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de Queiroz FL, Lacerda-Filho A, Alves AC, de Oliveira FH, Neto PRF, de Almeida Paiva R. Conditions associated with worse acceptance of a simplified accelerated recovery after surgery protocol in laparoscopic colorectal surgery. BMC Surg 2021; 21:229. [PMID: 33941146 PMCID: PMC8091501 DOI: 10.1186/s12893-021-01206-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 04/14/2021] [Indexed: 11/15/2022] Open
Abstract
Background Enhanced Recovery Surgical Programs were initially applied to colorectal procedures and used as multimodal approach to relieve the response to surgical stress. An important factor that negatively impacts the success of these programs is the poor tolerance of these patients to certain items in the adopted protocol, especially with regard to post-operative measures. The identification of these factors may help to increase the success rate of such programs, ensuring that benefits reach a greater number of patients and that resources are better allocated. Thus, the aims of this study were to assess the results of the implementation of a Simplified Accelerated Recovery Protocol (SARP) and to identify possible factors associated with failure to implement postoperative protocol measures in patients submitted to laparoscopic colorectal surgery. Methods 161 patients were randomly divided into two groups. The SARP group (n = 84) was submitted to the accelerated recovery program and the CC group (n = 77), to conventional postoperative care. The SARP group was further divided into two subgroups: patients who tolerated the protocol (n = 51) and those who did not (n = 33), in order to analyze factors contributing to protocol nontolerance. Results The groups had similar sociodemographic and clinical characteristics. The SARP group had a shorter hospital stay, better elimination of flatus, was able to walk and to tolerate a diet sooner (p < 0.0001). Complications rates and readmissions to emergency room were similar between groups. Multivariate analysis revealed that prolonged operating time, stoma creation and rates of surgical complications were independently associated with poor adherence to SARP (p < 0.0001). Conclusions The use of our SARP resulted in improved recovery from laparoscopic colorectal surgery and proved to be safe for patients. Extensive surgeries, occurrence of complications, and the need for ostomy were variables associated with poor program adhesion. Trial registration Trial Registry: RBR2b4fyr—Date of registration: 03 October 2017.
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Affiliation(s)
- Fábio Lopes de Queiroz
- Colorectal Surgery Department, Hospital Felicio Rocho, Rua Felipe Dos Santos, 760, 501-3, Belo Horizonte, Minas Gerais, CEP 30180160, Brazil.
| | - Antonio Lacerda-Filho
- Department of Surgery at the School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Adriana Cherem Alves
- School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil.,Semper Hospital- Belo Horizonte, Belo Horizonte, Brazil
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Relationship between nutritional status and immediate complications in patients undergoing colorectal surgery. JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1016/j.jcol.2013.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Abstract
Introduction several complications may occur during colorectal surgical procedures and factors, such as nutritional status, substantially contribute to this problem.
Objective evaluate the relationship between nutritional status (determined by different tools) and the emergence of early postoperative complications, as well as analyze social parameters, lifestyle, food intake, and time to diet reintroduction.
Methods case series study conducted in the surgical proctologic ward of the Hospital Barão de Lucena, Recife, Pernambuco, with individuals of both sexes diagnosed with colorectal cancer who underwent a surgical procedure involving at least one anastomosis. Social, demographic and clinical data, life style, dietary intake, nutritional status, and the immediate postsurgical complications were evaluated.
Results among the 31 patients studied, there was a higher prevalence of females (74.2%), mean age of 61.9 ± 12.4 years old, and the rectum was the primary site of cancer in 54.8%. Most patients came from the countryside, were retirees, had lower education, consumed too much red meat, processed meats, and fats, with low consumption of fruits and vegetables, and were sedentary. Regarding nutritional status, nutritional risk was found in 58.1%, mean BMI of 25.7 ± 6.8 kg/m2, and 54.8% had significant weight loss. Additionally, 38.7% had some of the immediate complications, particularly paralytic ileus and abdominal distension. There was a delay in the onset of renourishment, and there was no association between nutritional status and immediate complications.
Conclusion colorectal cancer is closely related to eating habits and lifestyle. Patients with this malignancy have a marked weight loss; however, in this study, we found no association between nutritional status and the incidence of postoperative complications.
