22nd European Congress of Trauma & Emergency Surgery

Chairs

Prof.

Prof. Dr.

Code yellow: Platelet to erythrocyte ratio and mortality in massively transfused trauma patients

Disaster and military medicine

Emergency surgery

Abstract text (incl. references and figure legends) Introduction The optimal transfusion ratio of platelets (PLT), plasma and red blood cells (RBC) in trauma patients with massive hemorrhage is still a subject of discussion. The objective of this study is to assess the effect of platelet transfusion on mortality in trauma patients who received massive transfusion. Material &amp; Methods Data were collected from four Dutch level-1 trauma centers. All trauma patients aged ≥ 16 years who were admitted and received ≥ 6 RBC / 6 hours or ≥ 10 RBC / 24 hours from the time of injury were included. Patients were divided based on platelet to RBC ratio (no platelets, low (&lt;1:5) and high (≥1:5)) and plasma:RBC ratio (low (&lt;1:1) and high (≥1:1). Results A total of 297 patients were included. Patients in the high PLT ratio group had lower mortality rates at six hours as compared to the low PLT ratio and no PLT group (9% vs. 26% vs. 32%, p=.002). The odds ratios (OR) for survival beyond six-hours were 0.970 (95% CI 0.951-0.991) for the injury severity score, 2.4 (95% CI 1.22-4.81) for in hospital use of fibrinogen concentrate and 6.14 (95% CI 1.88-20.45) for plasma:RBC ratio of 1:1. Sub analysis of 229 (77%) patients with blunt injury showed that a plasma:RBC ratio of ≥1:1 resulted in a survival benefit at all studied time intervals. Conclusions Trauma patients who received massive transfusion with a PLT:RBC ratio of ≥ 1:5 had lower mortality at six hours as compared to a PLT:RBC ratio of &lt; 1:5 or no platelets. Additionally, a plasma:RBC ratio of ≥ 1:1 and in hospital use of fibrinogen concentrate were associated with lower mortality rates at six hours. For patients with blunt injury, a plasma:RBC ratio of ≥1:1 was associated with lower mortality rates at all studied time intervals as compared to lower plasma:RBC ratios. 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

Oral presentation

Open abdomen versus definitive primary closure in nontraumatic emergency patients: A weighted survival comparison.

Visceral trauma

Abstract text (incl. references and figure legends) I:Open Abdomen (OA) is getting consensus in the emergency surgery community (ES) but its effectiveness is still debated. Our aim was to estimate the 90-days mortality in nontrauma patients (pts) who underwent OA vs definitive primary closure (DC) during emergency laparotomy (EL). M:Consecutive pts who underwent EL at the IRCCS-HumanitasResearchHospital between 01/2015 and 12/2022 were reviewed and divided in two groups (OA vs DC). Differences were balanced by inverse probability weighting (IPW), and 90-day mortality was estimated by Kaplan-Meier method. Subgroup analysis was carried out for pts with Manheim score&gt;26 (MS), or with a diagnosis of bowel obstruction (BO), bowel ischaemia (BI), perforation (PE). R:320 pts were enrolled, 167 DC and 153 OA. Groups were significantly different for ASA, Charlson Index (CI), Transfusions rate, P-Possum score, Manheim score grade, Clinical Frailty scale Score (CFSS), diagnosis and type of resection. After IPW, two pseudo populations were created: 227 DC and 186 OA. The 90-day mortality was 50.8% for DC and 60.8% for OA (HR0.793,95%CI:0.40-1.55,p:0.502,fig.1A). At Cox regression, CFSS (HR 1.125,95%CI:1.01-1.25,p:0.033), BI (HR5.531,95%CI:2.37-12.89,p&lt;0.001) and No-resection (HR 2.970,95%CI: 1.56-6.64,p:0.001) resulted being predictors of 90-day mortality. OA did not modify the risk of 90-days mortality in case of MS, BO and PE. In case of BI, performing OA (HR0.056,95%CI:0.01-0.22,p:0.001, fig.1B), P-Possum score (HR1.060,95%CI:1.01-1.11,p:0.033), large bowel resection (HR6.442,95%CI:1.28-32.31,p:0.040) and No-resection (HR9.880,95%CI:3.01-32.35,p:0.002) were predictors of death. C:OA is not superior to DC in most of the setting explored, even in case of severe peritonitis. Bowel ischaemia is the only setting in which OA reduce the risk of mortality. R:Proaño-Zamudio JA,Delayed fascial closure in nontrauma abdominal emergencies: A nationwide analysis.Surgery.2022 Nov;doi:10.1016/j.surg.2022.06.025. Fig1A-B. 90-Day survivalDisclosure: 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

