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Resume La prise en charge des saignements massifs du mediastin posterieur chez les patients traumatises severe reside en une chirurgie de type damage control ou bien une arterio embolisation. Nous rapportons le cas d’un traumatise severe presentant une burst fracture rachidienne compliquee d’un hemothorax massif necessitant l’utilisation de compresses hemostatiques (Quick Clot Combat Gauze). Une telle prise en charge a deja ete decrite lors d’experiences animales ou bien exceptionnellement lors de cas cliniques. Les compresses hemostatiques pourraient etre une alternative en cas d’hemostase chirurgicale difficile, mais leur usage intracorporel a besoin d’etre etudie au travers d’essais randomises controles.

Riassunto Le fistole eso-tracheo-bronchiali benigne acquisite dell’adulto sono situazioni cliniche rare, ma sempre complesse. Questa patologia si verifica, il piu delle volte, in pazienti debilitati da un lungo ricovero in terapia intensiva e associa una contaminazione cronica dell’albero bronchiale a una grave malnutrizione. La strategia terapeutica e multidisciplinare e combina il trattamento medico con una gestione endoscopica e chirurgica. Deve concentrarsi sulla definizione del momento ottimale per la riparazione chirurgica, mentre la tecnica utilizzata dipendera dalla sede della fistola. Se si deve privilegiare la riparazione ideale, a volte puo essere necessaria l’esclusione temporanea o definitiva del tubo digerente. Dopo un breve richiamo fisiopatologico ed eziologico, la strategia terapeutica viene descritta in dettaglio e illustrata con l’ausilio di foto e video.

Resume La thoracotomie de ressuscitation est une procedure exceptionnelle dont la pratique reste, en France, marginale. Ses objectifs sont au nombre de 5 et repondent point par point aux causes d’arret cardiaque traumatique : lever une tamponnade pericardique, controler une hemorragie cardiaque, realiser un massage cardiaque interne, clamper l’aorte thoracique descendante et controler les lesions pulmonaires et les autres hemorragies intrathoraciques. Cette demarche s’integre dans une strategie de Damage control, avec un objectif de temps operatoire inferieur a 60 minutes. Elle est indiquee chez les patients victimes d’un arret cardiaque traumatique penetrant si la duree de la RCP est

Resuscitation thoracotomy is a rarely performed procedure whose use, in France, remains marginal. It has five specific goals that correspond point-by-point to the causes of traumatic cardiac arrest: decompression of pericardial tamponade, control of cardiac hemorrhage, performance of internal cardiac massage, cross-clamping of the descending thoracic aorta, and control of lung injuries and other intra-thoracic hemorrhage. This approach is part of an overall Damage Control strategy, with a targeted operating time of less than 60minutes. It is indicated for patients with cardiac arrest after penetrating thoracic trauma if the duration of cardio-pulmonary ressuscitation (CPR) is15minutes, or10minutes in case of closed trauma, and for patients with refractory shock with systolic blood pressure65mm Hg. The overall survival rate is 12% with a 12% incidence of neurological sequelae. Survival in case of penetrating trauma is 10%, but as high as 20% in case of stab wounds, and only 6% in case of closed trauma. As long as the above-mentioned indications are observed, resuscitation thoracotomy is fully justified in the event of an afflux of injured victims of terrorist attacks.

Resume La prise en charge des traumatismes penetrants abdominaux, pelviens, vasculaires et des confins depend du statut hemodynamique du blesse et du type de lesions, sachant que l’association lesionnelle est la regle. Leur gravite est liee au risque hemorragique initial puis au risque septique secondaire et enfin aux sequelles des associations lesionnelles. En cas d’instabilite hemodynamique, l’objectif de la prise en charge est l’obtention rapide de l’hemostase et de la coprostase. Cette attitude conduira a realiser une laparotomie d’emblee pour les plaies abdominales, un packing sous-peritoneal (PSP) et la mise en place d’un ballon d’occlusion aortique (REBOA) au dechoquage pour les plaies pelviennes, la pose d’un shunt vasculaire temporaire (SVT) pour les traumatismes des vaisseaux proximaux des membres et la ligature pour les lesions hemorragiques des vaisseaux distaux et enfin le controle des saignements exteriorises au moyen de garrot tourniquet, de pansement compressifs jonctionnels ou de compresses hemostatiques pour les plaies des confins. En cas de stabilite hemodynamique, des examens d’imagerie preoperatoire permettront un bilan lesionnel plus precis, notamment en ce qui concerne les lesions retroperitoneales ou thoraco-abdominales, difficilement explorable chirurgicalement. Les voies d’abord chirurgicales seront larges, systematisees, agrandies a la demande permettant d’appliquer les principes du damage control.

