Treatment of emothorax from penetrating and contusive trauma. A single institute experience of 135 cases.

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Abstracts

11^th European Congress of Trauma and Emergency Surgery May 15–18, 2010

Brussels, Belgium

Congress President Stefaan Nijs Leuven, Belgium

Eur J Trauma Emerg Surg 2010;36:1–238 DOI 10.1007/s00068-010-8888-z

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Abstracts of the 11^th European Congress of Trauma and Emergency Surgery

May 15–18, 2010, Brussels/Belgium

Organized by

European Society for Trauma and Emergency Surgery Belgian Trauma Society

Contents

ORAL PRESENTATIONS Sunday, May 16, 2010 3 Shoulder

6 Obstruction 9 Nailing 12 Infection 17 Liver 20 Thorax

24 Disaster & Military Surgery 27 Biomechanics

31 Hip 34 Ankle – Foot 38 Health Economics 42 Shoulder – Forearm – Hand 45 Visceral Trauma

48 Elbow 52 Ankle – Foot 56 Bone Healing

Monday, May 17, 2010 59 Prothesis Shoulder 63 Spleen

66 Disaster & Military Surgery 70 Trauma Registries 73 Polytrauma 76 Education 80 Biomechanics 83 Hip

86 Spine

90 Vascular Lesions 93 Monitoring Sic Patients 97 Abdomen

100 Pelvis 103 Biomechanics

Tuesday, May 18, 2010 107 Knee

111 Disaster & Military Surgery Trauma causes individual patterns of

injury and involves shock, fractures, soft tissue and organ injuries. Treat- ment therefore requires the joint effort of emergency medicine, ortho- pedic and trauma surgery, critical care medicine and rehabilitation. Both scientific progress and the in-depth experimental and clinical research within individual disciplines contrib- ute to the ongoing continuous improvement of trauma care.

The EUROPEAN JOURNALOF TRAUMAAND EMERGENCY SURGERY aims to open an interdisciplinary forum that allows for the scientific exchange between basic and clinical science related to pathophysiology, diagnostics and treatment of traumatized patients.

The journal covers all aspects of clinical management, operative treatment and related research of traumatic injuries.

Clinical and experimental papers on issues relevant for the improvement of trauma care are published. Reviews, original articles, short communi- cations and letters allow the appropri- ate presentation of major and minor topics. The papers published are allo- cated to one of the following sections of the journal:

Biomaterials, Experimental Research, Foot and Ancle Trauma, Hand Trauma, Intensive Care, Neurotrauma, Pediatric Trauma, Pelvic Trauma, Polytrauma, Recon structive Surgery, Spine Trauma, Sports Injuries, Thoracic and Abdominal Trauma, Upper and Lower Extremity.

The EUROPEAN JOURNALOF TRAUMAAND EMERGENCY SURGERY invites articles not only from Europe but also from the United States, Japan, and other countries. The journal is peer-reviewed according to international standards and each paper submitted will be scrutinized by two or three referees and a biostatistical consultant.

For articles describing

important new findings, accelerated peer-review and fast track publication are made available.

Cited in: EMBASE/Excerpta Medica .

CINAHL® . Science Citation Index Expanded (SciSearch)

Aims and Scope

Official Publication of the European Society for Trauma and Emergency Surgery

114 Telemedicine-Monitoring 118 Laparascopy

122 Polytrauma 125 Hand 128 Research 132 Acetabulum 136 Education 140 Pediatric Trauma 143 Hip

146 Shoulder 150 Knee – Foot 153 Research E-POSTERS

Sunday, May 16, 2010 158 Vascular Lesions 163 Lower Extremity 169 Polytrauma; Research 176 Lower Extremity

Monday, May 17, 2010 181 Upper Extremity

188 Pelvis – Acetabulum – Spine 193 Education – Trauma Registries 200 Hand – Lower Extremity

Tuesday, May 18, 2010 206 Emergency Surgery 212 Disaster & Military Surgery,

Trauma Registries 217 Visceral Trauma 229 AUTHORS,

INDEX

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SHOULDER

S001 Fractures of the Clavicle: Operative Treatment as New Standard?

P. Lichte¹, M. Burggraf², D. Nast-Kolb², G. Taeger²

1Department of Trauma Surgery, University of Aachen, Aachen, Germany,

2Department for Trauma Surgery, University of Essen, Essen, Germany

Introduction: Frequently fractures of modern sport disciplines are fractures of the clavicle. Most of them are uncomplicated and still treated without operation. Therefore there is a lack of bigger studies about the treatment of clavicle fractures by elastic stable intramedullary nailing (ESIN). Nevertheless this method becomes more and more popular, especially for young and active people. Intention of this investigation was to analyze risks and results of this method to check the indication for operative treatment of simple fractures in this group of patients.

Material and Methods: This study is a retrospective analysis of 33 patients whose fractures of the clavicle were treated by intramedullary nailing. Crucial for the decision for operation was the individual request of the patient after information of the relative indication.

Included were 26 patients with fractures of the middle third, 4 fractures of the lateral third and 3 fractures with concomitant shoulder injuries from 2004 to 2008. The duration of operation, intraoperative radioactive loading and complications were analyzed from the medical file. The functional outcome was measured by the CONSTANT- Score. The anatomical reduction was proved by measuring the difference of the length of both clavicles (3 – 48 month after operation).

Results: The average duration for the middle third was 66 min (22- 163), for the lateral third 73 (59-100) minutes and for fractures with concomitant injuries 65 min (21-101). The mean radioactive surface dose was 1,19 cGy/cm². Four complications (12%) cause revision operations: one secondary dislocation which leads to pseudarthrosis and two imminent penetrations of the medial end of the nail. One patient had developed a painful pseudobursa due to lateral pene- tration of the nail. Additional there were two prematurely nail extractions because of medial irritation of the soft tissue. Altogether we documented complications in 18% of the operations. Overall an open reduction was necessary in 37%. After healing there has been no significant shortening of the fractured clavicle in comparison of both sides. The CONSTANT-Score showed good postoperative results (average: 96, median: 100, lowest 75/100).

