Modern teaching of military surgery: why and how to prepare the orthopaedic surgeons before deployment? The French experience.

PURPOSE: Improved survival of combat casualties in modern conflicts is especially due to early access to damage control resuscitation and surgery in forward surgical facilities. In the French Army, these small mobile units are staffed with one general surgeon and one orthopaedic surgeon who must be able to perform any kind of trauma or non trauma emergency surgery. METHODS: This concept of forward surgery requires a solid foundation in general surgery which is no longer provided by the current surgical programs due to an early specialization of the residents. Obviously a specific training is needed in war trauma due to the special pathology and practice, but also in humanitarian care which is often provided in military field facilities. RESULTS: To meet that demand the French Military Health Service Academy created an Advanced Course for Deployment Surgery (ACDS), also called CACHIRMEX (Cours Avancé de CHIRurgie en Mission EXtérieure). Since 2007 this course is mandatory for young military surgeons before their first deployment. Orthopaedic trainees are particularly interested in learning war damage control orthopaedic tactics, general surgery life-saving procedures and humanitarian orthopaedic surgery principles in austere environments. CONCLUSION: Additional pre-deployment training was recently developed to improve the preparation of mobile surgical teams, as well as a continuing medical education for any active-duty or reserve surgeon to be deployed.

Effectiveness of a specific trauma training on war-related truncal injury management: A pre-post study.

BACKGROUND: Non-Compressible Torso Hemorrhage (NCTH) is the leading cause of preventable death in combat casualty care. To enhance the French military surgeons' preparedness, the French Military Health Service designed the Advanced Course for Deployment Surgery (ACDS) in 2008. This study evaluates behavioral changes in war surgery practice since its implementation. METHODS: Data were extracted from the OPEX® registry, which recorded all surgical activity during deployment from 2003 to 2021. All patients treated in French Role 2 or 3 Medical Treatment Facilities (MTFs) deployed in Afghanistan, Mali, or Chad requiring emergency surgery for NCTH were included. The mechanism of injury, severity, and surgical procedures were noted. Surgical care produced before (Control group) and after the implementation of the ACDS course (ACDS group) were compared. RESULTS: We included 189 trauma patients; 99 in the ACDS group and 90 in the Control group. Most injuries were combat-related (88 % of the ACDS and 82 % of the Control group). The ACDS group had more polytrauma (42% vs. 27 %; p= 0.034) and more e-FAST detailed patients (35% vs. 21 %; p= 0.044). Basics in surgical trauma care were similar between both groups, with a tendency in the ACDS group toward less digestive diversion (n= 6 [6 %] vs. n= 12 [13 %]; p= 0.128), more temporary closure with abdominal packing (n= 17 [17 %] vs. n= 10 [11 %]; p= 0.327), and less re-operation for bleeding (n= 0 [0 %] vs. n= 5 [6 %]; p= 0.046). CONCLUSION: The French model of war trauma course succeeded in keeping specialized surgeons aware of the basics of damage control surgery. The main improvements were better use of preoperative imaging and better management of seriously injured patients.

Triage of mass casualties in war conditions: realities and lessons learned.

PURPOSE: The authors made a retrospective analysis of three triage situations of war wounded in Chad and Rwanda in which mass casualties overwhelmed available medical facilities. METHODS: The triage classification is based on the waiting period for surgery. The categories are: extreme, first, second and third emergencies, expectant, walking wounded. RESULTS: In Chad, 23 wounded adults were received in 24 hours, and 19 were operated up on within 48 hours. In Rwanda 1, 94 wounded were received in two hours, of whom 68 were operated upon, 23 on the first day. In Rwanda 2, 59 wounded were received in 12 hours, treatment of extreme and first emergencies required 48 hours, while second and third emergencies were treated during the three following days. CONCLUSIONS: These episodes were very different when considering the setting, the number of casualties, the type of wounds, the logistical and medical difficulties. The authors report the difficulties faced and the lessons learned. "Il faut toujours commencer par le plus douloureusement blessé sans avoir égard aux rangs et aux distinctions." You must always begin with those who are most seriously wounded without regard to rank or other distinction. Baron Larrey (1766-1842), surgeon to Napoléon's Imperial Guard.

[Specificities of war surgery, and capacities of the military health service]. / Spécificité de la chirurgie de guerre et capacités du service de santé des armées.

