22nd European Congress of Trauma & Emergency Surgery

Chairs

Prof.

Double-barrel ileocolonic stomy – A simple technique with an easy local reversal in emergency synchronous resections in Crohn's disease complicated with ileosigmoid fistula

Emergency surgery

Education

Abstract text (incl. references and figure legends) Introduction Internal fistulas are missed preoperatively in one-third of the cases. In complicated ileocecal localization and synchronous involvement of the sigmoid colon, the surgeon is always faced with the main question – to perform a stoma or not and what type of stoma to choose. According to the literature, the mean rate of stoma in these cases is 31%. Results From 2014 to 2022 a total of 70 operations on 56 patients were performed. Of them, 11 (19.6%) had ISF with a mean age of 32 years (20-47) and a mean disease duration of 7.3 years (2-12). All patients had a weight reduction of 15 kg (5-45), mean serum albumin of 33 g/l (26-43), and mean haemoglobin of 124 g/l. Preoperative diagnosis of ISF was set in 55% of cases. Five cases (45.5%) were operated on in an emergency setting. In four a double-barrel ileocolonic stomy was performed – ileoascendo stomy in three and ileo-transverse stomy in one. They were reversed through a local laparotomy and side-to-side functional mechanical anastomosis via GIA 100 mm and 80 mm one month later. In one case a proximal ileostomy was performed. All cases had an uneventful recovery. Conclusion ISFs occur in up to 20% of the operated patients. In case of right and left colonic resection in an emergency setting a double-barrel ileocolostomy is recommended because its easier reversal by local laparotomy and side-to-side mechanical anastomosis. An alternative to this approach is a proximal ileostomy, which was performed in one case.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.) Nothing to declare.

Quick shot presentation

Is minimally invasive inguinal hernia repair performed in emergency surgery in spain?: A nationwide survey

Visceral trauma

Abstract text (incl. references and figure legends) AIM: To describe and assess whether minimally invasive inguinal hernia repair is performed in emergency surgery or not in Spain. MATERIAL AND METHODS An Anonymous survey with 26 questions was sent to all Surgery Residents in Spain by email by Spanish Surgeons Association. Responses were analyzed using both qualitative and quantitative methods RESULTS The survey collected a total of 161 answers; 63% of Spanish hospitals declared to have an abdominal wall surgery unit. A total of 83.4% of participants performed minimally invasive abdominal wall surgery in their hospital, but in 78,2% of hospitals this surgery was conducted by 1 or 2 senior surgeons. During elective surgery, a totally extraperitoneal (TEP) repair is preferred to a transabdominal preperitoneal (TAPP) approach. In emergency operation due to a complicated inguinal hernia, more than 93% declared the use of minimally invasive surgery. Nevertheless, only 3% declared this use in more than 50% times. During emergency surgery, TAPP approach is preferred to a TEP repair. Spanish general surgery residents training in minimally invasive inguinal hernia repair is poor; just 6% performe more than 20 elective surgeries during their residency. In addition, less than 1% performe at least one emergency surgery. CONCLUSION This survey shows that minimally invasive techniques in inguinal hernia repair in emergency surgery are underutilized. Greater focus should be placed on the development of dedicated training in these techniques for elective surgery, and therefor emergency one. 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 have nothing to declare.

Are return to theatre figures a reliable marker for quality of care in emergency laparotomy? A critical review of 'return to theatre data' at a single site