Conclusion: ESIN with titan nails is an alternative method of treatment with good results. Nevertheless we documented complications in 18%. In the literature complication rates from 4 – 31% has been described. The complication rate of ESIN seems to be comparable to the conservative treatment. In our opinion the relevant intraoperative radioactive dose is an often underestimated factor. The operation time is often longer than thought before starting and often an open reduction is necessary. Because of these reasons the conservative therapy should still be the standard. ESIN can be an alternative especially for young athletic ambitious patients after a detailed information about the risks.

Disclosure: No significant relationships.

S002 Plate Fixation Versus Nonoperative

Treatment of Displaced Midshaft Clavicular Fractures. A Prospective Multi-center Clinical Trial

P. E. Flikweert, G. D. J. van Olden

Trauma Surgery, Meander Medisch Centrum Amersfoort, Amersfoort, The Netherlands

Introduction: The optimal management of clavicle fractures is still controversial, although the nonoperative treatment remains the standard in most fractures. Recent studies have reported a higher nonunion rate and unsatisfactory functional results after nonoperative treatment. Therefore, there is an increasing interest in the primary operative management of displaced midshaft fractures.

However, no treatment-consensus exists at this moment. The goal of the present study was to compare plate fixation with nonoperative treatment of displaced midshaft clavicle fractures in adults with a minimum of 24 weeks follow-up.

Material and Methods: In a multi-center prospective clinical trial patients with a fully displaced midshaft clavicle fracture were included within one week after the injury. After a standard information procedure, patients were asked if they wanted to have a operative or a nonoperative treatment. Outcome analysis included standard clinical follow-up, the Constant shoulder score, the Dis- ability of the Arm, Shoulder and Hand (DASH) score and complication rate at 6 and 24 weeks after the injury.

Results: Between January 2008 and October 2009 a total of 93 patients were included: 41 patients were treated operatively (90.2% men, mean age 41.5 years) and 52 patients were treated nonoperatively (82.7% men, mean age 40.9 years). Constant and DASH scores were significantly higher in the operative group compared with the nonoperative group at 6 weeks (92 vs 78 and 13.1 vs 26.5). There was no significant difference at 24 weeks (97 vs 95 and 5.6 vs 6.4). In both groups two patients developed pseudartrosis, all four required surgery. In the nonoperative group symptomatic malunion was more frequent: twelve patients at 24 weeks (23.0%) versus none in the operative group. Other complications in the operative group were mostly hardware related: pain and irritation requiring plate removal after consoli- dation in four patients (9.8%), two broken plates due to the earlier mentioned pseudartrosis (4.9%), one early outbreak of the plate (2.4%) and one woundinfection (2.4%). Furthermore, patients with heavy professional work activities returned to their jobs at an average of three weeks after injury in the operative group compared with seven weeks in the conservative group. At 24 weeks after the injury, the patients in the operative group were more satisfied compared to those in the nonoperative group (56% vs 46%).

Conclusion: Operative fixation of a displaced midshaft clavicle fracture results in improved functional outcome at 6 weeks after injury and in a higher satisfaction rate at 24 weeks. This study shows that patients with heavy jobs restarted their professional activities sooner if they were treated operatively. Furthermore, higher satisfaction with the appearance of the shoulder may be a reason for surgery.

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S003 Minimal Invasive Plate Osteosynthesis (MIPO) of Clavicle Fracture with Locking Plate (LCP)

T. S. Mueller, C. Sommer¹

1Chirurgie, Kantonsspital Graubuenden, Chur, Switzerland

Introduction: The unstable shoulder girdle with a fracture of the clavicle (floating shoulder, ipsilateral serial rib fractures) is a classical indication for a plate osteosynthesis of the clavicle. Despite a relatively high complication rate (5-30%), such as implant failure, non-union and refracture after implant removal, open reduction and internal plate fixation (ORIF) has been the gold standard for many years. This open procedure with direct reduction maneuvres might be blamed for at least some of the complications due to iatrogenic damage of the blood supply of the fracture fragments. Our hypothesis is that a closed method with indirect reduction might reduce some of the complications. The goal of our study was to test the practicability of the MIPO- technique in clavicle fractures in unstable shoulder girdles.

Material and Methods: Between 2001 and 2009 we included, out of internally fixed 130 shaft fractures in total (66x plate, 64x elastic nail), 18 patients with either a floating shoulder (n = 8) or a clavicle fracture in combination with ipsilateral serial rib fractures (n = 10), in this study. Operative technique: A locking compression plate (LCP) 3.5 with 10-12 holes was anatomically shaped to the anterior (-caudal) contour of the contralateral clavicle and then inserted percutaneously from lateral to medial using a short incision at the anterior border of the lateral end of the clavicle. Using mainly indirect maneuvres, the fracture was reduced and then fixed in a pure bridging technique never using interfragmentary lag screws. Free unloaded ROM was allowed immediately after the operation with full loading 6-12 weeks later. Follow-up examination was performed 1 to 4 years later with clinical (DASH-score, shoulder function, length measurement) and radiological (fracture healing, length measurement) examination.

Results: 17/18 fractures healed without complications. Clinical and radiological length measurement showed no significant differences to the contralateral side (range: +5 mm to -5 mm). In all patients a very good functional result was achieved with an average DASH score of 4.2 (0-18). One implant failure occured two years after the initial trauma in a road workman. At reoperation only a partial consoli- dation of the original fracture was observed. Restabilization and bone grafting led to an uneventful healing.

