22nd European Congress of Trauma & Emergency Surgery

Prof. Dr.

Chairs

Professor

Whole blood transfusion in the treatment of trauma patients with acute hemorrhage, a systematic review and meta-analysis: The whole is greater than the sum of the parts

Emergency surgery

Polytrauma

Abstract text (incl. references and figure legends) Introduction Whole blood (WB) transfusion received renewed interest after recent armed conflicts. Despite the possible benefits of WB, effectiveness of WB as compared to blood component transfusion (BCT) is still topic of debate. Therefore, we investigated whether WB ± BCT transfusion results in a survival benefit as compared to BCT in patients with acute hemorrhage. Material &amp; Methods Electronic databases were searched from inception to 14th of September. Studies comparing resuscitation with WB (with or without BCT) to BCT only in patients with traumatic hemorrhage were included in the meta-analysis. Sub analyses were performed on the effectiveness of WB in the treatment of massive hemorrhage and on platelet (PLT):Red Blood Cell (RBC), plasma:RBC and WB:RBC ratios. Methodological quality of studies was interpreted using the Cochrane risk of bias tool. Results Random effect pooled odds ratio (OR) for 24-hours mortality in civilian and military patients was 0.72 (95% CI 0.53 - 0.97). In sub analysis of studies conducted in civilian setting (n=11), early (4-hours, 6-hours and Emergency Department) and 24-hours mortality were reduced in WB groups compared BCT groups: OR 0.65 (95% CI 0.44 – 0.96) and OR 0.71 (0.52 – 0.98). WB groups received significant higher PLT:RBC (p=0.030) during early treatment and significant higher PLT:RBC and Plasma:RBC ratios during 24-hours of treatment (p=0.031 and p=0.007). Transfusion ratios did correlate for early Plasma:RBC ratio and early mortality (WB±BCT, R2 = 0.79 and BCT, R2 = 0.95). The overall risk of bias in the majority of studies was judged as serious due to serious risk on confounding and selection bias, and unclear information regarding co-interventions. Conclusions Civilian trauma patients with acute hemorrhage had lower odds on early and 24-hours mortality when treated with WB and BCT as compared to BCT only. Due to serious risk of bias, superiority or inferiority of WB as compared to BCT remains to be demonstrated. Nevertheless, WB is an important adjunct in the treatment of traumatic hemorrhage due to logistical benefits.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.) I and co-authors declare no conflicts of interest for the study entitled: ''Whole blood transfusion in the treatment of civilian and military trauma patients with acute hemorrhage, a systematic review and meta-analysis''

Oral presentation

Prof.

Management of acute cholecystitis in patients older than the expected life expectancy: Is the Tokyo guideline 2018 (TG18) still practical?

Visceral trauma

Abstract text (incl. references and figure legends) Introduction The Tokyo Guideline 2018 (TG18) has been accepted for managinf acute cholecystitis (AC), but the application in elderly patients is still unknown. Our aim was to investigate the feasibility of applying the TG18 to elderly patients Material &amp; Methods From Jan. 2011 to Oct. 2021, 166 AC patients aged 85 years or older were treated and reviewed. The patients were divided according to the TG18 severity grading (mild, moderate, and severe AC). Within each group, the clinical outcomes were compared between those who were managed following the TG18 and those managed deviating from the TG18. Results Among all 166 patients, 87 (52.4%) were treated according to the TG18. For the mild AC group, the patients treated following the TG18 had a significantly shorter overall length of hospital stay (8.1 vs. 16.3 days, p &lt; 0.001) and fewer biliary complications (0.0% vs. 32.7%, p = 0.007). For the moderate AC group, patients who were treated following the TG18 had a longer first hospitalization (11.6 vs. 7.7 days, p = 0.011) but lower ICU admission rate (10.0% vs. 38.9%, p = 0.027). For those who underwent cholecystectomy, mild AC patients who were treated following the TG18 had a shorter operation time (111.1 vs. 145.6 minutes, p = 0.023) and could be discharged earlier after the operation (2.7 days vs. 4.6 days, p = 0.022). For the moderate AC group, a lower ICU admission rate (6.3% vs. 40%, p = 0.034) and a lower postoperative complication rate (0.0% vs. 30.0%, p = 0.046) were observed in patients who were treated following the TG18. There was no significant difference between the patients who were treated following and deviating from the TG18 in the severe AC group. Conclusions For elderly AC patients, our results revealed that the TG18 is still a valid guideline for treating extremely old patients with AC. Optimal outcomes can still be achieved by following the TG18 for these groups of patients. References Tokyo Guideline 2018, Surgical endoscopyDisclosure: 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.) I have no financial interest, and nothing to disclosure.

