at least 3 months of full treatment (e.g. 90 pills) the 6 months preceding BC diagnosis. A Cox proportional hazard model was used to estimate the hazard ratio (HR) for each molecule. The model was adjusted on more than 100 confounding variables: social factors, comorbidities and other comedications by Inverse Probability of Treatment Weighting (IPTW). We assumed that the adjustment was sufficient to control for confounding if the standardized mean difference of each confounder after adjustment did not exceed 0.1. Molecules which did not pass the adjustment quality test were discarded. Results: Overall, 235,368 patients were included in the study. Among 219 selected drugs, 91 passed the adjustment quality test. The full set of results is available on a web application (https://adrenaline.curie.fr). Several drugs or drug classes were associated with an improved survival: statins (e.g. rosuvastatin, HR=0.65, p&amp;lt; 0.001); proton-pump inhibitors (HR=0.93; p=0.002); or beta-blocking agents (atenolol, HR=0.78, p=0.003). Conversely, anti-anemic preparations (folic acid and ferrous sulfate) had a significant deleterious effect (HR = 1.63; p&amp;lt; 0.001). Drugs from the same therapeutic class, could have different effects: within benzodiazepines, bromazepam was protective (HR = 0.91; p = 0.038) while oxazepam was deleterious (HR = 1.37; p &amp;lt; 0.001). Conclusion: ADRENALINE reports the impact on BC survival of 219 widely prescribed drugs. It can be used to identify molecules with a potential protective or deleterious effect relative to BC. Some of them are currently under mechanistical investigation within a drug screening program. This atlas highlights candidates to drug-repurposing trials or pharmacovigilance warnings, and will be extended to cancers of other localizations in a near future. Citation Format: Elise Dumas, Beatriz Grandal, Paul Gougis, Sophie Houzard, Aurélien Latouche, Aullène Toussaint, Samar Alsafadi, Judith Abecassis, Lidia Delrieu, Thierry Dubois, Nadir Sella, Marc Espie, Bernard Asselain, Annabelle Ballesta, Benjamin Marande, Eric Daoud, Enora Laas, Amyn Kassara, Floriane Jochum, Elaine Del Nery, Elodie Anthony, Christine Le Bihan-Benjamin, Philippe-Jean Bousquet, Chloé-Agathe Azencott, Fabien Reyal, Anne-Sophie Hamy. Comedications at Breast Cancer diagnosis impact overall survival: results from the ADRENALINE (Atlas for DRug and brEast caNcer survivAL INtEraction) study (n=235,368) [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P3-07-06.

Excess mortality among non-COVID-19 surgical patients attributable to the exposure of French intensive and intermediate care units to the pandemic.

The mobilization of most available hospital resources to manage coronavirus disease 2019 (COVID-19) may have affected the safety of care for non-COVID-19 surgical patients due to restricted access to intensive or intermediate care units (ICU/IMCUs). We estimated excess surgical mortality potentially attributable to ICU/IMCUs overwhelmed by COVID-19, and any hospital learning effects between two successive pandemic waves. This nationwide observational study included all patients without COVID-19 who underwent surgery in France from 01/01/2019 to 31/12/2020. We determined pandemic exposure of each operated patient based on the daily proportion of COVID-19 patients among all patients treated within the ICU/IMCU beds of the same hospital during his/her stay. Multilevel models, with an embedded triple-difference analysis, estimated standardized in-hospital mortality and compared mortality between years, pandemic exposure groups, and semesters, distinguishing deaths inside or outside the ICU/IMCUs. Of 1,870,515 non-COVID-19 patients admitted for surgery in 655 hospitals, 2% died. Compared to 2019, standardized mortality increased by 1% (95% CI 0.6-1.4%) and 0.4% (0-1%) during the first and second semesters of 2020, among patients operated in hospitals highly exposed to pandemic. Compared to the low-or-no exposure group, this corresponded to a higher risk of death during the first semester (adjusted ratio of odds-ratios 1.56, 95% CI 1.34-1.81) both inside (1.27, 1.02-1.58) and outside the ICU/IMCU (1.98, 1.57-2.5), with a significant learning effect during the second semester compared to the first (0.76, 0.58-0.99). Significant excess mortality essentially occurred outside of the ICU/IMCU, suggesting that access of surgical patients to critical care was limited.

Intérêts de la centralisation de la chirurgie du cancer de l’ovaire en France

To examine the current state for ovarian cancer surgery in France from 2009 to 2016 and to examine the impact of the volume of activity on morbidity and mortality by institution. National retrospective study analyzing surgical sessions for ovarian cancer from the program of medicalization of information systems (PMSI), from January 2009 to December 2016. Institutions were divided according to the number of annual curative procedures into 3 groups: A<10; B: 10-19; C≥20. A propensity score (PS) and the Kaplan-Meier method were employed for statistical analyses. In total, 27,105 patients were included. The 1-month mortality rate in group A, B and C was 1.6; 1 and 0.7%, respectively (P<0.001). Compared to group C, the Relative Risk (RR) of death within the first month was 2.22 for group A and 1.32 for group B (P<0.01). After MS, the 3- and 5-year survival in group A+B and group C were 71.4 and 60.3% (P<0.05) and 56.6, and 60.3% (P<0.05), respectively. The 1-year recurrence rate was significantly lower in group C (P<0.0001). An annual volume of activity>20 advanced stage ovarian cancers is associated with a decrease in morbidity, mortality, recurrence rate and improved survival.

Malpractice litigation after spinal surgery: A review of allegations in France in 1990–2020

ObjectiveSpinal surgery is among the specialities with the highest rates of complications and of peri-operative morbidity and mortality. The number of spinal surgeries performed is rising year on year in France. The objectives of this study were to identify the main reasons for malpractice claims after spinal surgery in France, to evaluate the impact of avoidable errors, and to examine differences between civil lawsuits (private institutions) and administrative lawsuits (public institutions). HypothesisThe leading reasons for malpractice litigation are avoidable errors such as inadequate patient information, errors in indications, and inadequate post-operative monitoring. Material and methodsWe reviewed malpractice claims related to spinal surgery and recorded in two French databases (Legifrance and Doctrine) in 1990–2020. We combined the indexing term “surgery” with any of the following terms: “disc”, “spine”, “cervical”, “vertebral”, “lumbar”, “scoliosis”, “disc replacement”, and “fusion”. The search was performed by three orthopaedic surgeons who were blind to patient data and recorded the allegations, verdicts, and pay-outs. ResultsWe included 275 claims. The main plaintiff allegations were inadequate information (34.5%), infection (22%), spinal-cord injury (17%), and errors in indication (13%). Among these reasons, 56.7% may have been partly avoidable. In private institutions, claims for infection and for erroneous indication were significantly more common than in public institutions (p=0.02 for both), whereas the opposite was true for spinal-cord injury (p<0.001). ConclusionAfter spinal surgery in France, the most common malpractice allegation was inadequate information. Over half the claims were related to potentially avoidable factors. Among allegations, errors in indication were significantly more common in civil than in administrative lawsuits. Level of proofIV, retrospective observational database study.