Pancreaticoduodenal artery aneurysms due to median arcuate ligament syndrome: what we need to know.

Median arcuate ligament (MAL) syndrome is a rare and poorly known cause of abdominal pain. MAL narrows the celiac artery (CA), resulting in true distal aneurysms, including pancreaticoduodenal artery (PDA) aneurysms. These aneurysms often have an aggressive course, as rupture can result in hemorrhagic shock. CT scan appears to be the most effective investigation for the diagnosis of PDA aneurysms and may reveal possible celiac artery compression. In this series, we describe four cases of PDA aneurysm: two ruptured aneurysms treated by an endovascular procedure and two non-ruptured aneurysms treated by surgery. It was also decided to treat CA stenosis in three of the four patients based on the clinical presentation (ruptured or non-ruptured) and the presence of peripancreatic collateral vessels on imaging. This strategy contrasts with the approach commonly reported in the literature, in which MAL section is mandatory due to the high risk of ischemia rather than the potential risk of recurrent aneurysm. Medical teams should be aware of this disease to improve diagnosis and patient management.

Posterior urethral injuries associated with pelvic injuries in young adults: computerized finite element model creation and application to improve knowledge and prevention of these lesions.

INTRODUCTION: Young adult males involved in motorcycle accidents are particularly at risk for posterior urethral injury whenever pelvic injury occurs. Posterior urethral injuries remain problematic because their diagnosis may be missed, and during the initial treatment response the urethral injury can be aggravated by urethral catheterization. Few anatomical and clinical tools exist that establish a correlation between injuries and fractures of the pelvic ring and the risk of posterior urethral injury. METHOD: Based on experience with traffic accident modeling, a computerized finite element model was conceived integrating the specific anatomic structures concerned. This model was extrapolated from a CAT scan of a young adult. The anatomic structures concerned in urethral and pelvic ring trauma (PRT) were isolated, placed in 3D and given biomechanical properties. The model was verified according to available experiments on PRT. RESULTS: To apply the model, we recreated a lateral impact mechanism on the pelvic ring. Stretching between the prostatic and membranous portions of the urethra (before and after visualization of a pelvic fracture) as well as timing of injury was studied. CONCLUSION: The model's application permitted us to analyze precisely the link between lateral impact trauma of the pelvic ring and lesions of the posterior urethra and to identify an urethra stretching prior to visualization of a pelvic fracture. Utilization of the model with other mechanisms of injury should allow for better comprehension of this associated trauma, improved prevention, iatrogenic aggravation of, and care for, these serious injuries.

Necrotizing fasciitis of the abdominal wall following an emergency colostomy: a case report.

Necrotizing soft-tissue infections (NSTIs) are acute surgical conditions that demand prompt and multi-faceted treatment. Early recognition, appropriate resuscitation measures, aggressive surgical debridement, and targeted antimicrobial therapy significantly affect the overall outcome and survival of NSTI patients. Necrotizing fasciitis refers to a particular type of NSTI, where necrosis of the skin, subcutaneous tissue and fascia is predominant and there is very little muscle involvement. A 51-year-old woman presented with necrotizing fasciitis of the abdominal wall following colostomy for obstructive colon carcinoma. In this particular case, stoma relocation was necessary because of the need for large parietal surgical debridement.

Arterial grafts for proper palmar digital artery reconstruction: An anatomical study.

Digital ischemia due to arterial defects need urgent surgical management. The traditional treatment consists of vascular reconstruction using a reversed autologous venous graft as a bypass. Very few studies have described the use of arterial grafts for digital artery reconstruction. This cadaver study characterized the forearm perforator arteries to assess the potential feasibility of using them as donor grafts for digital artery reconstruction. Eleven forearms and twenty hands were dissected from freshly injected cadavers. All clinically significant perforators (>0.5 mm) derived from radial or ulnar arteries and digital arteries were evaluated. The digital palmar arteries were measured at three points: metacarpophalangeal (MCP) joint, proximal interphalangeal (PIP) joint, and distal interphalangeal (PIP) joint. In the 11 forearms analyzed, 5.5 ± 1.3 perforators from radial or ulnar arteries with a diameter of at least 0.5 mm were found per dissection. The mean diameters were 0.9 ± 0.18 mm proximally and 0.8 ± 0.15 mm distally; the mean length was 35.6 ± 11.35 mm. The mean diameters for the dominant and non-dominant arteries were 1.5 and 1.3 mm at the MCP, 1.3 and 1.0 mm at the PIP, 0.8 and 0.7 mm at the DIP, respectively. The forearms are good donor sites as they have large-diameter arteries of suitable length for arterial grafting. These new arterial grafts may be suitable for vascular reconstruction of digital arteries starting from the PIP joint.

