Page 1

 

!"##  $%&'  #!"

()(  6 3

May / June 9 


14 a 16 de maio Fortaleza / CE Centro de Eventos do Ceará

SOBRACIL 2020 15º Congresso Brasileiro de Videocirurgia 4º Congresso Brasileiro e Latinoamericano de Cirurgia Robótica

www.sobracil.org.br/congresso

100

95

75

Realização

25 Patrocinador exclusivo 5

www.programajovemcirurgiao.com.br

SOBRACIL BR - ANUNCIO JC e SOBRACIL 2020 quarta-feira, 12 de junho de 2019 16:22:35

0


CONTENTS / SUMÁRIO Rev Col Bras Cir 2019; 46(3)

ORIGINAL ARTICLE Laparoscopic nephrectomy for urolithiasis: when is better to avoid it Nefrectomia laparoscópica por nefrolitíase: quando é melhor evitar Alexandre Danilovic; Thiago Augusto Cunha Ferreira; Fábio Carvalho; Fábio César Miranda Torricelli; Giovanni Scala Marchini; Eduardo Mazzucchi; Willian Carlos Nahas; Miguel Srougi ......................................................................................................................................... e2092 Bariatric surgery and the coronary artery calcium score Cirurgia bariátrica e o escore de cálcio coronariano Daniel da Costa Lins; Patrícia S. Gadelha; Fernando Santa-Cruz; Luciana Teixeira de Siqueira; Josemberg Marins Campos; Álvaro Antônio Bandeira Ferraz .......................................................................................................................................................................................... e2170 The use of computed tomography for penetrating heart injury screening O uso da tomografia computadorizada na triagem da lesão cardíaca penetrante Adenauer Marinho de Oliveira Góes Júnior; Édpo Vinicius Lenzi de Oliveira; Flávia Beatriz Araújo de Albuquerque; Eduardo Gorayeb Martins; Mariseth Carvalho de Andrade; Simone de Campos Vieira Abib ................................................................................................................. e2154 Risk factors associated with hospital mortality in mitral valve reoperation Fatores de risco associados à mortalidade hospitalar em reoperação valvar mitral José Dantas de Lima Júnior; Jorge Eduardo Fouto Matias; Henrique Jorge Stahlke Júnior ............................................................................ e2176 Multiple victims incident simulation: training professionals and university teaching Simulação de incidente com múltiplas vítimas: treinando profissionais e ensinando universitários Daniel Souza Lima; Izabella Furtado de-Vasconcelos; Erika Feitosa Queiroz; Thaís Aguiar Cunha; Vitória Soares dos-Santos; Francisco Albert Eisntein Lima Arruda; Julyana Gomes Freitas .............................................................................................................................................. e2163 Abbreviated preoperative fasting favours postoperative oral intake at lower hospital admission costs for cancer patients Jejum pré-operatório abreviado favorece realimentação pós-operatória com menor custo de internação hospitalar em pacientes oncológicos. Phillipe Geraldo de Abreu Reis; Camila Polakowski; Marina Lopes; Danilo Saavedra Bussyguin; Raphaella Paula Ferreira; Vinicius Basso Preti; Flávio Daniel Saavedra Tomasich ................................................................................................................................................................ e2175

TEACHING Safety checklist in outpatient surgery teaching Checklist de segurança no ensino de cirurgia ambulatorial Kátia Sheylla Malta Purim; Carolina Gomes Gonçalves; Lucas Binotto; Anne Karoline Groth; Ayrton Alves Aranha Júnior; Mauricio Chibata; Christiano Marlo Paggi Claus; Fernanda Keiko Tsumanuma ........................................................................................................................ e2197

Rev Col Bras Cir

Rio de Janeiro

Vol 46

Nº 3

may/jun

2019


Official Organ of the Journal of the Brazilian College of Surgeons

LIBRARIAN

Lenita Penido Xavier

EDITOR

GUILHERME PINTO BRAVO NETO, TCBC-RJ Professor Associado IV do Departamento de Cirurgia da Faculdade de Medicina da Universidade Federal do Rio de Janeiro (UFRJ) - Rio de Janeiro - RJ - BR

ASSOCIATE EDITORS

FELIPE CARVALHO VICTER, TCBC - RJ Universidade do Estado do Rio de Janeiro (UERJ) - Rio de Janeiro – RJ - BR FERNANDO PONCE LEON, TCBC- RJ Universidade Federal do Rio de Janeiro (UFRJ) - Rio de Janeiro - RJ - BR

WRITING ASSISTANT

David da Silva Ferreira Júnior

GRAPHIC DESIGN

GN1 Sistemas e Publicações

RESPONSIBLE JOURNALIST João Maurício Carneiro Rodrigues Mtb 18.552

ADVICE OF REVIEWERS ABRÃO RAPOPORT, ECBC-SP - Universidade de São Paulo (USP) - São Paulo - SP - BR ADRIANA DAUMAS P. GUIMARÃES, TCBC-AM - Universidade Federal do Amazonas (UFAM) - Manaus - AM - BR AGNALDO SOARES LIMA, TCBC-MG - Universidade Federal de Minas Gerais (UFMG) - Belo Horizonte - MG - BR ALBERTO BICUDO SALOMÃO, TCBC-MT - Universidade Federal de Mato Grosso (UFMT) - Cuiabá MT - BR ALDO DA CUNHA MEDEIROS, ECBC-RN-Universidade Federal do Rio Grande do Norte (UFRN), Natal - RN - BR ALEXANDRE FERREIRA OLIVEIRA, TCBC-MG - Universidade Federal de Juiz de Fora (UFJF), Juiz de Fora - MG - BR ALFREDO GUARISCHI, TCBC-RJ - Instituto Nacional do Câncer (INCa) - Rio de Janeiro - RJ - BR ÁLVARO ANTONIO BANDEIRA FERRAZ, TCBC-PE - Universidade Federal de Pernambuco (UFPE), Recife – PE - BR ANA CRISTINA DE OLIVEIRA MARINHO, ACBC-RJ – Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro – RJ - BR ANA CRISTINA GOUVEIA MAGALHÃES - Universidade Federal do Rio de Janeiro (UFRJ), Rio De Janeiro- RJ – BR ANDRÉ GUSMÃO CUNHA, TCBC-BA - Universidade Federal da Bahia (UFBA) - Salvador - BA - BR ANDY PETROIANU, TCBC-MG – Universidade Federal de Minas Gerais (UFMG), Belo Horizonte - MG-BR ANTONIO CARLOS ACCETTA, TCBC-RJ - Universidade Federal Fluminense (UFF) - Niteroi - RJ - BR ANTONIO CARLOS LIGOCKI CAMPOS, TCBC-PR - Universidade Federal do Paraná (UFPR) - Curitiba - PR - BR ANTONIO CARLOS VALEZI, TCBC-PR – Universidade Estadual de Londrina (UEL), Londrina - PR – BR ANTONIO JOSÉ GONÇALVES, TCBC-SP - Faculdade De Ciências Médicas da Santa Casa de São PauloSão Paulo - SP - BR ARLINDO MONTEIRO DE CARVALHO JR., TCBC - PB -Universidade Federal da Paraíba (UFPB), João Pessoa - PB - BR ARMANDO GERALDO FRANCHINI MELANI, TCBC-SP – ICARD América Latina – São Paulo - SP –BR BRUNO MOREIRA OTTANI, TCBC-DF - Sociedade Brazileira de Cirurgia Bariátrica e Metabólica (SBCBM) - Brasília - DF - BR BRUNO MORISSON – Sociedade Brazileira de Angiologia e Cirurgia Vascular (SBCV), Rio de Janeiro RJ - BR CARLOS ALBERTO PORCHAT, TCBC-RJ - Hospital Clementino Fraga Filho da Universidade Federal do Rio de Janeiro (HUCFF), Rio de Janeiro - RJ - BR CARLOS ANSELMO LIMA, TCBC-SE- Universidade Federal de Sergipe (UFSE), Aracaju - SE-BR CARLOS DELROY - Universidade Federal de São Paulo (UNIFESP) - São Paulo - SP – BR CARLOS TEIXEIRA BRANDT, ECBC-PE – Universidade Federal de Pernambuco (UFPE) – Recife - PE – BR CLÁUDIO DE SABOYA DAVID, TCBC-RJ - Instituto de Pós-Graduação Médica Carlos Chagas (IPGMCC) - Centro - RJ - BR DAYSE COUTINHO VALENTE, TCBC-RJ- Instituto Fernando Luiz Barroso – Rio de Janeiro - RJ - BR DIOGO FRANCO, TCBC-RJ- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro - RJ - BR DOMINGOS ANDRÉ FERNANDES DRUMOND, TCBC-MG - Universidade Federal de Minas Gerais (UFMG) - Belo Horizonte - MG - BR DJALMA JOSE FAGUNDES, ECBC-SP - Universidade Federal De São Paulo (USP), São Paulo - SP - BR EDNA FRASSON DE SOUZA MONTERO, TCBC-SP- Universidade Federal de São Paulo (UNIFESP), São Paulo – SP - BR EDUARDO CREMA, TCBC-MG - Universidade Federal do Triângulo Mineiro (UFTM), Uberaba - MG - BR EDUARDO HARUO SAITO, TCBC-RJ - Universidade do Estado do Rio De Janeiro (UERJ), Rio de Janeiro - RJ-BR ELIZABETH GOMES DOS SANTOS, TCBC-RJ - Universidade Federal Do Rio De Janeiro (UFRJ), Rio de Janeiro – RJ - BR FÁTIMA CARNEIRO FERNANDES - Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro - RJ - BR FLAVIO DANIEL SAAVEDRA TOMASICH, TCBC-PR - Universidade Federal do Paraná (UFPR), Curitiba – PR - BR FLÁVIO MALCHER M. DE OLIVEIRA, TCBC-RJ - Hospital Universitário Gaffrée e Guinle (HUGG), Rio de Janeiro - RJ - BR FLORENTINO DE ARAUJO CARDOSO FILHO, TCBC-CE - Universidade Federal do Ceará (UFCE) Fortaleza - CE - BR FREDERICO AVELLAR SILVEIRA LUCAS, TCBC-RJ - Instituto Nacional Do Câncer (INCa), Rio de Janeiro - RJ - BR GIULIANO ANCELMO BENTO, ACBC- RJ – Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro – RJ – BR

GUSTAVO PEIXOTO SOARES MIGUEL, TCBC-ES - Universidade Federal do Espírito Santo (UFES) Vitório - ES - BR HAMILTON PETRY DE SOUZA, ECBC-RS- Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre - RS –BR HAROLDO VIEIRA DE MORAES Jr. - Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro RJ - BR HELIO MACHADO VIEIRA JR., TCBC-RJ HENRI CHAPLIN RIVOIRE, TCBC-RS - Universidade Federal do Rio Grande do Sul (UFRS), Porto Alegre - RS - BR HENRIQUE MURAD, ECBC-RJ - Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro - RJ – BR IRAMI ARAUJO FILHO, TCBC-RN - Universidade Federal do Rio Grande do Norte (UFRN), Natal – RN - BR IZIO KOWES, TCBC-BA - Instituto de Ensino e Simulação em Saúde (INESS) - Salvador - BA - BR JOAQUIM RIBEIRO FILHO, TCBC-RJ - Universidade Federal do Rio de Janeiro (UFRJ) - Rio de Janeiro - RJ - BR JOSÉ ANACLETO DUTRA RESENDE Jr. - Hospital Universitário Pedro Ernesto (HUPE), Rio de Janeiro - RJ - BR JOSÉ EDUARDO DE AGUILAR-NASCIMENTO, TCBC -MT-Universidade Federal De Mato Grosso (UFMT), Cuiabá – MT –BR JOSÉ EDUARDO FERREIRA MANSO, TCBC-RJ – Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro – RJ – BR JOSÉ JÚLIO DO REGO MONTEIRO FILHO, TCBC-RJ - Sociedade Brazileira de Videocirurgia e Robótica (SOBRACIL) - Rio de Janeiro - RJ - BR JOSÉ LUÍS DE SOUZA VARELA, TCBC-RJ JOSÉ LUIZ BRAGA DE AQUINO, TCBC-SP- Pontifícia Universidade Católica de Campinas (PUCCAMP), Campinas – SP - BR JOSÉ MARCUS RASO EULÁLIO, TCBC-RJ – Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro – RJ – BR JOSÉ MAURO DA SILVA RODRIGUES, TCBC-SP - Pontifícia Universidade Católica de São Paulo (PUCSP), São Paulo - SP – BR JOSÉ SÉRGIO FRANCO, TCBC-RJ - Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro – RJ – BR JOSÉ WILSON NOLETO - Universidade Federal da Paraíba (UFPB), João Pessoa - PB - BR JULIO CESAR BEITLER, TCBC-RJ – Universidade Estácio de Sá – Rio de Janeiro –RJ - BR JÚLIO CEZAR UILI COELHO, TCBC-PR – Universidade Federal do Paraná (UFPR), Curitiba –BR KÁTIA SHEYLA MALTA PURIM - Universidade Positivo (UP), Curitiba-PR-BR LAERCIO ROBLES, TCBC-SP - Hospital Santa Marcelina - São Paulo - SP -BR LEONEL DOS SANTOS PEREIRA - Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro - RJ - BR LISIEUX EYER DE JESUS, TCBC-RJ- Universidade Federal Fluminense (UFF), Niteroi - RJ - BR LUCIANO ALVES FAVORITO – Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro – RJ – BR LUCIO FILGUEIRAS PACHECO MOREIRA, ACBC-RJ – Instituto de Transplantes – Rio de Janeiro – RJ - BR LUIZ AUGUSTO MALTONI JR., TCBC-RJ - Hospital Fundação do Câncer - Rio de Janeiro - RJ - BR LUIZ CARLOS DUARTE DE MIRANDA, ACBC-RJ - Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro - RJ - BR LUIZ CARLOS VON BAHTEN, TCBC-PR- Universidade Federal do Paraná (UFPR), Curitiba - PR - BR LUIZ GUSTAVO DE OLIVEIRA E SILVA, TCBC-RJ- Hospital Federal de Ipanema/Ministério da Saúde- Rio de Janeiro – RJ - BR MANOEL XIMENES NETO, ECBC-DF - Universidade de Brasília (UnB), Brasília -DF-BR MANUEL DOMINGOS DA CRUZ GONÇALVES, ECBC-RJ- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro – RJ – BR MARCELO AUGUSTO F. RIBEIRO JR., TCBC-SP - Universidade de Santo Amaro (UNISA), São Paulo SP – BR MARCO ANTONIO MARQUES LEITE, ECBC-RJ - Sociedade Brazileira de Cirurgia Bariátrica e Metabólica - Rio de Janeiro - RJ - BR MARCOS ALPOIM FREIRE – TCBC-RJ- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro –RJ – BR MARCOS BETTINI PITOMBO, TCBC-RJ – Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro – RJ - BR MARIA APARECIDA DE ALBUQUERQUE CAVALCANTE - Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro - RJ - BR MARIA FERNANDA MARTINELLI TRABULSI, TCBC-SP - Santa Casa de Misericórdia de São José do Rio Preto - São José do Rio Preto - SP - BR MARIA ISABEL TOULSON CORREIA, TCBC-MG - Universidade Federal de Minas Gerais (UFMG) - Belo Horizonte - MG - BR


MARIA DE LOURDES P. BIONDO SIMÕES, TCBC-PR – Pontifícia Universidade Católica do Paraná (PUCPR), Curitiba – PR-BR MAURÍCIO AUGUSTO S. MAGALHÃES COSTA, TCBC-RJ - Sociedade Brazileira de Mastologia (SBM), Rio De Janeiro - RJ – BR MAURICIO GONÇALVES RUBINSTEIN, TCBC-RJ – Universidade Federal do Estado do Rio de Janeiro (UFRJ), Rio de Janeiro – RJ – BR MAURO DE SOUZA LEITE PINHO, TCBC-SC – Universidade da Região de Joinville (UNIVILLE), Joinville – SC - BR MIGUEL LUIZ ANTONIO MODOLIN, ECBC-SP - Universidade de São Paulo (USP), São Paulo - SP- BR NELSON ADAMI ANDREOLLO, TCBC-SP - Universidade Estadual de Campinas (UNICAMP), Campinas – SP - BR ORLANDO JORGE MARTINS TORRES, TCBC-MA - Universidade Federal do Maranhão (UFMA), São Luís - MA - BR OSVALDO MALAFAIA, ECBC-PR- Universidade Federal do Paraná (UFPR), Curitiba – PR- BR PAULO FRANCISCO GUERREIRO CARDOSO, ACBC-RS- Fundação Faculdade Federal de Ciências Médicas de Porto Alegre (UFCSPA), Porto Alegre – RS- BR PAULO GONÇALVES DE OLIVEIRA, TCBC-DF- Universidade de Brasília (UnB), Brasília - DF - BR RAFAEL RODRIGUEZ FERREIRA, TCBC-RJ RAMIRO COLLEONI NETO, TCBC-SP - Universidade Federal de São Paulo (UNIFESP) - São Paulo SP- BR RENATO ABRANTES LUNA, TCBC-RJ – Hospital Federal dos Servidores do Estado do Rio de Janeiro (HSE), Rio de Janeiro – RJ- BR RENI CECÍLIA LOPES MOREIRA, TCBC-MG - Colégio Brazileiro de Cirurgiões (CBC/MG) - MG - BR RICARDO ANTONIO CORREIA LIMA, TCBC-RJ – Universidade Federal do Estado do Rio de Janeiro (UNIRIO), Rio de Janeiro – RJ – BR

RICARDO BREIGEIRON, TCBC-RS - Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre - RS - BR RICARDO SILVA GUIMARÃES, TCBC-RJ - Universidade Federal Fluminense (UFF) - Niteroi - RJ - BR ROBERTO CAMPOS MEIRELLES, TCBC-RJ - Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro - RJ - BR RODRIGO ALTENFELDER SILVA, TCBC-SP- Faculdade de Ciências Médicas da Santa Casa de São Paulo - São Paulo - SP-BR ROGERIO APARECIDO DEDIVITIS, TCBC-SP- Universidade De São Paulo (USP), São Paulo - SP - BR RUBENS ANTONIO AISSAR SALLUM, TCBC-SP - Hospital das Clínicas da Faculdade de Medicina da USP - São Paulo - SP - BR RUFFO DE FREITAS JÚNIOR, TCBC-GO- Universidade Federal de Goiás (UFGO), Goiânia – GO – BR SILVIO HENRIQUES DA CUNHA NETO, TCBC- RJ - Universidade Federal do Rio de Janeiro (UFRJ) - Rio de Janeiro - RJ - BR SIZENANDO VIEIRA STARLING, TCBC-MG - Hospital João XXIII - Belo Horizonte - MG - BR TÉRCIO DE CAMPOS, TCBC-SP- Faculdade de Ciências Médicas da Santa Casa de São Paulo - São Paulo - SP - BR THALES PAULO BATISTA, TCBC-PE- Faculdade Pernambucana de Saúde (FPS)/ Instituto de Medicina Integral Professor Fernando Figueira (IMIP), Recife - PE - BR VIVIAN RESENDE, TCBC-MG - Universidade Federal de Minas Gerais (UFMG), Belo Horizonte - MG - BR WANDA ELIZABETH MASSIERE Y CORREA, TCBC-RJ – Pontifícia Universidade Católica do Rio de Janeiro (PUCRJ), Rio de Janeiro – RJ - BR WELLINGTON ANDRAUS, TCBC-SP - Universidade de São Paulo (USP) - São Paulo - SP - BR WILSON CINTRA JR., TCBC-SP-Universidade de São Paulo (USP), São Paulo - SP - BR

NATIONAL CONSULTANTS ALCINO LÁZARO DA SILVA, ECBC-MG - Universidade Federal de Minas Gerais (UFMG) - Belo Horizonte - MG - BR. ALUIZIO SOARES DE SOUZA RODRIGUES, ECBC-RJ - Universidade Federal do Rio de Janeiro (UFRJ)Rio de Janeiro - RJ - BR. ANTONIO PELOSI DE MOURA LEITE, ECBC-SP - Instituto de Moléstias Cardiovasculares de São José do Rio Preto - SP - BR DARIO BIROLINI, ECBC-SP - Universidade de São Paulo (USP) - São Paulo - SP - BR FERNANDO MANOEL PAES LEME, ECBC-RJ - Faculdade de Medicina de Campos (FMC) - Campos - RJ - BR GASPAR DE JESUS LOPES FILHO, TCBC-SP - Universidade Federal de São Paulo (UNIFESP) - São Paulo - SP - BR GUILHERME EURICO BASTOS DA CUNHA, ECBC-RJ - Universidade Federal Fluminense (UFF) -Niteroi - RJ - BR

HELÁDIO FEITOSA DE CASTRO FILHO, TCBC-CE - Universidade Federal do Ceará (UFCE) Fortaleza - CE- BR ISAC JORGE FILHO, TCBC-SP- Universidade de Ribeirão Preto (UNAERP)- Ribeirão Preto - SP - BR JOSÉ REINAN RAMOS, TCBC-RJ - Hospital Vitória - RJ - BR LUIZ GUILHERME BARROSO ROMANO, ECBC-RJ MARCOS FERNANDO DE OLIVEIRA MORAES, ECBC-RJ – Fundação do Câncer - RJ - BR ORLANDO MARQUES VIEIRA, ECBC-RJ - Universidade Federal do Rio de Janeiro (UFRJ) - Rio de Janeiro - RJ - BR PAULO ROBERTO CORSI, TCBC-SP - Faculdade de Ciências Médicas da Santa Casa de São PauloSP - BR ROBERTO SAAD JR., TCBC-SP - Faculdade de Ciências Médicas da Santa Casa de São Paulo - SP - BR SAMIR RASSLAN, ECBC-SP - Universidade de São Paulo (USP) - São Paulo - SP - BR

INTERNATIONAL CONSULTANTS ARNULF THIEDE - University Hospital of Würzburg, Würzburg, Germany CLAUDE DESCHAMPS - University of Vermont Medical Group, Vermont, USA EDUARDO PARRA-DAVILA - Florida Hospital Celebration Health, Florida, USA EMILIO DE VICENTE LÓPEZ – Hospital Universitario Madrid Sanchinarro, Madrid, España

KARL-HERMANN FUCHS - Goethe University of Frankfurt, Germany MURRAY BRENNAN - Memorial Sloan-Kettering Cancer Center, New York, USA ULRICH ANDREAS DIETZ - University of Würzburg, Medical School, Würzburg, Germany WALTER WEDER - Klinikdirektor - UniversitätsSpital Zürich, Switzerland

FORMER EDITORS 1967 - 1969 JÚLIO SANDERSON

1969 - 1971 JOSÉ HILÁRIO

1973 - 1979 HUMBERTO BARRETO

1980 - 1982 EVANDRO FREIRE

1980 - 1982 EVANDRO FREIRE

1983 - 1985 JOSÉ LUIZ XAVIER PACHECO

1986 - 1991 MARCOS MORAES

1992 - 1999 MERISA GARRIDO

2000 - 2002 JOSÉ ANTÔNIO GOMES DE SOUZA

2002 - 2005 GUILHERME PINTO BRAVO NETO

2006 - 2015 JOSÉ EDUARDO FERREIRA MANSO

THE JOURNAL OF THE BRAZILIAN COLLEGE OF SURGEONS is indexed in Latindex, Lilacs and Scielo, Scopus, Medline / PubMed, DOAJ, Free Medical Journals, and sent every two months to all members of the CBC, to its subscribers, to medical institutions, libraries, hospitals and study centers, to publications with which it keeps exchange and to its advertisers.

