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23rd European Congress of Trauma & Emergency Surgery

Ass. Prof.

Code High Risk Abdomen – CHRA: A novel pathway for the immediate imaging and management of acute abdomen

Emergency surgery

Trauma and Emergency surgery | Miscellaneous

Introduction Patients with surgical acute abdomen often present with deranged physiology and require emergency laparotomy (EL). Many patients are frail with significant comorbidities. EL is associated with high mortality. In accordance with the ERAS EL Guidelines (part 1-preoperative phase) which put stress on the timing of CT imaging and inspired by the established pathway for the imaging of acute stroke, we created a dedicated pathway for the immediate imaging of high-risk surgical patients (Code High Risk Abdomen – CHRA). Objectives The objective was to reduce the time from patient presentation in the emergency department (ED) to EL and thereby improve its outcomes. Methods From Q1 2021 to Q3 2023, adult patients presenting to our ED with peritonitis, sepsis of suspected abdominal origin or abdominal pain in the presence of frailty were included in the CHRA pathway. The CHRA CT imaging was assessed immediately by in-house radiologists at daytime or remote teleradiologists out-of-hours. Results For CHRA patients (n = 187), the mean time from ED presentation to CT report was 57 minutes. The mean time from ED presentation to EL was 3.5 hours. The mean time from the decision to operate within 2 hours to EL was 1.5 hours. The outcomes of our ERAS EL bundle compared to prior implementation of ERAS EL (in parenthesis) were: 5.3% (12%) 30-day mortality and 14% (20%) grade 3-4 Modified Clavien-Dindo complications. All CT assessments outsourced to the teleradiology service were reported within 1 hour. No discrepancy was detected between the primary radiology reports and the main perioperative surgical findings. Conclusion Our study indicates that the CHRA pathway helped reduce time to EL. As time is of utmost importance in surgical emergencies requiring EL, shortened time to source definition and control lead to significant impact on hard endpoints. Outsourcing CHRA CT reporting to a teleradiology provider does not seem to impact the efficiency of this novel pathway.No

Abstract talk

Factors influencing non-operative management and outcomes of acute cholecystitis in the United States: A nationwide U.S. Study

Research

Introduction: Cholecystitis is a prevalent condition, accounting for significant morbidity and costs. Management involves operative (Op-I) versus non-operative (NonOp-I) interventions. The World Society of Emergency Surgery cites lack of consensus regarding cholecystitis management. Objectives: Identify socio-demographic variables and outcomes related to operative vs. non-operative management of cholecystitis. Patients &amp; methods: We analyzed the 2020 Nationwide Inpatient Sample (NIS), focusing on adults (age≥18 years) diagnosed with cholecystitis, using ICD-10-CM diagnostic criteria. Management strategies (Op-I vs. NonOp-I) were categorized by ICD-10-PCS codes. The primary outcome was management approach and secondary outcomes were cost and length of hospital stay. Results: Among 94,424 patients diagnosed with cholecystitis, 40,385 (43%) underwent Op-I, while 54,039 (57%) pursued NonOp-I. NonOp-I patients were older than Op-I (64 yrs. vs. 58yrs, p&lt;0.001), with a higher prevalence of diabetes (23% vs. 15%, p&lt;0.001). Conversely, obesity (BMI 30+) was higher among Op-I (25% vs. 18% p&lt;0.001) than NonOp-I. NonOp-I patients were more likely to have government insurance (Medicaid or Medicare) (72% vs. 59%, p&lt;0.005), less likely to be discharged home (44% vs.78%, p&lt;0.004), had longer lengths of stay (8.1 vs. 5.2 days, p&lt;0.001) and higher inpatient costs ($26,661 vs. $20,965, p&lt;0.001). In adjusted analyses, there was higher odds of NonOP-I among older patients [60-69 years: aOR 1.4; 70-79 years: aOR 1.5, p Conclusion: Our national analysis strongly supports operative management during index admission, with special consideration to the elderly and diabetic populations. NonOp-I leads to greater healthcare utilization and higher costs. Further analysis is warranted to determine why elderly females are more often stratified to NonOp-I, as both clinical factors and possible treatment biases might impact this patient population. No

