Dynamic analysis of commonly used biochemical parameters to predict common bile duct stones in patients undergoing laparoscopic cholecystectomy.

BACKGROUND: The prediction of persistent common bile duct stones (CBDS) in patients during choledocholithiasis crisis is challenging. We developed a model based on the course over time of commonly used biochemical parameters to reduce the rate of unnecessary endoscopic cholangiopancreatography (ERCP) and the risk of perioperative discovery of CBDS. METHODS: Medical charts of patients who presented between 2010 and 2015 for symptomatic gallstone disease with suspected choledocholithiasis were reviewed and compared according to the presence/absence of CBDS on preoperative ERCP or during cholecystectomy. RESULTS: 210 patients were included. Unnecessary ERCP and the discovery rate of CBDS were 9.0 and 22.4%, respectively. Multivariate analysis demonstrated age ≥80 years, neutrophils ≥12000/µL and gamma-glutamyl transpeptidase (GGT) ≥300 units/L at admission, alkaline phosphatase ≥180 units/L at days 3-5 post admission, and a decrease in C-reactive protein ≤10%, aspartate aminotransferase ≤35%, GGT ≤25%, and total bilirubin ≤15% between day 0 and days 3-5 to be predictive of CBDS. The area under the receiver-operator characteristic curve was 0.881. When used to select patients for preoperative ERCP, diagnostic accuracy was 94.8% when three predictors were present. Negative and positive predictive values were 100% in the absence of predictors and when five predictors were present, respectively. Unnecessary ERCP and CBDS discovery rates both decreased to 2.6%. CONCLUSIONS: Commonly used biochemical parameters correctly predict CBDS when they are analysed in a dynamic setting rather than at discrete time points. The proposed model constitutes a reliable tool to decrease unnecessary ERCP and perioperative discovery rates of CBDS.

Predictive factors of severe complications for ampullary, bile duct and duodenal cancers following pancreaticoduodenectomy: Multivariate analysis of a 10-year multicentre retrospective series.

BACKGROUND: Postoperative outcomes following pancreaticoduodenectomy are well described for pancreatic cancers. Due to a lower incidence rate, complication rates and relative predictive factors are less detailed for ampullary, bile duct and duodenal cancers. METHODS: Medical charts of patients operated on between 2001 and 2011 for an ampullary, bile duct or duodenal cancer were reviewed. Data were retrospectively studied with respect to demographics, surgical management, postoperative complications and histological findings. Specific complication rates were reported, and predictive factors for severe morbidity and mortality were determined by multivariate analysis. RESULTS: 135 patients were identified: 55 ampullary, 55 bile duct and 25 duodenal cancers. Twelve patients (8.9%) deceased postoperatively, and 36 others (26.7%) presented severe complications. Sixty-seven percent of the pancreas was soft, and pancreatic hardness was found to be the main protective factor against severe morbidity (HR = 0.36, 95% CI = 0.14-0.94, P = 0.037). Age and postpancreatectomy haemorrhage were independent predictors for death (HR = 14.63, 95% CI = 1.57-135.77, P = 0.018, and HR = 14.71, 95% CI = 2.86-75.62, P = 0.001, respectively). Only the use of an external transanastomotic duct stent significantly reduced both the morbidity (HR = 0.37, 95% CI = 0.16-0.83, P = 0.016), and the mortality (HR = 0.12, 95% CI = 0.02-0.69, P = 0.017). CONCLUSIONS: Pancreaticoduodenectomy for ampullary, bile duct and duodenal cancers is a high-risk procedure. The systematic use of transanastomotic duct stents would significantly decrease the complication rate. Older patients should beneficiate from specific preoperative evaluation using an adapted index. Omental flap techniques to prevent a postpancreatectomy haemorrhage should be efficient. Effects of preoperative octreotid to harden the pancreas should be clarified.

Three-dimensional variability of the mesentery and the superior mesenteric artery: application to virtual trauma modeling.

