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Retrospective studies suggest that coronavirus disease (COVID-19) commonly involves gastrointestinal (GI) symptoms and complications. Our aim was to prospectively evaluate GI manifestations in patients hospitalized for COVID-19.This international multicentre prospective cohort study recruited COVID-19 patients hospitalized at 31 centres in Spain, Mexico, Chile, and Poland, between May and September 2020. Patients were followed-up until 15 days post-discharge and completed comprehensive questionnaires assessing GI symptoms and complications. A descriptive analysis as well as a bivariate and multivariate analysis were performer using binary logistic regression. p0.05 was considered significant.Eight hundred twenty-nine patients were enrolled; 129 (15.6%) had severe COVID-19, 113 (13.7%) required ICU admission, and 43 (5.2%) died. Upon admission, the most prevalent GI symptoms were anorexia (n=413; 49.8%), diarrhoea (n=327; 39.4%), nausea/vomiting (n=227; 27.4%), and abdominal pain (n=172; 20.7%), which were mild/moderate throughout the disease and resolved during follow-up. One-third of patients exhibited liver injury. Non-severe COVID-19 was associated with ≥2 GI symptoms upon admission (OR 0.679; 95% CI 0.464-0.995; p=0.046) or diarrhoea during hospitalization (OR 0.531; 95% CI 0.328-0.860; p=0.009). Multivariate analysis revealed that worse hospital outcomes were not independently associated with liver injury or GI symptoms.GI symptoms were more common than previously documented, and were mild, rapidly resolved, and not independently associated with COVID-19 severity. Liver injury was a frequent complication in hospitalized patients not independently associated with COVID-19 severity.

Background Iatrogenic bile duct injury (IBDI) is a challenging surgical complication. IBDI management can be guided by artificial intelligence models. Our study identified the factors associated with successful initial repair of IBDI and predicted the success of definitive repair based on patient risk levels. Methods This is a retrospective multi-institution cohort of patients with IBDI after cholecystectomy conducted between 1990 and 2020. We implemented a decision tree analysis to determine the factors that contribute to successful initial repair and developed a risk-scoring model based on the Comprehensive Complication Index. Results We analyzed 748 patients across 22 hospitals. Our decision tree model was 82.8% accurate in predicting the success of the initial repair. Non-type E (p p p Discussion Machine learning algorithms for IBDI are a novel tool may help to improve the decision-making process and guide management of these patients.

BACKGROUND: The management of a vascular injury during cholecystectomy is still very complicated, especially in centers not specialized in complex hepatobiliary surgery.; METHODS: This was a multi-institutional retrospective study in patients with vascular injuries during cholecystectomy from 18 centers in 4 countries. The aim of the study was to analyze the management of vascular injuries focusing on referral, time to perform the repair, and different treatments options outcomes.; RESULTS: A total of 104 patients were included. Twenty-nine patients underwent vascular repair (27.9%), 13 (12.5%) liver resection, and 1 liver transplant as a first treatment. Eighty-four (80.4%) vascular and biliary injuries occurred in nonspecialized centers and 45 (53.6%) were immediately transferred. Intraoperative diagnosed injuries were rare in referred patients (18% vs 84%, P= .001). The patients managed at the hospital where the injury occurred had a higher number of reoperations (64% vs 20%, P ? .001). The need for vascular reconstruction was associated with higher mortality (P= .04). Two of the 4 patients transplanted died.; CONCLUSION: Vascular lesions during cholecystectomy are a potentially life-threatening complication. Management of referral to specialized centers to perform multiple complex multidisciplinary procedures should be mandatory. Late vascular repair has not shown to be associated with worse results. Copyright © 2022 Elsevier Inc. All rights reserved.