PUBLISHING, SUBSCRIPTIONS and ADMINISTRATION Rua Visconde de Silva, 52 - 3º andar - Botafogo - 22271-092 - Rio de Janeiro - RJ - Brazil Tel.: + 55 21 2138-0659; Fax: + 55 21 2286-2595; E-mail: revistacbc@cbc.org.br http//www.cbc.org.br

International Standard Serial Number ISSN 0100-6991

PRINTING AND FINISHING Gráfica e Editora Prensa Ltda Rua João Alvares, 27 Saúde - Rio de Janeiro - RJ Tel.: (21) 2253-8343

JOURNAL OF THE BRAZILIAN COLLEGE OF SURGEONS Indexed in Latindex, Lilacs and Scielo, Scopus, Medline/PubMed, DOAJ and Free Medical Journals

GRAPHIC DESIGN GN1 Sistemas e Publicações GRAPHIC DESIGN – COVER Libertta Comunicação


Programação dos Cursos Continuados de Cirurgia Geral em 2019 NÚCLEO CENTRAL

SÃO PAULO

Programação

Programação

16/03 - Módulo I: – Cirurgia do Esôfago 13/04 - Módulo II: – Abdome Agudo 29/06- Módulo III – Cirurgia Endócrina 20/07 - Módulo IV – Trauma 31/08 - Módulo V – Educação Médica/Honorários 21/07 - Módulo VI – Cirurgia Oncológica 30/11 - Módulo VII – Cirurgia Minimamente Invasiva e Robótica

23/03 - Módulo I: Esôfago, Estômago, Intestino delgado e Bariátrica 13/04 - Módulo II: Fígado, Transplantes, Hérnias abdominais 25/05 - Módulo III: Painel de especialidades: Uro, tórax, cabeça e pescoço 15/06 - Módulo IV: Vias biliares e pâncreas 27/07 - Módulo V: Coloproctologia 31/08 - Módulo VI: Urgências não traumáticas 28/09 - Módulo VII: Urgências traumáticas 26/10 - Módulo VIII: Painel de especialidades: Vascular, cirurgia pediátrica e plástica

Horário: 8h30 às 13h Local: Centro de Convenções CBC – Rua Visconde de Silva, 52 – 1º andar – Botafogo – Rio de Janeiro – RJ. Informações: Tel: (21) 2138-0650 e 2138-0656 www.cbc.org.br/eventos/agenda/

Horário: 8h30 às 13h Local: Associação Paulista de Medicina – APM Av. Brig. Luis Antônio, 278 – 9° andar, no Bairro da Bela Vista – São Paulo - SP Informações: (11) 3101-8792 ou ainda pelo e-mail: contato@cbcsp.org.br ou pelo WhatsApp (11) 97395-0280

CEARÁ

GOIÁS

Programação

Programação

27/02 - Módulo I: Cirurgia da Tireoide, Paratireoide e das Glândulas Salivares/ Cirurgia da Adrenal 27/03 - Módulo II: Cirurgia da Mama/Bases da Cirurgia Torácica 24/04 - Módulo III: Cirurgia das Hérnias/Abdome Agudo não Traumático 29/05 - Módulo IV: Hemorragia Digestiva e Hipertensão Porta/Cirurgia do Esôfago 26/06 - Módulo V: Cirurgia do Fígado e Vias Biliares/ Cirurgia do Estômago 31/07 - Módulo VI: Cirurgia do Intestino Delgado/ Cirurgia do Cólon, Reto e Ânus 28/08 - Módulo VII: Cirurgia do Pâncreas e Cirurgia do Baço/Bases da Cirurgia Vascular 25/09 - Módulo VIII: Cirurgia dos Tumores da Pele e Cirurgia Ambulatorial/Bases da Cirurgia Ginecológica 30/10 - Módulo IX: Bases da Cirurgia Pediátrica/ Cirurgia Minimamente Invasiva 2 7/11 - Módulo X: Cirurgia Bariátrica e Metabólica/ Bases Da Cirurgia No Paciente Idoso

22/03 - Módulo I: Trauma 26 e 27/04 - Módulo II: Cuidado pré-hospitalar no Trauma 14 e 15/06 - Modulo III: Cirurgia Bariátrica e Metabólica 23 e 24/08 - Módulo IV: Hérnia da Parede Abdominal 13 e 14/09 - Módulo V: Urgências Abdominais não traumáticas 18 e 19/10 - Módulo VI: Afecções Benignas das Vias Biliares e Pâncreas 22 e 23/11 - Módulo VII: Cuidados Pré-Operatórios – da Nutrição à Cirurgia

Horário: 19h às 21h Local: auditório da Coocirurge Av. Desembargador Moreira, 760 – salas 804 a 806 – Aldeota – Fortaleza Informações: Tel: (85) 31817580

Horário: 8h às 12h Local: Conselho Regional de Medicina Rua T-27, número 148 – setor Bueno Informações: (62) 394 1374 / E-mail: cbcgoias@gmail.com

PARANÁ Programação 13/03/2019 - Módulo I: Trauma Cervical 11/04/2019 - Módulo II: Abdome Agudo Infeccioso 09/05/2019 - Módulo III: Trauma de Tórax 13/06/2019 - Módulo IV: Abdome Agudo Oclusivo 11/07/2019 - Módulo V: Complicações pós-operatórias de cirurgia bariátrica 08/08/2019 - Módulo VI: Cirurgia Hepatobiliar 12/09/2019 - Módulo VII – 10/10/2019 - Módulo XVIII: Manejo das Fístulas Digestivas 14/11/2019 - Módulo XIX: Manejo do Choque Hipovolêmico Horário: 19h30 às 21h Local: Conselho Regional de Medicina do Paraná Rua Vitório Viezzer, 84 – Curitiba - PR Informações: (41) 324045 E-mail: eventos@crmpr.org.br


Original Article

DOI: 10.1590/0100-6991e-20192092

Laparoscopic nephrectomy for urolithiasis: when is better to avoid it. Nefrectomia laparoscópica por nefrolitíase: quando é melhor evitar. Alexandre Danilovic1; Thiago Augusto Cunha Ferreira, ACBC-SP1; Fábio Carvalho Vicentini1; Fábio César Miranda Torricelli1; Giovanni Scala Marchini1; Eduardo Mazzucchi1; Willian Carlos Nahas1; Miguel Srougi, TCBC-SP1 A B S T R A C T Objective: to investigate the risk factors for conversion to open surgery in laparoscopic nephrectomy (LN) for urolithiasis. Methods: we reviewed data on all patients over 18 years of age submitted to LN between January 2006 and May 2013 at our institution. We analyzed the Charlson's index, the ASA score, renal function by the equation and stage of MDRD (Modification of Diet in Renal Disease), preoperative computed tomography (CT) findings, complications by the ClavienDindo classification and conversion rate. We used logistic regression analysis to determine the risk factors for conversion. Results: eighty-four patients underwent LN, 16 (19%) sustaining convertion to open surgery due to the strong adhesion of the renal hilum to the adjacent organs. Other causes associated with conversion were excessive bleeding (n=6) and lesion of the large intestine (n=3). In the univariate analysis, previous renal surgery, perirenal fat blurring, renal abscess, perirenal abscess, pararenal abscess, fistula, adherence to the liver or spleen, and adherence to the intestine were associated with conversion. In the multivariate analysis, pararenal abscess and adherence to the intestine were significant risk factors for conversion. Conclusion: pararenal abscess and bowel adhesions demonstrated in the preoperative CT are risk factors for conversion to open surgery in LN due to urolithiasis. Keywords: Nephrectomy. Laparoscopy. Risk Factors. Urolithiasis.

INTRODUCTION

T

he prevalence of kidney calculi is approximately 8% of the population and its incidence is increasing over the past two decades in both men and women of different age groups1. Renal calculus disease is a benign pathology, but can cause progressive loss of renal function, end-stage kidney disease and ultimately death2. Treatment aims to preserve renal function and to eradicate kidney calculi. However, nephrectomy may be necessary in cases of severe urinary infection or chronic pain in a kidney with a poor function3. Laparoscopy is considered the gold standard approach for nephrectomy due to less postoperative pain, short recovery and better cosmetic outcomes. However, the massive inflammatory process that sometimes is associated to complicated calculus disease

causes technical difficulties, owing to the presence of a significant fibrotic component. The ultimate presentation in this scenario is xanthogranulomatous pyelonephritis (XGP), accompanied by perirenal fat proliferation that infiltrates the renal fossa structures, including the renal hilum4. Owing to its severe inflammatory nature, distinct surgical complications are expected from those found in nephrectomy for donation or kidney cancer5. Furthermore, some patients present with adverse conditions, such as renal abscess, renocutaneous fistula and visceral or intestinal adhesions. The conversion rate to open procedure is expected to be higher in patients with renal calculus comparing with other affections6. In this retrospective study, we searched for preoperative predictive factors for conversion to open surgery in laparoscopic nephrectomy (LN) for urolithiasis.

1 - University of São Paulo, Faculty of Medicine, Discipline of Urology, São Paulo, SP, Brazil.

Rev Col Bras Cir 46(3):e20192092


Danilovic Laparoscopic nephrectomy for urolithiasis: when is better to avoid it.

2

METHODS We retrospectively evaluated all consecutive patients older than 18 years of age submitted to LN for urolithiasis from January 2006 to May 2013 in a tertiary reference center. Nephrectomy was accomplished due to pain in excluded kidneys or severe urinary infection. Initial surgical approach was proposed by the surgeon and discussed with the patient. Informed consent was obtained from all patients. We obtained the approval of the local Institutional review board for the study protocol. This work was approved by the Institutional Ethics Committee with the following reference number: 1,905,989. Preoperative assessment

We assessed renal function by the equation of the Modification Diet for Renal Disease (MDRD)7 for estimated glomerular filtration rate and staged according to National Kidney Foundation. We estimated the split renal function with 99m technetium dimercaptosuccinic acid renal scintigraphy (99mTc-DMSA). We evaluated comorbidities with the Charlson Index and the American Society of Anesthesiologists (ASA) score8. We carried out computed tomography scans preoperatively in all patients.

Findings of hydronephrosis, fat stranding, adherence to surrounding structures (Figure 1) and abscess (renal, perirenal and pararenal) (Figure 2) were based on the radiologists report. Operative technique

Residents performed the procedures under direct supervision of experienced laparoscopic surgeons. We carried out LN through a transperitoneal approach. Under general anesthesia, we positioned patients in a 45-degree supine-oblique position. We created pneumoperitoneum with CO2 up to 15mmHg intra-abdominal pressure. We used four trocars (two 10mm and two 5mm). On the right side, we positioned an extra trocar in the epigastric region to move the liver cranially and adequately expose the right kidney. We dissected the kidney and perirenal fat outside the Gerota fascia 5. We approached the renal hilum as close as possible to the inferior vena cava on the right side, and to the aorta on the left side. We clipped the renal arteries and veins with Hem-o-lockÂŽ clips and divided them. We clipped the ureter and sectioned it close to the iliac vessels. We removed the specimen fragmented in a bag through the umbilical incision or undivided through a suprapubic incision. We sent the specimen for pathologic analysis in all cases.

Figure 1. Tomographic findings of the kidneys affected by calculi and the spectra of the inflammatory process: A) hydronephrosis caused by an obstructing calculus; B) perirenal fat infiltration due to severe inflammatory infiltration; C) adherence to liver; D) adherence to the psoas muscle. Rev Col Bras Cir 46(3):e20192092


Danilovic Laparoscopic nephrectomy for urolithiasis: when is better to avoid it.

3

Figure 2. Tomographic findings showing abscess formation due to kidney inflammatory disease: A) renal abscess; B) perirenal abscess; C) pararenal abscess.

Postoperative complications

Table 1. Preoperative data.

Postoperative complications were reported according to the Clavien-Dindo classification9. Statistical analysis

We analyzed the categorical variables using the Chi-square and the Fisher's exact test and continuous ones using the Student’s t-test and analysis of variance (ANOVA). We performed a logistic regression analysis to evaluate the association between clinical and pathological data and the risk of conversion to open surgery. We conducted statistical analyzes with the aid of the SPSS Statistics v16.0 (Chicago, SPSS Inc.).

RESULTS Eighty-four patients with a poor functioning kidney associated to pain or severe infection underwent nephrectomy in our Institution (Table 1) in the study period. The main tomographic findings were hydronephrosis (71.4%), fat stranding (63%) and adherence to liver/spleen (29.6%).

Preoperative data Gender (female) Age (mean±SD) BMI (mean±SD, kg/m2) Prior renal surgery Renal size (mean±SD, cm) Left kidney DMSA renal scan (mean±SD, %) MDRD (mean±SD, ml/min/1.73m2) Charlson index (mean±SD) ASA score       1       2       3       4 Staghorn calculus Tomographic findings       Hydronephrosis       Fat stranding       Renal abscess       Perirenal abscess       Pararenal abscess       Adherence to liver/spleen       Adherence to bowel       Adherence to muscle

n (%) 67 (79.7) 47.8±14.2 26.6±5.5 37 (44) 11.7±3.83 44 (52.3) 8±9.8 69.45±28.03 1.26±1.9 22 (26.2) 52 (61.9) 8 (9.5) 2 (2.4) 47 (55.9)   60 (71.4) 53 (63) 15 (17.8) 7 (8.3) 3 (3.5) 25 (29.6) 20 (23.8) 16 (19)

BMI= body mass index; SD= standard deviation; MDRD= modification of diet in renal disease formula; DMSA= dimercaptosuccinic acid; ASA= American Society of Anesthesiologists.

Rev Col Bras Cir 46(3):e20192092


Danilovic Laparoscopic nephrectomy for urolithiasis: when is better to avoid it.

4

Conversion rate was 19% (16 of 84 patients). The main cause of conversion was inadequate exposure of the renal hilum due to severe adhesion and inflammation, seen in all converted cases. Other causes for conversion included excessive bleeding during the operation (6/16, 37.5%) and large intestinal injury (3/16, 18.8%). Complications according to the Clavien classification are summarized in table 2. Two vena cava injuries were repaired by running laparoscopic suture. Open splenectomy was performed in the immediate postoperative period in one patient due to a splenic laceration. There were five intestinal injuries: two duodenal, one repaired laparoscopicaly and other converted to open procedure, one colonic and one small bowel injuries that resulted in conversion. One patient died due to unrecognized colonic injury and peritonitis. Table 3 shows the pathological reports. Table 2. Complications according to the Clavien classification.

Clavien classification I II III a III b IV a IV b V

n (%) 62 (73.8) 11 (13.1) 3 (3.5) 1 (1.2) 5 (5.9) 1 (1.2) 1 (1.2)

Table 3. Pathology report.

Pathology report Xanthogranulomatous pyelonephritis Atrophy Chronic pyelonephritis Pyonephrosis Nephrocalcinosis

n (%) 16 (19) 18 (21.4) 32 (38) 10 (11.9) 8 (9.5)

In the univariate analysis, conversion was significantly associated to prior renal surgery (68.7% vs. 38.2%, p=0.043), perirenal fat stranding

(97.3% vs. 55.8%, p=0.004), renal abscess (37.5% vs. 13.2%, p=0.03), perirenal abscess (25% vs. 4.4%, p=0.023), pararenal abscess (18.7% vs. 0%, p=0.006), fistula (18.7% vs. 0%, p=0.006), adherence to liver or spleen (56.2% vs. 23.5%, p=0.015) and adherence to bowel (75% vs. 11.7%, p<0.0001) (Table 4). In the multivariate analysis, only pararenal abscess (p=0.0052) and adherence to bowel (p<0.0001) were significant risk factors for conversion (Table 5). Postoperative hospital stay was relatively higher in the conversion group (5.4Âą3.1 vs. 3.19Âą2,3 days, p=0.005).

DISCUSSION Laparoscopy is the procedure of choice for performing nephrectomy10. Nowadays, the vast majority of nephrectomies are performed for donation or treatment of renal cancer10,11. Nephrectomy due to complications of urolithiasis is performed in a few situations, including kidneys with poor function associated to chronic pain, symptomatic or recurrent infections, abscess or fistulae formation and suspect malignant degeneration3. LN due to urolithiasis is a challenging procedure, requiring a skillful surgical team. The inflammatory process creating a toxic fat involves the renal hilum, leading to a very difficult dissection of the renal artery and vein. Moreover, bulky adenopathy, adhesion to bowel, liver, spleen, pancreas or muscle are frequent. En block clamping or initial clamping of the renal vein are eventually required maneuvers to control the renal hilum, diverting from standard nephrectomy. On certain occasions, it is impossible to find a cleavage plane between the large vessels and the urinary tract, forcing the surgeon to leave patches of kidney tissue adhered to these structures. On the right side, the difficulty is even higher due to the nearby vena cava and the duodenum.

Rev Col Bras Cir 46(3):e20192092


Danilovic Laparoscopic nephrectomy for urolithiasis: when is better to avoid it.

5

Table 4. Univariate analysis of risk factors for conversion in laparoscopic nephrectomy for urolithiasis.

Female Age >70 years BMI ≥30kg/m2 Prior renal surgery DMSA <20% Charlson >2 ASA score       1       2       3       4 Kidney size =12cm Tomographic findings       Hydronephrosis       Fat stranding       Renal abscess       Perirenal abscess       Pararenal abscess       Fistula       Adherence to liver/spleen       Adherence to bowel       Adherence to muscle Pathological diagnosis       Xanthogranulomatous Pyelonephritis       Atrophy       Chronic Pyelonephritis       Pyonephrosis       Nephrocalcinosis

Conversion n(%) 13 (81.2) 1 (62) 2 (12.5) 11 (68.7) 15 (93.7) 7 (43.7) 4 (25.0) 9 (56.2) 3 (18.7) 0 (0.0) 7 (43.7)   11 (68.7) 15 (93.7) 6 (37.5) 4 (25.0) 3 (18.7) 3 (18.7) 9 (56.2) 12 (75.0) 5 (31.2)   6 (37.5) 2 (12.5) 6 (37.5) 2 (12.5) 2 (12.5)

Pure laparoscopy n(%) 54 (79.4) 2 (3.0) 18 (26.4) 26 (38.2) 63 (92.6) 16 (23.5) 18 (26.4) 43 (63.3) 5 (7,3) 2 (3.0) 17 (25)   49 (72.0) 38 (55.8) 9 (13.2) 3 (4.4) 0 (0.0%) 0 (0.0%) 16 (23.5) 8 (11.7) 11 (16.1)   10 (14.7) 16 (23.5) 26 (38.2) 8 (11.7) 6 (8.9)

p-value 1.000 0.474 0.336 0.043 1.000 0.125 0.557       0.217   0.767 0.004 0.033 0.023 0.006 0.006 0.015 <0.0001 0.175   0.105 0,449 0.711 0.165 0.105

SD= standard deviation; MDRD= modification of diet in renal disease formula; ASA= American Society of Anesthesiologists.

Table 5. Multivariate analysis of risk factors for conversion in laparoscopic nephrectomy for urolithiasis.

Risk factors Fat stranding Renal abscess Perirenal abscess Pararenal abscess Adherence to liver/spleen Adherence to bowel

Chi-square 0.121 0 0.016 7.808 3.007 30.424

Rev Col Bras Cir 46(3):e20192092

p-value 0.728 0.9996 0.8978 0.0052 0.0829 <0.0001


Danilovic Laparoscopic nephrectomy for urolithiasis: when is better to avoid it.

6

In our series, we observed two cases of duodenum injury and two cases of vena cava tearing repaired by laparoscopic suture. Such technical difficulties lead many urologists to question the laparoscopic approach in such cases12,13. In this scenario, the literature suggests that LN due to calculi and inflammatory disease should be performed by approaching the kidney from outside the Gerota fascia, leading to a safer procedure14,15. Conversion rate is still higher than the one observed in LN for other conditions. Zelhof et al., in a study of 142 cases selected from all the nephrectomies performed in the United Kingdom due to benign conditions, demonstrated higher conversion rates to open procedure in patients with renal calculi than for radical nephrectomy for T1 disease16. A recent retrospective study with 96 laparoscopic nephrectomies for calculus disease evidenced a conversion rate of 7.2%17. Conversion to open procedure was necessary because it proved impossible to dissect the renal hilum due to xanthogranulomatous pyelonephritis (n=4) or major associated lesions (n=3). In other recent prospective study with 44 patients submitted to LN for benign non-functioning kidney diseases, six (13.6%) were converted to open surgery due to vascular lesions, malfunctioning of surgical devices and no localization of the atrophic kidney15. Our study reports a 19% (16/84) conversion rate in nephrectomies exclusively for urolithiasis. In all converted cases, the appropriate access to the renal hilum was hampered due to the intense inflammatory process. Conversion to open nephrectomy also results in longer hospital stay (5.4Âą3.1 vs. 3.19Âą2.3 days, p=0.005), highlighting the importance of choosing the proper access prior to nephrectomy. There are few evidences in the medical literature establishing predictive factors for open conversion in LN. Angerri et al. showed that

extensive areas of pyelonephritis are a major risk for conversion17. Rassweiler et al. reported seven conversions to open procedures in a multicentric study with 482 LN, of which two involved an XGP kidney18. In our series, there were more cases with XGP in the conversion group (25.0% vs. 14.7%; p=0.105), however there was no significant difference between groups regarding pathological findings. Previous renal ipsilateral surgery increases difficulty due to anatomical changes in already operated kidneys, in addition to scarring processes and adhesions to nearby tissues6. In our study, cases with prior renal surgery were more frequent among converted procedures but this fact was not significant in the multivariate analysis. Preoperative enhanced CT scan plays an important role in inflammatory kidney diseases, determining the extension of the inflammatory process. The pattern of differential enhancement in these cases reflects the underlying pathophysiology of tubular obstruction caused by inflammatory debris within the lumen, interstitial edema, and vasospasm19. Perirenal fat infiltration occurs when the inflammation of the renal parenchyma is severe and the inflammatory infiltration spreads beyond the renal capsule to the perirenal fat. Renal abscess formation, perinephric abscess formation (perirenal and pararenal) and pyonephrosis indicate a more severe inflammatory status, resulting in fistulae and adherences to adjacent structures. Hydronephrosis is caused by an obstructing calculus. These tomographic findings predict an upcoming complex procedure. Herein we demonstrated the key importance of tomographic features in predicting conversion to open nephrectomy. In univariate analysis, fat stranding, renal, perirenal and pararenal abscess, fistula and adherences to adjacent structures were significantly more frequent in the conversion group.

Rev Col Bras Cir 46(3):e20192092


Danilovic Laparoscopic nephrectomy for urolithiasis: when is better to avoid it.

Multivariate analysis revealed that pararenal abscess and adherence to the bowel were significant risk factors for conversion to open procedure. All patients who presented a pararenal abscess on preoperative tomography had their procedures converted to open access, which gives this parameter statistical significance even with a reduced number (n=3). There are some limitations of our study, such as the small number of cases and its retrospective nature. However, as far as we know, this is the first report to look for preoperative predictive factors for

7

conversion from laparoscopic to open nephrectomy due to calculous disease. A prospective multicentric study with a large number of patients might confirm our data. In conclusion, conversion rate for LN due to urolithiasis was 19% in our series. Risk factors for conversion to open nephrectomy were pararenal abscess and adherence to the bowel as identified in preoperative CT. In these cases, the procedure is associated with an increased degree of technical difficulty. Therefore, initiating nephrectomy by the open access should be considered.

R E S U M O Objetivo: investigar os fatores de risco de conversão para cirurgia aberta na nefrectomia laparoscópica (NL) para urolitíase. Métodos: foram revisados os dados de todos os pacientes maiores de 18 anos de idade submetidos à NL entre janeiro de 2006 e maio de 2013 em nossa Instituição. Índice de Charlson, escore ASA, função renal pela equação e estágio de MDRD (Modification of Diet in Renal Disease), achados de tomografia computadorizada (TC) pré-operatória, complicações pela classificação de Clavien-Dindo e taxa de conversão foram analisados. Determinaram-se os fatores de risco para conversão por meio de regressão logística. Resultados: oitenta e quatro pacientes foram submetidos à LN, sendo que 16 (19%) tiveram seu procedimento convertido para cirurgia aberta devido à forte aderência do hilo renal aos órgãos adjacentes. Outras causas associadas à conversão foram sangramento excessivo (n=6) e lesão do intestino grosso (n=3). Na análise univariada, cirurgia renal prévia, borramento da gordura perirrenal, abscesso renal, abscesso perirrenal, abscesso pararrenal, fístula, aderência ao fígado ou baço e aderência ao intestino foram associados à conversão. Na análise multivariada, abscesso pararrenal e aderência ao intestino foram fatores de risco significativos para a conversão. Conclusão: abscesso pararrenal e aderência ao intestino demonstrados na TC pré-operatória são fatores de risco de conversão para cirurgia aberta em LN por urolitíase. Descritores: Nefrectomia. Laparoscopia. Fatores de Risco. Nefrolitíase.

5.

REFERENCES 1.

2.

3.

4.

Scales CD Jr, Smith AC, Hanley JM, Saigal CS; Urologic Diseases in America Project. Prevalence of kidney stones in the United States. Eur Urol. 2012;62(1):160-5. Jungers P, Joly D, Barbey F, Choukroun G, Daudon M. ESRD caused by nephrolithiasis: prevalence, mechanisms, and prevention. Am J Kidney Dis. 2004;44(5):799-805. Pearle MS, Goldfarb DS, Assimos DG, Curhan G, Denu-Ciocca CJ, Matlaga BR, Monga M, Penniston KL, Preminger GM, Turk TM, White JR; American Urological Assocation. Medical management of kidney stones: AUA guideline. J Urol. 2014;192(2):316-24. Thornton E, Mendiratta-Lala M, Siewert B, Eisenberg RL. Patterns of fat stranding. AJR Am J Roentgenol. 2011;197(1):W1-14.

6.

7.

8.

Duarte RJ, Mitre AI, Chambô JL, Arap MA, Srougi M. Laparoscopic nephrectomy outside gerota fascia for management of inflammatory kidney. J Endourol. 2008;22(4):681-6. Tepeler A, Akman T, Tok A, Kaba M, Binbay M, Müslümanoglu AY, et al. Retroperitoneoscopic nephrectomy for non-functioning kidneys related to renal stone disease. Urol Res. 2012;40(5):559-65. Levey AS, Bosch JP, Lewis JB, Greene T, Rogers N, Roth D. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group. Ann Intern Med. 1999;130(6):461-70. Sankar A, Johnson SR, Beattie WS, Tait G, Wijeysundera DN. Reliability of the American Society of Anesthesiologists physical status scale in clinical practice. Br J Anaesth. 2014;113(3):424-32.

Rev Col Bras Cir 46(3):e20192092


Danilovic Laparoscopic nephrectomy for urolithiasis: when is better to avoid it.

8

9.

10.

11.

12.

13.

14.

15.

Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240(2):205-13. Raghuram S, Godbole HC, Dasgupta P. Laparoscopic nephrectomy: the new gold standard? Int J Clin Pract. 2005;59(2):128-9. Morris DS, Miller DC, Hollingsworth JM, Dunn RL, Roberts WW, Wolf JS Jr, et al. Differential adoption of laparoscopy by treatment indication. J Urol. 2007;178(5):2109-13; discussion 2113. Kapoor R, Vijjan V, Singh K, Goyal R, Mandhani A, Dubey D, et al. Is laparoscopic nephrectomy the preferred approach in xanthogranulomatous pyelonephritis? Urology. 2006;68(5):952-5. Tobias-Machado M, Lasmar MT, Batista LT, Forseto PH Jr, Juliano RV, Wroclawski ER. Laparoscopic nephrectomy in inflammatory renal disease: proposal for a staged approach. Int Braz J Urol. 2005;31(1):22-8. Kaba M, Pirinççi N, Taken K, Geçit I, Demiray Ö, Eren H. Laparoscopic transperitoneal nephrectomy in non-functioning inflammatory kidneys with or without renal stone. Eur Rev Med Pharmacol Sci. 2015;19(23):4457-61. Jain S, Jain SK, Kaza RCM, Singh Y. This challenging procedure has successful outcomes: laparoscopic nephrectomy in inflammatory renal diseases. Urol Ann. 2018;10(1):35-40.

16. Zelhof B, McIntyre IG, Fowler SM, Napier-Hemy RD, Burke DM, Grey BR; British Association of Urological Surgeons. Nephrectomy for benign disease in the UK: results from the British Association of Urological Surgeons nephrectomy database. BJU Int. 2016;117(1):138-44. 17. Angerri O, López JM, Sánchez-Martin F, MillánRodriguez F, Rosales A, Villavicencio H. Simple laparoscopic nephrectomy in stone disease: not always simple. J Endourol. 2016;30(10):1095-8. 18. Rassweiler J, Fornara P, Weber M, Janetschek G, Fahlenkamp D, Henkel T, et al. Laparoscopic nephrectomy: the experience of the laparoscopy working group of the German Urologic Association. J Urol. 1998;160(1):18-21. 19. Craig WD, Wagner BJ, Travis MD. Pyelonephritis: radiologic-pathologic review. Radiographics. 2008;28(1):255-77; quiz 327-8. Received in: 12/17/2018 Accepted for publication: 01/29/2019 Conflict of interest: none. Source of funding: FAPESP (Foundation for Research Support of the State of São Paulo). Process 2013/18223-6. Mailing address: Alexandre Danilovic E-mail: alexandre.danilovic@gmail.com drthiagoferreira@yahoo.com.br

Rev Col Bras Cir 46(3):e20192092


Original Article

DOI: 10.1590/0100-6991e-20192170

Bariatric surgery and the coronary artery calcium score. Cirurgia bariátrica e o escore de cálcio coronariano. Daniel da Costa Lins1; Patrícia S. Gadelha2; Fernando Santa-Cruz3; Luciana Teixeira Álvaro Antônio Bandeira Ferraz, TCBC-PE4

de

Siqueira4; Josemberg Marins Campos, TCBC-PE4;

A B S T R A C T Objective: to investigate the impact of bariatric surgery on the coronary artery calcium score (CACS), and to establish predictors of progression of this score in patients with obesity. Methods: prospective study that evaluated 18 obese patients before and after bariatric surgery. All patients were submitted to computed tomography scans and blood tests (total cholesterol, LDL, HDL, triglycerides, fasting plasma glucose, A1C, insulin, serum calcium, C-peptide and C-Reactive Protein) in order to determine CACS and Framingham risk score (FRS). Results: the FRS decreased 50% between the pre and postoperative evaluations. The mean CACS increased significantly at the late postoperative period, going from 8.5 to 33.1. HDL levels had also increased between the pre and postoperative periods. All of the other quantitative variables reduced significantly at the postoperative evaluation. When dividing CACS into four degrees, it was observed that 22.2% presented CACS=0 at the postoperative evaluation. The prevalence of mild CACS decreased from 77.8% to 50%, while moderate CACS remained the same (11.1%). Severe CACS increased from 11.1% to 16.7%. Older ages were linked to CACS progression, and this was the only variable that presented statistical association with progression. Conclusion: bariatric surgery leads to positive cardiovascular outcomes, apparently regardless of CACS. Keywords Obesity. Bariatric Surgery. Atherosclerosis. Coronary Artery Disease.

