Wses bergamo una hotel july 7 9 final program by SBAIT -Sociedade Brasileira de Atendimento Integrado ao Traumatizado

World Journal of Emergency Surgery World Society of Emergency Surgery

2nd World Congress Bergamo, July 7-9, 2013

SCIENTIFIC PROGRAM

UNA Hotel Bergamo, Italy

WJES & WSES Meeting 2

Table of Contents

Faculty

General Information

Floor Plan

Supporters

Program, Sunday, July 7, 2013

Program, Monday, July 8, 2013

Program, Tuesday, July 9, 2013

Abstracts, July 7, 2013

Abstracts, July 8, 2013

Abstracts, July 9, 2013

125

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Presidents: L. Ansaloni – Italy F. Catena – Italy E. Moore - USA

Scientific Committee: Biffl W. - USA Leppaniemi A. - Finland Moore F. - USA Sartelli M. - Italy

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Faculty Agresta F. (Italy)

Leppaniemi A. (Finland)

Amaral J. (USA)

Lyadov V.K. (Russia)

Ansaloni L. (Italy)

Kelly M. (UK)

Bailey I. (UK)

Kim F. (USA)

Bendinelli C. (Australia)

Kluger Y. (Israel)

Biffl W. (USA)

Koike K. (Japan)

Campanelli G. (Italy)

Jeekel J. (Nl)

Campanile F. (Italy)

Maier R. (USA)

Caputo P. (Italy)

MandalĂ V. (Italy)

Catena F. (Italy)

Melotti G.L. (Italy)

Catani M. (Italy)

Monsellato I. (Italy)

Cennamo V. (Italy)

Moore E.E. (USA)

Chiara O. (Italy)

Moore F. (USA)

Coccolini F. (Italy)

Peitzmann A. (USA)

Coimbra R. (USA)

Piccoli M. (Italy)

Di Carlo I. (Qatar)

Pinna A.D. (Italy)

Di Saverio S. (Italy)

Pisano M. (Italy )

Falanga A. (Italy)

Poggetti R. (Brazil)

Faist E. (Germany)

Rausei S. (Italy)

Fette A. (Hungary)

Romagnoli F. (Italy)

Fornaro R. (Italy)

Sakakushev B.E. (Bulgaria)

Fraga G. (Brazil)

Sartelli M. (Italy)

Gargiulo M. (Italy)

Schiavina R. (Italy)

Giuliani G. (Italy)

Stahel P. (USA)

Gordini G. (Italy)

Tugnoli G. (Italy)

Iacono C. (Italy)

Vettoretto N. (Italy)

Ivatury R. (USA)

Viale P.L. (Italy)

WJES & WSES Meeting 7

Organizing Secretariat:

MI&T Viale Carducci, 50 40125 Bologna info@mitcongressi.it Phone: +39 335 5918811 Fax: +39 051 0822077

WJES & WSES Meeting 8

General Information Congress Venue

UNA Hotel Bergamo 4th Floor

Name Badges

Please wear your badge for all conference sessions

Coffee breaks

Coffee breaks partecipants

Lunch

Lunch will be provided to all partecipants

CME Credit

CME credit has been requested for Italian ECM

Language

The official language of the Meeting is English. No simultaneous translation will be provided

Slide Center

Inside each meeting room

Speakers

Report to the slide center located in each meeting room to 2 hours before the scheduled time of your presentation

will

provided

all

All presentations should be POWERPoint. A laptop computer will be provided. Bring your presentation on a CD, DVD (as data-storagemedium), or USB-memory key (stick). Please make sure to have all necessary files (also movie/video files) on the data medium. Please note the connecting to the symposium network and using a private laptop for the conference will not be allowed.

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4th Floor

WJES & WSES Meeting 10

UNRESTRICTED GRANT BY

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Program World Journal of Emergency Surgery World Society of Emergency Surgery

 Sunday, July 7, 2013  Athena Room 8.00

Chairs: Ansaloni L. (Italy), Moore E.E. (USA) Opening Lecture Pinna A.D. (Italy) - The Kodak Effect ORAZIO CAMPIONE PRIZE Leppaniemi A. (Finland) Hot spot: ACUTE CARE SURGERY- WHAT’S IN A NAME? Kashuk J.L. MD FACS EmCare Acute Care Surgery Dallas, TX USA Position paper: Gastroduodenal perforated- bleeding ulcers Di Saverio S., Cennamo V. (Italy)

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9.00 ACUTE GASTRIC BLEEDING ULCER, A CASE REPORT Cartari C.1, Martellosio V.2, Abbiati F.2, Dionigi P.3 1 Scuole Specialità Chirurgia Generale di Pavia, 2U.O. Chirurgia Generale Ospedale di Stradella, 3Direttore DEA I.R.C.C.S. S. Matteo di Pavia Italy PEPTIC ULCER PERFORATION: A 3-YEAR EXPERIENCE OF A SURGERY DEPARTMENT Mora H., Muralha N., Gonçalves F., Gouveia A., Barbosa J., Costa-Maia J. Centro Hospitalar de São João Portugal

GENERAL

10.00 FAST TRACK SURGERY IN EMERGENCY OPERATIONS FOR PEPTIC ULCER PERFORATION AND ACUTE DESTRUCTIVE CHOLECYSTITIS Boris E., Plovdiv G., Sakakushev B.E. Medical University/University Hospital St, Bulgaria, First Clinic of General Surgery Position paper: ACUTE APPENDICITIS Agresta F. (Italy)

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PROTEIN C AS AN EARLY MARKER OF SEVERE SEPTIC COMPLICATIONS IN DIFFUSE BACTERIAL PERITONITIS Karamarkovic A. Clinic for Emergency surgery, Clinical Center of Serbia, Faculty of medicine University of Belgrade, Serbia REDUCING NEGATIVE APPENDECTOMY RATES: A QUANTITATIVE ANALYSIS OF FACTORS PREDICTING NEGATIVE APPENDECTOMY Konczalik Wojciech, Samrat Mukherjee, Long Kyle, Banerjee Saswata Queens Hospital, Romford UK APPENDICECTOMY: WHICH TERAPY? Calabrò M., Gatti L., Corlianò A. Clinica Chirurgica Università del Piemonte orientale Italy

10.45 SINGLE ACCESS LAPAROSCOPIC APPENDECTOMY IN A TREATMENT OF ACUTE APPENDICITIS Pashayeva J.R., Lyadov V.K., Ermakov N.A., Egiyev V.N. Federal Medical and Rehabilitation Center, Moscow, Russia THE INFLUENCE OF HOSPITAL STAY ON POSTOPERATIVE COMPLICATIONS AFTER LAPAROSCOPIC APPENDECTOMY Jong Min Lee1, Ji Young Jang1, Seung Hwan Lee1, Hongjin Shim2, Jae Gil Lee1 1 Department of Surgery, Yonsei University College of Medicine, 2Department of Surgery, Yonsei University Wonju College of Medicine Korea POSTOPERATIVE COMPLICATION RATES FOR LAPAROSCOPIC VERSUS OPEN APPENDECTOMY Wataru Ishii M.D.1, Yohei Okada M.D.1, Tetsuya Ichikawa M.D.1, Yusuke Arai M.D.1, Kazumasa Oda M.D.1, Ken Sakakibara M.D.1, Satoshi Higaki M.D.1, Norio Sato Ph.D.2, Ryoji Iizuka M.D.1, Kaoru Koike Ph.D.2, Makoto Kitamura Ph.D.1 1 Kyoto Second Red Cross Hospital Department of Emergency Medicine, 2Kyoto University Department of Primary Care and Emergency Medicine Japan LESSONS LEARNED WITH LAPAROSCOPIC MANAGEMENT OF ALL COMPLICATED GRADES OF ACUTE APPENDICITIS Carlos Augusto Gomes, Cleber Soares Junior, Rodrigo de Oliveira Peixoto, Camila Couto Gomes and Felipe Couto Gomes. UFJF (Universidade Federal de Juiz de Fora) Brazil EMERGENCY MANAGEMENT OF APPENDICEAL MASS AND ABSCESS Demetrashvili Z., Pipia I., Kenchadze G. Tbilisi State Medical University, Georgia MODIFIED MINI-LAPAROSCOPIC APPENDECTOMY: A NONVISIBLE-SCAR SURGICAL ALTERNATIVE Saavedra-Perez D., Ginesta C., Valentini M., Vidal O., Benarroch G., García-Valdecasas J.C. Hospital Clinic of Barcelona

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SATISFACTION

AFTER

LAPAROSCOPIC

12.15 PREDICTIVE VALUE OF ABNORMALLY RAISED SERUM BILIRUBIN IN ACUTE APPENDICITIS Chambers A.C., Davies H., Bismohun S., Patil A. Great Western Hospital, Swindon, UK Hot spot PRELIMINARY RESULTS OF ASAA (ANTIBIOTIC VS. SURGERY IN UNCOMPLICATED ACUTE APPENDICITIS) RANDOMIZED STUDY: TIME TO DIE OR TO BECOME WSES STUDY? Poiasina E. (Italy), Pisano M. (Italy) Position paper: SURGICAL SITE INFECTIONS Koike K. (Japan)

13.00 Symposium “The Open Abdomen” Chairs: Catena F. (Italy) – Leppaniemi A. (Finland) PHYSIOPATHOLOGY OF ABDOMINAL COMPARTMENT SYNDROME Biffl W. (USA)

HYPERTENSION:

THE NEED TO MEASURE THE INTRABDOMINAL PRESSURE Manfredi R. (Italy) THE OPEN ABDOMEN IN TRAUMA Chiara O. (Italy)

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THE

ABDOMINAL

THE OPEN ABDOMEN IN SEPTIC PATIENTS AND IN ACUTE PANCREATITIS Leppaniemi A. (Finland) THE MANAGEMENT OF OPEN ABDOMEN Di Saverio S. (Italy), Tugnoli G. (Italy) TECHNICAL EVOLUTION IN THE MANAGEMENT OF OPEN ABDOMEN Fattori L. (Italy)

14.00 Position paper: ACUTE PANCREATITIS Leppaniemi A. (Finland) SURGICAL MANAGEMENT OF ACUTE PANCREATITIS: OUR EXPERIENCE D’Aloisio G., D’Agostino G., Oldani A., Butera F., Garavoglia M. University of Eastern Piedmont "Amedeo Avogadro" A.O.U. Maggiore della Carità Novara, Italy PROGNOSTIC ROLE OF C-REACTIVE PROTEIN AND MATRIX METALLOPROTEINASE-9 IN ACUTE PANCREATITIS Brachini G., Mingoli A., Binda B., Mariotta G., Mogini V., Miglior E., Saracino A. Sapienza University Rome, Italy ABDOMINAL COMPUTED TOMOGRAPHY (CT) SCAN IN ACUTE PANCREATITIS (AP): SOONER OR LATER? Aral M., Melo R.B., Castro S., Oliveira M., Graça L., Costa-Maia J. Centro Hospitalar Sao Joao, Portugal SIGNS OF SUPPURATION OF PERI / PANCREATIC COLLECTIONS IN ACUTE PANCREATITIS Khokha V.1, Khokha D.2 1 City Hospital, Mozyr, Belarus, 2Medical University, Gomel, Belarus

15.00 STEP-UP APPROACH TO ACUTE NECROTIC-HAEMORRHAGIC PANCREATITIS: CAN TIGECYCLINE BE INCLUDED IN ANTIBIOTICS THERAPEUTIC STRATEGY? Morganti L., Cultrera R., Vasquez G., Andreotti D., Maccatrozzo S., Cappellari L., Stano R., Occhionorelli S. Ferrara, Italy REVIEW AND RE - EVALUATION OF THE SCORE SYSTEMS DEFINING THE BEHAVIOR IN PATIENTS WITH ACUTE PANCREATITIS Georgi Minkov MD, c PhD; Yovcho Yovtchev MD PhD; Alen Petrov MD c PhD; Stoyan Nikolov MD University Hospital, Department of Surgery, Bulgaria

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EVALUATION OF EMERGENCY SURGICAL ADMISSION BURDEN OF ACUTE PANCREATITIS Ayantunde A., Choudhury S., Yousaf A., Praveen B. Southend University Hospital, United Kingdom ENDOSCOPIC AND SURGICAL TREATMENT IN PATIENTS AFFECTED ON ACUTE BILIARY PANCREATITIS Fornaro R., Frascio M., Stabilini C., Imperatore M., Bruno S., Curletti G.l., Perotti S., Gianetta E. Department of Surgery, University of Genoa, Italy

16.00 Chairs: Amaral J. (USA), Ansaloni L. (Italy) Position paper: ACUTE CHOLECYSTITIS Campanile F. (Italy), Pisano M. (Italy) LAPAROSCOPIC CHOLECISTECTOMY: THE EXPERIENCE OF A YOUNG SOURGEON Prando D., Torchiaro M., Verza L.A., Rubinato L., Azabdafdari A., Roveran A., Vacca U., Agresta F. Chirurgia Generale, Ospedale Civile di Adria, ULSS 19 regione del Veneto Italy Hot spot HARMONIC SCALPEL AND ACUTE CHOLECYSTITIS Catena F., Tarasconi A. Parma (Italy) MINI-APPROACH CHOLECYSTECTOMY FOR THE COMORBIDITIES Abdullaev E.G., Babyshin V.V., Gachabayov M., Abdullaev A.E. Vladimir City Hospital of Urgent Medical Aid, Vladimir, Russia

PATIENTS

WITH

DURATION OF ATTACK DOES NOT PREDICT MORBIDITY AFTER LAPAROSCOPIC CHOLECYSTECTOMY FOR ACUTE CHOLECYSTITIS Milovanov V.V., Lyadov V.K., Ermakov N.A., Egiev V.N. Surgical Department, Federal Medical and Rehabilitation Center, Moscow, Russia GALLSTONES MEDIATED ABDOMINAL BLEEDING REQUIRING EMERGENCY LAPAROTOMY: REPORT OF A UNIQUE CASE Cocozza E., Livraghi L., Berselli M., Mangano A., Latham L., Fontana F., Bianchi V., Farassino L. Azienda Ospedaliera Ospedale di Circolo e Fondazione Macchi, Varese Italy

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17.00 Chairs: Biffl W. (USA), Sartelli M. (Italy) Position paper: ACUTE DIVERTICULITIS Moore F. (USA) OPEN VERSUS LAPAROSCOPIC CHOLECYSTECTOMY IN ACUTE CHOLECYSTITIS. A META-ANALYSIS. Coccolini F., Camagni S.,Colaianni N., Faustinelli G., Gheza F., Giulii Capponi M., Lotti M., Manfredi R., Magnone S., Nita G., Pisano M., Piazzalunga D., Poletti E., Poiasina E., Ansaloni L. USC Chirurgia I, Ospedale Papa Giovanni XXIII, Bergamo, Italy ELECTIVE SURGICAL SOURCE CONTROL OF COMPLICATED DIVERTCULITIS: CRUCIAL FACTORS FOR DECISION MAKING Faist E. (Germany) IS IT POSSIBLE TO CONTAIN THE USE OF CT SCAN DURING CLINICAL PRACTICE IN RELATION TO ACUTE DIVERTICULAR DISEASE WITHOUT JEOPARDIZING THE PROSPECT OF RECOVERY? OUR PRELIMINARY EXPERIENCE Caputo P., Rovagnati M., Carzaniga P.L. Dpt. of Surgery, L.Mandic Hospital- Merate (Lecco) Italy COMPLICATED DIVERTICULITIS: “RETHINKING THE RULES” AND THE GOALS Romagnoli F., Catani M., De Milito R., Farina A., Ragozzino R., Modini C. Emergency Department - Umberto I Policlinico di Roma, La Sapienza Università di Roma, Italy

18.00 Position paper: ADHESIVE SMALL BOWEL OBSTRUCTION Catena F. (Italy)

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SIGMOID DIVERTICULITIS PERFORATION: LAPAROSCOPIC TREATMENT Cocorullo G., Carollo G., Di Maggio M.A., Fontana T., Agrusa A., Salamone G., Gulotta G. Department of General, Emergency and Transplant Surgery (GENURTO)-Unit of General and Emergency Surgery, University of Palermo, Italy IS LIMITED USE OF CT SCAN JUSTIFIED IN ACUTE DIVERTICULITIS (AD)? RESULTS FROM A 100 CASES SERIES Caputo P., Rovagnati M., Carzaniga P.L. Merate Hospital via L. Mandic- Merate (LC) Italy PNEUMORETROPERITONEUM AND PNEUMOMEDIASTINUM REVEALING A LEFT COLON PERFORATION Montori G., Di Giacomo G., Zeineb M., Angot C., Al Samman S., Cheynel N. Division of General and Emergency Surgery, Centre Hospitalier Universitaire Bocage, Dijon, Fr. SURGICAL TREATMENT OF DIVERTICULITIS OF THE COLON Fornaro R., Frascio M., Stabilini C., Curletti G.l., Imperatore M., Bruno S., Perotti S., Gianetta E. Department of Surgery, University of Genoa, Italy EARLY OUTCOME AFTER SURGERY FOR ADHESIVE SMALL OBSTRUCTION: 5-YEARS EXPERIENCE Mazzoni G., Raparelli L., Vagni V., De Bartolomeo R., Mazzarella Farao R. Ospedale di Viterbo (Italy) HOSTILE ABDOMEN: DEFINITON, PREDICTORS AND CLASSIFICATION Gerych I. Danylo Halytskyâ&#x20AC;&#x2122; Lviv National Medical University, Ukraine Hot spot PAI score and PAI Study Coccolini F. (Italy)

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BOWEL

 Monday, July 8, 2013  Chairs: Ansaloni L. (Italy), Moore F. (USA)

Athena Room 8.00 Minimum Data Set in Emergency General Surgery An International Collaboration Sugrue M. (Ireland) Surgeon Letterkenny Hospital - Donegal Clinical Research Academy Ireland Position paper: HEMO-PNEUMOTHORAX Maier R. (USA) Hot spot: STRENGHTS AND WEAKNESSES OF LETTERKENY COURSE Michael Sugrue Donegal Clinical Research Academy Letterkenny Ireland STRENGHTS AND WEAKNESSES OF LETTERKENY COURSE Sugrue Donegal M. Clinical Research Academy Letterkenny, Ireland

EMERGENCY

SURGERY

EMERGENCY

SURGERY

NEEDLE DECOMPRESSION OF TENSION PNEUMOTHORAX, IS OUR EDUCATION OF THE PREHOSPITAL PROVIDER ADEQUATE? Buchanan D.Z., Dominguez Ekeh A.P., Tchorz K.M., Woods R.J., K, McCarthy M.C., Dennlinger L.A, Saxe J.M. Wright State University Dayton Ohio Position paper: OBSTRUCTED - PERFORATED COLORECTAL CANCER Ansaloni L., Pisano M. (Italy) TRAUMA & EMERGENCY SURGERY EDUCATION AND TRAINING IN PORTUGAL Mesquita C. Portuguese Medical Association, College of Competence in Emergency Medicine National Steering Group for Emergency Surgery Education Portugal

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9.00 COLONIC STENT PLACEMENT AS A BRIDGE TO SURGERY IN PATIENTS WITH LEFT-SIDED MALIGNANT LARGE BOWEL OBSTRUCTION. AN OBSERVATIONAL STUDY Tartarini D., Cappellari L., Occhionorelli S., Stano R., Vasquez G. Azienda Ospedaliera Universitaria di Ferrara, Surgical Department, Emergency Surgery Service Italy LAPAROSCOPIC RESECTION AFTER STENTING IN INTESTINAL OBSTRUCTION FOR CARCINOMA: A SINGLE-CENTER RETROSPECTIVE STUDY Gatti A.1, Spinelli A., Locatelli A.1, Strada D.1, Ferrara E.2, Elmore U.1, Bona S.1, Montorsi M.1 1 Dept. of General Surgery, Istituto Clinico Humanitas, IRCCS, Rozzano (MI) – Medical School of Digestive Surgery, University of Milan; 2Service of Endoscopy, Istituto Clinico Humanitas, IRCCS, Rozzano (MI) Italy Position paper: OESOPHAGEAL PERFORATIONS Ivatury R. (USA) MANAGEMENT OF ESOPHAGEAL PERFORATION: OUR EXPERIENCE Feleppa C., Banchini F., Delfanti R., Grassi C., Capelli P. Ospedale Guglielmo da Saliceto di Piacenza, U.O. Chirurgia Generale Vascolare Senologica Italy MANAGEMENT OF ESOPHAGEAL PERFORATION IN 18 PATIENTS TREATED OVER A 10-YEAR PERIOD Rausa E., Macchitella Y., Bona D., Bernardi D., Bonavina L. IRCCS Policlinico San Donato, University of Milano Medical School, Italy

10.00 BAROTRAUMATIC PERFORATION OF THE PHARYNX AND THORACIC OESOPHAGUS FOLLOWING BITE OF INNER TUBE OF MOTORCYCLE TIRE: A CASE REPORT Balamoun H. Faculty of medicine, Cairo university, Egypt PERFORATION OF OESOPHAGOJEJUNAL OESOPHAGOJEJUNAL TUBE Mesquita C., Oliveira J., Castro-Sousa F. Coimbra University Hospital Portugal BLEEDING CONTROL OF AN SENGSTAKEN-BLAKEMORE TUBE Mesquita C., Patrão R. Coimbra University Hospital Portugal

ANASTOMOSIS

AORTOESOPHAGEAL

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FISTULA

WITH

“DISPHAGIA AND EMERGENCY” Fiorito R. Tor Vergata University Rome, Italy CLINICAL MANAGEMENT OF ESOPHAGEAL PERFORATION; OUR EXPERIENCE Oldani A., Butera F., Garavoglia M. SCDU Clinica Chirurgica Università del Piemonte Orientale "Amedeo Avogadro" A.O.U. "Maggiore della Carità" Novara, Italy

11.00 Position paper: RUPTURED ABDOMINAL ANEURYSMS Bendinelli C. (Australia) LIFE-SAVING EMERGENCY LAPAROTOMIES FOR A CASE SERIES OF RARE RUPTURED SPLENIC ARTERY ANEURYSMS. Ley-Hui Tan M., Sverrisdottir A. Queen’s Hospital, Belvedere Road, Burton upon Trent, Staffordshire EMERGENCY ENDOVASCULAR TREATMENT FOR A GIANT RUPTURED HYPOGASTRIC ANEURYSM IN A PATIENT SUFFERING FROM EHLERS-DANLOS SYNDROME Poletto G.L., Giorgetti P.L., Popovich A., Casabianca E., Busoni C., Pedicini V., Poretti D., Brambilla G. IRCCS Istituto Clinico Humanitas, Rozzano (MI), Italy ABDOMINAL AORTIC ANEURYSMS: IS THE PRESSURE ON? Patil A.V., Aggarwal R., Tomlinson H., Singh-Ranger R. Great Western Hospital, Swindon, Wiltshire (UK) Position paper: ACUTE BOWEL ISCHAEMIA SakaKushev B.E. (Bulgaria) Position paper: ACUTE LIMB ISCHAEMIA Gargiulo M. (Italy)

12.00 Position paper: ACUTE UROLOGICAL CONDITIONS Schiavina R. (Italy)

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PELVIC - UROGENITAL TRAUMA IN PEDIATRIC SURGERY REVISITED Fette A. University of Pecs, Medical School, Hungary USE OF NPTWI IN FOURNIER’S GANGRENE Salamone G., Atzeni J., Agrusa A., Cocorullo G., Gulotta G. Dipartimento discipline Chirurgice, Oncologiche e Stomatologiche Palermo, Italy

University of

Position paper: ABDOMINAL SEPSIS – CIAOW STUDY Sartelli M., Viale P.L. (Italy) RISK FACTORS IN COMPLICATED INTRA-ABDOMINAL INFECTIONS: PRELIMINARY DATA FROM A SINGLE CENTRE PARTICIPATING TO THE CIAO STUDY Rausei S., Marzorati A., Borroni G., Boni L., Dionigi G., Dionigi R. Department of Surgery, University of Insubria (Italy) Hot spot POSTOPERATIVE DELIRIUM IN EMERGENCY SURGERY: PROPOSAL FOR A WSES STUDY INITIATIVE. Giulii-Capponi M. (Italy)

13.00 WJES - WSES Board 14.00 Chairs: Campanelli G. (Italy), Mandalà V. (Italy) Consensus Conference and Guidelines COMPLICATED ABDOMINAL WALL HERNIA Sartelli M. (Italy) UK hernia database Catena R. (UK) TOTAL EXTRAPERITONEAL (TEP) HERNIOPLASTY WITH INTESTINAL RESECTION ASSISTED BY LAPAROSCOPY OF A STRANGULATED RICHTER FEMORAL HERNIA Saavedra-Perez D., Ginesta C., Valentini M., Vidal O., Benarroch G., García-Valdecasas J.C. Hospital Clinic of Barcelona Spain

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Chairs: Catena F. (Italy), Moore E.E. (USA) Position paper: ACUTE PROCTOLOGICAL CONDITIONS Vettoretto N. (Italy) PERINEAL TRAUMA BY IMPALEMENT Banchini F., Feleppa C., Bandone M., Albertario S., Capelli P.o Ospedale Guglielmo da Saliceto di Piacenza, U.O. Chirurgia Generale Vascolare Senologica Italy

15.00 AN INCREASING TREND IN RETAINED RECTAL FOREIGN BODY Ayantunde A.A., Unluer Z. Southend University Hospital UK IS IT SAFE TO POSTPONE SURGERY OF PATIENTS DIAGNOSED WITH PERIANAL ABSCESS? Eran Brauner, Mariya Neymark, Offir Ben-Ishay, Mahmoud Atamla, Yoram Kluger Department of General Surgery, Rambam Health Care Campus, Haifa, Israel Position paper: SPLEEN TRAUMA Peitzmann A. (USA) LAPAROSCOPIC TREATMENT OF SPLENIC INJURY IN BLUNT ABDOMINAL TRAUMA Ali Ibrahim Yahya, Hussen E Shwereif, Mustafa Ahemed Ekheil, Ahmed Thoboot, Kalid Amar Algader, Najla Endasha Zliten Teaching Hospital Libya NON-OPERATIVE MANAGEMENT OF SPLENIC TRAUMA IMPROVEMENT AFTER EMERGENCY DEPARTMENT CREATION. TEN-YEAR EXPERIENCE OF A SINGLE CENTER Mogini V., Mingoli A., Mariotta G., Reali C., Cirillo B., Silvestri V., Marenga G. Sapienza University Rome, Italy, UOD Chirurgia del Politrauma, Dip. di Emergenza e Accettazione, Policlinico Umberto I Italy

16.00 A NEW TECHNIQUE FOR SPLEEN AUTOTRANSPLANTATION Di Carlo I., Toro A. Department of Surgical Sciences, Organ Transplantation and Advanced Technologies, University of Catania. Cannizzaro Hospital, Catania, Italy.

WJES & WSES Meeting 25

Position paper: LIVER TRAUMA Tugnoli G. (Italy) NON OPERATIVE TREATMENT VS OPERATIVE TREATMENT IN HEPATIC TRAUMA: A TEN- YEAR EXPERIENCE Saracino A., Mingoli A., Mariotta G., Reali C., Migliori E., Natili A., Marenga G. Sapienza University, Rome, Italy BILIOMA IN TWO YEARS OLD CHILD AFTER CONSERVATIVE MANAGEMNET OF BLUNT HEPATIC TRAUMA Ali I Yahya, Hussen E. Shwereif, Mustafa A. Ekheil, Fatma Algyead, Ahmed Salem Thoboot Zliten Teaching Hospital Libya SPLENECTOMY IN HYPERREACTIVE MALARIAL SPLENOMEGALY: ANALYSIS OF 9 PATIENTS, SURGERY, AND OUTCOME Santoni R.*, Righetti C.*, Morgagni D.**, Margarino C.*, Passariello L.* * Azienda Ospedaliera San Martino, Genova, **Azienda Ospedaliera Morgagni Pierantoni, Forlì Italy MANAGEMENT OF LIVER AND SPLEEN TRAUMA, THREE- YEAR EXPERIENCE Stabina Solvita, Kaminskis Aleksejs, Pupelis Guntars, Lunins Romans Riga East University Hospital Clinical Centre of Emergency Medicine “Gailezers”, Latvia

17.00 TRAUMATIC LIVER RUPTURE WITH RIGHT HEPATIC VEIN INJURY Kaminskis Aleksejs, Stabina Solvita, Pupelis Guntars, Lunins Romans Riga East University Hospital, Clinical Centre of Emergency Medicine “Gailezers” Latvia POSTTRAUMATIC PSEUDOANEURYSM OF RIGHT HEPATIC ARTERY AFTER GUNSHOT THORACHO-ABDOMINAL INJURY. A CASE REPORT AND REVIEW OF THE LITERATURE Dogjani Agron1, Hasanaj Blenarda1, Qamirani Xhafer1, Petrela Eliziana2, Dhima Arben3 1 Department of Surgery, Universitary Hospital of Trauma, Tirana, Albania, 2Head of Statistic Deparment, in University Hospital "Nene Tereza", Tirana, Albania, 3 Department of Radiology, in American Hospital Tirana, Albania PERIHEPATIC PACKING AND ARTERIOGRAPHY IN THE OPERATING ROOM AS A DAMAGE CONTROL STRATEGY FOR SEVERE HEPATIC INJURIES Mastropietro T.*, Cataldi C.*, Salvatelli M.*, Truosolo B.*, Morucci M.**, Riu P.**, Marini P.* * General surgery, S. Camillo Hospital Rome, **Vascular radiology, S.Camillo Hospital Rome Italy

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 Tuesday, July 9, 2013  Athena Room 8.00 Chairs: Kelly M. (Australia), Melotti G.L. (Italy) Position paper: CARDIO- THORACIC TRAUMA Moore E.E. (USA) PENETRATING CARDIAC INJURIES. WHAT CAN GENERAL SURGEONS DO IN HOSPITAL WITHOUT ON-SITE CARDIAC SURGERY CAPABILITY? Canini T., Sallusti M., Bertazzoni P.M., Barcella A. Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy VACUUM PACK CLOSURE METHOD USING THORACIC DRAINAGE SYSTEM Kubota T., Miyazaki K., Mizokami K., Miyabe A., Kanda Y. Department of General Surgery Tokyo Bay Urayasu Ichikawa Medical Center Japan COIL EMBOLIZATION OF A PULMONARY ARTERY PSEUDOANEURYSM PRESENTING WITH HEMOPTYSIS 7 DAYS AFTER THORACOTOMY FOR BLEEDING PENETRATING INJURY Canini T., Montagnolo G.G., Bertazzoni P.M., Barcella A., Nicolini A.* Department of Surgery and Emergency Surgery and *Operative Unit for Interventional Radiology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy PENETRATING CHEST PATIENTS NEEDING SURGERY – WHO WILL SURVIVE, AND WHAT RESOURCES WILL BE NEEDED? Doll D.1,2, Tugby Y.H.3, Degiannis E.1 1 Department of Trauma & Burns, Chris Hani Baragwanath Academic Hospital, Soweto, Johannesburg, South Africa, 2Department of Surgery, St Mary´s Hospital, Vechta, Germany, 3Department of Surgery, Baskent University, Izmir, Turkey

9.00 PENETRATING CHEST PATIENTS IN THE NEED FOR SURGERY – INDICATIONS, INJURIES AND PROCEDURES TO DO Doll D.1,2, Tugby Y.H.3, Degiannis E.1 1 Department of Trauma & Burns, Chris Hani Baragwanath Academic Hospital, Soweto, Johannesburg, South Africa, 2Department of Surgery, St Mary´s Hospital, Vechta, Germany, 3Department of Surgery, Baskent University, Izmir, Turkey

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URGENT THORACOTOMY FOR PENETRATING SURGICAL CENTRE EXPERIENCE Necchi M., Strada G., Garatti M., Bottura R. Emergency Ong Onlus Italy

CHEST

TRAUMA:

KABUL

LAPAROSCOPIC REPAIR OF POST TRAUMATIC DELAYED DIAPHRAGMATIC HERNIA WITH INTRATHORACIC MESENTROAXIAL GASTRIC VOLVULUS A CASE REPORT Singh R., Bansal D., Pushkarna V. Fortis Escorts Hospital India SPONTANEOUS DIAPHRAGMATIC RUPTURE DURING STATIC GYMNASTIC EXERCISE Costa S., Corbellini C., Villa R., Leone P., Contessini Avesani E. Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Università degli Studi di Milano Italy MANAGEMENT AND OUTCOMES OF RIB FRACTURES WITHOUT SURGICAL FIXATION AT A LEVEL 1 TRAUMA CENTER Weber D.G., Bendinelli C., Balogh Z.J. Deptartment of Traumatology, John Hunter Hospita Australia

10.00 POST TRAUMATIC DIAPHRAGMATIC HERNIA IN BLUNT ABDOMINAL TRAUMA: FROM URGENCY TO EMERGENCY De Martino M.1, Viganò J.2, Sgarella A.2, Dominioni T.2, Dionigi P.1 1 Department of Surgical Science, University of Pavia, 2General Surgery Unit I, Fond. IRCCS Pol. San Matteo, Pavia Italy Position paper: PELVIC TRAUMA Poggetti R. (Brazil) Hot spot HEMODINAMICALLY UNSTABLE PELVIC TRAUMA: RESULTS OF THE FIRST ITALIAN CONSENSUS CONFERENCE Magnone S., Manfredi R., Piazzalunga D., Coccolini F., Ansaloni L. (Bergamo) Italy ARE FRACTURE PATTERNS AND AGE PREDICTIVE FACTORS OF SEVERE HAEMORRHAGE IN PELVIC TRAUMA PATIENTS? Mariani A., MD^, Prestini L., RN°, Bertuzzi M., SD°, Luperto M., MD^, Ronchi A., MS^, Chiara O., MD^, Cimbanassi S., MD^. ^Trauma Team Dip. DEA-EAS, Ospedale Niguarda Ca’Granda Milano, °Quality Department , Ospedale Niguarda Ca’Granda Milan Position paper: DUODENO- PANCREATIC TRAUMA Biffl W. (USA)

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11.00 MANAGEMENT PERSPECTIVE Iacono C. (Italy)

THE

PANCREATIC

TRAUMA:

THE

HBP

SURGEON

REVIEW OF TRAUMATIC PANCREAS INJURY IN KOREA: LITERATURE REVIEW Seung Hwan Lee1, Ji Young Jang1, Hongjin Shim2, Jae Gil Lee1 1 Department of Surgery, Yonsei University College of Medicine, 2Department of Surgery, Yonsei University Wonju College of Medicine Korea PYLORIC EXCLUSION - AN EASY WAY TO DO IT Mesquita C. Coimbra University Hospital Portugal Position paper: GASTROINTESTINAL TRAUMA Bailey I. (UK)

12.00 Hot Spot: CORROSIVE INGESTION AND THE SURGEON Kelly M. (Australia) RISK FACTORS OF THE MORTALITY AND ANASTOMOTIC LEAKAGE AFTER EMERGENT SMALL BOWEL RESECTION Tae Hwa Hong1, Seung Hwan Lee1, Ji Young Jang1, Hongjin Shim2, Jae Gil Lee1 1 Department of Surgery, Yonsei University College of Medicine, 2Department of Surgery, Yonsei University Wonju College of Medicine Korea COMBINED LIVER, KIDNEY, SILENT PANCREATIC INJURY AND OVERLOOKED SMALL BOWEL LESION AFTER DIAGNOSTIC LAPAROSCOPY IN POLYTRAUMA PATIENT Stabina Solvita, Kaminskis Aleksejs, Pupelis Guntars Riga East University Hospital, Clinical Centre of Emergency Medicine Gailezers Latvia

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13.00 Symposium “Coagulation hot topics in emergency and trauma surgery”

Chairs: Gordini G. (Italy), Biffl W (USA) DVT PREVENTION IN EMERGENCY SURGERY Falanga A. (Italy), Ansaloni L. (Italy) NEED AND TIMING OF DVT PREVENTION IN TRAUMA PATIENTS Magnone S. (Italy) PATHOPHYSIOLOGY OF TRAUMA INDUCED COAGULOPATHY Moore E. (USA) MANAGEMENT OF TRAUMA INDUCED COAGULOPATHY Agostini V. (Italy)

14.00 Position paper: ABDOMINAL VASCULAR TRAUMA Chiara O. (Italy) Position paper: Extremity Vascular Trauma, Neck, Chest Fraga G. (Brazil) VASCULAR TRAUMA: CONSIDERATIONS ON EXPERIENCE OF 15 YEARS Scabini M., Mosso F., Negri C., Zaghis M., Celoni M., Capelli P. Ospedale Guglielmo da Saliceto di Piacenza Italy TREATMENT OF BLUNT TRAUMATIC SUBISTHMIC AORTIC RUPTURE IN POLITRAUMATIC PATIENTS Mastropietro T.*, Cataldi C.*, Salvatelli M.*, Truosolo B.*, Ferrer C.**, Morucci M.***, Cao P.**, Marini P.* * General Surgery 1 San Camillo Hospital Rome, **Vascular Surgery S. Camillo Hospital Rome, ***Interventional Radiology S. Camillo Hospital Rome Italy

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15.00 Position paper: DAMAGE CONTROL ORTHOPEDICS Stahel P. (USA) PYOGENIC VERTEBRAL OSTEOMYELITIS COMPLICATING ABDOMINAL PENETRATING INJURY: CASE REPORT AND REVIEW OF THE LITERATURE Bertazzoni P., Zefelippo A., DeRai P., Marini A. UO Chirurgia d’Urgenza - Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico di Milano Italy Position paper: ABDOMINAL DAMAGE CONTROL/RECONSTRUCTION Coimbra R. (USA) Hot spot TIMING IN ACUTE CARE SURGERY CLASSIFICATION (TACS CLASSIFICATION) Kluger Y. (Israel)

