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23rd European Congress of Trauma & Emergency Surgery

Prof. Dr. med.

Prof.

Prof. Dr.

Autograft harvested with a novel, less invasive surgical tool displays a high osteogenic capacity

Research

Introduction: Iliac crest bone graft (ICBG) is considered the gold standard for treatment of non-unions. However, it faces challenges such as donor site complications and volume limitations. Recently, a surgical vacuum filter system (BoneFlo, TissueFlow GmbH, Germany) was introduced to the market which can be fitted with a β-TCP (TriCalciumPhosphate) foam sponge (Cerasorb, Curasan, Germany). This sponge is then saturated with bone marrow during surgery. The osteogenic capacity of this graft has not yet been determined. Objectives: To examine the osteogenic capacity of the bone graft material obtained from the surgical suction filter system (SF-BG) by means of a 3D cell culture model, using patient derived grafting material. Materials and Methods: Samples were collected during non-union surgeries (N=12). The surgical vacuum filter system was used upon opening the intramedullary canal. Cerasorb soaked in whole blood was used as control. To create uniform scaffolds, a 6mm biopsy punch was used. Samples were cultured for 7, 14, and 21 days in osteogenic medium. At each time point, an ALP assay was performed and RNA was isolated, followed by qPCR for osteogenic mRNAs and miRNAs. Results: On days 7, 14, and 21, ALP concentrations were 145, 244, and 407 µM, respectively, significantly exceeding those of the whole blood samples (54, 55, and 28 µM, respectively). An increase in the expression of osteogenic marker genes (RunX2, OSX, OCN, OPN) was observed compared to the control samples. Furthermore, there was an upregulated expression of miRNAs associated with osteoblastogenesis, mineralization, and angiogenesis. Conclusion: The SF-BG demonstrated elevated ALP expression, along with heightened patterns of osteogenic mRNA and miRNA expression. This novel bone grafting substitute holds promise as an alternative in situations requiring a graft extender or autograft when dealing with limited volumes. Further research is required to confirm its clinical effectiveness.No

Abstract talk

3D-printed, tubular, porous pure polylactate-based scaffolds show excellent healing results in the rat femoral defect model after 8 weeks and are not further improved by bioglass doping at different concentrations

Trauma and Emergency surgery | Miscellaneous

Introduction Long bone defects are a therapeutic dilemma, as the gold standard - autologous bone transplantation - has many disadvantages such as donor morbidity. 3D printing can produce individual scaffolds for treatment of these defects. Preliminary work showed in vitro improved adhesion and osteogenic gene expression of human MSCs with bioglass (BG) added to polylactate (PLA) filament. The hypothesis of the study was that adding different Bioglass concentrations would improve bone healing in vivo. Methods For the animal study, previously evaluated filaments of a custom-made Bioglass-doped PLA filament (0%, 5%, 10%, 20% g/g BG = BG-5, BG-10, BG-20) were 3D-manufactured into highly porous scaffolds. This resulted in four groups: The scaffolds in pure polylactate form (BG-0) and with ascending bioglass contents have been evaluated in vivo in the 6 mm femoral defect model of the rat (n=8/group, 8 weeks healing time). Primary study variables were bending stiffness and bone density (BMD) in the µCT analysis. Statistics: Kruskal-Wallis test + Bonferroni corrected posthoc analysis according to Dunn, p&lt;0.05 is significant. Results, Conclusion The hypothesis of an improved bone healing in BG groups was rejected. Defects treated with PLA (BG-0) showed significantly improved bending stiffness, increased BMD and a restitutio ad integrum similar to the control group, with qualitative bone formation (Fig.1). The doping of the Bioglass groups (BG-5, BG-10, BG- 20) showed a very heterogeneous result of the bone formation reactions from strong bone formations to nonreactive. These results show that 3D-printed thin-walled porous tubular structures have a high bone regenerative potential (even superior to the gold standard in most cases) in the animal model used without the addition of bioactivators, cancellous material or regenerative cells. However, a comparison of the bioglass groups also shows that the amount of bioglass added brings about decisive changes in bone healing.No.