Laparoscopic Hartmann's procedure is a safe and effective alternative for emergent surgical management of complicated diverticulitis: A NSQIP-based, propensity score matched analysis study

Abstract text (incl. references and figure legends) Introduction: As many as 25% of patients with acute diverticulitis will present with complicated disease. The procedure of choice for emergent management of complicated diverticulitis has been the open Hartmann&quot;s procedure. We analyzed the NSQIP database to compare outcomes in patients who underwent emergent laparoscopic Hartmann&quot;s procedure for complicated diverticulitis to those who had an open Hartmann&quot;s procedure. Methods: Data analyzed was from the ACS-NSQIP database. We identified patients with complicated colonic diverticulitis using ICD-10 codes, and who required either a laparoscopic or open Hartmann&quot;s procedure from 2015 - 2019. Propensity score method (PSM) was utilized to match patients in each of the two surgical groups on several important covariates. Results: Prior to PSM analysis, 4,570 patients had an open Hartmann&quot;s procedure, while 456 had laparoscopic Hartmann&quot;s procedure from 2015 to 2019. PSM analysis based on the aforementioned covariates yielded 374 open Hartmann&quot;s and 374 laparoscopic Hartmann&quot;s patients. Laparoscopic Hartmann&quot;s patients had similar post-operative outcomes when compared to open, including mortality (5.08% vs. 4.55%; p=0.8642), wound disruption (1.34% vs. 1.6%; p=1.0), superficial surgical site infections (SSSI) (2.41% vs. 5.35%; p=0.0614), median LOS (10.5 d vs. 10.6 days; p=0.9630), any readmission within 30 days (11.76% vs. 9.63%; p=0.4282). Laparoscopic Hartmann&quot;s procedures were slightly longer compared to open, (median procedure time; 129 vs. 116.5 minutes). Conclusion: Laparoscopic Hartmann&quot;s procedure is a safe and effective alternative to open Hartmann&quot;s procedure for emergent surgical management of complicated diverticulitis. More studies are needed to determine differences in long-term outcomes between these two procedures.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.

Comparison of the Alvarado and AIR Scales in the diagnosis of acute appendicitis when associated with IL6 (interleukin 6) and NLI (neutrophil-lymphocyte index).

Education

Abstract text (incl. references and figure legends) Introduction: The diagnosis of acute appendicitis(AA) can be a challenge for young surgeons so several clinical tools have been developed seeking to optimize its diagnosis Objectives: To comparatively evaluate the Alvarado and AIR scales in order to determine which one is more valid in the diagnosis of appendicitis. greater validity in the diagnosis of acute appendicitis (AA) alone and in association with IL 6 and NLI, in our population Materials and methods: Prospective, comparative, observational study in patients with abdominal pain suggestive of AA who had their Alvarado, AIR, IL 6 and NLI values recorded over a period of 12 months and whose values were correlated with the final diagnosis of AA. A bivariate and multivariate analysis was performed for an OR with a 95% CI was performed using IBM SPSS Statistics v.26 and STATA v.14 Results: During the time of the study, data were collected from 139 patient.Bivariate analysis: AIR scale presents, for a score between 5-8, a PPV (positive predictive value) of 80%, sensitivity(S) of 85.3% and specificity(E) of 75%; in score ≥ 9 a PPV 89% with S 17%, E 98.4%. Presenting a ROC curve of 0.87 (CI: 8.81-0.93) The Alvarado scale, for a score between 5-7, presents a PPV 66%, S 92%, E 45.3%, in scores ≥8 a PPV of 87.2%, S 45.3% and E 92%. It presented an ROC curve 0.8 (CI:0.73-0.87) Multivariate analysis: Alvarado scale when associated with IL-6 the diagnostic yield is improved with an ROC curve of 0.849, while for AIR we did not evidence changes in its diagnostic yield (ROC curve: 0.86) NLI when associated with the diagnostic scales did not present a statistically significant role Conclusions: - In our series, AIR scale has greater diagnostic validity to diagnose or exclude appendicitis compared to Alvarado scale - By associating scores ≥ 5 on the Alvarado scale with IL-6, a significant increase in the diagnostic accuracy of AA is achieved - NLI in association with diagnostic scales was not useful in our series 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.

