Karim Saidi

Hassane Zouhal
email: hassane.zouhal@univ-rennes2.fr

Daniel Boullosa

Gregory Dupont

Anthony C Hackney

Benoit Bideau

Urs Granacher
email: prof.u.granacher@uni-potsdam.de

Abderraouf Ben Abderrahman

Prof H Zouhal

Biochemical markers and wellness status during a congested match play period in elite soccer players Original Investigation

Keywords: training, congested calendar, overtraining, overreaching, recovery

Objectives:

To analyze biochemical markers, wellness status and physical fitness in elite soccer players in relation to changes in training and match exposure during a congested period of match play. Methods: Fourteen elite soccer players were evaluated three times (T1, T2, and T3) over 12 weeks ([T1-T2: six weeks regular period of match play], [T2-T3: six weeks congested period of match play]). Players performed vertical jump tests, the repeated shuttle sprint ability test (RSSA), and the Yo-Yo intermittent recovery test (YYIR1) at T1, T2, and T3.

Plasma C-reactive protein (CRP), creatinine, and creatine kinase (CK) were analyzed at T1, T2, and T3. Wellness status was measured daily using Hopper questionnaires (delayed onset of muscle soreness [DOMS], stress, fatigue, sleep quality). Training session rating of perceived exertion (sRPE) was also recorded on a daily basis. Results: A significant increase was found in stress, fatigue, DOMS scores, and Hopper index during the congested period (between T2-3) as compared with the regular period (between T1-2), (0.001<p<0.008, 0.8<ES<2.3).

Between T2-3, significant relationships were found between the Δ% of CRP, and Δ% of CK with the Hopper index and the Δ% of fatigue score. In addition, the Δ% of fatigue score and Δ% of DOMS score correlated with Δ% YYIR1 and Δ% RSSAbest (0.49<r<p<0.01).

Conclusions: An intensive period of congested match play significantly compromised elite soccer players' physical fitness and wellness status. Elite soccer players' wellness status reflects declines in physical fitness during a congested period of match play while biochemical changes do not.

Introduction

The physiological demands of soccer have increased over the past decades due to a higher density of soccer matches, and an increase in mean intensity of matches. [START_REF] Carling | Are physical performance and injury risk in a professional soccer team in match-play affected over a prolonged period of fixture congestion?[END_REF] During periods when the schedule is particularly congested (i.e., two matches per week over several weeks), the recovery time between successive matches is only 2-3 days, which may be insufficient to allow full recovery of the players. [START_REF] Carling | Are physical performance and injury risk in a professional soccer team in match-play affected over a prolonged period of fixture congestion?[END_REF][START_REF] Dellal | The effects of a congested fixture period on physical performance, technical activity and injury rate during matches in a professional soccer team[END_REF] As a result, players may experience acute and chronic fatigue potentially leading to underperformance and an increased injury risk. [START_REF] Dellal | The effects of a congested fixture period on physical performance, technical activity and injury rate during matches in a professional soccer team[END_REF][START_REF] Saidi | The Interplay Between Plasma Hormonal Concentrations, Physical Fitness, Workload and Mood State Changes to Periods of Congested Match Play in Professional Soccer Players[END_REF] To prevent imbalances and overtraining during congested schedules, biochemical assessments are commonly used. [START_REF] Rowsell | Effects of cold-water immersion on physical performance between successive matches in high-performance junior male soccer players[END_REF] This procedure could be used in soccer clubs as it typically involves the assessment of blood markers indicating inflammation and muscle damage. [START_REF] Pascoal | Pre-Season training affects negatively the immunological parameters and creatine kinase but not power performance in young soccer players[END_REF][START_REF] Coppalle | Relationship of pre-season training load with in-season biochemical markers, injuries and performance in professional soccer players[END_REF] Creatine kinase (CK), C-reactive protein (CRP), and creatinine are biochemical markers that are often used to ACCEPTED MANUSCRIPT / CLEAN COPY quantify muscle damage and inflammation. [START_REF] Djaoui | Monitoring training load and fatigue in soccer players with physiological markers[END_REF] These biochemical parameters are sensitive to training periods differing in volume and intensity and frequency of matches during the competitive period. [START_REF] Walker | Biomarker response to a competitive season in Division I female soccer players[END_REF] Coaches and sports scientists conceptualized soccer as a psycho-physiological complex sport [START_REF] Haddad | Influence of fatigue, stress, muscle soreness and sleep on perceived exertion during submaximal effort[END_REF] where subtle changes in training load could affect wellness status and, ultimately physical performance. [START_REF] Saidi | The Interplay Between Plasma Hormonal Concentrations, Physical Fitness, Workload and Mood State Changes to Periods of Congested Match Play in Professional Soccer Players[END_REF][START_REF] Rowsell | Effects of cold-water immersion on physical performance between successive matches in high-performance junior male soccer players[END_REF][START_REF] Pascoal | Pre-Season training affects negatively the immunological parameters and creatine kinase but not power performance in young soccer players[END_REF][START_REF] Coppalle | Relationship of pre-season training load with in-season biochemical markers, injuries and performance in professional soccer players[END_REF][START_REF] Djaoui | Monitoring training load and fatigue in soccer players with physiological markers[END_REF][START_REF] Walker | Biomarker response to a competitive season in Division I female soccer players[END_REF][START_REF] Haddad | Influence of fatigue, stress, muscle soreness and sleep on perceived exertion during submaximal effort[END_REF][START_REF] Thorpe | Monitoring fatigue during the in-season competitive phase in elite soccer players[END_REF] Therefore, several studies reported the usefulness of psychological questionnaires for monitoring changes in training-related stress, wellness, strain and recovery to detect early signs of tiredness and potential overtraining in high-performance sport programs. [START_REF] Hooper | Monitoring overtraining in athletes recommendations[END_REF][START_REF] Coutts | Monitoring changes in rugby league players' perceived stress and recovery during intensified training[END_REF] Recently, Thorpe et al. [START_REF] Thorpe | Monitoring fatigue during the in-season competitive phase in elite soccer players[END_REF] have reported that daily training load had affected these wellness measurements in elite soccer players of the English Premier League. In addition to training load, there are various contextual aspects, particularly those related to environmental conditions such as social factors, personality trait, moment of the season, league ranking, and match importance, that could influence players' status and, hence, their perceived wellness level. [START_REF] Chamari | Injury rates in professional soccer players during Ramadan[END_REF][START_REF] Fessi | Changes of the psychophysical state and feeling of wellness of professional soccer players during pre-season and in-season periods[END_REF] However, to the best of our knowledge, there is little information concerning the relation between biochemical markers, players' wellness, and physical fitness in elite soccer players during different competitive periods of a soccer season. Therefore, the aims of this study were to examine fluctuations in inflammatory and muscle damage markers, wellness status (including perceived ratings of sleep, fatigue, stress, and muscle soreness), and physical fitness during a competitive soccer season, which included a congested period of match play and to examine the inter-relation between all of these parameters. Based on relevant literature data, 3-9- 10-14 it was hypothesized that biochemical parameters and wellness status may be altered after the congested periods of competition, which, in turn, could cause negative changes in players' physical fitness which would be evident through the associations between selected measures.

Methods

Participants

Initially, 22 elite male soccer players from the same soccer club within the first soccer division of Tunisia were enrolled in this study. Over the course of the study, eight players were injured and did not complete all training sessions. Athletes who attended less than 85% of the scheduled training sessions and matches were therefore excluded from the study. Finally, 14 players (age 20.9 ± 0.8 y; height: 177 ± 5 cm; mass: 72.4 ± 5.2 kg) were eligible for inclusion in this study.

The enrolled players had the longest match exposure over the experimental period (accumulated match time = 1032.50 ± 161.05 minutes). All participants signed informed consent forms ACCEPTED MANUSCRIPT / CLEAN COPY outlining commitment, benefits, potential risks, and the study's procedures, which were approved by the local Ethics Committee of the medical staff of the soccer club and conformed to the Declaration of Helsinki.

Procedures

The study was carried out during a period of 12 weeks within the competitive season, and was designed to analyze inflammation, muscle damage, workload, physical fitness, and wellness status to changes in training and match exposure during a congested period of match play.

Testing of players started 6 weeks after the beginning of the second competitive period following the winter break. During this period, players trained five times per week with one match. All players were evaluated three times during the study; T1 was in the middle of the regular period (uncongested) (week 1); T2 was at the end of the regular period (before the congested period; week 6). T3 was completed after the congested period (week 12; after the season) (figure 1).

The assessments were performed over three days in the same order during the T1, T2 and T3 testing sessions. On the first day, blood samples were collected at each time point to monitor muscle damage (creatine kinase [CK]) and inflammation (C-reactive protein [CRP] and creatinine). On the second day, participants performed three physical fitness tests (the squat jump (SJ), the countermovement jump (CMJ), and the repeated shuttle sprint ability test (RSSA). On the third testing day, participants performed the Yo-Yo intermittent recovery test level 1 (YYIR1). In order to minimize diet-induced performance changes, players were asked to standardize and follow the same nutritional plan 24 hours before each test session. Before each training session and match, the Hopper index was evaluated to monitor sleep, stress, delayed onset of muscular soreness (DOMS), and fatigue. Session ratings of perceived exertion (sRPE; CR-10Borg's scale) were recorded on a daily basis in order to quantify training load (TL= sRPE × training session time in minutes) and competitive load (CL= sRPE × match time), monotony, and strain. [START_REF] Foster | Monitoring training in athletes with reference to overtraining syndrome[END_REF]

Training program during the regular and congested competitive periods

The duration of each training session was 90 min± 8 min for all players. Training sessions were performed during the afternoon (3:30 to 5:00PM). Tables 1a and1b summarize the training program during the regular and congested periods of match play.

