22nd European Congress of Trauma & Emergency Surgery

Chairs

Posterolateral dislocation of the elbow with thrombosis of the brachial artery: A case report

Abstract text (incl. references and figure legends) Case history: A 57-year-old woman with history of CKD and kidney transplant, undergoing dialysis treatment that required an arteriovenous fistula in her right upper limb, in which she suffered a trauma after a fall with her arm extended. Clinical findings: She presented a deformity in her right elbow associated with limited extension of the wrist and thumb and weak distal pulses. Investigations/Results: The radiograph showed a posterolateral elbow dislocation. Closed reduction was performed and elbow stability was verified. The patient manifested intense pain and coldness in the distal upper limb with no evidence of distal pulses on examination. An assessment was made with Vascular Surgery without detecting pulse by echo-Doppler. Angio-CT scan showed thrombosis of the distal region of the brachial artery. Diagnosis: Posterolateral elbow dislocation with thrombosis of the brachial artery. Therapy and Progressions: An urgent intervention was performed by catheter thrombectomy and repair with an allogeneic pericardium patch, with recovery of pulses. After the intervention an elbow orthosis was placed and rehabilitation was started one month later. After two years of follow-up, the patient has recovered a complete range of motion except 20º and has had no more vascular episodes in this limb. Comments: Brachial artery thrombosis associated with a simple elbow dislocation is very rare. If after closed reduction there is evidence of absence of distal pulses and symptoms of acute ischemia, it is mandatory to perform complementary tests such as an echo-Doppler, more accessible, or angio-CT, the gold standard. If acute limb ischemia is confirmed, surgical exploration is required to repair the injury and restore distal blood flow. References: Marcheix, B., Chaufour, X., Ayel, J., Hollington, L., Mansat, P., Barret, A., Bossavy, J.P. (2005). Transection of the brachial artery after closed posterior elbow dislocation. Journal of vascular surgery, 42(6), 1230-1232.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

Skeletal trauma and sports medicine

Poster

The management of cryptoglandular anorectal abscesses – A snapshot of the local practice in Malta

Abstract text (incl. references and figure legends) Introduction Anorectal abscesses are a common surgical problem, most patients requiring drainage of the abscess and evacuation of source of sepsis. Despite being so common, locally there is no agreed common approach on management. Method Data collection was retrospective from surgical admission databases. 83 patients were admitted in 2020 with primary anorectal abscesses. 9 patients were excluded from the study as 3 were re-admitted with the same problem and 6 had inflammatory bowel disease. Results 74 patients were included, 58 males and 16 females with a median age of 42 years. 10 patients had T2DM and 5 were immunocompromised. 3 patients were in the early post-operative period for perineal surgery. All patients had a complete blood count and electrolytes taken whilst 21 (28.4%) had a serum glucose test. Prior to surgery, 14 (18.9%) had a CT scan whilst 3 (4.1%) had an MR performed. 1 (1.4%) patient had an US of the testes, which showed an incidental anorectal abscess. 14 (18.9%) patients had an MR in the post-op phase. 28 (37.8%) patients had antibiotics prior to admission, whilst all patients had antibiotics during admission. 72 (97.3%) patients underwent emergency incision and drainage (I&amp;D), only 3 (4.1%) of which had a documented proctoscopy performed. 68 (91.9%) patients were prescribed antibiotics on discharge. 3 (4.1%) patients had no antibiotics on discharge and 3 (4.1%) patients completed a 7-day course as inpatients. Conclusion According to BMJ Guidelines, all patients with an anorectal abscess should have their white cell count, electrolytes and blood glucose checked. In our data, 53 (71.6%) patients did not have their glucose checked. Although use of antibiotics is not routinely recommended in patient with anorectal abscess, all patients were given antibiotics on admission and 68 (91.9%) patients also on discharge. References Whiteford M, Hyman N, Brown S. (2021). Anorectal abscess - Symptoms, diagnosis and treatment. BMJ Best Practice US.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