Athena Room 16.00 Chairs: Moore F. (USA), Sugrue M. (Ireland) LAPAROSCOPY FOR TRAUMA 1 Mandalà V. (Italy) BABY EMERGENCY SURGICAL SERVICE OFF LIMITS Fette A. University of PéCs, Medical School, Hungary; Senior Experten Service Bonn, Germany LAPAROSTOMY AS TREATMENT OPTION IN TOTAL PERITONITIS WITH SEVERE SEPSIS Sakakushev B.E. Medical University/University Hospital St George Plovdiv, First Clinic Of General Surgery Bulgaria

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Athena Room 17.00 THE ROLE OF CELL-FREE DNA MEASURED BY A FLUORESCENT TEST IN THE ASSESSMENT OF ISOLATED TRAUMATIC HEAD INJURIES Shaked G., Czeiger D., Yair S., Douvdevani A. Soroka University Medical Center and Ben-Gurion University Israel A NEW SURGICAL DRAINAGE DEVICE Carletti M. S.M. Goretti General Hospital Latina, Dept. of Emergency Italy STOMAS IN EMERGENCY SURGERY: A SINGLE CENTER EXPERIENCE Cocorullo G., Carollo G., Di Maggio M.A., Fontana T., Salamone G., Agrusa A., Gulotta G. Department of General, Emergency and Transplant Surgery (GENURTO)-Unit of General and Emergency Surgery, University of Palermo, Italy BEDSIDE LAPAROSCOPIC: AN INSTITUTION EXPERIENCE OVER SIX YEARS Cocorullo G., Di Maggio M.A., Carollo G., Fontana T., Agrusa A., Salamone G., Gulotta G. Department of General, Emergency and Transplant Surgery (GENURTO)-Unit of General and Emergency Surgery, University of Palermo, Italy MANAGEMENT OF ACUTE ABDOMINAL PAIN AFTER LAPAROSCOPIC ROUX-N-Y GASTRIC BYPASS Abboud W., Mahajna A., Kluger Y., Assalia A. Rambam health care campus, Haifa, Israel

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Athena Room 18.00 NECROTIZING FASCIITIS - A CHALLENGE TO THE SURGEON Gomes A., Constantino J., Marques C., Pereira J., Pinheiro L.F. Centro Hospitalar Tondela- Viseu Portugal PERFORATIONS IN NEC. EMERGENCY CALL FOR THE PEDIATRIC SURGEON Fette A. Hungary CRANIOFACIAL NECROTIZING FASCIITIS: OUR EXPERIENCE OF ELEVEN CASES Gerych I., Stoyanovsky I. Danylo Halytsky’ Lviv National Medical University, Ukraine CELL SAVER BLOOD DECREASES MORTALITY WITHOUT AN INCREASED NEED FOR FRESH FROZEN PLASMA IN PATIENTS WHO REQUIRE MASSIVE TRANSFUSIONS. DO WE HAVE THE RATION RIGHT? Isaak, Edahn J., Tchorz, Kathryn M., Slapak Colleen, McCarthy M.C., Saxe J. Wright State University USA COMPARISON OF MORTALITY RATES FOR EMERGENCY ADMISSIONS OF GENERAL SURGEONS AND BREAST SURGEONS Parker J., Jenkinson L. Betsi Cadwaladr University Health Board Wales UK EVALUATION OF THE INDICATORS DETERMINING THE DECISION MAKING FOR RELAPAROTOMY Yovtchev Y. MD, PhD, Minkov G. MD, cPhD, Petrov Al. MD, mPhD, Stoyan Nikolov MD, Vlaykova T. PhD University Hospital/Department of surgery Bulgaria

Minerva Room 16.00 Chairs: Leppaniemi A. (Finland), Sartelli M. (Italy) LAPAROSCOPY FOR TRAUMA 2 Piccoli M. (Italy) LAPAROSCOPY IN PENETRATING ABDOMINAL TRAUMA Hang Joo Cho, Ji-Hoon Kim, Sung Jib Kim Uijongbu St. Mary’s Hospital, The Catholic University of Korea

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Minerva Room 17.00 SUICIDE ATTEMPT MAKES UP A LARGE PROPORTION OF PENETRATING TRAUMA CASES UNDERWENT SURGERY IN NECK, CHEST, OR ABDOMEN: THREE-YEAR EXPERIENCE IN A JAPANESE TERTIARY EMERGENCY CENTER Yoshimitsu Izawa, Keisuke Yamashita, Kenji Matsumoto, Keiichiro Tominaga, Reiko Mochiduki, Takafumi Shinjo, Chikara Yonekawa, Masaki Ano, Masayuki Suzukawa Department of Emergency and Critical Care Medicine, Jichi Medical University Japan EMERGENCY GENERAL SURGERY: WEIGHING ACUTE CARE SURGERY’S ELEPHANT David J. Ciesla, Etienne E. Pracht, Oliver L. Gunter, Adil H. Haider, John Y. Cha, Shahid Shafi University of South Florida USA

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Minerva Room 18.00 ONE-YEAR ACTIVITY RESULTS OF EMERGENCY SURGERY AT THE EMERGENCY DEPARTMENT OF POLICLINICO UMBERTO I OF ROME: DATABASE ANALYSIS Mariotta G., Mingoli A., Cirillo B., Silvestri V., Magliocchetti R., Binda B., Brachini B., Modini C. Sapienza University, Rome, Italy MULTIVISCERAL ABDOMINAL GUNSHOT WOUNDS: REPORT OF A CASE OF COMPLEX SURGERY Montin U.1, Carraro A.1, Marchi R.1, Soda C.2, Ricci U.M.2, Tedeschi U.1 1 Department of General Surgery and Odontoiatrics, 1 st General Surgery, University Hospital of Verona, Italy, 2Department of Neuroscience, Neurosurgery, University Hospital of Verona, Italy MYATLS - AN INNOVATION Brighton G., Abuznadah W., Brasel K. American College of Surgeons USA THE LAPAROSCOPIC APPROACH IN ACUTE DIFFUSE PERITONITIS: A RETROSPECTIVE STUDY ON MINIMALLY INVASIVE SURGERY IN EMERGENCY SETTING Romagnoli F., Catani M., De Milito R., Romeo V., Ragozzino R., Modini C. Umberto I Policlinico di Roma Italy

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Abstracts

Sunday, July 7, 2013

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ACUTE CARE SURGERY- WHAT’S IN A NAME? Jeffry L Kashuk MD FACS Director, Surgical Research and Academic Development EmCare Acute Care Surgery, Dallas, TX USA A new discipline called “Acute Care Surgery” has emerged within the traditional “General Surgery” domain. In parallel, the continued fragmentation of the surgical disciplines into super-specialty “organoriented surgeons” has resulted in a paradigm shift away from the traditional concept of the general surgeon who operates on many parts of the body under a variety of conditions. This trend has been a topic of considerable debate worldwide among surgical leaders. Still, young trainees continue to gain post-residency specialization training in their chosen fields. The expected result will be a diminishing number of surgeons available to enter the practice of traditional “general surgery,” with young talented surgeons relegated to practicing surgery only on an outpatient basis despite their desire to continue working under the auspices of a department of surgery. All acute and emergency cases in many locations world-wide are cared for by a general surgery trainee alongside an attending surgeon on call. The attending surgeon, however, may be a subspecialist such as a colorectal or transplant surgeon, depending on the pre-established call schedule. Similarly, chest or vascular emergencies are most commonly managed by the corresponding expert, who is called in by the emergency department or general surgery team. The public is often quite knowledgeable about the expertise of the medical staff, and most patients, given the opportunity, will seek out a subspecialist to manage their surgical problem when a nonemergency, elective, or semi-elective surgery is required. The creation of the acute care surgery discipline raises many important questions. Is it a true subspecialty? Is further fragmentation of general surgery into another specialty appropriate? What role will such a specialty have during times of critical need, such as war and mass casualty scenarios? Is sufficient manpower available for round the clock staffing of an ACS1 service? Ultimately, changes in the health care system should result in improvements in patient care. Accordingly, a key question is: Will the emergency surgery patient benefit from the expertise of an ACS specialist dedicated to emergency issues? While this trend has occurred in many locations in the world, with growing evidence of substantial benefit, is Israel ready for an expert in acute surgical disease – an ACS specialist? The objective of this presentation is to outline the current state of the evolution of acute care surgery and its anticipated impact on the future of general surgery in the United States, other regions of the world.

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ACUTE GASTRIC BLEEDING ULCER, A CASE REPORT 1

Cartari C.1, Martellosio V.2, Abbiati F.2, Dionigi P.3 Scuole SpecialitĂ Chirurgia Generale di Pavia, 2U.O. Chirurgia Generale Ospedale di Stradella, 3Direttore DEA I.R.C.C.S. S. Matteo di Pavia

Introduction: The incidence of acute upper gastrointestinal bleeding is 50150 cases per 100,000 population per year and the gastroduodenal ulcers are responsible of 35-60% of cases. Mortality remains high, about 4% of cases. Methods: Presentation of a case report and review of the recent literature Results: Male, 75 yrs old, in warfarin therapy for atrial fibrillation. Hospitalization in march for melena and hemorrhagic shock caused by gastric ulcer massive bleeding. During the emergency endoscopic exam, performed after cardiopulmonary resuscitation and transfusion, we founded an ulcer of the gastric angulus with clot. Discharged after 10 days with PPI and Fe Therapy. Rehospitalization after 4 days for rebleeding, we performed an emergency gastrectomy for bleeding and perforated ulcer. Conclusions: Mortality for upper GI bleeding remains high (about 4%), the prognosis is more unfavorable in elderly with comorbidities and in patients non-responsived at the medical therapy with PPI. That's why it is important early diagnosis with life support and endoscopic or surgical therapy in case of relapse.

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PEPTIC ULCER PERFORATION: A 3-YEAR EXPERIENCE OF A GENERAL SURGERY DEPARTMENT Mora H., Muralha N., Gonçalves F., Gouveia A., Barbosa J., Costa-Maia J. Centro Hospitalar de São João Introduction: The incidence of peptic ulcer perforation (PUP) has declined over the past 2 decades due to the higher prevalence of gastric ulcer prophylaxis and Helicobacter pylori erradication. The mortality, however, remains high reaching about 5 to 20%. Methods: Retrospective simple analysis of clinical data of patients who underwent surgery for peptic ulcer perforation between January 2010 and March 2013. Results: Eighty-two patients underwent surgery for PUP (75% male). The mean age was 55. In 2012 there was a slight increase in the incidence of PUP. 44% of patients had peptic ulcer prophilaxys, but half of them had stopped medication in 2012, for economical reasons. Sixty seven patients underwent a Graham patch procedure, 10 simple suture, 4 gastrectomy and 1 gastrotomy + suture. Twenty of these procedures were performed laparoscopically. The median length of stay was 7 days and the oral diet was reintroduced, on average, by day 4. Mortality rate was 14,6%. Complication rate was 22%. Conclusions: In spite of the avalailability of peptic ulcer prophilaxys and treatment, there has been an increase of incidence of PUP in 2012 which can be related to therapeutic interruption for economical causes. Our mortality and morbidity levels are in accordance to the literature.

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STOMACH AND DUODENAL PEPTIC ULCER DISEASE, COMPLICATED BY A BLEEDING: PROBLEMS, TREATMENT PROSPECTS Khadjibayev A.M., Melnik I.V., Eshmuratov A.B., Khashimov M.A., Shelaev O.I., Djamaldinov I.M., Mirahmedov N.N. Republican Research Center of Emergency Medicine Introduction: Stomach and duodenal ulcer is extended disease all over the world which suffer people at young and middle age basically. Methods: For 10 years of functioning of system of emergency medical aid in RRCEM and its 13 branches on inpatient treatment there were 25946 patients with bleedings from chronic stomach and duodenal ulcers. Stomach ulcer is diagnosed in 6791 (26,2 %) cases, and duodenal ulcer are revealed at 19155 (73,8 %) patients. Results: On the basis of not surgical treatment of ulcer bleedings lies combined application of methods of therapeutic endoscopy and modern means of conservative therapy of ulcer disease. By force of application only conservative therapy succeeded to achieve bleeding control at 7550 (29,1%). Methods of therapeutic endoscopy are used for the purpose of temporary, and in a number of cases eventual bleeding control and preventive maintenance. Application in the course of treatment of endoscopic hemostasis was required at 11728 (45,2%) patients. There were most widely applied monoactive electrocoagulation - 6099 (52%), chipping of ulcers by an ethanol solution -4480 (38,2%), combination of two above-stated ways-1114 (9,5%), argon-plasmal coagulation-35 (0,3%). There were operated 5671 (21,9%) patients: in an emergency order - 595(10,5%), in urgent-1963(34,6%), postpone - 3113 (54,9%). Resection techniques of interventions are applied at 4679 (82,5%) patients, organ survival operations on a basis of vagotomy were used at 346 (6,1%) and palliative â&#x20AC;&#x201D; at 646 (11,4 %) patients. In total it is noted 390 (1,5%) lethal outcomes, after operation from them have died 194 (3,4%). Conclusions: Thus, main principles of rendering of emergency medical aid to patients with gastrointestinal bleedings are: emergency diagnostics; temporary bleeding control; elimination of hemorrhagic shock and anemia; eventual bleeding control. In treatment of bleedings from chronic stomach and duodenal ulcers an active-individualized medical tactics, including endoscopic hemostasis, dynamic endoscopy, forecasting of probability of development of relapse of a bleeding, an individual approach in arrangement of a choice of terms and volume of operative intervention should be applied.

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EXPERIENCE OF THE COMBINED USE OF ENDOSCOPIC METHODS OF HEMOSTASIS FOR PEPTIC ULCER BLEEDINGS Khadjibayev A.M., Eshmuratov A.B., Melnik I.V., Shelaev O.I., Khashimov M.A., Djamaldinov I.M., Mirahmedov N.N. Republican Research Center of Emergency Medicine, Uzbekistan, Tashkent Introduction: Aims: Bleeding from the upper gastrointestinal tract is one of the main problems of urgent surgery. Priority in the treatment of patients with bleeding from the upper gastrointestinal tract is endoscopic hemostasis. The most pressing issues are to determine the indications for surgical treatment and prevention of recurrence of bleeding. The aim of investigation was to study the possibility of combined with 30% ethanol injection and argon-plasma coagulation (APC) for peptic ulcer bleedings (PUB). Methods: Total 220 patients [male: 138 (62.7%), women: 82 (37,3 %)] with PUB were enrolled in Surgery department of Republican Research Center of the Emergency Medicine (Tashkent) during the period from November 2010 to May 2012. For the treatment of PUB injection with 30% of ethanol solution and monopolar high frequency argonplasmal electrocoagulations «Electropulse RCh-350» device were used. The argon stream was consisted of 1 l/mines, a current strength – 20—30 Wt, time of influence for a bleeding source – 5 seconds. Results: 65 patients with major peptic ulcer haemorrhages received combined injection therapy with 30% of ethanol solution and APC; there were 42 male and 23 female with a mean age of 63.4 ± 1.2 years (range 18-92). The bleeding site was duodenal in 49 patients, gastric in 16 patients. Endoscopic findings were the following: active bleeding in 33 patients (4 spurting, 29 oozing), non bleeding visible vessels in 28 patients and fresh adherent clots in 4 patients. Initial haemostasis was achieved in 64/65 patients (98.4%). Re-bleeding was observed in 3/64 cases (4.7%). Surgery was necessary in 2/65 patients (3%). No major complications resulted from this treatment. Conclusions: Rates of initial hemostasis were significantly higher with combined therapy (injection + APC) compared to APC treatment alone. We believe that injection and APC combined therapy is an effective and safe method for treatment of gastrointestinal ulcer bleeding.

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SUCCESSFUL OPEN ABDOMEN TREATMENT FOR MULTIPLE ISCHEMIC DUODENAL PERFORATED ULCERS IN DERMATOMYOSITIS Villa R., Costa S., Focchi S., Corbellini C., Vigorelli M., Contessini Avesani E. Chirurgia Generale e d'Urgenza - Ospedale Maggiore Policlinico di Milano Introduction: Dermatomyositis is an autoimmune disease characterized by proximal myopathy, cutaneous Gottron papules and heliotrope rash; intestinal involvement associated to acute vasculitis is less common but could be a life-threatening condition. Methods: A 21-year-old woman, affected by dermatomyositis, presented to our attention with a three day story of severe abdominal pain, no bowel movement and biliary vomit. She was diagnosed with acute abdomen. A CT scan with bowel contrast demonstrated the presence of a leakage from the retroperitoneal aspect of duodenum. Results: Our first approach consisted in primary repair of the duodenal perforation with omentopexy. Post-operative course was complicated by hemorrhage. A reintervention showed a new perforation associated with multiple ischemic intestinal areas. We performed a gastroenteric anastomosis with functional exclusion of the damaged duodenum and positioning of drainages to create a biliary fistula. A nutritional enteric tube and an open abdomen vacuum-assisted closure system to monitor the fistula creation and to prevent abdominal contamination and collections, were positioned. To reduce the amount of biliary leakage, a percutaneous transhepatic biliary drainage was placed, with progressive fistula flow disappearance in four months. Conclusions: In patients with dermatomyositis, when clinical findings and symptoms suggest abdominal vasculitis, it is very important to be aware of the risk of bowel and particularly duodenal perforations. Open abdomen treatment favours control of contamination by gastrointestinal contents, offers temporary abdominal closure, permits ICU care and delays definitive surgery. Declaration of personal and funding interests: none.

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OUR EXPERIENCE OF SURGERY FOR BLEEDING OR PERFORATION IN GASTRIC CANCER Tamaz Gvenetadze National Medical Center Introduction: Emergency procedures for gastric cancer (GC) complicated by acute bleeding (BLGC) or perforation (PFGC) is one of the serious problems for emergency surgery end have worse outcomes than elective surgery. Temporal trends in emergency surgery for GC are analyzed by comparing the postoperative complications (PC) and operative mortality (OM). Methods: We present retrospective study of the rate complications and operative mortality after surgery in 170 patients with BLGC 15 (8.8% urgently) and urgent surgery in conditions of peritonitis in 77 patients with PFGC from 2000 to 2011 years. The average age of the patients with BLGC was 58,6 7,1 end with PFGC 52,2 5,3 years, male/female ratio accordingly was 5,3: 1and 3,4:1. The correlations of PC end OM with localization, macroscopically and microscopically characteristics and cancer stage, methods of surgery were analyzed. Results: Radical total or subtotal gastrectomia were performed at 98 (57,6%) for BLGC end at 45 (58,5%) patients for PFGC; surgical procedures were palliative or symptomatic at 72 (42,4%) and at 32 (41,5%) respectively. The total postoperative morbidity rate was 32% for BLGC and 36,1% for PFGC. The overall OM rate for BLGC was 9,5% (16 patients), after radical -6,1% (6), not radical - 16,6% (12) and for PFGC 7,8% (6), 3,2% (1) 11,1% (5) respectively. PC and OM were correlated to many different factors, which were analyzed. Conclusions: Surgery for complicated GC can be performed safely with enough low postoperative morbidity and mortality rate.

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FAST TRACK SURGERY IN EMERGENCY OPERATIONS FOR PEPTIC ULCER PERFORATION AND ACUTE CHOLECYSTITIS Sakakushev B.E. General Surgery Clinic Medical University / University Hospital “St George” Plovdiv Bulgaria Introduction: Although the rate of peptic ulcer perforation in the last decade went low, it’s mortality and morbidity, as well as these of destructive acute cholecystitis remains significantly high, costly and resource consuming. Enhanced Recovery after Surgery/ERAS/ and Fast Track Surgery/FTS/ programs are rapidly developing in colorectal surgery, less in upper gastrointestinal surgery and as far as we are concerned, have not been applied in urgent and emergency surgery. Methods: To investigate the safety and efficacy of FTS we studied retrospectively 60 patients operated on urgently for acute peritonitis, due to peptic ulcer perforation/n=22/ and destructive cholecystitis/n=38/ in our clinic for a 16 month’s period /2011, January the 1st - 2012 April 30th /. We explored for elements and variables coinciding with ERAS programs and compared outcomes of surgical strategies with or without FTS. The 12 ERAS elements in the study protocol were classified as preoperative, intraoperative, or postoperative depending on the interventions, presuming that for a study to be qualified as ERAS intervention, it should have at least five of the all 12 elements, more than one from each group. Results: Men prevailed in peptic ulcer perforation/15/22/, while in women dominated in destructive cholecystitis /22/38/. Mean age of the patients was 61.2 years/21 – 92/. Most of the patients had had more than one comorbid disease, presenting with high risk - ASA I – 2, ASA II – 15, ASA III – 34 и ASA IV – 7, ASA V- 2. The most common operations performed were cholecystectomy – 36/60 and pyloroplasty – 11/6. The ERAS group patients /n=28/, operated on by one and the same surgical team had have early oral intake of liquids and solids on day 1- 2, removal of urinary catheter and nasogastric tube on day 1-2, early mobilization in and out of bed on day 2, early removal of abdominal drain/s/, until 3rd day. They had also earlier return of bowel function, decrease in pulmonary complications and shorter hospital stay, compared with the other, non-ERAS group /n=32/, operated on by other surgical teams, following conventional postoperative regimen. Conclusions: Early oral feeding, early mobilization, discharge or lack of nasal tubes and intra-abdominal drains and urinary catheters in urgent upper gastrointestinal surgery are feasible, safe, with no evidence of increased morbidity. FTS result in faster recovery of bowel function with shorter bed stay. ERAS has not integrated evidence-based knowledge to optimize peri-operative care for urgent surgical operations for acute

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peritonitis due to peptic ulcer perforation and destructive cholecystitis and needs therefore further prospective randomized trials to confirm its feasibility.

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REDUCING NEGATIVE APPENDECTOMY RATES: A QUANTITATIVE ANALYSIS OF FACTORS PREDICTING NEGATIVE APPENDECTOMY Konczalik Wojciech, Samrat Mukherjee, Long Kyle, Banerjee Saswata Queens Hospital, Romford, UK Introduction: Negative appendectomies are associated with unnecessary risk to patient health and increases financial strain on the healthcare budget. Our aim was to identify clinical, pathological and radiological factors which could assist in excluding appendicitis in patients presenting acutely with right iliac fossa pain. Methods: Retrospective study reviewing all appendicectomies performed in a one year period in a District General Hospital. Clinical documentation of all negative appendicectomies (NA), defined as the absence of transmural appendiceal inflammation, was reviewed and data regarding patient presentation, biochemistry and radiological imaging was extracted. Relevant statistical analysis was performed. Results: 457 appendicectomies performed in the study period, with 78 being negative (NA rate = 17.07%). 63% of those patients were females. The mean age at presentation was 24.3, Standard Deviation (SD) = 13.1 years. Mean neutrophil count on admission was 7.52 x 109/L (SD = 4.4), mean leukocyte count = 10.73 x 109/L (SD = 4.62); mean Alvarado score = 5 (SD 1.72). 6.4% of patients had ultrasound findings suggestive with appendicitis, compared to 1.3% of CT and 0% of MRI. Statistically significant correlations (defined as P<0.05): young age and sex, CT findings, Ultrasound findings; Low Alvarado and nausea/vomiting, anorexia. Conclusions: Young age, low Alvarado score, negative radiological investigations, normal inflammatory markers, no anorexia and female sex have been found to be correlated in negative appendectomy patients. This may imply that these factors existing in combination may predispose to a negative appendectomy, which will help guide decisions regarding surgical intervention.

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APPENDICECTOMY: WHICH TERAPY? Calabrò M., Gatti L., Corlianò A. Clinica Chirurgica Università del Piemonte Orientale Introduction: In this study our goal is to compare laparotomy appendicectomy (LT) with video laparoscopic appendicectomy (VLS), in terms of recovery days, post-operatory complication with surgery reoperation or without it. Methods: We have conducted a cohort analitic study, with patients admitted to the surgery department in Maggiore hospital in Novara, with clinical and laboratory diagnosis of acute appendicitis, to treat. The patients were 441, 180 female and 261 male, with age between sixteen and seventy-eight years. Results: We performed 224 VLS and 217 LT from January the 1st 2001, until 31th December 2012; this period is divided in two parts: from January 2001 until December 2004 and from January 2005 until December 2012. In the first period 7 VLS and 153 LT were made, in the second one the VLS were 217 while the LT only 64. The average of recovery days for LT in the first period was 3,9 while in the second was 5,1, instead for VLS it was 3,3. The rate of surgical conversion was 14% for the first period and 3,7% for the second. The number of relaparotomy was 6 in both periods after LT. The rate of the other complications like abdominal pain and temperature treated with medical therapy, was4,3%. Conclusions: The superiority of VLS is underlined by less hospitalization days. VLS allowed to clean better the abdomen cavity to avoid postoperation complications and then the use of endobag to extract the stub prevented wound infection. At the end VLS permitted to discriminate gynecological from gastroenteric disease.

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SINGLE ACCESS LAPAROSCOPIC APPENDECTOMY IN A TREATMENT OF ACUTE APPENDICITIS Pashayeva J.R., Lyadov V.K., Ermakov N.A., Egiyev V.N. Federal Medical and Rehabilitation Center, Moscow, Russia Introduction: Method of single-port appendectomy in the treatment of acute appendicitis is used in the world recently. This method allows you to achieve a good cosmetic result, and perhaps reduce the number of wound complications. We performed 45 appendectomies through a single transumbilical access (study group). Methods: A prospective analysis of case histories of 237 patients who had surgery for acute appendicitis from November 2009 to March 2013. In the study group were 9 patients with complicated forms. The control group included 192 patients data who underwent laparoscopic appendectomy three puncture (15 cases of complicated forms). Results: No significant differences in baseline characteristics between the groups were not. The mean operative time in the study group was 65,4 ± 14,9 minutes, in the control group 62,8 ± 16,2 minutes (p> 0.05). One patient in control group with diffuse purulent peritonitis had the day after appendectomy and sanitation of the abdominal cavity to perform scheduled remedial relaparoscopy. Deaths were not. Average length of stay in the study group was 2,4 ± 1,4 bed-days (from 1 to 8 days) in the control group - 3,8 ± 1,3 bed-days (1 to 15 days). Conclusions: Thus, our data the single access does not extend the duration of laparoscopic appendectomy, is not accompanied by a high number of complications. Effectiveness and patient safety in complicated forms of acute appendicitis, and the importance of cosmetic advantages of this method requires further prospective evaluation.

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THE INFLUENCE OF HOSPITAL STAY ON POSTOPERATIVE COMPLICATIONS AFTER LAPAROSCOPIC APPENDECTOMY Jong Min Lee1, Ji Young Jang1, Seung Hwan Lee1, Hongjin Shim2, Jae Gil Lee1 1 Department of Surgery, Yonsei University College of Medicine, 2 Department of Surgery, Yonsei University Wonju College of Medicine Introduction: Laparoscopic appendectomy result in less postoperative pain, better cosmetic effect and shorter length of hospital stay, compared with open appendectomy. Many studies was reported about the postoperative hospital stay. The aim of this study was to evaluate the relationship between the length of hospitalization and complication rate after laparoscopic appendectomy. Methods: From January 2011 to December 2012, ninety-nine patients who underwent laparoscopic simple appendectomy were analyzed retrospectively. The patients were divided into two groups, admission within 48 hours and more than 48 hours. Postoperative complications such as wound infection, postoperative ileus and readmission were evaluated in the two groups. Results: Patients’ mean age was 49.3 ± 16.5 years and hospital stay was 3.7 ± 2.6 days respectively. The mean time from arrival at the emergency room to start of surgery was 550.6 ± 301.5 min. Among 99 patients, 38 patients were discharged within 48 hours, whereas 61 patients stayed longer than 48hours after surgery. There was no difference of the overall complication rate between two groups (10.5% vs 16.4%, p = 0.557). In addition, wound complication (7.9% vs 11.5%), occurrence of postoperative obstruction (2.6% vs 1.6%) and gastrointestinal symptoms (0 vs 3.3%) had no significant difference (p = 0.737, p = 1.000 and p = 0.522) in the two groups. Conclusions: Patients who underwent laparoscopic appendectomy due to uncomplicated acute appendicitis may be safely discharged within 48hour. Henceforth, Laparoscopic appendectomy in an outpatient setting deserves consideration to shorten waiting time for operation.

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POSTOPERATIVE COMPLICATION RATES FOR LAPAROSCOPIC VERSUS OPEN APPENDECTOMY Wataru Ishii M.D.1, Yohei Okada M.D.1, Tetsuya Ichikawa M.D.1, Yusuke Arai M.D.1, Kazumasa Oda M.D.1, Ken Sakakibara M.D.1, Satoshi Higaki M.D.1, Norio Sato Ph.D.2, Ryoji Iizuka M.D.1, Kaoru Koike Ph.D.2, Makoto Kitamura Ph.D.1 1 Kyoto Second Red Cross Hospital Department of Emergency Medicine, 2 Kyoto University Department of Primary Care and Emergency Medicine Introduction: Laparoscopic appendectomy is widely performed nowadays and it has been reported less complications. Although we performed laparoscopic, we still more operated openly. We conducted this study in order to evaluate whether laparoscopic appendectomy (LA) was an alternative therapeutic method to open appendectomy (OA) for acute appendicitis in our institute. Methods: In a retrospective survey, we analyzed 248 patients who underwent LA or OA at Kyoto 2nd red cross hospital between January 2011 and December 2012. Appendicitis was classified into two groups comparing clinical records and postoperative complications. Slight group was catarrhal or phlegmonous and serious group was gangrenous or perforated. Results: Acute appendicitis was treated in 210 patients by OA and 38 patients by LA. The median operative time in OA was 54.5 minutes and LA was 63.5 minutes (p<0.05). Slight group was 166 patients (OA; 141 and LA; 25) and serious group was 82 patients (OA; 69 and LA; 13). Postoperative complications were related to longer hospital stay compared to without complications (14.3 days vs 6.6 days, p<0.05). In serious group LA resulted in fewer wound infection compared to OA (7.7% vs 15.9%, p<0.05), however LA resulted in higher postoperative abscess compared to OA (23.1% vs 5.8%, p<0.05). Conclusions: We need to make efforts to reduce postoperative complications in order to shorten hospital stay for patients operated appendectomy. LA will become the first choice for serious acute appendicitis if we arrange the way of washing in abdominal cavity and reduce postoperative abscess successfully.

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LESSONS LEARNED WITH LAPAROSCOPIC MANAGEMENT OF ALL COMPLICATED GRADES OF ACUTE APPENDICITIS Carlos Augusto Gomes, Cleber Soares Junior, Rodrigo de Oliveira Peixoto, Camila Couto Gomes and Felipe Couto Gomes UFJF (Universidade Federal de Juiz de Fora) Introduction: Laparoscopy has not been consolidated yet as the approach of choice in the treatment of complicated acute appendicitis. Stratification of these clinical forms and an individualized analysis of the results by grade may provide new lessons and evidences. In this context, it is necessary to study the safe and effectiveness of laparoscopy in the management of different grades of complicated acute appendicitis. Methods: Prospective study of 131 patients with complicated acute appendicitis, who underwent a laparoscopic appendectomy from 2009 to 2011. Patients with gangrenous and/or perforated appendicitis, which led to abscess formation and degrees of peritonitis, were considered and were graded as 3A (segmental necrosis), 3B (base necrosis), 4A (abscess), 4B (regional peritonitis), and 5 (diffuse peritonitis). Results: The operative time; surgical complication (bleeding, iatrogenic injury, enteric leak); surgical site infection and conversion rate, were the outcomes that have chosen to evaluate the procedure. The grade 3A was the most frequent with 45 (34.3%) patients and the grade 3B was the least frequent with 12 (9.2%).The mean operative time was (67.54 Âą 28.13 minutes) and the grade 4A was the one that presented the higher operative time (78.24 Âą 28.72 minutes). The wound and intra-abdominal infection rates were 2.9% and 4.3%, respectively, the conversion rate was 4.3% and there were no operative complications. Conclusions: The laparoscopic management of all complicated grades of acute appendicitis is safe and effective and should be the procedure of first choice. The laparoscopic grading system allows us to assess patients in the same stage of the disease.

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EMERGENCY MANAGEMENT OF APPENDICEAL MASS AND ABSCESS Demetrashvili Z., Pipia I., Kenchadze G. Tbilisi State Medical University, Georgia Introduction: Management strategy of appendiceal mass or abscess is surrounded by controversy. Out of 2 methods of treatment (conservative management and emergency surgery) each one is characterized by positive and negative sides. This study was performed to identify the outcomes of emergency operations. Methods: We retrospectively analyzed 27 patients with appendicitis presenting with abscess or mass, who had emergency surgery in Tbilisi State’s Medical University’s central hospital’s General Surgery’s department. Results: The mean age was 35,7 years and ratio of males to females was 15:12. Abdominal pain was present in 25 (92,6%) patients with duration of average 8,7 days. Right lower quadrant tenderness with accompanying mass was present in 10 (37%) patients. The body temperature was an average 37,7°C. On the blood test, the number of leucocytes was an average 13,800/mm³. By computed tomography and ultrasonography correct preoperation diagnosis were made for 25 patients. Out of 27 patients, 18 of them had appendectomy, 7 – ileocecectomy and 2 – right hemicolectomy. There were 3 (11%) complications after surgery (all wound infection). Mean hospital stay was 7,4 days. Conclusions: For appendiceal mass or abscess treatment, may widely be used emergency surgery. While choosing surgery method, the area of inflammation and adhesion in this area needs to be taken under consideration. In these cases, sometimes, instead of a simple appendectomy needs to be done ileocecectomy or right colectomy.

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MODIFIED MINI-LAPAROSCOPIC APPENDECTOMY: A NONVISIBLE-SCAR SURGICAL ALTERNATIVE Saavedra-Perez D., Ginesta C., Valentini M., Vidal O., Benarroch G., GarcĂa-Valdecasas J.C. Hospital Clinic of Barcelona, Spain Introduction: Laparoscopic appendectomy via the three-trocar technique is widely used for appendectomy. Nowadays, new costly and complex techniques as the single incision laparoscopic (SILS) and natural orifice surgery (NOTES) have been developed to face the increasing concern about body image. This video demonstrates the mini-laparoscopic approach for acute appendicitis in one patient of our initial prospective case series. Methods: Between October and December 2012, patients <40 year old, with a body mass index <30kg/m2, and with suspected early phase of acute appendicitis were enrolled. All operations were performed by the same surgical team. Three ports were used: a 12mm intraumbilical port, a 5mm suprapubic port, and a 2.3mm port placed in the right iliac fossa. The position of the surgical team was modified according with the standard laparoscopic appendectomy. The operator was positioned in the patient left, in a cephalic position, the first assistant stayed at the operator left, and the scrub nurse facing them. The screen was placed on the right side but at the patient-right-upper quadrant. Always preserving an optimal laparoscopic triangulation, the 5mm/30Âş laparoscope was placed in the 5mm suprapubic trocar. Demographics, clinical, and surgical characteristics were recorded. Results: A total of 7 patients with a mean age of 25 +- 6years underwent this approach. The mean duration of the operation was 50+-10 min. Total incision surface was in all cases of 19.3mm. Right parietocolic visualization since the suprapubic port was better than at the standard periumbilical one, and mesoappendix dissection was also facilitated since this optical position. The operation was completed successfully in all patients, and conversion to either standard laparoscopic or open surgery was not required. All patients experience oral intake reintroduction after 12 hours and were discharged after 42 hours of the surgery without any complication. The appearance of the abdominal scars was excellent in all the patients at 10 days after surgery. Conclusions: Modified mini-laparoscopic appendectomy was feasible and safe in this initial experience, and could represent a reproducible alternative to standard and advanced minimal invasive techniques. The view provided via the suprapubic position makes access to and dissection of the appendix easier.

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LAPAROSCOPIC APPENDECTOMY IN PATIENTS OVER 65 YEARS OLD: CLINICAL AND SURGICAL CHARACTERISTICS Saavedra-Perez D., Ginesta C., Sampson J., Hidalgo N.J., Valentini M., Vidal O., Morales X., Martinez A., Benarroch G., Garcia-Valdecasas J.C. Hospital Clinic of Barcelona, Spain Introduction: Studies on laparoscopic appendectomy exclusively among the elderly population are scarce. The aim of this study was to evaluate the clinical, pathological and surgical characteristics of patients over 65 years old with acute appendicitis. Methods: This was a prospective observational study (January 2010December 2011). Patients >65 years old with suspected diagnosis of acute appendicitis were enrolled. Demographic, clinical, surgical and postoperative characteristics were evaluated under a univariate analysis comparing the elderly (65-79-year-old) with the super-elderly (>80-yearold) patients. Results: A total of 512 patients were diagnosed with acute appendicitis in our emergency department, 51 patients (10%) were evaluated: 35 (69%) belonged to the elderly and 16 (31%) to the super-elderly group. Superelderly patients had higher rates of peripheral vascular disease (25%vs6%, p=0.047), dementia (19%vs3%, p=0.049), chronic lung disease (25%vs6%, p = 0.047), and a higher median Charlson comorbidity index (3vs5.5, p<0.001). Atypical presentation was evidenced in 85% of the patients, and abdominal ultrasound and/or computed tomography were employed in the 81%. The laparoscopic approach was completed in 97% (34/35) and in 94% (15/16) of the elderly and super-elderly group respectively, without conversion to open surgery. Although there were no differences in the means of time for the total surgical delay, super-elderly patients had higher rates of perforation (81%vs42%, p=0.022) and peritonitis (88%vs60%, p=0.045). Postoperative complications were present in 23% (8/35) and 44% (7/16) of the patients for each group (p=0.19), being the 65% of them grade I. Two patients died in the postoperative period because of medical complications, both patients presented perforated appendicitis, peritonitis and severe septic shock, and underwent emergent exploratory laparotomy. Medians for hospital stay were 3 and 5.5 days for the elderly and super-elderly group, respectively (p=0.06). The same differences were found in the subgroup analysis of patients with perforated appendicitis. Conclusions: Laparoscopic appendectomy could have a positive impact on the number and grade of postoperative complications, shorting the hospital stay of complex elderly patients with evolved acute appendicitis, and importantly preventing through the potential lost of individual performance

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in this special group of patients. These results should be confirmed by randomized and prospective population based studies.

