Use and misuse of biomarkers and the role of D-dimer and C-reactive protein in the management of COVID-19: A post-hoc analysis of a prospective cohort study.

OBJECTIVE: Coronavirus disease 2019 (COVID-19) is associated with high mortality among hospitalized patients and incurs high costs. Severe acute respiratory syndrome coronavirus 2 infection can trigger both inflammatory and thrombotic processes, and these complications can lead to a poorer prognosis. This study aimed to evaluate the association and temporal trends of D-dimer and C-reactive protein (CRP) levels with the incidence of venous thromboembolism (VTE), hospital mortality, and costs among inpatients with COVID-19. METHODS: Data were extracted from electronic patient records and laboratory databases. Crude and adjusted associations for age, sex, number of comorbidities, Sequential Organ Failure Assessment score at admission, and D-dimer or CRP logistic regression models were used to evaluate associations. RESULTS: Between March and June 2020, COVID-19 was documented in 3,254 inpatients. The D-dimer level ≥4,000 ng/mL fibrinogen equivalent unit (FEU) mortality odds ratio (OR) was 4.48 (adjusted OR: 1.97). The CRP level ≥220 mg/dL OR for death was 7.73 (adjusted OR: 3.93). The D-dimer level ≥4,000 ng/mL FEU VTE OR was 3.96 (adjusted OR: 3.26). The CRP level ≥220 mg/dL OR for VTE was 2.71 (adjusted OR: 1.92). All these analyses were statistically significant (p<0.001). Stratified hospital costs demonstrated a dose-response pattern. Adjusted D-dimer and CRP levels were associated with higher mortality and doubled hospital costs. In the first week, elevated D-dimer levels predicted VTE occurrence and systemic inflammatory harm, while CRP was a hospital mortality predictor. CONCLUSION: D-dimer and CRP levels were associated with higher hospital mortality and a higher incidence of VTE. D-dimer was more strongly associated with VTE, although its discriminative ability was poor, while CRP was a stronger predictor of hospital mortality. Their use outside the usual indications should not be modified and should be discouraged.

Use and misuse of biomarkers and the role of D-dimer and C-reactive protein in the management of COVID-19: A post-hoc analysis of a prospective cohort study

OBJECTIVE: Coronavirus disease 2019 (COVID-19) is associated with high mortality among hospitalized patients and incurs high costs. Severe acute respiratory syndrome coronavirus 2 infection can trigger both inflammatory and thrombotic processes, and these complications can lead to a poorer prognosis. This study aimed to evaluate the association and temporal trends of D-dimer and C-reactive protein (CRP) levels with the incidence of venous thromboembolism (VTE), hospital mortality, and costs among inpatients with COVID-19. METHODS: Data were extracted from electronic patient records and laboratory databases. Crude and adjusted associations for age, sex, number of comorbidities, Sequential Organ Failure Assessment score at admission, and D-dimer or CRP logistic regression models were used to evaluate associations. RESULTS: Between March and June 2020, COVID-19 was documented in 3,254 inpatients. The D-dimer level ≥4,000 ng/mL fibrinogen equivalent unit (FEU) mortality odds ratio (OR) was 4.48 (adjusted OR: 1.97). The CRP level ≥220 mg/dL OR for death was 7.73 (adjusted OR: 3.93). The D-dimer level ≥4,000 ng/mL FEU VTE OR was 3.96 (adjusted OR: 3.26). The CRP level ≥220 mg/dL OR for VTE was 2.71 (adjusted OR: 1.92). All these analyses were statistically significant (p<0.001). Stratified hospital costs demonstrated a dose-response pattern. Adjusted D-dimer and CRP levels were associated with higher mortality and doubled hospital costs. In the first week, elevated D-dimer levels predicted VTE occurrence and systemic inflammatory harm, while CRP was a hospital mortality predictor. CONCLUSION: D-dimer and CRP levels were associated with higher hospital mortality and a higher incidence of VTE. D-dimer was more strongly associated with VTE, although its discriminative ability was poor, while CRP was a stronger predictor of hospital mortality. Their use outside the usual indications should not be modified and should be discouraged.

