Gastrointestinal symptoms and complications in patients hospitalized due to COVID-19, an international multicentre prospective cohort study (TIVURON project).

BACKGROUND: Retrospective studies suggest that coronavirus disease (COVID-19) commonly involves gastrointestinal (GI) symptoms and complications. Our aim was to prospectively evaluate GI manifestations in patients hospitalized for COVID-19. METHODS: This international multicentre prospective cohort study recruited COVID-19 patients hospitalized at 31 centres in Spain, Mexico, Chile, and Poland, between May and September 2020. Patients were followed-up until 15 days post-discharge and completed comprehensive questionnaires assessing GI symptoms and complications. A descriptive analysis as well as a bivariate and multivariate analysis were performer using binary logistic regression. p<0.05 was considered significant. RESULTS: Eight hundred twenty-nine patients were enrolled; 129 (15.6%) had severe COVID-19, 113 (13.7%) required ICU admission, and 43 (5.2%) died. Upon admission, the most prevalent GI symptoms were anorexia (n=413; 49.8%), diarrhoea (n=327; 39.4%), nausea/vomiting (n=227; 27.4%), and abdominal pain (n=172; 20.7%), which were mild/moderate throughout the disease and resolved during follow-up. One-third of patients exhibited liver injury. Non-severe COVID-19 was associated with ≥2 GI symptoms upon admission (OR 0.679; 95% CI 0.464-0.995; p=0.046) or diarrhoea during hospitalization (OR 0.531; 95% CI 0.328-0.860; p=0.009). Multivariate analysis revealed that worse hospital outcomes were not independently associated with liver injury or GI symptoms. CONCLUSION: GI symptoms were more common than previously documented, and were mild, rapidly resolved, and not independently associated with COVID-19 severity. Liver injury was a frequent complication in hospitalized patients not independently associated with COVID-19 severity.

[Abdominal and gastrointestinal symptoms of Dengue fever. Analysis of a cohort of 8559 patients]. / Síntomas abdominales y gastrointestinales del dengue. Análisis de una cohorte de 8.559 pacientes.

INTRODUCTION/AIM: Dengue fever is a common disease in tropical and subtropical regions and is characterized by fever, headache, and joint and muscle pain. Occasionally, patients develop abdominal and gastrointestinal symptoms but information about the real frequency of these manifestations is lacking. The aim of this study was to determine the frequency of abdominal and gastrointestinal symptoms in a cohort of patients with Dengue fever. PATIENTS AND METHODS: We performed a retrospective review of 8559 patients with a diagnosis of Dengue fever during the 2006 epidemic to determine the frequency of abdominal and gastrointestinal symptoms. RESULTS: Abdominal and gastrointestinal symptoms were present in 67% of patients. The most frequent symptom was nausea (n=4453, 52%), followed by abdominal pain (n=3058, 36%), vomiting (n=2477, 29%), diarrhea (n=1471, 17%), hepatomegaly, (n=144, 2%), gastrointestinal bleeding (n=34, 0.3%) and ascites (n=8, 0.1%). Hospitalization was required in 1640 patients (19%), of which 1210 (74%, p=0.0001) had some abdominal and gastrointestinal symptoms. In this group, the most frequent symptoms were nausea (n=972, 59%), abdominal pain (n=692, 42%), vomiting (n=668, 41%) and diarrhea (n=393, 24%). Among patients admitted to our hospital for Dengue, 70% showed alterations in liver function tests. CONCLUSIONS: Our findings suggest that close to 67% of patients with Dengue fever have abdominal and gastrointestinal symptoms or abnormalities in liver function tests. Abdominal and gastrointestinal symptoms were significantly more frequent in patients who were hospitalized. The differential diagnosis of an acute febrile syndrome with abdominal pain or gastrointestinal symptoms in patients living in endemic areas or who have recently travelled to certain regions should include Dengue fever.

Diagnosis and surgical management of gallbladder cancer: a review.

