22nd European Congress of Trauma & Emergency Surgery

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Prof.

Pleural empyema with late evolution and the importance of early surgical evaluation: A case report

Abstract text (incl. references and figure legends) Case history: A 55-year-old male, obese, hypertensive, alcoholic, went to the emergency service due to ventilator chest pain, chills, cough and dyspnea that had been progressing for one month. He reported crushing trauma from a fall of a desk on his chest. Clinical findings: He was evaluated by the general surgery team and was tachycardic, tachypneic, no vesicular murmurs in the left hemithorax, but present on the right. Investigation/Results: Previous chest X-ray: ribs fracture on the right. New chest X-ray: left pleural effusion with visible air-fluid level. Chest and total abdomen contrast-enhanced tomography: large pleural effusion on the left, air-fluid levels, probable pleural empyema. Diagnosis: Post-traumatic pleural empyema. Therapy and Progressions: Antibiotic therapy was started. Left chest drainage was performed, without complications. The material collected was sent for bacteriological analysis, whose results showed positive bacterioscopy for gram-positive cocci (viridans group streptococci) and negative BAAR research. The paciente stayed in the intensive care unit for 24 hours and had a good clinical evolution. He was treated in the ward with subsequent pleuroscopy and pulmonary decortication and was discharged from the hospital with a scheduled outpatient return. Comments: Post-traumatic empyema without penetrating injury is rare, severe and with high morbidity and mortality. Thus, the analysis of the clinical history, physical examination and imaging tests associated with the follow-up of the patient by an experienced surgeon are essential for successful treatment and better prognosis. References: Arsenijević, M. et al. PLEURAL EMPYEMA MENAGEMENTE: BRIEF REVIEW OF LITTERATURE. Ser J Exp Clin Res 2021; Dogrul, B. N. et al. Blunt trauma related chest wall and pulmonary injuries: An overview. CJT. vol. 23,3 2020; Kim, et al. Chest Trauma: Current Recommendations for Rib Fractures, Pneumothorax, and Other Injuries. Curr. Anesthesiol. Rep. vol. 10,1 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

Emergency surgery

Skeletal trauma and sports medicine

Poster

Anaylsis of risk factors and prognosis in low-energy thoracic penetrating trauma

Abstract text (incl. references and figure legends) Introduction: Chest trauma is a serious injury, account for 20–25 % of deaths in trauma. In some countries high-energy gunshot wounds have been reported for the majority of chest penetrating injuries. However, in area where firearms are restricted, blunt trauma is the majority of thoracic injury and penetrating injury is relatively rare. Also, many of the penetrating trauma is caused by low-energy injuries in this area. Therefore, there are not many studies on low-energy penetrating trauma. The purpose of this study is to analyze the prognosis and risk factors of patients who treated for low-energy thoracic penetrating trauma. Material and Methods: Clinical data was collected retrospectively from medical records of patients who treated with thoracic penetrating injury admissions between Mar. 2016 and Mar. 2022 in single center. Demographic data, transfusion, injury characteristics, trauma score, and survival outcome of all the patients were reviewed based on Trauma Database. Results: A total of 33 trauma patients treated during this period. The overall survival rate to hospital discharge was 84.8% (survival=28). In baseline characteristics, median age was 50 years, ISS was 18, TRISS was 95.59%, chest AIS median value was 4 and the average ICU stay was 42.2 hours. In the comparison between the survival group and the non-survival group, ISS, transfusion, other organ injury, systolic blood pressure was not statistically significant (17 vs 18, p=0.47). Also, there was no statistical correlation between the amount of transfusion and ISS (p =0.15). Among the entire cohort, the survival group showed high GCS (15 vs. 8, p=0.02) and TRISS values (95.6 vs 28.0, p=0.01). Conclusion: In this study, we proposed it is difficult to predict the transfusion with the anatomic injury in low-energy thoracic penetrating trauma. And, TRISS are expected to predict survival rate rather than another trauma score, but further studies are needed in a larger number of patients.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