"Pop in a scope": attempt to decrease the rate of unnecessary nontherapeutic laparotomies in hemodynamically stable patients with thoracoabdominal penetrating injuries.

BACKGROUND: Management of patients with thoracoabdominal penetrating injuries is challenging. Thoracoabdominal penetrating trauma may harbor hollow viscus injuries in both thoracic and abdominal cavities and occult diaphragmatic lesions. While radiological tests show poor diagnostic performance in these situations, evaluation by laparoscopy is highly sensitive and specific. Furthermore, minimally invasive surgery may avoid unnecessary laparotomies, despite concerns regarding complication and missed injury rates. The objective of the present study is to evaluate the diagnostic and therapeutic performance of laparoscopy in stable patients with thoracoabdominal penetrating injuries. METHODS: Retrospective analysis of hemodynamically stable patients with thoracoabdominal penetrating wounds was managed by laparoscopy. We collected data regarding the profile of the patients, the presence of diaphragmatic injury, perioperative complications, and the conversion rate. Preoperative imaging tests were compared to laparoscopy in terms of diagnostic accuracy. RESULTS: Thirty-one patients were included, and 26 (84%) were victims of a stab wound. Mean age was 32 years. Ninety-three percent were male. Diaphragmatic lesions were present in 18 patients (58%), and 13 (42%) had associated injuries. There were no missed injuries and no conversions. Radiography and computerized tomography yielded an accuracy of 52% and 75%, respectively. CONCLUSION: Laparoscopy is a safe diagnostic and therapeutic procedure in stable patients with thoracoabdominal penetrating wound, with low complication rate, and may avoid unnecessary laparotomies. The poor diagnostic performance of preoperative imaging exams supports routine laparoscopic evaluation of the diaphragm to exclude injuries in these patients.

Prevention of Fascial Dehiscence with Onlay Prophylactic Mesh in Emergency Laparotomy: A Randomized Clinical Trial.

BACKGROUND: Fascial dehiscence (FD) occurs in up to 14.9% of high-risk patients undergoing emergency laparotomy. Although prophylactic mesh can prevent FD, its use in emergency operations remains controversial. STUDY DESIGN: A prospective randomized clinical trial was conducted at the Hospital das Clínicas from Faculdade de Medicina da Universidade de São Paulo in Brazil. It was performed among high-risk patients, defined according to Rotterdam risk model, undergoing midline emergency laparotomy. The patients were randomized into the suture group (SG), with slowly absorbable running sutures placed with a 36-mm-long needle at a suture-to-wound length ratio of 4:1, and the prophylactic mesh group (PMG), with fascial closure as in the SG but reinforced with onlay polypropylene mesh. The primary end point was incidence of FD at 30 days post operation. RESULTS: We analyzed 115 patients; 52 and 63 were allocated to the SG and PMG, respectively. In all, 77.4% of the cases were for colorectal resection. FD occurred in 7 (13.5%) patients in the SG and none in the PMG (p = 0.003). There was no difference between the groups in number of patients with surgical site occurrence (SSO) or SSO requiring procedural intervention. However, some specific SSOs had higher incidences in the mesh group: surgical site infection (20.6% versus 7.7%; p = 0.05), seroma (19.0% versus 5.8%; p = 0.03), and nonhealing incisional wound (23.8% versus 5.8%; p = 0.008). Of SSOs in the PMG and SG, 92.3% and 73.3%, respectively, resolved spontaneously or with bedside interventions. CONCLUSIONS: Prophylactic onlay mesh reinforcement in emergency laparotomy is safe and prevents FD. Surgical site infection, seroma, and nonhealing incisional wound were more common in the mesh group, but associated with low morbidity within 30 days post operation.

Continuous peritoneal lavage with vacuum peritoneostomy: an experimental study.

