22nd European Congress of Trauma & Emergency Surgery

Chairs

Professor

Aortic dissection complicated by coronary malperfusion and cardiac tamponade

Abstract text (incl. references and figure legends) Case history:A forty-year-old smoker male presented to the ED for pleuritic chest pain and shortness of breath of 1 hour. His medical history included obesity, obstructive sleep apnea, hypertension, and right diaphragmatic palsy secondary to viral illness. Clinical Findings:He was alert and oriented, but in respiratory distress. He was tachycardic with blood pressure 135/87 mmHg in the right arm and 123/66 mmHg in the left arm. He was afebrile with an oxygen saturation 89% on room air improved to 94% on a non-rebreather. Physical exam was notable for diffuse expiratory wheezing. The remainder of the exam was unremarkable. Investigation:EKG demonstrated sinus tachycardia with an incomplete right bundle branch block. Bedside TTE demonstrated a moderate pericardial effusion with more than 30% mitral inflow variability with inspiration and a plethoric IVC with minimal respiratory variation. A TTE performed 5 months prior showed an ejection fraction of 65% and a dilated ascending aorta with a diameter of 5 cm. Laboratory studies were normal including a CBC, chemistries, D-dimer and 2 sets of troponin. Diagnosis:Computed tomography angiography showed moderate-sized pericardial effusion (hemopericardium) with acute intramural hematoma of the ascending aorta, aortic arch, descending thoracic aorta, right coronary artery, left coronary artery and left vertebral artery. No intimal flap in the aortic lumen nor any filling defect in the main and segmental pulmonary arteries. Therapy:The patient was started on an esmolol infusion at 50 mcg/kg/min and was taken to the operating room for an ascending aortic repair, in which an aortic tear above the right coronary sinus was seen with a thrombosed false lumen, as well as hemopericardium. His postoperative course was uncomplicated, and he was discharged home five days later in stable condition. Figure1.EKG with sinus tachycardia and incomplete RBBB with TTE four-chamber view of pericardial effusion Figure2.Coronal view of the CTA 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

Emergency surgery

Poster

Prof.

The impact of hospital strategy to quarantine COVID-19 cases on the care efficiency and surgical outcome in patients with acute abdomen in Taiwan

Abstract text (incl. references and figure legends) Purpose: To investigate the impact of COVID-19 on the care system and surgical outcome in patients with acute abdomen. Materials and methods: We reviewed 4426 acute abdomen patients operated for three emergency conditions of bowel ischemia, intestinal obstruction and hollow organ perforation and a less urgent acute appendicitis. For comparison, we divided the time frame into 3 specific time periods: period 1: 2017/1-2019/12, pre-COVID-19 era, n=2556; period 2: 2020/1-2022/03, n=1693; and period 3: 2022/4-2022/7, n=177. During period 2, it was mandatory for patients with COVID-19 infection or travel/contact history to be operated in a negative-pressurized operation room, while during time period 3, exposure history was neglected and only confirmed cases were operated with special precautions. Results: Compared to patients of pre-COVID era, after COVID-19 outbreak, the time interval from surgical consultation to operation was significantly prolonged for patients without COVID-19 infection, and was even longer for patients with COVID-19 infection (2.2 (1.3-3.0) vs 2.4 (1.5-3.9) vs 5.2 (2.2-10.4) hrs for each group, p&lt;0.001). Further analysis revealed time prolongation only occurred in the appendicitis cases (2.4 vs 3.8 vs 10.1 hrs, p&lt;0.001) but not emergency cases (2.1 vs 1.9 vs 2.7 hrs, p=0.743). The similar pattern of non-delay in emergency case can also be demonstrated when comparing the three time periods (2.4 vs. 3.6 vs. 9.3 hrs in appendicitis cases, p&lt;0.001; 2.1 vs. 2.1 vs. 2.0 hrs in emergency cases, p=0.632). Nonetheless, the post-operative length of hospital stay and peri-operative morbidity were similar between Pre- and Post-COVID-19 era, while higher disease-related mortality in emergency cases was observed after COVID-19 outbreak Conclusion: The COVID-19 pandemic significantly changed disease pattern and clinical practice for patients with acute abdomen. However, the quality of care for emergent acute abdomen cases was not affected.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

Disaster and military medicine

Can median sternotomy be comparable to anterolateral thoracotomy in the initial approach of patients with severe chest trauma?