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ASSESSING PATIENT SATISFACTION AFTER LAPAROSCOPIC APPENDECECTOMY Agarwal A., Haque M. University of Manchester, UK Introduction: Assess satisfaction of patients, aged >16, who had a laparoscopic appendecectomy between 01/01/12 to 31/09/12. Methods: Patients meeting the criteria were telephoned and asked questions from a questionnaire assessing satisfaction pre-operatively, intraoperatively and post-operatively, and satisfaction with different healthcare providers. Results: 83.3% patients were overall satisfied with healthcare provided. A mean score of 4.4 was given by all patients for all responses. Information given post-operatively had the lowest score of any variable with 4.2. 86.4% all responses were very satisfied or satisfied. Conclusions: The standard set for the criteria was met. On the whole patients were satisfied with all components of care, most satisfied with intra-operative care and the surgeons and least satisfied with the information provided and care from the nurses.

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PREDICTIVE VALUE OF ABNORMALLY RAISED SERUM BILIRUBIN IN ACUTE APPENDICITIS Chambers A.C., Davies H., Bismohun S., Patil A. Great Western Hospital, Swindon, UK Introduction: Appendicitis is a clinical diagnosis aided by White Cell Count (WCC), C - reactive protein (CRP) and radiological investigations. Bilirubin levels may distinguish acute appendicitis from perforated or gangrenous appendicitis. Enabling prioritisation of patients with perforated appendicitis on operating lists and reducing investigations. This work validates research with UK data. Methods: A retrospective study of 1347 patients who have undergone either laparoscopic or open appendicectomy between 2008-2011. Data collected included Sex, Age, Length of Stay, admission WCC, Neutrophil count, CRP and bilirubin. Histology was recorded as Normal, Inflamed, Gangrenous/Perforated. Statistical analysis was performed with KruskalWallis and binary logistical regression. Results: Kruskal-Wallis indicated bilirubin levels were significantly different (H = 128.87, df = 4, p <.001), post hoc analysis with Bonferonni adjustment showed perforated/gangrenous to be significantly higher than all other groups (p<0.001). Serum bilirubin was also analysed with regard to perforation/gangrene and the clinical relevance of the bilirubin level, was it abnormal or normal. These results showed if the appendix was perforated/gangrenous then 49.2% had bilirubin of <=18 (normal result in GWH) attaining to non-significance statistically. Combination of WCC, CRP and Bilirubin indicated a inflamed or Perforated appendix with a sensitivity and specificity of 74% with AUROC 0.806. Conclusions: Our studyâ&#x20AC;&#x2122;s results indicate that serum bilirubin is not an independent marker of perforation but use can be made of serum biomarkers especially when combined with one another. It contradicts previous research undertaken. Appendicitis should still be predominantly a clinical diagnosis.

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SURGICAL MANAGEMENT OF ACUTE PANCREATITIS: OUR EXPERIENCE D'Aloisio G., D'Agostino G., Oldani A., Butera F., Garavoglia M. University of Eastern Piedmont "Amedeo Avogadro" A.O.U. Maggiore della CaritĂ Novara, Italy Introduction: The management of necrotising pancreatistis is still evolving, with many controversies in Literature about conservative versus invasive treatment, surgical timing and procedures. Methods: From February 1995 to January 2013, 65 patients were admitted for severe acute pancreatitis. Diagnosis was defined by the presence of at least one of the following criteria: - Ranson score > 3 - Apache II score > 8 - Evidence at CT scan of pancreatic necrosis. Results: 38 patients (58.46%) underwent conservative treatment. Surgical approach was necessary in 27 cases (41.54%). In 8 patients surgery was performed within 48 hours because of the rapid worsening and evolution towards sepsis and multi organ failure. Surgical procedures comprehended debridment, necrosectomy, peritoneal washing and drainage; 8 patients (41.54%) underwent postoperative continuous peritoneal washing; V.A.C. therapy was applied in 4 cases (20.77%), because of abdominal compartimental syndrome. Reiterated surgery was necessary in all patients; reâ&#x20AC;&#x201C;operation were performed on the basis of worsening of clinical and or radiological status. Postoperative mortality rate was 18.51%, overall 7.69%. Conclusions: Management of severe acute pancreatitis is a challenge; intensive conservative treatment should be the first approach, but in cases of sepsis or multi organ failure, surgery is necessary. We prefer intensive monitoring delaying surgery until elements of sepsis occurs. Continuous peritoneal washing can reduce reiterated surgery. Mortality rates remain high.

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PROGNOSTIC ROLE OF C-REACTIVE PROTEIN AND MATRIX METALLOPROTEINASE-9 IN ACUTE PANCREATITIS Brachini G., Mingoli A., Binda B., Mariotta G., Mogini V., Miglior E., Saracino A. Sapienza University Rome, Italy Introduction: Few early prognostic indicators are known to support clinical decision-making to reduce morbidity and mortality in acute pancreatitis (AP). C-reactive protein (CRP) and Matrix Metalloproteinase 9 (MMP-9), are under evaluation. Methods: The aim of this prospective study was the assessment of serum CRP and MMP-9 as early prognostic markers in AP. Sixty-five patients were enrolled from 2006 to 2011. The CRP level and Ranson, APACHE II and Balthazar scores were calculated in all patients, the MMP-9 level was dosed in 26 patients, all at admission and after 48 hours. Results: Mean patient’s age was 60.5 ys. Forty-eight patients developed mild AP and 17 severe AP. Within the severe group mortality was 17.6%. Six patients (35.3%) had pancreatic necrosis and 7 (41.2%) persistent organ dysfunction. In the MMP-9 group there were 15 mild AP and 11 severe AP. All the scoring systems, CRP at 0 and 48 hours and MMP-9 at admission were significantly higher in the severe AP group: CRP 0hr 141.4±94 mg/L vs 42.6±55.6 mg/L p=0.001; CRP 48hr 194.9±87.2 mg/L vs 71.1±81.5 mg/L p<0.001; MMP-9 0hr 27.6±6.3 ng/ml vs 16.2±7.7 ng/ml p<0.001. A multivariate logistic regression model revealed that CRP at 48 hours was the most reliable prognostic factor of pancreatitis severity (p=0.0276). A positive correlation between MMP-9 calculated at admission and pancreatitis severity (p=0.0489) was also observed. Conclusions: These results, even in a small number of patients, suggest that early MMP-9 level and 48 hours CRP are valuable predicting factors for severe pancreatitis

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ABDOMINAL COMPUTED TOMOGRAPHY (CT) SCAN IN ACUTE PANCREATITIS (AP): SOONER OR LATER? Aral M., Melo R.B., Castro S., Oliveira M., Graรงa L., Costa-Maia J. Centro Hospitalar Sao Joao, Portugal Introduction: AP follows a mild course in 80% of cases; 5-10%, however, develop pancreatic necrosis. Early CT may be performed to distinguish AP from other intra-abdominal conditions or to identify early pancreatic necrosis. We analyzed 1 year of AP in our center and our practice and yield of CT. Methods: Retrospective observational study. Etiology, disease course, CT timing, Balthazar score and clinical management were evaluated in all patients with an AP diagnosis during 2012. AP severity was classified according to Atlanta 2012 classification. Results: Two hundred and nineteen patients were admitted with acute pancreatitis and 36 with acute-on-chronic pancreatitis; 53,7% were male, with a median age of 62 years. Etiology was biliary (51,8%), alcoholic (21,2%), unknown (14,9%), iatrogenic (6,3%). AP was mild in 80,8% of patients; 5,9% had a severe disease. At least one CT (range 1-12) was acquired in 43,8% of patients. Practice, timing, and Balthazar score in early CTs were not significantly different between mild and severe AP. Clinical management was not altered after early CT In 83,3% of patients; in 16,7% prophylactic antibiotics were started, in spite of no evidence of infected necrosis. Conclusions: CT was frequently acquired early in the course of AP, but it had few implications in clinical management. Clinicians should be more restrictive in the use of early CT, to prevent unnecessary radiation exposure and to save costs.

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SIGNS OF SUPPURATION OF PERI / PANCREATIC COLLECTIONS IN ACUTE PANCREATITIS 1

Khokha V.1, Khokha D.2 City Hospital, Mozyr, Belarus, 2Medical University, Gomel, Belarus

Introduction: The mortality and morbidity significantly increases when peri / pancreatic collections in patients with acute pancreatitis(AP) become infected. Methods: Case histories of patients over the period 2010-2012 in Mozyr city hospital with acute pancreatitis were analyzed and divided into two groups. Group 1 - who underwent percutaneous or surgical drainage of collections. Group 2 - who were treated conservatively. We analyzed temperature, leukocytosis, number of band neutrophils, hemoglobin, erythrocyte sedimentation rate (ESR) on admission and on the day of diagnosing a collection or draining/operation, size and density of collection. Results: 28 patients were included. Group 1 - 17 men, mean 43.9 years, 4 women, mean 53. Group 2 - 6 men (mean 40.2 years) and one woman of 56 years. Alcohol was etiologic factor in 79%. There were no statistically significant differences in temperature, leukocytosis, neutrophil shift and ESR between the groups. Density and size of collections on RCT in group 1 were greater: 19.3 [13.9 - 32.6] Hu and 17,5 [16-18,8] Hu; 7,9 [6-8, 8]cm3 and 5.1 [4.8 - 6.5] cm3 respectively. Furthermore, patients from group 1 were significantly more often hospitalized to the intensive care (75% and 14%), period from onset of disease was longer (7 [3-16] and 1 [1-2] days), and hyperthermia was observed later (at 17 [12 - 24.8] and 7 [5-9] day of hospitalization). Conclusions: 1. Period from the onset of the disease, the day of hyperthermia, the size and density of peri/pancreatic collection may be prognostically important in the diagnosis of infection.

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STEP-UP APPROACH TO ACUTE NECROTIC-HAEMORRHAGIC PANCREATITIS: CAN TIGECYCLINE BE INCLUDED IN ANTIBIOTICS THERAPEUTIC STRATEGY? Morganti L., Cultrera R., Vasquez G., Andreotti D., Maccatrozzo S., Cappellari L., Stano R., Occhionorelli S. Dipartimento di Chirurgia d'Urgenza-Arcispedale S'Anna- Cona, Ferrara, Italy Introduction: Acute necrotic-haemorrhagic pancreatitis (ANP) is a severe and life-threatening disease whose prevalence is increasing. Antibiotic strategy is still discussed; in literature there are no clear guidelines about when and what kind of antibiotics are best to use. The present study investigates the option of an antibiotic protocol which includes tigecycline. Methods: This retrospective analysis included 20 clinically homogeneous patients, who referred for severe pancreatitis. All the patient population has been investigated by means of case report forms into which clinical resolution, recovery time, short and long term complications and eventual death causes have been reported. Results: Eighteen patients (18/20) underwent a conservative approach; among these 2 cases benefited of also a US/CT-guided percutaneous fluid collections drainage. Four have benefited from tigecycline. Only 2 (2/20) patients undergo surgical dĂŠbridment with a mortality rate of 100% (2/2). Antibiotics administration started according to general conditions, leukocytosis and fever. First choice is broad spectrum antibiotic as penicillin and quinolone. In case of failure we used off label, as second-third choice, we use tigecycline in association. Conclusions: Combined antimicrobial therapy, which include tigecycline, result in successful resolution of septic shock. Large trials and multicentric studies are still necessary to fully understand the safety profile and efficacy of tigecycline in ANP treatment.

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REVIEW AND RE - EVALUATION OF THE SCORE SYSTEMS DEFINING THE BEHAVIOR IN PATIENTS WITH ACUTE PANCREATITIS Georgi Minkov MD, c PhD; Yovcho Yovtchev MD PhD; Alen Petrov MD c PhD; Stoyan Nikolov MD University Hospital, Department of surgery, Bulgaria Introduction: Adequate assessment of the clinical status of patients with acute pancreatitis is the basis for rapid control of topical and systemic complications. For this purpose 35 years ago created the Ranson criteria, and subsequently introduced new scales for reporting local and systemic complications (Glasgow (Imrie) scale, Marshall scores; MOD; LOD; SOFA; acute physiology and chronic health evaluation II (APACHE II) score, BISAP and CT severity index (CTSI); Japanese severity score system (JSS). Methods: This study examined and analyzed all available medical information related to the specificity, sensitivity and disadvantages of the currently used scale for assessing patients with acute pancreatitis. The scope of study covered the period from month January 1974 to Month February 2013. Committed is gathering and analyzing information published in PUBMED and MEDLAIN systems. Results: The efforts of many collectives in recent years were focused on clinical evaluation and treatment of patients with acute pancreatitis. This is apparent from published data in all international guidelines. Proposed scores systems helped differentiate and monitoring of local and systemic complications and helped in taking decision for surgical behavior. Although using different components with strong predictive capabilities, no scale is characterized by a high enough sensitivity and specificity to ensure complex evaluation of patients with acute pancreatitis. None score system does hold that a comprehensive assessment designed to individualize and monitor those parameters influencing our decisions about appropriate treatment. Conclusions: So the collected information contributes to the development of evidence in support of our opinion that the scales used for clinical evaluation of patients with acute pancreatitis remain important for the proper management for this disease. However, none of them can not be used as both an individual assessment and a comprehensive approach in treating disease.

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EVALUATION OF EMERGENCY SURGICAL ADMISSION BURDEN OF ACUTE PANCREATITIS Ayantunde A., Choudhury S., Yousaf A., Praveen B. Southend University Hospital, UK Introduction: Acute pancreatitis is a significant emergency associated with significant morbidity and mortality even in the best of centres. Aim to evaluate our emergency surgical admission burden of acute pancreatitis and aetiological factors. Methods: Confirmed acute pancreatitis admitted to our emergency surgical admission unit between 2005 and 2010 were reviewed. Data collected relate to patients demography, clinical and pathological factors. The incidence of the aetiological factors, length of hospital stay, associated morbidities and mortality rate were calculated. Results: There were 857 admissions in 597 patients with acute pancreatitis over the study period. The median age was 55 (17-121) years with male to female ratio of 1.3:1. A progressive rise in the cases per year was noted. The commonest aetiological factor was cholelithiasis in 45%, then alcohol abuse 30%, hypercholesterolaemia 5.3%, drugs related 2%, hypercalcaemia 1.3%, post ERCP in 0.8% and idiopathic cause accounted for 15.6%. Patients with alcoholic pancreatitis were generally younger. 148 patients had multiple admissions with median admission rate of 6 (2-26). Median hospital stay was 6 (1-199) days. Only 14.3% of patients with cholelithiasis had cholecysteomy within 2 weeks of their admission. Complications included respiratory 18%, 9% developed confirmed pancreatic pseudocyst and 4.4% acute kidney failure. A positive correlation between alcoholic induced pancreatitis and recurrent presentation was found. There was 8% (48/597) mortality rate. Conclusions: This study showed a rising incidence in the cases of acute pancreatitis admitted to the surgical emergency unit. Within 2 weeks cholecystectomy rate was lower than recommended for gallstone pancreatitis.

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ENDOSCOPIC AND SURGICAL TREATMENT IN PATIENTS AFFECTED ON ACUTE BILIARY PANCREATITIS Fornaro R., Frascio M., Stabilini C., Imperatore M., Bruno S., Curletti G.L., Perotti S., Gianetta E. Department of Surgery, University of Genoa, Italy Introduction: The results of endoscopic and surgical treatment in 42 pts affected on acute biliary pancreatitis (ABP) are reported. Methods: All pts were managed according to the same protocol. Performed diagnosis (pain, serum amylase, ultrasonography) and evaluated the severity (Ransonâ&#x20AC;&#x2122;s criteria, glucose and urea levels, CT scan), the 42 pts underwent to ERCP, within 24 hours in 16 pts (predicted severe disease) or within 72 hours in 26 pts (predicted mild disease). Results: The endoscopic sphincterotomy (ES) was performed in 36 pts with stones in the common bile duct (CBD); it was successful in 94,5% (34 pts: 6 pts underwent more than one session to confirm or achieve CBD clearence). The morbidity was 8% (3 pts: 2 bleeding, 1 perforation). There were no deaths. The cholecistectomy was performed in 32 pts within 2-10 weeks from the initial attack of ABP. There were 3 minor complications (respiratory, laparotomy, urinary infection), no major intraoperative or postoperative morbidity, no mortality. Conclusions: The mortality, but can surgical treatment. of pancreatitis and find the aetiology within 72 hours.

ABP is still associated with significant morbidity and be managed safely with a combined endoscopic and We recommend one stop tests for severity stratification imaging within 24 hours of admission in AP in order to so that ERCP and sphincterotomy can be performed

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LAPAROSCOPIC CHOLECISTECTOMY: THE EXPERIENCE OF A YOUNG SOURGEON Prando D., Torchiaro M., Verza L.A., Rubinato L., Azabdafdari A., Roveran A., Vacca U., Agresta F. Chirurgia Generale, Ospedale Civile di Adria, ULSS 19 Regione del Veneto, Italy Introduction: Fundamental treatment for acute cholecystitis is cholecystectomy (1). There is strong evidence that early laparoscopic cholecystectomy for acute cholecystitis offers an advantage in the length of hospital stay without increasing the morbidity or mortality (2). Is it safe even if it is performed by young surgeon that had not yet completed the learning curve? Methods: We considered two group of consecutive patients that underwend laparoscopic cholecystectomy from March 2011 to March 2012. Group A underwent cholecystectomy for acute cholecystitis and group B for cholelitiasis. All the surgical operation were perfomed by the same young surgeon assisted by an expert surgeon. Results: Group A: 15 patients, median age 66.86 (range 91-46); 7 female/ 8 male, duration of surgical operation was 57.1 min and hospital stay 2.42. Group B: 15 patients, median age 40 (range 22 â&#x20AC;&#x201C; 72); 7 female/8 male, duration of surgical operation was 48.5 and hospital stay 2 days. There have been no complications in both groups; there has been no statistical difference between the hospital stay (p=0.11). The median duration of the operation has been 2,42 days for group A and 2 days for group B, but it has been not significative (p=0.06). Conclusions: Laparoscopic Cholecistectomy, for cholelitiasis and acute cholecystitis, is safe if performed by young surgeon in presence of an expert surgeon.

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MINI-APPROACH CHOLECYSTECTOMY FOR THE PATIENTS WITH COMORBIDITIES Abdullaev E.G., Babyshin V.V., Gachabayov M., Abdullaev A.E. Vladimir City Hospital of Urgent Medical Aid, Vladimir, Russia Introduction: Patients with higher risk of physiologic complications of pneumoperitoneum who were presented with different comorbidities leading to cardiorespiratory failure, coagulopathies, hepatorenal dysfunction, fetal death etc., especially those with acute cholecystitis, became the subject of this retrospective analysis. Methods: From 2007 to 2012, 780 cholecystectomies by mini-approach were performed, from those 409(52.5%) for acute cholecystitis. Comorbidities of these patients included ischemic heart disease, poorlycontrolled hypertension, chronic obstructive lung disease, severe diabetes mellitus, liver cirrhosis, pregnancy, polymorbidity. Several criteria, especially morphologic conditions, intraoperative and postoperative complications and mortality were analyzed. Results: 364 (89%) were without and 45 (11%) were with common bile duct (CBT) pathology including choledocholithiasis- 19(42.2%), acute cholangitis- 15 (33.3%), Mirizzi syndrome- 8 (17.7%), diverticula- 2 (4.4%), choledochal cyst- 1 (2.2%). Intraoperative complications (CBT injury) observed in 2 patients (0.48%), postoperative complications- in 21 patient (5.13%). The commonest type of complications appeared to be local wound complications- 1.71%. Other complications include acute pancreatitis, biloma, adult respiratory distress syndrome, deep vein thrombosis, pulmonary embolism, gastrointestinal bleeding, miscarriage risk etc. Mortality appeared to be 0.48%: 1 patient- adult respiratory distress syndrome, 1 patient- pulmonary embolism. Conclusions: Mini-approach cholecystectomy is the best choice for the patients with acute cholecystitis and sub- or decompensated comorbidities. Besides this, mini-approach cholecystectomy can be a good alternative to laparoscopic cholecystectomy for elective biliary surgery for the patients with comorbidities and a technique of conversion from laparoscopic to open cholecystectomy.

WJES & WSES Meeting 71

DURATION OF ATTACK DOES NOT PREDICT MORBIDITY AFTER LAPAROSCOPIC CHOLECYSTECTOMY FOR ACUTE CHOLECYSTITIS Milovanov V.V., Lyadov V.K., Ermakov N.A., Egiev V.N. Surgical Department, Federal Medical and Rehabilitation Center, Moscow, Russia Introduction: Optimal treatment algorythm for acute calculous cholecystitis is not clearly defined. Some studies suggest that the duration of acute inflammation for more than 3 days might be a contraindication to an urgent cholecystectomy because of potential surgical morbidity. We conducted a retrospective analysis of the results of laparoscopic cholecystectomy for acute calculous cholecystitis regarding the duration of pain. Methods: We included the data of 113 patients with acute cholecystitis, treated in our Surgical Department from January 2008 to December 2010. The mean age was 50-13 years (26-90). All patients underwent a standard laparoscopic cholecystectomy. In 57 patients surgery was performed within first 3 days from the start of the cholecystitis attack (Group 1), in 56 cases the duration of attack constituted more than 3 days (Group 2). Surgery was performed by experienced surgeons as well as trainees under supervision, equally distributed between the groups. Statistical analysis was performed using SPSS Statistics v.20. Significant differences were considered at p<0.05. Results: The following complications were encountered: Group 1: infiltrate (3), pancreatitis (1). Group 2 - intraabdominal bleeding (1), pancreatitis (1). There were no statistically significant differences between Group 1 and Group 2. Regarding mean operative time (72 vs 79 min, p=0.24), mortality (0 vs 1, p<0.05), number of complications (4 vs 2 p = 0.15), average hospital stay (4.5 vs 3.6 days, p = 0.122). Conclusions: Laparoscopic cholecystectomy for acute calculous cholecystitis is feasible and safe regardless of the duration of attack in specialized centers of endoscopic surgery.

WJES & WSES Meeting 72

GALLSTONES MEDIATED ABDOMINAL BLEEDING REQUIRING EMERGENCY LAPAROTOMY: REPORT OF A UNIQUE CASE Cocozza E., Livraghi L., Berselli M., Mangano A., Latham L., Fontana F., Bianchi V., Farassino L. Azienda Ospedaliera Ospedale di Circolo e Fondazione Macchi, Varese, Italy Introduction: Spontaneous hemoperitoneum (blood within the peritoneal cavity unrelated to trauma) can be a life-threatening situation. It is more frequently diagnosed via multiple imaging modalities and often unsuspected from its clinical presentation. Its causes can be: vascular, splenic, gynecological, hepatic and altered coagulation status. A non-previouslypublished cause of hemoperitoneum is described. Methods: A 82-years-old male patient presented a recent-onset-pain in the right-upper-abdominal quadrant. The cardiovascular / neurological / physical findings were normal. The abdominal Ultrasound described perisplenic / parietocolic fluid and an atrophic gallbladder containing stones. An abdominal Computed Tomography was performed showing hematic fluid in the peri-hepatic region and active bleeding of unknown origin in the pericholecistic area. An arteriography was performed showing a pseudoaneurism and active bleeding of the RHA. No endovascular treatment was indicated and an emergency surgical procedure was performed. Results: A right-subcostal-laparotomic-incision were performed. An important hemo-peritoneum was detected. The Pringleâ&#x20AC;&#x2122;s surgical maneuver and several washings of the abdominal cavity were performed. An erosion of the hepatic artery due to a big gallbladder-stone was the cause of the hemorragy. The arterial tear was repaired via Prolene 5/0â&#x201E;˘ and further reinforcement has been achieved applying haemostatic products on the former site of blood loss. Finally, a peritoneal toilette was performed. Three surgical drains were placed. The post-operative time was characterized by a biliary fistula development (from the cystic duct stump) successfully treated via an endoscopic stent placement. Conclusions: This clinical case is, at our knowledge, the first one described in English scientific literature presenting a spontaneous-hemoperitoneum related to a gallbladder stone-mediated-hepatic-vascular erosion. In this case the early diagnosis made possible an early surgical intervention and a related positive outcome for the patient.

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PREVALENCE OF SEVERE IATROGENIC INJURY IN PATIENTS WITH CHOLELITHIASIS AND SUPRAUMBILICAL INCISION UNDERGOING LAPAROSCOPIC CHOLECYSTECTOMY Gomes C.A., Murillo Bastos Netto J., Cléber Soares Júnior, Gonçalves Leite I.C., Couto Gomes C., Couto Gomes F. Universidade Federal de Juiz de Fora (UFJF) and Faculdade de Ciências Médicas e da Saúde de Juiz de Fora (Suprema), Brazil Introduction: Little is known about the prevalence of severe iatrogenic injury among patients with cholelithiasis and supraumbilical incision who are submitted to laparoscopic cholecystectomy. Methods: From 738 patients with cholelithiasis submitted to laparoscopic cholecystectomy, 32 presented supraumbilical incision. The development of iatrogenic biliary, vascular and hollow viscera injury were considered severe and were evaluated. A 2x2 contingent table was used to calculate the prevalence and the reason of prevalence between those with and without supraumbilical scar. Results: Two patients with supraumbilical incision had visceral perforation and four without previous supraumblical incision had biliary injury. The prevalence of iatrogenic injury in the patients with supraumbilical incision was 6,25%, whereas in the group without incision was 0,57% (p=0,02). The reason of prevalence was 11,03 (IC 95% 2,1-58,02), showing that in the group with supraumbilical incision the frequency of iatrogenic lesions is 11 times higher than in the group without scar. The imprecision of the confidence interval is due to the fact that the exposure in study, as well as the prevalence of the outcome, are rare. Conclusions: Patients with cholelithiasis and previous supraumbilical incision, when submitted to laparoscopic cholecystectomy, present a significative greater risk of injury and they should be advised about their increased chance of this possibility.

WJES & WSES Meeting 74

IS IT POSSIBLE TO CONTAIN THE USE OF CT SCAN DURING CLINICAL PRACTICE IN RELATION TO ACUTE DIVERTICULAR DISEASE WITHOUT JEOPARDIZING THE PROSPECT OF RECOVERY? OUR PRELIMINARY EXPERIENCE Caputo P., Rovagnati M., Carzaniga P.L. Dpt. of Surgery, L.Mandic Hospital- Merate (Lecco), Italy Introduction: According to modern guidelines defining the importance of correctly identifying when diagnostic instruments should be used, both to safeguard patientsâ&#x20AC;&#x2122;health and of the impact on health expenditure, we carried out this study so as to asses the possibility of limiting the use of Computerised Tomography (CT scan) and preferring Ultrasound testing (US) in the field of acute diverticular disease. Methods: We performed a retrospective work by reassessing the medical records of 100 admission to our department over a period of 12 months. All patients has been observed in First Aid dept. and arrived with a diagnosis of acute diverticulitis, formulated in the Emergency Room (time 1:T1), on the basis of 85 US and 29 CT scans. 93 patients out of 100 were classified with the Hinchey score upon the admission. It was considered necessary to proceed with a deferred test 72 hours (time 2:T2) after Hs attribution by means of 29 US and 79 CT scan, 21 cases were assessed using both methods. At the T2 test, there was a shift of Hs class to 38 (40,8%) cases. 30 cases were upgraded (78,9%) and 8 were downgraded (21.1%). There were no changes of class in Hs 3 and 4. 12 patients underwent Operative Approach (OA) by Ultrasuond Percutaneous Drainage (UPD) or surgery. None patients Hs0, Hs 1a and Hs 1b despite being affected by localized peritonism, underwent OA. We observed the comparison of radiological medical results between the US-T1 and CT-T2 diagnoses and the degree of consensus. Results: For classes Hs 0,H1a,H1b, we found no significant changes in T2. In this clinical area we were unable to prove any advantage in using CT scan diagnosis, particularly in T2 as regards the program of therapeutic procedures to adopt in the absence of clinical deterioration. The average hospitalization curve was directly proportional to the increasing of Hs classes, with a vertical drop for Hs3 and Hs4 which were sudden underwent to OA. Conclusions: The assignment of an admission class using Hs is in order to choose the therapy. CT scan is more sensitive and specific than the US scan, making CT scanning in T2 determinant in doubtful or deteriorating cases. We have no evidence to need to make significant changes to therapy for classes below H2a so is justifiable to consider CT scan control by default in this patients to be superfluous.

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COMPLICATED DIVERTICULITIS: “RETHINKING THE RULES” AND THE GOALS Romagnoli F., Catani M., De Milito R., Farina A., Ragozzino R., Modini C. Emergency Department - Umberto I Policlinico di Roma, La Sapienza Università di Roma, Italy Introduction: The gold standard treatment in event of complicated colonic diverticulitis has changed many times in the decades, “rethinking” the rules on different surgical approach and access. The aim of our study was to investigate predictive factors for conservative and operative treatment in complicated diverticulitis, their advantages and disadvantages. Methods: Patients admitted to the Emergency Department of Umberto I Policlinico di Roma, tertiary level hospital, for complicated diverticulitis between 2007-2009 have been retrospectively analyzed. Patients presented haemorrhagic complication and IV Hinchey score were excluded from the analysis. Predictive factors for treatment, therapeutic pathways and follow up have been studied. Results: 34 patients were treated conservatively, mean age 65.4, 58% ASA score>3, mortality rate 2.9%, mean hospital stay was 7 days. 39 patients were treated operatively, 13 after failed conservative treatment, mean age 60.4, 62% ASA score >3. Dehiscence rate 10.7%, morbidity and mortality rate were 28% and 10.25% respectively. Hansen&Stock-score and volume of fluid collection at CT resulted independent factors for treatment, long history of diverticulosis and higher duration of symptoms resulted protective factors. No differences were found between groups for mortality rate and follow-up outcomes, except for greater hospital admission rate and need for surgery in the conservative group. Conclusions: Conservative treatment is clearly indicated in those patients who present low risk of failure because of its long hospital stay, recurrences and need for subsequent hospital admission and surgery. Alternatively operative treatment maintains high early and late complication rate. The best approach and focused surgery remain an open issue.

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SIGMOID DIVERTICULITIS PERFORATION: LAPAROSCOPIC TREATMENT Cocorullo G., Carollo G., Di Maggio M.A., Fontana T., Agrusa A., Salamone G., Gulotta G. Department of General, Emergency and Transplant Surgery (GENURTO)Unit of General and Emergency Surgery, University of Palermo, Italy Introduction: The progressive increase in the incidence of sigmoid diverticulitis perforation of general population is a particularly timely topic; in the last decade it has gradually imposed laparoscopic treatment to a large extent in selected cases. Methods: Referring to Hincheyâ&#x20AC;&#x2122;s classification, in the period 2010-2013, we treated 46 cases, 26 of them in laparoscopic surgery. There have been 27 surgical interventions of resection-anastomosis (RA) in single-time for 16 Hinchey I (14L) patients, 7 Hinchey IIa (5 L) patients, 6 Hinchey IIb (4 L) patients, 8 Hinchey III (4 L) patients. In 13 patients (3 Hinchey III and 10 Hinchey IV) we performed Hartmannâ&#x20AC;&#x2122;s procedure. 1 (Hinchey IV) of them died and another 3 (Hinchey III) underwent laparoscopic treatment. Results: On Hinchey I-II-III patients 3 conversion cases were recorded and the rest underwent laparoscopic techniques; we recorded only 3 case of fistulization that required a second look. Conclusions: The laparoscopical resection-anastomosis in single-time, also with diverticulitis perforation in Hinchey I, II, III, proved to be feasible and safe in our casuistry with superimposable results to the international literature.

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IS LIMITED USE OF CT SCAN JUSTIFIED IN ACUTE DIVERTICULITIS (AD)? RESULTS FROM A 100 CASES SERIES Caputo P., Rovagnati M., Carzaniga P.L. Merate Hospital via L. Mandic- Merate (LC), Italy Introduction: Amount of ionized radio-diagnostics became an issue in forensic medicine. Aim of the study was to rule out a safe threshold for the need of CT scan in acute diverticulitis (AD). Methods: Consecutive patients admitted between January 2008 and December 2010 were retrospectively reviewed. Inclusion criteria was AD as primary diagnosis at admission. Diagnostic procedures were recorded. For complicated AD, Hinchey score (H) was calculated after CT. Correlation between second-step imaging and therapeutic action was analyzed. Results: Study cohort included 100 patients. Twelve patients underwent operative procedures. US-guided percutaneous drainage was needed in 5 cases, and surgery in 7 (2 patients undergoing both). Either US or CT was required in 92 patients. Overall 105 US and 118 CT were performed. CT diagnosed complicated AD in 63.8% of cases, while US was sufficient in 14 cases (15.2%). After CT scan, no operative procedures were needed in H1a/H1b. In H2a/H2b, 2/3 (66.6%) and 2/2 (100%) patients respectively underwent operative procedure. Delayed CT changed therapeutic action overall in 5%. When peritoneal inflammation was present, second-step CT upgraded H in 58.6% of cases (but surgery was needed in only 4.3%). Conclusions: Limitation of second-step CT scan to H0, H1a or H1b appears to be safe in AD.

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PNEUMORETROPERITONEUM AND PNEUMOMEDIASTINUM REVEALING A LEFT COLON PERFORATION Montori G., Di Giacomo G., Mzoughi Z., Angot C., Al Samman S., Cheynel N. Division of General and Emergency Surgery, Centre Hospitalier Universitaire Bocage, Dijon, France Introduction: Left colon perforation usually occurs in complicated diverticulitis or cancer. The most frequent signs are intraperitoneal abscess or peritonitis. In case of retroperitoneal colonic perforation diagnosis may be difficult. Methods: A 59-year-old woman presented with left thigh pain, abdominal discomfort associated with mild dyspnea. Computed tomography (CT) scan showed air bubbles and fecal material in the retroperitoneum, with subcutaneous emphysema extended from the left thigh to the neck. CT also revealed portal vein gas and thrombosis with multiple liver abscesses. Results: An emergency laparotomy revealed a perforation of the proximal left colon. No masses were found. A left colectomy was performed. Retroperitoneum was drained and washed extensively. A negative pressure wound therapy was applied. A second look laparotomy was performed 48 h later. The retroperitoneum was drained by only one large laminar drain. An end-colostomy was performed ICU post-operative stay was 9 days, and surgery definitive airway was removed on the third postoperative day. Conclusions: Pneumoretroperitoneum and pneumomediastinum are rare signs of colonic retroperitoneal perforation. The diagnosis may be delayed especially in the absence of peritoneum irritation. CT scan might be useful in those cases and the treatment may be as rapid as possible to improve prognosis.

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SURGICAL TREATMENT OF DIVERTICULITIS OF THE COLON Fornaro R., Frascio M., Stabilini C., Curletti G.L., Imperatore M., Bruno S., Perotti S., Gianetta E. Department of Surgery, University of Genoa, Italy Introduction: The management of complicated diverticular disease of the colon is still not well clear. Methods: During the last decade were observed 422 patients with various degree of diverticular disease of the colon, all of whom were symptomatic. 51 patients underwent surgery: 29 for stenosis or oclusion (24 e 5), 4 for fistulas, 18 for perforation. The operations, 26 of which were emergencies while 25 were elective, included: 21cases of one-stage resection and anastomosis without protective colostomy, 16 with colostomy, 8 Hartmannâ&#x20AC;&#x2122;s procedures, 7 Mikuliczâ&#x20AC;&#x2122;s operations, 1 suturing of the diverticulum with colostomy. Results: The incidence of complications was 17,6% -9 cases-, 7 following emergency surgery and 2 after elective procedures). The intraoperative mortality was zero, while postoperatively it was 5,8% (3 cases, 2 after emergency procedures and 1 following elective surgery). Conclusions: The best results (lowest morbility and mortality rates) occurred with the radical procedures, especially the resection-anastomosis with or without colostomy, which allowed the removal of the septic focus from the peritoneal cavity and thus a rapid recovery in a high number of cases.

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EARLY OUTCOME AFTER SURGERY FOR ADHESIVE SMALL BOWEL OBSTRUCTION: 5-YEARS EXPERIENCE Mazzoni G., Raparelli L., Vagni V., De Bartolomeo R., Mazzarella Farao R. Ospedale di Viterbo, Italy Introduction: Post-operative intraperitoneal adhesions represents a heterogeneous clinical condition. Multiple patients characteristics and surgeonsâ&#x20AC;&#x2122; attitude influence the management, which therefore is difficult to standardize both for timing and type of surgery. The aim of this study was to evaluate early outcomes in patients treated with a fast diagnostic and therapeutic approach. Methods: A prospective database of consecutive patients operated on in urgency for small bowel obstruction was reviewed. All patients with severe symptoms or rapid impairment, underwent an early CT scan to assess the indication to surgery. Peri-operative features were analyzed with univariate and multivariate analyses to test their effects on morbi-mortality. Results: From January 2007 to December 2011 ninety eight patients were evaluated. Eleven patients were operated on in emergency, eighty seven patients underwent CT scan sooner than six hours after admission. Mortality and morbidity were 5.1% and 23.4% respectively. At univariate analysis patients with lower peri-operative values of albuminemia, intestinal signs of ischemia, matted adhesions and high ASA grade showed a higher incidence of complications. However in multivariate analysis only lower post-operative serum albumin level was associated with increased morbidity. Conclusions: Timing of surgery in the management of patients with small bowel obstruction is pivotal but blurred. Early CT scan identifies patients without clear clinical signs requiring surgery, and hints prompt operation decreasing post-operative complications. In this group of patients the most powerful prognostic factor remain the post-operative serum albumin level.

