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Seja Membro Acadêmico da maior associação cirúrgica da América Latina

O Colégio Brasileiro de Cirurgiões cria categoria especial para acadêmicos de medicina VISITE O SITE DO CBC: www.cbc.org.br • Confira as inúmeras atividades e serviços para sua formação e desenvolvimento. • Pré-requisitos para ser Membro Acadêmico do CBC Informe-se também na Secretaria Geral do CBC Tel.: (21) 2138-0653/0654 Sede: Rua Visconde de Silva, 52 - 3º andar Botafogo - Rio de Janeiro - CEP: 22271-092


CONTENTS / SUMĂ RIO Rev Col Bras Cir 2018; 45(2)

OR IGINAL ART ICLE S Influence of advanced age on postoperative outcomes and total loss following breast reconstruction: a critical assessment of 560 cases InfluĂŞncia da idade avançada sobre a evolução pĂłs-operatĂłria e a perda total da reconstrução mamĂĄria: anĂĄlise crĂ­tica de 560 reconstruçþes Walter Koiti Matsumoto; Alexandre Mendonça Munhoz; Alberto Okada; Eduardo Montag; Eduardo Gustavo Arruda; Alexandre Fonseca; Orlando Ferrari; JosĂŠ Augusto Brasil; Lia Pretti; JosĂŠ Roberto Filassi; Rolf Gemperli ............................................................................. e1616 Pectoralis major myocutaneous flap in Head And Neck Surgery reconstructions: critical analysis O retalho do mĂşsculo peitoral maior nas reconstruçþes em Cirurgia de Cabeça e Pescoço: anĂĄlise crĂ­tica Marcelo Benedito Menezes; Kassem Samir Saleh; Marianne Yumi Nakai; Lucas Porto Maurity Dias; Norberto Kodi Kavabata; AntĂ´nio JosĂŠ Gonçalves .................................................................................................................................................................... e1682 The impact of decongestive physical therapy and elastic bandaging on the control of pain in patients with venous ulcers O impacto da terapia fĂ­sica descongestiva e da bandagem elĂĄstica no controle da dor de pacientes com Ăşlceras venosas Geraldo Magela SalomĂŠ; Lydia Masako Ferreira ................................................................................................................................. e1385 Factors associated with changes in creatine phosphokinase (CPK) in trauma patients submitted to the “Red Waveâ€?, with evolution to rhabdomyolysis Fatores associados Ă variação da creatina fosfoquinase (CPK) em pacientes vĂ­timas de trauma, submetidos Ă  “Onda Vermelhaâ€?, com evolução Ă  rabdomiĂłlise Mario Pastore Neto; Rafael ValĂŠrio Gonçalves; Carla Jorge Machado; Vivian Resende ............................................................................... e1604 Anthropometric and clinical profiles of post-bariatric patients submitted to procedures in plastic surgery Perfil antropomĂŠtrico e clĂ­nico de pacientes pĂłs-bariĂĄtricos submetidos a procedimentos em cirurgia plĂĄstica Simone CorrĂŞa Rosa; Jefferson Lessa Soares de Macedo; Luiz Augusto Casulari; Lucas Ribeiro Canedo; JoĂŁo Vitor Almeida Marques .. e1613 Pulmonary function in women: comparative analysis of conventional versus single-port laparoscopic cholecystectomy AnĂĄlise comparativa da função pulmonar em mulheres submetidas Ă  colecistectomia laparoscĂłpica convencional e por portal Ăşnico Marisa de Carvalho Borges; Aline Borges Gouvea; Stephania Ferreira Borges Marcacini; Paulo Fernando de Oliveira; Alex Augusto da Silva; Eduardo Crema ................................................................................................................................................................................ e1652 Hemodynamic evaluation of elderly patients during laparoscopic cholecystectomy Avaliação hemodinâmica de pacientes idosos durante colecistectomia vĂ­deo-laparoscĂłpica Luiz Paulo Jacomelli Ramos; Rodrigo Barcellos AraĂşjo; Maria do Carmo Valente Castro; Maria Roberta Meneguetti Seravalli Ramos; JosĂŠ Antonio Cunha-e-Silva; Antonio Carlos Iglesias ................................................................................................................................. e1659 Predictors of chest drainage complications in trauma patients Fatores preditores de complicaçþes da drenagem de tĂłrax em pacientes vĂ­timas de trauma CecĂ­lia AraĂşjo Mendes; Elcio Shiyoiti Hirano ...................................................................................................................................... e1543 Profile of the General Surgery resident: what are the changes in the 21st Century? Perfil do residente de Cirurgia Geral: quais as mudanças no SĂŠculo XXI? Samir Rasslan; Mariana Sousa Arakaki; Roberto Rasslan; Edivaldo Massazo Utiyama .......................................................................... e1706 Predictors of poor follow-up after bariatric surgery Fatores preditivos da perda de seguimento de pacientes submetidos Ă  cirurgia bariĂĄtrica Giselle de Queiroz Menezes Batista Belo; Luciana Teixeira de Siqueira; Djalma A. Agripino Melo Filho; FlĂĄvio Kreimer; Vânia Pinheiro Ramos; Ă lvaro AntĂ´nio Bandeira Ferraz ........................................................................................................................................................ e1779 Use of an algorithm in choosing abdominoplasty techniques Emprego de um algoritmo na escolha de tĂŠcnicas de abdominoplastia JĂşlio Wilson Fernandes; Renata Damin; Marcos VinĂ­cius Nasser Holzmann; Gabriel Gomes de Oliveira Ribas ....................................... e1394 Inflammatory and nutritional statuses of patients submitted to resection of gastrointestinal tumors Estado inflamatĂłrio e nutricional em pacientes submetidos Ă  ressecção cirĂşrgica de tumores do trato gastrointestinal Ana ValĂŠria Gonçalves Fruchtenicht; Aline Kirjner Poziomyck; Audrey Machado dos-Reis; Carlos Roberto Galia; Georgia Brum Kabke; LuĂ?s Fernando Moreira ............................................................................................................................................................................. e1614


























































Perception of body image by patients undergoing bariatric surgery Percepção da imagem corporal em pacientes submetidos à cirurgia bariåtrica Rosana Maria Resende Lacerda; Alessandra Ramos Castanha; Josemberg Marins Campos; à lvaro Antônio Bandeira Ferraz; Lucio Vilar ......... ......................................................................................................................................................................................................... e1793

RE VIEW ART ICLES Fecal microbiota transplantation in the treatment of Clostridium difficile infection: state of the art and literature review Transplante de microbiota fecal no tratamento da infecção por Clostridium difficile: estado da arte e revisão de literatura Bruno Amantini Messias; Bårbara Freitas Franchi; Pedro Henrique Pontes; Daniel à tila de Andrade Medeiros Barbosa; CÊsar Augusto Sanita Viana ............................................................................................................................................................................................... e1609





















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PHYSIOMESHÂŽ OPEN e SECURESTRAPÂŽ OPEN Parte de um portfĂłlio inovador desenhado pela ETHICON para o reparo da hĂŠrnia.

Johnson & Johnson Medical Brasil, uma divisão de Johnson & Johnson do Brasil Indústria e ComÊrcio de Produtos para Saúde Ltda. Av. Presidente Juscelino Kubitscheck, 2041 - Complexo JK - Bloco B - São Paulo/SP, CEP 04543-011 Š Johnson & Johnson do Brasil Indústria e ComÊrcio de Produtos para Saúde Ltda., 2016. Responsåvel tÊcnico: Nancy Mesas do Rio - CRF-SP nº 10.965 - Elaborado em: 03/2018. PHYSIOMESHŽ OPEN - Registro ANVISA nº 80145901768 SECURESTRAPŽ OPEN - Registro ANVISA nº 80145901386

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Órgão Oficial do Colégio Brasileiro de Cirurgiões EDITOR Guilherme Pinto Bravo Neto TCBC-RJ Associate Professor, Department of Surgery, Faculdade de Medicina, Universidade Federal do Rio de Janeiro-UFRJ-Rio de Janeiro-RJ-Brasil.

ASSOCIATE EDITORS FELIPE CARVALHO VICTER TCBC - RJ - UNIVERSIDADE DO ESTADO DO RIO DE JANEIRO - UERJ – RIO DE JANEIRO – RJ, BRASIL RODRIGO MARTINEZ TCBC-RJ - UNIVERSIDADE FEDERAL DO RIO DE JANEIRO – UFRJ - RIO DE JANEIRO – RJ – BRASIL FERNANDO PONCE DE LEON ACBC- RJ – UNIVERSIDADE FEDERAL DO RIO DE JANEIRO – UFRJ – RIO DE JANEIRO – RJ-BRASIL

LIBRARIAN Lenita Penido Xavier

WRITING ASSISTANT David S. Ferreira Júnior

GRAPHIC DESIGN HG Design Digital Ltda.

RESPONSIBLE JOURNALIST João Maurício Carneiro Rodrigues

ADVISORY BOARD ABRÃO RAPOPORT - ECBC-SP - Hospital Heliópolis - São Paulo - SP - BR ALDO DA CUNHA MEDEIROS - ECBC-RN - Universidade Federal do Rio Grande do Norte – Natal – RN - BR ALEXANDRE FERREIRA OLIVEIRA - TCBC-PE - Universidade Federal de Pernambuco – Recife – PE - BR ÁLVARO ANTONIO BANDEIRA FERRAZ - TCBC-PE - Universidade Federal de Pernambuco – Recife – PE - BR ANA CRISTINA GOUVEIA MAGALHÃES - Universidade Federal do Rio de Janeiro- Rio de Janeiro- RJ – BR ANDY PETROIANU - TCBC-MG – Universidade Federal de Minas Gerais – Belo Horizonte – MG - BR ANTONIO CARLOS VALEZI - TCBC-PR – Universidade Estadual de Londrina - Londrina - PR – BR ANTONIO JOSÉ GONÇALVES - TCBC-SP – Faculdade de Ciências Médicas da Santa Casa de São Paulo- São Paulo - SP - BR ARLINDO MONTEIRO DE CARVALHO JR. - TCBC-PB - Universidade Federal da Paraíba João Pessoa - PB - BR CARLOS ALBERTO PORCHAT - TCBC-RJ - Hospital Clementino Fraga Filho da Universidade Federal do Rio de Janeiro - RJ - BR CARLOS ANSELMO LIMA - TCBC-SE- Universidade Federal de Sergipe – Aracaju - SE - BR CARLOS DELROY - Universidade Federal de São Paulo - São Paulo - SP - 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- Rio de Janeiro – RJ - BR DJALMA JOSE FAGUNDES - ECBC-SP - Universidade Federal de São Paulo – São Paulo – SP – BR EDMUND CHADA BARACAT - TCBC – SP - Universidade Federal de São Paulo – São Paulo – SP – BR EDNA FRASSON DE SOUZA MONTERO - TCBC-SP- Universidade Federal de São Paulo – São Paulo – SP – BR EDUARDO CREMA - TCBC-MG - Universidade Federal do Triângulo Mineiro - Uberaba MG - BR EDUARDO HARUO SAITO - TCBC-RJ- Universidade do Estado do Rio de Janeiro – Rio de Janeiro - RJ - BR ELIZABETH GOMES DOS SANTOS - TCBC-RJ - Universidade Federal do Rio de Janeiro – Rio de Janeiro – RJ - BR FÁTIMA CARNEIRO FERNANDES - Universidade Federal do Rio de Janeiro - Rio de Janeiro - RJ - BR FLÁVIO DANIEL SAAVEDRA TOMASICH - TCBC-PR – Hospital de Clínicas da Universidade Federal do Paraná – Curitiba –PR- BR FLÁVIO MALCHER M. DE OLIVEIRA - TCBC-RJ - Hospital Universitário Gaffrée e Guinle - Rio de Janeiro - RJ - BR FREDERICO AVELLAR SILVEIRA LUCAS - TCBC-RJ - Instituto Nacional do Câncer – Rio de Janeiro - RJ - BR GIULIANO ANCELMO BENTO - ACBC- RJ – Universidade do Estado do Rio de Janeiro – Rio de Janeiro – RJ – BR GUSTAVO PEREIRA FRAGA - TCBC-SP - Universidade Estadual de Campinas – Campinas - SP – BR HAMILTON PETRY DE SOUZA - ECBC-RS - Pontifícia Universidade Católica do Rio Grande do Sul – Porto Alegre - RS – BR HAROLDO VIEIRA DE MORAES Jr. - Universidade Federal do Rio de Janeiro - Rio de Janeiro - RJ - BR HENRI CHAPLIN RIVOIRE - TCBC-RS -Universidade Federal do Rio Grande do Sul - Porto Alegre - RS - BR HENRIQUE MURAD - ECBC-RJ - Universidade Federal do Rio de Janeiro - Rio de Janeiro - RJ - BR JOSÉ ANACLETO DUTRA RESENDE Jr. - Hospital Universitário Pedro Ernesto-UERJ - Rio de Janeiro - RJ - BR JOSÉ EDUARDO DE AGUILAR NASCIMENTO - TCBC-MT-Universidade Federal de Mato Grosso – Cuiabá – MT –BR JOSÉ EDUARDO FERREIRA MANSO - TCBC-RJ – Universidade Federal do Rio de Janeiro – Rio de Janeiro – RJ – BR JOSÉ LUIZ BRAGA DE AQUINO - TCBC-SP - Faculdade de Ciências Médicas - PUC Campinas - SP - BR JOSÉ MARCUS RASO EULÁLIO - TCBC-RJ – Universidade Federal do Rio de Janeiro – Rio de Janeiro – RJ – BR JOSÉ MAURO DA SILVA RODRIGUES - TCBC-SP - Pontifícia Universidade Católica de São

Paulo - São Paulo - SP - BRA JOSÉ WILSON NOLETO - Universidade Federal da Paraíba - 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 – Curitiba - PR – BR KATIA SHEYLA MALTA PURIM - Universidade Positivo - Curitiba - PR - BR LEONEL DOS SANTOS PEREIRA - Universidade Federal do Rio de Janeiro - Rio de Janeiro - RJ - BR LISIEUX EYER DE JESUS - TCBC-RJ- Universidade Federal Fluminense – Niterói – RJ – BR LUIZ CARLOS DUARTE DE MIRANDA - ACBC-RJ - Universidade Federal do Rio de Janeiro - Rio de Janeiro - RJ - BR LUIZ CARLOS VON BAHTEN - TCBC-PR- Universidade Federal do Paraná – Curitiba - PR – BR LUIZ GUSTAVO DE OLIVEIRA E SILVA - TCBC-RJ- Hospital Federal de Ipanema/Ministério da Saúde- Rio de Janeiro - RJ - BR LUIZ RONALDO ALBERTI - Universidade Federal de Minas Gerais – Belo Horizonte – MG –BR MANOEL XIMENES NETO - ECBC-DF –Universidade de Brasília – Brasília - DF - BR MANUEL DOMINGOS DA CRUZ GONÇALVES - ECBC-RJ- Universidade Federal do Rio de Janeiro- Rio de Janeiro –RJ – BR MARCOS ALPOIN FREIRE - TCBC-RJ- Universidade Federal do Rio de Janeiro- Rio de Janeiro – RJ – BR MARIA APARECIDA DE ALBUQUERQUE CAVALCANTE - Universidade Federal do Rio de Janeiro - Rio de Janeiro - RJ - BR MARIA DE LOURDES P. BIONDO SIMÕES - TCBC-PR – Pontifícia Universidade Católica do Paraná – Curitiba – PR - BR MARCELO AUGUSTO F. RIBEIRO JR. - TCBC-SP - Universidade de Santo Amaro- UNISA - São Paulo - SP - BR MAURÍCIO AUGUSTO S. MAGALHÃES COSTA - TCBC-RJ - Sociedade Brasileira de Mastologia - Rio de Janeiro - RJ - BR MAURO ANTÔNIO C. GUIMARÃES FILHO - Hospital Moinho dos Ventos - Porto Alegre - RS- BR MAURO DE SOUZA LEITE PINHO - TCBC-SC – Universidade da Região de Joinville – Joinville - SC - BR NELSON ADAMI ANDREOLLO - TCBC-SP – Universidade Estadual de Campinas Campinas - SP - BR NELSON ALFRED SMITH - Universidade Federal do Rio de Janeiro- Rio de Janeiro – RJ – BR NELSON FONTANA MARGARIDO – TCBC-SP – Universidade de São Paulo – São Paulo – SP – BR ORLANDO JORGE MARTINS TORRES - TCBC-MA - Universidade Federal do Maranhão - São Luís - MA - BR OSVALDO MALAFAIA - ECBC-PR- Universidade Federal do Paraná – Curitiba –PR- BR PAULO FRANCISCO GUERREIRO CARDOSO - ACBC-RS- Fundação Faculdade Federal de Ciências Médicas de Porto Alegre – Porto Alegre – RS - BR PAULO GONÇALVES DE OLIVEIRA - TCBC-DF - Universidade de Brasília – Brasília - DF - BR RENATO ABRANTES LUNA - TCBC-RJ - Hospital Federal dos Servidores do Estado do Rio de Janeiro - Rio de Janeiro - RJ - BR RICARDO ANTONIO CORREIA LIMA - TCBC-RJ – Universidade Federal do Estado do Rio de Janeiro- Rio de Janeiro – RJ – BR RICARDO VITOR COHEN - TCBC-SP - Hospital Alemão Oswaldo Cruz - São Paulo - SP - BR ROBERTO CAMPOS MEIRELLES - TCBC-RJ - Universidade do Estado do Rio de Janeiro - Rio de Janeiro - RJ - BR RODRIGO ALTENFELDER SILVA - TCBC-SP - Faculdade de Ciências Médicas da Santa Casa de São Paulo - São Paulo - SP-BR RODRIGO FELIPPE RAMOS - TCBC - RJ - Universidade Federal Fluminense - Niterói - RJ - BR ROGERIO APARECIDO DEDIVITIS - TCBC-SP - Universidade de São Paulo - São Paulo SP - BR RUFFO DE FREITAS JÚNIOR - TCBC-GO - Universidade Federal de Goiás - Goiânia – GO – BR SILVIA CRISTINE SOLDÁ - TCBC-SP- Faculdade de Ciências Médicas da Santa Casa de São Paulo- São Paulo - SP - BR SILVIO HENRIQUES DA CUNHA NETO – TCBC- RJ - Universidade Federal do Rio de Janeiro- Rio de Janeiro – RJ – BR SIZENANDO VIEIRA STARLING - TCBC-MG - Hospital João XXIII - Belo Horizonte - MG - BR THALES PAULO BATISTA - TCBC-PE- Faculdade Pernambucana de Saúde/ Instituto de Medicina Integral Professor Fernando Figueira - Recife - PE - BR VIVIAN RESENDE - TCBC-MG - Universidade Federal de Minas Gerais - Belo Horizonte MG - BR WILSON CINTRA JR. - TCBC-SP-Universidade de São Paulo- São Paulo- SP - BR


NATIONAL CONSULTANTS ALCINO LÁZARO DA SILVA, ECBC-MG - Universidade Federal de Minas Gerais - MG ALUIZIO SOARES DE SOUZA RODRIGUES, ECBC-RJ - Universidade Federal do Rio de Janeiro - UFRJ - RJ ANTONIO PELOSI DE MOURA LEITE, ECBC-SP - Instituto de Moléstias Cardiovasculares de São José do Rio Preto - SP DARIO BIROLINI, ECBC-SP - Faculdade de Medicina da Universidade de São Paulo - SP EUGÊNIO AMÉRICO BUENO FERREIRA, ECBC-SP - Faculdade de Medicina de Jundiaí - SP FERNANDO LUIZ BARROSO, ECBC-RJ - Hospital Municipal de Ipanema - RJ. FERNANDO MANOEL PAES LEME, ECBC-RJ - Faculdade de Medicina de Campos - RJ GASPAR DE JESUS LOPES FILHO, TCBC-SP - Universidade Federal de São Paulo - SP GUILHERME EURICO BASTOS DA CUNHA, ECBC-RJ - Universidade Federal Fluminense - RJ HELÁDIO FEITOSA DE CASTRO FILHO, TCBC-CE Universidade Federal do Ceará - CE ISAC JORGE FILHO, TCBC-SP - Universidade de Ribeirão Preto - SP. JOSÉ REINAN RAMOS, TCBC-RJ - Hospital Vitória-RJ LUIZ GUILHERME BARROSO ROMANO, ECBC-RJ MARCOS F. MORAES, ECBC-RJ - Universidade Gama Filho-RJ

ORLANDO MARQUES VIEIRA, ECBC-RJ - Universidade Federal do Rio de Janeiro-RJ ROBERTO SAAD JR., TCBC-SP - Faculdade de Ciências Médicas da Santa Casa de São Paulo-SP SAMIR RASSLAN, ECBC-SP - Faculdade de Medicina da Universidade de São Paulo-SP SAUL GOLDENBERG, ECBC-SP - Universidade Federal de São Paulo- Escola Paulista de Medicina - SP

INTERNATIONAL CONSULTANTS ARNULF THIEDE - Department of Surgery, University of Würzburg Hospital, Oberdürrbacher Str. 6, D-97080 Würzburg, Germany CLAUDE DESCHAMPS - M.D - The Mayo Clinic, MN,USA EDUARDO PARRA-DAVILA - Florida Hospital Celebration Health - 400 Celebration Pl, Kissimmee, FL 34747, USA. EMILIO DE VICENTE LÓPEZ – Sanchinarro Hospital, Madrid, Spain KARL H. FUCHS - Markus-Krankenhaus Frankfurter Diakonie-Kliniken, Wilhelm- Epstein-Straße 4, 60435 Frankfurt am Main MURRAY BRENNAN - HeCBC Department of Surgery, Memorial SloanKettering Cancer Center, New York NY, USA ULRICH ANDREAS DIETZ - Department of Surgery I, University of Würzburg, Medical School, Würzburg, Germany W. 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 2002 - 2005 JOSÉ ANTÔNIO GOMES DE SOUZA GUILHERME PINTO BRAVO NETO

2006 - 2015 JOSÉ EDUARDO FERREIRA MANSO

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

PUBLISHING, SUBSCRIPTIONS and ADMINISTRATION Rua Visconde de Silva, 52 - 3º andar - Botafogo - 22271-092 - Rio de Janeiro - RJ - Brasil Tel.: + 55 21 2138-0659; Fax: + 55 21 2286-2595; E-mail: revistacbc@cbc.org.br http//www.cbc.org.br PRINTING AND FINISHING Gráfica e Editora Prensa Ltda Rua João Alvares, 27 Saúde - Rio de Janeiro - RJ Tel.: (21) 2253-8343

International Standard Serial Number ISSN 0100-6991

GRAPHIC DESIGN Artur Farias

GRAPHIC DESIGN – COVER Libertta Comunicação JOURNAL OF THE BRAZILIAN COLLEGE OF SURGEONS

Indexed in Latindex, Lilacs and Scielo, Scopus, Medline/PubMed, DOAJ and Free Medical Journals


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Original Article

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Influence of advanced age on postoperative outcomes and total loss following breast reconstruction: a critical assessment of 560 cases Influência da idade avançada sobre a evolução pós-operatória e a perda total da reconstrução mamária: análise crítica de 560 reconstruções WALTER KOITI MATSUMOTO1; ALEXANDRE MENDONÇA MUNHOZ1,2,3; ALBERTO OKADA3,4; EDUARDO MONTAG3,4; EDUARDO GUSTAVO ARRUDA3,4; ALEXANDRE FONSECA3,4; ORLANDO FERRARI4; JOSÉ AUGUSTO BRASIL1; LIA PRETTI4; JOSÉ ROBERTO FILASSI2,3,5; ROLF GEMPERLI, TCBC-SP4. A B S T R A C T Objective: to evaluate the role of age in the risk of postoperative complications in patients submitted to unilateral breast reconstruction after mastectomy, with emphasis on total reconstruction loss. Methods: we conducted a retrospective study of patients submitted to breast reconstruction, whose variables included: oncological and reconstruction data, postoperative complications, including loss of reconstruction and complications of surgical wound. We divided the patients into two groups, according to the classification of the Brazilian National Elderly Policy and the Statute of the Elderly: young (age <60 years) and elderly (60 years or more). We also grouped them according to the World Health Organization classification: young people (age <44 years), middle age (45-59 years); elderly (age 60-89 years) and extreme advanced age (90 years or older). We applied the surgical risk classification of the American Society of Anesthesiologists to investigate the role of the preoperative physical state as a possible predictor of complications. Results: of the 560 patients operated on, 94 (16.8%) were 60 years of age or older. We observed a local complication rate of 49.8%, the majority being self-limited. The incidences of necrosis, infection and dehiscence were 15.5%, 10.9% and 9.3%, respectively. Patients older than 60 years presented a chance of complication 1.606 times greater than the younger ones. Forty-five (8%) patients had loss of the reconstruction; there was no statistically significant difference in the mean age of the patients who presented this result or not (p=0.321). Conclusion: in selected patients, breast reconstruction can be considered safe; most documented complications were limited and could be treated conservatively. Keywords: Reconstructive Surgical Procedures. Mastectomy. Age groups. Postoperative complications. Breast neoplasms.

INTRODUCTION

B

reast reconstruction is a well established procedure and is considered the standard treatment for patients with breast cancer who wish to repair the oncologic defect1. The choice of the reconstruction technique depends on the individual characteristics of each patient and is also influenced by the analysis of the surgical risk profile by the plastic surgeon2,3. Data from the Brazilian Institute of Geography and Statistics (IBGE) show that the elderly population is the one with the highest growth rates in Brazil, and similar demographic patterns can be found in other countries4,5. At the same time, the incidence of breast cancer increases with age, with 50% of cases occurring in women over 65 years of age6. The technological advances in

medical treatment, among other factors, led to an increase in life expectancy, suggesting that the elderly population will require an increasing number of surgical procedures7. With advancing age, the decrease in the efficiency of the healing process and the reduction of cardiovascular function may represent an increase in the perioperative risk of this subgroup of cancer patients7-9. In addition, advanced age is often referred to as an independent risk factor for complications in general surgery patients9,10. However, few studies have evaluated the influence of age on the complications rates and on the disadvantages and benefits of breast reconstruction7,8,11-13. Some clinical series that evaluated the impact of age on complications in specific reconstruction techniques demonstrated greater clinical and surgical morbidity11-13.

1 - Sírio-Libanês Hospital, Plastic Surgery, São Paulo, SP, Brazil. 2 - Faculty of Medicine, University of São Paulo, Mammary Reconstruction Group, São Paulo, SP, Brazil. 3 - University of São Paulo, Cancer Institute of the State of São Paulo, São Paulo, SP, Brazil. 4 - Faculty of Medicine, University of São Paulo, Division of Plastic Surgery, São Paulo, SP, Brazil. 5 - Sírio-Libanês Hospital, Mastology, São Paulo, SP, Brazil.

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Considering that data on breast reconstruc-

24 hours despite surgical treatment).

tion in the Brazilian elderly population are limited, this

We compared demographic and comorbidity

study sought to investigate the postoperative complications in this specific patients’ group. The main objective of the study was to globally quantify the effect of age on postoperative complications. We also sought to investigate the relationship between age and total loss of the breast reconstruction.

data between age groups based on the NEP and WHO classifications. As the oldest patient in the sample was 88 years old, we grouped all patients older than 60 years for statistical analysis. To compare the continuous variables for the occurrence of complications (yes or no) or by any other categorical variable with two categories, we used the Student’s t-test. To compare the continuous variables with more than two categories, we used the analysis of variance (ANOVA) model. To compare the categorical variables for the occurrence of complications (yes or no) or by any other categorical variable with two or more categories, we used the chi-square test. We used the Fisher’s exact test or the Likelihood Ratio when necessary. We also used the simple logistic regression model to verify which variables, individually, related to the occurrence of complications, to obtain the Odds Ratio (OR) for the occurrence of the mentioned outcomes for each variable. After the logistic regression analysis for each clinical risk factor and for the complications, we conducted a multivariate logistic regression analysis. However, some of the variables were significantly correlated with the others, and it was not possible to include all variables in the same model. Therefore, we chose to construct new variables with the combination of variables considered as risk factors. The new variables, combined two to two, were part of a simple logistic regression model. The value of p=0.05 was considered statistically significant. We used the SPSS software for Windows 7.0 (SPSS Inc. Chicago, Illinois) for all statistical analysis.

METHODS We carried out a retrospective cohort that identified all patients submitted to unilateral breast reconstruction at the Cancer Institute of the State of São Paulo (ICESP) and at the Sírio-Libanês Hospital (HSL). We conducted this study in accordance with the ethical guidelines of the Declaration of Helsinki, and it was approved by the Ethics and Research Committees of the respective institutions (approval protocols 474/13 and 714.543). We analyzed the database of each institution (ICESP/HSL) for information on clinical complications associated with breast reconstruction. We excluded patients with incomplete information. The variables included were: oncological data, reconstruction data (technique), postoperative complications, including loss of reconstruction, surgical wound complications (reconstruction site and donor area), early infection (during hospitalization for reconstruction), late infection, seroma, dehiscence, hematoma. We divided the patients according to the classification of the Brazilian National Elderly Policy and the Statute of the Elderly (NEP)14 in two groups: young people (age <60 years) and elderly (60 years or more). We also divided them into groups according to the World Health Organization (WHO) classification15: group I, young people (age <44 years); group II, middle age (age 45-59 years); group III, elderly (age 60-89 years), and group IV, extreme old age (90 years or more). We applied the American Society of Anesthesiologists (ASA) classification to investigate the role of preoperative physical status as a possible predictor of complications: Class 1 (healthy patient), Class 2 (mild or moderate systemic disease), Class 3 (severe systemic disease), Class 4 (severe systemic disease with constant risk of life), and Class 5 (patient to die within

RESULTS We analyzed the medical records of 560 consecutive patients (ages between 23 and 88 years) treated between October 2010 and May 2016. The minimum postoperative follow-up time was nine months, with an average of 35.6 months (range of nine to 66). According to the WHO classification, 153 patients (27.3%) were in group I, and 94 (16.8%), in group III. According to the NEP classification, 466 (83.2%) were young and 94 (16.8%) were elderly. Both in young patients (50.6%, 236 of 466 cases) and in the elderly ones (38.3%, 36

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of 94), reconstruction with alloplastic materials was the

a tumor in situ, and 26 (4.6%), as T0. In this sample,

most common reconstruction modality. Table 1 shows

215 (38.4%) patients underwent neoadjuvant chemo-

the distribution of reconstruction techniques in the different age groups. With respect to the oncological characteristics, 141 (25%) patients were classified as T1, 186 (33.2%), as T2, 95 (17%), as T3, 36 (4%), as T4, 63 (11.3 %), as

therapy, 249 (44.5%), adjuvant chemotherapy, three (0.7%) received neoadjuvant radiotherapy, and 335 (59.9%), adjuvant radiotherapy. The local recurrence rate was 6.6% and the incidence of distant metastases was 4.1%.

Table 1. Distribution of reconstruction techniques by age groups.

Age

Autogenic (%)

Breast reconstruction technique Alloplastic (%) Autogenic + Alloplastic (%)

Age Groups (NEP) <60 years Âł60 years p-value Age Groups (WHO) Young Middle-age Elderly/Extremely old Total p-value

119 (25.6) 35 (37.2)

236 (50.6) 36 (38.3) 0.042

111 (23.8) 23 (24.5)

36 (23.5) 83 (26.5) 35 (37.2) 154 (27.5)

79 (50.6) 157 (50.6) 36 (38.2) 272 (48.6) 0.145

38 (24.8) 73 (23.3) 23 (24.4) 134 (23.9)

NEP: National Policy for the Elderly and the Elderly Statute; WHO: World Health Organization.

The comparison of the different age groups (NEP and WHO classifications) showed no relation between age and Body Mass Index (BMI, p=0.217). Patients with diabetes mellitus (DM) had a significantly higher mean age (58 years) than non-diabetic ones (49.4 years, p<0.001). Advanced age was an independent risk factor for DM (OR 4.57, p<0.001). Similarly, we found a significant relationship between age and systemic arterial hypertension (SAH, p<0.001). The comparison between non-hypertensive and hypertensive patients showed a significant increase in the proportion of elderly patients in the second group (p<0.001). Among the elderly patients, 71 (75.5%) were non-smokers, 14 (14.9%) were former smokers and nine (9.6%) were smokers. In relation to smoking, the groups of young and old (NEP classification) were statistically similar (p=0.408). However, considering the WHO classification, there was a significant difference (p=0.007), with a higher percentage of young patients in the nonsmoking contingent compared to smokers and former smokers. ASA 1 patients represented 30.7%

(172/560) of the sample, while those ASA 2 and 3 accounted for 69.3%. No patient had an ASA 4 or 5 status (Table 2). Of the 560 patients, 279 (49.8%) developed local complications, most of them minor complications that did not require reoperation and could be treated on an outpatient basis. Seroma was the most frequent complication, with a total incidence of 22.1% (124/560), representing almost 45% of all complications. The incidences of necrosis, infection, dehiscence and hematoma were 15.5%, 10.9%, 9.3%, and 2.7%, respectively. Seroma occurred in 101 of the 466 (21.7%) young patients, and in 23 of the 94 (24.5%) elderly patients. There was no significant difference in the mean age between groups with or without seroma (p=0.333), infection (p=0.471), dehiscence (p=0.918) or necrosis (p=0.411). Patients with hematoma had a mean age of 58.8 years, while patients who did not evolve with it were 50.9 years old on average (p=0.004). After statistical analysis, we found a significant relationship between total reconstruction loss (8% of the

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whole sample) and the variables BMI, seroma, infection

than those without it (27.8kg/m2, p=0.002). The ASA

and necrosis. Patients who presented a loss of recons-

score did not show a significant correlation with the inci-

truction had significantly higher mean BMI (30.2kg/m2)

dence of complications (p=0.139).

Table 2. Distribution of Comorbidities by age groups.

Comorbidities Age

Mean BMI (SD)

SAH (%)

DM (%)

Smoking (%)

ASA 2 and 3 (%)

113 (24.2)

26 (5.6)

65 (13.9)

302 (64.8)

55 (58.5)

20 (21.3)

9 (9.6)

88 (93.6)

< 0.001

< 0.001

0.408

< 0.001

15 (9.8)

1 (0.6)

14 (9.1)

83 (54.2)

98 (31.3)

25 (8)

51 (16.3)

219 (70)

55 (58.5)

20 (21.3)

9 (9.6)

88 (93.6)

168 (30)

46 (8.2)

74 (13.2)

389 (69.3)

< 0.001

< 0.001

0.007

< 0.001

Age Groups (NEP) <60 years Âł60 years p-value Age Groups (WHO) Young Middle-age Elderly/Extremely old Total p-value

27.2 (4.8) 27.1 (4.9) 0.905 26.6 (4.4) 27.5 (5) 27.1 (4.9) 27.2 (4.8) 0.146

SD: standard deviation; SAH: Systemic Arterial Hypertension; DM: Diabetes Mellitus; NEP: National Policy for the Elderly and the Elderly Statute; WHO: World Health Organization; BMI: body mass index.

Patients who did not present complications had a mean age of 48.8 years, while the mean age of those who presented them was 51.4 years (Table 3). Considering only those who developed complications, 20.1% (56/279) were elderly. Patients 60 years of age or older presented a 1.606-fold greater risk of complications than did patients younger than 60. Obese patients had a 2,276-fold greater risk of complications when compared to non-obese patients (Table 4). Patients both elderly and obese presented a 3.16-fold higher risk of complications than did patients without any of these risk factors (p=0.005), as shown in Table 4. Patients with diabetes presented a risk of complications 2.471 times the risk of complications without DM. Elderly and diabetic patients presented a 2.67-fold greater risk of complication than non-diabetic young women (p=0.048). We observed a significant increase in complication rates in the advanced age groups (p=0.015) (Table 3); each one-year

increment corresponded to a 2.4% increase in the risk of complications, as demonstrated by the logistic regression analysis. The same analysis showed that the elderly/ extremely old patients presented a complication chance 2.1 times higher when compared to the younger age groups. Forty-five patients (8%) had total loss of reconstruction, 37 of the 466 young women (7.9%) and eight of the 94 elderly women (8.5%). We found no significant difference in the mean age between the patients who presented this outcome and those who did not (p=0.331), as shown in Table 3. Comparison of the young and old patients showed that the total loss of reconstruction was statistically equivalent in both groups (p=0.974). Likewise, there was no significant difference in the incidence of this complication among the young, middle-aged and elderly/extremely old age groups (p=0.405).

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Table 3. Distribution of age groups with averages, standard deviations, medians and range in the groups with and without complications and with or without total loss of reconstruction.

Groups Age Average (SD) Median (range) Age Group (NEP) <60 years – n (%) ³60 years – n (%) Age Group (WHO) Young – n (%) Middle-age – n (%) Elderly/Extremely old – n (%) Age (years) Average (SD) Median (range)

Without complications 48.8 (10.5) 48 (23-83)

With complications

p-value

51.4 (10.2) 51 (23-88)

0.003

243 (86.5) 38 (13.5)

223 (79.9) 56 (20.1)

0.05

90 (32) 153 (54.4) 38 (13.5) Without total loss of reconstruction 51.4 (10.2) 51 (23-88)

63 (22.6) 160 (57.3) 56 (20.1) With total loss of reconstruction 49.7 (9.8) 50 (23-70)

0.015

p-value 0.321

SD = standard deviation; NEP: National Policy for the Elderly and the Elderly Statute; WHO: World Health Organization. Table 4. Correlation of risk factors versus age groups and complications (singly, one by one, and two by two). Results of the logistic regression analysis.

Isolated Risk Factor

OR

95% CI

p-value

1.606 2.276 2.471 1.945 1.671 OR

(1.024-2.519) (1.548-3.346) (1.288-4.74) (1.345-2.812) (1.014-2.754) 95% CI

0.039 0.001 0.006 0.001 0.044 p-value

2.053 3.164

(1.427-2.951) (1.408-7.11)

0.001 0.005

1.720 2.675

(1.105-2.675) (1.009-7.088)

0.016 0.048

1.392 2.974

(0.951-2.038) (1.602-5.52)

0.089 0.001

1.837 1.489

(1.254-2.692) (0.394-5.627)

0.002 0.557

Age group (³60 vs. <60) BMI (obese vs. non-obese) DM (Yes vs. No) Hypertension (Yes vs. No) Smoking (Yes vs. No) Risk factor Age group and BMI Any of the two vs. none Both simultaneously vs. none Age group and DM Any of the two vs. none Both simultaneously vs. none Age group and Hypertension Any of the two vs. none Both simultaneously vs. none Age group and Smoking Any of the two vs. none Both simultaneously vs. none

BMI: body mass index; DM: Diabetes Mellitus; OR: odds ratio; CI: confidence interval.

