Diagnostic accuracy of symptoms as a diagnostic tool for SARS-CoV 2 infection: a cross-sectional study in a cohort of 2,173 patients.

BACKGROUND: The SARS-CoV-2 pandemic continues to be a priority health problem; According to the World Health Organization data from October 13, 2020, 37,704,153 confirmed COVID-19 cases have been reported, including 1,079,029 deaths, since the outbreak. The identification of potential symptoms has been reported to be a useful tool for clinical decision-making in emergency departments to avoid overload and improve the quality of care. The aim of this study was to evaluate the performances of symptoms as a diagnostic tool for SARS -CoV-2 infection. METHODS: An observational, cross-sectional, prospective and analytical study was carried out, during the period of time from April 14 to July 21, 2020. Data (demographic variables, medical history, respiratory and non-respiratory symptoms) were collected by emergency physicians. The diagnosis of COVID-19 was made using SARS-CoV-2 RT-PCR. The diagnostic accuracy of these characteristics for COVID-19 was evaluated by calculating the positive and negative likelihood ratios. A Mantel-Haenszel and multivariate logistic regression analysis was performed to assess the association of symptoms with COVID-19. RESULTS: A prevalence of 53.72% of SARS-CoV-2 infection was observed. The symptom with the highest sensitivity was cough 71%, and a specificity of 52.68%. The symptomatological scale, constructed from 6 symptoms, obtained a sensitivity of 83.45% and a specificity of 32.86%, taking ≥2 symptoms as a cut-off point. The symptoms with the greatest association with SARS-CoV-2 were: anosmia odds ratio (OR) 3.2 (95% CI; 2.52-4.17), fever OR 2.98 (95% CI; 2.47-3.58), dyspnea OR 2.9 (95% CI; 2.39-3.51]) and cough OR 2.73 (95% CI: 2.27-3.28). CONCLUSION: The combination of ≥2 symptoms / signs (fever, cough, anosmia, dyspnea and oxygen saturation < 93%, and headache) results in a highly sensitivity model for a quick and accurate diagnosis of COVID-19, and should be used in the absence of ancillary diagnostic studies. Symptomatology, alone and in combination, may be an appropriate strategy to use in the emergency department to guide the behaviors to respond to the disease. TRIAL REGISTRATION: Institutional registration R-2020-3601-145, Federal Commission for the Protection against Sanitary Risks 17 CI-09-015-034, National Bioethics Commission: 09 CEI-023-2017082 .

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.

[Answer to comment on article "Acute appendicitis. Surgical and non surgical treatment"]. / Respuesta a comentario al artículo "Apendicitis aguda. Manejo quirúrgico y no quirúrgico".

No abstract.

Sin abstract.

[Acute appendicitis. Surgical and non-surgical treatment]. / Apendicitis aguda. Manejo quirúrgico y no quirúrgico.

Appendicitis represents a common disease for the surgeon with a relative risk between 7-8%. It was thought that if more time passed between diagnosis and treatment, the risk for complications, such as perforation or abscess formation, was higher; nevertheless; the evolution is variable, making necessary the development of different strategies such as antibiotic use only, interval surgery or endoscopic treatment. The purpose of this study is to make a revision in the management of appendicitis comparing conservative and surgical treatment. It is known that traditional management of appendicitis is appendectomy with a complication rate of 2.5% to 48%. Nowadays, laparoscopy is the approach of choice by many surgeons and there have proposed new invasive techniques such as endoscopic treatment with the use of prosthesis and ambulatory surgery. Antibiotic use is essential in the management of appendicitis. Its use as the only strategy to treat this disease has the purpose of lowering costs and diminishing complications related to surgery or the resection of the organ. We conclude that the ideal management of appendicitis remains controversial and it will depend of the clinical characteristics of each patient and the resources available.

La apendicitis es una urgencia común para el cirujano. El riesgo estimado para presentarla es de 7-8%. Se pensaba que la apendicitis era un continuo donde, mientras más tiempo pasaba entre el inicio de síntomas y el tratamiento, el riesgo de complicaciones (necrosis, perforación y formación de abscesos) era mayor; sin embargo, la evolución es variable por lo que se han propuesto estrategias terapéuticas como el uso de antibióticos, cirugía de intervalo o tratamiento endoscópico. El objetivo de este estudio es hacer una revisión de la literatura acerca del manejo de apendicitis comparando manejo quirúrgico y conservador. Es sabido que el manejo tradicional para apendicitis es la apendicectomía, con tasa de complicación del 2.5 hasta el 48%. El abordaje ha cambiado de abierto a laparoscópico y han surgido nuevas técnicas invasivas como el manejo endoscópico con endoprótesis y la cirugía ambulatoria. El manejo antibiótico es esencial en apendicitis y su uso como terapia única en apendicitis tiene como objetivo disminuir la morbilidad asociada al evento quirúrgico, a la resección del órgano y a disminuir costos. Nuestra conclusión es que el manejo adecuado de la apendicitis es controversial y dependerá del estado clínico del paciente y de los recursos con que se dispongan.

