MD Lionel Rebibo

MD Karim K Maurice

MD Martin Nimer

Mouna Ben Rehouma

MD Philippe Montravers

Professor Simon Msika
email: simon.msika@aphp.fr

Laparoscopic sleeve gastrectomy as day-case surgery: a review of the litterature

Keywords: sleeve gastrectomy, day-case surgery, ambulatory surgery, inpatient surgery, outcomes

Day-case surgery (DCS) in digestive surgery is a hot topic and new indications for DCS in the field of gastrointestinal surgery have recently been described. Laparoscopic sleeve gastrectomy (LSG) has become a very popular bariatric procedure in recent years. LSG is a reproducible, standardized procedure with a short operating time and possibly simple perioperative management. It therefore meets the criteria to be performed as a DCS procedure. Recent published series of LSG as DCS have demonstrated its feasibility. In this review on the LSG performed as day-case surgery, we focused on the management of risks associated with DCS and the results of such type of management. A literature search was conducted in the PubMed and Embase database. Six studies were selected, comprising a total of 6227 patients. Most of published series were retrospective single-center studies. Inclusion criteria were similar between most studies (primary SG for most series, patients with a body mass index (BMI) ≥ 40 kg/m 2 or a BMI ≥ 35 kg/m 2 in the presence of comorbidities) while exclusion criteria were based on literature data for some studies (using series on risk factors for morbidity and mortality after RYGB) and personal experience for other series. The mortality rate of LSG as DCS range from 0 to 0.08% while the overall complication rate ranges from 0 to 10%. The unplanned overnight admission rate after LSG range from 0.8 to 8%. The unscheduled hospitalizations rate range from 2.1% to 8.5%. LSG performed as DCS is feasible with good results, but cannot be proposed for all patients. A good selection is necessary in other to avoid increase risk of morbidity and mortality.

surgery (DCS), body mass index (BMI), obstructive sleep apnea (OSA)

INTRODUCTION

Prevalence of morbid obesity increases worldwide. Bariatric surgery has been demonstrated to be the most effective therapy for achieving sustained weight loss and managing obesityrelated complications, like type 2 diabetes, arterial hypertension, dyslipidemia, and cardiovascular disease [START_REF] Sjöström | Bariatric surgery and long-term cardiovascular events[END_REF] . Laparoscopic sleeve gastrectomy (LSG) is currently the most performed bariatric surgery in France [START_REF] Lazzati | Bariatric surgery trends in France: 2005-2011[END_REF] and in the USA [START_REF] Spaniolas | The Changing Bariatric Surgery Landscape in the USA[END_REF] , due to its excellent weight loss success in the short-term follow-up and its relative technical facility compared to RYGB.

Recent series also showed that the rate of complications after LSG compared to Roux-en-Y gastric bypass (RYGB) are less in the short post-operative course, and in the long-term as well [START_REF] Zak | Laparoscopic Roux-en-Y gastric bypass patients have an increased lifetime risk of repeat operations when compared to laparoscopic sleeve gastrectomy patients[END_REF] .

The majority of LSG performed, particularly in case of first line surgery, has short operating times [START_REF] Berger | The Impact of Different Surgical Techniques on Outcomes in Laparoscopic Sleeve Gastrectomies: The First Report from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)[END_REF] with few surgical post-operative complications with a gastric leaks rate of 1.5%, a post-operative bleeding rate of 1.3% and a gastric stenosis rate of 0.1% [START_REF] Stroh | Results of More Than 11,800 Sleeve Gastrectomies: Data Analysis of the German Bariatric Surgery Registry[END_REF] . The length of hospitalization that surrounds this type of surgery has been shortened due to a change in perioperative management [START_REF] Berger | The Impact of Different Surgical Techniques on Outcomes in Laparoscopic Sleeve Gastrectomies: The First Report from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)[END_REF] . Many series have shown that simplification of the perioperative management by dropping routine upper gastrointestinal contrast studies in the days following surgery and reducing routine abdominal drainage, could allow reducing length of hospital stay without increasing the risk of post-operative complications, therefore allowing to consider outpatient management.

Day-case surgery (DCS) does not require an overnight hospital stay. Depending on geographic area, DCS could be completely different. In France, patients undergoing surgery as DCS are operated in the morning and discharged home in the evening [START_REF] Noel | Ambulatory surgery for sleeve gastrectomy: terminology and concept[END_REF] . DCS is distinct from overnight-stay surgery or one-day surgery, in which the patient is discharged to home the day after the operation (i.e. after a night as an inpatient). Innovative indications have subsequently emerged for more major surgery, such as the treatment of gastro-oesophageal reflux disease [START_REF] Trondsen | Day-case laparoscopic fundoplication for gastro-oesophageal reflux disease[END_REF] , laparoscopic colectomy [START_REF] Gignoux | Short-term Outcomes of Ambulatory Colectomy for 157 Consecutive Patients[END_REF] or minor laparoscopic liver resection [START_REF] Rebibo | Minor laparoscopic liver resection as day-case surgery (without overnight hospitalisation): a pilot study[END_REF] . The results of these published series show that more complex surgery can be performed in an outpatient setting with good results and without increased morbidity and mortality, provided patients are rigorously selected for this type of management. Concerning bariatric surgery, first procedures performed as DCS included gastric banding implementation [START_REF] Kormanova | Is laparoscopic adjustable gastric banding a day surgery procedure?[END_REF][START_REF] Wasowicz-Kemps | Laparoscopic gastric banding for morbid obesity: outpatient procedure versus overnight stay[END_REF] then series on LSG and Roux-en-Y gastric bypass [START_REF] Morton | Is ambulatory laparoscopic Roux-en-Y gastric bypass associated with higher adverse events?[END_REF] have been described.

Here, we review the literature data on the LSG performed as day-case surgery focusing on the associated risk management and the results of such type of management.

RESEARCH

Search strategy and selection criteria

Two reviewers independently searched the PubMed and Embase databases for articles related to LSG and day-case surgery between 2003 and 2018. The search terms were "sleeve gastrectomy", "day-case surgery", "outpatient" and "ambulatory". Only full, original articles written in English were selected. For each selected article, the list of references was checked for studies not listed in the PubMed and Embase databases or not found in the search.

Data extraction and analysis

The two reviewers extracted the following data from each selected study: first author, date, type of study (prospective or retrospective) and the number of included patients. The data were separated into two categories: those related to pre-operative selection and management of patients undergoing LSG as DCS, and those related to results of such type of management (complications and data relative to DCS).

Assessment of the quality of selected publications

The methodological quality of the diagnostic studies was independently evaluated by the two reviewers according to the Standards for Reporting of Diagnostic Accuracy (STARD) criteria [START_REF] Bossuyt | Standards for Reporting of Diagnostic Accuracy. The STARD statement for reporting studies of diagnostic accuracy: explanation and elaboration[END_REF] . The studies were graded based on items relevant for this review. Studies were divided into groups as a function of the calculated STARD score; a score of 8 or 9 indicates good quality; a score of 6 or 7 indicates fair quality and a score of 5 or less indicates poor quality.

Any disagreements between the two reviewers over data quality were resolved by consensus.

According to our search results, a total of 54 studies related to LSG and DCS were published between 2000 and 2018 (Figure 1). Only six of these studies were relevant. On these 6 series, there was three single centre retrospective studies [15 -17] , two single centre prospective studies [START_REF] Rebibo | Laparoscopic sleeve gastrectomy as day-case surgery (without overnight hospitalization)[END_REF][START_REF] Badaoui | Satisfaction rate of patients undergoing sleeve gastrectomy as day-case surgery compared to conventional hospitalization: a prospective nonrandomized study[END_REF] and one retrospective, comparative, national database analysis [START_REF] Inaba | How safe is sameday discharge after laparoscopic sleeve gastrectomy?[END_REF] . On these 6 series, two series reported the same population of DCS but one focused on surgical data while the other focused on anaesthesiology data (Table 1). These studies represent a total of 6227 patients.

HOSPITAL AND STUDIES CHARACTERISTIC

On the different single centre series (Table 1) evaluating results of LSG performed as DCS, two US series included outpatient surgery centre without possibility of overnight admission in the same hospital [START_REF] Billing | Outpatient laparoscopic sleeve gastrectomy in a free-standing ambulatory surgery center: first 250 cases[END_REF][START_REF] Lalezari | Laparoscopic sleeve gastrectomy as a viable option for an ambulatory surgical procedure: our 52-month experience[END_REF] . In another French series, LSG performed as day-case surgery was performed in a dedicated ambulatory unit in a university hospital centre with possibility of admission in the department of digestive surgery in case of an unplanned overnight stay [START_REF] Rebibo | Laparoscopic sleeve gastrectomy as day-case surgery (without overnight hospitalization)[END_REF] .

In another Canadian series, LSG were performed in a tertiary bariatric centre with no

RISK MANAGEMENT

Criteria for patient selections

All published series met the inclusion criteria of the National Institutes of Health [START_REF]Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults--The Evidence Report. National Institutes of Health[END_REF] , i.e. patients with a body mass index (BMI) ≥ 40 kg/m 2 or a BMI ≥ 35 kg/m 2 in the presence of comorbidities likely to be improved by bariatric surgery in case of primary LSG. BMI could be lower in case of revisional LSG.

Concerning exclusion criteria for DCS, the 4 single-center published series have different exclusion criteria based on personal experience [START_REF] Billing | Outpatient laparoscopic sleeve gastrectomy in a free-standing ambulatory surgery center: first 250 cases[END_REF][START_REF] Lalezari | Laparoscopic sleeve gastrectomy as a viable option for an ambulatory surgical procedure: our 52-month experience[END_REF] or literature data [START_REF] Garofalo | Fully Ambulatory Laparoscopic Sleeve Gastrectomy: 328 Consecutive Patients in a Single Tertiary Bariatric Center[END_REF][START_REF] Rebibo | Laparoscopic sleeve gastrectomy as day-case surgery (without overnight hospitalization)[END_REF] . All have in common, as exclusion criteria, the distance from the center performing surgery and the presence of an accompanying person for the discharge of the outpatient unit. The two other series used literature data to select patients for DCS, including studies evaluating risk factors for morbidity and mortality after GBP [START_REF] Fernandez Az | Experience with over 3,000 open and laparoscopic bariatric procedures: multivariate analysis of factors related to leak and resultant mortality[END_REF][START_REF] Demaria | Obesity surgery mortality risk score: proposal for a clinically useful score to predict mortality risk in patients undergoing gastric bypass[END_REF] to determine their exclusion criteria. One series use the criteria of DeMaria [START_REF] Demaria | Obesity surgery mortality risk score: proposal for a clinically useful score to predict mortality risk in patients undergoing gastric bypass[END_REF] as an exclusion criterion, namely an age ≥ 55 years and a BMI ≥ 55 kg/m 2 [START_REF] Bossuyt | Standards for Reporting of Diagnostic Accuracy. The STARD statement for reporting studies of diagnostic accuracy: explanation and elaboration[END_REF] . In another series [START_REF] Rebibo | Laparoscopic sleeve gastrectomy as day-case surgery (without overnight hospitalization)[END_REF] , the presence of an obstructive sleep apnea (OSA) (with or without the need for C-PAP) was considered as an exclusion criterion based on a study where the presence of obstructive sleep apnea is a risk factor for morbidity and mortality after GBP [START_REF] Inaba | How safe is sameday discharge after laparoscopic sleeve gastrectomy?[END_REF] . However, the presence of obstructive sleep apnea was not an exclusion criterion in the rest of the studies [15 -17] (Table 1). Concerning revisional surgery (patients with history of gastric banding), two studies performed LSG as DCS with or without simultaneous gastric banding removal [START_REF] Garofalo | Fully Ambulatory Laparoscopic Sleeve Gastrectomy: 328 Consecutive Patients in a Single Tertiary Bariatric Center[END_REF][START_REF] Lalezari | Laparoscopic sleeve gastrectomy as a viable option for an ambulatory surgical procedure: our 52-month experience[END_REF] in contrary to the other series [START_REF] Billing | Outpatient laparoscopic sleeve gastrectomy in a free-standing ambulatory surgery center: first 250 cases[END_REF][START_REF] Rebibo | Laparoscopic sleeve gastrectomy as day-case surgery (without overnight hospitalization)[END_REF] .

