22nd European Congress of Trauma & Emergency Surgery

Chairs

Prof.

Iatrogenic hemobilia – Two successive episodes due to a lesion of the common hepatic duct and delayed intrapancreatic arterio-biliary fistula manifested with hemorrhagic shock and managed by emergency pancreatoduodenal resection

Abstract text (incl. references and figure legends) Introduction Hemobilia is a rare cause and usually self-limiting of upper gastrointestinal bleeding. Its intermittent nature may lead to significant diagnostic delay. Rarely, the bleeding originates from the pancreas. To the best of our knowledge, we report a well-documented unique case of two successive life-threatening episodes of iatrogenic hemobilia. Case report The first episode of hemobilia was due to an iatrogenic lesion of the common hepatic duct during laparoscopic cholecystectomy. The contrast CT showed hematoma in the gallbladder fossa and dilated common bile duct filled with clots (Fig. 1). The common bile duct was filled with blood clots, and there was a lesion of 5 mm. The intervention was completed by Kehr drain. ERCP was performed later. Ten months later he was admitted for bleeding but no visible bleeding source was detected via FGDS, capsule endoscopy, and MRCP. During the fourth readmission due to massive life-threatening hemobilia, Quincke's classic triad was presented. The endoscopy showed a clot at the major duodenal papilla. The angiography revealed bleeding at the communication of superior and inferior pancreatoduodenal arteries. Because of the unstable hemodynamics, the patient was taken to the operative room. The cholangioscopy found a bleeding arterial vessel at the intra-pancreatic part of the common bile duct. Because of impossible embolization an emergency Traverso-Longmire pancreatoduodenal resection was performed. The patient had an uneventful recovery. The finding from the microscopic examination was compatible with an intrapancreatic arterio-biliary fistula (Fig. 2). Conclusion The diagnosis of hemobilia depends on a high index of suspicion because Quincke's classic triad is rarely seen. In life-threatening bleeding, the decision-making depends on hemodynamic stability. Angioembolization is the cornerstone of the treatment, whereas the surgery is reserved only for unstable hemodynamic or unsuccessful embolization cases. emergency pancreatic head resection is a procedure of last resort, it can be life-saving in cases with intractable bleeding due to intrapancreatic arteriobiliary fistula.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.) Nothing to declare.

Education

Emergency surgery

Poster

Frontal sinus osteomyelitis due to orbital metastasis of colorectal adenocarcinoma: A double surgical emergency

Abstract text (incl. references and figure legends) Case History 75 y/o women, with medical history of DM type 2, hypertension and preseptal right cellulitis treated with oral antibiotics with poor clinical response. A head CT is preformed in the ED in which osteomyelitis of the greater wing of the sphenoid bone and subperiosteal abscess of the orbit are observed. Combined orbital and endoscopic transnasal approach was preformed by the ORL team and samples were sent for pathological examination. On the 10th postoperative period, the patient presented gastrointestinal obstructive symptoms. Clinical findings Abdominal distention and tympanic to percussion and vomiting, suggested an intestinal obstructive syndrome Investigation An urgent abdominal CT was preformed. Diagnosis Focal stenosing descending colon neoplasia and a 10 cm cecum, with competent ileocecal valve. Pathology samples from de the ORL surgery confirm adenocarcinoma infiltration Therapy A subtotal colectomy with ileosigmoid anastomosis was performed. Blood test and biochemical analysis (amylase and bilirubin levels) of the intraabdominal drainage were preformed at fist, third and fifth postoperative days with normal results. Persistence of orbital infection required consultation of the ORL team during hospital stay. The patent was discharged at the 12 postoperative day. Comments Colorectal cancer is the second cause of death due to cancer in our county. Approximately, 20% of all colorectal cancer have metastasis at diagnosis. Orbital metastasis are an extremely rare metastasis site for colorectal adenocarcinoma presentation and only few cases are reported in literature. Due to the obstructive behavior of the tumor of our patient, an emergency subtotal colectomy was necessary with excellent postoperative recovery and early chemotherapy and radiotherapy treatment. References Biller, Leah H, 2021, Diagnosis and Treatment of Metastatic Colorectal Cancer: A Review, JAMADisclosure: 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 aortic thrombus presenting as low back pain with neurological deficits

