Use of failure-to-rescue after emergency surgery as a dynamic indicator of hospital resilience during the COVID-19 pandemic. A multicenter retrospective propensity score-matched cohort study.

BACKGROUND: Surgical failure-to-rescue (FTR, death rate following complications) is a reliable cross-sectional quality of care marker, but has not been evaluated dynamically. We aimed to study changes in FTR following emergency surgery during the COVID-19 pandemic. MATERIAL AND METHODS: Matched cohort study including all COVID-19-non-infected adult patients undergoing emergency general surgery in 25 Spanish hospitals during COVID-19 pandemic peak (March-April 2020), non-peak (May-June 2020), and 2019 control periods. A propensity score-matched comparative analysis was conducted using a logistic regression model, in which period was regressed on observed baseline characteristics. Subsequently, a mixed effects logistic regression model was constructed for each variable of interest. Main variable was FTR. Secondary variables were post-operative complications, readmissions, reinterventions, and length of stay. RESULTS: 5003 patients were included (948, 1108, and 2947 in the pandemic peak, non-peak, and control periods), with comparable clinical characteristics, prognostic scores, complications, reintervention, rehospitalization rates, and length of stay across periods. FTR was greater during the pandemic peak than during non-peak and pre-pandemic periods (22.5% vs. 17.2% and 12.7%), being this difference confirmed in adjusted analysis (odds ratio [OR] 2.13, 95% confidence interval [95% CI] 1.27-3.66). There was sensible inter-hospital variability in FTR changes during the pandemic peak (median FTR change +8.77%, IQR 0-29.17%) not observed during the pandemic non-peak period (median FTR change 0%, IQR -6.01-6.72%). Greater FTR increase was associated with higher COVID-19 incidence (OR 2.31, 95% CI 1.31-4.16) and some hospital characteristics, including tertiary level (OR 3.07, 95% CI 1.27-8.00), medium-volume (OR 2.79, 95% CI 1.14-7.34), and high basal-adjusted complication risk (OR 2.21, 95% CI 1.07-4.72). CONCLUSION: FTR following emergency surgery experienced a heterogeneous increase during different periods of the COVID-19 pandemic, suggesting it to behave as an indicator of hospital resilience. FTR monitoring could facilitate identification of centres in special needs during ongoing health care challenges.

Small fragments of hyaluronan are increased in individuals with obesity and contribute to low-grade inflammation through TLR-mediated activation of innate immune cells.

BACKGROUND AND AIM: Extracellular matrix (ECM) components released during excessive fat mass expansion are considered potential endogenous danger/alarm signals contributing to innate immune system activation. The aim of the current study was to specifically measure plasma levels of low molecular weight (LMW) hyaluronan (HA) and to evaluate its role as pro-inflammatory damage-associated molecular pattern (DAMP) on leukocyte response in the context of human obesity. SUBJECTS AND METHODS: Participants were selected according to their body mass index (BMI, kg/m2) as non-obese (BMI < 29.9, n = 18) and obese (BMI > 29.9, n = 33). Plasma samples were size-dependent fractionated using ion-exchange chromatography to specifically obtain LMW HA fractions that were subsequently quantified by ELISA. Cell incubation experiments with synthetic HA molecules were performed on freshly Ficoll-isolated neutrophils (PMN) and peripheral blood monocytes (PBMC). Leukocyte and adipose tissue gene expression was assessed by real-time PCR and NF-κB activation by western blot. Plasma cytokine levels were measured by fluorescent bead-based (Luminex) immunoassay. RESULTS: We observed a statistically significant increase in the circulating levels of HA fragments of LMW in individuals with obesity which were consistent with significant up-regulated expression of the LMW HA synthesizing enzyme hyaluronan synthase-1 (HAS-1) in obese adipose tissue. Gene expression assessment of HA receptors revealed up-regulated levels for TLR2 in both obese PMN and PBMC. Synthetic HA molecules of different sizes were tested on leukocytes from healthy donors. LMW HA fragments (15-40 kDa) and not those from intermediate molecular sizes (75-350 kDa) induced a significant up-regulation of the expression of major pro-inflammatory cytokines such as IL-1ß, MCP-1 and IL-8 in PBMC. Importantly, LMW HA was able to induce the phosphorylation of IKK α/ß complex supporting its pro-inflammatory role through NF-κB activation. CONCLUSION: Circulating LMW HA molecules are elevated in obesity and may play an important role in triggering low-grade inflammation and the development of metabolic complications.