Abstract text (incl. references and figure legends) Introduction: Severe chest trauma represents an important cause of death of traumatic origin, only a minority of patients will require open surgical management and this can be initially performed through different incisions that allow rapid and effective stabilization according to current guidelines; the initial approach chosen may play an important role in the morbidity and mortality of this group of critically injured patients, there is concern that the median sternotomy may have inferior surgical results in the initial approach of patients with severe chest trauma compared with anterolateral thoracotomy, to address this gap in the literature, we conducted a review of cases presented in the last 9 years in a 1-level trauma hospital. Methods: A retrospective review of patients with systolic blood pressure less than 90mmHG who required emergency anterolateral thoracotomy versus patients who underwent an initial approach with median sternotomy between January 1, 2012, and December 31, 2021, included in this study was conducted. the trauma registry of the pan-american trauma society, at the clinic: Valle de Lili Foundation, Cali Colombia. Results: 123 patients were included, 10 patients underwent a median sternotomy and 113 patients underwent an anterolateral thoracotomy as the initial approach, no significant differences were found in the two groups in age, mechanism of trauma, ISS, RTS, TRISS, hospital stay and mortality (E: 1 (7.1%) vs T: 42 (16%) p-value 0.7). Conclusions: No evidence was found that median sternotomy is an inferior initial approach to emergency anterolateral thoracotomy in hemodynamically unstable patients with severe chest trauma. 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

Unusual case of acute appendicitis: A case report

Abstract text (incl. references and figure legends) Case history: Neuroendocrine tumor (NET) of the appendix is the most common type of appendiceal cancer and is rare in the paediatric population. Appendiceal NET is detected in 0.1%-2.3% in all appendectomy specimens. The clinical manifestations of this cancer are not specific and could be very similar to those of acute appendicitis. Clinical findings:In th case report, a 14-year-old boy presented in our clinic with acute right lower quadrant abdominal pain and an ultrasound suggesting acute appendicitis complicated with an abscess. Investigation/Results: It was performed an emergency laparoscopic appendectomy. Diagnosis: The child was diagnosed with a NET of the appendix, by histopathological and immunohistochemistry examination of the specimen.Therapy and Progressions: After studying the tumor characteristics and the possibility of spread disease, it was performed a subsequent right hemicolectomy. Comments: The prognosis of the appendiceal NET is excellent, with more than 90% survival probability at 10 years and an overall risk of metastases of &lt;10%. References: WHO Classification of Tumors Editorial Board. Digestive system WHO Classification of Tumors. 5th ed. Lyon: IARC press 2019. Rault-Petit B, Do Cao C, Guyétant S, et al. Current management and predictive factors of lymph node metastasis of appendix neuroendocrine tumors:a national study from the French Group of Endocrine Tumors. Ann Surg 2019;270:165-71. Volante M, Grillo F, Massa F, et al. Neuroendocrine neoplasms of the appendix, colon and rectum. Pathologica 2021 Feb; 113:19-27. https://doi.org/10.1097/SLA.0000000000002736 Moris D, Tsilimigras D, Vagios S, et al. Neuroendocrine neoplasms of the appendix: a review of the literature. Anticancer Research 2018; 38: 601-612. doi: 10.32074/1591-951X-230 Morais C, Silva E, Brandão P, et al. Neuroendocrine tumor of the appendix – a case report and review of the literature. Journal of Surgical Case Reports 2019; 3:1-4. doi: 10.1093/jscr/rjz086 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

