22nd European Congress of Trauma & Emergency Surgery

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Feasibility and clinical outcome of resuscitative endovascular balloon occlusion of the aorta in patients with traumatic shock: A-single center 5-year experience

Emergency surgery

Polytrauma

Abstract text (incl. references and figure legends) Abstract Introduction Resuscitative endovascular balloon occlusion of the aorta(REBOA) has been recently performed as an adjunct to resuscitation for patients with traumatic shock. However, the effectiveness of REBOA is still debated due to differences in indications of each center and the lack of medical records. The purpose of this study is to investigate the effectiveness and feasibility of REBOA by analyzing the clinical results from a single center. Material &amp; Methods From August 2016 to September 2021, 96 patients who underwent REBOA at a regional trauma center according to the center's treatment algorithm for traumatic shock patients were included. Medical records, including the time of the decision to proceed with the REBOA procedure, time of operation, and type of aortic occlusion; and clinical outcomes were collected prospectively and analyzed retrospectively. Results The overall success rate of the operation was 97.9%. Excluding the 5 cases in which no inflation was performed after balloon insertion, the survival rate of 89 patients was 32.6%. In the survival group, blood pressure was high before REBOA procedure(p=0.002) and after aortic occlusion(p=0.03). The total aortic occlusion time was short in the survivor group(p=0.001), and the number of partial aortic occlusion was significantly high(p=0.014). The non-survival group had more acidosis(p&lt;0.001) with a higher lactate concentration(p&lt;0.001). Conclusions REBOA could be feasible as a bridge therapy for resuscitation in patients with traumatic shock. Prompt and accurate decision-making to perform REBOA and followed by damage control surgery could improve patients" survival rate and clinical outcomes. References Belenkiy SM, Batchinsky AI, Rasmussen TE, Cancio LC. Resuscitative endovascular balloon occlusion of the aorta for hemorrhage control: Past, present, and future. J Trauma Acute Care Surg. 2015;79(4 Suppl 2):S236-42 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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Operation for necrotizing fasciitis: Is amputation needed?

Skeletal trauma and sports medicine

Abstract text (incl. references and figure legends) 【Introduction】 Necrotizing fasciitis (NF), a life-threatening soft tissue infection, develops rapid and requires repeated surgery including debridement or amputation. This study aimed to assess the treatment and prognosis of NFs and investigate the need for major amputations. 【Materials and methods】We included patients with NF treated at the Advanced Critical Care Center, Gifu University Hospital, during a 13-year period (April 2009 to December 2021). Their charts were reviewed and data were analyzed in terms of demographic and microbiological characteristics and therapeutic course including operations and mortality. 【Results】This study included 32 patients (men: 27 and women: 5) with an median age of 60 (IQR: 46.3–72.5) years. 13 patients had diabetes mellitus and 2 had rheumatic arthritis and used steroids. The median laboratory risk indicator necrotizing fasciitis was 8 (6.25–8.25), and 18 (8–68) mg/dL. Streptococcus species were the most detected bacteria, and 27 patients were treated with carbapenem. The median antibiotic duration was 24.5 (IQR: 15–33.3) days. All patients underwent debridement operation on day 1, and the median number of surgical interventions was 2 (1–8). 3 patients underwent major thigh amputation. Three patients died (mortality rate: 9.4%). 【Discussion】The mortality and major amputation rates (9.4% and 9.4%, respectively) were lower than those reported previously. In this study, even when patients had multiple organ failure or septic shock, major amputation was not always needed because of effective communication between the infection control team and intensive care specialists, resulting in radical debridement without amputation. 【Conclusion】A multidisciplinary approach can be an effective strategy for lowering mortality and amputation rates in patients with NF. 【Reference】 Pelletier J, et al, :Necrotizing Soft Tissue Infections (NSTI): Pearls and Pitfalls for the Emergency Clinician. J Emerg Med. 2022 Apr;62(4):480-491.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.

Persistent inflammatory immunosuppression and catabolism syndrome (PICS): An understimated clinical problem in surgery