Resume Introduction En France, le traitement non operatoire (TNO) des traumatismes penetrants n’est pas une prise en charge communement admise. Le but de notre etude est d’evaluer la faisabilite du TNO comme traitement de certaines plaies penetrantes de l’abdomen dans 3 hopitaux du sud-est de la France. Methodologie Cette etude est multicentrique et retro-prospective de janvier 2010 a septembre 2013. Tout patient ayant une plaie penetrante de l’abdomen par arme blanche (AB) ou par arme a feu (AF) est inclus. Les patients presentant des signes d’abdomen aigu ou une instabilite hemodynamique sont immediatement pris en charge au bloc operatoire. Ceux qui sont stables beneficient d’une tomodensitometrie (TDM) avec injection. Si aucune lesion intra-abdominale necessitant une chirurgie en urgence n’est retrouvee au TDM les patients sont surveilles de facon rapprochee. Les criteres evalues dans l’etude sont le taux d’echec du TNO et sa morbidite, le taux de procedure non therapeutique (PNT) et sa morbidite, la duree d’hospitalisation et une analyse de cout. Resultats Cent patients sont inclus. Un patient est mort a l’admission. Vingt-sept sont selectionnes pour un TNO (20 AB et 7 AF). Le taux de morbidite est de 18 %. Le taux d’echec est de 7,4 % (2 patients) et il n’y a aucun mort. Soixante-douze patients ont ete operes et parmi eux 22 ont eu une PNT. Dans ce sous-groupe, la morbidite est de 9 % et la mortalite nulle. La duree mediane d’hospitalisation est de 4 jours pour le groupe TNO et de 5,5 jours pour le groupe opere. L’analyse de cout montre un avantage economique certain du TNO. Conclusion La realisation d’un TNO pour certains traumatismes penetrants de l’abdomen est faisable, meme en France. Les indications peuvent etre etendues a certaines plaies par AF. Les criteres cliniques sont clairement definis mais les criteres scannographiques doivent etre plus detailles pour ameliorer la selection des patients. Le TNO reduit le cout et la duree d’hospitalisation.

Background: Optimal surgical management of spinal injuries as part of life-threatening multiple traumas remains challenging. We provide insights into the surgical management of spinal injuries in polytrauma patients. Methods: All patients from our polytrauma care network who both met at least one positive Vittel criteria and an injury severity score (ISS) >15 at admission and who underwent surgery for a spinal injury were included retrospectively. Demographic data, clinical data demonstrating the severity of the trauma and imaging defining the spinal and extraspinal number and types of injuries were collected.Results: Between January 2012 and December 2016, 302 (22.2%) patients suffered from spinal injury (143 total injuries) and 83 (6.1%) met the inclusion criteria. Mean ISS was 36.2 (16-75). Only 48 (33.6%) injuries led to neurological impairment involving the thoracic (n = 23, 16.1%) and lower cervical (n = 15, 10.5%) spine. The most frequent association of injuries involved the thoracic spine (n = 42). 106 spinal surgeries were performed. The 3-month mortality rate was 2.4%.Conclusions: We present data collected on admission and in the early postoperative period referring to injury severity, the priority of injuries, and development of multi-organ failure. We revealed trends to guide the surgical support of spinal lesions in polytrauma patients.

Use of chronic intermittent hemodialysis is recent in Chad, where it remains underdeveloped. Vascular access is most commonly by catheter. The objective of our study was to demonstrate the feasibility of arteriovenous fistula (AVF) surgery for hemodialysis during deployments as part of the medical civic action program (MEDCAP).We prospectively included all patients admitted for AVF creation at Camp Kossei forward surgical unit in N'Djamena (Chad) between December 2016 and February 2017. Surgery was performed by an experienced vascular surgeon. The data collected included age, sex, cause of kidney failure, type of anesthesia, AVF location, and the duration of the intervention and hospitalization. Patients were examined one month after the procedure to evaluate the functionality, morbidity, and mortality of the AVF.We performed 17 AVF in 3 months. Male to female ratio was 3. High blood pressure was the main cause of chronic kidney failure (55%). All interventions were conducted under locoregional anesthesia. Overall, 35% of fistulae were radiocephalic, 41% brachiocephalic, and 24% brachiobasilic. The mean duration of intervention was 58 minutes and that of hospitalization one day. No deaths occurred. Global morbidity, including non-functioning AVF, was 25%.Our study showed that AVF surgery is feasible during deployment, especially in Chad, and meets the needs of the local healthcare facilities. It should be developed and taught to local surgeons.

