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July / August 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

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95

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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

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CONTENTS / SUMÁRIO Rev Col Bras Cir 2019; 46(4) ORIGINAL ARTICLE Implementation of a surgical screening system for urgent and emergent cases in a tertiary hospital Implementação de um modelo de triagem cirúrgica para casos urgentes em um hospital terciário Monique Antonia Coelho; Pedro Luiz Toledo de Arruda Lourenção; Silke Tereza Weber; Erika Veruska Paiva Ortolan ................................. e2211 Dietary supplementation with Camu-Camu versus sleeve gastrectomy in wistar rats weight control Análise dos efeitos da suplementação dietética com Camu-Camu comparada à gastrectomia vertical no controle de peso de ratos wistar Hercules Magalhães Olivense do Carmo; Feliph Miquéias Alcântara de Souza; Ana Clara Leal Soares; João Abner Marins Munhoz; Francisco Glauco de Araújo Santos; Nilton Ghiotti de Siqueira; Romeu Paulo Martins Silva ........................................................................................ e2238 Safety and quality in surgery: surgeons’ perception in Brazil Segurança e qualidade em cirurgia: a percepção de cirurgiões no Brasil Maria Isabel Toulson Davisson Correia; Flávio Daniel Saavedra Tomasich; Heládio Feitosa de-Castro Filho; Pedro Eder Portari Filho; Ramiro Colleoni Neto ............................................................................................................................................................................................ e2146 Surgical site infection in bariatric surgery: results of a care bundle Infecção de sítio cirúrgico após cirurgia bariátrica: resultados de uma abordagem com pacote de cuidados Álvaro Antonio Bandeira Ferraz; César Freire de Melo Vasconcelos; Fernando Santa-Cruz; Maria Améllia R. Aquino; Vinícius G. Buenos-Aires; Luciana Teixeira de Siqueira ...................................................................................................................................................................... e2252 Can the Zuckerkandl Tubercle assist in the location of the inferior laryngeal nerve during thyroidectomies? O tubérculo de Zuckerkandl pode auxiliar na localização do nervo laríngeo inferior durante tireoidectomias? Carlos Alberto Ferreira de Freitas; Amauri Ferrari Paroni; Andreza Negreli Santos; Rônei Jorge Santos da Silva; Rafael Oliveira de Souza; Tatyanne Ferreira da Silva; Maria Margarida Morena Domingos Levenhagen ............................................................................................................. e2249

Rev Col Bras Cir

Rio de Janeiro

Vol 46

Nº 4

jul/aug

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.

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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 7/1 1 - 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-20192211

Implementation of a surgical screening system for urgent and emergent cases in a tertiary hospital. Implementação de um modelo de triagem cirúrgica para casos urgentes em um hospital terciário. Monique Antonia Coelho1; Pedro Luiz Toledo de Arruda Lourenção2; Silke Tereza Weber3; Erika Veruska Paiva Ortolan2 A B S T R A C T Objective: to evaluate the applicability of the "Timing of Acute Care Surgery" (TACS) color classification system in a tertiary public hospital of a developing country. Methods: we conducted a longitudinal, retrospective study in a single center, from March to August 2016 and the same period in 2017. We opted for the selection of four surgical specialties with high demand for emergencies, previously trained on the TACS system. For comparisons with the previous classifications, we considered emergencies as reds and oranges and urgencies, as yellow, with an ideal time interval for surgery of one hour and six hours, respectively. Results: Non-elective procedures accounted for 61% of the total number of surgeries. The red, orange and yellow classifications were predominant. There was a significant improvement in the time before surgery in the yellow color after the TACS system. Day and night periods influenced the results, with better ones during the night. Conclusion: This is the first study to use the TACS system in the daily routine of an operating room. The TACS system improved the time of attendance of surgeries classified as yellow. Keywords: Mass Screening. Operating Room Information Systems. Surgery Department, Hospital.

INTRODUCTION

T

he screening process is extremely important when there are not enough resources for the needs of all patients, especially in reference hospitals in developing countries1-2. Screening is commonly applied to catastrophes and emergency relief units. However, in a surgical center scenario, with a large number of elective and non-elective surgeries, there is no standardized nomenclature to classify emergency surgeries. In most hospitals, getting a room for emergency surgery depends on dialogue and negotiation3. In others, emergency surgeries are performed in the order of arrival3-4. The National Confidential Inquiry into Patient Outcome and Death (NCEPOD) in England classifies surgeries in immediate, urgent, accelerated and elective5.

In 2013, the World Society for Emergency Surgery Study Group (WSES) recommended the use of a color system to classify emergency surgeries to reduce the loss of information and to allow the establishment of standardized language among the teams. Timing of Acute Care Surgery (TACS) was based on a survey of a panel of specialists about the ideal time for more frequent emergency surgeries6. However, since its publication, no study has presented the use of such color classification in the daily dynamics of a surgical center. Therefore, the purpose of this study was to evaluate the applicability of the TACS classification system in a tertiary public and teaching hospital of a developing country with a large number of nonelective surgeries6.

1 - Sao Paulo State University “Júlio Mesquita Filho” (Unesp), Botucatu Medical School, Post-Graduation Program in Surgical General Bases, Botucatu, São Paulo, Brazil. 2 - Sao Paulo State University “Júlio Mesquita Filho” (Unesp), Botucatu Medical School, Department of Surgery and Orthopedics, Botucatu, Sao Paulo, Brazil. 3 - Sao Paulo State University “Júlio Mesquita Filho” (Unesp), Botucatu Medical School, Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery, Botucatu, Sao Paulo, Brazil. Rev Col Bras Cir 46(4):e2211


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Coelho Implementation of a surgical screening system for urgent and emergent cases in a tertiary hospital.

METHODS This is a longitudinal, retrospective, single-center study, held in the periods from March to August 2016 (before implementation of the color system) and from March to August 2017 (after the implementation of color system) at the Botucatu Medical School Hospital. This is a tertiary-level hospital, with 450 beds, responsible for the care of a region with 2 million inhabitants. The surgical center has 14 rooms, 12 for elective surgeries and two for non-elective ones. The rooms for elective surgeries may also be used for non-electives, if necessary, or after they become vacant.

The TACS color classification system (Figure 1) was implemented throughout the surgical center. For this analysis, we selected four specialties with great surgical emergency volume: Digestive System Surgery, Pediatric Surgery, Vascular Surgery and Orthopedics. Before the TACS clssification, we used only two classifications: urgencies and emergencies. Prior to the implementation, for a period of four months (from November 2016 to February 2017), all teams were trained to use the new, to-beimplemented system. We compared all non-elective procedures from March to August 2016, the period before the implementation of the color system, with operation up to six hours for urgencies and immediate care

Figure 1. Color classification for non-elective TACS (Timing of Acute Care Surgery)6.

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Coelho Implementation of a surgical screening system for urgent and emergent cases in a tertiary hospital.

for emergencies, with the ones in the period from March to August 2017, when the TACS color classification was in effect. For comparison, surgeries previously classified as emergencies were equated with reds and oranges of the color system and those classified as urgencies in 2016, with yellow ones in 2017. We could not compare the procedures classified as green and blue, since these modalities did not have equivalents in 2016. The ideal time to surgery (iTTs) for emergency care in 2016 was considered six hours and one hour, respectively, as suggested by the World Society of Emergency Surgeries. The relationship between the actual time to surgery (aTTs) and the iTTs was calculated before and after the implementation of the TACS color classification. The time of surgery care is considered satisfactory when this ratio is equal to 1. We calculated the aTTs/iTTs ratios before and after the implementation of the TACS classification, and compared them using the Student's t-test or the Mann-Whitney test, according

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to the data distribution, which we analyzed with the Shapiro-Wilk test. The level of significance was 5%. We used a binomial logistic regression to analyze the influence of daytime and nighttime, weekday versus weekends, and patient origin (ward versus ICU and emergency room). This study was approved by the Ethics in Research Committee of the Botucatu Medical School (CAAE: 59707416.9.0000.5411).

RESULTS The non-elective surgeries of the four specialties analyzed accounted for 61% and 61.2% of the total, respectively, in 2016 and 2017. Although there were no changes in the physical structure of the surgical center, in 2017 there was a 7.8% increase in the total number of surgeries. Table 1 summarizes the number of non-elective surgeries among the four specialties in the two years, comparing emergencies with red and orange and urgencies with yellow.

Table 1. Comparison of non-elective surgeries divided among the four specialties before and after the implementation of the TACS color classification.

Year

2016

2017

Specialty Gastroenterology Surgery Pediatric Surgery Vascular Surgery Orthopedics Gastroenterology Surgery Pediatric Surgery Vascular Surgery Orthopedics

Emergencies 186/437 (42.5%) 58/149 (38.9%) 112/202 (55.4%) 179/480 (37.3%) Red + Orange 275/476 (57.7%) 43/100 (43.0%) 125/178 (70.2%) 362/627 (57.7%)

Urgencies 251/437 (57.5%) 91/149 (61.1%) 90/202 (44.6%) 301/480 (62.7%) Yellow 201/476 (42.3%) 57/100 (57.0%) 53/178 (29.8%) 265/627 (42.3%)

* Binomial testing.

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p* <0.01 <0.01 0.02 <0.01 <0.01 0.04 <0.01 <0.01

Total

1,268

1,381


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Coelho Implementation of a surgical screening system for urgent and emergent cases in a tertiary hospital.

After the implementation of the TACS classification, in 2017, there was a predominance of the classification of surgeries in red, orange and yellow (Figure 2).

Figure 2. Total surgeries performed by the four specialties in the period from March to August of 2017, according to the TACS color classification.

When analyzing all specialties together, the comparison of surgeries classified as emergency versus red or orange in 2016 and 2017, respectively, showed that the actual time to surgery (aTTs) was better before TACS (p<0.0001). There was no difference in aTTs in the comparison between emergencies in 2016 and red in 2017 (p=0.98). Regarding the comparison between urgencies in 2016 and yellow ones in 2017, there was a decrease in aTTs (p<0.001). Table 2 shows the same analysis, separated by the specialties. When analyzing all the specialties were, there was no difference in the relation between the actual and the ideal time to surgery (aTTs/iTTs) before and after the TACS classification (p=0.315).

Table 2. Analysis of the actual time to surgery (aTTs) before and after the TACS classification among the specialties.

Gastroenterology Surgery Pediatric Surgery Vascular Surgery Orthopedics   Gastroenterology Surgery Pediatric Surgery Vascular Surgery Orthopedics   Gastroenterology Surgery Pediatric Surgery Vascular Surgery Orthopedics   Gastroenterology Surgery Pediatric Surgery Vascular Surgery Orthopedics

Median (min/max) Mean (SD)*** Mean (SD)*** Median (min/max)   Median (min/max) Median (min/max) Median (min/max) Median (min/max)   Median (min/max) Median (min/max) Median (min/max) Median (min/max)   Median (min/max) Median (min/max) Median (min/max) Median (min/max)

Emergency 120 (50/750) 180 (55/535) 110 (10/600) 100 (15/785) Emergency 120 (50/750) 180 (55/535) 110 (10/600) 100 (15/785) Emergency 120 (50/750) 180 (55/535) 110 (10/600) 100 (15/785) Urgency 240 (56/800) 220 (50/630) 180 (40/900) 240 (25/1395)

* Mann-Whitney test; ** Student's t test; *** SD=standard deviation.

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Red 100 (11/710) 160 (41/420) 118 (20/540) 114 (16/1142) Orange 130 (7/1040) 134 (19/705) 150 (40/1360) 139.5 (20/888) Red + Orange 125 (7/1040) 150 (19/705) 120 (20/1360) 130 (16/1142) Yellow 120 (10/813) 105 (10/1245) 115 (14/980) 120 (10/1375)

p 0.050* 0.540** 0.320** 0.250* p 0.150* 0.815* 0.006* <0.0001* p 0.660* 0.907* 0.063* <0.0001* p <0.0001* <0.0001* 0.0006* <0.0001*


Coelho Implementation of a surgical screening system for urgent and emergent cases in a tertiary hospital.

Table 3 shows the aTTs/iTTs ratio before and after the TACS classification. There was a decrease in this ratio for Pediatric Surgery and an increase for the other specialties. Surgeries taking place on working days or on weekends, as well as the origin of the patients (ICU and ER versus wards) did not influence the aTTs/iTTs ratio before and after TACS (p=0.914 and p=0.127, respectively). In contrast, the comparison between day and night periods showed better results for the nocturnal periods, with 64.7% of surgeries with a ratio of 1 (p<0.001).