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HOSTILE ABDOMEN: DEFINITON, PREDICTORS AND CLASSIFICATION Gerych I. Danylo Halytsky’ Lviv National Medical University, Ukraine Introduction: We define «hostile abdomen» (HA) as the abdomen with (1) persistent loss of natural free spaces between intra-abdominal organs and structures of abdominal compartment (anterior abdominal wall, retroperitoneal space, pelvic concavity, etc.), (2) pathological changes of their normal anatomical proportions and (3) syntopy, caused by the massive dense (aggressive) adhesions. Methods: From 2000 to 2013, we prospectively collected 32 consecutive patients with HA (8 female, 24 males, median age of 43 years). HA were determined using chart review and an expert panel. Etiology, predictors, disease course, intraoperative findings and data of abdominal visualization were evaluated. Results: HA was a consequence of previous laparotomies (>2), peritonitis, severe pancreatitis, anastomotic leakage, ostomy, open/staged abdomen techniques, prolonged intestinal intubation, Crohn’s disease, radiotherapy or peritoneal canceromatosis. The main prediction’ criteria of HA include: (1) anamnestic data (typical clinical situations that cause HA), (2) clinical data (massive defects, deforming scars or retraction of edges of anterior abdominal wall, enterocutaneous or “enteroatmospheric” fistulae, persistent bowel obstruction etc.) and (3) data of abdominal visualization (free intraabdominal space, proportion and syntopy). We have developed a classification of HA by completeness and type of lesions of abdominal compartment (abdominal cavity and the abdominal wall). Conclusions: HA is a complex surgical problem. Clear definitions of HA, its predictors and pragmatic classification allow to develop a definitive plan for the management of a patient with this pathology through the maximal individualization of treatment approaches.

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Abstracts

Monday, July 8, 2013

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NEEDLE DECOMPRESSION OF TENSION PNEUMOTHORAX, IS OUR EDUCATION OF THE PREHOSPITAL PROVIDER ADEQUATE? Buchanan D.Z., Dominguez Ekeh A.P., Tchorz K.M., Woods R.J., McCarthy M.C., Dennlinger L.A., Saxe J.M. Wright State University Dayton, Ohio Introduction: Prehospital needle decompression has long been considered life-saving in patients with tension pneumothorax. The process improvement (PI) study of needle decompression noted an increase in the number of non-therapeutic needle decompressions. As a part of our regional PI process we evaluated all needle decompression cases presenting to the single regional level one trauma center. Methods: A retrospective study of all needle decompressions which arrived at a urban level one trauma center were evaluated as part of normal PI process. Data collected included; age, sex, type of injury, ISS, AIS, RTS, CXR radiological reading and independent CXR review, CT scan reading, site evaluation of needle decompression, number of required chest tube placements Results: 63 patients presented over a 3 year period with needle decompression. Initial CXR was positive for pneumothorax in only 36% of the patients. None of the patients showed evidence of tension pneumothorax. CT evaluation showed pneumothorax in 80% but was completely normal in 20%. Indications for needle decompression rarely associated with ATLS guidelines. Conclusions: Review of educational guidelines for needle decompression which operate under a regional protocol do not appear to follow ATLS guidelines. Vague guidlines led to nontherapeutic needle decompressions in the majority of cases. Furthermore inaccurate placement was seen in the majority of cases. Evaluation of this data has led to a substantive change in the regional prehosptial protocols for needle decompression and a change in teaching methods by the Level 1 Trauma Center.

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TRAUMA & EMERGENCY SURGERY EDUCATION AND TRAINING IN PORTUGAL Mesquita C. Portuguese Medical Association, College of Competence in Emergency Medicine - National Steering Group for Emergency Surgery Education, Portugal Introduction: The Portuguese Medical Association (Ordem dos Médicos, OM) is the official entity that regulates all the medical and surgical activities in Portugal, being his duty to protect the public interest. There are three official ways to differentiate: Specialty (vertical), Subspecialty (vertical) and Competence (transversal). Doctors may access to a subspecialty or a competence as a second step, after a specialty. Methods: Doctors must be registered with to practise medicine or surgery. OM also sets the standards and outcomes for basic medical education. After graduating from medical school and completing their foundation training, doctors usually complete a third and even a fourth stage of postgraduate training, whose standards are set by the Colleges. These are responsible for promoting the development of postgraduate medical education and training for all, establishing standards and requirements and making sure they are met across the country. Results: Emergency Medicine exists as a competence since 2002 and goes behind the pre-hospital acute care. The College strongly supports the development of an autonomous College of Competence on Emergency Surgery (trauma surgery included) and it exists, since 2007, a national Steering Group on Emergency Surgery Education (Grupo de Trabalho para a Formação Específica em Cirurgia de Emergência), with 13 representatives from general surgery (7), neurosurgery (1), orthopaedics (1), thoracic (1), vascular (1), urological (1) and paediatric surgery (1). All general surgeons are IATSIC members and representatives of the existing trauma and emergency surgery societies: Sociedade Portuguesa de Cirurgia, Grupo Trauma, Associação Lusitana de Trauma e Emergência Cirúrgica and Sociedade Portuguesa de Trauma. Those who are DSTC national faculty also lead the National Steering Committee for DSTC, after a memorandum of understanding signed with IATSIC in 2008. The other members are representatives of the colleges of the most relevant surgical specialties in this field. Conclusions: The main objective of this multidisciplinary steering group is the development of an autonomous College to rule, soon, the emergency surgery education and training in Portugal and act as national representative near the UEMS and other international institutions.

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COLONIC STENT PLACEMENT AS A BRIDGE TO SURGERY IN PATIENTS WITH LEFT-SIDED MALIGNANT LARGE BOWEL OBSTRUCTION. AN OBSERVATIONAL STUDY Tartarini D., Cappellari L., Occhionorelli S., Stano R., Vasquez G. Azienda Ospedaliera Universitaria di Ferrara, Surgical Department, Emergency Surgery Service, Italy Introduction: Acute left-sided malignant colonic obstruction is common in elderly patients, in which emergency surgery is related with high morbidity and mortality rates, and often necessitates a two-step resection. Although the use of self-expanding metallic stents (SEMS) in elderly patients has not been adequately described yet, there are almost two international important trials which are still in progress, the stenting technique is established to be, by the international literature, an useful treatment with low morbidity and mortality. Itâ&#x20AC;&#x2122;s also a bridge to surgery, since the insertion of a SEMS can decompress the obstruction, making bowel and patient preparation possible and facilitating single-stage surgical resection. Palliative stenting can improve quality of life when compared to surgery in patients with metastasis or high co-morbidity. The aim of this study is to analyze mortality, avoidance of stoma, short- and long-term survival in patient with malignant left-sided large bowel obstruction who underwent to stent placement in our Emergency Surgery Unit, which is operative since November 2010 in our city Hospital in Ferrara. Methods: Between November 2010 and December 2012 a total of 15 patients with acute left-sided malignant large bowel obstruction suitable for colonic stent application were admitted to Emergency Surgery Unit. Among these patients, 9 underwent to self-expanding metallic stent placement (group A), the other (group B) 6 patient underwent to emergency surgery. In this observational not-randomized study we analyzed the efficacy and safety of SEMS placement for patients either as a bridge to surgery or as a palliation, beside the short term and long term outcomes, versus those patients operated straight. Results: Self-expanding metallic stents were successfully implanted in 9 of the 15 patients with acute left-sided malignant large bowel obstruction. No acute procedure-related complication was observed. All the patients in group A kept the stent in place for an average of 7,7 days, then everyone underwent to surgery. A large bowel resection with one-time recanalization was performed in 8 of the 9 patients. None Hartmann resection was necessary. Only one underwent again to surgery because of a dehiscence, a stoma was necessary. Between the other 6 patients in group B who underwent directly to surgery, In one case was necessary an Hartmann resection, another one incurred in dehiscence of the anastomosis that required reoperation with stoma creation.

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Conclusions: Placement of SEMS seems to be an useful alternative to emergent surgery in the management of acute left-sided bowel obstruction, both as a bridge to surgery and as a palliative procedure. SEMS can provide an effective and safe therapeutic option compared to emergency surgery, most of all in elderly patients, with a lower mortality rate, a significantly higher rate of primary anastomosis and the avoidance of stoma. However, to fully determine their role for these indications, more data and more high level evidence is required.

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LAPAROSCOPIC RESECTION AFTER STENTING IN INTESTINAL OBSTRUCTION FOR CARCINOMA : A SINGLE-CENTER RETROSPECTIVE STUDY Gatti A.1, Spinelli A., Locatelli A.1, Strada D.1, Ferrara E.2, Elmore U.1, Bona S.1, Montorsi M.1 1 Dept. of General Surgery, Istituto Clinico Humanitas, IRCCS, Rozzano (MI) â&#x20AC;&#x201C; Medical School of Digestive Surgery, University of Milan, 2Service of Endoscopy, Istituto Clinico Humanitas, IRCCS, Rozzano (MI), Italy Introduction: To assess the outcome of laparoscopic and open colic resections after stenting in intestinal obstruction for carcinoma is challenging. Methods: Retrospective data of 34 patients referred to our center between september 2006 and febbrary 2013 for colic resection after SEMs placement. Results: Interval between SEMs placement and surgery was 6.3 days (range 1-18). Patients treated with primary palliative intent (n=7), had an interval of 147 days (range 30-315). 4 of them (57%) had neaodiuvant chemotherapy for advanced tumour with liver metastasis. We performed 20 laparoscopic (59%) and 14 open colic resections. Mortality was 0%. Operative time was 192 minutes in laparoscopic group, and 183 minutes in open group. 19 (95%) versus 8 patients (57%) had primary anastomosis in laparoscopic and open group, respectively. 6 Hartmannâ&#x20AC;&#x2122;s were performed by laparotomy, 3 patients had life-long colostomy. Median post-operative stay was 6.95 days for laparoscopic group (range 7-23) and 10.8 days (range 7-22) for open group. For laparoscopic group major complications occurred in 10% of patients (n=2), 7% (n=1) for open group. Only one reintervention. In laparoscopic group a shorter median interval between surgery and initiation of adjuvant chemotherapy was observed (5 weeks vs. 6 weeks). We assessed 14,7% (n=5) of incisional hernias in a 35 month follow up, exclusively in open group. Conclusions: After stent placement elective surgery is safe and feasible. Despite the limitation of rectrospective series, the endolaparoscopic approach provides lower incidence of stomas, limited hospital stay and shorter interval between surgery and chemotherapy, avoiding occurrence of incisional hernias.

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MANAGEMENT OF ESOPHAGEAL PERFORATION : OUR EXPERIENCE Feleppa C., Banchini F., Delfanti R., Grassi C., Capelli P. Ospedale Guglielmo Da Saliceto Di Piacenza, U.O. Chirurgia Generale Vascolare Senologica, Italy Introduction: Esophageal perforation represent a surgical emergency whose mortality rate can be up to 60% (this depending on several factors: cause of perforation and its location, timing of surgical procedure, surgery etc). Up today there is not yet a general consensus about the ideal treatment of this emergency condition. Methods: Usually surgery has been considered the gold standard approach to esophageal perforation. However recent literature data reveal that non operative management in selected cases can be successful. We report four different cases, 3 male patients and 1 female patient with different etiology of esophageal perforation followed by 4 different management. Results: A 43 years old patient presented a cervical esoshageal perforation during upper endoscopy. A CT scan showed a pneumomediastinum and subcutaneous emphysema. No sepsis was present : a conservative method was performed. A 52 years old patient presented an intra abdominal esophageal perforation. A two stage surgery (exclusion, diversion followed later by esophageal reconstruction) was performed. A 63 years old patient with spontaneous thoracic esophageal rupture was treated by primary closure reinforced with pleural flap. A 55 years old patient with accidental drinking of caustic agent was treated with a two stage procedure with esophageal resection followed by colonic reconstruction. Conclusions: Esophageal perforation management represents a challenge for general surgeons because of the necessity of early diagnosis and the choice of treatment which depends on patient performance, ethiology and site of perforation, status of the esophagus and timing of diagnosis.

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MANAGEMENT OF ESOPHAGEAL PERFORATION IN 18 PATIENTS TREATED OVER A 10-YEAR PERIOD Rausa E., Macchitella Y., Bona D., Bernardi D., Bonavina L. IRCCS Policlinico San Donato, University of Milano Medical School, Italy Introduction: Esophageal perforation is a surgical emergency in the majority of the patients. The timing and the most appropriate surgical management of this life-threatening condition is still debated. Methods: Eighteen consecutive patients treated between 2004 and 2012 were retrospectively studied. There were 11 men and 7 women, mean age 61,2 years (range 27â&#x20AC;&#x201C;85). The site of perforation was the cervical esophagus in 4 patients (22%), thoracic esophagus in 5 (28%), and esophagogastric junction in 9 (50%). The etiology of perforation was iatrogenic in 13 patients (72%), spontaneous in 4 (22%), and from foreign body in 1 (6%). ASA score was used to stratify the preoperative patientâ&#x20AC;&#x2122;s risk: 11 patients (61%) were classified ASA 1-2, and 7 (39%) ASA 3-4. The main primary treatment was surgical in 10 patients (55,5%), endoscopic in 7 (39%), and conservative in 1 (5,5%). Results: Hospital mortality rate was 16% (3/18). In these three patients the etiology of the perforations was iatrogenic, the site was the thoracic esophagus, and the average diagnostic delay was 6 hrs (range 4-8); all of them were ASA 3-4. Mortality was significantly higher in patients with perforation of thoracic esophagus (p = 0,01), in ASA 3-4 (p = 0,017), and in those with diagnostic delay < 24 hrs (p = 0,047). Conclusions: The management of esophageal perforations requires an individual approach; the outcome is related to the etiology, the site, and the general patient condition.

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BAROTRAUMATIC PERFORATION OF THE PHARYNX AND THORACIC OESOPHAGUS FOLLOWING BITE OF INNER TUBE OF MOTORCYCLE TIRE: A CASE REPORT Balamoun H. Faculty of medicine, Cairo university, Egypt Introduction: Pharyngo-oesophageal perforation is a life threatening injury, with high morbidity and mortality which requires early recognition and intervention. we report a rare case of a 10 years old boy who had a separate pharyngeal and thoracic oesophageal tears following bite of inner tube of motorcycle tire, which were recognized late. Methods: Urgent neck exploration revealed ruptured pharynx, defunctioning loop pharyngostomy, neck drainage and feeding jejeunostomy were performed at first stage, followed by oesophagogram which showed second injury at the lower thoracic oesophagus, gastrooesophageal disconnection was done, followed 2 months later by gastric transposition for oesophageal replacement. Results: Marked improvement of the patientâ&#x20AC;&#x2122;s general condition, feeding through the jejunostomy was established, mediastinitis improved, chest drains were removed, and the patient was transferred to paediatric surgery specialty hospital, where gastric transposition was performed for oesophageal replacement. Conclusions: Pharyngo-oesophageal perforation is a life threatening injury, early recognition of the injury is crucial for early intervention and primary repair, late recognition of the injury leads to multiple operations, with high morbidity and mortality.

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PERFORATION OF OESOPHAGOJEJUNAL ANASTOMOSIS BY OESOPHAGOJEJUNAL TUBE Mesquita C., Oliveira J., Castro-Sousa F. Coimbra University Hospital, Portugal Introduction: The AA highlight the importance of the damage control philosophy in difficult emergency surgery situations like the perforation of an oesophagojejunal anastomosis by an oesophagojejunal tube. Methods: Man, 78yo, 3rdPOD after total gastrectomy with precolic reconstruction for gastric cancer (T2N2MxR0) in another institution. No significant past diseases. Mechanically ventilated, septic shock with purulent drainage from right hemithorax and blue drainage from right abdominal upper quadrant after â&#x20AC;&#x153;methilene blueâ&#x20AC;? swallow. Distended abdomen. Relaparotomy with median frenotomy (Pinotti) and damage control procedures for oesophagojejunal and cardiophrenic pleural sinus perforation by an esophagojejunal tube, with right pleural empyema, mediastinitis and peritonitis: primary closure of the perforation, washing and drainage of the pleura, mediastinum and peritoneum, delayed abdominal closure (DAC, Rotondo and Schwab) and intensive care unit (ICU). On 5thPOD, revision of the mediastinum and peritoneum, no evidence of fistula: internal pleural drain retired, fibrin glue and collagen placed to protect the anastomosis, DAC and ICU. On 8th POD, anastomotic leak: a T-tube (Kehr) has been placed as a minimal drainage procedure; DAC and ICU. On 10thPOD, descendent feeding jejunostomy and abdominal closure. On 14thPOD, subfrenic abscess on CT scan: surgical drainage through the upper third of the previous closed laparotomy. On 32ndPOD, intestinal suboclusion: drainage jejunostomy above the feeding one. On 41stPOD, right pleural drainage: oesophagoscopy, T-tube removed and expansible silicon covered oesophageal prosthesis inserted, covering the anastomotic fistula. On 62ndPOD, patient left the ICU. Results: On 77thPOD, patient sent back to the institution where he has been operated first. On 99thPOD, endoscopical removal of the prosthesis with baritated swallow control, with patient sent back home. Conclusions: This case highlights the importance of the damage control philosophy in difficult emergency surgery situations like the perforation of an oesophagojejunal anastomosis by an oesophagojejunal tube.

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BLEEDING CONTROL OF AN AORTOESOPHAGEAL FISTULA WITH A SENGSTAKEN-BLAKEMORE TUBE Mesquita C., Patrão R. Coimbra University Hospital, Portugal Introduction: Aortoesophageal fistulas (AEF) are relatively rare but lifethreatening causes of upper gastro-intestinal bleeding, causing massive exsanguination. AEF may be primary or secondary. The majority is secondary and usually occurs in a setting of prior aortic reconstructive procedures. Transient self limited “herald bleed” may precede exsanguination. A Sengstaken-Blakemore tube can be life-saving as a first procedure, apart from the potential complications of its use, like esophageal and gastric ulceration and perforation, bronchoesophageal fistula and acute airway obstruction. Methods: A 48-year-old male patient with known pré-existing chronic hepatic disease and esofagogastric varices underwent emergency stent graft placement because of rupture of a proximal descending aortic aneurysm. A few hours later the patient produced massive bright red hematemesis covering the bed and the near floor of the ICU. This emergency situation has been controlled by immediate endotraqueal intubation, fluids and the successful introduction of a SengstakenBlakemore tube. Results: The endoscopic control, next day, showed the origin of the bleeding was not the varices but an AEF related with the ruptured aneurism. Conclusions: A Sengstaken-Blakemore tube can be life-saving as a first procedure, apart from the potential complications of its use, like esophageal and gastric ulceration and perforation, bronchoesophageal fistula and acute airway obstruction.

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DISPHAGIA AND EMERGENCY Fiorito R. Tor Vergata University, Roma, Italy Introduction: Actually the oesophageal and cardias carcinoma is a high morbility and mortality disease too.The main reason is a underestimated disphagic disease with a delayed clinical evaluation. The result is a very low quality of life and severe mortality. The purpose of this study was to reduce the high grade of the disphagia and improve the quality of life in patients affected by oesophagus cancer stenosis using a MultiDisciplinary Therapeutic Approach. Methods: In our last Universitary Endoscopic Ambulatory,during 10 years, we observed 135 patients affected by oesophageus disease.The grave or severe disphagia was the more frequent symptom. Sometime, there were other symptoms linked to disphagia (tab.1). The 89% cases arrived to our evaluation without an adeguate clinical-endoscopic-radiological documentation.All had previously been treated with anti H2 and pro-kinetic drugs for several months.We observed. 1) Primitive Neoplasm (78/120 p.=65%). 2) Secondary Neoplasm (12/120 p.= 10%). 3) Neoplastic Recurrences (17/120 p.=14.5%). 4) Flogistic Disease (5/120p.=4.16%). 5) Achalasia (5/120p.=4.16). 6) Barrett’s Disease (3/120p.=2.5%) (tab.2-3). Male/female ratio was 2.5/1.Various risk factors were classified (smoke=60%,Alchohol intake over 1000cc/die=60%,Obesity=25%, Barrett =2.5%) (tab.4) All the patients were valued with accurate clinical evaluation using a Multianalises Score System (tab.5-6-7-8-) In evaluating operability,we considered several parameters concerning the General Clinical Status and the Neoplasm Stage (TNM) (tab.9-10-11) Surgical treatment was established for only a few patients (15/135) which might gain advantages one-step open-surgical oesophagectomy,alone or combined to chemo-radio therapy,in according to international leterature. The others 120 patients with disphagia (III°rd level=80 p., IV°th level = 40 p.) were valued no-responders to classic open-VLS Surgery (tab.1213).They were treated with ELS (Endoscopic Laser Surgery) alone or combined to others treatments (EGDS Savary Dilatation,Endoprosthesis, XRays Therapy). Flexible fibre CO2 Laser and single-use pinches were employed to perform this kind of treatment.The Endoscopic Laser Energy was administered with a continuous power flow (20-40 Watts) and mixed Technique.We used a specific treatment to single patient and disease.The single dose ranged 800-2000 Joules.The procedure was cyclically repeated every 15-60 days.The Total Dose ranged 2000-6000 Joules.In general,we prefered the EGDS Savary Dilatation before the LES and positionating self expanding covered or non-covered stents (102)after ELS according Radiologist collegues. If necessary,RadioTherapy (mean dose 39 Gy) was associated too.

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Results: We obtained a total recanalisation in flogistic disphagia disease.We obtained an important recanalisation in the first 12 months in the 85% of the neoplastic stenosis and an enough recanalisation in the 60% of the cases between 12-24 months from the first treatment.After 24 months,we obtained an useful canalisation only in the 30% of the cases(tab.14).We registered some complications link to the treatment.(tab.15).The only one intra-operative death was in a 78 y.old patient affected by cardiomegaly.Probably,the cause was an arrest hearth because of the fatality laser energy propagation.So,the mortality for this laser-surgery treatment was lower than 1% and also the morbidity was reduced when compared to the other centers ‘dates.We registered oesophagus Iatrogenous perforations (3) too.These healed spontaneously after specific therapy (2) using thoracic drainage,antibiotic drugs,total parenteral nutrition).It has been necessary to place only one covered endoprosthesis. Our protocol provided a 3-years follow-up with long term survival ranging 30-900 days. Conclusions: ELS could be considered the main treatment to inoperable oesophageal cancer.According our dates we think that the Treatment don’t influence the survival,reduces absolutely the disphagic symptoms and improve the quality of life. The Cost/Benefit is profitable too.(tab.16) Tab.1 Symptom % Dysphagia 78 Epigastric pain 6 Heatburn 3 Weight loss only 3 Odinophagia 2 Vomiting/Regurgitation 2 Fatigue 2 GastroIntestinal bleeding 1 Nausea 1 Indigestion 1 Sore throat 1 Tab.2 Patology Diagnosis n.patients % Primitive Cancer 78 65 Secondary Cancer 12 10 K. Recurrences 17 14.5 Flogistic disease 5 4.16 Achalasia 5 4.16 Barrett’esophagus 3 2.5 Tab.3 Primitive Cancer n.patients % Cervical esoph. 10/78 12.8 Thoracic 17/78 21.7 Cardias 51/78 66.5 Tab.3 Secondary Cancer n.patients % Cervical esoph. (from laringeal K.) 7/12 58.2 Cardias (from lung-mediastinic K.) 5/12 39.7 Tab.4 Risk Factors Smoke 70 % Alcohol 60 % Obesity 30 % Barrett’s esophagus 2.5 % Tab.5 Clinical Evaluation General Status Pulmonary Function Cardio-Vascular Function Hepatic Function Renal Function Neurological Function Diabetes Tumor Stage Tab.6 Clinical Evaluation - General Status Sex Age Karnofsky Index Alcohol Abuse Tobacco Abuse Weight loss Dispepsia Mental Cooperation Blood examination Tab.7 Clinical Evaluation - Pulmonary/Renal Function Vital Capacity V.C Focal Expiratory Volume FEV 1 Peak Flow PaO2 mm/Hg PaCO2 mm/Hg Creatinine Clearance mg/ml Tab.8 Clinical Evaluation Cardiac/Hepatic Function ECG X-rays Chest Cardiologist Visit Serum Albumin Bilirubin P.T- P.T.T Aminopyrine Breath Test Cirrhosis Tab.9 Clinical Evaluation - Mental cooperation / Risk Karnofsky Index > 80 & good cooperation / Normal Karnofsky Index < 80 & good cooperation/ Compromised Karnofsky Index < 80 & bad cooperation/Severely impaired Tab.10 Clinical Evaluation - Cardiac Function / Risk Normal Normal Compromised Increased Severely impaired Highest Tab.10 Clinical Evaluation -Pulmonary Function / Risk VC > 90% PaO2 >70 mm/Hg Normal VC < 90% PaO2< 70 mm/Hg Compromised Tab.11 Clinical Evaluation – Hepatic Function / Risk ABT > 0.4 Normal ABT < 0.4 no Cirrhosis

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Compromised Cirrhosis Severely Impaired Tab.12 Conditions for inoperable patients III th Stage Neoplasm T3 N2 M0-1 Age over 75 Cardio-Vascular disease Coagulopaties Weight loss Immuno Compromised Tab.13 PreOperative Disphagia Patients III grade IV grade 120 80 40 Tab.14 PostOperative Disphagia grade % n.patients Follow-up/months I 85 102/120 <12 I 60 72/120 >12 <24 II 30 36/120 >24 Tab.15 Intra-Peri Operative Complications n.patient % Exitus 1/120 0.83 Iatrogenous perforation 3/120 2.5 Re â&#x20AC;&#x201C; Stricture (after RadioTherapy) 2/120 1.66 Tab.16 Cost effectiveness in the management of oesophageal K. Surgery RadioTherapy Laser Stents No Treatm. Median Cost $ 8070 4720 3520 2450 1390 Range 2540-39780 3364- 6687 2530- 6340 1647- 5550 1132- 2348 Cost /month Survival 457 364 342 / /

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CLINICAL MANAGEMENT OF ESOPHAGEAL PERFORATION; OUR EXPERIENCE Oldani A., Butera F., Garavoglia M. SCDU Clinica Chirurgica Università del Piemonte Orientale "Amedeo Avogadro" A.O.U. "Maggiore della Carità" Novara, Italy Introduction: Esophageal perforation is a rare and life threatening condition, with high mortality rate (at least 20% in Literature). Ruptures are usually iatrogenic; other causes are penetrating sharp injuries, ingestion of caustic substances, and the so – called Boerhaave syndrome. A delayed diagnosis results in a negative outcome. Methods: From 2002 to 2012, we observed 11 patients with esophageal rupture. Causes were iatrogenic (4, 36.4%), foreign body ingestion (2, 18.2%), Boerhaave Syndrome (2, 18.2%) caustic ingestion (1, 9.0%), blunt trauma (1,9.0%), cancer (1, 9.0%). Diagnosis was achieved within 24 hours in 4 patients (36.4%), later in 7 (63.6%). Results: 3 patients treated within 24 hours (27.3%) underwent primary repair; in the remaining 8 cases (72.7%) esophageal exclusion was performed; this option was preferred in 7 patients with severe mediastinitis whose perforation has been diagnosed after 24 hours, and in 1 case of early recognised lesion caused by foreign body ingestion with an important wall damage. Mortality rate was 18.2%. All the 6 surviving patients after exclusion underwent reconstruction after a median period of 6 months (range 4–12 months); in four case tubulised stomach has been used, in the remaining two reconstruction has been achieved using the right colon. Conclusions: Our experience confirms that primary repair is suitable in perforations diagnosed within 24 hours of the event. Exclusion is appropriate in critical patients, with delayed diagnosis and acute mediastinitis. In presence of severe lesions with high contamination, even if diagnosis is achieved within 24 hours, direct repair could be contraindicated.

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LIFE-SAVING EMERGENCY LAPAROTOMIES FOR A CASE SERIES OF RARE RUPTURED SPLENIC ARTERY ANEURYSMS Ley-Hui Tan M., Sverrisdottir A. Queenâ&#x20AC;&#x2122;s Hospital, Belvedere Road, Burton upon Trent, Staffordshire, UK Introduction: Splenic artery aneurysm (SAA) is rare and its aetiology is multifactorial. Ruptured-SAA (rSAA) has high mortality (25-70%). The double-rupture phenomenon is reported in 20-30% cases, that is when the initial bleed is contained within the lesser sac before blood escapes into peritoneal cavity causing hypovolaemic shock. Methods: A case series of three women, of whom 2 were pregnant presented to emergency department with splenic artery aneurysms. The three cases of rSAAs are described. The delayed presentation of hypotensive shock suggested, "double-rupture". All patients survived following emergency laparotomy following underunning of the aneurysmal artery and splenectomy, but no foetus survival. Results: Case-1: A 31yo female who was discharged following an improvement to acute left-sided abdominal pain presented a month later with similar pain, hypotension and an episode of loss of consciousness. Urgent CT-scan suggested splenic rupture. An emergency laparotomy revealed haemoperitoneum and rSAA. Case-2: A 41yo pregnant patient presented with acute left-sided abdominal pain and an episode of loss of consciousness. 6 hours later developed hypovolaemic shock. Emergency laparotomy revealed haemoperitonuem from rSAA. Case-3: A 23yo pregnant patient presented with severe abdominal pain, and hypotensive shock an hour later. Emergency c-section showed no evidence of placental abruption. Laparotomy found haemoperitoneum from rSAA. Conclusions: Although a ruptured-SAA is rare it is an important differential diagnosis for acute abdominal pain especially during pregnancy. The challenge is to diagnose SAA before it ruptures or if rSSA whilst it is contained to reduce morbidity and mortality.

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EMERGENCY ENDOVASCULAR TREATMENT FOR A GIANT RUPTURED HYPOGASTRIC ANEURYSM IN A PATIENT SUFFERING FROM EHLERS-DANLOS SYNDROME Poletto G.L., Giorgetti P.L., Popovich A., Casabianca E., Busoni C., Pedicini V., Poretti D., Brambilla G. IRCCS Istituto Clinico Humanitas, Rozzano (MI), Italy Introduction: Type-4 Ehlers-Danlos syndrome (Vascular-EDS) is an inherited connective tissue disorder marked by severe arterial complications, seldom observed in other EDS types. The prevalence of EDS ranges between 1/10,000 and 1/25,000 (V-EDS: 5-10%). Vascular complications may affect all anatomical areas, mostly large- and mediumsized arteries. Our study presents the case of a 60 y.o. male with EDS, hospitalized following severe abdominal pain with a pulsatile, uneven tumescence in the right iliac fossa. Methods: The patient –who underwent surgery several times, consequence of multiple aneurysms (left radial and humeral arteries; palmar arteries; splenic artery; bilateral iliac artery; common, superficial and deep right femoral artery; right gluteal artery; intrapetrous ICA; right mammary artery) – underwent Angio-CTA scan, showing a “…large aneurysm of the right hypogastric artery (maximum diameter 10 cm); occlusion at the origin of the hypogastric artery consequent to prior surgery. Plausible rupture with haemorrhagic suffusion, uncertain identification of feeding vessels”. A microcatheter retrograde superselective embolization (Glubran 2 acrylic glue mixed with Lipiodol Ultra-Fluid) was performed -by a left transfemoral percutaneous access- on the median sacral and left hypogastric arteries feeding vessels. Control CTA scan showed a completely thrombosed aneurysm. Results: Follow-up CTA scans (the latest one performed at 24 months) are confirming the complete exclusion of the hypogastric aneurysm. Conclusions: Patients suffering from vascular EDS often have a remarkably vast vascular history, which sometimes requires nonconventional treatment. In this specific case, a description was offered of an effective treatment for a giant ruptured hypogastric aneurysm, based purely on a percutaneous approach, performed under emergency.

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ABDOMINAL AORTIC ANEURYSMS: IS THE PRESSURE ON? Patil A.V., Aggarwal R., Tomlinson H., Singh-Ranger R. Great Western Hospital, Swindon, Wiltshire. UK Introduction: Studies have implied that periods of low atmospheric pressure could be associated with an increased incidence of ruptured abdominal aortic aneurysms (rAAA). Decreased atmospheric pressure is thought to increase intra-mural tension predisposing to rAAA. The aim of our study was to determine whether low atmospheric pressure is associated with rAAA. Methods: 131 patients with confirmed rAAA over a 10-year period were identified from retrospective hospital records. Daily pressure readings from the local meteorology station were obtained for the days on which ruptures occurred. The mean daily atmospheric pressure was calculated for the entire period of the study. Studentâ&#x20AC;&#x2122;s t-test was used for analysis. Results: Mean atmospheric pressure from the days of rupture (1013.78mB) was lower than the mean daily pressure over the 10 year period (1014.73). However this did not attain statistical significance (p = 0.1237). Conclusions: Our study does not demonstrate a significant relationship between atmospheric pressure and rAAA. This contradicts previous reports that suggest a significant association between low atmospheric pressure and the incidence of AAA rupture.

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PELVIC - UROGENITAL TRAUMA IN PEDIATRIC SURGERY REVISITED Fette A. University of Pecs, Medical School, Hungary Introduction: To treat pelvic - urogenital trauma in children will force the pediatric surgeon to manage not only the physical but also the psychological impact on this sensitive body area with usually a lot of delicate structures involved. Methods: The records of 25 children, median age 6 (range 2-13) years, m:f ratio = 1.3:1, who have been transfered to a busy international emergency pediatric surgeon, have been revisited. Their evaluation started from on scene presentation until final follow up consultation. In detail, the pelvic - urogenital trauma has been caused by: • roll - over injury (5 pts) • penetrating/perforating injury (3 pts) • straddle injury (6 pts) • extraction injury (3 pts) • medical injury (4 pts) • burns injury (2 pts) • sexual abuse/aussault injury (2pts). Results: The overall treatment of pelvic - urogenital trauma, especially in emergencies, is complex and the surgeon has to be familiar with a variety of techniques, surgical and non-surgical in front of a broad theoretical background. Besides this, attention have to be paid to psycho-social aspects, too, in order to prevent psychological or post traumatic stress disorder (PTSD) syndromes. In the majority of our cases a successful outcome could be achieved. Conclusions: Since pelvic - urogenital trauma is rare, no common traditional clinical pathways exist. Therefore, even emergency treatment must be tailored for the individual case by the surgeon in charge. Disclosure: No funding, no sponsoring, no financial interest.

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USE OF NPTWI IN FOURNIER'S GANGRENE Salamone G., Atzeni J., Agrusa A., Cocorullo G., Gulotta G. Dipartimento discipline Chirurgice, Oncologiche e Stomatologiche, University of Palermo, Italy Introduction: Fournier's gangrene (FG) is defined as a fulminant form of infective necrotizing fascitis of the perineal, genital or perianal regions. Even with appropriate treatment approaches, mortality is high as 4 to 67%. There have been many advances in management of Fournier gangrene including use of vacuum assisted closure and hyperbaric oxygen therapy. Methods: a 72 y.o. male with swelling, redness, pain on palpating and necrosis of the penis, scrotum and perineal area including the perianal area, with diabetes mellitus type II, previous non Hodgkin lymphoma recent surgery for perianal fistula, was admitted in our clinic. Because of the extensive involvement of the anus and its sphincter was necessary, as the first surgical time, the packaging of a terminal colostomy on sigma. After that, he underwent radical surgical debridement with excision of all necrotic material. Have been made abundant washing with hydrogen peroxide and betadine. Was used negative pressure wound therapy with controlled instillation of fluids (NPTWi). The treatment was then completed with hyperbaric oxygen therapy. This treatment was performed for 40 days until discharge. Results: the surgical treatment associated with NPTWi and hyperbaric oxygen therapy have allowed the resolution of the septic and an almost complete wound healing. Conclusions: Early recognition and aggressive surgical excision are mandatory for success in patients with Fournier's gangrene. The use of NPTWi in the treatment of Fournier's gangrene improves clinical outcomes and reduces hospital stay.

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RISK FACTORS IN COMPLICATED INTRA-ABDOMINAL INFECTIONS: PRELIMINARY DATA FROM A SINGLE CENTRE PARTICIPATING TO THE CIAO STUDY Rausei S., Marzorati A., Borroni G., Boni L., Dionigi G., Dionigi R. Department of Surgery, University of Insubria, Italy Introduction: The CIAO study is a multicenter observational study currently about complicated intra-abdominal infections management. For its accrual, between January and April 2012 we included 21 patients with infected peritonitis. We performed a risk analysis for this series. Methods: Nineteen out of 21 patients underwent surgery for treatment of abdominal infection: specifically, 7 patients presented with a colonic perforation, 3 with acute colonic diverticulitis, 3 with gastroduodenal perforation, 2 with acute cholecystitis, 2 with appendicitis, 1 with postoperative leaks and 1 with small bowel perforation. We observed no postoperative deaths. Hence, end points for this univariate analysis were hospital stay and reoperation. Results: Median postoperative hospital stay was 11 days (range: 7-37 days). Risk factors significantly associated with a length of stay > 11 days were age, diagnosis of malignancy, localized peritonitis (versus generalized one), colonic perforation, non-adequate source control (evaluated by surgeons after the procedure), sampling for intra-abdominal microbiological evaluation. Reoperation rate was 33% (7/21). Risk factors significantly associated with reoperation were colonic perforation, non-adequate source control and delay in the initial intervention. Conclusions: In the setting of complicated intra-abdominal infection, patient-, disease- and treatment-related risk factors for surgical outcomes are detectable also in a very small series of patients. The assessment of surgeon after an emergency abdominal procedure for infected peritonitis plays an important role in the management of this condition.