INTRODUCTION

O

besity is a condition associated with the development of risk factors for cardiovascular disease, systemic arterial hypertension (SAH), dyslipidemia, insulin resistance and type-2 diabetes mellitus (DM2)1,2. Still, some studies have shown that obesity alone is related to increased cardiovascular risk, favoring events such as angina, acute myocardial infarction, heart failure and sudden death3-5. This major propensity for cardiovascular disease (CVD) appears to result from the endothelial dysfunction and subclinical inflammation characteristics of obesity6. Given this scenario, establishment of an early, non-invasive diagnosis of CVD and its complications is of utmost importance in the population with obesity.

A series of clinical scores has been used to estimate the risk of CVD development, Framingham Risk Score (FRS) being one of the most disseminated in clinical practice7. This score consists of a multivariate statistical model that takes into account age, gender, smoking, diabetes, hypertension, total cholesterol, HDL and LDL in asymptomatic patients with no previous coronary artery disease (CAD), aiming at the risk of CVD in 10 years. However, the application of clinical scores alone to predict future cardiovascular risk is limited. Thus, there is a need to incorporate in clinical practice more objective methods that are capable of quantifying the risk of developing CVD. In this context, the coronary arteries calcium score (CCS), measured by computed tomography (CT), appears

1 - Federal University of Pernambuco, Health Sciences Center, Program of Postgraduate in Surgery, Recife, PE, Brazil. 2 - Real Hospital Português de Beneficência de Pernambuco, Radiology Service, Recife, PE, Brazil. 3 - Federal University of Pernambuco, Health Sciences Center, Medical School, Recife, PE, Brazil. 4 - Federal University of Pernambuco, Health Sciences Center, Medical School, Department of Surgery, Recife, PE, Brazil. Rev Col Bras Cir 46(3):e20192170


Lins Bariatric surgery and the coronary artery calcium score

2

as a useful screening tool, being able to noninvasively detect vascular calcifications in vivo11,12. CCS has been an independent predictive factor for the occurrence of future cardiovascular events7. Bariatric surgery, one of the most effective methods for weight loss, has presented interesting results regarding cardiovascular risk, reducing risk factors and preventing future deleterious events of this nature, as observed in previous studies13. This procedure is associated with endothelial improvement and reduction of the subclinical inflammation, present in obesity14. Given the reduction of mortality and cardiovascular disease with bariatric surgery, it is to be expected that such patients present with improvement, or at least slower progression, of CCS in the postoperative period15. This study aimed to investigate the impact of bariatric surgery on CCS and to establish the predictive factors of this scoreâ&#x20AC;&#x2122;s progression in obese patients. We also studied the FRS before and after surgery, aiming at more precisely determining the changes in future cardiovascular risk.

METHODS We conducted a prospective study at the Hospital das ClĂ­nicas of the Federal University of Pernambuco during the period between 2014 and 2018. We used CT without intravenous contrast to determine the CCS in the preoperative and late postoperative periods of patients undergoing bariatric surgery, both through Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). We selected the sample according to the criteria of the Brazilian Society of Bariatric and Metabolic Surgery (SBCBM): BMI between 30 and 34.9 kg/m2 associated with at least one severe comorbidity; BMI between 35 and 40 kg/m2 associated with any comorbidity; or BMI>40kg/m2 independent of comorbidities.

The study included patients with obesity classes II and III, of both genders, with age between 18 and 75 years, who presented positive CCS in the preoperative evaluation. We excluded from the sample the patients who experienced CAD, including angina, myocardial infarction and coronary revascularization. We also excluded patients with negative CCS in the preoperative evaluation and those who refused undergoing the CT scan. All patients underwent preoperative evaluation, when they were questioned about the presence of cardiovascular risk factors, such as hypertension, hypercholesterolemia, smoking, and medication use. Blood samples were collected after a 12-hour fast to analyze the biochemical variables, including total cholesterol, HDL, LDL, triglycerides, fasting glucose, glycosylated hemoglobin (A1C), insulin, serum calcium, C-peptide, and C-reactive protein (CRP). We repeated these exams in the late postoperative period, aiming to determine the patients' FRS. We defined hypertension as systolic pressure >130mmHg or diastolic pressure >80mmHg, and diabetes, as fasting blood glucose >6.5%, or use of antidiabetic drugs. We considered hypercholesterolemia as total cholesterol >200mg/dl or the use of lipidlowering medications, and hypertriglyceridemia, as triglycerides >150mg/dl. All patients underwent CT for CCS determination. We obtained 48 contiguous slices, with intervals of 3mm, starting 1cm below the carina and progressing in the caudal direction, aiming at covering the entire coronary tree. Image acquisition occurred between 60% and 80% of the electrocardiographic R-R interval. Images were interpreted by an experienced radiologist, using the Agatson method to calculate the CCS.

Rev Col Bras Cir 46(3):e20192170


Lins Bariatric surgery and the coronary artery calcium score

3

We defined a coronary calcium focus as the presence of three or more pixels with more than 130 Hounsfield units. Total CCS was calculated by summing the score of each of the three main epicardial coronary arteries (left anterior descending, circumflex and right coronary arteries). We stratified the CCS results in four categories (0: absent; 0.1-99: mild; 100-400: moderate; >400: severe). We carried out the evaluations in two different moments, before and after (late postoperative) and compared them. The study was approved by the Ethics in Research Committee of the Health Sciences Center of the Federal University of Pernambuco (CEP/CCS/UFPE), according to Resolution nยบ 196/96 of the National Health Council, under CAAE protocol number 00895712.5.0000.5208. We expressed the results through absolute frequencies and percentages for the categorical variables, and mean, median, standard deviation and 25th and 75th percentiles for the quantitative variables. We applied the ShapiroWilk test for the normality of the distribution. We compared the pre and postoperative evaluations with the T-test for paired samples when the distribution displayed normality, and the Wilcoxon test otherwise. We used the Fischer's exact test, the Mann-Whitney test, Student's t-test for equal variances, and the Student's test for different variances to analyze the categorical variables. To assess whether distributions showed the same variance, we applied the Levene test (F-test). The level of significance was set at 0.05.

RESULTS We recruited 202 patients, all candidates for bariatric surgery, at our center. Of these, we included only 18 in the study. Ten underwent RYGB, and eight, SG. The sample was composed of 55.6% men and 44.4% women. The average age was 55.3 years, ranging from 31 to 71. The mean postoperative follow-up time was 2.2 years, ranging from 1.5 to 4.0. As for comorbidities, 83.3% had DM2, 83.3% SAH, and 38.9%, hypercholesterolemia. Table 1 shows the clinical and laboratory variables. BMI, calcium, insulin, C-peptide, fasting glycemia, A1C, total cholesterol, LDL and triglycerides had a statistically significant decrease in the postoperative period. The mean values of HDL and CCS displayed a statistically significant increase in the postoperative evaluation. In the FRS evaluation, that calculates the risk of cardiovascular development in 10 years, we observed a significant reduction of the average score, from 6% in the preoperative period to 3% in the late postoperative period (p<0.001) (Figure 1).

Figure 1. Framingham risk score before bariatric surgery.

Rev Col Bras Cir 46(3):e20192170


Lins Bariatric surgery and the coronary artery calcium score

4

Table 2 shows the CCS evaluation in the pre and postoperative periods. In the initial evaluation, the majority of patients (77.8%) were stratified as mild risk, none as absent risk, and the rest as moderate (11.1%) or severe (11.1%) risk. In the postoperative evaluation, half of the patients were stratified as light risk, 22.2% as absent risk, 11.1% as moderate risk and the remaining 16.7% as severe risk. There was no statistically significant difference (p=0.414) between the pre and postoperative evaluations, though.

Table 3 shows the relation of CCS progression with variables age, gender, type of surgery and follow-up time. No variable, except for age, showed statistical significance in the comparison between those patients who progressed and those who did not. Age was more advanced in the group that progressed in CCS (p=0.034). Table 4 presents an analysis of the clinical and laboratory parameters according to CCS progression. There was no statistically significant association between the CCS progression and the parameters evaluated.

Table 1. Clinical and laboratory parameters in the pre and postoperative periods of bariatric surgery.

Parameters BMI* CCS** Calcium CRP*** Insulin C-peptide FG A1C## Total cholesterol LDL HDL Triglycerides

Preoperative 42.56±4.66 8.50 9.67±0.66 3.40±5.12 29.19±20.18 4.68±2.12 132.17±46.74 6.89±1.31 196.94±38.40 113.78±28.18 42.55±8.65 217.17±118.26

Postoperative 28.18±3.37 33.10 9.14±0.53 2.46±5.91 6.14±2.54 1.97±0.54 93.50±27.18 5.54±0.61 157.89±32.88 91.22±25.81 51.02±11.09 96.67±31.05

p-value p <0.001 p(2)=0.002 p(1)=0.010 p(1)=0.095 p(1)<0.001 p(1)<0.001 p(2)<0.001 p(1)<0.001 p(1)=0.001 p(1)=0.009 p(1)=0.001 p(1)<0.001 (1)

(1) Student's t-test; (2) Wilcoxon test; BMI*: body mass index; CCS**: coronary calcium score; CRP**: C-reactive protein; FG#: fasting blood glucose; A1C##: glycosylated hemoglobin.

Table 2. Evaluation of coronary calcium score (CCS) in the pre and postoperative periods of bariatric surgery.

CCS* Total Absent Light Moderate Severe

Preoperative n (%) 18 14 (77.8) 2 (11.1) 2 (11.1)

Postoperative n (%) 18 4 (22.2) 9 (50.0) 2 (11.1) 3 (16.7)

(1) Wilcoxon test; CCS*: coronary calcium score.

Rev Col Bras Cir 46(3):e20192170

p-value(1)   0.414    


Lins Bariatric surgery and the coronary artery calcium score

5

Table 3. Progression of coronary calcium score according to age, gender, type of surgery and time of postoperative follow-up.

  Total Age (years) Gender       Male       Female Procedure       RYGB**       SG*** Follow-up time       Up to 2 years       More than 2 years

CCS* Progression Yes n (%) No n (%) 13 (72.2) 5 (27.8) 58.46±8.30 47.20±11.58   8 (80.0) 2 (20.0) 5 (62.5) 3 (37.5)     7 (70.0) 3 (30.0) 6 (75.0) 2 (25.0)     8 (66.7) 4 (33.3) 5 (83.3) 1 (16.7)

p-value p(1)0.034   p =0.608 (2)

p =1,000 (2)

p(2)=0.615

(1) Mann-Whitney test; (2) Fisher's test; CCS*: coronary calcium score; RYGB**: Roux-en-Y gastric bypass; SG***: sleeve gastrectomy.

Table 4. Evaluation of anthropometric and biochemical parameters, according to the progression or not of coronary calcium.

  BMI**     A1C***     Total cholesterol     LDL     HDL     Triglycerides     CRP#    

  Preop Postop Difference Preop Postop Difference Preop Postop Difference Preop Postop Difference Preop Postop Difference Preop Postop Difference Preop Postop Difference

CCS Progression* Yes 41.5±4.8 27.6±3.3 13.86 6.8±1.4 5.6±0.7 1.18 192.8±39.4 160.5±33.0 32.38 108.2±26.7 91.4±27.9 16.85 43.0±9.0 52.5±11.7 9.54 228.4±133.8 98.5±35.2 129.85 3.72±5.89 2.71±6.81 1.01

No 45.3±3.0 29.6±3.5 15.73 7.1±1.3 5.3±0.4 1.82 207.6±37.7 151.2±35.4 56.40 128.2±29.5 90.8±22.1 37.40 41.4±8.7 47.1±9.4 5,68 188.0±65.0 91.8±18.3 96.20 2.58±2.52 1.80±2.93 0.77

p-value p(1)=0.068 p(1)=0.257 p(1)=0.301 p(1)=0.553 p(1)=0.347 p(1)=0.333 p(1)=0.522 p(1)=0.730 p(1)=0.257 p(1)=0.218 p(1)=0.961 p(1)=0.200 p(1)=0.693 p(1)=0.459 p(1)=0.374 p(1)=0.693 p(1)=0.921 p(1)=0.767 p(1)=0.522 p(1)=0.961 p(1)=0.882

(1) Mann-Whitney test; CCS*: coronary calcium score; BMI**: body mass index; A1C***: glycosylated hemoglobin; CRP#: C-reactive protein. Rev Col Bras Cir 46(3):e20192170


Lins Bariatric surgery and the coronary artery calcium score

6

DISCUSSION Bariatric surgery significantly reduces the occurrence of cardiovascular events3,16,17. Adams et al. showed, in a retrospective study, that longterm mortality was significantly lower in the group submitted to bariatric surgery than the obese group, with a 56% reduction in the prevalence of CAD18. Batsis et al. used the FRS and the PROCAM score to assess the risk of developing cardiovascular diseases in 197 patients submitted to RYGB, comparing with a control group of 163 subjects from the Rochester Epidemiology Project19. The FRS decreased more in the post-RYGB group (from 7% to 3.5%, p<0.001) than in the control group (7.1% to 6.5%, p=0.13) 19. Vogel et al., also using the FRS, found a reduction in the risk of developing cardiovascular diseases in 10 years in 39% in Men and 25% in Women 20. In the present study, there was a 50% reduction in the FRS, decreasing from 6% in the preoperative period to 3% in the late postoperative period. The results are in agreement with those reported by Batsis et al. 19. However, our study provides an assessment with longer follow-up. Priester et al. compared the CCS of patients submitted to RYGB (test group) with a control group composed of obese individuals21. Using this methodology, they found CCS=0 in 72% of the test group and only 49% in the control group. They also observed that the test group displayed a lower average CCS compared the control one (30±109 x 103±325).

We found 22.2% of CCS=0 in the postoperative period. This is important for strengthening the hypothesis that bariatric surgery reduces patients’ CCS, since there was no preoperative case of CCS=0. On the other hand, there was progression of the mean CCS in the postoperative period (from 8.5 to 33.1, p=0.002), despite improvements in all comorbidities and in FRS. This is intriguing, given that the literature has already demonstrated that bariatric surgery reduces cardiovascular risk, and that CCS progression itself is considered a factor of future cardiovascular disease and mortality18,22. Similarly, other studies have shown that the use of statins do not halt CCS progression either, yet such drugs contribute to reduce patients’ cardiovascular risk in the long term23. When analyzing the sample according to CCS progression, we found that age was the only measure related to the score progression. In patients with CCS progression, ages were more advanced compared with the group in which there was no progression (58.46 x 47.2 years, p=0.034). Similarly, other studies have pointed out that CCS tends to progress with the patient's age, and that this phenomenon is more intense in men12,24. In the present study, however, we did not find a statistically significant difference between genders. In contrast with our results, Gadelha et al. observed a direct relation between DM2 and SAH and CCS progression22. DM2, SAH and dyslipidemia are classic cardiovascular factors and are related to a higher propensity for cardiovascular disease development. this context, it is a plausible to infer that obese patients, showing the aforementioned comorbidities, would display a worse progression of CCS. In our sample, we had no statistically significant relationship between comorbidities and CCS progression.

Rev Col Bras Cir 46(3):e20192170


Lins Bariatric surgery and the coronary artery calcium score

7

Regarding the type of surgery performed, we also could not find a statistically significant difference in the progression of CCS between individuals submitted to RYGB or SG. Both techniques presented similar results as to CCS Progression during patients postoperative follow-up. There has been evaluation of the impact of bariatric surgery on CCS through cross-sectional studies21. The present study appears to be the first prospective, cohort study to analyze the effects of bariatric surgery on coronary calcium. This methodology renders the data analysis more reliable, since a comparison is made between the initial evaluations, prior to surgery, and the final evaluation, in the late postoperative period. The greatest limitation of this work was the sample size. Our sample was reduced because among the 202 patients who were candidates for surgery, only 18 had preoperative positive CCS. Another important limitation was the absence of a control group with obese individuals under clinical treatment

only. If we had used a control group, we could rate how effective bariatric surgery is in relation to clinical treatment in reducing the risk of future cardiovascular events. There was an increase in the mean coronary calcium in the late postoperative period compared with the preoperative one. The single variable that was statistically significant with the progression of the coronary calcium score was patients’ age. The mean Framingham risk score was reduced by 50% between the pre and the late postoperative periods. Taking into consideration the results of this study, the authors conclude that bariatric surgery provides positive cardiovascular outcomes - as evidenced by the reduction in the Framingham score - independently of the coronary calcium score. However, future prospective studies with larger samples and long-term follow-up are needed to obtain more robust conclusions about the mechanisms by which bariatric surgery leads to a reduction in the occurrence of coronary artery disease.

R E S U M O Objetivo: investigar o impacto da cirurgia bariátrica no escore de cálcio coronariano (ECC) e estabelecer fatores preditivos de progressão desse escore em pacientes obesos. Métodos: estudo prospectivo de 18 pacientes obesos antes e depois da cirurgia bariátrica. Todos os pacientes foram submetidos à tomografia computadorizada e a exames laboratoriais com dosagens sanguíneas de colesterol total, LDL, HDL, triglicerídeos, glicose de jejum, A1C, insulina, cálcio sérico, peptídeo C e proteína C-reativa, para determinar o ECC e o escore de risco de Framingham (ERF). Resultados: o ERF reduziu 50% entre as avaliações pré e pós-operatórias. O ECC médio aumentou significativamente no período pós-operatório, aumentando de 8,5 para 33,1. Os níveis de HDL também aumentaram no pós-operatório. Todas as outras variáveis quantitativas reduziram significativamente no pós-operatório. Ao estratificar o ECC em quatro categorias, foi observado que 22,2% da amostra apresentou ECC=0 no pós-operatório. A prevalência de ECC leve reduziu de 77,8% para 50%, enquanto que ECC moderado permaneceu igual no pré e no pós-operatório (11,1%). ECC grave aumentou de 11,1% para 16,7%. Idade avançada foi associada à progressão do ECC, e essa foi a única variável que apresentou correlação estatística com a progressão do ECC. Conclusão: cirurgia bariátrica produz desfechos cardiovasculares positivos, que, aparentemente, ocorrem de forma independente do ECC. Descritores: Obesidade. Cirurgia Bariátrica. Aterosclerose. Doença da Artéria Coronariana.

Rev Col Bras Cir 46(3):e20192170


Lins Bariatric surgery and the coronary artery calcium score

8

REFERENCES 1.

2.

3.

4.

5.

6.

7.

8.

Kirkil C, Aygen E, Korkmaz MF, Bozan MB. Quality of life after laparoscopic sleeve gastrectomy using BAROS system. Arq Bras Cir Dig. 2018;31(3):e1385. Emerging Risk Factors Collaboration, Wormser D, Kaptoge S, Di Angelantonio E, Wood AM, Pennells L, Thompson A, Sarwar N, Kizer JR, Lawlor DA, Nordestgaard BG, Ridker P, Salomaa V, Stevens J, Woodward M, Sattar N, Collins R, Thompson SG, Whitlock G, Danesh J. Separate and combined associations of body-mass index and abdominal adiposity with cardiovascular disease: collaborative analysis of 58 prospective studies. Lancet. 2011;377(9771):1085-95. Remígio MI, Santa Cruz F, Ferraz Á, Remígio MC, Parente G, Nascimento I, et al. The impact of bariatric surgery on cardiopulmonary function: analyzing VO2 recovery kinetics. Obes Surg. 2018;28(12):4039-44. Hubert HB, Feinleib M, McNamara PM, Castelli WP. Obesity as an independent risk factor for cardiovascular disease: a 26-year follow-up of participants in the Framingham Heart Study. Circulation. 1983;67(5):968-77. Ndumele CE, Matsushita K, Lazo M, Bello N, Blumenthal RS, Gerstenblith G, et al. Obesity and subtypes of incident cardiovascular disease. J Am Heart Assoc. 2016;5(8):pii. e003921. Rossi R, Iaccarino D, Nuzzo A, Chiurlia E, Bacco L, Venturelli A, et al. Influence of body mass index on extent of coronary atherosclerosis and cardiac events in a cohort of patients at risk of coronary artery disease. Nutr Metab Cardiovasc Dis. 2011;21(2):86-93. Joshi PH, Patel B, Blaha MJ, Berry JD, Blankstein R, Budoff MJ, et al. Coronary artery Calcium predicts cardiovascular events in participants with a low lifetime risk of Cardiovascular disease: the Multi-Ethnic Study of Atherosclerosis (MESA). Atherosclerosis. 2016;246:367-73. Jahangiry L, Farhangi MA, Rezaei F. Framingham risk score for estimation of 10-years of cardiovascular diseases risk in patients with metabolic syndrome. J Health Popul Nutr. 2017;36(1):36.

9. Greenland P, LaBree L, Azen SP, Doherty TM, Detrano RC. Coronary artery calcium score combined with Framingham score for risk prediction in asymptomatic individuals. JAMA. 2004;291(2):210-5. 10. Polak JF, Szklo M, O’Leary DH. Carotid intima-media thickness score, positive coronary artery calcium score, and incident coronary heart disease: the Multi-Ethnic Study of Atherosclerosis. J Am Heart Assoc. 2017;6(1):pii. e004612. 11. Arad Y, Spadaro LA, Goodman K, Newstein D, Guerci AD. Prediction of coronary events with electron beam computed tomography. J Am Coll Cardiol. 2000;36(4):1253-60. 12. Budoff MJ, Young R, Lopez VA, Kronmal RA, Nasir K, Blumenthal RS, et al. Progression of coronary calcium and incident coronary heart disease events: MESA (Multi-Ethnic Study of Atherosclerosis). J Am Coll Cardiol. 2013;61(12):1231-9. 13. Sjöström L, Peltonen M, Jacobson P, Sjöström CD, Karason K, Wedel H, et al. Bariatric surgery and long-term cardiovascular events. JAMA. 2012;307(1):56-65. 14. Lupoli R, Di Minno MN, Guidone C, Cefalo C, Capaldo B, Riccardi G, et al. Effects of bariatric surgery on markers of subclinical atherosclerosis and endothelial function: a meta-analysis of literature studies. Int J Obes (Lond). 2016;40(3):395-402. 15. Sturm W, Tschoner A, Engl J, Kaser S, Laimer M, Ciardi C, et al. Effect of bariatric surgery on both functional and structural measures of premature atherosclerosis. Eur Heart J. 2009;30(16):2038-43. 16. Cardoso L, Rodrigues D, Gomes L, Carrilho F. Shortand long-term mortality after bariatric surgery: A systematic review and meta-analysis. Diabetes Obes Metab. 2017;19(9):1223-32. 17. Shin SH, Lee YJ, Heo YS, Park SD, Kwon SW, Woo SI, et al. Beneficial effects of bariatric surgery on cardiac structure and function in obesity. Obes Surg. 2017;27(3):620-5. 18. Adams TD, Gress RE, Smith SC, Halverson RC, Simper SC, Rosamond WD, et al. Long-term mortality after gastric bypass surgery. N Engl J Med. 2007;357(8):753-61.

Rev Col Bras Cir 46(3):e20192170


Lins Bariatric surgery and the coronary artery calcium score

9

19. Batsis JA, Sarr MG, Collazo-Clavell ML, Thomas RJ, Romero-Corral A, Somers VK, et al. Cardiovascular risk after bariatric surgery for obesity. Am J Cardiol. 2008;102(7):930-7. 20. Vogel JA, Franklin BA, Zalesin KC, Trivax JE, Krause KR, Chengelis DL, et al. Reduction in predicted coronary heart disease risk after substantial weight reduction after bariatric surgery. Am J Cardiol. 2007;99(2):222-6. 21. Priester T, Ault TG, Davidson L, Gress R, Adams TD, Hunt SC, et al. Coronary calcium scores 6 years after bariatric surgery. Obes Surg. 2015;25(1):90-6. 22. Gadelha PS, Campos JM, Moraes F, da F S LeĂŁo M, Ferraz Ă A. Altered coronary artery calcium scores before bariatric surgery. Springerplus. 2014;3:199. 23. Miyoshi T, Kohno K, Asonuma H, Sakuragi S, Nakahama M, Kawai Y, Uesugi T, Oka T, Munemasa M, Takahashi N, Mukohara N, Habara S, Koyama Y, Nakamura K, Ito H; PEACH Investigators. Effect of intensive and standard pitavastatin treatment with or without eicosapentaenoic acid on

progression of coronary artery calcification over 12 months - prospective multicenter study. Circ J. 2018;82(2):532-40. 24. Schmermund A, Erbel R, Silber S; MUNICH Registry Study Group. Multislice Normal Incidence of Coronary Health. Age and gender distribution of coronary artery calcium measured by four-slice computed tomography in 2,030 persons with no symptoms of coronary artery disease. Am J Cardiol. 2002;90(2):168-73. Received in: 02/27/2019 Accepted for publication: 04/03/2019 Conflict of interest: none. Source of funding: none. Mailing address: Fernando Santa-Cruz. E-mail: f.santacruzoliveira@gmail.com recifol@bol.com.br

Rev Col Bras Cir 46(3):e20192170


Original Article

DOI: 10.1590/0100-6991e-20192154

The use of computed tomography for penetrating heart injury screening. O uso da tomografia computadorizada na triagem da lesão cardíaca penetrante. Adenauer Marinho de Oliveira Góes Junior, TCBC-PA1,2,3; Édpo Vinicius Lenzi de Oliveira4; Flávia Beatriz Araújo de Albuquerque5; Eduardo Gorayeb Martins5; Mariseth Carvalho de Andrade6; Simone de Campos Vieira Abib, TCBC-SP3 A B S T R A C T Objective: to determine if computed tomography represents a safe option for penetrating heart injury screening. Methods: retrospective transversal study which confronted tomographic findings with the ones detected in surgical exploration in patients that had undergone surgery because of suspected cardiac trauma from January, 2016 to January, 2018. Results: seventy-two cases were analysed; 97.2% of them were males, and the most prevalent age range was 20 to 29 years; 56.9% of them presented injuries caused by firearm shots and 43.1% by cutting weapons. In 20 cases, computed tomography suggested heart injury, confirmed in 13 cases during surgery. Sensitivity of computed tomography was 56.5%, reaching a specificity of 85.7%. Conclusion: computed tomography must not be adopted as a routine for the screening of penetrating heart injuries. Keywords: Heart. Wounds and Injuries. Heart Injuries. Tomography. Diagnosis.

