22nd European Congress of Trauma & Emergency Surgery

Chairs

Prof.

Techniques for mesoappendix transection and appendix resection: Insights from the ESTES SnapAppy study

Emergency surgery

Education

Abstract text (incl. references and figure legends) Introduction: Surgically managed appendicitis exhibits great heterogeneity in techniques for mesoappendix transection, and appendix amputation from its base. It is unclear whether a particular surgical technique provides outcome benefit or reduces complications. Material &amp; Methods: We undertook a pre-specified subgroup analysis of all patients who underwent laparoscopic appendectomy at index admission during SnapAppy. We collected routine, anonymized observational data regarding surgical technique, patient demographics and indices of disease severity, without change to clinical care pathway or usual surgeon preference. We used Poisson regression models with robust standard errors to calculate incident rate ratios (IRRs) and 95% confidence intervals (CIs). Results: 3768 consecutive adult patients were followed up from date of admission for 90 days. The mesoappendix was divided hemostatically using electrocautery in 1,564(69.4%) and an energy device in 688(30.5%). The appendix was amputated by division of its base between looped ligatures in 1,379(37.0%), with a stapler in 1,421(38.1%) and between clips in 929(24.9%). While no statistical difference in outcomes could be detected between different techniques for division of the appendix base, a decreased risk of any [adjusted IRR (95% CI): 0.58 (0.41-0.82), p = 0.002] and severe [adjusted IRR (95% CI): 0.33 (0.11-0.96), p = 0.045] complications could be detected when using energy devices. Conclusions: Safe mesoappendix transection and appendix resection are accomplished using heterogeneous techniques. Despite the overall well-tolerated heterogeneity of approaches to acute appendicitis, increasing disease acuity or complexity appears to encourage homogeneity of intra-operative surgical technique towards advanced adjuncts.Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) Nothing to disclose

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Graded surgical trainee operative autonomy in emergency appendectomy mirrors case-complexity – Insights from the Snapappy prospective observational study

Abstract text (incl. references and figure legends) Introduction: Graded mentored exposure to pathologies and operative techniques is a cornerstone of surgical training. Appendectomy is one of the first procedures surgical trainees perform independently. We hypothesize that, given the embedded training ethos in surgery coupled with the steep learning curve required to achieve trainer-recognition of independent competency, &quot;real world&quot; clinical outcomes following appendectomy for the treatment of acute appendicitis are operator agnostic. Material &amp; Methods: This study is a subgroup analysis of the SnapAppy international time-bound prospective observational cohort study, including all consecutive patients aged ≥15 who underwent appendectomy for appendicitis during a three-month period in 2020-2021. Patients were grouped based on operating surgeon experience (trainee only, trainee with direct attending supervision, attending only). Poisson and quantile regression models were used to assess the relationship between surgical experience and postoperative complications or hospital length of stay (hLOS), respectively, while adjusting for confounders. Results: A total of 4,347 patients from 71 centers in 14 countries were included. Patients operated on by trainees were younger, had lower ASA classifications, and fewer comorbidities compared to those operated on by attendings. Additionally, trainees operated alone on fewer patients with appendiceal perforation (AAST severity grade ≥3: 8.7% vs 15.6%, p&lt;0.001). Regression analyses revealed no association between operator experience and complications (IRR 1.03 95%CI 0.83-1.28 for trainee vs attending; IRR 1.13 95%CI 0.89-1.42 for supervised trainee vs attending) or hLOS. Conclusion: Clinical outcomes following appendectomy do not differ depending on the experience of the operating surgeon. This may reflect the impact of linking case complexity with operator experience within the context of graduated autonomy throughout surgical training.Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) Nothing to disclose

Dr. med.

Prof. Dr.

PD Dr. rer. nat.

Prof. Dr. med.

