Acute mesenteric thrombosis in two patients with COVID-19. Two cases report and literature review.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) affects mainly the respiratory system, other organs may be involved, usually due to coagulation disturbances that lead to a high rate of thrombotic complications. CASE PRESENTATION: The first patient is 45 years-old who has been exposed to SARS CoV-2. Upon admission due to acute abdomen evidence surgery is performed in which an intestinal resection with an adequate post-surgical evolution takes place so the patient is discharged after 4 days with a prescription for oral anticoagulants. The second one is 42 years-old and has comorbidities. The patient is admitted upon evidence of COVID-19, after showing signs of vein mesenteric ischemia in a CT scan surgery is performed, however the patient dies 24 h after the intervention. DISCUSSION: Within severe cases of patients with COVID-19 the incidence of a symptomatology or gastrointestinal complications is high (39-73.8%). Thromboprophylaxis is recommended to all patients admitted for COVID-19, starting with heparin of low molecular weight as prophylaxis, as well as continuing with oral anticoagulants after being discharged. CONCLUSION: Despite the fact that knowledge of the disease is rapidly advancing, all available treatments are still nonspecific to SARS-CoV-2 and the optimal management of COVID-19 remains unclear. An unexplained clinical picture should raise the suspicion for rare conditions such as mesenteric thrombosis. Adequate prophylactic measures should be implemented both during hospitalization and after discharge.

Evaluation of C-reactive protein, procalcitonin and the PCR/PCT index as indicators of mortality in abdominal sepsis.

BACKGROUND: Biomarker combinations can improve timely diagnosis and survival. OBJECTIVE: To determine the usefulness of serum procalcitonin concentration (PCT), C-reactive protein (PCR) and the PCR / PCT index as predictors of mortality. METHOD: Retrospective study of patients diagnosed with abdominal sepsis during the period from April 2017 to February 2018. RESULTS: We included 182 cases. In the survivors, the mean PCR was 170 and procalcitonin (PCT) 10.5. In the deceased, the mean of C-reactive protein (CRP) was 328 and that of PCT was 17.6. When applying the student's t-test for independent samples, it was found that these differences were significant for PCR (p = 0.001); however, for PCT it was not significant (p = 0.460). Afterwards, the PCR/PCT index was studied, as a predictor of mortality, in the deceased cases a PCR/PCT score of 7534 (standard deviation [SD]: 19,303) and for survivors of 538 (SD:805) (p = 0.001) was obtained. CONCLUSION: CRP is associated with mortality, serum PCT does not correlate with mortality. The PCR/PCT index seems to be a better indicator to predict mortality in patients with abdominal sepsis due to secondary peritonitis.

ANTECEDENTES: Las combinaciones de biomarcadores pueden mejorar el diagnóstico oportuno y la supervivencia. OBJETIVO: Determinar la utilidad de la concentración sérica de procalcitonina (PCT), la proteína C reactiva (PCR) y el índice PCR/PCT como predictores de mortalidad. MÉTODO: Estudio retrospectivo de pacientes con diagnóstico de sepsis abdominal durante el periodo de abril de 2017 a febrero de 2018. RESULTADOS: Se incluyeron 182 casos. En los sobrevivientes, la media de los valores de PCR fue de 170 y la de PCT fue de 10.5. En los fallecidos, la media de los valores de PCR fue de 328 y la de PCT fue de 17.6. Al aplicar el estadístico t de Student para muestras independientes se obtuvo que estas diferencias resultaron significativas para la PCR (p = 0.001), pero no para la PCT (p = 0.460). Posteriormente se estudió el índice PCR/PCT como predictor de mortalidad: en los fallecidos se obtuvo un valor de 7534 (desviación estándar [DE]:± 19,303) y en los sobrevivientes de 538 (DE± 805) (p = 0.001). CONCLUSIÓN: La PCR se asocia con la mortalidad, mientras que la PCT no guarda relación con la mortalidad. El índice PCR/PCT parece ser un mejor indicador para predecir la mortalidad en los pacientes con sepsis abdominal por peritonitis secundaria.

Evaluation of the level of high density lipoproteins as a predictor of severity in abdominal sepsis.

Background: Alterations in the lipid profile are part of the acute phase response, this corresponds to the so-called lipemia of sepsis. Objective: To determine if the serum level of high density lipoprotein (HDL) is related to severity and mortality. Method: Retrospective, descriptive, cross-sectional study of patients diagnosed with abdominal sepsis. During the period from April 2016 to February 2017. The severity was determined by APACHE II, SOFA, Mannheim, CONUT, the presence of organic faults and mortality. Results: We included 154 cases, 59 female and 95 male; The main organ causing abdominal sepsis was the appendix 41.6%. The overall mortality was 14.3%. The presence of organic faults was 35.1%. The mean HDL level was 37.64 mg/dl (SD ± 16.16). The findings, subjected to statistical verification by Student's t-test, showed significance among the cases with SOFA > 4 (p = 0.01) and Mannheim > 26 (p = 0.001), CONUT > 6 (p = 0.001), presence of organic failures (p = 0.001), and mortality (p = 0.003). Conclusions: HDL levels are related to severity, with the development of organic failures and mortality in sepsis.