INTRODUCTION

T

he first successful repair of cardiac trauma was performed by Dr. Ludwig Rehn, from Frankfurt, Germany, in 1896, who operated on a right ventricle injury of a 22-year-old man that had suffered a penetrating injury in the fourth left intercostal space1. Presently, improvement on the pre-hospital and hospital care increase the survival rate of patients with penetrating heart injuries, allowing for a greater possibility of exams and diagnostic procedures and continued improvement in treatment2-5. Clinical characteristics of the patients depend on the nature of the injury mechanism: blunt or penetrating3. Penetrating injuries are the most serious and represent one of the main morbidity and mortality causes related to thoracic trauma3,6,7. These penetrating injuries are more frequent in young men, and cutting weapon and firearm wounds are the main mechanisms7.

Due to its anatomical position, the right ventricle, which accounts for most of the anterior surface of the heart (sternocostal), is classically described as the most vulnerable cardiac chamber, and death occurs mainly due to hypovolemic shock and to cardiac tamponade. A penetrating heart injury requires a precise diagnosis and immediate treatment2,3,6. In spite of the evolution seen in imaging methods, it is not always possible to identify heart injury by means of non-invasive techniques. The pericardial window is considered to be easily performed, with high sensitivity and low morbidity, and it remains the gold standard for diagnosing heart injury due to its capability of direct visualization of the pericardial sac. Nonetheless, it is less and less performed due to its invasive character3,4. In better equipped centers, the pericardial window can be substituted by less invasive methods, like FAST (Focused Assessment with Sonography for Trauma)3,8.

1 - Metropolitan Hospital for Urgencies and Emergencies, Vascular Surgery Service/ Trauma Surgery, Ananindeua, PA, Brazil. 2 - University Center of the State of Pará, Faculty of Medicine, Belém, PA, Brazil. 3 - Federal University of São Paulo, Department of Surgery, Postgraduate Program in Interdisciplinary Sciences, São Paulo, SP, Brazil. 4 - Metropolitan Hospital for Urgencies and Emergencies, General Surgery Service, Ananindeua, PA, Brazil. 5 - University Center of the State of Pará, Faculty of Medicine, Belém, PA, Brazil. 6 - State University of Pará, Department of Surgery, Postgraduate Program in Surgery and Experimental Research, Belém, PA, Brazil. Rev Col Bras Cir 46(3):e20192154


Góes Junior The use of computed tomography for penetrating heart injury screening.

2

However, this ultrasonographic examination requires appropriate equipment and trained doctors, who are not always available9. Axial computed tomography (CT) is usually performed to assess penetrating injuries in the thorax and, although many authors argue that this exam can be used to diagnose heart injuries, there are no guidelines suggesting this exam for this objective, nor references that quantify its sensitivity to detect heart injuries3,9-12. The objective of this study is to determine if CT represents a safe option to screen penetrating heart injuries.

METHODS Retrospective transversal study, based on the analysis of medical records of patients operated on suspicion of penetrating cardiac trauma admitted to the Metropolitan Hospital of Urgencies and Emergencies of Pará (HMUE) between January 1st, 2016 and December 31st, 2017. Inclusion criteria: patients of both genders and at any age who suffered penetrating injuries and who, after undergoing an axial computed tomography (CT) have undergone surgical exploration of the pericardial sac through subxiphoid pericardiotomy (pericardial window) or thoracotomy. Exclusion criteria: inability to retrieve, in the database, the imaging of tomographies and/ or non-identification in the medical record of the description of the operating act or inability to identify in this document terms that would allow a confrontation of the radiologic suspicion of penetrating heart injury with the surgical finding. An electronic search in the medical records of suspected cases was performed using the terms “pericardiotomy”, “pericardial window”, “cardiac suture”, “atrium”, “ventricle” and “thoracotomy”.

The following epidemiologic variables were researched: date and time of medical care, sex, age in years (classified by age ranges: <20, 20 to 29, 30 to 39, 40 to 49 and ≥50), trauma mechanism (classified as white gun, firearm or other mechanisms), injured intrapericardial structure (cardiac chambers classified in right/left atriums and right/left ventricles and intrapericardial portion of base vessels). Tomographies were assessed by a radiologist doctor and were found to suggest heart injury when one or more of the following findings was described: pneumomediastinum, pneumopericardium, mediastinal hematoma, hemopericardium, pericardial effusion, mediastinal hemorrhage, or in case terms like “compatible with heart injury” have been used to describe a finding. Operatory findings of heart injury were hemopericardium, solution of continuity in the pericardium and direct identification in one of the cardiac chambers or in the intrapericardial portion of the base vessels. By considering surgical exploration as the “gold standard” for diagnosing heart injuries, operatory findings were confronted with the ones of tomographies. Sensitivity, specificity, positive and negative predictive values (PPV and NPV, respectively) of CT were calculated to identify heart injuries in penetrating trauma. Patients were classified into four groups: Group A- positive tomographic and surgical findings; Group B- positive tomographic finding and negative surgical finding; Group Cnegative tomographic finding and positive surgical finding; and Group D- negative tomographic and surgical findings. Sensitivity and specificity of the pericardial window were also calculated by confronting the results of the positive windows with the findings of thoracotomy and comparing to the ones obtained for CT through the ROC curve.

Rev Col Bras Cir 46(3):e20192154


Góes Junior The use of computed tomography for penetrating heart injury screening.

The research was approved by the Research Ethics Committee (REC) from the University Center of Pará (CESUPA) - register: 3.054.905.

RESULTS Within the period set up as the study interval, 97 patients fulfilling the inclusion criteria; 25 patients were excluded from the study due to the impossibility of recovering the tomographic images, resulting in a casuistry of 72 cases. Epidemiologic variables: 70 male patients (97.2%; p<0.0001; G adherence test) and the most prevalent age range was 20 to 29 years (37.5%; p=0.0018; Chi-square adherence) (Table 1). As to the injury mechanism, 41 patients (56.9%) presented wounds caused by firearms (GSW) and 31(43.1%) by cutting weapons (p=0.2888; X2 test). Twenty-three cases were identified with operatory findings of heart injury (hemopericardium, solution of continuity in the pericardium or identification of a wound in one of the cardiac chambers), and in 17 (23.6%) patients injuries were found in at least one cardiac chamber, while in six patients (8.3%), although solutions of continuity have been identified in the pericardium or hemopericardium have been detected,

3

the exploration did not identify heart or intrapericardial vessels injuries. Sensitivity of the pericardial window was 100%, and specifity was 87.8%. The most injured cardiac chambers were the ventricles, appearing in 12 out of 17 patients (70.6%) (six patients showing injuries only in the left ventricle, four of them in the right ventricle, and two patients had injuries in both ventricles). The distribution of heart injuries according to the affected chamber can be found in table 2. Tomographic and surgical findings: Group A- positive tomographic and surgical findings: 13 patients (18.1%); Group B- positive tomographic finding and negative surgical finding: 7 patients (9.7%); Group C- negative tomographic finding and positive surgical finding: 10 patients (13.9%); and Group D- negative tomographic and surgical findings: 42 patients (58.3%). Among patients with positive tomographic findings (groups A+B=20 patients), surgical exploration did not confirm positive findings in seven patients, therefore, the PPV of the CT was 65%. Among patients with negative tomographic findings (groups C+D=52 patients), surgical exploration confirmed positive findings in 10 of them, therefore, the NPV of the TC was 80.7%.

Table 1. Sample characterization according to gender and age, in years.

Sample characterization Gender      Female       Male* Age range       <20       20 to 29*       30 to 39       40 to 49       ≥50

n 2 70   13 27 16 9 7

% (n=72) 2.8% 97.2%   18.1% 37.5% 22.2% 12.5% 9.7%

Source: Metropolitan Hospital for Urgencies and Emergencies. *G adherence test; **X2 test.

Rev Col Bras Cir 46(3):e20192154

p-value <0.0001*   0.0018**          


Góes Junior The use of computed tomography for penetrating heart injury screening.

4

When applying diagnostic tests, the sensibility obtained for CT was 56.5% and a specificity of 85.7% in relation to findings suggesting heart injuries. The pericardial window in this study showed 100% sensibility and 87.8% specificity, as shown in table 3. In order to assess the accuracy of the diagnostic methods used (computed tomography and pericardial window) a ROC curve was drawn to compare the area corresponding to the sensitivity and the specificity of each method, in comparison

to the parameter found by Mantovani et al.13, that considers a 97.4% sensitivity and 100% specificity for the pericardial window. The area of the curve representing the CT accuracy showed some distance in relation to the ideal sensitivity of 0.46 (#A), the pericardial window of 0.12 (#B) and the reference considered of 0.03 (#C), indicating poor accuracy of the CT and a considerable approximation of the pericardial window of the study to the parameter considered as golden for a comparison (Figure 1).

Table 2. Distribution of heart injuries according to affected chambers.

Heart injuries

Frequency

% (N=72)

17 55

23.6% 76.4% n=17 35.3% 23.5% 11.8% 11.8% 5.9% 5.9% 5.9%

Cardiac chamber      Injuried       Uninjuried Site of the heart injury       Left ventricle       Right ventricle       Right and left ventricles       Left atrium       Right atrium       Right and left atriums       Intrapericardial vessel

6 4 2 2 1 1 1

Source: Metropolitan Hospital for Urgencies and Emergencies.

Table 3. Diagnostic tests to identify cardiac trauma.

Exam performed

Cardiac Trauma Presence

Computed tomography (n=72)       Positive 13       Negative 10 Sensitivity: 56.5%; Specificity: 85.7%; PPV: 65%; NPV: 80.8% Pericardial window (n=63)         Positive 15       Negative 0 Sensitivity: 100%; Specificity: 87.8%; PPV: 100%; NPV: 92.1% Source: Metropolitan Hospital for Urgencies and Emergencies.

Rev Col Bras Cir 46(3):e20192154

Abscence

18.1% 13.9%

7 42

9.7% 58.3%

23.8% 0.0%

5 43

7.9% 68.3%


Gรณes Junior The use of computed tomography for penetrating heart injury screening.

Source: Metropolitan Hospital for Urgencies and Emergencies. #A: computed tomography; #B: pericardial window; #C: gold standard in the literature.

Figure 1. ROC curve of the results obtained by computed tomographies, pericardial window of the study and of the comparison gold standard.

DISCUSSION Penetrating heart injuries represent a significant mortality cause, and can be challenging either from the therapeutic or the diagnostic point of view, since they can be asymptomatic or oligosymptomatic for a variable period after a trauma occurs6,11,14. Most studies show that young men are the most struck by penetrating heart injuries, which is in consonance with our outcomes5,7,8,14-18. The most frequent mechanism among patients operated due to penetrating heart traumatism is stab wounds, in a proportion ranging from 39% to 81.4%3,7,8,15. Necropsy research suggests that firearm wounds (GSW) are the most frequent2 ones. This disagreement is probably due to the fact that firearm wounds (GSW) cause greater solutions of continuity in the pericardium and wider myocardial wounds, leading to profuse bleeding uncontrolled by the pericardium which evolve quickly to death by hypovolemia; as the majority of such patients would evolve to death before surgery, the operated population would tend to be predominantly victims of stab wounds2,5,6,10.

5

It is interesting to point out that among the 23 cases where operatory findings were classified as compatible with heart injury, in six patients there was hemopericadium, but no injury to any cardiac chamber or intrapericardial vessel was found (five cases went through pericardial window followed by thoracotomy, and in one case no pericardial window was performed). This finding of blood inside the pericardium, without detecting intrapericardial structure injury is described as a false positive result of the pericardial window, and this can happen in 18% to 30% of the cases8,19. According to the casuistry of the present study, this happened in 25% of the pericardial windows. Causes may include an insufficient hemostasis during dieresis (allowing the blood to mingle with the pericardial liquid and hindering interpretation) or the pericardial injury, causing bleeding into the pericardial sac without affecting the cardiac chambers; this mechanism is classically described when the pericardiophrenic artery is affected by the injury6. The right ventricle is often described as the most affected cardiac chamber in penetrating injuries, because it accounts for most of the anterior surface of the heart (sternocostal), with predominance ranging from 30% to 48%3,8,13,19-21. This study identified a non-significant prevalence of injuries in the left ventricle, amounting to eight cases (47.1%), followed by the right ventricle in six cases (35.3%), a distribution similar to the ones detected by other authors2,6. Diagnosis of penetrating heart injuries can be based on clinical data and complementary exams. Any diagnostic method (FAST, CT or pericardial window) must be performed only in stable patients. Patients in shock must be submitted to surgery immediately10,12. The literature points out FAST as an important complementary exam, which can be performed in the emergency room, and repeated whenever necessary, however it has a bias of being operator dependent.

Rev Col Bras Cir 46(3):e20192154


Gรณes Junior The use of computed tomography for penetrating heart injury screening.

6

It presents 100% sensitivity and 96.9% specificity13. In this study, no patient went through FAST due to unavailability of the device at the emergency room of the service3,6,10. Many authors still consider the pericardial window as the gold standard due to its 97% sensitivity and 100% specificity3,4,8,14; it is an invasive surgical procedure with low complication rates reported of up to 2.6%4,6,13. Other exams can be performed for a better assessment of patients who were victims of thoracic trauma. A study performed by Melo et al.10, in 2016, shows that patients who suffered penetrating thoracic traumas who were submitted to CT had findings related to mediastinal alterations in 20% of the exams. Other studies claim that CT has high sensitivity and specificity to detect penetrating heart injuries, associated to findings like pericardial pericardial effusion and pneumopericardium; however, such papers do not assign values to the exam sensitivity9,10,21. Although less specific radiological alterations, like a voluminous hemothorax, may be associated to a heart injury, only findings of pneumomediastinum, pneumopericardium, mediastinal hematoma, hemopericardium, pericardium effusion, mediastinal hemorrhage were considered as suggestive of heart injure on CT images because these are the findings classically described in the literature9,10,21. In spite of this, alterations like pneumodiastinum or mediastinal hematoma can occur in patients with injuries in other structures than the heart. In this study, CT sensitivity was 56.5% and its specificity was 85.7%, way below the FAST ones, which has an approximate sensitivity of 100% and a specificity of 96%8,22. Besides, just like among the 72 tomographies, 20 patients (27.8%) presented findings suggesting heart injury and, among such patients, in only 13 of them (18%) surgical findings were compatible, the Positive Predictive Value of CT

was 65%, that is, in 35% of the cases, patients with tomographic findings suggesting heart injury do not present an actual injury. On the other hand, in patients whose tomographies showed no findings suggesting heart injury (52 patients, or 72.2%), in only ten of them (13.9%) surgical findings compatible with heart injury were detected. Thus, a negative predictive value of 80.7% is obtained, that is, in 80.7% cases of patients with no tomographic evidence suggesting heart injury, this was not detected during surgery. In practical terms, it is possible to notice that, in hospitals where FAST is not available, tomographies are more and more requested for screening heart injuries. In the casuistry of the study, 68.2% of the patients submitted to the pericardial window after tomography obtained a negative result in the pericardial window, that is, if CT presented an accuracy which is enough for screening, approximately 70% of patients would be undergoing the pericardial window unnecessarily. It is as if patients were submitted do surgical exploration regardless of the CT findings. Among the limitations of this study is the relatively small sample, although superior to some of the articles published on CT findings in thoracic trauma, and the fact that the CT were performed using 16 channels CT scanners. Many hospitals own a CT scanner that is annexed or close to the emergency room, which makes it faster to get exams done and for the therapeutic decision making. More modern CT scanners produce finer cuts, increasing image definition, which is obtained within seconds23. However, the worldwide and national reality is heterogeneous regarding availability and quality of the exams and training of surgeons and radiologists to interpret suggestive findings of penetrating heart injury3,6.

Rev Col Bras Cir 46(3):e20192154


Góes Junior The use of computed tomography for penetrating heart injury screening.

Considering that the literature indicates an approximate sensitivity of 97% and an approximate specificity of 100%, either for the FAST or for the pericardial window3,6,8,9,21, the sensitivity and specificity values of the computed tomography obtained in this study indicate that this diagnostic

7

modality must not be recommended as a routine for the screening of penetrating heart injuries; in services where an ultrasonographic assessment of the pericardial sac cannot be urgently performed, a subxiphoid pericardiotomy remains an appropriate option.

R E S U M O Objetivo: determinar se a tomografia computadorizada representa uma opção segura para triagem de lesões cardíacas penetrantes. Métodos: estudo transversal retrospectivo, que confrontou os achados tomográficos com os detectados na exploração cirúrgica em pacientes operados por suspeita de trauma cardíaco no período de janeiro de 2016 a janeiro de 2018. Resultados: setenta e dois casos foram analisados; 97,2% eram do sexo masculino e a faixa etária mais prevalente foi de 20 a 29 anos; 56,9% apresentaram ferimentos por projéteis de arma de fogo e 43,1% por arma branca. Em 20 casos, a tomografia computadorizada foi sugestiva de lesão cardíaca, confirmada em 13 casos durante a cirurgia. A sensibilidade da tomografia computadorizada foi de 56,5% e a especificidade de 85,7%. Conclusão: a tomografia computadorizada não deve ser adotada rotineiramente para triagem de ferimentos cardíacos penetrantes. Descritores: Coração. Ferimentos Penetrantes. Traumatismos Cardíacos. Tomografia. Diagnóstico.

REFERENCES 1.

2.

3.

4.

5. 6.

7.

8.

Nicol AJ, Navsaria MB, Kahn D. History of cardiac trauma surgery. Continuing Medical Education. 2013;31(6):206-9. Araujo AO, Westphal FL, Lima LC, Correia JO, Gomes PH, Costa EM, et al. Trauma cardíaco fatal na cidade de Manaus/AM, Brasil. Rev Col Bras Cir. 2018;45(4):e1888. Karigyo CJT, Silva DR, Pelisson TM, Fan OG, Tarasiewich MJ. Trauma cardíaco penetrante. Rev Med Res. 2013;15(3):198-206. Reis ALFA, Neto ES, Pinto FNCS, Schettino KC, Silva LAC, Monte LFR, et al. Janela pericárdica: história e seu uso nos dias atuais. Rev Med Minas Gerais, Belo Horizonte: 2012;22(5):S32-S34. Albadani MN, Alabsi NA. Management of chest injuries: a prospective study. Yemeni J Med Sci. 2011;5:23-7. Kaljusto ML, Skaga NO, Pillgram-Larsen J, Tønnessen T. Survival predictor for penetrating cardiac injury; a 10year consecutive cohort from a scandinavian trauma center. Scand J Trauma Resusc Emerg Med. 2015;23:41. Silva LAP, Ferreira AC, Paulino RES, Guedes GO, Cunha MEB, Peixoto VTCP, et al. Análise retrospectiva da prevalência e do perfil epidemiológico dos pacientes vitimas de trauma em um hospital secundário. Rev Med (São Paulo). 2017;96(4):246-54.

9.

10.

11.

12.

13.

Uchimura MM, Battiston J, Moreira P, Stahlschmidt CMM, Lubachevski FL. Análise epidemiológica das pericardiotomias realizadas em um hospital universitário de Curitiba. Rev Col Bras Cir. 2010;37(2):92-5. Steven JC, Yong-Hing CJ, Galea-Soler S, Ruzsics B, Schoepf UJ, Ajlan A, et al. Role of Imaging in penetrating anda blunt traumatic injury to the heart. Radiographics. 2011;31(4):E101-15. Melo ASA, Moreira LBM, Pessoa FMC, Saint-Martin N, Ancilotti Filho R, Souza Jr AS, et al. Aspectos tomográficos do trauma torácico aberto: lesões por projéteis de arma de fogo e armas brancas. Rev Radiol Bras. 2016;50(6):372-7. Langdorf MI, Medak AJ, Hendey GW, Nishijuma DK, Mower WR, Raja AS, et al. Prevalence and clinical import of thoracic injury identified by chest computed tomography but not chest radiography in blunt trauma: multicenter prospective cohort study. Ann Emerg Med. 2015;66(6):589-600. American College of Surgeon. Advanced Trauma Life Support: student course manual. 9th ed. Chicago: American College of Surgeons; 2012. Mantovani M, Espinola JP, Fraga GP. Janela pericárdica transdiafragmática no diagnóstico de lesão cardíaca. Rev Col Bras Cir. 2006;33(1):29-34.

Rev Col Bras Cir 46(3):e20192154


Góes Junior The use of computed tomography for penetrating heart injury screening.

8

14. Naufel Júnior CR, Talini C, Barbier Neto L. Perfil dos pacientes vítimas de trauma torácico atendidos no Hospital Universitário Evangélico de Curitiba (HUEC). Rev Med UFPR. 2014;1(2):42-6. 15. Khorsandi M, Skouras C, Prasad S, Shah R. Major cardiothoracic trauma: eleven-year review of outcomes in the North West of England. Ann R Coll Surg Engl. 2015;97(4):298-303. 16. Souza VS, Santos AC, Pereira LV. Perfil clínicoepidemiológico de vítimas de traumatismo torácico submetidas a tratamento cirúrgico em um hospital de referência. Sci Med. 2013;23(2):96-101. 17. Mendes CA, Hirano ES. Fatores preditores de complicações da drenagem de tórax em pacientes vítimas de trauma. Rev Col Bras Cir. 2018;45(2):e1543. 18. Broska Júnior CA, Botelho AB, Linhares AC, DeOliveira MS, Veronse G, Naufel Junior CR, et al. Perfil dos pacientes vítimas de trauma torácico submetidos à drenagem de tórax. Rev Col Bras Cir. 2017;44(1):27-32. 19. Westphal FL, Lima LC, Netto JC, Silva JS, Santos Junior VL, Westphal DC. Trauma torácico: análise de 124 pacientes submetidos à toracotomia. Rev Col Bras Cir. 2009;36(6):482-6.

20. Spencer Netto FAC, Campos JM, Lima LFC, Riviera MACP, Kreimer F, Silveira RK. Fatores prognósticos de mortalidade em pacientes com trauma cardíaco que chegam à sala de cirurgia. Rev Col Bras Cir. 2000;28(2):87-94. 21. Raptis DA, Bhalla S, Raptis CA. Computed Tomographic Imaging of Cardiac Trauma. Radiol Clin North Am. 2019;57(1):201-12. 22. Aihara AY, Fernandes ARC, Viertler CM, Natour J. Tomografia multi-slice no sistema músculo-esquelético. Rev Bras Reumatol. 2003;43(6):372-6. 23. Navsaria PH, Nicol AJ. Haemopericardium in stable patients after penetrating injury: is subxiphoid pericardial window and drainage enough? A prospective study. Injury. 2005;36(6):745-50. Received in: 02/10/2019 Accepted for publication: 03/29/2019 Conflict of interest: none. Source of funding: none. Mailing address: Adenauer Marinho de Oliveira Góes Júnior E-mail: adenauerjunior@gmail.com edpolenzi@hotmail.com

Rev Col Bras Cir 46(3):e20192154


Original Article

DOI: 10.1590/0100-6991e-20192176

Risk factors associated with hospital mortality in mitral valve reoperation Fatores de risco associados à mortalidade hospitalar em reoperação valvar mitral José Dantas de Lima Júnior1; Jorge Eduardo Fouto Matias, ACBC-PR2; Henrique Jorge Stahlke Júnior2 A B S T R A C T Objective: to identify the factors associated with mortality in mitral valve reoperation, to create a predictive model of mortality and to evaluate the EuroSCORE. Methods: a total of 65 patients were evaluated from January 2008 to December 2017. It was verified the association of variables with death and a multiple logistic regression model was used to stratify patients. Results: hospital mortality was 13.8% and in the Death Group: EuroSCORE was 12.33±8.87 (p=0.017), the left ventricular ejection fraction (LVEF) was 45.33±5.10 (p=0.000), the creatinine was 1.56±0.29 (p=0.002), the prothrombin time (TAP) was 1.64 (p=0.001), pulmonary artery systolic pressure (PSAP): 66.1±13.6 (p=0.002), female: 88% (p=0.000), malnutrition: 77.7% (p=0.007), associated tricuspid disease: 44,4% (p=0.048), presence of ventricular arrhythmia: 77.7% (p=0.005), implantation of a biological prosthesis: 55.5% (p=0.034), bronchopneumonia and sepsis: 33,3% (p=0.048), systemic inflammatory response syndrome (SIRS): 55.5% (p=0.001), low cardiac output syndrome (LCOS): 88.8% (p=0.000). Conclusion: the factors associated with mortality were: EuroSCORE, LVEF, creatinine, TAP, PSAP, female, malnutrition, tricuspid disease, ventricular arrhythmia, implantation of biological prosthesis, SIRS, SBDC, bronchopneumonia and sepsis. The explanatory variables of death of the model were: EuroSCORE, creatinine, TAP, LVEF, length of stay in the intensive care unit (ICU), interval between surgeries and presence of ventricular arrhythmia. The high EuroSCORE is related to higher mortality. Keywords: Mitral Valve. Risk Factors. Reoperation. Hospital Mortality.

INTRODUCTION

T

he majority of patients undergoing mitral valve surgery should require further surgery at some late period of their survival. Valvular diseases of rheumatic origin remain prevalent in developing countries1, which causes many patients to undergo surgery very young and often require reoperation. Mitral valve reoperation presents a high surgical risk, as well as an important late mortality2. The factors predisposing to these results are complex and have extremely significant socio-regional characteristics and great variations. In Brazil, the number of reoperations is high, mainly due to the great use of biological prostheses, which have a limited life span due to the structural dysfunction of the prosthetic material3.

In the international literature4-6, multivariate analyzes were performed to identify risk factors for morbidity and mortality. In Brazil, data show that mortality during cardiac surgery is still high7, which can be explained partly by the socioeconomic differences of our population7-9. The use of predictors of risk events scores is well established but the difficulty is that the risk models derived and validated in one site usually present lower performance when applied in a different setting, even in the same place over time. In the history of cardiac surgery, the predicted risk model with the greatest impact was EuroSCORE II10, which is widely used in several heart surgery centers worldwide. Thus, the objective of this study was to identify factors associated with hospital mortality,

1 - Western State University of Paraná, Center for Medical and Pharmaceutical Sciences, Cascavel, PR, Brazil. 2 - Federal University of Paraná, Faculty of Medicine, Curitiba, PR, Brazil. Rev Col Bras Cir 46(3):e20192176


Lima Júnior Risk factors associated with hospital mortality in mitral valve reoperation

2

to create a predictive model of mortality adequate to our reality, and to evaluate the behavior of EurosCORE in a referral hospital.