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DE-Aguilar-Nascimento JE, SalomÃo AB, Caporossi C, Dock-Nascimento DB, Eder Portari-Filho P, Campos ACL, Imbelloni LE, Silva-Jr JM, Waitzberg DL, Correia MITD. ACERTO Project - 15 years changing perioperative care in Brazil. Rev Col Bras Cir 2021; 48:e20202832. [PMID: 33503143 PMCID: PMC10846405 DOI: 10.1590/0100-6991e-20202832] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 09/18/2020] [Indexed: 12/14/2022] Open
Abstract
The ACERTO project is a multimodal perioperative care protocol. Implemented in 2005, the project in the last 15 years has disseminated the idea of a modern perioperative care protocol, based on evidence and with interdisciplinary team work. Dozens of published studies, using the protocol, have shown benefits such as reduced hospital stay, postoperative complications and hospital costs. Disseminated in Brazil, the project is supported by the Brazilian College of Surgeons and the Brazilian Society of Parenteral and Enteral Nutrition, among others. This article compiles publications by the authors who belong to the CNPq research group "Acerto em Nutrição e Cirurgia", refers to the experience of other national authors in various surgical specialties, and finally outlines the evolution of the ACERTO project in the timeline.
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Affiliation(s)
- JosÉ Eduardo DE-Aguilar-Nascimento
- - Centro Universitário de Várzea Grande (UNIVAG), Direção do Curso de Medicina - Várzea Grande - MT - Brasil
- - Universidade Federal de Mato Grosso, Curso de Pós-Graduação em Ciências da Saúde - Cuiabá - MT - Brasil
| | | | - Cervantes Caporossi
- - Universidade Federal de Mato Grosso, Curso de Pós-Graduação em Ciências da Saúde - Cuiabá - MT - Brasil
| | | | - Pedro Eder Portari-Filho
- - Universidade Federal do Estado do Rio de Janeiro (UNIRIO), Departamento de Cirurgia Geral e Especializada - Rio de Janeiro - RJ - Brasil
| | | | | | - JoÃo Manoel Silva-Jr
- - Universidade de São Paulo, Divisão de Anestesiologia - São Paulo - SP - Brasil
| | - Dan Linetzky Waitzberg
- - Universidade de São Paulo, Departamento de Gastroenterologia - São Paulo - SP - Brasil
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Bicudo-Salomão A, Salomão RDF, Cuerva MP, Martins MS, Dock-Nascimento DB, Aguilar-Nascimento JED. FACTORS RELATED TO THE REDUCTION OF THE RISK OF COMPLICATIONS IN COLORECTAL SURGERY WITHIN PERIOPERATIVE CARE RECOMMENDED BY THE ACERTO PROTOCOL. ACTA ACUST UNITED AC 2019; 32:e1477. [PMID: 31859930 PMCID: PMC6918738 DOI: 10.1590/0102-672020190001e1477] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 09/03/2019] [Indexed: 12/11/2022]
Abstract
Background: Perioperative care multimodal protocol significantly improve outcome in surgery. Aim: To investigate risk factors to various endpoints in patients submitted to elective colorectal operations under the ACERTO protocol. Methods: Cohort study analyzing through a logistic regression model able to assess independent risk factors for morbidity and mortality, patients submitted to elective open colon and/or rectum resection and primary anastomosis who were either exposed or non-exposed to demographic, clinical, and ACERTO interventions. Results: Two hundred thirty four patients were analyzed and submitted to 156 (66.7%) rectal and 78 (33.3%) colonic procedures. The length of hospital postoperative stay (LOS) ≥ 7 days was related to rectal surgery and high NNIS risk index; preoperative fasting ≤4 h (OR=0.250; CI95=0.114-0.551) and intravenous volume of crystalloid infused > 30ml/kg/day (OR=0.290; CI95=0.119-0.706). The risk of postoperative site infection (SSI) was approximately four times greater in malnourished; eight in rectal surgery and four in high NNIS index. The duration of preoperative fasting ≤4 h was a protective factor by reducing by 81.3% the risk of surgical site infection (SSI). An increased risk for anastomotic fistula was found in malnutrition, rectal surgery and high NNIS index. Conversely, preoperative fasting ≤4 h (OR=0.11; CI95=0.05-0.25; p<0.0001) decreased the risk of fistula. Factors associated with pneumonia-atelectasis were cancer and rectal surgery, while preoperative fasting ≤ 4 h (OR=0.10; CI95=0.04-0.24; p<0.0001) and intravenous crystalloid ≤ 30 ml/kg/day (OR=0.36; CI95=0.13-0.97, p=0.044) shown to decrease the risk. Mortality was lower with preoperative fasting ≤4 h and intravenous crystalloids infused ≤30 ml/kg/day. Conclusion: This study allows to conclude that rectal procedures, high NNIS index, preoperative fasting higher than 4 h and intravenous fluids greater than 30 ml/kg/day during the first 48 h after surgery are independent risk factors for: 1) prolonged LOS; 2) surgical site infection and anastomotic fistula associated with malnutrition; 3) postoperative pneumonia-atelectasis; and 4) postoperative mortality.
