How to do an enucleation of a branch-duct intraductal papillary and mucinous neoplasm of the head of the pancreas (with video).

'How I do' video of an enucleation of cystic lesion of the pancreas.

Learning trauma surgery through cytoreductive surgery.

OBJECTIVES: Regarding war surgery (WS), the initial and continuing education of French military gastrointestinal surgeons (FMGIS) is considered flawed and inappropriate. This results from the low incidence of gastrointestinal (GI) trauma, its predominantly non-surgical management, and a daily surgical practice that strongly differs from WS. Conversely, cytoreductive surgery (CRS) of peritoneal metastases has similarities with WS which led us to assess its potential contribution to the initial and continuing education of FMGIS in WS. METHODS: We reported the activities of the GI surgery departments of the military teaching hospitals of Percy and Begin. The first one dedicated to traumatology and the second to CRS. We then specifically looked into the surgical procedures conducted by the FMGIS during deployment from January 2004 to December 2014. RESULTS: Amongst the 600 severe trauma patients admitted to the Percy trauma center between January 2019 and December 2020, 17 underwent abdominal surgery with a total of 25 procedures performed. During the same period, 61 patients undertook CRS in Begin with an average of 7 surgical processes per patient carried out and a total of 418 abdominal surgical procedures. Outside abdominal packing and nephrectomy (not performed in CRS), the numbers of splenectomy, gastrointestinal / gynecological resections (hysterectomy and/or adnexectomy), or liver resection were higher during CRS compared to abdominal trauma surgery with 10 times less patients (10 vs 1, 43 vs 9, 20 vs 0, 6 vs 0, respectively). CONCLUSION: CRS, through its similarities with WS, seemed to be an appropriate tool for the initial and continuing education of FMGIS in WS and, to an extent, of civilian trauma surgeons who could eventually treat terrorist attacks casualties on the national territory.

Surgical management of insulinoma over three decades.

BACKGROUND: This paper reports our experience of the perioperative management of patients with sporadic, non-malignant, pancreatic insulinoma. METHODS: A retrospective monocentric cohort study was performed from January 1989 to July 2019, including all the patients who had been operated on for pancreatic insulinoma. The preoperative work-up, surgical management, and postoperative outcome were analyzed. RESULTS: Eighty patients underwent surgery for sporadic pancreatic insulinoma, 50 of which were female (62%), with a median age of 50 (36-70) years. Preoperatively, the tumors were localized in 76 patients (95%). Computed tomography (CT) and magnetic resonance imaging allowed exact preoperative tumor localization in 76% of the patients (64-85 and 58-88 patients, respectively), increasing to 96% when endoscopic ultrasonography was performed. Forty-one parenchyma-sparing pancreatectomies (PSP) (including enucleation, caudal pancreatectomy, and uncinate process resection) and 39 pancreatic resections were performed. The mortality rate was 6% (n = 5), with a morbidity rate of 72%, including 24 severe complications (30%) and 35 pancreatic fistulas (44%). No differences were found between formal pancreatectomy and PSP in terms of postoperative outcome procedures. The surgery was curative in all the patients. CONCLUSION: CT used in combination with endoscopic ultrasonography allows accurate localization of insulinomas in almost all patients. When possible, a parenchyma-sparing pancreatectomy should be proposed as the first-line surgical strategy.

A decade in the battlefield (2004-2014): A French military perspective on the high mortality associated with non-exclusively orthopedic or brain combat injuries.

BACKGROUND: During the last few decades, French armed forces have regularly deployed in asymmetric conflicts. Surgical support for casualties of these conflicts occurs in NATO role 2 and 3 medical treatment facilities (MTF); definitive surgical care occurs in France following a strategic medical evacuation. The aim of this study was to describe the combat injury profile of these soldiers who presented with either non-exclusively orthopedic and/or brain injuries. METHODS: This descriptive study is a retrospective analysis of the surgical management of French casualties performed in role 2 or 3 MTF in Afghanistan, Mali, Niger, Djibouti and the Central African Republic between January 2004 and December 2014. RESULTS: One hundred patients were included. Forty had fragment wounds. The most severe lesions were of the head, neck or thorax. The average injury severity score (ISS) was 34.9 (IC 95% 29.8-40). 17 damage control procedures were performed. Thirty patients died with a mean ISS of 61 (IC 95% 56-67); 5 deaths were considered as preventable. The most frequent surgical procedures in the MTF were digestive (n=31) and thoracic surgery (n=19). Thirty patients needed second-look surgery in France; eleven had severe complications. No patient died following medical evacuation to France. CONCLUSIONS: Results from this study indicated that the mortality following non-exclusively brain or orthopedic injuries remains high in modern asymmetric conflicts. Level of Evidence IV.

What are the risk factors of failure of enhanced recovery after right colectomy? Results of a prospective study on 140 consecutive cases.