Spontaneous spleen rupture in legionnaires' disease

Abstract text (incl. references and figure legends) A 59-year-old male patient was admitted to the ER after a low-impact car accident subsequent to a loss of consciousness.His past medical history included dyslipidemia and HPB.At clinical examination,disorientation,fever and headache were observed.The other vital signs were within range.Blood test results showed mild leukocytosis and Hb levels at 13.2 g/L.Head CT scan,pelvic X-ray and FAST resulted negative,whilst chest X-ray showed a left upper lobe pneumonia.Legionella urinary antigen was detected positive.Hence the patient was hospitalized to the Internal Medicine Ward,where he was treated with supplemental oxygen therapy, steroids, bronchodilators and antimicrobial therapy (ceftriaxone and azithromycin, then switched to piperacillin/tazobactam and levofloxacin).After four days the patient became apyretic,and a follow-up chest CT scan was performed,showing splenomegaly.On the following day,the patient suffered from worsening abdominal pain.An emergency abdominal CT scan showed grade III spleen rupture and hemoperitoneum.Emergency laparotomy with splenectomy was performed,followed by a five-day admission in ICU.When clinical stability was achieved,the patient was transferred to the Internal Medicine ward.The patient was discharged on the 20th POD,after clinical resolution of pneumonia.Outpatient follow up after two weeks with abdominal US did not show post operative complications.Few cases of spontaneous spleen ruptures are described in literature.The mechanism of action of spontaneous spleen rupture associated with legionnaires" disease is still unknown,but it may be the result of splenomegaly,infectious state and thrombosis,resulting in spleen congestion and its rupture. We assume that the spontaneous spleen rupture was determined by the legionnaires' disease.Casanova-Roman M et al.Spontaneous rupture of the spleen associated with Legionella pneumonia.Can J Infect Dis Med Microbiol. 2010 Fall;21(3):e107-8. doi: 10.1155/2010/846419. PMID:21886641;PMCID:PMC2951811Disclosure: 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

Visceral trauma

A two steps incisional hernia repair in catastrophic abdomen: A case report

Abstract text (incl. references and figure legends) Case History: A 30-year-old man was admitted to hospital for massive abdominal bleeding after traffic accident. He underwent median laparotomy with right subcostal extension, open abdomen treatment for two months and multiple relaparotomies. The abdomen was closed using a bio A prosthesis and skin grafts because of a significant loss of substance of the right abdominal muscles. (fig 1-2) Clinical Findings: Giant incisional hernia &gt; 25cm wide occupying the entire median incision. Investigation/results: CT scans. Diagnosis: Giant incisional hernia following open abdomen treatment. Therapy and progressions: Two step surgery was performed: first step was the fixing of the inferior fascia and part of the right defect by using two Synecor mesh overlapping (fig 3) with an 18cm residual defect (5 months later). Prolonged medical and negative wound pressure therapy were necessary because of surgical site infection involving the mesh. Second surgery involved the use of Fasciotens Abdomen device (fig 4) which allowed to stretch the upper fascia and reduce the wall defects to 5cm by applying a diagonal-anterior traction (9 months later). The remaining defect was covered using Permacol mesh (fig 5). Comments: in damage control surgery leading to open abdomen treatment incision should be the most conservative as possible and a step-by-step closing strategy should be performed as soon as possible in order to decrease the risk of life threatening complications.1 Fasciotens in our experience avoided the use of a muscle flap for the reconstruction of the abdominal wall and it is an effective tool that enables primary closure of complex hernia with a significant gain in fascia length2 References: 1De Waele J.J, Kaplan M, Sugrue M, et al: How to deal with an open abdomen? Anaesthesiol Intensive Ther 2015; 47:372-8 2 Niebuhr H, Aufenberg T, Dag H, et al: Intraoperative Fascia Tension as an Alternative to Component Separation. A Prospective Observational Study. Front Surg. 2021;7:616669Disclosure: 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

Laparotomy under high spinal anaesthesia: Is it the way out for the anaesthetically high-risk patient with small bowel obstruction?

Abstract text (incl. references and figure legends) Case history:We discuss management of two frail patients with significant pulmonary disease and acute small bowel obstruction (SBO) requiring surgery. First patient was 78yrs old with atrial fibrillation, heart failure &amp; hypothyroidism. Second patient was 75yrs old with hypertension, pulmonary fibrosis &amp; previous MI. He had recently completed radical chemoradiotherapy for oesophago-gastric cancer and had an indwelling gastrostomy feeding tube.Clinical findings:Both patients had abdominal pain &amp; persistent bilious vomiting. There were no signs of peritonitis on examination. The first patient presented 2 days after onset of symptoms and appeared to have aspiration pneumonitis necessitating intravenous antibiotics.Investigations:CT scan in the first patient revealed high-grade SBO with transition within the mid ileum in keeping with adhesional obstruction. In the second patient, CT showed SBO with two transition points likely due to adhesive bands within the mid ileum &amp; the terminal ileum along with mesenteric oedema and thickening raising concern about closed loop obstruction.Diagnosis: adhesive SBO.Therapy: First patient was treated conservatively for 3 days with close monitoring but there was no resolution of obstruction, so surgery was carried out on day 4. In the second case, urgent surgery was planned shortly after presentation in view of CT findings. In both cases, patients were not fit for GA due to their chest conditions, therefore, decision made to operate under high spinal anaesthesia. In the first case, tight adhesional-band was found causing gangrenous constriction-ring in the bowel, however without perforation or contamination. This was divided &amp; limited resection re-anastomosis performed. In the second case, adhesions causing a closed loop were released.Comment:Regional anaesthesia can enable surgery for the fragile patient with SBO. Technique is key &amp; decision to operate has to be timely as this approach can&quot;t be adopted when contamination is present. 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