BACKGROUND: This study reports the challenges faced by French military surgeons in the management of thoracic injury during the latest Afghanistan war. METHODS: From January 2009 to April 2013, all of the civilian, French and Coalition casualties admitted to French NATO Combat Support Hospital situated on Kabul were prospectively recorded in the French Military Health Service Registry (OPEX(®)). Only penetrating and blunt thoracic trauma patients were retrospectively included. RESULTS: Eighty-nine casualties were included who were mainly civilian (61%) and men (94%) with a mean age of 27.9 years old. Surgeons dealt with polytraumas (78%), severe injuries (mean Injury Severity Score=39.2) and penetrating wounds (96%) due to explosion in 37%, gunshot in 53% and stabbing in 9%. Most of casualties were first observed or drained (n=56). In this non-operative group more than 40% of casualties needed further actions. In the operative group, Damage Control Thoracotomy (n=22) was performed to stop ongoing bleeding and air leakage and Emergency Department Thoracotomy (n=11) for agonal patient. Casualties suffered from hemothorax (60%), pneumothorax (39%), diaphragmatic (37%), lung (35%), heart or great vessels (20%) injuries. The main actions were diaphragmatic sutures (n=25), lung resections (wedge n=6, lobectomy n=4) and haemostasis (intercostal artery ligation n=3, heart injury repairs n=5, great vessels injury repairs n=5). Overall mortality was 11%. The rate of subsequent surgery was 34%. CONCLUSIONS: The analysis of the OPEX(®) registry reflects the thoracic surgical challenges of general (visceral) surgeons serving in combat environment during the latest Afghanistan War.Copyright © 2016 Elsevier Ltd. All rights reserved. Language: en

Resume L’accueil hospitalier des traumatises severes est multidisciplinaire, coordonne par un « trauma leader » et doit etre anticipe dans chaque etablissement amene a recevoir ces patients. Des l’acceptation du malade, l’ensemble de l’equipe doit se preparer en amont afin qu’il n’y ait pas de rupture avec la prise en charge pre-hospitaliere. Une strategie diagnostique et therapeutique protocolisee et connue de tous les acteurs permet d’optimiser la prise en charge des blesses hemorragiques instables, chez qui le bon geste d’hemostase doit survenir le plus precocement possible pour diminuer les consequences morbides du choc post-traumatique. Chez un patient en detresse ventilatoire, circulatoire ou neurologique, certains gestes chirurgicaux doivent parfois etre realises sans delai, par tout chirurgien en situation d’exception si necessaire. Nous detaillons ici l’ensemble de ces gestes salvateurs : abord invasif des voies aeriennes superieures, thoracostomie de decompression, principes des thoracotomie d’hemostase ou de ressuscitation, laparotomie d’hemostase, packing pelvien preperitoneal et exofixation du bassin par pelvi-clamp, craniotomie de decompression,… Ces procedures sont accessibles a tout praticien mais requierent une polyvalence et une formation prealable.

Damage control for thoracic trauma combines definitive and temporary surgical gestures specifically adapted to the lesions present. A systematic assessment of all injuries to prioritize the specific lesions and their treatments constitutes the first operative stage. Packing and temporary closure have a place in the care of chest injuries.

Resume La specificite du damage control au niveau thoracique est l’association de gestes chirurgicaux definitifs et provisoires adaptes aux lesions. Le bilan lesionnel systematique hierarchisant les lesions et leurs traitements constitue le premier temps operatoire. Le packing et la fermeture provisoire ont une place pour les atteintes thoraciques.

