Risk factors for severe morbidity and definitive stoma after elective surgery for sigmoid diverticulitis: a multicenter national cohort study.

BACKGROUND: In the decision to perform elective surgery, it is of great interest to have data about the outcomes of surgery to individualize patients who could safely undergo sigmoid resection. The aim of this study was to provide information on the outcomes of elective sigmoid resection for sigmoid diverticular disease (SDD) at a national level. METHODS: All consecutive patients who had elective surgery for SDD (2010-2021) were included in this retrospective, multicenter, cohort study. Patients were identified from institutional review board-approved databases in French member centers of the French Surgical Association. The endpoints of the study were the early and the long-term postoperative outcomes and an evaluation of the risk factors for 90-day severe postoperative morbidity and a definitive stoma after an elective sigmoidectomy for SDD. RESULTS: In total, 4617 patients were included. The median [IQR] age was 61 [18.0;100] years, the mean ± SD body mass index (BMI) was 26.8 ± 4 kg/m2, and 2310 (50%) were men. The indications for surgery were complicated diverticulitis in 50% and smoldering diverticulitis in 47.4%. The procedures were performed laparoscopically for 88% and with an anastomosis for 83.8%. The severe complication rate on postoperative day 90 was 11.7%, with a risk of anastomotic leakage of 4.7%. The independent risk factors in multivariate analysis were an American Society of Anesthesiologists (ASA) score ≥ 3, an open approach, and perioperative blood transfusion. Age, perioperative blood transfusion, and Hartmann's procedure were the three independent risk factors for a permanent stoma. CONCLUSIONS: This series provides a real-life picture of elective sigmoidectomy for SDD at a national level. TRIAL REGISTRATION: Comité National Information et Liberté (CNIL) (n°920361).

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.

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.

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.

[Lymphedema of the lower limbs: Initial manifestation of gastric linitis plastica]. / Lymphœdème des membres inférieurs révélant une linite gastrique.

BACKGROUND: Primary lymphedemas are constitutional abnormalities of the lymphatic system. Secondary lymphedemas occur after damage to the lymphatic system, mainly after cancer treatments or tumour mass compression. There are many other causes, including filariasis, which is nonetheless very rare in France. PATIENTS AND METHODS: A 52-year-old man presented with a two-month history of increased size of the left leg. He was asymptomatic and in good general condition. Clinical examination revealed non-pitting lymphedema and ipsilateral hydrocele without loco-regional compressive lymph node. Initial extensive explorations were unremarkable. Lymphoscintigraphy revealed low tracer fixation in the left leg. The symptoms continued to worsen, with exacerbation and bilateralization of the lymphedema. Two months later, axillary lymph nodes appeared corresponding to metastasis from a signet-ring cell carcinoma. Despite two lines of chemotherapy, the patient died 8 months later due to multiple metastatic disease. DISCUSSION: Our case is remarkable because the lymphedema was not related to extrinsic compression and was the first symptom of gastric cancer. In the absence of compression, endo-lymphatic micro-metastases could constitute the causative process. Acquired lymphedema of the lower limbs must be recognized as a potential early symptom of gastric carcinoma and should therefore prompt further investigations.

Feasibility of selective non-operative management for penetrating abdominal trauma in France.

INTRODUCTION: In France, non-operative management (NOM) is not the widely accepted treatment for penetrating wounds. The aim of our study was to evaluate the feasibility of NOM for the treatment of penetrating abdominal traumas at 3 hospitals in the Southeast of France. METHODOLOGY: Our study was multicentric and retroprospective from January, 2010 to September, 2013. Patients presenting with a penetrating abdominal stab wound (SW) or gunshot wound (GSW) were included in the study. Those with signs of acute abdomen or hemodynamic instability had immediate surgery. Patients who were hemodynamically stable had a CT scan with contrast. If no intra-abdominal injury requiring surgery was evident, patients were observed. Criteria evaluated were failed NOM and its morbidity, rate of non-therapeutic procedures (NTP) and their morbidity, length of hospital stay and cost analysis. RESULTS: One hundred patients were included in the study. One patient died at admission. Twenty-seven were selected for NOM (20 SW and 7 GSW). Morbidity rate was 18%. Failure rate was 7.4% (2 patients) and there were no mortality. Seventy-two patients required operation of which 22 were NTP. In this sub-group, the morbidity rate was 9%. There were no mortality. Median length of hospital stay was 4 days for the NOM group and 5.5 days for group requiring surgery. Cost analysis showed an economic advantage to NOM. CONCLUSION: Implementation of NOM of penetrating trauma is feasible and safe in France. Indications may be extended even for some GSW. Clinical criteria are clearly defined but CT scan criteria should be better described to improve patient selection. NOM reduced costs and length of hospital stay.

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.

Abbreviated laparotomy or damage control laparotomy: Why, when and how to do it?

The goal of abbreviated laparotomy is to treat severely injured patients whose condition requires an immediate surgical operation but for whom a prolonged procedure would worsen physiological impairment and metabolic failure. Indeed, in severely injured patients, blood loss and tissue injuries enhance the onset of the "bloody vicious circle", triggered by the triad of acidosis-hypothermia-coagulopathy. Abbreviated laparotomy is a surgical strategy that forgoes the completeness of operation in favor of a physiological approach, the overriding preference going to rapidity and limiting the procedure to control the injuries. Management is based on sequential association of the shortest possible preoperative resuscitation with surgery limited to essential steps to control injury (stop the bleeding and contamination), without definitive repair. The latter will be ensured during a scheduled re-operation after a period of resuscitation aiming to correct physiological abnormalities induced by the trauma and its treatment. This strategy necessitates a pre-defined plan and involvement of the entire medical and nursing staff to reduce time loss to a strict minimum.

Small bowel obstruction secondary to transport aircraft: coincidence or reality?

Small bowel obstructions (SBO) are a leading cause of admission to general surgery, posing the problem of the aetiology and treatment based on the diagnosis. More than 300 patients were admitted for SBO in 2011 in our institution. In our clinical practice, we have had to care for patients with SBO immediately after air travel, all of whom had an antecedent of abdominal surgery by laparotomy. The finding of episodes of acute SBO immediately following a commercial flight has never been reported in the literature. We report the cases of four patients for whom we offer several pathophysiological hypotheses, and we publish the first dietary rules for people with a history of intraperitoneal surgery to adopt during a flight.

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.