Antecedentes: Las alteraciones en el perfil de lípidos son parte de la respuesta de fase aguda, lo que corresponde a la denominada lipemia de la sepsis. Objetivo: Determinar si la concentración sérica de lipoproteínas de alta densidad (HDL) se relaciona con la gravedad y la mortalidad. Método: Estudio retrospectivo, descriptivo, transversal, de pacientes con diagnóstico de sepsis abdominal, durante el periodo de abril de 2016 a febrero de 2017. Se determinó la gravedad mediante APACHE II, SOFA, Mannheim, CONUT, la presencia de fallas orgánicas y la mortalidad. Resultados: Se incluyeron 154 casos, 59 mujeres y 95 hombres. El principal órgano causante de sepsis abdominal fue el apéndice (41.6%). La mortalidad global fue del 14.3%. La presencia de fallas orgánicas fue del 35.1%. El valor medio de HDL se situó en 37.64 mg/dl (desviación estándar: ± 16.16). Los hallazgos, sometidos a verificación estadística mediante la prueba t de Student, mostraron significancia entre los casos con SOFA > 4 (p = 0.01) y Mannheim > 26 (p = 0.001), CONUT > 6 (p = 0.001), presencia de fallas orgánicas (p = 0.001) y mortalidad (p = 0.003). Conclusión: Los valores de HDL se relacionan con la gravedad, con el desarrollo de fallas orgánicas y con la mortalidad en la sepsis.

Comparison between the body mass index and the Controlling Nutritional status to determine the severity in patients with abdominal sepsis.

BACKGROUND: The systemic response of the organism, in defense against the aggressor agent, generates acute catabolic response, which leads to deterioration of the nutritional status. OBJECTIVE: Compare the usefulness of the body mass index (BMI) and the CONUT scale to determine the severity in abdominal sepsis. METHODS: Retrospective, descriptive, cross-sectional study in patients with diagnosis of abdominal sepsis, from April 2016 to February 2017. RESULTS: We included 153 cases (61 female and 92 male); mean age of 47.44 years, the main organ causing abdominal sepsis was the appendix 43%. Mortality of 15%. An average BMI of 27.31, CONUT score of 5.5, was obtained. The findings, subjected to the Mann-Whitney u test, showed statistical significance when evaluating BMI against SOFA (p = 0.025); no significance was found when evaluating the BMI against APACHE II (p = 0.322), nor against mortality (p = 0.646). Regarding CONUT, significance was found when comparing against APACHE II, SOFA and mortality (p = 0.002, p = 0.001 and p = 0.007, respectively). CONCLUSIONS: The level of malnutrition determined by CONUT is related to the severity determined by APACHE II, SOFA and mortality. BMI is not related to severity by APACHE II or mortality; although it does seem to relate to the severity evaluated by the SOFA scale.

INTRODUCCIÓN: La respuesta sistémica del organismo, en defensa ante el agente agresor, genera una respuesta catabólica aguda que conduce a deterioro del estado nutricional. OBJETIVO: Comparar la utilidad del índice de masa corporal (IMC) y del índice de Control Nutricional (CONUT) para determinar la gravedad en pacientes con sepsis abdominal. MÉTODO: Estudio retrospectivo, descriptivo, transversal, en pacientes con diagnóstico de sepsis abdominal, de abril de 2016 a febrero de 2017. RESULTADOS: Se incluyeron 153 casos (61 mujeres y 92 hombres). El principal órgano causante de sepsis abdominal fue el apéndice (43%). La mortalidad fue del 15%. El IMC promedio fue de 27.31. El CONUT promedio fue de 5.5, Los hallazgos, sometidos a la prueba U de Mann-Whitney, mostraron al evaluar el IMC contra la escala SOFA (Sequential Organ Failure Assessment Score) una p = 0.025; no se encontró significancia al evaluar el IMC contra APACHE II (Acute Physiology and Chronic Health Evaluation) (p = 0.322) ni contra la mortalidad (p = 0.646). En cuanto a CONUT, se encontró significancia al compararla contra APACHE II, SOFA y la mortalidad (p = 0.002, p = 0.001 y p = 0.007, respectivamente). CONCLUSIÓN: El grado de malnutrición determinado por CONUT se relaciona con la gravedad determinada mediante APACHE II y SOFA, y con la mortalidad. El IMC no se relaciona con la gravedad por APACHE II ni con la mortalidad, aunque sí parece relacionarse con la gravedad evaluada mediante SOFA.

Controversial case: Revascularization of a popliteal vascular injury of poor prognosis.

