External Validation of Two Scoring Tools to Predict the Operative Duration and Open Conversion of Elective Laparoscopic Cholecystectomy in a Mexican Population.

INTRODUCTION: This study aimed to evaluate the use of laparoscopic cholecystectomy (LC) operative time (CholeS score) and conversion to an open procedure (CLOC score) outside their validation dataset in Mexican population. METHODS: Patients >18 years who underwent elective LC were analyzed in a single-center retrospective chart review study. Association between scores (CholeS and CLOC) with operative time and conversion to open procedures was assessed with Spearman correlation. The predictive accuracy of the CholeS score and CLOC score was evaluated by receiver operator characteristic. RESULTS: 200 patients were included in the study (33 excluded for emergency case or missing data). Spearman coefficient correlations between CholeS or CLOC score and operative time were 0.456 (p < 0.0001) and 0.356 (p < 0.0001), respectively. Area under the curve (AUC) for operative prediction time (>90 min) by CholeS score was 0.786 with a 3.5-point cutoff (80% sensitivity and 63.2% specificity). AUC for open conversion (CLOC score) was 0.78 with a 5-point cutoff (60% sensitivity and 91% specificity). The CLOC score had a 0.740 AUC (64% sensitivity and 72.8% specificity) for operative time >90 min. CONCLUSIONS: The CholeS and the CLOC scores predicted LC long operative time and risk for conversion to an open procedure, respectively, outside their original validation set.

Performance of the American College of Surgeons National Surgical Quality Improvement calculator for early postoperative outcomes following bile duct repair hepaticojejunostomy.

PURPOSE: A Roux-en-Y hepaticojejunostomy (HJ) is the preferred method for repairing bile duct injuries (BDIs). The American College of Surgeons (ACS) established the National Surgical Quality Improvement Program (NSQIP) online risk calculator to predict risks for morbidity and mortality. The objective of the study is to assess the use of the ACS NSQIP calculator for patients undergoing HJ for BDI repairs outside the NSQIP cohort. METHODS: An IRB-approved retrospective study of Bismuth-Strasberg type E BDI HJ (2008-2020) was performed. Clinical data was introduced in the NSQIP calculator, and morbidity and mortality were determined. Perioperative risk factors were obtained. Comparisons of postoperative complications and NSQIP-predicted complication rate were carried out. RESULTS: Eighty-two patients were included (age: 42.2 ± 15.7 years; 81% female; BMI 27.1 ± 4.4 kg/m2). The most common injury was E4 (36.3%). A total of 40.2% patients had a 30-day complication. Mortality was 2.4%. Preoperative sepsis and high body mass index (p = 0.01) were significantly related to complications (p = 0.01) (univariate analysis). Older age (p = 0.01) and higher ASA class (p = 0.02) were significantly related to mortality (univariate analysis). None was statistically significant in multivariate analysis. Comparison between morbidity and mortality and the calculated NSQIP was not statistically significant. Postoperative mortality had a statistically significant trend (C-value = 0.72, p = 0.055). CONCLUSION: Preoperative sepsis, high body mass index, age, and ASA classification were associated with worse outcomes in HJ BDI repair. The ACS NSQIP calculator did not have a good performance in a population outside the NSQIP data. Further larger studies will need to corroborate these results.

Establishing consensus on the perioperative management of cholecystectomy in public hospitals: a Delphi study with an expert panel in Mexico.

BACKGROUND: Several guidelines have put forward recommendations about the perioperative process of cholecystectomy. Despite the recommendations, controversy remains concerning several topics, especially in low- and middle-income countries. The aim of this study was to develop uniform recommendations for perioperative practices in cholecystectomy in Mexico to standardize this process and save public health system resources. METHODS: A modified Delphi method was used. An expert panel of 23 surgeons anonymously completed two rounds of responses to a 29-item questionnaire with 110 possible answers. The consensus was assessed using the percentage of responders agreeing on each question. RESULTS: From the 29 questions, the study generated 27 recommendations based on 20 (69.0%) questions reaching consensus, one that was considered uncertain (3.4%), and six (20.7%) items that remained open questions. In two (6.9%) cases, no consensus was reached, and no recommendation could be made. CONCLUSIONS: This study provides recommendations for the perioperative management of cholecystectomy in public hospitals in Mexico. As a guide for public institutions in low- and middle-income countries, the study identifies recommendations for perioperative tests and evaluations, perioperative decision making, postoperative interventions and institutional investment, that might ensure the safe practice of cholecystectomy and contribute to conserving resources.

Predictive Factors for Unsuccessful Use of Arteriovenous Fistula in a Population of End-Stage Renal Disease Patients in Southeastern Mexico.