Biochemical analyses

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For each soccer player, blood samples were always taken at the same time of day (between 08:00-10:00 AM) and assessed for inflammatory parameters (CRP and creatinine) and muscle damage markers (CK). A recovery period of 12 h was scheduled the day before the samples were taken and participants followed an overnight fast. On the test day, blood samples (15 ml) were taken in a seated position via the median antebrachial vein into vacutainer tubes (Vacuette®, Greiner bio One, France) without anti-coagulant and with EDTA (10ml). The blood was immediately centrifuged at 3000 rpm for 10 min and the serum was stored at -80°C until the analyses were carried out. The CRP was determined using the immunoturbidimetry method (CRP Latex/ Beckman Coulter AU 480 system). The CK activity was determined by the UV method (IFCC) using the N-acetyl-cysteine (EC 2.7.3.2/ Beckman Coulter, AU 480 system). Creatinine was determined by a kinetic modification of the Jaffe procedure, in which creatinine reacts with picric acid at alkaline pH to form a yellow orange complex (OSR6678/Beckman Coulter, AU 480). All samples were taken and handled within the same laboratory.

Quantification of the training and competitive loads

The 10-point Borg scale was used to quantify the perceived effort of the players approximately 15 to 20 minutes after each training session and match in response to the question "how hard the training session or match was?" [START_REF] Foster | Monitoring training in athletes with reference to overtraining syndrome[END_REF] The RPE scores were multiplied by the duration (in minutes) of the session or match to calculate the training load (TL) and competitive load (CL).

Total load or global load (GL) was calculated as the sum of training load and competitive load.

Monotony was calculated as the weekly average load divided by the standard deviation of the load. Strain was calculated as the total load multiplied by monotony. [START_REF] Foster | A new approach to monitoring exercise training[END_REF] Data were categorized into two competitive periods of training and games (the regular period and the congested period of match play).

Wellness status evaluation (Hopper index)

The Hooper questionnaire, consisting of 4 items (stress, fatigue, sleep, and DOMS) [START_REF] Hooper | Monitoring overtraining in athletes recommendations[END_REF] was administered every morning before the training session started. The scale ranged from 1 (very, very low) to 7 (very, very high) for stress, fatigue, and DOMS categories. In the specific case of sleep quality, 1= very, very good and 7= very, very bad. The Hooper index was calculated for each day, representing the sum of the 4 rates of the day. The sum of the weekly value for each competitive period (regular and congested period) was calculated and used for further analyses.

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Physical fitness tests

Vertical jumping

Each subject performed two different types of maximal vertical jumps, in the same order (i.e., SJ followed by CMJ), with hands akimbo and a 60s rest between each trial. The average of the best three trials was taken for further analysis. [START_REF] Claudino | The countermovement jump to monitor neuromuscular status: A meta-analysis[END_REF] The SJ was started with a knee angle of approximately 90°. After a short rest (2s) to avoid the storage of elastic energy, players performed the maximal vertical jump. The CMJ started from a standing position allowing for counter movement with the intention of reaching a knee angle of around 90° just before propulsion. Players were asked to jump as high as possible during both tests. Vertical jump height was evaluated using an opto electric system (Opto-Jump Microgate -ITALY). Jump height was calculated according to the following equation: jump height = 1/8 × g × t [START_REF] Dellal | The effects of a congested fixture period on physical performance, technical activity and injury rate during matches in a professional soccer team[END_REF] , where g is the acceleration due to gravity and t is the flight time. [START_REF] Prieske | Effects of surface instability on neuromuscular performance during drop jumps and landings[END_REF]

Yo-Yo intermittent recovery test level1 (YYIRTL1)

The YYIRT1 was used to assess players' ability to repeat high-intensity exercises. [START_REF] Bangsbo | The Yo-Yo intermittent recovery test[END_REF] The YYIRT1consists of repeated 2×20m runs back and forth between the starting, turning, and finishing line at progressively increasing speeds controlled by an audiometronome from a calibrated CD player. The subjects had a 10-s active rest period between each running bout.

The test was completed if the subjects failed twice to reach the finish line in time, or decided that he could no longer run at the required pace. The total distance covered (m) was recorded for further analyses.

Repeated shuttle sprint test

Repeated Shuttle Sprint Ability (RSSA) was tested to assess players' ability to repeat sprints. [START_REF] Impellizzeri | Validity of a repeated-sprint test for football[END_REF] After a 15-min warm up, players completed 6 × 40-m maximal sprints interspersed with 20 s of passive recovery. Blood lactate was measured immediately after the test using a portable lactate analyzer (Lactate Pro2, Matsport, France).

RSSA testing was conducted using an infrared photoelectric cell (Cell Kit Speed Brower, United States) with an accuracy of 0.01 s.

The best sprint time was recorded and used for further analysis (RSSAbest). In addition, the dependent variables included the mean time obtained over six sprints and the decrease in

performance (𝑅𝑆𝑆𝐴𝑑𝑒𝑐𝑟𝑒𝑚𝑒𝑛𝑡 = ([𝑅𝑆𝐴𝑚𝑒𝑎𝑛]/[𝑅𝑆𝐴𝑏𝑒𝑠𝑡] × 100) -100)].

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Statistical analyses

Data are expressed as means and standard deviations (SD). Normal distribution of data was tested and confirmed using the Kolmogorov-Smirnov test. Paired t-tests for dependent samples were used to identify differences in workload parameters (TL, Monotony, Strain), and Hopper index between the congested and the regular periods of match play. We computed a one-way analysis of variance (ANOVA) for repeated measures to determine differences between biochemical and physical fitness parameters measured during the congested vs. regular period of match play. Pearson's product-moment correlation coefficients (r) were computed to identify relations between all parameters. The magnitude of correlation coefficients was considered as trivial (r < 0.1), small (0.1 < r < 0.3), moderate (0.3 < r < 0.5), large (0.5 < r < 0.7), very large (0.7 < r < 0.9), nearly perfect (0.9 < r < 1.0), and perfect (r = 1.0). [START_REF] Hopkins | Modeling freshwater fish distributions using multiscale landscape data: a case study of six narrow range endemics[END_REF] Statistical significance was set at p < 0.05for all analyses. The 95% confidence intervals (CI)and effects sizes (ES) were calculated to compare differences in mean values for all analyzed parameters. When calculating ES, pooled standard deviations (SD) were used since no control group was available (Cohen's d=[M1-M2]/SDpooled). ES with values of 0.2, 0.5, and 0.8 were considered to represent small, medium and large differences, respectively. [START_REF] Cohen | Statistical power analysis for the behavioural sciences[END_REF] All statistical tests were processed using a statistical software (SigmaStat3.5, Systat, Inc, USA).

Results

Over the 12-week experimental period, 14 players were able to complete the study requirements according to the previously described study design and methodology. Overall, 16 matches were played. Six games were played during the 6 weeks of the non-congested period, and 10 games were played during the 6 weeks of congested match play. The 14 players included in this study performed all matches. The Mean ICC (Intraclass Correlation Coefficients) for the different parameters was presented in Table 2.

Workload parameters

Table 3 presents data of global load parameters and accumulated match time during the 12 weeks training period (regular vs. congested period of match play. All training parameters were significantly different between comparisons.

Figures 2 and 3 present individual and team measures of total, training and competitive loads

during regular and congested periods. Total load was significantly lower in the regular periods as compared to congested period. In contrast, training load parameters were higher in the regular ACCEPTED MANUSCRIPT / CLEAN COPY period as compared to congested period. The competitive load and accumulated match time were significantly higher in the congested period as compared to regular period. The weekly total and competitive loads were significantly higher during congested weeks as compared to regular weeks. The weekly training load parameters were higher in the regular period as compared to congested period (Figures 4 and5).

Physical fitness data

Results from the performance tests are provided in Table 4. There were no significant changes in CMJ Jump height, RSSAdecrement, and blood lactate between the three testing sessions.

However, The YYIR1, RSSAmean, RSSAbest performance and SJ height differed significantly in T3 after the congested period. Also, the YYIR1performance increased significantly from T1 to T2 after the regular period. The RSSAbest was significantly lower in T2 as compared to T1.

Biochemical data

Parameters connected to inflammation and muscular damage markers showed a number of changes during the competitive periods, the CRP was significantly higher in T3 as compared to T2 and T1. The CK was significantly higher in T3 as compared to T2 and T1. However, CRP and CK did not change significantly between T1 and T2. In addition, there were no significant differences in creatinine during the observation period (Table 5).

Wellness status

Changes in wellness scores at different competitive periods are presented in Table 6. The stress score was significantly higher after the congested period than in the regular period (p=0.001, ES=0.75). Moreover, the fatigue score increased after the congested period as compared to the regular period (p=0.008, ES=1.54). The DOMS score increased during the congested period compared with the regular period (p <0.001, ES=3.43). However, there was no alteration in the sleep score during the different competitive periods. Finally, the Hopper index increased significantly after the congested period compared with the regular period (p<0.001, ES=1.92) (Figure 6).

Relation between biochemical parameters and physical fitness

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No significant correlation between biochemical parameters and physical fitness performance was found during the congested period of match play. Only a significant relation was observed between Δ% CRP and Δ% SJ (r=0.55, p=0.03) during the regular period (Table 7).

Relation between biochemical parameters and wellness status

No significant relation was found between inflammatory and muscle damage parameters with wellness scores during the regular period (Table 8). Of note, we showed that the Δ% of CRP was correlated with the Hopper Index (r=0.53, p=0.04) and the fatigue score during the congested period (r=0.64, p=0.01). In addition, the Δ% of CK was correlated with the Hopper index (r=0.63, p=0.01) (Figure 7).