Contexte Les Serious Games (SG) correspondent a des jeux educatifs integrant des programmes de soins, d’education therapeutique et d’enseignement. La menace terroriste actuelle a fait ressortir un besoin de formation des equipes soignantes au triage des blesses en situation degradee. Objectif L’objectif est de montrer la superiorite de l’enseignement par SG concernant la performance du triage en analysant les facteurs de cette performance : acquisition des notions de triage et gestes qui sauvent, adhesion aux supports d’enseignement et gestion des emotions. Methodes TRAUMASIMS est un SG developpe par l’entreprise Medusims avec la participation du Service de Sante des Armees. Ce jeu immersif met l’apprenant en situation de medecin trieur confronte a un afflux de blesses. La population de l’etude correspond aux praticiens des armees en fin de formation initiale, randomises en deux groupes (Group SG = 40 ; Group controle = 40). Le groupe controle suit la formation existante en trois modules : enseignement magistral (1 h), simulation sur support textuel (2 h) et simulation pleine echelle (2 h). La simulation sur support textuel est remplacee dans le second groupe par le SG (2 h). La performance est evaluee lors de la simulation pleine echelle par 2 investigateurs independants ; l’acquisition des notions de triages par des pre et post tests ; l’acceptabilite et la performance immersive (realisme, immersion, sentiment de presence) du support par questionnaires ; et la gestion des emotions par autoevaluations successives (echelles d’evaluation cognitives validees en neuroscience). Resultats Les resultats preliminaires de cette etude, tant sur le plan emotionnel que sur le plan technique, seront exposes lors de notre presentation.

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.

Resume Introduction Le pneumothorax (PNO) catamenial est une entite clinique classique mais rare. Plusieurs cas rapportes dans la litterature permettent d’evoquer le diagnostic devant un PNO spontane droit en debut de periode catameniale chez les femmes trentenaires. La prise en charge medico-chirurgicale ne fait en revanche l’objet d’aucun consensus, le taux de recidive est tres eleve quelle que soit la prise en charge initiale. Patientes et methode Parmi 310 cas de PNO spontanes operes dans notre institution en dix ans, nous avons identifie cinq cas de PNO catameniaux. L’etude retrospective de ces dossiers a permis d’etudier les donnees operatoires initiales, notamment l’existence de lesions endothoraciques et le choix de la technique de symphyse pleurale. Le suivi des patientes etait clinique et radiologique. Ont ainsi ete etudie la prise d’un traitement hormonal adjuvant les recidives et leurs modalites de traitement. Resultats Il s’agit de cinq patientes d’âge moyen 37,6 ans (37,38) qui avaient presente 2,6 (2,3) episodes de PNO spontanes droit en periode catameniale avant leur hospitalisation en chirurgie pour un nouvel episode. Aucune patiente n’etait fumeuse. Deux d’entre elles avaient une endometriose pelvienne ou thoracique connue. Le geste chirurgical initial etait une pleurectomie parietale sous video-thoracoscopie deux fois associee a la mise en place d’une plaque de renfort parietal resorbable sur le diaphragme pour des fentes diaphragmatiques. Il n’y a pas eu de complications postoperatoires immediates, et la duree moyenne de sejour etait de 6,6 jours (5,9). Deux patientes ont eu un traitement hormonal adjuvant. Toutes les patientes ont eu au moins une recidive et trois d’entre elles ont du etre reoperees. Conclusion Le diagnostic de PNO catamenial doit etre evoque chez toute femme qui presente un pneumothorax spontane droit en periode catameniale. L’endometriose doit etre systematiquement recherchee. Une attitude therapeutique standardisee visant a etablir la place de chirurgie et la technique la plus appropriee ainsi que l’opportunite et la duree d’un traitement hormonal perioperatoire reste a definir.

Resume Introduction Les traumatismes fermes du thorax sont frequents. Il est souvent difficile d’apprecier leur gravite. Le risque de lesions occultes qui peuvent decompenser secondairement est reel. Etat des connaissances Comme souvent en traumatologie du tronc, peu de publications permettent de degager des standards diagnostiques et therapeutiques. Perspectives Les auteurs rappellent les bases physiopathologiques de ces traumatismes et proposent une prise en charge standardisee incluant le diagnostic et les premieres mesures therapeutiques. Conclusions Les traumatismes fermes du thorax doivent faire l’objet d’une evaluation initiale rigoureuse afin d’eviter les pieges diagnostiques qui peuvent conduire a des decompensations respiratoires graves.