Type of patients included as DCS

some cases. On the other hand, Lalezari et al [START_REF] Lalezari | Laparoscopic sleeve gastrectomy as a viable option for an ambulatory surgical procedure: our 52-month experience[END_REF] , used routine buttress material on the gastric staple line.

Mean operative time ranged from 54 to 60 minutes (30-161). In one series, a predicted operating time of more than two hours was considered as a preoperative exclusion criterion [START_REF] Billing | Outpatient laparoscopic sleeve gastrectomy in a free-standing ambulatory surgery center: first 250 cases[END_REF] . Only one series mentioned discharge from outpatient unit with abdominal drainage [START_REF] Billing | Outpatient laparoscopic sleeve gastrectomy in a free-standing ambulatory surgery center: first 250 cases[END_REF] whereas for the other studies, abdominal drainage was an exclusion criterion for outpatient management.

Postoperative risk management

Only one study mentioned the carrying out of a laboratory assessment before discharge [START_REF] Garofalo | Fully Ambulatory Laparoscopic Sleeve Gastrectomy: 328 Consecutive Patients in a Single Tertiary Bariatric Center[END_REF] .

The same series carried out a routine upper gastrointestinal contrast studies before discharge [START_REF] Garofalo | Fully Ambulatory Laparoscopic Sleeve Gastrectomy: 328 Consecutive Patients in a Single Tertiary Bariatric Center[END_REF] . In the series of Inaba et al [START_REF] Inaba | How safe is sameday discharge after laparoscopic sleeve gastrectomy?[END_REF] , routine upper gastrointestinal contrast studies were performed in 23% of cases before discharge while selective radiological evaluation was performed in less than 1% of cases (0.7%).

In another study, patients were discharged from the outpatient unit with an intravenous cannula in place and were systematically reviewed the day after surgery for further intravenous fluids of 1-2 liters [START_REF] Billing | Outpatient laparoscopic sleeve gastrectomy in a free-standing ambulatory surgery center: first 250 cases[END_REF] . Regarding early postoperative follow-up, patients were called in the evening of the surgery by the surgeon [START_REF] Rebibo | Laparoscopic sleeve gastrectomy as day-case surgery (without overnight hospitalization)[END_REF] and/or the day after by a nurse [16 -18] . Follow-up by "texting" was done in one series [START_REF] Rebibo | Laparoscopic sleeve gastrectomy as day-case surgery (without overnight hospitalization)[END_REF] . A scheduled consultation was also carried out for some authors. In the series of Rebibo et al [START_REF] Rebibo | Laparoscopic sleeve gastrectomy as day-case surgery (without overnight hospitalization)[END_REF] , scheduled consultation was performed at the 4 th postoperative day, based on the surgical team's own experience in the management of gastric leak after LSG, where 50% of their gastric leaks appeared on the 5 th post-operative day [START_REF] Pequignot | Is there a place for pigtail drains in the management of gastric leaks after laparoscopic sleeve gastrectomy?[END_REF] . In this series, a laboratory assessment including C-reactive protein was performed during the scheduled consultation. The scheduled consultation allowed diagnosing three gastric leaks, and the C-reactive protein allowed diagnosing a gastric leak in an asymptomatic patient. In another series, scheduled consultation was performed at post-operative days 7 [START_REF] Lalezari | Laparoscopic sleeve gastrectomy as a viable option for an ambulatory surgical procedure: our 52-month experience[END_REF] .

RESULTS OF SLEEVE GASTRECTOMY AS DAY-CASE SURGERY

Morbidity and mortality

The mortality rate ranged from 0 to 0.08%. (Table 4). The overall complication rate was acceptable, ranging from 0 to 10%, the majority were considered as minor complications.

When analyzing patients undergoing LSG as DCS in the single-center series (1499 patients), the rate of gastric leaks was 0.8% (n=13), while the rate of post-operative bleeding related to gastric staple line was 0.3% (n=5) and the rate of post-operative stenosis was 0.06% (n=1).

The rate of unscheduled reoperation after LSG as DCS in this same series was low (0.3%; n=5) and range from 0 to 3%. In the series of Inaba et al [START_REF] Rebibo | Laparoscopic sleeve gastrectomy as day-case surgery (without overnight hospitalization)[END_REF] , the rate of unscheduled reoperation was 0.6% (29 patients out of 4729 LSG).

Unplanned overnight admissions and consultations

The unplanned overnight admission rate after LSG ranged from 0.8 to 8%. Maybe that this rate of overnight admission could be impacted by the fact that facilities for discharge in the same hospital was not present in 3 of 4 single center study. Also, in the series of Garofalo et al [START_REF] Garofalo | Fully Ambulatory Laparoscopic Sleeve Gastrectomy: 328 Consecutive Patients in a Single Tertiary Bariatric Center[END_REF] , 37% of patients were discharged in a hotel, next to the center performing LSG, may explain the very low rate of unplanned admissions (1.8%). This data is missing in the two other US series [START_REF] Billing | Outpatient laparoscopic sleeve gastrectomy in a free-standing ambulatory surgery center: first 250 cases[END_REF][START_REF] Lalezari | Laparoscopic sleeve gastrectomy as a viable option for an ambulatory surgical procedure: our 52-month experience[END_REF] but it is likely that postoperative management was the same based on the low unplanned admission rate of 0.8%. In the French series, where such postoperative facilities were not available, the rate of unplanned admissions was 8% [START_REF] Rebibo | Laparoscopic sleeve gastrectomy as day-case surgery (without overnight hospitalization)[END_REF] , similar to first published series of cholecystectomies and laparoscopic fundoplication performed as DCS [START_REF] Mjåland | Outpatient laparoscopic cholecystectomy[END_REF][START_REF] Mariette | The safety of the same-day discharge for selected patients after laparoscopic fundoplication: a prospective cohort study[END_REF] .

Only one study mentioned the unscheduled consultation rate and concerns about 6% of patients undergoing LSG as DCS (Table 4).

Mid-term results and satisfaction rate

Regarding the results in terms of weight loss, only one series analyzed [START_REF] Billing | Outpatient laparoscopic sleeve gastrectomy in a free-standing ambulatory surgery center: first 250 cases[END_REF] the weight loss on follow-up on a three year period with a mean excess weight loss of 63.6% at two years. It also evaluated correction of comorbidities related to obesity during the same follow-up. The satisfaction rate of outpatient management was evaluated in one series [START_REF] Rebibo | Laparoscopic sleeve gastrectomy as day-case surgery (without overnight hospitalization)[END_REF] and was performed at three months after LSG with 96% of satisfaction. The dissatisfied patients were those having a major postoperative complication.

Badaoui et al. [START_REF] Badaoui | Satisfaction rate of patients undergoing sleeve gastrectomy as day-case surgery compared to conventional hospitalization: a prospective nonrandomized study[END_REF] in their prospective, comparative, evaluation of the satisfaction of general anesthesia of patients undergoing LSG as outpatient (62 patients) and as inpatient (62 patients) based on the EVAN-G questionnaire found a mean score of 66.4 in the outpatient group vs. 68.9 in the inpatient group (not significant difference). In the outpatient group, 19% of patients would have preferred to spend the first night in hospital while in the conventional hospitalization group, 82% of patients would have preferred outpatient management (average length of stay of 1.9 days (1-3)). Seventy-five percent of the patients had a high level of satisfaction.

Comparison between DCS and inpatient surgery

Two series have compared patients undergoing LSG as DCS to those hospitalized [START_REF] Garofalo | Fully Ambulatory Laparoscopic Sleeve Gastrectomy: 328 Consecutive Patients in a Single Tertiary Bariatric Center[END_REF][START_REF] Rebibo | Laparoscopic sleeve gastrectomy as day-case surgery (without overnight hospitalization)[END_REF] . According to Rebibo et al [START_REF] Rebibo | Laparoscopic sleeve gastrectomy as day-case surgery (without overnight hospitalization)[END_REF] , no significant difference were found in terms of the rate of major complications (p=0.35), gastric leaks (p=0.18), and reoperations (p=0.38) compared to inpatient management. This could be explained by the fact that patients undergoing LSG as DCS are considered to be "easier" patients with few risk factors for post-operative complications (decreased BMI without BMI over 60 kg/m 2 , few patients with type 2 diabetes…)

In the series of Inaba et al [START_REF] Inaba | How safe is sameday discharge after laparoscopic sleeve gastrectomy?[END_REF] , the rate of mortality was increased in case of DCS (not significant) and the rate of morbidity was also increased (1.31% for DCS vs. 0.84 for inpatient surgery; p < 0.05). In the analysis of cause for morbidity, significant differences were seen concerning the rate of cardiac arrest requiring cardiopulmonary resuscitation and the rate of post-operative pneumonia. The rate of reoperation was significantly increased in case of DCS (0.61% vs. 0.27% for inpatient) as same as the rate of readmission (2.14% vs. 1.65% for inpatient). This study found that LSG as DCS compared to inpatient was associated with an increased risk of overall morbidity (adjusted odds ratio (AOR) of 1.72), readmission (AOR of 1.4), and reoperation (AOR of 2.35). When we looked for their pre-operative demographic data, it is reasonable to think that some patients who underwent LSG as DCS should have been excluded for this type of management (i.e. patients with history of cardiac diseases, deep vein thrombosis or pulmonary embolism in particular).

Limitation of published series

Management of post-operative complications following LSG as DCS compared to inpatient is lacking. The question arises as to whether DCS management does not put an extra risk on the management of a surgical complication. Post-operative bleeding after LSG is probably the Achilles heel of proposing DCS compared to overnight hospitalization (even in case of 23 hours hospitalization) as this complication usually appears during the first 24 hours and so probably after discharge in case of LSG performed as DCS. However, according to different published series, this complication is very low with a post-operative bleeding rate of 0.3% (5 patients out of 6227) and data concerning how and when were diagnosed bleeding is lacking (after discharge or before discharge of DCS?). Also, occurrence of post-operative mortality for these patients is lacking. Concerning gastric leak and gastric stenosis, early discharge compared to discharge at 23 hours post-operatively should probably not impact diagnosis and/or management as these complications usually appears after a mean time interval of 5 days after SG [START_REF] Fernandez Az | Experience with over 3,000 open and laparoscopic bariatric procedures: multivariate analysis of factors related to leak and resultant mortality[END_REF] for gastric leak and 43 days for gastric stenosis [START_REF] Rebibo | Gastric Stenosis After Laparoscopic Sleeve Gastrectomy: Diagnosis and Management[END_REF] .