PD Dr.

The influence of trauma-activated platelet-rich fibrin on mesenchymal stem cells in vitro

Introduction: Treatment of large bone defects is one of the great challenges in contemporary orthopedic and traumatic surgery. The use of platelet rich fibrin (PRF) in combination with mesenchymal stem cells (MSC) as a natural supporting additive could help accelerating regeneration times. PRF is produced in a one-step procedure and has a supporting effect on regenerative cells. In the present study PRF from patients after surgical intervention was compared to healthy volunteers to evaluatethe potential impact on MSC. Methods: MSC were co-incubated with trauma-activated PRF from patients (trauma-PRF) respectively PRF obtained from healthy volunteers (control-PRF) using a modified Boyden chambers. MSCs metabolic activity (MTT) as well as osteogenic (COL1A, RUNX2) angiogenic (VEGF) and inflammatory (IL-6) marker gene expression was determined after incubation periods up to 120 h. Results: Incubation of MSC with PRF resulted in a significant depression of MSC"s metabolic activity after 24 h compared to medium control. The metabolic activity of MSC recovered to control level when co-incubated with trauma-PRF for 120hrs, whereas recovery was much lower when incubated with control-PRF. Gene expression of COL1A and RUNX2, was significantly reduced in MSC after incubation with both PRF types, whereas VEGF and IL-6 gene expression was significantly increased after 24 h co-incubation with trauma-PRF. Conclusion: Our results demonstrate that PRF derived from trauma patients affects MSC slightly differentially compared to PRF from healthy volunteers. PRF dampens MSC metabolic activity, though, this effect steadily decreased with the duration of co-incubation. The putatively reduced proliferation of MSC combined with the reduced expression of osteogenic genes but increased inflammatory activity of MSC might harm a quick development of a proosteogenic environment which should be considered, if PRF is generated in close temporal context of trauma.I have received no significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services or financial support related to this abstract. I hereby confirm that my abstract is based on previously unpublished data and that I own the rights to the written summaries of research or observations presented in the abstract, or that I have obtained permission for the acknowledged sources for other excerpts taken from copyrighted works. In submitting an abstract I hereby agree that the copyright of my abstract is transferred to the European Society of Trauma and Emergency Surgery. I hereby confirm that I will present my abstract at the congress in case it is accepted. Sponsor: none

Plasma from trauma patients induces transcriptional reprogramming of endothelial cell metabolism and inflammatory pathways

Polytrauma

Introduction: Trauma causes a thromboinflammatory milieu characterized by coagulopathy and metabolic perturbations, however, the transcriptional changes of the endothelium following trauma remain unknown. We hypothesized that when exposed to severely injured ex-vivo trauma plasma, there would be induction of pro-inflammatory genes. Materials &amp; Methods: Citrated plasma was collected upon arrival from trauma patients at a level 1 trauma center. Patients were divided by injury severity score (ISS) and base deficit (BD) (Group 1 ISS &lt; 15 BD &lt; 6, Group 4 ISS ≥ 15 BD &gt;6). HUVECs were grown to 80% confluence and incubated for 1 hour or 4 hours with 10% trauma patient ex-vivo plasma. We then performed a poly A-selected mRNA-seq analysis. A DESeq2 analysis was used for differential expression with Wald test and Benjamini-Hochberg correction to determine significance. Pathway analysis was performed using EnrichR via MSigDB Hallmark 2000 on those genes with p&lt;0.05 and a log 2 fold change of less than -1 or greater than 1. Results: The pathway analysis showed significantly different inflammatory and cell fate determination pathways between cells exposed to group 1 and group 4 plasma. The TNF alpha, NFkB, and TGF beta pathways were significantly downregulated in group 4 (Fig. 1a p&lt;0.001). At the 4-hour time point, wnt signaling, which is involved in both cell fate determination, migration, and glucose homeostasis is downregulated in group 4 (Fig. 1b p&lt;0.001). Conclusion: Multiple pro-inflammatory signaling pathways are differentially expressed between cells exposed to group 1 versus group 4 plasma. At later timepoints, regulation of energy homeostasis and cell fate determination becomes predominant. The genes identified in this analysis may create novel therapeutic targets in the treatment of trauma patients. Figure 1. RNA-seq pathway analysis at 1 and 4 hours Figure 2. PPI map from the genes at the 4-hour time point analysis using OmicsNet with the InnateDB databaseNo

