Surgical management of spine injuries in severe polytrauma patients: a retrospective study.

Background: Optimal surgical management of spinal injuries as part of life-threatening multiple traumas remains challenging. We provide insights into the surgical management of spinal injuries in polytrauma patients. Methods: All patients from our polytrauma care network who both met at least one positive Vittel criteria and an injury severity score (ISS) >15 at admission and who underwent surgery for a spinal injury were included retrospectively. Demographic data, clinical data demonstrating the severity of the trauma and imaging defining the spinal and extraspinal number and types of injuries were collected.Results: Between January 2012 and December 2016, 302 (22.2%) patients suffered from spinal injury (143 total injuries) and 83 (6.1%) met the inclusion criteria. Mean ISS was 36.2 (16-75). Only 48 (33.6%) injuries led to neurological impairment involving the thoracic (n = 23, 16.1%) and lower cervical (n = 15, 10.5%) spine. The most frequent association of injuries involved the thoracic spine (n = 42). 106 spinal surgeries were performed. The 3-month mortality rate was 2.4%.Conclusions: We present data collected on admission and in the early postoperative period referring to injury severity, the priority of injuries, and development of multi-organ failure. We revealed trends to guide the surgical support of spinal lesions in polytrauma patients.

The French Advanced Course for Deployment Surgery (ACDS) called Cours Avancé de Chirurgie en Mission Extérieure (CACHIRMEX): history of its development and future prospects.

INTRODUCTION: The composition of a French Forward Surgical Team (FST) has remained constant since its creation in the early 1950s: 12 personnel, including a general and an orthopaedic surgeon. The training of military surgeons, however, has had to evolve to adapt to the growing complexities of modern warfare injuries in the context of increasing subspecialisation within surgery. The Advanced Course for Deployment Surgery (ACDS)-called Cours Avancé de Chirurgie en Mission Extérieure (CACHIRMEX)-has been designed to extend, reinforce and adapt the surgical skill set of the FST that will be deployed. METHODS: Created in 2007 by the French Military Health Service Academy (Ecole du Val-de-Grâce), this annual course is composed of five modules. The surgical knowledge and skills necessary to manage complex military trauma and give medical support to populations during deployment are provided through a combination of didactic lectures, deployment experience reports and hands-on workshops. RESULTS: The course is now a compulsory component of initial surgical training for junior military surgeons and part of the Continuous Medical Education programme for senior military surgeons. From 2012, the standardised content of the ACDS paved the way for the development of two more team-training courses: the FST and the Special Operation Surgical Team training. The content of this French military original war surgery course is described, emphasising its practical implications and future prospects. CONCLUSION: The military surgical training needs to be regularly assessed to deliver the best quality of care in an context of evolving modern warfare casualties.

[Thoracic drainage technique for emergencies]. / Drainage thoracique en situation précaire.

The purpose of this report is to describe a simple, reproducible technique for pleural drainage. This technique that requires scant resources should be used only in life-threatening situations calling for pleural drainage. It is not intended to replace conventional techniques.

Arteriovenous fistulae for access to hemodialysis in Chad : feasibility study of a medical civic action program by a French army surgical unit.

INTRODUCTION: Use of chronic intermittent hemodialysis is recent in Chad, where it remains underdeveloped. Vascular access is most commonly by catheter. The objective of our study was to demonstrate the feasibility of arteriovenous fistula (AVF) surgery for hemodialysis during deployments as part of the medical civic action program (MEDCAP). METHODS: We prospectively included all patients admitted for AVF creation at Camp Kossei forward surgical unit in N'Djamena (Chad) between December 2016 and February 2017. Surgery was performed by an experienced vascular surgeon. The data collected included age, sex, cause of kidney failure, type of anesthesia, AVF location, and the duration of the intervention and hospitalization. Patients were examined one month after the procedure to evaluate the functionality, morbidity, and mortality of the AVF. RESULTS: We performed 17 AVF in 3 months. Male to female ratio was 3. High blood pressure was the main cause of chronic kidney failure (55%). All interventions were conducted under locoregional anesthesia. Overall, 35% of fistulae were radiocephalic, 41% brachiocephalic, and 24% brachiobasilic. The mean duration of intervention was 58 minutes and that of hospitalization one day. No deaths occurred. Global morbidity, including non-functioning AVF, was 25%. CONCLUSION: Our study showed that AVF surgery is feasible during deployment, especially in Chad, and meets the needs of the local healthcare facilities. It should be developed and taught to local surgeons.