Abstract text (incl. references and figure legends) Low back pain is most commonly caused by mechanical dysfunction.Although the differential for low back pain is quite broad,serious vascular or visceral disease may be the cause of low back pain in a small per&shy;centage of patients.Occlusive abdominal aortic thrombus is a rare but lifethreatening emergency with devastating consequences. A 71-year-old male patient presented to the Emergency Department with a 24 hour history of severe back pain radiating right leg.This was associated with leg weakness and paresthesia.He was a diabetic with hypertension and dyslipidemia, a heavy smoker and history of abdominal aortic aneurysm accompanied in other institution. The patient reported similarsymptoms over the past 2months with sudden acute worsening with prompted attendance at the ED.Clinical examination revealed low back pain and global left lower limb weakness with 1/5 power.Both feet were noted to be cool to the touch with a pale blueish discoloration with absence of peripheral pulses,poor capillary filling and coldness in both legs. An emergent CT angiogram was performed which demonstrated aortic thrombus extending from the origin of the SMA to the iliac bifurcation.A diagnosis of occlusive abdominal aortic thrombosis of the aneurysm was made. The patient underwent an emergency axillofemoral bypass with dacron prosthesis in the same day,which was successful,with efficacious restoration of blood flow. Nontraumatic acute thrombosis of the aorta is a lifethreatening condition that may present with apparently neurological symptoms and is an unusual occurrence, although well documented. Physicians and associate specialists should consider this at clinical assessment and any delay in diagnosing an aortic thrombosis has the potential for catastrophic clinical consequences. Successful management depends on efficacious restoration of blood flow and long-term outcome will be adversely implicated with advancing atherosclerotic disease and in patients who continue to smoke.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 case report of intra-articular calcaneal fracture in pediatric patient

Abstract text (incl. references and figure legends) Calcaneal fractures are rare in children and frequently missed injuries.The type of fracture varies with patient age and falls are the most common mechanism of injury. The majority of the fractures can be treated with a period of immobilization and a period of protected weight-bearing and have a favorable prognosis in the pediatric population. A 8-year-old male patient was brought to the Emergency Department after a fall from 1 meter of height.The patient was unable to ambulate and reported left calcaneal pain.After the general examination,a swelling and bruising at the level of the left heel accompanied by pain and functional impotence for mobilization of the ankle are highlighted.Mobility, sensitivity and distal vascular conserved. After a complete imagiological study (X-ray and CT),an intraarticular left calcaneal fracture with a Böhler angle of 30º and a Gissane angle of 139º was diagnosed, type 5B of the classification of pediatric calcaneal fractures. After evaluating the case,conservative treatment was decided.The patient remained immobilized 6 weeks with suropedic splint ,discharge for 2 weeks and subsequent rehabilitation.During the periodical controls, a satisfactory radiological evolution with preservation of the subtalar joints and the Böhler angle was observed.At one year of follow-up, the asymptomatic patient has a normal life with complete joint mobility.No obvious deformity or precise use of plantar orthosis for walking. The choice of treatment is unanimous in the case of non-displaced fractures,choosing an orthopedic treatment with immobilization and discharge.However,there is controversy among the displaced fractures.Some authors defend the non-surgical posture given the bone remodeling capacity.Nonetheless,other authors defend the anatomical reduction, especially in children older than 10 years The lack of studies with long-term follow-up and the possibility of performing both treatments make that surgeons can choose one of these options.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 abdomen: Analysis of indications, prognostic factors of mortality and outcomes in non-trauma patients undergoing emergency surgery

