22nd European Congress of Trauma & Emergency Surgery

Prof.

Chairs

Prof. Dr.

Fascial traction system for open abdomen closure after complications of a giant incisional hernia: A case report

Abstract text (incl. references and figure legends) CASE HISTORY 72-year-old male presented to the emergency department with diffuse abdominal pain and intestinal obstruction. Past medical history of sigmoidectomy due to large bowel volvulus. CLINICAL FINDINGS Clinical exploration revealed a giant multi-sacular incisional hernia (EHS class M2-4bW3 with loss of domain and M1-2 W2 with signs of incarceration). INVESTIGATION/RESULTS Abdominal CT scan showed giant hernia with a 12cm diameter ring containing jejunum, ileum and sigmoid colon, and an epigastric hernia with a 7 cm ring containing transverse colon and causing a retrograde dilation with a 9cm caecum. DIAGNOSIS Bowel obstruction secondary to incarcerated ventral hernia resulting in large abdominal wall defect. THERAPY AND PROGRESSIONS Despite an initial conservative treatment with NG-tube considering the complex hernia repair and the patient stability, on day 3 patient worsened and we decided an exploratory laparotomy. 30cm ischemic small bowel was encountered. Due to patient instability, we opted to resect the necrotic small bowel deferring the anastomosis and placing an open abdomen system with a mesh for fascial traction. In the second surgical revision an anastomosis was performed and after a 4º surgical review (POD 7), due to the impossibility for primary closure, a vertical fascial traction system (Fasciotens®) was placed, with 16cm of fascial defect. After 3 days of Fasciotens® therapy, on POD 10 fascial closure was performed by means of an anterior component separation and an onlay mesh. An ileostomy was performed too because of an anastomotic leak. COMMENTS Surgical management of complicated giant incisional hernias with loss of domain is challenging and a clear strategy remains to be defined. In this setting, the use of an open abdomen system combined with vertical fascial traction could be a good approach to achieve fascial closure without tension.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.

Emergency surgery

Poster

Asymptomatic intestinal ischemia secondary to thrombosis of the spleno-mesenteric portal axis: Usefulness of laparoscopic approach for diagnosis and therapeutical decision. Case report and review of the literature

Abstract text (incl. references and figure legends) CH:We present a case of a 77-year-old man complaining of mild abdominal pain and symptoms of intestinal obstruction, without fever nor nausea/vomiting, from 4 days before the admission to our emergency department. On past medical history ten years earlier a pulmonary thromboembolism treated with oral anticoagulants, currently treatment was acetylsalicylic acid. CF:abdomen was tender, painful on palpation in the center- and left abdominal quadrants without signs of peritoneal irritation. I/R:blood tests showed modest leukocytosis and an increase in CRP. On abdominal CT scan, the ileal jejunum walls appeared thick and poorly impregnated by contrast enhancement (fig 1). D: mesenteric ischemia due to MSPVT T:based on the radiological findings and the worsening of the symptoms the patient underwent surgery. Laparoscopic approach confirmed small bowel infarction plus free blood effusion. For this reason a changeover laparotomy was performed and a small bowel resection between jejunum and ileus was achieved (fig 2); due to the suffering of intestinal loops surgery was fulfilled with laparostomy. In the ICU, heparin was administered as a continuous infusion. Two days later, ileal jejunum anastomosis and wall synthesis were performed. On the 12th POD the patient was discharged with prescription for LMWH at anticoagulant dosage. One month later, he switched to oral anticoagulants. D:Our patient was clinically stable with no hepatosplenomegaly nor guarding, despite a CT scan positive for intestinal infarction. The diagnosis of acute intestinal ischemia related to splanchnic trunk thrombosis is particularly troublesome due to its non-specific presenting sign and symptoms. The treatment&quot;s choice requires a multidisciplinary approach. Emergency exploration by laparoscopy allows to reach the correct diagnosis, plus the real-time assessment of the intestinal infarction's extension,thus playing a double diagnostic and therapeutic role in those doubtful and tricky cases.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