Physical properties of soft tissue injury during the decision making of surgical treatment in ankle fractures

Skeletal trauma and sports medicine

Abstract text (incl. references and figure legends) Introduction The local soft tissue status (STS) guides surgical treatment strategies of fractures fixation. The aim of this study was to assess the physical properties of STS in lateral malleolar fractures that led to either temporal (TEMP) or definitive surgical strategy. Methods prospective double-blinded cohort study. Adult patients with closed lateral malleolar fracture eligible, if required surgical treatment.Exclusion: Previous injuries to the lower extremity, acute deep venous thrombosis, skin diseases, delayed presentation. primary outcome was the treatment strategy. Examination: circumference and bone-skin distance on plain radiograph. Physical properties assessment of the STS included optical measures of local perfusion and tactile measures of mechanical characteristics. Measurements were taken on admission and prior decision of treatment strategy. The contralateral not-injured ankle served as control. Results Forty patients at a mean age of 41 (±17.6) years were included. The circumference at admission was significantly higher when compared with the healthy site (28.6 ± 3.6cm versus 24.3 ± 2.7cm, p &lt; 0.001). The local perfusion (blood flow 109.6, SD 39.8 A.U. vs. 81.9, SD 15.5, p = 0.0051), and dynamic stiffness of the skin (679.4 N/m, SD 147 N/m vs 469.9N/m, SD 117.9 N/m, p &lt; 0.001) were significantly higher at the injured site. During TEMP, the local blood flow was higher when compared with definitive surgery (109.6, SD 39.8 vs. 94.5, SD 13.0, p = 0.023). The dynamic stiffness of the soft tissue was significantly higher during TEMP (679.4 N/m, SD 147.0 N/m vs. 573.0 N/m, SD 93.8 N/m, p &lt; 0.001) Conclusion Altered physical properties of the STS following injury include optical perfusion and dynamic stiffness at the surface. These changes might be indicative for the treatment strategy. The assessment tools could be implemented in routine clinical practice guiding decision making for either temporal or definitive surgical treatment strategies.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.) None of the authors have any conflicts to declare

Safe definitive surgery in polytrauma patients – Lactate alone is not enough for decision making

Polytrauma

Abstract text (incl. references and figure legends) Introduction Defining treatment strategy in polytrauma patients still is subject to numerous invesitgations and discussions. The goal of this study was to investigate pathophysiologic factors others than lactate as relevant guidance for treatemnt strategies in polytrauma patients Methods Retrospective cohort study including polytrauma patients (ISS&gt;16 points) and requriement of ICU. Exclusion: Patients with admission lactate above 2mmol/l. Primary outcome: Complications including pneumonia and mortatliy and imparied pathophysiologic variables with effect on decision making. Variables of interest: coagulopathy, temperature, soft tissue injury. Reults Inclusion of 485 patients, mean ISS 22.02 (SD 10.5), mean age 57.4 (SD 20.1) years admission lactate 1.2 (SD 0.4)mmol/l. In 8% of cases patietns had an increased INR (&gt;1.5), in 25.1% of cases patietns had increased coagulation time in ROTEM (above 80sec.), 7.4% of patietns were hypothermic (&lt;35.0°C and 65.6% of patients had relevant soft tissue injuries (AIS &gt;3 of any region). Patients with pathophysiologic coagulopathy had 3.1 higher risk for pneumonia and 2.9 times higher risk for mortality. Conclusion Despite normal lactate value, a substantial number of patients presented with hypothermia, coagulopathy, or severe soft tissue injury. These variables are predictive for complications such as pneumonia. lactate alone appears not to be enough for guiding treatment strategy in polytrauma 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.) none

Increasing trend of violence-related trauma and suicide attempts among pediatric trauma patients: A 6 years analysis of trauma mechanisms and the effects of the Covid-19 pandemic