Plasma from trauma patients induces transcriptional reprogramming of endothelial cell metabolism and inflammatory pathways

Exploring exosomal transcriptomics as a theragnostic signature in traumatic brain injury patients: A pilot study

Introduction: TBI is a major global cause of injury-related deaths. Survivors often experience neuropsychiatric symptoms, and the pathophysiological mechanisms for recovery post-TBI remain poorly understood. We hypothesize that &quot;exosomes&quot; which are nanovesicles, facilitating cell-to-cell communication, may be important mediators of molecular and cellular changes involved in neurological symptoms following TBI. We aim to characterize and quantify the plasma-derived exosomes using an exo-transcriptomic platform to compare inflammation-related gene expression profiles and correlate them with molecular and clinical variables in TBI patients Methods: The ongoing work is a pilot, prospective, case-control study with adult mild to severe, non-penetrating TBI patients (n=45), and 15 age-matched controls. Blood was sampled serially at baseline, 24 and 24 hrs post-injury. Exosomes and exosomal-RNA was isolated and purified using commercially available kits. The characterization of exosomes will be conducted using the dynamic light scattering (DLS) and immuno-blotting. Exosomal-RNA will be analyzed for of inflammatory gene profiling using TaqMan Human Inflammation array by RT-PCR. Results: We anticipate getting distinct gene expression profiles of differently upregulated or downregulated inflammatory genes that could serve as signature biomarkers for varying degrees of TBI severity. Dysregulation of these plasma exosomal RNAs might indicate neuronal inflammation that can last long after the injury and may result in persistent post-injury symptoms in TBI patients. Conclusions &amp; Significance: Characterizing exosomes and correlating them with molecular and real-time clinical characteristics would inform a foundational mechanistic framework for disease monitoring and outcome prediction post-TBI, and may serve as diagnostic and prognostic biomarkers or &quot;liquid biopsy&quot; to provide a rationale for pre-clinical, clinical and translational research focused on novel therapeutics.Nothing to declare. I don't have any conflict of intrest

Ass. Prof.

Fibrinogen Early In Severe paediatric Trauma studY (FEISTY Junior): A randomised clinical trial

Introduction: Early replacement of fibrinogen in paediatric haemorrhage has been reported to reduce 24-hour mortality. The time taken to deliver fibrinogen replacement has been studied in adults, with a median of 60mins for cryoprecipitate (cryo), and 29min for Fibrinogen concentrate (FC). There are no published studies comparing FC and cryoprecipitate in the children. Methods: This is a prospective multi-centre, randomised study enrolling children aged 3-months to 18-years with traumatic haemorrhage. Eligible patients were allocated to receive FC or cryo in patients with a FIBTEM A5 of ≤10mm. All other aspects of the current ROTEM guided treatment and damage-control approach were unchanged (Figure 1). The primary outcome was time to administration of fibrinogen replacement from time of identification of hypofibrinogenaemia. Clinical secondary and feasibility outcomes were also analysed. Results: 67 patients were included in the final analysis (Figure 2). Groups were similar at baseline for demographics and injury severity. There was no significant difference in the time to administration of FC (62min, 95% CI 33-100) or Cryo (65 mins, 95%CI 47-77). There was also no difference in red cell, plasma or platelet use at 6 and 24 hours. Thromboembolic adverse events were similar between groups. 90-day follow up data was collected for 51 participants. Analysis of response to fibrinogen replacement is ongoing. Conclusions: The time to administer FC in children is longer than that reported in adults. The reasons for this are likely to be multifactorial and represent complex interplay between patient and system factors. Further analysis of this data set will aim to identify and explore contributing factors to this observed difference. Importantly there is no difference in blood product use and adverse events between the two products. Outcomes of this preliminary study provide support for the use of FC in regional and remote centres without access to frozen blood products.Werfen and Haemoview Diagnostics have provided equipment and consumables for this study. They have had no input into study design, conduct, analysis or reporting. JW has received travel and educational support from Werfen and Haemoview Diagnostics. All other authors have not disclosures.