DISCUSSION This was the first time that the TACS classification was used in the day-to-day operation of a surgical center of a tertiary hospital in a developing country, with a large number of nonelective surgeries (61% of the total). Considering the expressiveness of the number of non-elective surgical interventions, the acquisition of correct information for the triage of surgical cases is a key point to know the specificities and peculiarities of the surgical center7.

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Despite the training on the use of colors in the TACS classification, the green and blue colors were practically not used by the studied specialties. The large number of surgeries and priorities may explain why these less urgent colors were poorly chosen. Although there was no difference in the aTTs/ iTTs ratio before and after the TACS classification, there was an increase in the number of elective and non-elective surgeries, without any change in the physical structure of the surgical center, which could indicate a better organization in the surgeries. The absence of difference in the comparison between emergencies in 2016 and the red color in 2017, and the worsening in the actual time to surgeries when compared to orange emergencies, raise the hypothesis of an incorrect classification of cases severity, requiring the creation of awareness strategies for teams to appropriately screen surgical cases according to the colors classification, performing the procedures in due time8. Among the specialties, Pediatric Surgery was the only that obtained improvement in aTTs after the TACS classification. This can be explained by the probable greater adherence to the colors classification,

Table 3. Analysis of aTTs/iTTs ratio before and after the TACS classification divided among the specialties.

Digestive System Surgery       N       Median (min/max) Pediatric Surgery       N       Median (min/max) Vascular Surgery       N       Median (min/max) Orthopedics       N       Median (min/max)

Before 437 1.17 (0.16/12.50)   149 0.92 (0.14/8.92)   202 1.25 (0.11/10.00)   480 1.06 (0.07/13.01)

* Mann Whitney test.

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After 476 1.67 (0.12/11.983)   100 0.67 (0.03/11.75)   178 1.67 (0.04/22.67)   627 1.17 (0.03/19.03)

p <0.01*   0.03   0.03   <0.01


Coelho Implementation of a surgical screening system for urgent and emergent cases in a tertiary hospital.

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since one of the authors of this research is of this specialty. Surgeries classified as red and orange have the precedence of using a room intended for routine surgeries, which can cause the classification in these colors without a real indication. On the other hand, the TACS classification was more effective for the cases considered yellow compared with the urgencies in the previous year. Based on these results, the permanent education is active in the teachinglearning process of the working teams, especially for resident physicians, and is implementing measures to check the veracity of the red and orange gradings9. Weekends and places of origin of patients did not influence the results. However, the nocturnal period was predictive of a better time of care. This can be explained by the fact that during the day there is a great disproportion between rooms

reserved for elective and non-elective surgeries, which does not happen during nights, when there are no elective surgeries. Although the teams were 70% smaller during the nights, the absence of the elective surgeries guaranteed a shorter service time. It is not possible to establish comparisons of our results with previous studies', because this is the first time this classification is implemented outside a disaster scenario. We conclude that the TACS rating improved time for surgeries classified as yellow. We intend to measure these parameters in the future to ensure the truthfulness of the use of colors. Other studies need to be done in different scenarios to test whether the TACS classification proposed by the World Society of Emergency Surgeries is superior to the routinely used subjective classifications.

R E S U M O Objetivo: avaliar a aplicabilidade do sistema de classificação de cores "Timing of Acute Care Surgery" (TACS) em um hospital público terciário de um país em desenvolvimento. Métodos: estudo longitudinal, retrospectivo, de um único centro, de março a agosto de 2016 e o mesmo período em 2017. Optou-se pela seleção de quatro especialidades cirúrgicas com alta demanda de urgências, as quais foram previamente treinadas sobre o sistema TACS. Para comparação com as classificações prévias de urgência e emergência, emergências foram consideradas como vermelhas e laranjas e urgências como amarelas, com intervalo de tempo ideal para cirurgia de uma hora e de seis horas, respectivamente. Resultados: os procedimentos não eletivos representaram 61% do número total de cirurgias. As classificações vermelha, laranja e amarela foram predominantes. Houve melhora significativa do tempo para a cirurgia na cor amarela após o sistema TACS. Períodos diurnos e noturnos influenciaram os resultados, com melhores resultados durante o período noturno. Conclusão: este é o primeiro estudo que usou o sistema TACS no dia a dia de um centro cirúrgico, e demonstrou que o sistema TACS melhorou o tempo de atendimento das cirurgias classificadas como amarelas. Descritores: Programas de Rastreamento. Sistemas de Informação em Salas Cirúrgicas. Centro Cirúrgico Hospitalar.

REFERENCES 1.

2.

3.

Kovacs MH, Feliciano KV de O, Sarinho SW, Veras AACA. Access to basic care for children seen at emergency departments. J Pediatr (Rio J). 2005;81(3):251-8. Poll MA, Lunardi VL, Lunardi Filho WD. Healthcare in emergency units: organization and ethical implications. Acta Paul Enferm. 2008;21(3):509-14. Costa ADS Jr. Assessment of operative times of multiple surgical specialties in a public university hospital. Einstein (São Paulo). 2017;15(2):200-5.

4. Romani HM, Sperandio JA, Sperandio JL, Diniz MN, Inácio MAM. Uma visão assistencial da urgência e emergência no sistema de saúde. Rev Bioética [Internet]. 2009 Jul 6 [cited 2018 Nov 10]; 17 (1):41-53. Available from: http://revistabioetica. cfm.org.br/index.php/revista_bioetica/article/ view/78. 5. National Confidential Enquiry into Patient Outcome and Death. The NCEPOD Classification of Intervention [Internet]. London: NCEPOD; 2004 [cited 2019 Feb 12]. Available from: https://www. ncepod.org.uk/classification.html.

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6.

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Kluger Y, Ben-Ishay O, Sartelli M, Ansaloni L, Abbas AE, Agresta F, et al. World society of emergency surgery study group initiative on Timing of Acute Care Surgery classification (TACS). World J Emerg Surg. 2013;8(1):17. Weiser TG, Haynes AB, Molina G, Lipsitz SR, Esquivel MM, Uribe-Leitz T, et al. Size and distribution of the global volume of surgery in 2012. Bull World Health Organ. 2016;94(3):201-209F. Wanis KN, Hunter AM, Harington MB, Groot G. Impact of an acute care surgery service on timeliness of care and surgeon satisfaction at a Canadian academic hospital: a retrospective study. World J Emerg Surg. 2014;9(1):4.

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Campos MCG, Senger, MH. O trabalho do médico recém-formado em serviços de urgência. Rev Soc Bras Clin Med. 2013;11(4):1-5.

Received in: 04/15/2019 Accepted for publication: 07/02/2019 Conflict of interest: none. Source of funding: none. Mailing address: Erika Veruska Paiva Ortolan E-mail: erika.ortolan@unesp.br erika_paiva@yahoo.com

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Original Article

DOI: 10.1590/0100-6991e-20192238

Dietary supplementation with Camu-Camu versus sleeve gastrectomy in Wistar rats weight control. Análise dos efeitos da suplementação dietética com Camu-Camu comparada à gastrectomia vertical no controle de peso de ratos Wistar. Hercules Magalhães Olivense do Carmo, TCBC-AC1 ; Feliph Miquéias Alcântara de Souza1; Ana Clara Leal Soares1; João Abner Marins Munhoz1; Francisco Glauco de Araújo Santos1; Nilton Ghiotti de Siqueira, TCBC-AC1; Romeu Paulo Martins Silva1 A B S T R A C T Objective: to compare the effects of the hydroalcoholic extract from the peel of Camu-Camu, a fruit plant belonging to the Myrtaceae family, widely distributed in the Amazon basin, with those of sleeve gastrectomy, on the weight and glycemia of Wistar rats. Methods: twenty-four Wistar rats underwent obesity induction through a hyperlipid diet for eight weeks (fat period), and were randomized into three groups: Control Group (CG), Camu-Camu Group (CCG) and Bariatric Surgery Group (BSG). After this period, all animals returned to a normal diet and the intervention period began: CG did not undergo any intervention beyond diet change; CCG animals underwent gavage procedure for administration of Camu-Camu hydroalcoholic extract, 1g/kg/day, for four weeks; and the BSG was submitted to the surgical procedure of sleeve gastrectomy. We followed all animals for four weeks. Results: there was only one loss in BSG due to a gastric fistula. We observed significant variations in the animals’ mean weight: the CG evolved with weight gain even after the withdraw of the hypercaloric diet, while the other two groups presented weight reduction. BSG presented a significant reduction of weight and BMI (p<0.05); CCG achieved a significant reduction only of the BMI (p<0.05). There were no statistically significant changes in the glycemic levels. Conclusion: in spite of reducing weight, the crude hydroalcoholic extract of the Camu-Camu peel was not able to be as efficient as sleeve gastrectomy in the control of body weight in Wistar rats. Keywords: Obesity. Gastrectomy. Bariatric Surgery. Phytotherapy. Rats, Wistar.

INTRODUCTION

O

besity is a worldwide epidemic and represents a serious public health problem due to the association with several morbid states. It is estimated that obesity is the second most common cause of preventable death, second only to smoking1-3. Moderate weight loss, with an approximate reduction of 5% to 10% of the original weight, is associated with significant clinical improvement in the patients, with an increase in insulin production, a decrease in blood pressure, triglyceride levels and glycated hemoglobin. Weight loss over 15%, such as those produced by bariatric surgery, also lead to the remission of obesity-related diseases1.

Bariatric surgery, when associated with a rigorous clinical and nutritional monitoring, is the most effective method to obtain long-term obesity control, which mainly benefits patients with comorbidities such as diabetes, hyperlipidemia, systemic arterial hypertension and sleep apnea, who have substantial improvement or even complete resolution of their diseases3-8. Dietary treatment, even associated with medication, induces on average a modest weight loss of up to 10% in a short period, but is often followed by weight regain. In the search for less invasive measures for the treatment of obesity, there has been a great demand for natural products capable of leading

1 - Federal University of Acre, Health and Sports Science Center, Rio Branco, AC, Brazil. Rev Col Bras Cir 46(4):e2238


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Carmo Dietary supplementation with Camu-Camu versus sleeve gastrectomy in wistar rats weight control.

to the discovery of new chemical entities and the development of starting materials for the synthesis of more specific and efficient drugs. Many Amazonian natural products have been used in experimental models for the identification of active principles with anorectic and hypoglycemic effects9,10. The Myrciaria dubia (HBK) McVaugh, known as CamuCamu, is a fruit plant belonging to the Myrtaceae family, widely distributed in the Amazon basin. The concentration of vitamin C found in Camu-Camu generally corresponds to 40 times that of an orange and 55 times that of a lemon11. Its phytochemical components promote the improvement of the lipid profile, reduction of oxidative stress, reduction of plasma glucose, insulin and lipid levels, as well as anti-inflammatory, hepatoprotective, antimicrobial and antigenotoxic activities11-15. Sotero Solis et al.16 verified antioxidant activity in the three components of Camu-Camu fruit, seed, pulp and peel, the best results being found in the latter. The objective of the study was to compare the effects of Camu-Camu hydroalcoholic peel extract with those of sleeve gastrectomy on the weight and glycemia of Wistar rats. The use of peel extract in the present study guarantees the novelty of its use as a proposal of intervention for the treatment of obesity.

we maintained controlled environmental conditions, with a temperature of 22ยบC, relative humidity of 55%, continuous aerial exhaust and light/darkness cicles of 12/12 hours. After the rats completed eight weeks of life, we randomly allocated them into three groups: Control Group (CG), Camu-Camu Group (CCG) and Bariatric Surgery Group (BSG). All a received a hypercaloric fattening diet - fat and water ad libitum for eight weeks (fattening period)18,19. After this period, all groups returned to the normal diet (normal chow and water ad libitum) and the intervention period began, which lasted four weeks. During these four weeks, the CG did not undergo any intervention other than the dietary change itself (withdrawal of fattening chow and return to normal chow); CCG was submitted to gavage procedures for the administration of Camu-Camu hydroalcoholic peel extract at a dose of 1g/kg/day; and the BSG underwent sleeve gastrectomy (Figure 1).

METHODS We used twenty-four male Wistar rats, an albino line of the species Rattus norvegicus domesticus, obtained with the laboratory of the Federal University of Acre. In agreement with the model used by the Manual of Care and Procedures with Laboratory Animals of the FCF-IQ/ USP Production and Experimentation Laboratory17,

Figure 1. Diagram showing the general study design. BMI: body mass index.

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Carmo Dietary supplementation with Camu-Camu versus sleeve gastrectomy in wistar rats weight control.

We studied the following variables of interest: body weight, BMI and serum glucose. We performed the measurements at three moments: at the beginning of the study, immediately before the introduction of the fattening diet (rats at 8 weeks of age); immediately after the end of the fattening period (rats at 16 weeks of age); and immediately after the end of the intervention period (rats at 20 weeks of age) (Figure 2). At the end of the intervention period, all rats were submitted to euthanasia.