Vascularization of the lateral and medial antebrachial cutaneous nerves by cutaneous perforator arteries: An anatomical study.

The forearm is an interesting donor site for non-vascularized nerve grafts, especially hand surgeons. Very few studies have described the use of the lateral and medial antebrachial cutaneous nerves (LABCN and MABCN, respectively) as vascularized nerve grafts (VNGs). The aim of this anatomical study was to analyze the characteristics and vascularization of these nerves to describe new potential donor sites for VNGs. Twelve forearms were dissected from fresh cadavers injected with red latex. The number of terminal branches, lengths, and proximal and distal diameters of both the LABCN and MABCN were studied. An anatomical description of the cutaneous perforator arteries from the radial and ulnar arteries that vascularized the nerve was also recorded: number of perforators, length, type of perforator (septo- or musculocutaneous), and location within the forearm (proximal, middle, and distal third). In over 80% of the specimens, the cutaneous perforator arteries from the radial and ulnar artery vascularized the LABCN and the MABCN, respectively. These arteries, found mostly in the proximal third of the forearm, had diameters >0.5mm. Most of them came from the radial and ulnar arteries (for LABCN and MABCN vascularization, respectively). In over 75% of the specimens, the nutrient arteries of both nerves also vascularized the superficial veins and the skin. We found that these nerves are vascularized by perforators arteries, which also participate in vein and skin vascularization. Altogether, this anatomical study shows that reconstructive surgeons could use new VNGs based on the perforator artery of the forearm.

Terrorist attack in Nice - The experience of general surgeons.

INTRODUCTION: After the attacks in Paris, France was again struck by terrorism in the city of Nice during the night of July 14, 2016. At 22:33 in the evening, a 19-ton truck drove into the crowd of holiday celebrators. The attack resulted in 458 wounded and 86 deaths. The purpose of this study was to describe the management of patients with abdominal trauma admitted alive in our institution, in the context of a massive influx of victims. MATERIAL AND METHODS: We performed a retrospective analysis of the management of adults with abdominal trauma arising from the terrorist attack in Nice. RESULTS: Among the 182 victims admitted to our trauma center, eleven patients presented with abdominal trauma. The median age was 44 years [14-63] and the median Injury Severity Score (ISS) was 34 [9-59]. Eight patients underwent urgent surgical treatment in the operating room including six for abdominal trauma. These patients were treated according to the principles of surgical damage control, albeit without the need for temporary abdominal closure or packing. Three patients could have had their lesions managed non-operatively had they been admitted outside this surge episode, which saturated the technical means of the receiving hospital. CONCLUSION: The terrorist attack that victimized the citizens of Nice resulted in the second largest number of dead of any attack on French soil. A large number of patients were admitted to the city's only center for adult trauma care. The management of these patients posed diagnostic, therapeutic and logistical problems. Increased use of pre-hospital pelvic restraint belts may help to reduce vehicular trauma. We do not feel that non-operative management of abdominal lesions can be envisaged in the context of a mass influx of victims. We recommend surgical hemostasis for patients with secondary hemorrhagic risk from visceral trauma in the context of a massive influx of victims.

Mechanical effects of load speed on the human colon.