Relation between wellness status and physical fitness

Several significant correlations were found between wellness scores and physical fitness during the congested period of match play (Table 9). The Δ% of fatigue score correlated with Δ%YYIR1(r=-0.49, p=0.04). In addition, the Δ% of DOMS score correlated with Δ% RSSAbest (r=0.51, p=0.04). Moreover, we observed a positive correlation between Δ% RSSAmean and Δ% Hooper index (r=0.54, p=0.04).

Relation between percentage of biochemical parameters, physical fitness, Hopper index, and workload parameters

Table 10 summarizes relationships between percentage changes of biochemical parameters, physical fitness, wellness score and workload parameters during the study. We observed that the Hopper Index were related to workload parameters during the regular period (GL: r=0.56, p=0.03; monotony: r=0.54, p=0.04; strain: r=0.56, p=0.03) and the congested period of match play (GL: r=0.66, p=0.009; CL: r=0.69, p=0.006, strain: r=0.69, p=0.006). The DOMS score was related to workload parameters during the congested period of match play GL: r=0.70, p=0.004, strain: r=0.71, p=0.004). The fatigue score was related to workload parameters (CL: r=0.52, p=0.02). In addition, the increase in CK level was related to monotony (r=0.69, p= 0.005) during the congested period. The increase in CRP was correlated to workload parameters (GL: r= 0.52, p=0.04, monotony: r=0.50, p=0.04; strain: r=0.51, p=0.03). Also, the change in RSSAmean were related to workload parameters during the congested period (CL: r=0.59, p=0.06), monotony: r=0.63, p=0.01; strain: r=0.65, p=0.01) and the change of YYIR1were related to strain (r=0.52, p=0.04).

Discussion

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The aim of this study was to examine fluctuations in inflammatory and muscle damage markers, wellness status and physical fitness during a competitive soccer season, which included a congested period of match play. In addition, the inter-relations among these parameters were assessed. Our findings suggest a significant increase in inflammatory and muscle damage markers as well as wellness measures (stress, fatigue, DOMS, and Hopper index) after the congested period of match play. Additionally, we observed a significant decrease in physical fitness performance. The change in wellness status was related to physical fitness performance decline.

In this study, CRP and CK concentrations were unchanged after the 6-week regular fixture period. However, increases were observed after the six-week congested fixture period as the players were exposed to a competitive load. The absence of a significant change in resting CRP and CK, in conjunction with physical performance test improvements (YYIR1 and RSSAmean, and RSSAbest) observed in regular period, would confirm an optimal training stimulus. On the contrary, the accumulated fatigue potentially caused by the increase in total load and competitive load seems to lead to an increment in CRP and CK after the congested competitive schedule. Nevertheless, the observed performance decline together with altered inflammatory and muscle damage markers after the congested periods can also be explained by the chronic effects of the 12-week competitive period which is note quadlto the acute effect of the last congested week of match play. In this regard, potential differences in the number of highintensity actions (e.g., decelerations) during matches between periods should not be disregarded as it would be expected a major role of these actions on muscle damage markers and inflammation. Activities during soccer matches and training sessions include high amounts of jumping, sprinting, and eccentric muscle actions. [START_REF] Mohr | Match performance of high standard soccer players with special reference to development of fatigue[END_REF] These results are in agreement with data reported by Walker et al. [START_REF] Walker | Biomarker response to a competitive season in Division I female soccer players[END_REF] who showed a significant increase in CK concentrations after 16 competitive weeks in female professional soccer players. The authors of this latter study demonstrated that the increase of CK could be caused by the elevated training and competitive loads. In addition, Pimenta et al. [START_REF] Pimenta | Analysis of creatine kinase and alpha-actin concentrations in soccer pre-season[END_REF] showed an increase for CK concentration after the pre-season period when the players were exposed to higher volume and intensity of training. Therefore, investigators have speculated that intensified training or match exposure could influence the increase of inflammation and muscle damage markers. [START_REF] Nédélec | Recovery in soccer[END_REF][START_REF] Souglis | Time course of oxidative stress, inflammation, and muscle damage markers for 5 days after a soccer match: effects of sex and playing position[END_REF] These type of muscle activities will result in micro tear of structural and contractile components in the muscle fibers [START_REF] Brancaccio | Creatine kinase monitoring in sport medicine[END_REF] leading to increased serum CK levels. [START_REF] Hartmann | Training and overtraining markers in selected sport events[END_REF] ACCEPTED MANUSCRIPT / CLEAN COPY Additionally, the current results suggest that the higher number of matches played in the last 6 weeks (10 matches, accumulated match times = 644.2 ± 125.9 minutes) potentially affect resting CRP and CK concentrations. Conversely, the current results disagree with the results of Coppalle et al. [START_REF] Coppalle | Relationship of pre-season training load with in-season biochemical markers, injuries and performance in professional soccer players[END_REF] who showed anon-significant change in CRP and CK levels after the pre-season period. Differences in study methodology between studies could partially explain these different outcomes. For example, the study of Coppalle et al. [START_REF] Coppalle | Relationship of pre-season training load with in-season biochemical markers, injuries and performance in professional soccer players[END_REF] and the current study analyzed the soccer season at different time points (e.g., pre-period and 12 weeks competitive periods).

Moreover, Coppalle et al. [START_REF] Coppalle | Relationship of pre-season training load with in-season biochemical markers, injuries and performance in professional soccer players[END_REF] for technical reasons, analyzed their blood samples one week after the end of the pre-season which may be sufficient time to allow the recovery of players. Of note, we observed no alterations in the creatinine concentrations during the 12-week competitive period. This result is in agreement with Heisterberg et al. [START_REF] Heisterberg | Extensive monitoring through multiple blood samples in professional soccer players[END_REF] who showed that the creatinine concentration was unaltered over the course of a soccer season. Thus, creatinine appears to be of minor interest for blood monitoring of elite soccer players. [START_REF] Djaoui | Monitoring training load and fatigue in soccer players with physiological markers[END_REF] Concerning the wellness status, we noted that the Hopper index, stress, fatigue, and DOMS scores were higher in the congested period as compared to the regular period of match play. Moreover, we also noticed that Hopper index increases were strongly related to workload parameters (total load, training load, competitive load, monotony and strain). This result agrees with data reported by Fessi et al. [START_REF] Fessi | Changes of the psychophysical state and feeling of wellness of professional soccer players during pre-season and in-season periods[END_REF] who showed significant associations between training load parameters and wellness measures (sleep, stress, fatigue, and muscle soreness) in professional soccer players. Accordingly, our data corroborate the outcomes presented by Buchheit et al. [START_REF] Buchheit | Monitoring fitness, fatigue and running performance during a pre-season training camp in elite football players[END_REF] and Thorpe et al. [START_REF] Thorpe | Monitoring fatigue during the in-season competitive phase in elite soccer players[END_REF] who demonstrated that the daily variations in training load affected wellness measures the following day in Australian Rules football and elite soccer players, respectively. These observations provide evidence supporting the sensitivity of these simples' measures to change in training load. It was hypothesized that fatigue and DOMS scores were affected by the greater total load and competitive load along with the higher number of matches played during the period of congested match play. Moreover, the congested period involved lower training loads compared with the regular period (3853.21 ± 2429.48 vs. 5581.28 ± 1074.25 A.U.). These differences are usually observed due to the different number of matches between conditions. These differences may be the results of the fact that there is less time to train (5 vs.

training days, on average) and that coaches intentionally reduced training volume in congested

weeks to control the players training in periods overloaded with matches. However, despite the training load reduction, global load (training and competitions) during congested periods involved a higher disruption of wellness status for players than regular periods. The ACCEPTED MANUSCRIPT / CLEAN COPY accumulation of the matches significantly increased players' stress after the congested period of match play. Further, the increase in stress scores can be explained because this period included the most important matches, that is, the play-offs. In contrast, we observed no difference in sleep score between regular and congested periods. These findings might be indicative of sleep perception not being sensitive to the workload. Indeed, for elite soccer, it was suggested that in a competitive period (with different training programs and level of competition), the perception of sleep quality may only provide information on potential recovery status rather than any association with workload. [START_REF] Clemente | Internal training load and its longitudinal relationship with seasonal player wellness in elite professional soccer[END_REF] The same tendency was found in the study of Nédélec, et al. [START_REF] Nédélec | Stress, sleep and recovery in elite soccer: A critical review of the literature[END_REF] who showed that training load affects fatigue and muscle soreness parameters to a larger extend compared with sleep. However, more in-depth research including physiological data on sleep, fatigue and muscle soreness are required.

In this study, no significant correlations were observed between biochemical parameters and players' performance in the YYIR1, RSSA, SJ and CMJ tests. Thus, we observed that the decline in the applied physical fitness tests during the congested period was associated with increases in CRP and CK concentrations. These findings are in agreement with previous reports who showed negative associations between changes in biochemical markers and performance declines with maintenance of higher CRP and CK values. [START_REF] Silva | Biochemical impact of soccer: an analysis of hormonal, muscle damage, and redox markers during the season[END_REF] In the current study, the decline in performance measures of physical fitness after the congested period of match play may be reflected in the observed increase in inflammation (CRP) and muscular damage (CK). Hence, Walker et al. [START_REF] Walker | Biomarker response to a competitive season in Division I female soccer players[END_REF] showed that the increased CK level was associated with the decline in vertical jump performance. This may suggest that the alteration in CK concentration might affect explosive-type performance such as jumping. Moreover, increases in CK level without impairments in muscle performance have been reported. [START_REF] Pimenta | Analysis of creatine kinase and alpha-actin concentrations in soccer pre-season[END_REF] Therefore, some caution should be taken when trying to predict muscle recovery and impairments from changes in serum CK concentrations. In the current study, we showed that the increase in CRP concentrations was correlated to the SJ height increases in the regular periods. Based on these contradictory results, we postulate that the observed significant correlations between inflammatory markers and physical fitness test performance should be interpreted with caution. Further, the reported relationships among these parameters do not reflect cause and effect relations and may be spurious. Our results further suggest that the increase in CRP and CK noted in T3 after the congested period of match play may reflect tiredness or a state of fatigue caused by inflammation and muscular damage. To determine more precisely the influence of fatigue on these biological variations, it is necessary to address these two variables. To do this, we examined potential correlations between the wellness scores and biochemical data.

