639 Emergency Surgical Approach to A Bleeding Pseudoaneurysm Of the Posterior Inferior Pancreaticoduodenal Artery After Failed Embolisation

Background Pseudoaneurysms of visceral arteries are uncommon, with a prevalence of 0.01% to 0.2%1. Initial treatment is radiological embolisation (RE)2. If this fails, surgical access to the pseudoaneurysm is extremely difficult. They are associated with major complications such as rupture, ischaemia and shock2, with a 20-70% mortality rate3. We report the case of a patient admitted with a life-threatening bleed from an aberrant inferior pancreaticoduodenal artery (IPDA) with failed RE. Case Summary A 44-year-old patient presented with right upper quadrant pain, shock and low haemoglobin. His computerised tomography (CT) scan showed a large retroperitoneal haematoma with active bleeding from a 5x6mm IPDA pseudoaneurysm. After resuscitation, access to the IPDA during RE via the coeliac axis and superior mesenteric artery was unsuccessful and he deteriorated. He underwent an emergency laparotomy, which showed the retro-peritoneal haematoma had ruptured into the peritoneal cavity through the transverse mesocolon. Four-quadrant abdominal packing and supra-coeliac manual compression of the aorta was utilised. The right colon was mobilised with full kocherisation of the duodenum. The gastrocolic omentum was divided to enter the lesser sac. The haematoma was evacuated and bleeding branches from the IPDA were suture ligated. He required 26 units of blood throughout admission and underwent 24-hour damage control laparostomy on intensive care. CT mesenteric angiogram post-surgery and re-look laparotomy showed no further active bleeds. He had an uneventful recovery and discharged safely. Conclusions RE of visceral artery pseudoaneurysms is challenging. Surgery remains the last resort and should be performed by appropriately trained specialist surgeons.

707 Principles of Damage Control Surgery in Trauma and Beyond: Experience at A Tertiary Centre

Damage control surgery (DCS) is an abbreviated laparotomy used as a temporising measure in critically unwell patients who have limited physiological reserves to tolerate complex definitive surgeries. The aim of DCS is to address life-threatening haemorrhage and manage abdominal contamination. Following an abbreviated laparotomy, patients are continuously resuscitated in intensive care unit until physiological stability can be maintained for definitive surgeries. The role of DCS in the trauma setting is well-described; however, its principles can also be applied in General Surgery for a variety of indications such as mesenteric ischaemia, uncontrolled haemorrhage, and secondary peritonitis. Judicious selection of the non-trauma patient who will benefit from this strategy is paramount. We present two cases of a polytrauma patient (Patient A), and non-trauma patient with abdominal septic shock (Patient B) who underwent DCS at our tertiary centre. Patient A is a 49-year-old male involved in a road traffic accident who sustained multiple injuries including liver laceration, splenic laceration, and colonic injury. Intra-abdominal packing and repair of serosal tears were performed, with a re-look laparotomy 48 hours later -- no further bleeding or visceral injuries were identified. Patient B is a 51-year-old gentleman who re-presented in septic shock due to infected retroperitoneal collection following a bleeding duodenal ulcer, initially managed radiologically. A T tube was inserted into the duodenum with two abdominal drains at initial DCS. After thorough washout, a feeding jejunostomy was sited at the re-look laparotomy. 30-days mortality is 0% and both patients are under follow-up.

Mucormycosis in a liver allograft after liver transplantation for secondary biliary cirrhosis due to bile duct injury

Introduction: Mucormycosis refers to a group of opportunistic mycoses that occur generally in immunocompromised patients and are caused by Mucorales, ubiquitous filamentous fungi with broad, thin-walled, sparsely septate, ribbon-like hyphae. Case report: A 57-year-old man with a history of secondary biliary cirrhosis due to inadvertent bile duct injury during cholecystectomy. He was referred to our center and underwent LT on June 2018. Due to severe coagulopathy he underwent exploratory laparotomy and abdominal packing for 48 hours. He recovered with good liver function and LFT´s with a tendency towards normalization. On post op day 8 the patient presented an episode of fever and a CT scan was performed showing a large zone of hypoperfusion with bubbles of gas in the liver dome. A percutaneous biopsy was taken for cultures. Preliminary results reported a filamentous fungus and liposomal amphotericin b was initiated with the suspicion of mucormycosis. The patient remained afebrile and asymptomatic. After 5 days of treatment a new image was performed, and progression of the lesion was noticed, due to these findings the patient was taken to the OR for surgical debridement. Involvement of the liver dome and diaphragm was noticed and a non-anatomic hepatectomy was performed. After surgery the patient required increasing amounts of vasopressors. Despite all the support he progressed to multiple organic failure and finally expired. The product of hepatectomy confirmed the diagnosis of mucormycosis (Rhizopus sp). Discussion: Despite all the efforts the patients’ clinical condition deteriorated after surgery showing the high mortality rate in liver transplant recipients that has been reported of 50 to 100%.

Exploring the Feasibility of Wearable Technologies to Provide Interactive Telepresence Sub-Specialist Support to Remote Clinicians Treating Patients with Traumatic Injuries

Introduction:Some patients presenting to rural or regional hospitals may be deteriorating so rapidly that emergency procedures might be necessary before transfer to specialist facilities. Such interventions might include placement of an ICC, establishing a surgical airway, evacuation of an EDH, laparotomy, or intra-abdominal packing. The treating clinician may have had little or no experience in the procedure. Interactive telepresence technology offers further point of care support to the treating clinicians through the virtual presence of a specialist from a major trauma center.Aim:To explore the feasibility of wearable interactive telepresence technology that can provide sub-specialist support to remote clinicians treating patients with traumatic injuries.Methods:Thirty-seven wearable near-field display devices and annotation software applications were tested against a set of pre-specified technical and user experience requirements. A shortlist of three devices and two software applications underwent usability evaluations with a convenience sample of 24 junior clinicians and sub-specialists. The junior clinicians trialed the wearable devices and the sub-specialists trialed the annotation applications in three simulated trauma scenarios. Measures included participants’ ratings of acceptance and workload, technical issues encountered (e.g. frequency of call drop-outs), and anecdotal comments.Results:Participants’ subjective ratings of the solutions and anecdotal feedback were positive. However, there was no clear solution that satisfied the functionality and ease-of-use requirements for all participants. For example, the solutions that were rated more favorably by the junior clinicians were rated less favorably by the sub-specialists, and vice versa.Discussion:This work provided preliminary evidence of the feasibility and usefulness of interactive telepresence technology in healthcare. A second phase of usability testing is currently underway to explore additional device and software combinations, including those with augmented reality functionality. Future phases of the project will evaluate the solutions under higher-fidelity conditions followed by in-situ trials across selected regional centers.