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TOTAL EXTRAPERITONEAL (TEP) HERNIOPLASTY WITH INTESTINAL RESECTION ASSISTED BY LAPAROSCOPY OF A STRANGULATED RICHTER FEMORAL HERNIA Saavedra-Perez D., Ginesta C., Valentini M., Vidal O., Benarroch G., GarcĂa-Valdecasas J.C. Hospital Clinic of Barcelona, Spain Introduction: Richter femoral hernia defined as an entrapment of only part of the circumference of the bowel in the hernia orifice, is a rare clinical condition with the highest strangulation and mortality rates. Due to the physiopathoplogic characteristics, clinical and radiologycal diagnosis would be difficult to perform prior its complication, highlighting the importance of surgical treatment. Laparoscopic approaches as the transabdominal preperitoneal (TAPP) and the total extraperitoneal (TEP) are safe and feasible for the non-complicated and incarcerated femoral hernias. Controversies remains about the best surgical approach. We describe the first clinical case of a TEP hernioplasty combined with intestinal resection assisted by laparoscopy for a strangulated Richter femoral hernia. Methods: The patient was a 94-year-old woman admitted to the emergency room with sings and symptoms of acute small bowel obstruction without systemic inflammatory response. Diagnosis of a strangulated left Richter femoral hernia was only possible during the initial exploratory laparoscopy. The remaining small bowel was normal and no other ipsi- or contra-lateral hernias were observed. We elected to perform an extraperitoneal approach for the mesh positioning, gaining access through the infraumbilical 12-mm trocar incision, and generating the preperitoneal space by standard dissection. With assistance of two 5-mm laparoscopic ports at hipogastrium and right flank, the TEP hernioplasty was achieved without incidents. Laparoscopy was resumed and non-viability of the affected bowel was confirmed. Segmental intestinal resection with end-toend manual anastomosis through the infraumbilical incision extended to 3cm was performed with previous protective bag insertion and confirmation of correct mesh position. Results: No intraoperative complications were present. Pathology evaluation demonstrated transmural ischemic necrosis with severe acute congestion and resection borders without ischemic changes. The patient recovered without immediate complications, with correct tolerance to the oral intake. She was discharged home at the 4th postoperative day. No wound complicatons were present. Conclusions: TEP approach for the acute hernioplasty completed with segmental bowel resection with laparoscopic assistance was successful in our particular case; suggesting its use for emergency hernia repair. However, factors as laparoscopic surgical experience, careful patient

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selection and correct preoperative diagnosis, must be considered before clinical studies in the emergency setting.

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PERINEAL TRAUMA BY IMPALEMENT Banchini F., Feleppa C., Bandone M., Albertario S., Capelli P. UO Chirurgia Generale Vascolare Senologica, Ospedale Guglielmo da Saliceto di Piacenza, Italy Introduction: Perineal trauma with penetrating wound are severe injuries with high rates of septic complications. They reppresent a difficult challenge for surgeon especially if a contemporaneous urogenital injury is present. Methods: We discuss two cases of perineal trauma by accidental impaling by implement farm with contemporaneous sphincterial rectal and urological lesions. Up today there is no literary consensus in management and only multidisciplinary approach is the mainstay for treatment. Results: A 14years old female patient was hospitalised for a penetrating lesion sectioning the external anal sphincter and penetrating the rectum in to douglas recex. colostomy was performed. Subsequent endorectal ultrasound revealed partial sphincterial section. Biofeedback was started with restoration of sphincetrial activity and colostomy closure. A 42 years old man was admitted for a penetreting lesion, with section of anal sphincetr and rectum, passing through the prostate and the uretra and penetreting the bladder. COLOSTOMY, urologic reconstruction and drainage of a septic abscess of the retius were performed. Manometry at 12month revealed partial sphincter activity. Further procedure must be considered. Conclusions: Perineal trauma represents a particular problem for the surgeon especially in emergency surgery, because of the possibility to create an extending iatrogenic lesion. A multidisciplinary approach is recommended to prevent this situation, with careful management of the situation.

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AN INCREASING TREND IN RETAINED RECTAL FOREIGN BODY Ayantunde A.A., Unluer Z. Southend University Hospital, UK Introduction: Retained rectal foreign body is no longer a rarity although concrete epidemiological data are lacking. Recent anecdotal reports suggest an increasing incidence. Delayed presentation and vague history by the patients leads to significant diagnostic and management challenges. This study highlights the rising trend in the presentation with retained rectal foreign body over a 5-year period. Methods: Retrospective review of the cases of retained rectal foreign bodies 2008-2012 was performed. Patientsâ&#x20AC;&#x2122; clinical data and yearly case presentation and data relating to hospital episodes were collected. Data analysis was by SPSS Inc. Chicago, IL, USA. Results: 25 patients presented over a 5-year period with a mean age of 39 (17-62) years and M: F ratio of 2:1. A progressive rise in cases was noted from 2008 to 2012 with 3, 4, 4, 6, 8 recorded patients per year respectively. The majority of the impacted rectal objects were used for self/partner-eroticism. The commonest foreign bodies were sex vibrators and dildos. 96% of the patients required extraction while one passed spontaneously. Two and 3 patients with easily palpable objects had retrieval in the ED and on the ward respectively while 19 patients needed examination under anaesthesia (EUA) for extraction. The mean hospital stay was 19 (2-38) hours. Identified associated psychosocial issues included depression, deliberate self-harm, illicit drug abuse, anxiety and alcoholism. There were no psychosocial problems identified in 15 patients. Conclusions: This study shows a progressive rising incidence of retained rectal foreign body with increasing use of various designed/improvised objects for sexual arousal.

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IS IT SAFE TO POSTPONE SURGERY OF PATIENTS DIAGNOSED WITH PERI- ANAL ABSCESS? Eran Brauner, Mariya Neymark, Offir Ben- Ishay, Mahmoud Atamla, Yoram Kluger Department of General Surgery, Rambam Health Care Campus, Haifa, Israel Introduction: Patients diagnosed with perianal abscess (PAA) may triage late for surgery due to overwhelming crowdedness of the Emergency Department with surgical emergencies. Data on the impact of timing of surgical intervention on outcome of patients diagnosed with PAA is lacking. The aim of this study was to examine actual time to surgery (aTTS) and its influence on outcome of patients diagnosed with PAA. Methods: All patients admitted from January 2011 through December 2012 with PAA were identified using patients' electronic files. Patients diagnosed with IBD were not included. Age, gender; initial temperature, WBC count, aTTS, antibiotic treatment and length of stay (LOS) were compared. Recurrent PAA was defined as repeat visit due to PAA or other local septic complication more than 10 days after the index operation. Results: 240 patients (median age 43.9±15.9, 68.3% male) were diagnosed with PAA during the study period. Median temperature on admission was 370 ±0.5 and median WBC count was 12,900±400. 5.4% suffered from Inflammatory Bowel Disease (IBD) and 16.7% from Diabetes Mellitus. Median time from ED admission to surgery was 591±289.9 minutes. Median LOS was 1(1-2) days. After excluding patients with IBD and <10 days recurrence, 182 patients recovered and didn’t experience recurrent PA disease. 23 were readmitted for PAA during the study period. Median actual time to surgery (aTTS), WBC and admission temperature didn’t differ significantly between patients with and without recurrence. Conclusions: Compulsory time delay of surgery does not increase LOS and has no impact on recurrence rate of patients diagnosed with PAA.

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LAPAROSCOPIC TREATMENT OF SPLENIC INJURY IN BLUNT ABDOMINAL TRAUMA Ali Ibrahim Yahya, Hussen E Shwereif, Mustafa Ahemed Ekheil, Ahmed Thoboot, Kalid Amar Algader, Najla Endasha Zliten Teaching Hospital, Libya Introduction: Blunt abdominal trauma is common trauma incident,usually due to road traffic accidents, rarely happened because of fall from height or fell of heavy object on the body or following assault, road traffic accident is common community problem, abdominal trauma can be treval where there is no internal bleeding or major where there is solid organ injury, moderate or severe trauma where there is significant bleeding, patients will need active treatment in the hospital, laparotomy still has role in severe blunt abdominal trauma,some patients will end with big wound and later big scar, with complication of hernia and may get intestinal obstruction due to adhesion and patient will end of visiting the hospital for recurrent attacks of intestinal adhesive obstruction, laparoscopy in trauma was used by surgeons since long time, but recently with development of laparoscopy, including equipments and training, trauma surgeons started utilizing laparoscopy in trauma including penetrating and blunt trauma for diagnosing and treating the injury. Methods: In our study we reviewed all files of patients underwent laparocopy for blunt abdominal trauma seventy six (76), fifty four were male and twenty two were female their age ranging from 9 years to 65 years, all those patients were admitted to our ICU, they had resuscitation according to ATLS protocols, full careful clinical examination were done for all patients, 6 patients had GCS less than 8 and were put on ventilator, other patients were conscious with different pattern of trauma, all patients had maintained vital signs, on abdominal examination all of our reviwed patients had guarding and tender abdomen looking moderately pale all patients had routine investigations and x rays according to the injury they had, U/S scan of the abdomen, ultrasound scan showed fluid in the abdomen, the fluid was mainly at left upper quadrant and left iliac fossa, three patients had clear splenic tears, all patients had intravenous fluid and non of them had blood transfusion before surgery, two units of blood was prepared for each patients, seventy six patients with blunt abdominal, went for diagnostic laparoscopy, under general anesthesia, four patients had the laparoscopy performed in ICU while they were on ventilator, with closed pneumoperitoneum we usually start with 8mmgh pressure, 11 mm port at umbilicus, those in whom we found that the trauma was involving spleen we add 3 more ports all at left side of the abdomen, all our patients had prophylactic antibiotic third generation cephalosporin at the induction of anaesthesia. Results: Laparoscopic finding three(3) patients had significant blood

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collection at left side of the abdomen, with splenic laceration grade iv, blood sucked and all abdominal organs were examined for injury, position of patient changed to lateral position, dissection of splenic pedicle and clipped, all small vessels delt with bioclamp, release of splenic attachment to colon and diaphragm, spleen removed through 5cm incision at left upper quadrant with ovum forcepes in big pieces, wash with saline and big drain left at site of the spleen six(6) patients had small laceration on the diaphragmatic surface of the spleen and not bleeding significantly and those patients had small lacerations of right lobe of the liver which was not bleeding significantly, suction of collected blood and two drain were placed on each side, the drains left for 24 hours and removed eight (8) patients had only splenic lacerations and no other injury and those lacerations were not bleeding,suction of the collected blood and drain was placed at side of the spleen and drain left for 24 hours one patient who was 9 years boy on laparoscopic examination the spleen was avulsed and found at left iliac fossa and the procedure converted to open, removal of the spleen and tying the splenic pedicle and the child had no other injury, drain left at left side of the abdomen for 48 hours patients with grade iv splenic injury 3 patients with simple laceration of spleen alone 8 patient with simple splenic and liver trauma 6 patient with avulsed spleen 1 no operative mortality, one patient had blood transfusion during splenectomy no significant morbidity and patient discharged home those who had splenectomy, discharged on 5th day postoperative day and those who had conservation of spleen discharged on 3th day discussion in our hospital we did one hundred and twenty four laparoscopic procedure for blunt and penetrating abdominal trauma, diagnostic laparoscopy is well known in trauma management long time, road traffic accident is common problem in libya and some un stable patients will need laparotomy as soon as possible, certain percentage of patients are stable but clinically they have intraabdominal injury which will not be safe if treated conservetivelly and in those patients certain percentage will end in negative laparotomy, with use of diagnostic and therapeutic laparoscopy certain patients saved from having negative laparotomy, and group of patients will benefit from performing therapeutic laparoscopy, with our experience in laparoscopy we adopted inclusion and exlusion criteria for use of laparoscopy in trauma. inclusion criteria like : 1. patient should be heamodynamically stable. 2. clinical examination revealed positive abdominal findings indicating intraabdominal injury. 3. ultrasound showing intraabdominal collection or solid organ injury. exclusion criteria 1.unstable patient. 2. patient deterioting rapidally. 3. inexperienced surgeon in laparoscopy. in our study we performed diagnostic and therapeutic laparoscopy for patients suspected having splenic trauma with or with out other intraabdominal trauma, we performed three laparoscopic splenectomy for three patients found that they had big splenic laceration which were not possible to safe the spleen, with excellent laparoscopic equipment and new version of haemstatic machines like bioclamp splenectomy can be done safely, minor lacerations of the spleen can be evaluated and seen better with laparoscopy as well as other visceral injury can be diagnosed with through laparoscopic examination, metabolic

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changes to traumatic surgery is less, no big wounds less hernia, less wound infection early discharge, no significant adhesions in the future, patients are discharged early, before use of laparoscopy there were patients end in negative laparotomy especially if patients admitted later night where there may be no easy access to ultrasound scan and CT scan, our residents can have training on use of laparoscopy in trauma, with use of laparoscopy we could safe patients from negative laparotomy, giving them chance to have their spleen stays in place if minorly injured, if needed to have the spleen removal can be done safely by key hole surgery. Conclusions: Use of Laparoscopy in blunt splenic trauma is safe procedure in haemodynamically stable patients, patient will be safed from having big incision, and complication of big wound, long hospital stay, intraabdominal viscera are inspected better, and will be safed from negative laparotomy.

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NON-OPERATIVE MANAGEMENT OF SPLENIC TRAUMA IMPROVEMENT AFTER EMERGENCY DEPARTMENT CREATION. TEN-YEAR EXPERIENCE OF A SINGLE CENTER Mogini V., Mingoli A., Mariotta G., Reali C., Cirillo B., Silvestri V., Marenga G. UOD Chirurgia del Politrauma, Dip. di Emergenza e Accettazione, Policlinico Umberto I, Sapienza University Rome, Italy Introduction: The growing knowledge about spleen function and overwhelming post splenectomy infections has led non-operative management (NOM) to become the gold standard treatment for splenic injuries of every American Association for the Surgery of Trauma (AAST) grade. To guarantee safety, NOM patients should be observed in an intensive or sub-intensive care setting for close monitorization. Moreover lab, radiology and operatory room should be rapidly and always available. Methods: All patients (n= 141) with blunt abdominal trauma and spleen injuries treated at â&#x20AC;&#x153;Policlinico Umberto Iâ&#x20AC;? from 1 January 2003 to 15 July 2012 were reviewed. Patients observed were then divided into two groups: a first one (G1; n=74) was composed of patients managed from 2003 to the end of 2007, before emergency re-organization, and a second one (G2; n=67) from 2008 to 2012, after Emergency Department (ED) establishment. Results: A significant, progressive increase in NOM rate was found in our analysis. NOM patients were 13 (18%) in G1 and 42 (63%) in G2. NOM rate increasing has been possible in a new, different organization of emergency surgery care, the ED, in which several and selected surgical equipes have been integrated into one working group providing trauma patients management with all emergency facilities and skills joined in a centralized area. NOM failed in 4 (30%) patients in G1 and 2 (3%) in G2. No significant differences were found in mortality rate (0,8% vs 1,1%, respectively). Conclusions: An integrated emergency department setting, the availability of a close patients monitorization and a trauma experienced surgical team allows surgeons to safely choice a non-aggressive treatment based only on hemodinamic parameters. Increase of NOM has guaranteed more patients to be managed in the best way suggested to literature to avoid long term morbidity without significant change in mortality.

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A NEW TECHNIQUE FOR SPLEEN AUTOTRANSPLANTATION Di Carlo I., Toro A. Department of Surgical Sciences, Organ Transplantation and Advanced Technologies, University of Catania. Cannizzaro Hospital, Catania, Italy Introduction: Although the efficacy of spleen autotransplantation is debated, this approach remains the only possibility for preserving splenic function after traumatic splenectomy.This report describes an alternative method for splenic autotransplantation in case of splenic trauma. Methods: After splenectomy, the organ was weighed and the undamaged part was cut transversely to prepare a segment of approximately 4 Ă&#x2014; 3 Ă&#x2014; 2 cm in size and of 35 g of weight to be transplanted. The greater omentum was pedunculated in its left lateral portion, and the previously prepared splenic tissue was implanted in a pouch created at the lower edge of the omentum.The omental peduncle containing the splenic tissue was fixed to the parietal peritoneum of posterior left upper quadrant of the abdomen where the native spleen was previously located. Results: This technique was performed in 7 patients after informed consent had been obtained.The functionality of the splenic implant was assessed after 3, 12 and 24 months by abdominal computed tomography and scintigraphy. These exams showed the functioning of the trasplanted splenic tissue in all patients. Conclusions: This new technique needs further evaluation, but it appears to be an easy and safe alternative for spleen autotransplantation.

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NON OPERATIVE TREATMENT VS OPERATIVE TREATMENT IN HEPATIC TRAUMA: A TEN- YEAR EXPERIENCE Saracino A., Mingoli A., Mariotta G., Reali C., Migliori E., Natili A., Marenga G. Sapienza University, Rome, Italy Introduction: The last 25 years were witnesses of notable change in hepatic trauma treatment with the choice of non operative management (NOM) in case of hemodynamic stability and absence of peritonism. Methods: We retrospectively collected and analyzed data of trauma patient with liver injury observed from 2003 to 2012. Patients were divided in two groups: G1, patients observed from 2003 to 2007 (66, 41,5%) and G2, from 2008 to 2012 (93, 58,5%). Results: One thousand fifty-nine patients have been treated. The number of patients/year has increased from 4 to 35 (9 times) due to changes in the regional organization of first aid for trauma patients. We used NOM for low grade trauma, mean ISS 21,3 (95,8% in grade I, 72,9% grade II, 52% grade III), while operative management (OM) was predominant in major trauma, mean ISS 27 (72% in grade IV and 55,5% grade V). However NOM was adopted in 48% in G1 patients and 64% of G2 patients. Mortality and morbidity rate were 67% - 57% and 6% - 32% for OM and NOM, respectively (p<0,0001). The length of hospitalization was 15 days for NOM and 30 days for OM (p<0,01). Furthermore, a correspondence was observed between hepatic enzymes increase and liver injury grade. Conclusions: NOM has shown to be superior to OM, not only in relation to mortality rate, but for the length of hospitalization and morbidity rate.

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BILIOMA IN TWO YEARS OLD CHILD AFTER CONSERVATIVE MANAGEMNET OF BLUNT HEPATIC TRAUMA Ali I Yahya, Hussen E. Shwereif, Mustafa A. Ekheil, Fatma Algyead, Ahmed Salem Thoboot Zliten Teaching Hospital, Libya Introduction: Conservetive management of liver injury is well known and practised in children, applied in patient which are stable, and saved patients from major laparotomy. Methods: Our patient was 2 years boy, his dad went over him by his car, brought to hospital, he was pale and hypotensive, he had resuscitation according to ATLS protocol, he improved, ultrasound showed liver trauma grade 3, and was confimed by CT scan, he had iv fluid and analgesia and blood transfusion, and antibiotics, he imroved and discharged in good condition. Results: Two months later the child started vomiting, on examination he was sick, with abdominal distension, there was mass at epigastric region ultrasound and CT scan confirmed that the mass at subhepatic region mainlt below left lobe, chid become sick, underwent laparotomy, on laparotomy there was mass below left lobe of liver and above the transverse colon, the mass was containing bile, and there was no communication between the cyst and other organs, the cyst was excised and drain was put, patient improved and dischaged in good condition. Conclusions: Conservative management of liver injury may go safely, but some times there may have rare complications, bilioma is one of the rare complication.

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SPLENECTOMY IN HYPERREACTIVE MALARIAL SPLENOMEGALY: ANALYSIS OF 9 PATIENTS, SURGERY, AND OUTCOME *

Santoni R.*, Righetti C.*, Morgagni D.**, Margarino C.*, Passariello L.* Azienda Ospedaliera San Martino, Genova, **Azienda Ospedaliera Morgagni Pierantoni, ForlĂŹ, Italy

Introduction: Malaria is a major problem in tropical and sub-tropical countries, with high morbidity and mortality. Hyperreactive Malarial Splenomegaly (HMS) is defined as a massive enlargement of the spleen resulting from abnormal immune responses after repeated exposure to the malaria parasites. The immunological basis seems to be due to polyclonal B cell activation by an unidentified malaria mitogen, leading to autoantibodies production. Splenectomy is indicated with patients have chronic disease, asthenia, abdominal and back pain, pancytopenia and high risk of rupture. Methods: From April 2010 to May 2012 nine patients underwent splenectomy for hyperreactive malarial splenomegaly in 4 African hospitals: Vohipeno Hospital, Madagascar, Comboni Centre in Sogakope, Ghana, Ebolowa Hospital, Cameroun and Holy Spirit Hospital in Makeni, Sierra Leone. They were 6 women and 3 men, and age was from 12 years to 62 years, spleen size was from 17 to 40 cm in lenght. Only in one case surgery was an emergency for spleen traumatic rupture. Surgery was always splenectomy with median laparotomy, duration of surgery was from 1,5 to 3 hours. Results: Mortality was nil,. Only four patients required a blood transfusion for pre-operative anaemia. Conclusions: Splenectomy is beneficial for symptomatic patients with clinical diagnosis of tropical splenomegaly syndrome. Spontaneous splenic injuries should be suspected when acute abdominal manifestations and signs of hemodynamic compromise occur in a background of malaria, immune suppression and hematological disorders. Surgery can be safely performed in highly selected patients but splenectomy makes them more susceptible to serious bacterial and parasitic infections.

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MANAGEMENT OF LIVER AND SPLEEN TRAUMA, THREE- YEAR EXPERIENCE Stabina Solvita, Kaminskis Aleksejs, Pupelis Guntars, Lunins Romans Riga East University Hospital Clinical Centre of Emergency Medicine “Gailezers”, Latvia Introduction: Nonoperative management (NOM) of splenic trauma was first described in 1968. year. Today has proved that not only isolated, but also a combination of visceral injuries can be treated conservatively. We present our first NOM experience of splenic and liver injury in Riga East University Hospital, “Gailezers”. Methods: Three year experience in the management of liver and spleen trauma was retrospectively analysed. NOM was chosen secondary to CT confirmed liver and spleen injury in hemodynamically stable and unstable patients without signs of hemorragic shock. Main outcomes were analysed comparing results of operative management (OM) and NOM. Results: Splenic and liver trauma was diagnosed in 138 patients: 42 female and 96 male with median age 35,5 years. Most common mechanisms of injury were road accidents in 64 cases, fall from the height in 36 cases, blunt trauma 26 and stabbed injuries in 12 cases. OM secondary to blunt trauma was provided in 61 patients, 35 with spleen, 17 with liver and 9 with combined spleen and liver injury. NOM was provided in 77 patients including 37 with spleen, 32 with liver and 8 with combined liver and spleen injury. NOM failed in 11 patients. Conclusions: NOM is recommended in hemodynamically stable patients with CT confirmed liver and spleen injuries when associated organ injuries are ruled out. Role of age, comorbidities and amount of blood loss should be independently evaluated when NOM is applied.

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TRAUMATIC LIVER RUPTURE WITH RIGHT HEPATIC VEIN INJURY Kaminskis Aleksejs, Stabina Solvita, Pupelis Guntars, Lunins Romans Riga East University Hospital, Clinical Centre of Emergency Medicine â&#x20AC;&#x153;Gailezersâ&#x20AC;?, Lavtia Introduction: The liver is the second most commonly injured organ in abdominal trauma, and liver damage is the most common cause of death after abdominal injury. Methods: Case report Results: A 21-year-old male was delivered to the hospital after moto accident with tachycardia125 beats/minute, arterial pressure 100/55mmHg and tachipnoe 26 x/min. Multiple free fluid collections in the abdominal cavity were detected on FAST and massive left side pneumothorax was eliminated by chest tube insertion. During the laparotomy 2000 ml hemoperitoneum and multiple liver lacerations involved 7th and 8th segment with extended to the hepatic veins was found. Duodenal suturing, cholecystectomy and perihepatic packing were done as damage control procedure due to hemodynamic instability of the patient. All packs were removed and right side nephrectomy was done 10 days after laparotomy. Conclusions: Perihepatic packing and damage control surgery can be the only life-saving option for high energy polytrauma patients with V-VI degree liver injury.

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POSTTRAUMATIC PSEUDOANEURYSM OF RIGHT HEPATIC ARTERY AFTER GUNSHOT THORACHO-ABDOMINAL INJURY. A CASE REPORT AND REVIEW OF THE LITERATURE Dogjani Agron1, Hasanaj Blenarda1, Qamirani Xhafer1, Petrela Eliziana2, Dhima Arben3 1 Department of Surgery, Universitary Hospital of Trauma, Tirana, Albania, 2 Head of Statistic Deparment in University Hospital "Nene Tereza ", Tirana, Albania, 3Department of Radiology in American Hospital Tirana, Albania Introduction: Pseudoaneurysm of the right hepatic artery is uncommon, appearing in approximately 1% of hepatic trauma cases and have a late onset. Although they are usually asymptomatic. Traumatic right hepatic artery pseudo-aneurysms are potentially life-threatening complications that can occur after blunt abdominal trauma and penetrant abdominal trauma. Methods: The investigation and management of these lesions must be individualized according to the clinical scenario. They should always be treated becasue of the high risk of complications, especially late hemorages. Currently the treatment of choice is endovascular embolization with coils or the exclusion of the pseudoaneurysm using other intravascular devices. But in developing countries the opportunity to have such equipment is impossible and in these conditions, the method used is exploring pseudoaneurysm. Results: The lateral defect in the right hepatic arterial wall was sewn with Prolene sutures, occluding the vessel; segmental hepatic arterial flow was maintained by collaterals. Within the aneurysmal cavity, a friable, necrotic area located antero-inferiorly in the segment VII-VIII of the liver. We present a case of post-traumatic hepatic artery pseudoaneurysm that was successfully treated using this exploring pseudoaneurysm and ligature of the injured artery. Conclusions: To summarize, for the treatment of visceral pseudoaneurysms it is necessary to know all therapeutic options and to evaluate the convenience of each one. In the absence of sophisticated imaging and intra-arterial embolisation, we contribute by adding our experience to the case reported in the bibliography.

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PERIHEPATIC PACKING AND ARTERIOGRAPHY IN THE OPERATING ROOM AS A DAMAGE CONTROL STRATEGY FOR SEVERE HEPATIC INJURIES Mastropietro T.*, Cataldi C.*, Salvatelli M.*, Truosolo B.*, Morucci M.**, Riu P.**, Marini P.* * General Surgery 1 S. Camillo Hospital Rome, **Vascular Radiology S.Camillo Hospital Rome, Italy Introduction: Uncontrolled bleeding is among the most important cause of death for politraumatic patients. The rapid management of the bleeding is one of the most important challange in the early phase of the trauma care. For the management of severe hepatic injuries (IV and V grade), the literature recommends the combined treatment packing and arteriography followed by arterial embolization. To be effective arteriography and embolization must be performed as soon as possible after admission, before the onset of trauma induced coagulopathy. If the arteriography has performed after 3 hours from the admission, the mortality increases Methods: During the year 2009, 22 patients with hepatic trauma underwent surgery, 8 with packing and arteriography performed in the operating room.The patients, who were not haemodinamically stable, with FAST positive, we performed on them an immediately damage control surgery. In the patients underwent to damage control surgery like perihepatic packing, the arteriography was performed in the operating room, with an important reduction of the time to access to the procedure. Results: Of the total 8 patients, 7 male 1 female, only 1 died. The complications have been: 1 necrosis of the hepatic segments and consequently necrosectomy, 1 perihepatic abscess treated by percutaneus drainage and 1 biliary stasis treated by nose biliary drain. Conclusions: The arteriography perfomed in the operating room, after perihepatic packing, allows a reduction of the time to access to the vascular procedure and a reduction in the time interval to control bleeding.

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SELECTIVE APPLICATION OF ENDOSCOPIC RETROGRADE CHOLANGIOGRAPHY IS INDICATED FOR MILD HYPERBILIRUBINEMIA PATIENTS AFTER BLUNT LIVER TRAUMA Kuo-Ching Yuan1, MD; Yon-Cheong Wong2, MD; Jen-Feng Fang1, MD; Chee-Jen Chang3, Ph.D; Shih-Ching Kang1, MD; Yu-Pao Hsu1, MD 1 Trauma and Critical Care Center, Division of General Surgery, Department of Surgery, Chang-Gung Memorial Hospital, Chang-Gung University, Linkou, Taiwan, 2Division of Emergency and Critical Care Radiology, Department of medical Imaging and intervention, Chang-Gung Memorial Hospital, ChangGung University, Linkou, Taiwan Introduction: Bile duct injury after blunt liver trauma is quite challenging. It significantly prolongs hospital stay and requires endoscopic retrograde cholangiography (ERC) for management. Early ERC reduces hospital stay but there is no specific indication. This study is to elucidate risk factors for bile duct injury and indications for early ERC. Methods: The registry of a trauma center here from June-2008 to June2011 was queried. Blunt liver trauma patients were selected for review. Data collected includes demographic data, laboratory, Injury Severity Score, liver injury grade and location, management, and hospital stay. Result of ERC confirms bile duct injury or not. Results: 231 of the 16,786 torso trauma patients had blunt liver trauma were included. There were 172 (74.5%) male patients and the mean ISS was 24.2. 76.6% patients received non-intervention treatment (no operation, no angioembolization), 15.1% received transcatheter angioembolization (TAE) and 10.8% received an operation. A bile duct injury occurred in 8 (3.5%) patients. Risk factors for bile duct injury after blunt liver trauma include high-grade liver injury, centrally-located, and use of TAE. A serum bilirubin level greater than 2.55 mg/dl provides a sensitivity of 100% and specificity of 85.1% for predicting major bile duct injury after blunt liver trauma. Conclusions: Bile duct injury after blunt liver trauma is rare, and the incidence is about 3.5%. Besides injury grade; centrally-located trauma or received TAE are also risk factors. ERC after blunt liver trauma is indicated early if the patient has risk factors or has serum bilirubin level higher than 2.55 mg/dl.

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SELECTIVE VASCULAR ISOLATION OF THE LIVER AS PART OF DAMAGE CONTROL FOR GRADE 5 LIVER INJURIES: SHOULDâ&#x20AC;&#x2122;T WE USE IT MORE FREQUENTLY? Rifat Latifi and Hatem Khalaf Hamad Medical Corporation, Doha, Qatar Introduction: Severe liver trauma Grade 4 and 5 carries a mortality of about 40% and represent major surgical challenge in patients with hemodynamic instability requiring immediate exploratory laparotomy. Although peri-hepatic packing and damage control may work, adjunct maneuvers such as early embolization or hepatic artery ligation may be required for severe injuries. Anatomic resection at the first operation is rarely tolerated. Methods: We report a case of a patient with blunt Grade 5 right lobe liver injury managed initially with Pringle maneuver, intra-hepatic and perihepatic packing,and followed by a ligation of the right portal vein, right hepatic artery, right hepatic vein, and repair of retro-hepatic inferior vena cava. Right hepatectomy was performed 36 hours later successfully. Results: Patient survived this major insult and has recuperated nicely. Conclusions: We suggest that selective vascular ligation, in addition to intermittent Pringle maneuver, should be part of the damage control and surgical armamentarium for severe liver injuries. This may allow anatomical resection at a later stage for hemodinamically unstable patients during the first operation.

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EFFECTIVENESS OF INTRA-AORTIC BALLOON OCCLUSION (IABO) FOR TRAUMATIC HEMORRHAGIC SHOCK Takayuki Irahara MD1, Norio Sato MD PhD2, Yuuta Moroe MD3, Reo Fukuda MD3, Yusuke Iwai MD3, Kyoko Unemoto MD PhD3, Hiroyuki Yokota MD PhD1 1 Department of Emergency and Critical Care Medicine, Nippon Medical School, 2Department of Primary Care and Emergency Medicine, Kyoto University, 3Emergency and Critical Care Center, Nippon Medical School Tama-Nagayama Hospital, Japan Introduction: Intra-aortic balloon occlusion (IABO) has occasionally been used to achieve proximal vascular control for the patients subjected to hemorrhagic shock especially with severe abdominal injury and/or pelvic fracture. The purpose of this study is to describe the effectiveness of IABO from our institutionâ&#x20AC;&#x2122;s experience. Methods: We retrospectively summarized the patients who underwent IABO at Emergency and Critical Care Center, Nippon Medical School TamaNagayama Hospital between January 2009 and March 2013. Statistical analysis was done about patient characteristics and other factors. Results: There were 21 patients who underwent IABO during this period. Mean age was 47.6 years old, 71% were male, mean Injury Severity Score (ISS) was 32.9. Systolic blood pressure (SBP) was significantly elevated by IABO (+ 40mmHg, p=0.0003). There was a significant difference between survivors (n=8) and non-survivors (n=13) regarding age (33.6 vs 56.2, p<0.02), Revised Trauma Score (RTS) (6.538 vs 5.262, p<0.03), Probability of Survival (Ps) (0.87 vs 0.51, p=0.003). Survivors needed less blood transfusion volume (16.8 units vs 29.8, p<0.02), and shorter total occlusion time (30 min vs 180, p=0.01) compared to non-survivors. Conclusions: Our study demonstrates that IABO tend to be used for comparatively severe trauma patients. IABO is effective to elevate blood pressure, but definitive hemostasis as soon as possible will be important for survival to shorten the occlusion time and reduce blood transfusion volume. (There is no COI to be disclosed.)

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Abstracts

Tuesday, July 9, 2013

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WJES & WSES Meeting 126

PENETRATING CARDIAC INJURIES. WHAT CAN GENERAL SURGEONS DO IN HOSPITAL WITHOUT ON-SITE CARDIAC SURGERY CAPABILITY? Canini T., Sallusti M., Bertazzoni P.M., Barcella A. Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy Introduction: Cardiac injuries remain amongst the most challenging of all traumatic injuries. The clinical presentations range from complete hemodynamically stability to acute cardiovascular collapse and frank cardiopulmonary arrest. It is essential for general surgeons to be prepared to tackle penetrating injury to the heart immediately. Methods: Four young males sustaining cardiac stab injuries were admitted to the Emergency Department between July 2011 and July 2012. The hospital was not equipped with a cardiac surgery unit. Two patients were hemodynamically stable, one had pulseless electric activity on arrival and one was critically unstable. Results: An emergency department thoracotomy was performed in the patient who had pulseless electric activity on arrival. Cardiac tamponade was relieved, internal cardiac massage started and continued along with digital compression of a right ventricle lesion. In the operating theatre the lesion was sutured with the help of the cardiothoracic surgeon from another hospital (since then the on-call service has been discontinued). The critically unstable patient was taken to the operating theatre and a left ventricular lesion and a double colonic transverse perforation were fixed. The two hemodynamically stable patients were successfully transferred to a hospital with cardiac surgery capability. Conclusions: In hospitals without cardiothoracic unit the general surgeon must be able to identify patients with possible cardiac injury and start appropriate resuscitation and/or investigation while alerting the staff to the need for life-saving manoeuvres (for critically unstable patients) or arranging the transfer to a higher-level-of-care hospital (for stable patients). Declaration of personal and funding interests: None

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VACUUM PACK CLOSURE METHOD USING THORACIC DRAINAGE SYSTEM Kubota T., Miyazaki K., Mizokami K., Miyabe A., Kanda Y. Department of General Surgery Tokyo Bay Urayasu Ichikawa Medical Center, Japan Introduction: Vacuum pack closure method is widely used as temporally abdominal closure in case of abdominal compartment syndrome related to severe trauma or septic abdomen. Recently we can use a commercialized product (V.A.C system), which is easy to use and very handy. However the device and materials are expensive and not available if one doesnâ&#x20AC;&#x2122;t have the products in emergency case. So we have tried to make a original vacuum pack system using the items which are available at any hospital. Here in, we introduce our original vacuum pack closure method (Tokyo Bay Method). Methods: Tokyo Bay Method is made with one plastic film, two large bore chest tube, one surgical drape and one thoracic drainage system. First, a plastic film is put on the abdominal contents and under the abdominal wall. Second, two large bore chest tube are applied the wound. Third, a surgical drape is laid on the abdominal wall. Finally, the chest tube is connected a thoracic drainage system in which the negative pressure is minus ten to minus fifteen centimeter water column. Results: We had fourteen patients of abdominal compartment syndrome related to abdominal surgery in our department form April. 2008 to Feb. 2013. All of them were applied to our Tokyo Bay Method. There were twenty four times of temporally abdominal closure in fourteen cases. Patients age were thirty to eighty-two, four women in ten men. Four were massive mesenteric ischemia. Four were severe panperitonitis related to lower gastrointestinal perforation. Three were necrotizing acute pancreatitis. Two are trauma. One was primary peritonitis caused by betahemolytic streptococci. The durations of temporally closure were one to seven days. In all cases, Tokyo Bay Method was easy to apply and really works. There were no leakages of ascitic fluid from the edge of the drape which some times bother ICU nurses. Conclusions: Our Tokyo Bay Method for temporally abdominal closure is easy, low cost and effective. We think it is worth to try, especially at the local hospital, which doesnâ&#x20AC;&#x2122;t have commercially available products.