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In our study, the CRP and CK concentrations were significantly correlated with wellness scores (Hopper index) during the congested period suggesting the involvement of wellness changes on CRP and CK responsiveness. Moreover, we found a significant positive correlation between the CRP and the fatigue score. This suggests that it is useful to follow variations in CRP and CK level to determine the degree of tiredness and change in wellness or vice versa. In addition, there appears a negative relation between physical fitness and wellness measures during a congested period of match play. Thus, the increase in wellness measures was associated with physical fitness declines. More precisely, we noticed that the Δ% of fatigue score correlated with Δ% YYIR1. In addition, the Δ% of DOMS score correlated with Δ% RSSAbest and we observed a positive correlation between Δ% RSSAmean_ and Δ% Hooper Index. These results cannot, however, be used to indicate whether changes in physical test performance are affected by changes in wellness scores (fatigue, DOMS, and stress) increased or vice-versa. Our results confirm that physical performance depends simultaneously on physical and wellness status.

Thus, it seems that the participation in a high number of matches during the congested period induced psychological stress on the soccer players.

In this study, we showed a positive correlation between monotony and CK during the congested period of match play. In addition, changes in CRP level showed significant relations with workload parameters. These results confirm that some biochemical markers are sensitive to competitive periods and soccer training which is in agreement with the study of Walker et al. [START_REF] Walker | Biomarker response to a competitive season in Division I female soccer players[END_REF] who showed that the CK increases are associated with training load increases and higher number of practices during 16 weeks of soccer training and competition. Thus, these biochemical levels can be used as a potential marker for variation in intensity of training and/or competition.

Limitations

It is important to highlight some limitations inherent to this work. This study did not have a control group which does not allow to identify the specific effects of a congested period on the examined markers. We acknowledge that the use of the Hopper questionnaire is limited in team sports. Different motivational levels of the team players may have affected the outcomes of the Hopper questionnaire. Internal training load was only measured by session-RPE and this may have constrained the real quantification of the physiological impact of the training. External load was not used in this study, nevertheless the physical quantification of training impact may be an interesting set of variables to justify the perception of DOMS and fatigue. Moreover, using jump height as a global measure may not sufficiently reflect fatigue in soccer players.

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Fatigued soccer players might still be able to alter their movement patterns which allow them to achieve similar performances as in unfatigued condition.

Strength of the study and implications for future research

Although data on inflammation and muscle damage, and performance are already available in the literature, our study is the first that combines all these markers together with total load (training and competitive load) during a soccer season including a congested period of match play. Our results suggest that the congested period of match play alters various parameters (e.g., C-reactive protein, CK, Hopper index) in elite soccer players. While the observed changes in inflammatory and muscle damage markers were unrelated with physical fitness declines, measures of wellness were. Future studies should analyze whether the accumulation of matches influences the players' physical and physiological responses during the match played (e.g., number of sprints, accelerations and decelerations, etc.) In addition, inflammatory and muscle damage markers could be analyzed immediately after the match during both, regular and congested periods.

Practical applications

The results of this study confirm the usefulness of wellness measures to provide information about the impact of training and competition on elite soccer players. In addition, our findings support the use of the Hopper questionnaire as a simple monitoring tool for identifying performance decrements in players exposed to highly competitive loads during the congested period.

Conclusions

The results of this study showed significant changes in selected biochemical markers, wellness status and physical fitness parameters during the final competitive period of the season (congested match play). The main findings were that elite soccer players' wellness status reflects declines in physical fitness during a congested period of match play while biochemical changes do not. Furthermore, CRP and CK changes correlate with wellness status (fatigue, DOMS, Hopper index), suggesting that it is useful to follow variations in CRP and CK levels to determine the degree of change in wellness status or vice versa. squat jump, CMJ, countermovement jump; *significant difference between T3-T2 and T3-T1 with p < 0.05; £ Significant differences between T2 and T1 with p < 0.05.

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Figure 1

 1 Figure 1 Experimental design. Abbreviations: RSSA, repeated sprint shuttle ability; SJ, squat jump; CMJ, countermovement jump; YYIR1, Yo-Yo intermittent recovery test-level 1;Sun, Sunday; Mon, Monday; Tue, Tuesday; Wed, Wednesday; Thu, Thursday; Fri, Friday; Sat, Saturday.RPE, Rating of Perceived exertion.

Figure 2

 2 Figure 2 Individual and team measures of total load and training load during the regular and congested periods of the season.

Figure 3

 3 Figure 3 Individual and team measures of competitive load and accumulated match time during the regular and congested periods of the season.

Figure 4

 4 Figure 4 Weekly total load and training load during the regular and congested periods of the season.

Figure 5

 5 Figure 5 Weekly competitive load and accumulated match time during the regular and congested periods of the season.

Figure 6

 6 Figure 6 Individual and team measures of the Hopper index during the regular and congested periods of the season. Abbreviations: A.U, Arbitrary units; P, player; R, regular period; C, congested period.

Figure 7

 7 Figure 7 Relation between biochemical parameters and wellness status during the congested period. (A) Correlation between Δ% CRP and Hopper Index. (B): correlation between Δ% CK and DOMS. Abbreviations: CRP, C-reactive protein; DOMS, delayed onset muscle soreness.

Figure 8

 8 Figure 8 Summary of the main findings of this study. Abbreviations: GL, global load; CRP, C-reactive protein; CK, creatine kinase. YYIR1, Yo-Yo intermittent recovery test level 1; SJ, squat jump; HI, Hopper index; DOMS, delayed onset muscle soreness.

  Abbreviations: YYIR1, Yo-Yo intermittent recovery test level 1; RSSA: repeated shuttle sprint

Table 2 :

 2 Intraclass correlation coefficient.

	Parameters	Mean Intraclass	95% confidence interval
		correlation coefficient	Lower bound	Upper bound
		(ICC)
	CRP	0.31	0.30	0.42
	Creatinine	0.51	0.43	0.57
	CK	0.69	0.58	1.25
	YYIR1	0.48	0.51	0.78
	RSSAmean	0.61	0.15	0.84
	RSSAbest	0.69	0.34	0.89
	RSSAdecrement	0.34	-1.26	0.58
	SJ	0.95	0.90	0.98
	CMJ	0.98	0.77	0.95
	Monotony	0.42	0.32	0.55
	Strain	0.89	0.83	0.98
	Hopper index	1.33	1.13	1.53
	Sleep	0.44	0.33	0.56
	Stress	0.43	0.35	0.52
	Fatigue	0.68	0.65	0.72
	DOMS	0.81	0.72	0.90
	Abbreviations: YYIR1, Yo-Yo intermittent recovery test level 1; RSSA, repeated shuttle sprint
	ability; SJ, squat jump; CMJ, countermovement jump; DOMS, delayed onset muscle soreness;
	CRP, C-reactive protein; CK, creatine kinase.

Table 3 :

 3 Global load parameters and accumulated match time during the 12 weeks training period (regular vs. congested period of match play).

	Training periods	From T1 to T2	From T2 to T3	p-value	Effect size
		Regular period	Congested period		(ES)
	Total load (A.U.)	12154.8 ± 929.4 13853.3 ± 2022.2	0.01*	1.3
	Training load (A.U)	9253.3 ± 702.0	6843.7 ± 194.5	< 0.001*	-1.3
	Competitive load (A.U) 2940.0 ± 624.1	6809.6 ± 2029.3	˂ 0.001*	3.9
	Monotony (A.U)	0.4 ± 0.7	1.8 ± 0.1	< 0.001*	3.7
	Strain(A.U)	817.7 ± 255.2	19843.9 ± 5973.4	< 0.001*	6.3
	Accumulated match	388.2 ± 55.1	644.2 ± 125.9	˂ 0.001*	3.3
	time (min)
	Abbreviations: A.U, Arbitrary units. *significant difference between regular and congested
	period with p < 0.001.

Table 4 :

 4 Changes in physical fitness test performance.

	Training periods	T1	T2	T3	p-value	Effect size (ES)
						ES1-2 -ES2-3
	YYIR1 (m)	2308.5 ± 363.5 2495.7 ± 339.0 1594.2 ± 295.1	< 0.001*£	0.7; -4
	RSSAmean(s)	8.2 ± 0.2	8.0 ± 0.1	8.5 ± 0.4	0.001*	-1.7; 0.4
	RSSAbest (s)	7.8 ± 0.3	7.5 ± 0.2	8.2 ± 0.2	< 0.001*£	-1.6; 4.4
	RSSAdecrement(%)	7.0 ± 3.1	7.2 ± 3.8	5.9 ± 3.0	0.93	0.08; -0.5
	[Lac]RSSA(mM/L)	18.4 ± 3.2	18.2 ± 2.8	20.2 ± 2.3	0.07	-0.09;-1.1
	SJ (cm)	37.9 ± 3.8	37.4 ± 3.2	34.2 ± 3.2	0.01*	-0.2; -1.4
	CMJ (cm)	38.7 ± 2.5	39.1 ± 2.6	38.8 ± 2.5	0.85	0.2; -0.1

Abbreviations: YYIR1, Yo-Yo intermittent recovery test level 1; RSSA, repeated shuttle sprint ability; [Lac]RSSA, Lactate concentration measured after repeated shuttle sprint ability-test; SJ:

Table 5 :

 5 Changes in inflammation and muscle damage markers.

	Parameters	T1	T2	T3	p-value	ES
						ES1-2 -ES2-3
	CRP (mg/L)	25.5 ± 7.3	32.1 ± 6.9	39 ± 5.6	0.001*£ 1.2; 1.5
	CK(UI/L)	268.5 ± 113.2	278.0 ± 133.4	417.6 ± 237.8 0.002 *£ 0.1; 1
	Creatinine (mg/L) 10.0 ± 0.8	10 ± 0.7	10.3 ± 1.0	0.2	0.1; 0.3
	Abbreviations: CRP, C reactive protein; CK, creatine kinase; *significant differences between
	T3 and T2 with p < 0.05; £ significant difference between T3 and T1 with p < 0.05.

