arotomy and confirmed the diagnosis: intestinal malrotation, obstruction of the third part of the duodenum (Ladd bands) and we continued with Ladd's procedure ...
S82 Introduction: The aim of this study is to identify factors associated with limb loss in patients with popliteal artery injuries. Materials and methods: Retrospective chart review of a prospectively collected data base of all patients with popliteal artery injuries presenting to the Groote Schuur Hospital Trauma Centre over 10 years. Results: One hundred and thirty six patients with popliteal artery injuries were identified. Penetrating trauma accounted for 81 (59.5%) injuries. Injury level: above the knee (39), at the knee (47), and below the knee (34). Associated injuries: fractures in 66 (48.5%), knee dislocation in 29 (21.3%) and popliteal vein injury in 59 (43.4%) patients. Limb viability on admission was assessed being ischaemic in 85 (64.4%) patients. Treatment of the arterial injury involved reversed vein grafting in 68, primary anatomises in 33, and prosthetic graft insertion in 11. The overall amputation rate was 37.5%. Mechanism of injury (p = 0.684), concomitant venous injury (p = 0.701), fracture (p = 0.183), knee dislocation (p = 0.784), and anatomical level of arterial injury (p = 0.393) were not associated with increased amputation rates. Delay between injury and definitive repair of more than 7 h in patients with ischaemic limbs (p = 0.0236) and the presence of a compartment syndrome (p = 0.003) were the only factors significantly associated with an increased amputation rate. Conclusion: In the current series, the amputation rate was 37.5%. The most significant factors associated with this finding were an ischaemic time of more than 7 h, and the presence of a compartment syndrome. Disclosure: No significant relationships.
Abstract Conclusion: Vascular trauma of the limbs represents a clinical entity for which immediate diagnosis and treatment is essential. To ensure the best possible outcomes, algorithms of care will need to guarantee the actual availability of diagnostic tools and surgeons. The current management approach, including use of angiography and prompt surgical management, results in successful outcomes after extremity arterial injuries. The use of shunt and fasciotomies in complex cases improves early results. References: 1. Mommsen P, Zeckey C, Hildebrand F, Frink M, Khaladj N, Lange N, Krettek C, Probst C. Traumatic extremity arterial injury in children: epidemiology, diagnostics, treatment and prognostic value of Mangled Extremity Severity Score. J Orthop Surg Res. 2010;5:25. 2. Burkhardt GE, Cox M, Clouse WD, Porras C, Gifford SM, Williams K, Propper BW, Rasmussen TE. Outcomes of selective tibial artery repair following combat-related extremity injury. J Vasc Surg. 2010;52(1):91–6. 3. Haddock NT, Weichman KE, Reformat DD, Kligman BE, Levine JP, Saadeh PB. Lower extremity arterial injury patterns and reconstructive outcomes in patients with severe lower extremity trauma: a 26-year review. J Am Coll Surg. 2010;210(1):66–72. Disclosure: No significant relationships.