[Obscure gastrointestinal bleeding due to gastrointestinal stromal tumors]. / Hemorragia gastrointestinal de origen oscuro por tumores de estroma gastrointestinal.

BACKGROUND: The gastrointestinal stromal tumours (GIST) are the most common soft tissue sarcomas of the digestive tract. They are usually found in the stomach (60-70%) and small intestine (25-30%) and, less commonly, in the oesophagus, mesentery, colon, or rectum. The symptoms present at diagnosis are, gastrointestinal bleeding, abdominal pain, abdominal mass, or intestinal obstruction. The type of symptomatology will depend on the location and size of the tumour. The definitive diagnosis is histopathological, with 95% of the tumours being positive for CD117. CLINICAL CASES: This is an observational and descriptive study of 5cases of small intestinal GIST that presented with gastrointestinal bleeding as the main symptom. The period from the initial symptom to the diagnosis varied from 1 to 84 months. The endoscopy was inconclusive in all of the patients, and the diagnosis was made using computed tomography and angiography. Treatment included resection in all patients. The histopathological results are also described. CONCLUSION: GIST can have multiple clinical pictures and unusual symptoms, such as obscure gastrointestinal bleeding. The use of computed tomography and angiography has shown to be an important tool in the diagnosis with patients with small intestine GISTs.

[Disseminated peritoneal hydatidosis manifested as intestinal ischaemia]. / Hidatidosis peritoneal diseminada manifestada como isquemia intestinal.

BACKGROUND: The hydatid disease, or echinococcosis, is endemic in Mediterranean countries, as well as in Australia, Asia, Africa, South America, and Canada. Among its complications is intraperitoneal rupture, a rare form of presentation, with highly variable symptoms. The treatment of choice is surgery plus adjuvant medical treatment in most patients. OBJECTIVE: A case is presented of a patient with disseminated peritoneal hydatidosis manifested as intestinal ischaemia. CLINICAL CASE: A 50-year-old male was admitted to the emergency room with a history of chronic abdominal pain that worsened in the last 24hours. He showed signs of sepsis in the physical examination and was subjected to surgery, in which intestinal ischaemia was found due to a disseminated peritoneal cystic disease, which had led to mesentery retraction. An intestinal resection with an end-ileostomy was performed. The results of the biopsy of the cystic lesions was disseminated peritoneal echinococcosis. Medical treatment was started with albendazole and praziquantel. CONCLUSION: This case shows a rare presentation of disseminated peritoneal hydatidosis, which led to intestinal ischaemia.

[Persistent elevation of Ca 19-9 and an unexpected finding. A case report]. / Elevación persistente de Ca 19-9 y un hallazgo inesperado. Reporte de un caso.

BACKGROUND: Tumour markers are substances produced by the tumour itself, or by the host in response to a tumour. These markers could be measured either in the blood or in body secretions. One of the most common tumour markers used in gastrointestinal diseases is Ca 19-9. It is the marker most used for pancreatic cancer, but can be elevated in many benign processes. Thus, it is not a specific marker. CLINICAL CASE: The case is presented of a male patient with 4 years of moderate abdominal pain, weight loss, and persistent elevation of Ca 19-9. After an extensive work-up, renal and hepatic cysts were found, as well as steatosis and, apparently, a gallbladder polyp. With these findings and the persistent elevation of Ca 19-9, it was decided to operate the patient. An exploratory laparoscopy was performed showing multiple, yellowish nodular lesions all over the hepatic surface suggestive of metastases, as well as simple hepatic cysts. Pathology reported biliary hamartomas, steatosis, and chronic cholecystitis. After 2years of follow up, although there is no evidence of malignant neoplasia, there is still an elevation of Ca 19-9. CONCLUSION: The persistent elevation of Ca 19-9 is probably due to the presence of multiple benign diseases such as steatosis, urolithiasis, hepatic and renal cysts, and cholecystitis. An algorithm is needed for healthy patients with elevated levels of Ca 19-9 marker, in order to lower costs, avoid misdiagnoses, and improve management.