The effect of preoperative immunonutrition intake on postoperative major complications in patients following cytoreductive surgery (CRS) with or without hyperthermic intraperitoneal chemotherapy (HIPEC) was assessed. The accuracy of C-Reactive Protein (CRP) for detecting postoperative complications was also analyzed. Patients treated within a peritoneal carcinomatosis program in which a complete or optimal cytoreduction was achieved were retrospectively analyzed. They were divided into two groups based on whether preoperative immunonutrition (IMN) or not (non-IMN) were administered. Clinical and surgical variables and postoperative complications were gathered. Predictive values of major morbidity of CRP during the first 3 postoperative days (POD) were also evaluated. A total of 107 patients were included, 48 belonging to the IMN group and 59 to the non-IMN group. In multivariate analysis immunonutrition (OR 0.247; 95%CI 0.071–0.859; p = 0.028), and the number of visceral resections (OR 1.947; 95%CI 1.086–3.488; p = 0.025) emerged as independent factors associated with postoperative major morbidity. CRP values above 103 mg/L yielded a negative predictive value of 84%. Preoperative intake of immunonutrition was associated with a decrease of postoperative major morbidity and might be recommended to patients with peritoneal carcinomatosis following CRS. Measuring CRP levels during the 3 first postoperative days is useful to rule out major morbidity.

To date, the topically effect of hyperoxygenated fatty acids (HOFA) on the control of surgical site infection (SSI) is still unclear.To assess the effect of topical application of a HOFA solution on the umbilical trocar site after laparoscopic cholecystectomy on SSI. The occurrence of trocar site incisional hernia (TSIH) was also analyzed.A prospective, double-blind, randomized trial was conducted in patients undergoing laparoscopic cholecystectomy, who also presented at least one of the following associated risk factors for SSI and TSIH such as Body Mass Index (BMI) above 30 kg/m103 patients were included, 51 (49.5%) in the HOFA group and 52 (50.5%) in the non-HOFA group. SSI rate was significantly lower in the HOFA group in comparison with the non-HOFA group (19.6% vs. 3.8%; p = 0.028). TSIH rates were similar in both groups (3.8% vs. 2%). Multivariate analyses showed that only HOFA decreased significantly SSI rate.Topical application of a HOFA solution at the umbilical trocar site after laparoscopy cholecystectomy decreased SSI rate.

A common complication after bariatric surgery is hair loss, which is related to rapid weight reduction, but zinc, iron, and other micronutrient deficiencies can also be involved. Little is studied after laparoscopic sleeve gastrectomy (LSG). A prospective observational study was performed of 42 morbidly obese females undergoing LSG. Incidence of hair loss was monitored. Micronutrients were investigated preoperatively and three, six, and 12 months after surgery. Sixteen patients (41%) reported hair loss in the postoperative course. A significant association was observed between hair loss and zinc levels ( P = 0.021) but mean zinc levels were within the normal range in patients reporting hair loss. Only three patients (7.7%) presented low zinc levels, all of them reporting hair loss. There was also a significant association between iron levels and alopecia ( P = 0.017), but mean values of the patients with hair loss were within normal range. Only four patients (10.2%) presented low iron levels, all of them presenting hair loss. A variable consisting of the addition of zinc 1 iron showed a significant association with hair loss ( P = 0.013). A cutoff point was established in 115 (odds ratio, 4; P = 0.006). All the patients but two reporting hair loss presented addition levels under 115. This variable showed sensibility 88 per cent, specificity 84 per cent, positive predictive value 79 per cent, and negative predictive value 91 per cent to predict hair loss. Hair loss is a frequent condition after sleeve gastrectomy. In most cases, iron and zinc levels are within the normal range. The variable addition (zinc 1 iron) is a good predictor of hair loss. Patients with addition levels below 115 are fourfold more susceptible to present hair loss. In these cases, zinc supplements achieve the stop of hair loss in most cases.

