Emmanuel Hornez

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

IntroductionGastrointestinal 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.MethodsSeventeen 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).ResultsMortality 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.ConclusionCS 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.

Enterolith ileus due to jejunal diverticulosis

Jejunal diverticulosis is a rare malformation that is often asymptomatic. Complications might be similar to those occurring in large-bowel diverticula but also include a much more particular event: intestinal obstruction due to migration and impaction of enterolith formed inside diverticula. This is a very uncommon entity; diagnosis and management are thus often delayed. Mostly surgical exploration is necessary because obstruction symptoms are unresponsive to medical treatment. The authors report a new case of enterolith ileus in a 74-year-old man, due to jejunal diverticulosis, and its successful surgical management in emergency. Only 39 similar cases have ever been reported in the literature.

The French Advanced Course for Deployment Surgery (ACDS) called Cours Avancé de Chirurgie en Mission Extérieure (CACHIRMEX): history of its development and future prospects

Introduction The composition of a French Forward Surgical Team (FST) has remained constant since its creation in the early 1950s: 12 personnel, including a general and an orthopaedic surgeon. The training of military surgeons, however, has had to evolve to adapt to the growing complexities of modern warfare injuries in the context of increasing subspecialisation within surgery. The Advanced Course for Deployment Surgery (ACDS)—called Cours Avancé de Chirurgie en Mission Extérieure (CACHIRMEX)—has been designed to extend, reinforce and adapt the surgical skill set of the FST that will be deployed. Methods Created in 2007 by the French Military Health Service Academy (Ecole du Val-de-Grâce), this annual course is composed of five modules. The surgical knowledge and skills necessary to manage complex military trauma and give medical support to populations during deployment are provided through a combination of didactic lectures, deployment experience reports and hands-on workshops. Results The course is now a compulsory component of initial surgical training for junior military surgeons and part of the Continuous Medical Education programme for senior military surgeons. From 2012, the standardised content of the ACDS paved the way for the development of two more team-training courses: the FST and the Special Operation Surgical Team training. The content of this French military original war surgery course is described, emphasising its practical implications and future prospects. Conclusion The military surgical training needs to be regularly assessed to deliver the best quality of care in an context of evolving modern warfare casualties.

Blind pouch syndrome following enteroanastomosis

A 51-year-old man presented to our unit with a 7-day history of abdominal pain that evolved acutely with fever in the last 2 days. His surgical history included an emergency right ileocolectomy that was performed 23 years ago because of an appendicular abscess, with reestablishment of the intestinal continuity by side-to-side isoperistaltic anastomosis. The clinical examination revealed conjunctival pallor, tachycardia, fever and abdominal tenderness. By abdominal computed tomography (CT), we noted a 14-cm intraperitoneal ‘abscess’ limited to its circumference by surgical clips, massive stranding of the surrounding fat and peritoneal effusion without pneumoperitoneum (Fig. 1). An emergency laparotomy was performed, finding a perforated dilated ileal stump. After resection and washing, we reestablished intestinal continuity by handsewn end-toside anastomosis. The patient recovered well and was discharged 5 days after admission. Side-to-side anastomosis is a reliable method of reestablishing intestinal continuity that avoids the difficulties and complications of end-to-end anastomosis. However, side-to-side anastomoses can affect complications if the proximal segment that is distal to the stoma is excessive. In such a case, the segment that projects beyond the stoma dilates, resulting in a gradually enlarging blind pouch that can ulcerate and perforate. The incidence of blind pouch syndrome is extremely low and can occur within 1 month to several years after anastomosis of the small bowels alone, small and large intestine, or colon alone. Although pouches can develop with end-to-side anastomosis, they are much more common with side-to-side procedures, but do not occur after end-to-end anastomosis. These pouches can affect either blind-end segments or solely the distal section of the afferent segment. No report has examined the association between stapled or handsewn anastomoses and the incidence of pouch formation. However, it appears that blind ends are less likely to fill with intestinal contents when they are generated in isoperistaltic fashion. The formation of pouches in side-to-side anastomosis results from (Fig. 2): the creation of an antiperistaltic segment in which peristalsis is directed towards the closed end; the disruption of the circular muscle layer, rendering circular contraction impossible and packing intestinal contents into the closed end. A blind end no longer than 2.5 cm beyond the stoma can dilate under such circumstances into a large blind pouch over years. Bacterial overgrowth in the stagnant bowel contents perturbs intestinal absorption, leading to malnutrition and causes the intestinal wall to become hypertrophic, oedematous and inflamed. Small ulcerations can develop, leading to intestinal intermittent bleeding and perforation in extreme cases. Enteroliths and tumours have also been described in persistent blind pouches. Symptoms are abdominal pain, asthenia because of chronic anaemia and inability to gain weight because of malnutrition and diarrhoea. Acute cases can also present as intestinal perforation, massive gastrointestinal bleeding and intestinal obstructions. The anaemia can either be microcytic, as result of iron deficiency that is caused by intestinal bleeding, or macrocytic, which predominates in cases of intestinal malabsorption. Abdominal CT usually identifies a Fig. 1. Coronal reformatted computed tomography of the abdomen. The image shows a typical aspect of the blind pouch, with an ovoid loop of distended bowel (asterisk) adjacent to staple lines (arrows). The stranding of the mesenteric fat suggests perforation of the pouch.

