Paul Balandraud

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.

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.

Multiple blast extremity injuries: is definitive treatment achievable in a field hospital for local casualties?

PurposeThe objective of this report was to analyse injury patterns and definitive management of local casualties with multiple blast extremity injuries in the Kabul International Airport Combat Support Hospital.MethodsA clinical prospective study was performed from July 2012 to January 2013. Afghan victims of a blast trauma with a minimum of two extremities injured and an Injury Severity Score (ISS) greater than 8 were included. Two groups were considered for analysis: group A including patients with amputations and group LS including patients with limb salvage procedures.ResultsDuring this period 19 patients were included with a total of 57 extremity injuries. There were six patients in group A and 13 patients in group LS, with a mean number of injuries of 3.5 and 2.8, respectively. The ISS, blood products utilization and overall time of surgery were significantly greater in group A.ConclusionReconstruction of multiple blast extremity injuries may be achieved in a field hospital despite limited resources and operational constraints. However, this activity requires the utilization of significant supplies and major investment from the caregivers deployed.

Preperitoneal pelvic packing

Severe pelvic traumatisms are associated with elevated mortality because of the high risk of exsanguination from multiple sources of bleeding. Treatment should encompass resuscitation, bone stabilization and hemorrhage control by arterio-embolization or surgery. Pre-peritoneal packing has been described in hemodynamically unstable patients who need damage control. The surgical technique of this simple and effective procedure is fully described by the authors with some complementary useful technical advices.

Penetrating pelvic trauma: Initial assessment and surgical management in emergency

Penetrating pelvic trauma (PPT) is defined as a wound extending within the bony confines of the pelvis to involve the vascular, intestinal or urinary pelvic organs. The gravity of PPT is related to initial hemorrhage and the high risk of late infection. If the patient is hemodynamically unstable and in hemorrhagic shock, the urgent treatment goal is rapid achievement of hemostasis. Initial strategy relies on insertion of an intra-aortic occlusion balloon and/or extraperitoneal pelvic packing, performed while damage control resuscitation is ongoing before proceeding to arteriography. If hemodynamic instability persists, a laparotomy for hemostasis is performed without delay. In a hemodynamically stable patient, contrast-enhanced CT is systematically performed to obtain a comprehensive assessment of the lesions prior to surgery. At surgery, damage control principles should be applied to all involved systems (digestive, vascular, urinary and bone), with exteriorization of digestive and urinary channels, arterial revascularization, and wide drainage of peri-rectal and pelvic soft tissues. When immediate definitive surgery is performed, management must address the frequent associated lesions in order to reduce the risk of postoperative sepsis and fistula.

Laparoscopic Management of Gallstone Ileus.

A 93-year-old woman was admitted to our unit with a 3-week history of right hypochondrium pain that had evolved acutely in the last 2 days. Her medical history included major cardiovascular diseases and a hysterectomy performed 40 years earlier. Clinical examination revealed non-specific diffuse abdominal tenderness with abdominal distension, vomiting, and loss of flatus, suggesting an adhesive intestinal obstruction. Routine admission blood tests demonstrated moderate sepsis and acute functional kidney failure, without liver function test abnormalities. Non-injected abdominal computed tomography (CT) was performed, and signs of chronic cholecystitis, pneumobilia with cholecysto-enteric fistula, and small-bowel obstruction due to a 3-cm gallstone impacted in the last jejunal loop were found (Fig. 1). The diagnosis of gallstone ileus was made, and the patient was taken to the operating room to undergo an emergency coelioscopy. The exploration showed small-bowel dilation but failed to reveal the gallbladder because of tight omental adhesions. After distal bowel adhesiolysis, the last jejunal loop was found and the gallstone localized. A 4-cm longitudinal enterotomy at the anti-mesenteric border was carried out and the impacted stone was brought out. The enterotomy was then closed by a continuous suture of absorbable monofilament (Fig. 2). Because of predictable surgical difficulties in this high-risk patient, we chose not to remove the gallbladder to avoid dealing with the cholecysto-enteric fistula repair. The postoperative course was uneventful and the patient was discharged on day 8 post-surgery. Gallstone ileus is a rare complication of calculous gallbladder disease (0.5 to 2 %) and represents 1 to 4 % of mechanical intestinal obstructions. 1 The pathology usually affects elderly patients and is the consequence of an evolved calculous cholecystitis that spontaneously fistulates into the digestive tract. Although the clinical presentation is unspecific, radiological exams can show small-bowel obstruction, ectopic gallstones and pneumobilia, due to the abnormal communication between the biliary tract and the bowels, thereby describing the classical Rigler triad in 15 % of cases. 1 Although a biliary-enteric fistula involves in most cases the gallbladder and the duodenum, in rare cases, the fistula originates directly from the biliary tract, thereby leading to a higher rate of cholangitis. Medical treatment may be attempted but usually fails because the calculous is often stuck at the ileo-caecal junction. In regard to surgical treatment, no consensus is available and four procedures are described as follows: enterotomy with stone extraction and cholecystectomy with fistula repair (one-stage procedure), enterotomy with stone extraction followed by fistula repair during a second intervention (twostage procedure), bowel resection and cholecystectomy with fistula repair or bowel resection alone. 2 Although the onestage procedure offers the most complete treatment, it is also the most complex one, thereby exposing the patient to a higher risk of enteric leakage after cholecysto-enteric fistula repair * Stéphane Bourgouin stephane_bourgouin@hotmail.fr