METHODS We performed a retrospective analysis of patients over 18 years old who had undergone mitral valve surgery at Hospital do Coração Nossa Senhora da Salete, in Cascavel - State of Paraná, Brazil. The Hospital is a tertiary care center, a reference in cardiology for the Unified Health System (SUS) of the 10th Health Region. This work was submitted to the Ethics Committee of the University Hospital of the State University of Western Paraná, with approval number 2042552. We evaluated 65 consecutive patients operated from January 2008 to December 2017. We defined hospital mortality as any cause of death during hospitalization and up to the 30th postoperative day. To evaluate the predictive factors of the occurrence of death, we verified the association of variables (factors) with death by means of univariate statistical analysis, that is, we calculated the Pearson and Spearman correlation coefficients and the matrices correlation coefficients. Subsequently, we used the variables to fit a multiple logistic regression model, with a significance level of 5%. The software used was the Statgraphics 5.1®. The data available for fitting the multiple logistic regression model were observations of a dichotomous "Y-response" variable, related to deaths, that is, it only assumed one of two values, '1' for the Death Group and '0' for the Survivor Group. The Death Group was formed by nine observations and the Surviving Group, by 56. The fitting was made looking for the variables most correlated with death in the correlation matrices between all variables preliminarily calculated and introduced in the model.

Thus, we found the significance of the model based on the corresponding p-value in a deviation analysis test, until seven explanatory variables were obtained, which explained 99.95% of the variance of the variable Y (death). The estimation of the model parameters (coefficients of the variables) was done by the maximum likelihood method using iterative process, and in the logistic regression we tried to maximize the probability of an event occurring. The variables evaluated were age, gender, functional class according to the New York Heart Association, EuroSCORE, malnutrition assessed by the Malnutrition Universal Screening Tool (MUST)11, time of preoperative hospitalization, diabetes, smoking, associated aortic or tricuspid disease, interval between surgery in years, patient bearer of native valves, bioprosthetic or mechanical valve, number of procedures, serum creatinine (mg/dl), hemoglobin (g/dl), and time of prothrombin activity (PT) at the time of admission expressed by the international normalized ratio (INR). Regarding the heart rhythm, we divided the patients into three groups: sinus rhythm, atrial fibrillation and ventricular arrhythmia. The echocardiographic variables evaluated were left atrium dimension, left ventricular diastolic dimension (LVDD), type of valvular dysfunction; stenosis or insufficiency pulmonary artery systolic pressure (PASP), left ventricular ejection fraction (LVEF) calculated by the Teichholz formula12, number of the surgery performed, whether it was the second, third or fourth, extracorporeal circulation time (ECT), type of implanted prosthesis, biological or mechanical, length of stay in the intensive care unit (ICU) in days, need of exploratory thoracotomy by bleeding in the immediate postoperative period, bronchopneumonia, sepsis, systemic inflammatory response syndrome (SIRS) and low cardiac output syndrome (LCOS).

Rev Col Bras Cir 46(3):e20192176


Lima Júnior Risk factors associated with hospital mortality in mitral valve reoperation

The access route was a new sternotomy and the extracorporeal circulation was established by aortic and bicaval cannulation. The femoral region was left exposed, but the femoral vessels were not dissected.

RESULTS Hospital mortality was 13.8% (9 patients). The mean age was 48±12 years; 49 patients (75%) were female. Table 1 shows the statistical description of the quantitative variables and table 2, the description of the qualitative ones. The most explanatory variables of death were EuroSCORE, surgery interval, left ventricular ejection fraction, serum creatinine, prothrombin activity time, length of stay in the intensive care unit and presence of ventricular arrhythmia. The equation of the final regression model is logistic for the sigmoid curve is:

3

death = exp (eta) / (1+exp (eta), where eta corresponds to the best linear combination of variables to explain (predict) the value of the death variable. Thus, the result obtained for the model was: eta= 598.681 - 3.06764 x EuroSCORE - 24,4945 x interval surgery - 7,46427 x LVEF + 53.6369 x creatinine + 23.9337 x PT(INR) - 7.36136 x ICU time - 77.5164 x ventricular arrhythmia. Tables 3 and 4 show the maximum likelihood estimates of the parameters when fitting the model with only one variable and with the seven variables, respectively. The deviation analysis showed that the model is significant, since the corresponding value is p<0.05 (5%), that is, there is a significant relationship between death and the seven factors, which explains 99.9567% (52.2583) of the data variance (52.2809), leaving as residue only 0.000433% (0.0226525) of unexplained variance.

Table 1. Descriptive statistics of the quantitative variables in the survivor and death groups.

Variable PREOPT* Age (years) EuroSCORE Surgery interval (years) Creatinine (mg/dl) Hemoglobin (mg/dl) PT** (INR) LA*** (mm) LVDD# (mm) PASP## (mmHg) LVEF### (%) ECT¥ (min) ICUT¥¥ (days)

Survivor group 3.22±3.83 47.2±11.5 3.33±2.62 11.48±3.21 1.19±0.28 10.31±1.96 1.19±0.22 48.75±3.81 58.30±4.84 51.45±8.61 57.64±7.32 107.28±33.827 2.82±2.05

Death group 4.33±2.41 52.9±15.1 12.33±8.87 9.78±0.98 1.56±0.29 10.67±2.0 1.64±0.15 49.67±3.91 59.44±3.91 66.1±13.6 45.33±5.10 131.1±52.9 6.22±5.15

p-value 0.111 0.190 0.017 0.190 0.002 0.649 0.001 0.470 0.115 0.002 0.000 0.104 0.193

*PREOPT: preoperative time; **PT (INR): prothrombin activity time (International Normalized Ratio); ***LA: left atrium; # LVDD: left ventricular diastolic diameter; ##PASP: pulmonary artery systolic pressure; ###LVEF: left ventricular ejection fraction; ¥ ECT: extracorporeal circulation time; ¥¥ICUT: time in the intensive care unit.

Rev Col Bras Cir 46(3):e20192176


Lima Júnior Risk factors associated with hospital mortality in mitral valve reoperation

4

Table 2. Descriptive statistics of the qualitative variables in the survivor and death groups.

Variable Gender      Women       Men NYHA class*       II       III       I MUST** nutrition       Nourished       Malnourished Smoking Diabetes Nº of surgery       2nd surgery       3rd surgery       4th surgery Native valva Biological prosthesis Mechanical prosthesis Sinus rhythm Atrial fibrillation Ventricular arrhythmia Type of valve dysfunction       Stenosis       Insufficiency Type of implanted prosthesis       Biological       Mechanical Associated disease       Tricuspid       Aortic Exploratory thoracotomy Bronchopneumonia Sepsis SIRS*** LCOS#

Survivor group 41 (73%) 15 (26.7%)   46 (82.1%) 9 (16%) 1 (1.7%)   40 (71.4%) 16 (28.5%) 10 (17.8%) 3 (5.35%)   52 (92.8%) 4 (7.14%) 0 (0%) 11 (19.6%) 43 (76.7%) 2 (3.56%) 17 (30.3%) 39 (69.9%) 7 (12.5%)   43 (76.7%) 13 (23.3%)   11 (19.6%) 45 (80.3%)   11 (19.4%) 7 (12.5%) 1 (1.78%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)

Death group 8 (88%) 1 (11.1%)   7 (77.7%) 2 (22.2%) 0 (0%)   2 (22.2%) 7 (77.7%) 2 (22.2%) 1 (11.1%)   5 (55.5%) 3 (33.3%) 1 (11.1%) 1 (11.1%) 8 (88.8%) 0 (0%) 2 (22.2%) 7 (77.7%) 7 (77.7%)   8 (88.8%) 1 (11.1%)   5 (55.5%) 4 (44.5%)   4 (44.4%) 0 (0%) 2 (22.2%) 3 (33.3%) 3 (33.3%) 5 (55.5%) 8 (88.8%)

p-value 0.000 0.433   0.865 0.932 1.000   0.047 0.007 0.667 0.077   0.553 0.155 0.327 0.185 0.333 1.000 1.000 1.000 0.005   0.185 0.670   0.034 1.000   0.048 1.000 0.365 0.048 0.048 0.001 0.000

*NYHA: New York Heart Association; **MUST: Malnutrition Universal Screening Tool; ***SIRS: systemic inflammatory response syndrome; #LCOS: low cardiac output syndrome.

Rev Col Bras Cir 46(3):e20192176


Lima Júnior Risk factors associated with hospital mortality in mitral valve reoperation

5

Table 3. Regression models estimated by maximum likelihood for one variable and constant.

Parameter Estimate Default error of the estimate Percentage explanation Constant -3.50934 0.714399 EuroSCORE 0.282525 0.2925050 33.4227% Surgery interval -0.23926 0.157969 5.3638% LVEF* -0.347234 0.112105 43.2946% Creatinine 3.34958 1.2349 17.8830% PT (INR)** 4.87934 1.67042 28.4254% ICUT*** 0.274311 0.102693 14.6581% # VA -4.19971 1.1452 44.5967%

p-value 0.00000 0.09400 0.00000 0.0022 0.0001 0.0056 0.00000

Chance ratio 1.33009 0.78720 0.70664 28.49080 131.5440 1.3156 0.0150

*LVEF: left ventricular ejection fraction; **PT (INR): prothrombin activity time (International Normalized Ratio); ***ICUT: length of stay in the intensive care unit; #VA: ventricular arrhythmia.

Table 4. Regression model estimated by maximum likelihood for the seven variables.

Parameter

Estimate

Default error of the estimate

Odds Ratio

Constant EuroSCORE Surgery interval LVEF* Creatinine PT** ICUT*** VA#

598.681 -3.06764 -24.4945 -7.46427 53.6369 23.9337 -7.36136 -77.5164

296.324 12.1711 7.6586 3.9079 100.806 40.4968 10.3726 37.0168

0.0465307 2.30243E-11 0.000573203 1.96893E23 2.4791E10 0.000635334 2.16297E-34

Contribution of Explanation of the the variable for model with only the model the variable   33.4227% 33.4227% 3.4240% 5.3638% 33.374% 43.2946% 3.159% 17.8830% 2.8966% 28.4254% 2.0128% 14.6581% 6.0527% 44.5967%

p-value

0.9791 0.0000 0.0000 0.9126 0.7829 0.7698 0.0002

*LVEF: left ventricular ejection fraction; **PT: prothrombin activity time; ***ICUT: length of stay in the intensive care unit; # VA: ventricular arrhythmia.

Table 5 shows the results of the likelihood ratio test for the parameters. Although only three had p-value below 0.05, the set of variables was the one that best fit, producing an explanation degree of 99.9567%. The model can be used to predict the response using information from each line of the data file (patient). So if the predicted value is greater than that of the cut line chosen by the researcher, the predicted response is to be true and if this predicted value is smaller, the response is predicted to be false. At the cutoff of 0.4 one gets 100% of all true answers correctly predicted as true, and 100% of all false correctly predicted to be false. In the present

case, true means death and false means no death, and the value predicted by the model is the estimated probability of death, that is, P (death =1). Figure 1 demonstrates the predictability of the model.

Figure 1. Model's death prediction capacity.

Rev Col Bras Cir 46(3):e20192176


Lima Júnior Risk factors associated with hospital mortality in mitral valve reoperation

6

Table 5. Proof of likelihood ratio for parameters.

Factor Interval surgery EuroSCORE LVEF* Creatinine PT** ICUT*** VA#

Chi-square 16.7415 0.000684113 19.1658 0.0120421 0.0759345 0.0856041 13.4505

Degrees of freedom 1 1 1 1 1 1 1

p-value 0.0000 0.9791 0.0000 0.9126 0.7829 0.7698 0.0002

*LVEF: left ventricular ejection fraction; **PT: prothrombin activity time; ***ICUT: length of stay in the intensive care unit; # VA: ventricular arrhythmia.

In the 'Box-and-whisker-plot' of the distribution of frequencies of the EuroSCORE variable for the 65 patients, the value of the EuroSCORE with the mean and SD are 4.58±5.05, showing that 80% have values less than or equal to 4.73684. Thus, 25% of the values are less than 2.21 (1st Quartile) and 75% are less than 3.82 (3rd Quartile) so that 25% are higher than 3.82. In the Survivor Group, the value of the EuroSCORE, mean and SD were 3.33±2.62, showing that 25% of the values are less than 2.21 (1st Quartile) and 75% are lower than 3.365 (3rd Quartile), and that 25% is greater than 3.365. In the Death Group, Mean and SD were 12.3278±8.86, therefore 77.78% have values greater than 5,0, 25% of the values are less than 5.3 (1st Quartile) and 75% are less than 20.31 (3rd Quartile), so that in this group 25% are superior to 20.31. There were no outliers in the Death Group. Thus, considering the frequency distribution of the EuroSCORE, the following criterion can be used in the prediction of death: EuroSCORE <4: probably no death; between 4 and 5: difficult to predict; and >5: probable death.

DISCUSSION Mitral reoperations present a higher risk of adverse events when compared with first surgeries which may compromise survival.

Mortality in this study was 13.8%, the most common cause being low cardiac output syndrome. This rate has been similar in recent studies4,6,13. This situation demonstrates that these patients still require more attention. The shorter interval between surgeries in the Death Group was considered explanatory by the model. Studies have shown that the mortality rate in patients who are reoperated within less than the usual time intervals present higher mortality, usually due to the presence of heart failure due to paravalvular reflux or to the injury of cardiac structures during the new sternotomy14,15. Likewise, patients submitted to a higher number of reoperations also present higher mortality due to the risk of cardiac lesions (right ventricle and innominate vein)4. Decreased left ventricular ejection fraction was associated with higher mortality in the univariate analysis and highly explanatory of death in the model. The published studies demonstrate that this is the most consistent factor in explaining mortality in mitral reoperation and warn of the need for reoperating patients before deterioration of the ventricular function6,13,14,16. Vohra et al.13 reported that patients with left ventricular ejection fraction <50% had EuroSCORE II of 12±4, thus showing their high risk. The association of this variable also shows good consistency, as demonstrated in our model.

Rev Col Bras Cir 46(3):e20192176


Lima JĂşnior Risk factors associated with hospital mortality in mitral valve reoperation

Likewise, increased creatinine was associated with death in the univariate analysis and was explanatory in the model, consistent with the literature, as described by several authors as an independent predictor of death6,13,14,16. High pulmonary artery pressure is a clinical and hemodynamic syndrome, which is a serious clinical situation, usually associated with mitral stenosis. During surgery, the right ventricle is significantly dilated and the trunk of the pulmonary artery is tense, death occurring due to ventricular failure17. High pulmonary artery pressure was associated with death in the univariate analysis but did not present a good explanation in the model. On the other hand, in the multivariate analyzes it was predictive of death when associated with tricuspid valve reflux17,18. The length of stay in the intensive care unit (ICUT) was explanatory for death in the model. These patients are those who require prolonged mechanical ventilation, pulmonary infections and have received greater transfusion of hemoderivatives that may cause pulmonary inflammatory response in mitral valve reoperations6,18. Longer hospital stay was also associated with higher mortality by other authors13,14. Prothrombin time (PT) was an explanatory factor of death in our study. Changing PT indicates depletion of vitamin K dependent factors. In Brazil, BrandĂŁo et al.9 reported that decreased prothrombin activity was associated with hospital mortality in valve reoperations in univariate analysis. Decreased prothrombin activity was found mainly in patients who had heart failure demonstrated by functional class III and IV (NYHA). These patients had an increased mortality rate, probably due to altered liver function4.

7

It is also worth noting that reoperations do not increase the risk of bleeding in the postoperative period19, but when there was a need for greater transfusion of blood products, mortality increased14. In the univariate analysis, women presented higher mortality, but there was no explanation for death in the model, as described in other studies13,18. The presence of ventricular arrhythmia (extrasystole) was associated with death in the univariate analysis and was explanatory of death in the model. We believe that its presence is a sign of ventricular dysfunction. Fukunaga et al.20 reported that arrhythmias were a factor associated with hospital mortality in valve reoperations. The presence of ventricular extrasystoles (VES)>5VES/min is also considered an isolated preoperative risk factor in noncardiac, elective surgeries and may also be related to myocardiopathy21. The prognosis of arrhythmia is related to the clinical manifestations of heart failure manifested by NYHA class III and IV, where myocardial injury due to valve dysfunction has usually occurred4. The presence of tricuspid reflux was associated with death in our series in the univariate analysis, but it was not explanatory of death in the model. However, Fukunaga et al.22 suggest that the correction of severe tricuspid reflux should be performed to improve hospital mortality. Teman et al.23 suggest that patients who will undergo mitral reoperation and have tricuspid reflux should be corrected prophylactically because they present lower mortality when the condition is less severe. The biological prosthesis implant was associated with higher mortality, but was not explanatory in the model. In routine reoperations, we prefer mechanical prosthesis implantation in young patients, in order to reduce the number of surgeries.

Rev Col Bras Cir 46(3):e20192176


Lima JĂşnior Risk factors associated with hospital mortality in mitral valve reoperation

8

Thus, when the mechanical prosthesis is not performed, it is due to technical difficulties such as a calcified or small orifice ring, where there may be difficulty in the proper functioning of the prosthesis. Another situation that impairs the mechanical prosthesis implantation is the valve ring lesion or lesion of cardiac structures, usually the atrioventricular disjunction, when the mortality is high20. It is noteworthy that in these cases there was increased ECT, renal insufficiency, cardiac lesions, situations related to higher mortality6,15,18,20. The risk of severe malnutrition was associated with death, but it was not explanatory in our model. The incidence of high-risk patients classified by MUST11 was 77% in the Death Group. These patients are generally associated with higher mortality, prolonged use of antibiotics, low cardiac output, greater use of inotropes and positive blood cultures24. MUST was the preferred score for stratifying the risk of malnutrition in the population with indication for cardiac surgery25. The greatest cause of death was low cardiac output syndrome in eight patients, and one patient died due to occlusion of the tracheostomy cannula by secretion. Other causes associated with death in the univariate analysis were: bronchopneumonia, sepsis, SIRS, which can be considered terminal phases, as described in other studies6,16,20, but in the model they were not explanatory. Prediction in cardiac surgery adopts a score based on factors considered as predictors of death or complications, but the literature is still not consensual about the best predictive system to be used26. Currently there are more than 20 models of risk scores in cardiac surgery27.

Among them, the most well-known and used is the EurosCORE II (European System For Cardiac Operative Risk)10. However, EuroSOCORE was designed for an older population with a low incidence of rheumatic disease and is not specific for valve surgery. This heterogeneity reported in the studies is a great problem in comparing the results in smaller centers13. On the other hand, Onorati et al.6 described the first multicenter European study, in which eight centers participated. Similarly, they found limitations, such as retrospective information recording, surgical routine different from each participating center, and differences among the population, but it would be closer to reality. Hence, we devised a score appropriate to our local population, trying to estimate hospital mortality more accurately. The deviation analysis showed that the model is significant (p<0.0000) and the seven variables explained 99.95% of the data variance. Factors that affect patient outcomes are numerous and often confound the rigor of the analyzes, so the result of the score should be evaluated in conjunction with the benefit of the procedure given by scientific knowledge, with team and patient autonomy in making decision and discussion of ethical principles. However, for validation, the score should be tested in a prospective multicenter study and compared to other prediction models. The description of the frequency of the EuroSCORE is another tool that can aid decision making. We conclude that the identification of risk factors and the creation of a predictive risk model appropriate to our reality, associated to the performance of the EuroSCORE, are important tools in improving survival in mitral reoperation.

Rev Col Bras Cir 46(3):e20192176


Lima Júnior Risk factors associated with hospital mortality in mitral valve reoperation

9

R E S U M O Objetivo: identificar os fatores associados à mortalidade em reoperação valvar mitral, criar um modelo preditivo de mortalidade e avaliar o EuroSCORE. Métodos: foram avaliados 65 pacientes submetidos à reoperação de valva mitral no período de janeiro de 2008 a dezembro de 2017. Foi verificada a associação das variáveis com o óbito e criado um modelo de regressão logística múltiplo para estratificar os pacientes. Resultados: a mortalidade hospitalar foi de 13,8% e, neste grupo, o EuroSCORE foi de 12,33±8,87 (p=0,017), a fração de ejeção do ventrículo esquerdo (FEVE) foi de 45,33±5,10 (p=0,000), a creatinina foi 1,56±0,29 (p=0,002), o tempo de atividade da protrombina (TAP): 1,64±0,15 (p=0,001), pressão sistólica da artéria pulmonar (PSAP): 66,1±13,6 (p=0,002), sexo feminino: 88% (p=0,000), desnutrição: 77,7% (p=0,007), doença tricúspide associada: 44,4% (p=0,048), presença de arritmia ventricular: 77,7% (p=0,005), implante de prótese biológica: 55,5% (p=0,034), broncopneumonia e sepse: 33,3% (p=0,048), síndrome da resposta inflamatória sistêmica (SIRS): 55,5% (p=0,001), síndrome do baixo débito cardíaco: 88,8% (p=0,000). Conclusão: os fatores associados à mortalidade foram: EuroSCORE, FEVE, creatinina, TAP, PSAP, sexo feminino, desnutrição, doença tricúspide, arritmia ventricular, implante de prótese biológica, SIRS, SBDC, broncopneumonia e sepse. As variáveis explicativas de óbito do modelo foram: EuroSCORE, creatinina, TAP, FEVE, tempo de internamento na unidade de terapia intensiva (UTI), intervalo entre cirurgias e presença de arritmia ventricular. O EuroSCORE elevado está relacionado à maior mortalidade. Descritores: Valva Mitral. Fatores de Risco. Reoperação. Mortalidade Hospitalar.

REFERENCES 1.

2.

3.

4.

5.

6.

7.

Guilherme L, Kalil J. Rheumatic fever: from sore throat to autoimmune heart lesions. Int Arch Allergy Imunnol. 2004;134(1):56-64. Cicekcioglu F, Tutum V, Babaroglu S, Mungan A, Parlar AI, Demirtas E, et al. Redo valve surgery with on-pump beating heart technique. J Cardiovasc Surg (Torino). 2007;48(4):513-8. De Bacco MW, Sant’Anna JRM, De Bacco G, Sant’Anna RT, Santos MF, Pereira E, et al. Fatores de risco hospitalar para implante de bioprótese valvar de pericárdio bovino. Arq Bras Cardiol. 2007;89(2):125-30. Fukunaga M, Okada Y, Konishi Y, Murashita T, Koyama T. Does the number of redo mitral valve replacements for structural valve deterioration affect early and late outcomes?: experience from 114 reoperative cases. J Heart Valve Dis. 2014;23(6):688-94. Bouhout I, Mazine A, Ghonohein A, Millàn X, EIHamamsy I, Pellerin M, et al. Long-term results after surgical treatment of paravavular leak in the aortic and mitral position. J Thorac Cardiovasc Surg. 2016;151(5):1260-6.e1. Onorati F, Perrotti A, Reichart D, Mariscalco G, Della Ratta E, Santarpino G, et al. Surgical factors and complications affecting hospital outcome in redo mitral surgery: insights from a multicentre experience. Eur J Cardiothorac Surg. 2016; 49(5):127-33.

8.

9.

10.

11.

12.

13.

Ribeiro AL, Gagliardi SP, Nogueira JL, Silveira LM, Colosimo EA, Lopes do Nascimento CA. Mortality related to cardiac surgery in Brazil, 2000-2003. J Thorac Cardiovasc Surg. 2006;131(4):907-9. Shibata MC, Flather MD, de Arenaza DP, Wang D, O´Shea JC. Potential impact of socioeconomic differences on clinical outcomes in international clinical trials. Am Heart J. 2001;141(6):1019-24. Brandão CMA, Pomerantzeff PMA, Souza LR, Tarasoutchi F, Grimberg M, Oliveira SA. Fatores de risco para mortalidade hospitalar nas reoperações valvares. Rev Bras Cir Cardiovasc. 2002;17(3):236-41. Nashef SA, Roques F, Sharples LD, Nilsson J, Smith C, Goldstone AR, et al. EuroSCORE II. Eur J Cardiothorac Surg. 2012;41(4):734-44. Stratton RJ, Hackston A, Longmore D, Dixon R, Price S, Stroud M, et al. Malnutrition in hospital outpatients and inpatients: prevalence, concurrent validity and ease of use of the ‘malnutrition universal screening tool’ (‘MUST’) for adults. Br J Nutr. 2007;92(5):799-808. Teichholz LE, Kreulen T, Herman MV, Gorlin R. Problems in echocardiographic volume determinations: echocardiographic-angiographic correlations in the presence of absence of asynergy. Am J Cardiol. 1976;37(1): 7-11. Vohra HA, Whistance RN, Roubelakis A, Burton A, Barlow CW, Tsang GM, et al. Outcome after redomitral valve replacement in adults patients: a 10year single-centre experience. Interact Cardiovasc Thorac Surg. 2012;14(5):575-9.

Rev Col Bras Cir 46(3):e20192176


Lima Júnior Risk factors associated with hospital mortality in mitral valve reoperation

10

14. Kwedar K, McNeely C, Zajarias A, Markwell S, Vassileva CM. Outcomes of early mitral valve reoperation in the Medicare population. Ann Thorac Surg. 2017;104(5):1516-21. 15. Park CB, Suri RM, Burkhart HM, Greason KL, Dearani JA, Greason KL, et al. Identifying patients at particular risk of injury during repeat sternotomy: analysis of 2555 cardiac reoperations. J Thorac Cardiovasc Surg. 2010;140(5):1028-35. 16. Taramasso M, Maisano F, Denti P, Guidotti A, Sticchi A, Pozzoli A, et al. Surgical treatment of paralvular leak: long-term results in a single-center experience (up to 14 years). J Thorac Cardiovasc Surg. 2015;149(5):1270-5. 17. Castilho-Sang M, Guthrie TJ, Moon MR, Lawton JS, Maniar HS, Damiano RJ Jr, et al. Outcomes of repeat mitral valve surgery in patients with pulmonary hypertension. Innovations (Phila). 2015;10(2):120-4. 18. Romano MA, Haft JW, Pagani FD, Bolling SF. Beating heart surgery via right thoracotomy for reoperative mitral valve surgery: a safe and effective operative alternative. J Thorac Cardiovasc Surg. 2012;144(2):334-9. 19. Miana LA, Atik FA, Moreira LF, Hueb AC, Jatene FB, Auler Júnior JO, et al. Fatores de risco de sangramento no pós-operatório de cirurgia cardíaca em pacientes adultos. Rev Bras Cir Cardiovasc. 2004;19(3):280-6. 20. Fukunaga N, Sakata R, Koyama T. Short- and longterm outcomes following redo valvular surgery. J Card Surg. 2018;33(2):56-63. 21. Loureiro BMC, Feitosa-Filho GS. Escores de risco perioperatório para cirurgias não-cardíacas: descrições e comparações. Rev Soc Bras Clin Med. 2014;12(4):314-20.

