22nd European Congress of Trauma & Emergency Surgery

Chairs

Prof.

The accumulative risk of acute kidney injury in trauma patients following repetitive contrast medium exposure

Abstract text (incl. references and figure legends) Introduction: Multiple contrast-enhanced radiology examinations (i.e. computed tomography or angiography) in trauma patients are commonly required for both diagnostic and therapeutic purposes. The actual risk of contrast-associated acute kidney injury (CA-AKI) is still unclear. This study evaluates the association of the accumulative contrast medium doses to CA-AKI. Materials and methods: Data from a level 1 trauma center during 2019-2021 were retrospectively reviewed. Patients receiving intravascular contrast-enhanced examinations (CE) for torso trauma within 7 days after injury were included. Those without serum creatinine levels at admission and 48 hours after the last exposure of contrast medium were excluded. AKI was defined by Kidney Disease: Improving Global Outcomes (KDIGO) grading system. Multivariate logistic regression (MLR) was performed to identify independent risk factors of AKI. The total amount of contrast medium (OminipaqueTM) exposed within 7 days were summed, and the cut-off point to predict AKI was determined by Youden index. Inverse probability of treatment weighting (IPTW) was used to adjust other factors and see if contrast dose was associated with AKI. Results: Among the 312 patients, 11.5% (36/312) had AKI and 5.1% (16/312) were KDIGO stage 3. Fifty-seven percent of patients received CE at least twice. The median amount of total contrast medium given was 156 mL. On MLR, for every 10ml increase of contrast dose, the odds ratio of AKI was 1.12 (95% CI 1.03-1.21, p=.010). By using 160 ml as a cut-off value and adjusting other factors by IPTW, patients with contrast dose ≥160 ml (which was roughly equivalent to the amount required for one CT and one angiography) had a significantly higher risk of AKI (19.3% vs 9.8%, p=.001). Conclusion: While repetitive CE are sometimes inevitable, it does come with costs. The CA-AKI risk increases as the amount of contrast medium accumulates in trauma patients who require repetitive examinations.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

Emergency surgery

Visceral trauma

Oral presentation

Evaluation of resuscitation effect of resuscitative endovascular balloon occlusion of the aorta with fixed inflation volume method in swine hemorrhagic shock model

Abstract text (incl. references and figure legends) Background: As the inflation volume of REBOA balloon increases, blood pressure rises, but complications due to distal ischemia are induced. In this study, the method of reaching the target SBP using a vasopressor while maintaining a partial occlusion of a certain inflation volume was compared with the conventional method. Method: Total 6 swine were subjected to a rapid 40 % blood loss of estimated total blood volume. The swine were randomized into 30% (R30), 60% (R60), and 100% (R100) inflation groups. REBOA was maintained for 60 minutes, then deflated and animals were monitored for additional 60 minutes. Resuscitation was performed with a target of SBP 90mmHg, and hemodynamics, administered fluid and vasopressor doses were recorded. Blood samples were analyzed at each stage of experiment (Figure 1). Results: Mean proximal MAP during resuscitation period was higher in the R30 group (Figure 4). At each time point, the difference in the mean heart rate among groups was statistically significant (p = 0.002) (Figure 5). After post-hoc analysis, there were significant differences in the mean heart rate between R30 and R100 groups at deflation period (p = 0.002) (Table 2). The average amount of fluid and vasopressor infused was greater in R100 group, although statistical difference was not shown (Table 3). The BUN, creatinine, and lactate values of each group with significantly different at each time point (p = 0.037, p = 0.003, p = 0.009, respectively). The R30 group showed significantly lower mean lactate values compared to the R100 group 60 and 120 minutes after hemorrhage (p = 0.024, p = 0.002, respectively) (Table 4). Conclusion: In a swine hemorrhagic shock model, the REBOA balloon 30% inflation group remained more hemodynamically stable compared to other groups and required less fluid and vasopressor during resuscitation. In addition, ischemia-reperfusion injury after REBOA balloon deflation seemed to be less in 30% inflation group with the lowest lactate level.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