Incarcerated obturator hernia: early diagnostic using helical computed tomography.

Obturator hernia is a rare event with poor clinical signs. Delayed diagnosis is a cause of increased mortality due to ruptured gangrenous bowel. We report a case of incarcerated obturator hernia which highlights the usefulness of computed tomography (CT) scanning in diagnosing this condition.

Isolated common femoral artery injury caused by blunt trauma.

The authors report an isolated common femoral artery injury caused by blunt trauma with dissection and secondary ischaemia. A 21-year-old man was admitted to hospital after being stabbed during acute alcoholic intoxication. He presented with a stab wound on the left leg and blunt trauma in the right groin. The surgical exploration of the left-sided wound did not disclose any vascular injury. After a 12-hour period of observation, the patient was discharged. Six hours later, he came back with severe ischaemia on the right leg caused by a femoral artery dissection. The patient underwent surgical revascularization, and fully recovered. Isolated artery blunt trauma is a rare event. In this observation, the absence of early symptoms resulted in delayed diagnosis.

[Respiratory complications after oesophagectomy for cancer]. / Complications respiratoires de l'oesophagectomie pour cancer.

Surgery is the cornerstone of treatment for resectable tumours of the oesophagus. Recent advances of surgical techniques and anaesthesiology have led to a substantial decrease in mortality and morbidity. Respiratory complications affect about 30% of patients after oesophagectomy and 80% of these complications occur within the first five days. Respiratory complications include sputum retention, pneumonia and ARDS. They are the major cause of morbidity and mortality after oesophageal resection and numerous studies have identified the factors associated with these complications. The mechanisms are not very different from those observed after pulmonary resection. Nevertheless, there is an important lack of definition, and evaluation of the incidence is particularly difficult. Furthermore, respiratory complications are related to many factors. Careful medical history, physical examination and pulmonary function testing help to identify the risk factors and provide strategies to reduce the risk of pulmonary complications. Standardized postoperative management and a better understanding of the pathogenesis of pulmonary complications are necessary to reduce hospital mortality. This article discusses preoperative, intraoperative, and postoperative factors affecting respiratory complications and strategies to reduce the incidence of these complications after oesophagectomy.

[Recent injuries to the left diaphragm: value of laparoscopy in Africa and Europe]. / Lésions récentes du diaphragme gauche: intérêt de la laparoscopie, en Afrique comme en Europe.

Management of recent diaphragm injury is challenging. The purpose of this report is to describe two patients who presented injuries to the left diaphrgmatic cupola, i.e., rupture due to blunt trauma in Europe and a stab wound in Africa. The value of laparoscopy for diagnosis and treatment are discussed in these contrasting settings.

[Surgical management of cardiac wounds: cardiac or general surgical service?]. / Plaies du coeur, prise en charge de chirurgie cardiaque ou générale?

OBJECTIVE: To define modalities of cardiac wound management with a special emphasis on the initial direction of the patient toward a surgical service, rapid diagnosis, and surgical treatment. METHOD: Sixteen patients with thoracic injury to the region of the heart treated between 1996 and 2006 were evaluated retrospectively. Pre-operative clinical data, echography, and CT results were collected; time elapsed between injury and treatment, type of surgical treatment, use of cardio-pulmonary bypass, morbidity and mortality were evaluated. RESULTS: There were 16 patients (12 men); age ranged from 18 to 80 with an average of 45.7 years. Nine patients had penetrating cardiac wounds, two had blunt trauma, and five suffered iatrogenic trauma. Cardio-pulmonary bypass was used in two cases. The mean time elapsed between trauma and surgical evaluation was 63 minutes (p=0.18). In all cases, surgery consisted of a myorraphy without coronary or valvular repair. Post-operative complications occurred in 4 patients (25%) and resulted in 2 deaths (12.5%). Complication and death were associated with a prolonged interval between injury and surgical management. CONCLUSION: Patients with cardiac wounds should be transported to the nearest surgical hospital. There are no benefits to cardio-pulmonary bypass in cardiac trauma.