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Affiliation(s)
- Alberto Bicudo-Salomão
- Postgraduate Program in Health Sciences, Federal University of Mato Grosso, Cuiabá, MT, Brazil
| | | | - Mariani Parra Cuerva
- Postgraduate Program in Health Sciences, Federal University of Mato Grosso, Cuiabá, MT, Brazil
| | - Michelle Santos Martins
- Postgraduate Program in Health Sciences, Federal University of Mato Grosso, Cuiabá, MT, Brazil
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Gianotti L, Beretta S, Luperto M, Bernasconi D, Valsecchi MG, Braga M. Enhanced recovery strategies in colorectal surgery: is the compliance with the whole program required to achieve the target? Int J Colorectal Dis 2014; 29:329-41. [PMID: 24337781 DOI: 10.1007/s00384-013-1802-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2013] [Indexed: 02/04/2023]
Abstract
PURPOSE The complexity of "fast track" (FT) surgery might decrease its applicability in daily practice and extensive diffusion. The aim of this study was to understand if the positive effect of FT on the outcome might be affected by the number, type, level of evidence of the components, or their possible combinations. METHODS We performed a Medline, Embase, Pubmed, and Cochrane Library literature search of randomized and non-randomized trials comparing FT to conventional care (CC) in elective colorectal operations. By a meta-analytic approach, the effect of FT was estimated by the risk ratio (RR) with a 95 % confidence interval (CI) for the risk of post-operative complications. RESULTS The analysis included 53 studies (36 non-RCTs with and 17 RCTs), with 4,100 patients in the FT group and 4,424 patients in the CC group for a total of 8,524 patients. Fifty-six different item combinations were observed. The median rate of strategy implementation was 50 %. The positive effect of FT over CC was observed regardless the number (<10 vs. ≥10) of strategies used (RR = 0.80; 95 % CI 0.66-0.98 and RR = 0.75; 95 % CI 0.65-0.87, respectively), the application of items with strong vs. low level evidence (RR = 0.78; 95 % CI 0.67-0.90 and RR = 0.76; 95 % CI 0.63-0.92, respectively), or the frequency (≥80 vs. <80 %) of items implemented (RR = 0.80; 95 % CI 0.69-0.93 and RR = 0.73; 95 % CI 0.61-0.87, respectively). CONCLUSION The positive effects of FT seem to be achieved regardless the multiplicity and variance of item grouping.
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Affiliation(s)
- Luca Gianotti
- Department of Surgery and Translational Medicine, Milano-Bicocca University, San Gerardo Hospital, Monza, Italy,
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Dock-Nascimento DB, Aguilar-Nascimento JED, Linetzky Waitzberg D. Ingestion of glutamine and maltodextrin two hours preoperatively improves insulin sensitivity after surgery: a randomized, double blind, controlled trial. Rev Col Bras Cir 2014; 39:449-55. [PMID: 23348639 DOI: 10.1590/s0100-69912012000600002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Accepted: 07/18/2012] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To investigate whether the abbreviation of preoperative fasting with a drink containing glutamine and dextrinomaltose improves organic response to surgical trauma. METHODS Thirty-six female patients adult (18-62 years) candidates for elective laparoscopic cholecystectomy were randomly divided into three groups: conventional fasting (fasting group), and two groups receiving two different diets, eight hours (400ml) and two hours before induction of anesthesia (200ml): carbohydrate (CHO) group (12.5% dextrinomaltose) and the glutamine (GLN) group (12.5% dextrinomaltose and 40 and 10g of glutamine, respectively). Blood samples were collected pre and postoperatively. RESULTS Twenty-eight patients completed the study. No pulmonary complication occurred. Gastric residual volume was similar between groups (p = 0.95). Postoperatively, all patients from the fasting group had abnormal glucose (> 110mg/dl), this abnormality being of 50% when compared to the CHO group (p = 0.14), and of 22.2% when compared to the GLN group (p = 0.01). All patients who had the fasting period shortened (CHO + GLN) had normal postoperative insulin, contrasting with 66.7% in the fasted group (p = 0.02). The abnormal sensitivity to insulin postoperatively rose from 32.1% to 46.4% of cases (p = 0.24), and it occurred in only 11.1% of patients in GLN group when compared to 55.5% in the fasting group (p = 0.02). CONCLUSION the abbreviation of preoperative fasting for two hours with dextrinomaltose and glutamine improves insulin sensitivity in patients undergoing elective laparoscopic cholecystectomy.
