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de Lesquen H, Paris R, Lacheze S, de la Villeon B, Menini W, Lamblin A, Vacher A, Balandraud P, Pasquier P, Avaro JP. Training for a Mass Casualty Incident: Conception, Development and Implementation of a Crew-Resource Management Course for Forward Surgical Teams. J Trauma Acute Care Surg 2024:01586154-990000000-00736. [PMID: 38745350 DOI: 10.1097/ta.0000000000004380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
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.
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Affiliation(s)
- Henri de Lesquen
- Departement of Thoracic and Vascular Surgery, Sainte Anne Military Hospital, Toulon, France
| | - Raphael Paris
- Department of Anesthesiology and Intensive Care (R.P., A.L.), Laveran Military Teaching Hospital, Marseille, France
| | - Solenn Lacheze
- Département Recherche Expertise Formation Aéromédicale, French Armed Forces Biomedical Research Institute, Brétigny sur Orge, France
| | - Bruno de la Villeon
- Department of Digestive and Endocrine Surgery, Laveran Military Teaching Hospital, Marseille
| | - William Menini
- Department of Anesthesiology and Intensive Care (R.P., A.L.), Laveran Military Teaching Hospital, Marseille, France
| | | | - Anthony Vacher
- Département Recherche Expertise Formation Aéromédicale, French Armed Forces Biomedical Research Institute, Brétigny sur Orge, France
| | - Paul Balandraud
- French Military Medical Service Academy, École du Val-de-Grâce, Paris, France
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Paris R, de Lesquen H, Bernaudon É, Chouvier J, Martin É. [In situ simulation training of medical-surgical teams in the management of severe trauma patients]. Rev Infirm 2024; 73:28-29. [PMID: 38242618 DOI: 10.1016/j.revinf.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2024]
Abstract
In the management of severe trauma, the aim is to assess the patient's clinical stability as quickly as possible, enabling referral to imaging (whole-body CT scan, embolization if necessary) or the operating room, or even the decision to perform in situ surgery (resuscitation thoracotomy). To cope with these critical situations, team training is essential, with the aim of ensuring the reproducibility of the difficulties encountered. High-fidelity in situ simulation is the ideal tool for meeting this training challenge.
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Affiliation(s)
- Raphaël Paris
- Service de réanimation, Hôpital d'instruction des armées Laveran, 34 boulevard Laveran, 13013 Marseille, France.
| | - Henri de Lesquen
- Service de chirurgie thoracique, Hôpital d'instruction des armées Sainte-Anne, 2 boulevard Sainte-Anne, 83000 Toulon, France
| | - Éric Bernaudon
- Service de réanimation, Hôpital d'instruction des armées Laveran, 34 boulevard Laveran, 13013 Marseille, France
| | - Julien Chouvier
- Service de réanimation, Hôpital d'instruction des armées Laveran, 34 boulevard Laveran, 13013 Marseille, France
| | - Édouard Martin
- Service de réanimation, Hôpital d'instruction des armées Laveran, 34 boulevard Laveran, 13013 Marseille, France
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Pfister G, Aries P, de Lesquen H, Mathieu L. Extremity injuries in the Sahelian conflict: lessons learned from a French Forward Surgical Team deployed in Gao, Mali. Eur J Trauma Emerg Surg 2023; 49:2121-2128. [PMID: 37392230 DOI: 10.1007/s00068-023-02319-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 06/25/2023] [Indexed: 07/03/2023]
Abstract
PURPOSE This study aimed to analyse extremity combat-related injuries (CRIs) and non-combat related injuries (NCRIs) treated in the French Forward Surgical Team deployed in Gao, Mali. PATIENTS AND METHODS A retrospective study was conducted using the French surgical database OpEX (French Military Health Service) from January 2013 to August 2022. Patients operated on for an extremity injury less than one month old were included. RESULTS During this period, 418 patients with a median age of 28 years [range 23-31 years] were included and totalized 525 extremity injuries. Among them, 190 (45.5%) sustained CRIs and 218 (54.5%) sustained NCRIs. Multiple upper extremity injuries and associated injuries were significantly more common in the CRIs group. The majority of NCRIs involved the hand. Debridement was the most common procedure in both groups. External fixation, primary amputation, debridement, delayed primary closure, vascular repair and fasciotomy were significantly predominant in the CRIs group. Internal fracture fixation and reduction under anaesthesia were statistically more frequent in the NCRIs group. The overall number of procedures and the overall number of surgical episodes were significantly higher in the CRIs group. CONCLUSION CRIs were the most severe injuries and did not involve the upper and lower limbs separately. A sequential management was required with application of damage control orthopaedics followed by several procedures for reconstruction. NCRIs were predominant and mostly involved the hand among the French soldiers. This review supports the fact that any deployed orthopaedic surgeon should be trained in basic hand surgery and preferably have microsurgical skills. The management of local patients requires the execution of reconstructive surgery and therefore imposes the presence of adequate equipment.