Summary Introduction In France, non-operative management (NOM) is not the widely accepted treatment for penetrating wounds. The aim of our study was to evaluate the feasibility of NOM for the treatment of penetrating abdominal traumas at 3 hospitals in the Southeast of France. Methodology Our study was multicentric and retroprospective from January, 2010 to September, 2013. Patients presenting with a penetrating abdominal stab wound (SW) or gunshot wound (GSW) were included in the study. Those with signs of acute abdomen or hemodynamic instability had immediate surgery. Patients who were hemodynamically stable had a CT scan with contrast. If no intra-abdominal injury requiring surgery was evident, patients were observed. Criteria evaluated were failed NOM and its morbidity, rate of non-therapeutic procedures (NTP) and their morbidity, length of hospital stay and cost analysis. Results One hundred patients were included in the study. One patient died at admission. Twenty-seven were selected for NOM (20 SW and 7 GSW). Morbidity rate was 18%. Failure rate was 7.4% (2 patients) and there were no mortality. Seventy-two patients required operation of which 22 were NTP. In this sub-group, the morbidity rate was 9%. There were no mortality. Median length of hospital stay was 4 days for the NOM group and 5.5 days for group requiring surgery. Cost analysis showed an economic advantage to NOM. Conclusion Implementation of NOM of penetrating trauma is feasible and safe in France. Indications may be extended even for some GSW. Clinical criteria are clearly defined but CT scan criteria should be better described to improve patient selection. NOM reduced costs and length of hospital stay.

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.

Le fistole esofago-tracheo-bronchiali benigne acquisite dell’adulto sono delle situazioni cliniche rare, ma sempre complesse. In effetti, questa patologia compare il piu delle volte in pazienti debilitati da un lungo ricovero in rianimazione e associa una contaminazione cronica dell’albero bronchiale a una denutrizione grave. La strategia terapeutica deve definire il momento ottimale della riparazione chirurgica. La tecnica dipende dalla sede della fistola. Benche debba essere privilegiata la riparazione ideale, puo essere a volte necessaria l’esclusione temporanea o definitiva della filiera digestiva.

Resume Les parasitoses pulmonaires sont des pathologies rares en France et de diagnostic difficile. Si de nombreux parasites peuvent etre responsables de manifestations respiratoires, seuls quelques uns peuvent se developper dans le parenchyme et y entrainer des complications relevant d’une prise en charge chirurgicale. L’exemple le plus commun est le kyste hydatique du poumon. Les auteurs passent en revue les cycles, les formes cliniques, le diagnostic et les principes therapeutiques des principaux parasites pulmonaires qui relevent d’une prise en charge chirurgicale.

Bronchial injury is a rare and serious complication after a blunt trauma. An early management can provide complete recovery. We describe two cases of blunt bronchial injury. The two cases showed some common features, but the surgical management was different and so the courses. Indications for a surgical management of this kind of lesion are not univocal in the literature. In most of the cases, non-operative management has to be discussed for moderate lesions in high-risk surgical population. We proposed a surgical indication for severe tracheo-bronchial injury (TBI), for TBI associated to other intra-thoracic lesion and for lesion involving carinal region. Co-operation with the emergency team is necessary.

Acute mediastinitis is a life-threatening complication (20 to 40 % of mortality) secondary to oropharyngeal abscesses, neck infections or oesophageal leak spreading into the mediastium. Early diagnosis and optimal therapeutic approach are crucial for patient survival. CT scanning of the cervical and thoracic area is a useful tool for diagnosis and follow-up. Treatment is based on broad-spectrum antibiotherapy, adequate surgery, mediastinal drainage, and treatment of possible organ failure. There is no surgical standardized attitude. Mini-invasive approach could be satisfactory when prompt diagnosis is established and the thoracic drainage is effective. Repeated postoperative CT scanning and close clinical and laboratory monitoring could make an additional thoracotomy a second-line procedure.

Mediastinal tumors are relatively uncommon, usually incidentally discovered on a chest X-ray in asymptomatic patients. Young adults are particularly concerned. Mediastinal masses represent a group of heterogeneous histological type cell. A definite diagnosis is essential leading to an adequate prompt therapeutic strategy when either benign disease or aggressive malignant tumor is conceivable. Indeed the therapeutic management of such tumors could be strictly medical, requiring exclusive surgical approach or includes a multimodal treatment. Clinical examination and imaging are important tools in the diagnostic approach. However the specific diagnosis could be complex and requires histological confirmation by an experienced pathologist after examination of large biopsies of the tumor. Several investigations, including surgical invasive exploration, should be quickly requested in order to achieve a final diagnosis and refer patients in an adequate therapeutic scheme without delay. The aim of this article is to point out the available diagnostic tools in mediastinal masses, including surgical approach, and to identify the role of surgical resection in specific subtypes.