Importance of minimally invasive surgery in the surgical treatment of acute hemothorax: Experiences from a maximum care center

Abstract text (incl. references and figure legends) Introduction Thoracic trauma is a common injury with high morbidity and mortality. Thoracotomy (THK) is recommended for the surgical treatment of acute intrathoracic injuries. Compared to minimally invasive thoracic surgical procedures (VATS), this represents a significant additional burden for the patient. At our institution, VATS operations are carried out as part of the interdisciplinary care of trauma patients at a supra-regional trauma center. Material &amp; Methods Monocentric retrospective cohort analysis of all patients who underwent surgery for acute intrathoracic bleeding between 01/2017 and 12/2021. Patients with thoracic trauma and previous thoracic interventions were included. Patient characteristics, type of injury (trauma vs. post-interventional, lateral location, ASA score), surgical main and secondary diagnoses, intra- and postoperative course were analyzed including complications. Results 93 patients (71% male, 66±18 years, ASA 3.38±0.85) underwent surgery for acute hemothorax: VATS n=60; THK n=33. Of these, 43/93 (46.2%) patients had acute chest trauma. 17% of VATS patients and 52% of THK patients were hemodynamically unstable at the begin of surgery. 10 VATS patients (17%) had to be converted to the open surgical procedure. The operating times (74±48 vs 125±69 minutes, p&lt;.001) and intraoperative bleeding amounts (319±506 vs 728±871 ml, p=0.008) differed significantly in the two treatment groups. 43% of VATS patients and 76% of THK patients had postoperative complications Mortality in the VATS group was significantly lower (7 vs 24%, p=0.028). Conclusions We can show that VATS is possible in more than 2/3 of the trauma patients. In the acute surgical setting, less than 20% of VATS interventions have to be stopped and continued as open surgery because of un-expected intraoperative findings. VATS operations can also be carried out safely in haemodynamically unstable patients.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

The management of colonic acute diverticulitis and the importance of "diagnostic and therapeutic assistance pathways" (DTAP) in emergency setting: A single center experience

Education

Abstract text (incl. references and figure legends) Introduction: Acute colonic diverticulitis (AD) is one of the most common clinical conditions encountered by surgeons and gastroenterologist in the acute setting. Although left-sided colonic diverticulosis remains more common among elderly patients, a dramatic rise of its incidence has been seen in younger age groups in recent years. There are several guidelines relating to the management of the disease but we don"t have data about the efficacy of diagnostic and therapeutic pathways in hospitals. Material and Methods: In San Camillo Hospital (Rome-Italy) a multidisciplinary panel of experts, coordinated by a central coordinator, was selected to create a diagnostic and therapeutic pathways (DTAP) able to optimization of care. Aims of the study was to evaluate the effectiveness of the DTAP in terms of reduction of hospitalization stay and clinical outcomes. Results: The use of the DTP began in 2021. During the first year 121 patients affected by Acute Diverticulitis (AD) were admitted in our department: - 88 (72.7%) patients with AD without hemorrhage: 32 (36.4%) patients with Complicated AD (68.7% underwent surgical resection and 31.3% have been treated conservatively) and 56 (63.6%) patients with uncomplicated AD (17.8% were discharged and 81.8% were admitted to the ward) -33 (27.3%) patients with AD with hemorrhage: 6 (18.2%) undervent surgical resection or selective embolization and 27 (81.8%) have been treated conservatively. Comparing these data with a cohort of patients before the use of DTAP (2015-2019), we have seen less surgical resection or selective embolization (35.3% vs 18.2%) with a significant reduction of time spent in emergency room (55% vs 23.9% for stay &gt; 24 hours) Conclusions: This new "diagnostic and therapeutic assistance pathways" (DTAP) is able to select patients who really need surgery and to reduce residence time in emergency room.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-operative management in penetrating thoracic trauma with hemopericardium, is it possible?