Disseminated Peritoneal Leiomyomatosis

A 53-year-old premenopausal woman was referred to our unit with a two-year history of progressive abdominal pain. The patient was nulliparous and had only benefited from umbilical hernioplasty 10 years ago. Physical examination found moderate pain of the abdomen with abdominal soft distension. No palpable mass was detected. Laboratory tests were normal. Abdomino-pelvic computed tomography (CT) and magnetic resonance imaging revealed massive infiltration of the lower parts of the abdomen by multiple enhancing solid and gelatinous lesions, covering all structures from the pelvis to the umbilic area without invading or compressing the intestine (Fig. 1), suggesting a benign form of pseudomyxoma per i tone i such as per i tonea l adenomucinosis. Thoracic CT found a similar 3-cm long cyst in the upper para-tracheal region. Colonoscopy was normal. Laparoscopic exploration was finally conducted and found, instead of classical puddles of mucin, multiple soft nodules of various sizes, massively infiltrating the great omentum, pelvis, pericolic gutters and the lower parts of the peritoneum, but preserving the small intestine (Fig. 2). Histopathology identified highly cellular interlacing bundles of smooth muscle cells, mimicking a leiomyosarcoma, although there were no nuclear atypia, mitotic figures, or signs of necrosis. Immunochemical analyses confirmed that the lesion was not malignant with a Ki67 ratio of 0%, intensively expressing desmin, caldesmon, estrogen, and progesterone receptors. A diagnosis of disseminated peritoneal leiomyomatosis was established. Because the disease was suspected to be metastatic and no signs of organic compression were noted, we decided to not perform surgical resection and proposed hormonal therapy using aromatase inhibitors. At one-year follow-up, the patient was fit and well, and imaging exams demonstrated stabilization of the disease. Disseminated peritoneal leiomyomatosis (DPL) is a rare disorder first described by Willson and Peale in 1952, characterized by widespread of myofibroblastic nodules in the peritoneal cavity, mimicking the peritoneal seeding of a malignant tumor. Although DPL has been described in postmenopausal women, the condition usually affects active women and has been associated with pregnancy, uterine leiomyoma, or prolonged oral contraceptive use. The pathogenesis of DPL is unclear but, according to Tavassoli and Norris, DPL results from the transformation under hormonal stimulation of subperitoneal mesenchymal stem cells which exhibits predisposition to metaplasia. This theory is supported by the fact that DPL is associated with other me t ap l a s t i c l e s i on s s u ch a s endome t r i o s i s o r endosalpingiosis. An iatrogenic cause of DPL has also been suggested, notably when power morcellators are used during laparoscopic surgery of uterine fibroids, as a result of the widespread fibroid pieces in the peritoneal cavity. Extraperitoneal localizations as in our case, however, suggest other possible means of dissemination. Preoperative diagnosis of DPL is challenging. As the disease is very little known, imaging studies usually shift towards peritoneal carcinoma or pseudomyxoma peritonei. The indolent course of the disease and the absence of an altered general condition usually suggest a borderline disease, but only histo* Clément Julien clementjulien@live.fr