Le vie di accesso toracoaddominali sono quelle di elezione per la chirurgia aortica, esofagea e in alcuni settori della chirurgia generale in elezione o in urgenza. Una buona conoscenza anatomica del diaframma e della regione toracoaddominale consente di adattare al meglio il gesto chirurgico alle circostanze. Dalla scelta dello spazio intercostale, dal tipo di dissezione e dalla sezione del diaframma dipendono la semplicita di esposizione e, in parte, il decorso generale dell’intervento. In queste vie di accesso la branca posteriore del nervo frenico viene ampiamente esposta e una buona conoscenza dell’anatomia del diaframma ne consente una buona sezione e riparazione. La via toracoaddominale puo essere scelta in due situazioni. Si puo trattare di un’indicazione nel settore della chirurgia in elezione, sia come prima scelta per avere una buona esposizione, sia in seconda battuta per ampliare verso il torace un accesso addominale o verso l’addome un accesso toracico. Puo inoltre essere scelta come accesso in regime di urgenza dettata da alcune circostanze particolari (patologia toracica traumatica chiusa o aperta, ferita toracoaddominale penetrante) in cui si preveda di dover ampliare una laparotomia verso il torace o, al contrario, un accesso toracico verso l’addome. In queste situazioni il chirurgo deve poter esporre e controllare tutti gli elementi vascolari degli organi sovra- e sotto diaframmatici in un unico campo operatorio. Questi accessi toracoaddominali non sono di esclusivo interesse dei chirurghi toracici o vascolari, ma di tutti i chirurghi che praticano la chirurgia generale in elezione o in urgenza. Nella prima parte di questo capitolo vengono approfondite le conoscenze anatomiche necessarie alla realizzazione di questi accessi. In una seconda parte viene descritta la tecnica chirurgica in dettaglio a seconda delle circostanze riscontate, con dettagli riguardanti la toracotomia posterolaterale con frenotomia, la toracofreno-laparatomia destra o sinistra, la toracolaparotomia o sternolaparotomia. Il testo e illustrato da schemi per una comprensione ottimale.

La mediastinite necrotizzante discendente acuta e una malattia infettiva gravata da cattiva prognosi quoad vitam in un buon numero di casi (mortalita dal 20% al 40%), causata dalla diffusione verso il mediastino di un processo infettivo a origine orofaringea o cervicale. Una diagnosi precoce e un’ottimale gestione terapeutica sono essenziali per la sopravvivenza dei pazienti. La TC toracocervicale e indispensabile per la diagnosi e la successiva gestione. La terapia si basa sugli antibiotici a largo spettro, la chirurgia e il drenaggio, nonche il trattamento di eventuali insufficienze d’organo. Sono stati proposti diversi approcci chirurgici ma la cervicotomia associata a una toracotomia convenzionale rappresentano la procedura piu appropriata. Una gestione meno invasiva puo essere raccomandata nel caso in cui la diagnosi venga fatta precocemente e che il drenaggio toracico sia efficace. La sorveglianza clinica, laboratoristica e strumentale puo indicare successivamente una toracotomia.

Surgery is the cornerstone of treatment for resectable tumours of the oesophagus. Recent advances of surgical techniques and anaesthesiology have led to a substantial decrease in mortality and morbidity. Respiratory complications affect about 30% of patients after oesophagectomy and 80% of these complications occur within the first five days. Respiratory complications include sputum retention, pneumonia and ARDS. They are the major cause of morbidity and mortality after oesophageal resection and numerous studies have identified the factors associated with these complications. The mechanisms are not very different from those observed after pulmonary resection. Nevertheless, there is an important lack of definition, and evaluation of the incidence is particularly difficult. Furthermore, respiratory complications are related to many factors. Careful medical history, physical examination and pulmonary function testing help to identify the risk factors and provide strategies to reduce the risk of pulmonary complications. Standardized postoperative management and a better understanding of the pathogenesis of pulmonary complications are necessary to reduce hospital mortality. This article discusses preoperative, intraoperative, and postoperative factors affecting respiratory complications and strategies to reduce the incidence of these complications after oesophagectomy.

