Effectiveness of a specific trauma training on war-related truncal injury management: A pre-post study.

BACKGROUND: Non-Compressible Torso Hemorrhage (NCTH) is the leading cause of preventable death in combat casualty care. To enhance the French military surgeons' preparedness, the French Military Health Service designed the Advanced Course for Deployment Surgery (ACDS) in 2008. This study evaluates behavioral changes in war surgery practice since its implementation. METHODS: Data were extracted from the OPEX® registry, which recorded all surgical activity during deployment from 2003 to 2021. All patients treated in French Role 2 or 3 Medical Treatment Facilities (MTFs) deployed in Afghanistan, Mali, or Chad requiring emergency surgery for NCTH were included. The mechanism of injury, severity, and surgical procedures were noted. Surgical care produced before (Control group) and after the implementation of the ACDS course (ACDS group) were compared. RESULTS: We included 189 trauma patients; 99 in the ACDS group and 90 in the Control group. Most injuries were combat-related (88 % of the ACDS and 82 % of the Control group). The ACDS group had more polytrauma (42% vs. 27 %; p= 0.034) and more e-FAST detailed patients (35% vs. 21 %; p= 0.044). Basics in surgical trauma care were similar between both groups, with a tendency in the ACDS group toward less digestive diversion (n= 6 [6 %] vs. n= 12 [13 %]; p= 0.128), more temporary closure with abdominal packing (n= 17 [17 %] vs. n= 10 [11 %]; p= 0.327), and less re-operation for bleeding (n= 0 [0 %] vs. n= 5 [6 %]; p= 0.046). CONCLUSION: The French model of war trauma course succeeded in keeping specialized surgeons aware of the basics of damage control surgery. The main improvements were better use of preoperative imaging and better management of seriously injured patients.

Training for a Mass Casualty Incident: Conception, Development and Implementation of a Crew-Resource Management Course for Forward Surgical Teams.

BACKGROUND: The purpose of this article is to describe the development of a crew resource management (CRM) training course dedicated for the forward surgical teams (FSTs) of the French Military Health Service. METHODS: Since 2021, the predeployment training of French FSTs has included a simulation-based curriculum consisting of organizational and human factors. It combines lectures, laboratory exercises, and situational training exercises to consider four fundamental "nontechnical" (cognitive and social) skills for effective and safe combat casualty care: (a) leadership, (b) decision-making, (c) coordination, and (d) situational awareness. RESULTS: The approach was based on three steps: (1) establishment of a conceptual framework of FSTs deployment; (2) development and implementation of an aircrew-like CRM training dedicated to combat casualty care; and (3) assessment of FSTs' CRM skills using an audio/video recording of a simulated mass-casualty incident. CONCLUSION: To ensure complete and high-quality predeployment training, French FSTs undergo a high-quality training that takes into account both technical and non-technical skills to maintain quality of combat care during mass-casualty incidents.

Ultra-forward surgical support for special operations forces. Conception, development and certification of the French Special Operations Surgical Team (SOST) airborne capability.

When special operations forces (SOF) are in action, a surgical team (SOST) is usually ground deployed as close as possible to the combat area, to try and provide surgical support within the golden hour. The French SOST is composed of 6 people: 2 surgeons, 1 scrub nurse, 1 anaesthetist, 1 anesthetic nurse and 1 SOF paramedic. It can be deployed in 45 min under a tent or in a building. However, some tactical situations prevent the ground deployment. A solution is to deploy the SOST in a tactical unprepared aircraft hold, to make it possible to offer DCS, to treat non-compressible exsanguinating trauma, without any ground logistical footprint. This article describes the stages of the design, development and certification process of the airborne SOST capability. The authors report the modifications and adaptations of the equipment and the surgical paradigms which make it possible to solve the constraints linked to the aeronautical and combat environment. Study type/level of evidence Care management Level of Evidence IV.

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.

Emergency department thoracotomy in a physician-staffed trauma system: the experience of a French Military level-1 trauma center.