Subclavian central venous catheter, complications at insertion / Catéter venoso central subclavio, complicaciones a la inserción

Background: Central Venous Catheters (CVC) are used as a tool in critically ill patients requiring hemodynamic monitoring and vasopressor support, as well as in stable patients requiring parenteral nutrition or chemotherapy. Placement of a CVC subclavian (CVCs) can present severe complications, even fatal. The aim of the present study was to determine the success of the placement of CVCs without ultrasonographic guidance and the number and type of complications associated with insertion. of these. Methods: In this retrospective cohort study we included all patient who were submitted to CVCs at the Hospital de Especialidades del Centro Médico Nacional Siglo XXI. The variables studied were: medical indication for the placement, insertion site, duration, withdrawal motive and if there were complications type number and management of these. Results: 283 patients aged 16-95 years were studied. Fifty-five percent of the patients had already had a catheter placed during a previous hospitalization. In 45% of the patients was the first placement, the antecedent of a previous placement did not increase the complications. The indications for the CVCs were: NPT, preoperative use, severe patients, chemotherapy, inability to channel, and plasmapheresis. Conclusions: Placement of a subclavian central venous catheter by trained personnel in patients without risk factors and even without ultrasonographic support is safe and effective, with a success rate of close to 100% in placement, severe complications below 2%, and zero mortality. If the attempts are reduced to two punctures the morbidity can be reduced to almost zero.

Introducción: Los catéteres venosos centrales (CVC) son utilizados tanto en pacientes gravemente enfermos que ameritan monitorización hemodinámica y apoyo vasopresor, como en pacientes estables que requieren nutrición parenteral o quimioterapia. La colocación de un CVC subclavio (CVCs) puede presentar complicaciones severas incluso mortales. El objetivo del presente estudio fue determinar el éxito de la colocación de CVCs sin guía ultrasonográfica y el número y tipo de complicaciones asociadas a la inserción de estos. Métodos: Estudio de cohorte retrospectivo, que incluyó a todos los pacientes a los cuales se les colocó un CVCs en el Hospital de Especialidades del Centro Médico Nacional Siglo XXI. Las variables estudiadas fueron: indicación médica para la colocación, sitio de inserción, duración, motivo de retiro y si se presentaron complicaciones. Resultados: Se estudió a un total de 283 pacientes de 16 a 95 años. En el 45% de los pacientes fue la primera colocación, el antecedente de una colocación previa no aumento las complicaciones. Las indicaciones para el CVCs fueron: nutrición parenteral, uso prequirúrgico, pacientes graves, quimioterapia, incapacidad para canalizar y plasmaféresis. Conclusiones: La colocación de un CVCs por personal capacitado en pacientes sin factores de riesgo y aun sin apoyo ultrasonográfico es segura y eficaz, con complicaciones graves menores al 2% y sin mortalidad. Si los intentos se reducen a dos punciones, la morbilidad puede reducirse aún más.

[Choledochal cyst during pregnancy. Report of 3 cases and a literature review]. / Quiste de colédoco y embarazo. Reporte de 3 casos y revisión de la bibliografía.

BACKGROUND: Choledochal cysts are rare. They usually present during childhood in women, but it can also be seen during pregnancy. Clinical signs and symptoms are obscured during this time, thus it can complicate the diagnosis and represent a life threatening complication for both the mother and the child. OBJECTIVE: To communicate the case of 3 pregnant patients with choledochal cyst. CLINICAL CASES: Three pregnant women in which choledochal cyst were diagnosed. Two developed signs of cholangitis. The first one underwent a hepatic-jejunostomy, but had an abortion and died on postoperative day 10. The second one had a preterm caesarean operation due to foetal distress and underwent a hepatic-jejunostomy 4 weeks later; during her recovery she had a gastric perforation and died of septic complications. The third one did not develop cholangitis or jaundice. She had an uneventful pregnancy and had a hepatic-jejunostomy 4 weeks later with good results. CONCLUSIONS: Management of choledochal cysts during pregnancy is related to the presence of cholangitis. When they do not respond to medical treatment, decompression of the biliary tree is indicated. Definitive treatment should be performed after resolution of the pregnancy.

[Surgical treatment of pancreatic pseudocysts]. / Tratamiento quirúrgico del seudoquiste de páncreas.