Laparoscopyc approach of complicated inguinal hernias: A challenge for the future

Abstract text (incl. references and figure legends) CASE HISTORY An 80 yo. male who presented to the emergency departmet with a 24 hour clinical course of vomiting and abdominal pain. CLINICAL FINDINGS The physical examination revealed a complicated right inguinal hernia INVESTIGATION In the abdominal x-ray a mild small bowel distention was found. DIAGNOSIS Small bowel obstruction due to a complicated inguinal hernia. THERAPY AND PROGRESSIONS With those results we decided to take the patient to the operating room and make a laparoscopyc aproach. On the initial laparoscopyc exploration an indirect incarcerated inguinal hernia was found. By the time the small bowel loop was reduced into the abdominal cavity we apreciated a milimetric perforation and enteric content inside the hernial sac. After taking a culture and cleaning the cavity, the hernial sac was plicated and a hernioraphy was performed suturing the conjoint tendon to the inguinal ligament. The incarcerated small bowell loop wall seem to be healthy, so a direct laparoscopyc closure of the perforation was performed . The postoperative evolution was good, been able to restart the oral intake at the 3rd postoperatoive day. The patient was discharged in postoperative day 6. COMENTS The laparoscopic aproach of inguinal hernias repair is a well known technique by most of the surgeons,but it haven´t become a commonly applied technique in the context of an emergency surgery, despite of its advanteges, such as the direct visuallization of the bowell during all the lenght of the surgery. As seen in this case, in the hands of an experienced surgeon; even the complicated cases can be resolved by this aproach, avoiding the complications of a laparotomy such as: pain, surgical site infections and incisional hernias. We belive that the laparoscopyc aproach of hernias in the contex of emergency surgery sholud became one of the skills of every surgeon. REFERENCES Öberg S, Rosenberg J. Contemporary inguinal hernia management. BJS, 2022,109, 244–246 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

Prof.

Mesenteric panniculitis: A case report of a rare and tricky condition

Abstract text (incl. references and figure legends) We present the case of an 84-year-old man known by our Emergency Department (ED) for a recent small bowel adhesiolysis without resections due to an internal hernia. He referred to our ED complaining stipsi and vomit after 12 days from surgery, specifically four days from hospital discharge. The physical examination showed a painful distended abdomen. Computed tomography (CT) showed a diffuse mesenteric and omental thickening associated to thickened small bowel walls without ischemic signs (Fig 1). Laboratory analysis showed slightly elevated white blood cell count and C-reactive protein. A positive test result for coronavirus was found without related symptoms. The first approach was conservative with nasogastric tube and gastrografin administration. A slow progression of gastrografin turned out and prokinetics drugs started. After 10 days the patient complained of increased abdominal pain and vomit, and a new CT was performed showing bowel obstruction (Fig 2). An explorative laparotomy was performed. The small bowel appeared strictly adherent with fibrous nodules in the mesentery. The features were highly suggestive of malignant lesions. The extemporaneous histologic examination of the nodules was negative for tumors. Thirty centimeters of convoluted small bowel were resected, and the anastomosis was performed. After four days a new laparotomy was necessary due to fecal peritonitis. All the small bowel appeared even more convoluted and an ileostomy was made. The patient died after three days due to septic shock. Mesenteric panniculitis (MP) was diagnosed in the final histology. MP can mimic different diseases. Diagnosis is extremely challenging, and the gold standard treatment is medical. Surgeons should be aware of mesenteric panniculitis to avoid misunderstanding. In our case report the MP's progression was fast after the first surgery for bowel obstruction. Coronavirus correlation cannot be excluded due to the fatty stranding described in both diseases.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

