Thrombocytosis and Hyponatremia as Predictors of Complicated Acute Appendicitis: Predictors of Appendicitis

BACKGROUND

Multiple serologic markers have been studied to predict complicated acute appendicitis (CAA) (C-reactive protein and procalcitonin); these increase health care costs and are not always available in medical centers in Mexico. There is a need for low-cost serologic markers to predict CAA and guide the preoperative management of patients. Our objective was to analyze the predictive value of hyponatremia and thrombocytosis for complicated acute appendicitis.

METHODS

We analyzed 274 patients with AA surgically treated and divided them into two groups: the CAA group and the uncomplicated AA group. We compared the serum values of sodium and platelet blood counts on presentation in the emergency room between the two groups and the proportion of patients with hyponatremia and/or thrombocytosis. Receiver operating characteristic analysis was performed for the two biochemical markers. Sensitivity, specificity, and positive and negative predictive values were calculated for complicated appendicitis in the presence of hyponatremia and thrombocytosis.

RESULTS

We found 87 patients with CAA and 187 with uncomplicated acute appendicitis. Patients with CAA presented with lower serum sodium values and higher platelet counts than uncomplicated patients. Hyponatremia was found in 54.8% of complicated patients and 29.2% in the uncomplicated group. Thrombocytosis was present in 11.6% of the complicated group and 3.2% in uncomplicated patients. We found a specificity and positive predictive value of 100% for complicated appendicitis in patients with hyponatremia and thrombocytosis.

CONCLUSIONS

In patients with abdominal pain and suspected acute appendicitis, the presence of hyponatremia and thrombocytosis is a strong predictive tool for the complicated disease. This is the first study to analyze the association between thrombocytosis and complicated appendicitis.

Reaching LDL-C Targets in Patients with Moderate, High, and Very High Risk for Cardiovascular Disease After Bariatric Surgery According to Different Guidelines

BACKGROUND

Cardiovascular disease (CVD) is highly prevalent in obese patients and is the leading cause of death. High levels of plasma low-density lipoprotein cholesterol (LDL-C) are associated with higher coronary artery disease (CAD) risk. The aim of the study was to assess the impact of the Roux-en-Y gastric bypass on the achievement of the currently proposed cardiovascular prevention goals after 1 year.

PATIENTS AND METHODS

We performed a retrospective analysis from a prospectively built database of patients who underwent a primary Roux-en-Y gastric bypass (RYGB) from 2004 to 2018. Patients with intermediate, high, or very high risk for CVD according to the 2018 AHA/ACC or the 2019 ESC/EAS guidelines were selected. An analysis of clinical and biochemical variables in 1 year was performed. Logistic multivariate regressions were made to assess the impact of preoperative and weight loss parameters in the achievement of LDL-C goals.

RESULTS

From 1039 patients, 70 met the selection criteria and were included in the analysis of the 2018 AHA/ACC guidelines, and 75 in the 2019 ESC/EAS guidelines. Mean decrease in LDL-C levels was 21.1 ± 40.2 mg/dL 1 year after surgery, and 29/34 patients were off medications. The percentage of patients achieving LDL-C goals according to the 2018 AHA/ACC guidelines was 27.1%, whereas according to the 2019 ESC/EAS guidelines, the percentages was 9.3%. The %TWL was associated with achieving LDL-C goals according to the 2018 AHA/ACC at 1 year.

CONCLUSIONS

RYGB induces a significant weight loss and an improvement in LDL-C levels 1 year after surgery. The number of patients that reached the goals varies according to the guidelines used and ranged from 9.3 to 27.1%.

LAW Trial - The Impact of Local Anesthetics Infiltration in Surgical Wound for Gastrointestinal Procedures (LAW): A Double-Blind, Randomized Controlled Trial

INTRODUCTION AND AIMS

Prior studies have suggested that infiltration of local anesthetics reduce the rate of surgical site infections (SSIs). Opioid usage has become an epidemic. Some analgesic modalities, such as epidural analgesia and transversus abdominis plane block are associated with shorter length of stay and lower opioid use. The aim of our study was to assess the relationship between local infiltration of bupivacaine with rates of SSI and pain control.