A rare cause of Hartman resection?

Abstract text (incl. references and figure legends) Case history A 88 year old patient presented with 4 weeks history of vomiting and abdominal pain , with associated abdominal distension clinical findings On examination patient was haemodynamically stable , with distended and hyperresonant percussion and tender in left iliac fossa Investigation/Results Patient abdominal xray showed circular opacity in sigmoid colon with a size of 34.9 mm Ct Abdomen and pelvis with contrast showed peripherally calcified laminated material and sigmoid diverticular disease. A flexible sigmoidoscopy also showed impacted stone in sigmoid colon region. Diagnosis The working diagnosis was stone stuck in recto sigmoid region which is rare entity Therapy and Progressions Our patient underwent hartman resection and made uneventful recovery following that . Comments Intervention in the correct time and deciding best surgical approach before the patient deteriorates or becomes clinically unstable is essential References 1)Sigmoid gallstone ileus: a challenging diagnosis Renuka Maleniea , Lisa Leoneb , MGF Gillilandb How to cite: Malenie R, Leone L, Gilliland MGF. Sigmoid gallstone ileus: a challenging diagnosis. Autopsy Case Rep [Internet]. 2019 9(2):e2019102. https://doi.org/10.4322/acr.2019.102 2)A systematic review of gallstone sigmoid ileus management Nicholas Farkas∗ , Vasha Kaur, Arun Shanmuganandan, John Black, Chantal Redon, Adam E. Frampton, Nicholas West Epsom and St Helier University Hospitals, Wrythe Lane, Carshalton, Sutton, London, SM5 1AA, United Kingdom 3)Images In... Sigmoid gallstone ileus: a rare cause of large bowel obstruction NT Ventham,1 T Eves,1 D Raje,2 P Willson2 1 London Deanery, London, UK 2 Department of General Surgery, Kingston Hospital, London, UK Correspondence to NT Ventham, n.ventham@hotmail.co.uk 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

Is it time for an international research core curriculum in acute care surgery? A perspective from the REsiDENT-1 trainees-led prospective multicenter trial

Abstract text (incl. references and figure legends) IntroductionACS is complex discipline including trauma surgery, emergency general surgery(EGS), surgical critical care, and rescue surgery.Most of ACS patients in Europe are affected by EGS disease disclosing the need for dedicated units.Multi-institutional registries are critical to obtain reliable data for research gaps identifications and improve outcomes.The Eastern Association for the Surgery of Trauma instituted research scholarship for trainees leading to a dramatic improvement in the number and quality of projects and publications. In Europe we are missing research programs for young surgeons with interest in ACS.We aimed to assess the feasibility of involvement of surgical residents(SR)in multi-institutional research and identify educational priority in research in EGS.MethodsIn May 2019 we published the REsiDENT-1 protocol for a multicenter prospective observational trial to assess the impact of peritoneal irrigation during laparoscopic appendectomy on postoperative intrabdominal abscess with a 90-day follow up.The trial is led by SR of the University of Milan.The trial was registered on clinicaltrials.gov(NCT05075252).We performed a survey among participants after three years to assess their experience and look for educational gaps.ResultsUp to September 2022 21 hospitals and 60 SR participated.We recruited 650 patients with a 77% follow-up.We identified the following educational gaps from the survey:research mentorship,educational courses to understand study design,formal approval,data collection and reporting,outcomes selection and interpretation.ConclusionPerforming multicenter research in EGS during training is feasible.We report strong interest among SR in research.The European Society for Trauma and Emergency surgery already showed the feasibility of collaborative research in EGS, and should foster standardized educational program to improve the quality of research projects in EGS and ACS and guarantee international mentor-mentee collaborationsDisclosure: 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

Prof. Dr.