PURPOSE: To investigate survival after emergency department thoracotomy (EDT) in a physician-staffed emergency medicine system. METHODS: This single-center retrospective study included all in extremis trauma patients who underwent EDT between 2013 and 2021 in a military level 1 trauma center. CPR time exceeding 15 minutes for penetrating trauma of 10 minutes for blunt trauma, and identified head injury were the exclusion criteria. RESULTS: Thirty patients (73% male, 22/30) with a median age of 42 y/o [27-64], who presented mostly with polytrauma (60%, 18/30), blunt trauma (60%, 18/30), and severe chest trauma with a median AIS of 4 3-5 underwent EDT. Mean prehospital time was 58 min (4-73). On admission, the mean ISS was 41 29-50, and 53% (16/30) of patients had lost all signs of life (SOL) before EDT. On initial work-up, Hb was 9.6 g/dL [7.0-11.1], INR was 2.5 [1.7-3.2], pH was 7.0 [6.8-7.1], and lactate level was 11.1 [7.0-13.1] mmol/L. Survival rates at 24 h and 90 days after penetrating versus blunt trauma were 58 and 41% versus 16 and 6%, respectively. If SOL were present initially, these values were 100 and 80% versus 22 and 11%. CONCLUSION: Among in extremis patients supported in a physician-staffed emergency medicine system, implementation of a trauma protocol with EDT resulted in overall survival rates of 33% at 24 h and 20% at 90 days. Best survival was observed for penetrating trauma or in the presence of SOL on admission.

Prognostic impact of splenic vessel involvement and tumor size in distal pancreatectomy for adenocarcinoma: a retrospective multicentric cohort study.

PURPOSE: Splenic vessel involvement occurs frequently in pancreatic ductal adenocarcinoma (PDAC) of the body and the tail (B/T) but the impact on survival is unknown. We assessed the influence of radiological and pathologic involvement of splenic artery (p-SA +) and vein (p-SV +) on patient outcomes after distal pancreatectomy (DP) for PDAC. METHODS: From 2013 to 2019, all DP for PDAC in five centers were included. Factors associated with overall (OS) and disease-free (DFS) survival were identified. RESULTS: Among the 76 patients included, 5 (6.6%) had p-SA + only, 11 (14.5%) had p-SV + only, and 24 (31.6%) had both p-SA + and p-SV + . The preoperative CT-scan accuracy to predict p-SV + and p-SA + was high (sensitivity: 91.4% and 82.8%, respectively; negative predictive value: 89.7% and 88.3%, respectively). The 5-year OS and DFS rates were 3.9% and 8.3%, respectively. Multivariate analysis identified splenic vessel involvement (i.e., p-SA + or p-SV + , or both p-SA + and p-SV +) as the only independent factor influencing DFS (HR 4.04; 95% CI [1.22-13.44], p = 0.023). Tumor size ≥ 30 mm was the only independent factor influencing OS (HR 4.04; 95% CI [1.26-12.95], p = 0.019) and was associated with a high risk of p-SA + (p = 0.001) and p-SV + (p < 0.001). CONCLUSION: Tumor size ≥ 30 mm and splenic vessel involvement occurred in more than half of the patients who underwent DP for PDAC and had negative impact on long-term survival. Preoperative CT-scan was reliable to identify splenic vessel involvement in B/T PDAC. Large tumor size and radiological splenic vessel involvement could be taken into account to propose a neoadjuvant treatment.

Role of Cancer Surgery in the Improvement of the Operative Skills of Military Surgeons During Deployment: A Single-Center Study.