Preoperative neutrophil-to-lymphocyte ratio behaves as an independent prognostic factor even in patients with postoperative complications after curative resection for gastric cancer.

PURPOSE: The aim of this study was to determine if the prognostic value of the preoperative neutrophil-to-lymphocyte ratio (NLR) could be modified by the presence of postoperative complications (POC) and their severity in patients with gastric adenocarcinoma resected with curative intent. METHODS: A retrospective study based on a prospective database of patients with resectable gastric adenocarcinoma treated with radical intention (R0) between January 1998 and February 2012. The primary endpoint was overall survival according to preoperative peripheral blood NLR and postoperative complications. Clinicopathological variables, preoperative blood tests, POC and its severity (Clavien-Dindo classification), type of POC (infectious or not infectious) and mortality were registered. A univariate and multivariate analysis (step forward Cox regression) was performed. The Kaplan-Meier method was used to assess overall survival. RESULTS: The 147 patients with gastric cancer who had undergone radical resection were included from an initial cohort of 209 patients. Univariant analysis: type of surgery, pT, pN, postoperative complications (Clavien-Dindo ≥ 3) and preoperative NLR ≥ 2.4 were significantly associated with survival (p < 0.05). Patients with POC showed worse long-term survival (p = 0.000), with no difference (p = 0.867) between infectious or non-infectious POC. NLR ≥ 2.4 was associated with infectious POC (p < 0.001). Patients with preoperative NLR ≥ 2.4 (p = 0.02) had a worse prognosis. Multivariate analysis: pN (p < 0.001), postoperative complications (p < 0.001) (HR 3.04; 95% CI: 1.97-4.70) and NLR ≥ 2.4 (p = 0.04) (HR = 1.55; 95% CI: 1.02-2.3) were independent prognostic factors. CONCLUSION: The preoperative inflammatory state of patients with gastric cancer measured by NLR behaves as an independent prognostic factor, even in patients with POC.

P-POSSUM as mortality predictor in COVID-19-infected patients submitted to emergency digestive surgery. A retrospective cohort study.

BACKGROUND: COVID-19 infection is associated with a higher mortality rate in surgical patients, but surgical risk scores have not been validated in the emergency setting. We aimed to study the capacity for postoperative mortality prediction of the P-POSSUM score in COVID-19-positive patients submitted to emergency general and digestive surgery. MATERIAL AND METHODS: Consecutive patients undergoing emergency general and digestive surgery from March to June 2020, and from March to June 2019 in 25 Spanish hospitals were included in a retrospective cohort study. MAIN OUTCOME: 30-day mortality. P-POSSUM discrimination was quantified by the area under the curve (AUC) of ROC curves; calibration was assessed by linear regression slope (ß estimator); and sensitivity and specificity were expressed as percentage and 95% confidence interval (CI). RESULTS: 4988 patients were included: 177 COVID-19-positive; 2011 intra-pandemic COVID-19-negative; and 2800 pre-pandemic. COVID-19-positive patients were older, with higher surgical risk, more advanced pathologies, and higher P-POSSUM values (1.79% vs. 1.09%, p < 0.001, in both the COVID-19-negative and control cohort). 30-day mortality in the COVID-19-positive, intra-pandemic COVID-19-negative and pre-pandemic cohorts were: 12.9%, 4.6%, and 3.2%. The P-POSSUM predictive values in the three cohorts were, respectively: AUC 0.88 (95% CI 0.81-0.95), 0.89 (95% CI 0.87-0.92), and 0.91 (95% CI 0.88-0.93); ß value 0.97 (95% CI 0.74-1.2), 0.99 (95% CI 0.82-1.16), and 0.78 (95% CI 0.74-0.82); sensitivity 83% (95% CI 61-95), 91% (95% CI 84-96), and 89% (95% CI 80-94); and specificity 81% (95% CI 74-87), 76% (95% CI 74-78), and 80% (95% CI 79-82). CONCLUSION: The P-POSSUM score showed a good predictive capacity for postoperative mortality in COVID-19-positive patients submitted to emergency general and digestive surgery.