BACKGROUND: A pancreatic pseudocyst is the collection of pancreatic secretions surrounded by fibrous tissue caused by pancreatic disease that affects the pancreatic duct. Clinical presentation is variable. Management includes percutaneous, endoscopic or surgical drainage and resection. MATERIAL AND METHODS: Review of a cohort of patients with pancreatic pseudocyst in a third level hospital. An analysis was performed on the demographic data, aetiology, clinical presentation, radiological and laboratory findings, type of surgical procedure, complications, recurrence and mortality. The statistical analysis was performed using Chi squared and Student t tests, with a p<0.05. RESULTS: A total of 139 patients were included, of whom 58% were men and 42% were women, with median age of 44.5 years. Chronic pancreatitis was the most common aetiology, present in 74 patients (53%). The main complaint was abdominal pain in 73% of patients. Median size was 18cm (range 7-29) and the most frequent location was body and tail of the pancreas. Internal surgical drainage was selected in 111 (80%) patients, of whom 96 were cystojejunostomy, 20 (14%) had external surgical drainage, and 8 (6%) resection. Complications were, pancreatic fistula (12%), haemorrhage (4%), infection (4%), and other non-surgical complications (4%). Complication rate was higher if the cause was chronic pancreatitis or if the management was external surgical drainage. Recurrence rate was 6%, and a mortality rate of 1%. CONCLUSION: Surgical management is a viable option for the management of pancreatic pseudocyst with a low complication and recurrence rate.

[Usefulness of hepatobiliary scintigraphy in the follow-up of patients with biliary reconstruction]. / Utilidad del colangiogamagrama en el seguimiento de pacientes con reconstrucción de vía biliar.

BACKGROUND: The relevance of biliary tract injury patients is not only related to diagnosis and treatment but also to follow-up for the possibility of late complications and medical and legal aspects. Hepatobiliary scintigraphy has played a principal roll in diagnosis of many hepatobiliary diseases. METHODS: We carried out a descriptive and retrospective study. Included were all patients with biliary tract injuries who underwent biliary reconstruction and liver biopsy. Clinical, laboratory exams and hepatobiliary scintigraphy follow-up was done. RESULTS: From January 2001 to december 2009 one hundred patients, sixty-five women and thirty-five men were registered. According to Strasberg's classification we had 13 % type E1, 17 % type E2, 38 % type E3 and 32 % type E4. All of them underwent biliary tract reconstruction, eighty-four Hepp-Couinaud type and sixteen conventional jejunum-hepatic anastomosis (Roux-Y). Liver biopsy demonstrated twelve patients with inflammation, forty-nine with cholestasis, nineteen with ductular proliferation and nineteen with fibrosis. When we compare pathologic results of liver biopsy with pre and postoperatively hepatobiliary scintigraphy we found significance in those patients with cholestasis and ductular proliferation in hepatobiliary scintigraphy elimination step, but none in those with inflammation and fibrosis. CONCLUSIONS: Hepatobiliary scintigraphy is an adequate study to the follow-up of patients who underwent hepatobiliary reconstruction been more significative in patients with cholestasis and ductular proliferation.

Introducción: la importancia de casos de lesión de vía biliar no solo involucra el diagnóstico y el tratamiento oportuno, sino también el seguimiento a largo plazo por la posibilidad de complicaciones tardías y los aspectos médico-legales. La medicina nuclear ha desempeñado un papel importante en el diagnóstico de múltiples enfermedades hepatobiliares. Métodos: estudio observacional, retrospectivo, transversal y analítico. Revisión de pacientes con lesión de vía biliar y sometidos a reconstrucción bilio-digestiva y biopsia hepática en la cirugía. Seguimiento clínico, con laboratorio y colangiogamagrama. Resultados: de enero de 2001 a diciembre de 2009 se evaluaron cien pacientes, treinta y cinco hombres y sesenta y cinco mujeres con edad promedio de 38.8 años. Los tipos de lesión de acuerdo con la Clasificación de Strasberg fueron: Tipo E1 (13 %); Tipo E2 (17 %); Tipo E3 (38 %), y Tipo E4 (32 %). Todos los pacientes fueron sometidos a cirugía reconstructiva de la vía biliar, 84 con técnica de Hepp-Couinaud y 16 pacientes con técnica convencional de hepático-yeyuno anastomosis en Y de Roux. Por biopsia hepática, doce pacientes con inflamación, cuarenta nueve colestasis, diecinueve ductopenias y diecinueve fibrosis. Conclusiones: la colangiogamagrafía, es un estudio adecuado en el seguimiento al valorar la captación y eliminación, su mejor utilidad es en pacientes con resultado histopatológico de colestasis y ductopenia.

[L-lactate as a serum marker of intestinal ischemia in patients with complicated intestinal obstruction]. / L-lactato como marcador sérico de isquemia intestinal en pacientes con oclusión intestinal complicada.