Figure 2. Study time line showing the moment of each measurement of the parameters analyzed.

Rats’ body measurements and BMI

We recorded rats’ body length in centimeters, the same pair of authors always performing the measurements, one for the immobilization of the animal and the other for the handling of the measurement tape. We defined as body length the distance between the tip of the nostril of the animal to the base of its tail. We measured the animals’ corporal weight in grams, using an Prix Lab analytical scale, model AS82220R2. We performed all body weight measurements in duplicate, and when discrepant

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by any value, we considered the mean between the two numbers as the final value for the weight. Blood samples

For glycemia analysis, each rat underwent a minimal incision at the end of its tail with the purpose of extracting a drop of blood to be processed by an Accutrend® Plus device (Roche). Camu-Camu

We used approximately 70kg of in natura Camu-Camu fruit, which we purchased at the "Cooperativa Mista de Produtores de Açaí e Frutas Regionais de Codajás”, Codajás, Amazonas". The formal identification of the Myrciaria dubia (HBK) McVaugh fruits was performed by Dr. Dionatas Ulises de Oliveira Meneguetti, registered in the Regional Council of Biology by the number of CRBio-6 n# 052581/06-D. We washed the fruits and submerged them in 1% sodium hypochlorite solution (10 drops of solution to 1 liter of water) for 15 minutes and, after cleaning, we peeled them and discarded the pulps. We froze the peels at -80ºC and lyophilized them with a Liotop type L101 Freeze Dryer, available at the Bionorte - Complexo UFAC Nanobiotechnology Laboratory. We subjected the resulting lyophilization product to maceration with ethanolic solution (ethanol-water ratio 7:3) for 48 hours, repeating the whole process for three consecutive times. After this step, the solvent was evaporated resulting in a crude residue of the hydroalcoholic extract of the CamuCamu fruit peel, which was again submitted to the lyophilization process for maximum water removal and retrieval of the extract in its final form. Gavage procedure

The gavage process, started for the CCG group after the end of the fattening period, was performed daily to ensure correct dose administration of 1g of extract for each kg of mouse weight per day (1g/kg/day).

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Carmo Dietary supplementation with Camu-Camu versus sleeve gastrectomy in wistar rats weight control.

The eight CCG rats received the extract by gavage. The procedure was always performed by the same pair of authors: one to immobilize the animal and the other to perform the gavage, without changing the roles between them. Sleeve gastrectomy

The rats were fasted for 12 hours before the sleeve gastrectomy surgical procedure. Thirty minutes before the procedure, they received antibiotic prophylaxis with ceftriaxone 50mg/ kg intramuscularly. They were anesthetized with ketamine (100mg/kg) and xylazine (10mg/ kg) intraperitoneally. During the procedure, we performed the resection of approximately 70% of the animal’s stomach. Gastric wall synthesis was performed with PDS® II 6-0 (polydioxanone) in two planes and closure of the abdominal wall and skin, performed with catgut 3-0 and nylon 4-0, respectively. Each animal submitted to the procedure was isolated in a cage without other animals and received cleaning and exchange of surgical dressing daily. We used tramadol chlorhydrate (10mg/kg subcutaneously every 8/8 hours for 3 days) for analgesia. Ethics in research

All the procedures applied during the experiment were in accordance with Law n# 11794/2008, which regulates the scientific use of animals in Brazil, and Normative Resolution n# 37, of January 27, 2018, of the Practical Euthanasia Guidelines of the National Council of Animal Experimentation - CONCEA. The euthanasia procedure was carried out as recommended by the CONCEA Resolution n# 37, in a quiet and clean environment, in an individualized manner (away from other animals), and quickly.

We used the method of indirect hypoxia, inducing unconsciousness before ceasing motor activity. To do so, we placed each animal in a chamber containing 100% inhalation agent (isoflurane) to ensure rapid and painless death. After the procedure, we confirmed death with the following signs: absence of respiratory movement; absence of heartbeat; pale mucous membranes; and absent corneal reflex. Before being discarded, the animal remained on observation for ten minutes. This study was approved by the Ethics Committee on Animal Use of UFAC, under process n# 23107.025548/2017-26 and protocol n# 54/2017. Statistical analysis

We analyzed the data with the GraphPad Prism® software version 5.0 (GraphPad, United States). We assessed normality with the ShapiroWilk test. We presented data as mean and standard deviation for parametric variables. We used The Student t test to compare continuous intergroup endpoints with homogeneity of variances, in case of symmetric distribution, and heterogeneity of variance, in case of asymmetric distribution. We used One-way ANOVA to evaluate possible differences between groups over time (pre and post-dietary supplementation with the Camu-Camu extract). We set the statistically significant threshold (p) at 0.05.

RESULTS Only one of the mice died 11 days after the surgical procedure due to complications of a gastric fistula. The average weight in grams of the animals showed a significant variation between the groups (Figure 3A); CG maintained an upward curve of weight gain (CG2: 377.87±72g/CG3: 421.25±97g)

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Carmo Dietary supplementation with Camu-Camu versus sleeve gastrectomy in wistar rats weight control.

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Figure 3. Variation of body weight, blood glucose and BMI during the three moments of the experiment. The figures 1, 2 and 3 after the acronym for each group indicate the moment of measurement as quoted in the methodology. CG= Control Group; CCG= Camu-camu Group; BSG= Bariatric Surgery Group. (A) variation of body weight throughout the experiment. ## Statistically relevant difference with p=0.0313 (Student's t-test); (B) line graph showing the ratsâ&#x20AC;&#x2122; body weight variation throughout the experiment; (C) variation of fasting glycemia; (D) tendency of variation of fasting glycemia; (E and F) variation of BMI throughout the experiment. The differences between the groups were analyzed by Student's t-test. # p=0.014; * p=0.8 (horizontal lines in Chart E).

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Carmo Dietary supplementation with Camu-Camu versus sleeve gastrectomy in wistar rats weight control.

(Figure 3B) even after finishing the fattening period. The other two groups, CCG and BSG, presented a decrease in the mean weight (CCG2: 412.75±66g/ CCG3: 402±60g/BCG2: 395.12±50g/ BCG3: 365.28±31g), the difference between the end weight of CG and BSG groups being statistically significance by the Student’s t test (p=0.0313). Figures 3C and 3D show the results of biochemical analysis for the determination of blood glucose levels between the end of the fattening period and the end of the study. Although the BSG values were better than those of the other groups, this difference was not statistically significant. The values found in the data analysis of the mean BMI of groups (Figures 3E and 3F) showed that the only intervention that could reverse the metabolic syndrome in rats was Sleeve Gastrectomy, p<0.05 in the Student's t test, corroborating the data found in the other measurements. The decrease in CCG BMI was also significant in relation to CG (p=0.0421).

DISCUSSION The use of Camu-Camu as medicinal fruit by the Amazonian peoples aroused interest in determining its efficacy in the treatment of various diseases. Therefore, its use as a possible treatment of obesity is relevant. The hypothesis that Camu-Camu is efficient in the treatment of the metabolic syndrome has already been tested in a work with obese rats20. The experimental group treated with 25ml/day of pulp of the M. dubia fruit presented loss of body weight, with a decrease of 31.7% when compared to the control group.

The treatment of obese rats with fruit resulted in a decrease in glycemia (23%), cholesterol (39.6%) and triglycerides (40.6%) compared with increases observed in controls: 19.4% glycemia, 60%cholesterol, and 44% triglycerides. A recent study showed that dietary supplementation with Camu-Camu extract (200mg/kg) was able to prevent obesity in rats submitted to a hypercaloric/hyperlipidic diet21. These animals had an increase in resting metabolism, which, in turn, led to a lower accumulation of fat. An important factor in this study was the presence of a group that received the same dose of vitamin C found in the 200mg/kg of Camu-Camu extract (6.6mg/kg), but did not present good results in relation to weight loss. Therefore, there is great possibility that only vitamin C is not the reason for the anorectic effect of Camu-Camu. The CCG of this study did not present results as expressive as those found in other studies 10. However, the lower values of BMI observed in the animals submitted to CamuCamu supplementation, even after only four weeks of intervention, indicate that the extract has the ability to regulate the inflammatory response induced by excess fat cells, proving to be a promising therapy for the treatment of obesity. Our study showed that the crude hydroalcoholic extract of the Camu-Camu peel, although not as efficient as sleeve gastrectomy in the body weight control of Wistar rats, leads to a statistically significant reduction in the BMI of the animals after its administration for four weeks.

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Carmo Dietary supplementation with Camu-Camu versus sleeve gastrectomy in wistar rats weight control.

7

R E S U M O Objetivo: comparar os efeitos do extrato hidroalcoólico da casca do Camu-Camu, uma planta frutífera pertencente à família Myrtaceae amplamente distribuída na bacia amazônica, com os da gastrectomia vertical, sobre o peso e a glicemia de ratos Wistar. Métodos: vinte e quatro ratos Wistar foram submetidos à indução de obesidade através de dieta hiperlipídica por oito semanas (período de engorda), e randomizados em três grupos: Grupo Controle (GC), Grupo Camu-Camu (GCC) e Grupo Cirurgia Bariátrica (GCB). Após esse período, todos os animais retornaram a uma dieta normal e iniciou-se o período de intervenção: o GC não sofreu nenhuma intervenção além da mudança da dieta; o GCC foi submetido ao procedimento de gavagem para administração de extrato hidroalcoólico de Camu-Camu 1g/kg/ dia por quatro semanas; e o GCB foi submetido ao procedimento cirúrgico de gastrectomia vertical. Todos os animais foram acompanhados por quatro semanas. Resultados: houve apenas uma perda no GCB devido à fístula gástrica. Observou-se variações significativas no peso médio dos animais: o GC evoluiu com aumento de peso mesmo após a retirada da dieta de engorda, enquanto os outros dois grupos apresentaram redução de peso. O GCB apresentou redução significativa do peso e do IMC (p<0,05); o GCC obteve redução significativa apenas do IMC (p<0,05). Não houve alterações estatisticamente significantes nos níveis glicêmicos. Conclusão: apesar de reduzir o peso, o extrato hidroalcoólico bruto da casca do Camu-Camu não foi capaz de se mostrar tão eficiente quanto a cirurgia de gastrectomia vertical no controle do peso corporal em ratos Wistar. Descritores: Obesidade. Gastrectomia. Cirurgia Bariátrica. Fitoterapia. Ratos Wistar.

REFERENCES 1.

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5. 6.

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Heymsfield SB, Wadden TA. Mechanisms, pathophysiology, and management of obesity. N Engl J Med [Internet]. 2017 Jan [cited]; 376(3):25466. Available from: http://www.nejm.org/ doi/10.1056/ NEJMra1514009 GBD 2015 Obesity Collaborators, Afshin A, Forouzanfar MH, Reitsma MB, Sur P, Estep K, et al. Health effects of overweight and obesity in 195 countries over 25 Years. N Engl J Med [Internet]. 2017 Jul [cited]; 377(1):13-27. Available from: http:// www.nejm.org/doi/10.1056/ NEJMoa 1614362 Tessier DJ, Eagon JC. Surgical management of morbid obesity. Curr Probl Surg. 2008;45(2):68-137. Shah M, Simha V, Garg A. Review: long-term impact of bariatric surgery on body weight, comorbidities, and nutritional status. J Clin Endocrinol Metab. 2006;91(11):4223-31. Brolin RE. Bariatric surgery and long-term control of morbid obesity. JAMA. 2002;288(22):2793-6. Schauer PR, Bhatt DL, Kirwan JP, Wolski K, Aminian A, Brethauer SA, et al. Bariatric surgery versus intensive medical therapy for diabetes - 5-year outcomes. N Engl J Med [Internet]. 2017 Feb [cited]; 376(7):641-51. Available from: http://www.nejm. org/doi/10.1056/NEJMoa1600869

Buchwald H, Avidor Y, Braunswald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292(14):1724-38. Erratum in: JAMA. 2005;293(14):1728. 8. Bose M, Oliván B, Teixeira J, Pi-Sunyer FX, Laferrère B. Do incretins play a role in the remission of type 2 diabetes after gastric bypass surgery: what are the evidence? Obes Surg. 2009;19(2):217-29. 9. Langley PC, Pergolizzi JV Jr, Taylor R Jr, Ridgway C. Antioxidant and associated capacities of Camu camu (Myrciaria dubia): a systematic review. J Altern Complement Med [Internet]. 2015 Jan [cited]; 21(1):8-14. Available from: http://online. liebertpub.com/doi/abs/10.1089/acm.2014.013 10. Arellano-Acuña E, Rojas-Zavaleta I, Paucar-Menacho LM. Camu-camu (Myrciaria dubia): Tropical fruit of excellent functional properties that help to improve the quality of life. Sci Agropecuaria [Internet]. 2016 Oct [cited]; 7(4):433-43. Available from: http:// revistas.unitru.edu.pe/index.php /scientiaagrop / article/view/1266 11. Rodrigues RB, Menezes HC de, Cabral LMC, Dornier M, Reynes M. An amazonian fruit with a high potential as a natural source of vitamin C: the camu-camu (Myrciaria dubia). Fruits. 2001;56(5):345-54.