Visceral trauma

Abstract text (incl. references and figure legends) Background: Trauma is the leading cause of morbidity and mortality in the pediatric population. During the Covid-19 pandemic (C-19), different trends for Pediatric Trauma (PT) were described. This study aims to explore the trend over time of PT in our center, also considering the effects of C-19, focusing on trauma mechanisms, violence-related trauma (VRT), and intentionality, especially suicide attempts (SA). Methods: All PT patients accepted at Niguarda Trauma Center (NTC) in Milan from January 2015 to December 2020 were retrospectively analyzed. We considered demographics and clinical variables and performed descriptive and year comparison analysis Results: 684 PT were accepted at NTC: 84 in 2015, 98 in 2016, 125 in 2017, 119 in 2018, 114 in 2019, and 144 in 2020 (p&lt;0.001); 66.2% male, mean age 9.88 (± 5.17). We observed more traffic-related, fall-related injuries and an increasing trend for VRT and SA, peaking in 2020. VRT and SA were higher among PT &gt; 12 years old. We report an increasing trend over time for head trauma (p=0.002). The Injury Severity Score did not significantly change. During C-19 we recorded a higher number of self-presenting patients with low priority codes. Conclusions: We herein report a higher number of traffic-related and fall-related PT over time. The increasing number of road and fall-related PT is in line with published reports. In 2020 we observed a peak of SA and VRT among PTs. The psychological impact of the C-19 restriction could explain this evidence. We highlighted an alarming trend among PT due to societal changes and the C-19. The long-term effects of C-19 on the mental health of the pediatric population should not be underestimated. Early focused educational and psychological interventions should be implemented among the pediatric population to prevent road-related trauma, SA and VRT. Surgical societies should cooperate with pediatric ones to build common strategies for prevention.References: Sanford et al.J.Pediatr.Surg.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

Longitudinal assessment of the inflammatory response: The next step in personalized medicine after severe trauma

Abstract text (incl. references and figure legends) Introduction: Infections in trauma patients are an increasing and substantial cause of morbidity, contributing to a mortality rate of 5–8% after trauma. With increased early survival rates, up to 30–50% of multitrauma patients develop an infectious complication. Trauma leads to a complex inflammatory cascade, in which neutrophils play a key role. Understanding the functions and characteristics of these cells is important for the understanding of their involvement in the development of infectious complications. Methods: Recently, analysis of neutrophil phenotype and function as complex biomarkers, has become accessible for point-of-care decision making after trauma. The aim of this narrative review is to discuss the potential use of longitudinal assessment of the neutrophil compartment by point-of-care flow cytometry. Results: There is an intriguing relation between the neutrophil functional phenotype on admission, and the clinical course (e.g., infectious complications) of trauma patients. Potential neutrophil based cellular diagnostics include subsets based on neutrophil receptor expression, responsiveness of neutrophils to formylpeptides and FcgRI (CD64) expression representing the infectious state of a patient. Conclusions: It is now possible to recognize patients at risk for infectious complications when presented at the trauma bay. These patients display increased numbers of neutrophil subsets, decreased responsiveness to fMLF and/or increased CD64 expression. The next step is to measure these biomarkers over time in trauma patients at risk for infectious complications, to guide decision making regarding timing and extent of surgery and administration of (preventive) antibiotics. Figure 1: Concept of the neutrophil subset response over time in a trauma patient at risk for infectious complications. Figure 2: Conceptual representation of surgical strategies after trauma.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

Visualization of the inflammatory response to injury by neutrophil phenotype categories

Abstract text (incl. references and figure legends) Introduction: The risk of infectious complications after trauma is determined by the amount of tissue damage and the resulting inflammatory response. Recently, it became possible to measure the neutrophil phenotype in a point-of-care setting. The primary goal of this study was to investigate if immunophenotype categories based on visual recognition of neutrophil subsets are applicable to interpret the inflammatory response to trauma. The secondary goal was to correlate these categories with patient characteristics, injury severity and risk of complications. Material &amp; Methods: A cohort study was conducted with patients presented at a level 1 trauma center. Data generated by automated point-of-care flow cytometry were gathered. Neutrophil phenotypes categories were defined by visual assessment of CD16/CD62L dot plots. Thereafter, the categories were validated by multidimensional analysis of neutrophil populations, by FlowSOM. All clinical parameters were extracted from the trauma registry. Results: The study population consisted of 380 patients. Seven distinct immunophenotype categories were defined, that consisted of different neutrophil populations as validated by FlowSOM. Injury severity scores and risk of infectious complications increased with ascending immunophenotype Categories 3-6. Injury severity was similarly low in Categories 0-2. Conclusions: The distribution of neutrophil subsets that were described in phenotype categories is easily recognizable for clinicians at the bedside. Even more, multidimensional analysis demonstrated these categories to be distinct subsets of neutrophils. Identification of trauma patients at risk for infectious complications by monitoring the immunophenotype category is a further improvement of personalized decision making in trauma care. Figure 1: Representative individual patient samples to illustrate the immunophenotype categories based on the occurrence of subsets of neutrophils in CD16/CD62LDisclosure: 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