OBJECTIVE: Despite advances in diffuse peritonitis treatment protocols, some cases develop unfavorably. With the advent of vacuum therapy, the use of laparostomy to treat peritonitis has gained traction. Another treatment modality is continuous peritoneal lavage. However, maintaining this technique is difficult and has been associated with controversial results. We propose a new model of continuous peritoneal lavage that takes advantage of the features and benefits of vacuum laparostomy. METHOD: Pigs (Landrace and Large White) under general anesthesia were submitted to laparostomy through which a multiperforated tube was placed along each flank and exteriorized in the left and lower right quadrants. A vacuum dressing was applied, and intermittent negative pressure was maintained. Peritoneal dialysis solution (PDS) was then infused through the tubes for 36 hours. The stability of peritoneostomy with intermittent infusion of fluids, the system resistance to obstruction and leakage, water balance, hemodynamic and biochemical parameters were evaluated. Fluid disposition in the abdominal cavity was analyzed through CT. RESULTS: Even when negative pressure was not applied, the dressing maintained the integrity of the system, and there were no leaks or blockage of the catheters during the procedure. The aspirated volume by vacuum laparostomy was similar to the infused volume (9073.5±1496.35 mL versus 10165±235.73 mL, p=0.25), and there were no major changes in hemodynamic or biochemical analysis. According to CT images, 60 ml/kg PDS was sufficient to occupy all intra-abdominal spaces. CONCLUSION: Continuous peritoneal lavage with negative pressure proved to be technically possible and may be an option in the treatment of diffuse peritonitis.

Can ultrasound be used as an adjunct for tube thoracostomy? A systematic review of potential application to reduce procedure-related complications.

BACKGROUND: chest tube insertions are commonly performed in various scenarios. Although frequent, these procedures result in a significant complication rate, especially in the acute care setting. Ultrasonography has been incorporated to interventional procedures aiming to reduce the incidence of complications. However, little is known about the applications of ultrasound in tube thoracostomies. The aim of this systematic review is to present the potential applications of ultrasonography as an adjunct to the procedure. METHODS: we searched Medline/Pubmed, EMBASE and Scopus databases. Out of 3012 articles, we selected 19 for further analysis. Thirteen of those were excluded because they did not meet the inclusion criteria. Ultimately, 6 articles were thoroughly evaluated and included in the review. RESULTS: The included articles show that ultrasound can be used to correctly identify a safe insertion site, to accurately find a vulnerable intercostal artery, and is reliable for timely diagnosis of drain malpositioning. CONCLUSION: this systematic review highlights the potential benefits of incorporating ultrasonography in tube thoracostomies. No randomized clinical trials are available. However, it is reasonable to assume that proper use of ultrasound may reduce procedure-related complications.

Continuous peritoneal lavage with vacuum peritoneostomy: an experimental study

OBJECTIVE: Despite advances in diffuse peritonitis treatment protocols, some cases develop unfavorably. With the advent of vacuum therapy, the use of laparostomy to treat peritonitis has gained traction. Another treatment modality is continuous peritoneal lavage. However, maintaining this technique is difficult and has been associated with controversial results. We propose a new model of continuous peritoneal lavage that takes advantage of the features and benefits of vacuum laparostomy. METHOD: Pigs (Landrace and Large White) under general anesthesia were submitted to laparostomy through which a multiperforated tube was placed along each flank and exteriorized in the left and lower right quadrants. A vacuum dressing was applied, and intermittent negative pressure was maintained. Peritoneal dialysis solution (PDS) was then infused through the tubes for 36 hours. The stability of peritoneostomy with intermittent infusion of fluids, the system resistance to obstruction and leakage, water balance, hemodynamic and biochemical parameters were evaluated. Fluid disposition in the abdominal cavity was analyzed through CT. RESULTS: Even when negative pressure was not applied, the dressing maintained the integrity of the system, and there were no leaks or blockage of the catheters during the procedure. The aspirated volume by vacuum laparostomy was similar to the infused volume (9073.5±1496.35 mL versus 10165±235.73 mL, p=0.25), and there were no major changes in hemodynamic or biochemical analysis. According to CT images, 60 ml/kg PDS was sufficient to occupy all intra-abdominal spaces. CONCLUSION: Continuous peritoneal lavage with negative pressure proved to be technically possible and may be an option in the treatment of diffuse peritonitis.