Concomitant Vascular War Trauma Saturating a French Forward Surgical Team Deployed to Support the Victims of the Syrian War (2013). Interest of the Vascular Damage Control

Vascular injuries from war require an emergency treatment whose objective is to quickly obtain hemostasis and the restoration of arterial flow. In this context of heavy trauma and limited means, damage control surgery is recommended and is based on the use of temporary vascular shunts (TVSs). We report the management of the simultaneous arrival of 2 vascular injuries of war in a field hospital. Patient 1 presented a ballistic trauma of the elbow with a section of the humeral artery (Gustillo IIIC). A TVS was set up during the external fixation of the elbow. Final revascularization was carried out and aponevrotomies of the forearm were performed. Patient 2 had a riddled knee with an open fracture of the femur, an avulsion of the popliteal artery, and a hemorrhagic shock. A strategy of damage control surgery was carried out with placing an arterial and venous shunt. Aponevrotomies of the leg were carried out before casting. For the traumatisms of the arteries of the members, the use of shunts is reserved for the lesions of the proximal vessels. Many vascular shunts available have the same performances to restore the arterial flow and prevent secondary thrombosis. The time before the final revascularization depends on the clinical condition of the patient. The value of anticoagulation in these cases was not shown.

Traumatisme fermé de l’aorte abdominale chez le polytraumatisé. Comment hiérarchiser la prise en charge à la phase aiguë ?

Blunt trauma of the abdominal aorta is rare. Secondary to high-energy trauma, it is observed mainly in association with complex lesions. Evaluation of injury to the aorta must be a priority due to the risk of life-threatening massive hemorrhage. The clinical presentation can be quite obvious but also variable and often misleading. If in doubt, a systematic injected whole body scan is essential to diagnose aortic lesions. Hemorrhage or ischemia dictates emergency laparotomy. Opening the retroperitoneum increases the risk of infection if there is an associated gastrointestinal tract injury and may contraindicate use of arterial prostheses. Endovascular treatment can be proposed for less symptomatic lesions, including intimal dissection. Stents can be inserted via a femoral approach. In the event of juxtarenal dissection, there is a risk of renal artery thrombosis. Endovascular treatment is currently not recommended. This treatment can be delayed for a few days if necessary. Morbidity is low and long-term results are good.

Fistule ilio-urétérale : complication redoutable d’un faux anévrisme iliaque infecté à Candida. À propos d’un cas

Arterio-ureteral fistula is a rare condition difficult to diagnose. The usual presentation associates acute paroxysmal hematuria with well-identified history and risk factors. We report the case of an 84-year-old man with a life-threatening complication of an ilio-ureteral fistula complicating an anastomotic iliac pseudoaneurysm after prothetic iliofemoral surgery, due to a fungic infection by Candida. After reporting the clinical case and the emergency surgical treatment, we present a review of the literature.

Paris Terrorist Attack on November 13, 2015 - Applying Wartime In-hospital Triage and Damage Control Strategies

of the scene: the teams are working in a scene that has not been secured, with possible presence of additional perpetrators. Personnel has to work using Personal Protective Equipment (PPE) due to that risk. Dealing with an injured perpetrator requires security checks, authorization of the security authorities on the scene, and moral dilemmas. Transportation times might be prolonged. This creates a unique environment that calls for specific on-scene protocols, as well as training of the personnel (staff and volunteers) to be able to successfully perform their tasks in this hostile environment. On-scene procedures, as well as unique procedures developed (eg, police escort to overcome traffic), and revised treatment protocols as result of lessons learned from incidents will be presented.

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.

Faut-il revasculariser en urgence les fistules artérielles trachéo-innominées ?

Tracheo-innominate artery fistulas are a rare but life-threatening complications (incidence between 0.1 and 1 %) occurring in tracheostomy patients. Surgery is the treatment of choice. Most authors recommend ligation of the innominate artery, which provides better results in terms of morbidity/mortality than revascularization surgery. We report here a case of innominate artery revascularization isolated from the trachea by a sternocleidomastoid pediculate interposition graft. The procedure was successful as demonstrated by the 2 years follow-up. Revascularization surgery should be reserved of specific cases. The risk of tracheal-mediated infections developing in contact with the vascular sutures warrants systematic use of an interposition graft isolating the trachea from the innominate artery.