22nd European Congress of Trauma & Emergency Surgery

Chairs

Prof.

Factors influencing the difficulty and the need for external help during laparoscopic appendectomy: Analysis of 485 procedures from the resident-1 multicenter prospective resident-led trial

Emergency surgery

Education

Abstract text (incl. references and figure legends) Introduction: Laparoscopic Appendectomy (LA) is the gold standard for approaching acute appendicitis.LA is considered an index procedure for surgical trainees but can become a nightmare also for senior surgeons when dealing with complicated appendicitis (perforation, intrabdominal abscess, peritonitis). In this study we aimed to identify preoperative predictive factors for technically challenging laparoscopic appendectomy (LA), in which external help is needed to complete the procedure laparoscopically. Material &amp; Methods: We retrieved the Resident-1 multicenter registry data, including pre-intra and postoperative clinical variables. The operator classified each procedure following a five-grade Likert scale to define technical difficulty. Grade 4-5 procedures identified challenging procedures needing external help, scrubbed in or not, to complete a LA. We performed a univariate analysis comparing Grade 1-3 versus 4-5 procedures and then built a logistic regression model to identify preoperative independent predictors of Grade 4-5 procedures. Results: Five hundred sixty-one patients were recruited from 2019 to 2021. Four hundred eighty-five patients were included in the final analysis. A BMI &gt; 30 kg/m2, preoperative CT scan, and the AIR score were independent predictors of complex LA with the need for external help to be completed. Patients undergoing such procedures were more frequently affected by CA, had longer operative times and had the worst postoperative outcomes. Conclusion: The preoperative identification of technically demanding LA could be helpful to optimize the preoperative planning, maximize surgeons&quot; preparedness, and include expert surgeons earlier in the procedure. A multi-institutional study to create and validate a scoring system for the technical difficulty of LA is desirable. Reference: Cioffi SPB et al. World J Emerg Surg. 2019;14:25. Published 2019 May 30. doi:10.1186/s13017-019-0243-4Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No

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Postoperative ICU care utilization and mortality in the multicentre hellenic emergency laparotomy study (HELAS)

Abstract text (incl. references and figure legends) Introduction: Emergency laparotomy (EL) is accompanied by high postoperative mortality and requires frequently postoperative care in the ICU. Herein, we explore the data of the HELAS study, to identify links between postoperative mortality and ICU stay. Material and Methods: HELAS is a multicentre prospective study undertaken between 01.2020 and 05.2021 including patients subjected to EL in 11 Greek hospitals. Demographics, clinical variables, and postoperative outcomes were prospectively registered in an online database. Chi-square and t-test was used to compare the distribution of variables between groups. Results: There were 633 patients, and 30-day postoperative mortality was 16.3%. 119 (18.8%) required postoperative treatment in the ICU and the median ICU stay was 7 days (ΙQR: 5.0-9.7). 100 (15.8%) were admitted in the ICU directly postoperatively, 22 (3.5%) after an initial stay in the ward and their mortality was 43.9% and 59.1%, respectively (p=0.2). 45 out of 103 of the patients who died did not receive any care in the ICU (43.7%). Most of the 189 patients of this cohort who were at very high risk for death (&gt;10%) were not treated in the ICU immediately after surgery (60.5%). 33 out of the 45 patients (73.3%) who did not survive and did not receive ICU care postoperatively were at very high risk for death (&gt;10%) according to the NELA risk calculator and most of them died within the first postoperative week. Post-operative utilisation of ICU was significantly lower in the Greek cohort compared with the NELA audit (25.8% vs 56.8%, p&lt;0.01) and 30-day postoperative mortality was significantly higher (16.3% vs 8.7%), despite similarities in demographics and risks between cohorts. Conclusions: This study underscores the underutilization of ICU care among patients undergoing emergency laparotomy and are at very high risk for postoperative death. References: 1. https://doi.org/10.1007/s00268-022-06723-6 2. https://doi.org/10.1093/bja/aet487 Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No

Prospective multicenter external validation of postoperative mortality prediction tools in patients undergoing emergency laparotomy