22. Fukunaga N, Okada Y, Konishi Y, Marashita T, Kanemitsu H, Koyama T. Impact of tricuspid regurgitation after redo valvular surgery on survival in patients with previous mitral replacement. J Thorac Cardiovasc Surg. 2014;148(5):1983-8. 23. Teman NR, Huffman LC, Krajacic M, Pagani FD, Haft JW, Bolling SF. “Prophylatic” tricuspid repair for functional tricuspid regurgitation. Ann Thorac Surg. 2014;97(5):1520-4. 24. Chermesh I, Hajos J, Mashiach T, Bozhko M, Shani L, Nir RR, et al. Malnutrition in cardiac surgery: food for thought. Eur J Prev Cardiol. 2014;21(4):475-83. 25. Lomivorotov VV, Efremov SM, Boboshko VA, Nikolaev DA, Vedernikov PE, Deryagin MN, et al. Prognostic value of nutritional screening tools for patients scheduled for cardiac surgery. Interact Cardiovasc Thorac Surg. 2013;16(5):612-8. 26. Soares Junior JL, Souza MNA. EuroSCORE como sistema de predição de risco em cirurgia cardíaca. J Med Health Prom. 2016;1(1):110-21. 27. Garofallo SB, Machado DP, Rodrigues CG, Bordim Jr O, Kalil RAK, Portal VL. Aplicabilidade de dois escores de risco internacionais em cirurgia cardíaca em centro de referência brasileiro. Arq Bras Cardiol. 2014;102(6):539-48. Received in: 03/11/2019 Accepted for publication: 03/31/2019 Conflict of interest: none. Source of funding: none. Mailing address: José Dantas de Lima Júnior. E-mail: dantaslima@uol.com.br

Rev Col Bras Cir 46(3):e20192176


Original Article

DOI: 10.1590/0100-6991e-20192163

Multiple victims incident simulation: training professionals and university teaching. Simulação de incidente com múltiplas vítimas: treinando profissionais e ensinando universitários. Daniel Souza Lima, ACBC-CE1; Izabella Furtado de-Vasconcelos2; Erika Feitosa Queiroz2; Thaís Aguiar Cunha2; Vitória Soares dos-Santos2; Francisco Albert Eisntein Lima Arruda3; Julyana Gomes Freitas2 A B S T R A C T Objective: to describe the teaching strategy based on the Multiple Victims Incident (MVI) simulation, discussing and evaluating the performance of the students involved in the initial care of trauma victims. Methods: a cross-sectional, and quantitative study was performed. A realistic MVI simulation involving students, and professionals from nursery and medical schools, as well as a prehospital care team was performed. Results: it was possible to notice that the classification according to the START method (Simple Triage and Rapid Treatment) was correct in 94.1% of the time from the analysis of 17 preestablished checklists. Following the primary evaluation with the ABCDE mnemonic, all steps were performed correctly in 70%. However, there was only supply of oxygen in high flow in 64.7% of the examination. The search for visible and hidden bleeding was performed in 70.6% of the examination. The neurological evaluation with the Glasgow coma scale and pupillary evaluation occurred in 70.6% of the victims. The victims exposure was performed in 70.6% of the examination. Conclusion: a simulated environment allows the consolidation and improvement of professional skills, especially when we are talking about a poorly trained area during the undergraduate program, such as the MVI. Early training and teamwork encourage clinical thinking, integration and communication, essential abilities when facing chaotic situations. Keywords: Simulation Training. Education. Medical. Mass Casualty Incidents. Emergency Medical Services.

INTRODUCTION

T

he World Health Organization (WHO) defines multiple victims incident (MVI) as an event that simultaneously generates a large number of victims so that it compromises the ability to a local response routinely available1. In Brazil, the Ministry of Health calls an MVI an incident that involves a number that equals of surpasses five victims2. Care within this scenario is dynamic and complex, demanding urgency services, organization, planning, and qualification of professionals3,4. This is a big challenge to be met in Brazil, where there is no line of care for trauma implemented, which is needed to face this serious public health issue1,5.

Such aspect brings together the Brazilian Society of Integrated Care of Trauma Victims (SBAIT) and the Brazilian College of Surgeons (CBC) in the search for joint actions aiming at changing this reality6. One of the strategies of MVI care is the prehospital triage process, whose aim is to identify and prioritize patients who need immediate intervention and/or removal4,7,8. One of the most widely used methods internationally and widely known in Brazil is the START (Simple Triage And Rapid Treatment). It classifies victims by colors, red meaning immediate priority and the other colors in descending order of priority are yellow, green and black5,8,9-11. The systematization of the initial care of trauma, in particular by the ABCDE mnemonic of

1 - University of Fortaleza (UNIFOR), Health of Science Center, Faculty of Medicine, Fortaleza, CE, Brazil. 2 - University of Fortaleza (UNIFOR), Health of Science Center, Nursing School, Fortaleza, CE, Brazil. 3 - Military Fire Brigade of the State of Ceará, Fortaleza, CE, Brazil. Rev Col Bras Cir 46(3):e2163


2

Lima Multiple victims incident simulation: training professionals and university teaching

primary evaluation, used by the Advanced Trauma Life Support® (ATLS®) and by the Prehospital Trauma Life Support® (PHTLS®), is also applied in cases of MVI. Some studies have shown that previous training of professionals in these educational programs might benefit the response in an MVI7,12. It is well established that health professionals need to be properly prepared for a variety of events with multiple victims, through training and exercises. The educational qualification process is essential for adequate care and error reduction, such as the ones that happen in triage4,13. Besides, in order to optimize emergency care, it is necessary an early improvement of the professionals, still in the undergraduate environment, mainly integrating students of Medicine and Nursing14. The simulation scenario is an educational tool that allows for the reproduction of reality in an interactive way, making it a supervised activity capable of developing technical skills (knowledge and abilities) and non-technical skills (communication, attitude, and teamwork). In this way, it provides the capacity of training in a safe, adequate, and contextualized environment14-16. The objective of this study was to describe the teaching strategy to undergraduates by using an MVI simulation, analysing the outcomes regarding the application of the START method and of the initial care by the ABCDE mnemonic.

Before the simulation, a symposium took place, aiming at training and preparing the participants, which lasted 20 hours. By the day of the simulation, the morning period was used for training the participants who would act in care that would emphasize the triage method used. Preparation of the victims according to their signs and symptoms lasted three hours. After the victims' characterization, and given the guidance about positioning and conduct during the simulation with the fire brigade, aiming at ensuring also the safety of the stakeholders, the simulation started and lasted one hour. Each victim was instructed about the identification, positioning in the scene, color classification according the START method, diagnosis, vital signs and characterization of the simulated injuries. The victims classified as red and

METHODS

yellow were followed up by "shadow students", the older members of trauma and emergency academic leagues (Figure 1). The students acting as shadows and the victims took part in a course before starting care aiming at preparing them for simulation. The role of the linkers was to convey to the people in charge of care in the scene the information about the signs and symptoms of the victims, and to evaluate the initial approach by applying a checklist (Table 1). This was adapted by professionals and teachers working at the Prehospital Care (PHC) to be used in an MVI, similar to the one used in a practice learning environment during the Objective Structured Clinical Examination (OSCE)17 of the disciplines.

This is a cross-sectional study that involved performing a realistic MVI simulation, in May, 2017, at the University of Fortaleza (UNIFOR) campus. The traumatic event simulated consisted of a bus-car collision, involving 56 victims played out by students of Medicine and Nursing.

Other participants of the simulation were professionals of the Urgency Mobile Care Service (SAMU - 192) from Fortaleza and Ceará, of the Rescue and Urgency Group (GSU) of the Military Fire Brigade from Ceará, and of the Integrated Coordination of Aerial Operations from the Public Safety and Social Defense Department.

Rev Col Bras Cir 46(3):e2163


Lima Multiple victims incident simulation: training professionals and university teaching

3

Figure 1. MVI simulation environment at the University: 1) shadow student; 2) student under evaluation; 3) victim.

Table 1. Objective structured clinical examination of trauma – primary evaluation.

Procedure Yes No Victim was correctly classified according to the START method   1. Description of IPE* use/Evaluation of scene safety     2. Evaluation of airway and control of the cervical spine           Performed manual control of cervical spine           Evaluated the airway permeability/clearing, if necessary (manual maneuver, aspiration,     use of orotracheal cannula)       Evaluated cervical spine and described correct the technique of the cervical collar     3. Evaluation of the respiratory pattern           Checked expansibility and symmetry (inspection)           Checked deformities, bleedings, hematomas, or other injuries (palpation)           Checked the breathing quality (superficial or deep; rapid or slow; silent or loud)           Installed oxygen (15l/min)     4. Evaluation of circulation/Signs of bleeding           Checked the pulse and checked the pulse quality (rapid or slow; full or thin; regular or irregular)           Performed examination of abdomen, long bones and pelvis searching for signs of bleeding.     Adopted containment measures.       Checked skin characteristics (color, temperature, humidity, CRT**)     5. Neurological Evaluation           Applied the Glasgow coma scale (classified TBI*** correctly)           Evaluated pupillarity diameter and photoreactivity     6. Hypothermia exposure and control           Checked extremity deformity           Exposure of victim with block rolling and protection against hypothermia     * IPE: individual Protection equipment; ** CRT: capillary refill time; *** TBI: traumatic brain injury. Rev Col Bras Cir 46(3):e2163


4

Lima Multiple victims incident simulation: training professionals and university teaching

GSU professionals acted in the hot zone, applying vehicle extrication techniques. After firefighters signaled safety in the scene, SAMU 192 professionals acted on the initial approach and the withdrawal of victims, who immediately underwent triage by a team of Medicine and Nursing academicians. A second team of academicians organized the distribution of the victims to colored canvases, and care in the Advanced Medical Station (PMA) (Figure 2). Supervision and evaluation of care at the PMA were performed by SAMU 192 teachers and professionals. The study was approved in the Research Ethics Committee from UNIFOR (protocol nยบ 2.505.271).

RESULTS The victims were classified into: red 10.7% (n=6), yellow 28.5% (n=16), green 46.4% (n=26) and black 14.2% (n=8). In this way, classification was correct in 94.1% of the cases. Only one victim who presented with parameters to be classified as yellow was considered green. Stemming from data of 17 checklists correctly filled in from the victims classified as red and yellow (Table 2) it was possible to verify that, when applying the mnemonnic of primary evaluation to ABCDE trauma (A- airway and cervical control, Bventilation, C- circulation, D- neurological evaluation,

Figure 2. Canvas used for the victims care according to the START method.

Rev Col Bras Cir 46(3):e2163


Lima Multiple victims incident simulation: training professionals and university teaching

E- exposure and hypothermia control) there was a manual stabilization of the cervical spine in 88.2% of care in the initial moment of the approach. Cervical evaluation was correctly performed in 76.5% of the cases, with the correct description of the technique of the cervical collar application. Verification and maintenance of the pervious airway occurred in all instances of care performed. When applying item B, 70.6% of the students performed the inspection examination, and 82.4% searched for information on the quality of ventilation. The oxygen availability in high flow occurred in 64.7% of the cases. Thoracic palpation was performed in 94.1% of care cases. Regarding the evaluation of circulation, in 82.4% of the cases there was the examination of the peripheral pulse. Perfusion analysis through information such as skin color, humidity, temperature and time of capillary filling, as well as the need for volume replacement were performed in 88.2% of the cases. The search for hidden sources of bleeding, through abdomen verification, long bones and pelvis reached 70.6%.

5

The Glasgow coma scale was correctly applied in 70.6% of the care, as well as pupillary evaluation. To complete the primary evaluation, in 82.4% of the cases the deformation in the extremities was evaluated, but in 29.4% of the care the victims were not correctly exposed nor protected against hypothermia.

DISCUSSION The teaching of medical emergencies, mostly in the subject area of MVI and disasters, is still inefficient to educate health professionals, specially physicians and nurses. As a result, there is a prevalence of hardships in urgency and emergency environments, since 70% of physicians, mainly the ones starting their carriers, have prompt care units as their initial clinical work scenario. The ones in charge of such units, most of the time are not qualified to act in a context which involves MVI, reinforcing the need of teaching in this subject area starting in the undergraduate environment18,19.

Table 2. Data from evaluated checklists.

 Primary evaluation A Manual control of the cervical spine Cervical spine evaluation + Cervical collar technique Evaluation of the pervious airway B Thoracic inspection Thoracic palpation Breathing quality Oxygen in high flow C Examination of the peripheric pulse Analysis of perfusion (humidity, skin color, temperature, time for capillary filling, and need for volume replacement) Research of bleeding sources D Glasgow coma scale Pupillary evaluation E Evaluation of deformation in the extremities Exposure and protection against hypothermia Rev Col Bras Cir 46(3):e2163

Rights 88.20% 76.50% 100% 70.60% 94.10% 82.40% 64.70% 82.40% 88.20%

Wrongs 11.80% 23.50% 0% 29.40% 5.90% 17.60% 35.30% 17.60% 11.80%

70.60% 70.60% 70.60% 82.40% 70.60%

29.40% 29.40% 29.40% 17.60% 29.40%


6

Lima Multiple victims incident simulation: training professionals and university teaching

A systematic review on a realistic simulation showed that this educational strategy is efficient and able to contribute to the training of professionals when used as an educational model for a multidisciplinary performance. Therefore, the involvement of students and professionals of the PHC during this developed simulation enhanced the teaching and learning process20. Triage is one of the most important pillars in MVI and disasters management. Health professionals education involves training and practice aiming at acting on these environments in a safer way, and at reducing the errors involved in care7,21. In this study, the hit rate in triage with the START method was high - over 90%. Similar outcomes were seen in a study by Simões et al., which contemplated a simulation involving 40 victims screened by professionals from SAMU 192 acting in several institutions5. The need for an MVI-specific training is reported in some studies, which also recommend their insertion in the schooling matrix, in undergraduate and graduate programs in health7,22,23. In a study performed with professionals from the American countryside, around 90% of them identified the need for training in MVI13. Dittmar et al. showed that triage skills reduce significantly one year after the training, indicating the need for educational programs for the continuous practice by professionals10. The performance of a simulation, the object of this study, was an unprecedented initiative in the environment of the university involved, searching to make the academicians and professionals aware of the importance of practicing this subject area. Chaotic situations might surprise prehospital care teams, such as the one that happened in a nightclub called Kiss, in the city of Santa Maria (RS, Brazil), where hundreds of youngsters were victimized.

Thus, our conclusion is that actions of training and prevention in MVI are needed as a permanent teaching subject in health, in order to produce an effective medical response, reducing vulnerability in care teams in such situations24. The principles of approach to trauma, based on the systematization of care into priority areas, initially developed by ATLS®, and later applied in the prehospital scenario by PHTLS®, is worldrenowned. The use of the ABCDE mnemonic for the identification and treatment of injuries which are life threatening are also applied in MVI care25. During data analysis, it became evident the correct application of the ABCDE mnemonic stages in values over 70% of the care performed, a value that is inferior to the one found in a study by Simões et al., which evaluated the performance of experienced professionals in PHC. The stage that presented the largest number of errors in its execution in both studies was "E", responsible for evaluating in an adequate way the exposure of a victim and the hypothermia control, which shows the negligence of initial care when going through this stage5. During an analysis of the stages taken separately, we could notice positive aspects that denote assimilation of the contents, such as the maintenance of the pervious airway in all care provided, and the incorrect indication of a definitive airway in only one patient. Intubation in the prehospital scenario remains controversial within the usual context of care, and in multiple victims' scenarios it is an approach even more challenging26. A negative aspect was the finding of prescription of oxygen offer in high flow in only 64.7% of the people treated, an evidence that this conduct still needs to be reinforced among the participants.

Rev Col Bras Cir 46(3):e2163


Lima Multiple victims incident simulation: training professionals and university teaching

The oxygen offer is one of the recommendations found in the initial treatment of trauma victims, but care should be taken regarding the harmful effects of hyperoxia27. In the simulation proposed by this study, in 70.6% of cared for individuals there was a research of visible and hidden sources of bleeding, an outcome that indicates the need for a larger emphasis to be given to this skill, since hemorrhage is the main cause of death potentially preventable in trauma11,28,29. After performing the simulation and the event feedback, it was possible to notice some aspects that interfered in the performance of the simulation, which could be perfected. One of the relevant aspects is victims' preparation. The victims' acting according to performance or nonperformance of the conducts demands previous training, evidencing that the contact between the victim and their shadow should be stimulated before, not only on the day of the event. Another aspect that proved confuse during the simulation was the displacement of the victims from the triage area to the canvases for care. The place of collection and the limitation of the material used in the simulation to care for the victims were not welldefined for the participants as well. The definition and detailing of the scene with all the participants, including the special groupings involved, should have been performed before the event, with a clear attribution of the ones in charge for each scene and

7

of the acting areas of the stakeholders, aiming at providing a more organized environment. The simulation environment described was an unprecedented activity because it integrated multiprotection care with a clinical context of MVI, consisting of an enriching experience that allowed for the performance of work by a health multidisciplinary team and reminded the stakeholders of the need for further training and for an early insertion, whilst still in the undergraduate level, of situations as the one simulated, in order to guarantee the excellence of teaching and of care, focusing on improving the qualification of health professionals. Therefore, we reached the conclusion that the application of skills to triage and primary evaluation following the ABCDE mnemonic performed by the participants of this study proved satisfactory. However, some aspects that can alter the outcome of the victims in a definitive way, as the evaluation of breathing and circulation, must be stimulated and trained with special emphasis and commitment.

Acknowledgements We wish to thank the University of Fortaleza and the Rescue and Urgency Group of the Military Fire Brigade from Ceará for their initiative to perform this event and for the incentive given to the teaching of Medicine and Nursing on the Emergency field.

R E S U M O Objetivo: descrever estratégia de ensino a partir da simulação de Incidente de Múltiplas Vítimas (IMV), discutindo e avaliando a atuação dos discentes envolvidos no atendimento inicial às vítimas de trauma. Métodos: estudo transversal com abordagem quantitativa que contemplou a execução de uma simulação realística de IMV, envolvendo discentes, docentes dos Cursos de Medicina e de Enfermagem, além de profissionais do atendimento pré-hospitalar. Resultados: a partir da análise de 17 checklists, foi possível perceber que a classificação segundo o método START (Simple Triage And Rapid Treatment) aconteceu de forma correta em 94,1% dos atendimentos. Seguindo a avaliação primária com o mnemônico ABCDE, todas as etapas foram realizadas de forma correta em 70%. Contudo, só houve oferta de oxigênio em alto fluxo em 64,7% dos atendimentos. A pesquisa por fontes de sangramento visíveis e ocultas foi realizada em 70,6% dos atendimentos. A avaliação neurológica com a escala de coma de Glasgow e avaliação pupilar ocorreu em 70,6% das vítimas. A exposição da vítima foi realizada em 70,6% dos atendimentos. Conclusão: ambientes simulados permitem a consolidação e o aperfeiçoamento de competências e habilidades profissionais, principalmente quando se trata de uma área pouco treinada na graduação, como o IMV. O treinamento precoce e o atendimento em equipe estimulam o raciocínio clínico, a integração e a comunicação, aspectos essenciais diante de situações caóticas. Descritores: Treinamento por Simulação. Educação Médica. Incidentes com Feridos em Massa. Serviços Médicos de Emergência.

Rev Col Bras Cir 46(3):e2163


Lima Multiple victims incident simulation: training professionals and university teaching

8

REFERENCES 1.

2.

3.

4.

5.

6.

7.

8.

9.

World Health Organization. Mass casualty management systems: strategies and guidelines for building health sector capacity. Geneva: World Health Organization; 2007. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Protocolos de intervenção para o SAMU 192. 2a ed. Brasília: Ministério da Saúde; 2016. Khajehaminian MR, Ardalan A, Keshtkar A, Hosseini Boroujeni SM, Nejati A, Ebadati E OME, et al. A systematic literature review of criteria and models for casualty distribution in trauma related mass casualty incidents. Injury. 2018;49(11):1959-68. Lima DS. Noções em incidentes com múltiplas vítimas. In: Lima DS. Emergência médica: suporte imediato à vida. Fortaleza: Unichristus; 2018. p. 271-84. Simões RL, Duarte Neto C, Maciel GS, Furtado TP, Paulo DN. Atendimento pré-hospitalar à múltiplas vítimas com trauma simulado. Rev Col Bras Cir. 2012;39(3):230-7. Fraga GP, Quintas ML, Abib SCV. Trauma e emergência: o SUS é a solução no Brasil? [editorial]. Rev Col Bras Cir. 2014;41(4):232-3. Lampi M, Junker J, Berggren P, Jonson CO, Vikström T. Pre-hospital triage performance after standardized trauma courses. Scand J Trauma Resusc Emerg Med. [Internet]. 2017 [cited 2019 Jan 5]; 25(1):53. Available from: https://sjtrem.biomedcentral.com/ articles/10.1186/s13049-017-0395-8 Atendimento Pré-hospitalar ao Traumatizado Básico e Avançado. PHTLS Pré-Hospital Trauma Life Support. Comitê do PHTLS da National Association of Emergency Medical Technicians (NAEMT) em cooperação com o Comitê de Trauma do Colégio Americano de Cirurgiões. 8a ed. Rio de Janeiro: Elsevier; 2017. Bhalla MC, Frey J, Rider C, Nord M, Hegerhorst M. Simple triage algorithm and rapid treatment and sort, assess, lifesaving, interventions, treatment, and transportation mass casualty triage methods for sensitivity, specificity, and predictive values. Am J Emerg Med. 2015;33(11):1687-91.

10. Dittmar MS, Wolf P, Bigalke M, Graf BM, Birkholz T. Primary mass casualty incident triage: evidence for the benefit of yearly brief re-training from a simulation study. Scand J Trauma Resusc Emerg Med. 2018;26(1):35. 11. American College of Surgeons. Advanced Trauma Life Support (ATLS). Student Manual. 10th ed. Chicago, IL: American College of Surgeons; 2018. 12. Intrieri ACU, Barbosa Filho H, Sabino MRLS, Ismail M, Ramos TB, Invenção A, et al. O enfermeiro no APH e o método START: Uma abordagem de autonomia e excelência. Rev UNILUS Ensino e 13.

14.

15.

16.

17.

18.

Pesquisa. 2017;14(34):112-28. Wehbi NK, Wani R, Yang Y, Wilson F, Medcalf S, Monaghan B, et al. A needs assessment for simulation-based training of emergency medical providers in Nebraska, USA. Adv Simul (Lond). 2018;3:22. Fernandes CR, Falcão SNRS, Gomes JMA, Colares FB, Maior MMMS, Correa RV, et al. Ensino de emergências na graduação com participação ativa do estudante. Rev Bras Clin Med. 2014;38(2):261-8. Kaneko RMU, Couto TB, Coelho MM, Taneno AK, Barduzzi NN, Barreto JKS, et al. Simulação in Situ, uma metodologia de treinamento multidisciplinar para identificar oportunidades de melhoria na segurança do paciente em uma unidade de alto risco. Rev Bras Educ. Med. 2015;39(2):286-93. Brandão CS, Collares CF, Marin HF. A simulação realística como ferramenta educacional para estudantes de medicina. Sci Med. 2014;24(2):187-92 Franco CAGS, Franco RS, Santos VM, Uiema LA, Mendonça NB, Casanova AP, et al. OSCE para competências de comunicação clínica e profissionalismo: Relato de experiência e metaavaliação. Rev Bras Educ. Med. 2015;39(3):433-41. Sardela Covos J, Covos JF, Scarel Brenga AC. A importância da triagem em acidentes com múltiplas vítimas. Ensaios Cienc., Cienc Biol Agrav Saúde. 2016;20(3):196-201.

Rev Col Bras Cir 46(3):e2163


Lima Multiple victims incident simulation: training professionals and university teaching

19. Fraga GP, Pereira Júnior GA, Fontes CER. A situação do ensino de urgência e emergência nos cursos de graduação de medicina no Brasil e as recomendações para a matriz curricular. In: Lampert JB, Bicudo AM. 10 anos das Diretrizes Curriculares Nacionais do Curso de Graduação em Medicina. Rio de Janeiro: Associação Brasileira de Educação Médica; 2014. p. 41-56. 20. Armenia S, Thangamathesvaran L, Caine AD, King N, Kunac A, Merchant AM. The role of high-fidelity team-based simulation in acute care settings. Surg J (N Y). 2018;4(3):136-51. 21. Pouraghaei M, Sadegh Tabrizi J, Moharamzadeh P, Rajaei Ghafori R, Rahmani F, Najafi Mirfakhraei B. The effect of start triage education on knowledge and practice of emergency medical technicians in disasters. J Caring Sci. 2017;6(2):119-25. 22. Storpirtis S, Nicoletti MA, Aguiar PM. Uso da simulação realística como mediadora do processo ensino-aprendizagem: relato de experiência da farmácia universitária da Universidade de São Paulo. Rev Grad USP. 2016;1(2):45-55. 23. Naser WN, Saleem HB. Emergency and disaster management training; knowledge and attitude of Yemeni health professionals- a cross-sectional study. BMC Emerg Med. 2018;18(1):23. 24. Atiyeh B. Desastre na boate Kiss, Brasil. [editorial]. Rev Bras Cir Plast. 2012;27(4):502. 25. Rodrigues MS, Galvão IM, Santana LF. Utilização do ABCDE no atendimento do traumatizado. Revista de Medicina. 2017;96(4):278-80.

9

26. Crewdson K, Rehn M, Lockey D. Airway management in pre-hospital critical care: a review of the evidence for a ‘top five’ research priority. Scand J Trauma Resusc Emerg Med. 2018;26(1):89. 27. Trimmel H, Beywinkler C, Hornung S, Kreutziger J, Voelckel WG. Success rates of pre-hospital difficult airway management: a quality control study evaluating an in-hospital training program. Int J Emerg Med. 2018;11(1):19. 28. Spinella PC, Holcomb JB. Resuscitation and transfusion principles for traumatic hemorrhagic shock. Blood Rev. 2009;23(6):231-40. 29. Geeraedts LM Jr, Pothof LA, Caldwell E, de Lange-de Klerk ES, D’Amours SK. Prehospital fluid resuscitation in hypotensive trauma patients: do we need a tailored approach? Injury. 2015;46(1):4-9. Received in: 02/22/2019 Accepted for publication: 05/07/2019 Conflict of interest: none. Source of funding: none. Mailing address: Daniel Souza Lima. E-mail: souzadl@hotmail.com izabella.furtado94@gmail.com

Rev Col Bras Cir 46(3):e2163


Original Article

DOI: 10.1590/0100-6991e-20192175

Abbreviated preoperative fasting favours postoperative oral intake at lower hospital admission costs for cancer patients. Jejum pré-operatório abreviado favorece realimentação pós-operatória com menor custo de internação hospitalar em pacientes oncológicos. Phillipe Geraldo de Abreu Reis, TCBC-PR1; Camila Polakowski2; Marina Lopes2; Danilo Saavedra Bussyguin, AcCBC-PR1; Raphaella Paula Ferreira1; Vinicius Basso Preti, TCBC-PR2,3; Flávio Daniel Saavedra Tomasich, TCBC-PR3 A B S T R A C T Objective: to evaluate the feasibility of abbreviated fasting in oncologic colorectal surgeries, as well as the impact on the surgical outcome of the patients. Methods: prospective randomized comparative study with patients undergoing elective colorectal cancer surgeries from May to September 2017. Patients were randomized electronically into two groups according to the preoperative fast to be adopted: conventional or abbreviated. Results: of the 33 patients included, 15 followed the abbreviated fasting protocol and 18 the conventional fasting. Both groups had comparable profiles. No patient underwent mechanical preparation of the colon. In 69.7% of the cases, surgery involved low rectal dissection. The procedures were equivalent in relation to intraoperative variables and severe complications. The time to achieve complete oral intake was shorter for abbreviated fasting (10 versus 16 days, p=0.001), as well as the length of inhospital stay (2 versus 4 days, p=0.009). Hospital costs were lower in the abbreviated fasting (331 versus 682 reais, p<0.001). The univariable analysis revealed a correlation between complete oral intake and abbreviated fasting [HR 0.29 (IC95%: 0.12-0.68] and abdominal distension [HR 0.12 (IC95% 0.01-0.94)]. After multivariable analysis, abbreviated fasting presented a lower time for complete oral intake [HR 0.39 (IC95%: 0.16-0.92]. Conclusion: the abbreviated preoperative fasting favors the metabolic-nutritional recovery, reducing the time for complete oral intake. The implementation of the abbreviation protocol reduces hospital admission costs. Keywords: Fasting. Cost Efficiency Analysis. Costs and Cost Analysis. Colorectal Neoplasms. Colorectal Surgery.