Surgical procedures on obese patients are expected to have a high incidence of surgical site infection (SSI). The identification of pre-operative or early post-operative risk factors for SSI may help the surgeon to identify subjects in risk and adequately optimize their status. We conducted a study of the association of comorbidities and pre- and post-operative analytical variables with SSI following laparoscopic sleeve gastrectomy for the treatment of morbid obesity.We performed a prospective study of all morbidly obese patients undergoing laparoscopic sleeve gastrectomy as a bariatric procedure between 2007 and 2011. An association of clinical and analytical variables with SSI was investigated.The study included 40 patients with a mean pre-operative body mass index (BMI) of 51.2±7.9 kg/m(2). Surgical site infections appeared in three patients (7.5%), of whom two had an intra-abdominal abscess located in the left hypochondrium and the third had a superficial incisional SSI. Pre-operatively, a BMI45 kg/m(2) (OR 8.7; p=0.008), restrictive disorders identified by pulmonary function tests (OR 10.0; p=0.012), a serum total protein concentration5.3 g/dL (OR 13; p=0.003), a plasma cortisol30 mcg/dL (OR 13.0; p=0.003), and a mean corpuscular volume (MCV)82 fL (OR 1.6; p=0.04) were associated with post-operative SSI. Post-operatively, a serum glucose128 mg/dL (OR 4.7; p=0.012) and hemoglobin11g/dL (OR 7.5; p=0.002) were associated with SSI.The study supports the role of restrictive lung disorders and the values specified above for preoperative BMI, serum total protein and cortisol concentrations, and MCV, and of post-operative anemia and hyperglycemia as risk factors for SSI. In these situations, the surgeon must be aware of and seek to control these risk factors.

C-Reactive protein (CRP) has been associated with the macro- and microvascular effects of hypertension and diabetes mellitus. Referring to serum cortisol, it has been proposed to contribute to the pathogenesis of metabolic syndrome, and it has been demonstrated that weight loss normalizes cortisol levels and improves insulin resistance. The aims of this study were to analyze CRP and cortisol levels pre- and postoperatively in morbidly obese patients undergoing a laparoscopic sleeve gastrectomy and to correlate them with weight loss and parameters associated with cardiovascular risk.A prospective study of all the morbidly obese patients undergoing laparoscopic sleeve gastrectomy as bariatric procedure between October 2007 and May 2011 was performed.A total of 40 patients were included in the study. CRP levels decreased significantly 12 months after surgery (median reduction of 8.9 mg/l; p = 0.001). Serum cortisol levels decreased significantly 6 months after surgery (median reduction of 34.9 μg/dl; p = 0.001). CRP values reached the normal range (5 mg/l) 1 year after surgery. Referring to cortisol, a significant association was observed with the cardiovascular risk predictor (triglyceride/high-density lipoprotein cholesterol ratio) from the 6th month after surgery onward (Pearson correlation coefficient, 0.559; p = 0.008).CRP levels are increased preoperatively and in the postoperative course up to 1 year after surgery. Serum cortisol levels remain elevated until the 6th month after surgery. From this moment onward, serum cortisol is associated with the cardiovascular risk predictor reflecting the cardiovascular risk decreasement during the weight loss.

Resumen Introduccion Clasicamente, se colocaba un drenaje subhepatico de forma sistematica en la colecistectomia para prevenir los abscesos intraabdominales, posibles sangrados postoperatorios y fistulas biliares. Con el tiempo se ha ido demostrando que el uso sistematico de drenaje no aporta beneficios, pero muchos estudios concluyen que, en circunstancias especiales (sangrado, signos inflamatorios en la vesicula biliar, apertura incidental o sospecha de fuga biliar) y segun la experiencia de cada cirujano, la indicacion de colocacion de un drenaje puede tener cabida. Material y metodos Realizamos un estudio prospectivo de 100 colecistectomias laparoscopicas consecutivas, intervenidas de forma electiva por colelitiasis sintomatica o polipos vesiculares. En 15 de ellas se coloco un drenaje subhepatico. Las indicaciones para colocarlo fueron: en 11 pacientes como «testigo» por sangrado del lecho vesicular controlado intraoperatoriamente y en 4 por apertura de la vesicula con salida de bilis de aspecto turbio-purulento. Las variables principales investigadas fueron la utilidad clinica que ha tenido la colocacion del drenaje, la estancia hospitalaria y la cuantificacion del dolor a las 24 h de la intervencion por parte del paciente mediante una escala analogico-visual. Resultados En ningun paciente la colocacion del drenaje tuvo utilidad alguna. La mediana de estancia hospitalaria aumento un dia en los pacientes con drenaje (p = 0,002). La mediana de dolor a las 24 h de la intervencion en los pacientes con drenaje fue mayor (p = 0,018). Conclusion La colocacion de un drenaje subhepatico tras colecistectomia laparoscopica programada aumenta el dolor postoperatorio y prolonga la estancia hospitalaria, pero no previene la aparicion de abscesos intraabdominales.

