Original articles
Received: 05 March 2024
Accepted: 31 July 2024
DOI: https://doi.org/10.22516/25007440.1191
Abstract
Introduction: Cirrhosis is a chronic, diffuse, and irreversible liver disease that represents the final stage of various liver conditions caused by different etiologies.
Objective: To characterize patients with liver cirrhosis treated at a hospital in Boyacá.
Methodology: A retrospective, cross-sectional descriptive study was conducted, including patients over the age of 18 who were treated at the Hospital Universitario San Rafael in Tunja with a diagnosis of liver cirrhosis of any etiology between January 01, 2016, and December 31, 2021.
Results: The age range of the study population was 28 to 89 years, with men accounting for the majority (77.51%). The most frequent complications observed were ascites and hepatic encephalopathy. A total of 12.8% of patients required admission to the intensive care unit (ICU), 38.7% were classified as having decompensated disease (Child-Pugh C), and the overall mortality rate was 34.6%.
Conclusions: Cirrhosis imposes a significant financial burden on both the healthcare system and patients. The primary cause of cirrhosis in this population was alcohol consumption, a modifiable risk factor. The higher prevalence in men may be attributed to greater exposure to risk factors, such as alcohol consumption, which is common in the country. The mortality rate for this condition remains high, and given the natural course of the disease, it significantly impacts patients’ quality of life, leading to an increased number of years lost due to disability and premature death.
Keywords: Cirrhosis, alcoholism, liver, mortality, ascites.
Resumen
Introducción: La cirrosis es una enfermedad crónica difusa e irreversible del hígado, consecuencia final de enfermedades hepáticas desencadenadas por diversas etiologías.
Objetivo: Caracterizar los pacientes con cirrosis hepática atendidos en un Hospital de Boyacá.
Metodología: Se realizó un estudio descriptivo de corte transversal y retrospectivo, en el que se incluyeron pacientes mayores de 18 años de edad atendidos en el Hospital universitario San Rafael de Tunja con diagnóstico de cirrosis hepática de cualquier etiología entre el 1 de enero de 2016 y el 31 de diciembre de 2021.
Resultados: La edad mínima de la población evaluada fue de 28 años y la edad máxima, de 89 años; la mayoría son varones, con un porcentaje de 77,51%. Las complicaciones que se presentaron con mayor frecuencia fueron la ascitis y la encefalopatía hepática. El 12,8% requirió estancia hospitalaria en la unidad de cuidados intensivos (UCI), el 38,7% estaba clasificado como una enfermedad descompensada (Child-Pugh C) y la mortalidad fue del 34,6%.
Conclusiones: Esta es una patología que genera altos costos tanto para el sistema de salud como para el paciente, cuya principal causa de cirrosis es el consumo de alcohol, que es un factor modificable. Hay una prevalencia mayor en el sexo masculino, lo cual se puede deber a factores exposicionales, como el consumo de alcohol, algo que es común en el país. La tasa de mortalidad de la patología es alta y, según el curso natural de la enfermedad, se afecta la calidad de vida del paciente, aumentando los años de vida perdidos por discapacidad y por muertes.
Palabras clave: Cirrosis, alcoholismo, hígado, mortalidad, ascitis.
Introduction
Cirrhosis is a chronic and diffuse liver disease triggered by various etiologies, with the most common being alcohol consumption, hepatitis virus infection, and non-alcoholic steatohepatitis1,2. Regardless of its etiology, the mechanisms leading to cirrhosis are shared. They begin with hepatocyte necrosis or lysis, resulting in the loss of hepatic parenchyma and inflammation. Healthy hepatic parenchyma is progressively replaced by fibrotic tissue and regenerative nodules, ultimately leading to liver failure, portal hypertension, and hepatocellular carcinoma3,4.
Early identification of the clinical features of cirrhosis allows physicians to guide their diagnostic strategy, reverse causal factors, establish timely treatment, and prevent complications5. Unfortunately, the diagnosis of cirrhosis is often made late nowadays, which means that management is primarily focused on treating complications of the decompensated disease. As a result, many patients eventually require liver transplantation. This leads to a significant impairment in their quality of life and, evidently, represents a major public health issue3.