BACKGROUND: The intestinal obstruction secondary to internal hernia is a diagnostic challenge. The absence of specific symptoms and signs during clinical examination often lead to underestimation of the severity and early surgical treatment. The purpose of this article is to review the clinical presentation of two patients with internal hernia, describe the clinical, biochemical and radiological findings, with emphasis on the L-lactate as an early serum marker of intestinal ischemia. CLINICAL CASES: Case 1: female, 44 years history of urolithiasis and 2 cesarean sections. Case 2: female, 86 year old with a history of open cholecystectomy, incisional and bilateral inguinal hernia repair with mesh placement. Both admitted with abdominal pain and intestinal obstruction data. The only significant laboratory finding was elevation of L-lactate. The abdominal films showed air-fluid levels, dilated loops of small intestine and colon. Abdominal contrast tomography showed free abdominal fluid id, internal hernia and torque of mesentery. In both cases, exploratory laparotomy was performed with bowel resection of ischemic segments, with uneventful recovery. CONCLUSIONS: Intestinal ischemia secondary to internal hernia is difficult lt to diagnose. In patients with a high suspicion, signs of intestinal obstruction by plain radiography, the elevation of L-lactate, could help in the early diagnosis of intestinal ischemia and immediate surgical treatment.

[Hepatic artery pseudoaneurysm: report of two cases]. / Pseudoaneurisma de arteria hepática: reporte de dos casos.

BACKGROUND: Hepatic pseudoaneurysm is rare and potentially fatal. It occurs as a consequence of injury to the vascular wall, erosion diathermy through clips, biliary leakage and secondary infection. The main symptom is intra-abdominal bleeding. OBJECTIVE: To communicate the case of two patients with hepatic pseudoaneurysm. CLINICAL CASES: Case 1: We present a 43 year-old male with a history of grade IV liver injury due to blunt abdominal trauma and managed surgically. Case 2: A 67 year-old man with bile duct injury after laparoscopic cholecystectomy. Both patients presented with biliary leakage, abdominal sepsis and late intra-abdominal bleeding. Tomographic studies showed the lesion. Superselective embolization was performed proximal and distal to the lesion with good results. During follow-up, none of them showed signs of recurrent bleeding. CONCLUSIONS: Hepatic artery pseudoaneurysm is rare and usually secondary to bile duct injury associated with vascular injury after cholecystectomy or liver trauma. Arteriography with embolization is the best diagnostic and therapeutic procedure. Surgery is indicated for hemodynamically unstable patients, embolization failure or rebleeding. Early diagnosis reduces morbidity and mortality of this complication.

Antecedentes: el pseudoaneurisma de la arteria hepática es una alteración rara y potencialmente mortal. El daño directo a la pared vascular, la erosión diatérmica a través de los clips, la fuga biliar y la infección secundaria son los factores precipitantes. La principal manifestación es la hemorragia intraabdominal. Objetivo: describir dos casos de pseudoaneurisma de la arteria hepática. Casos clínicos: Caso 1: paciente masculino de 43 años de edad con antecedentes de lesión hepática grado IV por traumatismo cerrado de abdomen tratado quirúrgicamente. Caso 2: paciente masculino de 67 años de edad con lesión en la vía biliar por colecistectomía laparoscópica. Ambos ingresaron con fuga biliar y sepsis abdominal. Durante la evolución posoperatoria sufrieron hemorragia intraabdominal. Por angiotomografía se observó un pseudoaneurisma de la arteria hepática en los dos pacientes. Se les realizó embolización superselectiva proximal y distal a la lesión, con buenos resultados. Durante su seguimiento no hubo nuevos episodios de hemorragia. Conclusiones: el pseudoaneurisma de la arteria hepática es muy raro y, por lo general, secundario a una lesión de la vía biliar, con lesión vascular concomitante por colecistectomía o traumatismo hepático. La angiotomografía es diagnóstica y la arteriografía con embolización es el recurso diagnóstico y terapéutico más recomendado. La intervención quirúrgica está indicada ante inestabilidad hemodinámica, embolización fallida y resangrado. El diagnóstico temprano reduce la morbilidad y mortalidad de esta complicación.

[Vaginal evisceration. Report of a case and a literature review]. / Evisceración vaginal. Informe de un caso y revisión de la bibliografía.

BACKGROUND: Vaginal evisceration is a rare event associated to be associated with several factors. In premenopausal women it is often associated with trauma during intercourse, rape, iatrogenic injury and introduction of foreign objects. In postmenopausal women 73% of cases are associated with previous vaginal surgery or hysterectomy. CASE REPORT: Here we present the case of a female patient who had a vaginal evisceration six days after an abdominal hysterectomy. The patient underwent an abdominal reduction of the small bowel, but due to irreversible vascular compromise it was resected. The vaginal cuff was closed with interrupted non-absorbable sutures. CONCLUSION: Vaginal evisceration is a rare disease associated with pelvic surgery. When it happens, it should be addressed as an emergency. The abdominal approach is the choice when there is trauma or intestinal ischemia, while the combined vaginal with laparoscopic approach is a good option in selected patients.