PURPOSE: Nausea and vomiting is the main cause of failure of enhanced recovery protocol (ERP) after right hemicolectomy. METHODS: From January 2013 to January 2018, all patients undergoing right hemicolectomy were prospectively included. Patients undergoing emergency surgery, additional complex procedure or temporary stoma, nasogastric tube (NGT) maintenance, or abdominal drainage were excluded. Failure of ERP was defined as nausea/vomiting precluding oral feeding after POD3 and/or the occurrence of postoperative ileus requiring NGT and/or length of stay (LOS) ≥ 8 days except for patients awaiting admission in rehabilitation unit. Risk factors of failure of ERP were identified using univariate and multivariate analysis. RESULTS: Among 306 patients undergoing right hemicolectomy, 140 fulfilled the inclusion criteria. Postoperative morbidity was 31%, and the mortality rate was nil. The mean postoperative hospital stay was 7 days (range 2-30). Successful ERP was achieved in 83 patients (59%). Causes of failure were major nausea/vomiting precluding oral feeding after POD3 in 36, postoperative ileus requiring NGT in 16 and LOS ≥ 8 days in 36. On multivariate analysis, preoperative anemia (OR 5.2; CI 95%, 1.3-21.1, p = 0.02) and platelet anti-aggregant/anti-coagulant (OR 4.5; CI 95%, 1.7-12.1, p = 0.003) were associated with the risk of failure of ERP. CONCLUSION: This study shows that anemia and medication with antiplatelet/anticoagulation therapy increase the risk of failure of ERP after right hemicolectomy that translates most of the time by nausea/vomiting and postoperative ileus. The presence of these factors should lead to adapt the strategy to improve outcome rather than be considered as contraindication to ERP.

Adrenalectomy during pregnancy: A 15-year experience at a tertiary referral center.

BACKGROUND: Adrenal lesions diagnosed during pregnancy remain rare, and their management is challenging because of maternal physiologic modifications, restricted imaging investigations, and contraindications to several treatments. Surgical issues of adrenalectomy during pregnancy and consequences on perinatal outcomes are poorly described. We therefore aimed to report maternal and fetal outcomes after adrenalectomy during pregnancy. METHODS: All pregnant women who underwent adrenalectomy over a 15-year inclusion period were identified from a prospectively maintained database. Surgical management and maternal and fetal outcomes were reviewed. RESULTS: From January 2003 to July 2018, a total of 12 women underwent adrenalectomy at a median gestation of 20 weeks. Of these women, 11 had hyper-secreting lesions, including 8 with cortisol oversecretion, and 11 had benign lesions, including cortisol-secreting adenoma (n = 5), pheochromocytoma (n = 2), primary pigmented, nodular adrenal disease (n = 1), severe Cushing's disease (n = 2), and hematoma (n = 1). A total of 3 patients with severe Cushing's disease (n = 2) and primary pigmented, nodular adrenal disease (n = 1) required bilateral adrenalectomy. One patient presented with a malignant adrenal Ewing sarcoma. Adrenalectomy during pregnancy was performed by the lateral laparoscopic transabdominal laparoscopic route in 9 patients. Postoperative morbidity occurred in 3 women. Maternal mortality was nil, but preterm birth occurred in 7 cases and intrauterine growth retardation was observed in 3 cases. Finally, among the 12 women, 10 had a child in good health. CONCLUSION: During pregnancy, a lateral laparoscopic transabdominal approach is a feasible procedure. Maternal outcome is acceptable but fetal outcome is determined by the underlying disease, with a worse outcome when the adrenalectomy is indicated for malignant lesions or Cushing's syndrome.

Direct Suturing of Sciatic Nerve Defects in High-degree Knee Flexion: An Experimental Study.

OBJECTIVE: We sought to elucidate the conditions of direct suturing of sciatic nerve defects in high-degree knee flexion. We aimed to establish a correlation among the defect length, defect location, degree of knee flexion, and eventual need for hip immobilization in extension. METHODS: We performed an experimental study by completing bilateral dissection of the sciatic nerve in 6 cadavers. Three groups of lesions were identified: at the buttock (BG), in the thigh (TG), and in the popliteal fossa (PG). For each defect, a direct, tensionless suture was performed with minimal knee flexion. Next, the hip was progressively flexed until rupture. The nerve defect length correlated with the degree of knee flexion and hip extension required to perform and protect the installed sutures. RESULTS: A 30° knee flexion allowed for direct suturing of defects >2 cm in the 3 groups. The largest suturable nerve defects measured 7 cm in the TG and PG and 6 cm in the BG. When considering the same-size defects, the required knee flexion tended to be significantly greater in the BG. A bowstringing effect was noted at the buttock and popliteal levels. Hip flexion placed tension on the nerve suture at all locations. CONCLUSIONS: The middle third of the thigh was the most compliant level, because the largest defects will be suturable without a visible bowstringing effect. Hip immobilization should be considered as soon as the defect has exceeded 2 cm, regardless of the location.