ESTES SnapSBO study protocol and preliminary results

Emergency surgery

Education

Introduction: Small bowel obstruction (SBO) and its complications are frequently seen in patients admitted in Emergency Departments. There is variation in the optimal use of imaging, the appropriate timing and duration of non-operative management attempts, anti-microbial therapies and the criteria for surgical management, which results in heterogeneity in approaches and outcomes across international clinical centers. Objective: ESTES SBO Snapshot aims to identify areas of practice variability that may result in differences in outcome. In this communication we present the study protocol and preliminary results. Methods: Prospective observational multicenter study recruiting consecutive patients admitted with SBO during 3 months (in a six months window), including all etiologies. Variables regarding clinical presentation, diagnostic workup, non-operative management, time to surgery, approach and outcomes, complications, length of stay, readmission and patient related outcomes measures are studied. Results: to date of recruitment kick-off, November 1st 2023, 90 centers in 22 countries have registered for participation. 61% are third level academic hospitals, 32% Regional and 7% Community hospitals, with 703.8±446 (mean±SD) hospital beds and 29±24 ICU beds and 91.8% with dedicated Emergency surgery operating room. Final day for new patient inclusion will be may 1st 2024 and we will present preliminary data regarding the number of patients enrolled to date of presentation. Conclusion:. Results can be hypothesis-generating and identify areas warranting further study in future randomized controlled trials. References: Bass GA, Kaplan LJ, Ryan ÉJ, et al. The snapshot audit methodology: design, implementation and analysis of prospective observational cohort studies in surgery. Eur J Trauma Emerg S. 2022;1–11. Detz DJ, Podrat JL, Castro JCM, et al. Small bowel obstruction. Curr Prob Surg. 2021;58(7):100893No

The ABC-C course: An innovative educational experience for optimal bleeding trauma management

Introduction: Bleeding is the first cause of preventable death in trauma, and courses focused on bleeding control techniques are essential for trauma surgeons. In 2022, an international group of trauma surgeons launched the "Advanced Bleeding Control Course" (ABC-C). Objectives: Describe the launch of a one-day course specifically designed to address the issue of prehospital and surgical management of severe bleeding in trauma patients. Methods: During the 2022 National Spanish Surgical Congress, an ABC-C was taught by skilled trauma surgeons from three different countries. The course consisted of twelve lectures covering the principles of hemorrhage control and four practical modules: tourniquets, US-guided femoral access, REBOA, and clinical case discussions. A post-course 25-question multiple-choice test was administered to evaluate knowledge retention. Lastly, an anonymous 1 to 5 Likert scale survey was conducted to gather opinions on the course's usefulness, format, organization, and overall satisfaction, with 5 being the best rating. Results: The course was attended by 31 junior surgeons and residents (71%). All the participants completed the post-course test, and the results indicated that the course format was highly effective in imparting knowledge, with the lowest test score being 85%. Additionally, 20 participants (65%) provided feedback through the post-course survey. The course received high ratings for its utility (4.85), methodology (4.75), and organization (4.70), which suggests that it was well-structured and well-organized. Conclusion: The "ABC-C" course is an outstanding program designed to equip trauma and acute care surgeons with advanced bleeding control techniques. The course uses a combination of lectures and hands-on training specifically focused on hemorrhage control. This approach has resulted in high levels of knowledge acquisition, and the participants have expressed their satisfaction with the activity.No disclosures to declare