It is difficult to give a list of all risk factors for complications which would be even more important to take into account in case of DCS. When we analyzed series published on DCS, most of them excluded patients with higher risk of bleeding such as increased BMI, patients with antiplatelet and/or anticoagulation therapy, history of gastric surgery (gastric banding in particular), OSA… For this unusual type of management, it might be interesting to use predictive score for complications and for bleeding in particular. For bleeding, as example, Janik et al [START_REF] Janik | Prediction Model for Hemorrhagic Complications after Laparoscopic Sleeve Gastrectomy: Development of SLEEVE BLEED Calculator[END_REF] , in their retrospective analysis, searched for risk factors for post-operative bleeding after LSG and found that no history of OSA and hypertension were predictive factors for bleeding. Aminian et al [START_REF] Aminian | Development of a sleeve gastrectomy risk calculator[END_REF] have described risk calculator for post-operative events, including bleeding and cardiac disorders, that can be interesting to use in the context of DCS.

Finally, another technical way to decrease the risk of post-operative bleeding, could be the use of staple line reinforcement which seems to decrease significantly the rate of bleeding [START_REF] Wang | The efficacy of staple line reinforcement during laparoscopic sleeve gastrectomy: A meta-analysis of randomized controlled trials[END_REF] .

CONCLUSION

LSG performed as DCS is feasible with good results, but most studies published were retrospective studies. Further prospective and comparative studies are needed to compare outpatient management with conventional management thus allowing a better selection of patients who are candidates for DCS without additional risks. LSG as DCS should not be proposed to all type of patients, especially those at risk of having an increase in post-operative morbidity and mortality.

FIGURE LEGEND

Series

Year of publication Type of study Exclusion criteria

Type of institution

Number of patients

Rate of SG as DCS

Billing [START_REF] Billing | Outpatient laparoscopic sleeve gastrectomy in a free-standing ambulatory surgery center: first 250 cases[END_REF] 2014

Single-center, retrospective

Weight ≥ 200kg, operating time ≥ 2 hours, anticipated history time over 2 hours, history of gastroplasty or prior surgery near the hiatus Outpatient surgery center 250 //

Rebibo [START_REF] Rebibo | Laparoscopic sleeve gastrectomy as day-case surgery (without overnight hospitalization)[END_REF] 2015

Single-center, prospective

Instable diabetes, obstructive sleep apnea, history of gastroplasty, BMI ≥ 60kg/m 2 University center 100 24

Garofalo [START_REF] Garofalo | Fully Ambulatory Laparoscopic Sleeve Gastrectomy: 328 Consecutive Patients in a Single Tertiary Bariatric Center[END_REF] 2016

Single-center, retrospective Age ≥ 55 years, BMI ≥ 55kg/m 2 , Instable diabetes, uncontrolled hypertension Tertiary bariatric center 328 33.4

Lalezari [START_REF] Lalezari | Laparoscopic sleeve gastrectomy as a viable option for an ambulatory surgical procedure: our 52-month experience[END_REF]

Dyslipidemi a rates

Billing [START_REF] Billing | Outpatient laparoscopic sleeve gastrectomy in a free-standing ambulatory surgery center: first 250 cases[END_REF] No 80 47 (23-74) 43 (30-71) MD MD MD MD Rebibo [START_REF] Rebibo | Laparoscopic sleeve gastrectomy as day-case surgery (without overnight hospitalization)[END_REF] No 93 35.9 (22-55) 42.4 (37.5-50.8) 6 13 0 7 Garofalo [START_REF] Garofalo | Fully Ambulatory Laparoscopic Sleeve Gastrectomy: 328 Consecutive Patients in a Single Tertiary Bariatric Center[END_REF] Yes 86.6 38.4 44.5 12.5 21.6 10.1 6.4 Lalezari [START_REF] Lalezari | Laparoscopic sleeve gastrectomy as a viable option for an ambulatory surgical procedure: our 52-month experience[END_REF] Yes 70.5 MD 43.3 MD MD MD MD Inaba [START_REF] Inaba | How safe is sameday discharge after laparoscopic sleeve gastrectomy?[END_REF] Unknown

Figure 1 :

 1 Figure 1: Review's flow scheme

Table 1 :

 1 Type of series on LSG performed as DCS.

Table 2 :

 2 Pre-operative data of published series on LSG as DCS.

				Male with BMI > 55 kg/m 2 , Female with BMI >
				60 kg/m 2 , weight > 500 lbs., no history of renal
				failure, organ transplant, or significant cardiac
			Single-center,	or pulmonary impairment, and not candidate to	Outpatient
		2018	retrospective	a transplantation	surgery center	821	//
			National database,
			retrospective,
	Inaba [20]	2018	comparative	Unknown	Unknown	4728	MD
	BMI: body mass index
	MD: missing data

When analyzing all single-center series, most of patients selected for DCS were females ranging from 70.5% to 93% (Table 2). The mean age of patients undergoing LSG as DCS range from 35.9 to 47 years old with a maximum age of 74 years old in the series of Billing et al [START_REF] Billing | Outpatient laparoscopic sleeve gastrectomy in a free-standing ambulatory surgery center: first 250 cases[END_REF] . The mean BMI ranged from 42.4 to 44.5 kg/m 2 with a maximum BMI of 71 kg/m 2 [START_REF] Billing | Outpatient laparoscopic sleeve gastrectomy in a free-standing ambulatory surgery center: first 250 cases[END_REF] . Data on comorbidities was not available in two series [START_REF] Billing | Outpatient laparoscopic sleeve gastrectomy in a free-standing ambulatory surgery center: first 250 cases[END_REF][START_REF] Lalezari | Laparoscopic sleeve gastrectomy as a viable option for an ambulatory surgical procedure: our 52-month experience[END_REF] while in other two studies, the most frequent comorbidity was hypertension followed by type 2 diabetes and dyslipidemia.

Three series of single center study included patients with OSA while it was considered as a contra-indication in the last one [START_REF] Rebibo | Laparoscopic sleeve gastrectomy as day-case surgery (without overnight hospitalization)[END_REF] .

On the other hand, Inaba et al [START_REF] Inaba | How safe is sameday discharge after laparoscopic sleeve gastrectomy?[END_REF] showed in their retrospective analysis of US database that the rate of patients with comorbidities were higher than those describe in single-center studies (Table 2). Also, some patients with prior cardiac events (myocardial infarction, percutaneous coronary intervention and transluminal coronary angioplasty, cardiac surgery) or history of pulmonary embolism underwent LSG as DCS while most of them would be cons-indicated for DCS in single-center studies.

Operative and perioperative management (Table 3)

In all published single center series, the anesthetic protocol was specific for outpatient management. Measures to prevent postoperative nausea and vomiting were carried out in the operating theatre. Local anesthetic was injected in all incision sites at the end of the surgery in three series [16 -18] and under the left diaphragmatic cupola in two series [START_REF] Garofalo | Fully Ambulatory Laparoscopic Sleeve Gastrectomy: 328 Consecutive Patients in a Single Tertiary Bariatric Center[END_REF][START_REF] Rebibo | Laparoscopic sleeve gastrectomy as day-case surgery (without overnight hospitalization)[END_REF] . Regarding surgical procedure, the size of the bougie used, the type of staples or the use of reinforcement was similar within the same study, regardless of the number of surgeons. The size of bougie used range from 34 to 40 Fr. Staple line reinforcement was used in two series.

Garofalo et al [START_REF] Garofalo | Fully Ambulatory Laparoscopic Sleeve Gastrectomy: 328 Consecutive Patients in a Single Tertiary Bariatric Center[END_REF] did not use routine staple line reinforcement but performed buttressing in

Series

Number of surgeons Trocar site Reinforcement Bougie size Operative time

Billing [START_REF] Billing | Outpatient laparoscopic sleeve gastrectomy in a free-standing ambulatory surgery center: first 250 cases[END_REF] 2 6 No 38 60 (31-161) Rebibo [START_REF] Rebibo | Laparoscopic sleeve gastrectomy as day-case surgery (without overnight hospitalization)[END_REF] 2 4 No 34 58 (30-105) Garofalo [START_REF] Garofalo | Fully Ambulatory Laparoscopic Sleeve Gastrectomy: 328 Consecutive Patients in a Single Tertiary Bariatric Center[END_REF] 4 5 Not routine (Buttress material) 36-40 MD Lalezari [START_REF] Lalezari | Laparoscopic sleeve gastrectomy as a viable option for an ambulatory surgical procedure: our 52-month experience[END_REF] 1 MD Buttress material 36 MD Inaba [START_REF] Inaba | How safe is sameday discharge after laparoscopic sleeve gastrectomy?[END_REF] Unknown Unknown Unknown Unknown 54.5 Billing [START_REF] Billing | Outpatient laparoscopic sleeve gastrectomy in a free-standing ambulatory surgery center: first 250 cases[END_REF] No 9 (3.6) 0 (0) 2 (0.8) MD 9 (3.6) 1 (0.4)

MD: missing data

Rebibo [START_REF] Rebibo | Laparoscopic sleeve gastrectomy as day-case surgery (without overnight hospitalization)[END_REF] Contacted the evening of the surgery and at POD 1, scheduled consultation at POD 4 9 (9) 0 (0) 8

) Garofalo [START_REF] Garofalo | Fully Ambulatory Laparoscopic Sleeve Gastrectomy: 328 Consecutive Patients in a Single Tertiary Bariatric Center[END_REF] Contacted at POD 1 33 (10) 0 (0) 6 (1.8) MD 28 (8.5) 2 (0.6)

Lalezari [START_REF] Lalezari | Laparoscopic sleeve gastrectomy as a viable option for an ambulatory surgical procedure: our 52-month experience[END_REF] Contacted at POD 2, scheduled consultation at POD 7 19 (2.3) 0 (0) MD MD 17 (2.1) 0 (0) Inaba [START_REF] Inaba | How safe is sameday discharge after laparoscopic sleeve gastrectomy?[END_REF] Unknown


Keywords: inhalation, intérêt, nutrition entérale, pneumopathies, prévention, réanimation, volume résiduel gastrique

La mesure du volume résiduel gastrique (VRG) était une pratique recommandée en réanimation pour la prévention des pneumopathies acquises chez les patients pris en charge par nutrition entérale. Cependant, cette pratique est remise en question par des études récentes. Le manque de fiabilité et de reproductibilité de la mesure, un impact préventif discutable et la perte significative d'apports caloriques amènent certains services à abandonner la mesure du VRG.

Dochead savoirs et pratiques

Sous-ochead

Intérêt de la mesure du volume résiduel gastrique en service de réanimation Dan Grey *

Infirmier

Christophe Gourc

Diététicien Unité transversale de nutrition, CHU de Montpellier, 371, avenue du Doyen-Gaston-Giraud, 34090 Montpellier, France recours à une nutrition artificielle [START_REF] Petit | Prise en charge nutritionnelle en réanimation : choc septique[END_REF]. En l'absence de contre-indication, la nutrition entérale (NE) devrait être utilisée dans les 24-48 heures après son admission [START_REF] Dhaliwal | The Canadian critical care nutrition guidelines in 2013: an update on current recommendations and implementation strategies[END_REF].

Une NE précoce est un moyen de maintenir l'intégrité structurelle et fonctionnelle de l'intestin, prévenant ainsi l'augmentation de la perméabilité intestinale, et le risque de translocation bactérienne en maintenant le système immunitaire humoral et cellulaire [START_REF] Mcclave | The physiologic response and associated clinical benefits from provision of early enteral nutrition[END_REF].

