Safe Introduction of Minimally Invasive Esophagectomy at a Medium Volume Center

BACKGROUND AND AIMS

Minimally invasive esophagectomy is a favored alternative in high-volume centers. We evaluated the introduction of, and transition to, minimally invasive esophagectomy at a medium volume tertiary referral center (10-20 esophagectomies annually) with focus on surgical results.

MATERIAL AND METHODS

Patients who underwent minimally invasive esophagectomy or open transthoracic surgery for carcinoma of the esophagus or gastroesophageal junction (Siewert I and II) during 2007-2016 were retrospectively studied. Sorted on surgical approach, perioperative data, surgical outcomes, and postoperative complications were analyzed and multivariate regression models were used to adjust for possible confounders.

RESULTS

One hundred and sixteen patients were included, 51 minimally invasive esophagectomy (21 hybrid and 30 totally minimally invasive) and 65 open resections. The groups were well matched. However, higher body mass index, neoadjuvant chemoradiotherapy, and cervical anastomosis were more frequent in the minimally invasive esophagectomy group. Minimally invasive esophagectomy was associated with less peroperative bleeding (384 vs 607 mL, p = 0.036) and reduced length of stay (14 vs 15 days, p = 0.042). Duration of surgery, radical resection rate, and postoperative complications did not differ between groups. Lymph node yield was higher in the minimally invasive esophagectomy group, 18 (13-23) vs 12 (8-16), p < 0.001, confirmed in a multivariate regression model (adjusted odds ratio 3.15, 95% class interval 1.11-8.98, p = 0.032).

CONCLUSION

The introduction of minimally invasive esophagectomy at a medium volume tertiary referral center resulted in superior lymph node yield, less peroperative blood loss and shorter length of stay, without compromising the rate of radical resection, or increasing the complication rate.

Identification of environmentally stable QTL for resistance against Leptosphaeria maculans in oilseed rape (Brassica napus)

Six stable QTL for resistance against L. maculans (phoma stem canker) have been identified by QTL × environment interaction analysis using data from five winter oilseed rape field experiments. Phoma stem canker, caused by Leptosphaeria maculans, is a disease of worldwide importance on oilseed rape (Brassica napus). Quantitative trait loci (QTL)-mediated resistance against L. maculans in B. napus is considered to be race non-specific and potentially durable. Identification and evaluation of QTL for resistance to L. maculans is important for breeding oilseed rape cultivars with durable resistance. An oilseed rape mapping population was used to detect QTL for resistance against L. maculans in five winter oilseed rape field experiments under different environments. A total of 17 QTL involved in 'field' quantitative resistance against L. maculans were detected and collectively explained 51% of the phenotypic variation. The number of QTL detected in each experiment ranged from two to nine and individual QTL explained 2-25% of the phenotypic variation. QTL × environment interaction analysis suggested that six of these QTL were less sensitive to environmental factors, so they were considered to be stable QTL. Markers linked to these stable QTL will be valuable for selection to breed for effective resistance against L. maculans in different environments, which will contribute to sustainable management of the disease.

Dramatic change in public attitudes towards vaccination during the 2009 influenza A(H1N1) pandemic in France

We investigated the potential impact of the 2009 influenza A(H1N1) pandemic on attitudes towards vaccination among people aged 18 to 75 years and living in metropolitan France. We used data from three national telephone surveys conducted on representative samples in 2000, 2005 and 2010 (n=12,256, n=23,931, n=8,573 respectively). In France, unfavourable attitudes towards vaccination in general dramatically increased from 8.5% in 2000 and 9.6% in 2005 to 38.2% in 2010. In 2010, among respondents who held unfavourable attitudes towards vaccination, 50% mentioned specifically their opposition to the influenza A(H1N1) vaccine. The sociodemographic profile associated with these attitudes also changed greatly. In particular, unfavourable attitudes towards vaccination in general became significantly more frequent among less educated people in 2010. These attitudes were also correlated with vaccination behaviours. For example, parents who were unfavourable towards vaccination in general were more likely to report that they had at least one child who did not get the measlesmumps- rubella vaccine. As this shift in attitude may have a significant impact on future vaccination coverage, health authorities should urgently address the vaccine confidence gap.

