Early Evaluation of a New French Surgery Course in the Best Practice of Dealing With Major Incidents and Mass Casualty Events.

OBJECTIVE: The main objective of this study is to evaluate the impact of a nationwide 5-month course aimed to prepare surgeons for Major Incidents through the acquisition of key knowledge and competencies. Learners' satisfaction was also measured as a secondary objective. DESIGN: This course was evaluated thanks to various teaching efficacy metrics, mainly based on Kirkpatrick's hierarchy in medical education. Gain in knowledge of participants was evaluated by multiple-choice tests. Self-reported confidence was measured with 2 detailed pre and post training questionnaires. SETTING: Creation in 2020 of a nationwide, optional and comprehensive Surgical Training in War and Disaster Situation as part of the French surgery residency program. In 2021, data was gathered regarding the impact of the course on participants' knowledge and competencies. PARTICIPANTS: The study included 26 students in the 2021 cohort (13 residents and 13 practitioners). RESULTS: Mean scores were significantly higher in the post-test compared to the pre-test, showing significant increase in participants' knowledge during the course: 73,3% vs. 47,3% respectively (p ≤ 0.001). Average learners' confidence scores to perform technical procedures showed at least a +1-point increase on the Likert scale for 65% of items tested (p ≤ 0.001). 89% of items showed at least a +1-point increase on the Likert scale when it came to average learners' confidence score on dealing with complicated situations (p ≤ 0.001). Our post-training satisfaction survey showed that 92% of all participants have noticed the impact of the course on their daily practice. CONCLUSION: Our study shows that the third level of Kirkpatrick's hierarchy in medical education was reached. This course therefore appears to be meeting the objectives set by the Ministry of Health. Being only 2 years old, it is on the road to gathering momentum and further development.

Modified Colson flap with subcutaneous liposuction for one-stage donor site removal: A case series.

OBJECTIVES: The aim of this study was to evaluate the functional and cosmetic results of an innovative procedure for modified Colson flap-graft consisting of immediate defatting of the flap by a liposuction cannula. METHODS: A cross-sectional study was performed among patients with deep hand burns requiring a modified Colson flap between 2018 and 2021. Outcomes included functional and cosmetic assessment of the hand through a quality-of-life questionnaire, a sensitivity scale and a scar assessment scale. RESULTS: During this period, 7 patients were operated on using our technique. One patient was lost to follow-up; 7 patients with a median age of 44 years were included, with a total of 10 burned hands. The burns were thermal in 5 out of 7 cases and the coverage concerned the whole hand in 50% of the cases. The flaps all received cannula defatting. The median time to flap weaning was 23 days (20 to 30 days). The median follow-up was 16 months. One case required remote flap weaning. The median POSAS (Patient and Observer Scar Assessment Scale) per patient was 4 and 2 per observer. The median BMRCSS (British Medical Research Council Sensory Scale) was 122. One case had recovered S2 sensitivity, the other cases had S3 or S4 sensitivity. CONCLUSION: Immediate defatting is one of the factors in tegumental quality allowing rapid functional recovery of the hand. The cannula defatting technique does not appear to require additional defatting time. The use of the liposuction cannula allows a one-step, homogeneous, and easier defatting, with a lower risk of devascularization.

[Marjolin ulcers after cultured epidermal autograft in severely burned patients: a rare case series and literature review]. / Marjolin ulcers after cultured epidermal autograft in severely burned patients: a rare case series and literature review.