INTRODUCTION: The maintenance of military surgeons' operative skills is challenging. Different and specific training strategies have been implemented in this context; however, little has been evaluated with regard to their effectiveness. Cancer surgery is a part of military surgeons' activities in their home hospitals. This study aimed to assess the role of oncological surgery in the improvement of military surgeons' operative skills. METHODS: Between January and June 2019, the surgical activities of the departments of visceral, ear, nose, and throat, urological, and thoracic surgery were retrospectively reviewed and assessed in terms of the operative time (OT). All surgeons working at the Sainte Anne Military Teaching Hospital were sent a survey to rate on a 5-point scale the current surgical practices on their usefulness in improving surgical skills required for treating war injuries during deployment (primary endpoint) and to compare on a 10-point visual analog scale the influence of cancer surgery and specific training on surgical fluency (secondary endpoint). RESULTS: Over the study period, 2,571 hours of OT was analyzed. Oncological surgery represented 52.5% of the surgical activity and almost 1,350 hours of cumulative OT. Considering the primary endpoint, the mean rating allocated to cancer surgery was 4.53 ± 0.84, which was not statistically different than that allocated to trauma surgery (4.42 ± 1.02, P = 0.98) but higher than other surgery (2.47 ± 1.00, P < 0.001). Considering the secondary endpoint, cancer surgery was rated higher than specific training by all surgeons, without statistically significant difference (positive mean score of + 2.00; 95% IC: 0.85-3.14). CONCLUSION: This study demonstrates the usefulness of cancer surgery in improving the operative skills of military surgeons.

Early versus delayed cholecystectomy for cholecystitis at high risk of operative difficulties: A propensity score-matching analysis.

BACKGROUND: Numerous studies have demonstrated the superiority of early (EC) over delayed (DC) cholecystectomy for acute cholecystitis (AC). However, none have assessed the effect of operative difficulty when reporting on treatment outcomes. METHODS: Outcomes of patients who underwent EC or DC between 2010 and 2019 were compared taking into account the operative difficulty evaluated by the Difficult Laparoscopic Cholecystectomy score (DiLC). For each patient, the DiLC score was retrospectively calculated and corresponded to the foreseeable operative difficulty measured on admission for AC. A propensity score was used to account for confounders. Primary endpoints were the length of stay (LOS) and the occurrence of a serious operative/post-operative event (SOE). RESULTS: DC in patients with DiLC≥10 reduced the risk of SOE without increasing the LOS. Conversely, DC in patients with DiLC<10 increased the LOS without improving outcomes. Multivariate analysis found EC in patients with DiLC≥10 as the main independent predictor of SOE. CONCLUSIONS: Provided prospective validation, DC for AC in patients with DiLC≥10 seems safer than EC and is not hospital-stay consuming.

Early management of severe abdominal trauma

To develop French guidelines on the management of patients with severe abdominal trauma. A consensus committee of 20 experts from the French Society of Anaesthesiology and Critical Care Medicine (Société française d'anesthésie et de réanimation, SFAR), the French Society of Emergency Medicine (Société française de médecine d'urgence, SFMU), the French Society of Urology (Société française d'urologie, SFU) and from the French Association of Surgery (Association française de chirurgie, AFC), the Val-de-Grâce School (École du Val-De-Grâce, EVG) and the Federation for Interventional Radiology (Fédération de radiologie interventionnelle, FRI-SFR) was convened. Declaration of all conflicts of interest (COI) policy by all participants was mandatory throughout the development of the guidelines. The entire guideline process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system for assessment of the available level of evidence with particular emphasis to avoid formulating strong recommendations in the absence of high level. Some recommendations were left ungraded.

Early management of severe abdominal trauma.