1-day appendectomy: More an opportunity than a challenge

Introduction: Over the past decades, appendectomies have been increasingly performed as "short-stay" or "ambulatory" procedures, with satisfactory outcomes and low complication rates. Yet, conventional hospitalization remains the routine procedure for acute appendicitis. Objective: This study was designed to validate day-stay laparoscopic appendectomy (LA) for non-complicated acute appendicitis (ncAA) Materials &amp; Methods: We retrospectively reviewed a consecutive series of 560 LA for acute appendicitis, performed in the last 3 years. Whenever possible, patients were offered 1-day appendectomy, defined as "discharge within 24h". Furthermore, we determine predictive factors for successful day-stay surgery (LOS &lt;24 h). In light of these findings, in 2023 we"ve started a prospective 1-day protocol of LA for ncAA at our institution. We prospectively analyzed outcomes and postoperative complications of the 50 patients who underwent 1-day appendectomy. Results: The average length of stay of the 560 patients retrospectively analyzed was 3.1 days. We also highlighted that there were no statistically significant differences between patients discharged in I, II or III POD, regarding both preoperative parameters (AIR score and Alvarado score) and intraoperative parameters (Mannheim Peritonitis Index). Moreover, predictive factors for safe and feasible day-stay surgery were AIR score &lt; 6 and Mannheim Peritonitis Index &gt; 11. In 2023, none of the 50 patients undergoing 1-day appendectomy reported major complications or 30-day hospital readmissions. Conclusions: 1-day protocol for laparoscopic appendectomy significantly increased the rate of outpatient management with more comfort for patients and no increase in morbidity or mortality. Because of the positive results from our study, this practice has now become the standard of care for ncAA at our institution. •LaFrançois M et al. Management of acute appendicitis in ambulatory surgery: is it possible? How to select patients? Ann Surg 2015;261:1167—72. No

The characteristics and clinical outcomes of elderly patients with acute appendicitis: Retrospective single center study

Introduction Elderly is a growing population and have more extensive medical histories and are expected to have a higher risk of complications such as perforation. The aim of study is to determine the impact of advanced age on clinical outcomes in patients undergoing appendectomy. Materials &amp; Methods From 2018 to 2022, a retrospective review was conducted on 1780 patient charts at National Health Insurance Ilsan Hospital who were diagnosed with appendicitis in the Emergency Room and underwent appendectomy. The patients were divided into two groups: elderly patient group (EPG) and non-elderly patient group (NEPG). Primary end point was length of days. Results Of the 1733 patients, 295 were assigned to EP, and 1438 in NEPG. The average age of NEPG and EPG were 42.4 and 75.0 years respectively. The proportion of ASA score of 3 or higher was 9.1% in the NEPG and 52.9% in EPG. Complicated appendicitis was observed in 39.6% of NEPG and 66.8% of EPG cases. The average length of stay was 3.5 in NEPG and 5.7 in EPG. Sub-analysis of simple appendicitis cases with NEPG and EPG revealed that the total length of stay was still had a shorter length of stay compared to EPG (2.7 vs 3.4 p=0.006). Furthermore, we conducted an analysis of risk factors associated with a length of stay for appendicitis at NHISIH. The results indicated that elderly had a 1.6 times higher likelihood of extended hospital stay than NEPG. Conclusion EPG exhibited a higher prevalence of complicated appendicitis and patients with higher ASA scores compared to the NEPG. Therefore, elderly patients require more intensive postoperative care which lead to resulting in prolonged hospital stays. Reference Lapsa S, Ozolins A, Strumfa I, Gardovskis J. Acute Appendicitis in the Elderly: A Literature Review on an Increasingly Frequent Surgical Problem. Geriatrics (Basel). 2021 Sep 18;6(3):93 Legends Characteristics of NEPG &amp; EPG of appendectomy patients The risk factors of length of stay after appendectomyNo

Prof.