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Affiliation(s)
- Georges Pfister
- Service de Chirurgie Orthopédique et Traumatologie, Hôpital d'Instruction des Armées Percy, 101 Avenue Henri Barbusse, 92140, Clamart, France.
| | - Philippe Aries
- Service de Réanimation, Hôpital d'Instruction des Armées Clermont-Tonerre, Rue du Colonel Fonferrier, 29240, Brest, France
| | - Henri de Lesquen
- Service de chirurgie thoracique, Hôpital d'Instruction des Armées Saint Anne, 2 boulevard Sainte-Anne BP600, 83000, Toulon, France
| | - Laurent Mathieu
- Service de chirurgie orthopédique et traumatologie, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69003, Lyon, France
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de Lesquen H, Paris R, Fournier M, Cotte J, Vacher A, Schlienger D, Avaro JP, de La Villeon B. Toward A Serious Game to Help Future Military Doctors Face Mass Casualty Incidents. J Spec Oper Med 2023:IJCP-BLY6. [PMID: 37126778 DOI: 10.55460/ijcp-bly6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
INTRODUCTION To prepare military doctors to face mass casualty incidents (MCIs), the French Army Health Service contributed to the development of TRAUMASIMS, a serious game (SG) for training medical responders to MCIs. METHODS French military doctors participated in a three-phase training study. The initial war trauma training was a combination of didactic lectures (Phase 1), laboratory exercises (Phase 2), and situational training exercises (STX) (Phase 3). Phase 1 lectures reviewed French Forward Combat Casualty Care (FFCCC) practices based on the acronym MARCHE (Massive bleeding, Airway, Respiration, Circulation, Head, hypothermia, Evacuation) for the detection of care priorities and implementation of life-saving interventions, triage, and medical evacuation (MEDEVAC) requests. Phase 2 was a case-control study that consisted of a traditional text-based simulation of MCIs (control group) or SG training (study group). Phase 3 was clinical: military students had to simultaneously manage five combat casualties in a prehospital setting. MCI management was evaluated using a standard 20-item scale of FFCCC benchmarks, 9-line MEDEVAC request, and time to evacuate the casualty collection point (CCP). Emotional responses of study participants were secondarily analyzed. RESULTS Among the 81 postgraduate military students included, 38 took SG training, and 35 trained with a text-based simulation in Phase 2. Regarding the error rates made during STX (Phase 3), SG improved FFCCC compliance (11.9% vs. 23.4%; p < .001). Additionally, triage was more accurate in the SG group (93.4% vs. 88.0%; p = .09). SG training mainly benefited priority and routine casualties, allowing faster clearance of the CCP (p = .001). Stress evaluations did not demonstrate any effect of immersive simulation. CONCLUSION A brief SG-based curriculum (2 hours) improved FFCCC performance and categorization of casualties in MCI STX.
