Management of postoperative pancreatic fistula after pancreaticoduodenectomy.

A postoperative pancreatic fistula (POPF) is the main complication after cephalic pancreaticoduodenectomy (CPD). Unlike its prevention, the curative management of POPFs has long been poorly codified. This review seeks best practices for managing POPFs after CPD. The diagnosis of a POPF is based on two signs: (i) an amylase level in drained fluid more than 3 times the upper limit of the blood amylase level; and (ii) an abnormal clinical course. In the standardised definition of the International Study Group of Pancreatic Surgery, a purely biochemical fistula is no longer counted as a POPF and is treated by gradual withdrawal of the drain over at most 3 weeks. POPF risk can be scored using pre- and intraoperative clinical criteria, many of which are related to the quality of the pancreatic parenchyma and are common to several scoring systems. The prognostic value of these scores can be improved as early as Day 1 by amylase assays in blood and drained fluid. Recent literature, including in particular the Dutch randomised trial PORSCH, argues for early systematic detection of a POPF (periodic assays, CT-scan with injection indicated on standardised clinical and biological criteria plus an opinion from a pancreatic surgeon), for rapid minimally invasive treatment of collections (percutaneous drainage, antibiotic therapy indicated on standardised criteria) to forestall severe septic and/or haemorrhagic forms, and for the swift withdrawal of abdominal drains when the risk of a POPF is theoretically low and evolution is favourable. A haemorrhage occurring after Day 1 always requires CT angiography with arterial time and monitoring in intensive care. Minimally invasive treatment of a POPF (radiologically-guided percutaneous drainage or, more rarely, endoscopic drainage, arterial embolisation) should be preferred as first-line treatment. The addition of artificial nutrition (enteral via a nasogastric or nasojejunal tube, or parenteral) is most often useful. If minimally invasive treatment fails, then reintervention is indicated, preserving the remaining pancreas if possible, but the expected mortality is higher.

Accuracy of imaging for predicting operative approach in Crohn's disease.

BACKGROUND: The aim of this study was to assess the accuracy of preoperative imaging in detecting the extent of disease and predicting the operative approach in patients with Crohn's disease. METHODS: Patients with Crohn's disease who were scheduled to undergo operation were evaluated before operation using computed tomography enteroclysis (CTE) and magnetic resonance enterography (MRE). Preoperative imaging findings were correlated with intraoperative and pathological findings to estimate the capabilities of preoperative imaging in detecting lesions due to Crohn's disease. The operative approach determined before surgery was compared with the procedure actually performed, which was based on intraoperative findings. RESULTS: Fifty-two patients with Crohn's disease were studied; 26 were evaluated before surgery with CTE and 26 with MRE. Eighty-nine lesions due to Crohn's disease were confirmed surgically (60 small bowel stenoses, 21 fistulas and 8 abscesses). CTE confirmed the presence of 38 of 41 lesions (sensitivity 93 per cent) and MRE 48 of 48 lesions (sensitivity 100 per cent); a correct estimation of the disease with an exact prediction of the operative approach was obtained in 49 (94 per cent) of 52 patients. Discrepant findings between preoperative imaging and operative findings were observed in three patients (6 per cent), who had CTE. CONCLUSION: Preoperative imaging using CTE or MRE is highly accurate for assessing Crohn's disease lesions before operation, allowing correct prediction of the operative approach.

Diagnosis and treatment of focal splenic lesions.

The spleen can be affected by many conditions, some of which are easily diagnosed by conventional imaging, mainly using computed tomography scans and magnetic resonance imaging. Despite the contribution of functional radiology techniques such as positron emission tomography, it is sometimes difficult to diagnose certain focal splenic lesions and definitive diagnosis sometimes requires histological confirmation by percutaneous biopsy or more rarely by diagnostic intervention. Once a diagnosis has been established, treatment is based mainly on surgery: total splenectomy for malignant lesions, or partial splenectomy whenever possible for benign lesions benign that are symptomatic and/or at risk of rupture.