Necrotiziting fasciitis due to a lumbar belt: A disgrace of a case

Abstract text (incl. references and figure legends) CASE HISTORY An 86 yo. female who presented to the emergency departmet with a 24hour clinical course of fever and hypotension. The patient reported an abdominal hematoma since the previous week when his lumbar belt was adjusted. The patient medical history was significant for: type 2 diabetes, asthma, AF and a recent L4 compression. CLINICAL FINDINGS The patients blood pressure was 96/54, pulse rate was 103 with regular rate and rhythm, and his temperature was 37.4ºC. The physical examination revealed a gangrenous lessions on the hypogastric area. INVESTIGATION/RESULTS The patient was stabilized, antibiotic treatment started and a blood analysis and an abdominal CT were made. The analysis showed a mild leucocitosis and an acute renal failure with no other significant alterations. The abdominal CT described a necrotiziting fasciitis of the anterior abdominal wall. DIAGNOSIS Necrotiziting fasciitis of the abdominal wall. THERAPY AND PROGRESSIONS With those results we decided to take the patient to the operating room. A complete debridation of all the necrotic tissue was performed, including all the infraumbilical and left lumbar area. Although all the treatment administrated by the intensive care unit the patient didn´t respond and passed away 72h after the surgery. COMENTS The necrotizating soft tissue infections are a important disseases due to its fast progresión and high mortality. A early treatment clearly influence the prognosis. Even though surgeons are used to the Fournier´s perineal gangrene, we don´t have to forget that it can appear in any other location and, such as in this case, it can develope from a minor wound. This should be in every surgeons mind at the time we inspect any soft tissue infection so we can treat it fast and effectively. REFERENCES Sartelli, M et al. 2018 WSES/SIS-E consensus conference:recommendations for the management of skin and soft-tissue infections. World J Emerg Surg 13, 58 (2018). 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

Surgical management of splenic trauma: 5-Year single center experience

Abstract text (incl. references and figure legends) Introduction: The spleen is one of the most commonly injured intra-abdominal organs in trauma patients. The priority for patients with splenic injury is to diagnose and promptly treat potentially life-threatening bleeding, so that emergency splenectomy remains a life-saving procedure. Material &amp; Methods: Single-center, cohort retrospective study including 22 trauma patients with splenic injuries who underwent surgery in a non-trauma center, from 2016 to 2020. The mechanism of injury, associated lesions, operative details and post-operative complications were analyzed. Results: Twenty-two patients (20 men) were included, with a median age of 48 years. The splenic injury occurred following blunt trauma due to motor vehicle collisions (in 12 patients) or falls (in 10 patients). Most of the patients had other associated lesions (86%), such as thoracic trauma. An emergent surgical approach was performed in 15 patients, whereas 7 patients remained under surveillance, with surgery being proposed due to hemodynamic instability or a drop in hemoglobin levels. 64% of the patients had grade IV or V splenic rupture. Splenectomy was performed in 20 patients, and the spleen was preserved in 2 patients. In 3 patients other procedures were performed along with splenectomy. The median postoperative time was 16 days and 11 patients had some kind of complications, most of which Clavien-dindo II. Five patients died during hospitalization. Conclusions: Spleen trauma can be a surgical emergency in blunt trauma patients and splenectomy is a procedure that should be performed when there is a life-threatening hemorrhage. Other associated injuries are common occurrences and should be considered and managed properly in trauma patients. References: Coccolini, F., et al: Splenic trauma: WSES classification and guidelines for adult and pediatric patients. World J Emerg Surg 12, 40 (2017). Maung A., Kaplan L.: Surgical management of splenic injury in the adult trauma patient. Uptodate.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 for complicated diverticular disease