According to 2019 data from the National Administrative Department of Statistics (DANE), Boyacá is one of the departments with the highest prevalence of alcohol consumption6. This factor is the leading cause of cirrhosis worldwide and accounts for a high rate of morbidity and mortality, resulting in a significant impact on the quality of life of individuals affected by the disease, particularly in developing countries such as Colombia7,8.
In 2018, the World Health Organization (WHO) estimated that alcohol consumption was responsible for three million deaths annually worldwide5. Alcohol is the most common cause of liver damage in approximately 60% of reported cases in Europe, North America, and Latin America9,10, where higher mortality rates due to cirrhosis secondary to alcohol consumption have been reported in countries such as Peru, Nicaragua, and Mexico8,9. In Colombia, the situation is similar. Although there is insufficient information regarding the clinical and sociodemographic characteristics of affected patients, some studies focused on the populations of Antioquia and Barranquilla show a high prevalence of the disease10-12.
Given the high mortality rate, the complexity of the disease, and its poor prognosis, it is crucial to emphasize the need for timely and early diagnosis. This is especially important for populations such as Boyacá, which shows a high prevalence of alcohol consumption and presents sociodemographic characteristics different from those studied in other regions of the country. Therefore, the objective of this study is to describe the sociodemographic and clinical characteristics of patients with liver cirrhosis.
Materials and methods
Type of study
A descriptive, cross-sectional, retrospective study was carried out.
Population and selection criteria
The target population included all patients over 18 years of age who were treated at the Hospital Universitario San Rafael de Tunja for liver cirrhosis of any etiology between January 1, 2016, and December 31, 2021, excluding those with incomplete medical records.
Data collection and analysis
Data collection was carried out by the investigators. Initially, the list of patients was identified using the International Classification of Diseases (ICD-10) code; subsequently, a Google Forms instrument was adopted to collect all the variables from the medical records.
The variables considered included: age at the time of cirrhosis diagnosis, sex of the patient, disease progression time, sociodemographic characteristics (place of origin, education level, social security affiliation, and type of health insurance), etiology of liver cirrhosis (alcoholic, autoimmune, viral, non-alcoholic fatty liver disease, drug-induced, secondary to hemochromatosis, primary biliary, secondary biliary, or unclassified), presence of complications (ascites, hepatic encephalopathy, spontaneous bacterial peritonitis, esophageal varices, gastrointestinal bleeding, hepatorenal syndrome), and the time of evolution between cirrhosis diagnosis and the diagnosis of these complications. Additionally, the presence of comorbidities (arterial hypertension, diabetes mellitus, chronic kidney disease, rheumatoid arthritis, gastric ulcers), number and duration of hospitalizations, the time between each hospitalization in patients with more than one admission, patients requiring management in an intensive care unit (ICU) and number of days spent in the ICU, patient mortality, time from disease diagnosis to death, and age at the time of death were recorded.
The database was registered in Excel version 2013 and analyzed using SPSS statistical package version 22. Univariate analysis was performed through descriptive statistics for each group, determining absolute and relative frequencies for categorical variables; for quantitative variables, measures of central tendency (mean, median) and measures of dispersion (standard deviation and interquartile range) were calculated.
Ethical considerations
Based on Resolution 8430 of 1993, this study is considered a no-risk investigation. Authorization for the review of medical records was obtained from the Ethics and Research Committee of the Hospital Universitario San Rafael de Tunja (Minutes No. 053).
Results
Selection of participants
During the study period, a total of 312 medical records were collected. However, during the review process, 23 records were excluded for the following reasons: 15 corresponded to patients with incomplete medical records with missing information, and 8 had ICD-10 coding that did not match the diagnosis of liver cirrhosis.
Sociodemographic characterization
The minimum age of the evaluated population was 28 years, and the maximum age was 89 years. The majority were male, accounting for 77.51%. A relevant finding is that the most frequent etiological agent was alcohol consumption. However, the type or degree of alcohol consumption is not known, as it could involve non-distilled alcohol, such as “guarapo” or “chicha,” which are frequently consumed in agricultural regions during working hours to quench thirst (Table 1).
Sociodemographic characterization
Table created by the authors.
Comorbidities and complications
The most frequently occurring complications were ascites and hepatic encephalopathy (Table 2).
Comorbidities and complications
Table created by the authors.
Prognosis
A total of 12.8% required hospital stay in the ICU, 38.7% were classified as Child-Pugh C disease, and the mortality rate was 34.6% (Table 3).