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Vasse M, Leone M, Boyer L, Michelet P, Goudard Y, Cardinale M, Paris R, Avaro JP, Thomas PA, de Lesquen H. Impact of the implementation of a trauma system on compliance with evidence-based clinical management guidelines in penetrating thoracic trauma. Eur J Trauma Emerg Surg 2023; 49:351-360. [PMID: 36063196 DOI: 10.1007/s00068-022-02071-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 08/05/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Since 2014, a trauma system (TS) for the Provence-Alpes-Cote-d'Azur (PACA) region has been set up with protocols based on the European guidelines for the management of bleeding trauma patients. The present study aims to assess compliance with protocols in penetrating thoracic trauma on admission to a level I trauma centre and to determine whether compliance impacts morbidity and mortality. METHODS This multicentric pre-post study included all penetrating thoracic trauma patients referred to Marseille area level I centres between January 2009 and December 2019. On the basis of the European guidelines, eight objectively measurable recommendations concerning the in-hospital trauma care for the first 24 h were analysed. Per-patient and per-criterion compliance rates and their impact on morbidity and mortality were evaluated before and after TS implementation. RESULTS A total of 426 patients were included. No differences between the two groups (before and after 2014) were reported for demographics or injury severity. The median (interquartile range) per-patient compliance rate increased from 67% [0.50; 0.75] to 75% [0.67; 1.0] (p < 0.01) after implementation of a TS. The 30-day morbidity-mortality was, respectively, of 17% (30/173) and 13% (32/253) (p = 0.18) before and after TS implementation. A low per-patient compliance rate was associated with an increase in the 30-day morbidity-mortality rate (p < 0.01). Severity score-adjusted per-patient compliance rates were associated with decreased 30-day morbidity-mortality (odds ratio [IC 95%] = 0.98 [0.97; 0.99] p = 0.01). CONCLUSION Implementation of a TS was associated with better compliance to European recommendations and better outcomes for severe trauma patients. These findings should encourage strict adherence to European trauma protocols to ensure the best patient outcomes.
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Affiliation(s)
- Matthieu Vasse
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, French Military Health Service, Toulon, France
| | - Marc Leone
- Department of Anesthesiology and Intensive Care, Hôpital Nord, Aix Marseille University, Hôpitaux Universitaires de Marseille, Marseille, France
| | - Laurent Boyer
- CEReSS-Health Service Research and Quality of Life Center, Department of Medical Information, Aix Marseille University, Hôpitaux Universitaires de Marseille, Marseille, France
| | - Pierre Michelet
- Emergency Department, Hôpital de la Timone, Aix Marseille University, Hôpitaux Universitaires de Marseille, Marseille, France
| | - Yvain Goudard
- Department of Visceral Surgery, Laveran Military Teaching Hospital, French Military Health Service, Marseille, France
| | - Michael Cardinale
- Department of Anesthesiology and Intensive Care, Sainte Anne Military Teaching Hospital,, French Military Health Service, Toulon, France
| | - Raphael Paris
- Department of Anesthesiology and Intensive Care, Laveran Military Teaching Hospital, French Military Health Service, Marseille, France
| | - Jean Philippe Avaro
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, French Military Health Service, Toulon, France
| | - Pascal Alexandre Thomas
- Department of Thoracic Surgery, Diseases of the Esophagus and Lung Transplantation, Hôpital Nord, Aix Marseille University, Hôpitaux Universitaires de Marseille, Marseille, France
| | - Henri de Lesquen
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, French Military Health Service, Toulon, France.
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de Malleray H, Cardinale M, Avaro JP, Meaudre E, Monchal T, Bourgouin S, Vasse M, Balandraud P, de Lesquen H. Emergency department thoracotomy in a physician-staffed trauma system: the experience of a French Military level-1 trauma center. Eur J Trauma Emerg Surg 2022; 48:4631-4638. [PMID: 35633378 DOI: 10.1007/s00068-022-01995-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 05/01/2022] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
| | | | - Jean-Philippe Avaro
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Eric Meaudre
- ICU, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Tristan Monchal
- Department of Visceral Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Stéphane Bourgouin
- Department of Visceral Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Mathieu Vasse
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Paul Balandraud
- Department of Visceral Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Henri de Lesquen
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France.