Gallbladder cancer is one of the most lethal carcinomas and continues to pose many challenges for surgeons. Identifiable risk factors for carcinoma of the gallbladder include cholelithiasis, an anomalous pancreaticobiliary junction, and focal mucosal microcalcifications. Adenocarcinoma is the primary histologic type in most patients and the tumor is frequently associated with Kras and p53 mutations. Radiologic and endoscopic advances in endoscopic ultrasonography and magnetic resonance cholangiopancreatogram, plus helical computed tomography, have enhanced preoperative staging. Surgical options include cholecystectomy for disease limited to the mucosa (Tis/T1) or a radical cholecystectomy (subsegmental resection of segments IVB and V plus a hepatoduodenal ligament lymphadenectomy) for advanced disease without signs of distant metastasis (T2-4/N0-N2). Some surgeons have advocated more radical hepatic resection including extended right hepatectomy or central bisegmentectomy plus caudate lobectomy. Japanese surgeons have reported studies that included patients having a pancreaticoduodenectomy to improve distal ductal margins and lymphadenectomy for T3 and T4 cancers. These patients have a lower rate of local recurrence but no survival advantage. Options for adjuvant therapy remain limited. Radiation therapy with fluorouracil radiosensitization is the most commonly used postoperative treatments. Current trials are investigating the role of capecitabine, oxaliplatin, and bevacizumab in the management of gallbladder carcinoma.

Long-term anastomotic complications after pancreaticoduodenectomy for benign diseases.

BACKGROUND: The study of long-term complications after pancreaticoduodenectomy (PD) for malignant disease has been problematic given the paucity of patients with long-term survival after diagnosis and surgical resection. We therefore studied patients who were surgically treated with a PD for a benign diagnosis to evaluate long-term anastomotic durability. METHODS: A retrospective analysis of 122 patients who had PD performed in the interval 1993-2003 inclusive for benign pancreatic diseases was undertaken. Long-term morbidity and mortality (specifically biliary, pancreaticojejunostomy [PJ], and gastrojejunostomy [GJ] strictures) were evaluated. RESULTS: Gender was equally represented with 53% female and 47% male. The median age at surgery was 55 years (range 15-81 years). The three most frequent diagnoses were chronic pancreatitis (40%), intraductal papillary mucinous neoplasm (16%), and cystic neoplasms (9%). Median follow-up in the 95 patients alive at last follow-up was 4.1 years (10 days-12.6 years). The 5- and 10-year survival rates were 83% (76, 91%) and 62% (49%, 78%), respectively. The observed survival was significantly lower than the expected survival in an age- and gender-matched U.S. white population, p<0.001 (one-sample log-rank test). The 5- and 10-year cumulative probability of biliary stricture was 8% (2%, 14%) and 13% (4%, 22%), respectively. For pancreatic strictures the 5- and 10-year rates were 5% (0%, 9%) and 5% (0%, 9%), respectively. No GJ strictures were noted. The management of biliary strictures was primarily with dilatation and stent (78%) and less commonly operative intervention (22%). Pancreatic strictures required surgery alone (25%), surgery followed by endoscopic intervention (25%), or endoscopic therapy alone (50%). CONCLUSION: Intervention for anastomotic strictures after pancreaticoduodenectomy is uncommon. Biliary strictures can usually be treated nonoperatively with dilation and stent. Our study likely underestimates the incidence of stricture formation. Prospective imaging studies may be warranted for a more accurate assessment of the rate of long-term anastomotic complications.

Efficacy and safety of neutral pH superoxidised solution in severe diabetic foot infections.

The use of antiseptics in wound care is often controversial and there is definitely a need for a non toxic, highly disinfective agent. This study assessed the efficacy of a neutral pH superoxidised aqueous solution (NpHSS) for infection control, odour reduction and surrounding skin and tissue damage on infected diabetic foot ulcerations. From November 2003 to March 2004, 45 patients with type 2 diabetes were randomised into a single-blind clinical trial comparing NpHSS (intervention group; n = 21) versus conventional disinfectant (control group; n = 16). All patients received comprehensive care including surgical debridement as appropriate, moist wound care, intensive glucose control and broad spectrum antibiotics. Treatment groups were matched in terms of sex, age (61.9 +/- 11.9 versus 67.8 +/- 11.6), years of diabetes duration (16.4 +/- 8.1 versus 17 +/- 10.2), obesity, HgAlc (7.1 +/- 2 versus 6.7 +/- 1.8), initial fasting glycaemia (163 +/- 59 versus 152 +/- 65.8 mg/dl), ulcer duration/week (13.7 +/- 24 versus 15.1 +/- 16.3), B/A Index (0.9 +/- 0.5 versus 1.14 +/- 0.7), depth and extent of infection/periwound cellulitis (groups B and C of the Tampico Hospital Classification) as well as aetiology (P = 0.647). Odour reduction was achieved in all NpHSS patients (100% versus 25%; P < 0.01) and surrounding cellulitis diminished (P < 0.001) in 17 patients (80.9% versus 43.7%). Nineteen patients in the NpHSS group showed advancement to granulating tissue stage (90.4% versus 62.5%; P = 0.05) with significantly less tissue toxicity (94% versus 31.2%; P < 0.01). A non toxic, NpHSS, as part of a comprehensive care regimen, may be more efficacious in infection control, odour and erythema reduction than conventional disinfectants in treatment of diabetic foot infections.