The aim of this study was to examine the mechanical behavior of the colon using tensile tests under different loading speeds. Specimens were taken from different locations of the colonic frame from refrigerated cadavers. The specimens were submitted to uniaxial tensile tests after preconditioning using a dynamic load (1 m/s), intermediate load (10 cm/s), and quasi-static load (1 cm/s). A total of 336 specimens taken from 28 colons were tested. The stress-strain analysis for longitudinal specimens indicated a Young's modulus of 3.17 ±â€¯2.05 MPa under dynamic loading (1 m/s), 1.74 ±â€¯1.15 MPa under intermediate loading (10 cm/s), and 1.76 ±â€¯1.21 MPa under quasi-static loading (1 cm/s) with p < 0.001. For the circumferential specimen, the stress-strain curves indicated a Young's modulus of 3.15 ±â€¯1.73 MPa under dynamic loading (1 m/s), 2.14 ±â€¯1.3 MPa under intermediate loading (10 cm/s), and 0.63 ±â€¯1.25 MPa under quasi-static loading (1 cm/s) with p < 0.001. The curves reveal two types of behaviors of the colon: fast break behavior at high speed traction (1 m/s) and a lower break behavior for lower speeds (10 cm/s and 1 cm/s). The circumferential orientation required greater levels of stress and strain to obtain lesions than the longitudinal orientation. The presence of taeniae coli changed the mechanical response during low-speed loading. Colonic mechanical behavior varies with loading speeds with two different types of mechanical behavior: more fragile behavior under dynamic load and more elastic behavior for quasi-static load.

Influence of gender, age, shelf-life, and conservation method on the biomechanical behavior of colon tissue under dynamic solicitation.

BACKGROUND: Data from biomechanical tissue sample studies of the human digestive tract are highly variable. The aim of this study was to investigate 4 factors which could modify the mechanical response of human colonic specimens placed under dynamic solicitation until tissue rupture: gender, age, shelf-life and conservation method. METHODS: We performed uniaxial dynamic tests of human colonic specimens. Specimens were taken according to three different protocols: refrigerated cadavers without embalming, embalmed cadavers and fresh colonic tissue. A total of 143 specimens were subjected to tensile tests, at a speed of 1 m s-1. FINDINGS: Young's modulus of the different conservation protocols are as follows: embalmed, 3.08 ±â€¯1.99; fresh, 2.97 ±â€¯2.59; and refrigerated 3.17 ±â€¯2.05. The type of conservation does not modify the stiffness of the tissue (p = 0.26) but does modify the stress necessary for rupture (p < 0.001) and the strain required to obtain lesions of the outer layer and the inner layer (p < 0.001 and p < 0.05, respectively). Gender is also a factor responsible for a change in the mechanical response of the colon. The age of the subjects and the shelf-life of the bodies did not represent factors influencing the mechanical behavior of the colon (p > 0.05). INTERPRETATION: The mechanical response of the colon tissue showed a biphasic injury process depending on gender and method of preservation. The age and shelf-life of anatomical subjects do not alter the mechanical response of the colon.

The infraorbital artery: Clinical relevance in esthetic medicine and identification of danger zones of the midface.

BACKGROUND: Over the past decade, cosmetic injections of dermal fillers or fat have become a popular procedure in facial rejuvenation in an overconsuming society. However, complications such as arterial embolism and occlusion can occur even with experienced injectors, especially in high-risks zones namely the glabella, the nasal dorsum or the nasolabial fold. The aim of this study was to define the vascular danger zones of the infraorbital area in order to provide guidelines helping avoid them. MATERIALS AND METHODS: The infraorbital artery, its main branches and their anastomoses with neighbouring vessels were studied in 18 fresh cadavers. Mimetic injections of inked hyaluronic acid were performed in the infraorbital area in the interest of analyzing its distribution and to determine potential vascular risks towards the infraorbital artery and its branches. RESULTS: The infraorbital artery and its branches were located in common injection regions and anastomosed to the supratrochlear artery, the dorsal nasal artery and the angular artery through the nasal branch of the infraorbital artery. Two danger zones could be depicted: injections can be risky when performed too superficially in the midcheek area, and likewise risky when performed in a periosteal layer in infraorbital hollow or tear-trough correction, because of an obvious possibility of retrograde embolism. CONCLUSION: The infraorbital artery can be involved in anatomic mechanism of arterial occlusion, further blindness and stroke, among the related neighbouring arteries. Based on the findings of this study, injections to the periosteum layer in tear-trough correction and above the periosteum on the zygomatic arch is not advised.

Liver injuries in frontal crash situations a coupled numerical - experimental approach.