Polytrauma

Critical view of safety and bailout procedures in laparoscopic cholecsystectomy for acute cholecystitis. Changing the pattern. A 10 years-experience on 316 patients

Abstract text (incl. references and figure legends) INTRODUCTION: Acute cholecystitis (AC) is common in acute care surgery. According to the Tokyo Guidelines 2018, the gold standard of treatment of AC is early laparoscopic cholecystectomy (LC). Even in high experienced settings, however, complication rate is high. Though biliary and vascular injuries are more frequent in LC rather than open cholecystectomy, the advantages of laparoscopy should be taken into account. The cystic duct and artery should be cautiously recognized before section of any element to avoid biliary and vasculr injuries during LC. In 1995, Strasberg introduced the Critical View of Safety (CVS) in cholecystectomy. Nevertheless, if anatomical landmarks couldn"t be safely identified, bailout procedures (subtotal or top-down cholecystectomy, open conversion) should be an alternative. MATERIALS AND METHODS: We retrospectively reviewed 316 consecutive LC for AC, at our institution, from Jan 1, 2013 to Sept 15, 2022. In the period 2013-17, some members of thes urgical team used to opt for open approach or liberal conversion in difficult cases. From 2018, our team shifted to LC for AC as a matter of principle, relying on CVS and bailout procedures. M/F ratio was 207/109, mean age 60,7 yrs, ASA status 2.06, TG18 grading 1.47, time to surgery 98 hrs, bailout rate 9%, operative time 122 min, LOS 5.04 days. Three patients died for septic shock. Comparing the 1st and 2nd period, open/lap ratio was 22.6% and 5.5%, conversion rate was 12.3% and 9.6%; morbidity rate was 25% (1 minor injury of biliary tree, 1 choledocal fistula, 4 minor bleeding) and 16.9%(2 minor biliary injuries, 1 choledocal fistula, 1 minor bleeding). DISCUSSION AND CONCLUSIONS: surgical treatment of AC cases could be technically challenging. Some key steps have been identified to realize the safest LC. In this series, the shift to baseline application of these criteria had significanty modified the early and mid-term outcomes, demonstrating efficacy and safety of the approach. 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

Emergency laparotomy outcomes in a dedicated emergency general surgery (EGS) unit – An 8-year review

Abstract text (incl. references and figure legends) Introduction Liverpool's EGS service is one of the first dedicated trauma and emergency surgery units in the UK, offering a collaborative approach to patient care with other general surgical specialties. Objective To assess the clinical outcomes in emergency laparotomies from a dedicated EGS service, with a collaborative model of care involving all other specialty teams. Methods A prospective database of all patients undergoing an emergency laparotomy between 1st June 2014 and 30th June 2022 at our institution was retrospectively analysed. Data were analysed using SPSS software. Results 1403 patients who underwent an emergency laparotomy were identified between 2014 and 2022, of which 583 were operated by the EGS service, and 820 during out of hours (OOH). Mean PPOSSUM predicted mortality was 15.61 for EGS patients and 16.10 for OOH. In 78% of EGS cases a consultant was recorded as being present, compared to 57.1% of OOH services, which was statistically significant (p&lt;0.00007). 81.3% of EGS patients were admitted to ITU/HDU post operatively with average stay of 6.4 days, compared to 82.2% of OOH who were admitted for an average of 6.7 days (national average 82.3%), which was statistically significant (p&lt;0.005). Length of stay for EGS patients was 19.3 days, compared to 22.5 days for OOH patients, p=0.32 (national average of 15.1). 30-day crude mortality for the EGS service was 10%, compared to 13.3% for OOH, which showed no significant difference (p = 0.11) and was comparable to the national average of 8.7%. Conclusion A dedicated consultant led EGS service has resulted in positive outcomes in mortality and length of ITU and hospital stay which are comparable to the national average. This has been achived through a hollistic and collaborative care. 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