DISCUSSION Advanced age is recognized as a risk factor for cancer, and 60% of new cases are diagnosed in pa-

tients over 60 years16,17. Moreover, the increase in life expectancy has increased the number of elderly patients who require surgeries for oncologic resections and reconstructions18. Despite the evolution of breast cancer

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Matsumoto Influence of advanced age on postoperative outcomes and total loss following breast reconstruction

treatment and the aging process of the female popula-

classification showed a higher incidence of complications

tion, treatment protocols in the elderly population are

in the advanced age group, although this difference oc-

19

Due to the scarcity of studies with sufficient evidence to define the risks and benefits for this population segment, elderly patients tend to receive incomplete treatment for breast cancer19,20. In fact, some studies have shown discrepancies in relation to breast reconstruction rates in the different age groups, and only a minority of the elderly patients with breast neoplasia choose to undergo reconstruction21. Another important point is the controversy in establishing the age limits between the different age groups and the lack of uniformity in the definition of the term elderly. Some studies used the age of 50 as a reference22, while others used 55 years23, 6024, or 65 years25. In the present study, we defined the age of 60 years as the limit between young and old, as recommended by the Brazilian National Elderly Policy14. This classification proved useful and clinically relevant, since the great reduction in breast reconstruction rates is observed after the fifth and sixth decades of life. We also used the WHO classification to include an international categorization usually employed in public health worldwide15. In breast reconstruction, it is essential to determine the anthropometric and clinical factors associated with higher complication rates25-27. Age13,23, smoking22,25,28, obesity22,23,25,27,28, SAH24,25,27 and DM24 are frequently mentioned as potential risk factors. In this

still based on studies with limited levels of evidence .

curred at the limit of significance (p=0.05). When we used WHO classification, we observed a significantly higher incidence of complications in the elderly/extremely old. Moreover, the overall rate of surgical complications in young and old patients was 47.8% and 59.6%, respectively, higher than those reported in other published series7,8,11-13,29. This is due to the inclusion of minor complications, such as mild to moderate seromas, which exhibited a total incidence of 22% and accounted for almost 45% of all complications. In spite of the high incidence of seromas when compared to other studies, we must be emphasize some points. Some studies with large samples are based on the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), which does not include some adverse events (such as seroma) in the list of complications22,23. Thus, if the seroma were excluded from the list of complications in this study, the results would become comparable to previously published clinical series7,8,11-13. Considering all types of adverse events, there was no significant difference in the mean age among patients who presented complications. In addition, the comparison of young and elderly patients did not show a significant difference in the isolated incidence of each type of complication, with the exception of hematoma. And although there is no consensus to characterize age as a risk factor for breast reconstruction, some studies

scenario, there is no consensus regarding the role of age on complications in patients with breast neoplasms undergoing reconstruction13-17. In this sample, patients with DM had a significantly higher mean age than nondiabetics, and there was also a significant relationship between age and SAH. Similarly, the mean age for ASA 1 patients was significantly lower than for patients classified as ASA 2 or 3. We found no significant relationship between smoking and obesity in elderly patients. Despite this, considering the WHO classification, we observed a greater percentage of young patients in the non-smokers group in relation to smokers and former smokers. Regarding breast reconstruction, some studies have compared the rates of complications among young and old patients7,8,11-13. In this study, the comparison of complication rates among age groups according to NEP

have demonstrated ASA classification as a predictor for perioperative complications7,30. In this series, patients classified as ASA 2 or 3 accounted for almost 70% of the entire sample. In contrast to observations from other studies7,30, the ASA classification did not demonstrate a significant correlation with the incidence of complications. At this point, we believe that this aspect should not contraindicate reconstruction, although one should take additional care in patients with a higher surgical risk. Despite the higher rates of complications in the present study, the total loss of reconstruction was less frequent than in other series with lower global rates of adverse events12,29. Furthermore, it is important to note that, although the complication rate was higher in elderly patients, this difference did not result in a higher incidence of total reconstruction loss. On the other hand,

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Matsumoto Influence of advanced age on postoperative outcomes and total loss following breast reconstruction

other studies have observed that age greater than 5022 and 55 years

23

7

fore, a selection bias that cannot be excluded. Although

were independent predictive factors for

the sample size of this series is significant, the notable

reconstruction loss. In a paradoxal way, the incidence of reconstruction loss was lower in patients who had presented seroma and necrosis than in patients who did not present such outcomes. One hypothesis to explain this finding is that the diagnosis of these two events motivated a rapid treatment by the medical team with intensive follow-up, re-hospitalization, drainage of collections, debridement of devitalized tissues and antibiotic therapy, which resulted, in the end, in lower reconstruction loss rates when compared to patients with subclinical infections. Regarding reconstruction techniques, almost 50% of the patients underwent reconstruction with alloplastic materials, 27% with autogenous tissues and 24% with a combination of alloplastics and autogenous tissues. Both young and elderly patients underwent alloplastic reconstruction more frequently. Like other authors, we did not find a correlation between age and the incidence of complications when performing the analysis of the alloplastic, autogenous and alloplastic / autogenous groups separately7,13,22,23,25,31. One of the obvious limitations of this study is the relatively small sample size in each subgroup of reconstruction technique. Future studies with a larger number of patients may reveal whether current findings are due to inadequate sample size or are a valid consideration. Other limitations of the present study require

reconstruction modalities may have prevented the analysis from achieving the desired statistical power. In addition, we could not perform comparisons of the results in patients with extreme old age, smoking and diabetics, as well as subgroups of different surgical techniques, so that the clinical relevance of the type of breast reconstruction in these groups remains controversial. Prospective studies will be needed to clarify this issue and to define which operative techniques are most appropriate for elderly patients. Second, questions about quality of life and the analysis of treatment costs were not part of the objectives of this study, but will be relevant to future research. Finally, although the postoperative complications reported by the medical team may be criticized for possible underreporting, the data in the present study reflect the unique experience of a single team in a tertiary hospital dedicated to the Brazilian population. We conclude that breast reconstruction is a valid option for adequately selected patients. This study showed that age is an independent risk factor for surgical complications, although the vast majority of these complications have been limited and could be treated conservatively. However, patients who are candidates for immediate reconstruction should be advised that age will not necessarily imply a greater risk of loss of reconstruction. Thus, it is appropriate to indicate breast recons-

attention. First, we collected the data prospectively but evaluated them retrospectively. In addition, the study was observational and non-randomized. There is, there-

truction in elderly patients and this procedure should be considered in counseling patients under treatment for breast cancer.

low incidence of some types of complication and some

R E S U M O Objetivo: avaliar o papel da idade no risco de complicações pós-operatórias de pacientes submetidas à reconstrução mamária unilateral pós-mastectomia, com ênfase na perda total da reconstrução. Métodos: estudo retrospectivo de pacientes submetidas à reconstrução mamária, cujas variáveis incluídas foram: dados oncológicos e da técnica de reconstrução, complicações pós-operatórias, incluindo perda da reconstrução e complicações da ferida operatória. As pacientes foram divididas de acordo com a classificação da Política Nacional do Idoso e Estatuto do Idoso em dois grupos: jovens (idade <60 anos) e idosas (60 anos ou mais). Também foram agrupadas de acordo com a classificação da Organização Mundial da Saúde: jovens (idade <44 anos); meia-idade (idade 45-59 anos); idosas (idade 60-89 anos) e velhice extrema (90 anos ou mais). A classificação do risco cirúrgico da Sociedade Americana de Anestesiologistas foi aplicada para investigar o papel do estado físico pré-operatório como possível preditor de complicações. Resultados: das 560 pacientes operadas, 94 (16,8%) apresentavam 60 anos ou mais. Observou-se taxa de complicações locais de 49,8%, a maioria, limitadas. As incidências de necrose, infecção e deiscência foram de 15,5%, 10,9% e 9,3%, respectivamente. Pacientes com 60 anos ou mais apresentaram chance de complicação 1,606 vezes maior do que as jovens. Quarenta e cinco (8%) pacientes apresentaram perda da reconstrução e não houve diferença estatisticamente significante na média de idade das pacientes que apresentaram ou não esse desfecho (p=0,321). Conclusão: em pacientes selecionadas, a reconstrução mamária pode ser considerada segura; a maioria das complicações documentadas foi limitada e pode ser tratada conservadoramente. Descritores: Procedimentos Cirúrgicos Reconstrutivos. Mastectomia. Grupos Etários. Complicações Pós-Operatórias. Neoplasias da Mama.

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REFERENCES

Johnson D, et al. Advanced age is a predictor of

1.

McKenna RJ Sr, Greene T, Hang-Fu LC, Hayes DF, Scanlon EF, Schweitzer RJ, et al. Implications for clinical management in patients with breast cancer. Long-term effects of reconstruction surgery. Cancer. 1991;68(5 Suppl):1182-3. 2. Lu SM, Nelson JA, Fischer JP, Fosnot J, Goldstein J, Selber JC, et al. The impact of complications on function, health, and satisfaction following abdominally based autologous breast reconstruction: a prospective evaluation. J Plast Reconstr Aesthet Surg. 2014;67(5):682-92. 3. Munhoz AM, Montag E, Filassi JR, Gemperli R. Immediate nipple-areola-sparing mastectomy reconstruction: an update on oncological and reconstruction techniques. World J Clin Oncol. 2014;5(3):478-94. 4. Anderson GF, Hussey PS. Population aging: a comparison among industrialized countries. Health Aff (Millwood). 2000;19(3):191-203. 5. Ramos LR, Veras RP, Kalache A. Envelhecimento populacional: uma realidade brasileira. Rev Saúde Pública. 1987;21(3):211-24. 6. Ogunbiyi SO, Lee S, Mathew J, Cheung KL. Primary breast cancer in the elderly: a systematic literature review on histological type and clinical outcome. Future Oncol. 2015;11(2):259-65. 7. Chang EI, Vaca L, DaLio AL, Festekjian JH, Crisera CA. Assessment of advanced age as a risk factor in microvascular breast reconstruction. Ann Plast Surg. 2011;67(3):255-9. 8. Girotto JA, Schreiber J, Nahabedian MY. Breast reconstruction in the elderly: preserving excellent quality of life. Ann Plast Surg. 2003;50(6):572-8. 9. Yanquez FJ, Clements JM, Grauf D, Merchant AM. Synergistic effect of age and body mass index on mortality and morbidity in general surgery. J Surg Res. 2013;184(1):89-100. 10. Gajdos C, Kile D, Hawn MT, Finlayson E, Henderson WG, Robinson TN. Advancing age and 30-day adverse outcomes after nonemergent general surgeries. J Am Geriatrics Soc. 2013;61(9):1608-14. 11. Butz DR, Lapin B, Yao K, Wang E, Song DH,

30-day

complications

after

autologous

but not implant-based postmastectomy breast reconstruction. Plast Reconstr Surg. 2015;135(2):253e-61e. 12. Lipa JE, Youssef AA, Kuerer HM, Robb GL, Chang DW. Breast reconstruction in older women: advantages of autogenous tissue. Plast Reconstr Surg. 2003;111(3): 1110-21. 13. Selber JC, Burgey M, Sonned SS, Kovach S, Wu L, Serletti JM. Free flap breast reconstruction in advanced age: is it safe? Plast Reconstr Surg. 2009;124(4):1015-22. 14. Küchemann BA. Envelhecimento populacional, cuidado e cidadania: velhos dilemas e novos desafios. Soc. Estado. 2012;27(1):165-80. 15. Ahmad OB, Boschi-Pinto C, Lopez AD, Murray CJ, Lozano R, Inoue M. Age Standardization of Rates: a new WHO standard [Internet]. Geneva: World Health Organization; 2001- [cited 2017 Feb 10]. Available from: http://www.who.int/ healthinfo/paper31.pdf 16. Ries LAG, Eisner MP, Kosary CL, Hankey BF, Miller BA, Clegg L, Edwards BK, editors. SEER Cancer Statistics Review, 1973-1998. Bethesda: National Cancer Institute. 2001 – [cited 2017 Feb 10]. Available from: https://seer.cancer.gov/ archive/csr/1973_1998. 17. Berger NA, Savvides P, Koroukian SM, Kahana EF, Deimling GT, Rose JH, et al. Cancer in the elderly. Trans Am Clin Climatol Assoc. 2006;117:14755; discussion 155-6. 18. Korc-Grodzicki B, Downey RJ, Shahrokni A, Kingham TP, Patel SG, Audisio RA. Surgical considerations in older adults with cancer. J Clin Oncol. 2014;32(24):2647-53. 19. Wildiers H, Kunkler I, Biganzoli L, Fracheboud J, Vlastos G, Bernard-Marty C, Hurria A, Extermann M, Girre V, Brain E, Audisio RA, Bartelink H, Barton M, Giordano SH, Muss H, Aapro M; International Society of Geriatric Oncology. Management of breast cancer in elderly individuals: recommendations of the International Society of Geriatric Oncology. Lancet Oncol. 2007;8(12):1101-15.

Rev Col Bras Cir 2018; 45(2):e1616


Matsumoto Influence of advanced age on postoperative outcomes and total loss following breast reconstruction

20. Bouchardy C, Rapiti E, Fioretta G, Laissue P,

21.

22.

23.

24.

25.

26.

27.

Neyroud-Caspar

I,

Schäfer

P,

et

9

immediate implant-based breast reconstruction:

al.

a 12-year experience with an analysis of patient

Undertreatment strongly decreases prognosis of breast cancer in elderly women. J Clin Oncol. 2003;21(19):3580-7. James R, McCulley SJ, Macmillan RD. Oncoplastic and reconstructive breast surgery in the elderly. Br J Surg. 2015;102(5):480-8. Hanwright PJ, Davila AA, Mioton LM, Fine NA, Bilimoria KY, Kim JY. A predictive model of risk and outcomes in tissue expander reconstruction: a multivariate analysis of 9786 patients. J Plast Surg Hand Surg. 2013;47(6):513-8. Fischer JP, Nelson JA, Serletti JM, Wu LC. Perioperative risk factors associated with early tissue expander (TE) loss following immediate breast reconstruction (IBR): a review of 9305 patients from the 2005-2010 ACS-NSQIP datasets. J Plast Reconstr Aesthetic Surg. 2013;66(11):1504-12. Miller AP, Falcone RE. Breast reconstruction: systemic factors influencing local complications. Ann Plast Surg. 1991;27(2):115-20. McCarthy CM, Mehrara BJ, Riedel E, Davidge K, Hinson A, Disa JJ, et al. Predicting complications following expander/implant breast reconstruction: an outcomes analysis based on preoperative clinical risk. Plast Reconstr Surg. 2008;121(6):1886-92. Munhoz AM, Montag E, Arruda E, Pellarin L, Filassi JR, Piato JR, et al. Assessment of immediate conservative breast surgery reconstruction: a classification system of defects revisited and an algorithm for selecting the appropriate technique. Plast Reconstr Surg. 2008;121(3):716-27. Munhoz AM, Aldrighi CM, Montag E, Arruda EG, Aldrighi JM, Gemperli R, et al. Clinical outcomes following nipple-areola-sparing mastectomy with

and breast-related factors for complications. Breast Cancer Res Treat. 2013;140(3):545-55. Ducic I, Spear SL, Cuoco F, Hannan C. Safety and risk factors for breast reconstruction with pedicled transverse rectus abdominis musculocutaneous flaps: a 10-year analysis. Ann Plast Surg. 2005;55(6):559-64. Randolph LC, Barone J, Angelats J, Dado DV, Vandevender DK, Shoup M. Prediction of postoperative seroma after latissimus dorsi breast reconstruction. Plast Reconstr Surg. 2005;116(5):1287-90. Serletti JM, Higgins JP, Moran S, Orlando GS. Factors affecting outcome in free-tissue transfer in the elderly. Plast Reconstr Surg. 2000;106(1):66-70. Woerdeman LA, van Schijndel AW, Hage JJ, Smeulders MJ. Verifying surgical results and risk factors of the lateral thoracodorsal flap. Plast Reconstr Surg. 2004;113(1):196-203; discussion 204-5.

28.

29.

30.

31.

Received in: 27/11/2017 Accepted for publication: 04/01/2018 Conflict of interest: Dr. Alexandre Mendonça Munhoz is a consultant at Allergan Corporations and Establishment Labs. None of the other authors has a potential conflict of interest. Source of funding: none. Mailing address: Alexandre Mendonça Munhoz E-mail: munhozalex@uol.com.br / walterkm3@gmail.com

Rev Col Bras Cir 2018; 45(2):e1616


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Pectoralis major myocutaneous flap in Head And Neck Surgery reconstructions: critical analysis. O retalho do músculo peitoral maior nas reconstruções em Cirurgia de Cabeça e Pescoço: análise crítica MARCELO BENEDITO MENEZES, TCBC-SP1; KASSEM SAMIR SALEH3; MARIANNE YUMI NAKAI2; LUCAS PORTO MAURITY DIAS1; NORBERTO KODI KAVABATA1; ANTÔNIO JOSÉ GONÇALVES, TCBC-SP1. A B S T R A C T Objective: to evaluate the results of the use of the pectoralis major flap in the reconstruction of head and neck surgeries. Methods: we conducted a retrospective study with data bank analysis and review of medical records of patients with head and neck cancer operated at the Discipline of Head and Neck Surgery, Surgery Department, São Paulo Holy Home of Mercy, using the pectoralis major flap for reconstruction, in a period of 16 years. We analyzed age, gender, primary site of neoplasia, clinical staging, preoperative radiotherapy (RT) and complications, classified as major and minor. Results: the series comprised 92 patients, of whom 86 (93.5%) were men; the mean age was 61.39 (±11.35) years; the most common primary sites were the mouth, in 35 cases (38%), oropharynx, in 21 (22.8%), and larynx, in 18 cases (19.6%). The majority of patients were in stage IV (88/92, 95.6%) and only four (4.3%) had preoperative RT. The overall complication rate was 48.9%, but only 6.5%, characterized as major complications. In the univariate statistical analysis, we found no factors related to the occurrence of complications. Only the primary neoplasm site presented marginal significance (p = 0.06). Conclusion: the pectoralis major flap is safe, with few complete and effective losses in reconstructions in head and neck surgeries, with low rates of major complications, being an option to be considered. Keywords: Head and Neck Neoplasms. Myocutaneous Flap. Pectoralis Muscles. Postoperative Complications.

INTRODUCTION

U

ntil the 1940s, reconstructions in head and neck surgeries (HNS) were limited by, and associated with, significant rates of complications. In the 1970s, these reconstructions underwent an expressive change

due to the description of the pectoralis major muscle myocutaneous flap (PMF), a procedure described by Ariyan1. After the description of this flap, reconstruction in HNS reached a higher level, with improvement of aesthetic and functional results. Even after the advent of the microsurgical flap, PMF is still an important and strategic flap, especially in services where there are limitations to the execution of the microsurgical flap or when there are restrictions to its use, such as in the absence of receptor vessels or in the presence

of severe comorbidities2. PMF has an excellent rotational arch, neurovascular pedicle, and axial blood supply, adequate aesthetic results, with a good amount of tissue for reconstruction, especially when there is a need for coverage of important cervical structures, such as the carotid artery, especially in patients submitted to previous radiotherapy. Among the limitations and problems of its use, there is the restriction in some sites due to its arc of rotation, possible difference in color between the skin flap reconstruction site when used after resection of extensive skin tumors, breasts asymmetry as a sequela in females and functional limitation of adduction and/or rotation of the arm3,4. Given its importance, this study aims to evaluate the complications of the PMF use in reconstructions in head and neck surgery.

1 - Irmandade da Santa Casa de Misericórdia de São Paulo, Discipline of Head and Neck Surgery, Department of Surgery, São Paulo, SP, Brazil. 2 Irmandade da Santa Casa de Misericórdia de São Paulo, São Luis Gonzaga Hospital, São Paulo, SP, Brazil. 3 - Arnaldo Vieira de Carvalho Foundation, Faculty of Medical Sciences of the Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil.

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Menezes Pectoralis major myocutaneous flap in Head And Neck Surgery reconstructions

2

METHODS

Epi Info version 7.2 software, with a significance level of 5%.

This is a retrospective observational study with data bank analysis and review of medical records of cases of head and neck cancer operated in the Discipline of Head and Neck Surgery of the Surgery Department of the São Paulo Holy Home of Mercy, from January 2001 to December of 2016, with PMF used for reconstruction. We excluded patients whose records had incomplete information. We analyzed the following variables: age, gender, primary site of malignant neoplasms (mouth, oropharynx, larynx, hypopharynx, skin and salivary glands), clinical staging according to AJCC (7th Edition)5 and preoperative radiotherapy, correlating them with complications, which were subdivided into major and minor complications. Among the major complications were necrosis and complete loss of the flap, requiring a new surgical intervention for correction, and among the minor ones, self-limited fistulas, partial self-limited dehiscence and partial necrosis, without the need for surgical intervention. For univariate statistical analysis, we used the

This work was approved by the Irmandade da Santa Casa de Misericórdia de São Paulo Ethics Committee, under the number 03297312800005258.

RESULTS The study sample consisted of 92 patients, of whom 86 (93.5%) were men, the mean age being 61.39 (±11.35) years. As for complications (Table 1), these occurred in 45 cases (48.9%), of which only six (6.5%) were major ones. Among the malignant neoplasm sites (Table 2), mouth (38%), oropharynx (22.8%) and larynx (19.6%) were the most affected, with 35, 21 and 18 patients, respectively, displaying a marginal level of statistical significance in relation to the occurrence of complications (p=0.062). As for the tumors’ clinical stage, 88 (95.6%) were stage IV, and preoperative radiotherapy was performed in four patients (4.3%); both variables showed no correlation with the occurrence of complications (p=0.48 and p=0.17, respectively).

Table 1. Distribution of major and minor complications.

Complication

N

% (n = 92)

No complication

47

51.1

Minor Major Total

39 6 92

42.4 6.5 100

Table 2. Distribution of major and minor complications according to primary sites.

None Complications

Minor Complications

Major Complications

Total

Mouth

19 (54.29%

14 (40%)

2 (5.71%)

35 (100%)

Oropharynx Larynx Hypopharynx Skin Other Total

14 (66.67%) 7 (38.89%) 1 (14.29%) 3 (37.5%) 3 (100%) 47 (51.09%)

5 (23.81%) 9 (50%) 6 (85.71%) 5 (62.5%) 0 39 (42.39%)

2 (9.52%) 2 (11.11%) 0 0 0 6 (6.52%)

21 (100%) 18 (100%) 7 (100%) 8 (100%) 3 (100%) 92

Tumor Site

Rev Col Bras Cir 2018; 45(2):e1682


Menezes Pectoralis major myocutaneous flap in Head And Neck Surgery reconstructions

DISCUSSION

3

pharynx and skin, the occurrence of complications was high (61.11%, 85.71% and 62.5%, respectively) with

Of the 92 patients submitted to reconstruction surgery using the pectoralis major flap, 45 (48.9%) had complications, a result similar to the findings of Pinto et al.6, in which the reported complication rate was 43.1%, half of them represented by major complications, relating the previous radiotherapy treatment to the worsening of results (p=0.04). McLean et al.7, studying 136 patients, reported only 18 cases with complications (13%). However, the authors did not evaluate tumor staging, which could explain the low rate of complications should the number of tumors in lower stages be higher. Still, of the 18 cases in which complications occurred, 13 had undergone radiotherapy, of which six had RT prior to the procedure. Thus, they considered RT as an important risk factor for the occurrence of complications. In our study, because of the small number of patients with RT prior to surgery (4.3%), we did not observe this association (p=0.48). In Lima’s work8, of the 116 patients evaluated, 73 presented complications (62.9%), and 31 (26%) of these were major ones. In the study by Tripathi et al.9, they reported a 40% complication rate, and 83% of the patients in the series had advanced stage disease, III and IV, without association of neoadjuvant treatment with the occurrence of complications. In our study, 95.6% (88/92) of the cases were stage IV tumors, which could explain the significant percentage of complications (48.9%). However, there was no statistically significant relation in our study (p=0.17). When analyzing the tumor sites (Table 2), we observed that in the tumors of the larynx, hypo-

a marginal level of significance (p=0.062). This can be explained by the need for radical surgery in advanced tumors of the larynx and hypopharynx, usually consisting of total pharyngolaryngectomy with reconstruction of the digestive tract in this segment, a complex procedure with a high possibility of complications, especially fistulas. In the case of advanced skin tumors, especially those of the face, when they compromise the external ear, mastoid, middle ear, among other structures of the skull base, where there is a need for extensive surgical resection and reconstruction, the occurrence of infection is significant, with possibility of dehiscence and partial loss of the flap. In addition, PMF has a weight that in these regions may be associated with dehiscence of the highest portion of the reconstructed area. Thus, in head and neck surgeries, PMF is generally used for reconstruction after extensive resections, since the flap presents a large volume (thickness), besides allowing a large diameter skin island, being little used to reconstruct small defects. Therefore, in most cases, patients have advanced clinical status, which could influence the evolution and postoperative complications. Although the percentage of complications found was 48.9%, major complications were not common (6.5%), showing that Pectoralis Major Myocutaneous Flap is a viable and safe option for Head and Neck Surgery reconstruction, especially in places where the microsurgical flap is not possible due to cost and infrastructure, or in patients with clinical contraindications for this type of reconstruction.

R E S U M O Objetivo: avaliar os resultados do uso do retalho de músculo peitoral maior nas reconstruções de cirurgias de cabeça e pescoço. Métodos: estudo retrospectivo com análise de banco dados e revisão de prontuários de pacientes com câncer de cabeça e pescoço operados na Disciplina de Cirurgia de Cabeça e Pescoço do Departamento de Cirurgia da Santa Casa de São Paulo em um período de 16 anos, utilizando-se o retalho de músculo peitoral maior para reconstrução. Foram analisados idade, sexo, sítio primário da neoplasia, estadiamento clínico, radioterapia (RT) pré-operatória e as complicações encontradas, classificadas em maiores e menores. Resultados: a casuística foi de 92 pacientes, dos quais 86 (93,5%) eram homens; a média de idade foi de 61,39 (dp±11,35) anos; os sítios primários mais acometidos foram boca em 35 casos (38%); orofaringe em 21 casos (22,8%) e laringe em 18 casos (19,6%). A maioria dos pacientes encontrava-se no estádio IV (88/92; 95,6%) e apenas quatro (4,3%) tinham realizado a RT pré-operatória. A taxa global de complicações foi de 48,9%, mas apenas 6,5% caracterizadas como complicações maiores. Na análise estatística univariada, não foram encontrados fatores relacionados à ocorrência das complicações. Apenas o sítio primário da neoplasia apresentou significância marginal (p=0,06). Conclusão: o retalho de músculo peitoral maior é seguro, com poucas perdas completas e eficaz nas reconstruções em cirurgias de cabeça e pescoço, com baixas taxas de complicações maiores, sendo uma opção a ser considerada. Descritores: Neoplasias de Cabeça e Pescoço. Retalho Miocutâneo. Músculos Peitorais. Complicações Pós-Operatórias.

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Menezes Pectoralis major myocutaneous flap in Head And Neck Surgery reconstructions

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REFERENCES

occurrences of complications and the final outcome. Sao Paulo Med J. 2010;128(6):336-41.

1.

2.

3.

4.

5.

6.

Ariyan S. The pectoralis major myocutaneous flap. A versatile flap for reconstruction in the head and neck. Plast Reconstr Surg. 1979;63(1):73-81. Bhanja A, Dâ&#x20AC;&#x2122;Souza DS, Roy C, Poddar RN. Reliability of the pectoralis major myocutaneous flap in reconstructive oral cancer surgery in developing countries: our experience. Med J Armed Forces India. 2016;72(Suppl 1):S1-S7. Fernandes R. Local and regional flaps in head and neck reconstruction: a practical approach. Hoboken (NJ): Wiley-Blackwell; 2014. University of Iowa Health Care. Pectoralis major myocutaneous flap and myofascial flap [Internet]. Iowa City: University of Iowa Health Care; 2017 [cited 2017 Nov 10]. Available from: https://medicine.uiowa. edu/iowaprotocols/pectoralis-major-myocutaneousflap-and-myofascial-flap Edge S, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A, editors. AJCC cancer staging manual. 7th ed. New York: Springer-Verlag; 2016. Pinto FR, Malena CR, Vanni CM, Capelli FA, Matos LL, Kanda JL. Pectoralis major myocutaneous flaps for head and neck reconstruction: factors influencing

7.

8.

9.

McLean JN, Carlson GW, Losken A. The pectoralis major myocutaneous flap revisited: a reliable technique for head and neck reconstruction. Ann Plast Surg. 2010;64(5):570-3. Lima VS, Pruinelli R, Gava VG, Silva VL. Myocutaneous flap of pectoralis major muscle: results and complications in a series of 116 cases. Rev Bras Cir PlĂĄst. 2010;25(3):484-9. Tripathi M, Parshad S, Karwasra RK, Singh V. Pectoralis major myocutaneous flap in head and neck reconstruction: an experience in 100 consecutive cases. Natl J Maxillofac Surg. 2015;6(1):37-41.

Received in: 18/12/2017 Accepted for publication: 25/01/2018 Conflict of interest: none. Source of funding: none. Mailing address: Marianne Yumi Nakai E-mail: mynakai@gmail.com / dr.goncalves@uol.com.br

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The impact of decongestive physical therapy and elastic bandaging on the control of pain in patients with venous ulcers O impacto da terapia física descongestiva e da bandagem elástica no controle da dor de pacientes com úlceras venosas GERALDO MAGELA SALOMÉ1; LYDIA MASAKO FERREIRA, TCBC-SP1 A B S T R A C T Objective: to evaluate pain in individuals with venous ulcers treated with elastic bandage and decongestant physical therapy. Methods: we studied 90 patients, divided into three groups with 30 patients each: a group treated with elastic bandage and decongestant physical therapy; a group treated with elastic bandage; and a group treated only with primary dressing according to tissue type and presence of exudate. We used the Pain Numerical Scale to quantify pain intensity and the McGill Pain Questionnaire for pain qualitative assessment. Results: in the first evaluation, all patients who participated in the study reported intense pain. In the fifth evaluation, the majority of patients treated with elastic bandaging and decongestant physical therapy did not report pain; the majority of patients in the elastic bandage group reported mild pain; and most patients treated only with primary dressing reported mild to moderate pain. During all five assessments using the McGill questionnaire, most patients in the elastic bandaging and primary dressing groups used descriptors of the sensory, affective, evaluative and miscellaneous groups to describe their pain. However, in the fourth and fifth evaluations, most patients who received decongestant physical therapy combined with elastic bandaging treatment did not use any of the descriptors. Conclusion: patients treated with decongestant physical therapy and elastic bandage presented pain improvement from the third evaluation performed on. Keywords: Leg Ulcer. Varicose Ulcer. Compression Bandages. Physical Therapy Modalities. Pain Measurement.

INTRODUCTION

which further delay the ulcer healing process9-14. The treatment of venous ulcers is based on the

C

urrently, chronic wounds are considered a worldwide epidemic, reaching about 1% of the general population1. In Western countries, they affect approximately 5% of the adult population. In Brazil, on average 3% of individuals have this type of wound2,3. According to Körber et al.4, 80% of chronic wounds are found in the lower limbs. The most frequent causes of such wounds include venous and arterial insufficiency, followed by neuropathy, lymphedema, trauma, rheumatoid arthritis, vasculitis, sickle cell anemia, osteomyelitis, cutaneous tumors and infectious diseases. The tissue repair process, especially of venous ulcers, is time-consuming and has a high rate of recurrence5, which leads to physical, social, psychological and economic changes that interfere with patients’ daily lives. These changes have a negative impact on their quality of life, especially when caused by venous ulcers5-8. As a consequence, anxiety and depression may occur,

appropriate evaluation of the patients and the wound, and the correct choice of dressing type according to the wound margin, size, location, tissue type and presence of exudate. Compressive and decongestant physical therapies associated to dressing have been shown to optimize therapeutic results. It should be emphasized that the choice of the type of primary dressing also depends on the evaluation of cost-benefit and time of use15,16. Compression therapy involving the application of pressure to the lower extremities is a key component for the treatment of chronic venous and lymphatic disease. Its main function is to neutralize gravity, which is a key factor for the disturbance of the venous and lymphatic return from the lower extremity and that results in pain improvement17. The decongestant physical therapy aims to create pressure differentials to promote the displacement of lymph and interstitial fluid, aiming at its reallocation into the bloodstream, reabsorbing the

1 - University of Vale do Sapucaí, Master’s Degree in Health Science, Pouso Alegre, MG, Brazil. Rev Col Bras Cir. 2018; 45(2):e1385


Salomé The impact of decongestive physical therapy and elastic bandaging on the control of pain in patients with venous ulcers

2

edema and treating different pathologies. This is achieved by gentle movements in circles with the hands, applied over the area to be treated, rhythmically and slowly, which result in edema decrease and pain improvement18. This study aims to evaluate pain in individuals with venous ulcer treated with elastic bandage and decongestant physical therapy.

METHODS We conducted a controlled, randomized, analytical and prospective study at the São João Outpatient Clinic of the University of Sapucaí Valley and at the wound clinic of the County Diabetes Education Center, after approval by the Ethics in Research Committee, opinion number 689,079. We studied 90 patients, divided into three groups with 30 patients each: a group treated with elastic bandage and decongestant physical therapy; a group treated with elastic bandage; and a group treated with primary dressing according to tissue type and presence of exudates, without elastic bandage. Inclusion criteria were age equal to or greater than 18 years, ankle / arm ratio between 1.0 and 1.4, patients who were not taking medication for pain. Exclusion criteria were wounds with clinical signs of infection. During the study, we excluded patients who missed outpatient care visits, those who started taking medication for pain and those whose wounds presented with signs of allergy or infection. We carried out the study from September 2015 to July 2017. We performed the first data collection at the time of inclusion of the patient in the study, and then every eight days, totaling five visits. In these consultations, the wound was evaluated and the primary dressing changed, but the patients were instructed to change the secondary dressing whenever saturation occurred. We randomized patients by process of sealed and opaque envelopes stored in the central of randomization. An independent individual generated a sequence of random numbers by placing them one by one in the sealed envelopes. Patients were drawn consecutively, through withdrawal of the envelope and allocation in one of the groups. All groups were evaluated daily by the researchers, and the indication of the dressing was made according to clinical evaluation, i.e, presence and amount of exudate, tissue type, signs of infection.

In the groups treated with elastic bandage, it was used daily, and withdrawn only for bathing. In the group treated with elastic bandaging and decongestant physical therapy, the latter was performed three times a week on alternate days, each session lasting 40 minutes, always performed by the researcher himself. The therapy was performed in this order: lower limb elevation at 30°, manual lymphatic drainage, compression with elastic bandages down to the knee region and myolymphokinetic exercises, which are exercises performed under elastic compression of the limb, with flexion-extension of the ankles, knees and hips, three times with 30 repetitions. The manual lymphatic drainage of the lower limbs began with the evacuation of the inguinal, popliteal and malleolar lymph nodes, followed by movements with slow and smooth rhythmic pressure, around 30 to 40 mmHg, directing the lymph to a group of closer lymph nodes, in the caudal-cranial direction. Before lymphatic drainage, the ulcer was cleaned and the lesion was left undressed; ulcer coverage was placed only after the end of lymphatic drainage. In cases where the ulcer had devitalized tissue, we performed enzymatic debridement with a 10% papain gel, varying the concentration when necessary, according to the need of each patient, until the total removal of the devitalized tissues. After this removal, papain application was suspended. Importantly, dressing technique was identical for all groups. Participants answered the questionnaire on socio-demographic data. To quantify the intensity of pain, we used the Numerical Pain Scale, graded from 0 to 10, where 0 means no pain and 10, the worst pain ever felt. Pain intensity was classified as: absence of pain (0), mild pain (1-3), moderate (4-6) and intense (7-10)19,20. We performed qualitative evaluation of the pain with the application of the McGill Pain Questionnaire. This questionnaire consists of words known as descriptors, which describe the sensation of pain that the patient may be feeling. The descriptors are organized into four major groups and into 20 subgroups. Each set of subgroups evaluates a group. The descriptors cover the areas: sensory (subgroup 1 to 10), affective (subgroup 11 to 15), evaluative (subgroup 16) and miscellaneous (subgroup 17 to 20)19,20. The sensorial-discriminative group (subgroups 1 to 10) refers to the mechanical, thermal and spatial properties of the pain; the affective-motivational group (subgroups 11 to 15) describes the affective dimension

Rev Col Bras Cir. 2018; 45(2):e1385


Salomé The impact of decongestive physical therapy and elastic bandaging on the control of pain in patients with venous ulcers

3

in the aspects of tension, fear and neurovegetative

chosen descriptors. These indices can be obtained in total

responses; the descriptors of the cognitive-evaluative

and for each of the four components of the questionnaire:

component (subgroup 16) allow the patient to express the overall assessment of the pain experience. Subgroups 17 through 20 comprise miscellaneous items. Each subgroup consists of two to six qualitatively similar descriptors, but with nuances that make them different in terms of magnitude. Thus, for each descriptor a number indicates its intensity19,20. The McGill questionnaire enabled measuring the number of descriptors selected and the pain index. The number of descriptors chosen corresponds to the words that the patient chose to explain the pain. The highest possible value is 20, since the patient can only choose at most one word per subgroup. The pain index is obtained with the sum of the intensity values of the

sensitive, affective, evaluative and miscellaneous19,20. We performed the statistical analysis with the SPSS 11.5 software. Were used the Friedman and the Chisquare tests, with significance levels of 5% (p=0.05).

RESULTS The socio-demographic variables of the participants can be seen in Table 1. Most of the participants were white, female, older than 60 and literate. Regarding lesion time, the majority of patients in all groups had the wound for over 11 years. There was no statistical difference between the variables.

Table 1. Socio-demographic variables.

Variables Schooling Literate Complete Elementary school Complete high school Total Age Group <50 years 50-59 years 60-69 years ³70 years Total Gender Male Female Total Smoker Yes No Total Time of wound <12 months 1-5 years 6-10 years ³11 years Total

Group Bandage + Therapy Bandage n % n %

Primary dressing n %

Total n

%

13 9 8 30

43.3 30.0 26.7 100

12 8 10 30

40.0 26.7 33.3 100

13 8 9 30

43.3 26.7 30.0 100

38 25 27 90

42.2 27.8 30.0 100

5 5 17 3 30

16.7 16.7 56.7 10.0 100

7 6 15 2 30

23.3 20.0 50.0 6.7 100

06 3 18 3 30

20.0 10.0 60.0 10.0 100

18 14 50 8 90

20.0 15.6 55.6 8.9 100

9 21 30

30.0 70.0 100

12 18 30

40.0 60.0 100

13 17 30

43.3 56.7 100

34 56 90

37.8 62.2 100

24 6 30

80.0 20.0 100

24 6 30

80.0 20.0 100

26 4 30

86.7 13.3 100

74 16 90

82.2 17.8 100

1 4 12 13 30

3.3 13.3 40.0 43.3 100

0 6 13 11 30

0 20.0 43.3 36.7 100

0 7 15 8 30

0 23.3 50.0 26.7 100

1 17 40 32 90

1.1 18.9 44.4 35.6 100

p value

0.981

0.941

0.541

0.735

0.683

Bandage= elastic bandage; therapy= decongestant physical therapy; Primary dressing= primary wound dressing without elastic bandage. Pearson’s Chi-square test; * Level of statistical significance (p£0.05). Rev Col Bras Cir. 2018; 45(2):e1385


SalomĂŠ The impact of decongestive physical therapy and elastic bandaging on the control of pain in patients with venous ulcers

4

Table 2 shows that in the first evaluation the

reported mild to moderate pain. Patients treated with

patients who participated in the study reported intense

elastic bandage reported moderate pain and the majority

pain. In the second, the majority of patients treated with elastic bandaging and decongestant physical therapy

of patients treated with primary dressing without elastic bandage reported severe to moderate pain.

Table 2. Results of the Numeric Pain Scale.

Evaluation

First assessment

Second assessment

Third assessment

Fourth assessment

Fifth assessment

Pain intensity Absent Mild Moderate Intense Total Absent Mild Moderate Intense Total Absent Mild Moderate Intense Total Absent Mild Moderate Intense Total Absent Mild Moderate Intense Total

Bandage + Therapy n % 0 0 0 0 13 43.3 17 56.7 30 100 0 0 11 36.7 14 46.7 5 16.7 30 100 0 0 23 76.7 7 23.3 0 0 30 100 16 53.3 14 46.7 0 0 0 0 30 100 24 80.0 6 20.0 0 0 0 0 30 100

Group Bandage Primary dressing n % n % 0 0 0 0 0 0 0 0 17 56.7 18 60.0 13 43.3 12 40.0 30 100 30 100 0 0 0 0 9 30.0 7 23.3 20 66.7 16 53.3 1 3.3 7 23.3 30 100 30 100 0 0 0 0 14 46.7 12 40.0 16 53.3 18 60.0 0 0 0 0 30 100 30 100 2 6.7 7 23.3 16 53.3 4 13.3 12 40.0 19 63.3 0 0 0 0 30 100 30 100 6 20.0 4 13.3 19 63.3 11 36.7 5 16.7 15 50.0 0 0 0 0 30 100 30 100

Total n 0 0 48 42 90 0 27 50 13 90 0 49 41 0 90 25 34 31 0 90 34 36 20 0 90

% 0 0 53.3 46.7 100 0 30.0 55.6 14.4 100 0 54.4 45.6 0 100 27.8 37.8 34.4 0 100 37.8 40.0 22.2 0 100

p value

0.010*

0.001*

0.001*

0.001*

0.001*

Bandage= elastic bandage; therapy= decongestant physical therapy; Primary dressing= primary wound dressing without elastic bandage. Friedman and Pearsonâ&#x20AC;&#x2122;s Chi-square tests; * Level of statistical significance (pÂŁ0.05).

In the third evaluation, the majority of patients treated with elastic bandaging and decongestant physical therapy reported mild pain; in the elastic bandage group, most reported moderate pain; and the majority of patients treated with primary dressing without elastic bandage reported moderate pain. In the fourth evaluation, the majority of patients

treated with elastic bandages and decongestant physical therapy did not report pain; in the elastic bandage group, most reported mild pain; and the majority of patients treated with primary dressing without elastic bandage reported moderate pain. In the fifth evaluation, the majority of patients treated with elastic bandaging and decongestant physical

Rev Col Bras Cir. 2018; 45(2):e1385


Salomé The impact of decongestive physical therapy and elastic bandaging on the control of pain in patients with venous ulcers

5

therapy reported no pain; in the elastic bandage group,

questionnaire, reported sensory, affective, evaluative and

most reported mild pain; and the majority of patients

miscellaneous descriptors. However, in the fourth and

treated with primary dressing without elastic bandage reported mild to moderate pain. Table 3 shows that most of the patients in the elastic bandage and primary dressing groups in the first to fifth evaluation, when answering the McGill

fifth evaluations, the majority of patients in the elastic bandage and decongestant physical therapy group reported none of the descriptors. All variables were statistically significant.

Table 3. Results of the McGill Pain questionnaire.