From clinical knowledge, it has been established that hepatic traumas frequently lead to lethal injuries. In frontal or lateral crash situations, these injuries can be induced by pure deceleration effects or blunt trauma due to belt or steering wheel impact. Concerning the liver under frontal decelerations, how could one investigate organ behaviour leading to the injury mechanisms? This work couples experimental organ decelerations measurements (with 19 tests on cadaver trunks) and finite element simulation, provides a first analysis of the liver behaviour within the abdomen. It shows the influence of the liver attachment system that leads to liver trauma and also torsion effects between the two lobes of the liver. Injury mechanisms were evaluated through the four phases of the liver kinematics under frontal impact: (1) postero-anterior translation, (2) compression and sagittal rotation, (3) rotation in the transverse plane and (4) relaxation.

Cellular and molecular events associated with the antitumor response induced by the cytosine deaminase/5-fluorocytosine suicide gene therapy system in a rat liver metastasis model.

The bacterial cytosine deaminase (CD) gene converts the non-toxic prodrug 5-fluorocytosine (5-FC) into 5-fluorouracil. We have previously shown, in a rat liver metastasis model from colon carcinoma, that intratumoral injection of a CD-expressing plasmid into the animals followed by 5-FC treatment results in the regression of the treated tumor as well as distant uninjected tumors. The aim of this study was to further analyze the mechanisms associated with tumor regression induced upon application of suicide CD/5-FC strategy. Tumor regression was associated with an increased apoptosis, the recruitment of natural killer cells, CD4- and CD8 T lymphocytes within the tumors and an increased expression of several cytokines/chemokines mRNAs. These data indicate that the CD/5-FC suicide strategy is associated with the triggering of cellular and molecular events leading to an efficient antitumor immune response involving both innate and acquired immunity.

[Pregnant woman and road safety: a numerical approach. Application to a restrained third trimester pregnant woman in frontal impact]. / Femme enceinte et accidentologie routière: intérêt de l'approche numérique. Application à un choc frontal au troisième trimestre de la grossesse avec analyse de l'effet de la ceinture de sécurité

OBJECTIVES: The goal of our work is the development of a numerical model of pregnant woman in driving position. We present an application to the study of injury mechanisms during a frontal car crash for a seat belt restrained pregnant woman in driving position. MATERIALS AND METHODS: We integrated a digital representation of a pregnant uterus, foetus and placenta in a previous existing numerical model of non pregnant Human body in driving position, the Humos model. The realization of a numerical simulation of a frontal car crash enabled us to analyze the part played by the safety belt in the organic traumatisms. RESULTS: Three phases were highlighted. The first phase consists of a translation forwards of the pregnant uterus during the impact. The second phase is a rotation forwards in the sagittal plan of the pregnant uterus with for axis of rotation the posterior wall of the pubis. The third phase is a vertical adjustment coupled to a translation of the uterus towards the back. This translation leads the uterus to impact the spine. CONCLUSION: The development of a pregnant numerical model in the field of accidentology allows the analysis of organic traumatisms. That makes it possible to study the role played by the existing safety systems. This model might make it possible to develop safety systems specific to the pregnant woman.

Cytosine deaminase/5-fluorocytosine-based vaccination against liver tumors: evidence of distant bystander effect.

BACKGROUND: The cytosine deaminase gene of Escherichia coli converts the nontoxic compound 5-fluorocytosine into 5-fluorouracil (5-FU), thereby acting as a suicide gene when introduced into cancer cells, killing the cells when they are exposed to 5-fluorocytosine. We analyzed the efficacy of using cytosine deaminase-bearing cancer cells as an autologous tumor vaccine in a rat model that mimics liver metastasis from colon carcinoma. METHODS: We introduced a plasmid vector containing the E. coli cytosine deaminase gene into a BDIX rat colon carcinoma cell line. Intrahepatic injection of the modified cells in syngeneic animals generates a single experimental liver "suicide tumor." We then analyzed the effect of 5-fluorocytosine treatment in terms of regression of cytosine deaminase-expressing cells in vivo as well as protection against wild-type cancer cells. RESULTS: Treatment with 5-fluorocytosine induced regression of cytosine deaminase-expressing (CD+) tumors, with seven of 11 treated animals being tumor free at the end of 30 days and a statistically significant difference in tumor volumes between treated and control animals (two-sided P<.0001). Intrahepatic injection of CD+ cells followed by 5-fluorocytosine treatment rendered the treated animals resistant to challenge with wild-type tumor cells, with no (zero of seven) treated animals developing wild-type tumors in contrast to all (four of four) control animals. Moreover, in animals with established wild-type liver tumors, injection of CD+ tumor cells followed by 5-fluorocytosine treatment produced a statistically significant increase in survival time (two-sided P<.0001). In vivo immunodepletion and immunohistologic analysis of experimental tumors indicate that natural killer cells are the major immune component involved in this antitumor effect. CONCLUSIONS AND IMPLICATIONS: Taken together, these results suggest the potential use of suicide gene-modified tumor cells as therapeutic vaccines against liver metastasis from colon carcinoma.