En réanimation, les troubles gastro-intestinaux sont particulièrement fréquents [START_REF] Deane | Mechanisms underlying feed intolerance in the critically ill: implications for treatment[END_REF]. Ces complications comprennent l'altération de la vidange gastrique, les distensions abdominales pouvant conduire à un syndrome pseudo-occlusif, la constipation et les diarrhées [START_REF] Ritz | Delayed gastric emptying in ventilated critically ill patients: measurement by 13 C-octanoic acid breath test[END_REF]. Ces troubles et leurs conséquences en termes de régurgitations, de risques d'inhalation et d'infection pulmonaire nosocomiale sont les principales limitations à une alimentation entérale précoce [START_REF] Montejo | Enteral nutrition-related gastrointestinal complications in critically ill patients: a multicenter study. The Nutritional and Metabolic Working Group of the Spanish Society of Intensive Care Medicine and Coronary Units[END_REF]. En réanimation, il s'y ajoute le risque particulier de pneumopathie acquise sous ventilation mécanique (PAVM) [START_REF] Elke | Gastric residual volume in critically ill patients: a dead marker or still alive?[END_REF].

La mesure du volume résiduel gastrique (VRG) chez les patients de réanimation intubés et recevant une NE était recommandée par les sociétés savantes jusqu'en 2003 dans le cadre de la prévention des PAVM [START_REF] Bleichner | Surveillance d'une nutrition entérale, complications, prévention[END_REF]. La constatation d'un résidu gastrique élevé amenait à réduire, voire interrompre, l'alimentation entérale malgré le déficit calorique engendré [START_REF] Beaucreux | Abandon de la mesure du résidu gastrique et pneumopathies acquises sous ventilation : des recommandations applicables dans la vraie vie[END_REF].

T1 Critères d'évaluation de l'intolérance à la NE T2 Définition de l'intolérance

Plusieurs critères ont été utilisés pour définir les phénomènes d'intolérance digestive à la NE :

• un résidu gastrique important de seuil critique variable ; • la présence de symptômes gastro-intestinaux (augmentation du périmètre abdominal, distensions abdominales, vomissements, diarrhées, inconfort subjectif, etc.) ; • des apports inadéquats de NE [START_REF] Elke | Gastric residual volume in critically ill patients: a dead marker or still alive?[END_REF].

Souvent, un VRG important (soit seul, soit associé avec des vomissements, des diarrhées et/ou des distensions abdominales) est le principal critère utilisé pour définir l'intolérance nutritionnelle [START_REF] Elke | Gastric residual volume in critically ill patients: a dead marker or still alive?[END_REF]. Les troubles de la vidange gastrique sous NE affecteraient de 30 à 40 % des malades sévèrement agressés (sous catécholamines, intubés et sédatés) et surviennent seulement dans les cinq premiers jours de la NE : ils ne représentent donc que 10 à 20 % des jours de NE en réanimation [START_REF] Raynard | Les "dix commandements" de la nutrition entérale en réanimation[END_REF].

Plusieurs publications ont cherché à définir les facteurs de risque associés au retard de vidange gastrique. Selon Raynard Bruno et Sellami-Delétang Noura, ce retard est favorisé par la ventilation mécanique, la sédation profonde, les états de choc, les infections intraabdominales ou la chirurgie sus-mésocolique récente. La gastroparésie est aussi plus fréquente chez les sujets âgés, les grands brûlés, les polytraumatisés et en cas de sepsis sévère. À partir de ces conclusions, ils ont pu proposer des populations à risque accru de gastroparésie [START_REF] Raynard | Les "dix commandements" de la nutrition entérale en réanimation[END_REF] :

• patients sous ventilation mécanique, sédatés et/ou sous catécholamines ; • patients polytraumatisés, cérébrolésés, brûlés graves ; • patients ayant subi une chirurgie sus-mésocolique de moins de sept jours ou ayant une infection intra-abdominale ; • patients diabétiques non contrôlés ; • patients de plus de 75 ans.

Cependant, pour considérer la mesure du VRG comme un outil efficace de prévention des pneumopathies, il faut pouvoir définir plus précisément la notion de "volume important" et déterminer une méthode fiable et reproductible de mesure.

T2 Le VRG en pratique

Actuellement, il n'existe pas de consensus sur le seuil de VRG définissant l'intolérance à la nutrition [START_REF] Elke | Gastric residual volume in critically ill patients: a dead marker or still alive?[END_REF]. Les seuils les plus fréquemment décrits pour l'arrêt de la NE sont de 200 à 250 cc, avec 25 % des études qui prennent un seuil < 150 cc, et 12,6 % > 500 cc [START_REF] Metheny | Monitoring for intolerance to gastric tube feedings: a national survey[END_REF]. S'ajoutent à cette problématique les divergences sur les méthodes de mesure du VRG [START_REF] Elke | Gastric residual volume in critically ill patients: a dead marker or still alive?[END_REF]. Selon Elke Gunnar, Felbinger Thomas W. et Heyland Daren K., les deux principales approches pour mesurer le VRG dans les services de réanimation sont [START_REF] Elke | Gastric residual volume in critically ill patients: a dead marker or still alive?[END_REF] :

• l'aspiration du contenu gastrique en utilisant une seringue ; • le drainage par gravité dans un réservoir.

Mais il existe plusieurs facteurs susceptibles d'influencer la mesure du VRG [START_REF] Elke | Gastric residual volume in critically ill patients: a dead marker or still alive?[END_REF] :

• des facteurs liés à la sonde (type, longueur, diamètre, nombre et taille des orifices distaux, position dans l'estomac, accès nasal, oral ou percutané) ; • des facteurs liés à la méthode (gravité/seringue/aspiration, viscosité du résidu, heure et la durée de la procédure) ; • des facteurs liés aux patients (position du patient, pression intra-abdominale, comorbidités, médicaments, liquides exogènes ou sécrétions physiologiques gastrointestinales) ; • des facteurs liés aux soignants (temps et effort engagés, temps d'arrêt de la NE avant la mesure).

Au total, les mesures apportent un reflet imprécis du VRG en raison des méthodes de mesure divergentes et des nombreux autres facteurs interférents, tels que la position ou encore le calibre de la sonde [START_REF] Petit | Prise en charge nutritionnelle en réanimation : choc septique[END_REF].

Ces facteurs peuvent avoir un impact important sur la mesure. Pour exemple, Metheny Norma A. et al. ont montré que les mesures obtenues avec une sonde large de 18 Ch étaient environ 1,5 fois plus importantes que celles obtenues avec des sondes fines de 10 Ch [START_REF] Metheny | Effect of feeding-tube propreties on residual volume measurements in tube-fed patients[END_REF]. Il paraît ainsi difficile de généraliser des seuils de VRG dans un service qui utilise des sondes de différents calibres.

Dans l'objectif d'obtenir une méthode de mesure reproductible, une étude de Søreide Eldar et al. [START_REF] Søreide | Studies of gastric content: comparison of two methods[END_REF] a pu montrer la bonne fiabilité d'une méthode de mesure par aspiration avec une sonde gastrique versus un contrôle fibroscopique. Le protocole d'aspiration consistait en l'introduction orale d'une sonde de Salem de 18 Ch sur 60 à 70 cm (suivi d'une vérification du bon positionnement par auscultation ou aspiration de liquide gastrique) puis au retrait progressif de la sonde en rotation avec une aspiration à 50 mmHg. La procédure était répétée deux fois. La précision était alors de 20 à 40 cc avec un intervalle de confiance à 95 %.

Enfin, il est intéressant de noter que la mesure du VRG est associée à une plus grande incidence d'occlusion des sondes d'alimentation, notamment celles de petit diamètre [START_REF] Powell | Aspirating gastric residuals causes occlusion of smallbore feeding tubes[END_REF].

Il est donc justifié, à travers toutes ces informations, de se poser la question de l'intérêt de la mesure du VRG.

T1 Intérêt de la mesure

Un essai contrôlé randomisé publié en 2013, réalisé sur 449 patients, a comparé deux groupes avec un même protocole de NE à adapter en fonction de la tolérance du patient [START_REF] Reignier | Effect of not -monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation and early enteral feeding: a randomized controlled trial[END_REF]. Dans le premier groupe, seuls les vomissements et régurgitations définissaient l'intolérance. Dans l'autre groupe, en plus des vomissements et régurgitations, le VRG était mesuré toutes les 6 heures. L'intolérance pouvait alors être définie par la mesure d'un VRG supérieur à 250 cc. La comparaison de la survenue de PAVM dans les deux groupes n'a pas montré de différence manifeste (malgré des vomissements significativement plus fréquents) : la mesure du résidu gastrique n'a pas eu d'impact préventif sur les PAVM.

Cette même étude n'a pas non plus montré de différence significative en termes d'infections acquises, de diarrhées acquises, de durée de recours à une ventilation mécanique, de durée de séjour ou de mortalité [START_REF] Reignier | Effect of not -monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation and early enteral feeding: a randomized controlled trial[END_REF]. Enfin, la proportion de patients recevant 100 % de leurs objectifs caloriques était significativement meilleure dans le groupe où la mesure du VRG avait été abandonnée [START_REF] Reignier | Effect of not -monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation and early enteral feeding: a randomized controlled trial[END_REF].

Une étude française récente, réalisée sur un effectif moindre de 209 patients, conclue aussi en l'absence d'impact de l'abandon de la mesure du VRG sur l'incidence de PAVM [START_REF] Beaucreux | Abandon de la mesure du résidu gastrique et pneumopathies acquises sous ventilation : des recommandations applicables dans la vraie vie[END_REF]. Depuis ces travaux, il est possible d'observer une évolution des recommandations nationales :

• En France, les recommandations de la Société française d'anesthésie et de réanimation (SFAR) (2014) disent selon un accord faible qu'il ne faut pas mesurer le VRG et selon un accord fort qu'il faut envisager l'administration de prokinétiques (métoclopramide et/ou érythromycine) pour permettre une amélioration de l'apport calorique global en cas de trouble de la vidange gastrique. Elles proposent aussi, selon un accord faible, d'envisager une injection postpylorique en cas de trouble de la vidange gastrique persistant aux prokinétiques [START_REF] Lefrant | Nutrition artificielle en réanimation[END_REF]. • Au Canada, les recommandations (de 2013) sont plus réservées. Elles jugent prématurée l'abandon de la mesure du VRG. Il est recommandé de maintenir cette pratique pour un seuil d'intolérance défini à partir de VRG de 250 à 500 cc [START_REF] Dhaliwal | The Canadian critical care nutrition guidelines in 2013: an update on current recommendations and implementation strategies[END_REF]. • En Allemagne, la German Society for Nutritional Medicine (2013) se montre favorable (accord de grade A) à l'abandon des mesures des VRG pour les patients ayant un diagnostic, à condition que les équipes des services de réanimation puissent gérer en toute sécurité une telle stratégie. L'adaptation des doses de NE est alors recommandée en cas de vomissement. Cependant, à cause du manque de représentation des patients de chirurgie dans les études, le maintien de la pratique de la mesure du VRG pour les patients ayant subi une chirurgie abdominale, en prenant en compte un VRG de 200 cc comme seuil de tolérance [START_REF] Hartl | S3-Guideline of the german society for nutritional medicine (DGEM) in cooperation with the GESKES and the AKE monitoring of artificial nutrition: specific aspects[END_REF] est prescrit.