[Abbreviated laparotomy for treatment of severe abdominal trauma: use in austere settings]. / Laparotomie écourtée pour traitement des traumatismes abdominaux sévères: application en milieu précaire.

Abbreviated laparotomy is a recent technique for management of patients with severe abdominal trauma. It is based on a unified approach taking into account the overall extent of injury and the victim's physiologic potential to respond to hemorrhage. It is the first step in a multi-modal strategy. The second step is the critical care phase. The third step consists of "second-look" laparotomy that should ideally be performed on an elective basis within 48 hours and is aimed at definitive treatment of lesions. The goal of abbreviated laparotomy is damage control using temporary quick-fix procedures limited to conspicuous lesions and rapid hemostasis and/or viscerostasis procedures so that the patient can survive the acute critical period. Tension-free closure of the abdominal wall, if necessary using laparostomy, is essential to avoid abdominal compartment syndrome. With reported survival rates of about 50% in Europe and the United States, this simple life-saving technique that requires limited resources should be introduced in Africa where severe abdominal trauma often involves young patients.

Specific elements of thoracic wound management.

Damage control for thoracic trauma combines definitive and temporary surgical gestures specifically adapted to the lesions present. A systematic assessment of all injuries to prioritize the specific lesions and their treatments constitutes the first operative stage. Packing and temporary closure have a place in the care of chest injuries.

Resuscitation thoracotomy.

Resuscitation thoracotomy is a rarely performed procedure whose use, in France, remains marginal. It has five specific goals that correspond point-by-point to the causes of traumatic cardiac arrest: decompression of pericardial tamponade, control of cardiac hemorrhage, performance of internal cardiac massage, cross-clamping of the descending thoracic aorta, and control of lung injuries and other intra-thoracic hemorrhage. This approach is part of an overall Damage Control strategy, with a targeted operating time of less than 60minutes. It is indicated for patients with cardiac arrest after penetrating thoracic trauma if the duration of cardio-pulmonary ressuscitation (CPR) is <15minutes, or <10minutes in case of closed trauma, and for patients with refractory shock with systolic blood pressure <65mm Hg. The overall survival rate is 12% with a 12% incidence of neurological sequelae. Survival in case of penetrating trauma is 10%, but as high as 20% in case of stab wounds, and only 6% in case of closed trauma. As long as the above-mentioned indications are observed, resuscitation thoracotomy is fully justified in the event of an afflux of injured victims of terrorist attacks.

Feasibility of selective non-operative management for penetrating abdominal trauma in France.

INTRODUCTION: In France, non-operative management (NOM) is not the widely accepted treatment for penetrating wounds. The aim of our study was to evaluate the feasibility of NOM for the treatment of penetrating abdominal traumas at 3 hospitals in the Southeast of France. METHODOLOGY: Our study was multicentric and retroprospective from January, 2010 to September, 2013. Patients presenting with a penetrating abdominal stab wound (SW) or gunshot wound (GSW) were included in the study. Those with signs of acute abdomen or hemodynamic instability had immediate surgery. Patients who were hemodynamically stable had a CT scan with contrast. If no intra-abdominal injury requiring surgery was evident, patients were observed. Criteria evaluated were failed NOM and its morbidity, rate of non-therapeutic procedures (NTP) and their morbidity, length of hospital stay and cost analysis. RESULTS: One hundred patients were included in the study. One patient died at admission. Twenty-seven were selected for NOM (20 SW and 7 GSW). Morbidity rate was 18%. Failure rate was 7.4% (2 patients) and there were no mortality. Seventy-two patients required operation of which 22 were NTP. In this sub-group, the morbidity rate was 9%. There were no mortality. Median length of hospital stay was 4 days for the NOM group and 5.5 days for group requiring surgery. Cost analysis showed an economic advantage to NOM. CONCLUSION: Implementation of NOM of penetrating trauma is feasible and safe in France. Indications may be extended even for some GSW. Clinical criteria are clearly defined but CT scan criteria should be better described to improve patient selection. NOM reduced costs and length of hospital stay.

Management specificities for abdominal, pelvic and vascular penetrating trauma.