Characteristics and outcomes of violent injuries over 2 decades

Abstract text (incl. references and figure legends) Introduction: In a Nordic context, there are few epidemiological studies on trauma patients hospitalised due to interpersonal violence. The purpose of this study was to identify the characteristics and outcomes of this patient group. Methods: We performed a retrospective analysis of the trauma registry at Stavanger University Hospital from 2004 through 2021. Patient demographics, assault mechanism, alcohol involvement, injury severity score (ISS), location of major injury (LOMI), clinical outcome and mortality were compared. Results: 499 patients were identified with a median age of 30 (SD 12.8, 7-79 years). 65% of the patients were in the age group 20-40 years. 86% were men (N = 429) and the male predominance was statistically significant in all age groups (p-value &lt; 0.002). Ethanol was detected in the majority of the patients (61.3%) with a median concentration of 2.04 (SD 0.822, 0.1-4.5). Most patients presented with blunt injuries (68.3%) with no statistically significant differences in age or gender. Median ISS was 6 (SD 8.2, 1-75) with 55.5% (N = 276) presenting with minor, 29% (N = 144) with moderate, 10.7% (N = 53) with severe injury and 4.8% (N = 24) with very severe injury. Injury severity did not significantly differ in blunt and penetrating injuries. Overall 30-day mortality rate was 2.6% (N=13) with most of these patients presenting with ISS &gt; 24 (p-value &lt; 0.001). No statistically significant difference in mortality was found between the age groups, but there were more fatalities in the female compared to the male population (p-value 0.002). Conclusion: Trauma patients admitted due to interpersonal violence are primarily young, male and under the influence of alcohol. The majority present with minor injuries (ISS &lt; 8) due to blunt trauma, while mortality rates are higher in those with ISS-score &gt; 24 and in women.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.) None

Flexure blow

Abstract text (incl. references and figure legends) Case History A seventy year old man, with no prior relevant medical history was admitted in the emergency room after agression from a shotgun from behind from 3 meters. Clinical Findings At admission, with ACS Class III hemorragic shock,tachycardia, polypnea, and 2L estimated blood loss. The entry point was in the posterior left hemithorax with 5 cm diâmeter, just inferior the the last ribs and other more disperse, laceration wounds, compatible with entry point from several leads. Diagnosis Thoracoabdominal CT scan with contrast showed a left hemothorax, with multiple leads in renal, perigastric and splenic region with no evident active hemorrhage or hemoperitoneum. Therapy and Progressions After inicial chest drain, with a 2000 cc hemothorax drainage and preoperative resuscitation, went to the operation room with General and Plastic surgery , where inicial faecal peritonitis was identified with multiple intraabdominal leads and AAST grade V splenic , grade III pancreatic and grade IV Splenic flexure colon injury which lead to Hartmann´s surgery, Distal pancreatectomy and Splenectomy. Plastic surgery executed a Latissimus Dorsi Myocutaneous flap after thorough debridement work. Fifteen days later the patient was diagnosed with a piothorax and Thoracic went to the OR for VATS debridement. After a prolonged hospitalization for antibiotherapy and complementary negative pressure wound therapy the patient was discharged. Comments Multidisciplinary approach from General, Plastic, Thoracic surgery and Intensive Medicine was the cornerstone for positive outcome in the management of this particular trauma patient, and shows the advantages of tertiary care facilities. 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

Enhanced recovery after surgery in emergency colorectal surgery

Abstract text (incl. references and figure legends) Introduction: Enhanced recovery after surgery (ERAS) programs have demonstrated unquestionable advantages for elective colorectal surgery. Up to 30% of colorectal operations are performed in emergency conditions. Can ERAS programs applied to patients having emergency colorectal surgery have the same benefits as in an elective setting? Material and method: ERAS has been applied in our department for elective colorectal patients for more than 10 years. Most measures from the ERAS protocol have become standard and some are being applied for all patients, even emergency colorectal surgery patients. We performed a retrospective study for emergency colorectal surgery cases admitted in the past 3 years. 95 patients underwent emergency colorectal surgery in our department between 2019 and 2021. We studied patient&quot;s compliance with each item of the ERAS protocol. We selected 63 patients that had a minimum of 12 ERAS measures applied. We compared this group of patients with a similar group selected from previous years admitions through a matching case process. The variables that we followed were GI recovery time, complications, hospital stay and cost and 30 day mortality. Results: The highest compliance was registered for intraoperative ERAS measures. The lowest compliance rate was noted for preoperative measures. GI recovery time was significantly lower in the ERAS group (62.2 hours vs. 75.2 hours) as was the hospital stay (7.4 vs. 10.8 days). Complication rate and 30 day mortality rate ware similar in both groups. Conclusions: Growing evidence demonstrating the safety, feasibility and benefits of ERAS program on surgical outcome following emergency colorectal surgery (more so for cases with no abdominal sepsis). The ERAS program is associated with a lower rate of overall complication and shorter length of hospital stay – without increased risks of readmission, reoperation and death after emergency colorectal 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

Open versus laparoscopic vs single port laparoscopic approach appendectomy: A 3 year retrospective study in a tertiary hospital