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COIL EMBOLIZATION OF A PULMONARY ARTERY PSEUDOANEURYSM PRESENTING WITH HEMOPTYSIS 7 DAYS AFTER THORACOTOMY FOR BLEEDING PENETRATING INJURY Canini T., Montagnolo G.G., Bertazzoni P.M., Barcella A., Nicolini A.* Department of Surgery and Emergency Surgery and *Operative Unit for Interventional Radiology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy Introduction: Post-traumatic pulmonary artery pseudoaneurysm is a rare complication of chest injuries. It has been suggested that the rarity of cases may be related to the lower arterial pressures in the pulmonary vasculature which allow the healing of the lesion by haemostasis. It usually presents with haemoptysis but may be asymptomatic. Methods: A young male sustained multiple stab wounds to the chest, face, head and hands. On arrival a chest tube was placed draining fresh blood and air. A CT scan showed an ongoing bleeding from a laceration of the right lower pulmonary lobe. The patient was taken to the operating room for a right thoracotomy and two bleeding lacerations were sutured. The patient was discharged on the 6th postoperative day. A week later the patient experienced hemoptysis and was recovered to another hospital. A CT scan revealed a right pulmonary artery pseudoaneurysm and the patient was transferred to our institution. Results: The presence of a pulmonary arterial pseudoaneurysm was confirmed by angiogram and the pseudoaneurysm obliteration was accomplished by coil embolization. The patient was discharged on the 3rd postembolization day and a chest CT performed one month later showed persistent resolution of the pseudoaneurysm. Conclusions: Post-traumatic pulmonary artery pseudoaneurysm should not be left untreated because of the high mortality rate associated with its rupture. Coil embolization of the sac is now the first-line management in hemodynamically stable patients as it safely treats the injury avoiding any further surgical intervention. Declaration of personal and funding interests: None

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PENETRATING CHEST PATIENTS NEEDING SURGERY – WHO WILL SURVIVE, AND WHAT RESOURCES WILL BE NEEDED? Doll D.1,2, Tugby Y.H.3, Degiannis E.1 Department of Trauma & Burns, Chris Hani Baragwanath Academic Hospital, Soweto, Johannesburg, South Africa, 2Department of Surgery, St Mary´s Hospital, Vechta, Germany, 3Department of Surgery, Baskent University, Izmir, Turkey 1

Introduction: Penetrating chest trauma is still a substantial proportion of trauma arriving in the trauma departments in Southern Africa, and 10–15% of these patients need urgent or Emergency Department Thoracotomy (EDT). The present study assessed outcome, quantified resources needed and compared it to previously reported experiences. Methods: All penetrating chest patients needing chest surgery admitted to the Chris Hani Baragwanath Academic Hospital were studied (36months). Results: 145 patients arrived alive; 8 patients in extremis underwent immediate EDT. 2 patients died in the ED, 6 in theatre and 13 on the Intensive Care Unit. 76% (16/21) died within day 1-2, further 10% (2/21) within the next week, and the remaining 14% from week 5 to 10. Cardiac and lung injuries had lowest mortality with 5% and 15%, while mortality exceeded 50% in oesophageal injuries, thoracoabdominal plus bowel or pancreatic or kidney injuries. In 14 patients with disseminated intravascular coagulopathy and damage control procedures mortality exceeded 60%. Stab deaths were uncommon following day 1, while gunshot weren’t. Longest ventilation and ICU therapy was seen in thoracic esophageal and hepatic injuries (ventilation 17,2 resp. 6,9 days), while neck and thoracic injuries needed surgery most often (4 resp. 4,2 ops). Mortality probability exceeds 50% following the second week not being dischargeable from ICU. Conclusions: Penetrating chest patients undergoing EDT with 38% mortality show better survival compared to esophageal or thoracoabdominal combination injuries; whereas hepatic injuries show 35% mortality needing 2,6 operations. Salvageable injuries – cardiac, lung and mediastinal – can be handled in field hospitals regarding outcome and resources. Potentially septic and multi-operation-injuries as identified should be shifted to larger and better staffed / equipped hospitals as soon as combat allows. Disclosure: This study was supported by the German Army Research Council grant M-SAB1-5-A015. There is no conflict of interest.

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PENETRATING CHEST PATIENTS IN THE NEED FOR SURGERY – INDICATIONS, INJURIES AND PROCEDURES TO DO Doll D.1,2, Tugby Y.H.3, Degiannis E.1 Department of Trauma & Burns, Chris Hani Baragwanath Academic Hospital, Soweto, Johannesburg, South Africa, 2Department of Surgery, St Mary´s Hospital, Vechta, Germany, 3Department of Surgery, Baskent University, Izmir, Turkey 1

Introduction: Penetrating chest trauma is still a substantial proportion of trauma arriving in the trauma departments in Southern Africa, and 10–15% of these patients need urgent Thoracotomy or Emergency Department Thoracotomy (EDT). The present study assessed reasons for urgent thoracotomy, organs most injured, and the procedures most often needed for each organ. Methods: All penetrating chest patients needing chest surgery admitted to the Chris Hani Baragwanath Academic Hospital were studied (36 months). Results: Indication for thoracotomy was initial chest drainage volume in 56/145 patients (39%), followed by cardiac depression or hemopericard on ultrasound(19%). Bleeding without cardiac compromise (24/145 resp.17%) was followed by chest X-Ray diagnostic (12%). Clinical diagnosis plus drainage volume were sufficient evidence in 124/145 patients for surgery. 67 thoracotomies (42 left sided) were followed by 44 sternotomies; 3 of the latter after xiphoid window. 21 combinations (thoracotomy-laparotomy, sternotomy-thoracotomy and sternotomy-subclavian) were done, as well as 2 triple procedures. In 88 lung injuries, 38 tractotomies, 14 segment resections and 8 through-and-through-sutures were done most often. 57 non-mediastinal vascular injuries needed 20 intercostal ligatures, 15 mammary ligatures and 5 pulmonary vein repairs. 37 cardiac injuries needed 29 ventricular sutures (15 right, 14 left sided), and 4 right atrial closures. 17 thoracoabdominal injuries including liver damage needed packing (n=6), suture-repair (n=5) or packing and plugging. 14 mediastinal non-cardiac injuries underwent 5 aortic repairs, 5 oesophageal repairs, and 2 caval repairs. Conclusions: Most of all decisions can be done on clinical grounds, the intercostal drain at close sight. Most of the injuries in the chest can be managed by simple procedures, as outlined above. There is no reason for the emergency surgeon not too familiar with penetrating chest surgery to be too respectful and refrain from opening the chest. Disclosure: This study was supported by the German Army Research Council grant M-SAB1-5A015. There is no conflict of interest.

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URGENT THORACOTOMY FOR PENETRATING CHEST TRAUMA: KABUL SURGICAL CENTRE EXPERIENCE Necchi M., Strada G., Garatti M., Bottura R. Emergency Ong Onlus, Italy Introduction: Emergency is an Italian NGO founded in 1994 and run in Afghanistan 3 hospitals for war wounded patients. Penetrating injuries to the chest present a frequent and challenging problem. Most of the civilian thoracic war injuries are penetrating, while military personnel suffer thoracic injury mainly due to blast.. This audit examines a three-years experience with penetrating thoracic trauma at the Kabul Surgical Centre. Methods: A retrospective review of patients who underwent emergency thoracotomy after penetrating chest injury between June 2007, and June 2010, at Kabul surgical Centre, was conducted. The mechanism of injury, gender, age, physiological and outcome parameters, concomitant injuries, time since injury, transfusion requirement, indications for thoracotomy, intra-operative findings, operative procedures, length of hospital stay (LOS) and rate of mortality were recorded. Results: We reviewed the records of 432 patients who were admitted and treated at Kabul Surgical Centre with penetrating thoracic trauma. For the study we analyzed data of 28 patients who underwent thoracotomy within 24 h after the penetrating trauma. Patients were primarily young (26,7 year) and males (100% of cases). The cause of injury were stab in 16 patients (57.1%), bullets in 11 (39.3%) and shrapnel in 1 (3.6%). Thirteen patients (46,4%) had concomitant injuries of various organs with the abdomen more frequently involved (n=7). Twenty-five patients (89.4%) underwent thoracotomy within 4 hours and 3 from 5 to 24 hours after injury. Indications for urgent thoracotomy where : blood pressure on arrival < 90 unresponsive to fluid (60.7%), clinical evidence of cardiac tamponade (14.3%), traumatic thoracotomy (10,7%) initial thoracostomy blood loss > 1500 ml (10.7%), and respiratory distress in one case. Operative approaches included anterolateral thoracotomy (n = 15), clamshell incision (n= 7), sternotomy (n= 4), posterolateral thoracotomy (n=2). In 7 cases a cardiac injury was identified. The other injuries identified were lung parenchyma bleeding (n= 14), internal vessels of the chest (n= 4), intercostals vessels (n=2) and pericardial injury with no myocardial involvement (n=1). The overall mortality was 32.1% (n=9). Concomitant injuries, gunshot, low systolic blood pressure on presentation were associated with increased mortality. Conclusions: Most penetrating injuries of the chest in war zones can be manage nonoperatively with double chest thoracostomy, but thoracic injuries that require operative surgical intervention can be quite challenging. Unresponsive shock and clinical evidence of cardiac tamponade

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are the major indications for urgent thoracotomy. Injuries to the heart and vessels of the chest are identified in more than one-third of patients. Antero-lateral thoracotomy is the most common operative approach. Gunshot wounds of the thorax and associated abdominal injuries affect mortality.

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LAPAROSCOPIC REPAIR OF POST TRAUMATIC DELAYED DIAPHRAGMATIC HERNIA WITH INTRATHORACIC MESENTROAXIAL GASTRIC VOLVULUS A CASE REPORT Singh R., Bansal D., Pushkarna V. Fortis Escorts Hospital, India Introduction: Traumatic diaphragmatic herniation after injury is an unusual presentation of trauma, Gastric volvulus cases are usually associated with congenital diaphragmatic hernia. Diagnosis is difficult and is based on imaging studies. Delayed presentation of traumatic diaphragmatic hernia with gastric volvulus is relatively unusual. Methods: Laparoscopic five port approach was used under general anaesthesia, and patient was placed in 45 degree head up position. After reducing the contents in the abdominal cavity. Primary closure of diaphragmatic tear was done. Results: Patient had uneventful post operative period. He was discharged on post op day three. After one month of follow up patient is doing well. Conclusions: The laparoscopic repair of intra thoracic gastric volvulus and diaphragmatic hernias has been proved to be feasible and safe. Patients with penetrating trauma to the left lower chest who do not have any other indication for a laparotomy should undergo laparoscopic evaluation of the left hemidiaphragm to exclude an injury.

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SPONTANEOUS DIAPHRAGMATIC RUPTURE DURING STATIC GYMNASTIC EXERCISE Costa S., Corbellini C., Villa R., Leone P., Contessini Avesani E. Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan; UniversitĂ degli Studi di Milano, Italy Introduction: Spontaneous rupture of the diaphragm (SRD) is an extremely rare condition accounting for less than 1% of diaphragmatic ruptures. SRD is a damage of the diaphragm due to an increased pressure in the chest wall and abdominal cavity without direct trauma. Methods: A 41-year-old female patient came to our emergency department with cough, severe epigastric and left sided chest pain that started during a static gymnic exercise (Yoga). Her clinical history was uneventful and she did not report any trauma. The physical examination was negative. Electrocardiogram and chest radiograph (CR) were normal. Results: At admission, a total body CT scan showed an elevation of right diaphragm due to stomach distention. Only two days after, for persistent symptoms, a CR with oral contrast was performed, showing about half of the stomach herniated into the right chest. An exploratory laparoscopy was performed: 6 cm defect of the left diaphragm extending to the tendinous center was detected, the stomach and spleen were herniated in the thorax. A subcostal laparotomy was made, the hernia was reduced and the diaphragm defect was sutured. Patient had a regular postoperative course. At 3-years follow-up, she was in good general condition. Conclusions: SRD is an uncommon event and the diagnosis is often difficult. SRD is a potentially life-threatening condition if misdiagnosed. The difficulty in achieving diagnosis early is due to nonspecific symptoms and signs and the limitations of the radiological investigation. There is not standardized surgical treatment but it is mandatory.

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MANAGEMENT AND OUTCOMES OF RIB FRACTURES WITHOUT FIXATION AT A LEVEL 1 TRAUMA CENTRE Weber D.G., Bendinelli C., Balogh Z.J. Deptartment of Traumtology, John Hunter Hospital, Australia Introduction: Rib fractures are common injuries and associated with significant morbidity and mortality. Recent studies have focused on the possible benefits of rib fracture fixation. We hypothesized that a centre not practicing rib fracture fixations has worse outcomes in patients with comparable demographics and injury severity. Methods: The Trauma Registry of a level 1 trauma centre (where rib fixation is not routinely performed) was queried for all patients with a thorax-skeletal Abbreviated Injury Scale (AIS) > 2, admitted from January 2011 to December 2012. Demographics, treatment modalities, and clinical outcome were recorded by a retrospective chart review. Results: 96 patients, with a mean age of 49.6 (± 19.1) years, were treated during the study period. Mean Injury Severity Score was 30.7 (± 13.1). Flail chest injuries were recorded in 33 patients. A pneumothorax, haemothorax and pulmonary contusion was reported in 74%, 34% and 61%, respectively. All patients were admitted to the intensive care unit, staying 7.42 (± 6.90) days. The 75 patients requiring endo-tracheal intubation were ventilated 6.49 (± 6.32) days (27 patients required a tracheostomy). Length of stay in hospital was 20.3 (± 19.7), during which 21% of the cohort developed a pneumonia. Overall mortality was 17%. Conclusions: This series provides a contemporary report on the demographics and outcomes in patients with serious thoracic skeletal wall injuries, from a centre not practicing routine chest wall fixation. This report can be considered the non-operative standard outcomes to be exceeded by rib fixation outcomes.

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POST TRAUMATIC DIAPHRAGMATIC HERNIA IN BLUNT ABDOMINAL TRAUMA: FROM URGENCY TO EMERGENCY 1

De Martino M.1, ViganĂ˛ J.2, Sgarella A.2, Dominioni T.2, Dionigi P.1 Department of Surgical Science, University of Pavia, 2Fondazione IRCCS Pol. San Matteo, Pavia, Italy

Introduction: Blunt diaphragmatic rupture (DR) is a rare but potentially severe condition. Its onset can be masked by multiple associated injuries, which are the main cause of mortality. The overall incidence of DR is 0.85.8% in blunt trauma, 2.5-5% in blunt abdominal trauma and 1.5% in blunt thoracic trauma. Correct diagnosis is difficult and, when delayed, could result in a life-threatening situation. Methods: A 46 years old male motorcyclist was admitted to ED after an accident. He was found 10 meters far from the site of the event. He was hypotensive, agitated and had anysocoria. Intubation was performed onsite for a worsening of the vital signs. At admission he had impending haemorrhagic shock (Hb 7 g/dL) and bland hypoxia. He underwent a total body CT scan that showed an open-book pelvic fracture, multiple limbs fractures, herniation of the stomach in the left emitorax with bilateral pleural effusion, left PNX, multiple ribs fractures, T6-T7 multi-fragmented fracture and free air and fluid in the abdomen. Orthopaedic surgeon placed a C-clamp to reduce the pelvic fracture. Suddenly the patient became haemodinamically unstable for a progressively severe hypoxemia. He was transferred in the O.R. for emergency laparotomy to relocate the stomach in its anatomic abdominal location. Blood gas exchange improved steadily with a relief of the hemodynamic instability. Sealing the diaphragmatic lesion completed the operation. The large and small bowel required a partial resection due to vascular lesions with local ischemia. Surgery was performed with a damage control procedure and the abdomen closed with a negative pressure device to prevent abdominal compartment syndrome due to retroperitoneal hematoma. Results: He was discharged on POD 39 of free diet and good conditions. However he was paraplegic because of a vertebral fracture. Conclusions: DR could become an emergency when the volume of the visceral misplacement affects lungs expansion and ventilation. Haemodynamic instability, which results from such condition, requires a prompt reaction from the trauma team. Correct treatments allow a full recovery and can save the patientâ&#x20AC;&#x2122;s life.

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ARE FRACTURE PATTERNS AND AGE PREDICTIVE FACTORS OF SEVERE HAEMORRHAGE IN PELVIC TRAUMA PATIENTS? Mariani A. MD1, Prestini L. RN2, Bertuzzi M. SD2, Luperto M. MD1, Ronchi A. MS1, Chiara O. MD1, Cimbanassi S. MD1 1 Trauma Team Dip. DEA-EAS, Ospedale Niguarda Ca’Granda Milano, 2 Quality Department, Ospedale Niguarda Ca’Granda Milan, Italy Introduction: Pelvic fractures are frequently associated with ominous bleeding. Old patients, because of their comorbilities maybe severly injuried. The aim of the study was to investigate if a correlation of fracture patterns and the age with severe haemorrhage does exist. Methods: We analyzed major trauma patients suffering from pelvic fracture admitted to Niguarda Hospital in eight years. All patients with potential extra-pelvic haemorrhage were excluded (Tab 1). Age threshold was 65 years. Cases were identified as patients treated with embolization or extraperitoneal packing (EPP) or massive transfusion (MT). Age, gender, hypotension, base excess (BE), lactate and Tile’s classification were identified as possible predictive variables for severe pelvic haemorrhage. Correlation between these variables and bleeding was investigated using chi-square (χ2) test and Odds Ratio (OR). All statistical analyses were performed using Statistical Analysis System (SAS), a p<0,05 was considered statistically significant. Results: Age ≥ 65 years and Tile’s C fracture were indipendent risk factors for severe haemorrhage (OR 2.46; 95% CI 1.16-5.18 – OR 2.58; 95% CI 1.13- 5.19, respectively), while gender, hypotension, BE and lactate did not. Conclusions: Adults older then 65 years are more prone to severe haemorrhage apart from fracture patterns, because of osteoporosis, atherosclerosis and impaired physiologic reserve (1,2). Therefore, elderly patients suffering from pelvic fractures, should be considered unstable untill proven otherwise. Bibliography: 1. SM Henry, TM Scalea et al. J Trauma. 2002; 53:15-20)(SC Mears, DJ Berry. Outcomes of displaced and on displaced pelvic and sacral fracture in elderly adults. J. Am Geriatr Soc 59:1309-1312,2011 2. RA Magnussen, MA Tressler et al. Predicting blood loss in isolated pelvic and acetabular high-energy trauma. J Orthop Trauma. Vol 21, No 9, Oct 2007).

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REVIEW OF TRAUMATIC PANCREAS INJURY IN KOREA: LITERATURE REVIEW Seung Hwan Lee1, Ji Young Jang1, Hongjin Shim2, Jae Gil Lee1 Department of Surgery, Yonsei University College of Medicine, 2 Department of Surgery, Yonsei University Wonju College of Medicine, Korea 1

Introduction: Traumatic pancreas injuries are rare condition, resulting in high morbidity and mortality. So, early diagnosis and interventions are very important to manage pancreatic injuries. The purpose of this study is to review the outcomes of the pancreatic injuries in Korean population. Methods: Original articles published from the Jan. 2001 to the Dec. 2012 were searched from the KoreaMed. Eight literatures are eligible to review the management options for operation or endoscopic retrograde cholangiopancreatography. We assessed the injury mechanisms, injury severity, combined injuries, type of operation, outcomes. Results: Men were 250 over 332 patients, with 36.3 years-old age. Main injury mechanism was traffic accident (63.0 %). Most patients had grade II or III injuries (69.9 %). Most common injury site except pancreas was liver, followed by chest, spleen. Operative managements had performed in 215 patients, including distal pancreatectomies, drainage procedures, and pancreaticoduodenectomies (122/63/20). Reported mortality was 11.5 %, and morbidity was from 49 % to 76.9 %. Length of hospital stay was 39.5 days. Risk factors of mortality were amount of transfusion, injury severity, base deficit, age, presence of shock, and injury severity score. Conclusions: This is just descriptive results of published literature of pancreatic injuries in Korean population. So, there were no conclusive results. National data bank or registry and retrospective data collection are required to assess the outcomes of the pancreatic injuries.

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PYLORIC EXCLUSION - AN EASY WAY TO DO IT Mesquita C. Coimbra University Hospital, Portugal Introduction: The vast majority of duodenal perforations (DP) can be treated by primary repair but more complex procedures must be considered for the most severe ones. Pyloric exclusion appears to offer the best combination of limited surgery with effective duodenal exclusion, but the pylorus is sometimes difficult to find in order to be sutured. Methods: Two patients with DP (1m/1fâ&#x20AC;&#x201C;45/25yo), 12 and 48 hours time delay and sepsis, have been recently operated: 1) 1st portion, anterior wall, after an impacted bone in a pre-existent duodenal ulcer, and 2) iathrogenic, 2nd portion, posterior wall, after an endoscopic right kidney operation. Pyloric exclusion and gastrojejunostomy have been done in both, after a primary repair in the first patient and a T-tube drainage in the second. In order to easily identify and bring the pylorus under traction to the gastrotomy site to be sutured, a Foley catheter has been passed through and the balloon inflated inside the duodenum. Both patients had image control studies 3 months later. Results: The use of a Foley catheter, as described, allowed the surgeon to suture the pylorus with no need of grasping instruments. Conclusions: When the pylorus is dificult to find, for duodenal exclusion and gastrenterostomy to repair a DP, an easy and safe way to do it is with a Foley catheter. It is passed through and the balloon inflated inside the duodenum, in order to bring the pylorus to the gastrotomy site to be sutured.

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RISK FACTORS OF THE MORTALITY AND ANASTOMOTIC LEAKAGE AFTER EMERGENT SMALL BOWEL RESECTION Tae Hwa Hong1, Seung Hwan Lee1, Ji Young Jang1, Hongjin Shim2, Jae Gil Lee1 1 Department of Surgery, Yonsei University College of Medicine, 2 Department of Surgery, Yonsei University Wonju College of Medicine, Korea Introduction: The study about the mortality and anastomotic leakage(AL) after small bowel resection is uncommon. The aims of study were to identify factors that could predict mortality and to investigate factors that could contribute to AL in the emergent small bowel resection. Methods: This study was retrospectively performed on 95 patients who underwent emergent small bowel resection between March 2008 and December 2012. It was analyzed whether variables such as preoperative, intraoperative, and postoperative conditions affect mortality and AL. Results: The mortality rate was 10 of 95 patients (10.5%). When patients were divided into two groups: the survivor group (85) and non-survivor group (10), age (54.4 ± 17.28 years vs. 67 ± 15.34 years, p = 0.030), use of immunosuppressive drug(17.6% vs. 50%, p = 0.032), preoperative hemoglobin level (12 ± 2.45 g/dL vs. 10.1 ± 3,0 g/dL, p = 0.021), postoperative vasopressor use (22.4% vs. 100%, p < 0.001), and postoperative sepsis (4.6% vs. 30%, p = 0.024) were associated with mortality. Five patients with AL had significantly longer operation time (443.4 ± 219.61 minutes vs. 225.7 ± 130.21 minutes, p = 0.008) and more postoperative bowel obstruction (60 % vs. 3.3 %, p = 0.001) than non-leakage (NL) group. However, the use of stapler for small bowel anastomosis was more frequent in NL group (54.4% vs. 0%, p = 0.024). In the multivariate analysis, the operation time was only the risk factor of AL (p = 0.049). Conclusions: The Age, use of immunosuppressive drugs, preoperative anemia, postoperative vasopressor use, and postoperative sepsis were associated with mortality after emergent small bowel resection. Moreover, long operation time and postoperative bowel obstruction were correlated with AL.

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COMBINED LIVER, KIDNEY, SILENT PANCREATIC INJURY AND OVERLOOKED SMALL BOWEL LESION AFTER DIAGNOSTIC LAPAROSCOPY IN POLYTRAUMA PATIENT Stabina Solvita, Kaminskis Aleksejs, Pupelis Guntars Riga East University Hospital, Clinical Centre of Emergency Medicine Gailezers, Latvia Introduction: Recognition of small bowel injuries are challenging and laparoscopic diagnostics needs sufficient expertize. Missed diagnose is the main cause of delayed surgical intervention directly linked to increased mortality. The aim of our case report is demonstration of diagnostic challenge in polytrauma patient with combined parenchymatous organ and small bowel injury. Methods: Case report. Results: 51-year-old female was delivered to the hospital after car accident. During the CT scan third degree of liver rupture, second degree of left kidney rupture and multiple bone fractures were found. In time of the diagnostic laparoscopy 200 ml of haemoperitoneum and liver lacerations involved 4th and 6th segment were found. On the second day signs of peritoneal irritation and sepsis mandate repeated intervention. Pending the laparotomy small bowel perforation was revealed and repaired. Two weeks after laparotomy 1000 ml of right side pleural effusion was drained, which contained 14000 U/L of lipase. Earlier not recognized pancreatic duct injury with pancreaticopleural fistula were successfully treated with Sandostatin. Conclusions: Recognition of combined parenchymatous organ and small bowel injuries are challenging and visual diagnostic workup is not always sufficient for recognition of full scale of injury. Provision of laparoscopic diagnostic procedure should be provided by expert. Further thorough observation may reveal late complications.

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VASCULAR TRAUMA: CONSIDERATIONS ON EXPERIENCE OF 15 YEARS Scabini M., Mosso F., Negri C., Zaghis M., Celoni M., Capelli P. Ospedale Guglielmo Da Saliceto di Piacenza, Italy Introduction: In civilian life, in recent years, there has been a progressive increase in vascular trauma in their entirety and the arts in particular: the main points of this list are represented by traffic accidents, accidents at work and above all iatrogenic injuries during vascular catheterization. Methods: We studied the incidence and etiology of these traumas, to evaluate the effectiveness and suitability of our therapeutic approach. We performed a retrospective review of our cases, 166 vascular trauma: 94 iatrogenic injuries from endovascular procedures (56.6%), 55 vascular lesions lacero-contuse/traumi from wounds closed (33.1%), 8 traumatic limb amputations (4.8%). Results: The interventions provided: 90 direct raffie, 29 direct anastomosis, 20 anastomosis with interposition vein graft, 12 vessel ligatures, 6 anastomosis with interposition of prosthetic graft, 5 endovascular embolization, 4 primary amputations. We had 3 cases of perioperative mortality (thoraco-abdominal trauma). Four replanted limb were followed by secondary amputation. Six prosthetic grafts: good iliac one; bad 5 peripheral, 2 cases of infection and 3 thrombosis. Twenty venous grafts and twenty-nine arterial direct anastomosis are patent longterm. Ninety raffie: well at a distance. Slurs and endovascular embolization have been practiced successfully without causing distal ischemia. Conclusions: -Vascular trauma are a complex reality that requires the intervention of several specialists and which further complicates clinical pictures in itself already very challenging. -Significant increase over the years of iatrogenic injuries related to the increase in endovascular procedures; -Angiography often proves decisive for the diagnosis / treatment of injuries.

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TREATMENT OF BLUNT TRAUMATIC SUBISTHMIC AORTIC RUPTURE IN POLITRAUMATIC PATIENTS Mastropietro T.*, Cataldi C.*, Salvatelli M.*, Truosolo B.*,Ferrer C.**, Morucci M.***, Cao P.**, Marini P.* * General Surgery 1 San Camillo Hospital Rome, **Vascular Surgery S. Camillo Hospital Rome, ***Interventional Radiology S. Camillo Hospital Rome, Italy Introduction: The diagnosis and the management of blunt thoracic aortic rupture has undergone many significant changes over the last decade. Rarely an aortic rupture is isolated, often is associated with other complex thoracic and abdominal injuries with a high mortality, more than 80% of patients with blunt thoracic aortic injury die before reaching the hospital, those that survive have a mortality rate of 30% in the first 6 hours, and 40-50% in the first 24 hours. The management of these patients is a big challange in the trauma care. Methods: From 2002 to 2012 we have treated 40 patients with thoracic subistmic aortic rupture associated with other thoracic and abdominal injuries. The diagnosis of thoracic aortic rupture has made with CT scan. All thoracic aortic rupture were traited with endovascular stent graft. Results: Our Experience 2002- 2012 40 Patients average age 40 (18-85 years) 39 Males 1Female. 6 covered of left subclavian artery, 1 left carotidsubclavian bypass Mortality: Overall 3/40 (2 traumatic cerebral haemorrhage, 1 MOF) In-Hospital related procedure: 0% Late related procedure 5.5% (1 aortic-bronchial fistula died 6 month after) No endoleak No paraplegia. Conclusions: 80-85% of blunt thoracic aortic injuries patients died on the scene. Endovascular procedure has changed the treatment of this injury with a reduction of mortality and morbidity. Todays the gold standard is the endovascular treatment with a mortality less than 8%.

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CAROTID ARTERY DISSECTION FOLLOWING POSTERIOR NECK TRAUMA (POSTER PRESENTATION) Altina Xhaferi, Medien Xhaferi, Astrit Hoxhaj, Gentjana Qirjako Medical University, Faculty of Medical technical Sciences- Tirana, Albania: National Trauma Center Introduction: Dissection of the carotid arteries can occur in the general population as a result of blunt trauma to the neck, such as a car accident or a fall, or from hyperextension of the neck in sports or exercise. Incidence of carotid artery dissection as a result of blunt injuries ranges to 3%. Methods: We present a case of dissection of the right common carotid artery in a male 25 years old after blunt neck trauma at the workplace Doppler ultrasound of neck region was performed followed by neck CT with intravenous contrast enhacement. Results: The patientâ&#x20AC;&#x2122;s conditions were stable, without motor and sensor deficits, without neurological problems, only with presence of subcutaneous emphysema on the right cervical region The patient complained of neck pain. The radiologic exam revealed a dissection of the right CCA associated with the stenosis of the lumen up 78 %. AngioCT scan of the neck revealed rupture of the intima in the right CCA, with significant stenosis of the lumen, without having the possibility of measuring the extension of the dissection due to the fresh and very mobile dissection flaps. The angiosurgeon of the case confirmed the radiologic diagnose. Conclusions: Carotid artery dissections should be considered in patients presenting with localized signs after severe trauma. They have varied presentations that depend on the location and the vessel involved. The heterogeneous clinical pictures associated with carotid artery dissections often lead to delays in diagnosis and treatment.

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PYOGENIC VERTEBRAL OSTEOMYELITIS COMPLICATING ABDOMINAL PENETRATING INJURY: CASE REPORT AND REVIEW OF THE LITERATURE Bertazzoni P., Zefelippo A., DeRai P., Marini A. UO Chirurgia d'Urgenza, Fondazione IRCCS CĂ Granda Ospedale Maggiore Policlinico di Milano, Italy Introduction: Vertebral osteomyelitis is a possible complication following abdominal penetrating injuries involving the retro-peritoneum. Diagnosis is often difficult due to subtle onset of back pain and signs of sepsis days or weeks after trauma. A case report of osteomyelitis following transperitoneal wound is presented. Methods: Clinical records and imaging of the patient were retrieved. Pubmed MEDLINE was interrogated using the following keywords: osteomyelitis, penetrating abdominal wounds, spinal injury. Relevant studies and reviews were analyzed. Clinical management of vertebral osteomyelitis associated with trans-peritoneal wounds was discussed in the light of literature review. Results: A 21 year-old male was admitted for abdominal penetrating wound from a pointed stick. CT scan showed a self-contained retroperitoneal hematoma secondary to inferior vena cava injury and no intra-peritoneal fluid. In few hours he developed peritonitis. On laparotomy, a perforation of transverse colon was detected and repaired. After 14 days the patient developed lumbar back pain and temperature. CT and MRI showed osteomyelitis at L3-L4. Broad-spectrum antibiotics were started and hyperbaric treatment, analgesia and bed rest were administered. Blood cultures remained negative. The patient showed no signs of systemic sepsis and made a full recovery in 2 months. Conclusions: In the presented case, osteomyelitis developed after transperitoneal stick injury. Conservative treatment was effective. According to literature review, non-operative management in stable injuries of the spine and antibiotic coverage for concomitant colonic perforation is recommended. Prolonged antibiotic therapy is the treatment of choice in case of uncomplicated vertebral osteomyelitis.

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BABY EMERGENCY SURGICAL SERVICE OFF LIMITS Fette A. University of Pécs, Medical School, Hungary; SES, Bonn, Germany Introduction: All over the world, surgical service for babies and infants is an ongoing challenge, pushing parents, the health care system and the pediatric surgeon - fast and easy - to or even off limits. Methods: Taking the limitations of our Western World as the baseline, extremes experienced in and during infant surgery either in the subtropics (Solomon Islands) or Siberia (Kazaksthan) are presented. Focusing, next to the specialist`s surgical techniques on perioperative essentials, like infrastructure & logistics, individual body knowledge & health education, and personal responsibility & decision making, as well. Results: Lessons learned are the fast and more general acceptance of different forms of patience & trust, in the majority influenced more by tradition & culture than by science & second opinion like in our culture. Sometimes even pronounced by the more liberal acceptance of less operative infrastructure & logistics in this health care systems. Conclusions: Together, all these aspects form a new definition of the term “personal responsibility” with a lot of lessons needed to be learnt. Disclosure: No funding, no sponsoring, no financial interest.

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LAPAROSTOMY AS TREATMENT OPTION IN TOTAL PERITONITIS WITH SEVERE SEPSIS Sakakushev B.E. Medical University/University Hospital St George Plovdiv, First Clinic of General Surgery, Bulgaria Introduction: Since its implementation from Steinberg in 1979, and popularization by Duff and Maetani in 1981, laparostomy/open abdomen/, has gained acceptance in the last decades as efficient surgical method for the operative treatment of intra-abdominal sepsis. The promising initial result soon revealed problems and complications of the left open abdomen. They were partially dealt by implementation of temporary closure methods, modified consequently into completely or partially opened techniques, using resorbable or non-resorbable meshes, zipping, etc. Recently prompt and understandable differentiation of the two main types of open abdomen was published, defining them into planned re-laparotomy and on-demand laparotomy, giving advantage to the latter. Though progress and understanding of open abdomen techniques have been registered, mortality in severe intra-abdominal sepsis due mainly to anastomosis dehiscence or visceral organ necrosis remains up to 30%. Methods: To assess the results of laparostomy we reviewed 32 patients with severe total peritonitis operated on in our clinic between 2005-2012. Medical records and operative protocols were analyzed for indication method planned or on demand laparotomy, number of re-laparotomies performed after the index operation, technique of and types of procedures maintained. Complications, additional procedures and mortality were revised. The procedures performed in different patients varied from 2 to 10, when restoration of abdominal cavity took place. In the initial operation, after debridement of pus, exudates, revision of the peritoneal cavity, necrectomy, resection of necrotic visceral segment, suture of lesions or anastomosis, lavage of the peritoneal cavity and decision for laparostomy, we leave open the operative wound, covering the small intestines with the greater omentum, and above them placing mesh, fixing it to the peritoneum and fascia with an average of 8-12 sutures. We cover the mesh with oozy dressing. First revision we usually perform on the 24 or 48 the hour. In every following intervention we revise all intra-abdominal regions, performing total separation of all small intestines for mastectomy or lesion suturing. In two complex cases we used VАС/vacuum assisted closure We used chlorhexidine or iodine solution for abdominal lavage. Closure of the abdomen is indicated when there is no abscess in the abdomen and the operative wound edges become organized. Total single or transfixed nylon sutures are generally applied for closure. Results: Patient’s age varied from 28 to 92 years /mean 65.4 /, 18 men and 14 women. Most of the patients /24 (75%)/ were with feculent

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peritonitis. Other causes were postoperative, due to anastomosis dehiscence, pancreatic, small bowel, gunshot. Co- morbidity was present in 23 patients. ASA Risk proportion showed dominance in IV and V groups. In 11 (33, 3%) patients postoperative complications have been registered: entero-coetaneous fistulae in 5 patients, secondary intestinal resection and reanastomosis/5/, wound dehiscence/2/, bleeding/2/. lethality 8/25%/. Conclusions: The three main principles of open abdomen are enhancing the re-intervention, control and prevention of the persisting/recurrent infection and management of the raised intra-abdominal pressure. Common indications for open abdomen are infected pancreatic necrosis, severe intraabdominal sepsis, ileus and trauma. Advantages of laparostomy are easy exploration of the abdominal cavity, lower risk of iatrogenic intestinal lesion, effective drainage of the infected collections, preventing multiple abscesses. Drawbacks of laparostomy are prolonged hospital stay, need for intensive care, raise of resources and costs. VАС/vacuum assisted closure/ and АВ Тhera Abdominal System are hopeful options for open abdomen treatment Open abdomen as a method of treatment in severe total peritonitis assures technical surgical advantages, affording better treatment and infection control, reduction of bacterial contamination, elimination of necroses and toxins, preventing secondary peritonitis and abscess, resulting in lower mortality and morbidity.

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SURGICAL CRITICAL CARE OF PATIENTS WITH SEVERE TRAUMA Tae-Huyn Kim M.D., Min-Ae Geum M.D., Dae Sung Ma M.D., Suk-Kyung Hong M.D., Ph.D Division of Trauma and Surgical critical care, Department of surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea Introduction: Severe trauma patients because of multiple damages, to understand the exact extent of the damage, treatment should be rapid. Surgical treatment and critical care of patients on the need to evaluate. Methods: The study design was an 2-year retrospective survey admitted in Intensive Care Unit (ICU) and Injury Severity Score (ISS) was score 15 points or more, Asan Medical Center (University of Ulsan College of Medicine, Seoul, Korea). A total of 153 patients were reviewed. Results: A total of 153 patients (113:40, Male: Female) with an average age of 47.64 ± 17.94 years. Average ISS score of the patients was 31.52 ± 16.33 points. Hypotensive shock was 64 patients (41.8%) occurred, in the average red blood cell transfusion was 6.83 ± 12.11. Ventilator therapy, 106 patients (69.2%) received an average 9.10 ± 9.90 days respiratory therapy was done. 35 patients (22.8%) showed the rhabdomyolysis, dual 11 patients (31.4%) was treated with hemodialysis. The incidence of injury in the abdomen injury of 102 (66.6%), pelvis and extremities of 102 (66.6%), thoracic injury of 96 (62.7%) occurred. Intensive care unit patients treated with 91 people (59.3%) underwent surgical treatment admitted in ICU with 160 operation numbers. Operation numbers were 60 cases, most in abdomen, 52 cases, pelvis and extremities, 13 cases, spine surgery, 11 cases, face and skin surgery, 11 cases, head, 10 cases, vascular surgery, 3 cases, thoracic surgery. 102 patients (66.6%) of the complications occurred in 32 patients with pneumonia, 26 patients with wound infection, 22 patients with renal failure, bacteremia, 20 patients, open the abdomen in 12 patients, compartment syndrome 3 patients occurred. ICU length of stay of patients with severe trauma, and 8.75 ± 10.06 days and hospital stay was 27.47 ± 23.34 days. 26 patients (17.0%) showed mortality. Patients who died in the mean ISS score of 50.46 ± 22.75 points, cause of death were brain death, 8 patients (30.7%), hemorrhagic shock, 7 patients (26.7%), septic shock, 6 patients (23.1%), multiple organ failure, 2 patients (7.7%), post-traumatic meningitis, 2 patients (7.7%), liver failure, 1 patients (3.8%). Conclusions: According to the experience of severe trauma care management of multiple damages to the activation of systematic operation plan is required. Surgical intensivist intensive resuscitation, surgical treatment through treatment integrated treatment.