Video Presentations EMERGENCY SURGERY 1 V1
O207 VASCULAR TRAUMA OF THE LIMBS: ELEVEN-YEAR MONOCENTRIC EXPERIENCE
LAPAROSCOPIC MANAGEMENT OF PERFORATED APPENDICEAL DIVERTICULITIS: A RARE CASE WITH VIDEO PRESENTATION G.O. Kucuk
E.M. Marone, D. Logaldo, A. Kahlberg, Y. Tshomba, R. Chiesa Vascular Surgery, San Raffaele Hospital, Milano, Italy
General Surgery, Samsun Vezirkopru Public Hospital, Samsun, Turkey
Introduction: Vascular trauma of the limbs is associated with significant mortality and morbidity rates. Aim of this article is to analyze results of surgical treatment of vascular trauma of the upper or lower limbs in a high volume Vascular Center. Materials and methods: A retrospective review of data collected between 1998 and 2009 was performed. Patients’ details, including cause and pattern of vascular injury, diagnostic modality, intervention, limb-salvage rate and long-term survival were recorded. Results: Between January 1998 and December 2009, 154 patients (mean age 43 years; range 9–76 years) presented to our Institution with vascular trauma of the upper (n = 41; 26.7%) or lower limbs (n = 106; 68.8%) or both (n = 7; 4.5%). The most common cause of vessel damage was road accident (52%), followed by workrelated (26%), self-inflicted (14%), recreation-related (6%) and other causes (2%). Thirty-six patients (23.4%) presented with major associated lesions. Primary amputation rate was 8.4%. Treatment included direct suture (35%), patch repair (20%), bypass grafting (41%) and endovascular treatment (4%). Vascular shunts were used in 7.3% of patients; fasciotomies were performed in 33% of patients. After limb revascularization, eight patients died because of major associated injuries. Overall limb salvage rate in this study was 82.9%. Survival rate of patients following peripheral vascular intervention was 96.4%.
Introduction: Appendiceal diverticulitis is a rare entity with clinical and pathological differences from acute appendicitis. It usually presents with atypical abdominal signs and it has a more rapid progression to perforation. In this case, a 40-year-old female with perforated appendiceal diverticulitis was described. Content: A 40-year-female patient was admitted to our hospital with a 3-day history of right lower-quadrant pain, anorexia and vomiting. The physical examination showed localized tenderness in the right lower quadrant of the abdomen. She said that she did not feel epigastralgia or pain shifting to the right lower abdomen. No rebound tenderness was observed. Abdominal ultrasonography demonstrated an enlarged swollen appendix with a cross section diameter of 11 mm and pouch-like projection filled with fluid in 7 mm diameter. Wall thickening of the appendix was 3 mm and it was more prominent than that seen in typical appendicitis. Laparoscopic appendectomy was performed. The resected appendix was 7 cm long, 1.0 cm in diameter with multiple diverticula, of which one was perforated. Microscopic study revealed a diverticulum with severe inflammation and perforation in its wall. She had an uneventful recovery and discharged 3 days after surgery. Discussion: Appendiceal diverticulum is a rare clinical entity with an incidence of 0.2–1.5% in surgical pathologic specimens. Diverticulum of the appendix may ultimately develop diverticulitis and it has a
Abstract high perforation rate. Laparoscopy with appendectomy is an important final diagnostic procedure for appendiceal diverticulitis because of difficulties in diagnosis. Disclosure: No significant relationships.
EMERGENCY SURGERY 2 V3 THERE WAS ONCE AN ACUTE APPENDICITIS… S. Costa1, B. Pereira2, S. Grac¸a1, E. Francisco1, J. Esteves1, A. Costa1, V. Santos1, J. Maciel1, A. Gandra3 Surgery, CHVNG/E, VNG, Portugal, 2CHVNG/E, VNG, Portugal, Surgery, Centro Hospitalar Vila Nova de Gaia e Espinho, EPE, VNGaia, Portugal 1
3
Introduction: The possibility of combining a diagnostic and therapeutic procedure grant the exploratory laparoscopy an increasingly important role in emergency surgery, that keeps growing, as the experience of surgeons develops. Content: We report the case of a 22 years old patient, healthy, who went to the ER because of a sudden abdominal pain in the epigastrium and hypogastrium without any other symptoms. The patient was afebrile, with soft and depressible abdomen, with tenderness in the right iliac fossa and hypogastrium, with a positive Blumberg sign. Analysis revealed leukocytosis and chest and abdomen radiograph did not show significant alterations. Exploratory laparoscopy was proposed and accepted, for differential diagnosis of ruptured ovarian cyst and acute appendicitis. Laparoscopy identified purulent peritonitis with Ileocecal appendix, uterus, fallopian tubes and ovaries of normal characteristics. At exploration, a perforated pyloric ulcer was identified. We performed suture of ulcer, omentoplasty and profuse washing of the abdominal cavity with sub-hepatic drain placement, laparoscopically. The postoperative period progressed uneventfully, and she restarted working at the 3rd postoperative week. Discussion: As shown in the present case, the advantages of a laparoscopic approach in emergency surgery are: the versatility of incisions and consequent aesthetic result, the excellence of the peritoneal toilette and shorter length of hospitalization and recovery. Disclosure: No significant relationships.