Continuous reinfusion of succus entericus associated with fistuloclysis in the management of a complex jejunal fistula on the abdominal wall.

INTRODUCTION: Fistuloclysis is an alternative method for enteral nutrition infusion, and has been successfully employed for the management of patients with high output small bowel fistula. However it has some deficiencies also. PRESENTATION OF CASE: A 42-year-old woman with multiple high output enterocutaneous fistula was submitted to fistuloclysis with reinfusion of chyme, after a period of several complications due to parenteral nutrition. DISCUSSION: Enteral nutrition provide better nutrition and fewer complications than parenteral nutrition. The enterocutaneous fistula usually does not allow enteral nutrition, however the use of fystuloclysis can fix this issue. The reinfusion of chyme provide the possibility of oral intake and better control of hydroeletrolitics disorders. CONCLUSION: More studies on the physiological effects of the chyme recirculation could add more data contributing to the clarification of this complex issue, but we believe that patients with high output and very proximal enterocutaneous fistula can be sucessfully treated with fistuloclysis and recirculation of chyme.

Acute postsurgical suppurative parotitis: current prevalence at Hospital das Clínicas, São Paulo University Medical School.

Postsurgical acute suppurative parotitis is a bacterial gland infection that occurs from a few days up to some weeks after abdominal surgical procedures. In this study, the authors analyze the prevalence of this complication in Hospital das Clínicas/São Paulo University Medical School by prospectively reviewing the charts of patients who underwent surgeries performed by the gastroenterological and general surgery staff from 1980 to 2005. Diagnosis of parotitis or sialoadenitis was analyzed. Sialolithiasis and chronic parotitis previous to hospitalization were exclusion criteria. In a total of 100,679 surgeries, 256 patients were diagnosed with parotitis or sialoadenitis. Nevertheless, only three cases of acute postsurgical suppurative parotitis associated with the surgery were identified giving an incidence of 0.0028%. All patients presented with risk factors such as malnutrition, immunosuppression, prolonged immobilization and dehydration. In the past, acute postsurgical suppurative parotitis was a relatively common complication after major abdominal surgeries. Its incidence decreased as a consequence of the improvement of perioperative antibiotic therapy and postoperative support. In spite of the current low incidence, we believe it is important to identify risks and diagnose as quick as possible, in order to introduce prompt and appropriate therapeutic measures and avoid potentially fatal complications with the evolution of the disease.

Controversies in the management of asymptomatic patients sustaining penetrating thoracoabdominal wounds.

The most challenging diagnostic issue in the management of thoracoabdominal wounds concerns the assessment of asymptomatic patients. In almost one-third of such cases, diaphragmatic injuries are present even in the absence of any clear clinical signs. The sensitivity of noninvasive diagnostic tests is very low in this situation, and acceptable methods for diagnosis are limited to videolaparoscopy or videothoracoscopy. However, these procedures are performed under general anesthesia and present real, and potentially unnecessary, risks for the patient. On the other hand, diaphragmatic hernias, which can result from unsutured diaphragmatic lesions, are associated with considerable morbidity and mortality. In this paper, the management of asymptomatic patients sustaining wounds to the lower chest is discussed, with a focus on the diagnosis of diaphragmatic injuries and the necessity of suturing them.