A phase 3 noninferiority trial to evaluate the efficacy and safety of TAK-330 (4-factor prothrombin complex concentrate [4F-PCC]) versus standard-of-care 4F-PCC for the reversal of factor Xa inhibitor-induced anticoagulation before urgent surgery or an invasive procedure

Abstract text (incl. references and figure legends) Introduction This study aims to evaluate the efficacy and safety of TAK-330 (4-factor prothrombin complex concentrate [4F-PCC], Takeda), versus current standard-of-care (SOC) 4F-PCCs, for the reversal of factor Xa (FXa) inhibitor-induced anticoagulation in patients who require urgent surgery/invasive procedure. Materials &amp; Methods This phase 3, randomized, multicenter, open-label, adaptive group sequential, noninferiority study aims to recruit 328 patients (≥18 years old) currently receiving an oral FXa inhibitor (rivaroxaban, apixaban or edoxaban) who require urgent surgery/invasive procedure with a high-risk of intraoperative bleeding within 15 hours after their last FXa inhibitor dose. Patients will be randomized 1:1 to receive TAK-330 or an active comparator SOC 4F-PCC before their procedure; the total dose should be ≤50 IU/kg (≤5000 IU/patient). The study design is shown in Fig. 1. Key exclusion criteria are acute major bleeding and a recent history of thromboembolism or disseminated intravascular coagulation. The primary endpoint is the intraoperative efficacy based on the Four-Point Intraoperative Hemostatic Efficacy Scale at the end of the procedure. The key secondary endpoint is the postoperative hemostatic efficacy assessed at 24±4 hours after study drug infusion. Additional secondary endpoints are use of blood products or nonstudy hemostatic agents for bleeding control up to 24±4 hours after study drug infusion; occurrence of thrombotic events, treatment-emergent adverse events, serious adverse events and adverse events of special interest; and occurrence of all-cause deaths (all within 30±3 days post surgery/invasive procedure or study completion). Results Not applicable. Conclusions Results from this study will provide efficacy and safety data on TAK-330 versus SOC 4F-PCCs for the reversal of direct oral FXa inhibitor-induced anticoagulation in patients requiring urgent surgery/invasive procedure. References ClinicalTrials.gov: NCT05156983 EudraCT: 2021-004138-12Disclosure: 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.) Conflicts of interest MKK is an employee of Takeda Pharmaceuticals International AG and a stockholder of Takeda Pharmaceutical Company Limited. HK is a contractor of Takeda Development Center Americas, Inc. JG is an employee of Massachusetts General Hospital and has received research support from Octapharma, Pfizer and Takeda, and has provided consulting services for AstraZeneca, Cayuga Biotech, CSL Behring and Ncontrol. JL serves on steering committees for Merck, Octapharma and Werfen. HA is an employee of Massachusetts General Hospital and Takeda Development Center Americas, Inc., as well as a stockholder of Takeda Pharmaceutical Company Limited. This study was funded by Takeda Development Center Americas, Inc. Medical writing support was provided by Jessica Boles, PhD, of PharmaGenesis London, London, UK, and funded by Takeda Pharmaceuticals International AG.

The effects of screening for troponin I among patients undergoing acute high-risk abdominal surgery

Abstract text (incl. references and figure legends) Introduction Acute h&shy;&shy;igh-risk abdominal (AHA) surgery is associated with a high risk of developing myocardial injury after non-cardiac surgery (MINS). MINS is diagnosed by an elevated troponin level (TnI) and significantly associated with an increased risk of both cardiac complications and mortality1. Thus, we implemented TnI screening as a standard care of AHA-patients to investigate whether TnI-screening for risk stratification with subsequent intervention and intermedial care to improve survival rates. We aim to compare the mortality rate after AHA surgery in patients undergoing postoperative TnI-screening and subsequent intervention with a historical group of patients not undergoing TnI-screening. Material &amp; Methods TnI-screening was implemented on March 1, 2019 at Copenhagen University Hospital – North Zealand. Patients undergoing AHA-surgery from then were included in the TnI-screening group. The control group consists of all patients from January 1, 2018 and until February 28, 2019. Patients in the TnI screening group underwent measurements of plasma-TnI preoperatively, and 6-12 hours and on postoperative day 1–4. Patients with an increased TnI-level were assessed individually to decide further treatment and higher level of care. Data on vital status is collected from the Danish Civil Registration System. Results Currently 398 patients are included in the TnI-screening group and 185 patients in the control group. Data are still being processed and will be ready for presentation in January 2023. Conclusions The conclusion will be based on the results. References Botto et al. Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes. Anesthesiology. 2014;120:564-78 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.) The authors declare no conflict of interest.