BACKGROUND: An arteriovenous fistula (AVF) is the preferred vascular access for long-term hemodialysis. The main disadvantage of AVF is the rate of nonmaturation or unsuccessful use for hemodialysis (FUHD). We described our findings in AVF creation and possible risk factors associated with FUHD. METHODS: This is a retrospective study of AVFs during a 6-year period. Variables collected at the time of creation were demographics, comorbidities, replacement therapy, preoperative laboratory tests, and estimated 6-month mortality on hemodialysis. All AVFs were created in the upper arms. Outcomes were FUHD, cannulation failure, and cumulative survival. Univariate and multivariate analyses were performed to find possible risk factors for FUHD. RESULTS: AVFs were created in 78 patients. Average age was 36.3 years, and 74.4% were male. Mean body mass index was 24.5 kg/m2. The most common etiologies were glomerulopathy (53.6%) and diabetes mellitus (13.4%). Estimated six-month mortality was 4.2%. One patient underwent AVF before hemodialysis (mean dialysis time 2.2 years). Nineteen AVFs were considered FUHD (23.2%). Cannulation failure was 15.9%. AVF 1-year and 3-year survival was 67.8% and 63.5%, respectively. FUHD had higher estimated six-month mortality on hemodialysis, shorter prothrombin time, and lower serum albumin level than successful AVF (univariate analysis) (P < 0.05) Short prothrombin time and albumin were confirmed for FUHD (multivariate analysis). A 3.3-gr/dL serum albumin cutoff point (area under the curve, 0.715; receiver operating characteristic) (P < 0.05) was determined for FUHD. CONCLUSIONS: The population referred for AVF creation possesses different characteristics in our center. Good AVF outcomes can be achieved. Preoperative serum albumin level and prothrombin time could be the possible risk factors associated with unsuccessful AVF use.

Factors associated with patency loss and actuarial patency rate following post-cholecystectomy bile duct injury repair: long-term follow-up.

PURPOSE: Several factors may contribute to bile duct injury (BDI) repair failure. The objective of our study was to evaluate factors that contribute to the loss of patency and influence the actuarial patency rate of BDI repairs in an 11-year period. METHODS: Retrospective review study of patients who underwent a hepaticojejunostomy for a type E Bismuth-Strasberg BDI (2008-2019). The outcomes are the following: primary patency attained, loss of primary patency, and actuarial primary patency rate. Logistic regression for loss of patency and Cox regression for actuarial patency rate were used. RESULTS: Seventy-nine patients (age 42.3 ± 15.8 years, 81% female) were studied. Most common index operation was open cholecystectomy (60.8%). Most common Bismuth-Strasberg lesion was E4 (38%). Primary patency was 93.4%. Mean follow-up was 36 ± 34 months. Ten-year actuarial patency was 53.9%. Factors associated with loss of patency were vasculobiliary injury, biliary stents, and 90-day biliary complications (univariate); number of surgeries before repair and postoperative cholangitis (univariate and multivariate) (p < 0.05). Factors that impacted actuarial patency rate were (univariate analysis) 90-day biliary complications; postoperative cholangitis and index treatment period stenosis (p < 0.05). No factors impacted actuarial patency rate in multivariate analysis. CONCLUSION: Postoperative cholangitis is associated with loss of patency and had potentially detrimental effect on the actuarial patency rate in BDI repair.

Differences in Post-Cholecystectomy Bile Duct Injury Care: A Comparative Analysis of 2 Different Health-Care Public Institutions in a Low- and Middle-Income Country: Southeast Mexico.

BACKGROUND: Mexican health system structure allows us to study the differences in bile duct injury (BDI) management. The study aimed to assess the differences in patients with complex BDI in 2 different public sector institutions using a new proposed standard terminology. METHODS: Retrospective review (2008-2019) in 2 public institutions (IMSS/SESVER). Bismuth-Strasberg E injuries with hepaticojejunostomy were included. Data are presented in a tabular reporting system. The outcomes were percent of patients attaining primary patency, loss of primary patency, and actuarial primary patency rate. RESULTS: Seventy-eight patients (IMSS: n = 37; SESVER: n = 41) without differences in demographic and preoperative assessment were studied. BDI occurred mostly in outside hospitals. Open cholecystectomy was the most common index operation in SESVER (73%, p = 0.02). IMSS had more surgeries (p = 0.007) and repair attempts (p = 0.06) prior to referral. Magnetic resonance cholangiopancreatography was more commonly used in IMSS patients. Biliary stents (45%) and cholangitis (29%) were more common in IMSS (p < 0.05). IMSS patients had longer follow-up than SESVER (p < 0.05). No differences in primary patency rates (IMSS: 89%, SESVER: 97%) and actuarial patency rates were noted. DISCUSSION: Despite differences in referral, preoperative, and operative events, good BDI repair outcomes can be achieved. Longer follow-up is needed to monitor these outcomes.

[Neutrophil-lymphocyte ratio as predictor of mortality in patients with necrotizing fasciitis]. / Índice neutrófilo-linfocito como predictor de mortalidad en pacientes con fascitis necrotizante.