Polytrauma

Abstract text (incl. references and figure legends) Objectives: The National Emergency laparotomy audit1 (NELA) collects data to measure outcomes for patients who have undergone emergency laparotomies from over 170 hospitals across England and Wales. A high rate of unplanned return to theatre (URTT) is used as a marker of "less-than-optimal" outcome. It is important to identify the causes for these return rates especially if higher than expected, in order to improve care. This review will look to identify whether NELA data submitted from a single site with higher than expected URTT accurately reflects true unplanned return to theatre for patients who have undergone emergency laparotomies. Method: Patient level data was reviewed from data submitted to the NELA database from a single site between 2016-2021 and compared with the patient clinical record. Results: Between 2016-2021, 822 patients were submitted to the NELA database after undergoing emergency laparotomy. 78 were identified as having URTT (9.5% vs national mean 6%). On reviewing patient data, 7 patients did not undergo return to theatre, 4 patients underwent laparotomy for elective complications and 14 underwent planned return. Only 53patients underwent emergency laparotomies with subsequent unplanned returns to theatre (6.4%). Conclusion: To provide useful information, the submission of data to collective datasets requires accuracy. If an adverse result is reported, the first step is always to critically scrutinise data, especially if data entry is performed by none dedicated staff who may be unfamiliar with precise terminology / criteria. Only after this has been performed should additional actions be considered. References: 1. NELA. About the Audit: Specific Objectives - The National Institute of Academic Anaesthesia https://www.nela.org.uk/nela_objectives 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

Rescue cholecystostomy as bridge therapy to lams in unfit patients: Our experience

Abstract text (incl. references and figure legends) Case history We present the case of a 94 years old woman with a past medical history of diastolic heart failure and dementia. The patient was in poor general condition with a Frailty Index of 7 and ASA 4. Clinical findings The patient was admitted to our Emergency department with right quadrant abdominal pain and fever. Vital parameters were stable. Investigation/Results Blood samples showed incremented CRP levels and WBC count. CT scan revealed acute cholecystitis. Diagnosis Acute cholecystitis in an elderly and fragile patient. Therapy and Progressions The patient underwent at first antibiotic therapy and cholecystostomy placement on the same day of arrival with progressive improvement of the general conditions. The drainage tube was closed after 14 days and later the patient was discharged. Afterwards, the patient was kept under regular clinical and ultrasound follow-up until cholecystoduodenal lumen apposing metal stent (LAMS) was endoscopically placed as definitive treatment. The post-procedural course was uneventful. The patient was discharged the day after the procedure. Comments From our small preliminary experience, we believe that using cholecystostomy as bridge therapy to definitive endoscopic stent is a life-saving procedure in patients unfit for surgery. It allows us to stabilize the acute situation and perform LAMS in an elective setting. Bridge cholecystostomy followed by elective cholecystoduodenal stenting may be considered safe also in low-volume LAMS centres. Moreover, it may improve by far the quality of life of patients unfit for surgery with a low complication rate. Amato, A., Sinagra, E., Celsa, C., Enea, M., Buda, A., Vieceli, F., Scaramella, L., Belletrutti, P., Fugazza, A.,Cammà, C.,Radaelli, F.,Repici, A.,Anderloni, A., 2021. Efficacy of lumen-apposing metal stents or self-expandable metal stents for endoscopic ultrasound-guided choledochoduodenostomy: a systematic review and meta-analysis. Endoscopy 53, 1037–1047. 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

Evolving practice in the management of acute colonic diverticulitis: A retrospective cohort study based on a propensity score matching analysis