Abstract text (incl. references and figure legends) Introduction: Risk stratification in emergency laparotomy (EL) is essential for informed decision-making and rational use of resources. Available risk prediction tools have not been validated adequately across diverse healthcare settings. In this study, we aim to perform a comparative external validation of 4 widely cited prognostic models. Materials and Methods: This is a multicenter study including consecutive patients undergoing EL in Greek hospitals. Inclusion and exclusion criteria of the National Emergency Laparotomy Audit (NELA) were used for validation of NELA risk calculator. Data capture will be done with the use of Redcap software. With an estimated postoperative mortality of around 15% based on an initial pilot stydy, a total of 650 patients will be required for an adequate sample size of at least 100 events. 30-day mortality risk predictions will be calculated for each patient using the American College of Surgeons – National Surgical Quality Improvement Program Surgical Risk Calculator, (ACS-SRC), surgeon-adjusted ACS-SRC, NELA, Portsmouth-Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) and Predictive OpTimal Trees in Emergency Surgery Risk (POTTER) tools. Predictive performances will be compared using scaled Brier scores, discrimination and calibration measures and plots, and decision curve analysis. Heterogeneity across hospitals will be assessed by random-effects meta-analysis. Results: With the participation of 12 Surgical Departments the appropriate data collection time will require 12-18 months and the publication of the comparative analysis is expected before the end of 24 months from the initiation of the study. Conclusions: This is the first study to compare 4 risk prediction tools in a prospective setting in European EL patients. References: 1. 10.1016/j.jamcollsurg.2013.07.385 2. 10.1016/j.bja.2018.06.026 3. 10.1046/j.1365-2168.1998.00840.x 4. 10.1097/SLA.0000000000002956Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No

Prof. Dr.

Anterograde biliary stenting during laparoscopic cholecystectomy as a rescue maneuver in extensive choledocholithiasis

Abstract text (incl. references and figure legends) Introduction: In case of choledocholithiasis therapeutic gold standard is endoscopic retrograde cholangiography (ERC) with stone extraction ± stent placement followed by laparoscopic cholecystectomy (lap CHE). When unnoticed choledocholithiasis is diagnosed by intraoperative cholangiography (IOC) during lap CHE and biliary decompression is required, anterograde stent placement via the cystic duct may be a rescue maneuver avoiding the necessity of intraoperative ERC. Methods: Case report of a patient with extensive cholecysto- and choledocholithiasis diagnosed by IOC during lap CHE. Results: An 85 years old female patient admitted with acute onset of abdominal pain and cholestasis diagnosed by blood test. Preoperative ultrasound revealed a moderately widened common bile duct (CBD) of 9mm. The patient was taken to the operating room to perform lap CHE. IOC revealed a large prepapillary biliary stone of 15 mm with widened CBD proximally (Fig. 1). Laparoscopic biliary stone clearance was not feasible due to the size of the stone. Moreover, intraoperative ERC was not possible due to unavailable ERC resources. Therefore, for biliary decompression, a 10cm, 7 Fr., double-pigtail cholangiocatheter was trans-cystically inserted over a guide-wire into the CBD along the stone and across the papilla into the duodenum (Fig. 2). The procedure was completed by CHE. Postoperatively, cholestasis rapidly improved and the patient was discharged at the third postoperative day. ERCP with stent and stone removal ± lithotripsy will follow in 3 months. Conclusion: Intraoperative anterograde trans-cystic CBD-stenting is a rescue maneuver to be considered in case of extensive choledocholithiasis and unavailable intraoperative ERC. It should be regarded as a bridging therapy to definitive treatment of choledocholithiasis by ERCP and eventually lithotripsy.Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No.

Dr. med.

Prof. Dr. med.

Standard practice in treatment of unstable pelvic ring injuries – Results of an international questionnaire