Background: Necrotizing fasciitis (NF) can affect any soft tissue and skin of the body. Its progression is rapid and it is associated with a high mortality rate. Therefore, the search for easily accessible and low-cost biomarkers that could predict the prognosis of patients with NF is necessary. Objective: To evaluate the role of neutrophil-lymphocyte ratio (NLR) as a predictor of mortality in patients with NF. Material and methods: Observational, cross-sectional, retrospective and analytical study of patients admitted between April and October 2020 in a tertiary-care hospital. The statistical tests used for the comparison of variables between the study groups were chi-square, Fisher's exact, Student's t and Mann-Whitney U. A receiver operating characteristic (ROC) curve was performed to determine the accuracy of NLR in predicting mortality in patients with NF. Results: A total of 25 patients were included and stratified into non-survivors and survivors. The non-survivor group had an elevated NLR value compared to survivors (15.57 [13.75] vs. 7.91 [4.13]; p = 0.065). The NLR had an area under the curve (AUC) of 0.729 (95% confidence interval [95% CI] 0.516-0.886; p = 0.044), sensitivity of 77.78% (40-97.2), and specificity of 75% (47.6-92.7). The optimal cut-off point obtained for NLR was > 9.21. Conclusions: An NLR value > 9.21 could be a predictor of mortality in patients with NF.

Introducción: la fascitis necrotizante (FN) puede afectar cualquier tejido blando y piel del cuerpo. Su progresión es rápida y está relacionada con un índice de mortalidad alto. Por lo tanto, la búsqueda de biomarcadores de fácil acceso y bajo costo que puedan predecir el pronóstico de los pacientes con FN es necesaria. Objetivo: evaluar el papel del índice neutrofilo-linfocito (INL) como un predictor de mortalidad en los pacientes con FN. Material y métodos: estudio observacional, transversal, retrospectivo y analítico de pacientes admitidos entre abril y octubre del 2020 en un hospital de tercer nivel. Las pruebas estadísticas utilizadas para la comparación de las variables entre los grupos de estudio fueron chi cuadrado, exacta de Fisher, t de Student y U de Mann-Whitney. Una curva característica operativa del receptor (ROC) fue realizada para determinar la precisión del INL en la predicción de mortalidad en pacientes con FN. Resultados: un total de 25 pacientes fueron incluidos y estratificados en no sobrevivientes y sobrevivientes. El grupo no sobreviviente tuvo un valor elevado del INL en comparación con los sobrevivientes (15.57 [13.75] frente a 7.91 [4.13]; p = 0.065). El INL tuvo un área bajo la curva (AUC) de 0.729 (intervalo de confianza del 95% [IC 95%] 0.516-0.886; p = 0.044), sensibilidad de 77.78% (40-97.2) y especificidad de 75% (47.6-92.7). El punto de corte óptimo obtenido para el INL fue > 9.21. Conclusiones: un valor de INL > 9.21 podría ser un predictor de mortalidad en los pacientes con FN.

Prospective validation of a preoperative scoring system for difficult laparoscopy cholecystectomy.

Difficult laparoscopic cholecystectomy (LC) is defined by its surgical outcomes, including operative time, conversion to open surgery, bile duct and/or vascular injury. Difficult LC can be graded based on intraoperative findings. The main objective of this study is to apply and validate the reliability of their proposed risk score to predict the operative difficulty of an LC, based on their own validated intraoperative scale. Single-center prospective cohort study from 01/2020-12-2023. 367 patients > 18 years who underwent LC were included. The preoperative risk scale and intraoperative grading system were registered. Surgical outcomes were determined. Predictive accuracy was evaluated by the Receiver Operator Characteristic curve, sensitivity, specificity, positive, and negative predictive values, and Youden's Index (J). Patients' mean age was 44.1 ± 15.3 years. According to the risk score, 39.5% LC were "low" risk difficulty, 49.3% were "medium" risk, and 11.2% were "high" risk difficult LC. Based on the intraoperative grading system, 31.9% were difficult LC (Nassar grades 3-4) and 68.1% were easy LC (Nassar grades 1-2). There was a statistically significant correlation (0.428, p < 0.05) between the preoperative risk score and the intraoperative grading system. The AUC for the preoperative risk score scale and intraoperative difficult LC was 0.735 (95% CI 0.687-0.779) (J: 0.34). A preoperative risk score > 1.5 had an 83.7% sensitivity and a 50.8% specificity for intraoperative difficult LC. A predictive preoperative score for difficult LC and a routine collection of the intraoperative difficulty should be implemented to improve surgical outcomes and surgical planning.

Low-Dose Thymoglobulin versus Basiliximab Induction Therapy in Low-Risk Living Related Kidney Transplant Recipients: Three-Year Follow-Up Study.

