22nd European Congress of Trauma & Emergency Surgery

Prof.

Chairs

Postoperative outcomes of emergency laparotomy during the Covid-19 pandemic. An analysis of the multicentre hellenic emergency laparotomy study (HELAS)

Abstract text (incl. references and figure legends) Introduction: Emergency Laparotomy (EL) is a common procedure with considerable morbidity and mortality. The COVID-19 pandemic has affected surgical patient care and availability of intensive care unit (ICU) beds worldwide. We present an analysis of the data of the prospective study HELAS with regard to differences before and during the pandemic in Greece. Material and Methods: The HELAS is a multicentre prospective study which was carried out between 01.2020 and 05.2021 and included patients subjected to EL in 11 Greek hospitals. We performed an analysis of postoperative pathways before (01.20-11.20) and after (11.20-5.21) the eruption of the pandemic in Greece, focusing on availability of ICU beds and patient outcomes. Chi-square test was used to compare the distribution of variables between groups. Results: 631 patients were included in the final analysis, with an estimated 30-day mortality of 16.3%. In the pre-pandemic cohort, 58 patients (17.4%) were admitted to the ICU directly after surgery, compared to 33 patients (11.1%) in the pandemic cohort (p=0.033). After risk stratification using the NELA prediction model, no differences were found between the two cohorts before and after the pandemic (p=0.295). 53 ''pre-pandemic'' patients (15.9%) died in the 30-day postoperative period, compared to 49 (16.4%) in the pandemic era (p=0.941). Conclusions: Fewer patients were admitted directly to the ICU following EL in Greece after eruption of the COVID-19 pandemic, but this difference did not lead in increased 30-day mortality rates. References: 1. https://doi.org/10.1007/s00268-022-06723-6 2. https://doi.org/10.1007/s00134-020-06229-6Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No

Education

Emergency surgery

Poster

Emergency surgery in a large urban area community hospital during SARS-CoV-2 pandemic. An interim analysis on acute appendicitis

Abstract text (incl. references and figure legends) Background Literature highlights a decrease in surgical treated appendicitis with an increased severity during the COVID-19 pandemic. The aim of this study was to analyse the effect of COVID lock-down on the population with appendicitis comparing clinical-pathologic data and outcome in two matching period (pre-pandemic and pandemic era) Materials and methods A retrospective analysis of patients admitted to two community urban hospital in Rome with diagnosis of Acute Appendicitis (AA) before and after the COVID-19 pandemic was performed. We compared patients patients with acute appendicitis in three groups named A (Pre Covid), B (Early Pandemic), and C (Late Pandemic). We evaluate the differences between the three groups in terms of onset of symptoms and severity, procedure difficulty, conversion rate, and short-term outcome. Results A total of 310 patients were identified. The time interval from onset of symptoms to arrival in the Emergency Department was significantly longer in both pandemic group; there was also a significantly longer time to surgery comparing to group A. The risk of complicated AA was higher in both pandemic groups. A significantly higher grade of difficulty was detected in both Covid-groups. However, no differences were observed in conversion rate. Post-operative complications rate showed no significant difference among all three groups. No patients was tested positive for SARS CoV-2 post-operatively. Conclusion AA treatment was comparable to pre-covid period in-hospital pre-surgery stay and early post-operative outcome. With an accurate respect of Pandemic Protocol is possible to maintain a high and safe standard of care for patients with acute appendicitis. 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 thyroidectomy. A challenge for the emergency surgeon