Beyond acute appendicitis: Ten-year monocentric experience of unexpected histological results after 1200 emergency appendicectomy

Background: Acute appendicitis is still one of the most frequently performed emergency procedures all over the world. Appendicecal neoplasm, although rare (1% of all the gastrointestinal tract neoplasm), represent a challenge for the surgeon in the light of the large volume of appendicectomy performed globally. The purpose of the study was to analyze our experience in terms of epidemiology, clinical and management of appendicular neoplasm after appendicectomy performed in an acute care setting. Material and methods: we perfoirmed a retrospective cohort analysis of all patients with acute appendicectomy underwent appendectomy at our istitution. Patients with a diagnosis of acute appendicitis (AA) were compared with patients with acute appendicitis and a histologically confirmed diagnosis of appendicular neoplasia (AN). The collected data included demographic features and clinical variables, diagnosis, pathological findings, and management Histological classification included LAMNs, nets, and adenocarcinomas. Results: we collected 1200 cases of AA. Of this 989 were included in the study as they underwent emergency/emergency appendectomy. We found a global prevalence of AN of 9.2% (92 patients). The incidence rate increases significantly with increasing age to 13.2% in patients between 40 and 89 (n = 438). Histologically, 47 of the cases (51.1%) were LMAN, 32 of the cases (34.8%) were NET, and 13 of the cases (14.1%) were adenocarcinoma. No difference was found in clinical presentations and the type of surgical approach, while we found a lower complicated appendicitis rate in the NA group. Conclusion: although rare, the ANs pose a question still open mainly by the introduction of non-operational treatment for acute appendicitis. Based on the results of this study we believe that laparoscopic appendectomy remains the gold standard of AA treatmentNo

Acute Diverticulitis surgical management and Sarcopenia: How to help the surgeon in the decision making

Background: Sarcopenia is a pathologic condition, in which muscles lose quantity and quality of its fibers. Although it is associated with ageing, it has been demonstrated that sarcopenia can appears earlier in life. The aim of this study is to investigate the prevalence of sarcopenia in patients with acute diverticulitis and its relation with outcome. Materials and methods: We enrolled 239 patients, 116 of them underwent surgery and 123 were treated non operatively. We collected data about surgery and complications of both non-operative and operative treatment. Moreover we measured for each patient the Skeletal Muscle Area (SMA), the Visceral Adipose Tissue (VAT), the Subcutaneous Adipose Tissue (SAT) and the IntraMuscolar Adipose Tissue (IMAT) using the Contrast-Enhanced CT at the admission in the ED to evaluate any correlation between these data and the complication rate and the need for surgery. Results Average age was patients is 61±15, with a mean BMI of 25,12. The 51,5% of our patients were treated conservatively and the 48,5% of our series underwent surgery. Among the CT group, patients who failed the conservative treatment had a statistically significant higher rate of sarcopenia. Moreover in surgically first treated patients, sarcopenia was associated with a higher rate of stoma and anastomotic leak. Conclusions: Sarcopenia is becoming a hot topic in elective surgery, in order to optimize the patient in the preoperative period, obtaining the best possible conditions for surgery. It is difficult to do the same with emergency patients, who usually arrive in the ED without having time to prepare themselves for surgery and without any preoperative study. Despite that, it seems that knowing their nutritional status can help the surgeon deciding what kind of treatment offer to the patient and understand which patient could need more attention identifying who is at greater risk of complications.No

Impact of unnecessary stays after trauma laparotomy: A retrospective analysis at a level 1 trauma centre in Canada

Visceral trauma

Introduction: Despite the strain on our healthcare systems, patients undergo unnecessary hospital stays after medical clearance, leading to the misallocation of resources and suboptimal care. While some factors are known to delay hospital discharges, there is a lack of specific data concerning patients undergoing trauma laparotomy (TL). This study aimed to comprehensively understand and identify the factors contributing to unnecessary stays among TL patients. Methods: We conducted a retrospective cohort study utilizing data from Montreal General Hospital, a level 1 trauma center in Montreal, Canada. Adult trauma patients who underwent TL between January 2016 and February 2020 were included. An unnecessary stay was defined as patients remaining in the hospital beyond the point of active treatment necessity at the trauma center. Patients were categorized into two groups: the timely group and the unnecessary stay group. T-tests and chi-square tests were used to assess differences between the two groups, and a multivariate logistic regression model was used to identify predictors of unnecessary stays. Results: A total of 219 patients met the study criteria. Among them, 64 (29.2%) experienced unnecessary stays following TL, resulting in an additional 513 days in the hospital. Patients with unnecessary stays were significantly older and had a higher proportion of mental disorders, blunt injuries, and higher injury severity scores. The two primary reasons for unnecessary stays were awaiting transfer to rehabilitation facilities (42.2%) and psychiatric departments (39.1%). Age, mental disorder, liver injury, and orthopedic procedures were significant predictors of unnecessary stays. Conclusion: Approximately 30% of our cohort experienced unnecessary stays. The primary reasons were closely linked to patient disposition from an acute care setting. This highlights the importance of improving early discharge planning and ensuring timely access to post-acute care.No