BACKGROUND: The optimal dose of rabbit anti-thymocyte globulin (r-ATG) in renal transplantation is still under debate. We previously reported that a low-dose r-ATG induction of 3 mg/kg can be used safely and effectively in low-risk kidney transplants with good results in the first year after transplantation compared to basiliximab induction. AIMS: The purpose of this study is to evaluate the long-term impact of this trial of low-dose r-ATG versus basiliximab on post-transplant outcomes (patient and graft survival, biopsy-proven acute rejection incidence [BPAR], infectious complications, and side effects). METHODS: Observational study (three-year follow-up) of a 12-month single-center, open-label RCT in de novo kidney allograft recipients assigned to receive either thymoglobulin or basiliximab before transplantation. RESULTS: Patients in the basiliximab group (BG) underwent more kidney transplant biopsies than patients in the low-dose r-ATG group (TG) (50 vs. 31.8%, p = 0.07). Although the 12-month cumulative incidence of BPAR was lower in BG, by the end of the three-year follow-up period this incidence was higher (22%) than in the low-dose TG (15%) (p = ns). Steroids were withdrawn more frequently in the TG group and sirolimus was most frequently indicated. Graft function and graft survival were higher in the low-dose TG than in the BG at three-year follow-up but not statistically significant. Patient survival was similar between groups (>90%). CONCLUSIONS: These three-year follow-up data confirm the efficacy and favorable safety aspects of the low-dose r-ATG (3 mg/kg) in low-risk kidney transplantation.

Neutrophil-to-lymphocyte ratio may predict complications and patency in bile duct injury repair.

BACKGROUND: Bile duct injury (BDI) repair surgery is usually associated with morbidity/mortality. The neutrophil-to-lymphocyte ratio (NLR) easily assesses a patient's inflammatory status. The study aims to determine the possible relationship between preoperative NLR (pNLR) with postoperative outcomes in BDI repair surgery. METHODS: Approved Ethics/Research Committee retrospective study, in patients who had a Bismuth-Strasberg type E BDI repair (2008-2023). Data registered was: morbidity, mortality, and long-term outcomes (primary patency and loss of primary patency) (Kaplan-Meier). Group comparison (U Mann-Whitney), receiver operator characteristic (ROC): area under curve [AUC]; cut-off value, and Youden index [J], and logistic regression analysis were used for pNLR evaluation. RESULTS: Seventy-three patients were studied. Mean age was 44.4 years. E2 was the commonest BDI (38.4%). Perioperative morbidity/mortality was 31.5% and 1.4%. Primary patency was 95.9%. 8.2% have lost primary patency (3-year actuarial patency: 85.3%). Median pNLR was higher in patients who had any complication (4.84 vs. 2.89 p = 0.015), biliary complications (5.29 vs. 2.86 p = 0.01), and patients with loss of primary patency (5.22 vs. 3.1 p = 0.08). AUC's, cut-off values and (J) were: any complication (0.678, pNLR = 4.3, J = 0.38, p = 0.007), serious complication (0.667, pNLR = 4.3, J = 0.34, p = 0.04), biliary complications (0.712, pNLR = 3.64, J = 0.46, p = 0.001), and loss of primary patency (0.716, pNLR = 3.24, J = 0.52, p = 0.008). Logistic regression was significant in any complication (Exp [B]: 0.1, p = 0.002), serious complications (Exp [B]: 0.2, p = 0.03), and biliary complications (Exp [B]: 8.1, p = 0.003). CONCLUSIONS: pNLR is associated with complications in BDI repair with moderate to acceptable predictive capacity. pNLR could potentially predict patency of a BDI repair.

Vein and artery diameter influence on arteriovenous fistula maturation and patency in a Mexican population.

BACKGROUND: There is no consensus of the optimal arterial and venous sizes on arteriovenous fistula (AVF) function and patency. The purpose of our study was to determine the influence of vein and artery sizes on maturation and patency in autologous first time AVF in a vascular access clinic of Mexican Social Security. METHODS: Approved IRB single-center retrospective study in patients referred for their first AVF from 01/2018/ to 04/2020. Perianastomotic inner vein diameter and single inner artery diameter was recorded by duplex ultrasound. Outcomes were: failure to mature (FTM) and cumulative primary patency survival. RESULTS: Eighty-six AVF's were created (mean age 45.5 ± 15.1 years; 62.8% male; mean BMI 25.9 ± 4.3 kg/m2). About 86% were brachiocephalic AVF. Eight (8.1%) AVF had FTM. Mean follow-up was 19.7 ± 8.5 months. Two-year patency survival was 81.4%. FTM vein and artery diameters (2.1 ± 0.3 and 2.8 ± 0.7 mm respectively) were smaller than successful AVF's (3.1 ± 0.9 and 3.5 ± 0.6 mm) (p < 0.05). ROC curve calculated a 2.15 mm vein diameter cutoff (AUC: 0.86) and a 2.95 mm artery diameter cutoff (AUC: 079) for FTM AVF's (83% sensitivity, 72% specificity both) (p < 0.05). AVF's created with a vein diameter <2.15 mm and <2.95 mm artery diameter had statistically significant lower patency survival than AVF's with larger vein and artery diameters (p < 0.05). CONCLUSION: Vein diameter <2.15 mm and artery diameter <2.95 mm influences AVF maturation and patency in a Mexican population.

Application of colon leakage score in the left-sided colorectal surgery.