INTRODUCTION: Popliteal injuries are significant health risk that could induce permanent functional impairment, limb loss, and in some cases death. Currently, there is a controversy about the required treatment between amputation and a limb salvage surgery, which in some cases could cause more prominent functional impairment than the amputation. Different indicators help to predict, in some extent, the risk of amputation, however most of them were described two decades ago. PRESENTATION OF CASE: A patient with a prolonged hot ischemia and in critical conditions, which had no favorable clinical indicators for revascularization is shown and discussed. By means of intraoperative analysis, it was decided to perform a revascularization for limb salvage, progressing with a positive outcome. DISCUSSION: Advancements in medical and vascular surgery, such as osteovascularized grafts, the use of flaps to cover large defects, the Ilizarov method for bone elongation and stabilization, the use of growth factors, negative pressure therapy, and the use of extracellular matrix, the improvements of intensive care units (ICU), among others, make necessary to revisit and reevaluate these indicators. The accuracy of these indicators has dropped significantly, and currently the medical evaluation cannot longer only depend on them. CONCLUSION: Our results suggest the need to revisit and improve the predicting indicators scores for amputation prognosis that should include a preoperative and transoperative analysis.

Minimally invasive therapy for epiphrenic diverticula: Systematic review of literature and report of six cases.

INTRODUCTION: Epiphrenic diverticula (ED) are infrequent and conventional surgical treatment entails aggressive open or transthoracic surgery. Minimally invasive treatment has changed the surgical approach but some surgical controversies are not resolved. OBJECTIVE: The objective of this study is to describe our experience in minimally invasive treatment of the ED and to perform a systematic review of the current literature in this subject. MATERIALS AND METHODS: We reviewed all data from the Hospital de Sant Pau, focusing on patients that underwent minimally invasive treatment for an ED since 1998 to date. Furthermore, we performed a systematic literature review focused on the minimally invasive approach for ED. RESULTS: A total of 6 patients have been treated (5 transhiatal and 1 with abdominal and thoracic approach). We found a predominance of males with a median age of 63. The diagnosis was made with an endoscopy, barium swallow and manometry. Half of the manometry results were pathologic. The surgical technique involved a diverticulectomy, myotomy and a Dor partial founduplication. Two patients that presented suture line leakage (SLL) were treated conservatively. No mortality was reported. The systematic review was carried out under the Preferred Reporting Items for Systematic Reviews and Meta-analyses scheme, with a total of 20 studies where 189 patients were found. No comparative or prospective randomised trials were found. Overall morbidity was 24%, with a SLL rate of 12%, hospital stay of 5 days and mortality of 1.5%. After a median follow-up of 42 months, 81.5% of the patients were asymptomatic. CONCLUSION: The minimally invasive approach for ED is a safe and feasible procedure.

Influencia de la inmunonutrición sobre el estado general, nutricional y estancia hospitalaria en pacientes postoperados de sepsis abdominal / Influence of immunonutrition on the general and nutritional state, and on the in-hospital stay, of patients operated secondary to abdominal sepsis

Objetivo: Valorar el efecto del uso de glutamina con alimentación temprana, en pacientes con sepsis abdominal resuelta quirúrgicamente, sobre el estado general de salud (Apache II), el catabolismo proteico (nitrógeno ureico urinario), las complicaciones y la duración de la estancia hospitalaria. Sede: Hospital General de México. Diseño: Ensayo clínico controlado. Analisis estadístico: Prueba t de Student. Método: Se seleccionaron 24 pacientes con sepsis abdominal que requirieron resolución quirúrgica en la Unidad de Urgencias en el Hospital General de México. Luego de 24 a 72 h del evento quirúrgico, se inició la alimentación enteral en dos grupos: el primero con glutamina más alimentación estándar y el segundo con alimentación estándar. El día 1 y en el 3ro del postoperatorio se midieron niveles de laboratorio y nitrógeno ureico urinario, para determinar la clasificación Apache II, las complicaciones infecciosas y las no infecciosas, el balance nitrogenado y la duración de la estancia hospitalaria. Resultados: No se encontró diferencia significativa en ninguno de los parámetros medidos entre el grupo de glutamina y el control; sin embargo, sí lo hubo en el valor de Apache II en el grupo de glutamina comparando intragrupo entre el primer día y el tercero (P < 0.05). Conclusiones: La alimentación enteral temprana suplementada con glutamina no presenta diferencia temprana en cuanto a la respuesta metabólica al trauma, estado nutricional ni utilización proteica.

Objective: To assess the effect of glutamine, together with early enteral nutrition in patients with surgically resolved abdominal sepsis, on the general health status (Apache II), protein catabolism (urinary urea nitrogen test), complications, and duration of in-hospital stay. Setting: General Hospital of Mexico. Design: Controlled clinical trial. Statistical analysis: Student's t test. Method: We chose 24 patients with abdominal sepsis from the Emergency Ward in the General Hospital of Mexico, who required surgical resolution. After 24 to 72 h of the surgery, enteral nutrition was started in two groups: the first with glutamine plus standard nutrition and the second with standard nutrition. On days 1 and 3 of the postoperative period, laboratory tests were performed and urinary urea nitrogen was measured to determine Apache II classification, infectious and non-infectious complications, the nitrogen balance, and duration of in-hospital stay. Results: No statistically significant difference was found in any of the measured parameters between the two groups (glutamine and control); however, a significant difference was found in the value of the Apache II in the glutamine group when compared intragroup on the first and third days (p < 0.05). Conclusions: Early enteral nutrition supplemented with glutamine does not reveal an early difference in terms of the metabolic response to trauma, nutritional state, or protein utilization.