Abstract text (incl. references and figure legends) Introduction: Complicated diverticular disease of the colon is a disabling disease and an important cause of hospital admissions. Acute colonic diverticulitis is one of the most common clinical conditions encountered by surgeons in the acute setting. Surgery can be considered a therapeutic option for these patients. Material &amp; Methods: Single center retrospective study that included all the patients who were submitted to emergency surgery because of complicated diverticular disease, from 2016 to 2020. Data recorded included baseline demographics, indication for surgery, operative details, length of hospital stay and complications. Results: This study included 27 patients, 83% males, with a median age of 56 years. 30% had known diverticular disease, most of them with previous hospital admissions. The main presenting symptom was abdominal pain. One patient was admitted for acute diverticular hemorrhage and the others for acute complicated diverticulitis (35% Hinchey III and IV). 41% of the patients underwent a colonic resection (44% Hartman procedure) and 50% were submitted to laparoscopic peritoneal lavage. The median pos-operative length was 10 days. 26% of the patients had post-operative complications – 4% had anastomosis dehiscence and 22% had wound infection. The mortality rate was 0%. 30% of the patients had other episodes of diverticulitis after hospital discharge. Conclusions: Complicated diverticular disease carries significant mortality and morbidity. Identification and prompt treatment of high-risk patients are important to reduce mortality and morbidity. Surgery still plays an important role for Hinchey II-IV patients. References: Köckerling F.: Emergency Surgery for Acute Complicated Diverticulitis. Viszeralmedizin 2015; 31(2). Sartelli, M., et al. 2020 update of the WSES guidelines for the management of acute colonic diverticulitis in the emergency setting. World J Emerg Surg 15, 32 (2020).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

Surgical treatment of acute colonic volvulus: 5-year single center experience

Abstract text (incl. references and figure legends) Introduction: Acute colonic volvulus is a torsion of colon around its mesenteric axis, which leads to acute large intestine obstruction and can result in life-threatening complications. A prompt diagnosis of this disease is essential for appropriate treatment to correct abnormal pathophysiological changes and restore intestinal transit caused by the volvulus. Material &amp; Methods: A retrospective review of 23 patients with acute colonic volvulus treated in a secondary Portuguese hospital, from 2016 to 2020. Data recorded included baseline demographics, indication for surgery, operative details, length of hospital stay and complications. Results: This study included 22 patients, 73% males, with a median age of 69 years. 47% of the patients had a previous episode of colonic volvulus that resolved with colonoscopic detorsion. The diagnosis was made by imaging exams in 67% of the patients. 73% were submitted to colonoscopy, which was effective in 91% of the patients. Nevertheless, there was a relapse in 80% of patients. All these patients were admitted to emergency surgery (laparotomic resection), 73% for sigmoid volvulus and 87% for cecum volvulus. 40% had a primary anastomosis and 60% had a Hartmann procedure. The mean post-operative period was 12 days. 67% had complications – of these, 20% needed a reoperation (for anastomotic dehiscence and hemoperitoneum). 27% of patients died during hospital admission. Conclusions: Acute colonic volvulus demands an early diagnosis and treatment for better outcomes. Colonoscopy is the primary emergency treatment of choice in uncomplicated acute colonic volvulus. Emergency surgery is considered for patients who have failed nonsurgical treatment or who have peritonitis. References: Lee K., et al.: Surgical Management of Sigmoid Volvulus: A Multicenter Observational Study. Ann Coloproctol 2020, 26(6). Thornton S., et al.: Sigmoid and Cecal Volvulus Treatment &amp; Management. Medscape (Updated Jul, 2022).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

Junctional traumatic vascular injuries after fall from horse

Abstract text (incl. references and figure legends) Case History A 45-year old female who fell from a horse. Clinical findings Hemodynamically instable patient with absence of motor function and sensory loss in the left leg. Investigation/results Computed tomography (CT) revealed a comminuted pelvic open-book fracture. CT-angiography showed occlusion of the left external iliac artery and laceration of the left external iliac- and femoral vein. Therapy and progressions Emergent surgical exploration was performed. Venorrhaphy of the lacerated external iliac- and femoral vein was performed. A right to left femoro-femoral crossover bypass was used to restore perfusion of the the left leg (Table 1). Ischemia time was estimated to be 6 hours. Five months postoperatively, duplex ultrasound showed graft patency, with good distal perfusion of the left leg, and an ankle-brachial index of 1.0. Comments The term junctional vascular injury is defined as vascular injury occurring at the junction of anatomically distinct regions. Major vascular structures bridge these junctional zones, making them prone to extensive damage and hemorrhage when injured, while acute bleeding control is complex. The majority of these injuries is repaired using interposition bypass grafts. It remains unclear whether autologous or synthetic grafts are best in the setting of acute vascular injury. Graft choice is generally dependent on graft availability, next to extent, instability, context, and type of vascular injury. Several studies compared prosthetic and autologous grafts in the setting of acute vascular injury. However, the level of evidence of these studies is doubtful, due to lack of long-term follow-up, and heterogeneity in type of vascular injury and surgical management. Also, essential variables determining graft outcome are seldomly reported. Future research should include multicenter, retrospective database review, comparing all used grafts to determine which graft provides better long-term outcomes in traumatic junctional vascular injury.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