Abstract text (incl. references and figure legends) Purpose/Introduction: Indications and results of Open abdomen (OA) in non-trauma patients are still scarce. The objective of this study is to report its indications and outcomes, and analyse prognostic factors of mortality. Methodology: This is a single-center retrospective study of a prospectively maintained clinical data on consecutive patients who underwent OA for non-traumatic emergencies from 2008 to 2021 in our center. We collected data about: demography, comorbidities, indications, intraoperative findings, surgical technique, complications, among others. Univariate and multivariate analysis was performed to elucidate the prognostic factors of mortality at 90 days. We used Chi-square test or Fisher&quot;s exact test, in categorical variables, and Student t-test for quantitative variables. Between-group differences were checked through Log-rank test. Cox regression we used to explore factors associated with mortality events at 90 days. Results: 94 patients (58 men, median age 66) underwent OA for non-traumatic emergencies. OA was performed mainly for peritonitis (n=54). 52 patients (55.3%) deceased, and 25 (26.6%) presented Clavien-Dindo complications &gt;IIIa. On multivariate analysis, 90-day mortality was significantly higher for pH&lt;7.25 (p=0.013), BMI (p=0.008) and Charlson Comorbidity Index (CCI) (p=0.003). Score-predicted versus observed mortality rates emphasize importance of altered physiology. No significant differences in survival according to aetiology were proven. Survival benefit was mainly for peritonitis and acute pancreatitis. Conclusion/s: OA is a controversial but safe surgical indication for selected non-trauma patients who have a high probability of morbimortality. Age, comorbidities, organ failure and altered physiology hinder better survival rates. * tables, figures and/or images are acceptable **Do not include references, 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

Chronological distribution and causes of mortality following emergency laparotomy – An 8 year study

Abstract text (incl. references and figure legends) Introduction Emergency laparotomies have a variable level of mortality and morbidity worldwide. Studying the causes and times of mortality in this patient cohort, could enable better patient care and improve future outcomes for these patients. We aimed to investigate the mortality data in laparotomy patients to investigate for trends in mortality and other patient and process characteristics. Methods Data for all emergency laparotomies undertaken between 2014 to 2022 were collected prospectively and retrospectively analysed. The Primary outcome was inpatient mortality. Demographics, clinical management and outcome data from this cohort was analysed using SPSS. Results 1410 laparotomies were undertaken, with an overall crude mortality rate of 11.9% ages ranged between 18-95 (mean = 72.5). The P-POSSUM mortality and morbidity scores for these patients ranged from 2-99 (mean 42.4) and morbidity 40.1-100 (mean 86.6) respectively. The time from date of operation from to death ranged from 24 hours to 123 days (mean = day 11.75), with a uni-modal distribution. In the first 48 hours post-operatively 28.57% (N = 56 patients) died, with a mean age of 70.6 and a mean P-POSSUM of 48.1 (SD 30.6). Within this group bowel perforation (N = 19 patients) and bowel ischaemia (N = 13 patients) where the most common intra-operative finding. The patients that died after 48 hours (N = 116 patients) had a mean age of 73.5 (SD 12.4) and a mean P-POSSUM of 39.6 (SD 29.9, P 0.92), compared to the patients that survived admission (N = 1241) with a mean age of 61.4 (SD 16.4) and a mean P-POSSUM of 15.6 (P&gt;0.01) Conclusion Emergency laparotomy has a high level of mortality and morbidity, with the first 48 hours carrying the highest risk particularly in those with bowel perforation or ischaemia.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 conflict of interest to declare

Early use of anticoagulants in patients with acute pancreatitis and association with the rate of splanchnic vein thrombosis