Abstract text (incl. references and figure legends) Case history A 45-year-old woman admitted for fever of 39ºC,odynophagia and otalgia. Personal history of hyperthyroidism due to Graves Basedow disease in treatment with antithyroid Clinical findings Blood pressure: 120/80 mmHg,heart rate: 120 bpm No submandibular or cervical adenopathies were palpable.Pharyngeal hyperemia without lesions in the oral cavity.Mild exophthalmos. Systematic urine and chest X-ray normal. Laboratory tests:absolute neutropenia,TSH &lt;0.005ulU/ml, free T3 8.83 pg/ml, free T4 3.66 ng/dl.Positive anti-TSH receptor and anti-TPO antibodies Results Antithyroid treatment is discontinued.Start with empirical antibiotic treatment,granulocyte colony-stimulating factor human, corticosteroids and beta-blockers Diagnosis Agranulocytosis,febrile neutropenia secondary to antithyroid treatment in hyperthyroidism due to Graves Basedow's disease Therapy and progressions Plasmapheresis are performed prior to surgery Urgent total thyroidectomy, visualizing 4 parathyroid glands and both recurrent laryngeal nerves with positive monitoring before and after exeresis. No post-surgical complications Hospital discharge:descending course of corticosteroids, Euthyrox. Regular analytics Comments In exceptional cases urgent surgical treatment of total thyroidectomy is necessary.Urgent hyperthyroidism surgery requires rapid pre-surgical optimization,plasmapheresis and is effective,safe and with results similar to elective treatment References Outcomes After Urgent Thyroidectomy Following Rapid Control of Thyrotoxicosis in Graves' Disease are Similar to Those After Elective Surgery in Well-Controlled Disease. Adibah Ali , Miguel Debono , Sabapathy P Balasubramanian . World J Surg. 2019 Dec;43(12):3051-3058Disclosure: 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

Empyema necessitatis of the gallbladder: laparoscopic management of a rare pathological entity and literature review

Abstract text (incl. references and figure legends) Case history:An 82-year-old man with history of NYHA III heart failure and recent cardiac surgery for ischemic disease presented to our Department complaining the sudden appearance of a slightly reddened, non-reducible mass in the right upper quadrant. Clinical findings:No other signs and symptoms were reported. Investigation/Results:Blood tests showed raised inflammatory markers. Hepatic function tests were normal. US features were equivocal, suggesting possible hernial defect. CT-scan revealed a 10x12.5 cm hypodense parietal lesion with hydro-air level in its context, communicating with the gallbladder. Diagnosis:Under local anesthesia, the collection was incised with extensive drainage of pus, bile, and multiple stones. Therapy and Progression:The patient was started on intravenous broad-spectrum antibiotics. After preoperative cardiological evaluation, the patient underwent deferred laparoscopic cholecystectomy. Postoperative course was characterized by transient renal dysfunction requiring diuretic therapy. The patient was discharged home on POD12. Comments:Empyema necessitatis of the gallbladder is a rare entity characterized by abdominal wall abscess communicating with the gallbladder, usually following chronic inflammation. Incidence and prevalence are greater in women and in the elderly. Cases reported in literature are sparse, mostly treated by open cholecystectomy. However, incision-drainage of abscess followed by deferred laparoscopic surgery is a safe and valid alternative even in frail, elderly patients, allowing for minimally invasive treatment and potentially faster recovery. References:Ayoub et al, Int J Surg Case Rep 2020;67:42-44. Brimo Alsaman et al, Ann Med Surg (Lond) 2020;59:180-185. ElTinay et al, Ann Med Surg (Lond) 2016;12:106-108. Singh et al, J Clin Diagn Res 2013;7(10):2321-2.Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No.