Influence of time to surgery on clinical outcomes in eldery hip fracture patients: An assessment of surgical postponement due to non-medical reasons

Abstract text (incl. references and figure legends) INTRODUCTION Factors associated with high mortality rates in geriatric hip fracture patients are frequently non-modifiable. Time to surgery however might be a modifiable factor of interest to optimize clinical outcomes after hip fracture surgery. This study aims to determine the influence of postponement of surgery due to non-medical reasons on clinical outcomes in acute hip fracture surgery. METHODS This observational cohort study enrolled consecutively admitted patients with a proximal femur fracture for which surgery was performed between 1 January 2018 and 11 January 2021 in two level II trauma teaching hospitals. Patients with medical indications to postpone surgery were excluded. RESULTS A total of 1,803 patients were included, of which 1,428 patients had surgery &lt; 24 hours and 375 had surgery ≥ 24 hours after admission. Prolonged total length of stay was found when surgery was performed ≥ 24 hours (6 (4 – 9) days versus 7 (5 – 10) days, p = 0.001). No differences in postoperative length of hospital stay nor in 30-day mortality rates were found. In subgroup analysis for time frames of each 12 hours, decubital ulcers and urinary tract infections were diagnosed more frequently when time to surgery increased. CONCLUSION Longer time to surgery due to non-medical reasons was associated with a higher percentage of postoperative decubital ulcers and urinary tract infections when time to surgery was more than 48 hours. No association was found between time to surgery and 30-day mortality rates or postoperative length of hospital stay.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

Skeletal trauma and sports medicine

Post-traumatic diaphragmatic hernia. The danger of a hidden enemy

Abstract text (incl. references and figure legends) Case history: 75-year-old patient, airplane pilot. Car accident in 2007 with closed thoracic, abdominal and pelvic trauma. After trauma patient continued flying with non-pressurized airplanes. The patient was admitted to the emergency room due to abdominal pain for 4 days, with associated nausea, vomiting and constipation. Clinical findings: The patient was hemodynamically stable. Slightly distended abdomen, tender on deep palpation in lower abdomen. No guarding. Results: A Thoracoabdominal CT scan showed an hernial defect of the right hemidiaphragm with 2.7 cm neck and liver medialization, through which a volvulated sigmoid colon was incarcerated with suffering signs. Passive atelectasis of themiddle and lower right lung lobes. Diagnosis: Complicated right diaphragmatic hernia with volvulated and incarcerated sigma. Therapy and Progression: Urgent surgery was performed, starting with an exploratory laparoscopy. The hernia was then reduced, diaphragmatic closure with v-lock 3/0 and resection of perforated sigmoid colon through assistance laparotomy and mechanical L-L anastomosis was completed. Patient was admitted to ICU. Postoperative day 6 the patient presented tachypnea and respiratory distress secondary to condensation and right pleural effusion, resolved with aspiration and respiratory physiotherapy. Discharged home on the 10th postoperative day. Comments: Post-traumatic diaphragmatic hernia occurs in 1-5% of cases. About 13% appear on the right side. Diaphragmatic injuries may be followed by immediate herniation of the abdominal viscera into the chest, or develop a late presentation. In our case, continuous exposure to environment pressure changes may have favored a progressive increase of the hernia volume. In many cases, its asymptomatic presentation delays diagnosis and may result in life-threatening complications. Laparoscopic repair of posttraumatic diaphragmatic hernias without mesh is safe and effective, and allows early postoperative recovery.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 with jejunal ileus and rare pathology