MATERIALS AND METHODS

We conducted a prospective, double-blinded randomized controlled trial in patients who underwent open major gastrointestinal procedures from July 2016 to June 2017. Patients were divided into two groups based on administration of 0.5% bupivacaine (n = 30) (group 1) or placebo (n = 30) (control group). Outcomes evaluated were SSI, postoperative opioid requirements and pain scores.

RESULTS

Patients in the bupivacaine group required a lower dose of epidural analgesia during the first 24 h (5.3 mcg/kg/h vs. 6.4 mcg/kg/h; p = 0.05). Opioid requirement was shorter in the bupivacaine group (3.5 ± 2.3 days vs. 5.7 ± 2.9 days; p = 0.01). No difference was found between groups in terms of SSI rates (0% vs. 6.7%, p = 0.49).

CONCLUSIONS

There is no clear association between bupivacaine infiltration and reduction of SSI rate according to our study. Wound bupivacaine infiltration is associated with a lower dose of epidural infusion and opioid requirements.

Roux-en-Y Gastric Bypass in Patients >60 Years of Age: Morbidity and Short-Term Outcomes

BACKGROUND

Obesity is a common disease in the elderly population, and bariatric surgery is the most effective intervention to achieve significant and sustainable weight loss. Many bariatric programs have established an arbitrary cutoff at the age of 60 to 65 years. The aim of this study was to evaluate the safety and short-term outcomes of Roux-en-Y gastric bypass (RYGB) in patients older than 60 years.

PATIENTS AND METHODS

We conducted a retrospective cohort study of patients who underwent RYGB from 2004 to 2019 in a single center. Logistic and linear multivariate regressions were made to compare complications and short-term outcomes between patients aged > 60 years and < 60 years. The statistical significance was set at p ≤ 0.05.

RESULTS

From 849 patients who underwent a primary RYGB, 57 were > 60 years of age. Overall, early and late complications were similar in both groups, except for unexpected intensive care unit (ICU) admission which was more frequent in the > 60 years group. Excess body weight loss (%EWL) and percentage total weight loss (%TWL) at 1 year in patients > 60 years old were 76.6 ± 21.8% and 30.73 ± 6.8%, respectively. Figures for the same parameters in the control group were 81.7 ± 19.9% (p = 0.09) and 34.3 ± 7.2 (p = 0.001), respectively.

CONCLUSIONS

In our experience, an age > 60 is not related to higher rates of overall early and late complications after RYGB. Comorbidity remission rates are similar to those in younger patients. Elderly patients had lower total weight loss at 1 year, but the %EWL was similar in both groups.

Hypoparathyroidism After Total Thyroidectomy: Importance of the Intraoperative Management of the Parathyroid Glands

BACKGROUND

Total thyroidectomy is the most common surgical procedure for the treatment of thyroid diseases. Postoperative hypocalcemia/hypoparathyroidism is the most frequent complication after total thyroidectomy. The aim of this study was to evaluate the rate of postoperative hypocalcemia and permanent hypoparathyroidism after total thyroidectomy in order to identify potential risk factors and to evaluate the impact of parathyroid autotransplantation.

PATIENTS AND METHODS

We performed a retrospective analysis of 1018 patients who underwent total thyroidectomy at our institution between 2000 and 2016. Medical records were reviewed to analyze patient features, clinical presentation, management and postoperative complications. Descriptive and inferential statistics were employed based on the natural scaling of each included variable. Statistical significance was set at p ≤ 0.05.