Severe necrotizing fasciitis with fateful outcome

Abstract text (incl. references and figure legends) Necrotizing fasciitis (NF) is rare.Incidence is 0,3/100000 cases.Despite increased awareness and treatment advances, mortality is high(30%).(1)(2) The rapid progression of this disease and the subtlety of early signs and symptoms may delay diagnosis and surgery.Risk factors as diabetes,obesity or malignancy increase the morbimortality.(3) CLINICAL CASE:58 years-old woman had cervical carcinoma in 2018 treated with chemotherapy, radiotherapy and brachytherapy. As complications: radiation enteritis and cystitis with colovesical fistula that needed derivative ileostomy. In 2015,posterior pelvic exanteration with coloanal anastomosis, vaginal reconstruction and ileostomy closure was performed.In 2020 she noticed presense of pus in her vagina. CT scan showed: anastomosis leak, rectovaginal fistula and posterior sinus. Now, she was admitted in ER after 3 weeks of malaise, right leg edema and functional limitation. Physical exam manifested hemodynamic compromised and right limb erythema. Blood test showed leukocytosis (16000), PCR 39mg/dl, Procalcitonin 22mg/dl. CT scan revealed rectovaginal fistula with a 8,2x4 cm collection; obturador, iliacus and thigh muscles fasciitis and coxofemoral joint osteomyelitis. An urgent intervention was performed evidencing the CT findings. We performed a surgical debridament of necrotic soft tissue, right coxofemoral joint resection, also we placed some drainages. Patient was admitted to intensive care due to severe sepsis.Subsequently, several surgeries were performed with no clinical improvement.Due to this critical situation, without medical or surgical sort out, a multidisciplinary committee decided to practice limitation of therapeutic effort, subsequently patient passed away. Comments: NF requires an aggressive treatment.Surgical delay increases morbimortality. Cancer,immunosuppression, obesity are risk factors. Hyperbaric treatment was described for NF. Actually there is not strong evidence for this recommendation.(2)(4) 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

Sars-Cov2 as a possible origin of spontaneous splenic rupture in a patient admitted to the critical care unit

Abstract text (incl. references and figure legends) Many symptoms have been related with COVID infection:respiratory,digestive,immunologic, prothrombotic(1)Trauma is the most usual cause of splenic rupture.Spontaneous rupture is rare and related to neoplasms and infections(malaria,HHV-4).(2)(3) Sars-Cov2 tropism towards the spleen is widely known so though prothrombotic and immune dysregulation make plausible an spontaneous splenic rupture in this context.(4)(5) Acute abdomen due to splenic rupture is a surgical challenge:arterial embolization or urgent splenectomy could be needed. We present a patient admitted to ICU, intubated due to COVID pneumonia with posterior hemodynamic deterioration secondary to spontaneous splenic rupture. Clinical Case:A 72 years male tourist with historial of hypertension and diabetes, vaccinated against SARSCov-2. Admitted to ICU for Covid19 bilateral pneumonia, requiring intubation and anticoagulation.On 17th day of admission he suffered a sudden hemodynamic deterioration.The CT scan showed pulmonary ground glass consolidations with splenic subcapsular hematoma and hemoperitoneum with no active bleeding.An urgent splenectomy was performed due to persistent hemodynamic instability despite resuscitation,polytransfusion and amines.Pathology exam showed 4.5cm capsular laceration with parenchymal exposure without other findings. Arrangements were made to transfer the patient to his country to continue intensive treatment. Conclussion: Proinflammatory and prothrombotic cytokines altere the splenic functionality and structure. We hypothesise that this dysregulation is the cause of spontaneous rupture, as occurs in other splenotrophic viruses. In case of inestability spleenectomy is mandatory.Embolization is used in those who respond to resuscitation without active bleeding.Surgery in Covid+ patients have higher morbimortality and complications. We believe that in case of abrupt hemodynamic deterioration in Covid+ patients, spontaneous splenic rupture should be taken into considerationDisclosure: 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