Assessment/Group First assessment Bandage + Therapy Bandage Primary dressing p value Total Second assessment Bandage + Therapy Bandage Primary dressing p value Total Third assessment Bandage + Therapy Bandage Primary dressing p value Total Fourth assessment Bandage + Therapy Bandage Primary dressing p value Total Fifth assessment Bandage + Therapy Bandage Primary dressing p value Total

None n %

Descriptors of the McGill Pain questionnaire Sensory Affective Evaluative Miscellaneous n % n % n % n %

Total n %

0 1 7

0 3.3 23.3

14 22 18

46.7 73.3 60.0

13 19 14

8

8.9

54

60.0

0 0 7

0 0 23.3

16 21 19

07

7.9

0 0 7

43.3 63.3 46.7

5 14 10

16.7 46.70 33.3

30 30 30

100 100 100

46

9 30.0 8 26.7 8 26.7 0.005* 51.1 25 27.8

29

32.2

90

100

53.3 72.4 63.3

5 13 19

16.7 44.8 63.3

56

62.9

0 0 23.3

16 21 19

7 7.8 n % 18 60.0 3 10.0 6 20.0 27 n 25 04 6

4 9 7

13.3 31.0 23.3

30 29 30

100 100 100

37

6 20.0 4 13.8 4 13.3 0.001* 41.6 14 15.7

20

22.5

89

100

53.3 70.0 63.3

5 7 18

16.7 23.3 60.0

4 6 7

13.3 20.0 23.3

30 30 30

100 100 100

56 n 08 18 20

62.2 % 26.7 60.0 66.7

30 n 1 4 19

33.3 % 3.3 13.3 63.3

17 n 2 3 7

18.9 % 06.7 10.0 23.3

90 n 30 30 30

100 % 100 100 100

30.0 % 83.3 13.3 20.0

46 n 3 21 20

51.1 % 10.0 70.0 66.7

24 n 0 4 18

26.7 % 0 13.3 60.0

12 n 2 3 6

13.3 % 6.7 10.0 20.0

90 n 30 30 30

100 % 100 100 100

35 38.9

44

48.9

22

24.4

11

12.2

90

100

5 16.7 4 13.3 4 13.3 0.001* 13 14.4 n % 1 3.3 3 10.0 4 13.3 0.001* 8 8.9 n % 0 0 2 6.7 4 13.3 0.001* 6 6.7

Bandage= elastic bandage; therapy= decongestant physical therapy; Primary dressing= primary wound dressing without elastic bandage. Friedman and Pearson’s Chi-square tests; * Level of statistical significance (p£0.05). Rev Col Bras Cir. 2018; 45(2):e1385


SalomĂŠ The impact of decongestive physical therapy and elastic bandaging on the control of pain in patients with venous ulcers

6

DISCUSSION

aggravates the woundsâ&#x20AC;&#x2122; painful process. Chronic pain can be considered as the perpetuation of acute pain, has

The increase in the number of ulcer patients in the population is a fact known to health professionals and subject of several discussions. Wound care is a great challenge to be faced daily, by both the patient and the caregivers and family members. Often the family and the health team are not prepared to help and understand all the aspects and difficulties that arise for the patient21-23. Among the participants of this study, women and the elderly were predominant. It is inferred that the occurrence of venous ulcer in females is associated with hormonal factors, pregnancy, puerperium and increased incidence of varicose veins, which may favor the onset of chronic venous insufficiency24-26. Most study participants were smokers. Smoking is known to impair tissue oxygenation, decrease the bodyâ&#x20AC;&#x2122;s resistance, increase susceptibility to infections, and slow healing. In addition, smoking alters the synthesis of collagen, making it difficult to heal wounds. Nicotine produces vasoconstriction, which increases the risk of ischemia and ulcer development; when already present, ulcers present difficulties in healing. In these cases, the cellular process is interrupted and abnormal functions derive from systemic or local factors or both in the healing process27. Pain should be evaluated considering the characteristics of each individual or group of patients that meet the same clinical conditions. In addition, the clinical status and cause of pain, such as trauma, ulcers, and burns, require careful evaluation so that the interventions required for each case are properly implemented28. In this study, patients in all groups reported severe pain in the first evaluation. In the fifth evaluation, however, the majority of patients treated with elastic bandage and decongestant physical therapy reported no pain, while the majority of patients with elastic bandage reported mild pain and most patients treated with primary dressing without elastic bandage reported mild to moderate pain. Wound pain results from tissue injury and the perception of pain depends on numerous factors related to the patient, wound type, the amount and intensity of external stimuli. The skin is richly innervated, which gives it the ability to capture various types of stimuli, and the presence of infection and necrosis

no biological alert function and generates suffering. In general, neurovegetative responses such as those found in acute pain do not occur, resulting from the adaptation of neuronal systems29-32. Pain causes discomfort, influences adherence to the treatment and interferes in the quality of life of the patient with venous ulcer. The pain can cause difficulty of locomotion, change of mood and sleep alterations. Pain is a very common symptom in patients with venous ulcers and its prevalence varies between 80 and 96% in this group. It may be persistent and / or exacerbated during dressing changes. Pain can also negatively influence healing because painful stimulation is associated with the release of inflammatory mediators that potentially reduce tissue repair and regeneration33,34. In the present study, most patients, when evaluated through the McGill questionnaire in all five evaluations, described pain using descriptors of the sensory, affective, evaluative and miscellaneous groups. However, in the fourth and fifth evaluation, the patients in the elastic bandage group and the decongestant physical therapy did not report any descriptors, in contrast to the patients in the other groups. The McGill Pain Questionnaire evaluates the sensory, affective and evaluative aspects of pain, describing the painful experience that the patients present. The sensory-discriminative dimension evaluates the temporal-spatial, mechanical and thermal aspects of pain; the affective-motivational dimension involves aspects of tension, fear, self-punishment and neurovegetative responses; and the cognitive-evaluative dimension assesses the overall situation of the individual and represents a judgment based on sensory and affective characteristics, previous experience and the significance of the situation.29,30. The compressive therapy available on the market is elastic bandages made of elastic fibers that provide compression during movement and rest. During ambulation, the calf muscles contract, the bandage expands, dissipating the force exerted by the contraction of this muscle and favoring the venous return. The effects of compression on the microcirculation include accelerating blood flow in the capillaries, reducing capillary filtration

Rev Col Bras Cir. 2018; 45(2):e1385


Salomé The impact of decongestive physical therapy and elastic bandaging on the control of pain in patients with venous ulcers

7

and increasing resorption by increasing tissue pressure,

(n=10) and the intervention group (n=10). Patents of the

improving drainage, resulting in decreased edema,

first group were treated only with conventional dressing

35-40

improved pain and ulcer healing . Manual lymphatic drainage, as a technique to aid venous return, is essential for the use of compression therapy. It increases the healing rate of venous ulcers when compared to uncompressed treatment, since it acts both in micro and in the macrocirculation, reducing pathologic reflux during ambulation and increasing ejection volume during the activation of the calf muscles, which favors reabsorption of edema and improves lymphatic drainage24. A study verified the effects of the decongestant physical therapy on the healing of venous ulcers. Twenty patients were divided into two groups: the control group

and those from the second group, with conventional dressing and decongestant physical therapy (combination of techniques: manual lymphatic drainage, compression bandaging, lower limb elevation, myolymphokinetic exercises and skin care). Both groups were treated for six months. The Patients who underwent decongestant physical therapy presented a significant reduction of edema and pain, as well as an improvement in the healing process24. The results of this study allowed us to conclude that the patients treated with decongestant physical therapy and elastic bandage presented improvement of pain in the fifth evaluation performed.

R E S U M O Objetivo: avaliar a dor em indivíduos com úlceras venosas tratadas com bandagem elástica e com terapia física descongestiva. Métodos: foram estudados 90 pacientes, divididos em três grupos com 30 pacientes cada: grupo tratado com bandagem elástica e terapia física descongestiva; grupo tratado com bandagem elástica; e grupo tratado sem bandagem elástica e com curativo primário conforme o tipo de tecido e exsudato. Utilizou-se a Escala Numérica de Dor para quantificar a intensidade da dor e o Questionário de Dor de McGill para a avaliação qualitativa da dor. Resultados: na primeira avaliação, todos os pacientes que participaram do estudo relataram dor intensa. Na quinta avaliação, a maioria dos pacientes tratados com bandagem elástica e terapia física descongestiva não relatou dor; a maioria dos pacientes do grupo da bandagem elástica relatou dor leve; e a maioria dos pacientes tratados apenas com curativo primário relatou dor leve a moderada. A maioria dos pacientes dos grupos bandagem elástica e curativo primário, nas cinco avaliações realizadas através do questionário de McGill, utilizou descritores dos grupos sensorial, afetivo, avaliativo e miscelânea para descrever a dor. Porém, na quarta e quinta avaliações, a maioria dos pacientes do grupo bandagem elástica e terapia física descongestiva não utilizaram nenhum dos descritores. Conclusão: os pacientes tratados com terapia física descongestiva e bandagem elástica apresentaram melhora da dor a partir da terceira avaliação realizada. Descritores: Úlcera da Perna. Úlcera Varicosa. Bandagens Compressivas. Modalidades de Fisioterapia. Medição da Dor.

REFERENCES 1. Silva FAA, Moreira TMM. Sociodemografic and clinical characteristics of customers with venous leg ulcer. Rev Enferm UERJ. 2011;19(3):468-72. 2. Santos VLCG, Sellmer D, Massulo MME. Confiabilidade interobservadores do Pressure Ulcer Scale for Healing (PUSH), em pacientes com úlceras crônicas de perna. Revista Latinoam Enfermagem. 2007;15(3):391-6. 3. Kelechi TJ, Johnson JJ; WOCN Society. Guideline for the management of wounds in patients with

lower-extremity venous disease: an executive summary. J Wound Ostomy Continence Nurs. 2012;39(6):598-606. 4. Körber A, Klode J, Al-Benna S, Wax C, Schadendorf D, Steinstraesser L, et al. Etiology of chronic leg ulcers in 31,619 patients in Germany analyzed by an expert survey. J Dtsch Dermatol Ges. 2011;9(2):116-21. 5. Van Hecke A. “Missing links” in venous leg ulcer management. Br J Nurs. 2011;20(11):S3. 6. Green J, Jester R. Health-related quality of life and chronic venous leg ulceration: Part 2. Br J Community Nurs. 2010;15(3):S4-6, S8, S10, passim.

Rev Col Bras Cir. 2018; 45(2):e1385


8

Salomé The impact of decongestive physical therapy and elastic bandaging on the control of pain in patients with venous ulcers

7. Salomé GM, Ferreira LM. Impact of non-adherent

18. Godoy JMP, Godoy MFG. Drenagem linfática

Ibuprofen foam dressing in the lives of patients with

manual: novo conceito. J Vasc Bras. 2004;3(1):77-80.

8. Lima EL, Salomé GM, Brito Rocha MJ, Ferreira LM. The impact of compression therapy with Unna’s boot on the functional status of VLU patients. J Wound Care. 2013;22(10):558-61. 9. Salomé GM, Almeida SA, Jesus Pereira MT, Massahud MR Jr, Oliveira Moreira CN, Brito MJ, et al. The impact of venous leg ulcers on body image and self-esteem. Adv Skin Wound Care. 2016;29(7):31621. 10. Moreira CNO, Marques CB, Silva MA, Pinheiro FAM, Salomé GM. Association of sociodemographic and clinical factors with spirituality and hope for cure of ostates. J Coloproctology. 2016;36(3):162-72. 11. Salomé GM, de Almeida SA, Mendes B, de Carvalho MR, Bueno JC, Massahud MR Jr, et al. Association of sociodemographic factors with spirituality and hope in patients with diabetic foot ulcers. Adv Skin Wound Care. 2017;30(1):34-9. 12. Porto e Silva MC, Salomé GM, Miguel P, Bernardino C, Eufrasio C, Ferreira LM. Evaluation of feelings helplessness and body image in patients with burns. Rev Enferm UFPE On Line. 2016;10(6):2134-40. 13. Vilela LHR, Salomé GM, Pereira RC, Ferreira LM. Pain assessment in patients with venous leg ulcer treated by compression therapy with Unna’s boot. J Tissue Sci Eng. 2016;7:171.

venous ulcers. Rev Col Bras Cir. 2017;44(2):116-24.

19. Peón AU, Diccini S. Dor pós-operatório em craniotomia. Rev Latinoam Enfermagem. 2005;13(4):489-95. 20. Pimenta CAM, Teixeira MJ. Questionário de dor de McGill: proposta da adaptação para a língua portuguesa. Rev Esc Enferm USP. 1996;30(3):473-83. 21. Salomé GM, Blanes L, Ferreira LM. Avaliação de sintomas depressivos em pessoas com diabetes mellitus e pé ulcerado. Rev Col Bras Cir. 2011;38(5):327-33. 22. Aguiar AC, Sadigursky D, Martins LA, Menezes TM, Santos AL, Reis LA. Social repercussions experienced by elderly with venous ulcer. Rev Gaucha Enferm. 2016;37(3):e55302. 23. Joaquim FL, Camacho ACLF, Silva RMCRAI, Leite BS, Queiroz RS, Assis CRC. Repercussão da visita domiciliar na capacidade funcional de pacientes com úlceras venosas. Rev Bras Enferm. 2017;70(2):287-93. 24. Azoubel R, Torres GV, Silva LWS, Gomes FV, Reis LA. Efeitos da terapia física descongestiva na cicatrização de úlceras venosas. Rev Esc Enferm USP. 2010;44(4):1085-92. 25. Pereira RC, Santos EF, Queiroz MA, Massahud MR Jr, Carvalho MRF, Salomé GM. Depression and wellness in elderly patients with venous ulcers. Rev Bras Cir Plast. 2014;29(4):567-74. 26. Angélico RCP, Oliveira AKA, Silva DDN, Vasconcelos QL, Costa IK, Torres GV. Perfil sociodemográfico,

14. Corrêa NF, Brito MJ, Carvalho Rezende MM, Duarte MF, Santos FS, Salomé GM, et al. Impact of surgical wound dehiscence on health-related quality of life and mental health. J Wound Care. 2016;25(10):56170. 15. Brizzio E, Amsler F, Lun B, Blättler W. Comparison of low-strength compression stockings with bandages for the treatment of recalcitrant venous ulcers. J Vasc Surg. 2010;51(2):410-6. 16. Jones JE, Robinson J, Barr W, Carlisle C. Impact of exudate and odour from chronic venous leg ulceration. Nurs Stand. 2008;22(45):53-4, 56, 58 passim. 17. Partsch H. Compression therapy: clinical and experimental evidence. Ann Vasc Dis. 2012;5(4):41622.

saúde e clínico de pessoas com úlceras venosas atendidos em um hospital universitário. Rev Enferm UFPE Online. 2012;6(1):62-8. 27. Uchimoto S, Tsumura K, Hayashi T, Suematsu C, Endo G, Fujii S, et al. Impact of cigarette smoking on the incidence of Type 2 diabetes mellitus in middle-aged Japanese men: the Osaka Health Survey. Diabet Med.1999;16(11):951-5. 28. Oliveira RM, Silva LMS, Freitas CHA, Oliveira SKP, Pereira MM, Leitão IMTA. Measurement of pain in clinical nursing practice: integrative review. Rev Enferm UFPE on line. 2014;8(8):2872-82. 29. Lourenco L, Blanes L, Salomé GM, Ferreria LM. Quality of life and self-esteem in patients with paraplegia and pressure ulcers: a controlled crosssectional study. J Wound Care. 2014;23(6):331-4,

Rev Col Bras Cir. 2018; 45(2):e1385


Salomé The impact of decongestive physical therapy and elastic bandaging on the control of pain in patients with venous ulcers

37. O’Meara S, Cullum NA, Nelson EA. Compression

336-7. 30. Almeida SA, Moreira CNO, Salomé GM. Pressure

31.

32.

33.

34.

35.

36.

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ulcer scale for healing no acompanhamento da cicatrização em pacientes idosos com úlcera de perna. Rev Bras Cir Plást. 2014;29(1):120-7. Elliott TE, Renier CM, Palcher JA. Chronic pain, depression, and quality of life: correlations and predictive value of the SF-36. Pain Med. 2003;4(4):331-9. Salomé GM, Ferreira LM; Almeida AS. Evaluation of pain in patients with venous ulcers after skin grafting. J Tissue Viability. 2014;23(3):115-20. Gonçalves ML, Gouveia Santos VL, Mattos Pimenta CA, Suzuki E, Komegae KM. Pain in chronic leg ulcers. J Wound Ostomy Continence Nurs. 2004;31(5):27583. Salomé GM, Blanes L, Ferreira LM. The impact of skin grafting on the quality of life and self-esteem of patients with venous leg ulcers. World J Surg. 2014;38(1):233-40. Abreu AM, Oliveira BRB, Manarte JJ. Treatment of venous ulcers with an Unna boot: a case study. Online Braz J Nurs. 2013;12(1):198-208. Abreu AM, Oliveira BGRB. Estudo da Bota de Unna comparado à bandagem elástica em úlceras venosas: um ensaio clínico randomizado. Rev Latinoam Enfermagem. 2015;23(4):571-7.

for venous leg ulcers. Cochrane Database Syst Rev. 2009;21(1):CD000265 38. Salomé GM, Espírito Santo PF, Ferreira LM. Disturbance of sleep in diabetic individuals without ulceration and diabetic individuals with ulceration on foot. Rev Enferm UFPE on line. 2017;11(9):3429-38. 39. Salomé GM, Ferreira LM. Locus of health control, body image and self-image in diabetic individuals with ulcerated feet. Rev Enferm UFPE on line. 2017; 11(9):3419-38. 40. Barbosa MLG, Salomé GM, Ferreira LM. Avaliação da ansiedade e da depressão em pacientes com úlcera venosa tratados com acupuntura. Rev Enferm UFPE on line. 2017;11(Supl. 9):3574-82. Received in: 10/12/2017 Accepted for publication: 09/01/2018 Conflict of interest: none. Source of funding: Capes Post-Doctorate Grant. Mailing address: Geraldo Magela Salomé E-mail: salomereiki@univas.edu.br / salomereiki@yahoo.com.br

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Original Article

q

Factors associated with changes in creatine phosphokinase (CPK) in trauma patients submitted to the “Red Wave”, with evolution to rhabdomyolysis Fatores associados à variação da creatina fosfoquinase (CPK) em pacientes vítimas de trauma, submetidos à “Onda Vermelha”, com evolução à rabdomiólise MARIO PASTORE NETO1; RAFAEL VALÉRIO GONÇALVES3; CARLA JORGE MACHADO2; VIVIAN RESENDE, TCBC-MG1 A B S T R A C T Objective: to identify and analyze factors associated with plasma creatine phosphokinase (CPK) levels in trauma victims with progression to rhabdomyolysis. Methods: we conducted a prospective, longitudinal study, with 50 patients submitted to the “Red Wave” protocol, with evolution to rhabdomyolysis after hospital admission. We studied the variables age, gender, trauma scores, mechanism and outcome, CPK at admission and final, intervals of days between laboratory evaluations, surgery and complications. We stratified CPK values in <500U/L, ³500 - <1000 U/L, and ³1000U/L, with calculation of the difference between the initial and final values. Results: at admission, 83% of patients (n=39) had CPK³1000U/L, with predominance of blunt trauma and thoracic injury (p<0.05), as well as orthopedic fracture, acute renal failure and gastrointestinal bleeding, CPK being lower in those without acute renal injury, with a trend towards statistical significance. There were no differences in final CPK stratification. Factors that were independently associated with the greater CPK variation were, positively, hospitalization time greater than one week and compartment syndrome, and negatively, acute renal injury. Conclusion: the CPK level of 1000U/L remains the lower limit, with importance for early intervention in worsening conditions such as digestive hemorrhage, acute renal injury and compartment syndrome, which implied greater absolute differences between initial and final CPK, in addition to blunt trauma, thoracic injury and orthopedic fracture. Keywords: Rhabdomyolysis. Creatine Kinase. Emergency Medical Services.

INTRODUCTION

R

habdomyolysis is a syndrome with a high life threatening potential, characterized by skeletal striated muscle injury, lysis of the myocyte and release of intracellular contents into the extracellular environment, including enzymes such as lactate dehydrogenase (LDH), aldolase, aspartate aminotransferase (AST), alanine aminotransferase (ALT) and creatine phosphokinase (CPK), as well as ions, such as potassium and phosphorus, myoglobin and uric acid, the latter due to increased catabolism of intracellular purines1,2. Its main complications are hyperkalemia, hypocalcemia, hyperuricemia, hepatic inflammation, cardiac arrhythmias, cardiac arrest and disseminated intravascular coagulation2-4. In later stages,

the patient may develop compartment syndrome and acute renal injury, which is associated with high morbidity and mortality and is present in about 4% to 50% of cases2,4. Regardless of the cause, the mortality rate can reach up to 8%2. The normal function of the myocyte is guaranteed by maintaining an ionic gradient (mainly sodium, potassium and calcium), which is established by the action of transmembrane transport proteins, such as sodium/potassium ATPase (Na+/K+ ATPase), whose enzymatic activities depend on the energy obtained from the degradation of adenosine triphosphate (ATP)3-5. In trauma (crush syndrome or crush injury) or depletion of the ATP stock (excessive consumption of alcohol or intense physical activity, for example), damage occurs to

1 - Federal University of Minas Gerais, Department of Surgery, Belo Horizonte, MG, Brazil. 2 - Federal University of Minas Gerais, Department of Preventive and Social Medicine, Belo Horizonte, MG, Brazil. 3 - Federal University of Minas Gerais, Faculty of Medicine, Belo Horizonte, MG, Brazil. Rev Col Bras Cir. 2018; 45(2):e1604


2

Pastore Neto Factors associated with changes in creatine phosphokinase (CPK) in trauma patients submitted to the “Red Wave”, with evolution to rhabdomyolysis

transmembrane transport proteins and, consequently, to

the severity of the condition, this study aims to identify and

the cell membrane, resulting in ionic imbalance, with great

analyze the factors associated with the greater variation of

+

++3,6

intracellular influx of Na and Ca

. As a result, there is

CPK during hospitalization in trauma patients submitted

myocyte lysis, due to increased intracellular influx of water

to the “Red Wave” protocol. Knowledge of these factors

++

by osmosis, activation of Ca -dependent proteases and ++

would allow reducing the chances of progression to

phospholipases, persistent, Ca -dependent myofibrillar

rhabdomyolysis, early identification of complications

contraction, and the inflammatory cascade resulting from

associated with worsening of the rhabdomyolytic

pathological interactions from the established fibrosis and

condition with increased CPK during hospitalization, and

3-6

necrosis processes . The progression of this muscle injury

early intervention in the complications associated with

process results in rhabdomyolysis.

greater CPK variation and, consequently, greater muscle

The findings of rhabdomyolysis are quantified

damage.

mainly through levels of plasma CPK, an enzyme expressed by several cell types in different tissues,

METHODS

participating in the formation of phosphocreatine from creatine, depending on ATP3,7,8. The phosphocreatine

We conducted a prospective, longitudinal

thus formed acts as an intracellular phosphate reservoir,

study, with a sample composed of 50 patients submitted

which can be used for the regeneration of adenosine

to the “Red Wave” protocol between 2011 and 2015,

diphosphate (ADP) in ATP, in order to maintain normal

with subsequent evolution to rhabdomyolysis after

7

admission to the Risoleta Tolentino Neves Hospital,

cellular functions . Trauma, whether penetrating or blunt, is

a tertiary university hospital which is reference for

associated with immediate elevation of plasma CPK values

trauma, urgency and emergency care in North Belo

in laboratory analysis . Acute myocardial infarction (AMI),

Horizonte9. Victims of violent crimes are a considerable

muscular dystrophy, acute renal injury (ARI), autoimmune

part of the care and population under analysis. The

myositis, malignant neoplasms and other inflammatory

“Red Wave” can be described as a set of medical

processes of mainly muscular involvement are also

and administrative tactical actions whose objective is

2,3

1,2,4

. Thus, timely

to perform thoracotomy and surgical procedures that

request and simple analysis of this biochemical marker

promote the cessation of severe hemorrhagic states in

are efficient ways to reduce the chance of progression of

an efficient and safe manner10.

related to elevated plasma CPK levels

rhabdomyolytic disease, especially to ARI. In addition, the

Of the 50 patients in the sample, admission

value of plasma CPK is directly proportional to the disorder

and final CPK values were present in the medical records

or disintegration of striated muscle tissue, due to the

of, respectively, 47 and 43 patients. We obtained the

concomitant leakage of intracellular muscle constituents

data from the RT (Collector®) database, and assessed

into the circulation. Considering the normal concentration

the following variables: medical records, age, gender,

of CPK<100U/L, concentrations five to ten times higher

RTS (Revised Trauma Score), ISS (Injurt Severity Score),

than the upper normal limit (such as 500-1000 U/L) are

TRISS (Trauma and Injury Severity Score), trauma

used to confirm rhabdomyolysis1,2,4,8.

mechanism and outcome, presence of digestive

Since plasma CPK analysis is a way to prevent

hemorrhage, acute renal injury, cardiac arrhythmia,

progression to rhabdomyolysis and its complications and

compartment

the level of circulating CPK is directly proportional to

hepatic, splenic, intestinal, thoracic, renal and vascular

muscle injury (either direct damage or complications such

injuries, orthopedic fractures, traumatic brain injury,

as compartment syndrome and ARI) and consequently to

admission and final CPK levels, with the interval of days

Rev Col Bras Cir. 2018; 45(2):e1604

syndrome,

compressive

syndrome,


Pastore Neto Factors associated with changes in creatine phosphokinase (CPK) in trauma patients submitted to the “Red Wave”, with evolution to rhabdomyolysis

3

between them, and surgery (laparotomy, thoracotomy,

square or Fisher’s test (if the expected number of cases

orthopedic or other).

in one category was less than 5), this being a univariate

The ISS is an anatomical scoring system, based

analysis. We determined the predictors independently

on the assignment of values from 1 to 6 (Abbreviated

associated with CPK difference by linear regression

Injury Scale, where 1 means minor, 2 moderate, 3 serious,

analysis. Values that had significance less than 20%

4, severe/life threatening, 5 critical/uncertain survival and

(p<0.20) in the univariate analysis were included

6, non-survivor) for each lesion, considering each of the six

in a linear model and the final model was obtained

regions of the body: head and neck, face, chest, abdomen,

by sequential deletion of variables. For this model,

extremities (including pelvis) and outer surface. In the case

we categorized some continuous variables. The level

of multiple lesions, only the highest values for each region

considered for significant results was 5% (p<0.05). In

are used, and the three largest values, in different body

order to evaluate the obtained multivariate model, we

segments, are folded and summed to produce the index.

performed the imtest test implemented in the software

The values range from 0 to 75, so that if any lesion equals

that, in addition to assessing the heteroskedasticity of

11

6, in any segment, the ISS is 75 automatically . RTS is

the final model, also tests for kurtosis and asymmetry

a physiological scoring system, with great reliability and

of the predicted data.

accuracy to predict death, being calculated from the first

The study was approved by the Ethics in Research

measurement of the Glasgow Coma Scale (ECG), systolic

Committee of the UFMG and the Risoleta Tolentino Neves

blood pressure (SBP) and respiratory rate (RR), ranging

Hospital, and submitted to the Plataforma Brasil (CAAE:

from 0 to 7.840812. We considered ISS levels below 25

44349515.5.0000.5149).

as low or moderate severity trauma; 25 to 34, severe trauma; 35 or more, very severe trauma13. We considered

RESULTS

that the probability of survival was satisfactory when RTS was equal to or higher than 6, that is, probability greater

The main descriptive results associated with

1

admission CPK categories are shown in table 1. The 47

We created six specific variables, which

patients had a mean age of 39.1 years (±16.8) and were

represent the distribution of admission and final CPK

mostly men (83.0%; n=39). The most common trauma

values in three distinct categories each: less than

mechanism was the blunt (68.1%, n=32). The mean RTS

than 90% .

8

<500U/L; ³500U/L - <1000U/L; ³1000U/L . In addition,

was compatible with survival over 90% (6.9; ±1.74) and

we created another specific variable that represents the

the ISS with low and moderate severity trauma (22.9;

absolute value of the difference between the final and

±12.4). Forty-five patients (95.7%) underwent some

admission CPK values.

surgical procedure, with a predominance of laparotomy

Once the variables were organized, we

(46.8%; n=22). As for lesions and complications, the most

performed the statistical analysis with the SPSS

common was orthopedic fracture (n=33, 70.2%), followed

Release 23.0.0.0 software for Windows. We expressed

by thoracic injury (n=24, 51.1%), digestive hemorrhage

continuous variables as mean and standard deviation,

(n=17, 36.2%), acute renal injury (n=16, 34%), liver injury

and analyzed them using the Student’s t-test; we

(n=13, 27.7%) and intestinal lesion (n=13, 27.7%).

analyzed categorical variables with the Pearson’s chi-

Rev Col Bras Cir. 2018; 45(2):e1604


4

Pastore Neto Factors associated with changes in creatine phosphokinase (CPK) in trauma patients submitted to the “Red Wave”, with evolution to rhabdomyolysis

Table 1. Results according to CPK range on admission.

Total (n=47) Age in years: mean (SD) Gender: n (%) Male Female Trauma mechanism: n (%) Blunt Penetrating Trauma outcome: n (%) Died Survived RTS: mean (SD) ISS: mean (SD) TRISS: mean (SD) ICU stay: n (%) Gastrointestinal bleeding: n (%) Acute renal injury: n (%) Cardiac arrhythmia: n (%) Compartmental Sd: n (%) Compressive Sd: n (%) Intestinal injury: n (%) Liver injury: n (%) Splenic injury: n (%) Kidney injury: n (%) Vascular injury: n (%) Orthopedic fracture: n (%) TBI: n (%) Thoracic lesion: n (%) Underwent surgery: n (%) Thoracotomy: n (%) Laparotomy: n (%) Orthopedic surgery: n (%) Other surgery: n (%)

Admission CPK Admission CPK Admission CPK <500 (n=4) ³500 and <1000 (n=4) ³1000 (n=39)

p

39.1 (16.78)

59.8 (29.06)

36.5 (14.62)

37.3 (14.43)

39 (83) 8 (17)

2 (89.4) 2 (10.6)

3 (75) 1 (25)

34 (87.2) 5 (12.8)

0.154

32 (68.1) 15 (31.9)

2 (50) 2 (50)

2 (50) 2 (50)

28 (71.8) 11 (28.2)

0.484

2 (50) 2 (50) 5.27 (3.64) 20.75 (5.74) 0.698 (0.404) 4 (100) 2 (50) 1 (25) 0 (0) 0 (0) 0 (0) 1 (25) 1 (25) 0 (0) 1 (25) 1 (25) 2 (50) 0 (0) 1 (25) 4 (100) 0 (0) 3 (75) 1 (25) 1 (25)

5 (12.8) 34 (87.2) 7.06 (1.47) 23.95 (13.22) 0.874 (0.238) 34 (89.4) 12 (30.8) 12 (30.8) 0 (0) 3 (7.7) 0 (0) 10 (25.6) 11 (28.2) 5 (12.8) 1 (2.6) 2 (5.1) 28 (71.8) 3 (7.7) 23 (59) 37 (94.9) 12 (30.8) 17 (43.6) 2 (5.1) 3 (7.7)

10 (21.3) 3 (75) 37 (78.7) 1 (25) 6.91 (1.74) 7.22 (0.73) 22.94 (12.42) 15.25 (4.57) 0.86 (0.25) 0.927 (0.061) 42 (89.4) 4 (100) 17 (36.2) 3 (75) 16 (34) 3 (75) 0 (0) 0 (0) 4 (8.5) 1 (25) 0 (0) 0 (0) 13 (27.7) 2 (50) 13 (27.7) 1 (25) 5 (10.6) 0 (0) 3 (6.4) 1 (25) 3 (6.4) 0 (0) 33 (70.2) 3 (75) 3 (6.4) 0 (0) 24 (51.1) 0 (0) 45 (95.7) 4 (100) 12 (25.5) 0 (0) 22 (46.8) 2 (50) 3 (6.4) 0 (0) 5 (10.6) 1 (25)

0.005

0.563 0.179 0.190 N/A 0.406 N/A 0.579 0.983 0.563 0.061 0.260 0.647 0.720 0.044 0.807 0.192 0.483 0.260 0.351

SD= Standard deviation; Sd= syndrome; ICU= Intensive Care Unit; TBI= traumatic brain injury; N/a= not applicable.

Regarding the CPK admission levels, the majority of patients presented values greater than or equal to 500 (n=43; 91.49%), with the predominance of patients with CPK greater than or equal to 1000 (n=39, 82.98%). Of these, the mean age was 37.3 years (±14.43) and were mostly men (87.2%; n=34). The most common trauma mechanism was the blunt (71.8%; n=28). The mean RTS

was compatible with survival above 90% (7.06; ±1.47) and the ISS, with low and moderate severity trauma (23.95; ±13.22). The mean ICU time lengths were longer than 30 days. Thirty-seven patients (94.9%) underwent surgery, with a predominance of laparotomy (43.6%, n=17), followed by thoracotomy (30.8%, n=12). As for lesions and complications, the most common was the

Rev Col Bras Cir. 2018; 45(2):e1604


Pastore Neto Factors associated with changes in creatine phosphokinase (CPK) in trauma patients submitted to the “Red Wave”, with evolution to rhabdomyolysis

orthopedic fracture (n=28, 71.8%), followed by thoracic injury (n=23, 59%), digestive hemorrhage (n=12, 30.8%), acute renal injury (n=12, 30.8%), liver injury (n=11, 28.2%) and intestinal lesion (n=10, 25.6%). There were significant differences between means and proportions for the following variables regarding the stratification by CPK at admission: trauma outcome (p=0.005), with predominance of the blunt between patients with higher levels of CPK, and chest injury (p=0.044), more frequent in patients with higher levels of CPK. The results of the final CPK categories are shown in table 2. The 43 patients had a mean age of

5

40.19 years (±16.6), with a predominance of men (81.4%; n=35). The most common trauma mechanism was the blunt (67.4%, n=29). The mean RTS was compatible with survival greater than 90% (n=7; ±1.69) and the ISS, with low and moderate severity trauma (22.58; ±12.88). The mean length of ICU stay was 35 days. Forty-two patients (97.7%) underwent surgery, with a predominance of laparotomy (46.5%; n=20). As for lesions and complications, the most common was orthopedic fracture (n=29, 67.4%), followed by thoracic injury (n=21, 48.8%), digestive hemorrhage (n=15, 34.9%), acute renal injury (n=15, 34.9%), intestinal lesion (n=12, 27.9%), and hepatic injury (n=11, 25.6%).

Table 2. Results according to CPK final levels.

Total (n=43)

Final CPK Final CPK Final CPK <500 (n=26) ³500 and <1000 (n=9) ³1000 (n=8)

Age in years: mean (SD) 40.2 (16.6) 44.6 (17.6) Male: n (%) 35 (81.4) 21 (80.8) Blunt mechanism: n (%) 29 (67.4) 17 (65.4) Death as outcome: n (%) 9 (20.9) 4 (15.4) RTS: mean (SD) 7 (1.69) 7.24 (1.12) ISS: mean (SD) 22.58 (12.88) 21.15 (10.77) TRISS: mean (SD) 0.87 (0.25) 0.92 (0.16) ICU stay: n (%) 38 (88.4) 24 (92.3) Gastrointestinal bleeding: n (%) 15 (34.9) 9 (34.6) Acute kidney injury: n (%) 15 (34.9) 10 (38.5) Cardiac arrhythmia: n (%) 0 (0) 0 (0) Compartmental Sd: n (%) 3 (7) 2 (7.7) Compressive Sd: n (%) 0 (0) 0 (0) Intestinal Injury: n (%) 12 (27.9) 7 (26.9) Liver injury: n (%) 11 (25.6) 7 (26.9) Splenic Injury: n (%) 4 (9.3) 2 (7.7) Kidney injury: n (%) 3 (7) 2 (7.7) Vascular injury: n (%) 3 (7) 2 (7.7) Orthopedic fracture: n (%) 29 (67.4) 17 (65.4) TBI: n (%) 2 (4.7) 1 (3.8) Thoracic injury: n (%) 21 (48.8) 14 (53.8) Underwent surgery: n (%) 42 (97.7) 26 (100) Thoracotomy: n (%) 11 (25.6) 5 (19.2) Laparotomy: n (%) 20 (46.5) 10 (38.5) Orthopedic surgery: n (%) 2 (4.7) 1 (3.8) Other surgery: n (%) 5 (11.6) 4 (15.4)

31 (10.9) 8 (88.9) 6 (66.7) 1 (11.1) 6.87 (1.84) 23 (10.68) 0.87 (0.26) 6 (66.7) 2 (22.2) 2 (22.2) 0 (0) 0 (0) 0 (0) 3 (33.3) 3 (33.3) 1 (11.1) 0 (0) 0 (0) 7 (77.8) 1 (11.1) 4 (44.4) 8 (88.9) 3 (33.3) 4 (44.4) 1 (11.1) 0 (0)

SD= Standard deviation; Sd= syndrome; ICU= Intensive Care Unit; TBI= traumatic brain injury; N/a= not applicable. Rev Col Bras Cir. 2018; 45(2):e1604

36.1 (14.6) 6 (75.0) 6 (75.0) 4 (50.0) 6.49 (2.7) 26.75 (20.6) 0.73 (0.39) 8 (100) 4 (50) 3 (37.5) 0 (0) 1 (12.5) 0 (0) 2 (25) 1 (12.5) 1 (12.5) 1 (12.5) 1 (12.5) 5 (62.5) 0 (0) 3 (37.5) 8 (0) 3 (37.5) 6 (75) 0 (0) 1 (12.5)

p

0.757 0.878 0.078

0.062 0.487 0.668 N/A 0.585 N/A 0.915 0.598 0.9 0.585 0.585 0.749 0.529 0.690 0.145 0.489 0.192 0.529 0.461


Pastore Neto Factors associated with changes in creatine phosphokinase (CPK) in trauma patients submitted to the “Red Wave”, with evolution to rhabdomyolysis

6

Regarding the final CPK ranges, the majority

means and proportions for the variables regarding

of patients had values lower than 500 (n=26; 60.47%).

stratification by the final CPK value: trauma outcome

Of these, the mean age was 44.62 years (±17.61) and they were mostly men (80.8%; n=21). The most common trauma mechanism was the blunt (65.4%, n=17). The mean RTS was compatible with survival above 90% (7.24; ±1.12) and the ISS, with low and moderate severity trauma (21,15; ±10,77). The mean time of ICU stay was 21 days. Twenty-six (100%) underwent surgery, with a predominance of laparotomy (38.5%; n=10). The most common lesions and complications were orthopedic fractures (n=17, 65.4%), followed by thoracic injury (n=14, 53.8%), acute renal injury (n=10, 38.5% %) and digestive hemorrhage (n=9; 34.6%). There were no significant differences between

(p=0.078), and time, in days, of ICU admission (p=0.062). Table 3 shows the mean CPK changes during the hospitalization period, according to the variables of the 43 patients with final CPK value filled in the sample. The highest mean variation observed was compartment syndrome (13658.67, ±8024.04), followed by intestinal lesion (7143.42, ±3125.68), digestive hemorrhage (6494.8, ±2502.51), TBI (6150.5, ±2018.5) and laparotomy (5331.55, ±1921.48). The lowest mean variation was related to orthopedic surgery (1469, ±1010), followed by renal injury (1815.67, ±1586.47), vascular lesion (2232.67, ±912.95) and female gender (2490.75, ±783.98).

Table 3. Results of patients stratification according to the CPK variation during hospitalization.

Variation of CPK (Final CPK - Admission CPK) Mean (SD) = 4261 (6105)

p

Gender Male

4666 (1123)

Female

2491 (784)

0.121

ICU stay

4478 (1046)

0.168

Gastrointestinal bleeding

6495 (2503)

0.197

Acute renal injury

2897 (815)

0.192

Compartmental Sd: mean (SD)

13659 (8024)

0.004

Intestinal injury: mean (SD)

7143 (3126)

0.053

Vascular injury: mean (SD)

2233 (913)

0.141

Orthopedic fracture: mean (SD)

3313 (537)

0.145

Orthopedic surgery: mean (SD)

1469 (1010)

0.112

Other surgery: mean (SD)

2557 (938)

0.187

SD= Standard deviation; Sd= syndrome; ICU= Intensive Care Unit; TBI= traumatic brain injury; N/a= not applicable.

The values with significance lower than 20% (p<0.20) included in the final linear regression model were gender (p=0.121), ICU stay (p=0.168), digestive hemorrhage (p=0.197), acute renal injury (p=0.112), compartment syndrome (p=0.004), intestinal lesion (p=0.053), vascular injury (p=0.141), orthopedic fracture (p=0.145), orthopedic surgery (p=0.112), and other

surgeries (p=0.187). Table 4 indicates the factors that were independently and positively associated with CPK variation: positively, hospitalization time greater than one week and compartment syndrome, and negatively, acute renal injury. There was no evidence of heteroscedasticity (p=0.784), asymmetry (p=0.403), or kurtosis (p=0.260).

Rev Col Bras Cir. 2018; 45(2):e1604


Pastore Neto Factors associated with changes in creatine phosphokinase (CPK) in trauma patients submitted to the “Red Wave”, with evolution to rhabdomyolysis

7

Table 4. Factors independently associated with the CPK difference.