Stent implantation in colorectal obstruction

Abstract text (incl. references and figure legends) Introduction: Large-bowel obstruction caused by advanced colonic cancer occurs in 8 % – 13 % of colonic cancer patients and represent challenging matters in terms of diagnosis, life-saving strategies, obstruction resolution and oncologic treatment. The management of this severe clinical condition has been controversial as well as the optimal timing of resection after decompression of left-sided obstructive colon cancer. Expert-based guideline recommendations have shifted from an interval of 5–10 days to approximately 2 weeks following self-expandable metal stent (SEMS) Material &amp; Methods: Precise analysis though systematic literature searches to know evidence-based statements has been performed to compare publish data to our experience. Results: During a period of 10 years, the number of acute intestinal obstruction treated in our center by stent placement due to colorectal cancer is reduced. Of these, only 15 were treated with a self-expanding colonic stent. 13 of them were male and 2 female. The mean age 72.85 years. The locations for placement were: 13.3% upper rectum neoplasia, 66.6% sigmoid neoplasia and 20% recto-sigmoid junction neoplasia. 60% had to undergo emergengy surgery due to complications derived from the placement of the stent, all intervening by laparotomy: in 50% of these, there was iatrogenic perforation of the colon during admission. These poor results may be related to the incipient experience of our center with the use of endoprosthesis, as well as the small number of patients treated by this route. It is also show worse results in patients with more advanced stages advanced stages of the disease (especially N+). Conclusions: Despite many studies that recommend the growing use of colonic stents to treat complications derived from colorectal cancer given its good results, in our center we need a more complete study with the treatment of a greater number of patients to recommend its use and reduce the rate of complications. 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

Splenic rupture after trauma in a patient under dual platelet therapy

Abstract text (incl. references and figure legends) Case history:A 77-year-old woman was admitted to the emergency department with left thoracic pain after fall followed by syncope, pallor, and sweating. Left thoracic pain worsened with deep inspiration. The patient was under dual anti-platelet therapy for NSTEMI (non-ST-elevation myocardial infarction) 4 months ago. Clinical findings:On arrival the patient was conscious, oriented, eupneic and hemodynamically stable. At physical examination referred pain on left chest palpation with small left lower thoracic ecchymosis. Pulmonary auscultation showed no changes and it was symmetrical. Mild pain on palpation of the upper quadrants of the abdomen, more intense on the left upper quadrant. Investigation and diagnosis:Blood work up showed hemoglobin 9,2 g/dl, WBC at 9700/mm³, platelets 19500 and thoraco-abdominal TC revealed hemoperitoneum in association with active bleeding from the spleen. Therapy and progressions:An emergency laparotomy revealed massive bleeding from a ruptured spleen and a splenectomy was carried out. During the surgery the estimated blood loss was 2500mL, hemoglobin 5,2 g/dl and 2 red blood cell transfusion units, 2 platelets units and 2g acid tranexamic was done. The post-operative course was uneventful, the patient returned the anti-platelet therapy 4 days after the surgery and was discharged on the 8th post-operative day without any complication. Comments:Abdominal or thoracic trauma can lead to life-threatening injuries,including splenic rupture. Careful physical examination and targeted exams should be a priority for obtaining a diagnosis. Extra care should be taken in patients on antiplatelet or anticoagulation therapy due to the increased risk of hemorrhage. In this case postoperative period was challenging due the need to restart antiaggregation for post-NSTEMI condition. References:Adrian A Maung, MD, FACSLewis J Kaplan, MD, FACS, Management of splenic injury in the adult trauma patient,In: Post TW,UpToDate;2022;Acessed October22.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

Prof. Dr.