[Sternalis muscle in breast surgery]. / Le muscle sternalis: derrière quel sein se cache-t-il?

The sternalis muscle is a normal anatomic variant, which exists in about 5 to 8% of people. It runs longitudinally superficial to pectoralis major, alongside the sternum. Although the sternalis seems common in cadaveric studies, physicians are not familiar with it, which may lead to confusion in diagnosis. Occasionally, the sternalis may be misinterpreted as a breast mass on mammogramm. In that case, computed tomography and magnetic resonance imaging are useful. We report herein two cases of sternalis muscles encountered during mastectomy.

Dynamic biomechanical characterization of colon tissue according to anatomical factors.

INTRODUCTION: The aim of this study was to determine the mechanical response of colonic specimens retrieved from the entire human colon and placed under dynamic solicitation until the tissue ruptured. MATERIAL AND METHODS: Specimens were taken from 20 refrigerated cadavers from different locations of the colonic frame (ascending, transverse, descending and sigmoid colon) in two different directions (longitudinal and circumferential), with or without muscle strips (taenia coli). A total of 120 specimens were subjected to tensile tests, after preconditioning, at the speed of 1m/s. RESULTS: High-speed video analysis showed a bilayer injury process with an initial rupture of the serosa / external muscular layer followed by a second rupture of the inner layer consisting of the internal muscle / submucosa / mucosa. The mechanical response was biphasic, with a first point of initial damage followed by a complete rupture. The levels of stress and strain at the failure site were statistically greater in terms of circumferential stress (respectively 69±22% and 1.02±0.50MPa) than for longitudinal stress (respectively 55±32% and 0.70±0.34MPa). The difference between longitudinal and circumferential stress was not statistically significant (3.17±2.05MPa for longitudinal stress and 3.15±1.73MPa for circumferential stress). The location on colic frame significantly modified the mechanical response both longitudinally and circumferentially, whereas longitudinal taenia coli showed no mechanical influence. CONCLUSION: The mechanical response of the colon specimen under dynamic uniaxial solicitation showed a bilayer and biphasic injury process depending on the direction of solicitation and colic localization. Furthermore these results could be integrated into a numeric model reproducing abdominal trauma to better understand and prevent intestinal injuries.

Haematopoietic toxicity of radium-223 in patients with high skeletal tumour burden.

UNLABELLED: In patients with metastasized, castration resistant prostate cancer (mCRPC) treatment with radium-223 (Xofigo) is an attractive therapeutic option. In particular, patients with high tumour load seem to profit from this treatment in regard of survival and quality of live. Aim of this study was to stratify mCRPC patients according to a quantitative imaging marker derived from routine bone scans (EXINI bone) and analyze haematopoietic toxicity of Xofigo in these patients. PATIENTS, METHODS: Toxicity and oncologic outcome were investigated in a cohort of 14 patients with high tumour load. Additionally, based on a web survey, experience of toxicity in 41 high tumour load patients in Germany in 2014 was collected. RESULTS: In patients with a bone scan index (BSI) greater than 5, significant toxicity occurred in more patients than expected from the ALSYMPCA trial. This was associated with application of fewer cycles. Similar experiences have been made in other centers in Germany. Approximately 7% of these patients will need very long time or will not recover from grade ≥ 3 toxicity. CONCLUSION: Close follow-up of haematopoietic indices and, in case of toxicity, early termination of therapy is in particular necessary in late stage disease where limited bone marrow reserve is likely.

Treatment of hepatic metastases of colorectal cancer by electrochemotherapy: an experimental study in the rat.