Acute postsurgical suppurative parotitis: current prevalence at Hospital das Clínicas, São Paulo University Medical School / Parotidite aguda pós-cirúgica: prevalência atual no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo

Postsurgical acute suppurative parotitis is a bacterial gland infection that occurs from a few days up to some weeks after abdominal surgical procedures. In this study, the authors analyze the prevalence of this complication in Hospital das Clínicas/São Paulo University Medical School by prospectively reviewing the charts of patients who underwent surgeries performed by the gastroenterological and general surgery staff from 1980 to 2005. Diagnosis of parotitis or sialoadenitis was analyzed. Sialolithiasis and chronic parotitis previous to hospitalization were exclusion criteria. In a total of 100,679 surgeries, 256 patients were diagnosed with parotitis or sialoadenitis. Nevertheless, only three cases of acute postsurgical suppurative parotitis associated with the surgery were identified giving an incidence of 0.0028 percent. All patients presented with risk factors such as malnutrition, immunosuppression, prolonged immobilization and dehydration. In the past, acute postsurgical suppurative parotitis was a relatively common complication after major abdominal surgeries. Its incidence decreased as a consequence of the improvement of perioperative antibiotic therapy and postoperative support. In spite of the current low incidence, we believe it is important to identify risks and diagnose as quick as possible, in order to introduce prompt and appropriate therapeutic measures and avoid potentially fatal complications with the evolution of the disease.

A parotidite supurativa pós-cirúrgica é infecção bacteriana da glândula que ocorre poucos dias até algumas semanas após procedimento cirúrgico. Os autores analisam a prevalência desta complicação cirúrgica nos últimos 25 anos do Hospital das Clínicas de São Paulo. Foram analisados os prontuários das cirurgias realizadas pelos serviços de Cirurgia do Aparelho Digestivo e Cirurgia Geral da Faculdade de Medicina da Universidade de São Paulo no período de 1980 a 2005, num total de 106790 cirurgias. Todos os prontuários que apresentaram entre os diagnósticos das altas complicações cirúrgicas, parotidite ou sialoadenite foram avaliados. Foram identificados 256 prontuários. Pacientes com outras complicações, ou que já apresentavam sialolitíase ou parotidite crônica anterior à internação foram excluídos do estudo. Foram identificados apenas três casos de parotidite aguda supurativa pós-cirúrgica, revelando incidência de 0,0028 por cento. A parotidite supurativa pós-cirúrgica foi complicação relativamente comum de grandes cirurgias abdominais no passado, com acentuada redução atual da sua incidência decorrente da antibioticoterapia de amplo espectro, além de preparação pré-operatória adequada e suporte pós-operatório dos pacientes. Apesar da baixa incidência atual, consideramos importante identificar seus fatores de risco, assim como realizar diagnóstico precoce, conduta terapêutica apropriada para evitar complicações letais associadas a esta infecção.

Controversies in the management of asymptomatic patients sustaining penetrating thoracoabdominal wounds: [review]

The most challenging diagnostic issue in the management of thoracoabdominal wounds concerns the assessment of asymptomatic patients. In almost one-third of such cases, diaphragmatic injuries are present even in the absence of any clear clinical signs. The sensitivity of noninvasive diagnostic tests is very low in this situation, and acceptable methods for diagnosis are limited to videolaparoscopy or videothoracoscopy. However, these procedures are performed under general anesthesia and present real, and potentially unnecessary, risks for the patient. On the other hand, diaphragmatic hernias, which can result from unsutured diaphragmatic lesions, are associated with considerable morbidity and mortality. In this paper, the management of asymptomatic patients sustaining wounds to the lower chest is discussed, with a focus on the diagnosis of diaphragmatic injuries and the necessity of suturing them.

Ferimentos pancreáticos / Pancreatic injuries

Realizou-se um estudo retrospectivo de 110 pacientes com lesoes pancreaticas traumaticas, atendidos no Pronto Socorro de Ciirurgia do Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo. A lesao acometeu a cabeca do pancreas em 37,3% dos casos, corpo em 22,7%, cauda em 21,8% e mais de um segmento pancreatico em 18,1% dos casos. A conduta adotada dependeu da localizacao e natureza da lesao. Nos ferimentos menores (65 casos) a conduta adotada foi de desbridamento, hemostasia e drenagem. Nos ferimentos maiores (transfixantes, contusoes graves, seccao total, lesao ductal ) a conduta adotada foi de resseccao em 36 casos que acometeram o corpo e cauda do pancreas, anastomose pancreato-jejunal em Y de Roux em 2 casos, gastroduodenopancreatectomia(GDP) em 6 casos e cistogastroanastomose em um caso. As complicacoes ocorreram em 40,9% dos casos. Vinte pacientes faleceram (18,1%). A mortalidade esteve intimamente relacionada ao numero de lesoes associadas, a presenca de hipotensao, a administracao, a localizacao da lesao e a etiologia do ferimento. Tendo em vista os resultados, acreditamos que as lesoes menores devam ser tratadas com hemostasia, desbridamento e drenagem as lesoes maiores devam ser ressecadas quando acometerem corpo e cauda e gastroduodenopancreatectomia nos ferimentos complexos duodeno-pancreaticos.