Abstract text (incl. references and figure legends) Introduction Splanchnic vein thrombosis (SVT) is a serious vascular complication that occurs in patients with complicated acute pancreatitis (AP). Our aim was to investigate the early use of low molecular weight anticoagulants (LMWA) in all patients with AP, their effectiveness on the rate of SVT and the risk of gastrointestinal bleeding (GIB). Material and methods We analyzed 128 patients with AP for the period of 3 years – 2018-2021 in Surgical Department of University Hospital Stara Zagora, Bulgaria. In all patients we started LMWA from the admission. We assessed the incidence of SVT and its relationship with the course of AP. Results In 7(5.4%) we found CT criteria for SVT. All the patients with SVT had moderate or severe disease. We detected the SVT in the period of 10th-14th day of the beginning in 4 patients and after 28th day in 3 patients. We found GIB just in one patient (0.8 %) – without SVT. In 2 patients (1.6%) the SVT was developed after laparoscopic debridement of infected necrosis. In 3 (43%) of these 7 patients we observed total thrombus resolution. Three of the patients died. Conclusion SVT in patients with AP is associated with complicated disease and increased mortality. LMWA are safe and may reduce the incidence of SVT in patients with AP.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

Fast track CT scan and geriatric trauma team as a first line treatment of elderly patients with low energy fall and head injury

Abstract text (incl. references and figure legends) Introduction Undertriage of the geriatric trauma patient is common. Studies from the trauma registry at Stavanger University hospital have shown that this group is often exposed to head trauma. As a result of these findings, we have introduced new guidelines. Material &amp; Methods We searched the trauma registry for patients ≥60 years of age, with ISS &gt;15 and no trauma team activation three consecutive years from 01.01.17–31.12.20. This group of patients were dominated by falls &lt;1m of height, head injuries as location of major injury (LOMI) with frequent use of anticoagulants and platelet inhibitors. To provide better care for this fragile group new guidelines were introduced 03.02.21. Patients meeting four criteria; head injury AND age ≥60 AND any use of anticoagulants/platelet inhibitors AND injury within 24 hours, get a fast track to CT cerebrum. If CT reveal findings of hemorrhage and/or fracture geriatric trauma team is activated. Results After introduction of the new guidelines 609 patients have been included from 03.02.21–03.02.22. Cerebral hemorrhage or skull fracture was seen in 34/609 and 25/34 had a geriatric trauma team activation. Subdural hematoma was encountered in 15/34 and, 13/34 had subarachnoid hemorrhage. Parenchymal or subcortical hemorrhage was encountered in 5/34 and 1/34 had skull fracture. Findings additional to head injury was seen in 5/34. Three patients underwent emergency surgery, 1 craniectomy and 2 radiologic coiling of other injuries. Mean time to CT in the undertriaged group identified before introduction of protocol was 118 minutes. After introduction of the new protocol the mean time from admittance to CT examination is now 18 minutes. Conclusions Introduction of guidelines with fast track CT cerebrum and geriatric trauma team has improved time to diagnosis drastically. Elderly patients with confirmed head injury are now taken care of immediately, by a defined and well-trained geriatric trauma team. 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

Giant ventral hernia with bowel obstruction – A clinical case

Abstract text (incl. references and figure legends) CASE HISTORY: A giant hernia is a challenge for surgeons and more so when in an emergency setting. The European Hernia Society (EHS) considers W3 hernias as the largest defect with more than 10 cm in width or length. Giant hernias produce a morbid condition with chronic inflammation of the mesentery and intestine which leads to the formation of bowel adhesions. CLINICAL FINDINGS: 64-year-old male presenting with abdominal pain, fever and constipation. Physical examination revealed a giant ventral hernia (figure 1), non-reducible, and an acute abdomen. The patient developed septic shock. INVESTIGATION/RESULTS: Abdominal CT scan revealed a small bowel obstruction. DIAGNOSIS: Small bowel obstruction due to a band adhesion in a strangulated giant ventral hernia. THERAPY AND PROGRESSIONS: Antibiotics were initiated, and an emergency midline laparotomy performed. Most of the small intestine was inside the hernia sac and the adhesion band involved the distal part of the ileum. Due to irreversible ischemia, a right hemicolectomy was performed. The hernia defect (EHS M3W3 - figure 2) was repaired with an interrupted suture using a non-absorbable stitch with no tension. After 46 days, the patient was discharged with no abdominal complications during hospital stay. COMMENTS: In an emergency setting, a primary fascial closure of a giant hernia in a infected surgical field may be possible. REFERENCES: 1. DAVIS, S. Scott. The SAGES Manual of Hernia Surgery. Second Edition. SAGES University Masters Program. Springer. 2019. 2. BRINDELLI, Arianna. 2017 update of the WSES guidelines for emergency repair of complicated abdominal wall hernias. World Journal of Emergency Surgery. 12:37. 2017. DOI 10.1186/s13017-017-0149-y 3. HENRIKSEN, N.A. Guidelines for treatment of umbilical and epigastric hernias from the European Hernia Society and Americas Hernia Society. British Journal of Surgery. Volume 107, Issue 3. p. 171-190. 2020. DOI: 10.1002/bjs.11489 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.