Background: Colon leakage score (CLS) was developed for risk prediction of anastomotic leak (AL) in the left-sided colorectal surgery. Although the risk factors for leakage are well known and accepted by the surgical community, an accurate forecast of AL is still a difficult task. Objective: The study aims to apply the CLS in patients undergoing left-sided colorectal surgery. Methods: Retrospective study in patients with the left-sided colorectal surgery and primary anastomosis without diverting stoma. CLS was calculated in patients, who were classified in AL and NO-AL groups. Predictive value of CLS was evaluated by receiver operator characteristic. Correlation between CLS and AL was determined. 208 patients (55% male, mean age 59 years) were included in the study. Results: Overall, AL was 7.2%. Mean CLS of all patients was 7.2 ± 3.2 (0-17). Patients with AL had a higher CLS (11.8 ± 2.3) than NO-AL patients (6.8 ± 3) (p = 0.0001). The area under the curve for the prediction of AL by CLS was 0.898 ([CI] 0.829-0.968, p = 0.0001). A CLS of 8.5 had 93% sensitivity and 72% specificity. There was a statistically significant odds ratio for CLS and AL (0.58: [CI] 0.46-0.73, p = 0.0001). Conclusion: CLS is a useful tool to predict AL in the left-sided colorectal surgery.

Antecedentes: La puntuación de fugas de colon (CLS) se desarrolló para la predicción del riesgo de fuga anastomótica (AL) en la cirugía colorrectal del lado izquierdo, con la finalidad de obtener un pronóstico preciso. Objetivo: Este estudio tiene el objetivo de aplicar el CLS en pacientes con cirugía colorrectal de lado izquierdo. Método: Estudio retrospectivo en pacientes con cirugía colorrectal izquierda y anastomosis primaria sin estoma de derivación. Se calculó el CLS en los pacientes, los cuales fueron clasificados en los grupos con AL y sin AL. Resultados: La media del CLS de todos los pacientes fue de 7.2 ± 3.2 (0-17). Los pacientes con AL tenían un CLS más alto (11.8 ± 2.3) que los pacientes sin AL (6.8 ± 3) (p = 0.0001). El área bajo la curva para la predicción de la AL mediante el CLS fue de 0.898 (intervalo de confianza (CI) 0.829-0.968; p = 0.0001). Un CLS de 8.5 tuvo una sensibilidad del 93% y una especificidad del 72%. Además, se obtuvo un Odds Ratio con una diferencia estadísticamente significativa para el CLS y AL (0.58; CI 0.46-0.73; p = 0.0001). Conclusión: La CLS es una herramienta útil para predecir la AL en la cirugía colorrectal del lado izquierdo.

Sperm concentrations do not correlate with semen parameters and hormone profiles in males recovered from COVID-19.

Background: Although the negative impact on fertility of men recovered from coronavirus disease 2019 (COVID-19) has been suggested, there is insufficient evidence, and the data are limited and contradictory. The present prospective study aimed to evaluate the sex-related hormones, semen parameters, erectile dysfunction (ED), and lower urinary tract symptoms (LUTS) in a cohort of men who recovered from COVID-19 and age-matched control men. Methods: Semen samples were collected from twenty-two men recovered from COVID-19 with a median time of 91.5 days and thirty-six control males. The semen parameters were evaluated according to the World Health Organization (WHO) laboratory manual to examine and process human semen. The blood samples were collected to assess the male hormone profile. ED and LUTS were evaluated with the International Index of Erectile Function 5 (IIEF-5) and the International Prostate Symptom Score (IPSS), respectively. Results: The follicle-stimulating hormone (FSH) (3.819±1.515 IU/L), luteinizing hormone (LH) (4.023±1.792 IU/L), prolactin (PRL) [12.60 (10.72-15.20) ng/mL], and testosterone (T) [4.345 (3.565-5.525) ng/mL] levels were at normal range in all males enrolled in the study. Levels of semen volume (control: 2.5 mL vs. COVID-19: 1.9 mL; P<0.05) and sperm concentration (control: 59×106/mL vs. COVID-19: 41.5×106/mL; P<0.005) were significantly lower in males recovered from COVID-19, but still technically well within normal regardless of WHO edition. All variables were examined through logistic regression analysis, demonstrating that only sperm concentration was an independent variable associated with men recovered from COVID-19 [odds ratio (OR) =1; 95% confidence interval (CI): 0.999-1.098; P=0.016]. According to correlation analysis, there was no correlation between sperm concentration and other semen parameters and sex-related hormone profiles. Furthermore, an absence of ED and LUTS in men who recovered from COVID-19 was evidenced using the IIEF-5 and IPSS, respectively. Conclusions: Reproductive-age males recovered from COVID-19 have normal sperm concentration. Sperm concentration did not correlate with other semen parameters, sex-related hormones, IIEF-5, and IPSS. Further studies should be performed to evaluate whether the lower sperm concentration and semen volume that were still within the normal range are a transient or prolonged downregulation resulting from the COVID-19 attack.