The advent of tissue engineering and the clinical applications with cultured epidermal autograft (CEA) have improved the prognosis of severely burned patients. Marjolin ulcers (MUs) are a well-known complication of burns. These malignant neoplasm transformations of burn scars are usually squamous cell carcinomas with a higher incidence of regional metastases. Radical surgery remains the treatment of choice. To identify cases of malignant transformation occurring at sites of CEA in a cohort of 68 massively burned patients. A retrospective single-centre study was performed from April 2017 to June 2019 at the Military Hospital of Clamart (France). A total of 34 patients treated between 1991 and 2013 (including one post-mortem) were included. Four cases of squamous cell carcinoma occurred in areas previously covered by CEA. The data from clinical and histopathological examination as well as treatment modalities are presented. One patient died as a result of the evolution of his squamous cell carcinoma, and two others required salvage amputation due to locoregional recurrence. The prevalence of these CEA-MUs is estimated at between 5.9% and 11.7% and the person-time incidence rate of CEA-related MUs is about 5.9 per 1,000 persons-years. In our study, the average time to malignant transformation seems considerably shortened (32-35 years for "classic burn MU" versus 15.7 years for CEA-MU). This first documented case series of CEA-MUs demonstrates the need to inform caregivers and educate patients. Further studies are needed to specify the true incidence of CEA-graft site malignancy.

[Acute inpatient treatment of severe burns]. / Prise en charge hospitalière des brûlures graves.

Acute inpatient treatment of severe burns. Acute in-hospital care of severely burned patients intricately combines surgery and intensive care. Systemic and supportive care is centered on hemodynamic management of the initial plasmorrhagic shock, airway control, enteral nutrition in order to compensate for hypercatabolism, analgesia and adjuncts. Infection is a major risk, to be prevented and managed topically. Sytemic administration of antibiotics is limited to documented sepsis. Smoke inhalation injury is diagnosed by fiberoptic bronchoscopy and managed with protective ventilation, iterative bronchoscopic cleansing, and nebulized heparin, mucolytics and bronchodilators. Emergent surgery in the burned patient includes initial treatment of associated trauma, escharrotomies, and fasciotomies in selected cases. Acute surgery is centered on early excision and skin autografts to restore cutaneous integrity. Reconstructive surgery is delayed.

Prise en charge hospitalière des brûlures graves. Le traitement hospitalier aigu des brûlés graves associe étroitement chirurgie et réanimation. Le traitement général est centré sur la gestion hémodynamique du choc plasmorragique initial, le contrôle des voies aériennes, la nutrition entérale pour compenser l'hypercatabolisme, l'analgésie-sédation, et la suppléance des défaillances. L'infection, risque majeur, est prévenue et traitée par voie locale en priorité : l'antibiothérapie systémique est réservée aux sepsis documentés. L'inhalation de fumées, de diagnostic fibroscopique, est traitée par ventilation protectrice, toilettes bronchiques itératives, et aérosols d'héparine, mucolytique et bronchodilatateur. La chirurgie du brûlé comprend, en urgence, le traitement prioritaire des traumatismes associés, les escarrotomies de décharge, voire les fasciotomies ; en phase aiguë, la restitution de l'intégrité cutanée par des excisions et autogreffes précoces ; à distance, la chirurgie réparatrice des séquelles.

Bioengineering a human plasma-based epidermal substitute with efficient grafting capacity and high content in clonogenic cells.

UNLABELLED: Cultured epithelial autografts (CEAs) produced from a small, healthy skin biopsy represent a lifesaving surgical technique in cases of full-thickness skin burn covering >50% of total body surface area. CEAs also present numerous drawbacks, among them the use of animal proteins and cells, the high fragility of keratinocyte sheets, and the immaturity of the dermal-epidermal junction, leading to heavy cosmetic and functional sequelae. To overcome these weaknesses, we developed a human plasma-based epidermal substitute (hPBES) for epidermal coverage in cases of massive burn, as an alternative to traditional CEA, and set up critical quality controls for preclinical and clinical studies. In this study, phenotypical analyses in conjunction with functional assays (clonal analysis, long-term culture, or in vivo graft) showed that our new substitute fulfills the biological requirements for epidermal regeneration. hPBES keratinocytes showed high potential for cell proliferation and subsequent differentiation similar to healthy skin compared with a well-known reference material, as ascertained by a combination of quality controls. This work highlights the importance of integrating relevant multiparameter quality controls into the bioengineering of new skin substitutes before they reach clinical development. SIGNIFICANCE: This work involves the development of a new bioengineered epidermal substitute with pertinent functional quality controls. The novelty of this work is based on this quality approach.