INTRODUCTION: Trauma is a major cause of death worldwide, mainly affecting a young male population. Blunt trauma of the abdomen can cause a trauma of the mesentery in 5 % of cases. Rapid decelerations and injuries by seat belts are the most common pathophysiological mechanisms. Three-dimensional anatomical scanning of the mesentery and gastrointestinal tract is the first essential step in modeling abdominal trauma in an attempt to understand the pathophysiology of mesenteric lesions and to improve the safety features of vehicles. OBJECTIVE OF THE STUDY: To analyze the individual variability of the mesentery and the superior mesenteric artery (SMA) from medical imaging and to develop a three-dimensional customizable finite element model. MATERIALS AND METHODS: In this retrospective study, one hundred abdominopelvic injected CT scans were analyzed from healthy patients. The evaluation criteria of the mesentery were its volume (total and the distribution of adipose tissue/non adipose tissue), the length of the SMA and the distance between duodenojejunal angle (DJA) and the ileocecal junction (ICJ). The variability of these measures has been studied by demographic (age and gender) and morphologic (height evaluated by the T11-L4 distance, the waist circumference and the thickness of the subcutaneous adipose tissue). RESULTS: Mean mesenteric volume was 644 cm(3) (ranges from 89 to 1,869 cm(3)), and the mean length of the SMA was 224.9 mm (ranges from 138.4 to 312.3). There was a statistically significant association between waist circumference and the total volume of the mesentery, its fat component and non fat component (p < 0.001). Waist circumference was the only morphological parameter associated with the length of the superior mesenteric artery and the length of the DJA to ICJ (p < 0.001). Subcutaneous adipose tissue and female sex were statistically associated with total mesentery volume (respectively, p = 0.005 and p = 0.001). Age was an independent predictor of the increased volume of the mesentery and the length of the SMA. The height of the subject changes the length of the SMA (p = 0.001). CONCLUSION: The assessment of the mesenteric variability highlighted three factors associated with its size and length: age, sex, and waist circumference. These parameters have to be taken into account to personalize numerical model in the area of virtual trauma.

Three-dimensional determination of variability in colon anatomy: applications for numerical modeling of the intestine.

BACKGROUND: Precise knowledge of variability in colonic anatomy is of great importance for numerical modeling studies of the abdomen. This knowledge would allow the creation of personalized models for the gastrointestinal tract used for surgical simulations or in studies of virtual trauma. MATERIALS AND METHODS: To determine the colonic configuration in the general population and define its variability by gender, age, and corpulence, the layout of the colon was determined via the following reference points: ileocecal junction, left and right colonic flexures, and colosigmoid junction (CSJ). Three-dimensional coordinates for each point were recorded on scanned sections of 100 healthy adults to examine the colonic layout under physiological conditions. Coordinates were repositioned in a new anatomical reference for comparison. The average points' coordinates, standard deviations, and distances between them were compared for each group. RESULTS: The right colonic flexure was the most variable point. The CSJ was the least variable. Gender affected mainly the height of the colonic flexures and the length of its segments. Age affected the length of the transverse mesocolon root. Corpulence affected both the position of the ileocecal and CSJs and the length of the right colon. Differences in size and perivisceral fat distribution between groups explained these differences. Three-dimensional anatomical models of the colon were defined for each group by statistical equations. CONCLUSION: These equations, combined with data concerning the actual lengths of the colonic segments, enable reconstruction of different anatomical models of the colon that are representative according to gender, age, and corpulence.

Emergency department thoracotomy in a physician-staffed trauma system: the experience of a French Military level-1 trauma center.

PURPOSE: To investigate survival after emergency department thoracotomy (EDT) in a physician-staffed emergency medicine system. METHODS: This single-center retrospective study included all in extremis trauma patients who underwent EDT between 2013 and 2021 in a military level 1 trauma center. CPR time exceeding 15 minutes for penetrating trauma of 10 minutes for blunt trauma, and identified head injury were the exclusion criteria. RESULTS: Thirty patients (73% male, 22/30) with a median age of 42 y/o [27-64], who presented mostly with polytrauma (60%, 18/30), blunt trauma (60%, 18/30), and severe chest trauma with a median AIS of 4 3-5 underwent EDT. Mean prehospital time was 58 min (4-73). On admission, the mean ISS was 41 29-50, and 53% (16/30) of patients had lost all signs of life (SOL) before EDT. On initial work-up, Hb was 9.6 g/dL [7.0-11.1], INR was 2.5 [1.7-3.2], pH was 7.0 [6.8-7.1], and lactate level was 11.1 [7.0-13.1] mmol/L. Survival rates at 24 h and 90 days after penetrating versus blunt trauma were 58 and 41% versus 16 and 6%, respectively. If SOL were present initially, these values were 100 and 80% versus 22 and 11%. CONCLUSION: Among in extremis patients supported in a physician-staffed emergency medicine system, implementation of a trauma protocol with EDT resulted in overall survival rates of 33% at 24 h and 20% at 90 days. Best survival was observed for penetrating trauma or in the presence of SOL on admission.