Multi-level bowel obstruction in a patient with previous truncal vagotomy

Abstract text (incl. references and figure legends) Case history:A 78-year-old gentleman attended the emergency department with a 5 day history of severe persistent epigastric pain, nausea, and vomiting. He had a medical history of hypertension, coronary artery bypass graft, renal stones, truncal vagotomy and spinal stenosis. Clinical findings:The abdomen was distended but soft with generalised tenderness, worse in the epigastric region. There were reduced bowel sounds and the PR examination identified hard stools in the rectum. Investigations:Vital signs were within normal range, with mildly raised CRP and lactate. A CT abdomen and pelvis revealed a high-grade small bowel (SB) obstruction; the stomach, duodenum and proximal jejunum were grossly distended above the level of a transition point. Diagnosis:The initial impression was of SB obstruction, likely adhesional in origin, secondary to previous abdominal surgery. Therapy:The patient underwent an emergency laparotomy. A food bolus was identified in the proximal SB, beyond which the bowel was collapsed. A 5 cm enterotomy was performed to deliver the bolus. Postoperatively, the patient experienced a post operative ileus. A repeat CT scan indicated a similar pattern of bowel dilation with no definite obstructing cause. Decision for a relook laparotomy was made. A large firm food bolus was found proximally to the previous enterotomy site, with multiple additional boluses in the jejunum and colon. Two further enterotomies were needed. Patient recovered slowly and discharged the 25th post operative day. Comments:This was a case of a multi-level SB obstruction secondary to food bolus, likely related to the previous truncal vagotomy. The gastroparesis and the contents of the dilated stomach were the reason of the second episode of SB obstruction, soon after the initial emergency laparotomy. This was a challenging and very rare event which should be in mind of all the emergency surgeons who deal with similar cases. References: Seeras K, et al. Truncal Vagotomy. 2021Disclosure: 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 challenging case of an adhesional small bowel obstruction post elective spigelian hernia repair

Abstract text (incl. references and figure legends) Case history: An 83-year-old woman was brought in by ambulance to the ED with recent onset of epigastric and right upper abdominal pain, reduced appetite and difficulties mobilising. She has a past medical history of left spigelian hernia (4 weeks ago), hysterectomy, 3 umbilical hernia repairs (with mesh), laparoscopic cholecystectomy, hypertension, asthma and left knee osteoarthritis. Clinical findings: The patient was alert, oriented, afebrile but uncomfortable with tachypnoea, tachycardia but normal blood pressure and SpO2. On examination the abdomen was soft, with generalised tenderness and bowel sounds present. Investigations/Results: Patient's blood showed mildly elevated CRP but normal WBC and albumin. A CT scan was requested which indicated signs of small bowel (SB) obstruction with a transition point in lower abdomen. Diagnosis: Adhesional SB obstruction. Therapy: A nasogastric tube was inserted and a trial with oral gastrografin was tried, but could not be tolerated by the patient. A second attempt failed too. Decision was to proceed with laparotomy. Transition point was found after extensive and difficult adhesiolysis. The SB had several adhesions with the abdominal wall, previous mesh and between bowel loops. Few serosal tears were repaired and few cms of ileum were resected and anastomosed. A drain was placed in pelvis. Patient was transferred to the ITU for post operative care. On the third post operative day, bilous fluid was seen coming around the drain, but not in it. A decision to proceed with second laparotomy identified a perforation of the ileum proximal to the anastomosis. Resection of part of the ileum was performed with a double-barrelled ileostomy. The patient, after a lengthy stay in ITU , was extubated and transferred to the ward. Comments: This was a challenging case from the operating as well the decision-making point of view of an adhesional SB obstruction post elective hernia repair in an elderly patient with comorbidities.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