Education

Abstract text (incl. references and figure legends) Introduction: PICSis a new clinical picture, often misunderstood, but rather diffused in the surgical and critical areas. PICS is a very complex and varied syndrome, representing a real clinical challenge both for diagnosis and treatment. We wanted to bring to the attention the clinical presentation of PICS. Materials and methods: we collected three patients who fit criteria for PICS. To identify PICS it is necessary: ICU stay &gt; 10 days, CRP &gt; 150 mcg/dL, lymphocyte count&lt;0,80x109/L, weight loss&gt;10% during hospitalization or BMI&lt;18, creatinine height index &lt;80%, albumin level &lt;3.0 g/dL, prealbumin level &lt;10 mg/dL, RBP level &lt;10 mcg/dL . The following intra-individual immunological variations were taken into account: lymphocyte count, C-reactive-protein (PCR), IL-6, IL-8, IL-10 and TNF-α, PCT, creatinine, albumin and pre-albumin, RBP, culture isolation. All these variable were measured longitudinally in this 3 patients Results: for all our patients the outcome was inauspicious. Two female and one male, mean age 44,45±5, mean ICU stay 38,33±16, surgical procedure of 3±1. We have whiteness a progressive and constant disruption of WBC and CRP, a rise of pro-inflammatory cytokines, no changes in anti-inflammatory cytokine. All these patients had a persistent catabolic and immunosuppressive state that lead to the development of several infections. Conclusion: abdominal infective syndrome was the trigger for PICS. Surgery, nutritional support and anti-infective drugs were unsuccessful. The patients experienced the so called indolent death. The clinical picture worsens constantly albeit small variations of bio-humoral parameters. We evidenced that no macro variation in the parameters evaluated has happened but the variations have been minimal. In our opinion, the use of IL and PCT is much more useful and meaningful than the use of CRP. We have noticed that in particular IL-8 has an important negative prognostic role.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

Acute intestinal ischemia and COVID-19: What do we know?

Abstract text (incl. references and figure legends) Introduction: COVID-19-related gastrointestinal manifestations have been attributed to pharmacologic effects, metabolic disorders and other opportunistic colonic pathogens. AII in COVID-19 patients may be due also to "viral enteropathy" and SARS-CoV-2-induced small vessel thrombosis. Acute Intestinal ischemia may involve the small and/or large bowel after any process affecting intestinal blood flow. A critical appraisal of personal experience regarding COVID-19 and AII was carried out comparing this with a systematic literature review. Patients and methods: A retrospective observational clinical cohort study and a systematic literature review including only COVID-19 positive patients with acute arterial or venous intestinal ischemia were performed. The primary endpoint was the mortality rate. Secondary endpoints were occurrence of major complications and length of hospital stay. Results: a total of 32 patients were collected. Surgery was performed in 24/32 patients (75.0%), with a mean delay time from admission to surgery of 6.0 ±5.6 days. Small bowel ischemia was confirmed to be the most common finding at surgical exploration (22/24, 91.7%). Acute abdomen at admission to the ED (Group 1) was observed in 10 (31.2%) cases, while 16 (50%) patients developed an acute abdomen condition during hospitalization (Group 2) for SARS-CoV-2 infection. Conclusions: Intestinal ischemia in patients with SARS-CoV-2 has been reported all over the world. The majority of the patients have a high CCI. GI symptoms were not always present at the admission. A high level of suspicion for intestinal ischemia should be maintained in COVID-19 patients presenting with GI symptoms or with incremental abdominal pain. Nevertheless, we have to consider a prompt indication for early abdominal CECT in patients with suggestive symptoms or biochemical markers of intestinal ischemia. 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

Iatrogenic non-clostridial gas gangrene in a diabetic patient – A case report

Abstract text (incl. references and figure legends) CASE HISTORY: A 77-year-old male, with type 2 diabetes, presented to the ER with acute pain in his left arm. Patient had no history of trauma, except from an intramuscular injection into his left deltoid muscle for COVID-19 vaccination 60 days ago. CLINICAL FINDINGS: Upon arrival, no clinical findings were identified. The differential diagnosis involved coronary disease and trauma. During his examination, the skin of the left arm showed rapidly increasing inflammation signs. RESULTS: X-ray and CT of the affected arm were suggestive of subcutaneous gas shadows. Blood tests resulted in a LRINEC score "8". DIAGNOSIS: The initial diagnosis set was gas gangrene of the arm possibly due to the intramuscular injection. THERAPY AND PROGRESSIONS: Patient was resuscitated with IV fluids and antibiotics. Multiple operations for excessive debridement of the necrotic soft tissue were performed. No bacteria were isolated from the tissue removed. Patient succumbed to multiple organ failure in the ICU one month later. COMMENTS: Gas gangrene is a rapidly progressive necrotic infection of the soft tissue associated with high mortality. Non-clostridial gas gangrene is relatively rare. The patient may show symptoms days after the initiative event. Thus, high clinical suspicion is necessary for prompt diagnosis. REFERENCES Wong CH, Khin LW, Heng KS, Tan KC, Low CO. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: A tool for distinguishing necrotizing fasciitis from other soft tissue infections*: Critical Care Medicine. 2004 Jul;32(7):1535–41. Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJC, Gorbach SL, et al. Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases. 2014 Jul 15;59(2):e10–52. FIGURE 1: X-ray of the left arm FIGURE 2: Surgical debridement of the left armDisclosure: 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

