[Place of preperitoneal pelvic packing in severe pelvic traumatisms: 20 cases in a French level 1 trauma center]. / Place du packing pré-péritonéal pelvien dans les traumatismes graves du bassin : étude à partir de 20 cas réalisés dans un trauma center de niveau 1 français.

BACKGROUND: The overall mortality of hemodynamically unstable patients with pelvic trauma is high. Their management is controversial concerning places of arterioembolization and pelvic packing associated with pelvic stabilization. The aim of this study was to collect the pre-peritoneal pelvic packing (PPP) performed in our institution over 10years in order to propose a management algorithm. METHOD: From January 2010 to December 2020, all patients with a hemodynamically unstable pelvic fracture who had PPP combined with pelvic stabilization were included. Data were collected prospectively and analyzed retrospectively. The main judgement criteria were early hemorrhage-induced mortality (<24h) and overall mortality (<30d). RESULTS: Twenty patients had PPP out of 287 polytrauma patients with pelvic fracture. The first-line PPP proposed in our algorithm significantly reduced the number of red blood cells (RBCs) (P=0.0231) and improved systolic blood pressure (SBP) (P<0.001) within 24hours of first-line PPP (compared with preoperative). Six patients (30%) were embolized postoperatively for active bleeding not necessarily pelvic. The overall mortality at 30days was 50% (10/20). CONCLUSION: PPP is a fast, easy, effective and safe procedure for venous, bone and sometimes arterial bleeding. PPP is part of damage control surgery and we propose it as a first-line procedure. AE remains complementary in a second step.

Eligibility criteria for ambulatory colectomy.

PURPOSE OF THE STUDY: To determine the statistical indicators aimed at identifying patients for whom ambulatory colectomy could be proposed without additional risk. PATIENTS AND METHODS: The medical charts of patients who benefited from scheduled colonic or rectal resection during conventional hospitalization stays between 2018 and 2019 were reviewed. Eligibility for ambulatory colectomy was defined by hospital stay≤4 days and absence of any postoperative complication. Patient characteristics were compared, and the results were modeled in the form of a decision-making tree. The effect of an enhanced recovery after surgery (ERAS) protocol for each sub-group was calculated. RESULTS: One hundred and ten (110) patients were selected (41 "eligible" and 69 "non-eligible"). Median age was 73 years (27-95). Nearly 80% of the patients were operated for cancer. In multivariate analysis, age (≥65 years, OR=3.15, CI95%=1.22-8.12), diabetes (OR=3.91, CI95%=1.03-14.8) and indication (sigmoidectomy for diverticulosis, OR=0.21, CI=95%=0.05-0.9) were the only identified independent variables. Likelihood for ambulatory eligibility was 83.3% (<65 years, sigmoidectomy pour diverticulosis, +ERAS=92%-96.9%), 58.3% (<65 years, other indication, +ERAS=63.4%-89.9%), 35.7% (≥65 years without diabetes, +ERAS=40.0%-55.9%) and 8.3% (≥65 years with diabetes, +ERAS=10.0%-20.1%). CONCLUSION: Sigmoidectomy for diverticulosis in a patient under 65 years age represents the best indication for ambulatory colectomy, a procedure that must not be proposed to diabetic patients over 65 years of age. In the other cases (<65 years operated in another indication and non-diabetic≥65 years), ambulatory surgery is possible, pending satisfactory application of the ERAS protocol.

One-stage laparoscopic procedure versus two-stage procedure in the management of common bile duct stones in patients aged 75 and more.

INTRODUCTION: The management strategy for common bile duct stones (CBD) in patients over 75years is a real challenge that requires balancing the efficacy of a multiplicity of procedures against their own morbidity. The objective is to compare one-stage surgical treatment versus the two-stage combination of endoscopy and surgery in terms of efficacy of clearing the CBD of stones and the morbidity and mortality in elderly patients. MATERIAL AND METHODS: This study included eighty-two patients over 75years of age with symptomatic CBD stones who presented between 2010 and 2017. Patients were treated either by one-stage surgery alone (S group, n=40) or by sequential endoscopy and surgery (ES group, n=42). RESULTS: Immediate and 30-day mortality, morbidity and duration of hospitalization were comparable. The failure rate for clearing CBD lithiasis was significantly higher in the ES group (26.2% vs. 7.5%, P=0.038, 95% CI). In multivariate analysis, two-stage treatment and multiple CBD stones were associated with a significantly higher risk of failure. Fewer anesthetic procedures were needed in the S group. Twelve patients (14.4%) had multiple stones packing the CBD (>3 stones); four were treated with choledocho-duodenal anastomosis and eight with endoscopic sphincterotomy and stone removal with 100% and 50% efficacy, respectively. CONCLUSION: The "surgery alone" attitude compared to 2-stage endoscopic and surgical management is associated with better efficacy in terms of clearing the CBD of lithiasis and requires fewer anesthetic procedures in elderly subjects while being comparable in terms of morbidity and mortality. In patients whose CBD is packed with multiple stones, choledocho-duodenal anastomosis is an alternative to endoscopy for management of choledocholithiasis.