Leukocytes from obese individuals exhibit an impaired SPM signature.

Specialized proresolving mediators (SPMs) biosynthesized from docosahexaenoic acids (DHAs) including resolvins (Rvs), protectins, and maresins are potent endogenous autacoids that actively resolve inflammation, protect organs, and stimulate tissue regeneration. Our hypothesis was that failure of resolution programs may lead to unremitting inflammation in obesity, contributing to the development of metabolic comorbidities in this condition. Obese individuals with persistent low-grade systemic inflammation showed reduced leukocyte production of the DHA-derived monohydroxy fatty acid 17-hydroxy-DHA (HDHA) and unbalanced formation of SPMs (in particular D-series Rvs) accompanied by enhanced production of proinflammatory lipid mediators such as leukotriene B4. Mechanistic studies attributed this impairment to reduced 15-lipoxygenase (LOX) activity rather than altered DHA cellular uptake. Moreover, leukocytes from obese individuals exhibited decreased 5-LOX levels and reduced 5-LOX Ser271 phosphorylation and distinct intracellular 5-LOX redistribution. However, 15-LOX appears to be the most critical factor for the deficient production of SPMs by obese leukocytes because the formation of D-series Rvs was completely rescued by incubation with the intermediate precursor 17-HDHA. These data provide proof of concept that administration of intermediate precursors of SPM biosynthesis (e.g., 17-HDHA) could be more efficient in overriding impaired formation of these proresolving lipid mediators in conditions characterized by dysfunctional LOX activity, such as obesity.-López-Vicario, C., Titos, E., Walker, M. E., Alcaraz-Quiles, J., Casulleras, M., Durán-Güell, M., Flores-Costa, R., Pérez-Romero, N., Forné, M., Dalli, J., Clària, J. Leukocytes from obese individuals exhibit an impaired SPM signature.

Wernicke's encephalopathy after sleeve gastrectomy: Literature review.

OBJECTIVE: To describe a case of Wernicke's encephalopathy after laparoscopic sleeve gastrectomy. SETTING: Emergency Department and gastrointestinal surgery department. CASE REPORT: A 20-year-old man class III obesity (BMI 50.17kg/m(2)) underwent laparoscopic sleeve gastrectomy with uneventful recovery. Five weeks after surgery he was admitted in the Emergency Department because of persistent vomiting and dysphagia to solids. Esophagogastroduodenal transit and upper gastrointestinal endoscopy were requested but no relevant findings were shown. Laboratory analyses showed vitamin B1 12.2ng/mL and 48h following admission the patient experienced generalized weakness, sialorrhea and restrictions of actions such as reading a book. Neurological evaluation found confusion, motor ataxia, diplopy and nystagmus. A brain magnetic resonance was normal. According to low level of vitamin B1 and symptoms found in the patient a presumed diagnosis of Wernicke encephalopathy was made and parenteral thiamine 100mg/day was started. The patient was discharged asymptomatic with oral intake of vitamin B1 600mg per day. CONCLUSION: Nutritional deficiencies after restrictive procedures are uncommon but easily preventable and can result in life threatening. With the upswing of bariatric surgery, surgeons and emergency physicians should be able to diagnose and treat those complications. Prophylactic thiamine should be administered to patients with predisposing factors.