Ischemic colitis of left side colon in an incarcerated – Retracted left inguinal hernia, resulting in septic shock and multiple organ failure

Abstract text (incl. references and figure legends) Case history Patient, male, 74 years old, came to the Emergency Department, reporting acute abdominal pain that began 3 days ago after a forced reduction of left inguinal hernia that was performed in another Hospital. Accompanying symptoms are diarrheal stools and reduced diuresis. From his history he referred coronary disease, arterial hypertension, hyperlipidemia, hyperuricemia. Clinical Findings The patient looked sick and had acute abdomen. The 4th day appeared bloody diarrhea with hemodynamic destabilization. Investigation/Results Laboratory blood test was performed. The 1st CT scan was carried out and showed mild smooth rectosigmoid wall thickening with opacification of the mesocolon, increased vascularity and small left inguinal hernia with fat content. A follow-up CT scan and sigmoidoscopy were performed, where ischemic colitis was found at 30 cm of sigmoid colon. Diagnosis Diagnosis of septic shock, caused by ischemic colitis as a result of the forceful retraction of the sigmoid colon as it was content of the inguinal hernia. Additionally acute renal failure with hepatic impairment was established. Therapy and Progressions He underwent an emergency laparotomy, Hartmann&quot; s sigmoidectomy with end colostomy under general anesthesia. He was hospitalized in the intensive care unit postoperatively. Hemodialysis sessions and thoracic puncture were required to treat renal failure and postoperative pleural effusion. He was hospitalized for a month and returned after 9 months for reversal surgery. Comments Ιnguinal hernia retraction is often attempted, however it appears that significant complications may occur. References https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2805903/ https://www.webmd.com/ibd-crohns-disease/ulcerative-colitis/facts-about-ischemic-colitis https://pubmed.ncbi.nlm.nih.gov/30689076/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

First case of internal hernia after revision of biliopancreatic diversion (Ceriani‘s procedure)

Abstract text (incl. references and figure legends) Internal hernia is one of the most common late surgical post-operative complications after bariatric surgery, especially in Roux-en-Y reconstructions. Ceriani described in 2017 a new (bariatic) procedure, that was designed to treat side effects (invalidating proctologic sequelae and chronic diarrhoea) and/or insufficient weight loss/weight regain after Biliopancreatic Diversion (BPD). This type of reconstruction (Ceriani&quot;s Procedure – CP) may resemble the biliopancreatic reconstruction in a distal Roux-en-Y gastric bypass (RYGB). A 57-year-old woman that underwent to CP in2020 due to inadequate weight loss. She presented to our Emergency Department in 2021 with severe abdominal pain and fever, denied any nausea or vomiting, normal bowel movement and diuresis. She denied any trauma or trigger for the pain. Physical exam was significant for abdominal distention, tenderness to palpation mainly in the left upper quadrant and mesogastrium. Due to these findings, the patient was sent for a CT of the abdomen and pelvis with intravenous contrast which showed findings compatible with bowel obstruction. Diagnostic laparoscopy was attempted emergently and confirmed bowel obstruction due to internal hernia. The patient underwent to adhesion lysis, internal hernia reduction and closure of inframesenteric defects as to prevent reoccurrence. Rapid surgical treatment is key to preventing bowel infraction necessitating resection. Presentation of bowel obstruction due to internal hernia in a patient with a story of previously bariatric surgery is variable, and while CT scans and physical examination may be helpful, the definitive diagnosis is, often, intraoperatively during emergency surgical exploration for &quot;acute abdominal pain&quot;. CP, like classical RYGB reconstruction, may lead to internal hernias. 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-reported outcome measures (PROMs) after laparoscopic cholecystectomy: Systematic review