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Carmo Dietary supplementation with Camu-Camu versus sleeve gastrectomy in wistar rats weight control.

12. Zanatta CF, Mercadante AZ. Carotenoid composition from the Brazilian tropical fruit camu-camu (Myrciaria dubia). Food Chem. 2007;101(4):1526-32. 13. Inoue T, Komoda H, Uchida T, Node K. Tropical fruit camu-camu (Myrciaria dubia) has anti-oxidative and anti-inflammatory properties. J Cardiol. 2008;52(2):127-32. 14. Akachi T, Shiina Y, Kawaguchi T, Kawagishi H, Morita T, Sugiyama K. 1-methylmalate from camu-camu (Myrciaria dubia) suppressed D-galactosamineinduced liver injury in rats. Biosci Biotechnol Biochem [Internet]. 2010 Mar; 74(3):573-8. Available from: http://www.tandfonline.com/doi/full/10.1271/ bbb.90775 15. De Souza Schmidt Gonçalves AE, Lellis-Santos C, Curi R, Lajolo FM, Genovese MI. Frozen pulp extracts of camu-camu (Myrciaria dubia McVaugh) attenuate the hyperlipidemia and lipid peroxidation of Type 1 diabetic rats. Food Res Int. 2014;64:1-8. 16. Sotero Solis V, Silva Doza L, García de Sotero D, Imán Correa S. Evaluación de la actividad antioxidante de la pulpa, cáscara y semilla del fruto del camu camu (Myrciaria dúbia H.B.K.). Rev Soc Quím Perú. 2009;75(3):293-9. 17. Neves SMP, Ong FMP, Rodrigues LD, Santos RA, Fontes RS, Santana RO. Manual de Cuidados e Procedimentos com Animais de Laboratório do Biotério de Produção e Experimentação da FCF-IQ/ USP. São Paulo: FCF-IQ/USP; 2013. 18. Rosini TC, Silva ASR, Moraes C. Obesidade induzida por consumo de dieta: modelo em roedores para o estudo dos distúrbios relacionados com a obesidade.

Rev Assoc Med Bras [Internet]. 2012;58(3):383-7. Available from: http://linkinghub.elsevier.com/ retrieve/pii/S0104423012705250 19. Nascimento AF, Sugizaki MM, Leopoldo AS, LimaLeopoldo AP, Luvizotto RAM, Nogueira CR, et al. A hypercaloric pellet-diet cycle induces obesity and co-morbidities in wistar rats. Arq Bras Endocrinol Metabol. 2008;52(6):968-74. 20. Nascimento OV, Boleti APA, Yuyama LKO, Lima ES. Effects of diet supplementation with Camucamu (Myrciaria dubia HBK McVaugh) fruit in a rat model of diet-induced obesity. An Acad Bras Ciênc. 2013;85(1):355-63. 21. Anhê FF, Nachbar RT, Varin TV, Trottier J, Dudonné S, Le Barz M, et al. Treatment with camu camu (Myrciaria dubia) prevents obesity by altering the gut microbiota and increasing energy expenditure in diet-induced obese mice. Gut. 2018; pii: gutjnl-2017-315565. Received in: 05/12/2019 Accepted for publication: 06/25/2019 Conflict of interest: none. Source of funding: This study was partially funded by CNPq (National Council for Scientific and Technological Development) and CAPES (Federal Agency for Support and Evaluation of Post-Graduate Education). Mailing address: Hercules Magalhães Olivense do Carmo E-mail: herculesdoc@uol.com.br

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Original Article

DOI: 10.1590/0100-6991e-20192146

Safety and quality in surgery: surgeons' perception in Brazil. Segurança e qualidade em cirurgia: a percepção de cirurgiões no Brasil. Maria Isabel Toulson Davisson Correia, TCBC-MG1 ; Flávio Daniel Saavedra Tomasich, TCBC-PR2; Heládio Feitosa de-Castro Filho, TCBC-CE3; Pedro Eder Portari Filho, TCBC-RJ4; Ramiro Colleoni Neto, TCBC-SP5 A B S T R A C T Objective: to evaluate the perception of surgeons, members of the Brazilian College of Surgeons (CBC), on safety and quality issues in surgery, based on projects of Brazilian Ministry of Health (MS), CBC, World Health Organization (WHO), and American College of Surgeons (ACS). Methods: a questionnaire based on WHO, CBC, and ACS initiatives was sent to all active and non-active CBC members, using Survey Monkey, in March 2018. Results: out of 7,100 members, 171 professionals answered the questionnaire. Out of these, the majority (63.2%) declared to perform general surgery, 88.9% indicated knowing the project called Safe Surgery developed by MS, 73.1%, the CBC manual, and 14.6%, the ACS Strong for Surgery. Among those who indicated knowing the MS project, 73.1% said that they were accustomed to use it as a routine, and, among those who indicated knowing the CBC manual, 46.2% said that they were accustomed to use it. Most of the surgeons (81.3%) indicated that they had experienced severe surgical failures, being failures related to surgical material (49.7%) and presence of foreign bodies (8.2%) the most common ones. There were distinct opinions on who was responsible for checking over the checklist. Conclusion: the importance of safety and quality in surgery is well known by surgeons, but the practice is varied. Serious adverse events had been experienced by many surgeons, mainly related to surgical material and foreign bodies. The concept of interdisciplinarity did not seem to be common practice. Data indicated the need to develop education projects and the obligation of audits. Keywords: Safety. Quality of Health Care. General Surgery. Near Miss. Healthcare.

INTRODUCTION

S

urgical procedures are part of the daily routine of modern Medicine. In Brazil, in 2017, there were around 150,000 operations/month recorded by Brazilian Unified Health System (SUS)1. Worldwide, it is estimated that, every year, from 187 to 280 million large surgical cases occur, representing about one operation for every 25 inhabitants2. There is no risk-free operation and therefore the indication of surgical treatment should always consider the risk/ benefit ratio of the procedure. Many adverse events could be avoided if safety and quality criteria were routinely used. In Australia, a study has indicated that 47.6% of surgical complications could have been avoided3. Surgical complications increase hospital costs, hospitalization time, and mortality.

In 2008, the World Health Organization (WHO) published an initiative called Safe Surgery Saves Lives4, and, based on this project, in 2009, the Brazilian Ministry of Health launched a campaign named Safe Surgery Saves Lives5. In turn, in 2014, the Brazilian College of Surgeons (CBC) published the Manual of Safe Surgery6, based on the principles advocated by the two documents mentioned above. In addition to adopting and disseminating the same initiative, the American College of Surgeons (ACS) developed a project called Strong for Surgery7. It was initially launched also in 2014, by Dr. Tom Varghese Jr., as part of the Surgical Care Outcomes Assessment Program (SCOAP) of the Foundation for Health Care Quality. The main objective of this project was to engage patients and surgeons in the fundamental principle of increasing the quality of provided surgical services, and, thus, improving results.

1 - Federal University of Minas Gerais, Medical School, Department of Surgery, Belo Horizonte, MG, Brazil. 2 - Federal University of Parana, Medical School, Departmnnet of Surgery, Curitiba, PR, Brazil. 3 - Federal University of Ceara, Medical School, Department of Surgery, Fortaleza, CE, Brazil. 4 - Federal University of Rio de Janeiro State, School of Medicine and Surgery, Department of General and Specialized Surgery, Rio de Janeiro, RJ, Brazil. 5 - Federal University of Sao Paulo, Paulista School of Medicine, Department of Surgery, Sao Paulo, SP, Brazil. Rev Col Bras Cir 46(4):e2146


Correia Safety and quality in surgery: surgeonsâ&#x20AC;&#x2122; perception in Brazil.

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The clinical benefits and economic impact after implementing these initiatives, regardless of whether in first-world or developing countriesâ&#x20AC;&#x2122; hospitals, are a reality8-12. However, we should highlight the importance, well-documented by some authors8,10, that the lack of standardization and interdisciplinary involvement, as well as the lack of several other essential aspects for the success of the appropriate implementation of the projects, may result in contradictory data13. Thus, similarly to the standardization adopted by aviation, it seems clear that the surgical practice guided by protocols, in particular by checklists, is associated with low rates of adverse events14-17 and should be carefully implemented in surgical centers. Besides the reduction of the complication rate associated with the use of checklists, there are also the improvement in communication among peers, encouragement of teamwork, and introduction of general safety attitudes11. Despite this, in Brazil, it is still common the fateful report of serious adverse events associated to the lack of standardization and responsibility towards the surgical patient, regardless of the type of hospital where the care is performed, a situation that has been widely disseminated by the media and which makes the population increasingly afraid of surgeons. The objective of the present study was to evaluate the knowledge of surgeons, in Brazil, regarding safety and quality in surgery.

METHODS A structured questionnaire (Figure 1) based on WHO, CBC, and ACS initiatives was sent to all active and non-active CBC members7,10, using Survey Monkey platform, in March of 2018.

Firstly, an electronic message was sent to the members inviting them to answer the first 14 questions of the questionnaire, by using the link to Survey Monkey page. If they were interested, they could then answer the other questions. This message was sent twice. Statistical analyses included frequency and chi-square tests for crossings between variables of interest, performed using SPSS program, version 19.0.

RESULTS Out of the 7,100 registered members, 171 professionals answered the questionnaire. Out of these, the majority (63.2%) declared to perform General Surgery, 12.3%, Digestive Surgery, 7.6%, Oncologic Surgery, 4.1%, Plastic Surgery, 2.3%, Head and Neck Surgery, 1.8%, Thoracic Surgery, 1.8%, Coloproctological Surgery, 1.2%, Urological Surgery, and 5.7%, surgeries of other specialties. The types of hospitals where these professionals work are recorded in table 1. The median number of beds of these institutions was 201, ranging from 11 to 2,500. Table 1. Types of hospitals where the physicians who answered the questionnaire worked.

Type of hospital Philanthropic Public Private University General Specialized National reference

n 22 52 59 38 114 34 23

% 12.9 30.4 34.5 22.2 66.7 19.9 13.5

Most of the interviewees (88.9%) indicated knowing the project called Safe Surgery developed by MS, 73.1% knew the CBC Manual, and 14.6%, the ACS Strong for Surgery.

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Correia Safety and quality in surgery: surgeonsâ&#x20AC;&#x2122; perception in Brazil.

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Figure 1. Applied questionnaire.

Among those who knew the MS project, 73.1% said that they were accustomed to use it as a routine in the hospitals where they worked; on the other hand, among those who knew the CBC Manual, only 46.2% used it routinely. There was no statistically significant difference for these questions, considering the type and size of hospital where the surgeons work (p=NS). Eighty-nine professionals (52%) reported that there was no record of surgical failures as routine in the hospitals where they work. Out of the ones who informed that there was such record, 39% work in private hospitals, 26.8%, in university hospitals, 20.7%, in public hospitals, and 13.4%, in philanthropic hospitals (p<0.05).

In specialized and general hospitals, the frequency of adverse event records was lower (24.3% and 38.6%, respectively) than in reference hospitals (78.3%), with p<0.05. In most hospitals, the nurse of the surgical block was responsible for recording the surgical failures, and, in some few cases, it was indicated that there was a safety and quality team, as well as the participation of the clinical director. Most of the surgeons (81.3%) indicated that they had experienced severe surgical failures, such as foreign body, error in laterality, lack of blood reserve when it has been essential, failures related to surgical material etc. These last ones (49.7%) and presence of foreign bodies (8.2%) were, isolatedly, the most common failures.

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Correia Safety and quality in surgery: surgeonsâ&#x20AC;&#x2122; perception in Brazil.

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However, 35.3% of the surgeons said that they had experienced more than one adverse event; several of them indicated that they had experienced all of those failures listed in the questionnaire (table 2). Table 2. Serious adverse events.

Type of event Lack of material Foreign body Laterality All mentioned Lack of blood products Others Total

n 85 14 4 4 2 47 152

Regarding the opinion on the use of checklists, the majority of the professionals (84.2%) indicated that they considered the requirement to be a great attitude, and 78.4% reported that they always presented them to the in-room team. Most of the surgeons said that the check over of the checklist should be assigned to the room nurse (65.5%), 18.1% defined that the anesthesiologist should be responsible for this practice, 12.9%, the surgeon himself (herself), and 3.5% said that it should be assigned to all.