Surgical emergencies in pregnancy – A retrospective analysis of 6 surgical departments

Abstract text (incl. references and figure legends) Introduction Surgical emergencies in pregnancy are a relatively rare entity, but whose management must be as prompt as possible in order not to have repercussions on the pregnant woman or the fetus. Both the precipitation and the postponement of the surgical moment can cause serious complications on the pregnancy, the vital risk being high. The diagnosis of these pathologies can be difficult both due to the physiological changes during pregnancy -as well as due to the restrictions imposed in what imaging investigations can be done which may have a detrimental effect to the fetus including teratogenic risk. The current study aims to analyze cases of surgical emergencies in pregnant women. Material and methods The study had a retrospective design - it analyzed the patients hospitalized between 2017-2022, multicentric - the cases were selected from 6 general surgery clinics in 5 cities in Romania and descriptive. The eligibility criteria for inclusion in the studio were: admission to the general surgery department, pregnancy, discharge diagnosis with specific surgical emergency. Results A total of 70 cases between the ages of 16 and 45 were identified. The most frequent surgical diagnoses were acute appendicitis (20/70) and cholecysto-pancreatic pathologies (23/70). The management was surgical in 44/70 cases under spinal anesthesia in 11/44 cases, under general anesthesia with orotracheal intubation 29/44 and local anesthesia in 4/44 cases. The median value of leukocytes at admission was 11.3 (6.36-24.45). Out of all 70 cases, only one death was recorded. In 2 cases, the fetus had to be extracted during the surgical intervention. Conclusions In the case of the patient with an ongoing pregnancy, the suspicion of acute abdomen must be treated with maximum attention because the delay in the diagnosis can have severe consequences. On the other hand, prompt management (conservative or operator) has a favorable prognosis for both the mother and the child.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

"Endome..WHAT?! No, thanks!We're surgeons!" Ultrasonography in Acute abdomen in emergency setting: Appendicitis or endometriosis?

Abstract text (incl. references and figure legends) BACKGROUND: Endometriosis affects between 5% and 45% of women of reproductive age, with chronic pelvic pain, dysmenorrhoea, dyspareunia, dyschezia. It is commonly defined as a gynecological pathology but the surgeon may find himself in an emergency regime to deal with this pathology in cases of suspected acute abdomen pictures with different differential diagnoses. What can the surgeon do to reduce the diagnostic error with the potential of transabdominal ultrasound TAS in the differential diagnosis in the emergency department? CASE REPORT: An hispanic 33 years old pregnant woman, admitted in ED complaining about abdominal pain in right lower quadrant for a few hours. The patient reported similar previous episodes whereby she was discharged from the hospital without a clear diagnosis. Medical history: past c-section, no medication, negative for dysmenorrhea. On Physical examination: pain on right lower quadrant, no rebound tenderness, no fever. Alvarado score was of 3 points. White Blood Cell count and C-reactive Protein were nominal. With a point of care ultrasound we discovered a patchy solid mass measuring 44 x 17 x 24 mm, with an anechoic part and Doppler signal, seemingly growing from the right rectus abdominis muscle and infiltrating the peritoneum (Image 1). The appendix presented normal caliber and sonographic features. No free fluid was present. We discharged the patient, scheduling an ultrasound guided thru-cut biopsy within few days. The biopsy finding was endometriosis and the patient was referred to a specialized centre.CONCLUSIONS: Opening up to these aspects not yet investigated by the literature could provide tools that reduce the diagnostic delay of the pathology which is still too wide today. TAS is considered to be scarcely sensitive to the pathology, but the question we ask ourselves as emergency surgeons is: do we know what to look for through this instrument? We report our experience with TAS images related to reported clinical 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