Plaies du cœur, prise en charge de chirurgie cardiaque ou generale ? J.-P. Avaro, D. Grisoli, V. Gariboldi, A. Piccardo, A. Riberi, F. Kerbaul, D. Metras, F. Collart Objectif : L’objectif du travail etait de definir les modalites de prise en charge chirurgicale des patients victimes de plaies du cœur, en particulier l’orientation des blesses, le diagnostic initial et la technique chirurgicale dans le traitement de ces lesions. Methode : Il s’agissait d’une etude retrospective de patients victimes de plaies de l’aire cardiaque et pris en charge dans un service de chirurgie cardiovasculaire entre 1996 et 2006. Les donnees etudiees etaient le type de lesions, les delais de prise en charge, les donnees cliniques et paracliniques pre-operatoires, la technique chirurgicale et l’utilisation d’une circulation extracorporelle, ainsi que la morbidite et la mortalite. Resultats : Seize patients (12 hommes/4 femmes) d’âge moyen 45,7 ans (18 a 80 ans) ont ete pris en charge pour traumatisme de l’aire cardiaque. Les etiologies etaient soit des plaies penetrantes (n = 9), des traumatismes fermes (n = 2), ou des traumatismes iatrogenes (n = 5). Le delai moyen de prise en charge chirurgicale etait de 63 min (0 a 180 min). Treize patients ont ete operes. Deux ont necessite une procedure sous circulation extracorporelle. La technique de reparation a toujours ete une myoraphie sans geste intracardiaque ou chirurgie coronarienne associee. La morbidite etait de 25 % et la mortalite de 12,5 %. Les complications et les deces sont survenus chez les patients qui ont eu les delais de prise en charge les plus longs. Conclusion : Les blesses victimes de traumatisme de l’aire cardiaque doivent etre orientes vers le centre chirurgical disponible le plus proche, qu’il possede ou non un service de chirurgie cardiaque. L’utilisation d’une circulation extracorporelle, dans le contexte traumatologique, ne semble apporter aucun benefice.

L’echinococcosi e una malattia parassitaria dovuta alla contaminazione dell’uomo dalla forma larvale della Taenia echinococcus granulosus. Il polmone e la sua localizzazione preferenziale dopo il fegato. La malattia e caratterizzata dallo sviluppo di uno o piu cisti nell’ambito del parenchima con rischio di rottura e di sovrinfezione. Il trattamento medico con albendazolo e poco efficace. La chirurgia e il solo trattamento radicale. Tutte le cisti devono essere operate, che siano sintomatiche o meno. Il fine del trattamento e l’eradicazione del parassita, conservando nel contempo il massimo di parenchima funzionale. La chirurgia conservatrice comprende le tecniche di enucleazione, di cistectomia previa aspirazione e di pericistectomia. Queste procedure sono associate alla chiusura delle fistole broncopleuriche. Il capitonnage della cavita residua non e procedura sistematica. Le resezioni (segmentectomie e lobectomie) sistematiche vengono realizzate in caso di distruzione parenchimale. I risultati della chirurgia sono buoni, con mortalita dell’1% e morbilita del 3–10%. Le principali complicazioni sono le fistole aeree prolungate.

Techniques chirurgicales - Appareil digestif - Epreuve corrigee par l'auteur. Disponible en ligne depuis le 06/10/2020

Resume Les traumatismes thoraciques sont des situations frequentes qui peuvent etre a l'origine d'une detresse respiratoire et/ou hemodynamique. Les etiologies principales sont les traumatismes fermes et les plaies penetrantes du thorax. Dans 30 % des cas, les lesions thoraciques s'inscrivent dans le cadre d'un polytraumatisme. L'enjeu majeur de la prise en charge de ces blesses est l'evaluation initiale en salle de dechocage. En se fondant sur la litterature et leur experience, les auteurs definissent la prise en charge des traumatises du thorax en s'interessant particulierement a la hierarchie des examens paracliniques, a la place du drainage thoracique, et aux indications chirurgicales. L'evaluation initiale des traumatises du thorax necessite l'application systematique d'une procedure standardisee dont le but est de hierarchiser les lesions et de realiser les gestes therapeutiques salvateurs adaptes. La cooperation entre le chirurgien, le reanimateur et l'urgentiste tout au long de la prise en charge diagnostique et therapeutique de ces traumatises graves est indispensable.

Resume Introduction Le pneumomediastin spontane est une cause meconnue de douleur thoracique chez le jeune adulte. Le pronostic en est toujours favorable. Cas clinique Les auteurs rapportent deux cas de pneumomediastins spontanes survenus chez des jeunes adultes dans deux circonstances etiologiques differentes. Le premier est survenu au decours d’un effort sportif, le second au cours d’une crise d’asthme. Conclusion La discussion insiste sur la frequence de cette pathologie chez le jeune homme, son etiopathogenie et son histoire naturelle. Notamment les auteurs s’appuient sur les donnees actuelles de la science pour expliquer l’absence de facteurs predisposants et l’extreme rarete des recidives de cette pathologie benigne. La meconnaissance de cette entite clinique peut conduire a des decisions excessives tant sur le plan diagnostic que therapeutique. Les auteurs proposent une conduite a tenir devant ce type de pathologie.