Anti-HLA sensitization in extensively burned patients: extent, associated factors, and reduction in potential access to vascularized composite allotransplantation.

Extensively burned patients receive iterative blood transfusions and skin allografts that often lead to HLA sensitization, and potentially impede access to vascularized composite allotransplantation (VCA). In this retrospective, single-center study, anti-HLA sensitization was measured by single-antigen-flow bead analysis in patients with deep, second- and third-degree burns over ≥40% total body surface area (TBSA). Association of HLA sensitization with blood transfusions, skin allografts, and pregnancies was analyzed by bivariate analysis. The eligibility for transplantation was assessed using calculated panel reactive antibodies (cPRA). Twenty-nine patients aged 32 ± 14 years, including 11 women, presented with a mean burned TBSA of 54 ± 11%. Fifteen patients received skin allografts, comprising those who received cryopreserved (n = 3) or glycerol-preserved (n = 7) allografts, or both (n = 5). An average 36 ± 13 packed red blood cell (PRBC) units were transfused per patient. In sera samples collected 38 ± 13 months after the burns, all patients except one presented with anti-HLA antibodies, of which 13 patients (45%) had complement-fixing antibodies. Eighteen patients (62%) were considered highly sensitized (cPRA≥85%). Cryopreserved, but not glycerol-preserved skin allografts, history of pregnancy, and number of PRBC units were associated with HLA sensitization. Extensively burned patients may become highly HLA sensitized during acute care and hence not qualify for VCA. Alternatives to skin allografts might help preserve their later access to VCA.

Cultured epithelial autografts in massive burns: a single-center retrospective study with 63 patients.

UNLABELLED: Cultured epithelial autografts (CEAs) have long been used to tackle limited donor site availability and difficulty of permanent skin coverage in massive burns, but this approach still has limited documentation. METHODS: In this retrospective, single-center study, medical records of patients treated with CEAs in our burn center from 1991 until 2008 were analyzed in search of factors associated with outcome. RESULTS: Out of 68 patients, 63 records were analyzable. Patients were aged 29 [17-41.5] years (seven children). Total body surface area (TBSA) burned was 81±10%, of which 69±14% TBSA full thickness. CEAs were first applied after 45±34 days, on a surface of 32±14% TBSA. Success rate at take down was 65±19%, correlating only with young age (r(2)=0.18; p=0.0006). At discharge, CEAs covered 26±15% TBSA. Infections (4.3±2 per patient), most frequently of skin, often complicated the clinical course. Mortality was 16% (10 patients). In multivariate analysis, the number of infections was the only factor associated with mortality (OR=2.05 per single infection, 95%CI 1.03-4.07, p=0.04). CONCLUSION: Although complex and costly, CEAs can be used with reasonable success and satisfying survival results for the treatment of massive burns. In this study, favorable outcome was principally associated with young age and low number of infectious complications.

Simultaneous Reconstruction of Achilles Tendon and Soft-Tissue Defects with a Composite Anterolateral Thigh Free Flap with Vascularized Fascia Lata.

INTRODUCTION: Reconstruction to treat segmental loss of the Achilles tendon combined with soft-tissue defects can be challenging, particularly after the recurrent ruptures that may occur during intense physical activity. STEP 1 PREOPERATIVE PLANNING: Design flap and use Doppler ultrasound for perforator mapping. STEP 2 DEBRIDE WOUND AND PREPARE RECIPIENT VESSELS: Use a two-team approach, one for the affected side and one for the unaffected side. STEP 3 HARVEST THE COMPOSITE ALT FLAP: Take care to include one or two perforator vessels in the flap and to avoid vessel damage throughout the dissection. STEP 4 PERFORM VASCULAR ANASTOMOSIS: Use the posterior tibial vessel as the recipient site for the microvascular anastomosis. STEP 5 RECONSTRUCT THE ACHILLES TENDON: Suture the rolled up vascularized fascia lata sheet; then check for tension. STEP 6 POSTOPERATIVE CARE: Gradual, protected weight-bearing begins at twelve weeks. RESULTS & PREOP/POSTOP IMAGES: For recurrent tendon rupture, this single-step reconstruction saves both time and expense and it provides a functional tendon reconstruction (enabling normal daily activities) with limited donor-site morbidity and an acceptable cosmetic result without the need for a later debulking procedure. WHAT TO WATCH FOR: IndicationsContraindicationsPitfalls & Challenges.