Conclusion: The MIPO technique is feasible even in clavicle fractures and can lead to good functional and cosmetic results. The advantage might be its low invasiveness which better preserves the vascular supply of the fracture fragments. However it is technically demanding mainly due to the small size of the fractured bone. Therefore in our opinion it requires a surgeon experienced in the MIPO technique of treating fractures of larger bones as tibia and femur.

S004 Is There a Real Problem with Removal of Locking Screws After Locking Compression Plating of the Clavicle?

P. Nagel¹, W. P. Zuidema²

1Trauma Surgery, Rode Kruis Ziekenhuis, Beverwijk, The Netherlands,

2Trauma Surgery, Vrije universiteit medisch centrum, Amsterdam, The Netherlands

Introduction: There are some reports on the difficulties of removing the locking compression plate in clavicle fractures, due to problems of removing the self tapping locking screws. We retrospectively investigated if this was also the case in our institution in removal of LCP plate of the clavicle and if this was incidential or becoming a trend.

Material and Methods: From October 2004 till October 2009, we have removed 30 locking compression plates after claviclefracture stabilization. All of the locking screws were inserted by trauma surgeons with the use of the torque limiting srewdriver according to the manufacturer’s recommendations. A total of 171 screws where removed. They consisted of fifty-one 3.5 mm self tapping cortical screws and hundred and twenty 3.5 mm self tapping locking screws.

Results: From the 30 locking compression plates that where removed after claviclefracture stabilization, in eleven patients (37%) a problem with removal of the plate arised. This was caused by a total of 17 self tapping locking screws. In all 17 cases jamming of the screwheads in the plate was found to be the reason. There was ‘‘cold welding’’

between the threaded head of the locking screw and the locking plate. For removal four different strategies were used. In two screws the head was drilled off and the plate removed and subsequent the rest off the screw removed with forceps. Five times the plate was bend around the screw and by rotating the plate (helicopter) both were taken out. In eight screws the recess of the head of the screws were enlarged and a conical extraction screwbit 3.5 was used to remove the screws. Two times a combination of cutting the plate and helicopter tecnique was used succesfull. In comparison the fifty-one 3.5 mm selftapping cortical screws were removed without any problem.

Conclusion: The locking compression plate is a usefull attribute in fracture treatment of the clavicle. However in one-third of the patients removal of locking compression plates and especially the 3.5 mm self tapping locking screws from the clavicle, becomes an increasingly challenging procedure. We find this an unacceptably high percentage.

References: Ehlinger M et al. Technical difficulties in hardware removal in titanium compression plates with locking screws. Orthop Traumatol Surg Res.(2009) 95(5): 373-376 Bae J-H et al. Technical difficulties of removal of locking screw after locking compression plating. Arch Orthop Trauma Surg. (2009) 129: 91-95

S005 Clinical Relevance of High Resolution MRI for Acromioclavicular Joint Instability

G. Oberleitner¹, C. Krestan², P. Stampfl³, P. Platzer¹, V. Ve´csei⁴, C. Fialka⁵

1Department of Trauma Surgery, Medical University of Vienna, Vienna, Austria,

2Department of Radiology, Medical University of Vienna, Vienna, Austria,

3Department of Trauma Surgery, Medical University of Vienna, Vienna, Austria,

4Department of Trauma Surgery, Medical University Vienna, Vienna, Austria,

5Department Traumatology, Medical University Vienna, Vienna, Austria

Introduction: In the clinical practice it is not possible to diagnose lesions of the intraarticular disc of the AC-Joint. Only in a small

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number of mri studies it was possible to describe the intraarticular disc. Until now there was no in vivo verifying of one of these MRI protocols. The introduction of a high resolution MRI protocol using a superficial coil (3D WATS and T2FFE) that has been developped in an ex-vivo model allows the visualisation of the intra-articular structures. The aim of this study is to ascertain the significance of the mentioned MRI protocol and the applicability in the clinical practice in a limited patients cohort with instability of the AC-Joint. The MRI findings are compared to the arthroscopic findings.

Material and Methods: In a one year period 16 patients with chronic acromioclavicular-joint dislocation Rockwood Type II and III were seen in the outpatient clinic The major symptom was pain followed by loss of power. Inclusion criteria where a history of more than three month the exclusion of subacromial pathologies, age over 18 and the indication for arthroscopic revision of the ac-joint. The radiological examiner was blinded to the clinical findings. The MRI-scan was performed on both sides. At the time of the operation the surgeon was blinded to the MRI reading. The surgical procedure was performed by arthroscopy in beach chair position. The surgical findings have been documented by video and also in a descriptive manner.

The examination was performed on a 1.0 T MRI-system .

Results: Throughout the radiological examination, in 9/13 patients a rupture of the intra-articular disc was suspected. In 3/13 cases degenerative alterations were described. In one case the reading was negative (e.g. ,,no rupture of the intra-articular disc’’). During the surgical examination 12/13 patients showed ruptures of the intraarticular disc. In one patient no signs of macroscopical disintegration of the disc could be detected. In the case with negative radiologiocal reading, the disc was verified as intact during surgery. In all other cases the disc was disintegrated, including those with the radiological reading ‘‘alterations without clear signs of rupture’’. The significance of the described MRI protocol was 75%.

Conclusion: The possibility to get more information about the intraarticular structures of the AC-Joint by the use of a promising preoperative diagnostic procedure like the MRI could help us in the understanding of the pathology beyond the instability.

References: 1. Fialka, C., Stampfl, P., Oberleitner, G., and Vecsei, V.:

Traumatic acromioclavicular joint separations - current concepts.