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Boudin L, de Lesquen H, Patient M, Romeo E, Rivière D, Cungi PJ, Savoie PH, Avaro JP, Dagain A, Bladé JS, Balandraud P, Bourgouin S. Role of Cancer Surgery in the Improvement of the Operative Skills of Military Surgeons During Deployment: A Single-Center Study. Mil Med 2021; 186:e469-e473. [PMID: 33135732 DOI: 10.1093/milmed/usaa327] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 07/29/2020] [Accepted: 08/20/2020] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Laurys Boudin
- Department of Oncology and Haematology, Sainte Anne Military Hospital, Toulon 83000, Var, France
| | - Henri de Lesquen
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Hospital, Toulon 83000, France
| | - Matthieu Patient
- Department of Oncology and Haematology, Sainte Anne Military Hospital, Toulon 83000, Var, France
| | - Emilie Romeo
- Department of Oncology and Haematology, Sainte Anne Military Hospital, Toulon 83000, Var, France
| | - Damien Rivière
- Head and Neck Surgery Department, Sainte Anne Military Hospital, Toulon 83000, France
| | - Pierre-Julien Cungi
- Department of Anaesthesia and Critical Care, Sainte Anne Military Hospital, Toulon 83000, France
| | - Pierre-Henri Savoie
- Department of Urology, Sainte Anne Military Hospital, Toulon 83000, France.,French Military Health Service Academy, Val-de-Grâce Academy, Paris 75005, France
| | - Jean-Philippe Avaro
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Hospital, Toulon 83000, France.,French Military Health Service Academy, Val-de-Grâce Academy, Paris 75005, France
| | - Arnaud Dagain
- French Military Health Service Academy, Val-de-Grâce Academy, Paris 75005, France.,Department of Neurosurgery, Sainte Anne Military Hospital, Toulon 83000, France
| | - Jean-Sébastien Bladé
- Department of Oncology and Haematology, Sainte Anne Military Hospital, Toulon 83000, Var, France
| | - Paul Balandraud
- French Military Health Service Academy, Val-de-Grâce Academy, Paris 75005, France.,Department of Digestive Surgery, Sainte Anne Military Hospital, Toulon 83000, Var, France
| | - Stéphane Bourgouin
- Department of Digestive Surgery, Sainte Anne Military Hospital, Toulon 83000, Var, France
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de Lesquen H, Bergez M, Vuong A, Boufime-Jonqheere A, de l'Escalopier N. Adding the Capacity for an Intensive Care Unit Dedicated to COVID 19, Preserving the Operational Capability of a French Golden Hour Offset Surgical Team in Sahel. Mil Med 2020; 186:e30-e33. [PMID: 33169148 PMCID: PMC7717289 DOI: 10.1093/milmed/usaa273] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/19/2020] [Accepted: 08/05/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction In April 2020, the military medical planning needs to be recalibrated to support the COVID-19 crisis during a large-scale combat operation carried out by the French army in Sahel. Material and Methods Since 2019, proper positioning of Forward Surgical Teams (FSTs) has been imperative in peer-to-near-peer conflict and led to the development of a far-forward surgical asset: The Golden Hour Offset Surgical Team (GHOST). Dedicated to damage control surgery close to combat, GHOST made the FST aero-mobile again, with a light logistical footprint and a fast setting. On 19 and 25 March 2020, Niger and Mali confirmed their first COVID-19 cases, respectively. The pandemic was ongoing in Sahel, where 5,100 French soldiers were deployed in the Barkhane Operation. Results For the first time, the FST had to provide, continuously, both COVID critical care and surgical support to the ongoing operation in Liptako. Its deployment on a Main Operating Base had to be rethought on Niamey, to face the COVID crisis and support ongoing operations. This far-forward surgical asset, embedded with a doctrinal Role-1, sat up a 4-bed COVID intensive care unit while maintaining a casualty surgical care capacity. A COVID training package has been developed to prepare the FST for this innovative employment. This far-forward surgical asset was designed to support a COVID-19 intensive care unit before evacuation, preserving forward surgical capability for battalion combat teams. Conclusion Far-forward surgical assets like GHOST have demonstrated their mobility and effectiveness in a casualty care system and could be adapted as critical care facilities to respond to the COVID crisis in wartime.