Giant retroperitoneal hematoma mimicking pancreatic solid neoplasm: Case presentation and a brief literature review

Abstract text (incl. references and figure legends) BACKGROUND: Spontaneous retroperitoneal hematoma is a relatively rare clinical entity with a high degree of morbidity and mortality. Much of the literature on the subject is limited to case series and retrospective cohort studies. The clinical presentation can be varied and insidious for the emergency surgeon. CASE REPORT Patient of 62 years old was admitted in satisfactory condition with complaints of pain in mesogaster, radiating to the back and lower abdomen, Not history of trauma and surgical inerventions. Bio-chemical analysis, cancer biomarkers were normal with the exception of PCR (3,24 mg/Dl). CT revealed pathological solid bilobed foam of 17x8x14 cm. Abdominal aorta free from aneurysmal dilatations. RMN confirmed the voluminous solid mass with a bilobed aspect with well defined margins. During the period of observation (30 days) there was an increase in predominantly direct bilirubin levels with mild pancreatic secretion. Ecoendoscopy performed in suspicion of a pancreatic neoplasm revealed a solid lesion with inhomogeneous echostructure, mainly hypoechoic with multiple anechoic gaps inside. Following an oncological evaluation, cyst was punctured and was performed FNAB that resulted as inconclusive findings, with numerous red blood cells and granulocytes. A control CT scan was performed 25 days away which revealed in the arterial phase, an aneurysm of 18mm pertaining to a small arterial branch of the pancreatic-duodenal arch is found; probably secondary to an ostial stenosis of the celiac trunk, and a voluminous buffered hematoma in the organization phase. Only at this point did we proceed to angioembolization at the level of a lower pancreatic-duodenal arch of the aneurysmal-pseudoaneurysmatic formation. CONCLUSIONS: Despite the fact that organized retroperitoneal hematomas are quite rare, their diagnosis can be extremely complex, requires detailed examination and ambiguous interpretation of the obtained results needs histological verification.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

Laparoscopic repair of a penetrating injury of the diaphragm

Abstract text (incl. references and figure legends) CASE HISTORY A 32-year-old male patient, with no known past medical history, was admitted to the emergency room after being stabbed multiple times by a cold weapon, during a conflict occurred in the previous hour. CLINICAL FINDINGS The victim presented with hypotension and tachypnea. He was agitated and noncompliant, requiring sedation. eFAST was negative for pericardial effusion, as well as for free fluid in the abdominal compartments, but positive for a left pneumothorax. A chest tube was placed, and he was intubated with improvement of his hemodynamic profile. He sustained multiple stab wounds: one in the epigastric region with peritoneal violation; two in the precordial area, near xiphoid process; and two around left scapula. INVESTIGATION CT scan revealed a pneumomediastinum with possible pericardial compromise; a small left pleural effusion with a partial collapse of the left lower lobe; and a perihepatic pneumoperitoneum without any free fluid in the abdominal cavity. DIAGNOSIS An exploratory laparoscopy was performed. The optical trocar was inserted through the epigastric wound and two additional ports were placed in both flanks. A 3.5 cm laceration, with herniated omentum, was found in the center of the diaphragm. Through the defect, a 1 cm pericardial laceration with no active bleeding was seen. There was no evidence of other organ injury. THERAPY AND PROGRESSIONS A tension-free repair was performed with a barbed suture 2/0. There was no indication for pericardial repair, after observation by a thoracic surgeon. He was discharged on day 5, after an uneventful course. He missed the follow up appointment. COMMENTS Any thoracoabdominal wound can cause a diaphragmatic injury, but the diagnosis can be challenging since the physical examination may be unremarkable, and up to 50% of diaphragmatic ruptures are missed on initial imaging. In stable patients, the laparoscopic repair of these injuries is safe and feasible with the appropriate skill set.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 3
Emergency surgery 1

Appointment

Chairs

Programme

Poster Session 3Emergency surgery 1

Appointment

Chairs

Programme

Poster Session 3
Emergency surgery 1