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and intensive ICU care and should serve planning, and

A RARE CAUSE OF OBSCURE GASTROINTESTINAL BLEEDING: A CASE REPORT Gachabayov M., Abdullaev E.G., Yaskin E.G., Borovkov I.N. Vladimir City Hospital of Urgent Medical Aid (The Hospital of Red Cross), Russia Introduction: Hemobilia is a rare cause of upper gastrointestinal bleeding, especially due to vascular conditions (9-15% of all hemobilia cases). Although hemobilia most commonly is minor, in major cases it can be a life threatening condition. Methods: We report the case of 49-year-old female with upper GI bleeding- hemobilia due to arterio-venous malformation of right hepatic vessels. Results: Case Description A 49-year-old female presented to emergency department with melena, hypotension, tachycardia, jaundice, severe posthemorrhagic anemia (Hb- 52 g/l) and palpable mass in right upper quadrant. On esophagogastroduodenoscopy no source and stigmata of bleeding was found. On ultrasonography (USG) a large cystoid mass (d~20 cm) under right hepatic lobe was found. The cyst was drained percutanously under USG guidance- reduced blood was obtained. On fistulography the cyst had a communication with right hepatic artery and common bile duct via erosive fistula which forms arterio-venous malformation. The right hepatic artery was embolized. No recurrent episodes of gastrointestinal bleeding were seen. Also subhepatic hematoma resolved. Conclusions: Discussion Hemobilia is a rare cause of either occult or overt obscure GI bleeding, especially hemobilia due to vascular conditions is very rare. Arterio-venous malformations of hepatic vessels can cause fatal hemorrhage. We must take them into consideration when we find hepatic or subhepatic hematoma. In cases of obscure gastrointestinal bleeding in the presence of Quincke\'s triad it is very useful to perform abdominal USG or CT. The definitive treatment of hemobilia due to vascular conditions is embolization.

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ACTIVATION OF FACTOR VII-ACTIVATING PROTEASE IN PATIENTS WITH DIFFUSE PERITONITIS: A MARKER FOR CELL DEATH Smirnov D. South Ural State Medical University, Department of Surgical Diseases, Russia Introduction: Cell death is a central event in the pathogenesis of sepsis and is reflected by circulating nucleosomes which correlate with outcome in septic patients. Factor VII-activating protease (FSAP) was identified to be the plasma protease responsible for nucleosome release. The aim of this study was to investigate FSAP activation in patients with diffuse peritonitis. Methods: We developed ELISAs to measure FSAP-C1-inhibitor and FSAPa2-antiplasmin complexes in plasma. FSAP-inhibitor complexes were measured in the plasma of 20 adult patients undergoing surgical treatment of secondary diffuse peritonitis (complications of acute appendicitis, cholecystitis and gastric ulcer perforation), 32 adult patients suffering from severe abdominal sepsis and 8 from septic shock. Results: We demonstrate plasma FSAP to be activated upon contact with apoptotic and necrotic cells by an assay detecting complexes between FSAP and its target serpins a2-antiplasmin and C1-inhibitor, respectively. By means of that assay we demonstrate FSAP activation in post-surgery patients, patients suffering from severe abdominal sepsis and septic shock. Levels of FSAP-inhibitor complexes correlate with nucleosome levels and correlate with severity and mortality in these patients. Conclusions: These results suggest FSAP activation (FSAP-AP and FSAPC1-inh complexes) to be a sensor for cell death in the circulation. We demonstrate FSAP activation in adults suffering from abdominal sepsis which increases with the severity of inflammation. Our results suggest that FSAP activation in sepsis might be involved in nucleosome release thereby contributing to septic lethality.

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EMERGENCY LAPAROSCOPY IN ELDERLY PATIENTS. OUR EXPERIENCE Roveran A., Torchiaro M., Verza L.A., Prando D., Azabdaftari A., Vacca U., Rubinato L., Agresta F. Dept of General Surgery Adria ULSS19 del Veneto, Italy Introduction: Today we are seeing an increasing in age in the general populations and as a consequence almost 40% of emergency procedures in surgery, generally speaking, are done in patients over 65 year old. Elderly patients has several co-morbidity (above all cardio-respiratory ones) and these have been considered a contraindications for a laparoscopic approach. Here in we want to report the experience of an emergency laparoscopic approach in patients over 65 in a context of a general surgery department in a community hospital. Methods: From March 2011 to March 2013., 87 patients over 65 years (mean age 79yy), have been approached laparoscopically for a non traumatic acute abdomen in the department of General Surgery of the Adria Hospital in Italy. Have been performed: 45cholecystectomies; 9 appendictomies, 15 adhesiolysis plus in 3 cases an ileal resection; 1 sigmoid resection and 2 right colectomies for cancer obstruction; 3 drainage for a diverticulitisâ&#x20AC;&#x2122; abscess; 2 direct suture in perforated peptic ulcer; 1 resection for gastric GIST; 7 explorative laparoscopies for obstruction due to advanced cancer; 2 diagnostic laparoscopies for acute intestinal ischemia. Results: The p.o. mortality was the two cases of intestinal ischemia. We had two redo procedures with an open approach in one case of diverticulitis and one case of PPU. The average hospital stay has been 2,6 days for cholecystectomy and adhesiolysis; 3,6 days for appendectomy; 9,5 days for colon resection. 10 patients were older than 90 years (7 cholecystectomies, 1 left colectomy, 1 appendicectomy, 1adhesiolysis) . We have registered no p.o. mortality in this subgroup of patients and at a telephone follow-up: has been reported that two of these last ones died several months later for a non surgical problem. Conclusions: The well known advantages of laparoscopic surgery, above all reduced hospital stay, are applicable to aged patients expecially in the emergency setting , provided no general contraindication to this approach.

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THE ROLE OF CELL-FREE DNA MEASURED BY A FLUORESCENT TEST IN THE ASSESSMENT OF ISOLATED TRAUMATIC HEAD INJURIES Shaked G., Czeiger D., Yair S., Douvdevani A. Soroka University Medical Center and Ben-Gurion University, Israel Introduction: Traumatic brain injury (TBI) remains a major cause of death and disability. The assessment of TBI by Glasgow Coma Scale and CT scan has limitations. A biomarker may be a useful adjunct. The present study evaluates a simple and rapid method to measure cell free DNA (CFD) in TBI patients. Methods: Thirty four patients with isolated head injury were enrolled into the study. Their demographic and clinical data were recorded. CFD levels were determined in patients' sera samples by a direct fluorescence method developed in our laboratory. Results: The CFD values measured on admission were significantly lower in patients with mild TBI reflected by an admission GCS >13 and in patients whose Glasgow Outcome Score (GOS) on discharge was 5 (normal function). Patients with high CFD values had 1.5 relative risk to require surgery, 2.8 relative risk to have impaired GOS on discharge, and longer in-hospital length of stay. In contrast, CFD values did not show significant differences between different degrees of severity of injury as reflected by two CT scan based schemes. Conclusions: CFD levels may be used as a marker to assess the severity of TBI and to predict the prognosis. Its use should be considered as an additional tool along with currently used methods or as a surrogate for them in limited resources conditions.

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A NEW SURGICAL DRAINAGE DEVICE Carletti M. Dept. of Emergency, S.M.Goretti General Hospital Latina, Italy Introduction: We have developed a specialized drainage (patent device) tube for General â&#x20AC;&#x201C;Thoracic Surgery and Minimally Invasive Surgery as a means to overcome the limited exposure typically for old and new surgical approaches. These system allow a better drainage, produce lesser skin injury, improve drainage results and reduce the drainage equipment and effective costs. Methods: The device is a single drainage tube 28 or 30 F in witch is inserted a second tube of 8 F silicone tube that can be freely and independently positioned alone in a second space. This special tube can be placed in the space between the heart and diaphragm (cardiothoracic surgery)so as a Y shaped drainage tube or used on general abdominal surgery. Results: The laminar flow in a drain is detected by Poiseulle's law. This device was used on 50 cases of urgent abdominal surgery (acute necrotizing pancreatitis, acute peritonitis due to bowel perforation and biliary tract lesions) using as major tube a diameter of 28, 30 or 32 F and internal silicone tube diameter of 8 F. On 48 cases of thoracic surgery (empyema, pleural effusion, extensive penetrating thoracic wound lesions) the device was in many cases associated to a doudle chest drain.Two patients in this group needs reoperation due to postoperative empyema development The double independent drainage device was altogether used in 98 cases achieving effective drainage of both thoracic and abdominal compartment without significative complications during and after removal. It is indicated in selective cases to help for compartment syndrome monitoring Conclusions: For a limited surgical exposure provided by the new Minimally Invasive Procedures in General and Thoracic Surgery, or in cases of Emergency General Surgery (multiple trauma patients) a new specialized draining equipment that can be inserted through a small incisions (porthaccess) or normal drainage sides is developed. We report the development of a new drainage device as well as a bifurcated mobile drain tube for simultaneous drainage of two distal areas. This device is free - on expertise hands - of complications.

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STOMAS IN EMERGENCY SURGERY: A SINGLE CENTER EXPERIENCE Cocorullo G., Carollo G., Di Maggio M.A., Fontana T., Salamone G., Agrusa A., Gulotta G. Department of General, Emergency and Transplant Surgery (GENURTO)Unit of General and Emergency Surgery, University of Palermo, Italy Introduction: The creation of a stoma is an established therapeutic procedure for “palliative” and “curative” treatment and today it is very used in a lot of situations. Thus, we use this procedure for both palliative and curative treatment in some diseases that have been described in our study. The prognosis of patients with palliative stoma depends on the advanced stage of the cancer, co-morbidities and their poor general state of health. Methods: Our study includes a period from April 2008 to January 2013. In that period we made 97 stomas in emergency. Among the first ones, 10 of them were made following the laparoscopic procedure (8 ileostomy; 2 colostomy) and the other 11 in open surgery. In curative stomas we have analyzed 4 topics: occlusion, perforation, bleeding, ischemia. In intestinal obstruction we applied Hartmann’s procedure or stoma like a “bridge” connected to a second resected stage or diverting stomas in “one step” operations. In intestinal perforation with diffuse purulent or faecal peritonitis and high risk of mortality and morbidity Hartmann's procedure was the first choice. We applied the Hartmann’s procedure in 76 intestinal occlusions/perforations, in 10 of them we did laparoscopic procedures (conversion rate 2/7), and in 66 we did open surgery. Exclusion criteria were: bowel dilatation exceeding 4 cm; previous surgery; suspect of malignant disease. Results: We made 21 palliative stomas: 10 laparoscopic procedures (8 ileostomy; 2 colostomy), 11 open surgery; conversion rate: 1/7 (14,3%). We did 76 Hartmann’s procedure for intestinal occlusion/perforation: 10 laparoscopic procedures, 66 open surgery, and conversion rate was 2/7 (28.6%). Conclusions: Thanks to these studies we know that packaging of a curative and palliative stoma can be achieved even in emergency, laparoscopically, taking into account that a minimally invasive approach is preferable, but we need more randomized controlled trials. However, notably in the case of stoma healing, which is associated with a bowel resection, it is necessary a long learning curve and it depends on the surgeon's skill.

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BEDSIDE LAPAROSCOPIC: AN INSTITUTION EXPERIENCE OVER SIX YEARS Cocorullo G., Di Maggio M.A., Carollo G., Fontana T., Agrusa A., Salamone G., Gulotta G. Department of General, Emergency and Transplant Surgery (GENURTO)Unit of General and Emergency Surgery, University of Palermo, Italy Introduction: The acute mesenteric ischemia (AMI) is an uncommon but serious disease, that is always associated with other systemic disease and with unfavourable prognosis. Cardiac failure, history of atrial fibrillation, and recent surgery have all been associated with fatal AMI in particular for patients who underwent cardiac surgery, as well as patients in ICU that frequently have a “low flow” syndrome. Methods: From January 2006 to October 2012 we examined 25 patients (18 men and 7 women) aged 57-85 years. these patients were in the ICU. 8 of them (32%) did not show humoral test or abdominal clinical features suggestive of AMI. Because of their critical conditions and the technical difficulty to transport them to the radiology department to have the CT we decided to perform a BEDSIDE laparoscopic. Results: N. 5 patients the outcome of exploration was negative (12%). In 3 other patients (12%) we saw an initial but massive ischemia, secondary to a “low flow” syndrome with exitus of the patients. In 17 patients (76%) AMI has been diagnosed, and then a laparotomy was performed followed by the resection of the intestinal tract involved. Conclusions: The bedside laparoscopic is possible and safe; it can get good results in a risk category of patients with a difficult case report and when the diagnosis is not feasible. The significant reduction of anesthesiological and surgical trauma makes the \"laparoscopic secondlook\" a substitute of the \"surgical second-look\". It needs to be applied more frequently with precise instructions for use.

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MANAGEMENT OF ACUTE ABDOMINAL PAIN AFTER LAPAROSCOPIC ROUX-N-Y GASTRIC BYPASS Abboud W., Mahajna A., Kluger Y., Assalia A. Rambam Health Care Campus, Haifa, Israel Introduction: Laparoscopic Roux-en-Y gastric bypass (LRYGB) has been shown to be an effective treatment for morbid obesity, both in terms of weight loss and improvement of co-morbidities. It has long been associated with the possible development of internal hernia. The reported incidence is estimated to be 1-5%. The clinical presentation could range from intermittent abdominal pain suggestive for small bowel obstruction with normal radiographs, to severe acute pain with ischemia of the small intestine. Methods: The technique of LRYGB in our institution entails the creation of the gastro-jejunostomy in the anti-colic, right-oriented limb without routine closure of the mesenteric defects. All patients undergone LRYGB were reviewed retrospectively. Cases presented with acute abdominal in the postoperative period were selected. Clinical and radiographical data were recorded. Results: Five patients out of 250 (2%) were re-admitted because of intermittent colicky abdominal pain. An additional patient from another institute was included. The mean time period from the index operation was 6 months. All but 1 had negative Plain abdominal films and normal CT scans. Five patients had multiple admissions for the investigation of the pain, including Ultrasound to rule out biliary disease, upper GI study and upper endoscopy, which were normal. In one patient, The CT scan showed internal herniation and was operated on an emergency basis. The other five were eventually re-operated on an urgent basis because of the suspicion of intermittent recurrent internal herniation. In 2 patients internal hernia without bowel ischemia was found and mesenteric defects were closed. In 4 patients no abnormality was found, but the mesenteric defects were closed. No complications and no mortality were observed. All patients became asymptomatic since then. Conclusions: Every patient following RYGB presenting with acute abdominal pain after the immediate postoperative period, should undergo an expedite investigation includingupper abdominal US, upper endoscopy, upper GI study and CT scan. If no apparent etiology is found, most probably, intermittent internal herniation of the small bowel through the mesenteric defects is the etiology and urgent diagnostic laparoscopy and closer of defects should be undertaken. Pros and cons of routine mesenteric defects closer will be discussed.

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NECROTIZING FASCIITIS - A CHALLENGE TO THE SURGEON Aline Gomes, Júlio Constantino, Concelho Marques, Jorge Pereira, Luis Filipe Pinheiro Centro Hospitalar Tondela- Viseu, Portugal Introduction: Necrotizing fasciitis is a rare infection of the fascia and soft tissues, rapidly progressive and life-threatening. In its early stage, requires a high level of diagnostic suspicion, because can be frequently difficult to differentiate from any other infections of the skin and soft tissues. Methods: The authors retrospectively studied 14 patients who had been admitted to the emergency department and hospitalized in the Department of Surgery 1 of the Hospital de São Teotónio de Viseu, from October 2004 to October 2009. Results: It was initially suspected of necrotizing fasciitis in 12 patients and promptly resulted in emergency surgery. The other two were admitted with septic shock and died in the next 24 hours. Seven patients didn't have comorbidities, neither an identifiable cause. The mean hospitalization duration was 44.5 days. Nine patients required re-operation and seven were admitted in the ICU. Six patients underwent aggressive surgical resection and thereby resulted in mutilation. The total mortality was 5 patients, mostly associated with Streptococcus pyogenes. Applying the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC), 13 patients had a score > 6 at admission. Conclusions: Necrotizing fasciitis can occur in otherwise healthy individuals, after minor trauma or without any identifiable cause. The most severe infections are associated with necrotizing infections type II. Prognosis depends on early diagnosis and aggressive treatment. Morbidity is often associated with mutilation. Treatment is difficult, consuming resources and requires multidisciplinary teams.

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PERFORATIONS IN NEC. EMERGENCY CALL FOR THE PEDIATRIC SURGEON Fette A. University of Pecs, Medical School, Hungary Introduction: Regarding the intestine of neonates “Necrotizing Enterocolitis (NEC)” is the most common medical and surgical emergency. “Focal Intestinal Perforation (FIP)” appears to be a distinct clinical entity, that occurs mainly in very low birth weight (VLBW) infants, where these FIPs finally account for the high percentage of gastrointestinal perforations. Despite most cases of early NEC can be managed successfully conservative, prompt surgical intervention is usually required for advanced or perforated NEC and virtually all FIPs. Such a perforation, the most serious complication possible, may occur in up to one - third of these patients. The initial cause of both, FIP and NEC, is typically multifactorial, and any of these neonatal intestinal perforation is characterized by a various spectrum of clinical presentations and anatomical findings. Methods: In this communication intestinal perforations like in a FIP, a pre/perinatal incident, and a perinatal gastric perforation are presented in due cause to illustrate the scope of “perforated NEC”. Results: Fundamentals in the treatment of both, NEC and FIPs, are the prompt diagnosis, adequate rescuscitation and a combined team approach including pediatric surgeons and neonatologists. Conclusions: However, not only in emerging countries, diagnosis and treatment will be challenging. Disclosure: No funding, no sponsoring, no financial interest.

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CRANIOFACIAL NECROTIZING FASCIITIS: OUR EXPERIENCE OF ELEVEN CASES Gerych I., Stoyanovsky I. Danylo Halytskyâ&#x20AC;&#x2122; Lviv National Medical University, Ukraine Introduction: Craniofacial necrotizing fasciitis (CFNF) is a devastating soft tissue infection due to rapidly progressive necrosis of the superficial fascia of the head and face, which is accompanied by severe sepsis and multiple organ failure. While predominantly necrotizing fasciitis affects extremities, abdominal wall and perineum, cases of CFNF are very rare. Methods: Eleven patients with CFNF (3 female, 8 males, median age of 56 years), who were treated in our clinic between 1999 and 2012 were retrospectively analysed for history, clinical, laboratory and intraoperative findings, and postoperative course. Most of them had co-morbidities: diabetes mellitus (4), alcoholism (3) and hormone-dependent asthma (1). Results: Disease typically begins with unspecific flu-like symptoms. The first manifestative symptom was swelling of scalp/face with the spread of oedema on periorbital regions - patients initially visited the different physicians (general practitioner, ophthalmologist, etc.). Delay with hospitalization to surgical department (2-7 days) leads to severe sepsis in all cases. Bilateral periorbital skin necrosis, leukocytosis and hyperglycemia at the admission were the factors related with poor prognosis. All patients received aggressive resuscitation, prompt radical debridement and adequate antibiotic therapy. In 8 cases wounds were closed by skin grafts or dermotension. Three patients (27.3%) died due to overwhelming sepsis. Conclusions: CFNF is associated with a high rate of primary misdiagnosis. Bilateral periorbital edema is a reliable clinical criteria for suspicion of CFNF. Periorbital skin necrosis, leukocytosis and hyperglycemia are predictors of poor prognosis. A delay in treatment due to difficulty in recognizing the CFNF may result in a catastrophic outcome.

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CELL SAVER BLOOD DECREASES MORTALITY WITHOUT AN INCREASED NEED FOR FRESH FROZEN PLASMA IN PATIENTS WHO REQUIRE MASSIVE TRANSFUSIONS. DO WE HAVE THE RATION RIGHT? Isaak Edahn J., Tchorz Kathryn M., Slapak Colleen, McCarthy M.C., Saxe J. Wright State University, USA Introduction: Massive transfusion protocols are now well accepted standards in all Level One trauma centers. The Committee on Trauma requires a protocol as a matter of recertification. A recent review of the protocol at our level one trauma center found several liters of blood were given in the course of a massive transfusion from the cell saver with no accounting for the potential need for concomitant fresh frozen plasma(FFP). We hypothesized that our need for (FFP) and other component therapy would be increased by increased concomitant use of the cell saver. Methods: We conducted a retrospective review of all massive transfusion cases presented to our transfusion committee. Review of all massively transfused trauma patients (receiving greater than 10 red blood cell units in the first 24 hours after admission) at a Level I trauma center from 10/2007 through 03/2010 were retrospectively evaluated based on: ISS (Injury Severity Score), Red cell to plasma ratio (R:P), Red cell plus cell-saver to plasma ratio (R+SC:P) given in the operating room; Average transfused plasma volume; Rigorous collection of compliance data and clinical status, The outcome measure was mortality at 100 days after admission. The independent samples t test was used to compare the cell saver (CS) group versus the non-cell saver (NCS) group with respect to ISS, R:P, R+SC:P. The chi square test was used to compare the two groups on the categorical variable of mortality. Results: 43 patients were evaluated. 22 were in the CS group and 21 in the NCS group overall mortality was 54%; 46% in the CS group and 62% in the NCS group. R:P was 1.4 in the CS group and 1.4 in the NCS group R+SC:P was 2.0 in the CS group, but still 1.4 in the NCS group. Average plasma volume transfused was 2600ml in the CS group and 1810 ml in the NCS group. No statistically significant difference in ISS or R:P between the groups. R+SC:P was statistically higher in the CS group (p=0.003). Mortality was statistically lower in the CS group (p=0.004). Coagulation profiles were similar in both groups. Conclusions: Cell saver blood clearly is providing additional coagulation factors despite washing of the RBC's. Reversal of dilutional coagulopathy does not adequately explain efficacy of increased plasma transfusion in trauma. Further study on the contribution of cell saver blood to and the effects of resuscitation in the era of 1:1:1 goals is needed.

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COMPARISON OF MORTALITY RATES FOR EMERGENCY ADMISSIONS OF GENERAL SURGEONS AND BREAST SURGEONS Parker J., Jenkinson L. Betsi Cadwaladr University Health Board, UK Introduction: Many trusts are facing the decision whether to exclude breast surgeons from their general on call surgical rota. This study aims to establish whether there is any difference in mortality rates in emergency surgical admissions between breast and general surgeons. Methods: Risk Adjusted Mortality Index data was collected from surgeons on the general on call rota in a North Wales Trust over a period of 31 months. Actual and predicted mortalities were compared to give excess death values for breast specialists and their general surgical colleagues. Statistical comparison was performed using the Mann Whitney U test. Results: Excess deaths for breast, colorectal and upper gastrointestinal were 3.1, -0.4 and -1.3 respectively. The difference in excess deaths between breast and general surgeons were not significantly different. Conclusions: Although further information needs to be collected, this information suggests that breast surgeons are performing as well as their general surgical colleagues in the on call rota and it may be appropriate for them to remain providing this service.

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EVALUATION OF THE INDICATORS DETERMINING THE DECISION MAKING FOR RELAPAROTOMY Yovtchev Y. MD, PhD, Minkov G. MD, cPhD, Petrov A. MD, mPhD, Stoyan Nikolov MD, T. Vlaykova T. PhD University Hospital/Department of surgery, Bulgaria Introduction The purpose of the study was to analyze clinical parameters related to the development of postoperative complication and to the indications for relaparotomy in patients operated for peritonitis. Methods For a 16-year period (January 1995 – December 2010) 482 emergency operations of severe peritonitis have been performed. A retrospective study on medical records of this group of patients was performed, taking consideration of all clinical parameters that were supposed to influence the decision making for relaparotomy and to be related to disease outcome. A new quantitative index was introduced to evaluate the necessity for relaparotomy. Results The average time for anastomosis insufficiency occurrence was 4.5±1.7 days. The onset of the first clinical signs associated with this complication and the evaluation of the need for reoperation were determined on the basis of criteria introduced by us, that consequently turned out to be statistically significant in decision making for relaparotomy (р=0.022). In this retrospective study, no relationship between empirical antibiotic therapy and either the decision for relaparotomy (p=0.655) or clinical outcome (p=0.431) was established. There was no statistically significant association between patients with one surgical intervention and those with relaparotomy due to anastomosis leakage (р=0.34). Conclusions The evaluation of the postoperative complication and the condition of every patient that needs relaparotomy is not possible without the active surveillance from the surgical team. Complementary diagnostic methods could assist in decision making for reoperation but could also provide falsely negative information and therefore, to result in considerably delayed relaparotomy. In such conditions, the benefits of antibiotic therapy would be insignificant and the clinical outcome - poor.

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LAPAROSCOPY IN PENETRATING ABDOMINAL TRAUMA Hang Joo Cho, Ji-Hoon Kim, Sung Jib Kim Uijongbu St. Mary's Hospital, The Catholic University of Korea, Korea Introduction: Laparoscopy is useful tool of various abdominal surgery. But, traditional approach of penetrating abdominal injuries is still exploratory laparotomy and the role of laparoscopy in penetrating abdominal injuries is still controversial. We investigate the role of laparoscopy in diagnosis and treatment of penetrating abdominal trauma. Methods: We retrospectively studied the patients who underwent laparoscopic exploration by stab wound in abdominal area at Uijongbuâ&#x20AC;&#x2122;s St. Maryâ&#x20AC;&#x2122;s hospital between May 2007 and December 2010. All patients were hemodynamically stable. Results: Nineteen patients were enrolled in this study. Three patients had intact peritoneum. Five patients had injuries through the peritoneum but had no internal organ injury and one patient had only omental injury. In five patients the procedure was converted to open laparotomy. They were one patient with sigmoid colon and meso colon injury and one patient with duodenal injury and small bowel injury and one patient with duodenal injury and and two patients with small bowel injuries. Two patients with small bowel injuries were repaired with mini laparotomy. Missed injuries were two. One is pancreas superficial injury and re-operation with bleeding control was conducted and the other is gastric injury with missed post wall injury. Three patients were treated with laparoscopic method. Among them, two patients were conducted laparoscopic primary closure with small bowel injury and one patient was conducted bleeding control with meso colon minor injury. There were no mortality cases in this study. Conclusions: Laparoscopy is a useful diagnostic tool in patients with stable penetrating trauma of abdomen. But, Retroperitoneal organ or deep injury should be examined carefully and if needed conversion laparotomy should be conducted. Small bowel injury is a good indication of laparoscopic management of stab wound.

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INTRAVENOUS IRON – CARBOXYMALTOSE (FERINJECT®) INFUSION IN ACUTE PERIOPERATIVE BLEEDING SITUATIONS REDUCES RED PACKED BLOOD CELL TRANSFUSION REQUIREMENT Hoenemann C.1, Von Hammerstein H.1, Boehringer H.1, Hagemann O.1, Doll D.2 1 Department of Anaestesiology and Intensive Care, St Mary´s Hospital, Vechta, Germany; 2Department of Surgery, St Mary´s Hospital, Vechta, Germany Introduction: Despite the actual literature some physicians still believe that the application of blood pre-operatively in elderly patients with anemia improves their fitness and reduces cardiovascular events (stroke, myocardial infarction) perioperatively. Although blood transfusions can be life-saving, they are not without risks. Infections (hepatitis B/C, HIV) were once the main risk, but they have become extremely rare with careful testing and donor screening. Transfusion reactions (TRALI, Acute immune hemolytic reaction, delayed hemolytic reaction, febrile response, etc.) and other non-infectious problems (Mixing up transfusions) are now main risks. The decreasing availability of allogeneic blood (e.g during summer vacation time), the rising total costs of transfusions and side effects mandate the search for alternatives, like patient blood management. One part of patient blood management could be the treatment of iron deficiency due to chronic or like in in this study acute blood loss. Thus the practicability of Ferinject® i.v. iron-carboxymaltose, its cost compared to RPC transfusion and its effect were to be investigated with this study. Methods: Prospective data mining with matched control group. The Control group received only RPC when anemic (Hb < 8,5 g/dl) in n=30 patients (group A) while in intensive care therapy, the iron group (n=30 pts) received only ferinject (group B), if Hb level decreased below 8,5 g/dl. Data were processed using Excel(R) and Graph Pad Prism (R). Results: All 30 pts in group A received in average 2,9 packed red blood cells, 13 patients of the iron group needed no further transfusions at all within this hospital stay, while n=17 pts received allogeneic transfusions while on the surgical ward (chi sqr, p<0,05). In group A each patient received in average 2,9 packed RBC, in group B only 1,6 packed RBC (ttest, p <0.05). Outcome in terms of discharge hemoglobin level were identical in group A and group B. Conclusions: RPC use was reduced by ~ 50 % in the Iron group. Total transfusion costs were higher in the group A, when taking the amount of transfusion and the overall total transfusion costs into account. The use of iron-dextromaltose enables to reduce blood transfusion requirement, while saving costs at the same time. This could be intensified even more by intensifying interdisciplinary cooperation (preoperative anemia screening

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and treatment, patient blood management, optimizing perioperative coagulatiuon, etc.). Nevertheless, we did not focus on adverse events during allogenic blood transfusion therapy, which is a point to be addressed in further studies, enlarging the iron application advantages in the perioperative settings. Dr. Boehringer and Dr. Hรถnemann received honoraria as lecturer from Vifor Pharma, Munich. Data are part of the doctoral thesis of Dr. von Hammerstein.

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PERITONITIS IN ADVANCED ABDOMINAL PREGNANCY: A CASE REPORT IN RURAL HOSPITAL IN EBOLOWA, CAMEROUN *

Santoni R.*, Righetti C.*, Gianni M.**, De Cian F.*, Berti Riboli E*. Azienda Ospedaliera San Martino, Genova, **Azienda Ospedaliera U.Parini, Aosta, Italy

Introduction: Every year, in the world, more than 500,000 women die because of complications during pregnancy or at birth, often performed without any kind of assistance, in critical hygienic conditions and inadequate health care facilities. In this context, the Sub-Saharan Africa holds a sad record: 1 mom to 16 (6%) dies from causes related to maternity, in industrialized countries, the ratio is 1 to 3,800 (0.02%) Abdominal pregnancy is a condition that is potentially life-threatening for the mother if not diagnosed. Methods: We report a case of 19 years old women who arrived in the rural hospital of Ebolowa, Cameroun with an advanced abdominal pregnancy. The young women did not know to be pregnant. She had sepsis and septic shock, with abdominal pain and tenderness, hypotension, severe anemia and fever. The only radiologic evaluation possible was abdominal ultrasonography which shows a 10 cm diameter mass in left iliac fossa, probably an abscess, with intra abdominal fluid collections and increased uterus. Explorative laparotomy confirmed an abscess outside left salpingo grown up around dead fetus of about 4 months old. Results: The patient underwent left salpingectomy,fetus removal, abscess drainage, and she was treated with antibiotics, hydration and blood transfusion. She was discharged after 10 days and today she is 21 years old and is a mother of 10 months baby. Conclusions: Late or not recognized ectopic pregnancy may be complicated considerably until the outcome lethal. The majority of deaths or cases of disability inflicted by pregnancy could easily be avoided: just a properly trained medical staff, simple technological tools for diagnosis, prenatal care, surgery in the event of serious complications.

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EPIDEMIOLOGY OF INJURIES IN FALL FROM HEIGHT. NIGUARDA HOSPITAL EXPERIENCE Mariani A., MD1, Prestini L. RN2, Bertuzzi M. PhD2, Di Fratta E. MD1, Casati A. MS1, Chiara O. MD1, Cimbanassi S. MD1 1 Trauma Team Dip. DEA-EAS, Ospedale Niguarda Ca’Granda Milano, 2 Quality Department, Ospedale Niguarda Ca’Granda Milan, Italy Introduction: Falls from height represent a distinct form of blunt trauma.The majority of studies are post-mortem evaluation. The aim of this study is to investigate if a correlation between the height of fall and type of injuriesdoes exist in our experience. Methods: We analyzed patients admitted to Niguarda Hospital after a fall from height during an eight years period. Weinvestigated demographic data, mortality and type of injuries. The height of fall was classified in meters as follow: 0-2.99; 3-5.99; 6-8.99; 9-11.99;≥12. Correlation between height and injuries was investigated usingchi-square test ( 2) test and Odds Ratio(OR). All statistical analyses were performed using Statistical Analysis System (SAS), a p<0.05 was considered statistically significant. Results: Six hundred-twentysix patients were admitted during the study period. Demographic data are shown in Tab1, epidemiology of injuries referred to height in tab 2-5 and the injuries significantly correlated with height in Tab 6. Head injury was present in 55.52% of patients, mostly after fall from 0-2.99 m;face injuries in 6.7 %, mostly in fall from 0-2.99 m;abdomen in 25.47%, mostly after fall from 9-12 m, thorax in 36.67% and extremity injuries in 49.58%, both mostly after fall from≥ 12 m(tab 36). Mortality was significantly higher after fall from ≥12 m (p<0.0006). Conclusions: In our experience, because of after fall from minor height (02.99m) patients cannot protect the head, this represented the most frequently injured district, according to the literature (1,2,3). Extremities were alsofrequently damaged.In order to obtain a more detailed data a multicentre prospective study is necessary. BIBLIOGRAFIA 1)T.C. Atanasijevic, S.N. Savic et al. Frequency and severity of injuries in correlation with the height of fall. J Forensic Sci, May 2005, Vol 50, No 3 2) K.G. Warner, R.H. Demling et al. The pathophysiology of free-fall injury. Ann Emerg Med. September 1986; 15:1088-1093 3)G.Lau et al. Forensic science international 93(1998) 33-44

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PREDICTIVE FACTORS OF DAMAGE CONTROL STRATEGY IN POLYTRAUMA Mariani A., MD1, Prestini L. RN2, Bertuzzi M. PhD2, Sammartano F. MD1, Chiara O. MD1, Cimbanassi S. MD1 1 Trauma Team Dip. DEA-EAS, Ospedale Niguarda Ca’Granda Milano, 2 Quality Department, Ospedale Niguarda Ca’Granda Milan, Italy Introduction: Damage Control Strategy (DCS) is an approach to prevent an irreversible physiologic insult in trauma (1,2). The aim of this study is to find parameters available in the first 15 minutes of patient arrival able to predict the need of DCS. Methods: We selected major trauma patients admitted in Niguarda Hospital in two years. Patients who didn’t undergo massive transfusion (MT) neither Damage Control Surgery (DCs) were identified as controls, while patients who underwent MT and/or DCs were identified as cases (Fig.1). The occurance studied was DCS (MT and/or DCs). We studied the parameters shown in Tab1. We had to exclude temperature because not collected in all patients. We studied also INR, even if we got this information in about 40 min from arrival, to check for eventual anticoagulant therapy. Chi-square test (χ2) test and Odds Ratio (OR) were used to correlate parameters to the occurance. Logistic regression was used to study the correlation to the occurance in different models, differnt models were compared together with likelihood ratio test (LRT)(Tab2). All statistical analyses were performed using Statistical Analysis System (SAS), a p<0.05 was considered statistically significant. Results: Our sample is shown in Tab3. Hypotension, heart rate, base excess, lactate, INR, haemoperitoneum and haemoglobin are significantly correlated with DCS (Tab1). The results of comparison between the models were depicted in Tab4. Models significantly correlated with the occurance were 2,6 (Fig 2,3). Haemoperitoneum was the most important parameter to predict DCS (OR 5.32; 95% CI 2.33-12.15). Conclusions: We tried to find a model to predict DCS (3). The emergency surgeon in front of SBP≤90 mmHg, Hb <8 g/L, BE ≤ -5 mmol/L and haemoperitoneum has to consider immediatly DCS. Bibliography: 1. MA Schreiber. Damage control surgery. Crit Care Clin; 20(2004):101-118. 2. JC Duchesne, K Kimonis, AB Marr, KV Rennie er At. Damage control resuscitation in Combination With Damage control Laparotomy: A survival advantage. J Trauma; July 2010, 69 (1): pagine 3. Yucel N, Lefering R, Maegele M, et al. Trauma Associated Severe Hemorrhage (TASH) score: probability of mass transfusion as surrogate for life threatening hemorrhage after multiple trauma. J Trauma; 2006 Jun; 60(6): 1228-36.

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PEDIATRIC TRAUMA. EIGHT YEARS EXPERIENCE IN NIGUARDA HOSPITAL OF MILAN Mariani A. MD1, Prestini L. RN2, Bertuzzi M. SD2, Boati P. MD1, Ballabio M. MS1, Chiara O. MD1, Cimbanassi S. MD1 1 Trauma Team Dip. DEA-EAS, Ospedale Niguarda Ca’Granda Milano, 2 Quality Department, Ospedale Niguarda Ca’Granda Milan, Italy Introduction: Trauma is still the most frequent cause of mortality and disability in pediatric population but pediatric involvemet is rare in trauma population. The aim of this study is to examine the correlation between the age of pediatric trauma patients and the type of injuries in different body regions. Methods: We analyzed pediatric patients admitted during eight years at Niguarda Hospital. We studied demographic data, mortality and type of injuries. Age was classified as: pre-school age (0-6 years), school age (712) and teenagers (13-17). Correlation between age and injuries was investigated using chi-square (χ2) test and Odds Ratio (OR). All statistical analyses were performed using Statistical Analysis System (SAS), a p<0,05 was considered statistically significant. Results: The epidemiologic data and the single group data are shown in tab 1-8. Motorcycle was the most common mechanism of injury in overall population (28.61%). Few type of injuries were correlated with age: pelvic fracture (p<0,03), maxillo-facial injuries (p<0,03) and splenic injury (p<0,03). Head injury was common in overall population (65.24%) followed by extremities (39.57%). Face injuries were more rapresented among teenagers (OR1.49; C.I. 95% 0.780-2.849), as such as thorax (OR 1.174; C.I. 95% 0.655-2.102), abdomen (OR 1.656; C.I. 95% 0.8403.268) and extremity injuries (OR 3.142; C.I. 95% 1.810-5.455). Overall mortality was 5.53% (fig 1-6). Conclusions: Pre-school age trauma patients are at high risk for head injury, while older patients suffer more from other disctrict injuries. Mortality was not significatly different among the age groups. Bibliography: 1) D. Sala, E. Fernandez et al. J Pediatric Surg 2000; 35:1478-1481. 2) Multiple trauma in pediatric patients. Pediatr Surg Int (2003) 19:417-423.