Variable

Coefficient

95% CI (robust)

p-value

Length of stay (reference: up to 7 days)

4221

1224;7218

0.007

Acute renal injury (reference: absent)

-3296

-6307;-285

0.033

Compartment syndrome (reference: absent)

11474

1179;14064

0.033

Linear regression equation intercept

1567

-161.7;3296

0.074

DISCUSSION In patients studied with ARI, CPK at admission was lower than those without ARI, with a trend towards statistical significance (p=0.096), a difference not observed in the stratification of patients with compartment syndrome. Statistically, this is the reason why the presence of ARI is associated with negative differences in CPK in the presence of other factors, such as hospitalization longer than one week and compartment syndrome. In practice, this result may represent that patients with rhabdomyolysis and lower admission severity, represented by lower CPK, are more likely to progress to ARI, but it should also be considered that CPK has peaks within 24 to 72 hours, and then declines gradually in seven to ten days, which may influence the results found depending on the length of time the patient is hospitalized1. Thus, there is a need for more studies on this relationship. In rhabdomyolysis, clinical findings are quantified from the laboratory analysis of CPK levels, which are typically elevated in such patients, thus constituting an important biomarker of the disease2,14. Thus, the literature establishes the CPK threshold greater than 500U/L to define significant rhabdomyolysis; other studies define CPK of 1000U/L as the lower limit for diagnosis14. Thus, the present study, based on previous studies, suggests the value of 1000U/L as the lower limit for CPK analysis, since 83% of the admission values of the patients admitted to the “Red Wave” with clinical diagnosis of rhabdomyolysis were above this threshold8,15. Rhabdomyolysis is basically a consequence of muscle injury, mainly associated with compartment syndrome, trauma (crush injury or reperfusion injury), and the most severe complication present in 13% to 50% of cases is ARI. Myoglobin deposit leads to renal vasoconstriction, intratubular deposits, and direct damage

to the renal tubules1,16. At admission, the patients in the present study had mainly orthopedic fracture (71.8%) and thoracic injury (59%), typically associated with trauma and, consequently, with muscle injury. ARI was present in about 31% of the patients, within the historical range of the literature. Rapid diagnosis and early intervention are essential for patient prognosis. In most cases, renal function, a major concern in this syndrome, recovers and the survival rate is around 78%17. Of the patients with CPK value assessed at the end of hospitalization, approximately 61% presented normalization of its levels (<500U/L). In addition, the survival rate was around 79% for all patients. Patients with CPK>1000U/L on admission had the highest survival rates in the study, probably because they demanded more attention from the medical team, with surgical procedures. The same was not observed for patients in the same category (CPK>1000U/L) at the end of hospitalization, with survival of 50%, due to the worse prognosis and irreversibility of the condition. The early diagnosis of rhabdomyolysis is mainly related to the recognition of a clinical condition compatible with the syndrome, before the laboratory evaluation of CPK levels, which, despite being a simple and cost-effective biochemical marker, may require extra essential time to the critical management in the emergency room. Concurrently, an effective treatment represents the effective management of the main lesions, so that the relation of an injury to the evolution of the patient’s clinical condition can be quantified from the variation of the CPK levels2,17. In this context, trauma alone is a common cause of rhabdomyolysis, either by the compression and associated muscle injury, or by concomitant lesions, requiring proper management. The present study points to digestive hemorrhage, acute renal injury and

Rev Col Bras Cir. 2018; 45(2):e1604


8

Pastore Neto Factors associated with changes in creatine phosphokinase (CPK) in trauma patients submitted to the “Red Wave”, with evolution to rhabdomyolysis

compartment syndrome as variables that are statistically

hemorrhage, acute renal injury, liver injury and intestinal

associated with a greater variation in CPK levels during

lesion, and in patients submitted to laparotomy, mainly,

hospitalization, independent of other factors, thus requiring greater attention from emergency teams16. Digestive hemorrhage, although severe and present in the descriptive results according to CPK variation during hospitalization, did not enter into the final model of the factors independently associated with CPK difference, probably because the other factors had a greater impact on CPK. The present study indicated a higher ratio of rhabdomyolysis with CPK values above 500U/L, and especially >1000U/L, at admission, in association with orthopedic fracture, followed by thoracic injury, digestive

and thoracotomy. From a practical point of view, the need for early request of plasma CPK in trauma victims is reinforced, with a value of 1000U/L as the lower limit for analysis. In addition, the clinical picture of the patient and the complications presented should be evaluated in order to intervene early in conditions related to aggravation of muscle injury and, consequently, rhabdomyolysis, such as orthopedic fracture, digestive hemorrhage and acute renal injury. However, there is a need for further studies in the area, in order to obtain a larger sample of comparative data.

R E S U M O Objetivo: identificar e analisar fatores associados à variação dos níveis plasmáticos de creatina fosfoquinase (CPK) em vítimas de trauma com evolução à rabdomiólise. Métodos: estudo longitudinal prospectivo, com 50 pacientes que seguiram para o protocolo “Onda Vermelha”, com evolução à rabdomiólise, após admissão hospitalar. Foram estudadas as variáveis: idade, sexo, escores, mecanismo e desfecho de trauma, CPK na admissão e final, intervalos de dias entre as avaliações laboratoriais, realização de cirurgia e complicações. Os valores da CPK foram estratificados em <500U/L; ³500 - <1000 U/L; ³1000U/L, com cálculo da diferença entre os valores inicial e final. Resultados: à admissão, 83% dos pacientes (n=39) apresentavam CPK³1000U/L, com predomínio de trauma contuso e lesão torácica (p<0,05), além de fratura ortopédica, lesão renal aguda e hemorragia digestiva, sendo que a CPK era menor naqueles sem lesão renal aguda, com tendência à significância estatística. Não houve diferenças na estratificação por CPK final. Fatores que se revelaram independentemente associados à maior variação da CPK foram, positivamente, o tempo de internação superior a uma semana e síndrome compartimental, e negativamente, lesão renal aguda. Conclusão: como achado, nível de CPK de 1000U/L permanece como limite inferior, com importância à intervenção precoce em condições de agravamento do quadro, como hemorragia digestiva, lesão renal aguda e síndrome compartimental, que implicaram maiores diferenças absolutas entre CPK inicial e final, além do trauma contuso, lesão torácica e fratura ortopédica. Descritores: Rabdomiólise. Creatina Quinase. Serviços Médicos de Emergência.

REFERENCES

Rhabdomyolysis. J Am Soc Nephrol. 2000;11(8):155361.

1. Petejova N, Martinek A. Acute kidney injury due to rhabdomyolysis and renal replacement therapy: a critical review. Crit Care. 2014;18(3):224. 2. Bagley WH, Yang H, Shah KH. Rhabdomyolysis. Intern Emerg Med. 2007;2(3):210-8. 3. Khan FY. Rhabdomyolysis: a review of the literature. Neth J Med. 2009;67(9):272-83. 4. Rosa NG, Silva G, Teixeira A, Rodrigues F, Araújo JA. Rabdomiólise. Acta Méd Port. 2005;18(4):271-82. 5. Vanholder R, Sever MS, Erek E, Lameire N.

6. Malinoski DJ, Slater MS, Mullins RJ. Crush injury and rhabdomyolysis. Crit Care Clin. 2004;20(1):171-92. 7. Baynes JW, Dominiczak MH. Bioquímica médica. 3. ed. Rio de Janeiro: Elsevier, 2011. 8. Torres PA, Helmstetter JA, Kaye AM, Kaye AD. Rhabdomyolysis:

pathogenesis,

diagnosis,

and

treatment. Ochsner J. 2015;15(1):58-69. 9. Miranda B. Hospital das Clínicas e Risoleta Neves reduzem leitos. O Tempo. Belo Horizonte. [Internet]. 2015 Jan 21. [cited 2017 fev 17]. Disponível em:

Rev Col Bras Cir. 2018; 45(2):e1604


Pastore Neto Factors associated with changes in creatine phosphokinase (CPK) in trauma patients submitted to the “Red Wave”, with evolution to rhabdomyolysis

9

http://www.otempo.com.br/cidades/hospital-

with rhabdomyolysis: do bicarbonate and mannitol

das-cl%C3%ADnicas-e-risoleta-neves-reduzem-

make a difference? J Trauma. 2004;56(6):1191-6.

leitos-1.977233 10. Palmer C. Major trauma and the injury severity score-where should we set the bar? Annu Proc Assoc Adv Automot Med. 2007;51:13-29. 11. Champion HR, Sacco WJ, Copes WS, Gann DS, Gennarelli TA, Flanagan ME. A revision of the Trauma Score. J Trauma. 1989;29(5):623-9. 12. Rezende R, Avanzi O. Importância do Índice Anatômico de Gravidade do Trauma no manejo das fraturas toracolombares do tipo explosão. Rev Col Bras Cir. 2009;36(1):9-13. 13. Alvarez BD, Razente DM, Lacerda DA, Lother NS, Von Bahten, Stahlschmidt CM. Analysis of the Revised Trauma Score (RTS) in 200 victims of different trauma mechanisms. Rev Col Bras Cir. 2016;43(5): 334-40. 14. Lima RS, da Silva Junior GB, Liborio AB, Daher EF. Acute kidney injury due to rhabdomyolysis. Saudi J Kidney Dis Transpl. 2008;19(5):721-9. 15. Brown CV, Rhee P, Chan L, Evans K, Demetriades D, Velmahos GC. Preventing renal failure in patients

16. Nayak S, Jindal A. Myoglobinuria and acute kidney injury. J Integr Nephrol Androl. 2015;2(2):50-4. 17. Keltz E, Khan FY, Mann G. Rhabdomyolysis. The role of diagnostic and prognostic factors. Muscles Ligaments Tendons J. 2014;3(4):303-12.

Received in: 14/11/2017 Accepted for publication: 22/01/2018 Conflict of interest: none. Source of funding: CNPq Research Productivity Grant of the corresponding author. Bolsa PIBIC / CNPq of the second author. Mailing address: Carla Jorge Machado E-mail: carlajmachado@gmail.com / carlajm@ufmg.br

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Anthropometric and clinical profiles of post-bariatric patients submitted to procedures in plastic surgery Perfil antropométrico e clínico de pacientes pós-bariátricos submetidos a procedimentos em cirurgia plástica SIMONE CORRÊA ROSA1,2; JEFFERSON LESSA SOARES DE MACEDO, TCBC-DF1,3; LUIZ AUGUSTO CASULARI2; LUCAS RIBEIRO CANEDO3; JOÃO VITOR ALMEIDA MARQUES3 A B S T R A C T Objective: to evaluate the profile of patients submitted to post-bariatric plastic surgery at the North Wing Regional Hospital, Brasília, DF. Methods: we conducted a prospective, descriptive and analytical study of patients submitted to Roux-en-Y gastroplasty, and subsequently to plastic surgery, from January 2011 to December 2016. We assessed body mass index before gastroplasty and after surgery plastic surgery, postoperative complications and comorbidities. Results: we studied 139 patients (130 women and nine men), with a mean age of 41 years, who underwent 233 operations. The mean BMI at the time of plastic surgery was 27.44kg/m2. The mean weight loss was 47.02kg and the mean maximum BMI was 45.17kg/m2. The mean time between bariatric surgery and plastic surgery was 42 months. The most important co-morbidities before plastic surgery were arterial hypertension (11.5%), arthropathy (5.4%), diabetes mellitus (5%) and metabolic syndrome (4.3%) (p<0.01). Of the 139 patients operated on, 76.97% underwent abdominoplasty followed by mammoplasty (42.46%), rhytidoplasty (17.27%) and brachioplasty (13.67%). Fourteen (13.08%) patients underwent herniorrhaphy combined with abdominoplasty. We performed anchor abdominoplasty in 19.42%. The rate of postoperative complications was 26.65%. Conclusion: the epidemiological profile of post-bariatric patients who underwent plastic surgery was similar to that reported in the literature, except for the low rate of associated surgeries and postoperative complications. Plastic surgery in post-bariatric patients has led to an improvement in the quality of life in most of these patients. Keywords: Bariatric Surgery. Surgery, Plastic. Abdominoplasty. Postoperative Complications.

INTRODUCTION

can be attributed to changes in physical appearance and the decline associated with dissatisfaction with one’s own

O

besity is a disease of epidemic proportions, often associated with increased morbidity and mortality, as well as increased health spending, and reduced life quality and expectancy1. Safety in the performance of bariatric surgery, represented by low rates of early and late complications (venous thromboembolism, surgical reintervention, prolonged hospitalization) and a mortality rate of 0.3%, together with a significant improvement in comorbidities, justify its inclusion as an important strategy in the treatment of severe obesity2,3. However, many patients are not prepared to deal with excess skin due to massive weight loss, which can lead to a decline in quality of life and an increased risk of weight regain4,5. These patients show stabilization or even decline in quality of life after the second year of gastric bypass surgery6, which

body image. Repairing plastic surgery plays an important role in stabilizing the quality of life of patients with massive weight loss after bariatric surgery, maintaining the improvement of the quality of life sustained in the long term7. This study aims to present the anthropometric profile, the presence of comorbidities and the quality of life of post-bariatric patients submitted to procedures in plastic surgery.

METHODS We carried out a prospective study in a public reference hospital for bariatric surgery, with individuals who underwent Roux-en-Y gastric bypass and were

1 - Asa Norte Regional Hospital, Plastic Surgery Service, Brasília, DF, Brazil. 2 - University of Brasília/FEPECS, Post-Graduation Course in Health Sciences, Brasília, DF, Brazil. 3 - Superior School of Health Sciences, Medical School, Brasília, DF, Brazil. Rev Col Bras Cir. 2018; 45(2):e1613


Rosa Anthropometric and clinical profiles of post-bariatric patients submitted to procedures in plastic surgery

2

subsequently operated on for body contouring, from

weight for six months, individuals who did not sign the

2011 to 2016, after massive weight loss. The same staff

informed consent form (ICF), patients submitted to other

team performed all operations at the Regional Hospital of

bariatric procedures after Roux-en-Y gastroplasty, and

Asa Norte, BrasĂ­lia, DF.

patients with postoperative follow-up of <12 months.

The body mass index (BMI) was used for the

All

patients

received

non-drug

diagnosis of obesity and the following criteria were used:

thromboprophylaxis, such as early ambulation and lower

normal weight (BMI between 18.5 and 24.9 kg/m2),

limb bandaging. We performed bladder catheterization,

overweight (BMI between 25 and 29.9 kg/m2), obesity

with catheter removal on the first postoperative day, and

2

grade I (BMI between 30 and 34.9 kg/m ), obesity grade 2

II (BMI between 35 and 39.9 kg/m ) and obesity grade III 2 8.9

(BMI Âł40kg/m ) .

prophylactic antibiotic therapy with 2g of IV cefazolin on the anesthetic induction. The variables analyzed before the restorative

2

Patients with BMI >40kg/m and those with BMI

surgery included age, gender, weight, height, BMI before

>35kg/m with associated comorbidities were submitted

bariatric surgery, BMI before reconstructive plastic surgery,

to bariatric surgery according to international standards.

total weight loss, quality of life analysis and complication

In addition, patients had previous attempts at weight

rate. After bariatric surgery, we considered comorbidities

loss for at least two years, absence of serious clinical

resolved when they were controlled without medication,

diseases identified by preoperative exams, absence of

and improved, when they were controlled by reduced

severe psychopathologies, absence of illicit drug use and

doses of medication.

2

alcoholism, age between 18 and 65 years and ability to

For

the

diagnosis

of

systemic

arterial

understand the explanations about the implications of the

hypertension, dyslipidemias, type 2 diabetes mellitus

surgical procedure. After bariatric surgery, the patients

and metabolic syndrome, were used the parameters

were kept in follow-up with the multidisciplinary team

listed in the respective guidelines of the Brazilian Society

until weight stabilization and control of comorbidities,

of Cardiology, currently described in the First Brazilian

when they were referred to the Plastic Surgery outpatient

Guideline for Diagnosis and Treatment of Metabolic

clinic.

Syndrome9,11. We performed the diagnosis of hepatic The percentage of excess weight loss (%EWL)

steatosis using preoperative abdominal ultrasonography.

was obtained from the following formula: weight loss

To evaluate the impact of post-bariatric plastic

after surgery / overweight X 100. Excess weight was

surgery on the quality of life of these patients, we used

calculated by subtracting the ideal weight, established for

the BAROS (Bariatric Analysis and Reporting Outcome

2 10

a BMI of 25Kg/m

, from the weight at the beginning

System) method. The Moorehead-Ardelt quality of life

of preoperative follow-up10. The BMI variation (delta-BMI)

questionnaire consists of five questions about self-

was calculated by the difference between the maximum

esteem, readiness for physical activity, social coexistence,

BMI before the bariatric surgery and the BMI at the

readiness for work and sexual activity12. Each of the five

moment of the repairing plastic surgery.

questions in the quality of life questionnaire corresponds

Inclusion

criteria

for

post-bariatric

repair

to five response possibilities that generate a final value for

surgery were: weight stability for at least six months after

each question. The patient selected the most appropriate

achieving the goal of weight loss for each case; absence

response for each item of the questionnaire after the

of illicit drug use or alcoholism; absence of moderate or

body contouring repair plastic surgery. The sum of the

severe psychotic or dementia pictures; and understanding

values attributed to each of the five questions expressed

of the need for weight maintenance and post-operative

the individual value of each case, ranging from -3 (lowest

follow-up with a multidisciplinary team throughout life.

quality of life possible) to +3 (best quality of life possible).

Exclusion criteria were smoking, gestational

After that, the final values of the questionnaire were

intention, weight instability with no maintenance of

categorized into five classes of quality of life: greatly

Rev Col Bras Cir. 2018; 45(2):e1613


Rosa Anthropometric and clinical profiles of post-bariatric patients submitted to procedures in plastic surgery

3

reduced, decreased, minimal or no change, improved and

followed by singles. Regarding schooling, patients with a

greatly improved.

median level predominated, followed by the fundamental included

level, both comprising 86.3% of the sample. The mean

necrosis,

time interval between bariatric surgery and the repairing

deep venous thrombosis and pulmonary embolism. We

plastic procedure was 42.51±28.20 months. Patients were

divided the complications into major and minor. Major

submitted to plastic surgery more frequently between

complications were those requiring a new surgical

25 and 48 months, followed by 18 to 24 months, both

procedure for hematoma drainage, seroma drainage,

representing 74% of the sample (Tables 1 and 2).

The hematomas,

complications seromas,

evaluated

dehiscences,

tissue

suturing of dehiscence areas or rehospitalization for systemic antibiotic therapy. We performed statistical analysis with the statistical package SPSS (Statistical Package for Social Sciences) version 20.0 for Windows (SPSS Inc. Chicago,

Table 1. Distribution by gender, origin, age groups, marital status and education level of post-bariatric patients undergoing reconstructive plastic surgery in the North Wing Regional Hospital, Brasilia, DF, from 2011 to 2016.

Variables

IL, USA). We described continuous variables using the

N

%

130

93.5

9

6.5

Gender

mean and standard deviation, and the categorical ones, with relative frequencies. We evaluated the normality

Female

of the variables with the Kolmogorov-Smirnov test. We

Male Origin

performed the comparisons between groups with the chisquare test for the dichotomous variables, the Student’s

DF

127

91.4

t-test for continuous variables with normal distribution,

Out of the DF

12

8.6

< 30

15

10.7

30-39

44

31.7

40-49

55

39.6

= 50

25

18.0

and the Mann-Whitney U-test for continuous variables

Age (years)

without normal distribution. The minimum significance accepted was the level of 5% (p<0.05). We elaborated this research in accordance with the resolution of the National Health Council number 466, of 12/12/2012. All individuals involved in this study

Marital status

were informed and signed the ICF for execution consent. In the present study, there was no conflict of interest. The

Married

86

61.9

project was approved by the Ethics in Research Committee

Single

40

28.8

of the Health Department of the Federal District, with the

Divorced

9

6.4

number CAAE 52738216.5.0000.5553.

Widowed

4

2.9

College

16

11.5

High school

72

51.8

Essential

48

34.5

Illiterated

3

2.2

Schooling

RESULTS There were 139 patients who underwent Rouxen-Y gastroplasty, 57.55% (80 patients) by laparoscopy and 42.45% (59 patients) by laparotomy. The mean age

Time interval (months) *

was 41.18 years ±9.63 (range 22 to 66). As shown in table 1, women were the most frequently operated. The

18 – 24

40

28.7

majority of patients came from the Federal District. The

25 – 48

63

45.3

most frequent age group was 40 to 49 years, followed by

49 – 72

25

18

> 72

11

9

30 to 39 years, both representing 71.3% of the casuistry. Married or stable partners were the most observed,

*

Time interval between bariatric surgery and plastic surgery.

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Rosa Anthropometric and clinical profiles of post-bariatric patients submitted to procedures in plastic surgery

4

Table 2. Profile of the patients before the reconstructive plastic surgery.

Characteristics

Mean ± Sd

Range

41.18 ± 9.63

22 to 66

119.98 ± 23.76

86 to 220

45.17 ± 7.99

35 to 88.13

Final pré-plastic BMI (kg/m )

27.44 ± 3.79

19.38 to 47

Total weight loss (kg)

47.02 ± 17.28

20 to 135

%EWL **

79.15 ± 13.01

50.90 to 111.70

Time interval (months) ***

42.51 ± 28.20

18 to 252

Age (years) Maximum weight (kg) BMI * (kg/m2) 2

*

BMI: body mass index; ** %EWL: percentage of excess weight loss; *** Time interval between the gastric bypass and plastic surgery.

The mean maximum BMI before bariatric 2

The mean percentage of excess weight loss (%EWL)

surgery was 45.17±7.99kg/m . Table 3 shows that patients

was 79.15±13.01. We also observed that patients who

undergoing bariatric surgery were often morbidly obese,

underwent post-bariatric plastic surgery were more

followed by patients classified as grade II obesity and

frequently overweight, followed by patients with normal

both represented 100% of the sample. Before repairing

BMI, both comprising 75.6% of the sample.

2

plastic surgery, the mean BMI was 27.44±3.79kg/m .

Table 3. Distribution of patients according to the degree of obesity determined by body mass index before the gastric bypass and before plastic surgery.

BMI (kg/m2)

Before the gastric bypass n (%)

Before the plastic surgery n (%)

< 25 (Normal)

--

32 (23.1)

25-29.9 (Overweight)

--

73 (52.5)

30-34.9 (Grade I)

--

31 (22.3)

35-39.9 (Grade II)

30 (21.6)

1 (0.7)

109 (78.40)

2 (1.4)

> 40 (Grade III)

The difference between the maximum BMI

greater than 50kg.

before bariatric surgery and the BMI before repairing

Table 4 shows the diseases present before

plastic surgery was 18.25±8.83. Of the patients, 29.5%

bariatric surgery. We observed that the most frequent

(41/139) presented a BMI variation greater than 20. The

morbidities were metabolic syndrome and arterial

mean weight loss before repair was 47.02kg ±17.28.

hypertension, followed by arthropathy, depression/

The mean maximum weight before bariatric operation

anxiety and diabetes mellitus. Obstructive sleep apnea,

was 119.98kg ±23.76 (Table 2). The mean weight before

esophagitis and dyslipidemia were the less common

restorative plastic surgery was 72.97kg ±12; 33.8%

morbidities.

(47/139) of the patients had a weight loss equal to or

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Rosa Anthropometric and clinical profiles of post-bariatric patients submitted to procedures in plastic surgery

5

Table 4. Distribution of patients according to the presence of associated diseases before and after gastric bypass

Associated diseases

Before gastric bypass n (%)

After gastric bypass n (%)

p

Metabolic syndrome

73 (52.5)

6 (4.3)

0.017

Hypertension

71 (51.1)

16 (11.5)

<0.001

Arthropathy

56 (40.3)

8 (5.4)

<0.001

Depression/Anxiety

55 (39.6)

39 (28.1)

<0.001

Diabetes mellitus

50 (36.0)

7 (5.0)

<0.001

Sleep apnea

31 (22.3)

2 (1.4)

0.008

Esophagitis

30 (21.6)

4 (2.9)

<0.001

Dyslipidemia

29 (20.9)

2 (1.4)

0.006

The vast majority of patients reported improvement or complete resolution of the various comorbidities after surgical treatment of obesity. However, as shown in table 4, some patients still had diseases by the time of the repairing plastic procedure, mainly depression/ anxiety and hypertension. The other comorbidities presented with low frequency, such as arthropathy, diabetes, metabolic syndrome, esophagitis, obstructive sleep apnea and dyslipidemia. A third of the patients (33.8% – 47/139) had undergone cholecystectomy before repairing plastic surgery. As for the daily number of drug pills that patients used before bariatric surgery, the mean was 4.17±3.17. After bariatric surgery, the mean decreased to 1.75±1.33, with statistical significance (p<0.001, 95% CI: 3.64-4.69). Seventy-three (52.5%) patients underwent a single plastic surgery, 49 (35.3%), two, and 17 (12.2%), three or more procedures. The mean number of repair procedures per patient was 1.60±0.74 (ranging from one to four surgical procedures per patient). One hundred and twenty-three patients (88.5%) underwent only one surgical procedure per stage, 16 (11.51%) had associated operations in the same surgical procedure, that is, two or more surgical procedures per stage. Table 5 presents the procedures of reconstructive plastic surgery. We observed that the majority of patients were submitted to abdominoplasty, the classic technique being the most used, followed by the anchor technique, and both techniques represented 76.97% of the procedures in the operated patients. Six patients had incisional hernias and eight had umbilical hernias, representing 13.08%

of patients undergoing abdominoplasty. We performed the herniorrhaphy along with the abdominoplasty. Table 5 also shows the techniques of mastoplasty. Mastopexy with prosthesis was the most frequently used, followed by reductive mastoplasty, and both techniques accounted for 42.46% of the procedures.

Table 5. Distribution of surgical procedures performed in post-bariatric patients operated in the North Wing Regional Hospital, Brasília, DF, from 2011 to 2016.

Surgical procedures

N

%

Classic

80

57.55

Anchor

27

19.42

With prosthesis

44

31.65

Reductive

15

10.79

Augmentation

11

7.91

Rhytidoplasty

24

17.27

Brachioplasty

19

13.67

Cruroplasty

13

9.53

Total pacients

139

Total procedures

233

Tummy Tuck

Mastoplasty

As for the other less frequent surgical procedures, we performed facial plastic surgery (rhytidectomy) in 17.27% (24/139) of the patients, arms plastic surgery

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Rosa Anthropometric and clinical profiles of post-bariatric patients submitted to procedures in plastic surgery

6

(brachioplasty) in 13.67% (19/139), and thighs plastic surgery (cruroplasty), in 9.35% (13/139) (Table 5). The mean weight of the flap of the abdomen removed in the abdominoplasty was 1,985.51g Âą1,268.32 (range 350-7,880g). Abdominal flaps weighing 1,000 to

Table 6. Distribution of patients according to the quality of life after repair plastic operation at the North Wing Regional Hospital, Brasilia, DF, from 2011 to 2016.

Classification of quality of life * Much worse

N (%) 0 (0)

Worse

2 (5.56)

2,000 to 3,000 g, both of which accounted for 70% of

Minimal or no change

1 (2.78)

the sample. The flaps weighing <1,000g were 17.76% of

Better

8 (22.22)

the sample, and flaps weighing >3,000g, 12.15%.

Much better

25 (69.44)

1,999 g were the most frequent, followed by those from

As for the volume of the mammary implant used in mastoplasties with prosthesis or augmentation, the mean was 268.62ml Âą40.33 (range 175-355ml). Regarding

the

complications

of

the

Total

36 (100)

* Score obtained from the Moorehead-Ardelt questionnaire. Distribution in five categories: much worse, score range -3.00 to -2.2; Worse, -2.00 to -0.75; Minimal or no change -0.50 to +0.5; Better, 0.75 to 2.00; and Much better, 2.25 to 3.00.

reconstructive plastic surgery, the smaller minor were more frequent than the major ones. The overall complication rate was 26.65% (37/139). The major complication rate was 9.35% (13 patients), five cases of dehiscence with need for resection, three cases of seroma requiring reoperation, three cases of internal hernia with intestinal obstruction, and two cases of wound infection requiring treatment with intravenous antibiotic therapy. The rate of minor complications was 17.3% (24 patients), seven cases of dehiscence without need for resection, seven cases of seroma requiring repeated punctures, six cases of hematoma with drainage or spontaneous resolution, and four cases of wound infection requiring treatment with oral antibiotic therapy alone. The mean surgical time was three hours and ten minutes, ranging from 160 to 270 minutes. We used vacuum drains in all abdominoplasty cases. We used general anesthesia in 119 patients (85.6%), and epidural, in 20 (14.4%). The mean hospitalization time was two days in 128 (92.1%) cases. Only 11 (7.9%) patients remained hospitalized for a longer period. We followed patients for at least six months. There were no cases of deep venous thrombosis, pulmonary embolism or deaths in the present study. Table 6 presents the assessment of quality of life after repairing plastic surgery in post-bariatric patients. We observed that more than 90% of the patients reported an improvement in the quality of life. The mean score obtained on the Moorehead-Ardelt quality of life questionnaire applied to 36 patients was 2.18.

DISCUSSION The common sequelae of successful weight loss after bariatric surgery remain stigmatizing in the form of excess skin and soft tissues. Body contouring restorative surgery helps to promote social and psychological reintegration for these patients. In addition, restorative plastic operations after gastroplasty aim to optimize the functional results obtained by bariatric surgery by removing excess skin7,13. Restorative plastic surgery plays an important role in stabilizing the quality of life of patients with massive weight loss after bariatric surgery, maintaining the improvement of the quality of life in the long term7. The present study showed that the majority of the patients consisted of women, as well as other studies13-18. Likewise, the mean age of 41 years was similar to that of other works15-17,19, but below the age of 44 years in an American work14 and 48 years evidenced by other series13,20. The mean BMI before plastic surgery of 27.4kg/m2 was similar to that found by other authors13-17, but well below the BMI of 35.6Kg/m2 verified by Shermak et al.21. Likewise, the mean delta-BMI of our patients, of 18.25Âą8.83kg/m2, was below the 20.7kg/m2 and 22.3kg/ m2 verified in other studies14,20. The mean weight loss before the restorative plastic surgery of 47kg was similar to that verified by Kervilier et al.13 and above the 33 to 40 kg observed by other authors2,18, but below the 51 to 53 kg found in other studies15,21.22. The mean percentage excess weight loss (%EWL) of 79.1% was above the

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Rosa Anthropometric and clinical profiles of post-bariatric patients submitted to procedures in plastic surgery

68.5% verified by Novais et al.23 and the 65.7% observed 10

2

7

The 42-month mean time between bariatric

by Silva et al. . Buchwald et al. , with 10,172 subjects

surgery and restorative plastic surgery was similar to the

submitted to the surgical procedure, found a mean EWL

47 months seen in another national study17, but higher

of 61.2% after two years of follow-up.

than the 22 months described in other studies20,21.

Among the 139 patients participating in the

As for the treatment of abdominal hernias during

study, there was a 98.6% reduction in the frequency

abdominoplasty, there was no need to use meshes. These

of grade III obesity. Overweight individuals submitted to

hernias are more common when reductive gastroplasty is

plastic surgery accounted for 52.5% of the sample, those

performed by open access19. In the present study, 57.5%

with normal BMI, 23.1%, and patients with residual

(80/139) of the patients underwent laparoscopic surgery,

obesity, 24.4%, similar to the data of Orpheu et al.16,

which reduced the risk of incisional hernia.

in which individuals with overweight represented 56.1%

In patients submitted to abdominoplasty,

of the sample and patients with BMI>30 accounted for

the technique chosen was determined by the type

27.5%.

of abdominal deformity presented by each patient, in

taking into account the patientâ&#x20AC;&#x2122;sâ&#x20AC;&#x2122; opinion and the

comorbidities after bariatric surgery, and at the time

There

was

a

significant

reduction

yearnings. In case of a great transverse excess of skin

of restorative plastic surgery, 5.7% of the patients

flaccidity, we performed the anchor abdominoplasty.

persisted with diabetes mellitus and only 11.5% of had

When the abdominal contour deformity had as its main

systemic arterial hypertension, a reduction of 77.5 % of

component the excess of vertical flaccidity, we performed

all hypertensive patients, similar to that found by other

a conventional abdominoplasty with a suprapubic

authors14,24. As for diabetes, Roux-en-Y gastroplasty

transversal scar.

proved to be very effective in controlling the glycemic

The

association

of

abdominoplasty

with

levels of obese diabetics, resulting in complete remission

other surgical procedures is frequent. Studies indicate

in most patients. In our study, we found a rate of complete

an association of abdominoplasty with other surgical

diabetes remission in 86.1% of patients operated on,

procedures (brachioplasty and mastoplasty) in up to 40%

similar to other authors that reported rates of remission

of operated patients, without significantly increasing the

2,25

ranging from 83% to 85%

. In an American study, the

rate of postoperative complications14,20.

prevalence of comorbidities was higher, reaching 32.5% 20

of arterial hypertension and 15% of diabetes .

Post-bariatric patients pose a number of challenges for the plastic surgeon. These patients often

Other comorbidities associated with obesity

present with residual medical comorbidities, nutritional

also displayed significant decreases in the study patients,

deficiencies and psychological problems, as well as

especially dyslipidemia, metabolic syndrome and sleep

complex body habits that make this group of patients

apnea syndrome. The remission rates of these diseases

at risk for postoperative complications. The overall

14,24

were above 90%, similar to those of other works

. This

postoperative complication rate in post-bariatric patients

significant improvement of comorbidities directly reflects

was 27%, similar to the studies by Kervilier et al.13, but

the drop in the number of pills and medications used by

below other studies with rates ranging from 35 to 50%14-

patients after bariatric surgery, as evidenced in our study.

16,20,21

Improvement in quality of life after repairing

. Suture dehiscence was the main complication,

followed by seroma, as in other series13,14,20.

plastic surgeries is not necessarily associated with a

There were no thromboembolic events, but

decrease in psychiatric symptoms, such as depression

other studies indicate an incidence rate of 0.3% to

and anxiety. In the present study, the prevalence of

1%16,17. The need for preventive measures is a constant

depression/anxiety fell from 39.6% to 28.1%. Even

among the authors, who recommend devices for

being a significant decrease in the prevalence of this

intermittent compression of the calf intraoperatively, as

comorbidity, it was a less expressive drop when compared

well as early ambulation and reduction of surgical time16.

to that of other comorbidities.

The low rate of major complications in this study, such Rev Col Bras Cir. 2018; 45(2):e1613


Rosa Anthropometric and clinical profiles of post-bariatric patients submitted to procedures in plastic surgery

8

as thromboembolic events, flap necrosis and low number

for deep venous thrombosis by reduced surgical time, early

of reoperations may be associated with the low number

ambulation, and good preoperative patient preparation.

of associated surgeries. Studies with the highest rates

Another important factor that may have contributed to

of complications generally had a higher percentage of

a lower rate of complications was the low presence of

associated procedures14,20. The association of operations

comorbidities at the time of repairing plastic surgery.

leads to a longer surgical time (> 6 hours), greater blood

Coon et al.26 studied 449 post-bariatric patients with a

loss and a greater need for blood transfusions, which

complication rate of 41.8%; however, the prevalence of

are factors that may favor an increase in the rate of

systemic arterial hypertension was 44.2%, and diabetes

14

was 22.3% among its patients. In the same study, more

postoperative complications . In the present study, 88.5% of the patients

than 50% of patients who sought plastic surgery had

underwent only one surgical procedure per stage and

residual obesity, whereas in our study, only 24.4% had

only 11.5% performed associated operations in the same

residual obesity at the time of plastic surgery.

surgical procedure. We usually do not recommend and

We observed a mean total result of the

do not associate surgical procedures, except in selected

Moorehead-Ardelt quality of life questionnaire of 2.18,

cases, after careful analysis of clinical, nutritional,

that is, body contouring surgery improved quality of life

emotional and social conditions. We also advocated and

in more than 90% of our patients.

prioritized non-pharmacological preventive management R E S U M O Objetivo: avaliar o perfil de pacientes submetidos à cirurgia plástica pós-bariátrica no Hospital Regional da Asa Norte, Brasília, DF. Métodos: estudo prospectivo, descritivo e analítico de pacientes submetidos à gastroplastia em Y- Roux e, posteriormente, à cirurgia plástica, no período de janeiro de 2011 a dezembro de 2016. Foram avaliados o índice de massa corporal antes da gastroplastia e depois da cirurgia plástica, as complicações pós-operatórias e as comorbidades. Resultados: foram estudados 139 pacientes (130 mulheres e nove homens) com média de idade de 41 anos e submetidos a 233 operações. O IMC médio no momento da cirurgia plástica foi de 27,44Kg/m2. A média de perda de peso foi de 47,02Kg e a média de IMC máximo foi de 45,17Kg/m2. O tempo médio entre a cirurgia bariátrica e a cirurgia plástica foi de 42 meses. As comorbidades antes da cirurgia plástica mais importantes foram: hipertensão arterial (11,5%), artropatia (5,4%), diabetes mellitus (5%) e síndrome metabólica (4,3%) (p<0,01). Dos 139 pacientes operados, 76,97% foram submetidos à abdominoplastia seguida de mamoplastia (42,46%), ritidoplastia (17,27%) e braquioplastia (13,67%). Quatorze (13,08%) pacientes foram submetidos à herniorrafia combinada à abdominoplastia. Abdominoplastia em âncora foi feita em 19,42%. A taxa de complicações pós-operatórias foi de 26,65%. Conclusão: o perfil epidemiológico dos pacientes pós-bariátricos que foram submetidos a cirurgia plástica foi semelhante ao relatado na literatura, exceto pela baixa taxa de cirurgias associadas e complicações pós-operatórias. A cirurgia plástica nos pacientes pós-bariátricos gerou uma melhora da qualidade de vida na maioria desses pacientes. Descritores: Cirurgia Bariátrica. Cirurgia Plástica. Abdominoplastia. Complicações Pós-Operatórias.

REFERENCES 1. Barros F. Qual o maior problema de saúde pública: a obesidade mórbida ou a cirurgia bariátrica no Sistema Único de Saúde? (Parte I) [editorial]. Rev Col Bras Cir. 2015;42(2):69. 2. Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292(14): 1724-37. Erratum in: JAMA. 2005;293(14):1728.

3. Longitudinal Assessment of Bariatric Surgery (LABS) Consortium, Flum DR, Belle SH, King WC, Wahed AS, Berk P, Chapman W, Pories W, Courcoulas A, McCloskey C, Mitchell J, Patterson E, Pomp A, Staten MA, Yanovski SZ, Thirlby R, Wolfe B. Perioperative safety in the longitudinal assessment of bariatric surgery. N Engl J Med. 2009;361(5):445-54. 4. Kitzinger HB, Abayev S, Pittermann A, Karle B, Kubiena H, Bohdjalian A, et al. The prevalence of body contouring surgery after gastric bypass surgery.

Rev Col Bras Cir. 2018; 45(2):e1613


Rosa Anthropometric and clinical profiles of post-bariatric patients submitted to procedures in plastic surgery

Obes Surg. 2012;22(1):8-12.

9

Reconstr Surg. 2010;125(2):691-8.

5. Ramalho S, Bastos AP, Silva C, Vaz AR, Brandão I,

15. Arthurs ZM, Cuadrado D, Sohn V, Wolcott

Machado PP, et al. Excessive skin and sexual function: relationship with psychological variables and weight regain in women after bariatric surgery. Obes Surg. 2015;25(7):1149-54. Karlsson J, Taft C, Rydén A, Sjöström L, Sullivan M. Ten-year trends in health-related quality of life after surgical and conventional treatment for severe obesity: the SOS intervention study. Int J Obes (Lond). 2007;31(8):1248-61. van der Beek ES, Geenen R, de Heer FA, van der Molen AB, van Ramshorst B. Quality of life long-term after body contouring surgery following bariatric surgery: sustained improvement after 7 years. Plast Reconstr Surg. 2012;130(5): 1133-9. Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser. 2000;894:i-xii, 1-253. Sociedade Brasileira de Endocrinologia e Metabologia. Sobrepeso e obesidade: diagnóstico. Brasília (DF): Associação Médica Brasileira; Conselho Federal de Medicina; 2004. Silva CF, Cohen L, Sarmento LA, Rosa FMM, Rosado EL, Carneiro JRI, et al. Efeitos no longo prazo da gastroplastia redutora em Y-de-Roux sobre o peso corporal e comorbidades clínico metabólicas em serviço de cirurgia bariátrica de um hospital universitário. ABCD Arq Bras Cir Dig. 2016;29(Supl

K, Lesperance K, Carter P, et al. Post-bariatric panniculectomy: pre-panniculectomy body mass index impacts the complication profile. Am J Surg. 2007;193(5):567-70; discussion 570. Orpheu SC, Coltro PS, Scopel GP, Saito FL, Ferreira MC. Cirurgia do contorno corporal no paciente após perda ponderal maciça: experiência de três anos em hospital público secundário. Rev Assoc Med Bras. 2009;55(4):427-33. Donnabella A, Neffa L, Barros BB, Santos FP. Abdominoplastia pós cirurgia bariátrica: experiência de 315 casos. Rev Bras Cir Plast. 2016;31(4):510-5. Parvizi D, Friedl H, Wurzer P, Kamolz LP, Lebo P, Tuca A, et al. A multiple regression analysis of postoperative complications after body-contouring surgery: a retrospective analysis of 205 patients: regression analysis of complications. Obes Surg. 2015;25(8):1482-90. Masoomi H, Rimler J, Wirth GA, Lee C, Paydar KZ, Evans GR. Frequency and risk factors of blood transfusion in abdominoplasty in post-bariatric surgery patients: data from the nationwide inpatient sample. Plast Reconstr Surg. 2015; 135(5):861e-868e. Vilà J, Balibrea JM, Oller B, Alastrué A. Post-bariatric surgery body contouring treatment in the public health system: cost study and perception by patients. Plast Reconstr Surg. 2014;134(3):448-54. Erratum in:

6.

7.

8.

9.

10.

11.

12.

13.

14.

1):20-3. Sociedade Brasileira de Cardiologia; Sociedade Brasileira de Hipertensão; Sociedade Brasileira de Nefrologia. [VI Brazilian Guidelines on Hypertension]. Arq Bras Cardiol. 2010;95(1 Suppl):1-51. Erratum in: Arq Bras Cardiol. 2010;95(4):553. Portuguese. Oria HE, Moorehead MK. Bariatric analysis and reporting outcome system (BAROS). Obes Surg. 1998;8(5):487-99. de Kervilier S, Hüsler R, Banic A, Constantinescu MA. Body contouring surgery following bariatric surgery and dietetically induced massive weight reduction: a risk analysis. Obes Surg. 2009;19(5):553-9. Coon D, Michaels J 5th, Gusenoff JA, Purnell C, Friedman T, Rubin JP. Multiple procedures and staging in the massive weight loss population. Plast

16.

17.

18.

19.

20.

21.

22.

23.

24.