Update about ventriculoperitoneal shunts: When to combine visceral and neurosurgical management?

Ventriculoperitoneal shunts (VPS) are the treatment of choice for chronic hydrocephalus. However, the rate of abdominal complications is far from negligible. Combined abdominal and neurological surgical management is often necessary. The goal of this study was to describe the abdominal complications related to VPS and their management. This update overviews: (1) acute or chronic abdominal complications after insertion of a VPS, especially those that call for involvement of visceral surgeons; and (2) the particular precautions necessary when neurosurgeons and visceral surgeons have to collaborate in case an abdominal operation is necessary in patients with a VPS.

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 patient's 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.

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.

Feasibility and limits of inguinal hernia repair under local anaesthesia in a limited resource environment: a prospective controlled study.

PURPOSE: Local anaesthesia (LA) has proven effective for inguinal hernia repair in developed countries. Hernias in low to middle income countries represent a different issue. The aim of this study was to analyse the feasibility of LA for African hernia repairs in a limited resource environment. METHODS: Data from patients who underwent herniorrhaphy under LA or spinal anaesthesia (SA) by the 6th and 7th Forward Surgical Team were prospectively collected. All of the patients benefited from a transversus abdominis plane (TAP) block for postoperative analgesia. Primary endpoints concerned the pain response and conversion to general anaesthesia. Secondary endpoints concerned the complication and recurrence rates. Predictors of LA failure were then identified. RESULTS: In all, 189 inguinal hernias were operated during the study period, and 119 patients fulfilled the inclusion criteria: 57 LA and 62 SA. Forty-eight percent of patients presented with inguinoscrotal hernias. Local anaesthesia led to more pain during surgery and necessitated more administration of analgesics but resulted in fewer micturition difficulties and better postoperative pain control. Conversion rates were not different. Inguinoscrotal hernia and a time interval <50 min between the TAP block and skin incision were predictors of LA failure. Forty-four patients were followed-up at one month. No recurrence was noted. CONCLUSIONS: Local anaesthesia is a safe alternative to SA. Small or medium hernias can easily be performed under LA in rural centres, but inguinoscrotal hernias required an ultrasound-guided TAP block performed 50 min before surgery to achieve optimal analgesia, and should be managed only in centres equipped with ultrasonography.

Hospital care in severe trauma: Initial strategies and life-saving surgical procedures.

Severe trauma patients should be received at the hospital by a multidisciplinary team directed by a "trauma leader" and all institutions capable of receiving such patients should be well organized. As soon as the patient is accepted for care, the entire team should be prepared so that there is no interruption in the pre-hospital chain of care. All caregivers should thoroughly understand the pre-established protocols of diagnostic and therapeutic strategies to allow optimal management of unstable trauma victims in whom hemostasis must be obtained as soon as possible to decrease the morbid consequences of post-hemorrhagic shock. In patients with acute respiratory, circulatory or neurologic distress, several surgical procedures must be performed without delay by whichever surgeon is on call. Our goal is to describe these salvage procedures including invasive approaches to the upper respiratory tract, decompressive thoracostomy, hemostatic or resuscitative thoracotomy, hemostatic laparotomy, preperitoneal pelvic packing, external pelvic fixation by a pelvi-clamp, decompressive craniotomy. All of these procedures can be performed by all practitioners but they require polyvalent skills and training beforehand.

Management of exsanguinating pelvic trauma: Do we still need the radiologist?

BACKGROUND: The hemodynamically unstable pelvic fracture are a diagnostic and therapeutic challenge. The current management is based on the control of pelvic bleeding by combining pelvic ring stabilization and embolization of pelvic arteries. The mortality of these patients, however, exceeds 30%. Recently the preperitoneal packing, based on the hemostatic tamponade of the pelvic cavity has been described. The objective of this study was to evaluate the interest of this new surgical procedure. The effectiveness of the standard algorithm is evaluated by analysis of pelvic injuries in 200 severe trauma treated at the Sainte-Anne Hospital. The results are then compared with literature data on the preperitoneal packing. PATIENTS AND METHODS: The profile injury, management and morbidity and mortality was evaluated in 200 polytrauma. After an initial phase of resuscitation, unstable pelvic fractures were treated with a circumferential belt followed by the application of an external fixator. Arteriography was performed for all patients with persistent hemodynamic instability. RESULTS: The mean injury severity score (ISS) was 31 (4-75). The mean trauma-related injury severity score (TRISS) was 74% (3-99). The proportion of hemodynamically unstable patients was 47%. Fifteen patients (41%) had severe bleeding. The median number of blood transfusion was 10 (4-42); eight patients (22%) underwent embolization. For two patients, reducing the pelvic fracture with an external fixator resulted in permanent hemostasis. Two patients underwent a laparotomy first, for the control of a hemoperitoneum. The mortality rate of the group of patients with hemorrhage was 33% (5/15). DISCUSSION: This high mortality leads to reconsider the place of pelvic embolization as firstline treatment. Some major drawbacks are noted: its effectiveness in treating venous bleeding, availability and duration of the procedure. The preperitoneal packing is a fast and effective surgical alternative. It seems to improve hemodynamic status of patients and significantly reduce the use of embolization and massive transfusion. Embolization is still indicated for patients not responding to surgery. However survival is not significantly improved.