Abstract text (incl. references and figure legends) Case history A difficult situation of a male patient, 58 years – old, who presented to the Surgical ED, for evaluation of 12 – hour history of sudden severe epigastric pain accompanied by blood stools, vomiting and fever. His medical history included Hashimoto's disease and plastic reconstruction of an umbilical hernia years ago. Clinical Findings At presentation, his vital signs were normal. On examination he appeared uncomfortable and he had tenderness with guarding and rebound tenderness mainly in upper abdomen. Investigation/Results Blood tests showed anemia, thrombocytopenia and high levels of CRP. In addition, impaired renal and hepatic function with electrolyte disturbances and extremely high levels of CPK. The abdominal radiograph showed hydro – air level. An abdominal CT scan with iv contrast medium followed and the findings were dilatation of jejunum as ileum. Diagnosis Βy combining the clinical laboratory findings with the imaging findings obtained the diagnosis of ileum. Therapy and Progressions The patient was admitted to the Hospital for further evaluation. Despite the conservative initial treatment, he experienced clinical deterioration and he was driven for exploratory laparotomy under general anesthesia. The findings were jejunal ileum with dilatation and ischemia. Furthermore, it was found block of lymph nodes in mesentery. Α segmental enterectomy of approximately 1 meter was performed, including the jejunum and the mesenteric lymph nodes. It was carried out 4th degree anastomosis of duodenum to ileum. The patient had normal postoperative care. Histology confirmed jejunal ischemia with reactive-type mesenteric lymph node lesions. Comments The jejunal ileus is a condition with difficulties both in diagnosis and in treatment. It will be presented with severe symptoms and requires immediate surgical treatment in the most of cases. References https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6587593/ 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 use of laparoscopy in a rare case of of gastric perforation by an intragastric balloon

Abstract text (incl. references and figure legends) Case history We reported a case of a 42-year-old obese woman IMC 42, who presented signs and symptoms of acute abdomen and a 3 month history of endoscopic placement of intragastric balloon (IGB). The patient get the intragastric balloon as a bridge therapy in order to face a bariatric procedure. Clinical findings The patient was referred to our Emergency Department with an acute onset of severe epigastric pain and a sensation of mass in the stomach. The pain started 24h before in the epigastrium and gradually progressed to the whole abdomen and was associated with nausea but no vomiting. Results Abdominal X-Ray did not reveal any free air under diaphragm, but it shows the big IGB (Image 1). TC Scan of Abdomen and Pelvis revealed moderate degree of free fluid in the abdomen and some tiny pockets of sub capsular air nearby the stomach and an impression of perforated stomach (Image 2). Diagnosis Gastric perforation with peritonitis caused by an IGB Therapy and progressions Patient was admitted and started on broad spectrum antibiotics, intravenous fluids. Patient accessed the operating room and a laparoscopy was performed by a consultant with 12 years of specialized training. The laparoscopy confirmed the gastric perforation caused by the IGB. We performed a gastrotomy to deflate the IGB filled with Methylene blue and extract it; the gastrotomy was closed with barbed suture. She recovered well from surgery and within days she was tolerating a diet. Broad spectrum antibiotics were given for 10 days. Comments Although, gastric perforation usually occurs in the first six months, it is a rare complication reported in 0.1%. An upper gastrointestinal endoscopy could be arranged to deflate the IGB but the use of laparoscopy in an emergency intervention is increasingly widespread and we cannot forget its benefits for the patient. References DOI:10.1007/s11695-010-0314-9 DOI:10.1007/s11695-012-0607-2 DOI:10.3748/wjg.15.5751 DOI:10.1016/j.ijscr.2020.09.005 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

Quain hernia, the urgency of the unlikely

Abstract text (incl. references and figure legends) Case history:We present the case of 68-year-old woman who has internal hernia secondary to a parametrial defect. She attended the emergency department for abdominal pain associated with vomiting for 72 hours.Clinical findings: The abdomen was distended, diffusely painful, with no peritonism. Nasogastric tube with 400cc intestinal debit.Investigation/Results:CT scan: Diffuse dilatation of practically all small bowel loops with change in calibre at right pelvic margin level, related to mechanical obstruction.Diagnosis/Therapy: She was taking to theatre with evidence of dilatation of the small bowel loops with change of calibre at pelvic level secondary to internal hernia formed by small bowel loops and hernial orifice in the right parametrium. Section of the ring at the level of the hernial orifice in the right parametrium, release of the small loop, which is undamaged, and its preservation was confirmed with indiocyanine green. Closure of the hernial orifice.Progressions:Postoperative evolution without incident.Comments:The broad ligament of the uterus consists in the two peritoneal layers covering the surface of the uterus. A defect can occur in both, most because of a congenital anomaly but also after birth trauma, surgery or pelvic inflammatory disease. Quain hernia through a defect in parametrium is extremely rare, representing less than 7% of all internal hernias being the ileum the structure involved in most occasions. More than 80% happened in multiparous or previously operated woman. The diagnosis is complex: patients do not usually present with a typical and striking clinical picture, but rather debut with non-specific abdominal pain that can make the diagnosis go unnoticed. CT or ultrasound scans can be useful. In conclusion, it is essential to make an early diagnosis when internal hernia is suspected in order to carry out early surgical treatment and reduce morbidity and mortality.References:doi:10.1016/0002-9378(79)90315-6.DOI: 10.1016/j.ijscr.2021.106599Disclosure: 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