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Affiliation(s)
- Henri de Lesquen
- 4th Forward Surgical Team, French Military Health Service, France.,Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, 8300, Toulon, France
| | - Marie Bergez
- 4th Forward Surgical Team, French Military Health Service, France.,Département d'Anésthésie-Réanimation, Etablissement Hospitalier Civilo Militaire de Metz., 57070 Metz, France
| | - Antoine Vuong
- 183ème Antenne Medical de Mont de Marsan, 12ème Centre Médical des Armées de Bordeaux, 4000 Mont de Marsan, France
| | | | - Nicolas de l'Escalopier
- 4th Forward Surgical Team, French Military Health Service, France.,Department of Orthopedic, Traumatology and Reconstructive Surgery, PERCY Military Teaching Hospital, 92140, Clamart, France
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Fievet L, Gossot D, de Lesquen H, Calabre C, Merrot T, Thomas P, Becmeur F, Grigoroiu M. Resection of Bronchogenic Cysts in Symptomatic Versus Asymptomatic Patients: An Outcome Analysis. Ann Thorac Surg 2020; 112:1553-1558. [PMID: 32599038 DOI: 10.1016/j.athoracsur.2020.05.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 04/19/2020] [Accepted: 05/01/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND The natural evolution of bronchogenic cysts (BCs) is unpredictable. Although most surgeons agree that symptomatic BCs should be resected, questions remain regarding the optimal management of asymptomatic mediastinal cysts. We present a case series of BCs to compare patients who underwent preventive operation with those who underwent surgical procedure after symptom onset. METHODS This 15-year multicenter retrospective study included 114 patients (32 children and 82 adults). Data on clinical history, pathology, mean hospital stay, intraoperative and postoperative complications, and associated intraoperative procedures were analyzed separately for symptomatic and asymptomatic patients. RESULTS A total of 53 asymptomatic patients (46.5%) were compared with 61 symptomatic patients (53.5%). There were significantly more adults in the symptomatic group than in the asymptomatic group (48 vs 34 patients, P < .05). A thoracoscopic approach was used in 88 patients (77%), with 7 conversions to thoracotomy (9%), all in symptomatic patients. There were significantly more additional procedures (20% vs 4%, P = .01) and more intraoperative complications (20% vs 4%, P = .01) in symptomatic patients, but postoperative complications between symptomatic and asymptomatic patients were similar. The postoperative length of stay was significantly longer in symptomatic patients (5.71 days vs 4 days, P < .001). Pathologic examination found significantly more inflammatory reactions in symptomatic patients. CONCLUSION Early surgical management of BCs may be recommended to prevent symptomatic complications, which are unpredictable and whose management is more complicated in advanced BCs. Surgery can be performed with a thoracoscopic approach, which is easier and safer when the cyst is small and uncomplicated.
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Affiliation(s)
- Lucile Fievet
- Department of Pediatric Surgery, Centre Hospitalier Régional Henri Duffaut, Provence-Alpes-Côte d'Azur, Avignon, France.
| | - Dominique Gossot
- Department of Thoracic Surgery, Institut Mutaliste Montsouris, Île de France, Paris, France
| | - Henri de Lesquen
- Department of Thoracic Surgery, North Hospital, Assistance Publique-Hôpitaux de Marseille, Provence-Alpes-Côte d'Azur, Marseille, France
| | - Charline Calabre
- Department of Pediatric Surgery, Centre Hospitalier Régional Universitaire Strasbourg, Alsace, France
| | - Thierry Merrot
- Department of Pediatric Surgery, La Timone Hospital, Assistance Publique-Hôpitaux de Marseille, Provence-Alpes-Côte d'Azur, Marseille, France
| | - Pascal Thomas
- Department of Thoracic Surgery, North Hospital, Assistance Publique-Hôpitaux de Marseille, Provence-Alpes-Côte d'Azur, Marseille, France
| | - François Becmeur
- Department of Pediatric Surgery, Centre Hospitalier Régional Universitaire Strasbourg, Alsace, France
| | - Madalina Grigoroiu
- Department of Thoracic Surgery, Institut Mutaliste Montsouris, Île de France, Paris, France