New tools for acute care surgeons. Endoscopic vacuum therapy as rescue treatment for upper GI complications

Endoscopic Vacuum Therapy (EVT) is an emerging option for upper GI complications and injuries. We report about successful EVT in 3 patients (Pt) with anastomotic dehiscence and duodenal perforation. Pt1 underwent total gastrectomy for adenocarcinoma, developing a &gt; 60% anastomotic dehiscence. Pt2 had a late 35% anastomotic fistula after proximal gastric resection and Orringer anastomosis for a EGJ GIST. Pt3 developed three duodenal perforations after laparoscopic nephrectomy. Pt1 and Pt3 underwent one and two reoperations, respectively, before EVT. Ten EVT sessions with biweekly changes were required for Pt 1. Pt 2 and 3 required 3 and 4 sessions, respectively, with weekly changes. Commercial EVT devices were used for Pt1 and Pt2; in Pt3 the difficulty in sliding the foam to the duodenum required a modified device. Following EVT, Pt 1 exhibited minimal residual fistula on radiological follow-up, managed conservatively to complete resolution. Pt 2 demonstrated complete resolution of the fistula. Pt 3 displayed sufficient granulation tissue, allowing for definitive fistula closure with clips and loops, with no evidence of recurrence in subsequent checks. All Pt were discharged at home and are healthy (FU 1-13 mo). EVT emerges as an effective treatment fo UGI defects, avoiding complex and often insufficient surgical approaches. Careful consideration of patient-specific factors, anatomical targets, and shaping of the device are pivotal in optimizing treatment outcomes. Acute care surgeons should become familiar with this tools as rescue treatment. Chevallay, M. et al (2023). Outcome of endoscopic vacuum therapy for duodenal perforation. Surgical Endoscopy, 37(3), 1846–1853.https://doi.org/10.1007/s00464-022-09686-w Kouladouros, K. (2023). Applications of endoscopic vacuum therapy in the upper gastrointestinal tract. World Journal of Gastrointestinal Endoscopy, 15(6), 420–433. https://doi.org/10.4253/wjge.v15.i6.420No

Epidemiology of secondary peritonitis and patterns of microbiological resistance in a Barcelona hospital from 2010 to 2020

Introduction:The decision of the appropriate empiric antibiotic therapy is complex and multi-factorial, it depends of microorganisms, the origin and the characteristics of the patients. Material and methods:It is an observational,unicentric,prospective study of consecutive cases of secondary peritonitis&gt;2, collecting epidemiological and microbiological data. The objective is the adequacy of the empiric antibiotic treatment comparing with mortality and predictive indices of severity. Results:833 patients were included, 69% community peritonitis(PC) and 31% nosocomial peritonitis(PN). The most common origin of PC was appendicular(38%). 27% of PC cultures and 39% of PN cultures were monomicrobial, with E.coli being the most common microorganism. In contrast, polymicrobial cultures were obtained in 73% of PC and 61% of PN, the most prevalent microorganisms being E.coli, K.pneumoniae, P.aeruginosa and Enterococcus spp. Gram-negative enterobacteriaceae with extended-spectrum beta-lactamases were isolated in 4% of patients with PC and in 15% of patients with PN. In addition, 5% of carbapenemase-producing isolates were also detected among PN patients. P.aeruginosa was isolated in 14% of PC and in 22% of PN, and no multidrug-resistant isolates were detected. Regarding enterococci, E.faecalis was isolated in 3% of PC and 13% of PN, and E.faecium was isolated in 5% of PC and 22% of PN, and a case of vancomycin-resistant enterococcus. Mortality was 16%. 93% had a Mannheim index&gt;20, 90% an ASA index&gt;II and 72% a Charlson index&gt;3. Within mortality, 47% of empiric treatments were classified as adequate. Inadequate or theoretically inadequate empiric antibiotic treatment is administered to 24% of patients with a Mainheim index&gt;20, 23% with a Charlson index&gt;3 and 25% with anASA&gt;II. Conclusions:Microorganisms cultured remain within the expected range, still need for surveillance of carbapenemases in PN and ESBL producers in PC. A quarter of empiric antibiotic treatments administered to patients with high severity indices were not correct. No