Table 6 :

 6 Changes in wellness status (Hopper index).

	Training periods From T1 to T2	From T2 to T3	p-value Effect size
		Regular period	Congested period		(ES)
	Sleep	6.6 ± 0.5	7.2 ± 0.9	0.06	1.1
	Stress	7.5 ± 0.5	9.0 ± 0.9	0.001* 0.7
	Fatigue	10.2 ± 1.4	11.4 ± 1.5	0.008* 1.5
	DOMS	7.0 ± 1.2	10.3 ± 1.5	0.001* 3.4
	Hopper index	33.5 ± 2.2	37.0 ± 2.9	0.002* 1.9
	Abbreviations: DOMS, delayed onset of muscular soreness; *significant difference between
	the congested and the regular period with p < 0.01.

ACCEPTED MANUSCRIPT / CLEAN COPY Abbreviations: YYIR1, Yo-Yo intermittent recovery test level 1; RSSA, repeated shuttle sprint 669 ability. SJ, squat jump; CMJ, countermovement Jump; CRP, C reactive protein; CK, creatine 670 kinase; *significant correlation between parameters. 671 672 ACCEPTED MANUSCRIPT / CLEAN COPY Abbreviations: DOMS, delayed onset muscle soreness; CRP, C-reactive protein; CK, creatine 674 kinase; HI, Hopper index; *significant correlation between parameters.

675 676 ACCEPTED MANUSCRIPT / CLEAN COPY

Table 9 :

 9 Relation between wellness scores and physical fitness test performance.

	677
	678
				Regular period				Congested period
					(T1-T2)					(T2-T3)
			Sleep Stress Fatigue DOMS HI	Sleep Stress Fatigue DOMS HI
	YYIR1 (m) r	0.41	-0.15	0.20	0.14	0.15	-0.03	0.7	-0.49	0.48	0.25
		p	0.14	0.60	0.47	0.61	0.58	0.90	0.78	0.04*	0.07	0.38
	RSSAmean	r	0.17	-0.32	0.30	0.40	0.21	0.09	0.25	-0.42	0.02	0.68
	(s)	p	0.54	0.25	0.29	0.15	0.46	0.72	0.37	0.13	0.91	0.007*
	RSSAbest (s) r	0.27	-0.02	-0.27	-0.08	0.08	-0.45	0.25	-0.25	0.51	0.20
		p	0.33	0.92	0.33	0.76	0.76	0.10	0.37	0.37	0.04*	0.47
	SJ (cm)	r	0.10	0.41	0.12	0.08	0.21	0.37	0.08	0.11	0.07	0.32
		p	0.73	0.13	0.68	0.76	0.45	0.18	0.77	0.68	0.80	0.25
	CMJ (cm)	r	-0.08	0.11	-0.23	-0.21	-0.21	-0.34	0.28	0.45	-0.27	0.10
		p	0.78	0.69	0.41	0.47	0.46	0.22	0.32	0.10	0.34	0.73
	681
	682
	683
	684
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Abbreviations: YYIR1, Yo-Yo intermittent recovery test level 1; RSSA, repeated shuttle sprint 679 ability; SJ, squat jump; CMJ, countermovement jump; HI, Hopper index; * significant 680 correlation between parameters.

Table 10 :

 10 Relation between percentage of biochemical parameters, physical fitness test 685 performance, wellness and workload parameters.

	686
					From T1 to T2				From T2 to T3
					Regular period				Congested Period
			GL	TL	CL	Monotony Strain GL	TL	CL	Monotony Strain
	CRP	r	0.30	0.07	0.25	0.38	0.40	0.52	0.07	0.18	0.50	0.51
	(mg/L)
		p	0.29	0.97	0.33	0.17	0.15	0.04*	0.78	0.53	0.04*	0.03*
	CK (UI/L) r	-0.47	0.42	-0.07	-0.5	-0.45	0.35	0.36	-0.10	0.69	0.30
		p	0.08	0.12	0.81	0.06	0.79	0.22	0.19	0.73	0.005*	0.29
	Creatinine	r	-0.49	-0.51	-0.16	0.30	-0.35	-0.25	-0.01	-0.01	-0.15	0.16
	(mg/L)
		p	0.07	0.06	0.56	0.22	0.51	0.21	0.96	-0.96	0.59	0.72
	Sleep	r	0.06	0.12	0.13	0.17
		p	0.81	0.66	0.64

Types of training Duration of a session (min)

Weekly frequency

T1-T2

Regular period

T2-T3

Congested period

Low-to-moderate intensity aerobic exercise 25-30


Myriam Mimouni

Marie Gosset

Hélène Bonsang-Kitsis

Myriam Deloménie

Charlotte Ngo

Anne-Sophie Bats

Fabrice Lécuru

Chef De Clinique

Praticien Hospitalier

Praticien Mcu-Ph

Anne-Sophie Hospitalo-Universitaire

Bats

Fabrice Pu-Ph

Lécuru

Pu-Ph

La laparoscopie, une voie d'abord privilégiée pour la chirurgie des cancers en gynécologie

Keywords: cancer gynécologique, laparoscopie, oncologie, qualité de vie, tolérance, traitement mini-invasif

Aujourd'hui, l'objectif du traitement contre le cancer, quelle que soit la spécialité concernée, est d'allier une efficacité maximale à une tolérance optimale, tout en maintenant une qualité de vie satisfaisante pour le patient. Les techniques de chirurgie mini-invasives comme la laparoscopie répondent à cet objectif. La laparoscopie est un abord de la cavité péritonéale qui ne nécessite que des incisions de petite taille (5 à 15 mm). Il s'agit d'une chirurgie abdominale à ventre fermé. Tous les cancers gynécologiques y sont éligibles qu'il s'agisse de l'endomètre, du col utérin ou de l'ovaire au stade précoce. La faisabilité de la laparoscopie doit cependant être évaluée au cas par cas. La laparotomie peut, en effet, s'avérer nécessaire pour réaliser un traitement chirurgical optimal. T1. Indications de la laparoscopie dans le traitement des cancers gynécologiques TEG1 La laparoscopie est un excellent moyen d'explorer l'ensemble de la cavité abdominale, de façon mini-invasive (figure 1). Dans certaines indications, par exemple le cancer de l'ovaire au stade de carcinose péritonéale, l'exploration laparoscopique de la cavité péritonéale fait partie du bilan initial de la maladie, au même titre que les examens d'imagerie. Elle se doit d'être peu invasive, rapide et ne doit en aucun cas différer le début des traitements. Elle permet une description détaillée de l'étendue des lésions et une évaluation de la résécabilité chirurgicale du cancer (score de Sugarbaker ou Peritoneal Carcinomatosis Index) [START_REF] Jacquet | Clinical research methodologies in diagnosis and staging of patients with peritoneal carcinomatosis[END_REF].

TEG1 La laparoscopie exploratrice peut être faite par un seul trocart ombilical (single port). Il s'agit d'un système par lequel passent l'optique et les pinces nécessaires pour les biopsies. La laparoscopie en mono-trocart permet une diminution des risques de dissémination pariétale de la maladie carcinomateuse (figure 2) [START_REF] Quaranta | evaluation of single-port laparoscopy for peritoneal carcinomatosis assessment in advanced ovarian cancer[END_REF].

Les gestes chirurgicaux réalisables par laparoscopie sont multiples. Ils sont indiqués dans un but thérapeutique ou diagnostique (stadification du cancer).

T2. Hystérectomie totale

TEG1 L'hystérectomie totale, faite dans le cadre du traitement du cancer, est souvent réalisée avec une annexectomie bilatérale. Après coagulation et section des ligaments et pédicules vasculaires, l'exérèse de la pièce opératoire est faite par voie vaginale. Selon l'indication, l'hystérectomie totale est réalisée de manière plus ou moins large. Elle peut être intra-faciale (cancer ovarien), extra-faciale (cancer endométrial sans atteinte cervicale) ou élargie aux paramètres (cancer cervical). L'hystérectomie totale élargie nécessite une dissection précise et rigoureuse des éléments à préserver siégeant dans le paramètre : l'uretère et les nerfs pelviens (nerf hypogastrique, plexus hypogastrique, nerfs splanchniques).

TEG1 La laparoscopie permet une grande précision quant à la dissection des nerfs grâce au fort grossissement de l'image par l'optique. La préservation de ces nerfs est importante pour la récupération postopératoire des fonctions urinaires, rectales et sexuelles. La préservation minutieuse de ces éléments améliore la qualité de vie postopératoire à court et long termes des patientes [START_REF] Bogani | Nerve-sparing approach improves outcomes of patients undergoing minimally invasive radical hysterectomy: a systematic review and meta-analysis[END_REF].