Plast Reconstr Surg. 2014;134(6):1436. Shermak MA, Chang D, Magnuson TH, Schweitzer MA. An outcomes analysis of patients undergoing body contouring surgery after massive weight loss. Plast Reconstr Surg. 2006;118(4):1026-31. Ferraz EM, Arruda PCL, Bacelar TS, Ferraz AAB, Albuquerque AC, Leão CS. Tratamento cirúrgico da obesidade mórbida. Rev Col Bras Cir. 2003;30(2):98105. Novais PFS, Rasera Jr I, Leite CVS, Oliveira MRM. Evolução e classificação do peso corporal em relação aos resultados da cirurgia bariátrica: derivação gástrica em Y de Roux. Arq Bras Endocrinol Metab. 2010;54(3):303-10. Schmid H, Goelzer Neto CF, Dias LS, Weston AC, Espíndola MB, Pioner SR, et al. Metabolic syndrome

Rev Col Bras Cir. 2018; 45(2):e1613


Rosa Anthropometric and clinical profiles of post-bariatric patients submitted to procedures in plastic surgery

10

resolution by Roux-en-Y gastric bypass in a real

Received in: 20/11/2017

world: a case control study. Rev Assoc Med Bras

Accepted for publication: 04/01/2018

(1992). 2015;61(2):161-9.

Conflict of interest: none. Source of funding: none.

25. Lopes EC, Heineck I, Athaydes G, Minhardt NG, Souto KE, Stein AT. Is bariatric surgery effective in reducing comorbidities and drug costs? A systematic review and meta-analysis. Obes Surg. 2015;25(9):1741-9. 26. Coon D, Gusenoff JA, Kannan N, El Khoudary SR, Naghshineh N, Rubin JP. Body mass and surgical complications in the postbariatric reconstructive patient: analysis of 511 cases. Ann Surg. 2009;249(3):397-401.

Mailing address: Simone CorrĂŞa Rosa E-mail: scrmacedo@yahoo.com.br / jlsmacedo@yahoo.com.br

Rev Col Bras Cir. 2018; 45(2):e1613


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Original Article

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Pulmonary function in women: comparative analysis of conventional versus single-port laparoscopic cholecystectomy Análise comparativa da função pulmonar em mulheres submetidas à colecistectomia laparoscópica convencional e por portal único MARISA DE CARVALHO BORGES1; ALINE BORGES GOUVEA1; STEPHANIA FERREIRA BORGES MARCACINI1; PAULO FERNANDO DE OLIVEIRA1; ALEX AUGUSTO DA SILVA1; EDUARDO CREMA, TCBC-MG1

A B S T R A C T Objective: to evaluate the pulmonary function of women submitted to conventional and single-port laparoscopic cholecystectomy. Methods: forty women with symptomatic cholelithiasis, aged 18 to 70 years, participated in the study. We divided the patients into two groups: 21 patients underwent conventional laparoscopic cholecystectomy, and 19, single-port laparoscopic cholecystectomy. We assessed pulmonary function through forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), and the FEV1/FVC ratio, measured before and 24 hours after the procedure. Results: in both groups, FVC and FEV1 were lower in the postoperative period than those obtained in the preoperative period, with a greater reduction in the group undergoing conventional laparoscopic cholecystectomy. Regarding the FEV1/FVC (%) values, there was no statistically significant difference in any of the groups or times analyzed. Conclusion: there was a greater decline in FVC and FEV1 in the postoperative group of patients submitted to conventional laparoscopic cholecystectomy. Keywords: Cholelithiasis. Cholecystectomy, Laparoscopic. Respiratory Function Tests. Pulmonary Function. Women.

INTRODUCTION

Abdominal surgical procedures may alter lung function, reducing lung volumes and capacities and,

D

espite the excellent results of laparoscopic surgery,

consequently, impairing gas exchange and increasing

the intention of having a ‘no-scar’ surgery did not

hospitalization time. In laparoscopic cholecystectomy,

1

stop. In 1985, Mühe performed the first laparoscopic

manipulation of the abdominal cavity, as explained by

cholecystectomy by means of a multicanal single-port

Ribeiro et al.5, leads to a decrease in pulmonary volumes and

trocar with only one incision in Germany. The first natural

capacities, which may result in hypoxemia and atelectasis

orifice transluminal endoscopic surgery (NOTES) occurred

due to diaphragmatic dysfunction. Diaphragmatic paresis

in 2007, further minimizing access trauma, with no

associated with the induced pneumoperitoneum may lead

visible scarring. The “competition” between standard

to atelectasis in bases, resulting in a collapse of alveolar

laparoscopy with three or four trocars, NOTES and single

ventilation, with alteration in ventilation-perfusion or

incision laparoscopy led to the rapid development of

shunt causing hypoxemia6.

special single-port trocars2. The evolution was due to the

The aim of this study was to evaluate

combination of the surgical ability developed in the video-

pulmonary function, through forced vital capacity (FVC),

laparoscopic techniques and the high technology of the

forced expiratory volume in the first second (FEV1), and

modern flexible instruments, aiming at reducing pain,

the FEV1/FVC ratio of women submitted to conventional

reducing hospitalization time, reducing the incidence of

and single-port laparoscopic cholecystectomy before and

3,4

hernias, and improving aesthetic results .

24 hours after the surgical procedure.

1 - Triângulo Mineiro Federal University, Department of Surgery, Uberaba, MG, Brazil. Rev Col Bras Cir. 2018; 45(2):e1652


Borges Pulmonary function in women: comparative analysis of conventional versus single-port laparoscopic cholecystectomy

2

METHODS

the pneumoperitoneum with carbon dioxide at a pressure of 14mmHg.

We carried out a prospective, cross-sectional

We

performed

single-port

laparoscopic

study in the discipline of Digestive System Surgery of

cholecystectomy with the patients in dorsal decubitus

the Clinics Hospital of the Triângulo Mineiro Federal

position under general anesthesia, with a discreet

University. We studied 40 women with symptomatic

proclivity and left lateralization, and the lower limbs

cholelithiasis, aged between 18 and 70 years, divided

placed in leggings (French or European position). The

into two groups: 21 patients submitted to conventional

surgeon stood between the patient’s legs, and the first

laparoscopic cholecystectomy, and 19, to single-port

assistant, on the left. We positioned the monitors at

laparoscopic cholecystectomy. The study was approved

the level of the patient’s right shoulder. We performed

by the Ethics in Research Committee of the Triângulo

a horizontal incision of about 1.5cm transumbilically

Mineiro Federal University (UFTM) - Opinion n 2503 - and

for placement of the Veress needle by puncture. When

all patients an informed consent form after clarification.

there was an umbilical hernia, we dissected the hernial

o

We recorded patient data on an evaluation

ring for placement of a needle or trocar under direct

form that contained information such as age and

vision. Thereafter, we induced pneumoperitoneum and

anthropometric variables. The inclusion criteria were

maintained it at 14mmHg with CO2 insufflation. In this

women with symptomatic cholelithiasis, aged between

incision, we inserted a 10-mm trocar through which we

18 and 70 years. Exclusion criteria were pregnancy,

positioned the 30° optic. We inserted a second trocar,

body mass index greater than 35kg/m², neurological

5-mm or 10-mm, above and to the right of the first, for

or cognitive deficits that made it impossible to perform

positioning the hook or scissors, among other instruments

the respiratory muscle strength test, systemic diseases

handled by the surgeon’s right hand. A third trocar (5-mm

and respiratory infections in the four weeks prior to the

or 3-mm) was inserted to the left and at the same height

start of the study and/or allergic sinus disease, chronic

of the second trocar for placement of the clamps. In cases

obstructive pulmonary disease (COPD), previous diagnosis

where it was necessary, we inserted a 2-mm trocar into the

of bronchial asthma, pleuropulmonary abnormalities,

right flank for the positioning of the apprehension clamp

chest deformities, suspected or confirmed liver cirrhosis,

to aid the exposure of the Calot triangle and dissection

coagulopathy (platelet count below 50,000/ul), double

of the cystic duct and cystic artery. When available, was

medication with platelets antagonists (acetylsalicylic acid

used a 5-mm, 30° optics at the time of placement of clips

and clopidogrel), acute pancreatitis, and jaundice.

into the cystic duct and cystic artery, allowing passage of

laparoscopic

the clipper through the 10-mm trocar previously inserted

cholecystectomy with the patients positioned in horizontal

into the umbilical scar. When not available, we inserted a

dorsal decubitus at the operative table and undergoing

second 10-mm trocar into the 5-mm trocar position.

general

Evaluation of Pulmonary Function

We

performed

anesthesia

with

conventional

perioperative

monitoring

performed with cardioscopy, non-invasive blood pressure

A specialist performed the spirometry in the

monitoring, pulse oximetry and capnography. We

Pulmonary Function Laboratory of the Pulmonology

introduced four trocars: one 10-mm trocar in the supra-

Department of UFTM. A computerized spirometer (Master

umbilical region for the optics, one 5-mm trocar on the

Screen PFT Jaeger) was used, and the examination was

right flank for cranial traction of the gallbladder and two

performed according to the standards of the American

other trocars on the same line, one 5-mm in the right

Thoracic Society (ATS). The patients were instructed to

hypochondrium for gallbladder traction, and one 10-mm

remain in a comfortable, sitting position for five to ten

trocar on the epigastrium, at the left side of the round

minutes before the test, and at the time of the test, they

ligament, for dissection and hemostasis. We maintained

were instructed to keep the head in a neutral and stable

Rev Col Bras Cir. 2018; 45(2):e1652


Borges Pulmonary function in women: comparative analysis of conventional versus single-port laparoscopic cholecystectomy

position. The procedure was explained and demonstrated,

3

vital capacity, confirm the hypothesis.

asking patients to inhale as deeply as possible and

FEV1 represents the amount of air exhaled in

exhaled quickly into the mouthpiece of the spirometer,

the first second of the FVC maneuver. It is the measure

thus preventing air leakage around the spirometer. The

of pulmonary function used to determine obstructive

examination was performed three times at five-minute

ventilatory disorders. FEV1 is measured by the introduction

rest intervals, and the best values were recorder in the

of time measurements (one second) in the FVC maneuver.

evaluation form.

It basically evaluates obstructive disorders. When FVC

The evaluation of pulmonary function through spirometry is one of the preoperative procedures

is diminished by restrictive disorders it will decrease proportionally.

performed routinely in patients of the UFTM Department

The FEV1/FVC ratio is the ratio between these

of Digestive Surgery to identify and quantify pulmonary

two measures and is the one that best evaluates the

functional alterations. In this study, spirometry was

presence of obstructive disorders. The expected value for

performed in two moments: before and 24 hours after

a given individual is derived from the chosen equation.

the surgical procedures. The parameters evaluated in this

For individuals up to 45 years old, the value of 75% or

study were forced vital capacity (FVC), forced expiratory

higher is expected. Below this value, the diagnosis of

volume in the first second (FEV1) and FEV1/FVC ratio. We

obstruction is suggestive and should be defined through

expressed the values obtained in liters/second and in

the parallel analysis of other values such as FEF25-75, FEV1

percentage of predicted.

and other terminal flows.

FVC is one of the spirometric variables used to determine ventilatory changes and is obtained through

RESULTS

forced expiratory maneuver. It represents the maximum volume of exhaled air with maximum effort, from the

Table 1 shows the mean ± standard deviation

point of maximum inspiration. When below 80% of

of age and the anthropometric variables of patients

predicted, in the presence of normal FEV1/FVC ratio, it

submitted to conventional and single-port laparoscopic

suggests restrictive disorder. Confirmation can be made

cholecystectomy. Height differed significantly between

by measuring total lung capacity (TLC). In the absence

groups (p=0.022). However, this anthropometric variable

of these methods, radiologic findings compatible with

is not related to the formation of gallstones.

restrictive disease, associated to the reduction of forced Table 1. Mean ± standard deviation of anthropometric variables and age.

Variables

CLC

SPLC

p

Age (years)

38.38±11.72

34.21±10.51

NS

Weight (kg)

69.4±16.76

64.81±9.63

NS

Height (m)

1.57±0.07

1.62±0.04

0.022

BMI (kg/m2)

27.9±6.52

24.52±3.67

NS

CLC: conventional laparoscopic cholecystectomy; SPLC: single-port laparoscopic cholecystectomy; BMI: body mass index; NS: not significant. Comparison between categories by the Fisher exact test. Comparison of numeric variables, expressed as mean ± standard deviation, by the Student’s t test.

The mean time between the beginning and the end of surgical procedures in the group undergoing conventional laparoscopic cholecystectomy was 62.15±27.75 minutes, and in the group submitted

to single-port laparoscopic cholecystectomy it was 60.12±18.16 minutes. The mean time between induction/ anesthesia and the end of surgical procedures in the group undergoing conventional laparoscopic cholecystectomy

Rev Col Bras Cir. 2018; 45(2):e1652


Borges Pulmonary function in women: comparative analysis of conventional versus single-port laparoscopic cholecystectomy

4

was 83.16±29.20 minutes, and in the group undergoing

patients (4.8%), sinusitis. In the group submitted to

single-port

was

single-port laparoscopic surgery, only one patient (5.3%)

80.50±18.37 minutes. Concerning the habits and living conditions questioned in the initial protocol regarding the presence or absence of respiratory diseases and smoking, we observed that in the group undergoing conventional laparoscopic surgery only two patients (9.5%) had bronchitis, one (4.8%) had allergic rhinitis and two

had sinusitis. Concerning smoking, we found that only three patients (14.3%) were smokers in the group undergoing conventional laparoscopic surgery; in the group undergoing sigle-port surgery, only six patients (31.6%) were smokers, as shown by table 2.

laparoscopic

cholecystectomy

it

Table 2. Comparative analysis the presence of respiratory diseases and smoking in patients undergoing conventional and single port laparoscopic cholecystectomy.

CLC n

SLPC %

n

p* %

Respiratory diseases

0.4

Bronchitisquite

2

9.5

0

0.0

Allergic rhinitis

1

4.8

0

0.0

Sinusitis

1

4.8

1

5.3

None

17

81.0

18

94.7

Smoking

0.19

Yes

3

14.3

6

31.6

No

18

85.7

13

68.4

CLC: conventional laparoscopic cholecystectomy; SPLC: single-port laparoscopic cholecystectomy; *Chi-square test.

Of the 40 patients participating in the study, the ones undergoing spirometry were 14 (66.6%) of the 21

tests of this patient were normal before and after the surgical procedure.

patients in the conventional laparoscopic cholecystectomy

In the single-port group five (31.25%) smokers

group and 16 (84.2%) of the 19 patients in the single-

performed the spirometric tests, three (18.75%) presented

portal group.

normal results before and after the surgical procedure, and

Regarding the presence of respiratory diseases,

two (12.5%) presented mild restrictive ventilatory disorder

only one (7.14%) patient with bronchitis from the group

after the surgical procedure. Only one patient in the group

undergoing conventional laparoscopic cholecystectomy

undergoing conventional laparoscopic cholecystectomy

underwent the spirometric tests. The tests of this patient

had respiratory disease and was a smoker, but she did not

were normal before and after the surgical procedure.

undergo the spirometric tests.

In the group submitted to single-port laparoscopic

When comparing the FVC values in the

reported

preoperative period with the postoperative period for

presenting respiratory system disease did not undergo

the conventional laparoscopic cholecystectomy group,

spirometry.

the means were, respectively, 3.20±0.12 liters and

cholecystectomy,

the

only

patient

who

Regarding smoking, only one (7.14%) smoker

2.52±0.14 liters, p=0,0005. When comparing the pre and

of the group undergoing conventional laparoscopic

postoperative FVC values for the single-port group, the

cholecystectomy performed the spirometric tests. The

mean results were 3.67±0.14 liters for 3.08±0.15 liters,

Rev Col Bras Cir. 2018; 45(2):e1652


Borges Pulmonary function in women: comparative analysis of conventional versus single-port laparoscopic cholecystectomy

5

p<0.0001. When comparing the values of FVC of the

conventional

versus

single-port

laparoscopic

cholecystectomy in the preoperative period, the means were, respectively, 3.20±0.12 liters versus 3.67±0.14 liters, p=0.0219 . When comparing the FVC values in the conventional versus single-port laparoscopic cholecystectomy in the postoperative period, the means were, respectively, 2.52±0.14 liters versus 3.08±0.15 liters, p=0.0119 (Figure 1).

Figure 2. The bars indicates the mean, and the lines, the standard error of the mean. *p<0.05 when comparing the two types of surgery at the same point in time (Student’s t-test); #p<0.05 when comparing the pre and preoperative levels of the same procedure (paired Student’s t-test).

Figure 1. The bars indicates the mean, and the lines, the standard error of the mean. *p<0.05 when comparing the two types of surgery at the same point in time (Student’s t-test); #p<0.05 when comparing the pre and preoperative levels of the same procedure (paired Student’s t-test).

When comparing the FEV1 values in conventional laparoscopic cholecystectomy in the preoperative period, the mean results were 2.69±0.12 liters for 2.12±0.13

When comparing the FEV1/FVC values of the conventional laparoscopic cholecystectomy in the preoperative period with the postoperative period, the means were, respectively, 84.12%±1.77% and 84.14%±2.13%. When comparing the FEV1/FVC values for laparoscopic cholecystectomy with a single-port in the preoperative period for the postoperative period, the mean results were 85.25±1.89% for 86.01±1.70%. When comparing the FEV1/FVC values in the conventional versus the single-port laparoscopic cholecystectomy in the preoperative period, the means were, respectively, 84.12%±1.77% versus 85.25%±1.89%. When comparing the values of FEV1/ FVC in the conventional laparoscopic cholecystectomy group with the single-port one in the postoperative period, the means were, respectively, 84.14±2.13% versus 86.01±1.70% (Figure 3).

liters, p=0,0007. When comparing FEV1 values for laparoscopic cholecystectomy with a single-port in the preoperative period for the postoperative period, the results of the mean values were 3.11±0.10 liters for 2.64±0.11 liters, p<0.0001. When the

comparing

conventional

versus

the

FEV1

single-port

values

of

laparoscopic

cholecystectomy in the preoperative period, the mean were, respectively, 2.69±0.12 liters versus 3.11±0.10 liters, p=0.0139 . When comparing the FEV1 values of the conventional versus single-port laparoscopic cholecystectomy in the postoperative period, the means were 2.12±0.13 liters vs. 2.64±0.11 liters, p=0.0068 (Figure 2).

Figure 3. The bars indicates the mean, and the lines, the standard error of the mean. *p<0.05 when comparing the two types of surgery at the same point in time (Student’s t-test); #p<0.05 when comparing the pre and preoperative levels of the same procedure (paired Student’s t-test).

Rev Col Bras Cir. 2018; 45(2):e1652


Borges Pulmonary function in women: comparative analysis of conventional versus single-port laparoscopic cholecystectomy

6

DISCUSSION

postoperative day in large thoracic-abdominal surgeries. The recovery of lung functions after laparoscopic with

cholecystectomy occurs between five and ten days20.

pulmonary mechanics and tend to develop restrictive

In laparoscopic cholecystectomy, the most expected

ventilatory changes, with a reduction in FEV1 and FVC,

pulmonary complication in the days following surgery is

which may reach approximately 40 to 50% of the

atelectasis, which varies from 10% to 35%21-23.

Some

surgical

procedures

interfere

preoperative value and remain reduced for at least one

Patients’ age may also be considered a factor

to two weeks . In most abdominal surgical procedures,

capable of interfering in the postoperative evolution. In

these derangements peak on the first postoperative day,

our study, the mean age of the two groups was not a risk

when the respiratory system becomes more vulnerable to

factor for pulmonary complications.

7

postoperative pulmonary complications . These changes

The incidence of postoperative pulmonary

occur especially in upper abdomen operations and

complications such as atelectasis, transient dyspnea and

are mainly determined by diaphragmatic dysfunction,

cough is higher in patients with chronic lung disease,

8,9

10-12

triggered by the surgical stimuli

increasing the risk of morbidity and mortality after any

.

Several causes have been suggested to explain

surgical procedure24. Patients included in the present

the decrease in lung volume in abdominal surgery,

study who reported having some type of respiratory

including pain, anesthesia, surgery time, surgical trauma,

disease did not present respiratory symptoms three

and others. However, today, what is most accepted is

months before surgery, which could interfere in the

that this decrease is caused by diaphragmatic paresis,

evaluation of lung function loss after the procedures

consequent to a reflex inhibition of the diaphragm13-15.

studied. Regarding the presence of respiratory diseases,

Ramos et al.16 showed mild restrictive ventilatory

only one patient with bronchitis, belonging to the group

disorders, more intense in the immediate postoperative

undergoing conventional laparoscopic cholecystectomy,

period, with reduction of FVC and FEV1 in both groups

was submitted to the spirometric tests. The results of

of patients when these two variables were compared pre

this patient were normal before and after the procedure.

and postoperatively.

In the group submitted to single-port laparoscopic

Changes in the pulmonary function in the

cholecystectomy, the only patient who reported having

postoperative of laparoscopic cholecystectomy are less

respiratory disease did not undergo spirometry. Therefore,

severe, as they produce minimal muscle disruption,

we cannot conclude that the presence of respiratory

minor postoperative pain and allow rapid ambulation .

diseases interfered with the spirometric results, since the

However, some factors specific to laparoscopic surgery

number of patients submitted to the test who presented

tend to increase the risk of thrombosis, such as longer

respiratory diseases was too small and insufficient for an

duration of the surgical act in the learning curve,

accurate statement.

17

insufflation pressure used for the pneumoperitoneum

Paschoal and Pereira25 showed that, regardless

causing venous stasis of the lower limbs and compression

of the patient’s preoperative conditions, the anesthetic

of the inferior vena cava and iliac veins, reversed

and surgical procedure produce changes in the pulmonary

Trendelemburg position – inverted supine position –

physiology that will be determinant in the postoperative

necessary for adequate exposure of the operative field

evolution. These factors are directly involved in the

that accentuates venous stasis, and hypercoagulability

origin of pulmonary complications, both in patients with

induced by the pneumoperitoneum18.

previous pulmonary problems and those who have never

Saad and Zambom19 reported a decrease in

had pulmonary disease.

lung capacity and FEV1 in the immediate postoperative

Smoking seems to be important in the genesis

period, but total recovery of these values on the fifth

of postoperative pulmonary complications, since it is

Rev Col Bras Cir. 2018; 45(2):e1652


Borges Pulmonary function in women: comparative analysis of conventional versus single-port laparoscopic cholecystectomy

associated with a decrease in the secretion transport, an 26-28

increase in mucus secretion, and in airway narrowing

.

7

conventional laparoscopic cholecystectomy, with a significant difference between groups (p=0.0308)33.

In our study, only one smoker in the conventional

Laparoscopic

cholecystectomy

is

a

laparoscopic cholecystectomy group underwent the

surgical procedure with less incidence of pulmonary

spirometric tests, with normal results before and after

complications because it has less potential to alter

the surgical procedure. In the single-port group, five

respiratory function34. The advantages of single-port

patients were smokers: the results showed mild restrictive

laparoscopic cholecystectomy compared to conventional

ventilatory disorder in two patients after the surgical

laparoscopic cholecystectomy include decreased surgical

procedure, and in the other three patients, the results

trauma, reduced postoperative pain, rapid postoperative

were normal before and after the surgical procedure.

mobilization, and shorter hospital stay35. In the present

The physiological disadvantages of prolonged

study, the values of FVC and FEV1 were significant when

anesthesia have been widely discussed and include,

comparing the two types of surgery at the same time and

among others, arrhythmias, myocardial depression,

also in the pre and postoperative periods. The results of

29,30

hypotension and hypoxia

. There is association

FVC in this study showed more satisfactory values in the

between the higher incidence of pulmonary complications

group of patients submitted to single-port laparoscopic

in the postoperative period of abdominal surgery with an

cholecystectomy at the times analyzed and in comparison

average time of surgery exceeding 210 minutes31. In the

with conventional laparoscopic cholecystectomy.

study by Chiavegato et al.6, there was an average surgical

FVC was characteristically reduced in restrictive

time of 112 minutes, which is already an advantage of

disorders. In the present study, we observed that in

laparoscopic cholecystectomy because it reduces the

the postoperative period of the group submitted to

probability of pulmonary complications. In the present

conventional laparoscopic cholecystectomy, two patients

study, this advantage was verified in both surgical

had mild restrictive ventilatory disorder, one patient,

procedures, since in the group submitted to conventional

moderate, and one, severe. One patient presented

laparoscopic cholecystectomy the mean time between

mild restrictive respiratory disorder in the pre and in the

induction of anesthesia and the end of the surgical

postoperative period. In the group of patients submitted

procedure was 83.16Âą29.20min, and in the group

to single-port laparoscopic cholecystectomy, five patients

submitted to single-port laparoscopic cholecystectomy,

presented mild restrictive ventilatory disorder in the

80.50Âą18.37min.

postoperative period.

The impairment of postoperative pulmonary

Our FEV1 results also showed more satisfactory

function is lower in laparoscopic surgery than in open

values in the group of patients submitted to single-port

surgery, which suggests a lower predisposition of

laparoscopic cholecystectomy at the times analyzed

these patients to the development of complications.

and

However, it has been shown that laparoscopy produces

cholecystectomy. FEV1 is reduced in obstructive airway

small changes, which do have an impact on lung

diseases, and in the present study, the only one patient

function, especially in patients with previous pulmonary

undergoing single-port laparoscopic cholecystectomy

compromise32. In the evaluation of respiratory muscle

presented mild obstructive ventilatory disorder. We

strength in patients of both groups, a greater decline in

observed a greater reduction of FVC and FEV1 in

the maximal inspiratory pressure (MIP) has been observed

the postoperative period in the group submitted to

after 24 hours in the group of patients submitted to

conventional laparoscopic cholecystectomy.

in

comparison

Rev Col Bras Cir. 2018; 45(2):e1652

to

conventional

laparoscopic


Borges Pulmonary function in women: comparative analysis of conventional versus single-port laparoscopic cholecystectomy

8

R E S U M O Objetivo: avaliar a função pulmonar, através da capacidade vital forçada (CVF) e volume expiratório forçado no primeiro segundo (VEF1), e a relação VEF1/CVF% de mulheres submetidas à colecistectomia laparoscópica convencional e por portal único, antes e 24 horas depois do procedimento. Métodos: quarenta mulheres com colelitíase sintomática, com idades entre 18 e 70 anos, participaram do estudo. As pacientes foram distribuídas em dois grupos: 21 pacientes foram submetidas à colecistectomia laparoscópica convencional e 19 à colecistectomia laparoscópica por portal único. Resultados: nos dois grupos submetidos aos procedimentos cirúrgicos os valores espirométricos da CVF e da VEF1 no pós-operatório foram inferiores aos valores obtidos no pré-operatório, com redução maior no grupo submetido à colecistectomia laparoscópica convencional. Quanto aos valores da VEF1/CVF (%) não houve diferença estatisticamente significativa em nenhum dos grupos ou tempos analisados. Conclusão: houve maior declínio na CVF e no VEF1 no pós-operatório do grupo de pacientes submetidas à colecistectomia laparoscópica convencional. Descritores: Colelitíase. Colecistectomia Laparoscópica. Testes de Função Respiratória. Função Pulmonar. Mulheres.

REFERENCES

function. Anesth Analg. 1981;60(1):46-52. 8. Fairshter RD, Williams JH Jr. Pulmonary physiology

1. Mühe E. Long-term follow-up after laparoscopic cholecystectomy. Endoscopy. 1992;24(9):754-8.

in the postoperative period. Crit Care Clin. 1987:3(2):287-306.

2. Navarra G, La Malfa G, Bartolotta G, Currò G. The

9. Grams ST, Ono LM, Noronha MA, Schivinski CI,

invisible cholecystectomy: a different way. Surg

Paulin E. Breathing exercises in upper abdominal

Endosc. 2008;22(9):2103.

surgery: a systematic review and meta-analysis. Rev

3. Hasukic S, Matovic E, Konjic F, Idrizovic E,

Bras Fisioter. 2012;16(5):345-53.

Halilovic H, Avdagic S. Transumbilical single-

10. Simonneau G, Vivien A, Sartene R, Kunstlinger F, Samii

port laparoscopic cholecystectomy. Med Arch.

K, Noviant Y, et al. Diaphragm dysfunction induced

2012;66(4):276-7.

by upper abdominal surgery. Role of postoperative

4. van den Boezem PB, Velthuis S, Lourens HJ,

pain. Am Rev Respir Dis. 1983;128(5):899-903.

Cuesta MA, Sietses C. Single-incision and NOTES

11. Ford GT, Whitelaw WA, Rosenal TW, Cruse PJ,

cholecystectomy, are there clinical or cosmetic

Guenter CA. Diaphragm function after upper

advantages laparoscopic study and

when

compared

to

conventional

abdominal surgery in humans. Am Rev Respir Dis.

cholecystectomy?

A

case-control

1983;127(4):431-6.

single-incision,

transvaginal,

comparing conventional

laparoscopic

technique

for

cholecystectomy. World J Surg. 2014;38(1):25-32. 5. Ribeiro S, Gastaldi AC, Fernandes C. Efeito

12. en M, Özol D, Bozer M. Influence of preemptive analgesia on pulmonary function and complications for laparoscopic cholecystectomy. Dig Dis Sci. 2009;54(12):2742-7.

pacientes

13. McAlister FA, Khan NA, Straus SE, Papaioakim M,

submetidos à cirurgia abdominal alta. Einstein.

Fisher BW, Majumdar SR, et al. Accuracy of the

2008;6(2):166-9.

preoperative assessment in predicting pulmonary

da

cinesioterapia

respiratória

em

6. Chiavegato LD, Jardim JR, Faresin SM, Juliano Y.

Alterações

funcionais

respiratórias

na

colecistectomia por via laparoscópica. J Bras

risk after nonthoracic surgery. Am J Respir Crit Care Med. 2003;167(5):741-4. 14. Joia Neto L, Thomson JC, Cardoso JR. Postoperative respiratory complications from elective and urgent/

Pneumol. 2000;26(2):69-76. 7. Craig DB. Postoperative recovery of pulmonary

emergency surgery performed at a university hospital.

Rev Col Bras Cir. 2018; 45(2):e1652


Borges Pulmonary function in women: comparative analysis of conventional versus single-port laparoscopic cholecystectomy

J Bras Pneumol. 2005;31(1):41-7.

9

Preoperative smoking habits and postoperative

15. Seo YK, Lee HJ, Ha TK, Lee KG. Effect of normal

pulmonary complications. Chest. 1998;113(4):883-9.

saline irrigation on attenuation of shoulder tip

27. Lindström D, Sadr Azodi O, Wladis A, Tønnesen H,

pain and on ß-endorphin levels after laparoscopic

Linder S, Nåsell H, et al. Effects of a perioperative

cholecystectomy. J Laparoendosc Adv Surg Tech A.

smoking cessation intervention on postoperative

2012;22(4):311-4.

complications: a randomized trial. Ann Surg.

16. Ramos GC, Pereira E, Gabriel Neto S, Oliveira EC.

2008;248(5):739-45.

Pulmonary performance test after conventional and

28. Warner DO, Borah BJ, Moriarty J, Schroeder DR, Shi

laparoscopic cholecystectomy. Rev Col Bras Cir.

Y, Shah ND. Smoking status and health care costs in

2007:34(5):326-30.

the perioperative period: a population-based study.

17. Staehr-Rye AK, Rasmussen LS, Rosenberg J, SteenHansen C, Nielsen TF, Rosenstock CV, et al. Minimal impairment

in

pulmonary

function

JAMA Surg. 2014;149(3):259-66. 29. Gehring H, Kuhmann K, Klotz KF, Ocklitz E, Roth-

following

Isigkeit A, Sedemund-Adib B, et al. Effects of propofol

laparoscopic surgery. Acta Anaesthesiol Scand.

vs isoflurane on respiratory gas exchange during

2014;58(2):198-205.

laparoscopic cholecystectomy. Acta Anaesthesiol

18. Salim MT, Cutait R. Complicações da cirurgia

Scand. 1998;42(2):189-94.

videolaparoscópica no tratamento de doenças

30. Uchiyama H, Shirabe K, Yoshizumi T, Ikegami

da vesícula e vias biliares. ABCD Arq Bras Cir Dig.

T, Soejima Y, Ikeda T, et al. Verification of our

2008;21(4):153-7.

therapeutic criterion for acute cholecystitis: “perform

19. Saad IAB, Zambom L. Variáveis clínicas de risco pré-

a subemergency laparoscopic cholecystectomy when

operatório. Rev Assoc Med Bras. 2001;47(2):117-24.

a patient is judged to be able to tolerate general

20. Williams-Russo P, Charlson ME, MacKenzie CR, Gold

anesthesia”--the experience in a single community

JP, Shires GT. Predicting postoperative pulmonary

hospital. Fukuoka Igaku Zasshi. 2013;104(10):339-

complications. Is it a real problem? Arch Intern Med.

43.

1992;152(6):1209-13.

31. Pereira EDB, Faresin SM, Juliano Y, Fernandes ALG.

21. Schauer PR, Luna J, Ghiatas AA, Glen ME, Warren

Fatores de risco para complicações pulmonares no

JM, Sirinek KR. Pulmonary function after laparoscopic

pós-operatório de cirurgia abdominal alta. J Pneumol.

cholecystectomy. Surgery. 1993;114(2):389-97.

1996;22(1):19-26.

22. Couture JG, Chartrand D, Gagner M, Bellemare

32. Bablekos

GD,

Michaelides

SA,

Roussou

T,

F. Diaphragmatic and abdominal muscle activity

Charalabopoulos

after endoscopic cholecystectomy. Anesth Analg.

control and mechanics after laparoscopic vs open

1994;78(4):733-9.

cholecystectomy. Arch Surg. 2006;141(1):16-22.

KA.

Changes

in

breathing

23. Torrington KG, Bilello JF, Hopkins TK, Hall EA Jr.

33. Borges MC, Takeuti TD, Terra JA Júnior, Silva

Postoperative pulmonary changes after laparoscopic

AAD, Crema E. Comparative study of respiratory

cholecystectomy. South Med J. 1996;89(7):675-8.

muscle strength in women undergoing conventional

24. Celli B. Respiratory muscle strength after abdominal surgery. Thorax. 1993;48(7):683-4.

and single-port laparoscopic cholecystectomy. Acta Cir Bras. 2017;32(10):881-90.

25. Paschoal IA, Pereira MC. Abordagem pré-operatória

34. Kundra P, Vitheeswaran M, Nagappa M, Sistla S.

do paciente pneumopata- riscos e orientações. Rev

Effect of preoperative and postoperative incentive

Soc Cardiol Estado de São Paulo. 2000;10(3):293-

spirometry on lung functions after laparoscopic

302.

cholecystectomy. Surg Laparosc Endosc Percutan

26. Bluman LG, Mosca L, Newman N, Simon DG.

Tech. 2010;20(3):170-2.

Rev Col Bras Cir. 2018; 45(2):e1652


10

Borges Pulmonary function in women: comparative analysis of conventional versus single-port laparoscopic cholecystectomy

35. Carus T. Current advances in single-port laparoscopic surgery. Langenbecks Arch Surg. 2013;398(7):925-9. Received in: 07/12/2017 Accepted for publication: 16/01/2018 Conflict of interest: none. Source of funding: none.

Mailing address: Eduardo Crema E-mail: cremauftm@mednet.com.br / marisaborges.uftm@gmail.com

Rev Col Bras Cir. 2018; 45(2):e1652


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Hemodynamic evaluation of elderly patients during laparoscopic cholecystectomy Avaliação hemodinâmica de pacientes idosos durante colecistectomia vídeolaparoscópica LUIZ PAULO JACOMELLI RAMOS, TCBC-RJ1; RODRIGO BARCELLOS ARAÚJO2; MARIA DO CARMO VALENTE CASTRO3; MARIA ROBERTA MENEGUETTI SERAVALLI RAMOS4; JOSÉ ANTONIO CUNHA-E-SILVA1; ANTONIO CARLOS IGLESIAS, ECBC-RJ1 A B S T R A C T Objective: to demonstrate hemodynamic changes during laparoscopic cholecystectomy in elderly patients with trans-esophageal echocardiography. Methods: we studied 31 elderly patients (aged 60 years or older), ASA I or II, who underwent elective laparoscopic cholecystectomy under general, standardized anesthesia, with cardiovascular parameters measured using transesophageal echocardiography at three different times: before the pneumoperitoneum (T1), after CO2 insufflation (T2) and at deflation (T3). We statistically evaluated changes in systolic, diastolic and mean blood pressure, heart rate, cardiac output and index, and ejection fraction. Results: although small, only the diastolic blood pressure (DBP) and ejection fraction (EF) variations were statistically significant. The mean ± standard deviation of DBP in mmHg at the different times were: T1=67.5±10.3; T2=73.6±12.4; and T3=66.7±9.8. And for EF, in percentage (%) they were: T1=66.7±10.4; T2=63.2±9.9; and T3=68.1±8.4. There was no statistical correlation between hemodynamic variations, age and number of patients’ comorbidities. Conclusion: laparoscopic cholecystectomy causes few hemodynamic changes that are well tolerated by the majority of the elderly patients; prior impairment of ventricular function represents a threat in elderly patients during surgery; there appears to be a lower hemodynamic effect caused by the pneumoperitoneum than by the patient’s positioning in a reverse Trendelemburg during surgery. Keywords: Blood Pressure. Hemodynamics. Echocardiography, Transesophageal. Aged. Laparoscopy. Pneumoperitoneum, Artificial.

INTRODUCTION

population1-6. Although several studies have evaluated the

C

holelithiasis is the most common surgical abdominal disease of the elderly, with a prevalence of 21.4% between 60 and 69 years and 27.5% in individuals older than 70 years1. The increase in life expectancy associated with a higher incidence of cholelithiasis in the elderly has resulted in a greater number of surgeries for the treatment of symptomatic disease in this group2. Laparoscopic cholecystectomy (LC) is currently the procedure of choice for the treatment of cholelithiasis, and is used very often even in the elderly, with comparable efficacy to the young

hemodynamic changes due to pneumoperitoneum, the mechanisms involved in cardiovascular variations have not yet been fully elucidated. Works have been carried out in groups of non-homogeneous patients, under different intra-abdominal pressures and with different positions during surgery7-9. This study aims to demonstrate the hemodynamic changes resulting from the pneumoperitoneum in elderly patients submitted to LC and monitored with transesophageal echocardiography (TEE).

1 - Federal University of the State of Rio De Janeiro, Service of General and Digestive System Surgery, Rio de Janeiro, RJ, Brazil. 2 - Federal University of the State of Rio De Janeiro, Anesthesiology Service, Rio de Janeiro, RJ, Brazil. 3 - Federal University of the State of Rio de Janeiro, Cardiology Service, Rio de Janeiro, RJ, Brazil. 4 - Evandro Chagas National Institute of Infectology/FIOCRUZ, Clinical Research Laboratory, Rio de Janeiro, RJ, Brazil. Rev Col Bras Cir. 2018; 45(2):e1659


Ramos Hemodynamic evaluation of elderly patients during laparoscopic cholecystectomy

2

METHODS

insufflation of carbon dioxide (CO2) by the 11mm trocar until a pressure of 13mmHg was reached. The patients

Thirty-one elderly patients with cholelithiasis,

were operated on in the supine, neutral position, without

aged 60 years or older, diagnosed by abdominal

the reverse Trendelemburg (RT) position, common in this

ultrasonography at the Gaffrée and Guinle University

type of surgery.

Hospital (HUGG) over two years were submitted to

The variables obtained by transesophageal

elective LC and monitored with trans-esophageal

echocardiography were Cardiac Index (CI), Cardiac

echocardiography during the procedure.

Output (CO) and Ejection Fraction (EF), in addition to the

We included in the study the elderly classified

measurement of systolic blood pressure (SBP), diastolic

as ASA I or II (American Society of Anesthesiologist),

blood pressure (DBP), mean arterial pressure (MAP) and

after

and

heart rate (HR), recorded at three different times: before

with prior authorization from the HUGG Ethics in

the onset of pneumoperitoneum (T1), ten minutes after

Research Committee under the protocol number

CO2 insufflation (T2) and five minutes after deflation

11607913600005258.

(T3).

signing

the

informed

We

consent

excluded

form,

patients

with

significant esophageal or cardiovascular diseases, as well

We started with T1 before the onset of

as those who presented absolute contraindications to

pneumoperitoneum to measure the baseline values

TEE. We also excluded those with acute cholecystitis.

of

all

patients,

without

any

pneumoperitoneum

All patients underwent standardized general

interference. The T2 showed us the variables when the

anesthesia, with continuous monitoring. Anesthetic

pneumoperitoneum was already established and the

induction was done with Fentanyl 4mcg/kg, Propofol 2mg/

intra-abdominal pressure had already reached its plateau.

kg and Atracurium 0.5mg/kg after pre-oxygenation with

Finally, with T3 measurements we wanted to obtain the

100% oxygen for three minutes. Oro-tracheal intubation

values after a long period of pneumoperitoneum and also

(OTI) was performed two to three minutes after the

to be able to evaluate the difference of the hemodynamic

muscle relaxant. Anesthesia maintenance was performed

values with and without the influence of the CO2 pressure

with Sevorane.

in the peritoneal cavity.

The patients were ventilated under volume

We used the paired t-test for statistical analysis

controlled ventilation (VCV) mode, with a parameter

of the hemodynamic variations at the different moments.

programmed for total volume of 7ml/kg (eg VCV=490ml

For statistical analysis, comparison and discussion of

in a 70kg person), respiratory frequency (RF) of 12,

results, we display the results in mean and standard

positive end expiratory pressure (PEEP) of 5cmH2O, which

deviation (SD).

is physiological PEEP, and peak of 40cmH2O, with an

RESULTS

inspiratory/expiratory ratio (I:E) of 1:2. All patients were monitored with continuous electrocardiogram, pulse oximeter and capnography.