[Mortality-associated factors in major surgery: retrospective analysis in a referral center]. / Factores asociados a mortalidad en cirugia mayor: análisis retrospectivo en un centro de referencia.

BACKGROUND: There are very few studies that analyze surgical morbidity and mortality in the general population and the factors associated with those events. OBJECTIVE: To determine factors associated to mortality in surgical procedures performed in a tertiary referral center in Mexico City. METHODS: We retrospectively analyze surgical mortality in 4,157 consecutive surgical procedures performed in a one-year period from 1/1/2000 through 12/31/2000. Categorical variables were analyzed with the chi-square test and continuous variables with the t-Student test. Significance was defined as p < 0.05. RESULTS: During the study period there were 76 postoperative deaths, representing a mortality rate of 1.82%. Mean patient's age in the entire cohort was 48.7 +/- 17.6 years and for the patients who died in the postoperative period 57.8 +/- 17.8 years (p < 0.05). Sixty-six percent of deaths were attributed to the primary or surgical disease. In 33.8% of postoperative deaths an adverse event was identified as responsible for the outcome. In 23% of cases there was a potentially preventable event, representing 0.3% of surgical procedures. Most patients (96.9%) had at least one comorbid condition and 61.5% had two or more. Almost 80% of surgical deaths occurred in patients with ASA score III of IV and albumin levels below 3.5 g/dL. Most common cause of death was sepsis, reported in 35% of patients who died in the postoperative period. CONCLUSION: Surgical mortality in our series is low. In 0.3% of procedures it was detected a potentially preventable event. Postoperative deaths occurred in older patients with low albumin levels.

Clinicopathologic characteristics of gastric cancer in a young patient population.

The aim of this study was to analyze the clinicopathologic characteristics of young patients with gastric cancer with special attention to hereditary gastric cancer in a tertiary referral university hospital. Charts from all patients 40 years of age or younger at the time of diagnosis, during the period from January 1, 1987 to December 31, 2001, were retrospectively reviewed. Demographic variables, family history of gastric cancer, clinicopathologic characteristics, and treatment-related variables were analyzed. Overall survival was the main outcome variable. Survival curves were constructed by means of the Kaplan-Meier method, univariate analysis was performed with the log-rank test, and multivariate analysis with Cox regression. Significance was considered at P<0.05. During the study period, 558 cases of gastric cancer were seen at our institution, 83 (14.8%) were in patients 40 years of age or younger. Mean patient age was 33.2 years. Forty-five patients (54.2%) were male. Fourteen patients (16.9%) had a family history of gastric cancer. Five patients (6%) fulfilled the criteria of hereditary gastric cancer. Surgery was performed in 88% of patients, but only 35% of the operations had a curative intent. Operative mortality was 2.4%. On univariate analysis, advanced tumor stage, hypoalbuminemia, low performance status, diffuse type, pangastric tumor location, noncurative surgery, and lack of adjuvant chemotherapy had a significant negative impact on survival. On multivariate analysis, advanced tumor stage, pangastric tumor location, and absence of adjuvant chemotherapy were significantly associated with poor prognosis. Family history of gastric cancer or hereditary gastric cancer did not have any impact on prognosis. There is a high frequency of gastric cancer in young patients at our institution. Most patients present in advanced stages, which favors a poor overall survival. Family history of gastric cancer or hereditary gastric cancer did not have a significant impact on survival. Complete resection and adjuvant chemotherapy appeared to confer the only chance of prolonged survival.

Surgery for stage IV gastric cancer.