Encephalitis Associated With SARS-CoV-2 Infection in a Child With Chiari Malformation Type I.

BACKGROUND/AIM: There is increasing evidence that patients infected with SARS-CoV-2 develop neurological manifestations such as encephalitis. The purpose of this article was to present a case of viral encephalitis associated with SARS-CoV-2 in a 14-year-old child with Chiari malformation type I. CASE REPORT: The patient manifested frontal headache, nausea, vomiting, skin pallor, right side Babinski sign and was diagnosed with Chiari malformation type I. He was admitted with generalized seizures and suspected encephalitis. Brain inflammation and viral RNA in the cerebrospinal fluid suggested SARS-CoV-2 encephalitis. These findings indicate that the SARS-CoV-2 test in CSF of patients with neurological manifestations, confusion, and fever during the COVID-19 pandemic should be carried out even when there is no evidence of respiratory infection. To our knowledge, this presentation of encephalitis associated with COVID-19 has not yet been reported in a patient with a congenital syndrome such as Chiari malformation type I. CONCLUSION: Further clinical data are needed to determine the complications of encephalitis due to SARS-CoV-2 in patients with Chiari malformation type I to standardize diagnosis and treatment.

The Role of Aspartate Aminotransferase-to-Lymphocyte Ratio Index (ALRI) in Predicting Mortality in SARS-CoV-2 Infection.

COVID-19 has a mortality rate exceeding 5.4 million worldwide. The early identification of patients at a high risk of mortality is essential to save their lives. The AST-to-lymphocyte ratio index (ALRI) is a novel biomarker of survival in patients with hepatocellular carcinoma, an organ susceptible to SARS-CoV-2 infection. For this study, the prognostic value of ALRI as a marker of COVID-19 mortality was evaluated. For this purpose, ALRI was compared with the main biomarkers for COVID-19 mortality (neutrophil-to-lymphocyte ratio [NLR], systemic immune-inflammation index [SII], platelet-to-lymphocyte ratio [PLR], lactate dehydrogenase (LDH)/lymphocyte ratio [LDH/LR]). A retrospective cohort of 225 patients with SARS-CoV-2 infection and without chronic liver disease was evaluated. In the non-survival group, the ALRI, NLR, SII, and LDH/LR were significantly higher than in the survival group (pcorrected < 0.05). ALRI had an area under the curve (AUC) of 0.81, a sensitivity of 70.37%, and a specificity of 75%, with a best cut-off value >42.42. COVID-19 patients with high ALRI levels had a mean survival time of 7.8 days. Multivariate Cox regression revealed that ALRI > 42.42 (HR = 2.32, 95% CI: 1.35-3.97; pcorrected = 0.01) was a prognostic factor of COVID-19 mortality. These findings prove that ALRI is an independent predictor of COVID-19 mortality and that it may help identify high-risk subjects with SARS-CoV-2 infection upon admission.

Hepato-pancreato-biliary surgery in Mexico and Latin America during the COVID-19 pandemic (2020): Results from AMHPB survey.

BACKGROUND: The Mexican Hepato-Pancreato-Biliary Association (AMHPB) conducted a survey, aiming to gather experience and opinions of HPB surgeons about HPB surgery in the 2020 COVID-19 pandemic year. METHODS: An online survey was conducted (33 items: demographics, patient referral, COVID-19 screening and limitations, hospital occupancy and surgical practice) to AMHPB members and attendees of the previous meetings of the Society through a self-administered questionnaire. Answers were excluded if respondents were not from Latin America. RESULTS: 88 participants answered (47.5 ± 10 years, 94% male and 65.9% Mexicans). About 8% worked in COVID-19 converted hospitals. About 1.1% did not perform pre-operative COVID-19 testing. Polymerase chain reaction (33%) was the most common COVID-19 pre-operative test. The number of patient referrals decreased 62.5%. About 29.5% had one patient who died from COVID-19 during preoperative surgical evaluation. About 64.7% answered that surgical case volume decreased. About 17% and 23% respondents considered that surgical morbidity and mortality increased, respectively. Hospital resources and COVID-19 infection were responsible for change in surgical outcomes. Lack of ICU beds (54%) was the most common cause of surgical cancellation. CONCLUSION: COVID-19 had a strong negative impact on HPB surgery in Mexico and Latin America in terms of patient reference, case volume and surgical outcomes.