Variables to establish the prognosis
Table created by the authors.
Discussion
Cirrhosis follows an evolving course marked by different clinical stages. For a long time, it has been recognized that the natural history of cirrhosis is dominated by a prognostic milestone represented by the development of complications related to portal hypertension and liver dysfunction, such as gastrointestinal bleeding, hepatic encephalopathy, jaundice, and ascites formation. This led to the division of the disease course into two distinct clinical states: a compensated phase, characterized by preserved quality of life and an average survival exceeding 12 years, and a decompensated phase, marked by the onset of complications, with an average survival reduced to 2-4 years3,5.
In the compensated phase, patients are typically asymptomatic or present with nonspecific symptoms. During this stage, the liver is still able to perform its essential functions, and the patient’s quality of life remains relatively stable. In contrast, the decompensated phase is characterized by the onset of evident symptoms such as ascites, hepatic encephalopathy, jaundice, gastrointestinal bleeding, and other severe complications. These events can lead to prolonged hospitalizations, liver transplantation, and even death13-16. Acute decompensation is defined by the rapid development of one or more major complications, such as grade 2 or 3 ascites, acute hepatic encephalopathy, gastrointestinal bleeding, or acute bacterial infections. Additionally, the study defined multi-organ failure as a criterion for diagnosing acute-on-chronic liver failure (ACLF), which can worsen the prognosis and increase mortality13-16.
Clinical events occurring during a period following acute decompensation can help classify patients into different groups based on disease progression. This classification identifies clinical trajectories that reflect various levels of instability and mortality risk13-16.
Cirrhosis is the final result of chronic liver diseases, secondary to excessive alcohol consumption, viral hepatitis, or non-alcoholic fatty liver disease, which is becoming increasingly common due to the rise in obesity, type 2 diabetes mellitus, and sedentary lifestyles3,4. In our findings, the male sex represents the vast majority of cases, which contrasts with other studies conducted in Colombia, where a higher prevalence of cirrhosis in females was reported 10,17-19.
The population affiliated with the contributory health regime was a minority. In Colombia, two other studies have reported the type of affiliation to the health system, finding that 77.1% and 60% of the population, respectively, were affiliated with the contributory regime10,20. The reason why the majority of the population in our study had subsidized health coverage is partly due to the characteristics of the population covered by the hospital, which is mainly composed of agricultural workers from the central region of the country.
The main etiologies of liver cirrhosis in our population are consistent with findings from other studies, in which alcoholic, autoimmune, and viral causes are among the most frequent10,17,21. Globally, one-quarter of cirrhosis-related deaths are attributable to alcohol consumption22. Furthermore, in the Americas, there is a noticeable shift from predominantly viral etiologies toward an increase in alcohol-related cirrhosis. This trend is associated with improved control of viral diseases and a rise in alcohol consumption23.
The variable of educational level emerges as a factor of particular relevance. Although the lack of complete data across the entire population limits its analysis, education remains an important factor. Most cases of cirrhosis occur in individuals with low levels of education, which is also related to the high prevalence of alcoholic liver cirrhosis and affiliation with the subsidized health insurance regime. This suggests an association between low educational level, poverty, and alcohol consumption, as individuals engaged in agricultural work do not typically consider “guarapo” or “chicha” as alcoholic beverages, but rather as drinks to quench thirst during workdays. Prospective studies are needed to evaluate the composition of these substances and, in this way, address a multidimensional problem that requires an interdisciplinary approach, considering both medical and sociocultural aspects. The interrelationship among these factors highlights the need for a comprehensive and collaborative understanding to effectively address this issue and its determinants23.
Up to 50% of patients with cirrhosis, particularly those with alcoholic etiology, may experience decompensation with the development of ascites9,24, a figure consistent with our findings. However, it is notably higher compared to other national studies, where prevalence ranges from 13% to 36%10,18. This can be mainly explained by the high proportion of patients with alcohol-related cirrhosis in our population.
Spontaneous bacterial peritonitis is a serious complication in cirrhotic patients with ascites, and its prevalence ranges from 10% to 25% among hospitalized patients24. However, in our population, it was a rare complication, possibly due to the high prevalence of gastrointestinal bleeding and, consequently, the administration of antibiotics, which could reduce the frequency of this complication.