European Surgery. 36:20-24, 2004. 2. Heers G, Go¨tz J, Schubert T, Schachner H, Neumaier U, Grifka J, Hedtmann A: MR imaging of the intraarticular disc of the acromioclavicular joint: a comparison with anatomical, histological and in vivo findings. Skeletal Radiol.

2007 Jan;36(1):23-8.

S006 Evaluation of the Clavicle Hook-plate for Treatment of Acromioclavicular Joint Dislocation: A Cadaver Study

P. Nagel¹, W. P. Zuidema²

1Trauma Surgery, Rode Kruis Ziekenhuis, Beverwijk, The Nether- lands,

2Trauma Surgery, Vrije universiteit medisch centrum, Amsterdam, The Netherlands

Introduction: The purposes of this study was to determine if an angle stable clavicle hook-plate causes subacromial bony or rotator cuff impingement and to evaluate if this is caused by surgical technique or characteristics of the implant in the treatment of acromioclavicular (AC) joint dislocation.

Material and Methods: A fresh-frozen cadaver torso was utilized.

Open reduction and internal fixation of the AC joint was accom- plished with the Synthes Aˆ clavicle hook-plate in two positions.

Afterwards dissection of the shoulder region was performed. Eval- uations was performed with the shoulder in various glenohumeral positions to assess for subacromial bony or soft-tissue impingement.

Results: The dissection of the shoulder showed that there was no subacromial bony impingement of the hook-plate if placed in the correct position. The distance between the greater tuberosity and the hook-plate with 90Aˆ of shoulder forward flexion and with 90Aˆ of abduction was more than sufficient if the hook-plate was in the correct position. A more anterior placement of the hook-plate causes subacromial bony impingement.

Conclusion: This study demonstrated that the clavicle hook-plate can reduce the AC joint anatomically, does not cause bony impingement, and does not cause rotator cuff impingement if correctly positioned.

A slightly more anterior position could be responsible for pain and impingement symptoms reported in patients after treatment with the angle-stable hook-plate.

References: Renger RJ, Roukema GR, Reurings JC, Raams PM, Font J, Verleisdonk EJ. The clavicle hook plate for Neer type II lateral clavicle fractures. J Orthop Trauma. 2009 Sep;23(8):570-4.

Tambe AD, Motkur P, Qamar A, Drew S, Turner SM Fractures of the distal third of the clavicle treated by hook plating. Int Orthop.

2006 Feb;30(1):7-10. Epub 2005 Oct 19 Muramatsu K, Shigetomi M, Matsunaga T, Murata Y, Taguchi T. Use of the AO hook-plate for treatment of unstable fractures of the distal clavicle. Arch Orthop Trauma Surg (2007) 127:191-194.

S007 Outcomes of Management of Acute Acromioclavicular Joint Dislocation Using Tight Rope Device

S. A. Jain¹

1Trauma & Orthopaedics, Heart of England NHS Trust, Birmingham, UK

Introduction: To assess the safety, efficacy and outcome of treating grade III and above AC joint dislocations using Tight Rope device in young and active patients.

Material and Methods: Twenty patients who sustained grade III and above AC joint dislocations underwent Tight Rope fixation (Arth- rex) of the AC joint were studied prospectively. The average age in the cohort was 38 yr with 13 dominant and 7 non-dominant arms affected. Seventeen patients sustained grade III AC joint dislocation and three sustained lateral end clavicle fracture.

All patients were operated by a single surgeon (PDS). A 1.5 cm bra- strap incision is made about 2 cm medial to the AC joint. After drilling a 4 mm hole with a cannulated drill through the clavicle and coracoid a Tight Rope is inserted, the clavicle is reduced and stabi- lized with the implant. Reduction of AC joint is confirmed using fluoroscopy. All patients followed a standardized rehabilitation program and early physiotherapy. Patients were followed up at 6 weeks, 3 months and 6 months following surgery.

Results: The average Oxford shoulder score at 6 months following surgery was 52 (range 40-59), with restoration of near normal shoulder range of movements. All patients returned to their original occupation at average 8 weeks. One patient had failure of fixation which required revision surgery using hook plate fixation.

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Conclusion: Tight Rope fixation offers a safe, effective and more anatomical fixation for AC joint dislocation and displaced lateral end clavicle fractures in young and active patients without the need for metal work removal.

OBSTRUCTION

S008 Abbreviated Emergency Laparotomy in the Non-trauma Setting

B. Person¹, T. Dorfman¹, H. Bahouth¹, A. Osman¹, A. Assalia¹, Y. S. Kluger²

1General Surgery, Rambam Medical Center, Haifa, Israel,

2General Surgery, Rambam medical center, Haifa, Israel

Introduction: Although the application of damage control surgery for trauma has been widely reported and defined, similar approach in non-trauma patients has not been well detailed.

Material and Methods: Study design: A retrospective analysis of data from non-trauma patients who underwent emergency laparotomy between May 2006 and December 2008. Demographics, indications for surgery and outcome of patients who had definitive laparotomies (DL) and patients who had damage control laparotomies (DCL) were compared. Appendectomies were excluded.

Results: Two-hundred ninety-one patients (55% males) were included. Thirty-one (10.7%) underwent DCL (58% males). Mean age of patients who had DL and DCL was 65 and 62.8 years respectively.

Peritonitis and mesenteric ischemia were more common indications in patients with DCL than DL: 48.4% vs. 30.4% (p = 0.04) and 32.3% vs. 3.5% (p < 0.0001) respectively. Twenty-nine percent of patients who had DCL were hemodynamically unstable. Mortality rates were 54.8% and 16.5% in patients with DCL and DL respectively (p < 0.0001). Patients who died after DCL and DL were significantly older than patients who survived (75 vs. 47.3 and 74 vs.