Ruptured hepatic artery aneurysm – Case report

Abstract text (incl. references and figure legends) We present a case of a forty-nine year-old man with a past history of hypertension, nephrolithiasis and diverticulosis. The patient goes to the emergency department complaining of a sudden onset of intense epigastric pain and vomiting.He was apyretic, blood pressure 199/122 mmHg, heart rate 90 bpm, O2 saturation 98% with tenderness of the epigastric region. After being given analgesia, the patient becomes diaphoretic, pale and hypotensive.Blood analysis reveals high lactate levels (3.7 mmol/L) and low hemoglobin (6.0 g/dL). Volume resuscitation yields a good response. Abdominal ultrasound shows intrabdominal fluid and contrast enhanced CT (fig 1) reveals perihepatic fluid and in the parietocolic gutters and a left hepatic artery aneurism (HAA).The patient is taken to the operating room and a massive hemoperitoneum was found (about 2 liters) with a hematoma in the lesser sac. An aneurism in a left hepatic artery branch going to the 4b segment was found and ligated. The patient was then transferred to the ICU and had no complications in the post-operative period, being discharged a week after the surgery. In the follow-up appointments the patient remained asymptomatic and with normal hemoglobin levels. HAA is quite infrequent with a reported incidence of 0.002-0.4%. Atherosclerosis, mediointimal degeneration, trauma and infection are known risk factors. HAA are difficult to diagnose since most are asymptomatic or are found incidentally. They can also present with rupture with life threatening hemoperitoneum, requiring a rapid response, since this condition can be rapidly fatal. In the acute setting, surgery is the preferred option. In our case simple ligation was feasible since it was a branch aneurism and the patient had no history of liver dysfunction. Otherwise, arterial reconstruction could be needed to prevent liver ischemia and failure Ref: Man CB et al, Ruptured hepatic artery aneurysm presenting as abdominal pain: a case report. Cases J. 2009 Sep 8;2:8529Disclosure: 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.

Impact of COVID 19 on severity and management of acute cholecystitis: A collaborative multicentric audit study in Romania (COVAC study)

Abstract text (incl. references and figure legends) Introduction: Covid19 pandemy influenced the incidence and management of many surgical diseases among them acute cholecystitis We aimed multicentric collaborative retrospective audit study under the auspices of Romanian Society for Trauma and Emergency Surgery regarding the severity and management of acute cholecystitis in the university and clinical county emergency hospitals in Romania. Material and method. Using a specially designed form, data were collected about the total number of acute cholecystitis cases, severity, surgical approach, conversions, intraoperative and postoperative complications, reinterventions and mortality for the years 2018 to 2021. Comparison was made between the years &quot;18-&quot;19 and &quot;20-&quot;21. 5 surgical departments from university emergency hospitals and 1 from county emergency hospital responded so far, so we report partial results. Results. Total number of acute cholecystitis decreased in 2020 and 2021, being at 50.66% and 59.70% compared to 2018 and 55.39% and 65.30 compared to 2019. Gangrenous forms increased from 18% and 19% to 27.63% and 34.82% respectively; localized abscesses, from 10.26 and 4.2% to 5.25 and 6%; biliary peritonitis from 4.5 and 4.2% to 8.15 and 7.8%. Laparoscopic approach decreased from 92.8 and 95.4 % to 68.5 and 78.7%, rate of conversions nearly doubled, from 6.7 and 7.17% to 15.7 and 13.8%. Incidence of postoperative complications also increased from 3.7 and 4.2% to 8.6 and 4.6%, reintervention rate from 1.73 and 1.6% to 3.42% and 1.5%. Mortality rate was also higher 5.2% and 3.8% compared to 1.6 and 1.9%. Conclusions. During the pandemics years (2020, 2021) surgical departments had to deal more severe cases of acute cholecystitis, more conversions from laparoscopic to open surgery, higher rate of intraoperative incidents, postoperative complications, reinterventions and mortality compared to prepandemic years 2018-2019.Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No

The best closure techniques in patients treated with open abdomen: Proposal for an algorithm