The prevalence of esophageal varices increases with the progression of liver disease (Child-Pugh class A: 43%, class B: 71%, class C: 76%)25. Approximately 50% of patients with newly diagnosed cirrhosis have esophageal varices, and peptic ulcers are present in 35% of cases26,27. These figures are lower than those reported in our population. Nonetheless, our figures also remain lower compared to other studies conducted in Colombia: Vélez et al. reported a prevalence of 62.1%17, and Escorcia & Marrugo reported 62.6%10.
The prevalence of overt hepatic encephalopathy at the time of cirrhosis diagnosis ranges from 10% to 14%, and from 16% to 21% in decompensated cirrhosis28,29. National studies are also consistent with international literature, reporting prevalences between 5.6%18 and 22.5%10. The higher figures observed compared to other studies may be related to the high prevalence of alcohol-related cirrhosis, which is associated with a greater number of cases of hepatic encephalopathy.
The most common comorbidity was arterial hypertension. Our findings are consistent with the frequency of hypertension in the general Colombian population, considering that the reported national prevalence of arterial hypertension is 28.14%30,31. The second most common comorbidity was type 2 diabetes mellitus32-34. This latter finding aligns more closely with the general population prevalence and with our reported prevalence of diabetes in cirrhotic patients. However, compared to other studies, the frequency of this condition remains high, possibly due to specific dietary habits of the regional population, which are based on high carbohydrate consumption.
The high percentage of patients with rheumatoid arthritis in our population is noteworthy, considering that, according to the latest audited and analyzed period reported by the Cuenta de Alto Costo de Colombia (Colombian High-Cost Account), corresponding to the period between July 1, 2020, and June 30, 2021, only 0.27% of the Colombian population is affected by this pathology35. Among the group of cirrhotic patients with autoimmune etiology, one patient (8.3%) had arthritis as a comorbidity. This suggests that as autoimmunity becomes a more common etiology of cirrhosis in our setting, the occurrence of polyautoimmunity in these patients also increases.
The frequency of the history of biliary lithiasis in our population of cirrhotic patients was higher than what has been reported in the literature. In the general population, the prevalence of this condition is approximately 10%, and in Colombia, it is 8.6%36. However, this could be related to the local epidemiology of lithiasis, highlighting the need for further local research on this topic.
Conclusions
Liver cirrhosis is a pathology that generates high costs for both the healthcare system and the patient. The main cause of cirrhosis is alcohol consumption, a modifiable risk factor. There is a higher prevalence in males, which is attributed to exposure-related factors. The mortality rate of this condition is high, and according to the natural course of the disease, the patient’s quality of life is significantly affected, increasing the years of life lost due to disability and death.
References
Patel R, Mueller M. Alcoholic Liver Disease. 2022. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022.
Vorobioff JD, Contreras F, Tanno F, Hernández L, Bessone F, Colombato L, et al. Latin American survey on demographic aspects of hospitalized, decompensated cirrhotic patients and the resources for their management. Ann Hepatol. 2020;19(4):396-403. https://doi.org/10.1016/j.aohep.2020.03.007
Ginès P, Krag A, Abraldes JG, Solà E, Fabrellas N, Kamath PS. Liver cirrhosis. Lancet. 2021;398(10308):1359-1376. https://doi.org/10.1016/S0140-6736(21)01374-X
Wilson R, Williams DM. Cirrhosis. Med Clin North Am. 2022;106(3):437-446. https://doi.org/10.1016/j.mcna.2021.12.001
Engelmann C, Clària J, Szabo G, Bosch J, Bernardi M. Pathophysiology of decompensated cirrhosis: Portal hypertension, circulatory dysfunction, inflammation, metabolism and mitochondrial dysfunction. J Hepatol. 2021;75 Suppl 1(Suppl 1):S49-S66. https://doi.org/10.1016/j.jhep.2021.01.002