63 years respectively, p < 0.0001). Median hospital stay was 21 and 9 days for patients with DCL and DL respectively (p < 0.05). Pa- tients who underwent DCL had significantly more wound infections, sepsis and multi-organ failure.

Conclusion: The philosophy of damage control surgery may be ap- plied to non-trauma patients as some of the prerequisites for the decision to elect this strategy are the same. Metabolic disturbances, hemodynamic instability and peritonitis are the most common indications for damage control surgery in non-trauma patients.

S009 Acute Obstructing Colon Cancer:

Characteristics and Prognosis

1L. Bo¨rjesson, F. al-Ayoubi, R. Sjo¨dahl, C. Wallon¹

Department of Surgery, Emergency Surgery and Trauma, Linko¨ping, Sweden

Introduction: Cancer of the colon is a common disease. The choice of treatment after diagnosis is surgery, in an elective setting, to remove the tumor. However, a large number of patients present with colonic obstruction requiring acute surgery before the diagnosis is known, or before the set date for elective surgery. Previous studies have shown

a worse outcome for patients who undergo surgery in the acute setting compared to patients in scheduled care. The aim was to establish characteristics and prognosis in patients with acute obstructing colon cancer compared to patients who underwent elective colon cancer surgery.

Material and Methods: All patients diagnosed with colon cancer during 2000-06 in the Linkoping area were identified through the Swedish colorectal cancer register (n = 438). A retrospective analysis of patients with colonic obstruction (n = 88) was done using various criteria from the medical records. Exclusion criteria were acute surgery due to reason other than obstruction (n = 57), non-surgical treatment (n = 44), other diagnosis (n = 13), or missing medical records (n = 11).

Results: 88 patients underwent surgery for acute colonic obstruction (a.c.o.) and 225 patients had an elective operation (e.o.). The median age was 74 years in a.c.o. and 76,5 in e.o. There were 55% men and 45% women in the a.c.o. and 42% men and 58% women in the e.o groups respectively. The preoperative ASA score was similar in a.c.o.

and e.o groups. TNM-stage for a.c.o and e.o. were: stage I 1% vs.

20%, stage II 30% vs. 38%, stage III 34% vs. 29%, stage IV 35% vs.

12%. Postoperative mortality (within 30 days) was 9% in the a.c.o.

and 2% in the e.o groups. Surgical complications were diagnosed in 16% after a.c.o. and in 14% after e.o. Other postoperative complications occurred in 19% in a.c.o. and in 13% in e.o groups. The overall 2-year survival was 50% in a.c.o. and 79% in e.o groups respectively. When sub-grouped according to tumor-stage, the 2-year survival was; stage I: 100% in a.c.o. and 91% in e.o; stage II: 70% in a.c.o. and 88% in e.o.; stage III: 70% in a.c.o and 74% in e.o.; stage IV: 13% in a.c.o. and 39% in e.o.

Conclusion: Acute surgery due to colonic obstruction of colon cancer is common. Tumor stage seems to be more advanced in patients with obstructing disease than in patients scheduled for elective surgery and consequently the rate of complications is higher and the outcome is worse. However, when stratified for different TNM-stages, the worse outcome in 2-year survival for patients with acute obstructing colonic cancer still remains. The explanation for this difference is to be elucidated in further studies.

S010 Preoperative Colonic Stenting Versus One Stage Surgery in Colonic Occlusion

A. Ardito¹, L. Fattori², L. Nespoli³, G. Pesenti⁴, A. Nespoli⁵

1General Surgery-chirurgia Iii, Osp San Gerardo, Monza, Italy,

2Surgery Chirurgia Iii, OSP San Gerardo, Monza, Italy,

3Surgery-Chirurgia Iii, Osp San Gerardo, Monza, Italy,

4Surgery-Chirurgia Iii, san gerardo hospital, Monza, Italy,

5General Surgery, Osp San Gerardo, Monza, Italy

Introduction: Acute colonic obstruction due to malignancies is often a surgical emergency. Hartmann’s procedures or one stage- resection with primarary anastomosis (with or without ileostomy) have been the treatment of choice. However these procedures are associated with a significant morbidity and mortality rate. Self expanding metallic stents (SEMS) have shown their efficiency as palliative treatment in colonic cancer. Colonic stenting has been advocated as a‘‘bridge’’ towards surgical procedures in potentially resectable diseases. The aim of this study is to evaluate the efficacy of colonic stenting in the emergency treatment of large bowel occlusion either for palliation or to enable to planned surgical procedure.

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Material and Methods: From January 2004 to July 2009, 103 patients were enrolled into the study. Group A: 50 patients (pts) (mean age 69 y/o) who underwent standard surgical procedures and 53 pts.- mean age 72- who underwent stenting. In this group 15 patients were not eligible for surgery and thus stenting was the palliative treatment of the disease; in 38 pts (group B) a planned delayed surgery was carried out. Age, gender, body mass index (BMI), comorbidities, surgical procedure, ASA score, transfusions, morbidity and mortality have been recorded.

Results: Group A and group B were similar in age, gender, BMI and comorbidities. About stenting placement no perforative complication has been observed, 7.5% of patients reported anal pain, 5.6% had self-limiting local bleeding, in 7.5% there was stent migration and in 3.7% failure of stent placement which was attributed to stent obstruction. A trend to a better outcome seems to be observed in stentig placement compared to emergency surgery: transfusion 38%

in gr.A and 26.3% in gr.B, anastomotic leakage 18.8%(A) vs 7.6%(B), surgical site infection 54% (A) vs 23.6%(B) cardio-pul- monary complications 38% (A) vs. 18.4%(B).

Conclusion: This study seems to suggest that insertion of SEMS is efficient in the treatment of colonic occlusion allowing a planned surgery. Preoperative stenting is associated with improved primary anastomotic rates and fewer post operative complications.