Abstract text (incl. references and figure legends) Background: several abdominal wound closure techniques are available to achieve wound closure in post-traumatic and septic open abdomen (OA). Currently, OA-negative pressure therapy (OA-NPT) and mesh mediated fascial traction are usually the first choice. However, there is not an algorithm to follow in order to offer the best patient tailored approach. Materials and Methods: a retrospective analysis of outcomes of 50 patients treated with open abdomen was performed. They were divided in groups according to the OA treatment, Bogota-bag (BB) vs OA-NPT, and the different closure techniques applied, such as direct closure, mesh mediated closure and closure achieved performing components separation. Results: OA-NPT was associated to a longer hospital stay and OA treatment length compared to BB (in both cases p &lt; 0.001). Definitive closure was achieved in all the thirty-two surviving patients. DC was performed in 17 patients. Among these, 7 were treated with BB and 10 with NPT without any difference in the DC rate (p 0.7). 15/32 patients underwent Ramirez component separation. There was no difference between DC and CS groups for the number of re-operation before definitive closure, but hospital stay was longer in patients treated with CS (37 vs 28 days, p &lt; 0.001). Overall, 11 patients were managed with mesh mediated traction that did not determine any difference in terms of bleeding, mortality and post incisional hernia rates, but the ICU stay was slightly longer and close to the statistical significance level (p 0.07). Conclusion: the use of OA-NPT is an established technique worldwide. In accordance with our results, we propose an algorithm that could suggest which treatment choose and when. Further prospective studies on larger cohorts are needed to validate it.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

Gastric remanent perforation after Roux-en-Y gastric bypass

Abstract text (incl. references and figure legends) Case history: A 40-year-old female patient with a past medical history of morbid obesity treated in 2021 with RYGB, weight loss 60 kg in a year (prior to RYGB her BMI measured 45 kg/m2 and now 28 kg/m2). Preoperative gastroscopy esting H. pylori was negative. She presented to our emergency department with a diffuse abdominal pain that started suddenly and located in epigastric and mesogastric region without any fever. Clinical findings showed a normofrequent, normotensive afebrile patient with diffuse abdominal tenderness and rebound. Laboratory results were leukocytosis and neutrofilia. The computed tomography (CT) of the abdomen showed suspicions of a perforated pyloric ulcer. A diagnostic laparoscopy was performed. It showed a widespread infectious peritonitis and two gastroentero anastomosis perforations as chronic ulcers. Surgery was performed with a primary closure with Graham epiploplasty. She had an unremarkable post-operative course, and she was discharge on the 6th postoperative day. Comments: Bariatric surgery has been the most effective way of long-lasting weight loss. Regarding the safety and efficacy of bariatric surgery, it has a lower all-cause mortality compared to nonsurgical care. However, surgical complications of RYGB don"t go unnoticed: internal hernia (6%), anastomotic stenosis (12%), gastric erosion (7%) and intestinal obstruction (5%) are longer-term complications.Gastric remnant perforation after RYGB is rare complication. Several mechanisms have been proposed to explain it such as H. Pylori infection (prevalence of 53% among bariatric patients). Also, it"s well known that acid produced in the gastric remnant may remain unneutralised. Early diagnosis is crucial in post bariatric emergencies. A CT scan may provide valuable information in treatment planning, time is important for morbidity and mortality in peptic ulcer perforation. References: doi: 10.1007/s11695-020-04537-w, doi: 10.1308/rcsann.2018.0216.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 last swim after death: Liver abscess due to migration and perforation of a fisherbone – 2 case studies

Abstract text (incl. references and figure legends) We hereby present two cases of liver abscess caused by ingestion of fisherbones.Case 1:62 year old man brought by severe prostration.He presents with respiratory distress, severe hypotension, tachycardia and neurological dysfunction.Case 2:58 year old woman admitted with fever, epigastric pain, nausea and vomiting during the course of 3 days.Blood analysis showed leucocytosis and elevation of CRP in both cases. In the first case, there was also kidney and liver injury with hyperbilirubinemia. CT scans were performed, showing heterogeneous lesions located in the segments III and IVb measuring 90x75mm and 36x43mm, respectively. Additionally, an endoscopic ultrasonography was performed on the second case.According to clinical and radiological findings, a liver abscess was diagnosed in relation with the presence of a foreign body, in both cases.The first was submitted to emergent drainage due to its critical state.The second was proposed to urgent surgery due to its unresponsiveness to antibiotics.Percutaneous drainage was neither available or successful.Both went under laparoscopic drainage and removal of the fishbone in the emergency OR.The pos-operative course was uneventful and antibiotics were adjusted accordingly.The patients were discharged 20 and 9 days after surgery, respectively.We believe these liver abscess were caused by perforation and migration of an ingested fishbone through the stomach/duodenum and reaching the liver.Less than 1% of ingested bodies cause perforation and rarely cause liver abscess, although its incidence is increasing.Because the mortality is high, emergent drainage must be considered and, preferably, minimally invasive, as performed in these cases. References: Leggieri N, et al.[Migrated Foreign Body Liver Abscess-Ilustrative case report, systematic review and proposed diagnostic algorithm. Medicine 2010; 89: 85-95 Graça L, Viamonte B, Carvalho C, et al.BMJ Case Rep 2019; 12:e230452. doi: 10.1136/bcr-2019-230452Disclosure: 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 expanding cervical hematoma due to spontaneous rupture of the inferior thyroid artery

