22nd European Congress of Trauma & Emergency Surgery

Prof. Dr.

Chairs

Prof.

Application of negative pressure wound therapy during chronic wound treatment in traumatology practice

Abstract text (incl. references and figure legends) Background: Negative pressure wound therapy (NPWT) has become the golden standard regarding care of high risk, enlarged or chronic wounds within Traumatology. However, there is conflicting literature on its impact on infectious complications. Our aim was to compare the effects of NPWT and conventional treatment on wound complications after total endoprosthesis (TEP). Materials and methods: Retrospective cohort study (e.sz.: 69/2019-SZTE). A total of 369 patients underwent TEP implantation with wound complication at the Traumatology Department from 2015 to 2022. The patients were divided into two groups, whether they received NPWT (n=64) or not (Control group, n=32). The primary outcome according to wound healing was healed, chronic wound and exitus. The secondary outcome measures included the number and the frequency of dressing change, lenght of antibiotic (Ab) treatment, and hospital stay. Results: There was no difference in the number and the frequency of dressing change between groups. However, the 25 % of wounds in the NWPT group healed and 45 % of cases turned into chronic wounds, compared to the Control (41% and 42 %) The mortality rate was twice as high in the NWTH group and the lenght of hospital stay and Ab treatment was longer when compared to the Control group (8,97 days vs 6,08 days). Conclusion: Based on the results, when NPWT therapy is utilized in appropriate amounts and quality, the results are good, However, not all facets of the study were proven true and further studies may be necessary to fully understand the method of NPWT.Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No

Education

Visceral trauma

Poster

Severe hepatic trauma – A challenging case

Abstract text (incl. references and figure legends) CASE HISTORY A 40-year-old woman suffered thoracoabdominal trauma after trying to stop her moving car, developing a severe hepatic injury. CLINICAL FINDINGS The patient was admitted to the emergency room (ER) hemodynamically stable, with abdominal pain and tenderness in the right upper quadrant. INVESTIGATION/RESULTS E-FAST was positive, so CT-TAP was performed. DIAGNOSIS CT-TAP revealed an isolated severe hepatic injury grade V AAST / III WSES without active bleeding. THERAPY/PROGRESSIONS The initial approach was nonoperative management with monitoring in the ICU. On the eighth day, the patient's clinical condition deteriorated. Abdominal paracentesis revealed a choleperitoneum and a laparoscopic exploration and drainage were proposed. The patient underwent 11 surgical interventions due to recurring hemorrhagic shock, including 7/8 debridement segmentectomy and embolization of a right hepatic artery branch. She had multiple complications, stayed 53 days at the hospital, 23 days at home hospitalization and was admitted twice to the ER. The patient is now fully recovered. COMMENTS The liver is the most commonly injured organ in blunt abdominal trauma. Most injuries resolve with nonoperative management and surgery is necessary for only 14% of patients. However, deciding the best treatment for the patient can be a challenge. The guidelines for the treatment of hepatic trauma have changed considerably. There is a growing consensus that nonoperative therapy is the main treatment if conditions allow. The surgeon must always be prepared to intervene when there's an alteration in the patient's clinical condition. This challenging case shows that surgeons' experience, knowledge and technical skill greatly influence the patient's prognosis. REFERENCES aast@aast.org, Liver Injury Scale 2018 Christmas, A., et al, Management of hepatic trauma in adults, UpToDate, Feb 2022 Coccolini, F., et al, Liver trauma WSES 2020 guidelines, World J Emerg Surg, 2020 15:24Disclosure: 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

Failed splenic salvage strategy after trauma: A septic infarction after arterial percutaneous selective embolization