INTRODUCTION

T

here has been more and more discussion about perioperative handling of patients who undergo elective surgery. There has also been more demand for conduct based on evidence in services aiming at improving the quality of patient care1-4. New preoperative and perioperative protocols and strategies have been developed continuously aiming at a faster postoperative recovery and early hospital discharge, as well as reducing morbimortality and surgical complication rates5-7. ERAS (Enhanced Recovery After Surgery), the multicenter European group, proposes a multimodality approach protocol integrated to the perioperative care, which resulted in better recovery after colon surgery.

Besides, randomized clinical studies comparing ERAS to traditional postoperative care showed a reduction in the length of hospital stay for the ERAS group8-14. Similarly, in 2005, project ACERTO (Aceleração da Recuperação Total - Total Recovery Acceleration) was started in Brazil, based on the concepts of the ERAS group4,6. A comparative study of patients who underwent elective surgery under ACERTO protocol and patients who received traditional care indicated that the ACERTO group showed a reduction in both the length of inhospital stay and postoperative morbidity5. In colorectal surgery, the main points taken into account refer to the nutritional approach (perioperative nutritional support, reduction of preoperative fasting time and early release of dietary

1 - Erasto Gaertner Hospital, Study Projects and Research Center (CEPEP), Curitiba, PR, Brazil. 2 - Erasto Gaertner Hospital, Nutrition Service, Team of Multidisciplinary Nutrition Therapy (EMTN), Curitiba, PR, Brazil. 3 - Erasto Gaertner Hospital, Abdominal Surgery Service, Curitiba, PR, Brasil. Rev Col Bras Cir 46(3):e2175


2

Reis Abbreviated preoperative fasting favours postoperative oral intake at lower hospital admission costs for cancer patients

restrictions post surgery), the limitation of the use of drains and restriction in the use of nasogastric catheters, restriction of perioperative intravenous hydration and the systematic use of preoperative mechanical preparation of the colon in colorectal surgery13,15. Special attention has been given to the rational use of antibiotics, to pain control, to postoperative nausea to vomiting, to the emotional preparation of patients and to a physical therapy approach that promotes ultra-early mobilization and early return to activities9,10,16. The basis of this new multimodal approach lies in randomized studies which showed consistently that the use of the so-called "fast track" programs can promote an early return of the intestinal function and an improvement of patients' physiological functions, resulting in a reduction in the length of in-hospital stay and operative morbidity. The first rule of the program is: the day of surgery is the first day of patient recovery2,4,17,18. The protocols established so far, based on the perioperative handling of patients who underwent medium and major surgery, regardless of the segment of the gastrointestinal tract used, have been set up in general hospitals, with no selection of the base disease - with only the selection of the surgical procedure applied10,19-21. The medical literature shows but a few reports of similar protocols applied in leading cancer hospitals specialized in treating patients with more advanced stages of cancer who are, in the great majority, malnourished9-11,20-22. We carried out this study in order to evaluate the influence of the abbreviated preoperative fasting over the surgical outcomes in patients who underwent colorectal surgery due to cancer, as well as the impact over hospital stays costs.

METHODS Single-blind, randomized, prospective, comparative study carried out between May and September 2017. Colorectal cancer patients referred to surgery at Erasto Gaertner Hospital (HEG) in the City of Curitiba, State of Paranรก, were selected for the study. The project was approved by the hospital's Research Ethics Committee under number 2492/16 (CAAE 54503616.6.0000.0098). Patients over 18 years old, with planned elective surgery, (ileocolectomy, left colectomy, abdominal rectosigmoidectomy or rectal dissection), diagnosed with colorectal cancer at any clinical stage and who agreed in taking part in the study were electronically randomized into two groups: abbreviated fasting and conventional fasting (control group). The abbreviated fasting group received one dose of Maltodextrin at 6am on the morning of surgery, and another dose at 10am - two hours before the time scheduled for the procedure. The control group remained in absolute fast since the night before surgery. As per routine, all patients underwent outpatient nutritional assessment and preoperative follow-up, as well as postoperative fluid restriction. None of the patients underwent preoperative mechanical bowel preparation. It was not possible to administer placebo to the control group patients as it would interfere with the habitual fasting. The surgical team did not know to which group each patient belonged, which constituted the single-blind aspect. All surgical technical aspects followed the usual Service routine, surgeon preference and availability of resources in the National Health System (SUS) - use of drains, suture wires, staplers, colostomy procedures, open or minimally invasive, etc.

Rev Col Bras Cir 46(3):e2175


Reis Abbreviated preoperative fasting favours postoperative oral intake at lower hospital admission costs for cancer patients

Postoperative care in intensive care units was individualized according to the clinical laboratory and anesthesia parameters. Surgical complications were classified according to Clavien-Dindo23. Patients were followed daily by the team during in-hospital stay. After discharge, all patients were reassessed on the seventh, 14th and 28th days after surgery, and after that, they were reassessed quarterly for at least 12 months. Costs with medicines, nutrition and hospital supplies were assessed by balance sheet linked to permission granted by the SUS for in-hospital stay for each patient. Data was exhibited as averaged and standard deviation and interquartilian range for non-normal data distribution. Students' t-test was applied for continuous numerical variables. Mann-Whitney's non-parametric test was used for independent numerical variables with non-normal distribution. The chi-squared test with Fisher's correction was used for categorical variables. Patients' survival rates were estimated by the Kaplan-Meier method and compared using the log-rank test. Outcome predictors were identified by Cox regression. The data collected was tabulated and analyzed by the systems SPSS v23.0 and STATA v15, in which p<0.05 was considered statistically significant.

3

Figure 1. Patient inclusion diagram.

The profile of both groups was comparable in terms of average age, gender, body mass index, percentage of preoperative weight loss, preoperative immunonutrition, previous comorbidities (systemic hypertension, diabetes mellitus, acute myocardial infarction, chronic obstructive pulmonary disease), anesthetic risk (American Society of Anesthesiology - ASA), neoplasm staging and preoperative cancer treatment (preoperative radiotherapy and chemotherapy), as per table 1. None of the patients underwent preoperative mechanical preparation of the colon, following Service routine. In 69.7% of the cases, the performed surgery involved rectal dissection in the pelvic cavity (rectosigmoidectomy and abdominoperineal resection). figure 2 shows the types of surgery performed.

RESULTS For the study, 36 patients were randomized, and three were excluded because they did not take the product for logistic reasons. Of the 33 patients in the study, 15 followed the abbreviated fasting protocol and 18, the conventional 8-hour preoperative fasting protocol (control group), as shown on figure 1. Figure 2. Types of surgeries performed.

Rev Col Bras Cir 46(3):e2175


4

Reis Abbreviated preoperative fasting favours postoperative oral intake at lower hospital admission costs for cancer patients

Table 1. Profile of patients in the study.

Patient profile Age (years) Gender, masculine BMI* (Kg/m2) % PP** Preoperative NT*** SAH# DM## Previous AMI### COPD¥ ASA¥¥      I       II       III Clinical staging       I       IIA       IIB       IIIA       IIIB       IIIC Postoperative pelvic radiotherapy Preoperative chemotherapy

Total (n=33) Abbreviated fasting (n=15) Control (n=18) 64 (56.50-72.50) 60 (56-72) 67 (56.70-75.00) 16 (48.50) 7 (46.70) 9 (50.00) 26 (22.20-29.20) 25 (20.80-27.90) 26.30 (22.60-30) 10.80 (9.50-23.10) 10.70 (9.00-28.00) 17.60 (17.00-17.80) 14 (42.40) 8 (53.30) 6 (33.30) 18 (54.50) 8 (53.30) 10 (55.60) 7 (21.20) 2 (13.30) 5 (27.80) 3 (9.10) 2 (13.30) 1 (5.60) 1 (3.00) 0 1 (5.60)     1 (3.00) 1 (6.70) 0 24 (72.70) 11 (73.30) 13 (72.20) 8 (24.20) 3 (20.00) 5 (27.80)       10 (30.30) 6 (40.00) 4 (22.20) 6 (18.20) 2 (13.30) 4 (22.20) 2 6.10) 1 (6.70) 1 (5.60) 3 (9.10) 0 3 (16.70) 9 (27.30) 3 (9.10) 10 (30.30) 10 (30.30)

5 (33.30) 1 (6.70) 4 (26.70) 5 (33.30)

4 (22.20) 2 (11.10) 6 (33.30) 5 (27.80)

p 0.34 0.84 0.36 0.37 0.24 0.89 0.31 0.43 0.35 0.49     0.51             0.67 0.73

*BMI: body mass index; **%PP: percentage of weight loss; ***NT: nutritional therapy; #SAH: systemic arterial hypertension; ## DM: diabetes mellitus; ###AMI: acute myocardial infarction; ¥COPD: chronic obstructive pulmonary disease; ¥¥ASA: American Society of Anesthesiology.

The procedures were equivalent in both groups in terms of average length of surgery, colostomy procedure, surgical pathway of access, use of drain in the surgical bed, postoperative fluid restriction and use of antibiotics as a prophylactic measure. Besides, the outcomes were comparable in terms of length of ICU stay, diet acceptance on the first day after surgery, postoperative nausea and vomiting, abdominal distention, severe surgical complications (Clavien-Dindo 4 and 5), need for reoperation, post-surgery sepsis, intestinal fistula and surgical site infections. The length of average post-surgery follow-up was 14.8 months.

The time to achieve complete oral intake was significantly shorter in the group which underwent abbreviated fasting (10 versus 16 days, p=0.001), as well as the length of in-hospital stay (2 versus 4 days, p=0.009) and operative morbidity (up to 30 days). As to hospital costs with medicines and hospital supplies used during in-hospital stay, the group which underwent abbreviated fasting showed significantly lower values in relation to the control group (R$ 331 versus R$ 682, p<0.001). Table 2 shows the comparative results of postoperative outcomes and of the characteristics of the procedures performed for the groups in the study.

Rev Col Bras Cir 46(3):e2175


Reis Abbreviated preoperative fasting favours postoperative oral intake at lower hospital admission costs for cancer patients

5

Table 2. Characteristics of procedures and outcomes in the groups.

Postoperative evolution Colostomy Surgery length Open access pathway Drain surgical bed Postoperative fluid restriction Postoperative prolonged antibiotic use Length of in-hospital stay Prolonged ICU* stay Diet acceptance on 1st postoperative day Time to complete oral intake (days) Nausea/Vomiting Abdominal distension Severe complication (Clavien Dindo 4/5) Reoperation Morbidity up to 30 days Postoperative sepsis Intestinal fistula Surgical site infections Average in-hospital stay cost (R$) Follow-up time (months)

Total 16 (48.50) 180 (150-240) 27 (81.80) 23 (69.70) 29 (87.90) 9 (27.30) 3 (2-5) 6 (18.20) 28 (84.80) 12 (10-16) 5 (15.20) 6 (18.20) 8 (24.30) 5 (15.20) 4 (12.10) 3 (9.10) 6 (18.20) 4 (12.10) 522.86 14.80 (11.80-16.00)

Abbreviated fasting 5 (33.30) 184 (158-240) 11 (73.30) 11 (73.30) 13 (86.70) 2 (13.30) 2 (2-3) 1 (6.7) 13 (86.70) 10 (8-12) 2 (13.30) 1 (6.70) 2 (13.30) 2 (13.30) 0 0 2 (13.30) 1 (6.70) 331.69 15.20 (12.60-16.00)

Control 11 (61.10) 180 (146-255) 16 (88.90) 12 (66.70) 16 (88.90) 7 (38.90) 4 (3-9) 5 (27.80) 15 (83.30) 16 (10-16) 3 (16.70) 5 (27.80) 6 (33.40) 3 (16.70) 4 (22.20) 3 (16.70) 4 (22.20) 3 (16.70) 682.18 13.9 (3.60-15.80)

P 0.11 0.68 0.24 0.67 0.84 0.10 0.009 0.11 0.79 0.001 0.79 0.11 0.18 0.79 0.05 0.09 0.51 0.38 <0.001 0.16

*ICU: intensive care unit.

The univariate analysis with Cox regression for the outcome regarding complete postoperative oral intake showed a significant correlation with abbreviated fasting and postoperative abdominal distention (HR 0.29 IC95%: 0.12-0.68 and HR 0.12 IC95%: 0.01-0.94, respectively). However, there was no association with preoperative immunonutrition, postoperative nausea and vomiting, preoperative radiotherapy, colostomy procedure, surgical access pathway, drainage in the surgical bed, post-operative fluid restriction, severe surgical complications and prolonged antibiotic use.

Additionally, after multivariate analysis with Cox regression, only abbreviated fasting showed statistically significant association with complete postoperative oral intake (HR 0.39 IC95%: 0.160.92). The results of the univariate and multivariate analysis are shown on table 3. By analyzing the influence of abbreviated fasting over the time to complete postoperative oral intake, the group analyzed showed a much earlier progression in relation to the control group (10 versus 16 days, p=0.001), as shown on figure 3.

Rev Col Bras Cir 46(3):e2175


6

Reis Abbreviated preoperative fasting favours postoperative oral intake at lower hospital admission costs for cancer patients

Table 3. Univariate and multivariate analysis with Cox regression for complete postoperative food intake.

Variable Abbreviated fasting Preoperative NT* Nausea/Vomiting Abdominal distension Preoperative radiotherapy Colostomy Open access pathway Drain on surgical bed Postoperative fluid restriction Severe complication Postoperative prolonged antibiotic use

Univariate analysis HR IC95% p 0.29 (0.12-0.68) 0.005 1.23 (0.57-2.66) 0.58 0.74 (0.22-2.49) 0.62 0.12 (0.01-0.94) 0.005 1.18 (0.53-2.66) 0.67 0.83 (0.39-1.78) 0.64 0.55 (0.22-1.39) 0.23 1.17 (0.50-2.70) 0.70 1.25 (0.37-4.18) 0.70 0.52 (0.19-1.39) 0.16 0.51 (0.20-1.30) 0.14

Multivariate analysis HR IC95% p 0.39 (0.16-0.92) 0.03 5.71 (0.74-43.90) 0.09 -

*NT: nutritional therapy.

Figure 3. Time to achieve full oral intake due to abbreviated fasting.

DISCUSSION The prospective, comparative and randomized character of the current study reinforces the validity of the data findings, since the sample was followed with scientific rigor and under controlled conditions for reliable data registration and control, despite the low number of patients included. A great portion of the studies already published on the same subject are retrospective, based on non-prospective international databases, or opinion polls with surgeons10,24.

Electronic randomization was effective, seeing that the profile of the patients analyzed was homogeneous, showing clinical and epidemiological characteristic similarities within the compared groups. The re-introduction of a complete postoperative food intake is a key factor for the immunophysiological recovery of the patients who underwent abdominal procedures25,26. The presence of intestinal transit assessed by peristaltic movement represents a predominant factor of the assessment of postoperative recovery in the majority of the surgical services, and allows for a safe diet progression8,9,12,17. Hospital costs are directly related to the length of the stay. Each in-hospital day reflects a rise in treatment cost, especially in prolonged stays due to severe surgical complications requiring the use of antibiotics and enteral/parenteral special diets20,22. In this study, we noticed that the abbreviated fasting for patients who underwent colorectal cancer surgery helped with physiological recovery and the early return to a full diet. Even after taking into account several factors corresponsible for this recovery through multivariate Cox regression for

Rev Col Bras Cir 46(3):e2175


Reis Abbreviated preoperative fasting favours postoperative oral intake at lower hospital admission costs for cancer patients

confounding factors, abbreviated fasting revealed itself as the main statistically significant factor to support a return to full diet. A similar result was found by Li et al.21. Despite the fact that other factors leading to a prolonged in-hospital stay, such as complications, fistulae, etc., do not have statistical significance, the indirect indicator of such results (days of in-hospital stay) supports the use of abbreviated fasting in more patients. Possibly, the sample size limitation prevented the occurrence of more significant results, such as those presented by Seretis et al.19. One of the main analysis of this study is the assessment of intra-hospital stay costs. The difficulty to indicate a breakdown of the values in relation to the items used during inhospital stay in most of the public services in the country prevents this assessment from being applied to other contexts. Thanks to the management model using electronic patient's medical charts and a reliable data collection regarding hospital admission cost, it was possible to assess rigorously all hospital supplies applied to each patient in this study.

7

The savings in hospital admission costs for the abbreviated fasting group show that the full use of the industrialized product does not have a negative impact over the final cost. On the contrary, it revealed itself as very cost-efficient, and it should be encouraged in other cancer services in Brazil. Such saving supports the findings published by Nelson et al.20. We have come to the conclusion that abbreviated preoperative fasting favors the metabolic-nutritional recovery, contributing to the reduction of time to complete postoperative oral intake in patients who underwent surgery for treating colorectal cancer. The implementation of the fasting abbreviation protocol reduced hospital admission costs, and should be recommended.

Acknowledgements We wish to thank the Nutritional Therapy Multidisciplinary Team for the logistic organization and leadership in implementing the ACERTO protocol on all fronts at the institution. We wish to thank the Anesthesiology Service at the Erasto Gaertner Hospital for the support and for agreeing to change the fasting protocol for our study.

R E S U M O Objetivo: avaliar a viabilidade de abreviação do jejum em cirurgias colorretais oncológicas, bem como, o impacto no desfecho cirúrgico dos pacientes. Métodos: estudo prospectivo comparativo randomizado com pacientes submetidos à cirurgias eletivas colorretais, por câncer, no período de maio a setembro de 2017. Os pacientes foram randomizados eletronicamente em dois grupos de acordo com o jejum pré-operatório a ser adotado: convencional ou abreviado. Resultados: dos 33 pacientes incluídos, 15 seguiram o protocolo de jejum abreviado e 18 de jejum convencional. Ambos os grupos apresentaram perfis comparáveis. Nenhum paciente foi submetido a preparo mecânico do cólon. Em 69,7% dos casos, a cirurgia envolveu dissecção baixa do reto. Os procedimentos foram equivalentes em relação às variáveis intraoperatórias e complicações graves. O tempo para atingir realimentação plena foi menor para o jejum abreviado (10 versus 16 dias, p=0,001), assim como, o tempo de internação hospitalar (2 versus 4 dias, p=0,009). Os custos hospitalares foram menores no jejum abreviado (331 versus 682 reais, p<0,001). A análise univariável revelou correlação entre a realimentação plena e o jejum abreviado [HR 0,29 (IC95%: 0,12-0,68] e com a distensão abdominal [HR 0,12(IC95%: 0,01-0,94)]. Após análise multivariável, o jejum abreviado apresentou menor tempo para realimentação plena [HR 0,39(IC95%: 0,16-0,92]. Conclusão: o jejum pré-operatório abreviado favorece a recuperação metabóliconutricional, diminuindo o tempo para realimentação plena. A implantação do protocolo de abreviação do jejum reduz custos de internação hospitalar. Descritores: Jejum. Análise Custo-Eficiência. Custos e Análise de Custo. Neoplasias Colorretais. Cirurgia Colorretal.

Rev Col Bras Cir 46(3):e2175


8

Reis Abbreviated preoperative fasting favours postoperative oral intake at lower hospital admission costs for cancer patients

REFERENCES 1.

2.

3.

4.

5.

6.

7.

8.

9.

Watanabe T, Itabashi M, Shimada Y, Tanaka S, Ito Y, Ajioka Y, Hamaguchi T, Hyodo I, Igarashi M, Ishida H, Ishiguro M, Kanemitsu Y, Kokudo N, Muro K, Ochiai A, Oguchi M, Ohkura Y, Saito Y, Sakai Y, Ueno H, Yoshino T, Fujimori T, Koinuma N, Morita T, Nishimura G, Sakata Y, Takahashi K, Takiuchi H, Tsuruta O, Yamaguchi T, Yoshida M, Yamaguchi N, Kotake K, Sugihara K; Japanese Society for Cancer of the Colon and Rectum. Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines 2010 for the treatment of colorectal cancer. Int J Clin Oncol. 2012;17(1):1-29. Pimenta GP, de Aguilar-Nascimento JE. Prolonged preoperative fasting in elective surgical patients. Nutr Clin Pract. 2014;29(1):22-8. Perrone F, da-Silva-Filho AC, Adôrno IF, Anabuki NT, Leal FS, Colombo T, et al. Effects of preoperative feeding with a whey protein plus carbohydrate drink on the acute phase response and insulin resistance. A randomized trial. Nutr J. 2011;10(1):66. Aguilar-Nascimento JE, Salomão AB, Caporossi C, Diniz BN. Clinical benefits after the implementation of a multimodal perioperative protocol in elderly patients. Arq Gastroenteol. 2010;47(2):178-83. de Aguilar-Nascimento JE, Perrone F, de Assunção Prado LI. [Preoperative fasting of 8 hours or 2 hours: what does evidence reveal?]. Rev Col Bras Cir. 2009;36(4):350-2. Portuguese. Bicudo-Salomão A, Meireles MB, Caporossi C, Crotti PLR, de Aguilar-Nascimento JE. Impact of the ACERTO project in the postoperative morbi-mortality in a university hospital. Rev Col Bras Cir. 2011;38(1):3-10. Alito MA, de Aguilar-Nascimento JE. Multimodal perioperative care plus immunonutrition versus traditional care in total hip arthroplasty: a randomized pilot study. Nutr J. 2016;15:34. Erratum in: Nutr J. 2016;15(1):55. van Rooijen S, Carli F, Dalton S, Thomas G, Bojesen R, Le Guen M, et al. Multimodal prehabilitation in colorectal cancer patients to improve functional capacity and reduce postoperative complications: the first international randomized controlled trial for multimodal prehabilitation. BMC Cancer. 2019;19(1):98.

10.

11.

12.

13.

14.

15.

16.

17.

Shida D, Tagawa K, Inada K, Nasu K, Seyama Y, Maeshiro T, et al. Modified enhanced recovery after surgery (ERAS) protocols for patients with obstructive colorectal cancer. BMC Surg. 2017;17(1):18. Shida D, Tagawa K, Inada K, Nasu K, Seyama Y, Maeshiro T, et al. Enhanced recovery after surgery (ERAS) protocols for colorectal cancer in Japan. BMC Surg. 2015;15:90. Kim JY, Wie GA, Cho YA, Kim SY, Sohn DK, Kim SK, et al. Diet modification based on the Enhanced Recovery After Surgery Program (ERAS) in patients undergoing laparoscopic colorectal resection. Clin Nutr Res. 2018;7(4):297-302. Kaska M, Grosmanová T, Havel E, Hyspler R, Petrová Z, Brtko M, et al. The impact and safety of preoperative oral or intravenous carbohydrate administration versus fasting in colorectal surgery - a randomized controlled trial. Wien Klin Wochenschr. 2010;122(1-2):23-30. Currie A, Soop M, Demartines N, Fearon K, Kennedy R, Ljungqvist O. Enhanced Recovery after Surgery interactive audit system: 10 years’ experience with an international web-based clinical and research perioperative care database. Clin Colon Rectal Surg. 2019;32(1):75-81. Erratum in: Clin Colon Rectal Surg. 2019;32(1):e1. Byrnes A, Banks M, Mudge A, Young A, Bauer J. Enhanced Recovery After Surgery as an auditing framework for identifying improvements to perioperative nutrition care of older surgical patients. Eur J Clin Nutr. 2018;72(6):913-6. Bousquet-Dion G, Awasthi R, Loiselle SÈ, Minnella EM, Agnihotram RV, Bergdahl A, et al. Evaluation of supervised multimodal prehabilitation programme in cancer patients undergoing colorectal resection: a randomized control trial. Acta Oncol. 2018;57(6):849-59. Siegel RL, Miller KD, Jemal A. Colorectal cancer mortality rates in adults aged 20 to 54 years in the United States, 1970-2014. JAMA. 2017;318(6):572-4. Pexe-Machado PA, de Oliveira BD, Dock-Nascimento DB, de Aguilar-Nascimento JE. Shrinking preoperative fast time with maltodextrin and protein hydrolysate in gastrointestinal resections due to cancer. Nutrition. 2013;29(7-8):1054-9.

Rev Col Bras Cir 46(3):e2175


Reis Abbreviated preoperative fasting favours postoperative oral intake at lower hospital admission costs for cancer patients

18. Echeverri J, Goldaracena N, Singh AK, Sapisochin G, Selzner N, Cattral MS, et al. Avoiding ICU admission by using a fast-track protocol is safe in selected adult-to-adult live donor liver transplant recipients. Transplant Direct. 2017;3(10):e213. 19. Seretis F, Kaisari P, Wanigasooriya K, Rawstorne E, Seretis C. Institutional variations in nutritional aspects of enhanced recovery pathways after elective surgery for colon cancer. J BUON. 2017;22(3):692-5. 20. Nelson G, Kiyang LN, Chuck A, Thanh NX, Gramlich LM. Cost impact analysis of Enhanced Recovery After Surgery program implementation in Alberta colon cancer patients. Curr Oncol. 2016;23(3):e221-7. 21. Li L, Jin J, Min S, Liu D, Liu L. Compliance with the enhanced recovery after surgery protocol and prognosis after colorectal cancer surgery: a prospective cohort study. Oncotarget. 2017;8(32):53531-41. Erratum in: Oncotarget. 2017;8(52):90605. 22. Pedziwiatr M, Wierdak M, Nowakowski M, Pisarska M, Stanek M, Kisielewski M, et al. Cost minimization analysis of laparoscopic surgery for colorectal cancer within the enhanced recovery after surgery (ERAS) protocol: a single-centre, case-matched study. Wideochir Inne Tech Maloinwazyjne. 2016;11(1):14-21.