Baseline circulating ghrelin does not predict weight regain neither maintenance of weight loss after gastric bypass at long term.

BACKGROUND: Predictors of weight loss (WL) or weight regain (WR) after Roux-en-Y gastric bypass (RYGBP) are not established. The aim of this study was to analyze the usefulness of some baseline peptides (leptin, insulin, and ghrelin) as biomarkers of WL and WR in morbid obese patients after RYGBP at long term. METHODS: Seventy-six morbid obese (47 women, age 41.6 ± 9.6 years, body mass index [BMI] 52.1 ± 8 kg/m(2)) patients were evaluated at baseline and at 1, 2, and 6 years after surgery. RESULTS: Excess body weight loss after 6 years was of 63.9%. Age, BMI, and studied hormones at baseline or their changes over time did not predict long-term excess body weight loss. WR greater than 10% was observed in 36.8% of patients between 2 and 6 years of follow-up, but it was not correlated with BMI, age, or baseline peptide concentrations. CONCLUSION: Measurement of ghrelin, insulin, and leptin before surgery is not useful as predictors of WL or WR at long term after RYGBP.

Phlegmonous gastritis: A rare entity as a differential diagnostic of an acute abdomen. Description of a case and a bibliographic review.

Phlegmonous gastritis is a rare bacterial infection of the gastric wall, which progress rapidly. It is characterized by a purulent inflammation that can affect the entire gastrointestinal tract and presents a high mortality rate. We are reporting a case of phlegmonous gastritis in an HIV-seropositive man successfully treated with antibiotics. Moreover, a review of the English andSpanish literature is carried out, from 1980 to the present time.The most frequently involved microorganism is Streptococcus spp. (57 %), but the polimicrobial infection is also frequent (17 %). The most important symptom is the intensive epigastric pain associated with vomits and most cases were diagnosed by CT and/or fibrogastroscopy. There are many existing risk factors described.The main one is the immunesuppression, although in 40 % of the cases no risk factors were identified. The global mortality is 27 % without identifying significant differences between antibiotics and surgical treatment, for that reason it is recommended to initiate antibiotic treatment right from the beginning and postponing surgery for the refractory cases and complications.

Gastritis flemonosa: una entidad poco frecuente como diagnóstico diferencial del abdomen agudo. Descripción de un caso y revisión bibliográfica / Phlegmonous gastritis: a rare entity as a differential diagnostic of an acute abdomen. Description of a case and a bibliographic review

La gastritis flemonosa es una infección bacteriana poco frecuente y rápidamente progresiva de la pared gástrica. Se caracteriza por una inflamación purulenta que puede afectar a todo el tracto gastrointestinal y que presenta un índice elevado de mortalidad. En este trabajo se comunica un caso de gastritis flemonosa en un paciente seropositivo para la infección por VIH tratado exitosamente con antibioticoterapia. Además, se realiza una revisión de los casos publicados en la bibliografía médica, en inglés y español desde 1980 hasta la actualidad. El microorganismo más frecuentemente implicado es Streptococcus spp. (57 %), pero también destaca la infección polimicrobiana (17 %). El síntoma más común es el dolor epigástrico intenso asociado a vómitos y la mayoría de casos fueron diagnosticados mediante TC y/o endoscopia. Existen numerosos factores de riesgo descritos, el principal es la inmunosupresión, aunque en el 40 % de los casos no se identificó ningún factor de riesgo. La mortalidad global es del 27 %, sin identificar diferencias significativas entre el tratamiento antibiótico y quirúrgico, por lo que se recomienda instaurar el tratamiento antibiótico de manera precoz y reservar la cirugía para los casos refractarios y las complicaciones (AU)