[Management of testicular torsion by a general surgeon isolated in Africa]. / Prise en charge de la torsion du testicule par un chirurgien généraliste isolé en Afrique.

The onset of sudden and intense scrotal pain exposes to several problems when it occurs in a young man in Africa. Among the possible etiologies, testicular torsion is the surgical emergency to rule out, because beyond 6 hours of evolution the functional prognosis of the testicle is concerned. The septic evolution towards a purulent melting, in case of exceeded torsion, is also possible. Of slightly lower incidence than in Western countries, lack of awareness of this pathology by local health actors, the precariousness or health isolation of certain populations in certain under-medicalized regions, contribute to diagnostic and therapeutic delays. This often leads to a pejorative development, loss of the testicle being directly correlated with the delay in treatment. Testicular torsion has thus been identified as one of the main causes of male infertility in Africa. However, clinical diagnosis and surgical treatment require few resources and remain accessible in an environment with low resources or in precarious conditions. Indeed, despite the contribution of ultrasound in certain situations, the clinical picture is at the center of the diagnosis and therapeutic decision making. At the slightest doubt, surgical exploration is necessary. The multi-tunic anatomy of the testicle facilitates its surgical fixation in the event of conservation, ideally by triangulation of single-strand non-absorbable thread. Simultaneous fixation of the contralateral testicle is currently the subject of debate in the literature. In Africa, the benefit/risk balance, taking into account in particular the difficulty of subsequent access to care, justifies, from our point of view, performing contralateral orchidopexy at the same time. Depending on the appearance of the testicle and, to a lesser extent, the duration of the evolution of the symptoms, orchidectomy may be necessary. This article describes the clinical picture of spermatic cord torsion and the orchidopexy technique.

Accidental section of the ulnar nerve in the wrist during arthroscopy.

Arthroscopy of the wrist is a frequently performed procedure. Its role in diagnosis and treatment is significant. The complications of arthroscopy are well known and are described in the literature. We describe a case of accidental section of the ulnar nerve during repair of the triangular fibrocartilage complex during arthroscopy. The nerve section was caused by the trocar used for drainage in the 6U portal. We propose to establish the injury mechanism and describe a safe procedure for this examination.

Early versus delayed cholecystectomy for cholecystitis at high risk of operative difficulties: A propensity score-matching analysis.

BACKGROUND: Numerous studies have demonstrated the superiority of early (EC) over delayed (DC) cholecystectomy for acute cholecystitis (AC). However, none have assessed the effect of operative difficulty when reporting on treatment outcomes. METHODS: Outcomes of patients who underwent EC or DC between 2010 and 2019 were compared taking into account the operative difficulty evaluated by the Difficult Laparoscopic Cholecystectomy score (DiLC). For each patient, the DiLC score was retrospectively calculated and corresponded to the foreseeable operative difficulty measured on admission for AC. A propensity score was used to account for confounders. Primary endpoints were the length of stay (LOS) and the occurrence of a serious operative/post-operative event (SOE). RESULTS: DC in patients with DiLC≥10 reduced the risk of SOE without increasing the LOS. Conversely, DC in patients with DiLC<10 increased the LOS without improving outcomes. Multivariate analysis found EC in patients with DiLC≥10 as the main independent predictor of SOE. CONCLUSIONS: Provided prospective validation, DC for AC in patients with DiLC≥10 seems safer than EC and is not hospital-stay consuming.

Closed Cyst Resection for Liver Hydatid Disease: a New Standard.