Abstract text (incl. references and figure legends) Introduction The recent increase in admissions for acute diverticulitis(AD) adds pressure on the healthcare system, leading to unnecessary hospitalizations and increased length of stay(LOS). To overcome this issue, in our center an outpatient surgical point of care ultrasound(POCUS) facility was established and a follow-up program was started for all AD. The aim of this study is to evaluate the impact on admissions, LOS, and healthcare costs before and after the introduction of the program Materials and Methods This is a retrospective cohort study based on medical records of patients consecutively diagnosed with AD in a 2-year frame before(Group 2-May 2019/September 2020) and after the program started(Group 1-May 2021/September 2022). The study was conducted at Cattinara University Hospital. Patients undergoing non-operative management(NOM) were propensity score matched(PSM) according to WSES diverticulitis grade Results In Group 1, 15(32.6%) of the 46 patients who had undergone NOM were hospitalized. In Group 2, 60 underwent NOM and 59(98.3%) were admitted. After the PSM analysis, 44 patients for each group were considered. In Group 1, 13(29.5%) patients were hospitalized, 43(97.7%) in Group 2(p&lt;0.001). On the other hand, WSES AD grade differed in hospitalized patients (p=0.014) as shown in Table 1. This led to a significant cost reduction(p&lt;0.001). No statistically significant differences were found in LOS and readmissions Conclusions Our results show a remarkable change in AD management before and after the institution of the new follow-up program. POCUS follow-up allows closer and more accurate surveillance of the patients in outpatient settings, permitting early detection of complications, and leading to a remarkable optimization of the healthcare system resources management References Lai W, et al. The Value of a Surgical Assessment Unit Ultrasound Facility. BMJ Qual Improv Rep. 2017;6(1) Tab 1. AD grade in hospitalized patients after PSMDisclosure: 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

Please contact the speaker via yoshix2.kendo.med@gmail.com if you have question about the presentation.

The endoscopic component separation technique can prevent abdominal compartment syndrome by increasing intra-abdominal volume

Abstract text (incl. references and figure legends) Introduction: Abdominal compartment syndrome (ACS) is a serious condition that causes respiratory and circulatory disturbances due to organ ischemia, decreased preload, and diaphragmatic elevation caused by increased intra-abdominal pressure. There is no established minimally invasive technique to treat ACS in its early stages. Although there is no established minimally invasive technique for early ACS, there are some literature reports that suggest the usefulness of increasing intra-abdominal volume with endoscopic component separation (ECS), which is mainly used in the hernia field. We investigated how much intra-abdominal volume can be increased by ECS in an actual operation. Material &amp; Methods: We measured and compared the amount of carbon dioxide gas required to insufflate to 8 mmHg before and after ECS for giant inguinal hernias. Results: The volume of carbon dioxide required to insufflate to 8 mmHg before and after ECS increased from 1.5L to 2.1L, an increase of 600mL. Conclusions: The ECS can be easily performed by a skilled surgeon in a relatively short time, and is not invasive because the wound is small. The ECS increased intra-abdominal volume by 600mL, suggesting that ECS is a minimally invasive procedure that can be performed early in the treatment of ACS.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

How is left-sided diverticulitis managed? An observational study from 2015 to 2020 in a tertiary hospital

Abstract text (incl. references and figure legends) INTRODUCTION: Diverticulitis is the inflammation and infection of one or more diverticula. Abdominal CT confirms the diagnosis and enables the classification of the disease according to Hinchey. The present study aimed to determine the management in a single medical center in Spain. MATERIAL &amp; METHODS: Data for this descriptive retrospective analysis were collected from the electronic medical records of all patients diagnosed with left sided colonic diverticulitis by CT from September 2015 to December 2020. RESULTS: During the study period, 384 patients with diverticulitis were admitted to our institution, of which 166 fit inclusión criteria (43%). Mean age was 60.5 years old. A total of 60% were men. The main presenting symptom was left abdominal pain. Hinchey classifcation was: IA 47%; IB 29%; II 9%; III 14% and IV 1%. All patients were treated with intravenous antibiotics, but 26% needed an urgent surgery. 50% of them recieved a Hartmann, laparoscopic lavage and drainage was performed in 23% and in 27% a sigmoidectomy with primary anastomosis. Median length of hospital stay was 8 days. Recurrence was present in almost 30% patients. CONCLUSIONS: Although CT is the established method of choice for acute diverticulitis diagnose, in our centre is performed in less than 50%. Most common Hinchey classification is grade IA. Antibiotics were offered to all patients. Surgery is performed in at least 25% of patients, Hartmann is the most common procedure, followed by primary anastomosis. REFERENCES: Sartelli M, 2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting. World J Emerg Surg [Internet]. 2020;15(1). Qaseem A, et al . Diagnosis and management of acute left-sided colonic diverticulitis: A clinical guideline from the American College of Physicians. Ann Intern Med [Internet]. 2022;175(3):399–415Disclosure: 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