T2. Curage ganglionnaire

TEG1 Le curage ganglionnaire est l'exérèse des ganglions drainant l'appareil génital. Dans les cancers gynécologiques, les ganglions sont situés le long des gros vaisseaux (vaisseaux iliaques, aorte, veine cave) : il s'agit d'un curage pelvien et lombo-aortique.

TEG1 Le curage lombo-aortique peut être réalisé par deux voies d'abord laparoscopiques différentes : intra-péritonéale et extra-péritonéale. Il s'agit d'une chirurgie mini-invasive suppléant la laparotomie médiane sus-et sous-ombilicale. L'indication des curages ganglionnaire a actuellement tendance à être revue : il n'est plus fait de manière systématique dans le cancer de l'ovaire [START_REF] Harter | LION: Lymphadenectomy in ovarian neoplasms. A prospective randomized AGO study group led gynecologic cancer intergroup trial[END_REF].

TEG1 De même, il est progressivement remplacé par la procédure du ganglion sentinelle pelvien dans le cancer du col et de l'endomètre (essais en cours SENTIRAD [START_REF] Lambret | Protocole SENTIRAD[END_REF] et SENTICOL III [START_REF] Arcagy -Gineco | Étude SENTICOL III -Cancer Utérus[END_REF]). Le ganglion sentinelle est le plus proche de la tumeur, susceptible d'être atteint par la maladie.

Le principe est d'analyser uniquement ce ganglion. S'il est atteint, le curage ganglionnaire devra être fait sinon, aucun autre geste ne sera réalisé. Le ganglion sentinelle peut être repéré via plusieurs produits différents injectés sur le col utérin (bleu patenté, traceur radioactif ou vert d'indocyanine). Cette technique en plein essor, permet de diminuer la morbidité opératoire et postopératoire liée aux curages ganglionnaires extensifs sans pour autant ″sous″-traiter les patientes.

TEG1 Les autres gestes couramment indiqués réalisables par laparoscopie sont l'omentectomie, l'appendicectomie, la résection digestive lorsqu'elle est nécessaire.

T1. Intérêts de la chirurgie mini-invasive

TEG1 Souvent, la chirurgie est la première étape du traitement contre le cancer. Elle sera suivie de chimiothérapie et/ou radiothérapie et/ou curiethérapie. Il est important d'obtenir une cicatrisation satisfaisante et une récupération de l'état général avant de pouvoir débuter le traitement adjuvant. Cependant, un délai court entre la chirurgie et le début des traitements joue un rôle pronostique important pour la patiente. Ce délai sera d'autant plus réduit que la convalescence sera rapide, chez des patientes souvent déjà fragilisées par le cancer avant même de débuter toute thérapie (dénutrition, anorexie, asthénie).

TEG1 Dans ce contexte, la chirurgie mini-invasive présente un intérêt majeur dans la prise en charge des cancers gynécologiques. Elle permet une convalescence postopératoire significativement plus courte qu'après une chirurgie ouverte. La réhabilitation précoce est fréquente, avec une reprise de l'alimentation et une mobilisation souvent possibles le soir même de l'intervention. La durée d'hospitalisation est plus courte. Le taux de complications graves est moins important [START_REF] Beck | Robotic, laparoscopic, or open hysterectomy: surgical outcomes by approach in endometrial cancer[END_REF]. La douleur due à la cicatrice pariétale, proportionnelle à la taille de cette dernière, est amoindrie dans les suites immédiates grâce à la micro-chirurgie. La laparoscopie permet ainsi de limiter la prise d'antalgiques [START_REF] Galaal | Laparoscopy versus laparotomy for the management of early stage endometrial cancer[END_REF][START_REF] Wang | The outcome of laparoscopy versus laparotomy for the management of early stage cervical cancer-meta analysis[END_REF]. TEG1 Par ailleurs, les patientes prises en charge pour un cancer gynécologique auront dans leur parcours un risque non négligeable d'être opérées plusieurs fois en cas de récidive. Les adhérences postopératoires dues à une première chirurgie rendent très complexe une nouvelle chirurgie pour récidive. Celle-ci peut se compliquer de plaies d'organes ou d'un échec de l'intervention du fait d'un accès intra-abdominal rendu impossible par les adhérences intestinales. La chirurgie mini-invasive est peu pourvoyeuse d'adhérences et facilite l'accès à la cavité péritonéale lors de chirurgies multiples [START_REF] Ouaïssi | Post-operative adhesions after digestive surgery: their incidence and prevention: review of the literature[END_REF]. Si elle est possible, elle doit donc être privilégiée par le chirurgien. TEG1 Enfin, le préjudice esthétique imposé par une chirurgie mini-invasive est moins important que celui d'une laparotomie.

T1. Place de la chirurgie robotisée dans le cancer gynécologique

La chirurgie robotique, initialement développée pour la pathologie bénigne, est en plein essor dans le domaine de la cancérologie (figure 3). En comparaison avec la laparoscopie classique, elle semble diminuer les douleurs et complications postopératoires ainsi que la durée d'hospitalisation. Elle augmente le confort du chirurgien, paramètre important pour les procédures longues nécessitant des dissections précises comme la colpo-hystérectomie élargie faite dans le traitement du cancer du col utérin. Enfin, la chirurgie robotique semble intéressante pour les patientes présentant une obésité, facteur de risque majeur du cancer de l'endomètre [START_REF] Gaia | Robotic-assisted hysterectomy for endometrial cancer compared with traditional laparoscopic and laparotomy approaches: a systematic review[END_REF][START_REF] Park | Surgical and clinical safety and effectiveness of robotassisted laparoscopic hysterectomy compared to conventional laparoscopy and laparotomy for cervical cancer: A systematic review and meta-analysis[END_REF].

T1. Limites de la laparoscopie

TEG1 Lors de l'exploration de la cavité péritonéale, la laparoscopie permet une large visualisation de l'ensemble de la surface du péritoine. Cependant, elle n'autorise pas la palpation des organes, pouvant dans certains cas rendre imparfaite la description des lésions profondes.

TEG1 Par ailleurs, dans le cadre de la chirurgie à visée thérapeutique, la laparotomie garde sa place dans le traitement du cancer. Lorsque la carcinose péritonéale est étendue, et si les lésions apparaissent résécables, une laparotomie est indiquée plutôt qu'une laparoscopie afin de favoriser l'exérèse la plus complète possible des lésions, tout en respectant un temps opératoire raisonnable pour la patiente. Par exemple, l'accès au diaphragme rétro-hépatique et à l'espace de Morison (entre le rein gauche et le foie), souvent atteints massivement par la maladie, n'est pas possible de manière optimale par laparoscopie. Dans ce cas, dans l'intérêt de la patiente, il est indispensable de privilégier la laparotomie, même si cela implique une chirurgie plus lourde. TEG1 Enfin, la laparoscopie peut être rendue impossible par le volume utérin ou de la masse ovarienne. L'accès aux pédicules utérins peut être gêné par la largeur de l'utérus. Dans le cadre d'un cancer gynécologique, le morcellement de l'utérus habituellement réalisé dans la pathologie bénigne utérine ou la ponction de kyste ovarien sont formellement contre-indiqués. En effet, ces gestes seraient pourvoyeurs de dissémination de la maladie tumorale intra-abdominale, grevant ainsi le pronostic de la patiente. Il sera alors nécessaire de réaliser une laparotomie pour l'exérèse de la pièce opératoire.

T1. Conclusion

La chirurgie mini-invasive répond à l'objectif d'un traitement efficace contre le cancer associé à une tolérance satisfaisante. Elle permet une chirurgie précise et complète tout en minimisant le temps de convalescence, facteur important dans le pronostic des patientes mais aussi leur qualité de vie.

Même si la laparoscopie est devenue la voie d'abord prioritaire dans la chirurgie cancérologique, la laparotomie reste indispensable dans certaines indications pour un traitement chirurgical optimal, notamment dans les maladies carcinomateuses étendues.

Par ailleurs, l'intérêt de la laparotomie pourrait se discuter à nouveau dans des indications pour lesquelles une laparoscopie était devenue aujourd'hui la voie d'abord de référence. En 2018, un essai de phase 3 (LACC) a été présenté à la Société de gynécologie oncologique (SGO) et remet en cause le traitement laparoscopique des cancers précoces du col utérin. L'étude conclut à une survie sans récidive et une survie globale significativement diminuée dans le groupe ″laparoscopie″ par rapport au groupe ″laparotomie″ avec des odds ratios respectivement de 3,74 (p = 0,002) et 6 (p = 0,004) [START_REF] Leitao | The LACC trial: has minimally invasive surgery for early-stage cervical cancer been dealt a knockout punch?[END_REF].

La chirurgie robotique étant en plein essor, notamment pour les colpo-hystérectomies élargies, il serait intéressant de comparer la laparotomie à la laparoscopie robotisée plutôt qu'à la laparoscopie classique.

Figures Mim_fig1

Figure 2 .Figure 3 .

 23 Figure 1. La laparoscopie est un excellent moyen d'exploration de l'ensemble de la cavité abdominale, de façon mini-invasive, dans certaines indications, elle fait partie du bilan initial de la maladie.


Frédérique Larrarte
email: frederique.larrarte@univ-eiffel.fr

Augustin Doumic
email: augustin.doumic@orange.fr

Nicole Goutal
email: nicolegoutal@edf.fr

Floods in housing estate : some experimental data

Keywords: Erosion, Open channels, Profilers, Bathymetry

The water cycle can be affected by violent events such as earthquakes, tsunamis, floods, … In France, 17 millions of inhabitants are exposed to flood risk. One challenge during floods is to be able to access to people refugee over buildings. In order to investigate the hydraulic context generated by the grouped obstacles representative of a submerged housing estate, a preliminary experimental study was conducted. We experimentally study the flow in the presence of rows of macro-roughnesses representative of a submerged housing estate, and this for situations representing both current and more intense floods. After presenting the experimental configurations, the experimental results are given and discussed. The first conclusions are completed by the perspectives.