References: 1) Baque P, Chevalier P Karimdjee Solihi et al. Colos- tomy vs self expanding metallic stents: comparison of the two tec- niquesin acute tumoral left colon obstruction. Ann Chir 2004:129;353-358 2) Olmi S, Scaini A, Cesana G, Dinelli M, et al.

Acute colonic obstruction:endoscopic stenting and laparoscopic resection. Surg Endosc 2007:21;2100-2104 3) Martinez-Santos C, Lobato RF, Jose´ Manuel Fradejas JM et al. Self-Expandable Stent Before Elective Surgery vs. Emergency surgery for the treatment of malignant colorectal obstructions: comparison of primary anastomosis and morbidity rates. Dis Colon Rectum 2002;45:401-406 4) Khot UP et al., Systematic review of the efficacy and safety of colorectal stents. Br J Surg 2002;89:1096-1102.

S011 Small Bowel Obstruction due to Intestinal Adhesions

S. Tamulis, E. V. Gaidamonis¹

1Surgical, Vilnius Unuversity Emergency Care Hospital, Vilnius, Lithuania

Introduction: To evaluate the results of the treatment of patients with the small bowel obstruction due to intestinal adhesions.

Material and Methods: Medical records for the patients treated with small bowel obstruction due to adhesions from 1995 to 2005 were reviewed. The patient’s age, gender, previous abdominal operations, method of the treatment and outcomes were analyzed.

Results: There were 1594 patients admitted to the Vilnius University Emergency Hospital during 10 years period. Appendectomy as a previous operation was recorded in 40% of cases. Surgery was required in 457 of the cases (28.7%). Strangulated small bowel was found in 197 patients (43,1%). In 404 cases (88,4%) the surgical procedure was limited to adhesiolysis, whereas in 53 cases (11,6%) an intestinal resection was performed. Enterodecompresion tube was used in 156 cases (34,1%). The operative mortality was 4,8% (22

cases). Mortality after the treatment due to strangulation was 3,9%

(18 cases).

Conclusion: There were 29% of surgicaly treated patients. Main reasons of adhesions formation was previous performed apendectomy and midline lower laparotomy. The criteria of uneffective conservative treatment were absent of the positive results of the physical, laboratory, rentgenological and ultrasound examination. Mortality after the strangulated small bowel resection was higher. Operative enterodekompresios reduces the risc of the postoperative complications and mortality.

S012 Prospective Controlled Randomized Trial on Prevention of Postoperative Abdominal Adhesions by Icodextrin 4% Solution After Laparotomic Operation for Small Bowel Obstruction Caused by Adherences

F. Catena¹, L. Ansaloni², A. Pinna³

1Emerg Surg, St Orsola-Malpighi University Hospital, Bologna, Italy,

2Emerg Surg, SMUH, Bologna, Italy,

3General and Emerg Surgery, SMUH, Bologna, Italy

Introduction: Adhesive small intestine occlusion (ASIO) is an important cause of hospital admission and are associated with significant morbidity and mortality, placing a substantial burden on healthcare systems worldwide. Icodextrin 4% solution is a high- molecular-weight a-1,4 glucose polymer that is approved in Europe for use as an intra-operative lavage and a post-operative instillate to reduce the occurrence of post-surgery intra-abdominal adhesions.

The current clinical study evaluates the safety and effectiveness of icodextrin 4% for decreasing the incidence, extent, and severity of adhesions in patients after abdominal surgery for ASIO.

Material and Methods: The study project is a prospective, randomized controlled investigation. The safety and efficacy of icodextrin 4% is compared to no antiadhesion treatment (control) in a parallel group, prospective, randomized study with a blinded evaluation of efficacy end points. Subjects with ASIO and surgical indication to laparotomy are enrolled and randomized. Patients are submitted to adhesiolysis with bowel resection if necessary with or without anastomosis. The first group receives traditional treatment (control group) whereas the second group is treated with icodextrin 4% before abdomen closure.

Results: 91 patients were randomized to have icodextrin 4% solution and 90 patients to have traditional treatment. The recurrence rate was 2.1% in the icodextrin groups vs 11.1% after a mean period of 31.2 months (p < 0.05). No complications icodextrin -related were found.

Conclusion: These data showed that the use of icodextrin 4% solution in ASIO is safe and can reduce the risk of re- obstruction. a Trial supported by the World Society of Emergency Surgery.

References: Trials. 2008 Dec 18;9:74.

Prospective controlled randomized trial on prevention of postoperative abdominal adhesions by Icodextrin 4% solution after laparotomic operation for small bowel obstruction caused by adherences [POPA study: Prevention of Postoperative Adhesions on behalf of the World Society of Emergency Surgery].

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Catena F, Ansaloni L, Lauro A, Ercolani G, D’Alessandro L, Pinna A.

S013 Is it Safe to Perform Resection and Primary Anastomosis in Perforation of the Left Colon in an Emergency Setting?

M. Jimenez Fuertes¹, D. Costa Navarro²

1Hepatobiliopancreatic Surgery, Emergency and Politrauma Surgery Unit, Torrevieja Hospital, Valencia, Spain,

2General and Digestive Tract Surgery, Torrevieja-salud Hospital, Alicante, Spain

Introduction: Hartmann operation has been the Standard for the treatment of left colon perforations in the emergency surgery. This implies that in most of the cases, a second operation should be done to perform reconstructive surgery. We report on a series of left colon resection with primary anastomosis in the emergency setting in Torrevieja Hospital.

Material and Methods: Over a period of 18 months (March 2008 through September 2009), 32 cases of left colon perforation were done for different causes. All the operations were done by two surgeons of the same surgical team. The operations consisted on left colon resection with primary anastomosis without intraoperative mechanical irrigation nor protective ileostomy nor colostomy.