Abstract text (incl. references and figure legends) Case history A 54-year-old woman was admitted to the ED presenting with neck swelling which had enlarged over the course of a day, cervical stiffness, and heavy pain. The patient had no stridor but complained of dysphagia. She was a smoker and denied symptoms of upper respiratory tract infection, trauma, or the use of any medications, including anticoagulants. Clinical findings A large, firm, and non-fluctuant left-sided neck swelling was observed. All peripheral pulses were palpable, and she remained hemodynamically stable. Bedside ultrasound showed an extensive heterogenous mass compatible with a hematoma. Investigation/Results After orotracheal intubation the patient was transferred to our tertiary care center. Angio-CT confirmed a 6.7x7.4x10.0 cm hematoma dislocating the trachea and the left lobe of the thyroid to the right. Doubts remained as to the source of the bleeding. Diagnosis Angiography with superselective catheterization of the left inferior thyroid artery revealed active extravasation of contrast in its middle third. Therapy and Progressions Embolization with 8 microcoils deployed along the course of the artery stopped the bleed. Due to significant mass effect and the risk of unsafe extubation she underwent surgery. Intraoperatively considerable hemorrhagic infiltration was noted within the strap muscles, the hematoma was evacuated, the artery was ligated, and an active drain was inserted. Recovery was uneventful after extubation on the next day. The patient was discharged 3 days after the operation free of symptoms. Comments A spontaneous hematoma is a rare differential diagnosis of cervical mass posing a potentially life-threatening condition. Smoking is a risk factor for atherosclerosis which may have led to arterial fragility. The importance of securing the airway as soon as possible cannot be underestimated. The optimal management sequence for cases of cervical hematoma should be intubation, diagnosis, and angiography before surgery.Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No

When minimally invasive surgery becomes a catastrophe

Abstract text (incl. references and figure legends) Introdution: Major vascular injuries are the second most common cause of death during laparoscopy, after death from anesthesia, with a mortality rate of 6.37 %. Obesity, previous abdominal surgeries, surgical experience, inflammatory bowel disease and pelvic inflammatory disease are known risk factors to injuries during the entry phase in laparoscopy. Clinical report: A 47 years old woman, BMI 42.2 kg/m2, was proposed to an elective left hemicolectomy after 2 diverticulitis episodes in a 6 months period, at a secondary hospital. As soon as the Veress needle was inserted, blood was seen. After the first trocar was placed, an median retroperitoneal inframesogastric hematoma was seen and the surgeon did an unsuccessful attempt to control the bleeding. Since there was hemodynamic instability, a conversion was made. An infrarrenal aortic laceration was seen and clamps were put in place to stop the bleeding. The patient was then transferred to a tertiary hospital to be intervened by vascular surgery. An aortoplasty with patch of the great safenous vein and trombectomy of the ilio-distal arteries was performed. The time occurred between the injury and the beginning of the vascular surgery was 2hours. A total of 15 red blood cells pool, 12 plasma units, 3grams of fibrinogen and 1 pool of plaquelets were transfused. During the intensive care stay, the patient developed leg compartment syndrome, with the need of fasciectomy and a moderate ARDS, making it harder to manage the disease The patient was discharged after 73 days to a continued care unit. Conclusion: Major vascular injuries require rapid and effective hemostasis. Major vascular entry injuries are infrequent but should be studied and strict protocols put in place, since it has high morbimortality and a small period were measures can be taken. A close cooperation between general surgeons, vascular surgeons, intensivists and imunohemoterapists is essential to achieve a positive outcome.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