Abstract text (incl. references and figure legends) Introduction Healthcare requires patient feedback to improve outcomes and experience. This study undertook a systematic review of the depth, variability, and digital suitability of current patient-reported outcome measures (PROMs) in patients undergoing laparoscopic cholecystectomy. Material &amp; Methods A PROSPERO-registered systematic review was undertaken for all relevant English language articles using PubMed version of MEDLINE, Scopus, and Web of Science electronic databases in June 2021. The search used Boolean operators and wildcards and included the keywords: laparoscopic cholecystectomy AND patient outcome OR patient-reported outcome OR patient-reported outcome measure OR PRO OR PROM. Articles published from 1 January 2011 to 2 June 2021 were included. Results A total of 4960 articles were reviewed in this study, of which 44 were found to evaluate PROMs in patients undergoing laparoscopic cholecystectomy and underwent methodological index for non-randomized studies (MINORS) grading. Twenty-one articles met all inclusion criteria and were included in the qualitative data synthesis. There was significant heterogeneity in PROMs with eight different comprehensive PROM tools used in the 21 studies. There was wide variation in the time points at which PROMs were recorded. Fourteen of 21 studies recorded PROMs before and after surgery, 7 of 21 recorded PROMs only after surgery. Follow-up intervals ranged from 3 days to 2 years after surgery. Conclusions This study identified that while post-laparoscopic cholecystectomy PROMs are infrequently measured currently, tools are widely available to achieve this in clinical practice. PROMs may not capture all the outcomes but should be incorporated into future cholecystectomy outcome research. The EQ-5DTM (EuroQoL Group) provides a simple platform for the modern digital era. References Melly, C. et al.,(2022). Patient-reported outcome measures (PROMs) after laparoscopic cholecystectomy: Systematic review. BJS Open, 6(3).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 case of right upper abdominal pain

Abstract text (incl. references and figure legends) A 29 years-old woman referred to our Emergency Department complaining right upper abdominal pain and nausea. She denied fever and urinary tract symptoms. Her previous medical history only included a sleeve gastrectomy. The physical examination revealed right upper quadrant tenderness and leucorrhoea. Lab tests revealed leucocytosis (WBC 22479x106/L ), increased C-reactive protein (4 mg/dL), mild hyperamylasaemia,transaminases and bilirubin in their normal range. Pregnancy was excluded. Based on these findings, cholecystitis was suspected. The abdominal US showed cholelithiasis and pericecal fluid but no signs of cholecystitis. The transvaginal US showed right luteal cyst and peri-salpinx free fluid. In presence of an uncertain diagnosis, an abdominal contrast-enhanced CT scan was performed and showed an increased perihepatic enhancement in the arterial phase (Fig.1-2). Fitz-Hugh-Curtis Syndrome was diagnosed. Endocervical culture positive for Chlamydia trachomatis confirmed the diagnosis. The patient was admitted to medical ward and intra-venous antibiotics were administered. The symptoms gradually improved and she was successfully discharged. Ten-day follow-up was negative. Fitz-Hugh-Curtis Syndrome is a rare manifestation of Pelvic Inflammatory Disease, involving around 4% of adolescents.1 It consists of perihepatitis, caused by inflammatory adhesion involving liver surface.2 It commonly presents with right upper quadrant abdominal pain, worsened with movement and breathing, and associated with fever, nausea and vaginal discharge. It may mime other acute abdominal pathologies and its diagnosis is frequently done after diagnostic laparoscopy. It should be kept in mind as differential diagnosis of cholecystitis, appendicitis, renal colic, viral hepatitis and ectopic pregnancy. 1. Sonavane AD. Fitz-Hugh-Curtis syndrome.Indian J Med Res.2017 Jan;145(1):147 2. Shikino K. Fitz-Hugh-Curtis syndrome.BMJ Case Rep.2019 Feb13;12(2) Fig.1 Axial CT Fig.2 Coronal CT 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