A cost-effective pulsatile femoral arterial access trainer designed for Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)

Introduction: The resuscitative endovascular balloon occlusion of the aorta (REBOA) has gained popularity in recent years for hemorrhage control in trauma patients. This is a complex technique usually performed under stress and thus requires intensive and high fidelity training to master. Commercial simulators are available for the training of REBOA. However they are usually expensive and not always reusable, which makes them unaffordable for many centers. This paper describes a novel, low cost, reusable,ultrasoundable, pulsatile, high fidelity and user friendly simulator for REBOA training. Methods:Pulsatile Flow Generator. A microcontroller generates a square alternating electric signal, amplified by a custom circuit, and fed to a 25 Watt diaphragmatic pump for pulsatile flow modification. A control circuit and console control up to five pumps, the zone of inflation can be identified, flow and rate can be modified. Ultrasound phantom. The ultrasoundable substance was synthesized by combining polyvinyl-chloride, calcium carbonate, titanium oxide, and mineral oil. A human groin was fabricated through additive manufacturing techniques, specifically 3D printing. To mimic the anatomical structure of femoral arteries and veins, plastic pipes were incorporated into the design. Blood mimicking agent. A solution consisting of red food colorant, sodium benzoate USP, and water is employed to replicate viscosity and improve sound reflection on liquid being pumped through a simulator. Results: A pulsatile phantom to train Femoral Arterial Access (FAA) and REBOA was obtained with, pulsatile blood flow, ultrasound capable, realistic ultrasound images, easy to operate, reusable (up to 100 punctures) and with a cost of less than 200Î. Conclusion: The widespread use of this simulator, which can be easily replicated through comprehensive documentation, has the potential to democratize FAA training and effectively facilitate the implementation of REBOA into trauma systems. NO

Yellow May campaign: Educational interventions for traffic accident prevention in Campinas - SP (Brazil)

Introduction: Traffic accidents are considered a public health issue, with approximately 45000 annual deaths. Most of these tragedies result from inappropriate behaviors, such as speeding. In 2014, the Yellow May campaign was created to promote road safety, and the "Trauma Prevention" project joined forces with EMDEC (Municipal Development Company of Campinas) to support this cause in Campinas. The actions aimed to raise awareness among the population regarding traffic accidents, with the purpose of promoting the safety of drivers, motorcyclists, cyclists, and pedestrians. Materials &amp; methods: Activities in bars included dialogues with customers, distribution of informative pamphlets, and the use of breathalyzer simulators. Educational blitzes involved conversations with motorcyclists about safety equipment and distribution of kite-cutting antennas. The Bicycle Ride promoted guidance on the safe use of bike lanes. The medical service simulation to 15 victims took place on John Boyd Dunlop Avenue, which records the highest number of accidents in the city. Results: The blitzes reached 800 motorcyclists, instructing them about personal protective equipment and kite-cutting antennas. In bars, more than 1200 consumers were reached, with breathalyzer tests and warnings about the legal consequences of excessive alcohol consumption and driving. The Bicycle Ride brought together 400 cyclists, raising awareness about safety on bike lanes. The simulation had a significant social impact. Approximately 500 pedestrians were educated about recklessness in traffic (fig 1 and 2). Video of the actions on social media reached over 6000 views, extending the reach beyond physical boundaries. Conclusion: Educational actions play a fundamental role in raising awareness about road safety. It is hoped that participants will become advocates for good practices in traffic, expanding these initiatives. FRAGA, G. P. et al. Maio amarelo: um movimento ativo para prevenir lesões no trânsito. Revista do Colégio Brasileiro de Cirurgiões, v. 42, p. 200–201, 2015.No

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