Are high admission C-Reactive protein level and longer in-hospital delay to surgery associated with increased risk of complicated appendicitis? A retrospective monocentric study on 412 patients

Abstract text (incl. references and figure legends) I: The aim of the study is to assess the role of CRP values in detecting complex appendicitis and to debate the effects of delayed appendectomy, analyzing the complication rate and the hospitalization length. M: We retrospectively considered 412 patients who underwent surgery for acute appendicitis from January 2015 to December 2021 at Humanitas Research Hospital, Milan. Admission CRP value and timing (&lt;12h; 12-24h;&gt;24h) between Emergency Room (ER) access and surgery has been collected for every patient. Intra-Operatory (IO) findings according to AAST, post-operative stay and complication rate, according with Clavien Dindo Classification, were evaluated. R: 168 patients (41%) had complicated appendicitis (AAST 3-4-5), while 244 patients (59%) had uncomplicated appendicitis (AAST 1-2). Admission CRP levels were higher in patients with complicated appendicitis (p-value 0.002). Median in hospital delay were 20 hours. 102 patients underwent surgery within 12 hours of admission to ER, 174 between 12-24 h and 136 over 24h, respectively. Patients with uncomplicated appendicitis were more in the 12-24h group than in the &gt;24h group (p 0.015). No statistically differences were found between timing of surgery and IO findings for the other groups. No differences found for hospitalization length and complications rate between the three groups. CRP levels did not relate with complications, but high levels of CRP linked with longer hospitalization (p 0. 002). C: High CRP values on admission can help to detect complicated appendicitis and longer hospitalization. Prolonged in-hospital delays before appendectomy, nor CRP levels, was not associated with increased risk of complicated appendicitis or adverse outcomes. R: C-Reactive protein is an independent surgical indication marker for appendicitis: a retrospective study. Shozo Yokoyama et al. World Journal of Emergency Surgery volume 4: 36 (2009).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

Gallstone Ileus: A case report

Abstract text (incl. references and figure legends) A 47-year-old obese female patient presented to the emergency department with colicky epigastric pain and vomiting since the day before, without further changes in bowel habits. She had an episode of gallstone pancreatitis 9 years earlier with follow-up loss due to missed appointments. She had no previous abdominal surgery. The patient had no fever or other abnormal vital signs on physical examination but abdominal epigastric tenderness without guarding or rebound tenderness. Blood tests demonstrated leukocytosis and abdominal radiography showed pneumobilia and signs of small bowel obstruction (figure 1). CT scan revealed intrahepatic duct dilation, pneumobilia, contracted gallbladder with thickened wall, dilated small bowel loops and a slight radio-opaque stone (25mm) located in the terminal ileum, suggesting a gallstone ileus (figure 2). Exploratory laparoscopy revealed a small bowel obstruction, 20cm proximal to the ileocecal valve, caused by a large gallstone (figure 3). Through a Pfannenstiel incision, a 3cm longitudinal enterotomy was made proximal to the gallstone (figure 4). A 5cm stone was removed (figure 5) and the enterotomy was closed transversely. The patient had an uneventful postoperative recovery and was discharged home 4 days later. Gallstone ileus is a rare cause of mechanical bowel obstruction caused by an impacted stone and an uncommon presentation of gallstone disease (0.5%). The stones are invariable large (&gt;25mm) and obstruction is most frequent at the level of the terminal ileum.1 Management of this condition is usually possible by a small enterotomy, extraction of the stone and primary closure of the bowel.2 1. Chang, L., et al. (2017). Clinical and radiological diagnosis of gallstone ileus: a mini review. Emergency Radiology, 25(2), 189–196. doi:10.1007/s10140-017-1568-5 2. Vera-Mansilla C., et al. (2022). Surgical Treatment of Gallstone Ileus: Less Is More. Visc Med, 38:72-77. doi: 10.1159/000518451Disclosure: 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 GIST - A Case Report