OBJECTIVE: To develop French guidelines on the management of patients with severe abdominal trauma. DESIGN: A consensus committee of 20 experts from the French Society of Anaesthesiology and Critical Care Medicine (Société française d'anesthésie et de réanimation, SFAR), the French Society of Emergency Medicine (Société française de médecine d'urgence, SFMU), the French Society of Urology (Société française d'urologie, SFU) and from the French Association of Surgery (Association française de chirurgie, AFC), the Val-de-Grâce School (École du Val-De-Grâce, EVG) and the Federation for Interventional Radiology (Fédération de radiologie interventionnelle, FRI-SFR) was convened. Declaration of all conflicts of interest (COI) policy by all participants was mandatory throughout the development of the guidelines. The entire guideline process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system for assessment of the available level of evidence with particular emphasis to avoid formulating strong recommendations in the absence of high level. Some recommendations were left ungraded. METHODS: The guidelines are divided in diagnostic and, therapeutic strategy and early surveillance. All questions were formulated according to Population, Intervention, Comparison, and Outcomes (PICO) format. The panel focused on three questions for diagnostic strategy: (1) What is the diagnostic performance of clinical signs to suggest abdominal injury in trauma patients? (2) Suspecting abdominal trauma, what is the diagnostic performance of prehospital FAST (Focused Abdominal Sonography for Trauma) to rule in abdominal injury and guide the prehospital triage of the patient? and (3) When suspecting abdominal trauma, does carrying out a contrast enhanced thoraco-abdominal CT scan allow identification of abdominal injuries and reduction of mortality? Four questions dealt with therapeutic strategy: (1) After severe abdominal trauma, does immediate laparotomy reduce morbidity and mortality? (2) Does a "damage control surgery" strategy decrease morbidity and mortality in patients with a severe abdominal trauma? (3) Does a laparoscopic approach in patients with abdominal trauma decrease mortality or morbidity? and (4) Does non-operative management of patients with abdominal trauma without bleeding reduce mortality and morbidity? Finally, one question was formulated regarding the early monitoring of these patients: In case of severe abdominal trauma, which kind of initial monitoring does allow to reduce the morbi-mortality? The analysis of the literature and the recommendations were conducted following the GRADE® methodology. RESULTS: The SFAR/SFMU Guideline panel provided 15 statements on early management of severe abdominal trauma. After three rounds of discussion and various amendments, a strong agreement was reached for 100% of recommendations. Of these recommendations, five have a high level of evidence (Grade 1±), six have a low level of evidence (Grade 2±) and four are expert judgments. Finally, no recommendation was provided for one question. CONCLUSIONS: Substantial agreement exists among experts regarding many strong recommendations for the best early management of severe abdominal trauma.

Unstable Pelvic Fracture Reduction Under Ultrasonographic Control.

Managing acute trauma cases in military and low-resource environments usually requires adapted medicosurgical protocols to achieve best medical results with limited technical capacity. We report a case of unstable pelvic fracture that needed ultrasonographic assessment for closed reduction before external stabilization. In our opinion, ultrasonographic control should be considered as a useful technique for unstable pelvic fracture reduction and an alternative to radiographic control.

Deployment of the Surgical Life-saving Module (SLM) in 2017: Lessons learned in setting up and training operational surgical units.

INTRODUCTION: The military operations carried out by the French armed forces, occasionally require the use of the Surgical Life-saving Module (SLM), to ensure the surgical support of its soldiers. Due to its extreme mobility and capacity of fast deployment, SLM is particularly useful in small-scale military operations, such as Special Forces missions. In 2017, the French SLM was for the first time used to ensure surgical support of allied forces, which were lacking forward surgical capabilities. MATERIALS AND METHODS: the SLM is a mobile, heliborne, airborne, surgical structure with parachuting capability onto land or sea, therefore essentially focused on life-saving procedures, also known as "damage control" surgery. Due to the need for mobility and rapid implementation, the SLM is limited to a maximum of 5 interventions or, in terms of injuries, to 1 or 2 seriously injured patients. RESULTS: Over a period of 2 months, 5 medical teams were successively deployed with the SLM. A total of 157 casualties were treated. The most common injuries were caused by shrapnel 561%), followed by firearms (36%), and blunt trauma (2.5%). Injuries included the limbs (56%), thorax (18%), abdomen (13%), head (11%), and neck (2%). The average ISS was 8.5 (1-25) with 26 patients presenting with an ISS greater than or equal to 15. The average NISS was 10.8 (1-75) with 34 casualties having an NISS equal to or greater than 15. The surgical procedures were broken down as follows: 126 dressings, 16 laparotomies, 7 thoracotomies, 12 isolated thoracic drains (without thoracotomy), 1 cervicotomy, 12 amputations, 7 limb splints, 2 limb fasciotomies, 2 external fixators and 1 femoral fracture traction. CONCLUSIONS: The numerous SLM deployments in larger operations highlighted its ability to adapt both in terms of equipment and personnel. Continuous management of equipment logistics, robust personnel training, and appropriate organization of the evacuation procedures, were the key elements for optimizing combat casualty care. As a consequence, the SLM appears to be an operational surgical unit of choice during deployments.