Management of intestinal invagination in adults: Presentation of a case series and a review of the literature

Visceral trauma

Abstract text (incl. references and figure legends) Introduction: Intussusception of the bowel is defined as the telescoping of a proximal segment of the gastrointestinal tract within the lumen of the adjacent segment. Intussusception is common in children but rare in adults. The goal of this study was to review retrospectively the symptoms, diagnosis, and treatment of intussusception in adults. Material &amp; Methods: From 2009 to 2020, we experienced 5 patients of intussusception in patients older than 18 years. The diagnosis and treatment of these patients were reviewed. Results: Three patients presented symptoms of intestinal subocclusion, one patient presented abdominal pain with low gastrointestinal bleeding and one patient was asymptomatic. All patients were diagnosed with abdominal ultrasonography and abdominal computed tomography. There were 2 patients of colonic (rectal) intussusception, 2 patients of ileocolic intussusception and 1 patient of enteric intussusception. Surgery was performed in all patients, and laparoscopy-assisted surgery was performed 3 patients. Among 5 patients, two patients were associated with benign tumor, one patient with malignant tumor and in two patients was not observed an apparent etiology. Conclusions: Preoperative diagnoses were possible in all patients. Surgery is the definitive treatment of adult intussusceptions. Reduction greatly benefited any surgery required and the extent of the resection regardless of the underlying disease and surgical site. References - Intussusception of the bowel in adults: a review. World J Gastroenterol . 2009 Jan 28;15(4):407-11. - Adult intussusception: a retrospective review.World J Surg. 2015 Jan;39(1):134-8.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

Successful resolution of hemodynamic shock in a patient with advanced pregnancy and diagnosis of placenta percreta

Abstract text (incl. references and figure legends) The incidence of placentation disorders is raising,1/2500 pregnancies are affected.(1) The physiopathology of placenta percreta is an anormal deciduation with aberrant anchorage of placental villi outside the endometrium,surpassing the serosa invanding other organs.Risk factors:advanced maternal age,myomectomy,cesarean.(2) Diagnosis by ultrasound and MRI.Termination of pregnancy + hysterectomy is indicated.In case of late diagnose or abortion reticence controlled induction of labor and cesarean+ hysterectomy is suggested.The aim: Obtaining living fetus and minimize bleeding which is the main cause of morbimortality. Embolization of uterine arteries is highly profitable.(2)(3) Clinical Case: 47-year-old woman with cesarea 7 years ago.Pregnancy by invitro fertilization in London (35+2 weeks) with placenta percreta diagnosis.At our center patient was evaluated by a multidisciplinary team and an elective surgery was planned. Hours later,she was admitted to ER sudden abdominal pain,hypotension,tachycardia.Ultrasound showed:live fetus and hemoperitoneum. Urgent surgery was indicated requiring polytransfusion and amines. Findings: Free blood (2L), aberrant infiltration of placental vessels throughout the uterus and 30 cm of sigma. Cesarean was successfully performed. Uterine artery embolization failed so an hemostatic balloon was placed in distal aorta controlling bleeding. Hysterectomy+ sigma resection was performed due to massive infiltration. Intestinal ends were left loose. A vacuum assisted therapy was placed keeping the abdomen opened for 48 hours. Due to instability, colostomy was performed in a second look surgery which was reconstructed 3 months later.Both patients were discharged a week later without complications. Conclusions:Advanced maternal age and previous uterine surgery are risk factors. Gestational control allows early diagnosis and let treatment strategy. Uterine artery embolization immediately after cesarean + hysterectomy seems the best treatment.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 difficult case of penetrating abdominal trauma