Right iliac fossa mass: Differential diagnosis

Abstract text (incl. references and figure legends) Case history: A 33 year-old female patient, presented to our emergency department with severe pain in the right iliac fossa (RIF). She was diagnosed by abdominal ultrasound, with a twisted calcificated teratoma 8,5cm sized. A laparoscopy was performed and it showed a hemorrhagic cyst rupture with hemoperitoneum, with no appendix exploration. Ovarian cystectomy was performed and patient was discharged. 3 days later, she came again to the emergency department because of persistent RIF pain. Clinical findings was RIF tenderness to palpation. Laboratory results showed leukocytosis and neutrophilia, PCR 16,41 mg/dl. CT scan showed a pelvic calcification mass 7 cm sized with inflammatory changes. Therapy: A new exploratory laparoscopy was performed. It showed a cystic mass 7 cm sized in the appendicular base. We decided to convert to open surgery and perform an ileocecal resection with ileocolic anastomosis. She has normal post-operative course and she was discharge on the 4th postoperative day. Comments: Acute appendicitis is the most common general surgical emergencies. Despite being so common, RIF continues to pose diagnostic challenges. The probability of the pathology underlying RIF pain not being appendicitis is proportionally higher in female patients, so a differential diagnosis between gynecological diseases is mandatory. RIF pain in female patients of reproductive age, the initial diagnosis approach includes ectopic pregnancy and ovarian pathology. In equivocal cases, a pelvic examination by gyneacologists can differentiate alternative pathology.When signs and symptoms are not suggestive, we can choose a procedure which is simultaneously diagnostic and therapeutic. An early exploratory laparoscopy improves diagnosis in female patients with an equivocal diagnosis and we should visualize gynecological structures and appendix. If there's no other diagnosis suspicion, appendicectomy must be performed. Refferences:0.1111/jpc.13737, 10.1016/j.ciresp.2019.02.006Disclosure: 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

Roux-en-y gastric bypass reversal surgery because of massive ischemia in internal hernia

Abstract text (incl. references and figure legends) Case history:45 year-old male with a past medical history of morbid obesity treated 15 years prior with RYGB, presented to our emergency department with severe abdominal pain and hemodynamic instability. Clinical findings were general tenderness to palpation and peritoneal irritation. Laboratory results showed leukocytosis, PCR 3,66 mg/dl and metabolic acidosis. A CT was performed which showed a massive small bowel ischemia. Therapy: A exploratory laparotomy was attempted emergently. A large mass of ischemic small bowel (5 meters biliopancreatic loop) was visualized with an internal herniation through jejunojejunal anastomosis. It was performed a demage control surgery: resection of ischemic bowel and abdominal vacuum therapy. At 48 postoperative hours, a second look surgery was performed objectifying no data of local ischemia. Bowel viability was: 50 cm biliopancreatic loop and 120 cm alimentary loop with high risk of short intestine syndrome. We decided an anatomic conversion of RYGB. He had an unremarkable post-operative course and he was discharge on the 6th postoperative day. Comments: Internal hernias are described as a complication of laparoscopic Roux-en-Y gastric bypass (RYGB), resulting in bowel obstruction in 5% and it may occur at Petersen"s space. Symptoms are nonspecific, so early diagnosis's important. Some patients with RYGB complications may be necessary reversal to normal anatomy. Most common indications are dumping syndrome, postpandrial hypoglycemia, malnutrition, among others. We performed a RYGB reversal to prevent malabsoptions consecuences given the small amount of viable bowel not resectioned. Otherwise, complications as small intestinal syndrome or several malnutrition could be happened. This procedure is safe with no reported mortality. However there is a high incidence of weight regain after RYGB reversal, so judicious patient selection must be considered. References:10.1016/j.soard.2016.02.023, 10.1007/s11695-016-2257-2.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

Poster Session 12
Emergency surgery 6

Appointment

Chairs

Programme

Poster Session 12Emergency surgery 6

Appointment

Chairs

Programme

Poster Session 12
Emergency surgery 6