INTRODUCCIÓN: La Asociación Mexicana Hepato-Pancreato-Biliar (AMHPB) realizó una encuesta con el objetivo de recopilar experiencias/opiniones de cirujanos HPB sobre cirugía HPB en el 2020 con pandemia COVID-19. MÉTODOS: Se realizó encuesta virtual (33 ítems: demografía, derivación de pacientes, tamizaje/limitaciones COVID-19, ocupación hospitalaria y práctica quirúrgica) a miembros de la AMHPB y asistentes a reuniones previas de la Sociedad a través de un cuestionario autoadministrado. Se excluyeron las respuestas que no fueran de América Latina. RESULTADOS: Respondieron 88 participantes (47.5 ± 10 años, 94% hombres y 65.9% mexicanos). 8% trabajaba en hospitales reconvertidos COVID-19. 1,1% no realizó prueba COVID-19 preoperatoria. La Polymerase chain reaction (33%) fue laprueba preoperatoria COVID-19 más común. Lareferencia de pacientes disminuyó 62,5%. El 29,5% tuvo paciente fallecido por COVID-19 durante la evaluación preoperatoria. 64,7% respondió que el volumen de casos quirúrgicos disminuyó. El 17% y23% consideraron que la morbilidad y mortalidad quirúrgicas aumentaron respectivamente. Los recursos hospitalarios e infección por COVID-19 influyeron en los resultados quirúrgicos. La falta de camas de UCI (54%) fue lo más común en cancelación quirúrgica. CONCLUSIÓN: COVID-19 tuvo un fuerte impacto negativo en la cirugía HPB en México y América Latina en referencia de pacientes, volumen de casos y resultados quirúrgicos.

Application and validation of a surgical risk calculator in a liver surgery cohort of patients in Veracruz, Mexico.

OBJECTIVE: Multiple models have tried to predict the morbidity and mortality of liver resections (HR). This study aims to determine the efficacy and validity of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) surgical risk calculator in a cohort of patients undergoing HR in Veracruz, Mexico. MATERIAL AND METHODS: Retrospective analysis of patients undergoing HR between 2005 and 2019. To estimate the performance of the calculator, the observed results were compared with the average risk predicted by the calculator, using ROC curve, Brier score and Z test. RESULTS: 67 patients were evaluated, mean age 51.9 years of age, 50.7% female. The majority of resections (56.7%) were for malignancy and 62.1% were partial hepatectomies (up to 3 liver segments). The morbidity was 25.4% and the mortality 4.5%. There was a good prediction in the complications (serious complication: C = 0.725 statistic, Brier score 0.26, p = 0.006 and any statistical complication C = 0.731, Brier score 0.33, p = 0.005) and mortality (C = 0.922 statistic, Brier score 0.005, p = 0.014). CONCLUSIONS: The application of the ACS-NSQIP calculator in patients undergoing HR has good discrimination power and good predictive ability. Prediction of postoperative risks achieves a preoperative planning of the appropriate procedure.

OBJETIVO: Múltiples modelos han intentado predecir la morbilidad y mortalidad de las resecciones hepáticas (RH). Este estudio tiene por objetivo determinar la eficacia y validez de la calculadora de riesgo quirúrgico del American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) en una cohorte de pacientes sometidos a RH en Veracruz, México. MATERIAL Y MÉTODOS: Análisis retrospectivo de pacientes sometidos a RH entre 2005 y 2019. Se compararon los resultados observados con la media del riesgo previsto por la calculadora, mediante Curva ROC, score de Brier y prueba Z. RESULTADOS: Se evaluaron 67 pacientes, con 51.9 años de edad media, un 50.7% de sexo femenino. La mayoría de las resecciones (56.7%) fueron por patología maligna y el 62.1% fueron hepatectomías parciales. La morbilidad fue del 25.4% y la mortalidad del 4.5%. Hubo una predicción buena en las complicaciones (complicación seria, estadística: C: 0.725, score Brier: 0.26, p = 0.006 y cualquier complicación, estadística: C: 0.731, score Brier: 0.33, p = 0.005) y la mortalidad (estadística C: 0.922, score Brier: 0.005, p = 0.014). CONCLUSIONES: La aplicación de la calculadora ACS-NSQIP en pacientes sometidos a RH tiene buen poder de discriminación y buena habilidad predictiva. Predecir riesgos postoperatorios logra una adecuada planeación preoperatoria del procedimiento.

Hepatopancreatobiliary surgery in a Mexican social security hospital during the COVID-19 pandemic.

INTRODUCTION: Data on hepatopancreatobiliary (HPB) surgery and COVID-19 are scarce. The objective of the study was to determine the outcomes HPB procedures during the COVID-19 pandemic and compare results to the previous year. METHODS: IRB approved study of HPB procedures (April, 2020-November, 2020). Primary endpoints: Thirty-day surgical morbidity/mortality, including COVID-19 infection. Secondary endpoints: Comparison between 2019 and 2020 procedures. RESULTS: Twenty-five patients were included. In 2020, HPB procedures decreased 31.6%. About 60% developed complications (Clavien-Dindo Grade III, 20%). Three patients developed post-operative COVID-19 infection (two deaths: 66% COVID-19 mortality). When compared to the previous year, there were more emergency cases, ventilator-assisted patients (p < 0.05) and pre-operative acute renal failure (p = 0.06). Clavien-Dindo complication grades were higher in 2020. Thirty-day mortality was also higher (16% vs. 5.6%). CONCLUSION: HPB surgical activity was negatively influenced by COVID-19 on 30-day morbidity/mortality. HPB patients who developed post-operative COVID-19 infection had a complicated course with significant mortality.