Intestinal fistulas: Conservative treatment with stem cells of adipose origin (ADSC)

Background: For intestinal fiustula treament we can identify multiple strategies: operative (surgery aimed at the isolation and/or resection of the fistula), non-operative (placement of prostheses and clips endoscopically, fibrin glue). In recent years, mesenchymal stem cells of adipose origin (ADSC) have aroused particular interest, both for their wide possibility of use as a tool to improve wound healing and for the absence of ethical problems. The objective of the study is the evaluation of the use of ADSC as a valid alternative to surgical and endoscopic procedures in the treatment of intestinal fistulas. Methods: We report our preliminary experience with 3 cases: a 36y/o man,diagnosed with esophageal-gastric anastomosis fistula after subtotal esophagectomy for stenosis due to ingestion of caustics ; a 32y/o with 3 ileal entero-atmospheric fistulas in outcomes of multiple intestinal perforations treated with excluding ileostomy and Negative Pressure Wound Therapy (NPWT);. 42 y/o male diagnosed with fistula of the descending colon, after acute hemorrhagic necrotic pancreatitis treatedwith necrosectomy and abdomen with NPWT. For all three patients the treatment with ADSC has included a phase of collection of adipose tissue by liposuction microcannulus; a phase on the bench, with emulsification and centrifugation of the liposuction to obtain perivascular stromal tissue (tSvFem) emulsified; the last phase involves identification of the via fistoloso, curetage (if necessary), suture of the inner orifice and inoculum of stem cells. Results: In all 3 cases, a complete healing was achieved with long-term closure of the fistula. Conclusion: Despite current management strategies, digestive fistulas remain an extremely debilitating complication associated with a high rate of both morbidity and mortality, thus necessitating the development of innovative therapies. In our experience, autologous stem cells could therefore allow tissue repair, after direct inoculation in the fistula, promoting tissue regeneration and growth. The optimization of the strategies of use of ADSC can therefore represent the future target of treatment of this pathology. No

Investigating endotheliopathy via the whole endothelial glycocalyx across burn severity

Introduction: Endothelial cells (ECs) regulate hemodynamic responses to injury, infection, and inflammation. The endothelial glycocalyx (EG), a luminal layer of proteins, regulates passage of substances and inflammatory mediators [1]. Sepsis and shock can compromise the endothelium due to EG breakdown, leading to worse outcomes [2]. Endothelial Angiopoietin-1 (Ang-1) and Angiopoietin-2 (Ang-2) are dysregulated in burns [3]. Understanding EG breakdown in burns may lead to advancements in maintaining hemodynamic stability and improve outcomes for burn patients. Materials &amp; Methods: Burn patients aged 18 and older were prospectively collected and divided into two groups: TBSA&lt;20% and &gt;20%. Serum was analyzed for Ang-1, -2, Heparan Sulfate (HS), Hyaluronan (HA), and Syndecan-1 (Syn-1) at admission. GraphPad (Prism) software was used in statistical analysis. Results: Serum Ang-1 was higher in TBSA&gt;20% than TBSA&lt;20% (p=.0001). Serum Ang-2 was higher in TBSA &gt;20% than TBSA &lt;20% (p=.0053). Linear regression analysis of Ang-1 and -2 showed a positive association with TBSA and serum protein levels (p=0.0021, p=&lt;0.0001, respectively) (Fig. 1). Serum HS was lower in TBSA&gt;20% than TBSA&lt;20% (p=.0041). Linear regression analysis of HS showed a negative association with TBSA and level of serum protein (p=.0036) (Fig. 2). Fig.1. Serum Ang-1 and Ang-2 analysis in relation to TBSA. Fig. 2. Serum HS analysis in relation to TBSA. Conclusions: EG breakdown occurred in larger burns, shown by increases in Ang-1 and Ang-2. HS levels were increased in smaller burns. This may reflect a rapid clearance of HS or an increased production from remaining ECs in smaller burns. Future work includes investigating more time points post-burn with analysis of transmembrane proteins Syn-1 and Glypican-1 as luminal/transmembrane protein ratios may clarify degree of EG breakdown and resuscitation resistance. References: 1. Curry, et al. 2012. 2. Schmidt, et al. 2012. 3. Hueberger, et al. 2023.No

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