EMERGENCY SURGERY 3 V4 LAPAROSCOPIC MANAGEMENT OF APPENDIX CARCINOID PRESENTED WITH COMPLICATED APPENDICITIS: A RARE CASE WITH VIDEO PRESENTATION G.O. Kucuk General Surgery, Samsun Vezirkopru Public Hospital, Samsun, Turkey Introduction: An increasing number of surgeons are performing laparoscopy in the management of acute appendicitis. In this a case a
S83 26 year-old-male who was diagnosed as carcinoid tumour after pathological examination of resected appendix was discussed. Content: A 26-year-old male presented to the emergency department with a 4-day history of intermittent right lower quadrant abdominal pain, nausea, and vomiting. Upon further questioning, he stated that his abdominal pain had started after physical exercise in the right lower quadrant. The following morning his symptoms had subsided. Two days later pain recurred in the periumbilical region and localized to the right lower quadrant. In his history, he said that he felt similar abdominal pain 1 month ago. On physical examination, there was rebound tenderness in the right lower quadrant. Laboratory data revealed a white blood cell account of 17,200/mm3. Abdominal ultrasound demonstrated perforated appendicitis with a cross section diameter of 12 mm. The patient was taken for laparoscopy. Laparoscopic appendectomy with periappendicular abscess drainage was performed. The patient had an uneventful postoperative course and was discharged on postoperative day 4. Histologic examination of the appendix revealed carcinoid tumour of the appendix. Discussion: Inflammatory complications of appendix carcinoid may mimic acute appendicitis. Careful macroscopic and pathologic examination of the specimen is crucial to ensure appropriate definitive treatment. Disclosure: No significant relationships.
V5 SUBDIAGNOSED CASE—UPPER INTESTINAL OBSTRUCTION IN ADULT BY INTETSINAL MALROTATION C. Iorga1, V. Strambu2, C. Puscu1, S. Stoian1, P. Radu1, M. Bratucu1, A. Manta2, F. Popa2 1 General Surgery, st pantelimon hospital, bucharest, romania, bucharest, Romania, 2General Surgery, Sf Pantelimon Clinical Emergency Hospital, Bucharest, Romania
Introduction: A 19 years old female patient presented with the fourth episode of epigastric pain, nausea, vomiting. Content: Material and method: During 2005–2007 the patient was admitted three times in our clinic for epigastric pain, nausea, vomiting, the diagnosis was considered each time to be acute pancreatitis. This fourth episode, the most severe of all, did not improve after medical treatment, the general status of the patient worsened, the values of blood amylase raised. We performed an abdominal CT scan (not conclusive result), abdominal Doppler ultrasound (suggested the presence of vascular abnormalities), mesenteric arteriography which established the probable diagnosis of intestinal malrotation. Results: Once the probable diagnosis established we performed an open laparotomy and confirmed the diagnosis: intestinal malrotation, obstruction of the third part of the duodenum (Ladd bands) and we continued with Ladd’s procedure (described in children): section of the bands and appendectomy. The postoperative evolution was excellent, with spectacular improvement of the patient’s condition. Discussion: Conclusions: Intestinal malrotation is usually diagnosed in children in the first months of life; the condition in rarely seen in adults (incidence 0.2%). Adults are generally asymptomatic, the anomaly is discovered during laparotomy imposed by obstructive complications. The preoperative diagnosis is difficult, in our case arteriography was the most suggestive exam. Disclosure: No significant relationships.