Non-traumatic hepatic hemorrhage: An eventful first presentation in young females

Abstract text (incl. references and figure legends) Introduction: Spontaneous liver hemorrhage (SLH) causing a significant hemoperitoneum is a rare and potentially life-threatening condition. SHL that can be associated either with benign or malignant liver disorders. Being the diagnosis and management difficult, it contributes to a high mortality rate. It is unclear what the standard of care is at present. Case history: We report a case of a 32 year-old female patient, without a relevant past medical history other than oral contraceptive agents, who was admitted to the Emergency Department with epigastric and left upper quadrant abdominal pain. On admission, the patient was hemodynamically stable and blood tests revealed haemoblobin 12.4g/dL and slight elevation of inflamatory markers. An abdomino-pelvic computerized tomography (CT) scan was performed, showing an epigastric mass (14 x 9,5 cm), of the left liver (segments 2 and 3), with an extensive hiperdense area compatible with recent hemorrhage but without signs of active bleeding. The patient was admitted into the intensive care unit for close monitoring. Twenty-four hours after initial admission, Hb levels dropped to 8,9 and although the patient became slightly tachycardic, there were no signs of active hemorrhage on repeated CT scan It was decided by multidisciplinary discussion to program hepatectomy. The patient was admitted to the operation theatre for a lateral left segmentectomy and was uneventful. Conclusion: SLH can quickly become a life-threatening situation. Surgeons must be aware of this disease, as well as the available armamentarium in order to address these 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

A pneumonia that leads to the operating room

Abstract text (incl. references and figure legends) Case history: A 45-year-old man was admitted to the Internal Medicine Department and diagnosed with Pneumonia and left pleural effusion. Clinical findings: Despite early antibiotic treatment, the patient's status worsened clinically and analytically. Antibiotic treatment was escalated, from amoxiclav to piperacillin/tazobactam, and a thoracic CT showed a loculated pleural effusion with associated left lower lobe subsegmental atelectasis. A CT-guided percutaneous drainage of pleural fluid was performed and pigtail catheters were left in place. Investigation: The patient developed acute abdominal pain with hemodynamic instability after this procedure. After initial resuscitation and obtained hemodynamic stability, a thoracoabdominal CT scan was performed that diagnosed a large splenic hematoma with active hemorrhage. Diagnosis: The patient underwent emergent laparotomy and splenectomy for splenic laceration grade V (AAST). Therapy and Progression: The patient had a good clinical outcome and was discharged from the Surgery ward on the fifth postoperative day and transferred to the Pneumology ward for complementary treatment of Pneumonia. No other complications were identified, and the patient was discharged from the hospital on the 18th day. Comments: Nine to 40% of splenectomies are caused by iatrogenic injuries, most frequently occurring during abdominal surgery. Rarely, injuries to the spleen can occur during nonsurgical invasive procedures, and this injury may go undetected at an early stage until the patient develops symptoms. CT scan is the best diagnostic imaging test and should be performed only if the patient is hemodynamically stable. In case of HD instability, emergent splenectomy is mandatory. References: Galperin-Aizenberg M, Blachar A, Gayer G. Iatrogenic injury to the spleen-CT appearance. Semin Ultrasound CT MR. 2007;28(1):52-56.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