Education

A data-driven approach to implementing quality improvement in a trauma system

Abstract text (incl. references and figure legends) Introduction Unwarranted variation is the enemy of quality. New Zealand has previously observed high rates of death and variation in outcomes across the country. Investment in quality improvement has been prioritised to address this variation Materials and methods The population-based national registry provides a source of information on everyone who meets the threshold for major trauma. Initial work focussed on the patterns of injury, process indicators, and death as the sole measure of patient outcome. The system has evolved to include PROMs (Patient Reported Outcome Measures), and rehabilitation data to inform outcomes post-discharge from hospital. Quality Improvement focus has prioritised three areas: critical haemorrhage, traumatic brain injury, and rehabilitation. Approaches such as collaboratives and bundles of care have been a useful addition to more traditional approaches such as guidelines and policy. Results Approximately 2,500 people suffer major trauma each year, with an incidence rate of 52/100,000. Case fatality rate has reduced from 12% to 7.3% since 2015. Process of care are observed with more patients being transported to definitive care hospital from scene, and an increase in trauma calls and tertiary survey. DALY"s have decreased, and there is a notable reduction in the insurance costs associated with working people who have been seriously injured. There is minimal variation in outcomes and processes between regions. Conclusion An organised quality improvement program is an important component of contemporary trauma care. A focus on all aspects of the patient journey from pre-hospital, hospital and rehabilitation is important for systems to have oversight of. The key benefit is improvement in patient outcomes measured by death and improved rehabilitation for those that survive.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

Pancreatic injuries in children – Lessons learned from the last decade in a major northern European trauma center

Abstract text (incl. references and figure legends) Introduction Pediatric pancreatic injury is rare and associated with high risk of complications. The treatment of blunt pancreatic injuries in children remains controversial. We have standardized our protocol, addressing the ductal injuries with tail resection in Organ Injury Scale (OIS) grade 3 injuries and operative drainage in OIS grade 4 and 5 injuries, unless injury to the common bile duct (CBD). We present 10 years of experience. Methods Retrospective cohort study of all trauma patients under the age of 18 years admitted with pancreatic injury to our high volume trauma center and included in the Institutional Trauma Registry during the period 2010-2019. Results Twenty-five children with pancreatic injury were included with blunt mechanism of injury in 23/25 (92 %) and 10/25 (40 %) were handlebar injuries. Median ISS was 10 (IQR 10) and median LOS 13 days (IQR 3). A CT scan identified the injury in 20 cases (80 %), MRI in three and two patients were diagnosed during laparotomy. Two patients presented with combined pancreatic and duodenal injuries. Thirteen patients had OIS grade 1-2 injuries, 10 had OIS grade 3 and two had OIS grade 4 injuries. All patients with grade 3 injuries were treated with tail resection, 9 of them with splenic preservation. Three patients (30 %) developed a pancreatic fistula, all healed without intervention after 23, 24 and 25 days, respectively. Both OIS grade 4 patients were treated with surgically placed suction drainage and the fistulas healed after 21 and 27 days. The combined injuries had surgery for duodenal repair and drainage of their pancreas grade 2 injuries. No reoperations were required in the resection group and no pseudocysts were identified. ERCP was not necessary in any patients. Conclusions Standardized treatment of pancreatic injuries with spleen preserving tail resection of grade 3 and surgical drainage of grade 4 seems safe without any unforeseen complications or need for invasive procedures postoperatively.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

Non surgical gallbladder drainage versus cholecystectomy in fragile patients with acute cholecystitis. A high-volume center study