[Risk factors and evolution of enterocutaneous fistula after terminal ostomy takedown]. / Factores de riesgo y evolución de fístulas enterocutáneas posterior a cierre de ostomías terminales.

BACKGROUND: End-ileostomy or colostomies are constructed for source control in patients with severe abdominal sepsis. After takedown, enterocutaneous fistula represents one of the most feared complications. METHODS: A prospective base was created with all patients that underwent, during a 90 month period, end-ileostomy or colostomy takedown after abdominal sepsis. Pre-, intra- and postoperative data were obtained to identify the factors related to enterocutaneous fistula. RESULTS: There were 293 patients. Thirty patients (10%) developed enterocutaneous fistulas. In twenty-four patients the site was at the anastomosis. Identified risk factors related to enterocutaneous fistula were ASA score III or higher (p< 0.01), ostomy takedown >365 days after its creation (p< 0.05), reoperation (p< 0.001) and anastomotic dehiscence (p< 0.001). Of these patients, twenty (67%) had spontaneous closure of the fistula, and three more (10%) had surgical closure, and three patients (10%) died. CONCLUSIONS: Ten percent of patients develop enterocutaneous fistula after end-ileostomy or colostomy takedown. Patient selection and delaying time of surgery to obtain complete recovery of the patient are the most important factors to avoid this complication. Prognosis is related to the characteristics of the fistula (output and site) and medical treatment.

Antecedentes: la ostomía terminal para el control del foco séptico es un procedimiento que casi siempre se realiza en pacientes con sepsis abdominal grave. Unas de las complicaciones más importantes posteriores a la restitución del tránsito son las fístulas enterocutáneas. Material y métodos: estudio prospectivo de seguimiento durante 90 meses de todos los pacientes a quienes se realizó cierre de ileostomía y colostomía terminal indicada por sepsis abdominal. Se obtuvieron los factores preoperatorios, transoperatorios y evolución posterior a la cirugía. resultados: se estudiaron 293 pacientes; 33 (10%) con fístulas enterocutáneas. En 24 pacientes la localización de la fístula fue en la anastomosis. Los factores de riesgo identificados para la formación de fístulas fueron: escala de ASA III o mayor (p< 0.01), cierre posterior a 365 días (p< 0.05), reoperación (p< 0.001) y dehiscencia de la anastomosis (p< 0.001). De estos pacientes hubo cierre espontáneo en 20 (67%), cierre quirúrgico en 3 (10%) y 3 pacientes (10%) fallecieron. Conclusiones: la fístula enterocutánea es una complicación que sucede en 10% de los pacientes sometidos a cierre de ileostomía, o colostomía terminal. La selección de los pacientes y realizar la cirugía una vez que el paciente esté recuperado son los factores más importante para evitar complicaciones. El pronóstico depende de las características de la fístula (gasto y sitio) y del tratamiento instituido al paciente.

[Deep neck abscess. Factors related to reoperation and mortality]. / Absceso profundo de cuello. Factores asociados con la reoperación y mortalidad.

BACKGROUND: Deep neck abscesses are major complications that arise of odontogenic, pharyngeal, or cervicofacial foci, mainly in patients with morbidities that facilitate the spread to other spaces. Many of them require surgical treatment, and an appropriate evaluation and surgical drainage is required to obtain the best results. AIM: To identify factors which relate to reoperation and mortality in patient submitted to surgical treatment due to deep neck abscess. METHODS: Review of all patients with deep neck abscess who underwent surgical treatment in a Head and Neck Surgery Department in a third-level hospital during a two year period. RESULTS: There were 87 patients, 44 of which were female. The median age was 49 years old. Thirty-five patients (40%) had comorbidities, diabetes mellitus being the most common, found in 30 (34%) patients. Twenty-one patients (24%) required reoperation (primarily due to inadequate surgical drainage). The risk factors identified with it were presence of comorbidities (mainly diabetes mellitus) (p< 0.05), multiple deep neck spaces involvement (p< 0.001) and an ASA score of three or above (p< 0.01). Eight patients died, for a mortality of 9%. The factors related to mortality were multiple deep neck spaces involvement (p< 0.01), bilateral involvement (p< 0.05) and reoperation (p< 0.001). CONCLUSION: Deep neck abscesses appropriate evaluation and a complete surgical drainage of all deep space neck abscesses are primordial to avoid reoperation and improve survival.