Strategic proposal for a national trauma system in France.

In this road map for trauma in France, we focus on the main challenges for system implementation, surgical and radiology training and upon innovative training techniques. Regarding system organisation: procedures for triage, designation and certification of trauma centres are mandatory to implement trauma networks on a national scale. Data collection with registries must be created, with a core dataset defined and applied through all registries. Regarding surgical and radiology training, diagnostic-imaging processes should be standardised and the role of the interventional radiologist within the trauma team and the trauma network should be clearly defined. Education in surgery for trauma is crucial and recent changes in medical training in France will promote trauma surgery as a specific sub-specialty. Innovative training techniques should be implemented and be based on common objectives, scenarios and evaluation, so as to improve individual and team performances. The group formulated 14 proposals that should help to structure and improve major trauma management in France over the next 10 years.

Management of Chyloretroperitoneum After Lumbar Surgery by Anterior Approach.

BACKGROUND: Anterior lumbar approach, routinely used in spinal surgery, provides many advantages, specifically avoidance of manipulation and potential injury to nervous system structures; it also provides indirect central and foraminal decompression, with a complication rate of 1%-3%. Chyloretroperitoneum is a rare complication of spinal procedures using anterior lumbar approach. The aim of this study was to discuss diagnosis, treatment, and management of chyloretroperitoneum based on review of the international literature through 2017. METHODS: The literature review was conducted using the terms "chyloretroperitoneum," "spinal surgery," and "lymphocele." Additionally, an illustrative case of chyloretroperitoneum following anterior retroperitoneal lumbar approach was presented. RESULTS: In 33 cases, including the present case, clinical symptoms appeared after discharge in 75.8% (n = 25) and reflected direct mass effect. Abdominopelvic computed tomography permitted assessment of the fluid collection observed as a hypodense collection around the psoas muscle. In 24 cases, drainage of the chyloretroperitoneum was maintained for a mean duration of 2.9 days. Surgery was performed in 14 patients (42.4%) owing to lymphatic collection. In 5 cases, surgery was performed for direct lymphatic vessel treatment. Laparoscopic marsupialization of the collection and peritoneal fenestration were performed, especially after percutaneous drainage failure. CONCLUSIONS: Computed tomography was the most useful imaging modality for diagnosis and assessment of associated complications. If puncture alone is not sufficient and should be avoided, percutaneous computed tomography-guided drainage with sclerosing agent administration appears to be a safe and efficient first-line treatment. Laparoscopic fenestration should be used in cases of complicated or recurrent lymphoceles.

Influence of Age on Sleeve Gastrectomy Results.

INTRODUCTION: Sleeve gastrectomy (SG) has been a booming technique for 10 years. Bariatric surgery in patients over 50 years can be an effective solution on weight loss and comorbidities. The association with the nutritional and psychological care is essential to allow a true change of life mode. We are studying the mid-term (3-year) outcomes after SG in patients over 50 years of age. METHODS: This retrospective study analyzes patients treated between January 2011 and December 2013. The 129 patients were divided into three groups: under 35 years (n = 52), 35-50 years (n = 49), and over 50 years (n = 28). RESULTS: The excess weight loss at 3 years were 75% for the under 35 years, 82% for the 35-50 years, and 69% for the over 50 years. Follow-up compliance at 3 years was 66%, 68%, 75%, respectively. Comorbidities were improved in all three groups with no significant difference for each comorbidity. CONCLUSION: SG is an effective technique on weight and comorbidities. The results at 3 years are similar in patients over the age of 50 who seem more able to follow up and change lifestyle.