[Indications of vitamin K antagonists and aspirin in the atrial fibrillation of the elderly]

Non valvular atrial fibrillation is a public health concern because of the frequency and the severity of its embolic complications, particularly strokes. The aim of this paper is to analyze the recent recommendations for the prevention of embolic events and their application in the elderly. The recommendations for the prevention of stroke, published in 2001 on the basis of the results of randomized studies comparing vitamin K antagonists (VKA) and aspirin versus placebo, have been modified in August 2006. VKA are recommended in patients at high risk of stroke. In patients considered at moderate risk, the choice is now possible between VKA and aspirin, with a reduced dosage of aspirin (75 to 325 mg). The absolute risk of stroke related to age, hypertension, heart failure or diabetes is not yet evaluated. Further studies would be necessary in order to precise the recommendations for patients with only one of these risk factors: aspirin or VKA? In geriatric patients with several risk factors, VKA are under prescribed. A better knowledge of the embolic risk of atrial fibrillation, of the often overestimated hemorrhagic risk of VKA, of the quite underestimated hemorrhagic risk of aspirin and of the recommendations for prevention would be necessary.

Evaluation of current practices in surgical antimicrobial prophylaxis in primary total hip prosthesis—a multicentre survey in private and public French hospitals

Deep wound infection is a rare but dreaded postoperative complication after total hip prosthesis (THP) procedures but its incidence can be reduced by systemic antimicrobial prophylaxis. The objective of the present study was to evaluate whether antimicrobial prophylaxis for elective primary THP in patients without any history of hip infection, in orthopaedic wards, participating on a voluntary basis, in French public hospitals and private institutions, complies with published guidelines. Three types of data were collected from anaesthetic and surgical records (November 2000-January 2001) in participating hospitals: (1) administrative data on the hospitals and orthopaedic wards, (2) data on patients, (3) data on compliance of practices with five critical criteria derived from published French guidelines. These criteria concerned administration of prophylaxis, choice of antimicrobial agent, dose of first injection, timing of administration and total length of prophylaxis. Thirty institutions sent data files on 1257 THPs to the coordination centre. Compliance exceeded 80% for all criteria except one (interval between first and second injection). Cumulative compliance with the five criteria was 66.9%. Major compliance failures were an inappropriate interval between the first injection and incision, and total antimicrobial prophylaxis exceeding 48 h. Cumulative compliance was 87.9% in teaching hospitals, 61.8% in general hospitals and 67.7% in private institutions (P<1 x 10(-6)). It was slightly higher when the annual number of interventions was > or =100 (69.4 versus 62.3%; P<0.02). Although the protocol for antimicrobial prophylaxis in THP was clear and easy, one-third of practices did not conform with all five standards. Knowledge of the results by the participating institutions should encourage them to set up working groups to draft care protocols for THP and other surgical interventions, in order to improve practice and perhaps reduce costs.

Child health care policy and delivery in France

Medical and social protection of mothers, infants, and children began in France more than a century ago. A number of laws and regulations have improved the system, which is discussed in detail. The discussion includes an overview of health policy, service delivery, and the financing of care. Is the current French system of Maternal and Child Health responsible for the good health of today's children? This question is addressed through selected examples. Finally, failures and short-comings of the system are described, including the persistence of underserved groups, unequal access to care, and other problems. Solutions are feasible, and some are now being implemented.

Postneonatal infectious disease mortality: the French situation

Mortality caused by infectious and parasitic diseases represents a limited part of all postneonatal deaths in France, which have been stable for the past decade. This component is worthy of careful analysis because it is at least partially preventable. Statistics are presented and interpreted, with discussion on which disorders should be included in assessing the impact of infection on morbidity and mortality. Figures and international rankings change according to the inclusiveness of the definition chosen. There is need for epidemiologic and statistical research to make comparisons of mortality more clear. Morbidity is also important because of high incidence, frequent hospitalization, and a heavy social cost. Policy and services in France that relate to control and treatment of infection are described, as are shortcomings that call for further efforts.