Results: None of the patients included in the study presented with complications related to the anastomosis (no leakage nor dehis- cence). All patients were discharged before ten days.

Conclusion: Left colon resection with primary anastomosis for cer- tain patients with left colon perforation is safe and feasible, with good results. It is marked with lower economic cost insofar as a second reconstructive operation is no longer needed.

References: Operative management of diverticular emergencies:

strategies and outcomes. Schwesinger WH, Page CP, Gaskill HV 3rd, Steward RM, Chopra S, Strodel WE, Sirinek KR. Arch Surg. 2000 May;135(5):558-62; discussion 562-3. Primary resection and anastomosis for perforated left colon lesions.Umbach TW, Dorazio RA.Am Surg. 1999 Oct;65(10):931-3. Treatment of left-sided colonic emergencies: a comparison of US and UK surgical practices.Engledow AH, Bond-Smith G, Motson RW, Jenkinson A.Colorectal Dis. 2009 Jul;11(6):642-7. Epub 2008 Jul 15. Comparative study to determine the need for intraoperative colonic irrigation for primary anastomosis in left-sided colonic emergencies.Ortiz H, Biondo S, Ciga MA, Kreisler E, Oteiza F, Fraccalvieri D.Colorectal Dis. 2009 Jul;11(6):648-52. Epub 2008 Jul 4. Emergency left colon resection for acute perforation: primary anastomosis or Hartmann’s procedure? A case-matched control study.Breitenstein S, Kraus A, Hahnloser D, Decurtins M, Clavien PA, Demartines N.World J Surg. 2007 Nov;31(11):2117-24. Epub 2007 Aug 24. Safety of bowel resection for colorectal surgical emergency in the elderly. Pavlidis TE, Marakis G, Ballas K, Rafailidis S, Psarras K, Pissas D, Papanicolaou K, Sakantamis A.Colorectal Dis. 2006 Oct;8(8):657-62. Emergency operations for nondiverticular perforation of the left colon. Biondo S, Pare´s D, Martı´ Rague´ J, De Oca J, Toral D, Borobia FG, Jaurrieta E.

Am J Surg. 2002 Mar;183(3):256-60.

S014 Generalized Peritonitis due to Perforated Diverticulitis: Hartmann Procedure or Primary Anastomosis?

L. Trenti¹, L. Coromina², A. Mun˜oz³, T. Golda³, M. Millan³, R.

Frago³, D. Fraccalvieri³, E. Kreisler³, A. Rafecas³, S. Biondo³

1General Surgery, University of Modena and Reggio-Emilia, Modena, Italy,

2General Surgery, University Barcelona, Barcelona, Spain,

3General Surgery, University of Barcelona, Barcelona, Spain

Introduction: Hartmann’s procedure (HP) still remains the most frequent performed procedure in diffuse peritonitis due to perforated diverticulitis.^1–3Nevertheless it is associated with high morbidityand mortality¹. The aim of this study was to assess feasibility, morbidity and mortality of resection with primary anastomosis (PA) with or without diverting loop ileostomy versus HP in case of diverticular peritonitis.^2,3.

Material and Methods: We retrospectively reviewed our prospectively collected database from 1/95 to 12/08 of patients who were operated in the emergency department of Bellvitge University Hospital. Only patients operated on generalized diverticular peritonitis (Hinchey III-IV) were included. Data on patients’ demographics, ASA classification, Hinchey score, Peritonitis Severity Score (PSS), surgical procedure, post-operative morbidity, mortality and post-operative hospital stay were studied.

Results: A total of 87 patients [median age 66 (34-94) years], female 39.1% were included. Sixty (69%) had undergone HP and 27 (31%) PA. Only in 5 patients (5.7%) a diverting ileostomy was performed.

Overall post-operative morbidity was 74.7%, most frequent complications were wound infection 33.3%, respiratory complications 20.7% and sepsis 17.2%. Overall mortality was 33.3% (29 pt). These patients had a mean PSS of 11.1 while the survival group 8.6. There was an overall reintervention rate of 17.2%, after PA 11.1% and after HP 20.0%. Significant differences were found in the HP versus PA group in ASA score (ASA I-II: 20% v 81%, ASA III-IV: 80% v 18%) and the median PSS (11 versus 8). 62% (21/34 pt) with PSS £ 8 underwent PA, but none (0/31) with PSS ‡ 11. The post-operative morbidity was significantly higher for HP (86.2%) compared to PA (48.1%). Focusing on hospital stay there was a significant difference between PA (mean 15.1 days) versus HP (mean 27.9 days). In the stratified analysis considering patients with Hinchey III peritonitis we found a mortality of 45.7% (21/46 pt) in the HP group versus 7.7%

(2/26 pt) of the PA group. The mortality rate stratified for ASA and surgical procedure shows no difference in ASA I-II, but in ASA III-IV a lower postoperative mortality for HP (20.2%) versus PA (40.0%). Including only patients with PSS less than 11 (56 patients) there is a significantly lower morbidity in PA (80.1%) versus HP (89.7%).

Conclusion: Our data show that PA can be performed safely with lower morbidity and mortality for diverticular peritonitis in patients with ASA I-II, Hinchey III peritonitis grade or PSS less than 11 respectively to HP. These findings are supported by a shorter hospital stay in favor to PA.

References:

1. Vermeulen J, et al. Colorectal Dis. 2009 Jul;11(6):619-24. 2. Biondo S, et al. Br J Surg. 2006 May;93(5):616-22. 3. Zingg U, et al. Colo- rectal Dis. 2008 Oct 1. Epub

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S015 Emergency Abdominal Surgery in Elderly Patients: Risk Factors for Prognosis

G. Altaca¹, U. Sekmen², O. Ilgaz Kocyigit³, H. Karakayali²

1General Surgery, Baskent University, Ankara, Turkey,

2General Surgery, Baskent University, Ankara, Turkey,

3Anesthesiology, Baskent University, Ankara, Turkey

Introduction: Management of elderly patients requiring emergent abdominal surgery is complex due to often seen co-morbid diseases.