Abstract text (incl. references and figure legends) Case history: A 59-year-old male firefighter was a victim of penetrating abdominal trauma following an explosion. Clinical findings: The patient was admitted to the ER and managed according to the ATLS approach. He was an obese patient (BMI 43Kg/m2) and presented with tachycardia, abdominal pain, and two penetrating wounds, one on the right iliac fossa with evisceration of the small bowel and one on the left flank with evisceration of the omentum. Investigation: Chest radiography and E-FAST were performed, and laparotomy was proposed. Diagnosis: The patient underwent midline laparotomy. Multiple small bowel lesions were identified. A segmental enterectomy was performed, and a gastric band, placed ten years earlier, was removed. The patient was left with a laparostomy, VacPac Barker style. Therapy and Progressions: The patient underwent a total of eleven surgeries that involved laparostomy review, the construction of ileo-ileal anastomosis followed by resection of anastomosis due to anastomotic fistula, a terminal ileostomy, appendectomy for acute perforated appendicitis and debridement of fasciitis of the abdominal wall. He remained hospitalized for 100 days, 48 of which were in the ICU. Comments: The initial approach to the patient, including the perception of the injury mechanism and primary and secondary surveys, help in triage and prioritization decision-making. In unstable patients, a damage control therapy, with stabilization of the patient in the ICU and early re-interventions, should be chosen as the patient's clinical condition improves. These decisions must be individualized and adapted to the patient and the trauma. This approach, although complex, is the best therapeutic option in major trauma. References: Brenner M, Hicks C. Major Abdominal Trauma:Critical Decisions and New Frontiers in Management.Emerg Med Clin North Am.2018 Feb36(1):149-160. Isenhour JL, Marx J. Advances in abdominal trauma. Emerg Med Clin North Am. 2007 Aug;25(3):713-33.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

Duodenal perforation due to biliary stent migration: Report of two cases

Abstract text (incl. references and figure legends) CASE HISTORY: We present two unusual clinical cases of a 62 year-old man and a 69 year-old woman presented to our emergency department due to acute abdominal pain and fever; the first was affected by benign biliary stricture and the second patient by locally advanced pancreatic carcinoma. The man received ERCP and biliary plastic stent placement three months before and the woman almost two months before, she was on neoadjuvant treatment for her pancreatic cancer. CLINICAL FINDINGS: Both patients presented with upper abdomen tenderness, rebound tenderness and severe leukocytosis. RESULTS: CT scan revealed pneumoperitoneum due to biliary stent migration and perforation of the third portion of duodenum. THERAPY AND PROGESSIONS: In the fisrt case perforation was located in the third portion of the duodenum, in the second case near the angle of Treiz. Stent removal, primary suture of the injury and abdominal toilette were performed for both cases. Postoperative courses were regoular for both patients. COMMENTS: Biliary stents are the preferred method of managing malignant and benign biliary obstruction. Potential complications include stent occlusion, stent migration and cholangitis. Stent migration occurs in about 5-10% of biliary stenting patients and may be either proximal or distal. Intestinal perforation secondary to stent migration is rare and has been reported in the caecum, in the sigmoid colon and in the duodenum. Duodenal perforation is seen in most of the cases, explanation being the thin wall of the organ and relative fixed position of the duodenum, in particoular close to the angle of Treitz. REFERENCES: Ida Bagus B. JGH Open 2021;5(8):968-70 Wu X, Li G, Liu Z. Ann Trasl Med 2020;8(24):1690 Arhan M, Odemis B, Parlak E et al. Surg Endosc 2009;23:769-775 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

Prediction of difficult laparoscopic cholecystectomy in the scenario of upfront surgery for acute cholecystitis

Abstract text (incl. references and figure legends) Introduction Early intended laparoscopic cholecystectomy (LC) has been suggested as the standard treatment of acute cholecystitis if patients do not have other significant medical underlying conditions. Conversion to open cholecystectomy from intended laparoscopic LC or laparoscopic subtotal cholecystectomy may be encountered in the scenario. We aimed to identify the predictive factors for these difficult situations. Material &amp; Methods From January 2011 to February 2021, we reviewed the reports of abdominal computed tomography (CT) done at the emergency department of our institute. Initial treatment of acute cholecystitis, and clinical information, including demographic and laboratory data, upper abdomen operation history, and image parameters, were extracted from medical records. Patients who underwent early intended LC at the same hospitalization were enrolled for analysis. Conversion to open surgery and subtotal cholecystectomy were defined as difficult cholecystectomy. Results Of 1603 patients with acute cholecystitis, 593 underwent early intended LC, and 24 were difficult cholecystectomies. For patients of difficult cholecystectomy, male (p = 0.005), higher body mass index (BMI) (p = 0.004), diabetes mellitus (DM) (p = 0.007), previous upper abdomen operation history (p = 0.004), and cases combined with cholangitis (p &lt;0.001) were significantly higher compared to patients underwent LC. As for preoperative laboratory data, higher abnormal liver function (AST, p = 0.03, ALT, p = 0.023, TB, p = 0.013) as well as higher CRP level (p &lt;0.001) were observed in the difficult cholecystectomy group. Operation delays greater than 72 hours were also significantly higher in patients of the difficult cholecystectomy group. Conclusions Patients with higher BMI, DM, previous upper abdomen operation history, abnormal hepatic function, higher CRP level, and conditions combined with cholangitis have the potential risk of experiencing difficult cholecystectomy. 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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