Management specificities for abdominal, pelvic and vascular penetrating trauma

Management of patients with penetrating trauma of the abdomen, pelvis and their surrounding compartments as well as vascular injuries depends on the patients hemodynamic status. Multiple associated lesions are the rule. Their severity is directly correlated with initial bleeding, the risk of secondary sepsis, and lastly to sequelae. In patients who are hemodynamically unstable, the goal of management is to rapidly obtain hemostasis. This mandates initial laparotomy for abdominal wounds, extra-peritoneal packing (EPP) and resuscitative endovascular balloon occlusion of the aorta (REBOA) in the emergency room for pelvic wounds, insertion of temporary vascular shunts (TVS) for proximal limb injuries, ligation for distal vascular injuries, and control of exteriorized extremity bleeding with a tourniquet, compressive or hemostatic dressings for bleeding at the junction or borderline between two compartments, as appropriate. Once hemodynamic stability is achieved, preoperative imaging allow more precise diagnosis, particularly for retroperitoneal or thoraco-abdominal injuries that are difficult to explore surgically. The surgical incisions need to be large, in principle, and enlarged as needed, allowing application of damage control principles.

Duodenal Reconstruction Following Extended Right Colectomy: the Pedicled Ileal Flap Technique

An 87-year-old woman with no prior history was admitted for urinary sepsis, abdominal pain, and fever that had persisted for 3 days. Physical examination demonstrated abdominal tenderness with a mass that had developed at the right side of the abdomen. Laboratory tests showed moderate kidney failure with sepsis. Ultrasonography revealed dilation of the right pyelo-ureteral junction due to a mass compressing the ureter. Computed tomography (CT) confirmed the mass to be 20-cm in size, involving the right colon and fistulized in the retroperitoneum, the right ureter, and the genu inferius. The mesenteric vessels, inferior vena cava, and pancreatic head were free of tumor. A locally advanced right colonic carcinoma was suspected. After fluid resuscitation, broad-spectrum antibiotics, and preoperative nutritional support, the patient was taken to the operating room. En bloc mobilization of the right colon and kidney allowed us to pediculate the tumor on its duodenal adhesions. The antipancreatic border of the genu inferius was resected in free margins, leaving an 8 × 3 cm duodenal defect (Fig. 1). A 10-cm pedicled ileal flap was then taken and opened on its antimesenteric border in order to patch the duodenal defect. Appropriate patch size was determined by adjusting the antimesenteric resection to the duodenal diameter. Microvascularization at the patch extremities was enhanced by cutting the mesentery wider than the digestive patch, preserving the marginal vessels at the flap extremities. The ileal patch was then sewed to the duodenum using two continuous layers of absorbable monofilament (Fig. 2). The flap was retroperitonized, isoperistaltic ileotransversotomy was performed, and the mesenteric windows were closed. No signs of flap infarction, anastomotic leakage, or pouchitis were detected on postoperative CT. The patient was discharged 2 weeks later. The histological report confirmed a colonic adenocarcinoma that had extended to the duodenum, resected in free margins. The curative treatment of non-metastatic colorectal cancers includes surgical resection of the primary tumor with free margins. Although organized systematic screening has decreased the rate of unresectable tumors, nearly 12% of patients present at the time of surgery with advanced cancers adhering to adjacent structures. A rare but challenging situation occurs when tumors at the hepatic flexure invade the duodenum. In those cases, the need to extend the duodenal resection is balanced with the necessity of closing the duodenal defect while limiting the risk of postoperative fistula or duodenal stenosis. Techniques range from limited extramucosal seromyectomy for only adherent but non-invading tumors to extensive en bloc pancreaticoduodenectomywhen necessary. For intermediate cases, notably when the extent of duodenal invasion contraindicates limited resection, authors wisely recommend the use of pedicled intestinal flaps, such as Roux-en-Y duodenojejunostomy or ileal patch duodenoplasty. The Roux-en-Y duodenojejunostomy allows for the reconstruction of large duodenal defects but requires one more anastomosis. Furthermore, the intestinal loop can be difficult to mobilize and patch on the duodenal defect. Finally, this technique can * Stéphane Bourgouin stephane_bourgouin@hotmail.fr