Gallbladder spontaneous ventral herniation. An extremely rare surgical case report

Abstract text (incl. references and figure legends) Clinical history: A 79-year-old woman came to our attentionbecause of a painful and non-reducible palpable mass in the right subcostal region, with nausea and vomiting. Clinical findings: on blood tests, increased cholestasismarkers, white blood cells and PCR. A small, uncomplicatedepigatric hernia is also found on abdominal physicalexamination. Investigation/results: The abdominal CT showed a distendedand dysmorphic gallbladder, extending beyond the abdominalwall, the presence of an endoluminous lithiasis of 1.5 cm and other minute lithiasis formations. Therapy and progression: we decided for a laparotomic cholecystectomy surgery with median incision to repair the epigatric hernia at the same time. Upon exploration of the cavity, there is empty gallbladder loggia and gallbladder displaced towards the right side (Im.1).The body of the gallbladderengaged the abdominal wall with the fundus allocated in the subcutaneous tissue and containing a voluminous stone and numerous small contextual stones. Cholecystectomy has been performed and wall defects were repaired too. Comment: This case report is of interest due to the rarity of the diagnosis of spontaneous herniation of gallbladder. In fact, in literature there are only three clinical cases of spontaneousherniation of gallbladder through the abdominal wall. Furthercases of gallbladder involvement concern incisional or parastomal hernias. reference •Pijpers M, Hazebroek EJ, Coene PP, Beerman H, Vroegindeweij D. Herniation of the gall bladder through the abdominal wall. Australas Radiol. 2007 Dec;51 Suppl:B296-8. doi: 10.1111/j.1440-1673.2007.01825.x. PMID: 17991089. •El-Bakush A, Sherif K, Kambali S, Flathouse R, Quattromani F, Jumper C. Spontaneous ventral herniation of the gallbladder. Am J Med Sci. 2014 Jun;347(6):509. doi: 10.1097/MAJ.0b013e3182776a97. PMID: 23287655. 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

Pulsatile mass: The importance of phsysical examination

Abstract text (incl. references and figure legends) A 93-year-old woman was presented to our emergency department with swelling of the forehead 8 months after head blunt trauma. A pulsatile mass with a diameter of 2 cm, with an area of superficial necrosis was observed. Doppler ultrassonography revealed a pseudoaneurysm of the right superficial temporal artery. Under local anesthesia, the false aneurysm was removed, and the superficial temporal artery was ligated. The most likely diagnosis of a swelling after blunt trauma is a hematoma. Pseudoaneurysms are more associated with iatrogenic trauma after invasive vascular procedures. Superficial temporal artery pseudoaneurysm is a rare presentation of swelling after blunt trauma, with a limited number of cases described on literature. Many misdiagnoses as hematomas, if left untreated, it may rupture and can cause a life-threatening hemorrhage leading to hemodynamic instability. Surgical ligation and resection is the treatment of choice, and alternative therapies such as ultrasound-guided compression therapy and ultrasound-guided thrombin injection are an option in smaller masses. Thus, a cautious phsysical examination associated with a high index of suspicion is essential for an accurate differential diagnosis. Fig. 1 Doppler ultrasonography showing the characteristic to-and-fro curve Fig. 2 Excision was performed followed by ligation of the proximal and distal ends in the lesionDisclosure: 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 11
Emergency surgery 5

Appointment

Chairs

Programme

Poster Session 11Emergency surgery 5

Appointment

Chairs

Programme

Poster Session 11
Emergency surgery 5