Abstract text (incl. references and figure legends) INTRODUCTION: There are three operative modalities for appendectomy: open appendectomy (OA), laparoscopic appendectomy (LA) and single port laparoscopic appendectomy (SPLA). This study aimed to compare these procedures. MATERIAL AND METHODS: This was a 2-year retrospective study From January 2020 to May 2022, A retrospective study was carried out on a tertiary hospital with 485 patients diagnosed with acute appendicitis in emergency department. We reviewed all clinical histories and data analysis was performed from a descriptional point of view. RESULTS:485 adults (48% female) were diagnosed with acute appendicitis. Diagnose was made by clinical, laboratory and radiological findings. 80% patients were diagnosed by ultrasound. Nearly 73% of the cases had an LA, with 23% an OA, and 6% a SPLA. A total of 4% LA cases were converted to OA. Operation time was different; LA with 55 minutes, OA with 45 minutes and SPLA with 65 minutes. There were no differences in the antibiotic prophilaxis, postoperative pain, start of oral intake and deambulation. Length of hospital stay was 3 days for LA, 4 days for OA and 2,5 days por SPLA. Readmission was higher in OA with 5% vs 2% in LA group. No readmission por SPLA. Complicated appendicitis accounted for 37% of the patients with LA, 32% for OA and 47% for SPLA. Adenocarcinoma was presented in 3 patients: 2 in LA group and 1 in OA group. Posoperative complications were analysed by Claven-Dindo scale. 4.7% of LA presented Claven-Dindo &gt; III grade, this was similar for OA. SPLA did not present post-operative complications. There were more re-operations OA group (3%) versus LA (0.5%) and SPLA (0%). Incisional hernia was evaluated in all patients with one case in SPLA versus two cases in LA and one in OA. CONCLUSION: LA, OA, SPLA seem to have comparable efficacy and safety in adults with diagnosis of acute appendicitis. These three procedures are comparable in terms of complications, post-operative pain and 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

Comparing international classification of diseases – Based injury severity measures for predicting mortality in a Greek adult trauma population

Abstract text (incl. references and figure legends) Introduction: The International Classification of Diseases (ICD) is increasingly being used for performance monitoring in trauma patients. However, there is an ongoing debate on the preferrable approach between empirically derived metrics calculated directly from the ICD codes and mapped metrics after being converted to Abbreviated Injury Scale (AIS). The purpose of this study was to compare the performance of ICD-based Injury Severity Scores (ICISS) and AIS mapped scores generated by the ICD Program for Injury Categorisation in R software (ICDPIC–R) to predict mortality in a Greek trauma population. Material &amp; Methods: This retrospective single-center cohort study enrolled adult trauma patients (≥16 years) hospitalized between January 2015 and December 2019. For each patient were calculated two different ICISS values: multiplicative injury (ICISS) and single worst injury (SWI). Based on two mapping algorithms (Trauma Quality Improvement Program and National Inpatient Survey) provided by ICDPIC-R, three AIS-based severity scores were derived: Maximum AIS (MaxAIS), Injury Severity Score (ISS) and New Injury Severity Score (NISS). Models" prediction was performed using discrimination and calibration statistics. Results: A total of 35192 patients were included in the study. Median age was 61 ± 21 years and mortality rate was 2,1%. For the ICISS measures, the area under the curve ranges between 0,857 (95% CI 0.845–0.868) and 0,855 (95% CI 0.843–0.866), while AIS-based measures range between 0,866 (95% CI 0.853–0.878) and 0,837 (95% CI 0.820–0.854). Although Hosmer-Lemeshow chi-square statistic was slightly lower for AIS-based measures, visual inspection of calibration curves demonstrated comparable results to those from ICISS measures. Conclusions: No meaningful differences were found in performance between ICISS and AIS - mapped measures and thus both approaches could be applied in this population.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

Necrotizing fasciitis: Case report

Abstract text (incl. references and figure legends) Case history: 83 years old, diabetic, 10 days of evolution, pain, swelling and erythema on the right hand. Diagnosed 7 days before with right-hand cellulite. The patient returns due to the worsening of the condition, reporting more pain. Clinical Findings: Cellulitis was found below the right elbow and two plaque necrosis. The patient hand has paresthesia and motor impairment, with marked decrease in peripheral perfusion, with neurological involvement of the radial, median and ulnar nerve. Investigation /Results: Analytically with WBC 25000/L, CRP 26 mg/dL.CT Angiography: gas infiltration at volar and dorsal level of the distal ⅓ of the right forearm, with preserved arterial and venous permeability. Diagnosis: Necrotizing fasciitis in the right upper limb. Therapy and Progression: Decompressive fasciotomy was performed with surgical debridement of an infected site in the deep muscular compartment of the forearm. Multiple surgeries on different days were performed: surgical cleaning of the necrotic tissues; disarticulation of the first finger due to the progression of ischemia; amputation of the proximal 1/3 of the forearm and placed a Solid formulation of antibiotic therapy.Comments: Necrotizing fasciitis is an infection that causes the death of the soft tissues, and it is a severe disease that suddenly appears and has a fast evolution. Tissue findings may include discoloration, gross edema or ecchymosis, and signs of necrosis, thus generating severe pain. Managing requires a rapid diagnosis, immediate aggressive surgical treatment, and an extended debridement. Amputation may be required to handle the infection. Survivors often endure multiple surgeries and prolonged hospitalization and rehabilitation.References(Note:The maximum number of chars are 1800 instead of 2000)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