9

23. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240(2):205-13. 24. de Aguilar-Nascimento JE, de Almeida Dias AL, Dock-Nascimento DB, Correia MI, Campos AC, Portari-Filho PE, et al. Actual preoperative fasting time in Brazilian hospitals: the BIGFAST multicenter study. Ther Clin Risk Manag. 2014;10:107-12. 25. Polakowski CB, Kato M, Preti VB, Schieferdecker MEM, Ligocki Campos AC. Impact of the preoperative use of synbiotics in colorectal cancer patients: A prospective, randomized, double-blind, placebo-controlled study. Nutrition. 2019;58:40-6. 26. Laffitte AM, Polakowski CB, Kato M. Early oral re-feeding on oncology patients submitted to gastrectomy for gastric cancer. ABCD Arq Bras Cir Dig. 2015;28(3):200-3. Received in: 03/11/2019 Accepted for publication: 04/17/2019 Conflict of interest: none. Source of funding: none. Mailing address: Phillipe Geraldo de Abreu Reis. E-mail: phillipeareis@gmail.com dr.phillipeabreu@gmail.com

Rev Col Bras Cir 46(3):e2175


Teaching

DOI: 10.1590/0100-6991e-20192197

Safety checklist in outpatient surgery teaching. Checklist de segurança no ensino de cirurgia ambulatorial. Kátia Sheylla Malta Purim1; Carolina Gomes Gonçalves1; Lucas Binotto1; Anne Karoline Groth1; Ayrton Alves Aranha Júnior1; Mauricio Chibata, ACBC-PR1; Christiano Marlo Paggi Claus, TCBC-PR1; Fernanda Keiko Tsumanuma1 A B S T R A C T This article proposes the use of a safe surgical checklist in the teaching of the discipline of Ambulatory Surgery during medical graduation. It discusses its benefits and potential implementation and adherence difficulties. It underscores the importance of developing a patient safety culture and active learning methodologies to train students for greater commitment and accountability with the quality of care provided to the community in the academic outpatient clinic of the school hospital. Keywords: Checklist. Patient Safety. Ambulatory Surgical Procedures/education.

INTRODUCTION

P

atient safety is a growing worldwide demand and because of its magnitude it needs to be assimilated in all spheres of medical training and practice1. Among its goals are the safety of clinical and surgical procedures and full attention to the fundamentals and practices of safe surgeries2-4. The principle of not causing harm is attributed to Hippocrates and, in our country, disciplined by Article 1st of the Code of Medical Ethics which establishes that the physician is prohibited from causing harm to the patient, by action or omission considered as malpractice, recklessness, or negligence5. In Brazil, National Patient Safety Program (NPSP) was established by Ministry of Health (MH) Ordinance nº 529/20136. In 2014, Brazilian College of Surgeons (CBC) launched a safe surgery manual in order to reduce incidents and adverse health events7. Surveys show that checklists used by medical teams of hospital surgical centers to verify important aspects of patient safety improve care

quality and reduce morbimortality8,9. However, the known principles of surgical safety are still inconsistently applied10-14. Accidents, failures, or adverse health events can occur anywhere and with anyone, but it is estimated that in 95% of the cases they are caused by unsafe conditions and in 5% by human error4. In most of the time they do not cause damage, but in other situations they have serious, and even fatal, repercussions that could have been avoided8,11. Universities are trainers of human resources in health1,5,8 and it is fundamental to educate Medical students about their role and responsibility in the safety of the patient, environment, and surgical act. The care for health and safety1,3,5 and the documentation of these actions are tasks before which no doctor can be indifferent. Safety principles need to be experienced in medical training in order to achieve good safe surgery practices. In view of this, this article proposes a checklist model for application in undergraduate Medical courses in the context of outpatient surgery teaching at a school hospital in Curitiba-PR.

1 - Universidade Positivo, School of Medicine, Discipline of Outpatient Surgery, Curitiba, PR, Brazil. Rev Col Bras Cir 46(3):e20192197


Purim Safety checklist in outpatient surgery teaching

2

METHODS The discipline of Outpatient Surgery in question is developed through essentially practical activities, interspersed by one theoretical class per week with the purpose of guiding the study15. The teaching plan, work proposal, and pedagogical contract are presented in the first meeting and reinforced throughout the school year. In the first weeks, workshops on basic surgical and ambience techniques are offered, based on literature16,17. For in-home study, content is presented online through texts, scripts, slides, articles, and videos with basic concepts, exercises, links, and trusted sources of research. The important and current topics related to the discipline are strengthened through hybrid teaching, combining traditional methods with active learning approaches15, guided by Bloomâ&#x20AC;&#x2122;s taxonomy18 (Figure 1). The scenarios for practice are the outpatient clinics of a school hospital, equipped to perform small surgical procedures, carry out diagnosis, and/ or treat patients attended by Brazilian Unified Health

System (SUS). All cases are previously analyzed through anamnesis and physical examination with a professor. In case of surgical indication, the relevant preoperative exams are requested and the details of the diagnosis, treatment, risks, and possible complications of the indicated procedure are explained to the patient. Two printed copies of the Informed Consent Term (ICT) are given to the patient or to the person who is responsible for him/ her. No intervention is performed without the ICT, in compliance with the ethical and legal requirements of the professional practice5. In case of urgency, the procedure can be performed on the same day of the first consultation; elective surgeries are preferably scheduled for a later date, so that the patient or the person who is responsible for him/her can reflect on the risks/ benefits after verbal and written guidance and provide his/her phone number/contacts to be written down in the surgical scheduling book. If the case is of clinical resolution or needs to be forwarded, proper forms are filled out. At the end of the surgery, students complete the

Figure 1. Bloomâ&#x20AC;&#x2122;s taxonomy applied to Outpatient Surgery teaching and the estimated impact percentage on learning.

Rev Col Bras Cir 46(3):e20192197


Purim Safety checklist in outpatient surgery teaching

3

application for the histopathological examination in the hospitalâ&#x20AC;&#x2122;s online medical record system and fill out the surgery registration book and the record with the predetermined date for the patient to come back to hospital for consultation. Students also provide recipes/certificates together with their professors. In all cases in which parts of the surgical wound are removed, the request for histopathological examination is mandatory, and, in drainage of abscesses, a bacteriological examination of the secretion (Gramâ&#x20AC;&#x2122;s method and antibiogram of blood culture) is requested. The dynamics of participation in the surgical team is intended to enable the student to have better opportunities to construct the learning process under supervision, to train different functions and techniques, to elaborate medical documentation,

and to develop competences, attitudes, values, and ethics which are compatible with the practices of safe surgeries. The proposed checklist model for the Outpatient Surgery discipline (Figure 2) was based on current protocols1-4 and follows the principles of simplicity, wide applicability, and possibility of impact measurement. The protocol is divided into four fields to be filled at each surgical moment. Initially, the patientâ&#x20AC;&#x2122;s data are obtained: name, weight, age, procedure to be performed, and location, with attention to laterality. Next, the name of the student who occupies each function of the outpatient surgical center must be filled in. After the patient and student identification phase, the other steps have questions that must be checked before the start of surgery, during surgery, and before discharge.

Figure 2. Safe surgery protocol for teaching-learning in medical undergraduate program.

Rev Col Bras Cir 46(3):e20192197


Purim Safety checklist in outpatient surgery teaching

4

Before starting the procedure, it is essential to obtain the confirmation of the surgical site with the patient and to ensure that he/she has signed the ICT, as well as to verify a history of allergy or contraindication to vasoconstrictor in anesthetic solution. Measurement of blood pressure is necessary at this time, since an alteration of it may contraindicate the use of vasoconstrictor. In this stage, a recount of resources and surgical materials is also performed, besides the verification of the availability of individual protection equipments for all surgical team members. During the surgical procedure, it is recommended that all team members present themselves as previously determined in the identification chart and that the critical points of the surgery are reviewed. When necessary, the biopsy vessel must be identified and adequate for the size of the lesion. In addition, before finishing the procedure, it is crucial to report to the professor in charge any intercurrence that may have occurred during the process, focusing on how and why the fact has happened, its triggers, and what specific points need improvement. The last stage reinforces to the student the importance of the medical record, written in a complete, objective, and concise way, and the responsibility in requesting and completing complementary examinations. The request for a return in seven days is part of the Service routine, in which the same students who have performed the procedure do the postoperative, with the removal of stitches and guidelines, according to the evolution. The academic is still responsible to prepare the prescription under supervision and to orientate about alarm signals and the return before seven days, if necessary. The studentâ&#x20AC;&#x2122;s assessment, adapted from 17 literature , can be performed through the Likert scale, with three items: has not performed, has partially performed, and has completely performed.

DISCUSSION Patient safety actions are those produced by health and educational institutions that aim to reduce or eliminate risks in care that can cause harm to the patient1,4. The health services provided by school hospitals must serve the community with safety and quality based on current scientific knowledge. This checklist proposal allows the standardization of surgical procedures and enables a safer and more coordinated participation of students in the academic outpatient clinic, supported by technical/scientific evidences1,4,6 and the National Curricular Guidelines (DCN)15. Due to his/her responsibility in the team17, each academic has problems to solve, mobilizing different domains18 and decisions to make, in order to progress in the learning of dexterity and technical accuracy, medical communication, and humanization of the surgical assistance. It is essential to create spaces mechanisms for error containment and mutual support, which are propitious to communication, identification of failures, and analysis in group10,11 in order to restructure the process of education and professional qualification. Managing common conflicts in surgical settings, such as stress, among others, requires that professors value what is relevant, ask for results in a clear and coherent way, provide feedback, make pedagogical interventions, and articulate relationships with professional practice seeking to promote safe environment and acts. Studies demonstrate several obstacles to safety protocol adherence10,12,19,20. Research with health professionals has detected that 46.5% of the interviewees have not had training on safe surgery checklist19. Other research has revealed greater adherence in complex elective surgeries and a greater occurrence of incomplete filling in minor or emergency surgeries11.

Rev Col Bras Cir 46(3):e20192197


Purim Safety checklist in outpatient surgery teaching

5

Simple procedures and interventions also have risks11. Therefore, it is necessary to encourage the systematized teaching of safe care in order to sensitize students, since undergraduate program, on the importance of this teamwork and the advantages of promoting safety in surgery, fostering continuity and improvements in their everyday life and professionalization. Among the limitations for adherence to the checklist in outpatient surgery teaching, we can list the motivation of the professor, the number of students, the availability of surgical cases, besides structural, socio-professional, and local administrative factors. The checklist is a resource to educate future doctors and improve health care1,3. However, in

the permanent commitment of the entire hospital community and of each of the managers, directors, professors, students, professionals, patients, and employees in maintaining a system of adequate prevention, construction, and health care in order to ensure quality standards of teaching and of the surgical care provided.

order to achieve the safety culture, it is indispensable

clinics, according to their care particularities.

CONCLUSION The presented protocol has the potential to contribute to the learning of patient safety culture during Medical undergraduate program through the surgical training offered to students of Outpatient Surgery discipline. It also allows adaptations for emergency rooms, health units, and

R E S U M O Este artigo propõe a utilização de um checklist de cirurgia segura no ensino da disciplina de Cirurgia Ambulatorial durante a graduação em Medicina. Discorre sobre seus benefícios e potenciais dificuldades de implantação e adesão. Ressalta a importância do desenvolvimento da cultura de segurança do paciente e das metodologias ativas de aprendizagem para treinar os estudantes para maior compromisso e responsabilidade com a qualidade da assistência prestada à comunidade no ambulatório acadêmico do hospital escola. Descritores: Lista de Checagem. Segurança do Paciente. Procedimentos Cirúrgicos Ambulatórios/educação.

REFERENCES 1.

2.

3.

4.

Organização Mundial da Saúde. Segundo desafio global para a segurança do paciente: cirurgias seguras salvam vidas (orientações para cirurgia segura da OMS). Rio de Janeiro: Organização PanAmericana da Saúde; Ministério da Saúde; Agência Nacional de Vigilância Sanitária; 2009. 211p. Organização Pan-Americana de Saúde, Ministério da Saúde, Agência Nacional de Vigilância Sanitária. Manual: cirurgias seguras salvam vidas. ANVISA: Brasília; 2010. Brasil. Ministério da Saúde. Agência Nacional de Vigilância Sanitária. Resolução RDC no 36, de 25 de Julho de 2013. Institui ações para segurança do paciente em serviços de saúde e dá outras providências. Diário Oficial da União, Brasília (DF); 2013 Jul 26; Seção 1:32.

5.

6.

7.

PROQUALIS. Cirurgias seguras salvam vidas [Internet]. Rio de Janeiro; [2009?] [citado 2019 Mar 19]. Disponível em: http://proqualis.net/cirurgia/ Conselho Federal de Medicina. Código de Ética Médica. Resolução CFM Nº 2.222/2018. Corrige erro material do Código de Ética Médica [Internet]. Diário Oficial da União, Brasília (DF); 2018 Dez 11; Seção 1:205 [acesso em 2019 mar 10]. Disponível em: https://sistemas.cfm. org.br/normas/visualizar/resolucoes/BR/2018/2222 Brasil. Ministério da Saúde. Portaria no 529, de 1 de abril de 2013. Institui o Programa Nacional de Segurança do Paciente (PNSP). Diário Oficial da União, Brasília (DF); 2013 Abr 2; Seção 1:43. Colégio Brasileiro de Cirurgiões, editor. Manual de Cirurgia Segura [Ebook]. Rio de Janeiro: Colégio Brasileiro de Cirurgiões; 2010 [acesso em 07 mar 2019]. Disponível em: https://cbc.org.br/download-ebook-manual-de-cirurgia-segura/#wpcf7-f17353-o1

Rev Col Bras Cir 46(3):e20192197


Purim Safety checklist in outpatient surgery teaching

6

8.

9.

10.

11.

12.

13.

14.

15.

Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Herbosa T, Joseph S, Kibatala PL, Lapitan MC, Merry AF, Moorthy K, Reznick RK, Taylor B, Gawande AA; Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491-9. Peixoto SKR, Pereira BM, Silva LCS. Checklist de cirurgia segura: um caminho à segurança do paciente. Saude Ciênc Ação. 2016;2(1):114-29. White MC, Randall K, Capo-Chichi NFE, Sodogas F, Quenum S, Wright K, et al. Implementation and evaluation of nationwide scale-up of the Surgical Safety Checklist. BJS. 2019;106(2):e91-e102. Ribeiro HCTC, Quites HFO, Bredes AC, Sousa KAS, Alves M. Adesão ao preenchimento do checklist de segurança cirúrgica. Cad. Saúde Pública [Internet] 2017 [citado em 2019 Mar 12]; 33(10):e00046216. Disponível em: http://www.scielo.br/pdf/csp/ v33n10/1678-4464-csp-33-10-e00046216.pdf Motta Filho GR, Silva LFN, Ferracini AM, Bähr GL. Protocolo de Cirurgia Segura da OMS: o grau de conhecimento dos ortopedistas brasileiros. Rev Bras Ortop. 2013;48(6):554-62. Freitas MR, Antunes AG, Lopes BNA, Fernandes FC, Monte LC, Gama ZAS. Avaliação da adesão ao checklist de cirurgia segura da OMS em cirurgias urológicas e ginecológicas, em dois hospitais de ensino de Natal, Rio Grande do Norte, Brasil. Cad Saúde Pública. 2014;30(1):137-48. Fourcade A, Blache JL, Grenier C, Bourgain JL, Minvielle E. Barriers to staff adoption of a surgical safety checklist. BMJ Qual Saf. 2012;21(3):191-7. Brasil. Ministério da Educação. Resolução CNE/CES no 3, de 20 de junho de 2014. Institui Diretrizes Curriculares Nacionais do Curso de Graduação em Medicina e dá outras providências. Diário Oficial da União, Brasília (DF); 2014 Jun 23; Seção 1:8-11.

16. Purim KSM. Oficina de cirurgia cutânea. Rev Col Bras Cir. [Internet]. 2010 Aug [cited 2019 Mar 12];37(4):303-5. Available from: http://www. scielo.br/scielo.php?script=sci_arttext&pid=S010069912010000400012&lng=en 17. Purim KSM, Skinovsky J, Fernandes JW. Habilidades básicas para cirurgias ambulatoriais na graduação médica. Rev Col Bras Cir. [Internet]. 2015 Oct [cited 2019 Mar 12];42(5):341-4. Available from: http://www.scielo.br/scielo.php?script=sci_ arttext&pid=S0100-69912015000600341&lng=en 18. Ferraz APCM, Belhot RV. Taxonomia de Bloom: revisão teórica e apresentação das adequações do instrumento para definição de objetivos instrucionais. Gest Prod. [online]. 2010 [cited 2019 Mar 12];17(2):421-31. Available from: http://www. scielo.br/scielo.php?script=sci_arttext&pid=S0104530X2010000200015&lng=en&nrm=iso 19. Silva EFM, Calil ASG, Araújo CS, Ruiz PBO, Jericó MC. Conhecimento dos profissionais da saúde sobre checklist de cirurgia segura. Arq Ciênc Saúde. 2017;24(3):71-8. 20. Elias ACGP, Schmidt DRC, Yonekura CSI, Dias AO, Ursi ES, Silva RPJ, et al. Avaliação da adesão ao checklist de cirurgia segura em hospital universitário público. Rev SOBECC. 2015;20(3):128-33. Received in: 03/31/2019 Accepted for publication: 04/17/2019 Conflict of interest: none. Source of funding: none. Mailing address: Kátia Sheylla Malta Purim. E-mail: kspurim@gmail.com

Rev Col Bras Cir 46(3):e20192197


INSTRUCTIONS FOR AUTHORS SCOPE AND POLITICS The Journal of the Brazilian College of Surgeons (CBC), an official division of the CBC, is published bimonthly in one annual volume, and proposes the dissemination of articles of all surgical specialties, contributing to its teaching, development and national integration. Articles published in the Journal of the Brazilian College of Surgeons follow the uniform requirements recommended by the International Committee of Medical Journals Editors (ICMJE – www.icmje.org), and are submitted to a double blind peer review. The journal of the Brazilian College of surgeons supports the policies for registration of clinical trials of the World Health Organization (WHO) and the ICMJE, recognizing the importance of these initiatives for the record and international dissemination of information on clinical studies in open access. Thus, it will only accept for publication the clinical research articles that have received an identification number on a clinical trial registry validated by the criteria established by WHO and ICMJE. The identification number must be registered at the end of the abstract. Between three and five members of the Editorial Board, anonymous to the authors, receive the texts, also anonymously, and decide for their publication. In the event of conflict of opinions, the Director of publications will evaluate the need for a new appraisal. Rejected articles are returned to authors. Only the works within the journal’s publication standards will be submitted to evaluation. Approved articles may sustain editorial-type alterations, provided that they do not alter the merit of the work. GENERAL INFORMATION The Journal of the Brazilian College of Surgeons evaluates articles for publication in Portuguese (Brazilian authors) and English (foreign authors) that follow the rules for manuscripts submitted to biomedical journals prepared and published by the International Committee of Medical Journal Editors (ICMJE – www.icmje.org) [CIERM Rev Col Bras Cir. 2008; 35 (6): 425-41, or article on the website of the journal (www.revistadocbc.org.br)] with the following characteristics: • Editorial: Is the initial article of an issue, generally about a current subject, requested by the Editor to the author of recognized technical and scientific capacity. • Original Article: Is the full account of clinical or experimental research, with positive or negative results. It must consist of Abstract, Introduction, Methods, Results, Discussion and References, the latter limited to a maximum of 35, aiming to the inclusion, whenever possible, of articles from national authors and national journals. The title should be written in Portuguese and English, and should contain the maximum of information with the minimum of words, without abbreviations. It must be accompanied by the complete name(s) of author(s) followed by the name(s) of the institution(s) where the work was performed. If multicenter, Arabic numerals must indicate the provenance of each of the authors in relation to the listed institutions. Authors should send along with their names only one title and one that best represents their academic activity. The Abstract should have a maximum of 250 words and be structured as follows: objective, methods, results, conclusions and keywords in the form referred to by DeCS (http://decs.bvs.br ). • Review article: The Editorial Board encourages the publication of matters of great interest to the surgical specialties containing synthetic analysis and relevant criticism and not merely a chronological description of literature. I must contain an introduction with description of the reasons that led to the writing of the article, the search criteria, followed by text ordered in titles and subheadings according to the complexity of the subject, and unstructured abstract. When applicable, at the end there may be conclusions and opinions of authors summarizing the review contents. • Letters to the Editor: Scientific Comments or controversy regarding articles published in the journal of the CBC. In general, such letters are sent to the principal author of the article to response and both letters are published in the same journal issue, no replica being allowed. • Scientific Communication: Content that deals with the form of presentation of scientific communication, investigating the problems and proposing solutions. Due to its features, this section can be multidisciplinary, receiving contributions from doctors, surgeons and non-surgeons and other professionals from various areas. It must have an unstructured Abstract, Keywords and free text. • Technical Note: Information about a particular operation or procedure of importance in surgical practice. The original must not exceed six pages including pictures and references if necessary. It must have an unstructured Abstract, Keywords and free text. • Education: Freeform content that addresses the teaching of surgery, both in graduate and post-graduate levels. Unstructured abstract. • Bioethics in surgery: Discussion of bioethical aspects in surgery. The content should address bioethical dilemmas in the performance of surgical activity. Freeform. Unstructured abstract. • Case reports: May be submitted for evaluation and the approved reports will be published, mainly in electronic journal of case reports, the Journal of Case Reports of the Brazilian College of Surgeons which can be accessed through the Brazilian College of Surgeons’ website (www.cbc.org.br) or directly at www.relatosdocbc.org.br. ARTICLE SUBMISSION Sending articles for the Journal of the Brazilian College of Surgeons can only be done through the online platform for submission of scientific papers, which can be accessed through the Brazilian College of Surgeons’ website (www.cbc.org.br) or directly at www.rcbc.gnpapers.com.br.

FORM AND STYLE • Text: Manuscripts submitted for review by the Journal of the Brazilian College of Surgeons must be unpublished and should not be evaluated in whole or in part by another scientific journal. Images should be forwarded separately from the text, and in accordance with the instructions on the online submission platform. Articles should be concise, not exceeding 2500 words. The abbreviations should be as few as possible, limited to the terms mentioned repetitively, as long as they do not hinder the understanding of the text, and should be defined from the first use. • References: Must be predominantly of works published in the last five years, restricted to those cited in the text, in order of citation, numbered consecutively and presented according to the Vancouver format (rules for manuscripts submitted to Biomedical Journals ICMJE- www.icmje.org – CIERM Rev Col Bras Cir. 2008; 35 (6): 425-41-www. revistadocbc.org.br). Annals of congresses and personal communications will not be accepted as references. Citations of books and theses should be discouraged. The authors of the article are responsible for the accuracy of the references. • Acknowledgements: Should be made to people who importantly contributed to the work’s realization. TABLES (maximum of six) Tables should be numbered with Arabic numerals, with captions on the top containing one or two sentences, and explanations of symbols at the bottom. Cite the tables in the text in numerical order including only information necessary for understanding of important points of the text. The data presented should not be repeated in graphs. Tables should follow the above-mentioned Vancouver standards. Tables must be typed in the body of the text, and never sent as figures. FIGURES (maximum of six) Figures are all the photos, graphics, paintings and drawings. All figures must be referred to in the text, being numbered consecutively by Arabic numbers and accompanied by descriptive captions. Histological images should contain in the legends the histological technique used and the degree of magnification. All figures should be submitted separately at the end of the manuscript.

MANDATORY CONDITIONS (READ CAREFULLY) It is expressed that, with the electronic submission, the author (s) agree (s) with the following assumptions: 1) that there is no conflict of interests, compliant with the Brazilian Federal Council of Medicine (CFM) resolution No. 1595/2000 that prevents the publication of works and materials with promotional purposes of products and/or medical devices; 2) that one must cite the funding source, if any; 3) that the work was submitted to the respective Ethics in Research Committee which approved it, providing the aproval number in the text; 4) that all authors authorize that the article suffer changes in the submitted text to be standardized in the language format of the Journal, which can result in removal of redundancies, as well as tables and/ or figures that are deemed unnecessary to understanding the text, provided that it does not change its meaning. If there are disagreements of the authors about these assumptions, they should write a letter leaving explicit the point at which they disagree, which will be appraised by the Editor, who will decide whether the article can be forwarded for publication or returned to the authors. 5) that the authors are allowed to hold the copyright of their published work without restrictions. 6) that if there is conflict of interest, it should be quoted with the text: “the author (s) (provide names) received financial support of the private company (provide name) for this study”. When there is a research foment funding source, it must also be cited. 7) that the responsibility for concepts or statements issued on articles and announcements published in the Journal of the Brazilian College of Surgeons is entirely up to the author (s) and advertisers. 8) that works already published or simultaneously submitted for evaluation in other periodicals will not be accepted. 9) that each approved article will have a cost of R$ 1,000.00 (one thousand reais) for the authors. If the lead author is a member of the Brazilian College of Surgeons, there will be a 50% discount on the article’s fee. Case Reports, approved for publication in the Journal of Case Reports of the Brazilian College of Surgeons are exempt from charges.

CONTACT: 2016-Brazilian College of Surgeons Rua Visconde de Silva, 52-3the floor 22271-090-Rio de Janeiro-RJ-Brazil Tel: + 55 21 2138-0659 Fax: + 55 21-2286 2595 Address for submission of manuscripts: E-mail: revistacbc@cbc.org.br


ABOUT THE JOURNAL Basic information Objectives: To disseminate scientific works of the surgical area of medicine that contribute to its teaching and development. History: The publication and dissemination of scientific activities of its members is one of the aims of medical societies. The Brazilian College of Surgeons (Colégio Brasileiro de Cirurgiões – CBC), founded in 1929, already in its first statute provided for the issuance of the “Bulletin of the Brazilian College of Surgeons” as its official division, whose starting number was published in January 1930. In 1967, the National Directory of CBC changed its name to “Journal of the Brazilian College of Surgeons”. From 1974 on, the journal began to be published bi-monthly, on a regular basis, to the present day. The abbreviation for its title is Rev Col Bras Cir, which should be used in bibliographies, footnotes and in references and bibliographic legends.

Creative Commons The journal of the Brazilian College of Surgeons is licensed with a 4.0 International , non-commercial, Creative Commons Attribution. This license lets others remix, adapt and create from your work, for non-commercial purposes. Although the new works have to assign proper credit and may not be used for commercial purposes, users do not have to license these derivative works under the same terms.

Free access policy This journal provides free and immediate access to its content, following the principle that providing free scientific knowledge to the public provides greater democratization of world knowledge.

About APC (Article Processing Charges) In view of the high costs for publication of the journal, from the issue 1/2017 on, every approved article started to have a cost of R$ 1000.00 (1000 reais) for the authors. Articles in which the lead author is a member of the CBC will have a discount of 50% of the publication fee.

Anti-Plagiarism Policy The Journal of the Brazilian College of Surgeons uses the iThenticate program to identify plagiarism in articles submitted for publication.

Indexing sources · · · · · · ·

Latindex LILACS Scopus DOAJ Free Medical Journals MEDLINE/PUBMED SciELO

Intellectual property All journal content, except where otherwise stated, is licensed under a Creative Commons License of type CC-BY attribution.

Sponsors The Journal of the Brazilian College of Surgeons is sponsored by CBC through: · Annuity of its associated members · Money from advertisers · Article publication fee


!"#$%&'!$!%()!      

  

Profile for cbc cirurgioes

Revista do CBC v46n3-Inglês  

Revista do CBC v46n3-Inglês