Ministerio de Salud y Protección Social de Colombia. Minsalud entrega recomendaciones frente al consumo de alcohol en festividades [Internet]. Boletín de Prensa No 1272; 2021 [consultado el 10 de febrero de 2023]. Disponible en Disponible en https://www.minsalud.gov.co/Paginas/Minsalud-entrega-recomendaciones-frente-al-consumo-de-alcohol-en-festividades.aspx
Trifan A, Minea H, Rotaru A, Stanciu C, Stafie R, Stratina E, et al. Predictive Factors for the Prognosis of Alcoholic Liver Cirrhosis. Medicina (Kaunas). 2022;58(12):1859. https://doi.org/10.3390/medicina58121859
Jayathilaka R, Athukorala O, Ishara S, Silva D, Pathirage T. Alcohol brings burdens: A global and continent wise study on alcohol consumption and global burden of diseases. PLoS One. 2022;17(7):e0270998. https://doi.org/10.1371/journal.pone.0270998
Díaz LA, Idalsoaga F, Fuentes-López E, Márquez-Lomas A, Ramírez CA, Roblero JP, et al. Impact of Public Health Policies on Alcohol-Associated Liver Disease in Latin America: An Ecological Multinational Study. Hepatology. 2021;74(5):2478-2490. https://doi.org/10.1002/hep.32016
Caracterización epidemiológica y clínica de la cirrosis hepática en un centro regional del caribe colombiano: clínica general del norte. Enero 2012 a marzo 2017. Biociencias. 2018;13(1):17-30. https://doi.org/10.18041/2390-0512/bioc..1.2242
Escobar DM, Restrepo-Gutiérrez JC, Hoyos S, Navas MC. Efecto del consumo de alcohol al diagnóstico en la sobrevida de pacientes con cirrosis hepática en un Hospital Universitario de la ciudad de Medellín. Rev Colomb Gastroenterol. 2018;33(3):221-7. https://doi.org/10.22516/25007440.281
Martínez Leyva L, Palomino Besada AB, Quesada Meneses E, Oliva Rey JC, Yanes Cicard A, Descalzo García Y. Características epidemiológicas y clínicas de pacientes con cirrosis hepática. Rev Cub Med Mil. 2021;50(4):e02101479.
de Franchis R, Bosch J, Garcia-Tsao G, Reiberger T, Ripoll C; Baveno VII Faculty. Baveno VII - Renewing consensus in portal hypertension. J Hepatol. 2022;76(4):959-974. https://doi.org/10.1016/j.jhep.2021.12.022
D’Amico G, Pasta L, Morabito A, D’Amico M, Caltagirone M, Malizia G, et al. Competing risks and prognostic stages of cirrhosis: a 25-year inception cohort study of 494 patients. Aliment Pharmacol Ther. 2014;39(10):1180-93. https://doi.org/10.1111/apt.12721
Rinella ME, Neuschwander-Tetri BA, Siddiqui MS, Abdelmalek MF, Caldwell S, Barb D, et al. AASLD Practice Guidance on the clinical assessment and management of nonalcoholic fatty liver disease. Hepatology. 2023;77(5):1797-1835. https://doi.org/10.1097/HEP.0000000000000323
D’Amico G, Bernardi M, Angeli P. Towards a new definition of decompensated cirrhosis. J Hepatol. 2022;76(1):202-207. https://doi.org/10.1016/j.jhep.2021.12.023
Vélez Aguirre JD, Lepesqueur Guillén LH, Yepes Barreto IJ. La esteatohepatitis no alcohólica: una causa emergente de cirrosis en Colombia. Rev Colomb Gastroenterol. 2022;37(2):136-44. https://doi.org/10.22516/25007440.783
Prieto-Ortiz JE, Garzón Orjuela N, Sánchez-Pardo S, Prieto-Ortíz RG, Eslava Schmalbach J. Sobrevida en pacientes con cirrosis de acuerdo con su etiología. Cohorte retrospectiva. Rev Colomb Gastroenterol. 2022;37(1):24-32. https://doi.org/10.22516/25007440.703
Pereira D, María Á, Montoya G, Amador MB, Velásquez HV, Martínez JW, et al. Caracterización epidemiológica de pacientes con cirrosis en una consulta. Rev Médica Risaralda. 2014;20(5):86-94.
Departamento Administrativo Nacional de Estadística. Encuesta nacional de consumo de sustancias psicoactivas (ENCSPA) [Internet]. Bogotá: DANE; 2020 [consultado el 11 de febrero de 2023]. Disponible en: Disponible en: https://www.dane.gov.co/files/investigaciones/boletines/encspa/btencspa-2019.pdf
Huang DQ, Mathurin P, Cortez-Pinto H, Loomba R. Global epidemiology of alcohol-associated cirrhosis and HCC: trends, projections and risk factors. Nat Rev Gastroenterol Hepatol. 2023;20(1):37-49. https://doi.org/10.1038/s41575-022-00688-6
Huang DQ, Terrault NA, Tacke F, Gluud LL, Arrese M, Bugianesi E, et al. Global epidemiology of cirrhosis - aetiology, trends and predictions. Nat Rev Gastroenterol Hepatol. 2023;20(6):388-98. https://doi.org/10.1038/s41575-023-00759-2
Kimer N, Møller S, Bendtsen F. Alcohol-related liver cirrhosis and related complications. Ugeskr Laeger. 2021;183(14):V11200850.