Phlegmonous gastritis is a rare bacterial infection of the gastric wall, which progress rapidly. It is characterized by a purulent inflammation that can affect the entire gastrointestinal tract and presents a high mortality rate. We are reporting a case of phlegmonous gastritis in an HIV-seropositive man successfully treated with antibiotics. Moreover, a review of the English and Spanish literature is carried out, from 1980 to the present time. The most frequently involved microorganism is Streptococcus spp. (57 %), but the polimicrobial infection is also frequent (17 %). The most important symptom is the intensive epigastric pain associated with vomits and most cases were diagnosed by CT and/ or fibrogastroscopy. There are many existing risk factors described. The main one is the immunesuppression, although in 40 % of the cases no risk factors were identified. The global mortality is 27 % without identifying significant differences between antibiotics and surgical treatment, for that reason it is recommended to initiate antibiotic treatment right from the beginning and postponing surgery for the refractory cases and complications (AU)

Laparoscopic liver surgery: 8 years of multicenter Spanish register.

BACKGROUND: To present the data of laparoscopy in liver surgery and to assess the real indications and outcomes of this kind of approach. METHODS: From February 2000 to March 2008, a prospective study was performed on 182 patients from 15 Spanish surgical centres. RESULTS: A total of 308 lesions was collected. The mean age was 57 years old, and 61.5% were female. Among patients with cystic lesions we found: 45 simple cysts, 19 policystic diseases, 12 hydatidic cysts and 2 cystoadenomas. Among solid lesions (n = 104), we found 34 patients with benign pathology (12 focal nodular hyperplasia, 10 adenomas, 7 haemangyomas and 5 other lesions) and 70 with malignant pathology (38 metastases, 29 hepatocellular carcinomas, 2 cholangiocarcinomas and 1 lymphoma). The global rate of conversion was 8.8%. The global morbidity rate was 14.8%, and 5 of them required re-intervention. CONCLUSIONS: Nowadays there are strong criteria for patients being submitted to laparoscopy procedures based both on type and location features. The postoperative morbidity rate is low, also for hepatocellular carcinoma in cirrhotic liver. In case of malignant pathology, we think the use of ultrasonography is mandatory to obtain a free margin, which implies a long-term survival rate.

Effects of two variants of Roux-en-Y Gastric bypass on metabolism behaviour: focus on plasma ghrelin concentrations over a 2-year follow-up.

BACKGROUND: To study the effects of two variants of Roux-en-Y gastric bypass (RYGBP) on plasma ghrelin concentrations according to different exposure of gastric fundus to the nutrient pathway. METHODS: A prospective longitudinal 2-year follow-up study was conducted. Ninety-six morbidly obese (MO) patients (age range: 41.6 +/- 9.6 years, body mass index: 53 +/- 9.5 kg/m(2)) were assigned to two bariatric surgical (BS) procedures: one that preserves food contact with gastric fundus (ringed RYGBP, n = 50) and the other that avoids it (modified RYGBP, n = 46). Different anthropometric and biochemical parameters were studied, focusing on ghrelin concentrations at baseline and 6, 12, and 24 months post-BS. RESULTS: At 24 months post-BS, all metabolic parameters studied had improved in all patients compared with those at 1-year follow-up and baseline (p < 0.05). However, high-density lipoprotein cholesterol concentrations took 2 years to normalise in 80% of patients, interleukin-6 decreased significantly in relation to baseline only after 2 years from BS (p < 0.001), and tumour necrosis factor alpha concentrations did not significantly decrease during the 2 years of follow-up. Plasma ghrelin concentrations increased in both surgical groups compare to baseline during the first year (24.6% in modified RYGBP and 36.62% in ringed RYGBP) and remained stable at the second year of follow-up, with no statistical differences between groups. CONCLUSIONS: In the second year of follow-up after BS, morbidity continued to improve in MO patients despite a lesser weight loss in relation to the first year. An increase in plasma ghrelin concentrations was found, regardless of nutrient contact with gastric fundus. Furthermore, changes in plasma ghrelin concentrations appeared to be independent of weight loss.