INTRODUCTION

The water cycle can be affected by violent events such as earthquakes, tsunamis, floods, … In France, 17 millions of inhabitants (about a quarter of the national population) are exposed to flood risk, i.e 16.6 million euros of insurance indemnities expenses related with 1,463,000 flood-related claims between 1988 and 2013 [START_REF] Bonnefoy | Rapport d'information de Mme Nicole BONNEFOY, fait au nom de la MI sur la gestion des risques climatiques[END_REF]. And with climate evolution, floods will become more frequent and more intense. One challenge during floods is to be able to access to people refugee over buildings

The purpose of the present communication is to analyze the evolution of the velocity distribution for various flood situations from current to severe ones. [START_REF] Oukacine | Experimental flows through an array of emerged or slightly submerged square cylinders over a rough bed[END_REF] presented experimental data for a dense area and for emerged and submerged obstacles. Here we emphasize on the transition cases between emerged and submerged contexts (with just emerged and just submerged cases) and we present more graduated cases of submerged situations. This brief communication aims at giving complementary elements on upstream to downstream evolution of the velocity distribution.

This paper outlines the experimental setting (flume, measuring device, flow condition) before providing the results of the emerged and submerged flows as well as a comparison of the two flows. The major results are summarized in the conclusion.

EXPERIMENTAL SET-UP

Human settlement present a wide range of configuration. For this study, we focus on house and gardens configuration as defined by [START_REF] Stewart | Classifying urban climate field sites by "local climate zones": the case of Nagano, Japan[END_REF] as they can exist in recently urbanized areas on plain areas (figure 1). We also consider oceanic climate floods rising quite slowly and producing pseudo static situations such as the famous Paris 1910 flood that is a centennial one. In such context, the private houses are flooded but their roof remains out of water. With the climate evolution, theses building could be submerged. In this study, we represent a peri-urban settlement with aligned buildings (Figure 3) represented by square cylinders. The distances between the cylinders is taken equal to the square cylinder size in both streamwise and transverse direction (ie lx and ly). Each square cylinder has a side length Lx=Ly= 0.1 m.

Proceedings of the 39 th IAHR World Congress 19-24 June 2022, Granada, Spain The Froude number Fr ranges between 0.19 and 0.24 and the Reynolds number between 21850 and 34500, meaning a fluvial turbulent flow, with Fr=U/(gD) 1/2 and Re = U*h/, where g is the gravitational acceleration.

Table 1 presents all the experimental conditions.

RESULTS

The experiments were conducted for an aligned configuration and various flow rates corresponding to the 4 cases presented in Table 1.

Visual observations made during the experiments show that a wave very similar to a bow wave was generated by the array of square cylinders (Figure 4) The vertical distribution of the streamwise velocity has been measured on various verticals inside the array. Figures 5 to 8 present those profiles from upstream to downstream, from emerged to submerged cases and both between the square cylinders at y = -0,1 m (Figure 6a) and out of the array at y = 0,3 m (Figure 6b). First of all, it can be noticed on figures 5a, 6a, 7a and 8a that the flow is slowed up to one cylinder length (lx) upstream of the first raw. This is associated with a slowdown of the flow at the entrance of the array. This behavior goes to up to 20% of the in-going U velocity for the lower water levels (E095 and S105) whereas for the submerged S130 and S150 cases the velocity is less affected above the cylinders. On the opposite, once between the cylinders, the flow was accelerated and a fast vein flowing up to 40% faster than the incoming velocity was created. Moreover, the velocity distributions present very complex shapes that may be due to the fully tridimensional behavior of the flow where transverse variations of the 3 components of the velocity were observed by [START_REF] Oukacine | Etude expérimentale et numérique des écoulements à surface libre en présence d'obstacles émergés à faiblement submergés[END_REF]. Unfortunately, the experimental set-up used for the preliminary study did not allow us to measure the transverse and vertical components of the velocity. The complexity of the profiles decreases when the water level increases. And the S150 case presents velocity distribution with smooth variations. One noticeable point is the existence of a dip phenomenon that was unexpected if we consider that the channel is wide (the ratio of its width to the water level is above 10) but shows that, between two lines of square cylinders, the flow behaves as with a narrow channel; even when between 2 rows such as for xsc = 2lx.

Outside of the array but close to it (at 0.5 lx out of the last lane of square cylinders), the velocity distribution have complex shapes for the just emerged E095 (Figure 5b) and just submerged S105 cases (Figure 6b) whereas, for the more deeply submerged situations S130 and S150 (Figures 7b and8b) the profiles present progressive evolution. It can be noticed that, for the S130 and S150 cases, the flow is slightly accelerated at the level of the interval between the first and second rows of square cylinders and slightly slown down at the level of the interval between the second and third rows of square cylinders.

a) Between the cylinders b) outside of the array at y = 3lx

CONCLUSIONS

The present communication deals with settlements exposed to flooding situations from emerged to slightly submerged situations. First we presented briefly the context before detailing the experimental set-up. Second the results were presented and discussed.

Experimental vertical distribution of the streamwise velocity were measured inside and close to an array of aligned and equidistant square cylinders. The experiments have shown the influence of the cylinders on the flow and in particular the existence of a fast vein between the lines of aligned cylinders. The results also showed the hight influence of the cases, either emerged or submerged, on the velocity. Visual observations during the experiments have shown that the flow is rather complex that was corroborated by the upstream to downstream variations of the profiles. The given results indicate that the two others components of the velocity as well as the turbulent fluctuations would give interesting elements. Unfortunately, the profiler used for this preliminary study did not allowed to measure the those parameters and to measure the upper part of the flow.

This preliminary study will be continued to improve the experimental set-up for measuring that. Other configurations will be investigated too, in particular to investigate the influence of the distances (both streamwise and transverse) between the square cylinders.

ACKNOWLEDGEMENTS

The authors thank EDF R&D for giving them access to the experimental facilities and for funding A. Doumic's fellowship.

Figure 1 :

 1 Figure 1: Exemples of aligned housings (from Nantes Metropole, 2014) The experiments have been carried out at the Laboratoire d'Hydraulique Saint Venant in an open channel which is 16 m long, 2 m wide and 0.5 m high. A honeycomb has been placed at the pump outlet to calm the flow.Velocity measurements were performed with a Ubertone UBLab ultrasonic profiler (Figure2) fixed at the free surface. This set-up has the advantage of giving simultaneously a velocity profile while minimizing the disturbance of the flow except close to the free surface.

Figure 2 :

 2 Figure 2: View of instrumentation and its implementation in the channel.

Figure 3 :

 3 Figure 3: Experimental configuration: an array of aligned square cylinders.

Figure 4 :

 4 Figure 4: Free surface deformation for the E095 case.

  Proceedings of the 39 th IAHR World Congress 19-24 June 2022, Granada, Spain ©2022 IAHR. Used with permission / ISSN-L 2521-7119

Figure 5 :

 5 Figure 5: Upstream to downstream evolution of the velocity distribution for the E095 case

Figure 6 :

 6 Figure 6: Upstream to downstream evolution of the velocity distribution for the S105 case

Figure 7 :

 7 Figure 7: Upstream to downstream evolution of the velocity distribution for the S130 case

Figure 8 :

 8 Figure 8: Upstream to downstream evolution of the velocity distribution for the S150 case

Table 1

 1

		: experimental cases
	cases	H (m)	Q (m 3 /s) Fr	Re
	E095	0.095	0.044	0.24	21850
	S105	0.105	0.048	0.23	24150
	S130	0.130	0.060	0.20	29900
	S150	0.150	0.069	0.19	34500


Sébastien Kerever
email: sebastien.kerever@aphp.fr

Les prises de décision lors des limitations et arrêts des thérapeutiques (LAT)

Keywords: vie, limitations des thérapeutiques, réanimation

Les décisions de limitation et d'arrêt des thérapeutiques sont un sujet de préoccupation important et croissant dans de nombreuses spécialités médicales telles que l'oncologie, l'hématologie et plus particulièrement en réanimation. De nombreux articles ont été publiés ces dernières années sur cette thématique et concernent des recommandations sur la prise en charge médicale des patients concernés par ces décisions, sur le ressenti et le point de vue des patients et de leurs familles, sur des sujets comme l'éthique, ou de nouveaux textes de loi qui encadrent ces pratiques comme la loi Clayes Léonetti. A contrario, peu de publications se sont focalisées sur le positionnement et la participation des paramédicaux lors de ces prises de décision, leur rôle et leur ressenti restent à ce jour peu explorés, et parfois en contradiction avec les perceptions médicales.

Keywords à venir

Les décisions de limitation et d'arrêt des thérapeutiques sont un sujet de préoccupation important et croissant dans de nombreuses spécialités médicales telles que l'oncologie, l'hématologie et plus particulièrement en réanimation. De nombreux articles ont été publiés ces dernières années sur cette thématique et concernent des recommandations sur la prise en charge médicale des patients concernés par ces décisions, sur le ressenti et le point de vue des patients et de leurs familles, sur des sujets comme l'éthique, ou de nouveaux textes de loi qui encadrent ces pratiques comme la loi Clayes Léonetti. A contrario, peu de publications se sont focalisées sur le positionnement et la participation des paramédicaux lors de ces prises de décision, leur rôle et leur ressenti restent à ce jour peu explorés, et parfois en contradiction avec les perceptions médicales [START_REF] Ferrand | Discrepancies between perceptions by physicians and nursing staff of intensive care unit end-of-life decisions[END_REF].