Antecedentes: los abscesos profundos de cuello son complicaciones de infecciones, principalmente de origen odontogénico y de vías aéreas superiores, que afectan con mayor frecuencia a pacientes con morbilidades que favorecen la diseminación de la infección. Muchos requieren tratamiento quirúrgico, evaluación y drenaje apropiado para obtener los mejores resultados. Objetivo: identificar los factores relacionados con la reoperación y la mortalidad en pacientes con drenaje quirúrgico por absceso profundo de cuello. Material y métodos: estudio longitudinal, retrospectivo, observacional y comparativo efectuado con base en la revisión de todos los pacientes con absceso profundo de cuello que se operaron en un servicio de cabeza y cuello de un hospital de tercer nivel. Resultados: se estudiaron 87 pacientes, 44 de ellos eran mujeres. La mediana de edad fue de 49 años. El 40% tenían comorbilidades (35 pacientes) y la diabetes melltitus fue la más frecuente en 30 pacientes (34%). Se reoperaron 21 pacientes (24%), la mayoría por drenaje incompleto. Los factores de riesgo identificados fueron: comorbilidades (principalmente diabetes mellitus) (p< 0.05), mayor número de espacios afectados (p< 0.001) y una escala de ASA III o mayor (p< 0.01). La mortalidad fue de 9% (ocho pacientes). Los factores relacionados con mortalidad fueron: mayor número de espacios afectados (p< 0.01), afectación bilateral (p< 0.05) y reoperación (p< 0.001). Conclusión: en abscesos profundos de cuello la evaluación preoperatoria y el drenaje quirúrgico completo de todos los espacios afectados son primordiales para evitar la reoperación y mejorar la supervivencia.

Experiencia quirúrgica en el manejo del hiperparatiroidismo primario de un año en el Servicio de Cirugía de Cabeza y Cuello del Hospital de Especialidades del Centro Médico Nacional Siglo XXI / Surgical experience in the management of a 1-year primary hyperparathyroidism at the Head and Neck Surgery Service of the Specialty Hospital of the National Medical Center ''Siglo XXI''

Objetivo: Evaluar la utilidad de los métodos de diagnóstico, la efectividad de la paratiroidectomía y sus complicaciones. Sede: Hospital de Especialidades del Centro Médico Nacional Siglo XXI. Diseño: Estudio retrospectivo, descriptivo, observacional, transversal. Análisis estadístico: Medidas de tendencia central más pruebas de valor diagnóstico. Pacientes y método: Se incluyeron 21 pacientes adultos consecutivos operados por hiperparatiroidismo primario (HPTP), del 1 de enero al 31 de diciembre de 2009. Las variables analizadas fueron: edad, género, antecedentes familiares de patología paratiroidea, manifestaciones clínicas, cuantificación de niveles séricos de calcio, fósforo y hormona paratiroidea en preoperatorio y postoperatorio, depuración de creatinina y densitometría ósea; valor diagnóstico de estudios preoperatorios de localización y reporte histopatológico. Resultados: El 90% de los pacientes perteneció al sexo femenino y la edad media fue de 57 años. La nefrolitiasis, hipertensión arterial sistémica y fatiga fueron las manifestaciones clínicas y entidades asociadas con mayor frecuencia a hiperparatiroidismo primario. La ultrasonografía y la centellografía mostraron baja sensibilidad, bajo valor predictivo positivo, moderada especificidad y moderado valor predictivo negativo. El abordaje quirúrgico fue unilateral en 10 pacientes (47.5%), bilateral en 52.5%; la efectividad terapéutica fue de 85.7% en la primera intervención y 100% en la reintervención. Se registraron complicaciones en el 4.7% de los pacientes. Conclusión: En esta serie los pacientes con hiperparatiroidismo primario presentaron nefrolitiasis con mayor frecuencia; la sensibilidad diagnóstica de la ultrasonografía y centellografía en relación con la localización específica de las glándulas es inferior a lo informado. Se tuvo alta efectividad quirúrgica de la paratiroidectomía y baja frecuencia de complicaciones.