Of the 31 patients studied, nine were female,

measurement

and 22, male. The mean age was 67.2 years. Three

triggered every five minutes. These parameters were

patients were classified as ASA I, and 28, as ASA II.

recorded after OTI, during the pneumoperitoneum and

Among the latter, 22 (71%) had only one comorbidity

during the TEE study.

(systemic arterial hypertension – SAH); five (16.1%) had

Automatic

systemic

blood

pressure

We installed the pneumoperitoneum with a Veress needle and maintained it by continuous

two (SAH and type-2 diabetes mellitus – DM); and one (3.2%) had three (SAH, DM and arthrosis) (Table 1).

Rev Col Bras Cir. 2018; 45(2):e1659


Ramos Hemodynamic evaluation of elderly patients during laparoscopic cholecystectomy

parameters, with little expressive clinical repercussion.

Table 1. Patients’ Characteristics.

Frequency

Characteristics

3

The increase in systolic and diastolic blood pressure was

n

%

Male

9

29.0%

Female

22

71.0%

60-69

22

71.0%

70-79

9

29.0%

I

3

9.7%

II

28

90.3%

0

3

9.7%

1

22

71.0%

2

5

16.1%

3

1

3.2%

Gender

Age

ASA

Number od comorbidities

We studied the normality of the hemodynamic variables in T1 (prior to pneumoperitoneum) using the Kolmogorov-Smirnov normality test. The descriptive statistics of hemodynamic parameters at T1 were: SBP=108.3±14.8; DBP=67.5±10.3; MAP=82.9±11.3; HR=64.1±12.6; CO=4.14±1.33; CI=2.49±0.81; and EF=66.7±10.4. The p value of the Kolmogorov-Smirnov normality test did not present statistical significance in any of the evaluated parameters. After instilling the pneumoperitoneum, we observed a general small variation in the hemodynamic

minimal, although statistically significant in the case of DBP (p=0.014). The mean SBPs at the different moments were (mmHg): T1=108.3±14.8; T2=115.7±17.0; and T3=111.6±14.4. The variations found were: T2T1=7.1±21.6; and T3-T2=-4.1±21.7. Variations were not statistically significant, with p-value= 0.067 and 0.301, respectively. The mean DBPs at the different moments were (mmHg): T1=67.5±10.3; T2=73.6±12.4; and T3=66.7±9.8. The variations found were: T2T1=6.2±13.2; and T3-T2=-6.9±12.3. Variations were statistically significant, with p-value= 0.014 and 0.004, respectively (Figure 1 and Table 2).

Figure 1. Mean and 95% confidence interval of Diastolic Blood Pressure (DBP) in mmHg.

Table 2. Diastolic Blood Pressure (DBP) in mmHg.

Moment Statistic

Variation in DBP

T1 pre-insufflation

T2= 10min after insufflation

T3= 5min after deflation

T2-T1

T3-T2

Mean

67.5

73.6

66.7

6.2

-6.9

Standard deviation

10.3

12.4

9.8

13.2

12.3

0.014

0.004

p-value The mean MAPs at the different moments were (mmHg): T1=82.9±11.3; T2=88.5±13.7; and T3=82.5±10.7. The variations found were: T2-

T1=5.6±17.5; and T3-T2=-6.0±16.7. Variations were not statistically significant, with p value =0.082 and 0.054, respectively.

Rev Col Bras Cir. 2018; 45(2):e1659


Ramos Hemodynamic evaluation of elderly patients during laparoscopic cholecystectomy

4

The mean HRs, in beats per minute (bpm), at

-3.5±8.8; and T3-T2=4.9±8.9. Although small, the

the different times were: T1=64.1±12.6; T2=64.0±13.3;

decrease in ejection fraction was statistically significant,

and T3=65.7±8.3. The variations found were: T2-T1= -0.1±14.2; and T3-T2=1.7±11.0. Variations were not statistically significant, with p-value= 0.960 and 0.393, respectively. The mean COs, in ml/min, at the different moments were: T1=4.4±1.33; T2=4.26±1.39; and T3=4.42±1.18. The variations found were: T2T1=0,13±1,23; and T3-T2=0.16±1.12. Variations were not statistically significant, with p-value= 0.573 and 0.442, respectively. The mean CIs, in L/min/m³, at the different moments were: T1=2.49±0.81; T2=2.57±0.86; and T3=2.66±0.73. The variations found were: T2T1=0.08±0.73; and T3-T2=0.09±0.66. Variations were not statistically significant, with p-value= 0.527 and 0.451, respectively. The mean EFs, in percentage (%), in the different moments were: T1=66.7±10.4; T2=63.2±9.9; and T3=68.1±8.4. The variations found were: T2-T1=

decreasing 5.24% (p=0.035) in the variation of T2-T1. And in the period after CO2 deinsufflation the ejection fraction increased again (p=0.005) (Figure 2 and Table 3).

Figure 2. Mean and 95% confidence interval of Ejection Fraction (EF) in %.

Table 3. Eject fraction (EF) in %.

Moment Statistic

Variation in EF

T1 pre-insufflation

T2= 10 min after insufflation

T3= 5 min after deflation

T2-T1

T3-T2

Mean

66.7

63.2

68.1

-3.5

4.9

Standard deviation

10.4

9.9

8.4

8.8

8.9

0.035

0.005

p-value

Table 4 shows the averages of the study variables being compared at the different moments.

Table 4. Mean results at the different times.

p-value Statistic/Moment

T1

T2

T3

T2-T1

T3-T2

T2-T1

T3-T2

PAS mmHg

108.3

115.7

111.6

7.4

-4.1

0.067

0.301

DBP mmHg

67.5

73.6

66.7

6.2

-6.9

0.014

0.004*

MAP mmHg

82.9

88.5

82.5

5.6

-6.00

0.082

0.054

HR bpm

64.1

64.00

65.7

-0.1

1.7

0.96

0.393

CO ml/min

4.14

4.26

4.42

0.13

0.16

0.573

0.442

CI L/min/m²

2.49

2.57

2.66

0.08

0.09

0.527

0.451

EF %

66.7

63.2

68.1

-3.5

4.9

0.035

0.005*

* Statistical significance. Rev Col Bras Cir. 2018; 45(2):e1659


Ramos Hemodynamic evaluation of elderly patients during laparoscopic cholecystectomy

DISCUSSION

5

(p=0.035) (Figure 2) in relation to the period before CO2 insufflation, which clinically did not mean much.

Despite the already recognized advantages of LC

However, it is worth emphasizing that in patients with

in relation to conventional surgery , pneumoperitoneum

compromised ventricular function, this alteration may

leads to cardiovascular alterations that are well tolerated

represent a threat.

10

by healthy individuals, but can be a threat to patients

The main causes of hemodynamic changes

with comorbidities, frequent in the elderly. Several

during laparoscopic cholecystectomy are the mechanical

studies have demonstrated hemodynamic changes

compression of the pneumoperitoneum, the absorption of

during laparoscopic cholecystectomy, with conflicting

CO2, and the establishment of the reverse Trendelemburg

. Joris et al. showed that in healthy young

(RT) position, being difficult to determine the contribution

patients the combined effects of anesthesia, Reverse

of each of these factors to these alterations12. Decreased

Trendelemburg position and pneumoperitoneum lead

preload, increased afterload and systemic release of

to a 50% decrease in cardiac index associated with

humoral factors are associated with these changes19. In

increased MAP and systemic vascular resistance (SVR).

this study the patients were operated in neutral position

The same changes were presented by Mc Laughlin et

and the result shows timid changes in the cardiac

results

11-14

14

in similar work, with a significant reduction of the

function during pneumoperitoneum. It is noteworthy

CO. Nevertheless, in this same age group, there are

that the calibration at time T2 occurred only ten minutes

studies that did not show any change in CO16, MAP, HR

after the start of the pneumoperitoneum and, therefore,

or EF9. Similarly, several works with elderly individuals

with minimal CO2 absorption until then. These findings

also showed no significant changes in hemodynamic

may suggest that the RT position has a greater role in

17

the hemodynamic changes than the pneumoperitoneum

conclude that gradual abdominal insufflation up to

does. Other authors have already suggested the same19.

12mmHg, followed by a 10-degree tilt in the RT position,

Still in the same line, Dorsay et al.20 stated that the

do not alter cardiovascular stability, while maintaining

pneumoperitoneum alone has minimal hemodynamic

al.

15

parameters during pneumoperitoneum. Dhoste et al.

CO, in elderly ASA III patients. Joshi et al. evaluated

effects, and that the RT position would be responsible, in

patients with mean age of 67 years through TEE

their study, for the decrease in CO, having the decrease

monitoring during laparoscopic cholecystectomy, and

in venous return as etiology.

7

despite having observed increased MAP and SVR, did

We can conclude that laparoscopic laparoscopic

not find a change in the ejection fraction. Cunningham

cholecystectomy leads to hemodynamic changes, which

et al.12, similarly, also did not observe any change in this

are mostly discrete and clinically poorly expressive, and

parameter and suggest that the ventricular function

are well tolerated in elderly patients. Elderly patients with

remains preserved.

compromised ventricular function may be at increased

A recent study composed of young and

risk during laparoscopic surgery due to decreased ejection

elderly patients submitted to LC concluded that this

fraction. The effect of CO2 insufflation on hemodynamic

surgery

changes

changes alone was not significant. There may be a

caused mostly by CO2 insufflation, and that the higher

greater contribution of the RT position in hemodynamic

the established intra-abdominal pressure the higher the

aleterations than of the pneumoperitoneum instillation.

level of hemodynamic variation and the absorption of

In the present study, only changes in diastolic blood

induces

significant

hemodynamic

CO2 by the peritoneum . However, only the variations

pressure (DBP) and ejection fraction (EF) were statistically

of the MAP, PAS and HR, were evaluated in this study,

significant. There was no statistical correlation between

insufficient data for such affirmations. In our study, we

hemodynamic variations, age and number of patientsâ&#x20AC;&#x2122;

did not observe great variation in MAP, CO and CI. The EF

comorbidities.

18

changed slightly with pneumoperitoneum, falling 5.24%

Rev Col Bras Cir. 2018; 45(2):e1659


Ramos Hemodynamic evaluation of elderly patients during laparoscopic cholecystectomy

6

R E S U M O Objetivo: demonstrar as alterações hemodinâmicas durante a colecistectomia laparoscópica em pacientes idosos com auxílio da ecocardiografia trans-esofágica Métodos: foram estudados trinta e um pacientes idosos (com 60 anos de idade ou mais), ASA I ou II, submetidos à colecistectomia laparoscópica eletiva, sob anestesia geral padronizada, com aferição de parâmetros cardiovasculares através de ecocardiograma trans-esofágico em três momentos diferentes: antes do pneumoperitônio (T1), após a insuflação do CO2 (T2) e na desinsuflação (T3). As variações da pressão arterial sistólica, diastólica e média, da frequência cardíaca, do débito e do índice cardíaco, e da fração de ejeção foram avaliadas estatisticamente. Resultados: apesar de pequenas, somente as variações da pressão arterial diastólica (PAD) e da fração de ejeção (FE) foram estatisticamente significativas. A PAD, em mmHg, nos diferentes momentos, de acordo com a média e desvio padrão, foram: T1=67,5±10,3; T2=73,6±12,4; T3=66,7±9,8. E para a FE, em porcentagem (%), nos diferentes momentos, de acordo com média e desvio padrão, foram: T1=66,7±10,4; T2=63,2±9,9; T3=68,1±8,4. Não houve correlação estatística entre as variações hemodinâmicas, a idade e número de comorbidades dos pacientes. Conclusão: a colecistectomia laparoscópica causa poucas alterações hemodinâmicas que são bem toleradas pela maioria dos pacientes idosos; o comprometimento prévio da função ventricular representa ameaça em pacientes idosos durante a cirurgia; parece haver menor efeito hemodinâmico causado pelo pneumoperitônio do que pelo posicionamento do paciente em Trendelemburg reverso durante a cirurgia. Descritores: Pressão Arterial. Hemodinâmica. Ecocardiografia Transesofagiana. Idoso. Laparoscopia. Pneumoperitônio Artificial.

REFERENCES

9. D’Ugo D, Persiani R, Pennestri F, Adducci E, Primieri P, Pende V, et al. Transesophageal echocardiographic

1. Loureiro ER, Klein SC, Pavan CC, Almeida LD, da Silva FH, Paulo DN. Laparoscopic cholecystectomy in 960 elderly patients. Rev Col Bras Cir. 2011;38(3):155-9. 2. Yetkin G, Uludag M, Oba S, Citgez B, Paksoy I. Laparoscopic cholecystectomy in elderly patients. JSLS. 2009;13(4):587-91. 3. Tagle FM, Lavergne J, Barkin JS, Unger SW. Laparoscopic cholecystectomy in the elderly. Surg Endosc. 1997;11(6):636-8. 4. Annamaneni RK, Moraitis D, Cayten CG. Laparoscopic cholecystectomy in the elderly. JSLS. 2005;9(4):40810. 5. Yaman C, Renner S, Binder H, Oppelt P. Laparoscopy in elderly women. J Gynecol Surg. 2009;25(2):61-6. 6. Zhu Q, Mao Z, Jin J, Deng Y, Zheng M, Yu B. The Safety of CO2 pneumoperitoneum for elderly patients during laparoscopic colorectal surgery. Surg Laparosc Endosc Percutan Tech. 2010;20(1):54-7. 7. Joshi GP, Hein HA, Mascarenhas WL, Ramsay MA, Bayer O, Klotz P. Continuous transesophageal echoDoppler assessment of hemodynamic function during laparoscopic cholecystectomy. J Clin Anesth. 2005;17(2):117-21. 8. Goodale RL, Beebe DS, McNevin MP, Boyle M, Letourneau JG, Abrams JH, et al. Hemodynamic, respiratory, and metabolic effects of laparoscopic cholecystectomy. Am J Surg. 1993;166(5):533-7.

assessment

of

hemodynamic

function

during

laparoscopic cholecystectomy in healthy patients. Surg Endosc. 2000;14(2):120-2. 10. Efron DT, Bender JS. Laparoscopic surgery in older adults. J Am Geriat Soc. 2001;49(5):658-63. 11. Critchley LA, Critchley JA, Gin T. Haemodynamic changes

in

patients

undergoing

laparoscopic

cholecystectomy: measurement by transthoracic electrical

bioimpedance.

Br

J

Anaesth.

1993;70(6):681-3. 12. Cunningham AJ, Turner J, Rosenbaum S, Rafferty T. Transoesophageal echocardiographic assessment of haemodynamic function during laparoscopic cholecystectomy. Br J Anaesth. 1993;70(6):621-5. 13. Carter JF, Chang EY, Haynes G, Scardo JA. Hemodynamic effects of pneumoperitoneum during gynecologic laparoscopic surgery. J Gynecol Surg. 1997;13(4):169-73. 14. Joris JL, Noirot DP, Legrand MJ, Jacquet NJ, Lamy ML. Hemodynamic changes during laparoscopic cholecystectomy. Anesth Analg. 1993;76(5):106771. 15. McLaughlin JG, Seheeres DE, Dean RJ, Bonnell BW. The adverse hemodynamic effects of laparoscopic cholecystectomy. Surg Endosc. 1995;9(2):121-4. 16. Larsen JF, Svendsen FM, Pedersen V. Randomized clinical trial of the effect of pneumoperitoneum

Rev Col Bras Cir. 2018; 45(2):e1659


Ramos Hemodynamic evaluation of elderly patients during laparoscopic cholecystectomy

on

cardiac

function

and

haemodynamics

7

20. Dorsay DA, Greene FL, Baysinger CL. Hemodynamic

during laparoscopic cholecystectomy. Br J Surg.

changes

2004;91(7):848-54.

monitored with transesophageal echocardiography. Surg Endosc. 1995;9(2):128-33; discussion 133-4.

17. Dhoste K, Lacoste L, Karayan J, Lehuede MS, Thomas D, Fusciardi J. Haemodynamic and ventilatory changes during laparoscopic cholecystectomy in elderly ASA III patients. Can J Anesth. 1996;43(8):783-8. 18. Umar A, Mehta KS, Mehta N. Evaluation of hemodynamic changes using different intra-abdominal pressures for laparoscopic cholecystectomy. Indian J Surg. 2013;75(4):284-9. 19. Hirvonen EA, Poikolainen EO, Pääkkönen ME, Nuutinen LS. The adverse hemodynamic effects of anesthesia, head-up tilt, and carbon dioxide pneumoperitoneum during laparoscopic cholecystectomy. Surg Endosc. 2000;14(3):272-7.

during

laparoscopic

Received in: 08/12/2017 Accepted for publication: 1o/02/2018 Conflict of interest: none. Source of funding: none. Mailing address: Antônio Carlos Iglesias E-mail: aciglesias.lf@gmail.com / joseantoniocunha@yahoo.com.br

Rev Col Bras Cir. 2018; 45(2):e1659

cholecystectomy


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Original Article

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Predictors of chest drainage complications in trauma patients Fatores preditores de complicações da drenagem de tórax em pacientes vítimas de trauma CECÍLIA ARAÚJO MENDES1; ELCIO SHIYOITI HIRANO,TCBC-SP2

A B S T R A C T Objective: to identify predictors of chest drainage complications in trauma patients attended at a University Hospital. Methods: we conducted a retrospective study of 68 patients submitted to thoracic drainage after trauma, in a one-year period. We analyzed gender, age, trauma mechanism, trauma indices, thoracic and associated lesions, environment in which the procedure was performed, drainage time, experience of the performer, complications and evolution. Results: the mean age of the patients was 35 years and the male gender was the most prevalent (89%). Blunt trauma was the most frequent, with 67% of cases, and of these, 50% were due to traffic accidents. The mean TRISS (Trauma and Injury Severity Score) was 98, with a mortality rate of 1.4%. The most frequent thoracic and associated lesions were, respectively, rib fractures (51%) and abdominal trauma (32%). The mean drainage time was 6.93 days, being higher in patients under mechanical ventilation (p=0.0163). The complication rate was 26.5%, mainly poor drain positioning (11.77%). Hospital drainage was performed in 89% of cases by doctors in the first year of specialization. Thoracic drainage performed in prehospital care presented nine times more chances of complications (p=0.0015). Conclusion: the predictors of post-trauma complications for chest drainage were a procedure performed in an adverse site and mechanical ventilation. The high rate of complications demonstrates the importance of protocols of care with the thoracic drainage. Keywords: Thoracic Injuries. Drainage. Postoperative Complications.

INTRODUCTION

require larger surgery5. Properly performed chest seal drainage is

C

hest trauma is present in 10% to 15% of the

a safe procedure and about 80% of patients have

traumatized, accounting for 25% of all deaths ,

adequate resolution5,6. Complications, when they

mainly due to airway and ventilation compromise.

occur, can be caused by two factors: a) technical,

Ventilation may be altered by isolated or associated

due to lack of knowledge of the thoracic anatomy,

thoracic injuries, such as hemothorax, pneumothorax,

inadequate training, lack of experience or deficiency

pulmonary contusion, costal arch fractures, and

of supervision, when performed by a physician in

intercostal vessel lesions. In the first two examples,

training; and b) infectious, when the procedure is

the treatment is mostly represented by closed chest

performed in an inappropriate environment or without

drainage, a small surgical procedure that can be

due asepsis and antisepsis7.

1

performed even in Prehospital Care (PHC)2-4. It is

This study aims to identify predictive factors

important to note that less than 10% of blunt thoracic

related to the complications of thoracic drainage in

trauma and less than 30% of penetrating trauma will

trauma patients, correlating them with the literature.

1- Campinas State University, Discipline of Trauma Surgery, Faculty of Medical Sciences, Campinas, SP, Brazil. 2 - Campinas State University, Post-Graduate Program, Master’s Degree in Surgery Sciences, Faculty of Medical Sciences, Campinas, SP, Brazil. Rev Col Bras Cir. 2018; 45(2):e1543


Mendes Predictors of chest drainage complications in trauma patients

2

METHODS

RESULTS

This is a descriptive, analytical and retrospective study of 68 trauma patients who underwent closed chest drainage in water seal, in the PHC or in the Emergency Unit of the Clinics Hospital (CH) of the State University of Campinas (Unicamp), in the period from April 2013 to April 2014. We excluded Patients younger than 14 years. We requested waiver of the informed consent form, in accordance with Resolution no 196, of the Code of Medical Ethics. The opinion was approved by the Ethics in Research Committee under number 474339. We analyzed the variables gender, age, trauma mechanism, trauma indices, drainage time, associated injuries, graduation level of the physician who performed the procedure, drainage environment, complications and clinical evolution. The data were analyzed by Unicampâ&#x20AC;&#x2122;s FCM Biostatistics Service, which used the software Statistical Analysis System for Windows (SAS), version 9.4. SAS Institute Inc., 2002-2008, Cary, NC, USA8-10.

Of the 68 patients studied, 89% were male, with an average age of 35 years. The Revised Trauma Scores (RTS) had a median of 7.84 and the Trauma and Injury Severity Score (TRISS), of 98. The predominant trauma mechanism was the blunt one (67% of cases), the motorcycle event being the most prevalent, with 22%. Penetrating gunshot and stabbing injuries accounted for 16% of individual cases. When grouped together, the traffic events (motorcycling accidents, automobile accidents and running over) corresponded to 50% of the casuistry. Isolated thoracic lesions occurred in 14 patients, and the most frequent associated lesion was abdominal trauma, in 32% of cases, followed by head trauma and long bone fractures, each with 10%. The involvement of more than two body segments was present in 26% of the patients. Pulmonary contusion and rib fracture were the most frequent thoracic injuries (Figure 1).

Figure 1. Most frequent thoracic lesions.

Bilateral thoracic drainage was performed in 19% of cases. The duration of the drain ranged from one to 19 days, with a mean of 6.93 days. Patients who required mechanical ventilation remained longer with thoracic drainage, with statistical significance, p=0.0163. In 56 patients, thoracic drainage was carried out in a hospital setting, and in 89% (50 patients), performed by physicians in the first year of surgical specialization. The thoracic drainage rate in the PHC setting was 17.6% (12 patients), and presented a risk of complications nine times higher when compared to those performed in

a hospital environment, with p=0.0015 (Table 1).

Table 1. Incidence of complications after thoracic drainage according to the environment where it was performed.

Environment

Complications No (n/%)

Yes (n/%)

Hospital (n=56)

46 / 82.1

10 / 17.9

PHC* (n=12)

4 / 33.3

8 / 66.7

Total (n=68)

50 (73.5)

18 (26.5)

*PHC: Prehospital Care.

Rev Col Bras Cir. 2018; 45(2):e1543


Mendes Predictors of chest drainage complications in trauma patients

3

The overall complication rate was 26.5% (18 patients), and the malposition of the drain, with the need for new drainage, was the most frequent complication, with eight cases (Table 2). These occurred due to the position of the last drain hole outside the pleural cavity (n=4) and due to drainage introduced into the subcutaneous (n=2) or into the abdominal cavity (n=2).

associated with thoracic trauma (32 % of cases) and the most prevalent event was motorcycling. The

Revised

Trauma

Score

(RTS)

is

a

physiological index of the patient at admission, based on three parameters: neurological level (Glasgow Coma Scale â&#x20AC;&#x201C; GCS), systolic blood pressure and respiratory rate, the higher the value, the better the prognosis. The Injury Severity Score (ISS) is an anatomical index that classifies the severity of the lesions in each body segment. Trauma and

Table 2. Complications of thoracic drainage.

Complications

Injury Severity Score (TRISS) is an index that demonstrates

Cases

%

Residual Hemothotax

2

2.9

and is calculated by the association between RTS, ISS,

Residual Pneumothorax

3

4.4

patient age and type of trauma (blunt or penetrating).

Pneumonia

5

7.4

In the present study, 77.9% of the cases presented RTS

Re-drainage

8

11.8

between 5 and 8, with a survival probability of 80%. The

Total

18

26.5

median of the TRISS was 0.98, compatible with the low

the probability of survival of the traumatized individual

mortality of 1.4%. The complication rate of 26.5% was due to poorly positioned drains and residual hemothorax and

Thoracoscopy was indicated in two patients:

pneumothorax, which may also be related to drains

one for empyema (gastric perforation by the drain in one

that are poorly positioned in the pleural cavity, folded or

patient with traumatic diaphragmatic hernia) and another

directed to the diaphragm, which makes it difficult for

for residual hemothorax. The empyema patient evolved

air and liquids to escape. Residual hemothorax occurred

with incarceration and the need for pleurostomy.

in 2.9% of our cases and the treatment was performed

The mean length of hospital stay was 20 days.

by thoracoscopy. Post-trauma residual hemothorax

One death (1.5%) occurred due to multiple complications

in the work of Navsaria et al. occurred in 4.4% of

and the severity of the associated lesions.

patients submitted to thoracic drainage. Video-assisted thoracoscopic surgery (VATS) was successful in the

DISCUSSION

hygiene of the pleural space in 80% of cases and failed in 20% due to the presence of pulmonary incarceration,

Urban violence predominates in developing

requiring thoracotomy13. A study by Rezende Neto et

countries. In Brazil the death rate due to homicides in the

al. emphasizes that residual hemothorax contributes to

age group of 15 to 29 years is 20 times higher than the

an increase in hospitalization time, costs and morbidity,

rate of European countries11. In a study of the University

the infectious complication being 12 to 16 times more

Hospital in Damascus, Syria, with 888 patients with

frequent14. The definition and diagnosis of retained

thoracic trauma, traffic accidents were the main cause, in

hemothorax are not consensus, a fact that often leads to

areas outside the conflict zones. Accidents were the most

delayed treatment, increasing the chances of infectious

frequent mechanism (40% of cases), male gender was the

complications, prolonging hospital stay and drainage

most prevalent (89% of cases), mean age was 31 years

time.

and associated lesions occurred in 36% of patients, with

At the trauma center at the University of Medical

predominance of upper and lower limbs(19% of cases),

Sciences in Iran, Abbasi et al. demonstrated that it is

followed by abdominal and craniocerebral trauma (13%

safe to withdraw the drain in patients under mechanical

and 8% of the cases, respectively)12, This differs from our

ventilation, provided that the following criteria are met:

study, in which abdominal trauma was the lesion most

flow rate less than 300 milliliters in 24 hours, absence

Rev Col Bras Cir. 2018; 45(2):e1543


Mendes Predictors of chest drainage complications in trauma patients

4

of air leakage and radiographic examination with

gave a simple chest X-ray examination after drainage.

pulmonary expansion. They also point out that drainage

They concluded that, since this is a simple and salvage

withdrawal reduces morbidity, complications and reduces hospitalization time15. The criteria used in the Discipline of Trauma Surgery – Unicamp for the removal of the posttraumatic chest drain are: flow less than 100 milliliters in 24 hours, absence of air leakage, full lung expansion by simple chest X-ray and physical examination. The present study demonstrated that drainage withdrawal in patients under mechanical ventilation was late, with statistical significance (p=0.0163). Aylwin et al. evaluated the thoracic drainage performed in PHC and in the hospital by a trauma team according to the ATLS precepts. A sample of 57 patients presented an overall complication rate of 14%. Of these 31% were by poorly positioned tubes, and 17% had to be submitted to a new drainage. They concluded that there was no difference in the risk of drainage complications in the PHC and in-hospital, and that the in-hospital complication rates due to failures in the technique were high, which called attention to the adequate formation and training of the team16. In the present study, 17.6% were drained in the PHC, one case being in a primary health unit. This group of patients had a nine-fold greater risk of complications than the group submitted to thoracic drainage in our Service, with p=0.0015. The PHC environment is adverse and several local and external factors may contribute to the increase in the rate of complications, such as site contamination,

procedure in critical situations, the training of medical surgeons should be done at the beginning of the surgical career, with adequate supervision18. In the present study, 89% of in-hospital drainage was performed by a resident physician in the first year of surgical specialization. There was no statistical relation of greater complications between this group and the one drained by doctors with higher level of experience. In 2015, the impact of a protocol of Standardized Care with the Chest Drain (Cuidado Padronizado com o Dreno de Tórax – CPDT) in a public hospital, a reference for trauma in the city of Belo Horizonte/ Brazil, was evaluated as part of the Trauma Care Quality Improvement Program. The studied group presented an isolated lesion of the chest wall, lung and/or pleura, was hemodynamically stable and had an ISS inferior to 17. The implementation of CPDT was effective in the reduction of complications: significant reduction (p<0.05) of retained hemothorax, empyema, pneumonia, wound infection, length of hospital stay, and drain permanence. Respiratory physiotherapy attendance raised from 1% to 96% of patients, drainage in the surgical center, from 59% to 75%, and prophylactic antibiotic use, from 31% to 54%. The group receiving physical therapy twice a day had a 79% lower chance of retained hemothorax. Drainage in the surgical center was associated with reduced empyema, pneumonia and surgical wound

climatic variation (rain, wind), inadequate positioning, and limited material and resources. Kesieme et al. performed an evaluation among surgery resident physicians of the first year on anatomical points to perform thoracic drainage and revealed that 45% did not identify the correct site, the most common error being the very low insertion error (20%). They concluded that these are avoidable complications17. A study involving four teaching hospitals in Nigeria evaluated the level of resident doctors’ experience and knowledge in thoracic drainage and found that 10% of the interviewees had never performed the procedure, and 77% performed it for the first time in the first year of residence training. He also identified that 40% had never placed the chest drain in connection with continuous aspiration. Only 30% examined the patient again and

infection. The study emphasizes that pleuropulmonary complications prior to the implementation of CPDT did not meet acceptable international parameters, ranging from 11% to 31%, and that there was a decline to 6.5%19. Prehospital drainage, trauma mechanism, need for mechanical ventilation and injuries in other body segments are some of the predictors of chest drainage complications observed in the present study and listed in the literature12. These are variables that reveal the severity of the patient and the need for specific care. Therefore, the understanding of these variables will influence the management and evolution of patients submitted to thoracic drainage. The mortality rate in patients hospitalized for isolated chest injury is between 4% and 8%. When there

Rev Col Bras Cir. 2018; 45(2):e1543


Mendes Predictors of chest drainage complications in trauma patients

5

is another body segment involved, it increases to 10%

complications of post-traumatic thoracic drainage were

to 25%, and reaches 35% when there is compromise

adverse site to perform the procedure, such as in the

20

prehospital care setting, and mechanical ventilation, which determines a longer drainage time. Our complication rate is close to the upper limit of the literature, which demonstrates the importance of elaborating care protocols with patients submitted to thoracic drainage.

of multiple organ systems . In the present study, 18 patients (26%) presented lesions in more than two body segments, and one death occurred due to multiple organ lesions. We conclude that the predictive factors of R E S U M O

Objetivo: identificar fatores preditores de complicações da drenagem torácica em pacientes vítimas de trauma, atendidos em um Hospital Universitário. Métodos: estudo retrospectivo de 68 pacientes submetidos à drenagem torácica pós-trauma, no período de um ano. Foram analisadas as seguintes variáveis: sexo, idade, mecanismo de trauma, índices de trauma, lesões torácicas e associadas, ambiente em que foi realizado o procedimento, tempo de permanência do dreno, grau de experiência do executor do procedimento, complicações e evolução. Resultados: a média de idade dos pacientes foi de 35 anos e o sexo masculino foi o mais prevalente (89%). O trauma contuso foi o mais frequente, com 67% dos casos, e destes, 50% por acidentes de trânsito. A média do TRISS (Trauma and Injury Severity Score) foi 98, com taxa de mortalidade de 1,4%. As lesões torácicas e associadas mais frequentes foram, respectivamente, fraturas de costelas (51%) e trauma abdominal (32%). A média de permanência do dreno foi de 6,93 dias, sendo maior nos pacientes sob ventilação mecânica (p=0,0163). A taxa de complicações foi de 26,5%, com destaque para o mau posicionamento do dreno (11,77%). A drenagem hospitalar foi realizada, em 89% dos casos, por médicos do primeiro ano de especialização. A drenagem torácica realizada no atendimento pré-hospitalar apresentou nove vezes mais chances de complicações (p=0,0015). Conclusão: os fatores preditores de complicações para drenagem torácica pós-trauma foram: procedimento realizado em local adverso e ventilação mecânica. A alta taxa de complicações demonstra a importância dos protocolos de cuidados com a drenagem torácica. Descritores: Traumatismos Torácicos. Drenagem. Complicações Pós-Operatórias.

REFERENCES

a bridge between parametric and nonparametric statistics. Am Stat.1981;35(3):124-9.

1. Oikonomou A, Prassopoulos P. CT imaging of blunt chest trauma. Insights Imaging. 2011;2(3):281-95. 2. Calhon JH, Trinkle JK. Pathophysiology of chest trauma. Chest Surg Clin N Am. 1997;7(2):199-211. 3. Silas MG, Belluzzo GR, Miguel EG, Bahdur R, Pires AC. Traumatismos torácicos: análise de 231 casos. Arq Med ABC. 1990;13(1-2):19-21. 4. Symbas PN. Chest drainage tubes. Surg Clin North Am. 1989;69(1):41-6. 5. Block EF, Kirton OC, Windsor J, Kestner M. Guided percutaneous drainage for posttraumatic empyema thoracics. Surgery. 1995;117(3): 282-7. 6. Dural K, Gulbahar G, Kocer B, Sakinci U. A novel and safe technique in closed tube thoracostomy. J Cardiothorac Surg. 2010;5:21. 7. Kesieme EB, Dongo A, Ezemba N, Irekpita E, Jebbin N, Kesieme C. Tube thoracostomy: complications and its management. Pulm Med. 2012;2012: 256878. 8. Conover WJ, Iman RL. Rank transformations as

9. Fleiss JL. Statistical methods for rates and proportions. 2nd ed. New York: John Wiley & Sons; 1981. 10. Montgomery DC, Peck EA. Introduction to linear regression analysis. New York: John Wiley & Sons; 1982. 11. Brasil. Ministério da Saúde. Organização PanAmericana

da

Saúde.

Rede

Interagencial

de

Informações para Saúde. Demografia e saúde: contribuição para análise de situação e tendências. Brasília: Organização Pan-Americana da Saúde; 2009. 12. Al-Koudmani I, Darwish B, Al-Kateb K, Taifour Y. Chest trauma experience over eleven-year period at al-Mouassat university teaching hospital-Damascus: a retrospective review of 888 cases. J Cardiothorac Surg. 2012;7:35. 13. Navsaria PH, Vogel RJ, Nicol AJ. Thoracoscopic evacuation of retained posttraumatic hemothorax. Ann Thorac Surg. 2004;78(1):282-5; discussion 285-6.

Rev Col Bras Cir. 2018; 45(2):e1543


Mendes Predictors of chest drainage complications in trauma patients

6

14. Rezende Neto JB, Pastore Neto M, Hirano ES, Rizoli

15.

16.

17.

18.

Rev Col Bras Cir. 2015;42(4):231-7.

S, Nascimento Júnior B, Franga GP. Abordagem do

19. Fontelles MJP, Mantovani M. Trauma torácico:

hemotórax residual após a drenagem torácica no trauma. Rev Col Bras Cir. 2012;39(4):344-9. Abbasi HR, Farrokhnia F, Sefidbakht S, Paydar S, Bolandparvaz S. Chest tube removal time in trauma patients on positive ventilation pressure: a randomized clinical trial. Bull Emerg Trauma. 2013;1(1):17-21. Aylwin CJ, Brohi K, Davies GD, Walsh M. Pre-hospital and in-hospital thoracostomy: indications and complications. Ann R Coll Surg Eng. 2008; 90(1):54-7. Kesieme EB, Olusoji O, Inuwa IM, Ngene CI, Aigbe E. Management of chest drains: a national survey on surgeons-in-training experience and practice. Niger J Surg. 2015;21(2):91-5. Abreu EMS, Machado CJ, Pastore Neto M, Rezende Neto JB, Sanches MD. Impacto de um protocolo de cuidados a pacientes com trauma torácico drenado.

fatores de risco de complicações pleuropulmonares pós drenagem pleural fechada. Rev Col Bras Cir. 2000;27(6):400-7.

Received in: 23/11/2017 Accepted for publication: 09/01/2018 Conflict of interest: none. Source of funding: none. Mailing address: Elcio Shiyoiti Hirano E-mail: hirano.es@gmail.com / ceciliaaraujomendes@gmail.com

Rev Col Bras Cir. 2018; 45(2):e1543


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Profile of the General Surgery resident: what are the changes in the 21st Century? Perfil do residente de Cirurgia Geral: quais as mudanças no Século XXI?

SAMIR RASSLAN, TCBC-SP1; MARIANA SOUSA ARAKAKI1; ROBERTO RASSLAN, TCBC-SP1; EDIVALDO MASSAZO UTIYAMA, TCBC-SP1 A B S T R A C T Objective: to verify the profile of the General Surgery residents of the Clinics Hospital (HC) of the Faculty of Medicine of the University of São Paulo (FMUSP). Methods: we evaluated the residents approved in the public contest for the Medical Residency Program in General Surgery of HC-FMUSP in the years 2014, 2015 and 2016. We carried out the study by applying a questionnaire and gathering information from the Medical Residency Commission of the Institution. We analyzed data on identification, origin of the candidate, undergraduate school, surgical teaching received, reason for choosing Surgery, residency expectations, choice of future specialty and pretensions as to the end of medical residency. We also analyzed the result of the examination of access to specialties. Results: the mean age was 25.8 years; 74.3% of residents were male. The majority (84.4%) had attended public medical schools, 68% of which were in the Southeast region; 85,2% of the residents were approved in the first contest. The specialty choice was present for 75.9% of individuals at the beginning of the residency program, but 49.5% changed their minds during training. Plastic Surgery, Urology and Digestive System Surgery were chosen by 61.5%. Sixty hours per week work were considered adequate by 83.3%; 27.3% favored direct access to the specialty. At the end of the specialty, 53.3% intended to continue in São Paulo, and 26.2%, to return to their State of origin. A strict-sense post-graduate course was intended by 68.3%. Conclusion: the current profile of the resident reveals a reduction in the demand for General Surgery, an earlier definition of the specialty, options for increasingly specific areas and an activity that offers a better quality of life. Keywords: Internship and Residency. Education, Medical. Specialties, Surgical. Career Choice.

INTRODUCTION

Residency, as a proposal since its inception, consists in training under permanent supervision, with

R

esidency is a fundamental step in the training

teaching provided by the faculty, the resident having

of the physician to the conditions of exercising the profession appropriately. It is a resource set up world-wide, and considered the more efficient way of deepening the knowledge in a field of medical science1. It was introduced at the end of the 19th Century by William Halsted, Professor of Surgery, and William Osler, Professor of Internal Medicine, at the Johns Hopkins University Hospital in Baltimore, USA, with participation of other Professors of the Institution. In Brazil, it began in 1944, at the Hospital of the State Public Servant of Rio de Janeiro and at the Clinics Hospital (HC) of the Faculty of Medicine of the University of São Paulo (FMUSP)1.

responsibility for the patient’s care and participation in research, with a pyramidal progression system. The fundamental objective is to prepare the physician to act in clinical practice2. Among the four major areas of direct access general specialties, General Surgery is the second most popular choice, after Internal Medicine, and followed by Gynecology and Pediatrics. At HC-FMUSP, over the last years, the residency contest has displayed an average of ten to 12 candidates per position, for a two-year training course that constitutes a requirement for access to surgical specialties. Some factors influence the choice of specialty, such as the style or quality of life, the prestige of the

1 - Discipline of General Surgery and Trauma, Department of Surgery, Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil.

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Rasslan Profile of the General Surgery resident: what are the changes in the 21st Century?

2

RESULTS

area and the economic factor. However, for most undergraduate medical students, prestige and salary are less important than a proper balance between work and a private life3-7. Dermatology, Otorhinolaryngology and Ophthalmology are the three most sought specialties among those with direct access, with an average of more than 15 candidates per position. The demand for General Surgery has been declining in recent years, and this lack of interest has been attributed to the proliferation of surgical specialties, to overwork, to the greater number of female students in the medical undergraduate course, and mainly to the loss of role models to look up to, which has been referred to in numerous publications that discuss the subject8,9. Due to these aspects, the profile of the General Surgery resident has changed. The objective of this study is to assess the profile of general surgery residents of the HC-FMUSP, analyzing particularities of the training in the medical undergraduate course, the choice of specialty after the initial two years and the pretensions as to the end of the training.

METHODS We evaluated residents approved in the contest to fill the 48 vacancies/year of the Medical Residency Program in General Surgery of the HC-FMUSP, in the years of 2014, 2015 and 2016. The study was submitted to, and approved by, the Institution’s Ethics Committee, under the number 679416. We used data obtained from two sources: a questionnaire of optional filling applied in the first trimester of the program, and information from the Institution’s Medical Residency Commission (COREME). We collected identification (sex, age, marital status), candidate’s background, medical graduation school and number of contests participations until entering the residency. The questionnaire also analyzed the influence to choose the residency in surgery, the expectations for the two years of training, the choice of the future specialty and aspects related to the pretensions after the end of the program.