Emerging therapy for improving wound repair of severe radiation burns using local bone marrow-derived stem cell administrations.

The therapeutic management of severe radiation burns remains a challenging issue today. Conventional surgical treatment including excision, skin autograft, or flap often fails to prevent unpredictable and uncontrolled extension of the radiation-induced necrotic process. In a recent very severe accidental radiation burn, we demonstrated the efficiency of a new therapeutic approach combining surgery and local cellular therapy using autologous mesenchymal stem cells (MSC), and we confirmed the crucial place of the dose assessment in this medical management. The patient presented a very significant radiation lesion located on the arm, which was first treated by several surgical procedures: iterative excisions, skin graft, latissimus muscle dorsi flap, and forearm radial flap. This conventional surgical therapy was unfortunately inefficient, leading to the use of an innovative cell therapy strategy. Autologous MSC were obtained from three bone marrow collections and were expanded according to a clinical-grade protocol using platelet-derived growth factors. A total of five local MSC administrations were performed in combination with skin autograft. After iterative local MSC administrations, the clinical evolution was favorable and no recurrence of radiation inflammatory waves occurred during the patient's 8-month follow-up. The benefit of this local cell therapy could be linked to the "drug cell" activity of MSC by modulating the radiation inflammatory processes, as suggested by the decrease in the C-reactive protein level observed after each MSC administration. The success of this combined treatment leads to new prospects in the medical management of severe radiation burns and more widely in the improvement of wound repair.

Is the deltopectoral flap born again? Role in postburn head and neck reconstruction.

After extensive use for head and neck reconstruction, the deltopectoral flap has been supplanted by alternative methods of reconstruction and relegated to historical references. However, it remains a very valuable skin flap and should keep its place in the armamentarium of reconstructive surgeons for postburn head and neck reconstruction. We report here five cases of head and neck reconstruction using the deltopectoral flap: one case of perioral reconstruction after ballistic trauma, one case of nasal reconstruction after burn and three cases of neck reconstruction after burn contracture. Technical simplicity and reliability are the main features of this flap. The skin paddle is thin and pliable, and its surface can be extended after a flap delay. Previous tissue expansion can minimize donor site morbidity. The flap division necessitates a second surgical procedure. The major burn contractures of the neck are, in our opinion, an excellent indication of the deltopectoral flap.

[Treatment of radiation burns with surgery and cell therapy. A report of two cases]. / Irradiation aiguü localisée: chirurgie et thérapie cellulaire. A propos de deux cas.

Treatment of severe radiation burns remains a difficult challenge. Conventional surgical treatment (excision, skin grafting, skin or muscle flaps) often fails to prevent unpredictable and uncontrolled extension of the necrotic process. We report two clinical cases in which surgery was combined with mesenchymal stem cell (MSC) therapy. Clinical outcome was good and there was no recurrence of radiation inflammatory waves observed in the first patient after one year. This novel multi-disciplinary therapeutic approach, combining physical techniques, modern plastic surgery and cell therapy should improve the medical management of severe localized radiation burns.

[Urologic presentation of acute appendicitis: a frequent cause of delayed diagnosis, including in HIV infected patients]. / Présentation urinaire d'une appendicite aiguë: une cause fréquente de retard diagnostique, également chez le sujet infecté par le virus de l'immunodéficience humaine.

Acute appendicitis rarely presents in the form or urinary tract symptoms. Atypical forms of acute appendicitis occur more frequently in subjects infected by the human immunodeficiency virus (HIV). The authors report a case of acute appendicitis in an HIV-infected subject mimicking acute pyelonephritis secondary to obstruction. Atypical forms of acute appendicitis must be diagnosed and treated as early as possible. Computed tomography plays an essential role in the diagnostic assessment of abdominal and lumbar symptoms in HIV-infected patients.