Abstract text (incl. references and figure legends) Case History: 61 y/o male, with medical history of DM type II, victim of a motorcycle front collision accident and ejection from vehicle. In a urgent CT Splenic IV grade injury was documented without active bleeding. In a control abdomen CT, multiple postraumatic splenic pseudoaneurisym were reported and a percutaneos selective arterial embolization was made without incidences. Two weeks later after discharge, the patient returned to the ED for abdominal pain and fever. Clinical Findings: The patient arrives to the ED hemodynamically stable, tachycardic and febrile. Abdominal tenderness in left upper quadrant and peritoneal irritation was documented. Investigation Increased acute phase reactant in the blood test and a splenic infected infarction was seen in the CT were found. Diagnosis Septic splenic infraction post arterial embolization Therapy Antibiotics and symptomatic treatment was initially established, but, given persistent fever and clinical and laboratory worsening, urgent splenectomy was performed Comments Endovascular treatment for postraumatic solid organs injuries had change the algorithm in the politraumatized patient. In the last decades, the increasing demand of embolization had highlighted its complications. Our case is one of the most frequent complication after arterial embolization but, usually, the splenic salvage strategy is effective. It is important to recognize when the non operative treatment is failing for prompt splenectomy. References: 1. SPLEnic salvage and complications aftervsplenic artery EmbolizatioN for blunt abdomINal trauma: the SPLEEN-IN study, Warren Clements, 2020Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No

Polytrauma

Trauma to the superficial femoral artery – Different etiologies, different surgical approaches

Abstract text (incl. references and figure legends) The superficial femoral artery (SFA) is the most frequently injured vessel in lower limb traumas. It can be caused by a gunshot, blunt instrument, stab wounds and iatrogenic. We report two cases of traumatic lesions of the superficial femoral artery with two different etiologies and treatment approaches. The first is a case of a male patient, 34 years old. He was at the intensive care unit for organophosphate poisoning needing plasmapheresis. He developed a pseudoaneurysm of the right superficial femoral artery with an associated hematoma after a dialysis catheter insertion. He was approached surgically with the identification of a puncture lesion of the SFA and was treated with arterial resection and end-to-end anastomosis. The second is a case of a male patient, 21 years old, admitted to the emergency room after a penetrating trauma with a gunshot wound to the right leg. He presented hemodynamically unstable upon arrival, but with a good response to fluids and blood. After resuscitation, he had an angio-CT which showed a lesion of the SFA. He was taken to the operating room where a 2cm laceration with &gt;50% of circumference was observed. After resection of the affected segment, a primary repair was done with the interposition of a prosthetic graft. Both patients were discharged with good evolution and without complications. Open surgical repair is usually the first treatment option for traumatic penetrating lesions such as gunshots and also other complications such as pseudoaneurysms. Our surgical strategy consisted of performing proximal and distal vascular control of the SFA with complete resection of the defect. The reconstruction technique decision is always based on local findings. A. Gómez-Álvarez et al. Surgical treatment of a pseudoaneurysm of the femoral artery secondary to a gunshot wound. Clinical case report. Med Universit 2014 Mirenda.F et al.Gunshot injury of SFA. Surgical treatment without preoperative angiography:a case report. Chir Ital. 2006Disclosure: 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

Self-inflicted traumatic penile amputation: A case report

Abstract text (incl. references and figure legends) Penile and testicular amputations are very rare and are mainly caused by self-mutilation, assault, or accidental trauma. Penile injuries can be extremely disturbing to the physical and mental state of the patient. Management requires resuscitation and stabilization of the patient with particular attention to underlying psychiatric illness. We present the case of a 22-year-old man with history of psychiatric disorder that presented to the emergency department with a self-inflicted traumatic complete penile and scrotal amputation with a "katana". The patient also had an extensive right leg wound with loss of skin. At admission, he was hemodynamically stable, calm, with no signs of distress or pain. A Foley catheter was immediately inserted to prevent further contamination. With the collaboration of the police force, the amputated tissue was found at the patient"s home and preserved under hypothermic conditions in preparation for surgical replantation. He was immediately transferred to a tertiary care center with Plastic Surgery and Urology, where he was submitted to primary surgical reconstruction with penile replantation and subsequently skin graft to the leg wound. He was discharged after 6 weeks. At the 2 months follow-up visit, he showed a satisfactory cosmetic outcome, well-healed penile graft, and normal voiding. Genital reconstruction is challenging. We present the case of a young male with a self-mutilation lesion. The patient was submitted to a reconstructive procedure within 12 hours of the lesion occurrence. The work of the health professionals in coordination with the police was determinant to the success of this case. Self-mutilation is not considered to be an absolute contraindication to replantation. Jezior JR et al. Management of penile amputation injuries. World J Surg. 2001 Sanger JR et al. Penile replantation after self-inflicted amputation. Ann Plast Surg. 1992Disclosure: 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

