Combat casualties from two current conflicts with the Seventh French Forward Surgical Team in Mali and Central African Republic in 2014.

OBJECTIVES: The Seventh Airborne Forward Surgical Team (FST) has been deployed in Gao, Mali, and in Bangui, Central African Republic (CAR), for two 3-month periods in 2014. The initial role of the FST was to provide emergent care to French and coalition soldiers but it was expanded to include humanitarian assistance. The aim of the present study was to describe and compare injuries and surgical activity of the Seventh Airborne FST during these two conflicts. METHODS: All surgical patients treated by the FST between January and December 2014 have been included. Patient demographics, mechanisms of injury, surgical management including triage categories and types of surgery performed and evacuation modalities were recorded. RESULTS: During the 6-month deployment period in 2014, the FST performed 129 operations on 134 patients, 61 of which were trauma patients (45 battle injuries (BI)). The remaining 73 patients were treated as part of the humanitarian mission. Thirty of the BI were managed during the Malian conflict and 15 in CAR; 29 patients (64%) were military. The median Injury Severity Score (range) was 20 (10-34) in Mali and 8 (5-21) in CAR with median (range) evacuation time of 390 min (240-947) in Mali and 120 min (60-120) in CAR (p<0.0001). The most frequent mechanisms of injury were gunshot wounds in Mali (15/30) and road traffic accident in CAR (7/15). Extremity injuries were most common (58%) with head, face and neck injuries and thoracic injuries in 15% of cases each and 12% had suffered abdominopelvic injuries. Ten patients were categorised as T1 and underwent urgent surgery, five had damage control surgery and four received transfusion. The average length of stay was 2 days (1-2), with most patients being transferred to another hospital. CONCLUSIONS: Casualties from Mali and CAR presented with a wide variety of injury patterns, and there were some instances where damage control surgery and whole blood transfusion were necessary. Surgical equipment scales must allow treatment of a large variety of injuries including all body regions and extreme emergency procedures. These two conflicts differ in terms of scope, one being an urban guerrilla and the other an open conflict in a large desertic area. Long distances in the Malian desert increase significantly the evacuation time. It has to be taken into account in the FST location when coalition forces are deployed in such places.

Therapeutic Strategies for Advanced Pancreatic Neuroendocrine Tumors with Segmental Portal Hypertension.

BACKGROUND: Pancreatic neuroendocrine tumors (PNET) locally advanced may lead to significant local symptoms especially segmental portal hypertension (SPH) with risk of bleeding. The aim of our study was to evaluate the role of SPH on the PNET management in an expert center. METHODS: Forty-two patients treated for locally advanced PNET with SPH between January 1984 and December 2012 were retrospectively analyzed. RESULTS: The median age was 55 years (25-75). The median tumor size was 7.5 cm (3-20). Thirty four (80.9%) patients were metastatic mainly in the liver (n=33, 79%) with a frequent (n=16, 38.1%) involvement>20%. The surgery was impossible because of SPH in 7 (16.6%) cases. Pancreatic resection was performed in 28 (66.7%) cases by distal pancreatectomy. Neoadjuvant chemotherapy (n=24, 57%) had no impact on SPH with no modification of collateral circulation. Among operated on patients, complete macroscopic resection was obtained in 19 (67.8%) patients. The mortality and severe morbidity rate was respectively 3.6 and 18%. Five year overall survival (OS) was similar in operated and no operated patients. (61%; p=0.64). The 5-year OS was 77.9 or 55.4% in patients who underwent a complete or incomplete macroscopic resection of primary and metastases, respectively. CONCLUSION: PNET resection associated with SPH is feasible with a low morbimortality. SPH was not improved by chemotherapy. Prolonged survival was observed after complete macroscopic resection.

Fever of unknown origin: Importance of 18F-FDG PET/CT in the diagnosis of a late infectious complication after aneurysm bypass.

Persistent blood flow in aneurysmal sac after bypass-exclusion is well documented in the literature. Aneurysm enlargement, local compressive symptoms and even sac rupture are commonly described complications. Late secondary infection of popliteal artery aneurysm (PAA) following ligation and venous bypass is exceptional. We report the case of late PAA infection six years after bypass-exclusion in a 75 year-old man which was diagnosed by 18F-FDG PET/CT. The patient was successfully treated by aneurysm resection and antibiotics. The diagnosis of popliteal aneurysm infection is often clinical, echographic and sonographic, but computed tomography scan can be false negative in chronic low-grade infection. 18F-FDG PET/CT is able to accurately diagnose and localize infection with high sensibility and specificity.

[Cavernous hemangioma: rare incidentaloma of the adrenal gland]. / L'hémangiome caverneux : un incidentalome rare de la surrénale.

The hemangioma of the adrenal gland is an adrenal gland lesion rare, benign and usually asymptomatic. Discovered incidentally during an abdominal imaging study, it is part of incidentalomas. Imagery is the best to characterise these silent adrenal masses (computed tomography [CT], Magnetic Resonance Imaging [MRI]± Positron Emission Tomography [PET scan] with 18F-FDG). The main risks of the hemangioma are ignorance of malignancy, bleeding and abdominal mass syndrome. The analysis of the literature shows the importance of laparoscopy. A multidisciplinary discussion on this type of lesion appears indispensable both diagnostic and therapeutic.

One-stage laparoscopic procedure versus two-stage procedure in the management of common bile duct stones in patients aged 75 and more.