Abstract text (incl. references and figure legends) Introduction: Throughout the years several authors have described the utility of echocardiography in the detection of cardiac injuries and a successful non-operative management (NOM) of patients with penetrating precordial trauma who are stable and negative for hemopericardium. Yet, a NOM protocol (NOMP) for patients with positive hemopericardium without instability nor signs of cardiac tamponade has not been proposed. Methods: Patients with penetrating precordial trauma from 2019 to 2021 who had a positive E-FAST for hemopericardium, who were stable at arrival and had no signs of cardiac tamponade were included. They underwent the NOMP at our institution which consists in close monitorization and serial cardiac ultrasounds for 72-96 hours. If during follow-up, the patient presented hemodynamic instability or cardiac tamponade, surgery was performed. If on the contrary, the patient remained stable and asymptomatic, discharge was considered. Results: 14 patients with positive hemopericardium were reported. The median (IQR) age was of 34.5 years, 92.86% were males and 64.29% were gunshot wounds. 5 patients presented transient hypotension: 4 due to hemothorax and 1 due to hemoperitoneum. None of the patients presented instability nor cardiac tamponade during the NOMP. Median(IQR) ISS was of 10.5(10-14) and NISS of 16.5(11-27). 4 pericardial windows(PW) were performed; 2 positive, one in which a sternotomy was performed, they both reported contusions in right ventricle and right atrium and they were managed conservatively. None of the patients died. Median(IQR) ICU length of stay was 2(2-4) and hospitalization was of 7(3-10). Conclusion: The NOMP was successful in all 14 patients, none of the patients died. 2 patients with positive PW were stable and the injuries reported had no active bleeding and were managed conservatively. This strategy must be considered to avoid unnecessary surgical procedures in these patients. Further studies with bigger samples are required.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

Axillo-subclavian vessels trauma. Which patients can undergo endovascular treatment?

Abstract text (incl. references and figure legends) Introduction: Open treatment of subclavian and proximal axillar injuries requires complex exposures. Endovascular modalities are attractive, and their use has increased in the last two decades. We aimed to identify characteristics associated with a higher probability of endovascular treatment. Methods: We performed a retrospective analysis of the patients with axillo-subclavian injuries treated at a high-complexity trauma hospital in Cali, Colombia, from 2015 to 2021. Demographics, trauma characteristics, and details of the lesions and the treatment were registered. Continuous variables were compared with the Wilcoxon-Mann Whitney test. Categorical variables with Fisher's Exact test. Results: A total of 79 patients were treated, 89.5% male. Median age was 26.5 years. The most frequent mechanisms were penetrating (82.3%). Twenty patients (25.3%) were treated by endovascular means, in four of them in combination with open surgery. Endovascular treatment was significantly more frequent in blunt trauma patients, in subjects with systolic blood pressure higher than 75 mm Hg, and in subclavian artery injuries. Remarkably, 46.2% of the patients with systolic blood pressure between 76 and 89 mm Hg responded to resuscitation, and it was possible to study and treat them by endovascular means. The risk of requiring open management was higher in patients with hard signs of arterial injury, axillary artery injury, or associated venous injury.Ten patients (12.8%) died, all in the open surgery group. Conclusions: One-fourth of the cases could receive endovascular treatment. If immediate endovascular therapy is available, most hemodynamically normal and responder patients are candidates for endovascular treatment. 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.

PD Dr. Dr.

Prof. Dr. med.

Increasing use of whole body computed tomography scans in "non-shockroom" patients after trauma: Indications, findings and therapeutic consequences

Abstract text (incl. references and figure legends) Background: The whole-body computed tomography (WBCT) scan is an essential adjunct in the management of polytraumatized patients and has been shown to result in an improvement in survival prognosis. The goal of the present study was to analyze the role of the WBCT scan in "non-shockroom" trauma patients. Methods: Retrospective analysis of all patients admitted to our emergency department from 01/2019 – 12/2021 and who received a WBCT scan in a "non-shockroom" situation. Indications for WBCT scan, specific injuries and therapeutic consequences were examined. Results: During the 3-year study period, a total of 504 WBCT scans was performed. The number of WBCT scans significantly increased over the years (2019: n=78 (2.5% of all ED patients), 2020: n=91 (3.2%), 2021: n=335 (11.3%); p&lt;0.001). The most frequent WBCT scan indications included high energy trauma (n=228, 45.2%) and suspicion of multiple injuries on clinical examination (n=190, 37.7%). Overall, 56.7% of the scans (n=286) were positive. The encountered injuries consisted of chest trauma (n=155, 30.8%), head injury (n=111, 22.0%), spine fractures (n=95, 18.8%), intraabdominal organ lacerations (n=63, 12.5%), pelvic fractures (n=27, 5.4%), vascular injuries (n=24, 4.8%), and extremity fractures (n=12, 2.4%). Based on the findings of the WBCT scan, surgery and/or interventional radiology procedures were required in 77 (15.3%) patients and mostly included spine surgery (n=16) and thoracic surgery (n=8). Conclusion: The use of a WBCT scan has significantly increased and has become an integral part in our evaluation algorithm of trauma patients also in the "non-shockroom" situation. However, clear indication protocols are required to avoid unnecessary radiation exposure.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

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