Intraoperative techniques to prevent deep or organ-space surgical site infection after emergency surgery for perforation peritonitis: A prospective two-center observational study

Abstract text (incl. references and figure legends) Introduction: The rate of surgical site infection (SSI) after surgery for secondary peritonitis is very high. However, international guideline recommendations for intraoperative procedures to prevent SSI are controversial with insufficient evidence. This study aimed to reveal the relationship between intraoperative procedures of emergency surgery for perforation peritonitis and deep or organ-space SSI. Material &amp; Methods: This prospective, two-center observational study included patients aged ≥ 20 years who underwent emergency surgery for perforation peritonitis between April 2017 and March 2020. We compared patients with deep or organ-space SSI (Group S) to patients without SSIs or with superficial SSIs (Group C). Thereafter, we evaluated the association between intraoperative technical variables and deep or organ-space SSI using a multivariate logistic regression model. All multivariate analyses were adjusted for potentially relevant risk factors (e.g., age, body mass index, diabetes, smoking habit, and National Nosocomial Infection Surveillance risk index). Results: Of the 79 patients enrolled in this study, 15 were in Group S and 64 were in Group C. The use of a wound protector device was significantly associated with decreased odds of deep or organ-space SSI (adjusted odds ratios [AOR], 0.034; 95% confidence intervals [CI]: 0.0045–0.26, p = 0.001). A 1000 ml increase in intra-abdominal lavage with normal saline was significantly associated with increased odds of deep or organ-space SSI (AOR: 1.24, 95% CI: 1.01–1.54, p = 0.044). Conclusions: Wound protector devices should be used in emergency surgery for perforation peritonitis. Intra-abdominal massive or excessive lavage with normal saline for peritonitis has unsatisfactory benefits and increases the incidence of deep or organ-space SSI. Achieving consensus on this issue through a future randomized controlled trial is necessary. Reference: Surg Infect (Larchmt). 2012;13:257-65.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.

PD Dr.

Prof. Dr.

Morbidity and mortality associated with surgery for small bowel obstruction with and without bowel resection

Abstract text (incl. references and figure legends) Background Small bowel obstruction requires surgical therapy, usually in terms of adhesiolysis. In case of partial bowel ischemia, resection with anastomosis may be necessary. Morbidity and mortality associated with surgical treatment of small bowel obstruction have hardly been investigated. It is also unlcear whether 1) bowel resection and 2) timing of surgery (regular versus night-service) influence outcome. Methods This was a retrospective single-center evaluation. All patients with small bowel obstruction and surgical treatment of our institution from 2012-2021 were included. Patient characteristics were compared using Kruskal-Wallis and Chi2 tests, and postoperative complications (Clavien-Dindo graduation) were compared using Mann-Whitney U and Chi2 tests. Results 118 patients could be included in the analysis. Bowel resection was associated with a significantly increase of postoperative complications ≥ 3 according to Clavien-Dindo (50% vs. 25% without bowel resection; p = 0.005). Re-operation rate was also increased with bowel resection (43% vs. 20.8% without bowel resection; p = 0.009). No significant association between bowel resection and mortality was observed (p = 0.077). Timing of surgery had no significant (p=0.393) effect on morbidity or mortality. Conclusion Our results show that surgery for small bowel obstruction is associated with a significant postoperative morbidity. Bowel resection is associated with an increased rate of major complications and reoperations. Furthermore, from our data, timing of surgery (regular vs. night-service) did not influence outcome. Thus, medical urgency should be the only factor considered when scheduling surgery.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

Rare bacterial causes of small bowel perforations (SBP) in Europe: Report of two cases