INTRODUCTION: The management strategy for common bile duct stones (CBD) in patients over 75years is a real challenge that requires balancing the efficacy of a multiplicity of procedures against their own morbidity. The objective is to compare one-stage surgical treatment versus the two-stage combination of endoscopy and surgery in terms of efficacy of clearing the CBD of stones and the morbidity and mortality in elderly patients. MATERIAL AND METHODS: This study included eighty-two patients over 75years of age with symptomatic CBD stones who presented between 2010 and 2017. Patients were treated either by one-stage surgery alone (S group, n=40) or by sequential endoscopy and surgery (ES group, n=42). RESULTS: Immediate and 30-day mortality, morbidity and duration of hospitalization were comparable. The failure rate for clearing CBD lithiasis was significantly higher in the ES group (26.2% vs. 7.5%, P=0.038, 95% CI). In multivariate analysis, two-stage treatment and multiple CBD stones were associated with a significantly higher risk of failure. Fewer anesthetic procedures were needed in the S group. Twelve patients (14.4%) had multiple stones packing the CBD (>3 stones); four were treated with choledocho-duodenal anastomosis and eight with endoscopic sphincterotomy and stone removal with 100% and 50% efficacy, respectively. CONCLUSION: The "surgery alone" attitude compared to 2-stage endoscopic and surgical management is associated with better efficacy in terms of clearing the CBD of lithiasis and requires fewer anesthetic procedures in elderly subjects while being comparable in terms of morbidity and mortality. In patients whose CBD is packed with multiple stones, choledocho-duodenal anastomosis is an alternative to endoscopy for management of choledocholithiasis.

Feasibility and limits of inguinal hernia repair under local anaesthesia in a limited resource environment: a prospective controlled study.

PURPOSE: Local anaesthesia (LA) has proven effective for inguinal hernia repair in developed countries. Hernias in low to middle income countries represent a different issue. The aim of this study was to analyse the feasibility of LA for African hernia repairs in a limited resource environment. METHODS: Data from patients who underwent herniorrhaphy under LA or spinal anaesthesia (SA) by the 6th and 7th Forward Surgical Team were prospectively collected. All of the patients benefited from a transversus abdominis plane (TAP) block for postoperative analgesia. Primary endpoints concerned the pain response and conversion to general anaesthesia. Secondary endpoints concerned the complication and recurrence rates. Predictors of LA failure were then identified. RESULTS: In all, 189 inguinal hernias were operated during the study period, and 119 patients fulfilled the inclusion criteria: 57 LA and 62 SA. Forty-eight percent of patients presented with inguinoscrotal hernias. Local anaesthesia led to more pain during surgery and necessitated more administration of analgesics but resulted in fewer micturition difficulties and better postoperative pain control. Conversion rates were not different. Inguinoscrotal hernia and a time interval <50 min between the TAP block and skin incision were predictors of LA failure. Forty-four patients were followed-up at one month. No recurrence was noted. CONCLUSIONS: Local anaesthesia is a safe alternative to SA. Small or medium hernias can easily be performed under LA in rural centres, but inguinoscrotal hernias required an ultrasound-guided TAP block performed 50 min before surgery to achieve optimal analgesia, and should be managed only in centres equipped with ultrasonography.

Medical and surgical triage.

In terrorist attacks and industrial catastrophes, management of a massive afflux of wounded must adhere to logistic imperatives while at the same time taking into account basic traumatology principles. This implies a firm, unequivocal, and precise doctrine for all stages of care. Medical and surgical triage allows a logical classification of victims according to severity of injury, the necessity of treatment and the degree of urgency. Triage should be early, dynamic, and lead to a categorization that optimally utilizes resources while ensuring efficient management.

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.

[Indications and surgical technique of subtotal hysterectomy for a general surgeon practicing in austere environment with limited resources]. / Indications et technique chirurgicale de l'hystérectomie subtotale pour un chirurgien généraliste en situation isolée avec des ressources limitées.

Uterine fibromyomata in Africa, which represents the most frequent benign uterine disease, is a real public health. This pathology is frequent and most of times discovered at a late stage where the volume of the uterus is responsible for invalidating symptoms that impairs patients' quality of life. Subtotal hysterectomy, which preserves the cervix, is faster than total hysterectomy and reduces intraoperative (duration of operation, blood loss) and postoperative morbidity (urinary infection, vaginal cicatrization). Subtotal hysterectomy is adapted to countries with limited resources. Its realization requires the preoperative assessment of normal cervix and a regular post-operative follow-up of the cervix left in place.

[Management of penetrating abdominal trauma: what we need to know?]. / Prise en charge des traumatismes pénétrants de l'abdomen : des spécificités à connaître.

Penetrating traumas are rare in France and mainly due to stabbing. Knives are less lethal than firearms. The initial clinical assessment is the cornerstone of hospital care. It remains a priority and can quickly lead to a surgical treatment first. Urgent surgical indications are hemorrhagic shock, evisceration and peritonitis. Dying patients should be immediately taken to the operating room for rescue laparotomy or thoracotomy. Ultrasonography and chest radiography are performed before damage control surgery for hemodynamic unstable critical patients. Stable patients are scanned by CT and in some cases may benefit from non-operative strategy. Mortality remains high, initially due to bleeding complications and secondarily to infectious complications. Early and appropriate surgery can reduce morbidity and mortality. Non-operative strategy is only possible in selected patients in trained trauma centers and with intensive supervision by experienced staff.