Traumatic brain injury as a cause of cardiovascular collapse in trauma: Impact brain apnea

Abstract text (incl. references and figure legends) We report the case of a male patient, 54-year-old, previously autonomous, with a history of dyslipidemia, hepatic steatosis, smoking, alcohol abuse, and inhaled light drugs, that was a victim of a motorcycle crash. He was found next to the motorcycle with an intact helmet. Upon arrival of the emergency response team after about 7 minutes, he was found in cardiac arrest with PEA rhythm. CPR was started by protocol and endotracheal intubation was performed. After 2 minutes, return of spontaneous circulation was achieved with tachycardia and hypertension. Capnography was 68mmHg. EKG showed no signs of ischemia. GCS 3T and miotic pupils. Hypoglycemia of 58 mg/dL, corrected with dextrose. Tranexamic acid 1g was administered. The patient was transported to the hospital under mechanical ventilation. At hospital admission, he had a positive cannabinoid assay, normal EKG with negative troponins, CT scan of brain, spine, chest, abdomen and pelvis without acute alterations other than a fracture of the right zygomatic arcade. During hospitalization in the ICU, reversible causes for cardiac arrest were excluded. He performed subsequent CT brain scan at 24h without alterations, normal EEG and MRI brain scan with diffuse axonal lesions but without hypoxic-ischemic lesions. Extubation was performed on day 8. The patient showed progressive neurological improvement increasing in GCS to 15. The patient had adequate responses to past events, although recent and accident memory were affected. Motor rehabilitation was performed achieving standing and walking with support. Cardiac arrest following cranial trauma is often considered unsurvivable traumatic brain injury (TBI). However, Impact Brain Apnea (IBA), the phenomenon of apnea following TBI, may be a significant and preventable contributor to death attributed to primary injury. Wilson MH, Hinds J, Grier G, Burns B, Carley S, Davies G. Impact brain apnoea-A forgotten cause of cardiovascular collapse in trauma. Resuscitation.2016Disclosure: Do you have a significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services related to this abstract? (If not, please enter "No" in the text field.) No

Splenic artery embolization in trauma, is it a worthwhile procedure?

Abstract text (incl. references and figure legends) The gold standard of treatment for blunt splenic trauma in hemodynamically stable or resuscitation responders, in the absence of peritonitis and associated injuries requiring laparotomy is a non-operative management (NOM)1. Splenic artery embolization (SAE) is a valid tool that has greatly increased the successful rate of the NOM2. However, the literature is scarce and no specific information regarding the eventual complications rates related to this procedure are well reported and discussed3. We aimed to study the complication and mortality rates of patients undergoing SAE compared with those who had a standard splenectomy. In our observational study, between January 2017 and September 2022, we prospectively enrolled 20 consecutive patients (Group 1) who underwent SAE. A control group of 20 patients undergoing splenectomy (Group 2)were matched with those of Group 1 based on a propensity score model. Group 2 patients, operated on from January 2000 and January 2005 (before SAE was introduced in our hospital), were retrieved from our electronic database and hospital charts for additional information if lacking. Patients who underwent SAE had a higher incidence of complications (50%) than patients who underwent splenectomy (9,1%) (P&lt;0.05). The overall mortality rate was 12,3%, without any significant difference between the two groups (P=NS). NOM is currently the treatment of choice in patients with splenic trauma, especially in the presence of a medium-low grade injury, but its widespread use might increase the complication rate. Coccolini, F., et al.Splenic trauma: WSES classification and guidelines for adult and pediatric patients. WJES 12,40(2017). E. Girard, et al. Traumatismes spléniques et pancréatiques; Journal de Chirurgie Viscérale, 153,4, Suppl, Au 2016, Pag46-63. Gill, S., et al.Post-traumatic Splenic Injury Outcomes for Nonoperative and Operative Management: A Systematic Review. World J Surg 45, 2027–2036(2021). 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