T1 Conclusion

La mise en place d'une NE apporte la problématique de la tolérance gastrique, et les services de réanimation cumulent les facteurs de risque. Pourtant, la définition de l'intolérance gastrique par un seuil de VRG particulier semble difficile et est souvent remise en question dans les études.

De plus, se pose le problème de la mesure du VRG : il ne semble pas y avoir de consensus pour la méthode de mesure à utiliser, ni au niveau national, ni au niveau des services hospitaliers. Le manque de fiabilité et de reproductibilité des mesures ont amené la remise en question de cette pratique (pourtant fortement recommandée depuis quelques années), surtout qu'il a été montré que l'aspiration du résidu alimentaire créait un déficit calorique non négligeable chez des patients déjà à risque nutritionnel élevé.

Les études vont de plus en plus dans le sens d'un abandon de la mesure du VRG, qui ne semble pas avoir d'impact sur les conséquences néfastes de l'intolérance gastrique, notamment les pneumopathies. Dans ce sens, les recommandations évoluent à leur tour, à une vitesse différente selon les pays. De manière générale, la pratique systématique semble avoir disparue au profit de mesures de VRG pour certaines catégories de patients à risque, ou pour soutenir la mise en place d'autres actions, telles que le recours à des drogues prokinétiques.

Déclaration de liens d'intérêts

Les auteurs déclarent ne pas avoir de liens d'intérêts.

Références


Jennifer Uzan

MD Hélène Bonsang-Kitzis

MD Léa Rossi

MD Bastien Rance

PhD Anne-Sophie Bats

MD Marie Gosset

MD Myriam Deloménie

Eric Pujade-Lauraine

MD Fabrice Lécuru

M.D Charlotte Ngô
email: charlotte.ngo@aphp.fr

MD Eric Pujade- Lauraine

Prognostic impact of initial tumor load and intraperitoneal disease dissemination patterns in patients with advanced ovarian cancer undergoing complete cytoreductive surgery

Keywords: ovarian cancer, survival, peritoneal carcinomatosis, tumor load

de niveau recherche, publiés ou non, émanant des établissements d'enseignement et de recherche français ou étrangers, des laboratoires publics ou privés.

Introduction

Complete removal of visible disease is the most important prognostic factor in patients with advanced epithelial ovarian carcinoma (AEOC) [START_REF] Bristow | Survival effect of maximal cytoreductive surgery for advanced ovarian carcinoma during the platinum era: a meta-analysis[END_REF]. Extensive surgery to the upper abdomen (supra-radical surgery) has increased the rate of complete surgery allowing to validate the concept of maximal surgical effort which requires the development of high-level surgical skills [START_REF] Chi | Improved progression-free and overall survival in advanced ovarian cancer as a result of a change in surgical paradigm[END_REF]. Carcinomatosis is a peritoneal disease related to the dissemination of tumor cells of carcinomatous origin on parietal and visceral peritoneum through the blood, lymphatic and peritoneal fluid circulation. Stagnation sites for fluid in the peritoneal cavity are logically main sites of tumor deposits (cul-de-sac of Douglas, lower quadrant of the right mesocolic space (ileocecal junction), superior surface of the sigmoid mesocolon, the right parieto-colic gutter and the duodenum) [3]. Similarly, the areas of reabsorption of peritoneal fluid, such as diaphragmatic doms or the small and large omentum, are physiopathologically areas of concentration of tumor cells. In addition, other patterns of carcinomatosis dissemination have been suggested. The frequency of omental involvement with peritoneal carcinomatosis may be due to the presence of adipocytes that stimulate the growth of ovarian tumor cells through a transfer of energy [START_REF] Nieman | Adipocytes promote ovarian cancer metastasis and provide energy for rapid tumor growth[END_REF]. The impact of tumor load on prognosis is controversial. Some authors conclude that there is no influence of the initial tumor burden if surgery is complete, while others conclude that the tumor burden influences morbidity, overall survival and recurrence-free survival even after obtaining a zero tumor residue [START_REF] Gasimli | Prognostic and Predictive Value of the Peritoneal Cancer Index in Primary Advanced Epithelial Ovarian Cancer Patients After Complete Cytoreductive Surgery: Study of Tumor Bank Ovarian Cancer[END_REF][START_REF] Eisenkop | Relative influences of tumor volume before surgery and the cytoreductive outcome on survival for patients with advanced ovarian cancer: a prospective study[END_REF][START_REF] Horowitz | Does aggressive surgery improve outcomes? Interaction between preoperative disease burden and complex surgery in patients with advanced-stage ovarian cancer: an analysis of GOG 182[END_REF][START_REF] Rosendahl | Specific Regions, Rather than the Entire Peritoneal Carcinosis Index, are Predictive of Complete Resection and Survival in Advanced Epithelial Ovarian Cancer[END_REF].

Furthermore, the issue on prognosis of the impact of the initial distribution, i.e. localization of carcinomatosis, rather than only tumor load is unsolved.

Our objective was to investigate the relationship between initial total tumor burden, qualitative and quantitative distribution of peritoneal carcinomatosis on prognosis, in patients with AEOC and no residual disease after surgery. Our primary endpoint was PFS in the overall population, our secondary endpoint was PFS in two subgroups: patients with primary debulking surgery (PDS) and patients with interval debulking surgery (IDS).

Patients and Methods

We conducted a retrospective study in a teaching hospital (Hôpital Européen Georges Pompidou, Paris, France) of a prospectively maintained database concerning all patients diagnosed with ovarian cancer between October 2005 to April 2018. We use a systematic standardized operative report including a descriptive location of carcinomatosis (quantitative and qualitative) as well as a description and calculation of PCI (peritoneal carcinomatosis index). Inclusion criteria were: AEOC of serous subtype (FIGO stage III/IV), treated from October 2005 to July 2014 in order to have a sufficient follow-up, absence of residual macroscopic disease after PDS or IDS after NACT, high histological grade and explicit initial operative report. Patients had systematically a pre-therapeutic thoraco-abdomino-pelvic CT scan and a diagnostic laparoscopy. All cases were discussed in multidisciplinary meetings.

Patients data including clinical and biological characteristics, pathology, surgical data and chemotherapy characteristics were extracted. The tumor load was defined by the initial PCI.

Quantitative criteria were defined according to the PCI score as a continuous variable, but regarding also the number of areas affected, the number of area quoted 1 (inferior to 0•5cm), 2 (0•5 to 5cm) or 3 (superior to 5cm). Concerning the peritoneal carcinomatosis distribution, we focused on qualitative criteria regarding embryologic origin, adipocyte richness, anatomical localizations using the transverse mesocolon and the mesentery as reference.

Embryologic origin was divided in anterior intestine (abdominal oesophagus, stomach, anterior part of the duodenum, hepatic parenchyma, gallbladder, hepatic, cystic and common bile duct and ventral and dorsal pancreatic buds), middle intestine (posterior part of the duodenum, small intestine, caecum, appendix, right colon, proximal part of the transverse colon) and posterior intestine (distal part of the transverse colon, sigmoid and rectum), according to visual initial evaluation. Adipocytes rich areas corresponded to the greater and lesser omentum, the mesentery and mesocolon. Anatomical localizations were classified as supra mesocolic or infra mesocolic; infra mesocolic localizations were separated into right, left and central according to their location compared to the mesentery. The presence of supradiaphragmatic adenopathy was evaluated thanks to the pre-operative thoracic and abdominal CT.

Study data were collected and managed using REDCap electronic data capture tools hosted by the CARPEM translational research platform at HEGP, AP-HP, Paris, France [START_REF] Harris | Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support[END_REF].

The data were described as mean ± standard deviation or median [min-max] for quantitative variables and by numbers (percentage) for qualitative variables. Univariate survival analysis (PFS and OS) were performed with the logrank test, comparing the Kaplan-Meier curves of the variables involved. The date of cancer diagnosis was considered the beginning of the follow-up. The point date was 25 th April 2018. The variables reaching a significance of 0•1 were then included in a multivariate Cox model, adjusted to the main prognostic factors (age, PCI CA125 as a continuous variable, FIGO stage, constitutional BRCA status, antiVEGF therapy) to identify independent prognostic factors. A secondary, exploratory analysis was then carried out to evaluate PFS and OS in the following subgroups: "primary debulking surgery" or "interval debulking surgery". Statistical analysis were carried out using software R version 3.1.0 (http://lib.stat.cmu.edu/R/CRAN). This study was registered to the CNIL (Commission Nationale de l'Informatique et des Libertés (n°1875581), French national authority for personal data protection). Chemotherapy protocols were based on the association of paclitaxel and carboplatin. Three patients had neoadjuvant and adjuvant anti VEGF in the ANTHALYA trial and 35 patients had only adjuvant anti VEGF [START_REF] Rouzier | Efficacy and safety of bevacizumab-containing neoadjuvant therapy followed by interval debulking surgery in advanced ovarian cancer: Results from the ANTHALYA trial[END_REF].

Results

One

Population characteristics are described in

Surgical data are shown in Table 2. Forty patients (39•6%) had radical surgery and sixty-one patients (60•4%) had supra radical surgery [START_REF] Chi | Improved optimal cytoreduction rates for stages IIIC and IV epithelial ovarian, fallopian tube, and primary peritoneal cancer: a change in surgical approach[END_REF]. Twenty patients (19•8%) had a bowel resection. 24% of patients didn't undergo lymphadenectomy because they were randomized in an ongoing multicentric French trial (Pelvic and Aortic-Cava Lymphadenectomy Randomized for Ovarian Cancer, CARACO, ClinicalTrials.gov Identifier: NCT01218490).

Thirteen patients (12•7%) had supra diaphragmatic adenopathy diagnosed on preoperative thoracic and abdominal CT scan. Qualitative evaluation of peritoneal carcinomatosis is presented and compared between PDS group and IDS group in Table 3.

Twenty patients (19•8%) had an involvement of structures originating from the anterior intestine. Regarding quantitative criteria: two patients (1•9%) had all areas of the PCI affected reflecting an extensive disease; one patient (0•9%) had all areas of the PCI quoted 1, and one patient (0•9%) had all areas of the PCI quoted 3. Only 13 patients (12•8%) were free of area quoted 3 and 43 patients (42•2%) were free of area quoted 1. The mean PCI was 14 (±9).

These results show that a vast majority of patients had extensive and bulky peritoneal carcinomatosis. Patients receiving neoadjuvant chemotherapy had significantly more aggressive disease with more intestinal involvement, more bilateral diaphragmatic involvement and more stage IV disease (table 3).

We first investigated the relationship between tumor load, peritoneal distribution and survival in the total population. On multivariate analysis, PCI (HR 1.04

(1•0-1•09) p=0•05)
and adipocytes-enriched areas involvement (HR 2•07 (0•87-4•93) p=0•10) showed a trend to decreasing PFS, while it was not statistically significant. Adipocytes-enriched areas involvement remains significantly associated with a decreased OS (HR=4.36 ( We subsequently investigated the relationship between tumor load, peritoneal distribution and survival in the two subgroups of patients with primary debulking surgery and patients with interval debulking surgery. On multivariate analysis, we found an association with a decreased PFS only in the PDS subgroup for the following factors: PCI (HR=1•18

Discussion

Our study investigated, among patients with advanced high grade serous ovarian adenocarcinoma undergoing complete debulking surgery, the association between initial tumor burden, dissemination patterns, specific localization of disease and prognosis. We observed that in the whole population, the involvement of adipocytes-enriched areas had an impact on OS and PFS and that in the PDS subgroup, the involvement of the right inframesocolic space decreased PFS. None of peritoneal carcinomatosis localizations had any impact "IDS" subgroup. Nevertheless, patients with neoadjuvant chemotherapy had a higher tumor burden than patients with primary debulking surgery. Patients requiring NACT appear as an interesting group, with greater tumor load and different qualitative extension. The relative impact of these parameters should be better studied.