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Rinieri P, Ouattara M, Brioude G, Loundou A, de Lesquen H, Trousse D, Doddoli C, Thomas PA, D'Journo XB. Long-term outcome of open versus hybrid minimally invasive Ivor Lewis oesophagectomy: a propensity score matched study†. Eur J Cardiothorac Surg 2019; 51:223-229. [PMID: 28186271 DOI: 10.1093/ejcts/ezw273] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 06/28/2016] [Accepted: 07/05/2016] [Indexed: 12/16/2022] Open
Affiliation(s)
- Philippe Rinieri
- Department of Thoracic Surgery and Diseases of the Esophagus, North Hospital, Aix-Marseille University, Chemin des Bourrely, Marseille, France
| | - Moussa Ouattara
- Department of Thoracic Surgery and Diseases of the Esophagus, North Hospital, Aix-Marseille University, Chemin des Bourrely, Marseille, France
| | - Geoffrey Brioude
- Department of Thoracic Surgery and Diseases of the Esophagus, North Hospital, Aix-Marseille University, Chemin des Bourrely, Marseille, France
| | - Anderson Loundou
- Department of Biostatistics, Aix-Marseille University, Chemin des Bourrely, Marseille, France
| | - Henri de Lesquen
- Department of Thoracic Surgery and Diseases of the Esophagus, North Hospital, Aix-Marseille University, Chemin des Bourrely, Marseille, France
| | - Delphine Trousse
- Department of Thoracic Surgery and Diseases of the Esophagus, North Hospital, Aix-Marseille University, Chemin des Bourrely, Marseille, France
| | - Christophe Doddoli
- Department of Thoracic Surgery and Diseases of the Esophagus, North Hospital, Aix-Marseille University, Chemin des Bourrely, Marseille, France
| | - Pascal Alexandre Thomas
- Department of Thoracic Surgery and Diseases of the Esophagus, North Hospital, Aix-Marseille University, Chemin des Bourrely, Marseille, France
| | - Xavier Benoit D'Journo
- Department of Thoracic Surgery and Diseases of the Esophagus, North Hospital, Aix-Marseille University, Chemin des Bourrely, Marseille, France
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Mege D, Benezech A, de Lesquen H, Vitton V, Thomas PA. An Involuntary and Unexpected Treatment of Nutcracker Esophagus. Ann Thorac Surg 2017; 103:e545-e547. [PMID: 28528063 DOI: 10.1016/j.athoracsur.2016.12.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Accepted: 12/28/2016] [Indexed: 01/10/2023]
Abstract
A 76-year-old woman complained of painful dysphagia and loss of weight. Esophagoscopy results were negative, whereas computed tomography (CT) disclosed a 25-mm mediastinal tumor without a connection to the esophagus. A diagnosis of nutcracker esophagus was made on high-resolution esophageal manometry. Peroral endoscopic esophageal myotomy failed to improve the symptoms. Right video thoracoscopy allowed resection of the tumor, which looked like a neurogenic tumor of the posterior mediastinum that developed from the right vagus nerve. The patient's dysphagia dramatically improved postoperatively. Because the pathologic examination disclosed a benign solitary fibrous tumor of the pleura, we hypothesize that the motility disorder would have been resolved by the unilateral vagotomy.
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Affiliation(s)
- Diane Mege
- Department of Thoracic Surgery, North Hospital, Aix-Marseille University and Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | - Alban Benezech
- Department of Gastroentology and Endoscopic Explorations, North Hospital, Aix-Marseille University and Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | - Henri de Lesquen
- Department of Thoracic Surgery, North Hospital, Aix-Marseille University and Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | - Véronique Vitton
- Department of Gastroentology and Endoscopic Explorations, North Hospital, Aix-Marseille University and Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | - Pascal-Alexandre Thomas
- Department of Thoracic Surgery, North Hospital, Aix-Marseille University and Assistance Publique-Hôpitaux de Marseille, Marseille, France.
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de Lesquen H, Beranger F, Berbis J, Boddaert G, Poichotte A, Pons F, Avaro JP. Corrigendum to "Challenges in war-related thoracic injury faced by French military surgeons in Afghanistan (2009-2013)" [Injury 47 (2016) 1939-1944]. Injury 2016; 47:2841. [PMID: 27743599 DOI: 10.1016/j.injury.2016.09.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Henri de Lesquen
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France; French Military Health Service Academy, Ecole du Val-de-Grace, Paris, France.