We obtained responses from 85.4% of the residents and fully evaluated the data from COREME. The mean age was 25.8 years, with a predominance of males (74.3%), and 3% were married when they entered medical residency. For 85.2% of the residents, approval took place in the first contest for General Surgery, and 14.8% had already applied for the same specialty in previous years. In addition to the residency contest at the Clinics Hospital, 61.2% had applied for other services, with an approval rate of 97.2%. Regarding the Medical Graduation Course, 84.4% were from Public Schools, and 68% completed training in the Southeast region. Of the 144 selected residents, 49 (34%) were students graduating from FMUSP, with 66% of the places occupied by students coming from different medical schools in the country (Table 1). Table 1. Profile of General Surgery Residents – FMUSP (2014-2016).

Mean age

25.8 years

Male gender

74.3%

Married

3.3%

From the Southwest region

68%

Approved on the first exam

85.2%

From public schools

84.4%

From FMUSP Participated in surgical team during graduation

34% 48%

The choice for a surgical specialty was influenced by internships in the medical undergraduate course to 71.5%, who had the opportunity to assist and perform procedures during the internship. During graduation course, 48% reported having participated in surgical teams. The HC option was because it was a reference center. Regarding the specialty choice, 107 (75.8%) already had the career definition to follow at the beginning of the residency. In the evolution of the training, 53 (49.5%) changed the choice after going through all

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Rasslan Profile of the General Surgery resident: what are the changes in the 21st Century?

3

the Disciplines included in the program (Table 2). Plastic

vacancies, and the profile of selected residents has been

Surgery and Urology were the most desired, being the

changing in recent years. The candidates are young, with

main specialties chosen along with Digestive Surgery, by 61.5%.

an average age of 25.8 years, and 25.7% are female. This number is considered significant when compared with the percentage of women who had opted for surgery two to three decades ago. The most sought after specialties for women are Plastic Surgery, followed by Vascular Surgery. Since its implementation in 2006, the Advanced General Surgery Program has trained 58 residents, of which only nine (15.5%) were women. Even though women represent almost 50%, sometimes even more, of medical students, the option for General Surgery is not proportional, because excessive workload interferes with family life. In addition, due to the lower number of women surgeons in relation to men, and the fact that few of them hold leadership positions, there is a lack of models or examples that serve as stimuli for others to follow the surgical career6,10 . The number of candidates per position remains constant despite the indiscriminate opening of medical schools, many of which have not yet formed their first class, but surely the number of candidates should increase in the coming years. We should note that students from schools with a deficit structure do not normally enroll in the HC-FMUSP contest, as the probability of approval is small due to the significant demand, the high level of the exam and the application costs. Thus, it is not surprising that 84.4% of residents come from Public Schools, of which 68% have completed training in the Southeast

Table 2. Choice of Specialty - FMUSP (2014-2016).

Specialty defined at the beginning of the residency program

75.80%

Changed option

49.5%

In the residentsâ&#x20AC;&#x2122; opinion, 83.3% considered the 60 hours of training per week adequate, but 16.7% considered them insufficient. In addition, 27.3% favored direct access to the specialty. Regarding the meaning of the two-year training period, the questionnaire offered three choices, with the possibility of indicating more than one: confirmation of the specialty (52.8%), acquisition of basic technical requirements (78%) and General Surgery as a path to take towards the specialty (17.1%). Of the 144 residents who started the program, three dropped out and seven did not apply for the specialty. Of the 134 that applied, 42 (31.4%) were not approved, 83 (61.9%) continued in the HC-FMUSP and nine (6.7%) were able to find positions in other institutions (Table 3).

Table 3. Result of the specialty access exam â&#x20AC;&#x201C; FMUSP (2014-2016).

Approved for HC-FMUSP

61.90%

Approved for other institutions

6.7%

Non-approved

31.4%

As for the expectations after residency in the specialty, 53.3% intended to continue in SĂŁo Paulo, 11.9%, to work in the interior of the State, and 26.2%, to return to the State of origin. Still as plans for the future, 68.3% intended to attend Strict-Sense Post-Graduation.

DISCUSSION The General Surgery residency of the Clinics Hospital of FMUSP offers an expressive number of

region. However, it may be surprising that only 34.7% of the residents are students graduating from FMUSP, unlike in the past, when most of the places were occupied by them. Two aspects may explain these data: first, that in 2011, there was an increase in the number of vacancies for General Surgery, from 36 to 48; second, the decrease in the number of students who choose the specialty. On average, 20 to 30 students opt for General Surgery, and even if all pass the exam, vacancies would always be left for students from other Colleges. However, this is an open competition, and HC-FMUSP has distinguished itself by selecting excellent candidates from different Medical Schools and regions of the Country. In the United States, there has been a gradual decline in the demand for General Surgery by students in the end of the undergraduate course, falling from 12% to 6%8. Kleinert

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4

Rasslan Profile of the General Surgery resident: what are the changes in the 21st Century?

et al.6 analyzed the questionnaire responses sent to 1,098

showed preference for the specialty to which they would

medical students in Germany and found that 14% had

apply at the end of the second year of residency. This has

plans to choose a surgical specialty.

been referred to as frequent, since usually at the end of is

the undergraduate course the student has already defined

decreasing due to several aspects. The choice is focused

the specialty to pursue. However, 49.5% of the residents

on the specialties that allow a better style and quality of

changed their choice after completing all the stages in

life than that determined by the General Surgery, which

the different disciplines. In recent years, Plastic Surgery

involves a long time of training, intense dedication in the

and Urology, along with Digestive System Surgery, have

care of critically ill patients, prolonged period confined

been the most sought after areas among the nine offered

in the operating room and countless shifts. Interestingly,

at the end of training. More than 60% of the residents

that these aspects did not seem to have as much relevance

who completed the two years of General Surgery at

in the past.

HC-FMUSP chose them. However, we have observed

As

already

mentioned,

this

demand

Of the residency graduates in General Surgery

in recent years that of the 48 residents who complete

in the United States, only 30 to 40% act like general

the training, only eight to 12 (20%) make the option for

surgeons. The option is for other specialties, with a

Digestive Surgery or General Surgery Advanced Program

5

growing tendency for “mini or sub-specialties” . The

(the greater number for the former), the remaining 80%

surgeon who in the past saw the patient as a whole

opting for other specialties.

now acts in a certain body segment, when not in only

In the Medical Residency Program in Brazil,

one organ, or in the care of an exclusive disease. One

there are crucial problems. Thirty percent or more of

striking fact is the tendency for the surgeon to specialize

the undergraduate students do not have access to any

early, which is the subject of continuous discussion by

residency program, since the number of positions is less

several surgical entities, including the American Surgical

than the number of graduating physicians. The options

11,12

.

for those who do not have access to residency are

Due to the extraordinary technological advance, the

enrollment in the Armed Forces, work in the Family Health

“Halstedian” of training that has formed countless

Program, outpatient clinic/health clinic or in emergency

generations of skilled surgeons must be modified,

care/emergency room. This, as a rule, occurs without the

incorporating the new achievements, especially the

doctor still having adequate training for the professional

Association and the American College of Surgeons

13,14

. We are in the

exercise. Another issue is the fact that 30% of those who

era of video-surgery and robotics, which is the present

finish the General Surgery residency do not have access

and future of surgery. Because of scientific advancement,

to the specialty because the number of scholarships is

technology and the development of medical knowledge,

also lower, which determines a bottleneck in the training

new and young doctors aspire to be “super experts”. The

program. The option is to work as a General Surgeon,

trend towards sub-specialization is inevitable. Among the

especially in Emergency Room, waiting for a new attempt

several factors, one contributing aspect is the presumed

to complete training in the near future. In this way, they

inverse relationship between the surgical volume of a

work in one of the most complex and challenging areas

surgeon and the rate of operative complications and

of surgery, which is emergency surgery, forced to make

mortality. Patients want to be treated in centers of

quick decisions and face complex procedures for which

excellence and by surgeons with expressive experience

they are not adequately trained. Coleman et al.15, in

on specific diseases9,15,16.

working with residents after five years of training, found

practice in laboratories and simulators

Approximately 50% of the selected residents

that 38% of them did not feel prepared or confident for

had encouragement to choose the specialty during the

General Surgery practice. Even after a long training time,

undergraduate course, through participation and help in

training may be incomplete. In Brazil, the situation is even

operative procedures linked to a surgeon or surgical team.

more complex, given the limited quality of many programs

At the beginning of training, 75.8% of them already

and the time devoted to training the surgeon. In recent

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Rasslan Profile of the General Surgery resident: what are the changes in the 21st Century?

years, there has been a concern about the effectiveness

5

graduate degree is in the plans of almost 70%.

of training in order to make residents confident and

It is disturbing for a resident to consider these

competent, especially after reducing workload. This has

initial two years of training as a means of passage to the

generated studies analyzing different aspects of resident

specialty. This explains the position of not showing interest

education and training17-22.

or enthusiasm for procedures that are more complex 23,24

In our area, Santos and Salles

developed a

and for the care of critical or complicated patients. The

way to evaluate the technical ability of General Surgery

resident does not want to act on procedures that he/she

residents that will receive the specialist title at the end of

may never see or perform again. These observations are

the program. They selected surgical procedures of small,

most evident in the second year of residency, especially

medium and great difficulty. The conclusion was that the

in the second semester, when the selection exam for the

proposed evaluation is objective, practical and easy to

specialty is nearing. The resident is more concerned with

apply. The assessment of technical ability and knowledge

studying for the test than with learning. The other surgical

are fundamental in the qualification and certification of

specialties depend on General Surgery for education,

the surgeon.

clinical practice and research8.

Regrettably, Brazil is perhaps the only country

Another aspect to emphasize is that the

in the world that grants the title of Specialist in General

significant majority understands the 60 hours of work

Surgery after only two years of residency. Of the two

per week as sufficient. However, this time is considered

years of training, excluding the two months of vacation,

inadequate for surgical training, and the resident has the

there remain 22 that are distributed in ten or 12 areas/

right to interrupt activities once this workload limit has

specialties, and on average 40 to 45% of the total

been reached. The reduction of the workload aims to

workload is related to the stage in the General Surgery

offer the resident time for rest or study, but it is common

Service. In fact, it is a residency of “Surgery in General”

the practice of paid night shifts outside the educational

and not of General Surgery. In this analysis, one should

institution, compromising the normal activities of the

also consider the reduction of the workload for 60

following day.

hours per week, further reducing the resident’s stay in

This study presents limitations, since it evaluates

the Hospital. This was the subject of a recent editorial of

the population of a single institution, in a short period

the journal of the Brazilian College of Surgeons, entitled

of time, and with limited number of residents. Although

25

“Will two years be enough?” . The award of the title of

amenable to criticism, it certainly reflects the current state

specialist in General Surgery, the broadest area of Surgery,

of the General Surgery residency in our midst. In view of

after a period of short and insufficient training, deprives

the residents’ profile, it is necessary to review the training

the formation of the General Surgeon. In countries of the

time for the General Surgeon’s training, as well as to

European Union and in the United States, the recognition

discuss the need for the test to enter the specialty. We

of professional qualification is linked to training of four to

should reflect if direct access to the specialties would not

six years and the performance of a number of operative

be a more effective attitude from the economic point of

procedures. HC-FMUSP offers 46 vacancies for the nine

view and for the Surgeon’s formation.

surgical specialties. As many candidates opt for the

We conclude that the current residents’ profile,

same specialty, and because it is an open contest, the

when compared with the not-so-distant past, reveals a

number of non-selected is significant. Of the residents

reduction in the demand for General Surgery, a trend

who completed the two years of training, 31.4% were

towards early definition of the specialty, options for

not approved, and 61.9% remained in the institution.

increasingly specific or restricted areas, and an activity

Those who are not selected are among those who have

that offers better quality of life. The analysis of this study

applied for the most popular specialties. Regarding the

reflects the characteristics of the general surgery resident,

perspectives, more than 50% intend to remain in São

which are probably related to the inherent values of the

Paulo, including those from other states. A strict post-

current generation.

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Rasslan Profile of the General Surgery resident: what are the changes in the 21st Century?

6

R E S U M O Objetivo: verificar o perfil dos residentes de Cirurgia Geral do Hospital das Clínicas (HC) da Faculdade de Medicina da Universidade de São Paulo (FMUSP). Métodos: foram avaliados os residentes aprovados no concurso do Programa de Residência Médica em Cirurgia Geral do HC-FMUSP nos anos de 2014, 2015 e 2016. O estudo foi realizado por meio de coleta de dados de questionário e informações obtidas da Comissão de Residência Médica da Instituição. Foram analisados: dados da identificação, origem do candidato, escola da graduação, ensino cirúrgico recebido, razão da escolha pela Cirurgia, expectativas na residência, escolha da especialidade futura e pretensões ao término da residência médica. Também foi analisado o resultado do exame de acesso às especialidades. Resultados: a média de idade foi de 25,8 anos, sendo 74,3% do sexo masculino. A maioria (84,4%) cursou a graduação em escolas públicas, sendo 68% no Sudeste; 85,2% dos residentes foram aprovados no primeiro concurso. A escolha da especialidade estava definida em 75,9% no início da residência, porém 49,5% mudaram ao longo do treinamento. Cirurgia Plástica, Urologia e Cirurgia do Aparelho Digestivo foram escolhidas por 61,5%. Consideraram adequadas as 60 horas semanais 83,3%. Eram favoráveis ao acesso direto à especialidade 27,3%. Ao término da especialidade 53,3% pretendiam continuar em São Paulo e 26,2% retornar ao Estado de origem. A pósgraduação stricto sensu era pretendida por 68,3%. Conclusão: o perfil atual do residente revela redução na procura pela Cirurgia Geral, definição mais precoce da especialidade, opções por áreas cada vez mais específicas e uma atividade que ofereça melhor qualidade de vida. Descritores: Internato e Residência. Educação Médica. Especialidades cirúrgicas. Escolha da Profissão.

REFERENCES 1. Sampaio SAP. A implantação da residência médica no hospital das clínicas: 40 anos de história. São Paulo: FUNDAP; 1984. 2. Malangoni MA, Biester TW, Jones AT, Klingensmith ME, Lewis FR, Jr. Operative experience of surgery residents: trends and challenges. J Surg Educ. 2013;70(6):783-8. 3. Gelfand DV, Podnos YD, Wilson SE, Cooke J, Williams RA. Choosing general surgery: insights into career choices of current medical students. Arch Surg. 2002;137(8):941-5. 4. Debas HT. Surgery: a noble profession in a changing world. Ann Surg. 2002;236(3):263-9. 5. Cockerham WT, Cofer JB, Biderman MD, Lewis PL, Roe SM. Is there declining interest in general surgery training? Curr Surg. 2004;61(2):231-5. 6. Kleinert R, Fuchs C, Romotzky V, Knepper L, Wasilewski ML, Schroder W, et al. Generation Y and surgical residency - Passing the baton or the end of the world as we know it? Results from a survey among medical students in Germany. PLoS One. 2017;12(11):e0188114. 7. Hill EJ, Bowman KA, Stalmeijer RE, Solomon Y, Dornan T. Can I cut it? Medical students’ perceptions

8. 9.

10.

11.

12. 13.

14.

of surgeons and surgical careers. Am J Surg. 2014;208(5):860-7. Fernández-Cruz L. General surgery as education, not specialization. Ann Surg. 2004;240(6):932-8. Stitzenberg KB, Sheldon GF. Progressive specialization within general surgery: adding to the complexity of workforce planning. J Am Coll Surg. 2005;201(6):92532. Hill E, Vaughan S. The only girl in the room: how paradigmatic trajectories deter female students from surgical careers. Med Educ. 2013;47(6):547-56. Debas HT, Bass BL, Brennan MF, Flynn TC, Folse JR, Freischlag JA, Friedmann P, Greenfield LJ, Jones RS, Lewis FR Jr, Malangoni MA, Pellegrini CA, Rose EA, Sachdeva AK, Sheldon GF, Turner PL, Warshaw AL, Welling RE, Zinner MJ; American Surgical Association Blue Ribbon Committee. American Surgical Association Blue Ribbon Committee Report on Surgical Education: 2004. Ann Surg. 2005;241(1):18. Richardson JD. The role of general surgery in the age of surgical specialization. Am Surg. 1999;65(12):1103-7. Pellegrini CA, Warshaw AL, Debas HT. Residency training in surgery in the 21st century: a new paradigm. Surgery. 2004;136(5):953-65. Richardson JD. Workforce and lifestyle issues in

Rev Col Bras Cir. 2018; 45(2):e1706


Rasslan Profile of the General Surgery resident: what are the changes in the 21st Century?

7

general surgery training and practice. Arch Surg.

ready to practice? A survey of the American College

2002;137(5):515-20.

of Surgeons Board of Governors and Young Fellows

15. Coleman JJ, Esposito TJ, Rozycki GS, Feliciano DV. Early subspecialization and perceived competence in surgical training: are residents ready? J Am Coll Surg. 2013;216(4):764-71. 16. Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL. Surgeon volume and operative mortality in the United States. N Engl J Med. 2003;349(22):2117-27. 17. Bell RH Jr, Biester TW, Tabuenca A, Rhodes RS, Cofer JB, Britt LD, et al. Operative experience of residents in US general surgery programs: a gap between expectation and experience. Ann Surg. 2009;249(5):719-24. 18. Mattar SG, Alseidi AA, Jones DB, Jeyarajah DR, Swanstrom LL, Aye RW, et al. General surgery residency inadequately prepares trainees for fellowship: results of a survey of fellowship program directors. Ann Surg. 2013;258(3):440-9. 19. Sanfey H, Williams R, Dunnington G. Recognizing residents with a deficiency in operative performance as a step closer to effective remediation. J Am Coll Surg. 2013;216(1):114-22. 20. Friedell ML, VanderMeer TJ, Cheatham ML, Fuhrman GM, Schenarts PJ, Mellinger JD, et al. Perceptions of graduating general surgery chief residents: are they confident in their training? J Am Coll Surg. 2014;218(4):695-703.

22.

23.

24.

25.

Association. J Am Coll Surg. 2014;218(5):1063-72. e31. Hochberg MS, Billig J, Berman RS, Kalet AL, Zabar SR, Fox JR, et al. When surgeons decide to become surgeons: new opportunities for surgical education. Am J Surg. 2014;207(2):194-200. Santos EG, Salles GF. Construction and validation of a surgical skills assessment tool for general surgery residency program. Rev Col Bras Cir. 2015;42(6):40712. Santos EG, Salles GF. Are 2 years enough? Exploring technical skills acquisition among general surgery residents in Brazil. Teach Learn Med. 2016;28(3):2608. Santos EG. â&#x20AC;&#x153;I would like to be a surgeon, but ....â&#x20AC;? Will two years be enough [editorial]? Rev Col Bras Cir. 2016;43(2):70-1.

Received in: 11/01/2018 Accepted for publication: 15/02/2018 Conflict of interest: none. Source of funding: none. Mailing address: Roberto Rasslan E-mail: robertorasslan@uol.com.br / roberto.rasslan@hc.fm.usp.br

21. Napolitano LM, Savarise M, Paramo JC, Soot LC, Todd SR, Gregory J, et al. Are general surgery residents

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Original Article

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Predictors of poor follow-up after bariatric surgery Fatores preditivos da perda de seguimento de pacientes submetidos à cirurgia bariátrica GISELLE DE QUEIROZ MENEZES BATISTA BELO1; LUCIANA TEIXEIRA DE SIQUEIRA1; DJALMA A. AGRIPINO MELO FILHO1; FLÁVIO KREIMER, TCBC-PE1; VÂNIA PINHEIRO RAMOS1; ÁLVARO ANTÔNIO BANDEIRA FERRAZ, TCBC-PE1 A B S T R A C T Objective: to identify predictive factors of loss of follow-up of patients submitted to Roux-en-Y gastric bypass and sleeve gastrectomy in a 48-month period. Methods: we conducted a retrospective, cohort study from January 2010 to December 2012. We analyzed thirteen variables and compared them to loss of follow-up. Results: among the 559 patients studied, there was a great reduction in the frequency (43.8%) of the consultations from the second postoperative year on, with a significant loss in the 4th year (70.8%). In the univariate analysis, only the variable “excess weight” was associated with loss of follow-up. The proportion of overweight (>49.95kg) was higher in the follow-up group with greater loss (>3 absences) (p=0.025). In the logistic regression, patients exposed to a greater excess weight (>49.95kg) presented a two-fold higher risk for loss of follow-up (>3 absences) (OR=2.04, 95% CI 1.15-3.62; p=0.015). In the univariate analysis, at the 48th postoperative month, only the variable “mesoregion of origin” was associated with loss of follow-up (p=0.012). Conclusion: there was a progressive loss of follow-up from the second postoperative year on. Among the factors analyzed, only the variable “excess weight” greater than 49.95kg in the preoperative period was associated with loss of medical-surgical follow-up. In the 48th month of the postoperative period, there was a higher prevalence of loss of medical-surgical follow-up for patients outside the perimeter of the city of Recife (51%, p=0.052). Keywords: Obesity. Bariatric surgery. Gastric Bypass. Gastrectomy. Lost to Follow-Up.

INTRODUCTION

B

eing considered a severe health problem worldwide, obesity is affects around 13% of the world’s adult population (11% of men and 15% of women), and can reach up to 20% in 20251. Faced with the failure of conservative treatment after a period longer than two years, bariatric surgery is indicated as a strategic alternative for rapid weight loss, remission or improvement of comorbidities, and improvement of quality and expectancy of life2,3. Among the surgical techniques, Roux-en-Y gastric bypass (RYGB) has been advocated for providing excellent percentage loss of overweight, between 65% to 70%, and sustainable weight loss, particularly for those with metabolic syndrome or diabetes mellitus type 24,5. Sleeve gastrectomy (SG) has been highlighted in recent years because it presents relative technical simplicity, advantages in rapid weight loss, and lower complications rates when compared to Roux-en-Y gastric bypass6,7. However, these techniques are not exempt from complications in the short, medium and long term.

In view of the complexity of the surgical procedure, RYGB reaches postoperative complications rates of 15 to 20%, with deficiencies of proteins, vitamins and micronutrients, ulcers, stenosis, internal hernias, cholelithiasis, and inadequate weight loss and/or weight regain8. In this context, laparoscopic Sleeve gastrectomy (LSG) presents lower morbidity, but with complications that may require long-term reoperations. Therefore, regular medical-surgical and multiprofessional follow-up is extremely important to prevent and treat complication soon9,10. The Brazilian recommendations for postoperative follow-up emphasize the regularity and importance of maintaining it, to early detect metabolic and nutritional changes, as well as to monitor weight11-15. This postoperative follow-up presents major challenges. One is to keep the patients in the protocol of consultations adopted with the surgeon or multiprofessional team11. Studies report high followup loss rates, above 49%, in the first postoperative year9,12,16, but there is no consensus regarding the reasons for patients not adhering to the recommended follow-up

1 - Federal University of Pernambuco, Department of Surgery, Recife, PE, Brazil. Rev Col Bras Cir. 2018; 45(2):e1779


Belo Predictors of poor follow-up after bariatric surgery

2

protocol after bariatric surgery16,17.

Postoperative follow-up: The first postoperative

Thus, our objective was to identify the

outpatient visit was scheduled for 15 days after discharge.

predictive factors of the loss of follow-up of a cohort of patients submitted to Roux-en-Y gastric bypass and sleeve gastrectomy, in a period of 48 months. This aims to alert health professionals about the importance of investing in strategies that enhance patients’ adequate follow-up, which will enable the benefits of bariatric surgery to be sustainable, improve the health of society and reduce costs, especially for the Brazilian Unified Health System (SUS).

The other consultations followed a specific protocol of the surgeon: 1st month, 3rd month, 12th months. After this period, the control began to be annual, with evaluations at the 24th, 36th and 48th months. The surgeon requested the return to the office in the times determined by the norms of the follow-up. Thus, it was the responsibility of the patient to schedule the subsequent consultation. At the time of the consultation, the surgeon recorded the patient’s complaints, the pre-existing weight and preexisting comorbidities, the results of the laboratory tests,

METHODS

the treatment of clinical and/or surgical complications, the regularity of administration of the multivitamins,

We conducted a retrospective cohort study with patients with obesity grades II and III submitted to surgical treatment by open Roux-en-Y gastric bypass with retention ring or laparoscopic sleeve gastrectomy, from January 2010 to December 2012. We evaluated the outcome loss of follow-up at the 1st, 3rd, 12th, 24th, 36th and 48th months, with patients being categorized into YES and NO. We excluded patients who underwent revision of bariatric surgery, pregnant women and those who died during the study period. We collected the data between 2016 and 2017, and accessed biological, socioeconomic, anthropometric and clinical-surgical variables from patients’ electronic records.

tolerance to the prescribed diet, frequency of nutritional

Technical Procedures Preoperative evaluation: patients visited the surgeon on two occasions in the preoperative period. In the first one, preoperative examinations were requested, including cardiological, endocrinological, pneumological, nutritional and psychological evaluations, as well as laboratory tests, upper gastrointestinal endoscopy with a search for Helicobacter pylori, total abdominal ultrasonography, and others defined according to the patient’s needs. In the second, the surgeon informed the patients of the importance of adherence to the proposed treatment, in addition to signing a free informed consent form for the surgical procedure. At the end of the consultation, the surgeon and the patients jointly defined the surgical technique. After explaining the advantages and disadvantages of each procedure, the surgery was defined for each case and the date of the surgical procedure was set.

to summarize its values and determine intervals in the

consultations and practice of physical activity. All weight assessments in the pre- and postoperative periods were performed by the surgeon using a calibrated portable electronic scale with a 350kg capacity. We entered and stored the data in a Microsoft Office Access program spreadsheet and then transferred to Microsoft Office Excel, where we evaluated and corrected errors or inconsistencies. Subsequently, they were transferred to the SPSS software, where we carried out the analysis. Considering that not all continuous variables presented normal distribution, as evaluated by the Kolmogorov-Smirnov test, we chosen the median construction of the dichotomous variables. We compared proportions by Mantel-Haenszel’s X2 test, and the medians, by the Mann-Whitney U test. We performed logistic regression analysis to examine the contribution of each independent variable in the loss of follow-up. In this sense, the model was adjusted to a binary result (loss of follow-up defined as >3 absences, and follow-up= 3 absences), and included variables with p<0.20 found in the univariate analysis. We made the adjustments by a stepwise, gradual elimination of variables. We calculated adjusted odds ratios (OR) and their respective confidence intervals (95%). We considered as significant the statistical tests with probability <0.05. The the

Federal

Ethics

in

University

Research of

Committee

Pernambuco

of

CAAE:

40558315.8.0000.5208, created by resolution of the National Health Council of no 466/2012.

Rev Col Bras Cir. 2018; 45(2):e1779


Belo Predictors of poor follow-up after bariatric surgery

3

RESULTS

accumulated losses, these were greater for those patients who missed between two and three visits (64.9%) (Table 1).

We evaluated 559 patients (398 women and 161 men), with a median age of 35 years, predominantly between 30 and 39 years (34.1%). More than half of the patients were married (62%). There were 488 individuals (87.2%) coming from the Metropolitan Mesoregion of Recife, and 52% lived in the city of Recife. As for Recife residents, 61.1% had high socioeconomic status. The baseline BMI presented a general median of 40.76 kg/m2, with the highest value for the male group (42.27%, p<0.0001). The overall median overweight was 49.95kg, being higher in males (61kg, p<0.0001). Most patients denied alcoholism (64.4%), smoking (83.2%) and comorbidities (67.6%). Among those with at least one comorbidity, systemic arterial hypertension was the most frequent (51.2%). The majority of subjects in the study were from the Roux-en-Y gastric bypass group (66.5%). In the absolute and relative frequencies of the follow-up losses, there was an increase in the absence of consultations during the 48-month period. There was a great reduction in the frequency of consultations from the second year of the postoperative period on, with a significant loss in the 4th year (70.8%). As for the

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Table 4. Logistic regression analysis of the loss of follow-up (>3) within a period of 48 months post-op. 4

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In the univariate analysis performed in the 48th month of postoperative follow-up, among the biological, socioeconomic, anthropometric and clinicalsurgical variables, only the variable “mesoregion of origin” (p=0.012) was associated with loss of follow-up, although the “city of residence” had a higher frequency for residents of the Recife metropolitan region (51%, p=0.052).

DISCUSSION Most bariatric surgery centers have standard post-operative protocols, but loss of follow-up is a persistent problem after the first year. Postoperative adhesion benefits the patient regardless of the surgical technique used, not only for the prevention of longterm complications, but also for sustainable weight

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loss. International surveys indicate progressively low rates of adherence to scheduled appointments in the postoperative period: 50% in the first year, 30% in two years, and <10% in ten years9,18,19. In Brazil, despite extensive research, we found no specific studies on the rates of medical-surgical followup, only nutritional. The rates presented for adherence to nutritional follow-up varied significantly between one year (51% and 56%), two years (25.37%) and over two years (14.93%) post-surgery12,20,21. These results call attention to the possibility of patients recovering their old habits, mainly with problems associated with weight. It is noteworthy that, even though postoperative follow-up rates are within the literature, patients remain progressively absent from pre-established consultations by the surgeon. Then, it was necessary to identify the variables that predispose to loss of follow-up. Of the predictive factors analyzed, only the anthropometric variable “initial overweight” greater than 49.95kg was associated with loss of follow-up, with statistical significance, diverging from the results presented by other researchers17,22. In 2011, in an analysis to assess the relationship of weight loss success with adherence to postoperative consultations of bariatric surgery among 60 obese patients, Compher et al.22 presented an average of 70kg (±27.3) initial overweight for the group of patients with loss of follow-up (p-value >0.05). Jennings et al.17, in 2013, presented an initial overweight value for the group with loss of follow-up of 76.4kg (p=0.39). In both studies, there is concordance with the initial overweight greater than 49.95kg, but not statistically significant. A consensus has not yet been established in the literature, but a greater preoperative excess weight is more commonly associated with loss of follow-up19. The variable age was not associated with loss of follow-up, as in other studies22,23. A review article published in 2016 analyzed studies that aimed to identify factors predictive of adherence and loss of follow-up after bariatric surgery. Of the 44 articles analyzed, eight presented conflicting results regarding the variable age. Some presented results with no statistical significance, others showed an association between loss of follow-up and age below 43 and 45 years11. Khorgami et al.9, in 2015, justify the statistical significance for adherence in the consultations of middle-aged adults (40 to 59 years) due to their better understanding of the importance

given to health, greater stability at work, and private health plans. The absence of association between gender and the loss of follow-up found in our study corroborates the results obtained by Vidal et al.16, Jennings et al.17, Magalhães et al.20 and McVay et al.24, but are discordant from the results of Khorgami et al.9, which identified a significantly higher prevalence of follow-up loss in men (25.5%). McVay et al.24, in 2013, investigated adherence predisposing factors after Roux-en-Y gastric bypass. Among the analyzed factors, married marital status was not statistically significant, although it showed a higher adherence rate (54.6%, p=0.23). Our study also found no association between marital status and loss of followup, but married patients presented greater adherence (66.7%), corroborating the aforementioned casuistry. Family support may be a motivator for staying in health care. Scientific research has demonstrated an association between the loss of follow-up and the distance of the patient’s home from the medical office17,23,25. An American study showed that individuals who lived more distant from the office (>80km) were significantly more absent at scheduled appointments from the ninth postoperative follow-up month on, justified by the change of address, inability to drive long distances and climatic factors25. In England, Jennings et al.17, in 2013, evaluated the relationship between the distance between the patient’s home and the office and the evolution of weight loss, establishing an association: the most distant residents (>33km, p=0.03) lost less weight due to failure to follow up. In the present study, however, there was no association between the variables of the mesoregion of origin and city of residence with loss of follow-up at 48 months. This corroborates the work presented by Sockalingam et al.23 (p=0,05), although the univariate analysis of the 48th postoperative month displayed statistical significance in the association between the loss of follow-up and the residents of the Recife metropolitan mesoregion, including the city of Recife (p=0.011), more frequently for residents outside the perimeter of this municipality (between 10-74km, 51%, p=0.052). The body mass index in the preoperative period was not associated with the loss of follow-up, as reported in the results of Vidal et al.16 (p=0.182). Researches

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differed from the results presented. In the multivariate analysis, the highest preoperative BMI was associated with adherence to postoperative follow-up9. Some studies focused on the effectiveness of bariatric surgery in improving or curing the various morbidities associated with obesity. However, few papers studied the association between the presence of comorbidities in the preoperative period and the loss of follow-up. Magalhães et al.20, in 2012, observed no association between the presence of comorbidities in the preoperative period and adherence to follow-up during a 12-month period. The present study corroborates this nuance, since it did not identify an association between comorbidities and loss of follow-up at 48 months, although patients with systemic arterial hypertension presented a higher frequency in the loss of followup group (50.9%), possibly justified by the demand for other medical specialties, indirectly hampering the medical-surgical follow-up. These results differ from the publication by Khorgami et al.9, who showed in the multivariate analysis that type 2 diabetes mellitus, systemic arterial hypertension and obstructive sleep apnea are independent predictors of loss of follow-up. The RYGB and SG surgical techniques were not associated with loss of follow-up when compared in the univariate analysis, corroborating the results found by Vidal et al.16 (p=0.158). Spaniolas et al.26, in an attempt to identify the relationship between adherence to postsurgical consultations and loss of overweight among morbidly obese patients in the postoperative period of RYGB and SG, found a small but independent relationship

between the techniques studied with postoperative adherence and weight loss. The retrospective study has limitations. We had some difficulties regarding the revision of information sources, which we minimized by the standardization of data collection and the objective outcome definition. In addition, inconsistencies in follow-up after bariatric surgery, mainly due to the heterogeneity of methodologies, including different study designs, sample sizes, definitions and follow-up time, and types of bariatric surgery made it difficult to analyze the results12,20. Assuming that bariatric surgery is not the cure for obesity, future studies on the loss of postoperative follow-up become extremely important to alert health professionals about the need to include, in routine protocols, early detection of the predisposing factors of loss of follow-up, pre and post-operative educational activities programs focused on individual patients’ needs, and actively seeking those who fail in the postoperative period, as measures to increase the frequency in the consultations and obtain better results. The analysis of the data allowed us to conclude that there was a loss of progressive follow-up of the patients in the medical-surgical consultations from the second postoperative year on. Among the factors analyzed, only the variable overweight greater than 49.95kg in the preoperative period was associated with loss of medical-surgical follow-up. In the 48th month of the postoperative period, there was a higher prevalence of loss of medical-surgical follow-up for patients residing outside the perimeter of the city of Recife.

R E S U M O Objetivo: identificar os fatores preditivos da perda de seguimento de pacientes submetidos à derivação gástrica em Y de Roux e gastrectomia vertical num período de 48 meses. Métodos: estudo de coorte, retrospectivo, no período de janeiro de 2010 a dezembro de 2012. Treze variáveis foram analisadas e comparadas à perda de seguimento. Resultados: entre os 559 pacientes estudados, verificou-se grande redução na frequência (43,8%) às consultas a partir do segundo ano de pós-operatório com uma perda significativa no quarto ano (70,8%). Na análise univariada, apenas a variável “excesso de peso” esteve associada à perda de seguimento. A proporção de excesso de peso (>49,95kg) foi maior no grupo de seguimento com maior perda (>3) (p=0,025). Na regressão logística, os pacientes expostos a um maior excesso de peso (>49,95kg) apresentavam um risco duas vezes maior para perda de seguimento (>3 perdas) (OR=2,04; 1,15-3,62; p=0,015). Na análise univariada, no 48o mês do seguimento pós-operatório, apenas a variável mesorregião de procedência esteve associada à perda de seguimento (p=0,012). Conclusão: houve uma perda de seguimento progressiva a partir do segundo ano pós-operatório. Entre os fatores analisados, apenas a variável “excesso de peso” maior do que 49,95kg no pré-operatório esteve associada à perda de seguimento médico-cirúrgico. No 48o mês do período pós-operatório houve uma maior prevalência de perda de seguimento médico-cirúrgico para os pacientes fora do perímetro da cidade do Recife (51%, p=0,052). Descritores: Obesidade. Cirurgia Bariátrica. Derivação Gástrica. Perda de Seguimento.

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REFERENCES

bypass. Obes Sug. 2016;26(2):410-21. 9. Khorgami Z, Zhang C, Messiah SE, de la Cruz-Muñoz

1. NCD Risk Factor Collaboration (NVD-RisC). Trends in adult body-mass index in 200 countries from 1975 to 2014: a pooled analysis of 1698 population-based measurement studies with 19·2 million participants. Lancet. 2016;387(10026):1377-96. 2. Brasil. Ministério da Saúde. Gabinete do Ministro. Portaria no. 424, de 19 de março de 2013. Redefine as diretrizes para a organização da prevenção e do tratamento do sobrepeso e obesidade como linha de cuidado prioritária da Rede de Atenção à Saúde das Pessoas com Doenças Crônicas [portaria na Internet]. Diário Oficial da União 15 abr 2013 [acesso em 12 out 2017];Seção1,(76). Disponível em: http://www. brasilsus.com.br/legislacoes/gm/118324-424.html 3. Brasil. Ministério da Saúde. Portaria no 425, de 19 de março de 2013. Estabelece regulamento técnico, normas e critérios para a Assistência de Alta Complexidade ao Indivíduo com Obesidade. Diário Oficial da União 15 abr 2013 [acesso em 12 out 2017];Seção1,(59). Disponível em: Disponível em: http://www.brasilsus.com.br/legislacoes/ gm/118326-425.html 4. Hörchner R, Schweitzer D. Evaluation of weight loss failure, medical outcomes, and personal experiences after Roux-en-Y gastric bypass: a critical analysis. ISRN Obes. 2013:943423. 5. Farias G, Thieme RD, Teixeira LM, Heyde ME, Bettini SC, Radominski RB. Good weight loss reponders and poor weight loss reponders after Roux-en-Y gastric bypass: clinical and nutritional profiles. Nutr Hosp. 2016;33(5):574. 6. Rosenthal RJ; International Sleeve Gastrectomy Expert Panel, Diaz AA, Arvidsson D, Baker RS, Basso N, et al. International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of >12,000 cases. Surg Obes Relat Dis. 2012;8(1):8-19. 7. Ramos AC, Bastos ELS, Ramos MG, Bertin NTS, Galvão TD, Lucena RTF, et al. Resultados a médio prazo com a gastrectomia vertical laparoscópica. ABCD Arq Bras Cir Dig. 2015;28(Supl 1):61-4. 8. Abdeen G, Le Roux CW. Mechanism underling the weight loss and complications of Roux-en-Y gastric

N. Predictors of postoperative aftercare attrition among gastric bypass patients. Bariatr Surg Pract Patient Care. 2015;10(2):79-83. 10. Gourash W F, Ebel F, Lancaster K, Adeniji A, Koozer Iacono L, Eagleton JK, MacDougall A, Cassady C, Ericson H, Pories W, Wolfe BM, Belle SH; LABS Consortium Retention Writing Group. Longitudinal Assessment of Bariatric Surgery (LABS): retention strategy and results at 24 months. Surg Obes Relat Dis. 2013;9(4):514-9. 11. Gourash WF, Lockhart JS, Kalarchian MA, Courcoulas AP, Nolfi D. Retention and attrition in bariatric surgery research: an integrative review of the literature. Surg Obes Relat Dis. 2016;12(1):199-209. 12. Tess BH, Scabim VM, Santo MA, Pereira JC. Obese patients lose weight independently of nutritional follow-up after bariatric surgery. Rev Assoc Med Bras(1992). 2015;61(2):139-43. 13. Associação Brasileira para o Estudo da Obesidade e de

Síndrome

Metabólica.

obesidade,

Paulo:

ABESO;

Diretrizes

2016

[Internet].

2016

[citado

brasileiras

ed.

São

2017

set

01].

Disponível em: http://www.abeso.org.br/uploads/ downloads/92/57fccc403e5da.pdf 14. Sociedade

Brasileira

de

Cirurgia

Bariátrica

e

Metabólica; Colégio Brasileiro de Cirurgioes; Colégio Brasileiro de Cirurgia Digestiva; Sociedade Brasileira de Cirurgia Laparoscópica; Associação Brasileira para o Estudo da Obesidade; Sociedade Brasileira de Endocrinologia e Metabologia. Consenso bariátrico [Internet]. 2008 [citado 2017 set 01] Disponível em:

http://www.sbcb.org.br/arquivos/download/

consenso_ bariatrico.pdf 15. American College of Surgeons; American Society for Metabolic and Bariatric Surgery. Standards Manual. Resources of optimal care of the Metabolic and Bariatric Surgery Patient 2016 [Internet]. Accessed 2017 Dec 03. org/~/media/files/

Available in: https://www.facs. quality%20programs/bariatric/

mbsaqip%20standardsmanual.ashx 16. Vidal P, Ramón JM, Goday A, Parri A, Crous X, Trillo L, et al. Lack of adherence to follow-up visits after bariatric surgery: reasons and outcome. Obes Surg.

Rev Col Bras Cir. 2018; 45(2):e1779


Belo Predictors of poor follow-up after bariatric surgery

8

2014;24(2):179-83.

style. Obes Surg. 2013;23(12):2026-32.