The impact of the initial tumor burden on the survival of patients with advanced ovarian cancer in complete resection is controversial in the literature. In the 2000s, when obtaining a zero tumor residue became the main goal of cytoreductive surgery, some authors conclude that there was no influence of the initial tumor burden in case of complete macroscopic resection, while others conclude that tumor burden influences overall survival and survival without recurrence, even after a complete removal of the tumor 14,15 . Most of studies focused on the impact of the tumor burden on prognosis but not on specific regions. Rosendahl et al.

showed recently that specific regions were more predictive of survival than the entire PCI but they did not focus their analysis on patients with a complete cytoreduction [START_REF] Rosendahl | Specific Regions, Rather than the Entire Peritoneal Carcinosis Index, are Predictive of Complete Resection and Survival in Advanced Epithelial Ovarian Cancer[END_REF]. It is still difficult to find in the literature a study focused on the prognosis impact of specific region involvement in patients with complete cytoreduction rather than the impact on prediction of resectability.

Few studies have evaluated quantitative criteria such as the impact of implants size or confluence on survival in advanced ovarian cancer. In our study, we investigated the quantitative distribution of the tumor burden using the quantitative classification of PCI and we found, in univariate analysis, that for each additional zone reaching a score 3, the risk of recurrence was multiplied by 1•10. In their retrospective study on different types of cancer (ovary, stomach, colon, pseudomyxoma.), Spiliotis et al. showed that the increase in the number of affected areas was associated with a poorer prognosis [START_REF] Spiliotis | Mapping the location of peritoneal metastases using the peritoneal cancer index and the correlation with overall survival: a retrospective study[END_REF]. In the EORTC randomized study, a small initial tumor burden was associated with better OS, although the initial tumor burden was assessed by laparoscopy or laparotomy only in 34•6% in the "primary surgery" group and 38•3% in the "interval surgery" group [START_REF] Vergote | Neoadjuvant chemotherapy or primary surgery in stage IIIC or IV ovarian cancer[END_REF]. The study by Martinez et al. went further and found an influence of the size of the implants in the supramesocolic region on the PFS with a HR 1•39 [1•05-1•84] for 0-25mm implants and 1•52 [1•08-2 •12] for implants larger than 25mm [START_REF] Martinez | Surgical Complexity Impact on Survival After Complete Cytoreductive Surgery for Advanced Ovarian Cancer[END_REF].

Regarding lymph node involvement, para-aortic lymph node involvement was significantly associated with poorer prognosis. It has been shown that ovarian carcinoma with isolated lymph node involvement without carcinomatosis has a better prognosis. In our study, all patients with para-aortic lymph node involvement had associated peritoneal carcinomatosis.

We also found in univariate analysis that supradiaphragmatic lymph node (SDLN) involvement was associated with poorer prognosis but this was not confirmed in multivariate analysis probably because of too small sample size. In our study, this diagnosis was estimated with CT scan or PET/CT without any histological confirmation. Patient with SDLN involvement were more likely to receive NAC and these lymph nodes were not resected, making difficult their evaluation and the analysis of its prognostic impact. The prognostic impact of SDLN involvement has been recently studied by Lee et al [START_REF] Lee | Prognostic significance of supradiaphragmatic lymph node metastasis detected by 18F-FDG PET/CT in advanced epithelial ovarian cancer[END_REF]. They showed that patients with stage IV disease with SDLN involvement detected on PET/CT had a poorer prognosis than patients with stage III disease, but the same prognosis than patients with stage IV disease with another metastasis. In their study, resection of suspicious SDLN did not improve survival rates.

We chose to study qualitative criteria based on the physiology of peritoneal fluid circulation and on the role of tumor microenvironnement. Peritoneal fluid circulation results of a pressure gradient in the abdominal cavity. There are four peritoneal recesses where flow can be temporarily arrested: the Douglas pouch, the right lower quadrant, the right paracolic gutter and the sigmoid colon [3,[START_REF] Meyers | Distribution of intra-abdominal malignant seeding: dependency on dynamics of flow of ascitic fluid[END_REF]. These regions are the most involved in case of carcinomatosis. In our study, right mesocolic lesions were found to be significantly associated with a decrease in PFS in the PDS subgroup. In the study by Spiliotis et al. the involvement of zones 4, 5 and 8 of PCI (right and left mesocolic) was associated with a better prognosis than the zones 9, 10, 11 of PCI (proximal and distal jejunum and proximal ileum) [START_REF] Spiliotis | Mapping the location of peritoneal metastases using the peritoneal cancer index and the correlation with overall survival: a retrospective study[END_REF]. The hypothesis of the distribution of peritoneal carcinomatosis lesions according to the peritoneal fluid circulation had never been mentioned in the literature before. However, according to an in vitro study, the peritoneal fluid contains CD90 + / CD45-cells which, when co-cultured with gastric cancer cells, give cells with a mesothelial profile that favor the development of peritoneal metastases [START_REF] Kitayama | CD90+ mesothelial-like cells in peritoneal fluid promote peritoneal metastasis by forming a tumor permissive microenvironment[END_REF]. Histological analysis of these peritoneal metastases showed that these cells with mesothelial profile were embedded in the fibrous zone forming the microenvironment of the metastasis. This study thus raises the hypothesis of floating cells in the peritoneal fluid which, when in contact with cancer cells (primary lesion), favor the development of peritoneal metastases. Within tumor microenvironment, adipocytes have been shown to promote growth, invasion and metastasis [START_REF] Nieman | Adipocytes promote ovarian cancer metastasis and provide energy for rapid tumor growth[END_REF]. Therefore, we studied the influence of involvement of areas rich in adipocytes (large and small epiploon, mesentery, mesocolon). In multivariate analysis, this involvement was significantly associated with a decrease in survival in our whole population. Obesity was not associated with involvement of areas rich in adipocytes. These results are difficult to extrapolate due to the lack of literature. Some authors described the presence in the omentum of "milky spots" composed of immune cells and stromal cells which, together with the adipocytes, play a role in the dissemination of peritoneal carcinomatosis [START_REF] Clark | Milky spots promote ovarian cancer metastatic colonization of peritoneal adipose in experimental models[END_REF].

We analyzed the locations of peritoneal carcinomatosis according to their embryological origin, which had never been described in the literature. We observed that involvement of structures originating from the medium (posterior part of the duodenum, small intestine, caecum, appendix, right colon, proximal part of the transverse colon) and posterior intestine (distal part of the transverse colon, sigmoid and rectum) was associated with a decrease in PFS and OS in univariate analysis. We also found that involvement of the right paracolic gutter was associated with a decreased PFS in multivariate analysis in patients receiving primary surgery, which may correspond to the involvement of the caecum, appendix and right colon. We saw in our comparison that patients in the IDS group had a more aggressive disease with more intestinal involvement and in particular more involvement of the right side of the mesentery. This specific location may have a significant prognostic impact.

The major strength of our study is to provide detailed information on initial surgical findings and disease spread patterns. Limitations are the retrospective design of the study and limited number of cases, making subgroup analysis difficult.

Conclusion

In summary, the impact on survival of the initial tumor load in patients with complete resection remains unsolved. Some dissemination patterns appear to be associated with a decreased PFS (increase in the number of affected areas, involvement of adipocytes-enriched areas and the presence of right paracolic lesions). Thus, identifying patients with an initial tumor distribution at greater risk of recurrence would allow a tailored follow-up to diagnose recurrences earlier in order to improving their overall survival. Recent studies suggested that molecular subtypes are associated with peritoneal disease dissemination patterns and surgical outcomes [START_REF] Torres | Intraperitoneal disease dissemination patterns are associated with residual disease, extent of surgery, and molecular subtypes in advanced ovarian cancer[END_REF]. Indeed, the mesenchymal subtype is associated with the presence of upper abdominal disease and with a decreased rate of complete primary debulking surgery. Initial molecular profiling of AEOC, as well as imaging and laparoscopic peritoneal disease scoring, could allow to selecting patients more likely to receive neoadjuvant chemotherapy or to undergo supra-radical primary debulking surgery.

  hundred and one patients were included in the study. Median follow-up was 50•5 months [3•3-171•6], 55.5 months [3•3-171•6] and 45•2 months [9•8-135] in the whole population, the PDS group and the IDS group respectively. Median progression-free survival (PFS) was 21•2 months (19-25•3), 26•9 months (22-date point) and 17•4 months (14•8-22•5) in the whole population, the PDS group and the IDS group respectively. Median overall survival (OS) was 62•2 months (52-96•5), 83•4 months (53•8-date point) and 55•4 months (40-96•5) in the whole population, the PDS group and the IDS group respectively (Fig. 1).

( 1 •

 1 06-1•32) p=0•003) and right infra-mesocolic area involvement (HR= 3•37 (1•20-9•50) p= 0•02). We found an association with a decreased OS in both PDS and NAC subgroups for para-aortic lymph node involvement (HR= 3.87 (1•05-14•23) p= 0•03) and (HR= 3.25 (1•08-9•74) p= 0•03) respectively. The results of multivariate analysis are presented in tables 4B and 4C.

Figure 1 :

 1 Figure 1: survival curves: A, B, C Progression-free survival of whole population, PDS groupe and IDS group. D, E, F Overall survival of whole population, PDS group and IDS group.

Table 1 .

 1 Median age was 62 years old. Six patients (5•9%) had stage IIIA, 9 (8•9%) patients had stage IIIB, 64 (63•4%) patients had stage IIIC and 22 (21•8%) patients had stage IV, according to 2009 FIGO classification.

Table 1 : patients characteristics

 1

	Characteristics

Table 3 : qualitative distribution of peritoneal carcinomatosis, comparison between WP (whole population), PDS group (primary debulking surgery) and IDS group (interval debulking surgery).

 3

	Carcinomatosis	WP N= 101	PDS N=48	IDS N=53	p
	localization
	Embryologic primitive
	intestine
	Anterior intestine	20 (19.8%)	7 (14.6 %)	13 (28.9%)	0.09
	Medium intestine	38 (37.6%)	8 (16.7%)	30 (66.7%)	<0.0001
	Posterior intestine	53 (52.5%)	19 (40.4%)	34 (75.6%)	0.0007
	Areas rich in adipocytes	72 (77.4%)	28 (58.3%)	44 (97.8%)	<0.0001
	Infra-mesocolic
	Left side of the mesentery	66 (64.7%)	21 (43.8%°	33 (62.3%)	0.0625
	Right side of the mesentery	51 (57.8%)	13 (27.1%)	38 (71.7%)	<0.0001
	Supra-mesocolic	72 (78.3%)	28 (59.6%)	44 (97.8%)	<0.0001
	Diaphragmatic cupola
	Unilateral	21 (23%)	14 (29.8%)	7 (15.5%)
	bilateral	45 (49%)	10 (21.3%)	35 (77.8%)	<0.0001
	Paracolic gutters
	Right paracolic gutter	8 (9.3%)	2 (4.3%)	6 (15.4%)	<0.0001
	Left paracolic gutter	1 (1.2%)	1 (2.1%)	0
	Both	29 (33.7%)	5 (10.6%)	24 (61.5%)
	Susdiaphragmatic nodes	13 (13.1%)	2 (4.2%)	11 (21.6%)	0.01
	FIGO Stage
	IIIa	6 (5.9%)	5 (10.4%)	1 (1.9%)
	IIIb	9 (8.9%)	8 (16.7%)	1 (1.9%
	IIIc	64 (63.4%)	32 (66.7%)	32 (60.4%)
	IV	22 (21.8%)	3 (6.2%)	19 (35.8%)	<0.0002

Table 4 : multivariate analysis of progression free survival and overall survival. A, total population; B, primary debulking surgery subgroup; C, interval debulking surgery subgroup.