Despite routine supplementation of vitamins and minerals after bariatric surgery, an important number of patients suffer from deficiencies. Little is still known about the novel restrictive procedure, sleeve gastrectomy.A retrospective study of 30 morbidly obese patients undergoing a laparoscopic sleeve gastrectomy, between May 2008 and September 2010, was performed. Baseline albumin, ferritin, iron, zinc, calcium, vitamin D, parathormone (PTH), vitamin B12, and folic acid were obtained before operation and postoperative determinations 1, 3, 6, 9, 12, 18, and 24 months after surgery.Before surgery, 96.7% of the patients presented vitamin D deficiency, 20% had elevated PTH, 3.3% hypoalbuminemia, and 3.3% folic acid deficiency. One year after surgery, only one patient (3.3%) presented vitamin D deficiency and had elevated PTH. The rest of parameters were within normal range. The second year after surgery, the results remain similar. A significant difference was obtained when comparing preoperative vitamin D values and postoperative determinations 12 months after surgery (increase of 51.9 ng/dl, 95% confidence interval (CI) (41.8-61.3); p0.001). A significant difference was determined when comparing preoperative PTH values and postoperative determinations 3 months after surgery (decrease of 16.6 pg/ml, 95% CI (2.6-30.6); p = 0.03). A significant inverse correlation was observed between weight loss and vitamin D increase at the third month after surgery (Pearson correlation coefficient -0.948; p = 0.033).Postoperative values of vitamin D show a progressive increase, while PTH ones present a significant reduction, without any impact on serum calcium levels. We have demonstrated an inverse correlation between weight loss and vitamin D increase at the third month after surgery.

Resumen Introduccion El tratamiento de la colecistitis aguda puede ser inicialmente quirurgico o conservador con cirugia posterior, revisamos los casos encontrados en nuestro centro, como fueron tratados y la evolucion de los mismos. Material y metodos Realizamos un estudio retrospectivo del tratamiento realizado en 178 pacientes con colecistitis aguda durante un ano. Se evaluan variables relacionadas con las caracteristicas de los pacientes, clinica y exploracion, tecnicas diagnosticas, tratamiento realizado y evolucion. Resultados El 70,2% es tratado de forma conservadora (grupo A) y el 29,8% es intervenido en las primeras 72 h (grupo B). En el grupo A se trataron 96 casos con antibioterapia, 15 con antibioterapia y colecistostomia y 12 con antibioterapia y CPRE. En el grupo B se realizo colecistectomia urgente laparoscopica en el 60,4% de los casos y abierta en el 35,8%. En el grupo A el tiempo de ingreso fue de 11 dias, con evolucion satisfactoria en el 79,2%, tasa de mortalidad del 5,6% y tasa de reingresos del 10,7%. En el grupo B el tiempo quirurgico fue de 111+/−43, una media de 8,7 dias de ingreso, no precisaron tratamiento ademas de la cirugia el 68% de los casos. La evolucion fue satisfactoria en todos los casos menos en 7, no hubo mortalidad en este grupo. Tuvimos una tasa de reingreso del 2%. Conclusiones Continuamos realizando una proporcion importante de tratamiento conservador en detrimento de la cirugia urgente, en numeros absolutos este parece tener mayor tasa de complicaciones, de mortalidad y de tiempo de ingreso hospitalario.