[Management of seat-belt aorta in severe polytrauma: a review]. / 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.

[Necrosis of the glans penis: a complication of an injection of buprenorphin in a opioid abuser]. / Nécrose du gland après injection volontaire de buprénorphine dans un contexte de toxicomanie aux opioïdes.

Necrosis of the penis glans is commonly described after circumcision or strangulation. We report the case of a patient, opioid abuser, who presented an isolated glans necrosis after an injection of buprenorphin. The buprenorphin (Subutex) is a sublingual partial mu-opioid agonist used for the treatment of heroin dependance. Its intravenous or subcutaneous abuse is associated with local infection. The patient require a surgical intervention. After the failure of a mucosal graft, a soft skin graft was done.

[Is emergency revascularization of tracheo-innominate artery fistulae mandatory?]. / 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.

[Pyoderma gangrenosum mimicking abdominal sepsis after colorectal surgery]. / Pyoderma gangrenosum sur un orifice de drainage, pris pour un sepsis abdominal après une chirurgie colorectale.

This study reports a case of pyoderma gangrenosum arising at a drainage orifice after a colostomy for cancer. The initial clinical presentation suggested intra-abdominal sepsis but the clinical assessment did not fit with laboratory findings or the CT scan. Forty hours later, the patient developed a reddish-purple ulcer at the drainage orifice. A diagnosis of pyoderma gangrenosum was made and systemic corticosteroid therapy was started. A dramatic response occurred over the next two days, obviating the need for surgical re-intervention. Pyoderma gangrenosum is an ulcerating necrotizing skin disorder of unknown etiology. It usually arises in association with underlying disease (mainly inflammatory bowel disease) and often occurs in para-stomal sites. Pyoderma gangrenosum arising at surgical sites is often mistaken for a postoperative infection and treated inappropriately with debridement and reopening of the wound which only exacerbates the pathology. Pyoderma gangrenosum is effectively treated with systemic corticosteroids.

[Genotyping of blood group systems at the CNRGS. I: FY, JK, MNS systems]. / Génotypage des systèmes de groupe sanguin d'intérêt transfusionnel au CNRGS. I: les systèmes FY, JK, MNS.

AIM OF THE STUDY: Determination of blood group antigens from data obtained by using molecular methods (genotyping) has become an indispensable tool in the specialized immunohematology laboratories. The French National Reference Centre for Blood group typing (CNRGS) routinely performs genotyping of the FY, JK and MNS system (common genotyping), providing a phenotype deduced from genotyping data for FY1, FY2, JK1, JK2, MNS3 and MNS4 antigens. PATIENTS AND METHODS: We performed a study to evaluate the common genotyping prescriptions referred to the CNRGS over the last three years. RESULTS: Between February 2006 and February 2009, the CNRGS performed 2392 genotyping, including 981 common genotyping. Analysis of 172 common genotyping performed in 2008 showed that 63.8% of the prescriptions expressed a genotyping demand. Of the latter, 42.7% were genotyping prescriptions only, whereas 57.2% were prescriptions of genotyping associated with alloantibody identification. All prescriptions refer to blood group genotyping indications issued from guidelines, with no incorrect prescription, that are patients transfused within four months before blood sampling in 63.6% of cases or a positive direct antiglobulin test in 24.5% of cases. Lastly, 36% of the blood samples referred to the CNRGS had no genotyping prescription. Yet, common genotyping was performed by the CNRGS to get complete immunohematology data for antibody identification. CONCLUSION: Usefulness of blood group genotyping in specialized immunohematology laboratories is obvious. However, the strategy for implementation of molecular methods remains to be defined. Use of high-throughput DNA analysis should change our way of working.

[Ilio-ureteral fistula: a life-threatening complication of an iliac Candida-infected pseudoaneurysm. A case report]. / Fistule ilio-urétérale: complication redoutable d'un faux anévrisme iliaque infecté à Candida. A 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.