 4

	A: total population
	PFS	HR [95% CI]	p
	Infra-mesocolic involvement	1.49 [0,75-2.98]	0,25
	PCI	1.04 [1.0-1,09]	0,05
	Adipocytes-enriched areas involved	2.07 [0,87-4.95]	0,1
	OS
	PCI	1.05 [1.0-1,1]	0,08
	Total Nb of PCI areas involved	1,03 [0,94-1,14]	0,46
	Adipocytes-enriched areas involved	4.36[1.20-15.74]	0.02
	Para-aortic lymph node involvement	3.77 [1.65-8.64]	0.0007
	B: primary debulking surgery
	PFS	HR [95% CI]	p
	Infra-mesocolic right side involvement	3.37 [1.2-9.5]	0.02
	PCI	1.18 [1.06-1,32]	0,003
	OS
	age	1.05 [1.0-1,1]	0,08
	Infra-mesocolic right side involvement	1.87 [0,49-7.11]	0,36
	PCI	1.1[0.97-1.27]	0.1
	Para-aortic lymph node involvement	3.87 [1.05-14.23]	0.03
	C: interval debulking surgery
	PFS	HR [95% CI]	p
	age	1.64 [0.76-3.5]	0.2
	PCI	1.04 [0.98-1,1]	0,2
	OS
	age	1.99 [0.88-4.50]	0.09
	PCI	1.03[0.97-1.10]	0.3
	Para-aortic lymph node involvement	3.25 [1.08-9.74]	0.03

Acknowledgments: the authors are grateful to Mr Matthew Selwyn for reviewing English.


Dochead dossier Sous-dochead Aide à la décision clinique

Keywords: non technique, leader, leadership, prise de décision, simulation

Toute prise de décision nécessite un leader qui a la capacité d'orienter et de mobiliser durablement un groupe d'individus vers l'accomplissement de buts précis. Le leader doit présenter des compétences non techniques, fondées sur le comportement, la gestion des émotions et de la fatigue, le raisonnement médical, la communication, la prise de décision, la gestion de conflit, et la synergie avec l'équipe soignante. Ce leader ne bénéficie généralement pas d'une formation préalable. Le positionnement au sein d'une équipe et le leadership peuvent probablement s'apprendre, ou du moins se renforcer, et la simulation en est un excellent outil.

La qualité du leadership joue un rôle essentiel dans l'issue d'une situation clinique. Le leader est celui qui priorise et répartit les tâches [START_REF] Künzle | Ensuring patient safety through effective leadership behaviour: A literature review[END_REF]. Un leader inefficace est impliqué dans 50 % des issues défavorables en médecine aiguë en 2006 [START_REF]Update: sentinel event statistics[END_REF]. Il a été démontré qu'un défaut de leadership et des problèmes de communication étaient impliqués dans plus de 70 % des décès et des dommages corporels périnataux [START_REF] Thomas | Teaching teamwork during the Neonatal Resuscitation Program: a randomized trial[END_REF]. Une étude observationnelle déjà ancienne a cherché la relation entre le comportement du leader, la dynamique de groupe et la maîtrise des tâches, dans la prise en charge de 20 arrêts cardio-circulatoires [START_REF] Cooper | Leadership of resuscitation teams: "Lighthouse leadership[END_REF]. Les auteurs ont conclu que le leader, afin de faciliter la compréhension du problème posé, doit éviter son implication directe dans les gestes techniques et dans la mesure du possible se tenir en retrait, pour conserver une vision d'ensemble de la situation [START_REF] Cooper | Leadership of resuscitation teams: "Lighthouse leadership[END_REF]. Une étude observationnelle portant sur 7 chirurgiens prenant en charge 22 traumatisés graves a montré une corrélation positive entre l'efficacité clinique et la perception du leadership par les membres de l'équipe [START_REF] Sakran | Trauma leadership: does perception drive reality?[END_REF]. En effet, les équipes dirigées par des leaders perçus comme ayant une faible compétence de leadership ont pris du retard pour effectuer l'évaluation initiale des patients, ce qui semble influencer négativement le pronostic. Le leader doit présenter des compétences non techniques, fondées sur le comportement, la gestion des émotions et de la fatigue, le raisonnement médical, la communication, la prise de décision, la gestion de conflit, et la synergie avec l'équipe soignante. Chaque autre membre de l'équipe a également un rôle important de "follower". La mission du leader peut être transmise à tout moment à une autre personne lors d'une situation clinique, mais celleci doit être parfaitement identifiée par l'équipe et informée.

T1 Personnalité du leader

La participation et la motivation des membres de l'équipe varient en fonction de la personnalité du leader. En réalité, il est difficile de définir un style de leadership exemplaire. Parmi les caractéristiques du leader, on retrouve généralement la volonté de réussir, l'ambition et la ténacité. Les leaders doivent aussi être motivés, intègres et confiants en eux tout en étant stables émotionnellement, empathiques et sociables. Ils sont également habiles, intelligents, éloquents et experts dans leur métier. L'ensemble de ces qualités permettrait de susciter la loyauté et l'enthousiasme des subordonnés [START_REF]Le leadership en simulation[END_REF].

T2 Leadership basé sur le parcours

On pourrait aussi envisager que le leader soit quelqu'un qui tire son autorité de diplômes, d'appuis politiques, de réseaux professionnels ou de compétences, d'engagement et de réussite professionnels particuliers. La notion d'"expérience" permettant de prendre un leadership est très variable. En obstétrique, seule l'expérience de plus de trois ans serait positivement corrélée à un comportement efficace d'un leadership. Cependant, dans certaines situations cliniques assez rares, comme un choc anaphylactique, un jeune médecin ayant fait un stage aux urgences peut maîtriser la situation mieux qu'un ancien gynécologue [START_REF] Cornthwaite | Reducing risk in maternity by optimising teamwork and leadership: an evidence-based approach to save mothers and babies[END_REF]. En traumatologie, les chirurgiens ayant cinq ans d'expérience sont plus performants que les jeunes dans la prise en charge initiale des patients. Alors que pour les infirmières, deux ans d'expérience sont suffisants pour que les infirmières impliquées en soins soient confiantes [START_REF] Sakran | Trauma leadership: does perception drive reality?[END_REF].

T2 Leadership par le comportement

Fréquemment, le comportement du leader est analysé à partir d'une grille bidimensionnelle, l'une des dimensions étant la prise en compte de l'équipe et l'autre celle des résultats. Il semble qu'une attitude maximaliste dans les deux dimensions ne soit pas nécessairement la meilleure et qu'une attitude équilibrée, prenant à la fois en compte l'avis de l'équipe mais aussi les résultats, soit le meilleur comportement de leadership.

T2 Leadership basé sur le style

Différents styles psychologiques ont pu être décrits pour les leaders, du leader traditionnel fondé sur la coutume au leader charismatique fondé sur le rayonnement de la personne, on peut considérer le leader légal qui tire sa légitimité d'une élection ou d'une cooptation du groupe. On peut aussi définir un style autocratique en opposition à un style démocratique. Il est clair que le simple charisme ne peut, à lui seul, définir le leadership et le leader doit aussi être capable d'une certaine vision, de savoir prendre des risques pour lui-même, d'avoir une bonne sensibilité de l'environnement et donc du groupe, et d'être sensible aux besoins de ses collègues. On peut rajouter aussi une certaine part de non-conformisme. À l'heure actuelle, on a tendance à définir un modèle abouti de leadership qui serait le leadership transformationnel. Ce leadership transformationnel aurait tendance à s'opposer au leadership transactionnel. Le leadership transactionnel oriente l'équipe en clarifiant les rôles et tâches de chacun afin qu'ils atteignent leur objectif alors que le leadership transformationnel cherche à inciter chaque membre du groupe à transcender son intérêt personnel pour le bien de l'entreprise. Le leader transformationnel favorise l'innovation et la créativité car il mobilise l'ensemble des membres de l'équipe, souvent en période de crise, pour obtenir des réponses nouvelles aux problèmes. Alors qu'en santé on en est à protocoliser les prises en charge pour une meilleure efficience, certaines institutions comme l'armée américaine constatent que trop de conformisme et d'adhésion gênent l'action des officiers [START_REF]Le leadership en simulation[END_REF]. Dans le domaine de la santé, il est peut-être difficile d'envisager un leader charismatique, polyvalent et éternel. Le leader en période de crise n'est probablement pas le même que le gestionnaire de l'organisation d'un service, le meneur d'équipe en période de garde ou d'afflux massif de patients n'est probablement pas le même que celui qui oriente la recherche ou l'enseignement. Le meilleur leader est probablement celui qui est capable de passer d'un style à l'autre, en fonction des situations, de l'urgence et des autres membres du groupe. En aéronautique, quatre types de leadership ont été définis (figure 1), selon l'attention que porte le leader, soit à la tâche à effectuer, soit aux membres de l'équipe et à l'ambiance du groupe [START_REF]CRM standing group of the Royal Aeronautical Society[END_REF]. Chaque quadrant définit une forme particulière de conduite. Dans certaines situations d'urgence ou lorsque l'équipe est incapable de résoudre une situation dans les délais adéquats, le leader adopte une attitude plus dirigiste, s'affirmant face aux autres membres (type A4). Inversement, dans des situations où le leader ne prévoit pas de solution et lorsque les circonstances accordent un certain répit, il est possible de mettre en commun les idées de chacun (type A1). Dans le domaine de la santé, concernant les prises de décision, la majorité des soignants préfère un mode de fonctionnement consultatif, et qu'en cas de comportement directif, le leader doit éviter la rigidité (mémoire).

T1 Apprentissage du leadership grâce à la simulation en santé

Le leadership représente un maillon essentiel de la prise de décision dans les situations de crise. Dans la vie courante, au sein des équipes médicales et paramédicales, la fonction du leadership est généralement occupée par la personne la plus expérimentée, la plus "diplômée", ou la plus âgée, sans formation préalable ni préparation académique. Le positionnement au sein d'une équipe et le leadership peuvent probablement s'apprendre, ou du moins se renforcer, et la simulation en est un excellent outil. La simulation est une modalité pédagogique qui occupe une place importante pour l'apprentissage des procédures, et du travail en équipe lors des situations critiques et joue un rôle non négligeable à la formation du leadership. La prise en charge des patients est le plus souvent réalisée par une équipe multidisciplinaire dont la formation des membres est généralement hétérogène. La simulation est un excellent moyen de formation initiale ou continue qui permet d'améliorer la coordination entre les différents intervenants. Grâce aux situations simulées, dans un cadre qui ne met pas en péril le patient, la simulation est un outil d'entraînement, d'évaluation et d'échange qui permet aux professionnels de santé non seulement d'autoévaluer leurs connaissances et leur pratique mais aussi d'appréhender la notion de mobilisation optimale des ressources d'équipe et donc du leadership et des comportements "non techniques" [START_REF] Mcfetrich | A structured literature review on the use of high fidelity patient simulators for teaching in emergency medicine[END_REF][START_REF] Issenberg | Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review[END_REF][11].