Abstract text (incl. references and figure legends) In developed countries, adult small bowel perforations (SBP) are usually caused by obstruction due to gangrene, strangulated hernias ,trauma injuries, ingested foreign bodies and iatrogenic causes like endoscopic procedures and surgical procedures. Less often, SBP may result from inflammatory diseases, primary and secondary neoplasms, small bowel diverticula. Even though rear SBP secondary to a bacterial and parasites infection should be considered. We reported 2 cases of SBP due to bacterial infection in Europe. Case 1: a 43 y.o. woman transferred to our hospital for miliary tuberculosis; after 10 days, the patient complained vomit, abdominal pain and distension. CT scan revealed an ileum wall thickening and fluid distension with multiple hydro-air levels and abdominal free fluid. At emergency laparotomy, intestinal free fluid and a centimetric perforation, about 10 cm from the ileocecal valve, were found. A resection of greater omentum and 30 centimeters of ileum with an ileo-ileum anastomosis was realized. The microscopic and microbiologic exams on the surgical specimen revealed the tuberculosis nature of the lesion. Post operative course was 37 days long and uneventful. Case2: a 39 y.o man admitted to a medical department for prolonged fever, coming back from a trip to Senegal. At the objective examination he had only conjunctival jaundice and diarrhea. Blood test showed elevated inflammatory markers and Salmonella typhi at blood cultures. After 5 days of antibiotic therapy patient complained vomit, ague abdominal pain and contracture. The CT scan showed free air and fluid in all abdominal quadrants. At the emergency laparotomy, a centimetric perforation on a typhoid granuloma of the last ileal loop was found, An ileocolic resection and packaging of ileo-colostomy was performed. 7 days post-operative course was regular. In conclusion it is mandatory to keep in mind rare causes of SBP to accomplish quick, appropriate and effective treatment of these diseases.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.) .

Discrepancy of length of the injured arterial segment from open surgical repair in patients with blunt peripheral arterial injury compared to length of the filling defect from preoperative angiography: The role of primary arterial repair

Abstract text (incl. references and figure legends) Background: Blunt peripheral artery injury may be seen as long injured arterial segment because of the injury mechanism of blunt trauma. Methods: The survey was done for the patients with blunt peripheral arterial injury which was repaired by open surgery in a Level 1 trauma center from October 2019 to June 2022. After exploration and identification of the injured arterial segment, treatment decision was made. Primary repair/end-to-end anastomosis was done for the short injured arterial segment after resection with/without thrombectomy. Bypass surgery was done for the long injured arterial segment. Results: After 1 patient was excluded due to no preoperative computed tomography angiography (pCTA), 22 patients were analyzed. Age was 48.7±16.0 year, and male patient was 95.5% (21/22). Injury severity score was 18.1±11.5. For the injured artery, there was 45.5% (10/22) femoral artery, 22.7% (5/22) popliteal artery, 13.6% (3/22) brachial artery, 9.0% (2/22) iliac artery, and 9.0% (2/22) tibial artery. Length of the injured arterial segment from open surgical repair (L-OSR) and length of the filling defect from pCTA were 2.3±1.1cm vs 7.3±5.0cm (p&lt;0.001). L-OSR between primary repair/end-to-end anastomosis (77.3%, 17/22) and bypass surgery (22.7%, 5/22) was 1.85±0.8cm vs 3.6±0.9cm (p&lt;0.001). Conclusions: Primary repair can be used for the blunt peripheral artery injury given the tendency of short length of injured arterial segment despite the injury mechanism. Preoperative angiography findings such as long filling defect may mislead into either bypass surgery or endovascular intervention such as stent insertion. References: David V Feliciano, et al. Evaluation and management of peripheral vascular injury. J Trauma 2011 Jun;70(6):1551-6. 2. Michael A Peck, et al. Management of blunt peripheral arterial injury. Vasc Surg Endovasc Ther 2006 Jun;18(2):159-73.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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