Ferimentos traumáticos de esôfago / Traumatic wounds of the esophagus

Realizado um estudo retrospectivo de 45 pacientes atendidos no Serviço de Emergência do Hospital das Clínicas da Faculdade de Medicina da Universidade de Säo Paulo, no período de 1982 a 1989, com ferimentos traumáticos de esôfago. Trinta e quatro pacientes (75,5%) foram vítimas de ferimentos por projetil de arma de fogo, nove (20%) por arma branca e dois 4,4%) por trauma fechado. Trinta e quatro pacientes (75,5%) tiveram sua lesäo no segmento cervical do esôfago, sete (15,5%) no segmento torácico e quatro (8%) na porçäo abdominal. O esôfago cervical foi abordado por uma cervicotomia oblíqua esquerda sendo realizada sutura e drenagem com dreno de Penrose. Nas lesöes do esôfago torácico superior e médio, a abordagem foi por uma toracotomia póstero-lateral direita e na porçäo inferior do esôfago torácico a abordagem foi feita por uma toracotomia à esquerda. Nos ferimentos que acometiam menos da metade da luz, foram realizadas rafia e drenagem mediastinal ampla. Quando o ferimento era mais extenso, a conduta adotada foi esofagectomia. As lesöes do esôfago abdominal foram tratadas através de uma laparotomia, com sutura e drenagem. As complicaçöes ocorreram em 40% dos pacientes. Sete pacientes faleceram, porém um em conseqüência do ferimento esofágico. Os autores preconizam um tratamento cirúrgico precoce em todos os ferimentos traumáticos de esôfago. Sutura e drenagem, nestas circunstâncias, nos parecem boa conduta. Outras alternativas (esofagectomia, esofagostomia, gastrostomia) devem ser adotados somente nos casos extensos ou na presença de contaminaçäo mediastinal

Lesäo traumática de veia porta / Traumatic injury of the portal hepatic vein

Realizou-se estudo retrospectivo de 32 pacientes com lesäo de veia porta traumática, atendidos no Pronto Socorro de Cirurgia do Hospital das Clínicas da Faculdade de Medicina da Universidade de Säo Paulo, de abril de 1978 a 1988. As lesöes de veia porta foram divididas em três grupos segundo sua localizaçäo, a saber: grupo I - justa hiliar (11 pacientes), grupo II - pedículo hepático (14 pacientes), grupo III - retropancreático (7 pacientes). O grupo I e III englobam os pacientes com lesöes de difícil tratamento, determinando altas taxas de mortalidade, 54,5% e 71,4% respectivamente. As manobras cirúrgicas adotadas para a abordagem destas lesöes incluem a manobra de Pringle, de Kocher, hepatotomia e pancratotomia. O grupo II, compreendeu lesöes de naus fácil controle cirúrgico porque possibilitou o clampeamento vascular proximal e distal. Todos os pacientes apresentaram pelo menos uma lesäo abdominal associada, e em 30 pacientes esteve presente outra lesäo vascular concomitante. A mortalidade global de 13 pacientes (40,6%), sendo que 12 deles (37,5%) em conseqüência de sangramento. Tendo em vista os resultados, sugere-se que na presença de múltiplas lesöes associadas ou se a sutura for de difícil execuçäo, a ligadura de veia pode ser a melhor opçäo para o tratamento, principalmente nas lesöes justa hilares ou retropancreáticas