Abstract text (incl. references and figure legends) Case History A 79 year old man presented to surgical clinic with left lower abdominal pain, weight loss, anorexia, mild anaemia and intermittent sweating for 2-3 months. Family showed concerns of pancreatic cancer due to the above. Clinical Findings On examination, a large vague mass was palpable in the lower abdomen. Investigations/Results Bloods were abnormal, showing raised inflammatory markers. Tumour markers were negative. First CT scan performed showed features of cavitating abdominal mass, maybe cavitating GIST or malignant GIST, with superimposed secondary infection, measuring 9.5x16.5x19cm. Staging CT-TAP did not show metastatic disease. Patient booked for MDT. Diagnosis Gastrointestinal stromal tumour. Therapy and Progressions Before patient could be discussed in the MDT, patient presented after 9 days with signs of intraabdominal sepsis and a repeat CT scan confirmed an increase in size and perforation of the GIST. An urgent decision was taken and the patient was operated within 90 minutes of presentation. An underwent damage control surgery with bowel resection and resection of the GIST. Patient was very unwell intraoperatively and taken to ITU for recovery. Unfortunately, the patient passed away on post-op day 3. Comments Since it is established that GIST tumours are a very rare entity of gastrointestinal tumours with low incidence, and literature review shows GIST tumours have a tendency to enlarge significantly with a high mitotic rate which tend to perforate causing catastrophic intraabdominal sepsis. The tumour in our patient showed a very aggressive behaviour and perforated within 10 days of initial presentation. References 1) Mazur MT, Clark HB. Gastric Stromal Tumours: Reappriasal of Histogenesis. Am J Surg Pathol 1983;•••:7509-7519. 2) A.C. Sociedad Mexicana de Oncologia, Tumores del estroma gastrointestinal (GIST), avances en el conocimiento y manejo, Gaceta Mexicana de Oncología, 10 (2011 Jan-Feb)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 conflicts of interest

A new option in chronic wound infections

Abstract text (incl. references and figure legends) Introduction. Chronic wound infections of less tan 10 centimeters of diameter with purulent or serohematic continuos debit but less than 50 centimeter debit per day can be a challenge for a fast control of infection focus. Our everyday infection control of these wound infections is a prolonged time-consuming treatment during 2-3 months with a high cost, a high resources consumption and sometimes a delay in posterior treatment of these patients Matherial and methods. Main indication of portátil vaccum system was a continuos debit with almost 3 weeks of conventional cure without a better outcome ( 80% of patients).All were classified as American Society of anesthesiologist(ASA) II. 60 % of them suffered from abdominal Wall surgery: 20 % with a purulent continuos debit during 2 months in an eventroplasty in an incisional hernia in middle line, 20% eventroplasty in left subcostal incisional hernia with recurrence Wall abscess and without any response to several drainages and antibiotic treatments and 20 % due to continuos serohematic debit during 3 weeks in a eventroplasty in an incisional middle line hernia . 20 % was an early protective ileostomy closure of a patient suffered from rectal cáncer with a purulent continuos debit of 3 weeks and waiting for chemotheraphy after surgery and 20 % was a continuos debit in pfanestiel incisión in rectal cáncer waiting the chemotherapy treatment after surgery. Results. The average of number of changes was 3.4(2-6) although we have a short serie and in a patient the number of changes was 6, modifing actively change average. All patients were followed up during 2 months and in in 60% of them, a control ultrasonography of abdominal Wall was performed to check it. No problem was documented after the end of treatment. Conclusions.The use of a portátil vaccum system in wound infection without a control of it, not only reduces evidently control infection time but also decreases high sanitary cost.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