Effect on mortality from routine perioperative anaesthetic medication in hip fracture patients during the COVID-19 first wave in a UK tertiary hospital

Abstract text (incl. references and figure legends) Introduction Hip fracture patients are given medications at anaesthetic induction, which may include tranexamic acid (TXA) and dexamethasone. We aimed to investigate if either of these medications had an effect on the mortality of hip fracture patients. We also investigated if there was a difference in mortality rates between diabetic and non-diabetic patients, due to known effects of steroids on glucose homeostasis. Material and Methods Patients were selected from the local National Hip Fracture Database from February 2020 to August 2020. Data collected included injury type, management type, patient survival, diabetic status and anaesthetic medicines administered. Survival comparison significance was assessed by Fisher&quot;s exact test. Results 393 cases were identified, with 9 cases excluded due to incomplete records. 384 cases were included for analysis. There was a statistically significant worse mortality between patients who were given dexamethasone alone (68.1%) or TXA alone (78.4%) compared to those who were given both TXA and dexamethasone (86.1%). There was no significant statistical difference between the diabetic and non-diabetic patients receiving any combination of these drugs. Conclusions TXA and dexamethasone in combination seem to have a positive effect compared to with dexamethasone alone in this vulnerable patient cohort. Our data suggests that the pathological process in diabetes has no effect on the outcomes of using either drug, alone or together.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

From a digital rectal exam to hemorrhoidal necrosis

Abstract text (incl. references and figure legends) Case History: A 38 years old male patient entered the emergency room with complaints of pain in the anal region. The pain started after a great effort to defecate, referring that he had been feeling a mass in the perianal area for a month. Clinical Findings: Using left lateral decubitus position: edematous external hemorrhoids, with external hemorrhoidal pedicle at 9 o'clock, with advanced signs of poor arterial perfusion. On the digital rectal exam we found, the sphincter was normotonic, with feces in the rectal ampulla and the gloved finger was bloodless. The pedicle was reduced to the anal cavity. Investigation/Results: Analytically with WBC 11000/L, CRP 0.12 mg/dL, PCT 0.03 ng / mL, Hb 15.4 g/dL, serum creatinine 1.06 mg/dL. Diagnosis: Hemorrhoidal Necrosis. Therapy and Progression: Underwent excision of a necrotic hemorrhoidal pedicle, with no evidence of necrosis extension beyond the excised pedicle. Anatomopathological result: anorectal transition hemorrhoid with ischemic changes. Comments: Acutely thrombosed or strangulated hemorrhoids typically manifest with intense discomfort and irreducible hemorrhoids. The entrapped hemorrhoids may necrotize and drain. Surgical excision of the affected pile is advised in cases of significant discomfort, necrosis, or infection. Bibliography: Lohsiriwat V. Treatment of hemorrhoids: A coloproctologist's view.;De Schepper H, et al. Belgian consensus guideline on the management of hemorrhoidal disease.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

Visceral trauma

Non-lethal weapon injuries in the context of civilian trauma

Abstract text (incl. references and figure legends) Introduction: Non-lethal weapons (NLW) are designed to generate painful and superficial injuries. Recently in Colombia their use has increased in the civilian population. The associated injuries that NLW produce can confuse the surgeon who initially addresses them as gunshot wounds. Patients and methods: We described the case of patients who arrived at the emergency department with NLW injuries from 2021-2022. We recorded variables such as demographic characteristics, injury severity scores, vital signs at arrival, surgical procedures, and outcomes such as mortality and length of stay. Patients in whom mechanism of injury was not clear were excluded. Results: We included 26 patients with NLW injury. The median (IQR) age was of 29(25-37) and 92.31% were males. 18 (69.23%) of the patients presented a subcutaneous trajectory of the projectile, with a blunt-like/cinematic mechanism of injury. The most injured region was the neck (38.46%) with a median (IQR) AIS head and neck of 1(0-2). The median (IQR) of ISS and NISS was 5 (2-10) and 7.5 (2-17) respectively. Surgical treatment was required in 13 (52%) of the patients and the most common procedures were ophthalmologic and maxillofacial surgery. None of the patients died. Median (IQR) hospital length of stay was 2 (1-5) days and only 5 patients required ICU admission. Conclusion: NLW projectiles used by the civilian population have a different injury pattern. This might lead to confusion when managing these patients. As one injury can seem to be superficial and cause injury in internal structures, others may seem to be deep and devastating, with the sole compromise of the subcutaneous layer.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 5
Emergency surgery 3

Appointment

Chairs

Programme

Poster Session 5Emergency surgery 3

Appointment

Chairs

Programme

Poster Session 5
Emergency surgery 3