BACKGROUND: Electrochemotherapy, which consist of local or systemic administration of a cytotoxic agent followed by application of electric pulses to a tumor, has proved effective for various types of tumors in animals and for cutaneous and head and neck cancers in human beings. This is the first study to investigate the efficacy of electrochemotherapy for treatment of hepatic metastases of colorectal cancer in the rat. METHODS: After induction of a solitary hepatic metastasis in 36 male BDIX rats, the animals were randomized to one of four groups: B-E-(no treatment), B+E-(intratumoral bleomycin), B-E+ (application of electric pulses to the tumor), and B+E+ (electrochemotherapy: intratumoral bleomycin followed by application of electric pulses). RESULTS: Groups B-E and B-E+ had no tumor response. Group B+E had one partial response. Group B+E+ had seven partial responses and two complete responses. The difference in terms of response between group B+E+ and the other three groups was statistically significant (P < .05). Comparison of the mean posttherapy tumor volumes (B-E-, 50.6 mm3; B+E-, 58.7 mm3; B-E+, 46 mm3; and B+E+, 5.65 mm3) revealed a significantly smaller residual tumor in group B+E+ than in the other three groups (P < .05). CONCLUSIONS: Electrochemotherapy is an effective means to reduce the volume of hepatic metastases of colorectal cancer in the rat. Additional research is required to determine the optimum treatment duration, dose effects, volume of tumor that can be treated by electrochemotherapy, and impact on survival. Such experimental studies are indispensable prerequisites for clinical trials.

Regression of experimental liver tumor after distant intra-hepatic injection of cytosine deaminase-expressing tumor cells and 5-fluorocytosine treatment.

Cytosine deaminase (CD) gene of E. coli converts the non-toxic compound 5-fluorocytosine (5-FC) into 5-fluorouracil. We have introduced a vector expressing the CD gene in a rat colon carcinoma cell line. Expression of the CD gene confers 5-FC sensitivity to these cells in vitro and in vivo. In a bifocal model consisting in a simultaneous engrafment of a CD+ tumor on one lobe of the liver and a wild-type parental tumor on the opposite lobe, treatment with 5-FC results in regression of both type of tumors, indicating the existence of a distant bystander effect.

[Endometriosis of the rectus abdominis muscles]. / Endométriose des muscles grands droits de l'abdomen.

The authors report three cases of endometriosis of the rectus abdominis muscle, presenting as a mass of the abdominal wall associated with pain during menstruation in women with a history of cesarean section. Treatment consisted in wide surgical resection followed by prosthetic abdominal wall repair in one recurrent case. Abdominal wall endometriosis is a rare disease that can be explained by grafting of endometrial cells to the abdominal wall during laparotomy for pelvic surgery, particularly cesarean section. Isolation of the abdominal wall during cesarean section and irrigation of the abdominal wall at the end of the operation are two theoretical measures designed to prevent endometrial cell engraftment. When abdominal wall endometriosis occurs, only radical surgical resection can prevent recurrence.

[Colostomy vs self-expanding metallic stents: comparison of the two techniques in acute tumoral left colonic obstruction]. / Colostomie de décharge vs endoprothèse colique autoexpansive: comparaison des deux techniques dans l'occlusion colique gauche aiguë par obstacle tumoral.

UNLABELLED: Self-expanding metallic stents is an alternative treatment to colostomy that is the treatment of choice in acute tumoral left colonic obstruction. AIM OF THE STUDY: To compare morbidity, mortality, length of hospital stay and treatment performed after desobstruction using the two methods. PATIENTS AND METHODS: Thirty-three patients admitted for acute obstruction of the left colon were retrospectively separated in two groups depending on the type of intervention performed to treat the obstruction ("colostomy" group: 17 patients and "self-expanding stent group": 16 patients). We studied complications after desobstruction, hospital courses and surgical strategy performed after the acute phase. RESULTS: Time between desobstruction and colectomy was shorter in the "self-expanding stent group" than in the "colostomy group" (18.5 days versus 73 days). Age superior than 75 years and colostomy were the two main factors predicting the risk of definitive colostomy (P < 0.05). Global mean hospital stay was longer in the colostomy group (32.7 days versus 19.3 days, P = 0.02). Two perforations and one local recurrence occurred in the "self-expanding stent group". CONCLUSIONS: Self-expanding metallic stent can decrease the permanent colostomy rate and the number of interventions. The recurrence rate seems to be theoretically increased with the stenting method. Then, colostomy must be done for patients in curative situation. The self-expanding metallic stent should be used as a palliative care.