OBJETIVO: Los datos sobre cirugía hepatopancreatobiliar (HPB) y COVID-19 son escasos. El objetivo del estudio fue determinar los resultados de procedimientos de HPB durante la pandemia COVID-19 y comparar resultados con el año anterior. MATERIAL-MÉTODOS: Estudio de procedimientos HPB aprobado por el IRB (04/2020-11/2020). Criterios de valoración principales: morbilidad/mortalidad quirúrgica a los 30 días, incluida la infección por COVID-19. Criterios de valoración secundarios: comparación entre los procedimientos de 2019 y 2020. RESULTADOS: Se incluyeron 25 pacientes. En 2020, los procedimientos de HPB disminuyeron 31.6%. El 60% desarrolló complicaciones (grado III de Clavien-Dindo, 20%). 3 pacientes desarrollaron infección posoperatoria por COVID-19, (2 muertes: 66% de mortalidad por COVID-19). En comparación con el año anterior, hubo más casos de emergencia, pacientes asistidos por ventilador (p < 0.05) e insuficiencia renal aguda preoperatoria (p = 0.06). Los grados de complicación de Clavien-Dindo fueron más altos en 2020. La mortalidad a 30 días también fue más alta (16% frente a 5.6%). CONCLUSIÓN: La actividad quirúrgica de HPB fue influenciada negativamente por COVID-19 en la morbilidad/mortalidad a 30 días. Los pacientes con HPB que desarrollaron infección posoperatoria por COVID-19 tuvieron un curso complicado con una mortalidad significativa.

[Adrenal myelolipoma, review of the literature in Mexico apropos of two cases]. / Mielolipoma Suprarrenal, revisión de literatura en México a propósito de dos casos.

Background: Adrenal myelolipomas (ML) are rare benign neoplasms compound of adipose and myeloid tissue. Clinically they are usually asymptomatic, being diagnosed generally by incident. In Mexico, there are only 32 published cases of ML, these occur between 37 and 65 years, with the male-female ratio being 1:1.1, clinically they present with abdominal or lumbar pain, open surgery being the main surgical approach (89%). Clinical case: We made a literature review of ML in Mexico and present two clinical cases: a 67-year-old man in followup for diverticular disease and a 40-year-old woman with pain in the left upper quadrant. In both cases, tumor resection was performed measuring 9.5 cm and 13.3 cm long respectively. Conclusions: We present two new cases in our country that correspond to incidentalomas. In both cases, surgery was performed to confirm the diagnosis, as well as to prevent possible complications.

Introducción: los mielolipomas suprarrenales (ML) son neoplasias benignas poco frecuentes constituidas por tejido adiposo y mieloide. Clínicamente asintomáticas, suelen ser diagnosticados incidentalmente. En México existen solo 32 casos publicados de ML, presentándose en pacientes de entre 37 a 65 años, siendo la relación hombre-mujer 1:1.1, el síntoma más comúnmente reportado es dolor abdominal inespecífico, y la cirugía abierta es el principal abordaje quirúrgico empleado en nuestro país (89%). Caso clínico: presentamos una recopilación de la literatura actual sobre ML en México, además de dos casos clínicos de pacientes con ML: un hombre de 67 años con enfermedad diverticular y una mujer de 40 años con dolor en hipocondrio; en ambos se realizó resección tumoral, midiendo 9.5 cm y 13.3 cm, respectivamente. Conclusiones: presentamos dos casos nuevos en nuestro país que corresponden a incidentalomas. En ambos casos la cirugía se realizó para confirmar el diagnóstico, así como para prevenir posibles complicaciones.

Leukocyte glucose index as a novel biomarker for COVID-19 severity.

The severity of coronavirus disease 2019 (COVID-19) quickly progresses with unfavorable outcomes due to the host immune response and metabolism alteration. Hence, we hypothesized that leukocyte glucose index (LGI) is a biomarker for severe COVID-19. This study involved 109 patients and the usefulness of LGI was evaluated and compared with other risk factors to predict COVID 19 severity. LGI was identified as an independent risk factor (odds ratio [OR] = 1.727, 95% confidence interval [CI]: 1.026-3.048, P = 0.041), with an area under the curve (AUC) of 0.749 (95% CI: 0.642-0.857, P < 0.0001). Interestingly, LGI was a potential risk factor (OR = 2.694, 95% CI: 1.575-5.283, Pcorrected < 0.05) for severe COVID-19 in female but not in male patients. In addition, LGI proved to be a strong predictor of the severity in patients with diabetes (AUC = 0.915 (95% CI: 0.830-1), sensitivity = 0.833, and specificity = 0.931). The AUC of LGI, together with the respiratory rate (LGI + RR), showed a considerable improvement (AUC = 0.894, 95% CI: 0.835-0.954) compared to the other biochemical and respiratory parameters analyzed. Together, these findings indicate that LGI could potentially be used as a biomarker of severity in COVID-19 patients.