BACKGROUND: Although radical resections are recommended for the surgical management of liver hydatid disease (LHD), whether closed (CCR) or opened (OCR) cyst resections should be performed remains unclear. The aim of this study was to compare the postoperative and long-term outcomes of CCR and OCR for primary and recurrent LHD. MATERIALS AND METHODS: Medical charts of patients who underwent surgery at a single centre were retrospectively reviewed and compared with respect to major postoperative complications and recurrence rates. RESULTS: Seventy-nine CCRs and 37 OCRs were included. The major morbidity rates were 19% and 5% in the OCR and CCR groups, respectively (P = 0.036). In multivariate analysis, OCR (P = 0.030, OR = 5.37) and the operative time (P < 0.001, OR = 18.88) were the only independent predictors of major complications. The 5-year and 10-year recurrence rates were both 0% in the CCR group compared to 18% and 27%, respectively, in the OCR group (P < 0.001). The mean time to recurrence was 10.5 (± 8) years. DISCUSSION: Closed cyst resection for LHD is a safe and effective approach with a low risk of recurrence. Considering that recurrence could appear more than 10 years after surgery, follow-up of patients should be adapted.

Role of Cancer Surgery in the Improvement of the Operative Skills of Military Surgeons During Deployment: A Single-Center Study.

INTRODUCTION: The maintenance of military surgeons' operative skills is challenging. Different and specific training strategies have been implemented in this context; however, little has been evaluated with regard to their effectiveness. Cancer surgery is a part of military surgeons' activities in their home hospitals. This study aimed to assess the role of oncological surgery in the improvement of military surgeons' operative skills. METHODS: Between January and June 2019, the surgical activities of the departments of visceral, ear, nose, and throat, urological, and thoracic surgery were retrospectively reviewed and assessed in terms of the operative time (OT). All surgeons working at the Sainte Anne Military Teaching Hospital were sent a survey to rate on a 5-point scale the current surgical practices on their usefulness in improving surgical skills required for treating war injuries during deployment (primary endpoint) and to compare on a 10-point visual analog scale the influence of cancer surgery and specific training on surgical fluency (secondary endpoint). RESULTS: Over the study period, 2,571 hours of OT was analyzed. Oncological surgery represented 52.5% of the surgical activity and almost 1,350 hours of cumulative OT. Considering the primary endpoint, the mean rating allocated to cancer surgery was 4.53 ± 0.84, which was not statistically different than that allocated to trauma surgery (4.42 ± 1.02, P = 0.98) but higher than other surgery (2.47 ± 1.00, P < 0.001). Considering the secondary endpoint, cancer surgery was rated higher than specific training by all surgeons, without statistically significant difference (positive mean score of + 2.00; 95% IC: 0.85-3.14). CONCLUSION: This study demonstrates the usefulness of cancer surgery in improving the operative skills of military surgeons.

Disease-free survival following resection in non-ductal periampullary cancers: A retrospective multicenter analysis.

BACKGROUND: Predictors of recurrence following pancreaticoduodenectomy are well described for ductal periampullary cancers but lack reliability for non-ductal tumors. The purpose of this study is to analyze the disease-free survival (DFS) and to define the predictors of recurrence following resection for ampullary (AC), bile duct (BDC) and duodenal cancers (DC). MATERIALS AND METHODS: Clinico-pathological data of patients operated on between 2001 and 2011 were retrospectively reviewed. The effect of lymphatic invasion was specified using the lymph node ratio (LNR) and the number of positive nodes (NPN), with thresholds calculated with the likelihood ratio. Kaplan-Meier disease-free survival (DFS) curves were compared for all covariates by a log-rank test. Multivariate logistic regression analyses were performed to identify predictors of recurrence. RESULTS: 135 patients were identified. Mean follow-up was 49 ± 35 months. Median DFS was not reached for AC and was 36 and 18 months for DC and BDC, respectively. Five-year DFS was 52%, 43% and 32% for AC, DC and BDC, respectively. Predictors of recurrence were T4 tumors, neural invasion and preoperative biliary drainage for DC, ≥3 positive nodes and ≥4% loss of BMI for AC, and T3-T4 tumors for BDC. CONCLUSION: Loss of BMI ≥4% is a strong predictor of recurrence in AC, and the recurrence risk increases with the total number of lymph nodes invaded (0; 1-3; ≥4). Only T stage influences recurrence for BDC. Considering DC, the adverse effect of preoperative biliary drainage should be validated in randomized series.