In view of the recent evolution of military conflicts, particularly in the Afghan theater, and the conditions in which wounded warriors are managed in the field prior to hospitalization, the authors examine the technical specificities of medical teams, based on studies of avoidable mortality. War surgery has become a separate specialty, following the disappearance in France of the general surgical specialty, of which it was the military coun-terpart. The authors stress the role of hemorrhaging and its treatment, based on three strategies: damage control resuscitation, blood transfusion, and early evacuation within the "golden hour ". The French Armed Forces Health Service, in a new strategic plan, is refocusing its activity on war traumatology, through better education and training of medical-surgical teams and by opening up its scholarship structures to the French civilian public health service sector.

A 24-Year-Old Man With Recurrent Hemoptysis.

CASE PRESENTATION: A 24-year-old man was admitted for a new episode of hemoptysis. He reported 3 episodes of hemoptysis in the past 2 years. He had no other medical history and was a nonsmoker. As a Vietnamese person born and living in Vietnam, he was at risk for TB, but had not had contact with those having TB in his family or workplace, was never imprisoned nor homeless, and never traveled abroad. He never experienced pneumonia. He coughed up a small amount of fresh with air red blood (around 5 mL each time) several time for 3 days. He had no dyspnea, no chest pain, no fever, no asthenia, and no anorexia.

An uncommon therapeutic option for a challenging cause of pleural effusion.

Can you diagnose this challenging cause of pleural effusion? http://bit.ly/2VVwZv3.

Surgical management of penetrating thoracic injuries during the Paris attacks on 13 November 2015.

OBJECTIVES: The Paris terrorist attacks on 13 November 2015 caused 482 casualties, including 130 deaths and 352 wounded. Facing these multisite terrorist attacks, Parisian public and military hospitals simultaneously managed numerous patients with penetrating thoracic injuries. The aim of this study was to analyse this cohort, the injury patterns, and assess the results of this mobilization. METHODS: The clinical records of all patients admitted to Parisian public and military hospitals with a penetrating thoracic injury related to the Paris 13 November terrorist attacks were reviewed. RESULTS: The study group included 25 patients (7% of the casualties) with a mean age of 34 ± 8 years and a majority of gunshot wounds ( n = 20, 80%). Most patients presented with severe thoracic injury (Abbreviated Injury Score Thorax 3.3 ± 1.2), and also associated non-thoracic injuries in 21 cases (84%). The mean Injury Severity Score was 26.8 ± 9.4. Eight patients (32%) were managed with chest tube insertion and 17 (68%) required thoracic surgery. Lung resection, diaphragmatic repair, and lung suture were performed in 6 (36%), 6 (35%), and 5 cases (29%), respectively. Extra-thoracic surgical procedures were performed in 16 patients, mostly for injuries to the extremities. Postoperative mortality was 12% ( n = 3) and postoperative morbidity was 60% ( n = 15). CONCLUSIONS: The coordination of Parisian military and civilian hospitals allowed the surgical management of 25 patients. The mortality is high but consistent with what has been reported in previous series. The current times expose us to the threat of new terrorist attacks and require that the medical community be prepared.

Surgical challenges in a new theater of modern warfare: The French role 2 in Gao, Mali.

INTRODUCTION: On January 11th 2013, France launched Operation Serval in Mali following Resolution 2085 of the Security Council of the United Nations. Between January and March 2013, more than 4000 French soldiers were deployed to support the Malian National Army and the African Armed Forces. METHODS: All of the patients who had surgery during Operation Serval were entered into a computerised database. Patients' demographic data (age, sex, status) and types of performed surgical procedures (specialties, injury mechanisms) were recorded. RESULTS: 268 patients were operated on in Gao's Role 2 with a total of 296 surgeries. Among those operated on, 40% were Malian civilians, 24% were French soldiers, and 36% were soldiers of the International Coalition Forces. The majority of the surgeries were orthopaedic, and visceral surgeries were common as well, representing 43% of the total surgeries. Specialised surgical procedures including neurosurgery, thoracic, and vascular surgery were also performed. Forty percent of the surgeries were scheduled. War-related traumatic surgeries represented 22% of the surgical procedures, with non-war related surgeries and non-trauma emergency surgeries making up the rest. CONCLUSION: this analysis confirms the specific characteristic of asymmetric warfare that it results in a relatively reduced number of war-related casualties. Forward surgical teams have to deal with a wide range of injuries requiring several surgical specialties. Surgeries dedicated to medical aid provided to the population also represented an important part of the surgical activity. Because of the diversity and the technicality of the surgical procedures in Role 2, surgeons had to be trained in war surgery covering all of the surgical specialties, while they maintained their specific skills. In France in 2007, the French Military Health Service Academy (École du Val-de-Grâce, Paris, France) offered an advanced course in surgery for deployment in combat zones, with a special focus on damage control surgeries and the management of mass casualties incidents.