The lymph node ratio (LNR) and log odds of positive lymph nodes (LODDS) have been proposed to minimize the stage migration phenomenon. The value of the LODDS and LNR staging systems to predict and discriminate prognosis was assessed and compared to the International Union Against Cancer (UICC) TNM classification (pN). Three hundred and twenty-six patients with gastric carcinoma were retrospectively studied. Disease-specific survival rates were calculated for every pN, LNR, and LODDS category. Four LNR categories (0, 1-25, 26-75, and > 76 %) and four LODDS categories (-5 to -3, > -3 to -1, > -1 to 3, and > 3 to 5) were established. In the multivariate analysis, only the stage pT3-4 versus pT1-2 (HR 1.88, 95 % CI 1.11-3.20, p = 0.02) and LODDS as continuous variable (HR 1.40, 95 % CI 1.21-1.61, p < 0.001) remained as independent prognostic factors. In patients with < 16 lymph nodes retrieved, only the LODDS system could discriminate different disease-specific survival curves for every category. LODDS categories were able to discriminate subgroups with different prognoses in pN stages and LNR categories. The LODDS staging system was superior to the pN classification and LNR system to discriminate risk prognosis especially in patients with an insufficient number of retrieved lymph nodes.

Background: The optimal system for lymph node (LN) staging in gastric cancer is still a subject of debate. The aim of our study was to analyse the probability of error in negative LN (pN0) gastric carcinomas when a low number of LNs were harvested using a probabilistic model. Methods: Patients with gastric carcinoma who underwent R0 resection at three university hospitals between 2004 and 2009 were retrospectively included. A Bayesian model was used to analyse the probability of error for negative LNs (pN0) gastric carcinomas. Kaplan-Meier survival curves and the log-rank test were used to compare the overall and specific mortality of prognosis groups. Results: Of the 291 patients included, 123 were classified as pN0 (42%). A significant correlation was found between the extent of the LN dissection performed and the number of the LNs retrieved. According to the Bayesian model the carcinomas with 9 or fewer negative lymph nodes were considered to have a high risk (HR) of misclassification, whereas patients with 10-25 LNs analysed and those with more than 26 negative lymph nodes were considered to have a moderate risk (MR) and low risk (LR), respectively. The log-rank test showed a significant improvement in the disease-specific survival for the MR pN0 (p < 0.001) and LR pN0 (p < 0.04) but not for the HR pN0 patients compared to pN1 patients. Conclusions: The proposed probabilistic model is clinically useful for differentiating the prognosis in pN0 gastric carcinomas when an insufficient number of negative lymph nodes are retrieved. (C) 2013 Elsevier Ltd. All rights reserved.

El abordaje unilateral del hiperparatiroidismo primario constituye una opcion tecnica cada vez mas usada y apropiada debido a las caracteristicas de esta cirugia. Este tipo de abordaje ha sido posible por la aparicion del Tc sestamibi, de la subespecializacion de la cirugia y de la determinacion de la PTH intraoperatoria. A continuacion exponemos un estudio epidemiologico, descriptivo y retrospectivo desde enero de 2004 a diciembre de 2008. Durante este tiempo fueron intervenidos en el hospital Ramon y Cajal de Madrid un total de 195 enfermos por hiperparatiroidismo primario. De ellos, 140 fueron sometidos a exploracion unilateral por sospecha de adenoma unico. La correlacion entre los hallazgos gammagraficos y quirurgicos fue correcta en todos los casos (139) menos uno en cuanto a lo que a lateralidad se refiere. Fallo en 30 casos en los que se detecto mal la localizacion superior e inferior. En cuanto a los resultados, se extirpo el adenoma correctamente en 135 de los 140 pacientes. Asi podemos decir que la combinacion de la gammagrafia, de un cirujano con experiencia y el apoyo de la PTH intraoperatoria proporciona una elevada tasa de curacion en el caso de adenomas paratiroideos en el abordaje unilateral con una tasa de hipercalcemia recurrente o persistente entre el 3%-5%, tasa similar a la obtenida por cirujanos expertos al realizar una cervicotomia exploradora (considerada gold standard) pero con menor morbilidad postoperatoria, menor dolor y menor tiempo quirurgico.