Identification of frail geriatric trauma patient at risk for adverse outcomes after hip surgery by point-of-care neutrophil activation analysis

Abstract text (incl. references and figure legends) Geriatric patients with a hip fracture are at risk for adverse outcomes after hip surgery. Identification of an imbalance in the innate immune response to injury, as measured by neutrophil phenotype and responsiveness, could help identify frail patients that might not benefit from surgical treatment of a hip fracture. In this study we aim to investigate post hip fracture changes in the neutrophil compartment at the emergency department (ED) for geriatric hip fracture patients. Geriatric trauma patients with a hip fracture presented at the ED of a large regional teaching hospital, had one extra blood tube withdrawn and analyzed by a Point-of-Care flow cytometer. Neutrophil responsiveness to fNLF of geriatric hip fracture patients was compared to healthy controls. Patients with severe adverse events were compared with patients without adverse events. Up to know, 48 blood samples were succesfully analyzed. Compared to healthy controls, geriatric trauma patients showed elevated baseline CD10 and CD11b and decreased CD62L levels. Neutrophils were decreased responsive to fNLF-activation regarding CD10 and CD11b upregulation. Patients that developed severe adverse outcomes have decreased responsiveness of CD10 and CD11b on admission at the ED. This study shows that the assessment of the neutrophil compartment in geriatric hip fracture patients is feasible and revealed distinct activation patterns. Although power for statistical, clinical relevance is missing, this study is a first step toward immuno-based precision medicine for identifying frail patients with a high risk of severe adverse outcomes after surgery. We are currently continuing this research in a larger trauma geriatric cohort to be able to present more clinical relevant data at the congress. Figure 1. Neutrophil responsiveness (MFI fNLF+/MFI fNLF-) for geriatric hip fracture patients and healthy controls. Subgroup analyses compare patients with/withour severe adverse events.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

ICG-Fluorescence guided laparoscopic treatment for type III Mirizzi Syndrome: A video vignette

Abstract text (incl. references and figure legends) INTRODUCTION Mirizzi syndrome (MS) is a rare and challenging complication of cholelithiasis. Surgery is almost always required for definitive treatment, and the feasibility of a laparoscopic treatment is still controversial, with high conversion rates. Definitive preoperative diagnosis is essential to attempt a laparoscopic approach. ICG-Fluorescence guided laparoscopic cholecystectomy is nowadays recognized as a cost-effective method, able to improve intra-operative visualization, both in routine and complicated cases. Nevertheless, no cases of fluorescence guided surgery for MS have yet been reported. M&amp;M We describe the case of a 72 years old patient, with preoperative diagnosis of Mirizzi syndrome and endoscopic double biliary stent placement for complete lithiasic choledochal obstruction. RESULTS The patient underwent laparoscopy after ICG injection and the intraoperative finding was a MS type III, with a complete fusion of Hartmann pouch (occupied by the stone) with common bile duct. The video shows how the fluorescence was essential in identifying the residual, healthy wall of CBD and the limit between this one and the Hartmann pouch, where the fistula was located, thus guiding the surgeon during infundibulotomy for stone removal. The post-operative course was uneventful. CONCLUSIONS In the treatment of a complicated case of MS, ICG-fluorescence might be a very useful tool, allowing more widespread use of laparoscopic approach, reducing conversion rate and ensuring the best visualization of CBD anatomy. REFERENCES Chen H et al. Current trends in the management of Mirizzi Syndrome. Medicine 2018; 97:4(e9691) Zhao J et al. Safety and feasibility of laparoscopic approaches for the management of Mirizzi syndrome: a systematic review. Surgical Endoscopy 2020 34:4717–4726 Reeves JJ et al. The price is right: Routine fluorescent cholangiography during laparoscopic cholecystectomy. Surgery 2022;171(5):1168-1176Disclosure: 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 biochemical significance of ph in trauma-induced coagulopathy