Biliary peritonitis after endoscopic retrograde cholangiopancreatography.

Occurrence of a perforation after endoscopic CPRE sphincterotomy is a complication previously reported in the literature, with frequent repercussions on the duodenum and the periampullary region (Stapfer types 1 and 2); treatment modalities are strictly codified. During an endoscopic procedure, it may be associated with manipulation of a guide wire, generally leading to isolated pneumoretroperitoneum (Stapfer type 4), which is conservatively treated. Secondarily to endoscopic maneuvers, Stapfer type 3 may also occur, causing pancreatic or biliary ductal lesions. When perforation is highlighted following an endoscopic procedure, treatment depends on the presence of an intraperitoneal or retro-peritoneal liquid or aerial effusion. When perforation is contained and clinical tolerance remains satisfactory, conservative treatment is carried out. Conversely, in the event of poor tolerance or intraperitoneal contamination, emergency surgery is called for.

Surgical tracheotomy.

In spite of the ever-increasing hyper-specialization of gastro-intestinal surgeons, some surgical emergency procedures, such as tracheotomy, need to be mastered. The need for tracheotomy is sometimes so urgent that one cannot wait for a specialized surgeon to arrive or to transport the patient elsewhere. Even though percutaneous tracheotomy, as performed by intensive care physicians, represents an alternative to surgical tracheotomy, it is not always possible.

[Scrotal pilomatrixoma: a case report and review of the literature]. / Pilomatricome scrotal : à propos d'un cas et revue de la littérature.

Pilomatrixoma, calcifying epithelioma of Malherbe, is a cutaneous tumor, originating from the hair matrix, mostly affecting pediatric population. We report a particularly uncommon location of pilomatrixoma: the scrotal skin. A 46-year-old man, without history, has developed a scrotal, multinodular firm tumor, measuring 10 cm. Most often, its preoperative diagnosis is not possible, because of its clinical polymorphism. The precise diagnosis is histological, by the revealing of mummified cells. The treatment is surgical, with only purpose to perform complete removal of pathologic tissue, allowing to decrease the rate of local relapse.

Colonic volvulus after laparoscopic left colectomy.

Volvulus of the mobilized colon after laparoscopic left colectomy is rare. Contributing factors seem to be excessive length of the mobilized colon, absence of peritonization and absence of adhesions due to laparoscopy. Onset of colonic volvulus after laparoscopic left colectomy should lead to routine computerized tomography (CT), searching for an image suggestive of small intestinal incarceration under the neo-mesocolon, which might be an additional risk factor. Treatment consists of disincarceration of the small intestines while closing the mesocolic defect remains a subject of controversy.

Appendicular myxoglobulosis; a rare form of appendicular mucocele.

Myxoglobulosis is a particular, rare, form of appendicular mucocele, characterized by the presence of numerous, occasionally calcified, globules that are grouped together like grapes, and look like pearls or fish eggs, in the appendicular lumen. The diagnosis of myxoglobulosis is most often fortuitous, but sometimes, can be made in the face of acute appendicitis or another setting of abdominal pain. Imaging (sonography or computerized tomography (CT)) is highly suggestive when it shows a cystic, encapsulated, oblong, well-delineated mass, containing (heterogeneous, liquid, and viscous) mucus with calcified globules. In contrast to acute appendicitis, the wall of the appendix is thin (<6mm) and there is no peri-appendicular inflammation. Long-term complications are similar to other appendicular mucoceles, including invagination, bleeding, perforation, peritonitis and peritoneal pseudomyxoma.

[Role of self-expanding stent in the treatment of obstructing colorectal cancer]. / L'endoprothèse dans l'occlusion colique tumorale.