Material and Methods: Effects of age, sex, co-morbid disease, diagnosis, laboratory values, and type of surgery on complications, postoperative stay, and mortality in 39 consequtive patients older than 60 years of age who underwent emergent abdominal surgery in a 30-months’ period in a university hospital were analysed.

Results: Mean age was 74.5 years. M/F ratio was 13/26. Main causes were biliary system disease (30,8%), intestinal obstruction/perforation (38,5%), GI bleeding (12,8%), and acute appendicitis (12,8%). 59%

had at least one co-existing disease. Median ASA score was 3. Median postoperative stay was 11,5 days. Complication and mortality rates were 56% and 20,5%. Mean hsCRP at admission was higher in patients who died (p = 0,007). Other laboratory values including WBC were similar in patients who died and who survived. Mortality was significantly higher in patients with co-morbid diseases (p = 0.002). Among co-morbid diseases, chronic hemodialysis (n:7) significantly effected mortality (p = 0,0001). Being in the ICU at presentation (28%) significantly effected mortality (p = 0,02). Mortality rates were similar between different types of diseases or organs operated. Overall, ASA score demonstrated a trend effect on mortality (p = 0,05), and especially patients with ASA score III or IV had significantly higher mortality rates (p = 0,0001). Rate of complications correlated significantly with age ‡ 65 yrs (n:32) (rs= 0,39, p = 0,016). Age ‡ 75 yrs (n:21) significantly correlated with complications (r_s= 0,33, p = 0,04) and postoperative stay (r_s= 0,38, p = 0,02).

Conclusion: Age itself is not a determinant factor on mortality in elderly patients; however, it may increase complication rates. Mor- tality is increased mainly due to co-morbid illnesses. Chronic hemodialysis and admission to ICU are poor prognostic factors. Elderly patients should not be abandoned of having emergency abdominal surgery just because of their ages.

NAILING

S016 A New Radiation Free Targeting Device.

Preliminary Results

Y. Arlettaz¹

1Orthopaedics and Trauma, CHCVs Hoˆpital du Valais, Sion, Switzerland

Introduction: One of the most demanding steps of intramedullary nailing is the distal locking. Most of young surgeon are ‘‘affraid’’ to treat a long bone fracture by a nail because of the distal locking. The aim of this study is to evaluate a new frendly radiation free targeting device on cadavers.

Material and Methods: The study was conducted on fixed cadavers.

25 femurs were available. The method consists of the following steps:

determining the zero position of the device; opening the tip of the great trochanter; introducing the nail (Sirus nail 12X400 (Zimmer

Inc.)); introducing an emitter inside the nail to be positioned in the distal holes; adaptation of the guide on the standard handle with a receptor; moving the receptor to be aligned to the emitter; changing the receptor for the sleeve and performing the drilling and the locking. For the second or even third screw, the targeting device needs a little adjustment.

Results: On the 25 distal locking procedures (50 screws), we observed only one failure due to the breakage of the prototype. This translates as a 98% success rate for two screws with a mean time of 8.2 min.

Two surgeons conduct this study. Not only the inventor but also a inexperimented surgeon tested the new device with the same succes.

Conclusion: This new device has the advantage to be fully mechanical, to be solidly linked to the patient and to be totally radiation free.

It can be used in any hospital, by any surgeon. The procedure is easy to learn and reproducible. It could be adapted to any nail system and does not need external power supply.

References: Arlettaz Y, Akiki A, Chevalley F, Leyvraz PF. Targeting device for intramedullary nails: a new high-stable mechanical guide.

Injury. 2008 Feb;39(2):170-5. Epub 2007 Sep 19.

S017 Anterior Knee Pain After Tibial Intramedullary Nailing. Why?

N. Darabos¹, M. Cesarec², D. Grgurovic³, Z. Rutic³, E. Elabjer¹, A. Muljacic¹

1Department of Sports Traumatology, University Clinic for Traumatology, Medical School, University of Zagreb, Zagreb, Croatia,

2Traumatology, General Hospital Varazdin, Varazdin, Croatia,

3Department of Traumatology, General Hospital Varazdin, Varazdin, Croatia

Introduction: Anterior knee pain (AKP) is common complication following intramedullary nailing of tibial shaft fracture.

Material and Methods: We evaluated postoperative outcome results of 50 patients, operated in last 3 years, with healed fractures initially treated with intramedullary reamed nails with 2 or 3 interlocking screws on both parts of nail and with use of medial paratendinous incision for nail entry portal. Our aim was to analyze possible rela- tionship between AKP according to the VAS scale, and nail position marked as a distance from tip of nail to tibial plateau (NP) and to tuberositas tibiae (NT), measured postoperatively on L-L knee X-rays.

Results: Two groups of patients were formed on the basis of presence of pain related to AKP (the level of pain was neglected): with pain - Group A and without pain - Group B. The difference between two groups concerning NP and NT measurements appeared and it was statistically significant concerning NT measurement (p < 0.05), with high accuracy according to the Classification tree.

Conclusion: We presume that a position of a proximal tip of the nail and its negative influence on the innervation pattern of the area dorsal to patellar tendon could be the key factor of AKP. We con- clude that the symptoms of AKP will not appear if a tip of the nail position shall be more than 6,0 mm from tibial plateau (NP) and more than 2,6 mm from tuberositas tibiae (NT).

References: 1.Vaisto O, Toivanen J, Kannus P, Jarvinen M. Anterior knee pain and tigh muscle strength after intramedullary nailing of