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SUICIDE ATTEMPT MAKES UP A LARGE PROPORTION OF PENETRATING TRAUMA CASES UNDERWENT SURGERY IN NECK, CHEST, OR ABDOMEN: THREE-YEAR EXPERIENCE IN A JAPANESE TERTIARY EMERGENCY CENTER Yoshimitsu Izawa, Keisuke Yamashita, Kenji Matsumoto, Keiichiro Tominaga, Reiko Mochiduki, Takafumi Shinjo, Chikara Yonekawa, Masaki Ano, Masayuki Suzukawa Department of Emergency and Critical Care Medicine, Jichi Medical University, Japan Introduction: Suicide is one of the most important causes of death due to its high rate although there are almost no gunshot wounds in Japan. Suicide attempt could contribute to increase penetrating trauma cases. Methods: We reviewed all the penetrating trauma patients underwent surgery in neck, chest or abdomen between 2010 and 2012 in a tertiary emergency center in Japan retrospectively. Data were collected regarding cause of penetrating trauma, site of penetrating injury, and injured organs. Results: There were 87 patients underwent surgery in the neck, chest or abdomen. 28 were penetrating trauma. Of these, 14 (50%) were suicide attempt, 7 were homicide attempt. In the suicide attempt patients, the most common injury site was abdomen, and small intestine injury was the most of all injured organs. Conclusions: Suicide attempt accounts for a half of the surgical cases of penetrating trauma. Trauma surgeons need skills for dealing with penetrating trauma due to high rate of suicide attempt.

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EMERGENCY GENERAL SURGERY: WEIGHING ACUTE CARE SURGERY'S ELEPHANT Ciesla D.J., Pracht E.E., Gunter O.L., Haider A.H., Cha J.Y., Shafi S. University of South Florida, USA Introduction: Emergency General Surgery (EGS) is an emerging priority for care standards, research, and policy within Acute Care Surgery. Although the AAST has established an EGS definition, the relative burden of disease which may present on admission or develop as an inpatient is unknown. The purpose of this study was to establish a method to identify patients with EGS conditions and provide a population adjusted estimated burden of disease. Methods: The 2011 Florida AHCA discharge dataset which includes up to 30 diagnoses and procedure codes was used to identify injured and EGS patients by ICD-9 codes using the AAST definitions. Admissions classified as newborn or discharges from non-acute care hospitals were excluded. State population was obtained from US Census. Results: Of the 2.35 million discharges that met inclusion criteria, 26.5% of patients had at least one EGS diagnosis (15.1% of children, 24.8% of adults, and 30.1% of elderly). The populaiton adjusted incidence was 3261.4/100k population for all EGS discharges and 639.05/100k populaiton for all injury related discharges. Among EGS patients, 34.7% had more than one EGS diagnosis. Only 48% of EGS patients were captured by the principal diagnosis while 95% were captured by the first 10 diagnoses. The number of diagnoses required to capture patients varied by EGS diagnosis category from 2 (appendicitis) to 19 (foriegn body). Operation was performed in 34.2% of EGS patients and 33.4% required ICU care. Conclusions: EGS conditions are common among hospitalized patients and frequently require operative and ICU care. Identifying patients with EGS conditions is complicated by the prevalence of multiple diagnoses in over 1/3 of EGS patients. The number of diagnoses needed for complete capture of EGS patients depends on the specific EGS category. The overall incidence of 3,261.4 events/100k population is more than 6 times higher than the reported injury rate in this same population.

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THE EFFECTS OF CENTRALISING THE TRAUMA SERVICE ON GENERAL SURGERY EMERGENCY OPERATION WAITING TIMES FROM 2009-2013 IN A UK LEVEL 1 TRAUMA CENTRE: SERVICE IMPROVEMENT STRATEGIES AND LESSONS LEARNED Katz-Summercorn A.C., Hewett S.E.W., Nicolay C., Maguire P.Z., Ziprin P. Imperial College Academic Surgical Unit, UK Introduction: In 2010 trauma services were centralised in the UK. This led to concerns that it would increase pressure on emergency General Surgery provision. We have looked at the effects of this transition and service changes introduced on emergency waiting times in a London trauma centre over a 4-year period. Methods: Data was collected retrospectively for all patients who underwent General Surgery emergency operations before trauma centralisation (January-February 2009); after centralisation (2011); and after service improvement strategies (2013) had been introduced. Operation and time from booking to commencing anaesthesia were recorded using the prospectively-maintained theatre database. Results: 307 patients underwent surgery over these periods. The median waiting time in 2009 was 5.7 hours (0.3-91.7) and this had increased dramatically to 19.4 hours (0.03-120.3) in 2011. In 2013 this had reduced to 14.5 hours (0.53-51.2). There were no significant differences in booking numbers in each period, nor operations booked. For abscess incision and drainage, inpatient-waiting time had fallen from 23.3 (3.3-120.3) in 2011 to 4.2 hours (0.4-47.1) in 2013 after the introduction of an abscess patient pathway, whereby patients were not admitted but returned the next morning to a protected theatre slot. Conclusions: Centralisation of trauma services led to increased waiting times in our centre. The introduction of a trauma theatre, protected theatre time, a daytime emergency surgeon and an abscess pathway have resulted in clear improvements. The abscess pathway led to a reduction in long inpatient stays.

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HEPATIC PORTAL VENOUS GAS AND PNEUMATOSIS INTESTINALIS: TWO SUCCESSFUL CASES Castro S., Aral M., Soares C., Devesa V., Bessa Melo R., Graรงa L., Costa Maia J. Centro Hospitalar Sao Joao, Portugal Introduction: Hepatic portal venous gas (HPVG) is a rare condition and usually accompanies severe or lethal conditions. When accompanied by pneumatosis intestinalis (PI) it is more predictive of bowel ischemia and the mortality rates are higher. Methods: Two clinical cases of HPVG and PI from 2012 are reviewed and analyzed. Results: Case 1 - A 68 year-old male admitted in the Intensive Care Unit (ICU) for pneumonia developed an abdominal compartment syndrome (ACS). The computed tomography (CT) scan showed a large amount HPVG as well as PI. During an exploratory laparotomy, areas of ischemic, nonnecrotic bowel were observed and a laparostomy was decided. The patient subsequently underwent two more surgical procedures, with resection of ileal and colonic segments that had become necrotic, and construction of an ileostomy and colostomy. On day 7 after the first intervention, the abdomen was successfully closed. The patient was discharged 3 months later. Case 2 - A 53-year-old male was admitted in the emergency room for voluntary ingestion of pesticides. He developed an ileus with ACS, and the CT showed PI and HPVG. During laparotomy, a diffuse distended and ischemic, non-necrotic bowel was observed, and the abdomen was left open. A second-look operation was performed two days later and laparostomy was closed. The patient was discharged on the 23rd postoperative day. Conclusions: HPVG and PI are radiologic signs that may represent a wide range of pathologies and can be associated with a poor prognosis, depending on the underlying cause. Prompt evaluation and management is essential to improve survival especially in severe cases.

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OPEN ABDOMEN IN TOTAL PERITONITIS WITH SEVERE SEPSIS Sakakushev B.E. General Surgery Clinic Medical University / University Hospital “St George” Plovdiv, Bulgaria Introduction: Since its implementation by Steinberg in 1979, laparostomy/open abdomen/, has gained acceptance as efficient method for the operative treatment of intra-abdominal sepsis. The two main types of open abdomen are planned re-laparotomy and on-demand laparotomy, giving advantage to the latter. Though progress and understanding of open abdomen techniques have been registered, mortality in severe intraabdominal sepsis due mainly to anastomosis dehiscence or visceral organ necrosis remains up to 30%. Methods: To assess the results of laparostomy we reviewed 32 patients with severe total peritonitis operated on in our clinic from 2005 till 2012. Medical records and operative protocols were analyzed for planned or on demand laparotomy indications, number of re-laparotomies performed after the index operation, technique of and types of procedures maintained. Planned relaparotomy we usually perform 48 hour later. In two complex cases we used VАС/vacuum–assisted closure. Complications, additional procedures and mortality were revised. Results: Patient’s age varied from 28 to 92 years /mean 65.4 /, 18 men and 14 women. Most of the patients /24 (75%)/ were with feculent peritonitis caused by anastomosis dehiscence, bowel and pancreatic necrosis, gunshot injuries. Co- morbidity was present in 23 patients and ASA risk proportion showed dominance in IV and V groups. The number of procedures performed varied from 2 to 10, before restoration of abdominal cavity took place. In 11 (33, 3%) patients postoperative complications have been registered: entero-coetaneous fistulae in 5 patients, secondary intestinal resection and reanastomosis/5/, wound dehiscence/2/, bleeding/2/. lethality –8/25%/. Restoration of the abdominal wall is indicated when there is no abscess or necroses in the abdomen and the operative wound edges become organized. Conclusions: The technique of open abdomen enhances the reintervention, enables control and prevention of the persisting/recurrent infection and management of the raised intra-abdominal pressure. Advantages of laparostomy are easy exploration of the abdominal cavity, lower risk of iatrogenic intestinal lesion, effective drainage of the infected collections, preventing multiple abscesses. Drawbacks of laparostomy are prolonged hospital stay, need for intensive care, raise of resources and costs. Open abdomen in severe total peritonitis assures technical advantages, affording better treatment, infection control, reduction of bacterial contamination, elimination of necroses and toxins, preventing

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secondary peritonitis and abscess, resulting in lower mortality and morbidity.

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RADIOLOGICAL SPECTRUM OF ABDOMINAL EMERGENCIES IN A TERTIARY CARE TEACHING HOSPITAL IN INDIA Simmi Aggarwal, Ravinder Garg, Paramdeep Singh, Navreet Kaur GGS Medical College & Hospital, Faridkot, Punjab, India Introduction: Abdominal emergencies are a challenge to treat, both because of the uncertainty of diagnosis and also for the wide spectrum of pathologies that could be present. Trauma and abdominal pain are the most common symptoms at the time of presentation. Majority of the times, history and clinical examination alone do not lead to the diagnosis. Imaging modalities like X Ray, Ultrasound or CT are a necessary tool to diagnosis. Methods: It was a retrospective descriptive study done over a period of one year at a tertiary care teaching hospital in the northern region of India. All patients who presented to the emergency department of the hospital with emergency symptoms related to the abdomen were included in the study. All patients underwent radiological investigations (Plain X Ray abdomen, Ultrasonography, CT abdomen) as per the indication. Wherever the cause was found to be non- surgical, these patients were excluded from the study. The results obtained were analyzed for demographic profile, organ system involved, and radiological findings and for the co relation between clinical and radiological diagnosis. Results: A total of 120 patients were included in the study. There were 74 males and 46 females. The age ranged from 7 months to 80 years with a mean of 32.2 years. The cause for presentation to the emergency was trauma in 38 patients and pain abdomen in 82 patients. Among the pain abdomen patients, cause was gynecological in 15 patients, urological in 5 patients and gastrointestinal in 62 patients. Of these 62 patients, 27 patients were diagnosed with intestinal obstruction, 24 patients with acute pancreatitis, 5 patients with acute appendicitis, 4 patients were diagnosed with gut perforation, and 2 patients had mesenteric ischemia. Plain X ray abdomen was done in 42 patients, Ultrasound abdomen in 76 patients and CT abdomen in 31 patients. This included overlap of investigations as well. Of the 120 patients there were 4 deaths. Conclusions: Radiological imaging has an indispensable role in the emergency settings. It acts as a complimentary tool and aids in early diagnosis and treatment thereby reducing the mortality and morbidity.

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TWO CASE REPORTS OF BLUNT ABDOMINAL TRAUMA IN PAEDIATRIC AGE Medien Xhaferi, Altina Xhaferi, Arben Dhima, Xhafer Qamirani National Trauma Center - Tirana, Albania Introduction: Blunt abdominal trauma can cause different injuries. The liver and spleen seem to be the most frequently injured organ. The small and large intestines are the next most frequently injured organs. Recent studies show an increased number of hepatic injuries. We are presenting two different pathologies of paediatric age. Methods: We are presenting 2 cases of blunt abdominal trauma. Both of the patients were males 14 years old. 24 hours after the trauma they were admitted to the hospital with sudden increasingly abdominal pain. Both underwent laboratory and radiologic examinations. Surgical treatment was performed. Results: Case 1. Abdominal CT revealed presence of gas in the hepatic piortal venous system. The surgical findings were extended necrosis of intestine from duodenum up to the left colic (splenic) flexure. The status of the patient aggravated. He died 8 hours after the surgery Case 2. Plain XRay of abdomen and upper gastrointestinal tract radiography revealed a markedly distended stomach and blockage of the contrast to the duodenum. CT scan with iV Contrast of the abdomen showed an intraduodenal hematoma with associated duodenal obstruction. Surgical evacuation of hematoma was performed. General condition of the boy is good. Conclusions: Air in the portal venous system (HPGV) is a relatively rare but ominous sign, usually indicating serious intra-abdominal pathology. The prognosis is related to underlying pathology and not to the HPVG itself. Traumatic duodenal hematoma occurs in about 2-3% of paediatric patients with blunt abdominal trauma.

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ONE-YEAR ACTIVITY RESULTS OF EMERGENCY SURGERY AT THE EMERGENCY DEPARTMENT OF POLICLINICO UMBERTO I OF ROME: DATABASE ANALYSIS Mariotta G., Mingoli A., Cirillo B., Silvestri V., Magliocchetti R., Binda B., Brachini B., Modini C. Sapienza University, Rome, Italy Introduction: Since the end of 2011 was used a relational database (MS Access 2007 速) to record the epidemiological and clinical data of all patients treated and / or admitted to the various operating units of the Emergency Department of Policlinico Umberto I. We report the analysis of data on patients observed between 01/01/2012 and 31/12/2012. Methods: During the period under consideration 1032 patients were hospitalized (451 females - 43.7%; 581 males - 56.3%; mean age 55.6 ys: range 8-102 - Median 52 ys). Sixty-one patients were hospitalized more than once for a total of 1,098 admissions. During the same period 80 patients were observed but not hospitalized in the surgical ward: 32 patients died within a few hours of arrival in the emergency department and 48 patients (all trauma victims) were transferred to intensive care unit. 72.6% (807/1112) of patients underwent at least one surgical operation (509 patients 63.2% were operated within the first 48h; 458 within the first 24 hours). In 305 patients (27.4%) only medical treatment was performed. Two hundred and ten patients (18.9%) of the total sample were victims of trauma (mean age 48.8 ys, range 8-91 - Median 48.5 ys). The 40.9% of these patients (86/210) underwent at least one surgical treatment while the remaining 124 patients (59.1%) (mean age 55.5 ys, range 13-94 Median 58 ys) underwent endoscopic or radiological procedures or medical treatment alone. Results: Overall mortality was 9.4% (105 patients). The mortality observed in 807 patients who need surgery was 6.7% (54 patients), while the observed mortality in patients who underwent only medical treatment was 8.6% (24/278) excluding 27 patients died within a few hours of admission. Higher overall mortality was observed in 201 patients treated for multiple injuries, and were recorded 43 deaths (20.5%); 22 patients who died shortly after their arrival in the emergency department, 16 patients in intensive care unit and 7 patients admitted to the ward. Conclusions: The use of a relational database, a complex tool that requires many hours of work for its establishment and subsequent interrogation, can provide thousands of useful data for verification of the quality of the activity.

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MULTIVISCERAL ABDOMINAL GUNSHOT WOUNDS: REPORT OF A CASE OF COMPLEX SURGERY Montin U.1, Carraro A.1, Marchi R.1, Soda C.2, Ricci U.M.2, Tedeschi U.1 Department of General Surgery and Odontoiatrics, 1st General Surgery, University Hospital of Verona, Verona Italy, 2Department of Neuroscience, Neurosurgery, University Hospital of Verona, Verona, Italy 1

Introduction: Firearm trauma represents a lethal mechanism of injury. Mandatory exploration is the standard method for managing gunshot wounds in case of hemodynamic instability. Bullet trajectories involving multiple organs constitute a challenge in the surgical approach. We report a case of a 46 year-old male suffering multi-visceral abdominal gunshot trauma, who survived his injuries. Methods: A 46-male presented after a gunshot penetrating trauma, with an entrance wound at the right hemithorax on the anterior axillary line. A CT scan showed a long-distance trans-abdominal trajectory of the bullet from the entry wound overshooting the diaphragm and stopping at the lumbar vertebral body; no thoracic injuries. Results: At surgery he presented several abdominal injuries that include rapture of the right diaphragm, a laceration of the central hepatic segments though no hepatic hilar injuries, a blunt injury of the duodenum and pancreas, a perforated jejunal loop with an expanding peritoneal bleeding due to a caval laceration. The complex surgical repairs included caval sutures, hepatotomy with removal of burned tissue debris, diaphragmatic and jejunal rafia, duodeno-cephalo-pancreatectomy. Hereafter a new neurosurgical intervention was necessary to remove the bullet from the vertebral body. Patient survived his multiple injuries and his post-operative period was uncomplicated with a 30-day in-hospital stay. Conclusions: Gunshot injuries may be vast. The subsets of trauma remain a challenge for surgeons because of the advanced surgical skills needed and the importance of referring to a tertiary center. The unequivocal characteristic of success is defining the algorithm to streamline the clinical evaluation of injuries to proceed to an early intervention.

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MYATLS - AN INNOVATION Brighton G., Abuznadah W., Brasel K. American College of Surgeons, USA Introduction: The ATLS course is a proven systematic approach to treatment of the severely injured patient. We present the launch of myATLS the mobile companion to ATLS, which serves both as an educational tool for use on the course, as well as a practical, mobile and on demand Trauma reference tool. Methods: A multidisciplinary team was assembled at the ATLS conference in 2011. The team set out to create myATLS a mobile companion to the course, appealing to different learning styles through a variety of educational content, including videos, interactive skill-station algorithms and a dynamic resources section featuring calculators and useful illustrations. Results: MyATLS was launched at the ATLS Conference in September 2012. Feedback was received from 150 delegates and continues to be collated. Downloads have surpassed expectations on both iOS and android devices in over 140 countries, many currently without ATLS. Reviews and feedback so far have been positive and continue to refine development and updates of myATLS. Conclusions: The aim of myATLS is clear, it provides a far reaching, comprehensive, mobile companion and practical reference tool, designed to assist the Clinician providing emergency care for trauma patients. Set along side formal ATLS training, myATLS will continue to improve the quality of trauma care across the world.

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THE LAPAROSCOPIC APPROACH IN ACUTE DIFFUSE PERITONITIS: A RETROSPECTIVE STUDY ON MINIMALLY INVASIVE SURGERY IN EMERGENCY SETTING Romagnoli F., Catani M., De Milito R., Romeo V., Ragozzino R., Modini C. Umberto I Policlinico di Roma, Italy Introduction: Laparoscopy has been widely accepted in various emergency situations with unclear benefit in event of diffuse peritonitis (DP). Patients treated laparoscopically for DP between 2008 and 2010 were analyzed to clarify in which situation laparoscopy is beneficial or contraindicated. Methods: Patients in the study group were retrospectively reviewed including MPI and CPS. Outcomes: 30 days morbidity, mortality, post operative stay, conversion to open surgery, main costs. 24-months followup was recorded but not considered in the analysis. Group comparison: complicated versus not complicated and converted versus not converted. Conversion factors and index were studied with logistic regression and ROC curve. Results: Study Group: 114 patients, 53 males, 61 females, mean age 44,64 (SD 20,77), MPI 18,4 (SD 6,47), CPS -5,03 (SD 2,25). No mortality, morbidity rate 7%, conversion rate 21,05%, median hospital stay 5 days (1-47) were reported. No differences between complicated and not complicated patients were found. Patients converted to open surgery versus totally laparoscopic showed differences in every factor but CPS and complications. MPI and Expertise resulted to be independent factors for conversion at logistic regression. Conversion resulted in higher duration of procedure and length of post operative stay but not in higher rate of early complications. Conclusions: Laparoscopy seems to be safe and feasible option in event of DP, with acceptable conversion rate. Patients with higher MPI showed a higher probability of conversion to open surgery in non-experienced surgeon, resulting in longer duration of surgery and hospital stay, but not in higher mortality and morbidity rate.

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ARTERIOGRAPHY IN OPERATING ROOM ALLOWS AN IMPORTANT REDUCTION IN THE TIME TO CONTROL BLEEDING IN SEVERE TRAUMA Mastropietro T.*, Cataldi C.*, Cingolani E.**, Riccioni L.**, Nardi G.**, Marini P. * General Surgery 1 S. Camillo Hospital Rome. **Shock Trauma Intensive Care Unit S. Camillo Hospital Rome, Italy Introduction: Uncontrolled bleeding is among the most important cause of death for patients with major injuries. Bleeding control may be obtained through surgical interventions or transcatheter angiographic embolization (TAE) when indicated. To be effective TAE must be performed as soon as possible after admission before the onset of trauma induced coagulopathy, as a preserved clotting function is a key issue to allow TAE to be effective. Methods: The goal of this study is the comparison of the access time which the patients took for arteriography in the year 2005 and in the year 2009. In 2005 we took part in an Italian prospective study which considered the access time to arteriography in traumatic patients, and the arteriography has always been performed in another block, far from the operating room. In 2009 our operating room has been equipped with a portable angiographer to allow interventional angiography and surgery to be performed in the same site. Results: In 2005, 286 MT patients were admitted to the ED and 22 (7.7%) required emergency TAE. The average time interval between hospital admission and TAE was 3 hrs 30â&#x20AC;&#x2122;. In 2009 343 MT patients were admitted to the ED. Thirty required TAE (8.7%): 22 were submitted to TAE in the OR. The mean interval time from hospital admission was 1h 12â&#x20AC;&#x2122; for the patients treated in OR, with a three time reduction if compared with 2005. Conclusions: Arteriography performed directly in the operating room, in the unstable traumatic patients, dramatically reduces the time of access to procedure.

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MICE WITH GENETIC DEFICIENCY FOR COMPLEMENT RECEPTOR TYPE 2 (CR2) SHOW NEUROPROTECTION AFTER EXPERIMENTAL CLOSED HEAD INJURY Stahel P.F., Keene C.N., Neher MD., Rich M.C., Weckbach S., Bolden A.L., Losacco J.T., Holers V.M. Department of Orthopaedics and Department of Neurosurgery, Denver Health Medical Center, University of Colorado, School of Medicine, Denver, USA Introduction: The pathophysiology of traumatic brain injury is characterized by complement activation, leading to neuroinflammation and delayed neuronal cell death. Complement receptor type 2 (CR2) has recently been identified as a â&#x20AC;&#x153;key playerâ&#x20AC;? in orchestrating complementmediated immune responses. Methods: We hypothesized that mice deficient in the CR2 gene (CR2-/-) would be protected from complement-mediated secondary neuropathology after experimental closed head injury. Adult C57BL/6 male CR2-/- mice (n=98) and wild-type littermates (n=157) were subjected to focal closed head injury, using a standardized weight-drop device. Sham-operated mice served as internal controls. Outcome parameters consisted of neurological scoring, quantification of inflammatory mediators in brain tissue and serum by Western blots and ELISA, assessment of glial activation and complement deposition in injured tissue by immunohistochemistry, and detection of neuronal cell death by TUNEL histochemistry. Results: Head-injured CR2-/- mice showed a significantly improved neurological outcome for up to 72 hours after trauma, compared to wildtype mice. While the post-injury release of pro- and anti-inflammatory cytokines was in a similar range between both groups, complement C3 deposition was markedly reduced in injured brain hemispheres of CR2-/mice. In addition, the activation of GFAP-positive astrocytes and CD11bpositive microglia was attenuated in head-injured CR2-/- mice, compared to wild-type littermates. CR2-/- mice also showed a decreased extent of neuronal cell death at seven days post-trauma by TUNEL histochemistry. Conclusion: These data emphasize a central role of CR2 in promoting complement deposition, glial activation, delayed neurodegeneration and adverse neurological outcome after closed head injury. Targeting complement activation on the level of CR2 may represent a promising future approach for therapeutic immunomodulation after closed head injury.

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EMERGENCY SURGERY IN PATIENTS >90 YEARS‐OLD: IS IT WORTHWHILE? Tarasconi A., Abongwa H.K., Gomez T.B., Pietra N., Livrini M., Bertolani M., Giulii-Capponi M., Ansaloni L., Coccolini F., Roveran A., Agresta F., Mele M., Di Saverio S., Tugnoli G., Collura S., Vettoretto N., Baiocchi G., Portolani N., Catena F. Emergency Surgery Dept Parma University Hospital Italy, Italy Background: Unlike other surgical fields, such as cardiac surgery, where lots of studies have been made about safety, feasibility and outcome of surgical procedures in the elderly, there is lack of literature about emergency abdominal surgery in a elder population, specially in people over 90 years of age. The date available report a mortality over 50% at one from the operation. Objective: The aim of the study is to determine the morbidity--mortality 1 year after emergency abdominal surgery in the nonagenarian population and to identify any demographic and surgical parameter that could predict a poor outcome in this type of patients. Methods: The study is retrospective (2012 data) and multicenter. Patient inclusion criteria were: age > 90 years old, urgent abdominal surgery. Medical charts were reviewed and data collected were: gender, age, ASA score and comorbidities, hospital outcome and hospital lenght of stay, diagnosis, time elapsed between arrival to the ER and admission to the OR, primary and secundary surgical procedure, surgical procedure duration, open versus laparoscopic procedure, type of anesthesia. Phone call followup was performed for patient discharged alive and Kaplan-Meier estimator was created. Results: We identified 76 (20 males and 56 females) nonagenarian patients who underwent abdominal emergency surgery in 5 Italian hospitals (Parma, Bergamo, Bologna, Brescia, Adria); 59 (77,63%) were discharged alive and 31% were alive at the time of follow-up; median follow-up time was 5.1 months. Mean age was 92,5 years (range 90 – 100, SD 2,56), median ASA score was 3 (range 2 – 5); only 7 patients had no one of the comorbidities we looked for. Mean hospital length of stay (LOS) was 12,84 days (range 1-60, SD 11,26); mean time between ER referral and surgical procedure was 24,7 hours (range 1 – 168, SD 35,37) and mean surgical length was 88,71 minutes (range 20 – 280, SD 47,06). Most frequent diagnoses were: Typical surgery procedures include: colonic resection and anastomosis (7,9%), colonic resection and diversion (5,3%), large bowel diversion (7,9%), small bowel resection and anastomosis (13,16%), small bowel adhesiolysis (13,16%), small bowel adhesiolysis with ileostomy (1,31%),

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cholecystectomy (13,16%), hernia repair (17,1%), total or partial gastrectomy (2,62%), GEA (3,95%), appendectomy (3,95%), other procedures (10,49%). Of the 76 procedures, 12 were videolaparoscopic and 67 were performed under general anesthesia. Conclusions: Emergency abdominal surgery in patients over 90 years of age has poor short- medium term outcomes.

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IATROGENIC URETERAL INJURIES DURING ABDOMINO-PELVIC SURGERY Schiavina R., Diazzi D., Borghesi M., Vagnoni V., Romagnoli D., Brunocilla E., Colombo F., Martorana G. Urology Department, University of Bologna, Italy Introduction: Iatrogenic ureteral injuries (IUI) are relatively common complications of abdomino-pelvic surgery and, if untreated, could be responsible of infections, stenosis, fistulas, urinomas or renal function loss. Ureteral injuries are frequently symptomatic (back or low abdomen pain, peritonism, fever, sepsis, urine leakage). Methods: Most IUI occurs during gynecological, urological and general surgical procedures. Many risk factors are responsible for IUI: anatomical, pathological and technical. Previous surgery, radiotherapy or endometriosis are other important risk factors. When a IUI occurs, possible mechanism of damage are: clipping, ligation, resection, avulsion, traction, kinking and avascular necrosis. Diagnosis could be performed thought contrast enhanced CT, RMN and retrograde pyelogram. Results: Minor lesions could be treated with a conservative approach, such as â&#x20AC;&#x153;double Jâ&#x20AC;? ureteral stent placement (left in site for at least 30-40 days) or percutaneous placement of a nephrostomic catheter. Conversely, major lesions usually need a surgical repair, and several techniques have been described according to the site of ureteral damage. Pyelo-ureteral or ureter-ureteral anastomosis are performed in case of proximal or intermediate IUI; if a conservative management is not feasible, simple nephrectomy is needed. Many conservative approaches have been described for distal IUI, such as Politano-Leadbetter ureteral reimplantation (with a antireflux system), psoas-hitch technique (performed with mobilization, traction and anchorage of bladder to psoas muscle and ureteral resection of damaged ureteral tract and reimplantation) and Casati-Boari uretero-neo-cistostomy (performed with a vescical flap and vescical reconfiguration). Conclusions: In the hands of experienced surgeons, iatrogenic lesions of the proximal, intermediate or distal ureter are repaired with optimal postoperative results.

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SEVERE URETERAL STENOSIS: COMPLICATIONS AND POSSIBLE TREATMENTS Schiavina R., Vagnoni V., Romagnoli D., Diazzi D., Borghesi M., Brunocilla E., Colombo F., Martorana G. Urology Department, University of Bologna, Italy Introduction: Acute renal failure can be due to pre-renal, renal (medical conditions) or post renal causes (urological urgency). The obstruction usually consists of a urinary stone (70%), while the remaining part is made up of external compression (endometriosis, neoplastic lymph-node enlargement) or internal strictures (post endoscopic surgery, urothelial neoplasms).These conditions require an emergency decompression when the backward urinary stasis leads to urinary infection, which might evolve in a systemic sepsis. Methods: The gold standard imaging technique is CT, which provides the best quality information about the grade of hydroureteronephrosis, thought contrast enhanced CT, when feasible (if Creatinine levels are < 1.6 mg/dL), is useful to quantify the entity of obstruction and to assess the causes. Results: Usually decompression can be achieved by endoscopically positioning a ureteral catheter, called “open end catheter” or a self-blocking one “double J catheter”, which can be kept inside for a certain time. If the ureteral stricture is severe, the endoscopic procedure is not possible, because wires cannot pass the obstacle, and an external derivation is required, granted by the percutaneous placement of a nephrostomic catheter. This procedure consists of the puncture of the renal calyx with a needle performed under ultrasonographic and radiologic guide, throughout which the catheter is put inside the pelvis. Requirement for this procedure are the withdrawal of any anticoagulant/antiaggregant therapy ad a sufficient level of urinary dilatation. Conclusions: The nephrostomic catheter is the optimal way, in case of severe ureteral stenosis, to solve the subsequent infection (together with an appropriate antibiotic profilaxys) and to guarantee urinary decompression, in order to extinguish the urosepsis which may arise from obstruction and to allow further treatments for the ureteral stricture itself or its external causes.

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URINARY STONES: MANAGEMENT OF THE MOST COMMON EMERGENCY IN UROLOGY Schiavina R., Vagnoni V., Romagnoli D., Diazzi D., Borghesi M., Brunocilla E., Colombo F., Martorana G. Urology Department, University of Bologna, Italy Introduction: This is the most common emergency the Urologist has to deal with. Patients with urinary stones usually present with back pain, vomiting, and sometimes fever, but may also be asymptomatic. Methods: If available, ultrasonography (US) should be used as the primary diagnostic imaging tool, however, Non Contrast Computed Tomography (NCCT) is actually the gold standard for diagnosing acute flank pain, providing information about location, dimension and density of urinary stones. Results: The obstructed kidney with all signs of urinary tract infection (UTI), such as fever, augmented white blood cell count or C-reactive protein is a urological emergency. Urgent decompression is often necessary to prevent further complications in infected hydronephrosis and urinary rupture secondary to stone-induced obstruction. Currently, the obstruction can be solved by placing an indwelling ureteral catheter or the percutaneous placement of a nephrostomy catheter. Once this inflammatory condition is expired, it is possible to safely remove the obstructive stone with fragmentation of the stone by ultrasound or laser technology, performing a rigid or flexible ureteroscopy (URS) for intrauretheral stones, or a Retrograde Intra Renal Surgey (RIRS) for small intrarenal stones or percutaneous nephrolitotomy in big intra-renal stones. Conclusions: The ureteral catheter might be removed 15-21 days after the procedure, and US examination can be performed within 1 month after the removal. If stone fragments are found, a conservative management can be adopted if there is no obstruction or the patient is asymptomatic. If not so is suggest to perform a second placement of ureteral stent and a subsequent Shock Wave Lithotripsy or a second endoscopic removal of them.

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CAUSES AND MANAGEMENT OF SEVERE MACROHEMATURIA Schiavina R., Romagnoli D., Vagnoni V., Diazzi D., Borghesi M., Brunocilla E., Colombo F., Martorana G. Urology Department, Univeristy of Bologna, Italy Introduction: Macrohematuria, due to both benign (benign prostatic hyperplasia, acute or chronic cystitis, post radiation therapy or postendovescical chemotherapy cystitis, endovescical stones, nephropathies) and malignant causes (bladder cancer, upper urinary tract cancer and neoplasms of the kidney), is one of the most common symptoms in Urology. Methods: The first approach to macrohematuria is vescical cateterism with 3 tips. If bleeding is profuse, continuous washing might be established. A venous blood sample has to be taken, in order to evaluate the hemoglobine serum levels. Once the patient is stable, an ultrasonographic exam with evaluation of kidney, bladder and even prostate has to be performed, though the gold standard is contrast induced CT scan, which gives both anatomical and functional information about the urinary tract. Results: Many causes of macrohematuria are suggestive of elective treatment, but emergency arises when the blood loss is incoercible and threatens the patient's life. A cistoscopy is performed to evaluate bleeding both from prostatic lobes or vescical neoplasm, and to perform biopsy and diatermocoagulation of any active bleeding source. If a vescical (with findings suggestive of perivescical fat infiltration) or renal mass is founded at CT scan, a diagnostic endoscopic biopsy of the vescical neoplasm (in order to perform radical cistectomy with urinary diversion), or nephrectomy can be performed, which becomes urgencies if the neoplasm is already known and the blood loss is refractory to supply therapy. Conclusions: Macrohematuria have to be treated by supporting patient, investigating possible bleeding sources and has to be menaged as a surgical emergency when the blood loss is incoercible or dangerous for patientâ&#x20AC;&#x2122;s life.

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DIAGNOSTIC-THERAPEUTIC TIMING IN THE ACUTE SCROTUM: TESTICULAR TORSION Schiavina R., Vagnoni V., Romagnoli D., Diazzi D., Borghesi M., Brunocilla E., Colombo F., Martorana G. Department of Urology, University of Bologna - S.Orsola Malpighi Hospital, Bologna, Italy Introduction: The “acute scrotum” recognizes three main causes: vascular (torsion), sepsis (abscess, gangrene) and traumatic. Testicular torsion represent a real andrological emergency. Methods: The most significant contributions resulting from a nonsystematic review of the literature in the National Library of Medicine Database (MEDLINE), using the keywords “acute scrotum” and “testicular torsion”, and chapters of books of relevance to the topic were selected. Results: The rapidity of diagnosis is crucial in terms of outcomes. The presence of persistent symptoms for less than 6 hours, with clinical and instrumental signs suggestive for a testicular torsion, is mandatory for a surgical exploration considering that the recovery of the testis is 100% if the disease is faced within 6 hours, and it progressively reduces to 10% if the treatment is made over 24 hours. The onset of pain from 6-12 hours, in the absence of a clear objective examination, has to lean to further investigations (Echo-color Doppler) in order to clarify the cause of the acute scrotum. Conclusions: In the case of testicular torsion, timing is fundamental in order to attempt a salvage treatment of the testis.

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MANAGEMENT OF THE FOURNIER’S GANGRENE Schiavina R., Romagnoli D., Vagnoni V., Diazzi D., Borghesi M., Brunocilla E., Colombo F., Martorana G. Department of Urology, University of Bologna - S.Orsola Malpighi Hospital, Bologna, Italy Introduction: Fournier’s gangrene is a life-threatening condition and it is still burdened by a high mortality (7,5-50%). Sometimes, aesthetic and functional outcomes can be extreme and disfiguring. Methods: The most significant contributions resulting from a nonsystematic review of the literature in the National Library of Medicine Database (MEDLINE), using the keyword “Fournier’s gangrene”, and chapters of books of relevance to the topic were selected. Results: The necrotizing fasciitis of the perineum which can quickly spread to the skin of the entire scrotum, penis and even hypogastrium, “First step” of the surgical management is represented by surgical debridment with a complete toilette of the necrotic tissues; placement of drainages ensures the evacuation of the toxic exudate avoiding its resorption by local tissues. Afterwards, it is crucial to make an aggressive wound care. There is still a lack of randomized controlled trials to state the effectiveness of Hyperbaric Oxygen therapy as adjunctive tool. “Second step” aims to rebuild tissue structures with skin grafts. Conclusions: Early recognition of the disease and immediate surgical treatment are key elements in order to achieve a better prognosis.

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PRIAPISM: STATE OF THE ART Schiavina R., Vagnoni V., Romagnoli D., Diazzi D., Borghesi M., Brunocilla E., Colombo F., Martorana G. Department of Urology, University of Bologna - S.Orsola Malpighi Hospital, Bologna, Italy Introduction: Priapism is a condition characterised by a persistent painful erection that is not related to sexual desire. Methods: The most significant contributions resulting from a nonsystematic review of the literature in the National Library of Medicine Database (MEDLINE), using the keyword “priapism”, and chapters of books of relevance to the topic were selected. Results: The most common type of priapism - “low flow” or ischemic priapism - results from decreased venous and lymphatic drainage of the corpus cavernosum. “High flow” priapism is generally consequent to a traumatic arterial laceration. Conservative management of ischemic priapism is represented by corporal aspiration and, if this strategy fail, slow infusion of an (alpha) agonist (phenylephrine) may be tried; infusion of phenylephrine is contraindicated in “high flow” form because the drug will rapidly leak into the circulation, causing severe systemic hypertension. The shunts, as second-line treatment, must be performed in the ischemic priapism refractory to the intracarvenous treatment. Conclusions: The most significant contributions resulting from a nonsystematic review of the literature in the National Library of Medicine Database (MEDLINE), using the keyword “priapism”, and chapters of books of relevance to the topic were selected.

WJES & WSES Meeting 194