Abstract text (incl. references and figure legends) B: Acute cholecystitis (AC) is a frequent cause of admission at the emergency department but for frail and old patients, surgery is not always feasible. Percutaneous drainage (PT-GBD) and more recently endosonographic guided drainage (EUS-GBD) are gaining popularity as palliative or definitive treatments. The aim of the present study was to compare non-surgical (NS) and surgical (S) procedures. M: A five-year monocentic retrospective study was conducted, including patients ≥65 years old that underwent an urgent procedure. The S group included laparoscopic [LC] and open [OC] approach while NS PT-GBD and EUS-GBD. A descriptive analysis was carried out comparing the 2 groups and a subgroup analysis was added to compare PT-GBD and EUS-GBD. R:162 patients were included: 106 S (81 LC and 25 OC) and 54 NS (21 EUS-GBD and 33 PT-GBD). A statistically significant difference was encountered for Age, Charlson Comorbidity Index (CCI), Clinical Frailty score (CFS) and ACS risk score. NS patients were older, frailer and with a higher ACS risk. Moreover, they had more likely experienced a previous AC attack and they took more anticoagulants. In all cases of NS the procedure was successfully completed (Technical failure1,9%,p=0,73). No statistically significant difference was outlined for the overall complication rate (24,5% S vs 27,8% NS, p=0,8) but NS patients had more serious complications (CD&gt;3)(p=0,022) and they stayed longer at the hospital (5 days S vs 11 NS, p=0,011). Lastly, 90-day mortality was 4,5% in S and 9,8 in NS (p=0,066). From the subgroup analysis EUS-GBD patients resulted in having less overall and serious complications when compared to PT-GBD (respectively 39.4%vs9.5% and 27,3vs4,8%)(p&lt;0,001). The clinical success was obtained in 85,7%(vs63,6) (p=0,002) and Recurrence (R) was 14,3%(vs 21,9)(p&lt;0,001). C: Even if surgery still represents the gold standard for AC, EUS-GBD is a good alternative to PT-GBD in terms of clinical success, R and complication rate. 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.

PD Dr.

Prof. Dr.

Rescue screws – Outcome of sacroiliac screws placed in unstable pelvic ring injuries

Abstract text (incl. references and figure legends) Introduction Percutaneous sacroiliac screw fixation (SI) of unstable pelvic ring fractures with Rescue Screws is an established treatment to promptly stabilize the posterior pelvic ring and haemodynamic status. This intervention is performed under challenging conditions and might therefore be associated with complications. The aim of our study was to compare Rescue Screws with elective SI-screw fixations. Material&amp;Methods A retrospective study of trauma patients with acute pelvic ring injuries at a level one trauma center was performed. Patients ≥15 years, treated with sacroiliac/transsacral screw fixation were included. Rescue Screws were defined as immediate surgical stabilization after admission to trauma bay. Patients were stratified according to treatment strategy (RS: Rescue Screws; EL: elective screw placement). Outcome: screw breakage, loosening, malpositioning and reoperations. Results 252 patients were included between 11/2014 and 08/2021. 48 patients (43±18 years) were treated with Rescue Screws; 204 patients (61±20 years) received EL. The RS-group was more frequently polytraumatized (p&lt;0.001) than the EL-group (89.6% vs. 46.1%) with a higher overall ISS (30±12 vs. 17±10). Unstable pelvic ring fractures were diagnosed more often (p&lt;0.001) in the RS-group (91.7% vs. 48.0%) as well as concomitant shock (37.5% vs. 3.4%). The RS-group was more likely to develop implant complications (25.0% vs. 10.8%, p=0.018). There was no difference regarding reoperations before (p=0.986) or after (p=0.110) fracture consolidation. Conclusions Treatment of unstable pelvic ring fractures with Rescue Screws appears as a feasible treatment option for unstable pelvic ring situations at risk. Despite a higher overall risk of implant complications, Rescue Screws are not associated with elevated revision rates, which indicates a minor clinical relevance of these findings. Further studies are needed to compare Rescue Screws to other emergency interventions (e.g. C-Clamp). 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

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