| | - Fabien Beranger
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Julie Berbis
- Aix-Marseille University, EA 3279-Public Health, Chronic Diseases and Quality of Life - Research Unit, Marseille, France
| | - Guillaume Boddaert
- Department of Thoracic and Vascular Surgery, Percy Military Teaching Hospital, Clamart, France
| | - Antoine Poichotte
- French Military Health Service Academy, Ecole du Val-de-Grace, Paris, France
| | - Francois Pons
- French Military Health Service Academy, Ecole du Val-de-Grace, Paris, France
| | - Jean-Philippe Avaro
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France; French Military Health Service Academy, Ecole du Val-de-Grace, Paris, France
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de Lesquen H, Beranger F, Berbis J, Boddaert G, Poichotte A, Pons F, Avaro JP. Challenges in war-related thoracic injury faced by French military surgeons in Afghanistan (2009-2013). Injury 2016; 47:1939-44. [PMID: 27418455 DOI: 10.1016/j.injury.2016.06.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Revised: 05/31/2016] [Accepted: 06/03/2016] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Henri de Lesquen
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France; French Military Health Service Academy, Ecole du Val-de-Grace, Paris, France.
| | - Fabien Beranger
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France.
| | - Julie Berbis
- Aix-Marseille University, EA 3279 - Public Health, Chronic Diseases and Quality of Life - Research Unit, Marseille, France.
| | - Guillaume Boddaert
- Department of Thoracic and Vascular Surgery, Percy Military Teaching Hospital, Clamart, France.
| | - Antoine Poichotte
- French Military Health Service Academy, Ecole du Val-de-Grace, Paris, France.
| | - Francois Pons
- French Military Health Service Academy, Ecole du Val-de-Grace, Paris, France.
| | - Jean-Philippe Avaro
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France; French Military Health Service Academy, Ecole du Val-de-Grace, Paris, France.
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de Lesquen H, Avaro JP, Gust L, Ford RM, Beranger F, Natale C, Bonnet PM, D'Journo XB. Surgical management for the first 48 h following blunt chest trauma: state of the art (excluding vascular injuries). Interact Cardiovasc Thorac Surg 2014; 20:399-408. [PMID: 25476459 DOI: 10.1093/icvts/ivu397] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
This review aims to answer the most common questions in routine surgical practice during the first 48 h of blunt chest trauma (BCT) management. Two authors identified relevant manuscripts published since January 1994 to January 2014. Using preferred reporting items for systematic reviews and meta-analyses statement, they focused on the surgical management of BCT, excluded both child and vascular injuries and selected 80 studies. Tension pneumothorax should be promptly diagnosed and treated by needle decompression closely followed with chest tube insertion (Grade D). All traumatic pneumothoraces are considered for chest tube insertion. However, observation is possible for selected patients with small unilateral pneumothoraces without respiratory disease or need for positive pressure ventilation (Grade C). Symptomatic traumatic haemothoraces or haemothoraces >500 ml should be treated by chest tube insertion (Grade D). Occult pneumothoraces and occult haemothoraces are managed by observation with daily chest X-rays (Grades B and C). Periprocedural antibiotics are used to prevent chest-tube-related infectious complications (Grade B). No sign of life at the initial assessment and cardiopulmonary resuscitation duration >10 min are considered as contraindications of Emergency Department Thoracotomy (Grade C). Damage Control Thoracotomy is performed for either massive air leakage or refractive shock or ongoing bleeding enhanced by chest tube output >1500 ml initially or >200 ml/h for 3 h (Grade D). In the case of haemodynamically stable patients, early video-assisted thoracic surgery is performed for retained haemothoraces (Grade B). Fixation of flail chest can be considered if mechanical ventilation for 48 h is probably required (Grade B). Fixation of sternal fractures is performed for displaced fractures with overlap or comminution, intractable pain or respiratory insufficiency (Grade D). Lung herniation, traumatic diaphragmatic rupture and pericardial rupture are life-threatening situations requiring prompt diagnosis and surgical advice. (Grades C and D). Tracheobronchial repair is mandatory in cases of tracheal tear >2 cm, oesophageal prolapse, mediastinitis or massive air leakage (Grade C). These evidence-based surgical indications for BCT management should support protocols for chest trauma management.
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Affiliation(s)
- Henri de Lesquen
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Jean-Philippe Avaro
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Lucile Gust
- Department of Thoracic Surgery and Diseases of the Esophagus, Aix-Marseille University, Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, Marseille, France
| | | | - Fabien Beranger
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Claudia Natale
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Pierre-Mathieu Bonnet
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Xavier-Benoît D'Journo
- Department of Thoracic Surgery and Diseases of the Esophagus, Aix-Marseille University, Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, Marseille, France
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