Complicated chronic traumatic diaphragmatic hernia

Abstract text (incl. references and figure legends) CASE HISTORY 75-year-old male with a previous history of blunt abdominal trauma 30 years past arrived at the Emergency Department presenting with five days of abdominal pain, vomiting and constipation CLINICAL FINDINGS HD stable PE: distended and tympanic abdomen, with tenderness and palpation of an abdominal mass in the right upper quadrant without signs of peritoneal irritation RESULTS AND FINDINGS Laboratory tests: leuokocytosis of 16000 x10E3/microL (4.0 - 11.5). Normal coagulation profile CT Scan: right anterolateral diaphragmatic hernia with incarcerated right colon (Figure 1) THERAPY AND PROGRESSIONS Urgent laparotomy: Findings: right anterolateral diaphragmatic post-traumatic hernia with a 4 cm breach, containing deseroused and aperistaltic herniated right colon (Figure 2) Technique: right hemicolectomy with ileotransverse L-L anastomosis, diaphragmatic hernia reparation with non-absorbable suture and chest tube placement Acute respiratory distress requiring long term hospitalization–ICU COMMENTS Traumatic diaphragmatic injuries encompass less than 1% of trauma associated lesions1 Up to 60% develop unnoticed. Delayed diagnosis is associated with higher morbidity and mortality rates2 Blunt trauma leads to large rents in the diaphragm, most frequently the left hemidiaphragm3, unlike our case; and is more likely than penetrating trauma to lead to herniation of abdominal contents, most commonly the stomach and colon, into the chest Once the diagnosis is made, operation is mandatory REFERENCES Fair KA, et al. Traumatic diaphragmatic injury in the American College of Surgeons National Trauma Data Bank: a new examination of a rare diagnosis. Am J Surg. 2015 May;209(5):864-8 2. Zarour AM, et al. Presentations and outcomes in patients with traumatic diaphragmatic injury: a 15-year experience. J Trauma Acute Care Surg. 2013 Jun;74(6):1392-8 3. Tan KK, et al. Management of diaphragmatic rupture from blunt trauma. Singapore Med J. 2009 Dec;50(12):1150-3 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

POCUS in our daily work life: Mission impossible or endless opportunity

Abstract text (incl. references and figure legends) Introduction The concept of point of care ultrasound (POCUS) has been enhanced over the last decade. The ultimate goal is to incorporate POCUS into daily practice. However, its use and teaching are different from country to country and from hospital to hospital. Material &amp; Methods Observational prospective study about the daily use of POCUS in acute care surgery setting after a short training program (MUSEC Course). Results During the study period (5 months), 121 POCUS were performed by acute care surgeons. The most prevalent uses were for the diagnostic of pathology related to cholelithiasis (33 cases, 27%), EFAST (28 cases, 23%), diagnostic of abscesses in soft tissue infections (19 cases, 16%), evaluate hernia content (18 cases, 15%), evaluate the presence of intra-abdominal free fluid or intrabdominal collections (17 cases, 14%). Other uses were as an intraoperative guide or for interventional procedures (3 cases each, 2.5% each). In 75 cases (62%) as a result of performing the ultrasound there was a change in clinical attitude. Our concordance with radiological exams was 60% for the assessment of hernia content (compared to CT scan), 77% for the diagnosis of acute cholecystitis, 86% for EFAST assessment and the 100% for the diagnosis of abscess. Conclusions After a short training course, POCUS has been incorporated in our daily clinical practice, being a helpful tool in various pathologies. However, the training received has not been sufficient to be confident in performing ultrasound-guided interventional procedures. References Pereira J et al. Surgeon-performed POCUS for acute cholecystitis: indications and limitations: a ESTES consensus statement. Eur J Trauma Emerg Surg. 2020 Feb;46(1):173-183. Dietrich CF et al. Point of care ultrasound: a WFUMB position paper. Ultrasound in Med. &amp; Biol. 2017; 43(1):49-58 Beal EW et al. Point-of-Care Ultrasound in General Surgery Residency Training Journal of Ultrasound Medicine 2017; 36(12): 2577-2584 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 13
Emergency surgery 7

Appointment

Chairs

Programme

Poster Session 13Emergency surgery 7

Appointment

Chairs

Programme

Poster Session 13
Emergency surgery 7