Obstructed inguinal hernia in an elderly patient: Approaches and challenges of the emergency management

Abstract text (incl. references and figure legends) Introduction The incidence of inguinal hernia increases with age. This case study underlines the challenges of emergency management of an obstructed hernia in an elderly patient with co-morbidities: 89 year old male with prostate cancer and a saddle pulmonary embolus,on Rivaroxaban. Clinical findings The patient presented with bilateral painful irreducible inguinal hernias and vomiting. Investigations CT: right-sided inguinal hernia containing loops of small bowel with signs of obstruction and ischaemia,left-sided inguinal hernia contains sigmoid colon. Therapy and progressions: Due to bilateral painful hernias and signs of ischaemia emergency laparotomy was performed. Bowel was viable,reduction of both hernias required enlargement of internal inguinal rings. Bleeding from mesenteric sites required administration of prothromplex and tranexamic acid. After commencement of enoxaparin on 3rd post-operative day, a decline in haemoglobin was noted, and CT showed potential haemorrhage from a branch of the inferior epigastric artery. The patient underwent embolization and had a good recovery post-procedure. Comments Laparotomy approach was chosen due to presentation with bilateral tenderness and a suspicion of bowel ischaemia. With no specific reversal agent for Rivaroxaban, a combination of surgical haemostasis and procoagulation agents was utilized. Most likely, internal inguinal ring widening on the right side caused damage to a branch of the inferior epigastric artery. The patient was at high risk of postoperative bleeding - this was recognised early. Conclusion: This case illustrates complexity of an elderly surgical patient. With increasing number of elderly patients more cases will present similarly, but a good outcome can be achieved with appropriate decision making and cooperation of specialties. References: de Goede, B. et al. (2015) "Risk factors for inguinal hernia in middle-aged and elderly men: Results from the Rotterdam Study," Surgery, 157(3), pp. 540–546.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

ERAS survey in a low resources country

Abstract text (incl. references and figure legends) AIM. Studying the real situation of enhanced recovery after surgery(ERAS) measures in a low resources country in emergency surgery. Matherial and methods. We presented a survey in Bolivia about ERAS in emergency surgery promoted by spanish group of multimodal rehabilitation (GERM). Survey was divided in 3 parts: personal view of ERAS in emergency surgery, general aspects, everyday measures in acute appendicitis, acute cholecystitis and acute diverticula. Results. 60 surgeons from Bolivia contributed to the survey. 49.21 of them were 50 years old or more. 98.41% believed that ERAS measures in emergency surgery were good for patients but only 65.08% of them applied ERAS measures in emergency surgery in their hospitals. Only in 33.33 % of their hospitals an ERAS program in elective surgery was presented. In 32.26 %, an emergency surgery unit was. The heat body control was important for 78.2% applying measures to mantain body temperatura as in elective surgeries. Acute apendicitis: The first dose of antibiotic must be during the first hour of diagnosis for 38.30 % and 59.57% thought that after a first dosis, it wasn´t necessary an extra-dosis independent of time after first dose. In its diagnosis, 76.09% used Scores. Laparoscopic approach is the best option for86.96% but only in 34.04% was laparoscopic approach the mandatory approach. When they found purulent fluid , 82.98 % aspirated and cleaned the fluid. Control pain was performed by local anesthesia in trocar placements in 44.91%. Acute Cholecystitis: 53.19% recommended antibiotic treatment during a week. Only 39.53 put local anesthesia in trocar placements although 53.49% of them considered that that measure was good for pain control. Acute diverticula: CT is the best option for 80.85% although 53.19% beleived that ultrasound is very useful. Conclusions. ERAS programs would be a succes option after a positive attitude in Bolivian surgeonsDisclosure: 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 6
Emergency surgery 4

Appointment

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Poster Session 6Emergency surgery 4

Appointment

Chairs

Programme

Poster Session 6
Emergency surgery 4