DISCUSSION The second global challenge, launched between 2007 and 2008 by WHO's Global Alliance for Patient Safety, laid the groundwork for starting discussing safety in surgery. This initiative was released, in Portuguese, by MS in 2009 and by CBC in 20145. The campaign's motto was Safe Surgery Saves Lives and aimed to encourage managers of hospital institutions, as well as health professionals, to mobilize efforts to create standard surgical practices that would promote safety in surgery.

Interestingly, after more than ten years of this initiative, there are still surgeons who are unaware of this practice, as we could observe among our interviewees, 11.1% said that they did not know such piece of information. The concept of safe surgery involves measures adopted to reduce the risk of adverse events that may occur before, during, and after operations. Adverse surgical events are incidents that result in harm to the patient. Most of the surgeons who responded to the present inquiry reported that they had already experienced serious failures, the majority related to surgical material, due to lack of or damage to instruments or, still, inadequate instruments for the surgical act, as reported by some professionals specialized in bariatric procedures. Not necessarily, this failure had caused serious damages to the patients, since we did not evaluate this aspect. However, presence of foreign bodies, mostly compresses, and errors in laterality were recorded in considerable numbers, which can be classified as extremely severe. In this sense, if the Safe Surgery Checklist had been adopted, the errors in laterality could have been considerably minimized, since it is one of the first aspects contemplated by the WHO questionnaire and repeated in two moments (before anesthetic induction - sign in - and the surgical incision - time out)5,8. The introduction of the WHO checklist, whose standard should be applicable anywhere in the world and in different surgical settings, has been evaluated in eight global hospitals, located in first-world countries, but also in very poor countries8. There has been a 36% decrease in the rate of postoperative complications and mortality has fallen from 1.5% to 0.8%. Several factors certainly contribute to the reduction of complications and mortality when checklists are adopted, of which we highlight interdisciplinary work. It is interesting to note that, among the surgeons who answered the questionnaire,

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Correia Safety and quality in surgery: surgeonsâ&#x20AC;&#x2122; perception in Brazil.

65.5% said that the check over of the checklist should be assigned to the nurse and only the minority indicated that it was an everyone's job. Teamwork and continuing education, especially when there are integration and respect among peers, have already been evaluated as factors that contribute to better results8,17-20 in the adoption and follow-up of protocols, similarly to what happens in aviation. Grogan et al.17 have used aviation techniques, such as Crew Resource Management (CRM), in trauma teams, emergency care, surgical services, and others, through an eight-hour course, after the filling of a questionnaire on safety by the participants. After the training, there has been a positive impact in relation to 20 of the 23 items covered. McCulloch et al.18 have evaluated five surgical units in charge of Orthopedic procedures and Plastic and Vascular Surgeries, in the United Kingdom. All team members (surgeons, nurses, anesthetists, and others) have been exposed to several safety topics for four months. The intervention has been performed in different ways and the combination of actions in group/ team has resulted in better adherence rates to the protocols and increase in the quality of techniques/ abilities in relation to individualized actions. Still on teamwork, we should point out that lack of communication is one of the aspects associated with adverse events that can cause harm or be fatal to the patient21,22. Green et al.22 have emphasized the importance of questioning, by any member of the team, when who is in charge of the operative act may be performing any inappropriate action. That is, the hierarchy can and should be questioned whenever there is a risk of harm to the patient, and, for that, the team philosophy should prevail as a matter of necessity. It is interesting to note that the great majority of surgeons (88.9%)

5

stated that they knew Safe Surgery Saves Lives project, but more than 20% of the interviewees did not routinely introduce themselves to the other team members, and this is an essential step to be fulfilled, in a loud voice, before the surgical incision (time out)4,8. The present study should be evaluated with caution, due to the low number of professionals who electronically answered the questionnaire (<5%). Talking about questionnaries, its is considered a good response when there are at least 20% of returns23,24, and our rate was much lower. This can be an indicator of professionals' lack of interest in the subject. Besides, CBCâ&#x20AC;&#x2122;s database (7,100 registered members) does not reflect and represent the real number of surgeons in Brazil, which is a large continental country. We also did not evaluate the type of hospital and geographic region of the professionals who answered the inquiry, which prevented us from discussing the influence of these variables on the overall results. The study also did not allow us to associate number of reported adverse events with impact on risk for the patient, hospital costs, and general quality of care. Although better results on safety and quality aspects occurred in private and reference hospitals, initiatives of continuing education and development of a safety and quality culture, as well as the valorization of interdisciplinarity, should be fostered. In this sense, specialist entities, such as CBC, will be able to play a relevant role in developing partnerships with various institutions, providing information and teaching, besides working in partnership with MS in order to establish national security and quality rules. Our questionnaire showed that the importance of safety and quality in surgery was known by surgeons, but the practice was varied.

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Serious adverse events had been experienced by many surgeons, mainly related to surgical material and foreign bodies. The concept of interdisciplinarity

did not seem to be common practice. Data indicated the need to develop education projects and the obligation of audits.

R E S U M O Objetivo: avaliar a percepção dos cirurgiões, membros do Colégio Brasileiro de Cirurgiões (CBC), sobre temas de segurança e qualidade em cirurgia, com base em Projetos do Ministério da Saúde (MS), do CBC, da Organização Mundial de Saúde (OMS) e do Colégio Americano de Cirurgiões (ACS). Métodos: questionário com base nas iniciativas da OMS, do CBC e do ACS foi enviado pelo Survey Monkey a todos os sócios, ativos e não ativos, do CBC em março de 2018. Resultados: responderam ao questionário 171 profissionais dentre os 7.100 sócios. Desses, a maioria (63,2%) declarou praticar Cirurgia Geral, 88,9% indicaram conhecer o Projeto Cirurgia Segura do MS, 73,1%, o Manual do CBC e 14,6%, o Strong for Surgery do ACS. Entre os que conhecem o Projeto do MS, 73,1% disseram usá-lo como rotina e, entre os que conhecem o Manual do CBC, 46,2% usam-no. A maior parte dos cirurgiões (81,3%) indicou que já vivenciou falha cirúrgica grave, sendo aquelas relacionadas com material cirúrgico (49,7%) e presença de corpos estranhos (8,2%), isoladamente, as mais comuns. Houve opiniões distintas sobre a responsabilidade de conferência do checklist. Conclusão: a importância da segurança e qualidade em cirurgia é conhecida pelos cirurgiões, mas a prática é variada. Eventos adversos graves foram vivenciados por muitos cirurgiões, principalmente relacionados com material cirúrgico e corpos estranhos. O conceito de interdisciplinaridade parece não ser prática comum. Os dados indicam a necessidade de desenvolver projetos de educação e a obrigatoriedade de auditorias. Descritores: Segurança. Qualidade da Assistência à Saúde. Cirurgia Geral. Near Miss.

6.

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4.

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Frasão G. Em oito meses, número de cirurgias eletivas cresceu 39,1% no Brasil 2017 [Internet]. Brasília (DF): Ministério da Saúde; 2017[citado 2018 Dez 12]. Available from: http://portalms.saude.gov. br/noticias/agencia-saude/42101-em-oito-mesesnumero-de-cirurgias-eletivas-cresceu-39-1-no-brasil. Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, Berry WR, et al. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet. 2008;372(9633):139-44. Kable AK, Gibberd RW, Spigelman AD. Adverse events in surgical patients in Australia. Int J Qual Health Care. 2002;14(4):269-76. World Health Organization & WHO Patient Safety. The second global patient safety challenge: safe surgery saves lives [Internet]. Geneva: World Health Organization; 2008. [Available from: http://www. who.int/patientsafety/ safesurgery/ss_checklist/en/. Organização Mundial da Saúde. Segundo desafio global para a segurança do paciente. Cirurgias seguras salvam vidas. Rio de Janeiro: Organização PanAmericana da Saúde; Ministério da Saúde; Agência Nacional de Vigilância Sanitária; 2009. [Available from: http://bvsms.saude.gov.br/bvs/publicacoes/ seguranca_paciente_cirurgias_seguras_guia.pdf.

Colégio Brasileiro de Cirurgiões. Manual de Cirurgia Segura [Internet]. Rio de Janeiro: Colégio Brasileiro de Cirurgiões; 2014. [Available from: https://cbc. org.br/wp-content/uploads/2015/12/ManualCirurgia-Segura.pdf. 7. American College of Surgeons. Strong for surgery [Internet]. Chicago (IL): American College of Surgeons; 2018. [Available from: https://rise.articulate.com/ share/m-gYm0bwQyHECGSVbDrubx3w1iDunJ-c#/ lessons/cj30isngq00003c64hwbch8ye?_k=sgjdio. 8. 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. 9. de Vries EN, Dijkstra L, Smorenburg SM, Meijer RP, Boermeester MA. The SURgical PAtient Safety System (SURPASS) checklist optimizes timing of antibiotic prophylaxis. Patient Saf Surg. 2010;4(1):6. 10. van Klei WA, Hoff RG, van Aarnhem EE, Simmermacher RK, Regli LP, Kappen TH, et al. Effects of the introduction of the WHO “Surgical Safety Checklist” on in-hospital mortality: a cohort study. Ann Surg. 2012;255(1):44-9.

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Correia Safety and quality in surgery: surgeons’ perception in Brazil.

11. Haugen AS, Søfteland E, Almeland SK, Sevdalis N, Vonen B, Eide GE, et al. Effect of the World Health Organization checklist on patient outcomes: a stepped wedge cluster randomized controlled trial. Ann Surg. 2015;261(5):821-8. 12. Shrime MG, Alkire BC, Grimes C, Chao TE, Poenaru D, Verguet S. Cost-effectiveness in global surgery: pearls, pitfalls, and a checklist. World J Surg. 2017;41(6):1401-13. 13. Urbach DR, Govindarajan A, Saskin R, Wilton AS, Baxter NN. Introduction of surgical safety checklists in Ontario, Canada. N Engl J Med. 2014;370(11):1029-38. 14. Mitchell I, Schuster A, Smith K, Pronovost P, Wu A. Patient safety incident reporting: a qualitative study of thoughts and perceptions of experts 15 years after ‘To Err is Human’. BMJ Qual Saf. 2016;25(2):92-9. 15. Skinner L, Tripp TR, Scouler D, Pechacek JM. Partnerships with aviation: promoting a culture of safety in health care. Creat Nurs. 2015;21(3):179-85. 16. Van Spall H, Kassam A, Tollefson TT. Near-misses are an opportunity to improve patient safety: adapting strategies of high reliability organizations to healthcare. Curr Opin Otolaryngol Head Neck Surg. 2015;23(4):292-6. 17. Grogan EL, Stiles RA, France DJ, Speroff T, Morris JA Jr, Nixon B, et al. The impact of aviation-based teamwork training on the attitudes of health-care professionals. J Am Coll Surg. 2004;199(6):843-8. 18. McCulloch P, Morgan L, New S, Catchpole K, Roberston E, Hadi M, et al. Combining Systems and Teamwork Approaches to Enhance the Effectiveness of Safety Improvement Interventions in Surgery: The Safer Delivery of Surgical Services (S3) Program. Ann Surg. 2017;265(1):90-6.