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 Avance de Chirurgie en Mission Exterieure (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.

The authors report an isolated common femoral artery injury caused by blunt trauma with dissection and secondary ischaemia. A 21-year-old man was admitted to hospital after being stabbed during acute alcoholic intoxication. He presented with a stab wound on the left leg and blunt trauma in the right groin. The surgical exploration of the left-sided wound did not disclose any vascular injury. After a 12-hour period of observation, the patient was discharged. Six hours later, he came back with severe ischaemia on the right leg caused by a femoral artery dissection. The patient underwent surgical revascularization, and fully recovered. Isolated artery blunt trauma is a rare event. In this observation, the absence of early symptoms resulted in delayed diagnosis.

Catamenial pneumothorax (PNO) is a real clinical occurrence. Several cases are reported in the literature as a spontaneous PNO occurring during the catamenial period among women in their thirties. There is no consensus about management and the recurrence rate is very high whatever the initial treatment.Among 310 cases of spontaneous PNO operated in our institution in 10 years, we identified five cases of catamenial PNO. A retrospective study of these cases was used to study the initial operating data, including the existence of intrathoracic lesions and the choice of technique of pleurodesis. Patient follow-up was clinically and radiologically. Adjuvant hormonal therapies, recurrence of PNO and treatment modalities have been studied.These five patients of average age 37.6 years (37,38) who had 2.6 (2.3) episodes of right catamenial PNO before hospitalization in surgery department. No patient was smoker. Two of them had a known thoracic or pelvic endometriosis. The initial surgery was video assisted thoracic surgery with a parietal pleurectomy and twice a mesh upon the diaphragm. There were no immediate postoperative complications, and the average length of stay was 6.6 days (5.9). Two patients had adjuvant hormonal therapy. All patients had at least one recurrence and three of them had redo surgery.The diagnosis of catamenial PNO must be mentioned in any woman who has a spontaneous pneumothorax right in catamenial period. Endometriosis should be systematically sought. A standardized therapeutic approach to establish the role of surgery and the most appropriate technique as well as the appropriateness and duration of peroperative hormonal therapy remains to be defined.

Pulmonary parasitosis is scarcely encountered in France, and its diagnosis is quite difficult. If numerous parasites can be responsible for respiratory symptoms, only few of them can develop in the lung parenchyma and lead to complications necessitating a surgical treatment. The most common example is the hydatic disease of the lung. The authors review the biological cycles, clinical forms, diagnostic and treatment principles of those main lung parasites, which deserve surgical consideration.

Blunt chest trauma is a frequent injury and it can be difficult to evaluate its seriousness. The risk of acute decompensation because of an occult thoracic lesion is a significant and justified cause for concern.As is common in the case of trauma to the torso, few studies are available to guide the development of structured recommendations about the diagnosis and management of such injuries.The authors review the anatomical and physiological knowledge relevant to this kind of injury. They propose a standardized management for the diagnosis and emergency management of blunt chest trauma.The management of blunt chest trauma should include a very systematic first evaluation to avoid diagnostic pitfalls and decrease the risk of subsequent respiratory failure.

The purpose of this report is to describe a simple, reproducible technique for pleural drainage. This technique that requires scant resources should be used only in life-threatening situations calling for pleural drainage. It is not intended to replace conventional techniques.

Mediastinal tumors are relatively uncommon, usually incidentally discovered on a chest X-ray in asymptomatic patients. Young adults are particularly concerned. Mediastinal masses represent a group of heterogeneous histological type cell. A definite diagnosis is essential leading to an adequate prompt therapeutic strategy when either benign disease or aggressive malignant tumor is conceivable. Indeed the therapeutic management of such tumors could be strictly medical, requiring exclusive surgical approach or includes a multimodal treatment. Clinical examination and imaging are important tools in the diagnostic approach. However the specific diagnosis could be complex and requires histological confirmation by an experienced pathologist after examination of large biopsies of the tumor. Several investigations, including surgical invasive exploration, should be quickly requested in order to achieve a final diagnosis and refer patients in an adequate therapeutic scheme without delay. The aim of this article is to point out the available diagnostic tools in mediastinal masses, including surgical approach, and to identify the role of surgical resection in specific subtypes.