Challenges in war-related thoracic injury faced by French military surgeons in Afghanistan (2009-2013).

BACKGROUND: This study reports the challenges faced by French military surgeons in the management of thoracic injury during the latest Afghanistan war. METHODS: From January 2009 to April 2013, all of the civilian, French and Coalition casualties admitted to French NATO Combat Support Hospital situated on Kabul were prospectively recorded in the French Military Health Service Registry (OPEX(®)). Only penetrating and blunt thoracic trauma patients were retrospectively included. RESULTS: Eighty-nine casualties were included who were mainly civilian (61%) and men (94%) with a mean age of 27.9 years old. Surgeons dealt with polytraumas (78%), severe injuries (mean Injury Severity Score=39.2) and penetrating wounds (96%) due to explosion in 37%, gunshot in 53% and stabbing in 9%. Most of casualties were first observed or drained (n=56). In this non-operative group more than 40% of casualties needed further actions. In the operative group, Damage Control Thoracotomy (n=22) was performed to stop ongoing bleeding and air leakage and Emergency Department Thoracotomy (n=11) for agonal patient. Casualties suffered from hemothorax (60%), pneumothorax (39%), diaphragmatic (37%), lung (35%), heart or great vessels (20%) injuries. The main actions were diaphragmatic sutures (n=25), lung resections (wedge n=6, lobectomy n=4) and haemostasis (intercostal artery ligation n=3, heart injury repairs n=5, great vessels injury repairs n=5). Overall mortality was 11%. The rate of subsequent surgery was 34%. CONCLUSIONS: The analysis of the OPEX(®) registry reflects the thoracic surgical challenges of general (visceral) surgeons serving in combat environment during the latest Afghanistan War.

A Serious Game for Massive Training and Assessment of French Soldiers Involved in Forward Combat Casualty Care (3D-SC1): Development and Deployment.

BACKGROUND: The French Military Health Service has standardized its military prehospital care policy in a ''Sauvetage au Combat'' (SC) program (Forward Combat Casualty Care). A major part of the SC training program relies on simulations, which are challenging and costly when dealing with more than 80,000 soldiers. In 2014, the French Military Health Service decided to develop and deploy 3D-SC1, a serious game (SG) intended to train and assess soldiers managing the early steps of SC. OBJECTIVES: The purpose of this paper is to describe the creation and production of 3D-SC1 and to present its deployment. METHODS: A group of 10 experts and the Paris Descartes University Medical Simulation Department spin-off, Medusims, coproduced 3D-SC1. Medusims are virtual medical experiences using 3D real-time videogame technology (creation of an environment and avatars in different scenarios) designed for educational purposes (training and assessment) to simulate medical situations. These virtual situations have been created based on real cases and tested on mannequins by experts. Trainees are asked to manage specific situations according to best practices recommended by SC, and receive a score and a personalized feedback regarding their performance. RESULTS: The scenario simulated in the SG is an attack on a patrol of 3 soldiers with an improvised explosive device explosion as a result of which one soldier dies, one soldier is slightly stunned, and the third soldier experiences a leg amputation and other injuries. This scenario was first tested with mannequins in military simulation centers, before being transformed into a virtual 3D real-time scenario using a multi-support, multi-operating system platform, Unity. Processes of gamification and scoring were applied, with 2 levels of difficulty. A personalized debriefing was integrated at the end of the simulations. The design and production of the SG took 9 months. The deployment, performed in 3 months, has reached 84 of 96 (88%) French Army units, with a total of 818 hours of connection in the first 3 months. CONCLUSIONS: The development of 3D-SC1 involved a collaborative platform with interdisciplinary actors from the French Health Service, a university, and videogame industry. Training each French soldier with simulation exercises and mannequins is challenging and costly. Implementation of SGs into the training program could offer a unique opportunity at a lower cost to improve training and subsequently the real-time performance of soldiers when managing combat casualties; ideally, these should be combined with physical simulations.

Initial deployment of the 14th Parachutist Forward Surgical Team at the beginning of the operation Sangaris in Central African Republic.