Classically, a sub-hepatic drain was inserted routinely in a cholecystectomy to prevent intra-abdominal abscesses, possible post-surgical bleeding, and biliary fistulas. Over the years, it has been demonstrated that the systematic use of a drain does not have any benefits, and many studies conclude that, in special circumstances (bleeding, signs of gallbladder inflammation, incidental opening, or suspected bile leak), and depending on the experience of the individual surgeon, the insertion of a drain may be of use.[corrected] A prospective study was conducted on 100 elective laparoscopic cholecystectomies performed due to symptomatic cholelithiasis or gallbladder polyps. A sub-hepatic drain was inserted in 15 of them. The indications for inserting it were: in 11 patients as a "control" due to a gallbladder bed bleed controlled during surgery, and in 4 due to a gallbladder opening with the excretion of turbid-purulent bile. The main outcomes investigated were the clinical benefit achieved by the insertion of the drain, the hospital stay, and the quantifying of the pain by the patients 24h after surgery, using a visual analogue scale.The insertion of a drain was of no benefit to any patient. The median hospital stay increased by 1 day in patients with a drain (P=.002). The median pain score at 24h was higher in patients with a drain inserted (P=.018).The insertion of a sub-hepatic drain after elective laparoscopic cholecystectomy increases post-surgical pain and prolongs hospital stay, and does not prevent the occurrence of intra-abdominal abscesses.

Pancreatic pseudocyst extended to the mediastinum. Case report We report a 53 years old male consulting for chest pain and dyspnea. On physical examination, an epigastric mass was detected. A TC scan showed a collection located in the omental bursa, which protruded over the posterior gastric wall and ascended to the mediastinum. Due to the presence of pancreatic calcifi ca- tions, a pancreatic pseudocyst was suspected. The mediastinal cyst was drained percutaneously, leaving pig tail drainage in the cavity. Afterwards a cyst excision and Roux en Y gastrostomy was performed. After the surgical procedure the cyst became infected, requiring antimicrobials. After two weeks he was discharged in good conditions.

Introduction Acute cholecystitis treatment may initially be surgical or conservative with subsequent surgery; we reviewed the cases found in our centre, including their treatment and outcome. Material and methods We conducted a retrospective study of treatment in 178 patients with acute cholecystitis during one year. We evaluated variables associated with patient characteristics, as well as clinical data, diagnostic tests, treatment and outcome. Results The majority (70.2%) was treated conservatively (group A), and 29.8% were operated on in the first 72 h (group B). In group A, 96 patients were treated with antibiotics, 15 with antibiotic therapy and cholecystectomy, and 12 with antibiotics and ERCP. In group B urgent laparoscopic cholecystectomy was performed in 60.4%, and 35.8% had open cholecystectomy. In group A, admission time was 11 days, with satisfactory progress in 79.2%, mortality rate of 5.6% and 10.7% of readmissions. In group B, operation time was 111±43 min, a mean of 8.7 days hospital stay, and 68% of cases did not require further treatment after surgery. Outcome was satisfactory in all but 7, there was no mortality in this group. We had a return rate of 2%. Conclusions A significant proportion of conservative treatment was carried out at the expense of emergency surgery, although in absolute numbers conservative treatment seems to have a higher rate of complications, mortality and hospitalisation time.

Management of the short bowel syndrome is a multidisciplinary and very complex problem. The authors report the successful long-term results of an original combination of autologous gastrointestinal reconstruction in a boy who at the age of 16 years lost all but 5 cm of the small bowel. This case demonstrates that lengthening and antipropulsive interposition of a long segment of the colon can be another alternative to early transplantation in exceptional cases.