Facciorusso A, Antonino M, Orsitto E, Sacco R. Primary and secondary prophylaxis of spontaneous bacterial peritonitis: current state of the art. Expert Rev Gastroenterol Hepatol. 2019;13(8):751-759. https://doi.org/10.1080/17474124.2019.1644167
Kovacs TOG, Jensen DM. Varices: Esophageal, Gastric, and Rectal. Clin Liver Dis. 2019;23(4):625-642. https://doi.org/10.1016/j.cld.2019.07.005
Jakab SS, Garcia-Tsao G. Evaluation and Management of Esophageal and Gastric Varices in Patients with Cirrhosis. Clin Liver Dis. 2020;24(3):335-350. https://doi.org/10.1016/j.cld.2020.04.011
Kovacs TO, Jensen DM. Gastrointestinal hemorrhage. En: Goldman L, Schafer A (editores). Goldman-cecil medicine. 25.a edición. Saunders; 2016. p. 879-84.
Rose CF, Amodio P, Bajaj JS, Dhiman RK, Montagnese S, Taylor-Robinson SD, et al. Hepatic encephalopathy: Novel insights into classification, pathophysiology and therapy. J Hepatol. 2020;73(6):1526-1547. https://doi.org/10.1016/j.jhep.2020.07.013
Hoilat GJ, Ayas MF, Hoilat JN, Abu-Zaid A, Durer C, Durer S, et al. Polyethylene glycol versus lactulose in the treatment of hepatic encephalopathy: a systematic review and meta-analysis. BMJ Open Gastroenterol. 2021;8(1):e000648. https://doi.org/10.1136/bmjgast-2021-000648
García-Peña ÁA, Ospina D, Rico J, Fernández-Ávila DG, Muñoz-Velandia Ó, Suárez-Obando F. Prevalencia de hipertensión arterial en Colombia según información del Sistema Integral de Información de la Protección Social (SISPRO). Rev Colomb Cardiol. 2022;29(1):29-35.
Daza MT, Vega JAH, García AMV, Soler LA, Valderrama F. Situación de la enfermedad renal crónica, la hipertensión arterial y la diabetes mellitus en Colombia 2021. Colombia: Fondo Colombiano de Enfermedades de Alto Costo; 2022.
Schargrodsky H, Hernández-Hernández R, Champagne BM, Silva H, Vinueza R, Silva Ayçaguer LC, et al. CARMELA: assessment of cardiovascular risk in seven Latin American cities. Am J Med. 2008;121(1):58-65. https://doi.org/10.1016/j.amjmed.2007.08.038
Vargas-Uricoechea H, Casas-Figueroa LÁ. An Epidemiologic Analysis of Diabetes in Colombia. Ann Glob Health. 2015;81(6):742-53. https://doi.org/10.1016/j.aogh.2015.11.001
Corsi DJ, Subramanian SV, Chow CK, McKee M, Chifamba J, Dagenais G, et al. Prospective Urban Rural Epidemiology (PURE) study: Baseline characteristics of the household sample and comparative analyses with national data in 17 countries. Am Heart J. 2013;166(4):636-646.e4. https://doi.org/10.1016/j.ahj.2013.04.019
Daza MT, Vega JAH, García AMV, Soler LA, Valderrama F. Situación de la artritis reumatoide en Colombia 2021. Colombia: Fondo Colombiano de Enfermedades de Alto Costo; 2022.
Ruiz LC, Torres JM, Quemba LC, Parada LA, Vargas LJ. Factores asociados con colelitiasis en un hospital de Boyacá. Repert Med y Cirugía. 2022;31(3):251-5. https://doi.org/10.31260/RepertMedCir.01217372.1186
Notes
Author notes
*Correspondence: Ledmar Jovanny Vargas-Rodríguez. lejovaro@gmail.com
Conflict of interest declaration