How to predict difficult laparoscopic cholecystectomy? Proposal for a simple preoperative scoring system.

BACKGROUND: Few studies have used operative time as a reflection of the surgical difficulty to create a preoperative score of operative difficulty in laparoscopic cholecystectomies (DiLCs score). METHODS: Patients who benefited from cholecystectomy between 2010 and 2015 were reviewed. Difficult procedures were identified using the deviations from the operative time for simple cholecystectomies. Logistic regression analyses were carried out to build risk-assessment models and derive the DiLC score. RESULTS: Overall, 644 patients were identified. Multivariate analyses identified male sex, previous cholecystitis attack, fibrinogen, neutrophil, and alkaline phosphatase count to be predictive of operative difficulties. Risk-assessment model was generated with an area under the receiver-operator curve of .80. Internal validation was performed using the bootstrap method. CONCLUSIONS: The DiLC score is a simple and reliable tool which could be used to improve patient counseling, optimize surgical planning, detect procedures at risk, identify patients eligible for outpatient care, and enhance resident training.

Predictors of Survival in Ampullary, Bile Duct and Duodenal Cancers Following Pancreaticoduodenectomy: a 10-Year Multicentre Analysis.

INTRODUCTION: Predictors of survival following pancreaticoduodenectomy (PD) are well described for pancreatic cancers but are less detailed in ampullary (AC), bile duct (BDC) and duodenal cancers (DC). We therefore sought to evaluate the long-term results of PD for AC, BDC and DC, and to determine for each tumour the predictive factors of survival. METHODS: Medical charts of patients operated on between 2001 and 2011 were retrospectively reviewed. Univariate and multivariate analyses were performed to determine predictors of survival. RESULTS: One hundred thirty-five patients were identified. Mean follow-up was 47 ± 33 months. Median survival was not reached for DC and was 66 and 24 months for AC and BDC, respectively. Two-year and five-year survival rates were 80 and 51% for DC and 69 and 51% for AC, respectively. BDC had a significantly poorer prognosis, with two-year and five-year survival rates of 51 and 34%, respectively. Predictors of survival were weight loss, N stage and International Union Against Cancer (UICC) stage for AC, T stage and resection margin status for BDC and N stage for DC. CONCLUSION: AC, BDC and DC display distinctive predictors of survival related to the biological aggressiveness. Preoperative malnutrition worsens the prognosis. The effect of adapted nutritional management on the survival improvement has to be studied.

Surgical proctologic emergency in isolated sea-based environment: how it is performed in the French navy.

Proctologic emergency are very common and are a true challenge for a general practitioner (GP) in a sea-based environment. Performing simple surgical procedures could be essential for the management of these patients. Thrombosed external hemorrhoids are very painful and necessitate the extraction of the blood clot under local anesthesia. The perianal abscess and the pilonidal abscess are also painful entities and represent a significant septic risk. The surgical management of the latter two is simple but requires general anesthesia. Using ketamine and midazolam with these procedures offers a very high level of anesthetic safety. This short article describes the mentioned procedures that are richly illustrated.

Duodenal gastrointestinal stromal tumors (GISTs): arguments for conservative surgery.

INTRODUCTION: Gastrointestinal stromal tumors (GISTs) of the duodenum are rare. We sought to evaluate the postoperative courses and long-term outcomes of conservative surgery (CS) versus pancreaticoduodenectomy (PD) for patients with non-metastatic duodenal GISTs. METHODS: Seventeen patients underwent surgery for duodenal GISTs between January 2000 and January 2012; 11 patients underwent CS (CS group), and six patients underwent a PD (PD group). RESULTS: Mortality was similar between the two groups. Patients in the PD group had longer operative times, more tumors located on the pancreatic side of the duodenum, higher rates of post-operative complications including postoperative pancreatic fistulas, and a longer hospital stay, when compared with patients of CS group. All tumors were resected with clear surgical margins (R0 resection). The median disease-free survival times were not different. CONCLUSION: CS was safe and provided similar oncologic outcomes as PD. CS should be the procedure of choice in patients with GIST that does not involve the pancreatic side of the duodenum.