Traumatic horizontal transection of the pancreas

Abstract text (incl. references and figure legends) A 27-year-old patient was presented with a recent history of falling from a 2m high ladder, landing on a steel stick that penetrated the abdomen. On examination, the abdomen was mildly distended, painful for palpation, and showed peritoneal irritation. The penetrating wound was 8cm long, transverse, with oozing blood. Laboratory results were significant for lymphocytosis and elevated transaminases. CT of the abdomen revealed a complete transection of the pancreatic head. Due to uncontrolled bleeding and hemorrhagic shock, our patient required initial surgical damage control. Urgent laparotomy initially revealed that the pancreas between the head and the body was entirely horizontally interrupted. Several extensive fluid collections were in front of the tail and body of the pancreas, between the stomach and the spleen. The distal part of the pancreas was resected and the stump sutured. The critical issue for our patient was that the main pancreatic duct was damaged, and postoperative pancreatic fistula from the stump was a concern. Drainage tubes were appropriately positioned, and octreotide was administered to reduce pancreatic juice production. Postoperative hospitalization was complicated with postoperative pancreatic fistula, leading to an extended hospital stay. After successful conservative treatment, the patient was discharged one month after surgery and has remained free of further postoperative complications. Horizontal transection of the pancreas is uncommon and difficult to repair under unstable, emergency conditions; the timing and the choice of the procedure might be difficult. We want to emphasize the importance of early intervention and damage control management protocol for avoiding delayed morbidity and mortality. Fig.1: Abdominal CT scan (coronal) showing complete transection of the pancreas and peripancreatic fluid collections (P-pancreas, S-stomach) Fig.2: Abdominal CT scan (axial) showing pancreatic transection along the thoracolumbar spine.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

Is the 35mm occult pneumothorax rule for chest tube insertion following blunt isolated trauma generalizable to penetrating injury and the polytraumatized patient?

Abstract text (incl. references and figure legends) Introduction: Chest tube placement may be safely avoided in stable patients with a small occult blunt traumatic pneumothorax less than 35mm on CT scan. We assess the generalizability of this "35mm rule" following penetrating injury and in the polytraumatized patient. Materials &amp; Methods: We reviewed the records of all stable injured patients with occult pneumothorax identified on CT scan at our urban Level 1 trauma center from 01/01/2018 to 01/01/2022. We excluded patients with hemothorax, those who underwent needle decompression or chest tube placement prior to CT scan, resuscitative thoracotomy, cardiopulmonary resuscitation, or cannulation for ECMO.. Patient demographics, arrival vital signs, mechanism of injury (blunt, penetrating or polytrauma), hospital length of stay were identified from our institutional trauma registry. The radial intrapleural distance (in mm) was measured on initial CT. We assessed the association of the 35mm rule with successful observation or subsequent failure (clinical decompensation requiring chest tube placement). Results: Occult pneumothorax was identified on CT scan in 232 stable injured patients. Motor Vehicle Accidents accounted for 31%, pedestrians struck for 7.7%, falls for 19.4% and blunt assaults for 18.9%. Gunshot wounds (11.6%) or stab wounds (11.6%) were the cause of the penetrating injuries. Fifty-four patients (24%) were victims of penetrating trauma while 178 (76%) presented after blunt trauma. In patients with a pneumothorax Conclusion: Observation of pneumothoraxDisclosure: 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