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19. Trehan A, Barnett-Vanes A, Carty MJ, McCulloch P, Maruthappu M. The impact of feedback of intraoperative technical performance in surgery: a systematic review. BMJ Open. 2015;5(6):e006759. 20. Robertson E, Morgan L, New S, Pickering S, Hadi M, Collins G, et al. Quality improvement in surgery combining lean improvement methods with teamwork training: a controlled before-after study. PLoS One. 2015;10(9):e0138490. 21. Harden SW. Six things every plastic surgeon needs to know about teamwork training and checklists. Aesthet Surg J. 2013;33(3):443-8. 22. Green B, Oeppen RS, Smith DW, Brennan PA. Challenging hierarchy in healthcare teams ways to flatten gradients to improve teamwork and patient care. Br J Oral Maxillofac Surg. 2017;55(5):449-53. 23. Morton SM, Bandara DK, Robinson EM, Carr PE. In the 21st Century, what is an acceptable response rate? Aust N Z J Public Health. 2012;36(2):106-8. 24. Keller A. What is an acceptable survey response rate? [Internet]. East Lansing (MI): Michigan State University; 2014. Available from: http://socialnorms. org/what-is-an-acceptable-survey-response-rate/. Received in: 02/06/2019 Accepted for publication: 06/20/2019 Conflict of interest: none. Source of funding: none. Mailing address: Maria Isabel Toulson Davisson Correia E-mail: isabel_correia@uol.com.br

Rev Col Bras Cir 46(4):e2146


Original Article

DOI: 10.1590/0100-6991e-20192252

Surgical site infection in bariatric surgery: results of a care bundle. Infecção de sítio cirúrgico após cirurgia bariátrica: resultados de uma abordagem com pacote de cuidados. Álvaro Antonio Bandeira Ferraz, TCBC-PE1,2; César Freire de Melo Vasconcelos2; Fernando Santa-Cruz3 ; Maria Améllia R. Aquino3; Vinícius G. Buenos-Aires3; Luciana Teixeira de Siqueira1 A B S T R A C T Objective: to present a descriptive analysis of the results of a care bundle applied to obese patients submitted to bariatric surgery, regarding infection control. Methods: a care bundle was designed to control surgical site infection (SSI) rates in patients undergoing bariatric surgery. The bundle included smoking cessation, bathing with 4% chlorhexidine two hours before surgery, cefazolin (2g bolus) in anesthetic induction associated with a continuous infusion of the same drug at a dose of 1g over a two-hour period, appropriate trichotomy, glycemic control, supplemental oxygen, normothermia, intraspinal morphine for the relief of pain, and sterile dressing removal 48 hours after surgery. All patients were followed up for 30 days. Results: among the 1,596 included patients, 334 (20.9%) underwent open surgery and 1,262 (79.1%) underwent videolaparoscopic surgery. SSI rates were 0.5% in the group submitted to laparoscopic surgery and 3% in the one submitted to open surgery. The overall incidence of SSI was 1%. Intra-abdominal, respiratory tract, and urinary tract infections occurred in 0.9%, 1.1%, and 1.5% of the sample, respectively. Higher body mass index was associated with higher incidence of SSI (p=0.001). Among patients with diabetes, 2.2% developed SSI, while the rate of infection among non-diabetics was only 0.6%. Conclusion: the established care bundle, structured by core evidence-based strategies, associated with secondary measures, was able to maintain low SSI rates after bariatric surgery. Keywords: Surgical Wound Infection. Patient Care Bundles. Infection Control. Bariatric Surgery.

INTRODUCTION

D

espite all medical advances in the field of surgery and all the knowledge acquired over the last decades regarding infection control, surgical site infection (SSI) continues to be a subject of great concern in health institutions, and is closely related to increased nosocomial morbimortality1. In the U.S., SSI occurs in 2% to 5% of all patients undergoing surgery and is responsible for an increase of seven to ten days in the mean time of postoperative hospitalization, thus leading to an increase in health expenditure2,3. Among the various risk factors for the development of SSI, obesity deserves special attention due to its increasing incidence in the world4.

Thus, it is plausible to infer that surgical procedures performed primarily in obese patients, such as bariatric surgery, should be related to high SSI rates5. Data on the incidence of SSI after bariatric surgery vary from 1% to 21.7%, depending on the surgical access performed (laparoscopy or laparotomy)6. In view of the best knowledge of risk factors for SSI, several interventions with varying levels of evidence have been introduced in clinical practice with the aim of reducing the incidence of postoperative infection7. Care bundles have been implemented to this end and, even literature presenting conflicting data on this topic, their application seems to be a useful strategy to control SSI in the most diverse performed procedures3. Data on care bundles related to SSI prevention in bariatric

1 - Federal University of Pernambuco, Center of Health Science, Department of Surgery, Recife, PE, Brazil. 2 - Federal University of Pernambuco, Postgraduate Program in Surgery, Recife, PE, Brazil. 3 - Federal University of Pernambuco, Center of Health Science, Medicine Course, Recife, Pernambuco, Brazil. Rev Col Bras Cir 46(4):e2252


Ferraz Surgical site infection in bariatric surgery: results of a care bundle.

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surgery are scarce in literature. Thus, the objective of this study was to present a descriptive analysis of the results of a care bundle applied to obese patients submitted to bariatric surgery, regarding infection control.

METHODS A prospective cohort study performed at Hospital das ClĂ­nicas/Federal University of Pernambuco and Real Hospital PortuguĂŞs de BeneficĂŞncia de Pernambuco, from July 2008 to January 2018. The sample consisted of 1,596 patients who underwent bariatric surgery and joined a care bundle to control infection rates. This study included patients aged 18-65 years, of both genders, with body mass index (BMI) above 35kg/m2 and a formal indication for bariatric surgery according to the criteria of Brazilian Society of Bariatric and Metabolic Surgery. Patients with community-acquired infections, assessed through anamnesis and physical examination at the time of hospital admission, were excluded from the study, as well as those who reported infectious events within 30 days prior to surgery. In the preoperative period, about two hours before surgery, all patients underwent a 4% chlorhexidine soap solution bath. Depilation before hospitalization was completely prohibited and appropriate trichotomy was performed shortly before the surgical incision. Smoking cessation was recommended for the 30 days prior to surgery. Hemoglucotest (HGT) was performed every six hours and the glycemic target was established as values below 200mg/dl. All patients had their glycemia levels controlled below 200mg/dl according to HGT during surgery and up to 48 hours later. Body temperature was strictly controlled, aiming to

maintain normothermia throughout surgery and in the immediate postoperative period. In anesthetic induction, all patients received cefazolin (2g bolus) associated with a continuous infusion of the same drug at a dose of 1g over a two-hour period as antibiotic prophylaxis. Sterile dressings were removed within the first 48 hours postoperatively. Intraspinal morphine was administered in anesthetic induction. All patients received supplemental oxygen during surgery and in the post-anesthetic recovery room. All these interventions present in the care bundle used in this study are summarized below: smoking cessation within 30 days prior to surgery; preoperative bath with 4% chlorhexidine two hours before surgery; cefazolin (2g bolus) + 1g in continuous infusion for two hours; appropriate trichotomy shortly before the surgical incision; glycemic control (below 200mg/dl during surgery and up to 48 hours later); supplemental oxygen; intraoperative normothermia and in the immediate postoperative period; intraspinal morphine for postoperative pain control; sterile dressing removal within 48 hours after surgery. Appropriate trichotomy was defined as the hair removal only when strictly necessary, according to the judgment of the surgeon, and restricted to the operating room under aseptic conditions, shortly before surgical incision. All included patients adhered 100% to the care bundle presented to them. In addition to the interventions mentioned above, it was highly recommended to all patients a 10% loss of their weight before surgery. The main variables studied were: occurrence of superficial SSI (referred here only as SSI), BMI, type 2 diabetes mellitus (DM2), and surgical access (open or laparoscopic).

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Ferraz Surgical site infection in bariatric surgery: results of a care bundle.

All patients underwent SSI screening in the first 30 days postoperatively. In those cases where signs of SSI were evidenced, the surgeon proceeded with conservative measures to treat the infection, including drainage and saline wound cleaning and, if necessary, antibiotic therapy. A spreadsheet was created in Microsoft Excel and exported to SPSS software (version 18) for data analysis. Then, percentage frequencies of the variables were calculated, and the frequency distributions were determined. K-S test was applied to evaluate the normality of the distribution. In those cases where normality was confirmed, Student's t-test for paired samples was applied in order to compare the variables between the cases in which there was and there was not SSI. If the normality hypothesis were rejected, Wilcoxon test would be applied. All conclusions were made taking into account a significance level of 95% (p-value <0.05). The study was approved by the Research Ethics Committee of Federal University of Pernambuco (CEP/CCS/UFPE), according to Resolution nº 196/96 of the National Health Council, under CAAE: 52448616.0.0000.5208.

RESULTS This study had the participation of 1,596 patients with formal indication for bariatric surgery. Surgeries were performed by laparotomy (20.9%) and by laparoscopy (79.1%). In the preoperative period, 25.9% of the patients presented DM2; 30.9% presented BMI between 35 and 39.9 kg/m2; 58.9%, between 40 and 49.9 kg/m2, and 10.2%, above 50kg/m2. Complications such as SSI and seroma occurred in 16 (1%) and 231 (14.5%)

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patients, respectively. Intra-abdominal infection was evidenced in 0.9% of the patients (Table 1). Table 1. Sample distribution according to the studied variables.

Variable Total Surgery      Open       Laparoscopy DM2       Yes       No BMI       35-39.9kg/m2       40-49.9kg/m2       >50kg/m2 SSI       Yes       No Seroma       Yes       No Intra-abdominal infection       Yes       No

n 1,596

% 100.0

334 1,262

20.9 79.1

414 1,182

25.9 74.1

493 940 163

30.9 58.9 10.2

16 1,580

1.0 99.0

231 1,365

14.5 85.5

15 1,581

0.9 99.1

BMI: body mass index;DM2: type 2 diabetes mellitus; SSI: surgical site infection.

Table 2 correlates the occurrence of SSI with the other variables studied in this work. The increase in BMI was related to a higher incidence of SSI. Only 0.4% of the patients with BMI between 35 and 39.9 kg/m2 developed SSI while this index was of 3.7% in those with BMI>50kg/m2. Among those with BMI between 40 and 49.9 kg/m2, 0.8% presented SSI (p<0.05).

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Table 2. Correlation between the occurrence of surgical site infection (SSI) and the other studied variables.

Surgical site infection Variable (n)

BMI      35-39.9kg/m2 (493)       40-49.9 kg/m2 (940)       >50kg/m2 (163) DM2       Yes (414)       No (1182) Surgery       Open (334)       Laparoscopy (1,262)

Yes 2 (0.4%) 8 (0.8%) 6 (3.7%)   9 (2.2%) 7 (0.6%)   10 (3%) 6 (0.5%)

No 491 (99.6%) 932 (99.2%) 157 (96.3%)   405 (97.8%) 1,175 (99.4%)   324 (97%) 1,256 (99.5%)

p     0.001     0.005     <0.001  

BMI: body mass index; DM2: type 2 diabetes mellitus.

The presence of DM2 was also related to higher incidence of SSI. Among patients diagnosed with T2DM, 2.2% developed SSI, while only 0.6% of those without DM2 presented this condition, being this difference statistically significant (p<0.05). The surgical approach also showed relationship with SSI rates. Patients operated by laparoscopic access had SSI rates of only 0.5%, while the ones operated by laparotomy showed an incidence of 3% (p<0.05).

DISCUSSION Up to now, there is no literature study reporting the impact of care bundle interventions on obese patients undergoing bariatric surgery. Currently, there are several types of surgical care bundles reported in literature. However, these studies have presented varying numbers of interventions and different levels of evidence. The success of an approach using care bundles does not depend on isolated interventions. The systematic implementation of the care bundle designates the ideal surgical treatment7,8.

Koek et al.8 have carried out a study analyzing the impact of a national care bundle implementation on the reduction of SSI rates. Their care bundle has been composed of four elements: antibiotic prophylaxis, lack of hair removal, perioperative normothermia, and strict control of door openings in the operating room. They have found that full compliance with the entire bundle has led to a reduction in SSI risk, ranging from 14% to 37% when compared to other compliance levels. Tanner et al.7 have published a metaanalysis on the effectiveness of the care bundle in reducing the risk of SSI in patients undergoing colorectal surgery. However, they have stated that selective core elements with high levels of evidence, such as glycemic control, normothermia, appropriate trichotomy, and antibiotic prophylaxis, have not been sufficient to reduce the overall risk of infection among these patients. The care bundle proposed in the present study comprised five evidence-based core interventions - smoking cessation, normothermia, glycemic control, appropriate trichotomy, and antibiotic prophylaxis

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Ferraz Surgical site infection in bariatric surgery: results of a care bundle.

selection - besides four additional measures, including preoperative chlorhexidine bath, use of supplemental oxygen, administration of intraspinal morphine, and sterile dressing removal within 48 hours. Currently, there are well-established evidences in literature regarding smoking and the increased risk of developing SSI. Smoking cessation in the preoperative period leads to lower incidences of SSI 9. In their study, Nolan et al.10 have found that smoking, on the day of elective surgery, is responsible for a nearly twofold increase in the risk of SSI. Due to the lack of knowledge about the ideal timing of preoperative smoking cessation, the bundle designed in the present study included a recommendation for smoking cessation in the last 30 days prior to hospital admission. Preoperative antiseptic bath has shown encouraging results in a limited number of studies, including orthopedic, gynecological, and cardiothoracic surgeries11-14. Currently, literature is conflicting and there is no consensus on the efficacy of preoperative chlorhexidine bath in abdominal surgeries15. A systematic review published on Cochrane Database of Systematic Reviews has shown that there is no clear positive or negative evidence regarding the effectiveness of the preoperative bath or the chlorhexidine bath12. Despite the lack of evidence in literature, the use of chlorhexidine in preoperative baths has been incorporated into several protocols because of its proven ability to achieve excellent skin bacterial decolonization15.