As part of the operation Sangaris begun in December 2013 in the Central African Republic, the 14th Parachutist Forward Surgical Team (FST) was deployed to support French troops. The FST (role 2 in the NATO classification) is a mobile surgical-medical treatment facility. The main goal of the FST is to assure the initial damage control surgery and resuscitation for combat casualties, allowing for the early evacuation to combat support hospitals (roles 3 or 4), where further treatments are completed. During the first trimester of the operation Sangaris, 42 patients were treated at FST, of whom 29 underwent surgery. Almost 50% of patients operated on were French servicemen. All admissions were emergency admissions. Orthopedic surgery represented two-thirds of surgical interventions executed as a result of the high proportion of limb injuries. Fifty percent of injuries were specifically linked to combat. Surgery in an FST is primarily dedicated to the treatment of combat casualties with hemorrhagic injuries, but additionally plays a part in supporting general medical care of French troops. Medical aid to the general civilian population is justifiable because of the presence of medical treatment facilities, even in the initial implementation of a military operation.

Humanitarian Surgical Care Provided by a French Forward Surgical Team: Ten Years of Providing Medical Support to the Population of the Ivory Coast.

INTRODUCTION: The aims of this study were as follows: first to quantify and review the types of surgical procedures performed by military surgeons assigned to a Forward Surgical Team (FST) providing medical support to the population (MSP) in the Ivory Coast (IC), and second to analyze how this MSP was achieved. METHODS: Between 2002 and 2012, all of the local nationals operated on by the different FSTs deployed in the IC were included in the study. The surgical activity was analyzed and divided into surgical specialties, war wounds, nonwar emergency trauma, nontrauma emergencies, and elective surgery. Demographics, circumstances of health care management, wounded organs, and types of surgical procedures were described. RESULTS: Over this period, surgeons operated on 2,315 patients and performed 2,556 procedures. Elective surgery accounted for 78.7% of the surgical activity, nontrauma emergencies accounted for 12.7%, nonwar emergency trauma accounted for 8%, and war wounds accounted for 0.6%. The main surgical activities were visceral (43.8%) and orthopedic (including soft tissues) surgeries (38.5%). CONCLUSION: The FSTs contributed widely to MSP in the IC. This MSP required limited resources, standardization of the procedures and specific skills beyond the original surgical specialties of military surgeons to fulfill the needs of the local population.

Thoracoscopic renal denervation for intractable autosomal dominant polycystic kidney disease-related pain.

The authors report a case of intractable autosomal dominant polycystic kidney disease-related pain associated with normal renal function, treated with renal denervation. Renal denervation was performed via a thoracoscopic approach. The good medium-term result suggests that thoracoscopic sympatho-splanchnicectomy would be an attractive procedure for pain management in autosomal polycystic kidney disease.

Mediation of annexin 1 secretion by a probenecid-sensitive ABC-transporter in rat inflamed mucosa.

Annexin 1 is secreted by mammalian cells but lacks a leader signal sequence necessary to lead it to the classical secretory pathway via the endoplasmic reticulum. The mechanisms involved in the secretion of leaderless proteins remain uncertain. It has been suggested to involve membrane translocation via an ABC-transporter (ATP binding cassette). Using cultured inflamed mucosa from rectocolitis induced in rats, we studied if annexin 1 secretion followed the two main characteristics of ABC-transporter substrates: dependency on ATP hydrolysis and competitive inhibition by several other ABC-transporter substrates. Annexin 1 secretion is inhibited in a dose-dependent manner by two ATPase inhibitors. The inhibition reached 63.2+/-3.2%, 66.1+/-3.73% and 88.6+/-1.4% in the presence of 2mM vanadate, 0.5 and 1mM pervanadate, respectively. The efflux of calcein, a known ABC-transporter substrate, is similarly inhibited by 69.4+/-2.8% in the presence of 1mM pervanadate. Probenecid, an inhibitor of several ABC-transporters of the subfamilly ABCC or MRP (multidrug resistant associated protein), also inhibited annexin 1 secretion in a dose-dependent manner. As compared to control, 10mM probenecid reduced annexin 1 secretion by 72+/-20% and 20mM by 95.0+/-9%. By contrast, annexin 1 secretion is not blocked by other inhibitors of MRP1 (indomethacin, MK571), MRP2 (ochratoxin A1 or MK571), MRP5 (trequinsin or sulfinpyrazone) or by verapamil, cyclosporin A or glyburide. Taken together, our results show that annexin 1 secretion appears to share the efflux properties of ABC-transporter substrates.