Liver trauma requiring emergency surgery after successful cardio-pulmonary resuscitation: A close-range three-case series at single institution

Abstract text (incl. references and figure legends) H: A three-case series of CPR complications has been reported at our Institution in 2022. A 47-yo male with cognitive impairment was struck by cardiac arrest during CT-scanning showing suspected hiatal hernia perforation without abdominal findings. A 49-yo female with no medical history was transferred to our hospital after ROSC in pulmonary embolism-induced cardiac arrest treated with manual CPR and thrombolytic therapy. A 51-yo male with unknown history suffered from acute myocardial infarction causing cardiac arrest while driving to the hospital. Initially, out-of-hospital CPR was performed manually, then with LUCAS® device, achieving ROSC. F: Hypotension, acidosis and acute anemia were observed after ROSC. I: For the 1st case CT-scan was not meaningful and surgery was needed to reveal the noxa. The other two cases benefitted from Point Of Care US for detecting hemoperitoneum. D: All three cases consisted of hemoperitoneum due to left liver lacerations following CPR. T: In the 1st case, after ROSC through manual CPR, emergency laparotomy disclosed S2-3-4 lesions and oozing bleeding without gastric lesions. Abdominal packing was performed. Patient survived. Following FAST and CT scan, 2nd patient underwent emergency laparotomy confirming S3 laceration, S2-3 resection and hepatic packing. Patient survived. Despite angioplasty with stenting, 3rd patient was still hemodynamically unstable. FAST findings justified emergency laparotomy, left hepatic lobectomy and hepatic packing because of S3 injury. Patient died. C: CPR complications could require emergency surgery. CPR technique and anatomical factors could entail liver injuries. FAST exam after CPR should be included in the algorithms to investigate hemodynamic instability after ROSC. Principles of trauma laparotomy/liver trauma management should be in all general surgeons' background, since patients undergone CPR can be addressed to hospitals without specific trauma expertise. R: DOI 10.1007/s00134-008-1255-9Disclosure: 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

Seatbelt-related injury – blunt transection of the anterolateral abdominal wall with evisceration

Abstract text (incl. references and figure legends) Closed ruptures of the abdominal wall following seatbelt related trauma are uncommon and the incidence has been estimated at 1%. Whilst seatbelts have been responsible for a decreasing mortality and decreased severity of injuries from road traffic accidents, seatbelt related injury patterns arise from the transfer of kinetic energy to the abdominal wall and internal visceral organs. The presence of rupture of rectus abdominis muscle secondary to seatbelt injury should raise the suspicion of intra-abdominal injury. We report a case of 20 year old male patient who presented with a complete disruption of the entire anterolateral abdominal wall, following the seatbelt injury in a high speed motor vehicle collision. Abdominal computed tomography (CT) scan and further 3D modelation revealed the complete disruption of bilateral abdominal wall musculatures including traumatic abdominal wall hernia with hemoperitoneum and visceral injury. The patient was presented with signs of acute abdomen, a seatbelt sign and visible evisceration to the subcutaneous space, upon which the decision was made to perform emergency laparotomy. The patient had an abdominal wall disruption along the seatbelt sign, injuries of small bowel and colon coecum were also observed. The damage to small bowel mesentery and infarction of small and large bowel required intestinal resection. The patient underwent abdominal wall reconstruction by primary closure of the defect with absorbable monofilament sutures. During six months of follow-up no complications occurred. Transection of the rectus resulting from seatbelt injury highlights considerable amount of force transferred to the extra-abdominal compartment. This should raise suspicion of injury to intra-abdominal structures. Our case highlights the need for suspicion, investigation and subsequent surgical management of intra-abdominal injury following identification of this rare consequence of seatbelt 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

Poster Session 20
Visceral trauma 2

Appointment

Chairs

Programme

Poster Session 20Visceral trauma 2

Appointment

Chairs

Programme

Poster Session 20
Visceral trauma 2