RESULTS

Mean ± SD age was 46.79 ± 15.9 years; 112 (11.7%) were males and 844 (88.3%) females. A total of 642 (67.2%) patients underwent surgery for malignant disease. The rate of postoperative hypocalcemia, transient, protracted and permanent hypoparathyroidism was 32.8%, 14.43%, 18.4% and 3.9%, respectively. Permanent hypoparathyroidism was significantly associated with the number of parathyroid glands remaining in situ (4 glands: 2.5%, 3 glands: 3.8%, 1-2 glands: 13.3%; p ˂ 0.0001) [OR for 1-2 glands in situ = 5.32, CI 95% 2.61-10.82]. Other risk factors related to permanent hypoparathyroidism were obesity (OR 3.56, CI 95% 1.79-7.07), concomitant level VI lymph node dissection (OR 3.04, CI 95% 1.46-6.37) and incidental parathyroidectomy without autotransplantation (OR 3.6, CI 95% 1.85-7.02).

CONCLUSIONS

Identification and in situ preservation of at least three parathyroid glands were associated with a lower rate of postoperative hypocalcemia (30.4%) and permanent postoperative hypoparathyroidism (2.79%).

Presentación clínica de la apendicitis aguda en pacientes inmunocomprometidos por diabetes o VIH/sida

Introducción

Los pacientes inmunocomprometidos presentan respuesta inflamatoria limitada que puede retrasar el diagnóstico de la apendicitis aguda (AA).

Objetivo

Evaluar si el inmunocompromiso puede afectar el curso clínico y evolución de la AA.

Método

Análisis retrospectivo, comparativo, de pacientes sometidos a apendicectomía por AA: con VIH, diabetes mellitus tipo 2 (DM2) y sin otra patología.

Resultados

Se revisaron 128 pacientes con AA intervenidos quirúrgicamente (53.6 % del sexo femenino), edad media de 42.5 años, 15 (11.7 %) tenían diagnóstico de VIH, 47 (36.7 %) de DM2 y 66 (51.6 %) no cursaban con otra enfermedad. La proporción de leucocitosis fue menor en el grupo con VIH (66.7 %; p = 0.007). En los pacientes con VIH y DM2 se registró mayor tiempo de evolución: 66.9 ± 61.2y 90.1 ± 144 horas (p ≤ 0.001), mayor tiempo de estancia hospitalaria: 11.1 ± 17.1 y 6.5 ± 4.1 días (p ≤ 0.0001), mayor tasa de complicaciones: 20 y 23.8 % (p = 0.036). La complicación más frecuente fue la infección del sitio quirúrgico superficial y profunda. La hemicolectomía derecha fue más frecuente en el grupo con VIH (20 %, p = 0.017). No se registró mortalidad.

Conclusiones

La inmunodepresión afecta el curso clínico y evolución de la AA.

Introduction

Immunocompromised patients experience limited inflammatory response, which can delay acute appendicitis (AA) diagnosis.

Objective

To assess if immunosuppression can affect AA clinical course and evolution.

Method

Comparative, retrospective analysis of patients with HIV or type 2 diabetes mellitus (DM2) or with no other pathology who underwent appendectomy for AA.

Results

A total of 128 patients with AA who were surgically intervened were assessed (53.6% were of the female gender); mean age was 42.5 years, 15 (11.7%) had been diagnosed with HIV infection, 47 (36.7%) with DM2 and 66 (51.6%) had no other disease. The proportion of leukocytosis was lower in the HIV group (66.7%; p = 0.007). Patients with HIV and DM2 had longer evolution time (HIV 66.9 ± 61.2, DM2 90.1 ± 144 hours; p ≤ 0.001), longer hospital length of stay (HIV 11.1 ± 17.1, DM2 6.5 ± 4.1 days; p ≤ 0.0001), and a higher rate of complications (HIV 20%, DM2 23.8%; p = 0.036). The most common complication was superficial and deep surgical site infection. Right hemicolectomy was more common in the HIV group (20%; p = 0.017). There was no mortality registered.

Conclusions

Immunosuppression affects AA clinical course and evolution.

Correction to: Hypoparathyroidism After Total Thyroidectomy: Importance of the Intraoperative Management of the Parathyroid Glands

In the original version of the article, the last three column headings in Table 3 were mislabeled. The original article has been corrected. Following is the corrected table.