Malignant "Triton" tumor of the posterior mediastinum: prolonged survival after staged resection.

Malignant "Triton" tumor is a rare subtype of malignant peripheral nerve sheath tumor showing rhabdomyoblastic differentiation. We report the case of a 22-year-old patient who had excision of such a tumor by video-assisted thoracic surgery. He was reoperated on by thoracotomy 2 months later and received adjuvant radiation, with prolonged survival. Radical surgical excision of malignant Triton tumor followed by adjuvant radiation therapy may provide the longest survival and represent the treatment of choice.

Videothoracoscopic bleb excision and pleural abrasion for the treatment of primary spontaneous pneumothorax: long-term results.

BACKGROUND: The goal of this study was to evaluate the long-term efficiency of videothoracoscopic bleb excision and pleural abrasion for the treatment of primary spontaneous pneumothorax. METHODS: From July 1991 to December 1997, 182 patients with primary spontaneous pneumothorax were treated by a single technique at our institution. Seven patients had single-stage bilateral procedures and 11 other patients had staged bilateral procedures. Indications for operation were first episode with prolonged air leak, incomplete lung reexpansion, or job restrictions (n = 59), first ipsilateral recurrence (n = 57), second or third ipsilateral recurrence (n = 34), contralateral recurrence (n = 25), synchronous bilateral pneumothorax (n = 3), hemopneumothorax (n = 3), and tension pneumothorax (n = 1). All patient data were reviewed retrospectively, and 167 patients were available for late follow-up (92%). RESULTS: Mean operative time was 57 +/- 19 minutes. Conversion to thoracotomy was required in 1 patient (0.6%). Mean duration of pleural drainage was 5.8 +/- 1.2 days (range, 4 to 26 days), and mean postoperative stay was 7.7 +/- 1.6 days (range, 6 to 31 days). Postoperative complications occurred in 50 patients (27.4%), the most frequent being prolonged air leak (14.8%), and in-hospital mortality was 0%. After a mean follow-up of 93 +/- 22 months (range, 57 to 134 months; median, 84 months), five ipsilateral recurrences were noted (3%). Three recurrences occurred within 12 months of videothoracoscopy and required reoperation. Two patients had partial pneumothorax recurrence at 39 and 58 months, and were treated conservatively with chest tube insertion and tale slurry. After 1 year, 10.7% of patients complained of chronic chest pain or discomfort, although none was taking pain medication after 3 months. Most patients (89.8%) were satisfied or very satisfied of their operation. All patients had returned to sport activities within 2 years. CONCLUSIONS: Videothoracoscopic bullectomy and pleural abrasion is a reliable and safe method to treat primary spontaneous pneumothorax. Long-term recurrences occur with an acceptable rate that compares with results after limited thoracotomy. Chronic chest pain or discomfort is unpredictable and may represent a problem in a few patients.

Videothoracoscopic resection of neurogenic tumors of the superior sulcus using the harmonic scalpel.

Resection of neurogenic tumors located in the paravertebral sulcus carries a risk of injury to the adjacent nervous structures and also to critical intercostal arteries supplying the anterior spinal artery. To avoid such complications, we have used the Harmonic Scalpel (Ethicon Endo-Surgery, Cincinnati, OH) for the dissection of neurogenic tumors in 2 consecutive patients operated on by videothoracoscopy. The Harmonic Scalpel functions with ultrasonic energy, producing less heat than a regular electrocautery and allows a safer dissection of tumors located in the posterior mediastinum, particularly those located in the superior paravertebral sulcus.

Traumatic extrathoracic lung herniation.

Traumatic extrathoracic lung herniation is an exceptional complication of blunt chest trauma. We report the case of a 46-year-old man who was involved in a motorcycle accident and who suffered a left clavicle fracture-dislocation associated with multiple rib fractures and massive herniation of the left upper lobe through an upper anterior chest wall defect. Immediate surgical repair through an atypical transcostal vertical thoracotomy resulted in full recovery of pulmonary function at 1 year.

[An unusual mediastinal malignant tumor: thymic carcinoma]. / Une tumeur maligne rare du médiastin: le carcinome thymique.

Thymic carcinoma is a relatively rare neoplasm. Current incidence is difficult to assess. There is some controversy regarding its definition and its diagnostic criteria. We report a case of epidermoid carcinoma in a 48-year-old man located in the thymus area of the anterior mediastinum. Clinicopathological features and prognosis are reviewed.