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These conflicting results may be due to an absence of standardization in the applying method of the tests9. The present study implemented a 4% chlorhexidine gluconate detergent solution whole body bath two hours before surgical procedure. For antibiotic prophylaxis, first-generation cephalosporins have been widely used, especially in gastrointestinal surgeries, presenting high degree of evidence in literature. Specifically for bariatric surgery, cefazolin seems to be the most widely used antibiotic prophylaxis agent, being presented in the vast majority of published studies6. Some studies have evaluated the efficacy of other drugs, such as ertapenem and ampicillinsulbactam, but they present lower results when compared to cefazolin16. Many studies advocate the administration of antibiotic prophylaxis prior to surgical incision17. However, other parameters, such as initial dose, need for subsequent doses, and prophylaxis duration, remain varied among preoperative care protocols6,16. To provide optimal surgical care in terms of reducing the risk of SSI, it is of utmost importance to understand the pharmacokinetics of the drug chosen and the microbiota involved16,17. Alincoara et al.18 have evaluated the pharmacokinetics of cefazolin in obese patients undergoing bariatric surgery. It has been shown that cefazolin (2g bolus) in anesthetic induction, associated with a continuous infusion of the same drug at a dose of 1g for two hours during the surgical procedure, has been able to provide a concentration in the adipose tissue that has remained above the minimum inhibitory concentration throughout the surgical procedure.

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The present study included the same antibiotic prophylaxis used and advocated by Alincoara. In addition, factors such as hyperglycemia and hypothermia during the surgical procedure have been associated with a higher incidence of SSI. Thus, glycemic control and normothermia are widely adopted as measures to avoid SSI19. Regarding glycemic control, there are clear evidences that the maintenance of glycemic rates at levels close to the normal established values is an effective practice of infection control. However, it is still controversial how close to normal these levels should be maintained20,21. On the other hand, the evidences which support the maintenance of intraoperative normothermia are modest and there is no proven benefit of this practice in gastrointestinal surgeries22. Freeman et al.5 have conducted a prospective multicenter cohort study to assess SSI rates after bariatric surgery. They have found a 1.6% SSI rate among laparoscopically operated patients. In their retrospective study, Husain et al.23 have found a 2.1% SSI rate in laparoscopic bariatric surgery and a 20.8% SSI rate in bariatric surgery by laparotomy.

The current study, with the application of our care bundle, found an overall SSI rate of 1%. SSI occurred in only 0.6% of patients undergoing laparoscopic bariatric surgery and in 3% of those undergoing laparotomy. In addition, it was possible to observe that the increase in BMI and the presence of DM2 were responsible for a higher incidence of SSI, in agreement with current literature. As written before, there are several differences between one bundle and another, with several combinations of different interventions. However, it is important to emphasize that what should be sought is the systematic implementation of the whole care bundle rather than partial compliance with only some bundle interventions. In fact, the complete compliance of the care bundle among the multidisciplinary team is what leads to better surgical care7,8. Currently, there is no consensus on what the optimal care bundle in bariatric surgical treatment is. However, this study showed that a multidisciplinary approach, using selective core and evidence-based strategies along with adjunctive interventions, resulted in low rates of surgical infection following bariatric surgery.

R E S U M O Objetivo: apresentar uma análise descritiva dos resultados de um pacote de cuidados aplicado em pacientes obesos submetidos à cirurgia bariátrica, no que diz respeito ao controle de infecção. Métodos: um pacote de cuidados foi estruturado, visando a conter as taxas de infecção de sítio cirúrgico (ISC) em pacientes submetidos à cirurgia bariátrica. O pacote incluiu interrupção de tabagismo, banho com clorexidina 4% duas horas antes da cirurgia, cefazolina 2g em bolus na indução anestésica associada à administração da mesma droga com dose de 1g em infusão contínua, tricotomia apropriada, controle glicêmico, oxigênio suplementar, normotermia, controle da dor com morfina intrarraquidiana e remoção do curativo estéril 48 horas após a cirurgia. Todos os pacientes foram seguidos por 30 dias. Resultados: entre os 1.596 pacientes incluídos, 334 (20,9%) foram submetidos à cirurgia aberta e 1.262 (79,1%) à cirurgia videolaparoscópica. As taxas de ISC foram de 0,5% no grupo submetido à cirurgia laparoscópica e de 3% nos submetidos à cirurgia aberta. A incidência geral de ISC foi de 1%. Infecções intra-abdominal, do trato respiratório e do trato urinário ocorreram em 0,9%, 1,1% e 1,5% da amostra, respectivamente. Faixas mais elevadas de índice de massa corporal foram associadas a maiores incidências de ISC (p=0,001). Entre os pacientes com diabetes, 2,2% desenvolveram ISC, enquanto a taxa de infecção entre os não diabéticos foi de apenas 0,6%. Conclusão: o pacote de cuidados instituído, estruturado por estratégias centrais baseadas em evidências, associadas à medidas secundárias, foi capaz de manter baixas taxas de ISC após cirurgia bariátrica. Descritores: Infecção da Ferida Cirúrgica. Pacotes de Assistência ao Paciente. Controle de Infecções. Cirurgia Bariátrica.

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Ferraz Surgical site infection in bariatric surgery: results of a care bundle.

REFERENCES 1.

Young PY, Khadaroo RG. Surgical site infections. Surg Clin North Am. 2014;94(6):1245-64. 2. Merkow RP, Ju MH, Chung JW, Hall BL, Cohen ME, Williams MV, et al. Underlying reasons associated with hospital readmission following surgery in the United States. JAMA. 2015;313(5):483-95. 3. Waltz PK, Zuckerbraun BS. Surgical site infections and associated operative characteristics. Surg Infect (Larchmt). 2017;18(4):447-50. 4. Alexander JW, Rahn R, Goodman HR. Prevention of surgical site infections by an infusion of topical antibiotics in morbidly obese patients. Surg Infect (Larchmt). 2009;10(1):53-7. 5. Freeman JT, Anderson DJ, Hartwig MG, Sexton DJ. Surgical site infections following bariatric surgery in community hospitals: a weighty concern? Obes Surg. 2011;21(7):836-40. 6. Fischer MI, Dias C, Stein AT, Meinhardt NG, Heineck I. Antibiotic prophylaxis in obese patients submitted to bariatric surgery. A systematic review. Acta Cir Bras. 2014;29(3):209-17. 7. Tanner J, Padley W, Assadian O, Leaper D, Kiernan M, Edmiston C. Do surgical care bundles reduce the risk of surgical site infections in patients undergoing colorectal surgery? A systematic review and cohort meta-analysis of 8,515 patients. Surgery. 2015;158(1):66-77. 8. Koek MBG, Hopmans TEM, Soetens LC, Wille JC, Geerlings SE, Vos MC, et al. Adhering to a national surgical care bundle reduces the risk of surgical site infections. PLoS One. 2017;12(9):e0184200. 9. Itani KMF, Dellinger EP, Mazuski J, Solomkin J, Allen G, Blanchard JC, et al. Surgical site infection research opportunities. Surg Infect (Larchmt). 2017;18(4):401-8. 10. Nolan MB, Martin DP, Thompson R, Schroeder DR, Hanson AC, Warner DO. Association between smoking status, preoperative exhaled carbon monoxide levels, and postoperative surgical site infection in patients undergoing elective surgery. JAMA Surg. 2017;152(5):476-83.

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11. Wang Z, Zheng J, Zhao Y, Xiang Y, Chen X, Zhao F, et al. Preoperative bathing with chlorhexidine reduces the incidence of surgical site infections after total knee arthroplasty: A meta-analysis. Medicine (Baltimore). 2017;96(47):e8321. 12. Webster J, Osborne S. Preoperative bathing or showering with skin antiseptics to prevent surgical site infection. Cochrane Database Syst Rev. 2015(2):CD004985. 13. Johnson MP, Kim SJ, Langstraat CL, Jain S, Habermann EB, Wentink JE, et al. Using bundled interventions to reduce surgical site infection after major gynecologic cancer surgery. Obstet Gynecol. 2016;127(6):1135-44. 14. Edmiston CE Jr, Bruden B, Rucinski MC, Henen C, Graham MB, Lewis BL. Reducing the risk of surgical site infections: does chlorhexidine gluconate provide a risk reduction benefit? Am J Infect Control. 2013;41(5 Suppl):S49-55. 15. Prabhu AS, Krpata DM, Phillips S, Huang LC, Haskins IN, Rosenblatt S, et al. Preoperative chlorhexidine gluconate use can increase risk for surgical site infections after ventral hernia repair. J Am Coll Surg. 2017;224(3):334-40. 16. Ferraz ÁA, Siqueira LT, Campos JM, Araújo GC, Martins Filho ED, Ferraz EM. Antibiotic prophylaxis in bariatric surgery: a continuous infusion of cefazolin versus ampicillin/sulbactam and ertapenem. Arq Gastroenterol. 2015;52(2):83-7. 17. Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Steinberg JP, Weinstein RA; American Society of Health-System Pharmacists; Infectious Disease Society of America; Surgical Infection Society; Society for Healthcare Epidemiology of America. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. 18. Alincoara R, Ferraz ÁA, Coelho KP, de Lima Filho JL, Siqueira LT, de Araújo JG Jr, et al. Antibiotic prophylaxis in bariatric surgery with continuous infusion of cefazolin: determination of concentration in adipose tissue. Obes Surg. 2014;24(9):1487-91.

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19. Hranjec T, Swenson BR, Sawyer RG. Surgical site infection prevention: how we do it. Surg Infect (Larchmt). 2010;11(3):289-94. 20. Bratzler DW. Surgical care improvement project performance measures: good but not perfect. Clin Infect Dis. 2013;56(3):428-9. 21. Takesue Y, Tsuchida T. Strict glycemic control to prevent surgical site infections in gastroenterological surgery. Ann Gastroenterol Surg. 2017;1(1):52-9. 22. Lehtinen SJ, Onicescu G, Kuhn KM, Cole DJ, Esnaola NF. Normothermia to prevent surgical site infections after gastrointestinal surgery: holy grail or false idol? Ann Surg. 2010;252(4):696-704.

23. Husain F, Jeong IH, Spight D, Wolfe B, Mattar SG. Risk factors for early postoperative complications after bariatric surgery. Ann Surg Treat Res. 2018;95(2):100-10. Received in: 05/28/2019 Accepted for publication: 07/09/2019 Conflict of interest: none. Source of funding: none. Mailing address: Fernando Santa-Cruz E-mail: f.santacruzoliveira@gmail.com

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Original Article

DOI: 10.1590/0100-6991e-20192249

Can the Zuckerkandl tubercle assist in the location of the inferior laryngeal nerve during thyroidectomies? O tubérculo de Zuckerkandl pode auxiliar na localização do nervo laríngeo inferior durante tireoidectomias? Carlos Alberto Ferreira de Freitas1,2 ; Amauri Ferrari Paroni1; Andreza Negreli Santos2; Rônei Jorge Santos da Silva1; Rafael Oliveira de Souza, ACBC-MS2; Tatyanne Ferreira da Silva2; Maria Margarida Morena Domingos Levenhagen2 A B S T R A C T Objective: to evaluate whether the lateral projection of the thyroid gland, called Zuckerkandl's tubercle (ZT), can assist the surgeon in identifying the inferior laryngeal nerve during conventional open thyroidectomy. Methods: we conducted a prospective study with 51 patients submitted to thyroidectomy, with a total of 100 resected thyroid lobes, and observed the presence or absence of ZT in sufficient dimensions to be identified without image magnification, its base and height, its location in the gland, and its anatomical relationship with the inferior laryngeal nerve. Results: ZT was present in 68 of the 100 thyroid lobes analyzed (68%). The mean base was 6.7mm on the right side and 7.1mm on the left side, and the average height was 5.7mm on the right side and 6.1mm on the left side. In most of the lobes studied, the tubercle had a minimum height of 5mm (55.9%), with no significant difference between the right and left lobes of the thyroid gland. During surgery, 100% of the identified ZTs were anterior to the inferior laryngeal nerve, just below the nerve entry in the larynx. Conclusion: the ZT is a quite frequent entity and large enough to serve as an intraoperative anatomical reference for the inferior laryngeal nerve, next to its entry in the larynx, along with other anatomical references. Keywords: Thyroidectomy. Thyroid Gland. Laryngeal Nerves.

INTRODUCTION

T

he Zuckerkandl’s tubercle (ZT), described in 1867 by Madelung1 and popularized in 1902 by the Austrian anatomist Emil Zuckerkandl (1849-1910)2, is a posterolateral projection of the thyroid lobes, formed during the gland’s embryogenesis, indicating the point of fusion between the last branchial body and the main median thyroid process 3,4. The inferior laryngeal nerve (ILN) is the terminal branch of the recurrent nerve, which in turn is a branch of the vagus nerve. The ILN follows a different path in each side. On the right, it runs beneath the right subclavian artery on the upper chest, and on the left, it contours the aortic arch, having a much longer course within the mediastinum. Both run through the tracheoesophageal groove, pass between the thyroid, the trachea and the esophagus, and enter the larynx5.