BACKGROUND: Obstruction due to colorectal cancer is a common occurrence. It often arises in patients in poor general condition with malnutrition and advanced tumor stage. Prognosis can be improved by prompt resolution of obstruction through a mininimally invasive approach. GOAL: To analyze the management of cases of acute colorectal obstruction and evaluate the efficacity and morbidity/mortality associated with the use of endocolic stent prostheses. MATERIAL AND METHODS: This retrospective study at a single center evaluated patients presenting with acute colorectal obstruction between January 2003 and May 2008, assessing the patient sample, cancer characteristics, treatment, and morbidity/mortality. RESULTS: The mean age of the 26 patients was 75 years; ASA Class was greater than III in 63% of cases, The colorectal cancer was located in the sigmoid in 65% of cases and was a Stage IV tumor in 73% of cases. Placement of an endocolic stent was the primary intervention in 94% of patients. Morbidity was 12% and mortality was 4%. CONCLUSION: Colonic stenting is an effective therapeutic option in the elderly with painful symptoms of obstruction and should be the initial approach.

Lymphadenectomy of the hepatic pedicle during hepato-pancreato-biliary surgery.

Nodal involvement of the hepatic pedicle is variable and depends on the underlying hepato-bilio-pancreatic pathology. Although its value for ultimate prognosis has not been demonstrated, lymphadenectomy is usually performed to determine tumor stage and to inform the decision about eventual adjuvant treatment. Lymph node dissection of the hepatic pedicle requires a thorough understanding of the anatomy of hepatic lymphatic drainage as well as accurate analysis of pre-operative imaging in order to identify and locate abnormal lymph and to rule out anatomical variations that might complicate the surgical procedure.

Microbiology of French military casualties repatriated from overseas for an open traumatic injury.

BACKGROUND: This study aimed to describe the microbiological epidemiology of repatriated French soldiers with an open traumatic injury, and to measure the proportion of multidrug-resistant bacteria (MDRB). METHODS: Retrospective study including all French soldiers repatriated in 2011 and 2012 in Parisian military hospitals for open traumatic injury. Results of clinical samples and MDRB screening were collected. The antibiotic susceptibility was assessed using the agar disk diffusion method. Characterization of resistance mechanisms was performed using PCR. Genotyping of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) isolates was performed using rep-PCR. RESULTS: A total of 139 patients were included; 70% of them were repatriated from Afghanistan. At admission, 24/88 were positive for MDRB (28%), mainly ESBL-E but no carbapenemase-producing Enterobacteriaceae and vancomycin-resistant Enterococcus faecium were identified. Forty-five patients had lesion sample collection, and 28/45 had a positive culture. The most frequently isolated pathogens were Enterobacter cloacae, Pseudomonas aeruginosa, and Escherichia coli. For eight patients, a MDRB was isolated from the wound, mainly ESBL-E (7/8) but also one methicillin-resistant Staphylococcus aureus and one imipenem-resistant Acinetobacter baumannii. Among ESBL-E, the PCR evidenced the high prevalence of CTX-M15 enzymes. Rep-PCR performed on the 23 ESBL-producing E. coli isolates highlighted numerous profiles. CONCLUSIONS: Controlling the spread of ESBL-E is currently challenging for French Armed Forces. Despite any evidence of an epidemic clone, a high-level compliance with hygiene precautions is required throughout the chain of care to avoid cross contamination.

Hepatocellular carcinoma in a patient with congenital porto-systemic shunt.

Congenital porto-caval shunt is a rare anomaly that can result in direct shunt-related complications (encephalopathy, pulmonary hypertension) or indirect complications such as the development of benign or malignant hepatic neoplasms. Treatment consists of management of the complications and occlusion of the porto-caval shunt in one or two stages by either a surgical or an interventional radiology approach.

Management of a cornual ectopic pregnancy.

Cornual pregnancy is rare. Treatment involves expulsion of the pregnancy and hemostasis of the cornus if required by hemorrhagic rupture. Two techniques are proposed to achieve hemostasis of the uterine cornus, cornuotomy with suture, or corneal resection with salpingectomy, generally laparoscopically.

Triage in military settings.

