Franck Billmann

Histopathological tumor invasion of the mesenterico-portal vein is characterized by aggressive biology and stromal fibroblast activation

BACKGROUND Mesenterico-portal vein resection (PVR) during pancreatoduodenectomy for pancreatic head cancer was established in the 1990s and can be considered a routine procedure in specialized centers today. True histopathologic portal vein invasion is predictive of poor prognosis. The aim of this study was to examine the relationship between mesenterico-portal venous tumor infiltration (PVI) and features of aggressive tumor biology. METHODS Patients receiving PVR for pancreatic ductal adenocarcinoma of the pancreatic head were identified from a prospectively maintained database. Immunohistochemical staining of tumor tissue was performed for the markers of epithelial-mesenchymal transition (EMT) E-Cadherin, Vimentin and beta-Catenin. Morphology of cancer-associated fibroblasts (CAFs) was assessed as inactive or activated. Statistical calculations were performed with MedCalc software. RESULTS In total, 41 patients could be included. Median overall survival was 25 months. PVI was found in 17 patients (41%) and was significantly associated with loss of membranous E-Cadherin in tumor buds (p = 0.020), increased Vimentin expression (p = 0.03), activated CAF morphology (p = 0.046) and margin positive resection (p = 0.005). CONCLUSION Our findings suggest that PVI is associated with aggressive tumor biology and disseminated growth less amenable to margin-negative resection.

A pioneer in medicine and surgery: Charles Sédillot (1804–1883)

Professor Charles Sédillot (1804-1883) is one of the pioneers of modern medicine, surgery, anaesthesiology, histopathology and infectiology. Unfortunately, he remains unknown outside of the circles of French military medicine historians. He was the first surgeon in the world to offer techniques such as coxofemoral dislocation and internal urethrotomy, thus becoming a pioneer in endoscopic surgery. By introducing general anaesthesia in France, he revolutionised patient care. In addition, he laid the foundation for the modern, algorithmic treatment of tumours by adopting the principles of clinical histopathology. Long before the description put forth by Semmelweiss (1818-1865), he foresaw and understood the existence and action of microorganisms, which he termed microbes, in the development of postoperative infections. For his work, he was honoured by his peers in France but remained unknown beyond the borders of his homeland. Here, we present a succinct report of the considerable accomplishments of the life and work of this outstanding physician and surgeon.

Reduction of Acute Shoulder Dislocations in a Remote Environment: A Prospective Multicenter Observational Study

OBJECTIVE Acute dislocations of the glenohumeral joint are common in wilderness activities. Emergent reduction should take place at the site of trauma to reduce the patients pain and the risk of vascular and neurological complications. A limited number of reduction methods are applicable in remote areas. The aim of this study is to present our method of reduction of anterior shoulder luxation that is easily applicable in remote areas without medication, adjuncts, and assistants and is well tolerated by patients. METHODS A prospective observational study was conducted during a 5-year period. The patients included underwent closed manual reduction with our technique. After each reduction, the physician who performed the reduction completed a standardized detailed history, and reexamined the patient (for acute complications). The patients were contacted 6 months after the trauma to investigate long-term postreduction complications. RESULTS Reduction was achieved with our method in 39 (100.0%) of 39 patients. The mean pain felt during our reduction procedure was rated 1.7 ± 1.4 (on a scale of 10) using the visual analog scale scoring system. No complications were noted before or after the reduction attempts. We did not find any long-term complications. CONCLUSIONS The reduction method presented in the present study is an effective method for the reduction of acute shoulder luxations in remote places. Our data suggest that this method could be applied for safe and effective reduction of shoulder dislocation.

Effect of Advanced Trauma Life Support (ATLS) on the time needed for treatment in simulated mountain medicine emergencies

OBJECTIVE The number of tourists exploring mountainous areas continues to increase. As a consequence, rescue operations are increasing, especially for trauma and polytrauma victims. The outcome of such patients depends greatly on the duration of the prehospital stabilization. Limited medical training of mountain rescuers may adversely affect the outcome of patients. There is no study investigating high altitude trauma treatment. The aim of this study is to analyze the impact of advanced trauma life support (ATLS) principles in mountain trauma, and to discuss a possible role of ATLS in mountain medicine education programs. METHODS We designed 5 tasks representing life-threatening trauma problems encountered in mountain rescue. They were used to evaluate the physicians ability to adequately diagnose and react to trauma situations. We created 2 groups: 1) the ATLS group, consisting of physicians who passed the ATLS course and the mountain medicine course, and 2) the non-ATLS group, consisting of physicians who did not obtain the ATLS training but who did pass the mountain medicine course. We compared the time spent to complete the tasks in both groups. RESULTS In 4 of the 5 tasks (airway, breathing, circulation, and combination), the ATLS group completed the task significantly faster. In the environment task, however, the ATLS group was slower. This was the only not significant result. CONCLUSIONS ATLS principles adapted and implemented for high altitude medicine education may have a positive impact on high altitude trauma treatment and outcomes.

MicroRNA analysis of gastroenteropancreatic neuroendocrine tumors and metastases

The incidence of neuroendocrine neoplasias (NEN) continues to increase. Since the primary tumor cannot be diagnosed in some cases of metastatic disease, new biomarkers are clearly needed to find the most probable site of origin. Tissue samples from 79 patients were analyzed and microRNA profiles were generated from a total of 76 primary tumors, 31 lymph node and 14 solid organ metastases. NEN metastases were associated with elevated levels of miR-30a-5p, miR-210, miR-339-3p, miR-345 and miR-660. Three microRNAs showed a strong correlation between proliferation index and metastatic disease in general (miR-150, miR-21 and miR-660). Further, each anatomic location (primary or metastatic) had one or more site-specific microRNAs more highly expressed in these tissues. Comparison between primary tumors and metastases revealed an overlap only in pancreatic (miR-127) and ileal tumors (let-7g, miR-200a and miR-331). This thorough analysis of gastroenteropancreatic neuroendocrine tumors demonstrates site-specific microRNA profiles, correlation with proliferation indices as well as corresponding nodal and distant metastases. Using microRNA profiling might improve NEN diagnostics by linking metastases to a most probable site of origin.

Colicky Epigastric and Right Upper Quadrant Pain

Awoman inher50spresented toouremergencydepartmentwitha3-hourhistoryof sudden epigastric and right upper quadrant pain. She did not report any previous abdominal surgery. The colicky pain did not migrate during that period and occurred in paroxysms at 9to 10-minute intervals. The patient was afebrile and had no nausea or vomiting. Physical examination revealedmild tachycardia (96/min)andmoderateabdominal distension without signs of peritonism; the bowel soundswerehyperactive.Careful examination ruledout incarcerated hernias in the groin, femoral triangle, and obturator foramen. Blood analysis results showedmild leukocytosis (total white blood cell count, 10.5 × 103/μL [to convert to ×109 per liter, multiply by 0.001]) without elevation of theC-reactiveprotein level (<3mg/L [to convert tonanomolesper liter,multiplyby9.524]). Serum electrolyte levels were within the normal range. Computed tomography of the abdomenwas conducted (Figure). Video at jamasurgery.com