Conclusion

Dans le domaine de la santé, le leader à la fois entraîneur, communicant, organisateur, innovateur, négociateur, catalyseur, stratège, n'existe probablement pas, mais plusieurs personnes à tour de rôle peuvent probablement répondre à l'ensemble de ces objectifs de leadership à condition qu'elles y soient préparées (simulation) et informées (communication). A1 : L'aspect relationnel prime sur la tâche, le leader encourage une participation active du team dans la décision finale (attitude consultative ou participative). Le leader épaule. A2 : Le relationnel et la tâche sont d'égale importance, le leader va essayer d'expliquer sa décision et de la faire accepter par les autres (attitude persuasive). Le leader entraîne. A3 : Le relationnel et la tâche sont peu importants, le leader délègue en fait la décision au team et s'implique peu dans la décision (attitude démocratique). Le leader délègue. A4 : La tâche à accomplir prime sur le team, le leader donne des instructions précises au team et ne laisse pas de place à la discussion (attitude autocratique). Le leader dirige.

Déclaration de liens d'intérêts

1 .

 1 Figure1_Bazin.eps © J.-É. Bazin/Elsevier Masson SAS Figure 1. Définition du comportement du leader en fonction de sa préoccupation plus ou moins importante pour l'équipe ou pour la tâche à accomplir [d'après 8].A1 : L'aspect relationnel prime sur la tâche, le leader encourage une participation active du team dans la décision finale (attitude consultative ou participative). Le leader épaule. A2 : Le relationnel et la tâche sont d'égale importance, le leader va essayer d'expliquer sa décision et de la faire accepter par les autres (attitude persuasive). Le leader entraîne. A3 : Le relationnel et la tâche sont peu importants, le leader délègue en fait la décision au team et s'implique peu dans la décision (attitude démocratique). Le leader délègue. A4 : La tâche à accomplir prime sur le team, le leader donne des instructions précises au team et ne laisse pas de place à la discussion (attitude autocratique). Le leader dirige.


Danièle Dupanloup-Meistelman
email: d.dupanloup@chru-nancy.fr

et anesthésie locorégionale 3/6 Score de Chung et aptitude à la sortie

Dochead scores en anesthésie-réanimation

Sommaire Les scores en anesthésie-réanimation 1. Score d'Aldrete et sortie de salle de surveillance postinterventionnelle 2. Score de White et fast-tracking 3. Score de Chung et aptitude à la sortie 4. Score de sédation et réanimation 5. Score NIHSS et accident vasculaire cérébral 6.

L'hospitalisation ambulatoire est définie par la sortie du patient le jour même de son admission, sans nuit d'hébergement, pour tout acte chirurgical, médical, diagnostique ou thérapeutique réalisé sous anesthésie [START_REF]Recommandations formalisées d'experts. Prise en charge anesthésique des patients en hospitalisation ambulatoire[END_REF]. La chirurgie ambulatoire est encadrée par une réglementation précise depuis 1992. Les trois décrets du 2 octobre 1992 [2-4] comblent le vide réglementaire qui existait depuis de nombreuses années dans ce domaine. Deux arrêtés compléteront ces décrets [START_REF]et au contenu de la déclaration prévue à l'article 24 de la loi n° 91-748 modifiée portant réforme hospitalière[END_REF][START_REF]fixant le programme et les modalités de l'examen de contrôle des connaissances prévu à l'article 100 du décret n° 91-1197 du 27 novembre[END_REF]. Il est souhaitable d'utiliser un score pour autoriser la sortie, facile à mettre en oeuvre. Le score le plus utilisé actuellement est le Post Anaesthetic Discharge Scoring System modifié de Chung. Désormais, il n'est plus recommandé d'imposer une réalimentation liquide et solide avant la sortie de l'établissement. De même, il est possible après une anesthésie générale ou bloc périphérique de ne pas exiger une miction pour autoriser la sortie, en l'absence de facteur de risque lié au patient ou à la chirurgie. postinterventionnelle (SSPI) et que c'est le médecin anesthésiste qui autorise la sortie de salle de réveil. La sortie du patient de l'unité d'ambulatoire se fait en accord avec le médecin ayant pratiqué l'intervention. L'anesthésiste autorisera le départ après vérification du patient de l'aptitude à rejoindre son domicile. Le médecin ayant pratiqué l'intervention voit sa responsabilité engagée lors de la décision de sortie de l'unité de chirurgie ambulatoire. L'autorisation de sortie est une décision médicale authentifiée par la signature d'un des médecins de la structure. Sous l'angle de la responsabilité professionnelle, chaque praticien en charge du patient est responsable de ses actes.

Un document consignant les prescriptions médicales et les consignes postopératoires doit être remis et explicité au patient. Un médecin anesthésiste doit pouvoir être joint par téléphone en dehors des heures ouvrables du plateau technique en cas de survenue d'un événement imprévu en rapport avec l'anesthésie dans les suites immédiates et après sortie du patient.

Les conditions de transport et d'hospitalisation éventuelle doivent être organisées en amont de l'acte ambulatoire. En effet, il est indispensable de pouvoir hospitaliser le patient en fin d'acte, si son état le nécessite, au sein de l'établissement ou dans un autre établissement.

T1 Définition score d'aptitude à la rue

La sortie du patient ne peut s'envisager qu'après un séjour en salle de repos où le sujet est verticalisé passant du statut de malade, couché, à celui de patient, assis ou debout [START_REF] Massa | Anesthésie du patient ambulatoire[END_REF]. De nombreux critères de sortie spécifiques à l'ambulatoire ont été décrits. Ils permettent d'identifier l'absence de complications telles que le saignement, la présence de douleur ou nausées et vomissements postopératoires (NVPO), et incluent d'autres items comme la possibilité du patient à la marche ou la capacité à s'habiller seul. Dans tous les cas, les scores doivent répondre à un consensus entre praticiens de l'unité de chirurgie ambulatoire et être utilisés de façon systématique par les soignants. Le score le plus utilisé actuellement est le PADSS de Chung ou le score de Post Anaesthetic Discharge Scoring System (PADSS) modifié de Chung.

T1 Définition et principes

Le score d'aptitude à la rue de référence est le score modifié PADSS de Chung [START_REF] Chung | Discharge criteria--a new trend[END_REF] (Modified Post Anaesthetic Discharge Scoring System). En effet, dans le score PADSS (tableau 1) décrit préalablement par le Dr Chung, le critère boisson et miction avait été inclus. Désormais ce dernier critère n'apparaît plus indispensable pour autoriser la sortie. En effet, l'élimination du critère "boisson" permet d'écourter le séjour en unité de chirurgie ambulatoire sans induire d'effets secondaires. Il a pu être démontré que forcer un patient à boire quand il ne le souhaitait pas pouvait être source de nausées, vomissements. D'ailleurs, ce score modifié a depuis été validé avec succès sur des milliers de patients. De même la reprise de la miction n'est plus un critère de sortie car les facteurs de risque de rétention urinaire postopératoires sont connus : antécédents de rétention urinaire, anesthésie médullaire, chirurgie pelvienne ou urologique et pose d'une sonde urinaire en peropératoire. Il faudra veiller à prévenir le patient des risques de rétention.

TEG1 Le score modifié de Chung comporte cinq critères :

• constantes vitales (fréquence cardiaque [FC], pression artérielle [PA]) ;

• activité physique et orientation ;

• douleur et NVPO ;

• saignement ;

• prise de boisson et miction.

Chacun étant affecté d'une note variant de 0 à 2 (tableau 2). Les patients sont évalués une heure après l'intervention, puis toutes les trente minutes. La sortie est compatible avec un score de 9 ou 10.

TEG1 Les recommandations de Korttila (tableau 3) font apparaître le concept de sortie autorisée par l'anesthésiste et le chirurgien, la notion d'instructions écrites et les coordonnées de la personne à joindre en cas de problème. Les recommandations doivent être toutes validées avant le retour à domicile.

Le score modifié de Chung et les recommandations de Korttila [START_REF] Korttila | Recovery from outpatient anaesthesia. Factors affecting outcome[END_REF] constituent aujourd'hui les prérequis médicaux à la sortie des patients à leur domicile.

T1 Sortie après chirurgie ambulatoire chez l'enfant TEG1 Un score d'aptitude à la rue adapté à l'enfant a été proposé par l'équipe du centre hospitalier universitaire (CHU) de Rennes (tableau 4) [START_REF] Biedermann | Score de sortie pédiatrique en chirurgie ambulatoire[END_REF]. Ce score appelé Pediatric Post Anaesthetic Scoring System (Ped-PADSS) contient cinq critères : état d'éveil, douleur, nausées et/ou vomissements, constantes vitales et saignement du site chirurgical. Chaque critère est noté sur 2 : 0 = altération majeure, 1 = altération modérée, 2 = pas d'altération. La validation de la sortie nécessite un score supérieur ou égal à 9. L'équipe de Rennes a ajouté la vérification de trois conditions à la validation de la sortie : le souhait des parents de revoir le médecin anesthésiste-réanimateur (MAR), le souhait du MAR de revoir les parents ou l'enfant, et l'absence de dysphonie ou de dyspnée.

Il n'est pas nécessaire de faire boire un enfant avant sa sortie de l'hôpital et il ne faut pas forcer un enfant à manger sous risque de vomissements secondaires.

TEG1 Concernant la spécificité de l'enfant, il est simplement recommandé d'informer les parents de la présence nécessaire d'un accompagnant qui ne doit pas être le conducteur et qu'au-delà de 10 ans, la présence d'un deuxième accompagnant n'est plus recommandé [START_REF]Recommandations formalisées d'experts 2010 : sédation et analgésie en structure d'urgence (réactualisation de la conférence d'experts de la SFAR de 1999)[END_REF].

TEG1 Lors du retour à domicile, les parents seront en possession d'une ordonnance avec les traitements instaurés, ainsi que des consignes à respecter à domicile avec les critères de surveillance.

Ils auront également le numéro de téléphone joignable vingt-quatre heures sur vingt-quatre en cas de problème médical.

Déclaration de liens d'intérêts

L'auteur déclare ne pas avoir de liens d'intérêts.

Références

• Les signes vitaux doivent être stables depuis au moins 1 heure.

• Le patient doit être :

-orienté dans le temps et l'espace ;

-capable de ne pas vomir des boissons ;

-capable d'uriner ;

-capable de se vêtir seul ;

-capable de marcher seul.

• Le patient ne doit pas avoir :

-de nausées ou de vomissements ; -de douleur importante ; -de saignement.

• La sortie doit être autorisée à la fois par l'anesthésiste et par le médecin ayant pratiqué l'intervention.

• Des instructions écrites doivent être fournies au patient quant à la période postopératoire, ainsi que les coordonnées des personnes à joindre en cas de nécessité.

Un adulte responsable doit accompagner le patient à domicile et rester avec lui.