BACKGROUND: Surgical treatment for stage IV gastric cancer is controversial. METHODS: We analyzed the surgical experience with advanced gastric carcinoma in a tertiary referral center in Mexico City from 1995 through 2000. We analyzed surgical morbidity, mortality, and factors associated with prognosis. Survival was analyzed with the Kaplan-Meier method, and the curves were compared with the log-rank test. Significance was assigned at P <0.05. RESULTS: Seventy-six cases were identified. Mean patient age was 56 +/- 14.5 years. Thirty-nine patients (51.3%) were women. Patients were grouped according to surgical procedure: group 1 underwent resection (40 patients), group 2 underwent bypass procedures (10 patients), and group 3 underwent either celiotomy and biopsy alone or jejunostomy placement (26 patients). Twenty patients (26%) developed operative complications, but most were minor. There was no difference in morbidity between surgical groups and no difference according to patient's age. Operative mortality was 2.6%. Good palliation of symptoms was significantly more common in group 1 patients (82%) than in group 2 patients (60%) (P = 0.0001). Median survival was 8 months (95% confidence interval 4 to 12) for the entire cohort and 13, 5, and 3 months for groups 1, 2, and 3, respectively (P = 0.00001 for group 1 vs groups 2 and 3). CONCLUSIONS: Surgical resection for stage IV gastric cancer can be done with low operative mortality and acceptable morbidity rates, and it provides patients with good symptomatic relief. Advanced patient age is not a contraindication for surgical treatment.

[Biliary-colonic fistulas. Analysis of 2 cases and literature review]. / Fístulas biliocolónicas. Revisión de la literatura y análisis de dos casos con diferente etiología.

BACKGROUND: Bilioenteric fistulas are entities whose etiology can be diverse. OBJECTIVE: The aim of this paper was to present two cases of biliary-colonic fistulas with different presentations and to review existing literature regarding etiology, diagnosis, and management of these patients. METHODS: Two cases of biliary-colonic fistulas were reviewed. RESULTS: Case 1. A 48-year-old woman presented with lower gastrointestinal bleeding secondary to cholecystocolonic fistula in context of cholelithiasis. Case 2. A 60-year-old woman with multiple hepatic abscess associated with biliary-colonic fistula secondary to adenocarcinoma of gallbladder. CONCLUSIONS: Biliary-colonic fistulas are recognized complications of cholelithiasis. Association with neoplasia is less frequent. Preoperative diagnosis is difficult and management must be surgical.

[Intussusception in adults. Case report with uncommon etiology and review of the literature]. / Intususcepción en adultos: presentación de un caso con etiología poco común y revisión de la literatura.

OBJECTIVE: To present a case of adult intussusception with uncommon etiology. BACKGROUND: Intussusception is a relatively common cause of intestinal obstruction in children, but is a rare clinical entity in adults, representing less than one per cent of intestinal obstruction in this patient population. METHOD: We report on 72-year old female patient with intestinal obstruction due to ileocolic intussusception related to leiomyosarcoma of the terminal ileum. A synchronic adenocarcinoma in the cecum was identified. The patient underwent right hemicolectomy and terminal ileum resection with primary anastomosis. Her postoperative course was uneventful. The patient is free of all evidence of disease at 2 year of follow-up. A thorough review of the literature of adult intussusception was carried out. CONCLUSION: From this review, the recommendation is to resect all cases of adult intussusception, different from the recommended approach in pediatric population.

Pseudomyxoma extraperitonei: a rare presentation of a rare tumour.

Pseudomyxoma extraperitonei is rare lesion resulting from the rupture of an appendiceal mucocele into the extraperitoneal tissues. We report a case of an 80-year-old woman with a medical history for a left hemicolectomy and a laparoscopic cholecystectomy 11 and 6 years, respectively, referred to our hospital for abdominal pain of increasing severity localised to the right hemiabdomen. The abdominal examination revealed a mobile mass a multidetector CT was performed; the patient was taken to surgery which was performed with no complications. Histopathological analysis of the tumour reported a pseudomyxoma associated to a moderately differentiated adenocarcinoma. The patient remains asymptomatic at a 1-year follow-up.

Glomus tumour of the stomach: an unusual cause of gastrointestinal bleeding.

Glomus tumours are a rare type of subepithelial mesenchymal tumours that present in deep visceral organs such as the stomach, which are difficult to diagnose. We report a case of a 44-year-old woman with diabetes who presented with anaemia, abdominal pain and melena diagnosed preoperatively with a gastric glomus tumour initially misdiagnosed as a gastric ulcer located at the lesser curvature. Upon referral to our centre a repeat endoscopy and biopsy were performed. A partial gastrectomy was performed with no complications. Histopathological analysis of the tumour reported clear margins and immunostaining was positive for smooth muscle actin and collagen IV. The patient remains asymptomatic at 3-month follow-up.

Management of benign biliary strictures by percutaneous interventional radiologic techniques (PIRT).