Feasibility and safety of intraoperative bile duct clearance by sphincter of Oddi balloon dilatation: A prospective observational pilot study

Abstract text (incl. references and figure legends) Introduction: Concomitant cholecysto- and choledocholithiasis is common. Standard treatments are ERCP followed by cholecystectomy or laparoendoscopic rendez-vous. ERCP has drawbacks such as post-ERCP-pancreatitis (5%) or -bleeding (5%) and potentially more than one intervention to address common bile duct (CBD) stones. Safety and feasibility of an intraoperative antegrade transcystic single-stage approach during cholecystectomy with papillary balloon dilation and pushing of concrements to the duodenum has not been evaluated prospectively. The aim of the study was to evaluate this procedure regarding safety and stone clearance rate. Material &amp; Methods: Prospective single centre intervention study. 80 consecutive patients admitted to our institution between 1/2021 and 4/2022 with suspected or confirmed choledocholithiasis (stones ≤ 6 mm) and known cholecystolithiasis were included. Success of the procedure was defined as lack of filling defects in the intraoperative control cholangiography and absence of symptoms at 6 weeks follow up. Simon&quot;s two stage design was used to determine sample size. Aiming for 95% positive outcomes (no pancreatitis) and tolerating at most 15% negative outcomes, power analysis revealed 57 participants (80% power, alpha 0.05). Results: 57/80 patients (71%) fulfilled the inclusion criteria. While there was no postoperative pancreatitis, 2 patients (3.5%) had asymptomatic amylasemia 4h postoperatively. Stone clearance was achieved in 54 patients (94%). The main reason for failed stone clearance was the inability to push the guide wire along the concrement into the duodenum. Median number of CBD-stones was 1 (1-6). Median stone diameter was 4 mm (0.1-6 mm). Median intervention time was 28 min (14-129 min). Conclusions: Intraoperative bile duct clearance by balloon dilation of the sphincter of Oddi appears to be safe and highly feasible. Its overall superiority to the current standards requires evaluation in a randomized controlled trial.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

Patient characteristics or performance may affect outcomes for acute appendicitis across Europe. Analysis of appendicitis complications in ESTES snapshot audit 2020 data from Spain and Sweden

Abstract text (incl. references and figure legends) Introduction: Appendicitis management is heterogeneus. SnapAppy was an prospective observational international study. Aim of this subgroup analysis is to compare results among countries and analize complications. Methods: Patients from Spain and Sweden were selected. Main variable was complications. Mann-Whitney U and Pearson Chi2 were performed to compare cohorts of patients and variables association to complications. Results: 2,198 patients included. 17.5% developed complications (Sp20.7%vs.Sw14.1%;p&lt;0.001). They were mainly Clavien I-II with no differences in severe ones. Most frequent were pelvic abscess (3.7%) and postoperative ileus (3.6%). Complications associated with age, BMI, ASA score, and comorbidities. No differences in demography and major comorbidities were seen. Absence of RIF pain, symptoms&gt;48h or fever associated with complications. All presenting symptoms but guarding were more frequent in Sw, but not time to presentation. Increasing SIRS score related to complications and Sw had more &gt;2 SIRS patients. Preferred imaging was US in Sp and CT in Sw. CT associated to complications. Most patients received antibiotic prophilaxis, not associated to complications. Time to first antibiotic dose related to complications and was shorter in Sp. Time to surgery (Sp&lt;Sw), treatment other than appendectomy, need for percutaneous drainage, longer operative times, purulent fluid, converted/open surgery, other technical aspects associated to complications. Laparoscopic appendectomy was 91%. Sw had less open surgeries but higher conversions. Malignancy rate was similar but more negative appendectomies in Sp. Sw had more ambulatorization. Sp had less readmissions but higher LOS. Complications were significantly higher in hospitals with lower caseload. Conclusions: Some differences exist in demography, disease process, diagnostic-therapeutic management or centralization. None could individually explain difference in outcomes but help to guide future research.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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