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Costa HCBALD, Santos RL, Aguilar-Nascimento JED. Resultados clínicos antes e após a implantação do protocolo ACERTO. Rev Col Bras Cir 2013; 40:174-9. [DOI: 10.1590/s0100-69912013000300002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Accepted: 09/01/2012] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Comparar os resultados clínicos pós-operatórios de pacientes submetidos à cirurgia oncológica no Hospital de Câncer de Mato Grosso antes e após a implantação do protocolo ACERTO. MÉTODOS: Foram prospectivamente observados 271 pacientes durante dois períodos: o primeiro, entre abril e maio de 2010 (n=101) formado por pacientes submetidos a condutas convencionais (Fase 1) e o segundo, entre setembro a outubro de 2010 (n=171), formado por pacientes submetidos a um novo protocolo de condutas peri-operatórias estabelecidas pelo projeto ACERTO (Fase 2). As variáveis observadas foram: tempo de jejum pré-operatório, reintrodução da dieta no período pós-operatório, volume de hidratação e tempo de internação. RESULTADOS: Na comparação entre os dois períodos, na Fase 2 houve uma queda de aproximadamente 50% do tempo de jejum pré-operatório (14,7 [4-48] horas vs 7,2 [1-48] horas, p<0,001), houve redução de aproximadamente 35% do volume de fluidos intravenosos no pós-operatório imediato (p<0,001), de 47% no 1º PO (p<0,001) e de 28% no 2º PO (p=0,04), sendo a redução global de 23% (p<0,001). Não houve diferença no tempo de internação pós-operatória entre as duas fases (3,9 [0-51] vs. 3,2 [0-15] dias; p=0.52). Entretanto, nos pacientes cujo tempo de jejum pré-operatório foi de até 5 horas houve redução de um dia de internação (3.8 [0-51] vs 2.5 [0-15] dias, p=0,03). CONCLUSÃO: A adoção das medidas do projeto ACERTO é factível e segura em doentes oncológicos. Após a implantação do protocolo ACERTO reduziu-se o volume de fluidos intravenosos e quando o jejum pré-operatório foi reduzido o tempo de internação foi menor.
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Lins-Neto MÁDF, Leão MJDR, Alves EC, Fontan AJ. Preparo mecânico dos cólons é uma rotina necessária? ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2012; 25:25-8. [DOI: 10.1590/s0102-67202012000100006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
RACIONAL: O valor do preparo de cólon prévio nas operações colorretais continua discutível, visto que devido à tradição da rotina do preparo poucos estudos têm sido realizados para sustentação da operação segura sem o preparo mecânico. OBJETIVO: Verificar se há correlação entre as complicações pós-operatórias e a não utilização do preparo mecânico dos cólons nos pacientes operados. MÉTODOS: Foi realizado um estudo prospectivo nos pacientes submetidos a procedimentos cirúrgicos coloproctológicos abdominal sem prévio preparo intestinal. Foram coletadas informações antropométricas e epidemiológicas, co-morbidades existentes nos pacientes, antibioticoprofilaxia utilizada, complicações infecciosas e deiscências. RESULTADOS: A amostra foi composta de 126 pacientes, 57 homens e 69 mulheres com média de idade de 54 anos (19 a 89). Entre os pacientes que apresentaram comorbidades (43 pacientes - 34,12%), 30 (23,80%) eram hipertensos. A antibioticoprofilaxia foi utilizada em 89,70% dos pacientes. Dentre eles, 14,28% apresentaram complicações, sendo oito (6,34%) com infecção de ferida operatória, seis (4,76%) com deiscência de anastomose e quatro (3,17%) fístulas. CONCLUSÃO: O preparo dos cólons não é fundamental na rotina pré-operatória.
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