Polytrauma

Abstract text (incl. references and figure legends) Introduction Treatment protocol strategies for unstable pelvic ring injuries differ between institutions and regions. The aim of this international study was to identify treatment standards for unstable pelvic ring injuries. Material &amp; Methods A standardized questionnaire was developed by experts from the SICOT-Trauma committee. This questionnaire was distributed to the members of the SICOT society. Topics were treatment strategies, classification, staging procedures and preoperative planning. Answer options for treatment strategies were: 1) Always (A), 2) Often (O), 3) Seldom (S), 4) Never (N). Stratification was performed according to geographic regions. Results 358 experienced trauma surgeons from 83 countries (experience &gt;5 years=79%) conducted the survey from 09/05/22 to 10/12/22. The Y&amp;B (52%) and Tile/AO (47%) classifications were equally used. Rescue Screws (RS), C-Clamps (CC) and angioembolization (AE) are globally implemented in clinical practice (A+O: RS=24%, CC=25%, AE=21%). Percutaneous techniques are executed regularly (A+O) in 57%, whereas 65% of the respondents never use navigated techniques. External fixation is a frequently performed intervention worldwide (A+O=71%). Pelvic packing is globally not extensively implemented, as 28% never and 47% of surgeons seldom use it. REBOA is only utilized in specific continents. To be precise, in Europe/North America (A+O=19%/10%), whereas internationally 68% of participants never use REBOA. Only 7% of the respondents never perform preoperative 3D planning CT scanning. Conclusion The current international study is the first to identify regional differences and global similarities in treatment strategies of unstable pelvic ring injuries. Yet regional differences occur especially when it comes to more augmented techniques. New international consensus and standardized treatment guidelines are mandatory. References: NoneDisclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No

Compliance to guidelines in the management of acute appendicitis: how fare have we gone? A perspective from the largest Italian surgical educational network

Abstract text (incl. references and figure legends) IntroductionAcute appendicits (AA) is one of the most common surgical emergencies worldwide. Recent international guidelines (GL) defined various aspects of AA diagnosis and management, based on high-quality evidence, whereas some other are still controversial. We aimed to assess compliance with GL on a multicenter cohort of adult patients affected by AA.MethodsData were retrieved from the Resident-1 multicenter trainee-led Italian registry.We explored the adherence to GL on 7 selected clinical items(Tab1).We compared different subgroups considering procedures approached by residents vs surgeons, in university vs non-university hospitals, and in dedicated emergency surgery services vs non dedicated ones.Results653 patients with AA treated with laparoscopic appendectomy (LA) were recruited from 60 residents in 21 centres in the largest Northern Italian educational network.We identified low compliance to four items: no peritoneal lavage in 25.7%, no drain placement in 53.3%, no postoperative antibiotics for uncomplicated AA in 38.1% and antibiotics administered for ≤5 days for complicated AA in 34.2%.Procedures performed in ES services and university hospitals were associated with higher compliance concerning drain placement and no lavage. ConclusionWe identified poor compliance with four items among which two were based on moderate and two on high quality evidence, all with strong recommendation. Low compliance to drain placement and postoperative antibiotics regimens are red flags linked to non-negligible impact on postoperative pain, length of stay, efficacy of antibiotics therapies and resistance. The diffusion of dedicated ES services and the adoption of more evidence-based surgical practices are core issues to address. Specific clinical bundles are needed to fill these gaps and an international snapshot is necessary to explore the phenomenon worldwide.Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No

Influence of standardised template documentation of safety considerations for chest drain insertion in trauma

Abstract text (incl. references and figure legends) Introduction Chest drain insertion is a commonly performed procedure with significant risk of complications(1). Safety concerns surrounding the procedure have been highlighted nationally(2) and previous audits have demonstrated poor documentation following insertion. As a result, local guidelines and a template for documentation have been developed to ensure the relevant safety considerations have been followed. Materials &amp; Methods Data were collected retrospectively from the electronic patient record to identify patients who underwent chest drain insertion for traumatic haemothorax and/or pneumothorax in a one year period (March 2021 to February 2022). Use of a template (following national standard protocol) was assessed, as well as adherence to local guidelines and complication rates. Results were compared to a similar previous audit undertaken in 2019. Results A total of 79 chest drain insertions were identified for inclusion in a total of 60 patients. There were 11 bilateral insertions and 8 re-insertions. Overall, the template was used in 53%, compared to 37% in 2019. Where the template was used, mean documentation of safety considerations was 81%, compared to 32% in those whom it was not used. The rates of documented complications were 14% in patients for whom the template was used, compared to 24% where not used. Conclusions Use of the template highlights to the clinician the safety considerations relevant to chest drain insertion. Rates of complications were lower in those who utilised the template. Whilst use of template has improved, further efforts are required to encourage use, with the aim of improving patient safety and reducing complications. References (1) Harris A, O'Driscoll BR, Turkington PM. Survey of major complications of intercostal chest drain insertion in the UK. Journal of Postgraduate medicine. 2010; 86: 68–72 (2) Hooper C, Bucknall C, Welham SA, Reid K, Routh C, Maskell NA. Pilot Pleural Procedures Audit. British Thoracic Society, 2009Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No

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