Management of patients with penetrating trauma of the abdomen, pelvis and their surrounding compartments as well as vascular injuries depends on the patient's hemodynamic status. Multiple associated lesions are the rule. Their severity is directly correlated with initial bleeding, the risk of secondary sepsis, and lastly to sequelae. In patients who are hemodynamically unstable, the goal of management is to rapidly obtain hemostasis. This mandates initial laparotomy for abdominal wounds, extra-peritoneal packing (EPP) and resuscitative endovascular balloon occlusion of the aorta (REBOA) in the emergency room for pelvic wounds, insertion of temporary vascular shunts (TVS) for proximal limb injuries, ligation for distal vascular injuries, and control of exteriorized extremity bleeding with a tourniquet, compressive or hemostatic dressings for bleeding at the junction or borderline between two compartments, as appropriate. Once hemodynamic stability is achieved, preoperative imaging allow more precise diagnosis, particularly for retroperitoneal or thoraco-abdominal injuries that are difficult to explore surgically. The surgical incisions need to be large, in principle, and enlarged as needed, allowing application of damage control principles.

[Spontaneous pneumomediastinum in young adults: a benign clinical entity]. / Pneumomédiastin spontané du jeune adulte: une entité clinique bénigne.

INTRODUCTION: Spontaneous pneumomediastinum is a little known cause of chest pain in young adults. The prognosis is invariably good. CASE REPORT: The authors report two cases of spontaneous pneumomediastinum with different aetiologies developing in young adults. The first occurred during strenuous sport and the second during an asthma attack. CONCLUSION: The discussion stresses the frequency of this condition in young men, its pathogenesis and natural history. In particular the authors draw on the current scientific data to explain the absence of predisposing factors and the extreme rarity of relapse of this benign disorder. Poor acquaintance with this clinical entity may lead to unnecessary diagnostic and therapeutic actions. The authors suggest a guideline for the management of this disorder.

[Current management of stab wounds to the colon]. / Prise en charge actuelle des plaies coliques par arme blanche: applications en milieu tropical.

Stab wounds to the colon are a frequent surgical emergency. Local wound exploration under local anaesthesia is not required systematically. We recommend surveillance based on clinical observation and laboratory testing to detect peritoneal signs. If progression of symptoms is suspected, diagnostic peritoneal lavage (DPL) should be performed. Immediate surgical exploration is indicated in two cases, i.e., generalized peritonitis and haemodynamic instability due to internal bleeding. The preferred repair technique is direct suture or resection followed by a handsewn or mechanical anastomosis. The morbidity, cost and social consequences of colostomy must be taken into account. It should be considered as a salvage procedure for patients in critical condition or extensive colonic injury.

[Mesenteric trauma: management in austere environments]. / Traumatismes entéro-mésentériques en situation précaire.

Mesenteric trauma, i.e., injuries located in the bowel or organs supplied by the superior mesenteric artery, can be life-threatening. The incidence of these lesions is low. Most occur as result of blunt and penetrating abdominal trauma due mainly to gunshot wounds or road accidents. Management of these serious injuries can be challenging in the military field hospitals. The major problem in austere environment is the unavailabiity of computerized axial and other tools gene rally used for diagnosis. As an alternative to tomography diagnostic peritoneal lavage can be used with a high sensitivity for the detection of mesenteric trauma. The second difficulty is technical. General surgeons without vasular training or supplies must prepared to suspect and reonstuct lesions of the superior mesenteric available resources.

Hospital care in severe trauma: Initial strategies and life-saving surgical procedures.

Severe trauma patients should be received at the hospital by a multidisciplinary team directed by a "trauma leader" and all institutions capable of receiving such patients should be well organized. As soon as the patient is accepted for care, the entire team should be prepared so that there is no interruption in the pre-hospital chain of care. All caregivers should thoroughly understand the pre-established protocols of diagnostic and therapeutic strategies to allow optimal management of unstable trauma victims in whom hemostasis must be obtained as soon as possible to decrease the morbid consequences of post-hemorrhagic shock. In patients with acute respiratory, circulatory or neurologic distress, several surgical procedures must be performed without delay by whichever surgeon is on call. Our goal is to describe these salvage procedures including invasive approaches to the upper respiratory tract, decompressive thoracostomy, hemostatic or resuscitative thoracotomy, hemostatic laparotomy, preperitoneal pelvic packing, external pelvic fixation by a pelvi-clamp, decompressive craniotomy. All of these procedures can be performed by all practitioners but they require polyvalent skills and training beforehand.