Triage, a medical term derived from the French word "trier", is the practical process of sorting casualties to rationally allocate limited resources. In combat settings with limited medical resources and long transportation times, triage is challenging since the objectives are to avoid overcrowding medical treatment facilities while saving a maximum of soldiers and to get as many of them back into action as possible. The new face of modern warfare, asymmetric and non-conventional, has led to the integrative evolution of triage into the theatre of operations. This article defines different triage scores and algorithms currently implemented in military settings. The discrepancies associated with these military triage systems are highlighted. The assessment of combat casualty severity requires several scores and each nation adopts different systems for triage on the battlefield with the same aim of quickly identifying those combat casualties requiring lifesaving and damage control resuscitation procedures. Other areas of interest for triage in military settings are discussed, including predicting the need for massive transfusion, haemodynamic parameters and ultrasound exploration.

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.

Damage control: Concept and implementation.

The concept of damage control (DC) is based on a sequential therapeutic strategy that favors physiological restoration over anatomical repair in patients presenting acutely with hemorrhagic trauma. Initially described as damage control surgery (DCS) for war-wounded patients with abdominal penetrating hemorrhagic trauma, this concept is articulated in three steps: surgical control of lesions (hemostasis, sealing of intestinal spillage), physiological restoration, then surgery for definitive repair. This concept was quickly adapted for intensive care management under the name damage control resuscitation (DCR), which refers to the modalities of hospital resuscitation carried out in patients suffering from traumatic hemorrhagic shock within the context of DCS. It is based mainly on specific hemodynamic resuscitation targets associated with early and aggressive hemostasis aimed at prevention or correction of the lethal triad of hypothermia, acidosis and coagulation disorders. Concomitant integration of resuscitation and surgery from the moment of admission has led to the concept of an integrated DCR-DCS approach, which enables initiation of hemostatic resuscitation upon arrival of the injured person, improving the patient's physiological status during surgery without delaying surgery. This concept of DC is constantly evolving; it stresses management of the injured person as early as possible, in order to initiate hemorrhage control and hemostatic resuscitation as soon as possible, evolving into a concept of remote DCR (RDCR), and also extended to diagnostic and therapeutic radiological management under the name of radiological DC (DCRad). DCS is applied only to the most seriously traumatized patients, or in situations of massive influx of injured persons, as its universal application could lead to a significant and unnecessary excess-morbidity to injured patients who could and should undergo definitive treatment from the outset. DCS, when correctly applied, significantly improves the survival rate of war-wounded.

Gastrointestinal stenting: Current status and imaging features.

The use of stents in the gastrointestinal tract has been subjected to major changes. Initially, the use of stents was restricted to malignant strictures in patients with metastatic disease. But thanks to reduction of the morbidity and mortality rates, they are now used with curative intention and in patients with benign diseases after careful selection. However, for patients presenting with colon obstruction due to an advanced colon carcinoma, the mortality and morbidity are still high. The purpose of this review is to provide an overview of indications, techniques and further developments of the stents in the gastrointestinal tract and to highlight the predominant role of multidetector row computed tomography (MDCT) in the detection of potential complications.

[Hypothenar hammer syndrome: case report and review of the literature]. / Syndrome du marteau hypothénarien : cas clinique et revue de la littérature.

INTRODUCTION: Hypothenar hammer syndrome is a rare cause of upper extremity digital ischemia or Raynaud phenomenon, a diagnosis which should be considered in cases of iterative palmar trauma. Its treatment can be medical or surgical and should not suffer any delay. The best options remain controversial. METHODS: A 65-year-old patient presented with an ischemia of the last three fingers of the left hand. A partially thrombosed aneurysm of the left ulnar artery was diagnosed at imaging. After a partially effective medical treatment, a surgical treatment was performed with resection of the aneurysm and a vascular reconstruction with an autologous vein graft. The postoperative course was uneventful with disappearance of the symptoms and revascularization of the hypothenar area. CONCLUSION: Appropriate treatment for hypothenar hammer syndrome is controversial but whould always begin with medical care. The decision to perform surgery should be based on evidence of ulnar artery lesions and the associated symptoms.