ILN injury can lead to dyspnea, breathing difficulties and consequent worsening in quality of life, as well as psychological and social problems resulting from these changes6. The appropriate way to avoid ILN injuries during thyroidectomy is its careful identification and dissection until its entry into the larynx7, and a good knowledge of its anatomical relationship with the ZT may contribute to this identification8. There are several anatomical references used to ILN localization, such as the tracheo-esophageal groove and inferior thyroid artery and its branches. The palpation of the tracheoesophageal groove against the trachea can also assist in locating the ILN5. The literature is divergent regarding the percentage of ZT occurrence, the incidence even being different when the study is performed in cadavers or during surgery, when its identification is higher4. The presence of nodules in the posterolateral region of the thyroid may make it difficult to identify the ZT9.

1 - Federal University of Mato Grosso do Sul, Faculty of Medicine, Maria Aparecida Pedrossian University Hospital, Head and Neck Surgery Service, Campo Grande, MS, Brazil. 2 - Federal University of Mato Grosso do Sul, Faculty of Medicine, Campo Grande, MS, Brazil. Rev Col Bras Cir 46(4):e2249


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Freitas Can the Zuckerkandl tubercle assist in the location of the inferior laryngeal nerve during thyroidectomies?

The aim of this study was to identify the presence and dimensions of the ZT in a series of patients undergoing thyroidectomy and its anatomical relationship with the inferior laryngeal nerve during conventional thyroidectomy.

METHODS We conducted a prospective study of 51 consecutive patients submitted to conventional open thyroidectomy, with a total of 100 resected thyroid lobes, and observation of the presence or absence of ZT in sufficient dimensions to be identified without image magnification. We recorded its base and height, its location in the gland and its anatomical relationship with the inferior laryngeal nerve. Of the 51 thyroidectomies, 49 were total and two partial. Surgical indications were the presence of nodular goiter with suspected malignant neoplasia or with compressive effects. The analyzed group contained 43 women and eight men, aged 22 to 79 years. We excluded from the sample patients with large goiters or with nodular involvement of the tubercle region. All patients underwent the surgical procedure in a traditional, open way, and by the same surgical team. After identification of the trunk and branches of the inferior laryngeal nerve below the inferior thyroid artery, we followed its course toward its entry into the larynx, performing ligatures of the artery branches next to the thyroid gland, preserving the parathyroid glands and observing the presence or absence of ZT, its shape, base and height, and its anatomical relationship with the ILN. The study was submitted to and approved by the Human Research Ethics Committee of the Federal University of Mato Grosso do Sul (protocol n# 29/05), and those patients who agreed and signed the informed consent form participated in the research.

RESULTS We identified the ZT in 68 operated sides, from a total of 100 (68%), not being able to identify it in 32 of them (32%). There was no prevalence of one side of the thyroid gland. When present, we studied the ZT by measuring its largest diameters, base and height. The bases ranged between 2mm and 12mm, with an average 6.7mm on the right and 7.1mm on the left, and the height ranged between 2mm and 19mm, with 5.7mm average of the right and 6.1mm on the left. In one patient, we observed a narrow base and long height, appendicular-shaped ZT of 3mm x 19mm. In the others, the base was equal or greater than the height. In over half the cases, the ZT was more than 5mm high (55.9%), the remaining between 2mm and 5mm. In all patients in whom we identified the ZT, its relationship with the ILN was constant (Figure 1). In all of these, the ILN followed a course posteromedial to the ZT, being positioned between the tubercle and the trachea (Figure 2). Additionally, the ZT was in a position immediately below the ILN entry in the larynx, and its elevation exposed the ILN and the upper parathyroid (Figure 3).

Figure 1. Right thyroid lobe with the presence of a Zuckerkandl's tubercle in its posteromedial location over the inferior laryngeal nerve near its entry into the larynx - 1) Zuckerkandl's tubercle; 2) inferior laryngeal nerve; 3) right lobe of the thyroid gland.

Rev Col Bras Cir 46(4):e2249


Freitas Can the Zuckerkandl tubercle assist in the location of the inferior laryngeal nerve during thyroidectomies?

Figure 2. Left lobe of the thyroid gland with the Zuckerkandl's tubercle covering the lower laryngeal nerve near its entry into the larynx - arrow: left inferior laryngeal nerve; star: left Zuckerkandl's tubercle.

Figure 3. Left thyroid lobe after ligation of blood vessels and mobilization of the lobe, showing the inferior laryngeal nerve below the Zuckerkandl's tubercle, over the trachea, and the left superior parathyroid - arrow 1: left inferior laryngeal nerve; arrow 2: upper left parathyroid; star: left Zuckerkandl's tubercle.

We observed no complications related to the ILN in the studied patients.

DISCUSSION The Zuckerkandl's tubercle was described over a century ago. Despite this, it is little used as a reference in the location of the inferior laryngeal nerve. Previous studies have reported its incidence in most people (87% to 95%)10-13.

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Many of these studies used the 1998 Pelizzo classification, which classify it in degrees from 0 to 3: grade 0 - absent ZT; grade 1 - thickening at the ZT site; grade 2 - ZT less than 1cm; and grade 3 - ZT greater than 1cm14. Our series reveals that in most of the patients analyzed (68%) it was possible to identify the ZT during conventional open thyroidectomy, without any image magnification feature. This index was lower than that found in previous studies10-13. However, it is worth remembering that we reported only those ZT that we could identify during conventional thyroidectomy, and that, consequently, could guide the surgeon during dissection of the ILN. We considered in this study, therefore, only Pelizzo grades 2 and 314. Other studies have also observed lower ZT identification rates, such as the ones from Gauger et al. 15 (63%) and from Pelizzo himself (76.7%), which are similar to the results found in our study. When present, the ZT displayed a constant atomic relationship with the ILN. In this situation, the ZT can contribute to the identification and preservation of the ILN, especially in conjunction with other references, such as the tracheoesophageal groove and the inferior thyroid artery, and digital palpation. Moreover, this relationship between ZT and ILN occurs near the entry point of the ILN into the larynx, ie, where the nerve is very close to the thyroid gland, and at greater risk of injury8. Some studies that considered ZT with very small sizes also found a small proportion of nerves lateral to the ZT, always in less than 10% of cases8,10. When the ZT is larger in size, it is expected to be over the nerve, and also to have a close proximity to the upper parathyroid.

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Freitas Can the Zuckerkandl tubercle assist in the location of the inferior laryngeal nerve during thyroidectomies?

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The ILN position, posteromedial to the ZT, has been detected in other studies. Rajapaksha et al.12 and Irawati et al.13 observed that in all individuals with ZT, the ILN followed a pathway posteromedial to the tubercle, that is, between it and the trachea. In this position, the ZT surely contributes to the intraoperative localization of the ILN16. According to Singh et al.11, the elevation of the ZT allows the recurrent nerve to be easily and safely identified. We conclude that ZT is present in most patients submitted to thyroidectomy in sufficient

dimensions to contribute to the identification and preservation of the inferior laryngeal nerve during open conventional thyroidectomies, given the constant anatomical relationship between them. One should continue to used other anatomical references, such as the inferior thyroid artery and its branches, the tracheoesophageal groove, and digital palpation against the trachea. Associated with them, the Zuckerkandl’s tubercle, when present, is useful in identifying the inferior laryngeal nerve at its closest point to the gland, near its entry into the larynx.

R E S U M O Objetivo: avaliar se a projeção lateral da glândula tireoide, chamada tubérculo de Zuckerkandl (TZ), pode auxiliar o cirurgião na identificação do nervo laríngeo inferior durante a tireoidectomia convencional aberta. Métodos: estudo prospectivo de 51 pacientes submetidos à tireoidectomia, com um total de 100 lobos tireoidianos ressecados, e observação da presença ou não do TZ em dimensões suficientes para ser identificado sem magnificação de imagem, suas dimensões de base e altura, sua localização na glândula e sua relação anatômica com o nervo laríngeo inferior. Resultados: o TZ estava presente em 68 dos 100 lobos de tireoide analisados (68%). A dimensão média da base foi 6,7mm no lado direito e 7,1mm no lado esquerdo, e a altura média foi 5,7mm no lado direito e 6,1mm no lado esquerdo. Na maioria dos lobos estudados, o tubérculo tinha altura mínima de 5mm (55,9%) sem diferença significativa entre o lobo direito e esquerdo da glândula tireoide. Durante a cirurgia, 100% dos TZ identificados estavam anteriores ao nervo laríngeo inferior, imediatamente abaixo da entrada do nervo na laringe. Conclusão: o TZ é bastante frequente e em dimensões suficientes para ser usado como referência anatômica na localização intraoperatória do nervo laríngeo inferior, próximo à sua entrada na laringe, junto com as demais referências anatômicas. Descritores: Tireoidectomia. Glândula Tireoide. Nervos Laríngeos.

REFERENCES 1. 2.

3.

4.

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Madelung OW. Anat. U. Chirurg.: u.d. gland. Arch f Klin Chir Bd; 1867. Zuckerkandl E. Nebst Bemerkungen uber die Epithelkorperchen des Menschen. Anat Hefte. 1902;LXI:61-82. Yalçin B, Tagil SM, Kocabiyic N, Ozan H. Incidence and morphology of the zuckerkandl’s tubercle: an anatomic dissection study. SDÜ Tip Fak Derg. 2006;13(2):1-4. Henry BM, Sanna B, Vikse J, Graves MJ, Spulber A, Witkowski C, et al. Zuckerkandl’s tubercle and its relationship to the recurrent laryngeal nerve: a cadaveric dissection and meta-analysis. Auris Nasus Larynx. 2017;44(6):639-47.

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Freitas CAF, Freitas LCF, Santos L, Perrony JS. Identificação do nervo laríngeo inferior em tireoidectomias - validade da palpação digital. Rev Bras Cir Cabeça Pescoço. 2006;35(1):5-7. Yalçin B, Poyrazoglu Y, Ozan H. Relationship between the Zuckerkandl’s tubercle and the inferior laryngeal nerve including the laryngeal branches. Surg Today. 2007;37(2):109-13. Irkorucu O. Zuckerkandl tubercle in thyroid surgery. Is it a reality or a myth? Ann Med Surg (Lond). 2016;7:92-6. Gurleyik E, Gurleyik G. Incidence and surgical importance of zuckerkandl’s tubercle of thyroid and its relations with recurrent laryngeal nerve. ISRN Surg. 2012;2012:450589.

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Gil-Carcedo E, Menéndez ME, Vallejo LA, Herrero D, Gil-Carcedo LM. The Zuckerkandl tubercle: problematic or helpful in thyroid surgery? Eur Arch Otorhinolaryngol. 2013;270(8):2327-2. Yun JS, Lee YS, Jung JJ, Nam KH, Chung WY, Chang HS, et al. The Zuckerkandl’s Tubercle: a useful anatomical landmark for detecting both the recurrent laryngeal nerve and the superior parathyroid during thyroid surgery. Endocr J. 2008;55(5):925-30. Singh P, Sharma K, Agarwal S. Per operative study of relation of zuckerkandl’s tubercle with recurrent laryngeal nerve in thyroid surgery. Indian J Otolaryngol Head Neck Surg. 2017;69(3):351-6. Rajapaksha A, Fernando R, Ranasinghe N, Iddagoda S. Morphology of the tubercle of Zuckerkandl and its importance in thyroid surgery. Ceylon Med J. 2015;60(1):23-4. Irawati N, Vaish R, Chaucar D, Deshmukh A, D’Cruz A. The Tubercle of Zuckerkandl: an important landmark revisited. Indian J Surg Oncol. 2016;7(3):312-5.

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14. Pelizzo MR, Toniato A, Gemo G. Zuckerkandl’s tuberculum: an arrow pointing to the recurrent laryngeal nerve (constant anatomical landmark). J Am Coll Surg. 1998;187(3):333-6. 15. Gauger PG, Delbridge LW, Thompson NW, Crummer P, Reeve TS. Incidence and Importance of the tubercle of Zuckerkandl in thyroid surgery. Eur J Surg. 2001;167(4):249-54. 16. Viveka S. Review of surgical anatomy of tubercle of Zuckerkandl and its importance in thyroid surgery. Chrismed J Health Res. 2018;5(2):91-5. Received in: 05/24/2019 Accepted for publication: 07/15/2019 Conflict of interest: none. Source of funding: none. Mailing address: Carlos Alberto Ferreira de Freitas E-mail: caff2004@hotmail.com carlos.freitas@ufms.br

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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. 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