INTRODUCTION: Some biliary strictures may be manageable by percutaneous interventional radiologic techniques (PIRT), but long-term efficacy of this approach is scarce. METHODS: We reviewed retrospectively all patients with biliary strictures secondary to traumatic bile duct injury or strictured bilioenteric anastomoses. Patients in whom the initial management was by PIRT from 1998 through 2003 were selected. Subjects with sclerosing cholangitis, hepatic transplantation, or malignant strictures were excluded. Data were obtained from medical records and/or direct patient contact. Comparisons were made by Fisher's exact test and Wilcoxon rank-sum test. RESULTS: Twenty-seven patients with biliary strictures were treated by PIRT. Mean age was 54 years (range 11-86). Most frequent etiology was laparoscopic cholecystectomy injury in 11 patients (41%). Eight patients (29%) had undergone biliary resection for malignancy, seven (26%) a pancreatoduodenectomy, and one for presumed ischemic cholangiopathy; no strictures were secondary to neoplastic recurrence. PIRT was successful in 10 of 11 patients (91%) with short, isolated bile duct strictures secondary to laparoscopic cholecystectomy and in seven of 15 patients (41%) with strictured bilioenteric anastomosis, but not in the patient with ischemic cholangiopathy. Twenty patients (74%) were stent-free at follow-up. Anastomotic biliary strictures were more likely to fail PIRT than isolated strictures secondary to laparoscopic cholecystectomy injury (p=0.02). CONCLUSION: Percutaneous balloon dilatation and stenting can be an effective strategy for patients with bile duct strictures, especially short bile duct strictures after laparoscopic cholecystectomy. Anastomotic strictures are associated with less good results when managed by PIRT but are successful in up to 40% of patients.

Routine liver biopsy to screen for nonalcoholic fatty liver disease (NAFLD) during cholecystectomy for gallstone disease: is it justified?

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) and gallstone disease (GD) share common risk factors. There are no firm recommendations regarding screening of NAFLD in patients at risk. Our aim was to assess the prevalence of and factors associated with NAFLD in a cohort of patients operated for symptomatic GD and evaluate the usefulness of routine liver biopsy. METHODS: Ninety-five consecutive patients underwent a liver biopsy at the end of a standard laparoscopic cholecystectomy for symptomatic GD. Clinical, biochemical, demographic, and anthropometric variables were obtained prospectively. RESULTS: Fifty-two patients (55%) had biopsies compatible with NAFLD. These patients were classified according to the system proposed by Brunt et al. as follows: grade I, n = 27 (52%); grade II, n = 15 (29%); grade III, n = 10 (19%). Two grade III patients had zone III focal perisinusoidal fibrosis and three had overt cirrhosis. Only 13% of subjects had a suspected diagnosis of NAFLD preoperatively. In multivariate logistic regression, only obesity was significantly associated with NAFLD. There were no complications or mortality. DISCUSSION: Fifty-five percent of patients with GD have associated NAFLD. Awareness of this association may result in an earlier diagnosis. The high prevalence of NAFLD in patients with GD may justify routine liver biopsy during cholecystectomy to establish the diagnosis, stage, and possible direct therapy.

Single nucleotide polymorphisms in the promoter region of the E-cadherin gene in gastric cancer: case-control study in a young Mexican population.

BACKGROUND: Gastric cancer has a tendency to present at early age in the Mexican population, and it is frequently associated with a family history. A polymorphism at position -160 at the CDH1 promoter region has been reported to lead to transcriptional downregulation of the gene in vitro, with possible increase in the risk of gastric cancer. We evaluated the role of the -160A allele in the risk of gastric cancer in a young Mexican population. METHODS: Peripheral blood sample of Mexican patients younger than 45 years old with diagnosis of diffuse gastric cancer were obtained. We performed DNA extraction and analyzed the frequencies of -160 promoter polymorphism of E-cadherin gene by polymerase chain reaction-single strand conformational polymorphism. These frequencies were compared with those of healthy controls. The chi2 test for association was used to test differences of the genotype frequencies between normal controls and patients with gastric cancer. Findings were considered significant at P < .05. RESULTS: The frequency of the -160 A allele was significantly higher (P = .002) in 39 patients with diffuse gastric cancer compared with 78 matched controls. The odds ratio associated with the A-allele was 1.98 for C/A heterozygotes (95% CI 1.01-3.98) and 6.5 for A/A homozygotes (95% CI 2.1-19.6). We found an increased risk of diffuse gastric cancer according to family history, independent of the expression of the polymorphism. CONCLUSIONS: The -160 C/A polymorphism of the E-cadherin has a direct effect on the risk of diffuse gastric cancer at young age in Mexican population.