Objective: To assess the usefulness of the diagnostic methods and the efficacy of parathyroidectomy and its complications. Setting: Third level health care center (Specialty Hospital of the National Medical Center ''Siglo XXI'') Design: Retrospective, descriptive, observational, cross-sectional study. Statistical analysis: Central tendency measures and diagnostic value tests. Patients and method: The study included 21 consecutive adult patients subjected to surgery due to primary hyperparathyroidism (PHPT) from January 1st to December 31st 2009. Analyzed variables were: age, gender, familial antecedents of parathyroid pathology, clinical manifestations, pre-operative and post-operative serum levels of calcium, phosphorus, and parathyroid hormone levels, creatinine depuration, bone densitometry; diagnostic value of preoperative location study and histopathological report. Results: Ninety percent of patients were women with a mean age of 57 years. Nephrolithiasis, systemic arterial hypertension, and fatigue were the clinical manifestations most frequently associated with primary hyperparathyroidism. Ultrasonography and scintigraphy showed low sensitivity, low positive predictive value, moderate specificity, and moderate negative predictive value. Surgical approach was unilateral in 10 patients (47.5%), bilateral in 52.5%; therapeutic efficacy was of 85.7% for the first intervention, and of 100% for re-intervention. Complications were encountered in 4.7% of patients. Conclusion: In this series, patients with primary hyperparathyroidism presented nephrolithiasis more frequently, sensitivity of ultrasonography and scintigraphy in relation to specific location of glands was lower than reported. High surgical efficacy of the parathyroidectomy was achieved with low frequency of complications.

[Biliary ileus: 10-year experience. Case series]. / Íleo biliar. Experiencia de 10 años. Serie de casos.

BACKGROUND: Biliary ileus is present in 0.06% of patients with gallstones as an outcome of a cholecystoenteric fistula, most frequently presenting as an intestinal obstruction. It is a clinic entity occasionally diagnosed, which translates into a significant margin of complications and mortality ranging from 12 to 27%. Our objective is to report the experience in the treatment of this pathology in a tertiary care hospital. METHODS: We carried out a retrospective study in patients with a diagnosis of biliary ileus during a 10-year period. RESULTS: thirteen patients were included in the study, nine males (69%) and four females (31%) with a mean age of 57 years. All patients had intestinal occlusion symptoms. Preoperative diagnosis was achieved in three patients (23%). The most common surgery was intestinal resection with anastomosis (54%). One patient from the study group died (8%). Hospitalization length was a mean of 15 days and average follow-up was 11 months. CONCLUSIONS: Bilary ileus is a pathology of patients of advanced age and must be suspected when symptoms of occlusion are present, regardless of gender. Early diagnosis can mean earlier intervention and potentially less traumatic surgery. Treatment is focused on urgent laparotomy and resolution of the intestinal occlusion, leaving management of the biliary fistula to only selected cases.

Trombosis mesentérica venosa: Factores de riesgo, diagnóstico y resultados en el manejo quirúrgico / Venous mesenteric thrombosis: risk factors, diagnosis, and results of surgical management

Objetivo: Reportar la experiencia en el manejo quirúrgico de pacientes con trombosis mesentérica venosa. Sede: Hospital de Tercer Nivel. Diseño: Estudio observacional, descriptivo, transversal, retrospectivo, Análisis estadístico: Porcentajes como medida de resumen para variables cualitativas. Pacientes y métodos: Estudio retrospectivo en el que se incluyeron 8 pacientes intervenidos quirúrgicamente durante un periodo de 5 años. Cinco de los pacientes tenían antecedentes o factores asociados a trombosis. El síntoma más común en la mayoría fue dolor abdominal de más de tres días de evolución. En todos, la trombosis mesentérica venosa se clasificó como secundaria y fue necesario realizar resección intestinal del segmento afectado. Seis pacientes tuvieron buena evolución y permanecieron con manejo anticoagulante. Dos pacientes fallecieron por complicaciones embólicas pulmonares. Conclusiones: La trombosis mesentérica venosa es una entidad rara con sintomatología vaga. Antecedentes del paciente, sospecha diagnóstica y estudios de imagen son los factores más importantes para realizar el diagnóstico al que es infrecuente llegar antes de la operación. La cirugía con resección del segmento afectado conlleva a resultados aceptables.

Objective: To report our experience with patients with mesenteric vein thrombosis managed surgically. Setting: Third level health care hospital. Design: Observational, descriptive, retrospective study. Statistical analysis: Percentages as summary measure for qualitative variables. Patients and methods: During a 5-year period, eight patients with mesenteric vein thrombosis were managed surgically; five of them had known risk factors for the development of venous thrombosis or had previous events of thrombosis at other sites. Abdominal pain was the predominant symptom, in most cases of three or more days. All had secondary vein thrombosis and required resection of the affected bowel. Six of them survived and were kept on anticoagulation therapy. Two patients died due to pulmonary embolism. Conclusions: Mesenteric vein thrombosis is a rare entity with vague symptoms. Medical history of the patient, clinical suspicion, and radiological studies are the most important factors for diagnosis; this latter is rarely attained preoperatively. Surgical management with resection of affected bowel leads to acceptable outcomes.