T1 Limitations et arrêts des thérapeutiques (LAT)

Lors des prises de décision de LAT en réanimation, on peut distinguer trois grandes typologies de stratégies :

. les DNR orders (Do Not Resuscitate ou No Code) qui se définissent comme une consigne de ne pas réanimer le patient et de ne pas pratiquer de réanimation cardiopulmonaire en cas d'arrêt cardiaque ;

. le deuxième type de décision rencontré en réanimation et recensée dans la littérature lors des situations de fin de vie est la consigne de "limiter les thérapeutiques" ou Withholding Treatment, cette stratégie consiste à ne pas mettre en place de nouvelles thérapeutiques qui pourraient potentiellement maintenir le patient en vie comme la décision de ne pas introduire les antibiotiques en cas d'infection ou de ne pas mettre en place d'épuration extrarénale en cas d'insuffisance rénale ;

. enfin la dernière typologie de décision que l'on peut rencontrer est les "arrêts des thérapeutiques" ou Withdrawing Treatment, qui consistent à arrêter des traitements déjà mis en place et qui permettaient de maintenir le patient en vie comme l'arrêt des catécholamines.

Alors que la mortalité globale moyenne en réanimation se situe entre 15 et 20 % en fonction des spécialités, il apparaît que la moitié des patients admis dans ces mêmes réanimations seront concernés par une décision de limitation ou d'arrêt des thérapeutiques. Ceci signifie donc que 10 % des patients admis en réanimation, soit 1 patient sur 10, décéderont suite à une prise de décision de LAT. Une étude publiée en 2003 dans le Journal of the American Medical Association (JAMA) a montré que sur 31 417 admis dans 37 réanimations européennes entre 1999 et 2000, 4 248 sont décédés avant leur sortie de réanimation (13,5 % de mortalité globale). Parmi ces 4 248 patients décédés lors de leur séjour en réanimation, 3 086 ont été confrontés à une prise de décision de limiter les thérapeutiques, soit 72,6 % des patients [START_REF] Sprung | End-of-life practices in European intensive care units: the Ethicus Study[END_REF].

T1 Prise de décision

Le processus décisionnel de LAT est encadré par la loi du 2 février 2016 créant de nouveaux droits en faveur des malades et personnes en fin de vie (dite "loi Claeys Léonetti"). Cette loi promeut les droits des malades dans le cadre spécifique de la fin de vie. Elle incite le praticien à mettre en place tous les moyens à disposition pour sauvegarder la dignité du mourant et assurer sa qualité de vie en dispensant des soins palliatifs. Elle impose également au praticien de s'abstenir de toute obstination déraisonnable. Cette obstination déraisonnable est définie juridiquement par des actes qui apparaîtraient inutiles, disproportionnés ou n'ayant d'autre effet que le seul maintien artificiel de la vie. Pour autant, ce concept d'obstination déraisonnable est difficile à circonscrire dans une situation singulière : le seuil en est variable d'un patient à l'autre et révisable d'un moment à l'autre. Cette décision, qui reste médicale, doit donc reposer sur des données objectives et sur une concertation et une prise de décision collégiale. Cependant, dans la pratique quotidienne, les situations sont parfois différentes et de nombreux facteurs peuvent influencer cette prise de décision de LAT ou de poursuite des thérapeutiques. Les patients arrivant en réanimation, en plus de la gravité liée à la pathologie qui motive leur admission, peuvent présenter de nombreux antécédents ou comorbidités qui doivent être pris en compte au moment de l'admission en réanimation et, lorsque survient la question de la prise de décision de LAT. Lors de ces prises de décision de LAT, le médecin en charge du patient se doit de rechercher des informations objectives auprès des différentes personnes qui prennent part à cette décision et auprès du patient lui-même lorsque celui-ci est en capacité d'exprimer son point de vue, car la décision de LAT ne peut pas reposer sur une seule personne mais doit plutôt être la résultante d'une réflexion commune entre les différents acteurs. Il s'agit donc de tenir compte et de respecter l'avis et le point de vue de l'ensemble des personnes qui prennent part à cette prise de décision. Mais tous les acteurs ne souhaitent pas toujours y être associés et on sait que selon Azoulay et al. seulement la moitié des proches et des familles souhaitent être associés à ces prises de décision [START_REF] Azoulay | Half the families of intensive care unit patients experience inadequate communication with physicians[END_REF].

La temporalité est également une composante importante dans les situations de fin de vie et de prise de décision de LAT en réanimation. Le processus de décision de LAT doit reposer sur un recensement le plus exhaustif et le plus objectif possible des données en lien avec le patient (volonté du patient, habitudes de vie, souhaits exprimés auprès des proches, maladie chronique et antécédents). Ce recueil des données et cette recherche d'informations semblent difficilement réalisables dans l'urgence ou dans un contexte de décision rapide, « plus une situation est urgente et nécessite la mise en oeuvre de moyens techniques sophistiqués, plus le risque de faire abstraction de sa complexité, particulièrement éthique, est grand » [START_REF] Dorze | Limitation et arrêt des thérapeutiques en situation aiguë. Quel rôle pour le médecin anesthésiste-réanimateur dans une décision d'abstention d'un acte chirurgical urgent ?[END_REF]. Ces situations de prises de décision en urgence et de décisions urgentes engendrent parfois un phénomène où l'importance de "l'éthique" se retrouve partiellement occultée ou minorée au profit des aspects techniques et physiologiques de la réanimation. Au final, ce contexte de l'urgence dans la prise de décision de LAT peut être un obstacle car il empêche le recueil de données exhaustives et objectives nécessaires à la décision et il ne permet pas le cheminement et la maturation de cette même décision auprès des différents acteurs et peut avoir pour conséquences une perte de chance pour le patient. Ce contexte de l'urgence peut avoir des conséquences pour le patient et pour les équipes car il peut être décidé après une décision prise dans ces conditions de l'urgence une "dé-escalade" ou un changement de stratégie concernant le devenir du patient. Ces changements de décisions et ces remises en question de la décision initiale peuvent avoir des conséquences, des répercussions et un impact sur le bien-être des différents acteurs qui avaient pris part initialement à la décision de LAT.

Dans une étude publiée en 2018, Le Dorze et al. posent la question de mieux repérer les éléments nécessaires au processus décisionnel pour ne pas passer à côté de la décision la plus appropriée et la plus adaptée pour la situation et pour le patient [START_REF] Dorze | Limitation et arrêt des thérapeutiques en situation aiguë. Quel rôle pour le médecin anesthésiste-réanimateur dans une décision d'abstention d'un acte chirurgical urgent ?[END_REF].

Ils proposent ainsi la liste de questions ci-dessous qui peut nous faire réfléchir sur la façon dont le processus décisionnel a été construit et défini.

• La volonté du patient est-elle respectée ? • Le patient est-il en état d'exprimer sa volonté ? Si oui, sa volonté est-elle clairement exprimée ? Si non, sa volonté a-t-elle été recherchée à travers des directives anticipées, ou auprès de sa personne de confiance, ou à défaut auprès de sa famille ou de ses proches ? • La famille et les proches ont-ils été informés et/ou consultés ? Que pensent-ils de la situation et de la décision ? • Les soignants participants à la décision sont-ils identifiés et ont-ils librement exprimé leur point de vue ? • Une concertation avec l'équipe de soins a-t-elle eu lieu ? • Les médecins en charge du patient et responsables de la décision ont-ils été clairement identifiés ? • Une procédure collégiale a-t-elle pu se mettre en place ? Les conditions de la délibération et de la recherche d'une adhésion à la décision ont-elles été réunies ? • Les répercussions de la décision sur l'ensemble des intervenants de l'équipe soignante ont-elles été envisagées ?

T1 Conclusion

Les décisions de LAT en réanimation sont des processus complexes et

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  multifactorielles qui devraient prendre en compte le point de vue des différents acteurs qui souhaitent participer à ces prises de décision. Le patient doit rester au centre des préoccupations et les données permettant la prise de décision doivent être les plus objectifs possibles. Ces données objectives et personnalisées, qui doivent être rassemblées pour que la prise de décision de LAT soit la plus adaptée possible au patient et à sa situation, seront confrontées à des données subjectives liées au patient lui-même et aux valeurs culturelles et éthiques du médecin et de l'équipe qui portera cette décision. Cette expression des données subjectives des participants renvoie également à la problématique de la sélection ou non des personnes qui prendront part à cette prise de décision. Ces décisions de LAT en réanimation peuvent potentiellement avoir des conséquences en termes de vécu et de ressenti auprès des participants et des familles et on ne mesure pas encore très bien à ce jour les conséquences de ces décisions sur les acteurs, tant sur le plan psychologique que sur leur future capacité à prendre à nouveau part à ce type de décision. L'attention particulière qui doit donc être portée aux processus décisionnels relatifs aux limitations et aux arrêts des thérapeutiques en réanimation s'inscrit donc dans le cadre d'une démarche qualité dont la visée principale est le respect du patient. Dans ce cadre, il est essentiel de promouvoir tous les outils permettant de s'approcher au mieux de la volonté du patient, qui peut être exprimée soit par le patient lui-même, soit par des moyens tels que les directives anticipées. Le processus de délibération collective concerne les situations cliniques complexes dans lesquelles se trouvent des patients en fin de vie. Dans ces situations, où de nombreuses questions d'ordre éthique se posent, il existe une nécessité de croiser des avis argumentés différents pour enrichir la réponse et construire une décision adaptée à la situation et respectueuse du patient.