Abstract text (incl. references and figure legends) Introduction: The lethal triad of trauma from uncontrolled hemorrhage is well recognized after severe injury. Clinically, however, base deficit (BD) and lactate have been used instead of pH as predictors of outcome and to guide resuscitation. PH has been overlooked because of its logarithmic range and respiratory compensation, thought to limit its clinical usefulness. Thus, current therapy is aimed at stopping blood loss and resuscitating to BD and lactate clearance. Small changes in pH have significant biochemical effects on coagulation yet little is known about the effect of clinical pH measures on trauma-induced coagulopathy (TIC). We hypothesized that small changes in pH even within the "normal" physiologic range have biochemical outcomes that affect normal coagulation. Methods: Serum samples from 709 injured patients were collected upon arrival to an urban Level 1 Trauma Center. Linear regression models were used to establish the relationship between pH on coagulation values, controlling for BD and injury severity score (ISS). Results: Blunt injury was the predominant mechanism (57.12 %). The median age of patients was 35.7, mortality 10.3 %, ISS 17, pH 7.33, and BD -6. There is an inverse relationship between pH and international normalized ratio (INR), partial thromboplastin time (PTT), and clot lysis at 30 minutes (LY30) even when controlling for BD (p&lt; .05). There was no statistically significant association between BE and coagulation parameters in a model that includes changes in ph. Conclusions: There is an independent, inverse relationship between pH and INR, PTT, and LY30. This suggests pH has an underappreciated effect on coagulation biochemistry and may be a superior resuscitation endpoint for managing TIC. Further understanding of the impact that small changes in pH have on the biochemistry of the injured patient is essential to understanding and treating TIC. References: Moore et al. Trauma-induced coagulopathy doi:10.1038/s41572-021-00264-3.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

PD Dr.

Body mass composition in polytrauma – Does it help to predict the clinical course?

Abstract text (incl. references and figure legends) Background: Body mass composition (BC) correlates well with patient outcome but data regarding patients with multiple trauma (MT) is sparse. BC is calculated using computed tomography (CT) which is routinely performed in severely injured patients. Aside BC analysis on the level of the established 3rd lumbar vertebra level, this study will also investigate results on the 4th thoracic vertebra level as thoracic trauma is common in MT patients. Materials/Methods: MT-patients (ISS&gt;15) admitted to a level 1 trauma center were included. All received whole-body CT (WBCT) scan on admission. Muscle and fat tissue were assessed at the level of the 4th thoracic vertebra (T4) and the 3rdlumbar vertebra (L3) by using the software Slice-O-matic, version 5.0 (Tomovision, Montreal, QC, Canada) to detect potential correlations in regard to outcome parameters (duration of ventilation, hospital stay, local (i.e. pneumonia, wound infection) and systemic (i.e. MODS, SIRS) complications and mortality). Results: BC (low muscle mass and high visceral adipose tissue) variables correlated well with overall complication severity. T4 and L3 values predicted the severity of complications roughly the same way. Skeletal muscle radiation attenuation (SMRA) at L3, skeletal muscle index (SMI) and subcutaneous adipose tissue index (SATI) showed a significant association with the occurrence of systemic infections. Local infections presented an association with skeletal muscle index at T4 . Moreover, higher muscle mass at the T4 and the L3 level associated significantly with higher overall survival. Additionally, a statistically significant correlation of SATI at T4 level with hospital stay, length of stay in the ICU, and duration of ventilation was observed. Conclusion: Assessment of BC variables in MT is simple and helps to predict outcome. Moreover, information gained on T4 level offered comparable results to validated L3 level. Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No

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