17. Jennings N, Boyle M, Mahawar K, Balupuri S, Small P.

24. McVay MA, Friedman KE, Applegate KL, Portenier

The relationship of distance from the surgical centre on attendance and weight loss after laparoscopic gastric bypass surgery in the United Kingdom. Clin Obes. 2013;3(6):180-4. Higa K, Ho T, Tercero F, Yunus T, Boone KB. Laparoscopic Roux-en-Y gastric bypass: 10-years follow-up. Surg Obes Relat Dis. 2011;7(4):516-25. Moroshko I, Brennan L, O’Brien P. Predictors of attrition in bariatric aftercare: a systematic review of the literature. Obes Surg. 2012;22(10):1640-7. Scabim VM, Eluf Neto J, Tess BH. Adesão ao segmento nutricional ambulatorial pós-cirurgia bariátrica e fatores associados. Rev Nutr. 2012;25(4):497-506. Menegotto ALS, Cruz MRR, Soares FL, Nunes MGJ, Branco Filho AJ. Avaliação da frequência em consultas nutricionais dos pacientes após cirurgia bariátrica. ABCD Arq Bras Cir Dig. 2013;26(2):117-9. Compher CW, Hanlon A, Kang Y, Elkin L, Williams NN. Attendance at clinical visits predicts weight loss after gastric bypass surgery. Obes Surg. 2012;22(6): 927-34. Sockalingam S, Cassin S, Hawa R, Khan A, Wnuk S, Jackson T, et al. Predictors of post-bariatric surgery appointment attendance: the role of relationship

DD. Patient predictors of follow-up care attendance in Roux-en-Y gastric bypass patients. Surg Obes Relat Dis. 2013;9(6):956-62. 25. Lara MD, Baker MT, Larson CJ, Mathiason MA, Lambert PJ, Kothari SN. Travel distance, age and sex as factors in follow-up visit compliance in the post-gastric bypass population. Surg Obes Relat Dis. 2005;1(1):17-21. 26. Spaniolas K, Kasten KR, Celio A, Burruss MB, Pories WJ. Postoperative follow up after bariatric surgery: effect on weight loss. Obes Surg. 2016;26(4):900-3.

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Received in: 30/01/2018 Accepted for publication: 01/03/2018 Conflict of interest: none. Source of funding: none. Mailing address: Giselle de Queiroz Menezes Batista Belo E-mail: leli_belo@yahoo.com.br / marciavirginiodearaujo@gmail.com

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Use of an algorithm in choosing abdominoplasty techniques Emprego de um algoritmo na escolha de técnicas de abdominoplastia

JÚLIO WILSON FERNANDES, TCBC-PR1; RENATA DAMIN2; MARCOS VINÍCIUS NASSER HOLZMANN3; GABRIEL GOMES DE OLIVEIRA RIBAS3

A B S T R A C T Objective: to validate an algorithm for the choice of the abdominoplasty surgical technique among the five approaches established in the literature, according to the characteristics of the abdominal wall. Methods: we conducted a retrospective study of 245 patients undergoing abdominoplasty, for whom the method of choice of the surgical technique was the proposed algorithm, based on the degree of abdominal flaccidity determined by bimanual maneuver. We studied its applications and conveniences, as well as the complications inherent in each group studied. Results: according to the algorithm used, the most frequently chosen technique was “Technique IV” (transverse dermolipectomy of Pitanguy - or with a Baroudi-Kepke incision), in 25.71% of the cases. “Technique I” (mini abdominoplasty) had the lowest incidence and the lowest rate of complications. On the opposite, “Technique III”, dermolipectomy with remaining vertical scarring, presented a higher incidence of complications, requiring extreme caution in its indication, particularly in relation to patients’ expectations regarding the resulting scar and its legal aspects. Among all conducts, the most frequent complication was seroma, with a 10.2% occurrence, solved by simple syringe aspiration and use of elastic compression mesh. Conclusion: the proposed algorithm facilitated the choice of abdominoplasty techniques, offering satisfactory results, which are in line with the complication rates published in the world literature. Keywords: Abdominoplasty. Lipectomy. Abdominal Wall. Surgery, Plastic.

INTRODUCTION

T

he abdominal wall presents an important aesthetic and functional aspect in the human anatomy, being particularly affected by gestations, obesity, hernias and eventrations. The abdominal muscles and the sheath of the rectus abdominis muscle are of great importance in visceral restraint, in the dynamics to efforts and in postural aspects, also influenced by aging, reduced local innervation and bariatric procedures1. In the social, sporting and sensual ambit, the abdomen plays a relevant role, and its alterations can contribute to low self-esteem, with inconvenient psychological and family consequences. Currently, there has been an increase in the demand for abdominoplasty for patients who have undergone bariatric surgery, which corroborates the increase in the number of men in a sample previously dominated by women1,2.

The techniques of abdominal dermolipectomy preceded its application in Plastic Surgery, being previously used in General Surgery, particularly in the treatment of great hernias. Dermolipectomies were performed mainly in obese patients, in order to facilitate the approach to umbilical hernias. With the development and diffusion of the technique, many authors have developed specific instruments to aid in abdominal dermolipectomies, such as the La Roe retractors, the Skoog forceps (1955), the Pitanguy marker clamp and many others3,4. In the beginning, the abdominoplasty was limited to the direct resection of the skin and fat excess and correction of the underlying hernias, eventrations and diastases. With the advent of liposuction and its application in abdominoplasty, around 1980, professionals were able to achieve better aesthetic results for the procedure5. Initially, many authors reported an increase in the incidence of seroma, when liposuction was applied

1 - Positivo University, Discipline of Surgery (Plastic Surgery), Curitiba, PR, Brazil. 2 - Evangelical University Hospital of Curitiba, General Surgery Service, Curitiba, PR, Brazil. 3 - Evangelical University Hospital of Curitiba, Medical School, Curitiba, PR, Brazil. Rev Col Bras Cir. 2018; 45(2):e1394


Fernandes Use of an algorithm in choosing abdominoplasty techniques

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in previously detached regions3,6. Subsequent studies

lower abdomen1,10. However, when the flaccidity is

have shown that liposuction does not increase morbidity

not ideal, choosing the best surgical technique for

or particularly the incidence of seroma when used as an adjuvant in abdominal dermolipectomies7,8. Currently, liposuction is consecrated as a possible alternative to abdominal dermolipectomy, as a method associated with traditional techniques, or in the lipoabdominoplasty described by Juarez Avelar and refined by Osvaldo Saldanha, with innovative results9. Regarding the umbilical scar, the vast majority of the described techniques displays satisfactory results when there is sufficient flaccidity of the detached skin, to the point of allowing skin resection to the periumbilical circular incision performed to keep the umbilicus fixed in the abdominal wall. This is a point of great importance in trying to avoid a vertical scar in the midline of the

abdominoplasty can be a difficult decision. In addition, it is of great importance, for ethical and legal reasons, that the patient be aware of and accept the unpredictability in the appearance of the remaining scars after abdominal dermolipectomy, especially those that cannot be concealed by the usual bathing suits. The present study aims to validate an algorithm (Figure 1) to facilitate the indication of abdominoplasty techniques, among five approaches already established in the literature, using it in 245 patients. We studied its applications and conveniences, as well as the inherent complications of each group studied, in order to help in choosing the best technique.

Figure 1. Proposed Algorithm.

METHODS For the retrospective study, were selected 245 patients operated over a period of 24 years (1991-2015), during which we used the described algorithm. We did not include patients submitted to associated procedures, patients after bariatric surgery, and those who needed other techniques not contemplated in the algorithm (Figure 1), which combined five traditional techniques for abdominoplasty with the findings of physical examination

of each patient. This algorithm was developed for the selection of the procedure among the following five surgical techniques: Technique I – Detachment and dermolipectomy of the lower abdomen with liposuction: also known as “Miniabdominoplasty” or “Mini Tummy Tuck”, this procedure is limited to supra pubic dermal resection, with eventual plication of the infraumbilical fascia in the midline, associated with local lipectomy using the liposuction10. In these cases, it is also possible to reduce

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waist circumference and to smooth the iliac fossa by

by Jaime Planas15,16: the original technique consists in

plication of the oblique muscles10. The umbilical scar remains intact in this type of approach10-12. Technique II – Detachment of the umbilicus at its base and reinsertion a few centimeters below: a variation of the Pitanguy Transverse Dermolipectomy with transoperative liposuction of the anterior, lateral and lumbar region, described as a “Group IV” technique by Bozola10,11. The umbilical scar is detached from the linea alba in a “glove finger” fashion, without any incision in the skin, for later reinsertion a few centimeters below. Technique III – Abdominoplasty with remaining vertical scar: in the absence of enough skin to caudally traction the flap and allow excision of the previous site of the umbilical scar, there is a need for vertical incision in the midline as a remnant scar, which in some cases may be taken to the horizontal scar by setting an inverted “T”. In post-bariatric patients, a long vertical incision may be necessary to achieve better results and allow more easily corrected hernias13. Technique IV - Pitanguy Dermolipectomy: Classic transverse dermolipectomy, described by Pitanguy, with its incision performed along the upper limit of the pubic line. The incision has undergone variations in its design such as those of Sinder and Baroudi-Keppke, who position the scar laterally, parallel to the inguinal region14. When the detached flap reaches the umbilical height in the supra-aponeurotic plane, it is divided caudally along the midline of the abdomen and the circumferential incision is made around the umbilicus. The dissection continues until the costal margin is reached, leaving the umbilical scar attached by its pedicle to the anterior abdominal wall. The two sides of the flap are then tractioned inferiorly and medially, in order to estimate the amount of tissue to be excised14. Bonfatti1 uses the same approach, but with inferior traction of the flap in the lateral direction, avoiding the need for future surgical corrections on the sides of the abdomen. The end result, in this case, will be a slightly longer transverse scar. After resection of the exceeding adipose skin and panniculus, the umbilicus is drawn through a hole in the skin of the detached flap and is sutured to it. Aspiration drains are installed to prevent bruising at the end of surgery. Technique V – Previous resection of the infraumbilical segment based on the Over Pants technique,

the design of a triangular area, its upper angle being the umbilicus, and the base, the transverse suprapubic line. After detachment of the upper flap, it is caudally tractioned over the still undetached lower one (vest over pants maneuver), defining the extent of flap detachment, the extent of excision and the height of the resulting scar. Similarly, the technique V in our selection promotes a direct previous resection, without the need of over pants, optimizing time and hemostasis, without the need of the uncomfortable support of a heavy flap by the surgical assistant during abdominoplasty. For the technique choice, through the use of the algorithm, we previously considered two parameters: 1) The distance from the pubis to the umbilicus, usually 14 to 15 cm, at the L3-L4 level17,18; 2) The flaccidity of the skin, as evidenced by the bimanual maneuver: the patient is positioned in dorsal decubitus, with flexed elbows, thus presenting a small anterior flexion of the trunk (Figure 2). The examiner clutches the flaccid abdominal tissue with both hands, checking whether the umbilicus level reaches the pubic region: the tissue to be excised is contained between the thumb and the other four fingers of the examiner’s hands (Figure 2). Considering these parameters, the patients are classified into five different groups; figure 3 shows the groups submitted to the most invasive techniques (II, III, IV, V), according to their pre and postoperative characteristics.

Figure 2. Bimanual Maneuver.

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Fernandes Use of an algorithm in choosing abdominoplasty techniques

4

pubis was greater than or equal to 15cm, an indication for Technique II, when abdominoplasty was performed with repositioning of the umbilicus; the second situation was when the distance from the umbilicus to the pubis was less than 15cm, an indication for Technique III. In this case there was not enough flaccidity to resect the umbilical scar, and the supraumbilical flaccidity necessarily required traction of the skin at that level. It therefore resulted in a vertical scar in the midline, or even an inverted, lower T-scar in the lower abdomen if the flaccidity allowed it. When the bimanual test indicated the presence of sufficient skin for the resection of the original umbilicus site, we indicated the classic Technique IV: Pitanguy’s transverse dermolipectomy, with Sinder or Baroudi-Kepke incision, resulting in a single transverse scar. Finally, when the bimanual test indicated a great flaccidity of the skin, also known as “apron abdomen”, the patient was submitted to Technique V, in which the previous skin resection facilitated the surgical act. The variables analyzed were the occurrence and type of complications and their prevalence for each technique employed. The work was submitted to, and approved by, the Institution’s Ethics Committee, under the number 76367517500000103.

RESULTS

Figure 3. Pre and postoperative techniques II to V.

Then, the algorithm proposed assigned a technique for each of the groups, based on the characteristics found in each patient (Figure 1). The Technique I group comprised patients with flaccidity and/or lipodystrophy just below the umbilicus: the miniabdominoplasty technique was indicated for this situation, considering that there was no reason to detach the flap in the upper portion of the abdomen, or repositioning of the umbilicus. When there was flaccidity in the upper and lower abdomen, but the bimanual test showed not enough flaccid skin for scar resection due to umbilical circumcision, two situations were considered: the first was when the distance from the umbilicus to the

Of the 245 patients who had the abdominoplasty technique selected with the aid of the algorithm, three were male and 242 female. The mean age was 43 years. Table 1 shows the distribution of the operated patients according to the technique selected by the abdomen characteristics.

Table 1. Prevalence of techniques employed in the 245 patients.

Procedure

N

%

Technique I

30

12.24

Technique II

42

17.16

Technique III

56

22.85

Technique IV

63

25.71

Technique V

54

22.04

Total

245

100

Rev Col Bras Cir. 2018; 45(2):e1394


Fernandes Use of an algorithm in choosing abdominoplasty techniques

5

The complications occurring in each group

DISCUSSION

were seroma, hypertrophic scar, non-aesthetic scar and keloid. Table 2 presents the complications of patients

The

majority

of

patients

underwent

operated on in our series. In more than half of patients

abdominoplasty through technique IV. These patients had

who presented some type of complication, this was the

the ideal characteristics to the classic Pitanguy technique,

seroma (10.2%). The second most prevalent complication

with upper and lower abdomen lipodystrophy, moderate

was the occurrence of a hypertrophic scar, with a 4.48%

to severe skin excess in the lower abdomen, and frequent

incidence. This condition, commonly confused with keloid

striae, as well as different degrees of weakness of the

by patients, contrasts with true keloids found in only two

abdominal wall19.

patients (0.8%). Wide and hyperpigmented scars were

On the other hand, the group of patients

grouped and considered as “non-aesthetic scars”, and

with alterations restricted to the lower abdomen

occurred in 2.04% of patients.

and

submitted

to

miniabdominoplasty

were

the

least prevalent, considering its strict indications. In a prospective study of 151 female patients, Sozer et Table 2. Complications in the 245 patients undergoing abdominoplasty.

al.19 demonstrated an incidence of 5% of this type of

N

%

abdomen. As expected, the rate of complications was

Seroma

25

10.2

lower in patients operated on by techniques I and II, less

Hypertrophic Scar

11

4.48

Non-Esthetic Scar

5

2.04

Keloid

2

0.81

complications of 20.8%. This shows that even when the

Total

43

17.55

one adopts a highly strict algorithm in order to optimize

Complication

aggressive surgical approaches. Patients who underwent major surgeries, such as Techniques III, IV and V, had an average rate of small

the choices, one should be prepared to face a higher rate of complications in patients who undergo major Table 3 compares the total number of

procedures, such as the Pitanguy’s abdominoplasty or

procedures performed of each technique and their

the Over-Pants technique, besides the greater obesity of

respective

III

these patients, with all their intrinsic characteristics and

presented the greater number of complications (21.4%),

the greater caliber of vessels found in the transoperative

followed by techniques IV and V, with 20.6% and 20.3%,

period.

complications

incidence.

Technique

respectively. On the other hand, techniques I and II had

Staalesen et al.20 conducted a systematic review

the lowest rate of complications, with 6.6% and 11.9%,

of abdominoplasty results and found that the most

respectively.

frequent complications, dehiscence, seroma and cellulitis, were all characterized by prolonged healing time of the postoperative wound, but with low impact on the final

Table 3. Complications according to the abdominoplasty technique adopted.

Procedure

surgical result. The incidence of seroma has been reported between 1% and 57%, with an incidence around 10%,

N

%

as found in our series, generally considered acceptable21.

Technique I

30

6.66

The causes of seroma can probably be attributed to

Technique II

42

11.9

rupture of the vascular and lymphatic network, stress or

Technique III

56

21.42

Technique IV

63

20.63

Technique V

54

20.37

friction between the flap and the abdominal wall, dead space, and even release of inflammatory mediators, or simply to the empirical excessive use of electrocautery. Ardehali and Fiorentino21, in their meta-analysis, clearly

Rev Col Bras Cir. 2018; 45(2):e1394


Fernandes Use of an algorithm in choosing abdominoplasty techniques

6

emphasize the beneficial effect of progressive tension

able to accept the wide range of possible variations in

sutures under the flap, known as Baroudi sutures, in the

the resulting scar. However, the indication of technique

prevention of seromas, as well as, less effectively, the

III should be viewed with great caution: it is an extreme

preservation of the fascia of Scarpa on the abdominal

situation in which a miniabdominoplasty would not

flap.

solve the flaccidity of the supraumbilical skin, and an Although subjective, the experience of the

umbilical inferior positioning would not allow sufficient

author is that, in addition to the aforementioned factors,

skin excision without producing an unacceptably low

the use of a weight of 3kg to 5kg between the umbilicus

umbilicus. In such cases, one must value the patients’

and the pubis, and a rigorous rest for three weeks, during

complaints and their ability to understand that to eliminate

which the patient is allowed to ambulate for a maximum

or ameliorate the upper abdominal flaccidity, there will

of 20 minutes every two hours, has contributed to a

be risk of a vertical scar of unpredictable appearance in

significant reduction in the incidence of seromas since

a visible place (if an inverted “T” is not possible). This

2016, and drains are routinely removed in the morning

risk is to be accepted and formally agreed upon in the

after surgery, when the patient is discharged. This attitude

informed consent, which should be signed days before

emphasizes that the aim of the postoperative drains is

the surgical act. For some patients who do not accept

to avoid hematoma, and not to prevent seroma, whose

the abdominoplasty scars, when a slight flaccidity of

incidence is late.

the abdominal skin is evident, a palliative liposuction

Abhyankar

22

and

Bozola

18

recommend

may also be indicated. These patients, however, should

locating the umbilicus position through distance ratios

accept a relatively unpredictable outcome regarding

and different reference points, defining the distance

the resulting flaccidity, despite the improvement in the

ratio between the xiphoid appendix and the pubis at

abdomen lipodystrophic appearance. When planning

approximately 1.6:1 for a new aesthetically ideal umbilicus

abdominoplasty, every surgeon should also consider the

position. Although there are several descriptions for

need for plication of the rectus abdominis muscle sheet,

adequate umbilical positioning during abdominoplasty,

indicated in any technique by preoperative palpation,

only the patients of the Technique II group underwent

ultrasound, and especially by the transoperative aspect of

reinsertion of the umbilicus. For cosmetic reasons, we

the abdomen’s midline.

simply avoid any reinsertion within 12 centimeters of the pubic hair line.

We conclude that the proposed algorithm effectively

There were no complaints about the final scar

contributed

abdominoplasty

to

technique

the of

choice

our

of

the

patients.

The

in the charts analyzed, the follow-up being routinely one

optimization of this choice, already in the first visit, has

year. This fact reflects the author’s policy of ostensibly

allowed consistent information to the patients about the

informing patients about the scar as an expected

resulting scars, facilitating the decision towards surgery.

consequence and demonstrating realistic pictures of

In addition to satisfaction with the results, the levels of

scarring results considered “good” and “bad” during

complications in the techniques chosen with the use of

the consultations. The idea has been to identify, and

the proposed algorithm are similar to those described in

refuse prior to the procedure, any patient who is not

the literature.

Rev Col Bras Cir. 2018; 45(2):e1394


Fernandes Use of an algorithm in choosing abdominoplasty techniques

7

R E S U M O Objetivo: validar um algoritmo para a escolha da técnica cirúrgica de abdominoplastia, entre as cinco abordagens consagradas na literatura, de acordo com as características da parede abdominal. Método: estudo retrospectivo de 245 pacientes submetidos à abdominoplastias, em que o método de escolha da técnica cirúrgica teve como ferramenta o algoritmo proposto, baseado no grau de flacidez abdominal determinado por manobra bimanual. Foram estudadas suas aplicações e conveniências, bem como identificadas as complicações inerentes a cada grupo estudado. Resultados: de acordo com o algoritmo empregado, a técnica mais frequentemente eleita foi a “Técnica IV” (dermolipectomia transversa à Pitanguy - ou com incisão de Baroudi-Kepke), em 25,71% dos casos. A “Técnica I” (miniabdominoplastia) demonstrou a menor incidência e a menor taxa de complicações. A “Técnica III”, dermolipectomia com cicatriz vertical remanescente, ao contrário, apresentou maior incidência de complicações, requerendo extrema cautela na sua indicação, particularmente frente às expectativas dos pacientes quanto à cicatriz resultante e seus aspectos legais. Entre todas as condutas, a complicação mais frequente foi o seroma, com 10,2% de ocorrência entre os 245 casos operados, resolvido pela simples aspiração com seringa, e uso de malha compressiva elástica. Conclusão: o algoritmo proposto contribuiu para facilitar a escolha das técnicas na abdominoplastia, oferecendo resultados satisfatórios, que se alinham com as taxas de complicações publicadas na literatura mundial. Descritores: Abdominoplastia. Lipectomia. Parede Abdominal. Cirurgia Plástica.

REFERENCES

10. Bozola AR, Psillakis JM. Abdominoplasty: a new concept and classification for treatment. Plast

1. Fernandes JW, editor. Cirurgia plástica bases e refinamentos. 2a ed. Curitiba: Primax Edições; 2012. 2. Fraccalvieri M, Datta G, Bogetti P, Verna G, Pedrale R, Bocchiotti MA, et al. Abdominoplasty after weight loss in morbidly obese patients: a 4-year clinical experience. Obes Surg. 2007;17(10):1319-24. 3. O’Toole JP, Song A, Rubin JP. The history of body contouring surgery. Semin Plast Surg. 2006;20(1):5-8. 4. Sinder R. Cirurgia plástica do abdome. Rio de Janeiro: [s.n.]; 1979. 5. Matarasso A. Classification and patient selection in abdominoplasty. Plast Reconst Surg. 1996;3(1):7-14. 6. Di Giuseppe A, Shiffman MA, editors. Aesthetic plastic surgery of the abdomen. [ebook] Springer International Publishing; 2015. Available at: http:// link.springer.com/10.1007/978-3-319-20004-0. 7. Stevens WG, Cohen R, Vath SD, Stoker DA, Hirsch EM. Does lipoplasty really add morbidity to abdominoplasty? Revisiting the controversy with a series of 406 cases. Aesthet Surg J. 2005;25(4):353-8. 8. Dillerud E. Abdominoplasty combined with suction lipoplasty: a study of complications, revisions, and risk factors in 487 cases. Ann Plast Surg. 1990;25(5):333-8. 9. Saldanha OR, De Souza Pinto EB, Mattos WN Jr, Pazetti CE, Lopes Bello EM, Rojas Y, et al. Lipoabdominoplasty with selective and safe undermining. Aesth Plast Surg. 2003;27(4):322-7.

Reconstr Surg. 1988;82(6):983-93. 11. Bozola AR. Abdominoplasty: same classification and a new treatment concept 20 years later. Aesthetic Plast Surg. 2010;34(2):181-92. 12. Greminger RF. The mini-abdominoplasty. Plast Reconstr Surg. 1987;79(3):356-65. 13. Souto C, Tardelli HC. Cicatrização patológica: diagnóstico e tratamento. In: Mélega JM, Viterbo F, Mendes FH, editores. Cirurgia plástica - Os princípios e a atualidade. Rio de Janeiro: Guanabara Koogan; 2011. p. 9-15. 14. Converse J. Reconstructive plastic surgery; principles and procedures in correction, reconstruction and transplantation. In: Converse J, McCarthy J, Littler JW, editors. 2nd ed. Philadelphia, PA: W.B. Saunders Company; 1977. p. 3519-970. 15. Planas J. The “vest over pants” abdominoplasty. Plast Reconstr Surg. 1978;61(5):694-700. 16. Planas J, Bisbal J, del Calcho C, Palacin JM. Further advantages of the “vest over pants” abdominoplasty. Aesthetic Plast Surg. 1988;12(3):123-7. 17. Grey H. Gray Anatomia. 29th ed. Goss CM, editor. Rio de Janeiro: Guanabara Koogan; 1988. 18. Bozola AR. Abdominoplastias. In: Mélega JM, Zanini AS, Psillakis JM. Cirurgia Plástica Estética e Reparadora. Rio de Janeiro: Medsi; 1988. p. 807. 19. Sozer SO, Agullo FJ, Santillan AA, Wolf C. Decision

Rev Col Bras Cir. 2018; 45(2):e1394


Fernandes Use of an algorithm in choosing abdominoplasty techniques

8

making in abdominoplasty. Aesthetic Plast Surg.

Conflict of interest: none.

2007;31(2):117-27.

Source of funding: none.

20. Staalesen T, Elander A, Strandell A, Bergh C. A systematic review of outcomes of abdominoplasty. J Plast Surg Hand Surg. 2012;46(3-4):139-44. 21. Ardehali B, Fiorentino F. A meta-analysis of the effects of abdominoplasty modifications on the incidence of postoperative seroma. Aesthet Surg J. 2017;37(10):1136-43. 22. Abhyankar SV, Rajguru AG, Patil PA. Anatomical localization of the umbilicus: an Indian study. Plast Reconstr Surg. 2006;117(4):1153-7.

Mailing address: JĂşlio Wilson Fernandes E-mail: cirurgiaplasticajwf@uol.com.br / renatadamin@hotmail.com

Received in: 01/10/2017 Accepted for publication: 01/03/2018

Rev Col Bras Cir. 2018; 45(2):e1394


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Original Article

­

Inflammatory and nutritional statuses of patients submitted to resection of gastrointestinal tumors Estado inflamatório e nutricional em pacientes submetidos à ressecção cirúrgica de tumores do trato gastrointestinal ANA VALÉRIA GONÇALVES FRUCHTENICHT1; ALINE KIRJNER POZIOMYCK1; AUDREY MACHADO DOS REIS1; CARLOS ROBERTO GALIA1; GEORGIA BRUM KABKE1; LUIS FERNANDO MOREIRA, TCBC-RS1 A B S T R A C T Objective: to evaluate the association between the nutritional and the inflammatory statuses of patients with cancer of the gastrointestinal tract undergoing surgical resection and to identify predictors of mortality in these patients. Methods: we conducted a prospective study of 41 patients with gastrointestinal tract cancer submitted to surgery between October 2012 and December 2014. We evaluated the nutritional status by subjective and objective methods. We assessed the inflammatory response and prognosis using the modified Glasgow Prognostic Score (mGPS), Neutrophil/Lymphocyte Ratio (NLR), Onodera Prognostic Nutritional Index (mPNI), Inflammatory-Nutritional Index (INI) and C-Reactive Protein/Albumin ratio (mPINI). Results: half of the patients were malnourished and 27% were at nutritional risk. There was a positive association between the percentage of weight loss (%WL) and the markers NLR (p=0.047), mPINI (p=0.014) and INI (p=0.015). Serum albumin levels (p=0.015), INI (p=0.026) and mPINI (p=0.026) were significantly associated with the PG-SGA categories. On multivariate analysis, albumin was the only inflammatory marker independently related to death (p=0.004). Conclusion: inflammatory markers were significantly associated with malnutrition, demonstrating that the higher the inflammatory response, the worse the PG-SGA (B and C) scores and the higher the %WL in these patients. However, further studies aimed at improving surgical outcomes and determining the role of these markers as predictors of mortality are required. Keywords: Gastrointestinal Neoplasms. Nutritional Status. Inflammation. Mortality.

INTRODUCTION

changes that affect these patients in different ways3. There is growing evidence that the systemic

C

ancer has become a public health problem throughout the world, and it is unquestionable that the sharp increase in its incidence represents a crisis for the health systems of several countries1. Malnutrition, which is highly evident when the neoplasm reaches the gastrointestinal tract (GIT), is associated with decreased response to specific treatment and quality of life, with greater risks of postoperative infection and increased morbidity and mortality2. Several methods and tools for nutritional assessment have been proposed over the years to detect early malnutrition. However, there is no gold standard nutritional evaluation method established for cancer patients. The assessment is highly variable in clinical practice due to a large number of metabolic

inflammatory response associated with cancer has a great influence on disease-related outcomes4. A variety of prognostic methods for different types of cancer derive from a combination of several pre-existing, simple-to-use biochemical markers, easily measured and often available in clinical practice. On the other hand, inflammatory markers have been consistently studied because of the easy and potential application for cancer prognosis, such as the modified Glasgow Prognostic Score (mGPS), the Neutrophil/Lymphocyte Ratio (NLR), the Onodera Prognostic Nutrition Index (mPNI), the InflammatoryNutritional Index (INI) and the adapted version of the Prognostic Inflammatory-Nutritional Index (mPINI). Such markers and instruments based on inflammation could

1 - Federal University of Rio Grande do Sul, Post-Graduation Program in Surgical Sciences, Porto Alegre, RS, Brazil. Rev Col Bras Cir. 2018; 45(2):e1614


Fruchtenicht Inflammatory and nutritional statuses of patients submitted to resection of gastrointestinal tumors

2

be useful tools for assessing nutritional status in cancer

height, percentage of weight loss (%WL) and body

patients, based on the premise that these patients are in

mass index (BMI). Results of PG-SGA were classified as

a persistent state of chronic inflammation, a factor that

A (well nourished), B (moderately undernourished), and

contributes to nutritional depletion and the development

C (severely malnourished)10. BMI was classified according

of cachexia5. Therefore, recognizing the effects of systemic

to the tables proposed by WHO11 and by Lipschitz et al.12

inflammation on nutritional depletion could allow

for adult and elderly patients, respectively. We calculated

appropriate nutritional strategies with the objective of

the %WL according to the formula [(usual weight - actual

5,6

preventing progressive weight loss , reversing the clinical

weight) x 100 / usual weight] and classified it according to

picture through appropriate and targeted nutritional

Blackburn & Bistrian13.

intervention7, and minimizing or even eliminating the 8

For the evaluation of the inflammatory and prognostic statuses, we used the inflammatory markers

resulting morbimortality . Thus, the main objective of this study was to

modified Glasgow Prognostic Score (mGPS), Neutrophil/

evaluate the association between the nutritional and

Lymphocyte Ratio (NLR), Onodera Prognostic Nutrition

the inflammatory statuses in patients with GIT cancer

Index (mPNI), Inflammatory-Nutritional Index (INI), and

submitted to surgical resection, as well as to identify

modified

predictors of mortality in such patients.

(mPINI). At the time of the preoperative interview, we

Prognostic

Inflammatory-Nutritional

Index

requested the laboratory tests CRP, albumin, neutrophils

METHODS

and lymphocytes, necessary for classification of the markers, and the results were retrieved from the electronic

We conducted a prospective study of 41

medical records.

patients (20 women and 21 men), with mean age (±SD)

We considered levels of albumin <35g/L and

of 59 years (±12), attended at the Ambulatory Service of

CRP>10mg/L in the sample as altered. For classification

Gastrointestinal Neoplasms of Porto Alegre Clinics Hospital

of mGPS, we evaluated albumin and CRP and defined the

(HCPA/UFRGS) from October 2012 to December 2014.

score based on the combination of the results. Patients

This work belongs to the gastrointestinal tumors research

with high CRP (>10mg/L) and hypoalbuminemia (<35g/L)

line of the Southern Surgical Oncology Research Group

received a score equal to 2, associated with a worse

(SSORG), and was approved by the Ethics in Research

prognosis. Patients with only altered serum CRP (>10 mg/L)

Committee (HCPA/UFRGS) under protocol number IRB

received a score equal to 1, and those with no alterations in these values (serum CRP£10mg/L and albumin ³35g/L)

#13-0520. We included patients older than 18 years,

received score 04. For the classification of NLR (defined

with diagnosis of gastrointestinal cancer in different

as the ratio between the absolute neutrophil counts and

clinical stages , with indication of surgical treatment. All

the absolute lymphocyte count), we considered abnormal

patients were able to communicate, understand, and

values ³514.

9

provide written consent to participate in the study. We

We calculated the mPNI by the formula: 10 x

excluded patients with previous history of antineoplastic

serum albumin (g/dL) + 0.005 × lymphocyte count (per

treatment or patients undergoing chemotherapeutic and

mm3). Values <40 were related to the worse prognosis15.

radiotherapeutic treatment, as well as those with other

The INI, based on the albumin/CRP ratio, classifies

immunological or catabolic diseases, such as chronic

patients as well-nourished (ASG A) with values =1.25,

kidney disease and autoimmune diseases.

while malnourished ones (ASG C) display values =0.106.

All patients had their nutritional status assessed

The adapted version of the Inflammatory and Nutritional

during the preoperative outpatient visits through the

Prognostic Index (mPINI), determined by the CRP/albumin

Patient-Generated Subjective Global Assessment (PG-

ratio, stratifies patients as having no risk (<0.4), low risk

SGA).

anthropometric

(0.4 to 1.2), moderate risk (1.2 to 2.0) or high risk (>2)

variables, including current body weight (BW) and

of infectious and inflammatory complications16. For the

We

also

recorded

classical

Rev Col Bras Cir. 2018; 45(2):e1614


Fruchtenicht Inflammatory and nutritional statuses of patients submitted to resection of gastrointestinal tumors

mortality rate, we verified death through the electronic

Table 1- Characterization of the sample.

medical record or, when this information was not available,

Variables

by telephone contact with patients’ relatives. The mean follow-up time was 1.5 years (30 days to 4 years). For statistical analysis, due to the small sample size, we grouped the patients with mGPS scores 1 and 2,

3

Age (years), average (SD)

Total Sample (n=41) 59.0±12.0

Gender - n (%)

associated with a worse prognosis, and compared them

Male

21 (51.2)

with patients with score 0. We did the same for the PG-

Female

20 (48.8)

SGA, in which patients classified as grades B and C were

Ethnicity - n (%)

considered undernourished, while patients classified as

White

36 (87.8)

Non-White

5 (12.2)

grade A were considered well nourished. We described quantitative variables by mean and standard deviation or median and interquartile

Type of cancer - n (%)

range. For comparison of means, we used student’s t-test

UGIT

29 (70.7)

for independent samples and, in case of asymmetry, the

LGIT

12 (29.3)

Mann-Whitney test. We described qualitative variables

Length of stay (days); md (P25-P75);

using absolute and relative frequencies. For comparison

Death - n (%)

of proportions between the groups, we applied Pearson’s chi-square test or Fisher’s exact test. To evaluate

Current weight (kg); average (SD)

association between quantitative and ordinal variables,

BMI (kg/m2); average (SD)

we used Pearson or Spearman linear correlation tests,

BMI Classification - n (%)

17 (10-24) 25 (61.0) 63.2 ± 15.3 23.6±5.4

respectively. To control confounding factors in relation to

Malnutrition

10 (24.4)

death and malnutrition by PG-SGA, we used the Poisson

Eutrophy

16 (39.0)

Overweight

15 (36.6)

Regression model. As an effect measure, we calculated the Relative Risk (RR) with the respective 95% confidence intervals. The criterion for inclusion of a variable in the

%WL; average (SD)

multivariate model was a p-value <0.20 in the bivariate

1 month

2.40±5.34

analysis. On multivariate model for malnutrition, we

3 months

7.95±8.98

considered each marker separately to control effect of

6 months

10.6±8.57

multicollinearity, and calculated the risk of other variables in relation to the best predictor. The significance level adopted was 5% (p£0.05) and we analyzed the data with the SPSS software (Statistical Package for the Social Sciences), version 18.0.

%WL Severity - n (%) >5% in 1 month

9 (21.9)

>7.5% in 3 months

21 (51.2)

>10% in 6 months

22 (53.6)

PG-SGA - n (%)

RESULTS Of the 41 included patients, 29 (71%) had upper GIT tumors, and 12 (29%), lower GIT tumors. Among the most common tumors, 14 (34%) affected in the stomach, 12 (29%), the colon, and 11 (27%), the esophagus. Table

A

10 (24.4)

B

11 (26.8)

C

20 (48.8)

UGIT= upper gastrointestinal tract; LGIT= lower gastrointestinal tract; BMI= body mass index; %WL= percentage of weight loss; PGSGA= Patient-Generated Subjective Global Assessment; SD= Standard Deviation; md= median.

1 shows the characterization of the sample.

Rev Col Bras Cir. 2018; 45(2):e1614


Fruchtenicht Inflammatory and nutritional statuses of patients submitted to resection of gastrointestinal tumors

4

Most patients presented disease in advanced

inflammation represented by altered values of CRP

clinical stages, with 34 (83%) in stages III/IV. Twenty-five

(70%) and a high risk of complications represented by

(61%) patients died during the postoperative period. The

mPINI (73%). As for the other inflammatory markers,

mean time of death was ten months (one day to two

both mGPS (1 and 2) and mPNI (<40) displayed altered

years) and the mean time (md) of hospitalization was

results in the studied population (70% and 56%,

17 (10 to 24) days, with no relation to mortality in these

respectively). We observed statistically significant associations

patients (p=0.702). According to the evaluation of nutritional

between %WL at three months with NLR (rs=0.334,

status by the PG-SGA, almost half of the patients were

p=0.047) and %WL at six months with mPINI (rs=0.422,

malnourished (49%) or at risk of malnutrition (27%)

p=0.014) and INI (rs=-0.420, p=0.015), demonstrating

(classification of subgroups in C and B, respectively),

that the more altered the inflammatory markers, the

while the BMI classified only 24% of the patients as

higher the percentage of weight loss during the months

malnourished.

(Figure 1).

We found a high prevalence of systemic

Figure 1. Association between inflammatory markers and %WL.

We found no statistically significant association between the PG-SGA and the markers mGPS (p=0.090), NLR (p=0.432) and mPNI (p=0.417). In contrast, the

markers INI (p=0.026), mPINI (p=0.026) and albumin (p=0.015) were significantly associated with the PG-SGA categories (Table 2).

Rev Col Bras Cir. 2018; 45(2):e1614


Fruchtenicht Inflammatory and nutritional statuses of patients submitted to resection of gastrointestinal tumors

5

Table 2. Association of PG-SGA with inflammatory markers.

PG-SGA

Variables

p

A

B/C

GPS -n (%)

n=9

n=24

0

5 (55.6)

5 (20.8)

½

4 (44.4)

19 (79.2)

mPNI -n (%)

n=8

n=26

<40

3 (37.5)

16 (61.5)

³40

5 (62.5)

10 (38.5)

42.0 (4.5)

37.7 (5.5)

0.053 **

NLR -n (%)

n=9

n=27

0.432 *

<5

7 (77.8)

15 (55.6)

³5

2 (22.2)

12 (44.4)

2.4 (2.1-4.1)

4.8 (2.7-6.3)

0.136 ***

n=9

n=29

0.411 *

<3.5

1 (11.1)

8 (27.6)

³3.5

8 (88.9)

21 (72.4)

Albumin (g/dL) - average (SD)

4.3±0.51

3.79±0.53

0.015 **

n=9

n=24

0.090 *

£10

5 (55.6)

5 (20.8)

>10

4 (44.4)

19 (79.2)

10 (5.1-39.5)

49.1 (15.3-123)

0.054 ***

n=9

n=24

0.042#

Low risk (0.4-1.19)

2 (22.2)

3 (12.5)

Moderate risk (1.2-2.0)

3 (33.3)

1 (4.2)

High risk (>2)

4 (44.4)

20 (83.3)

1.96 (1.25-9.12)

18 (3.67-34.9)

0.026 ***

0.51 (0.12-0.86)

0.06 (0.03-0.29)

0.026 ***

mPNI - average (SD)

NLR - md (P25-P75) Albumin (g/dL) -n (%)

CRP (mg/L) -n (%)

CRP (mg/L) - md (P25-P75) mPINI - n (%)

mPINI - md (P25-P75); INI - md (P25-P75)

0.090 *

0.417 *

* Fisher exact test; ** student’s t test; *** Mann-Whitney Test; # Pearson’s Chi-square Test; PG-SGA= Patient-Generated Subjective Global Assessment; GPS= Glasgow Prognostic Score; mPNI= modified Prognostic Nutritional Index; NLR= Neutrophil/Lymphocyte ratio; CRP= C-Reactive Protein; mPINI= modified Prognostis Inflammatory and Nutritional Index; INI= Inflammatory Nutritional Index; SD= Standard Deviation; md= median.

There was a statistically significant association between mortality and tumor staging (p=0.008), BMI (p=0.021), PG-SGA (p=0.030) and %WL at one month (p=0.002), three months (p=0.003) and six months

(p=0.014). However, there was no association between the inflammatory markers and mortality outcome in the bivariate analysis (Table 3).

Rev Col Bras Cir. 2018; 45(2):e1614


Fruchtenicht Inflammatory and nutritional statuses of patients submitted to resection of gastrointestinal tumors

6 Table 3. Association of variables with death.

Death Nutritional Variables

Yes

No

n=25

n=16

n=25

n=16

Malnutrition

6 (24.0)

4 (25.0)

Eutrophy

14 (56.0)

2 (12.5)

Overweight

5 (20.0)

10 (62.5)

%WL - mean (SD)

n=25

n=16

1 month

4.16 (5.73)

-0.37 (3.17)

0.002*

3 months

11.2 (8.65)

2.93 (7.17)

0.003*

6 months

13.2 (7.95)

6.58 (8.16)

0.014*

n=25

n=16

0.030***

A

3 (12.0)

7 (43.8)

B/C

22 (88.0)

9 (56.3)

BMI Classification - n (%)

PG-SGA - n (%)

Death Inflammatory Variables

No

n=25

n=16

GPS - n (%)

n=18

n=15

0

5 (27.8)

5 (33.3)

½

13 (72.2)

10 (66.7)

mPNI - n (%)

n=20

n=14

<40

12 (60.0)

7 (50.0)

³40

8 (40.0)

7 (50.0)

NLR - n (%)

n=21

n=15

<5

10 (47.6)

12 (80.0)

³5

11 (52.4)

3 (20.0)

n=23

n=15

3.80±0.52

4.07±0.60

n=18

n=15

42.5 (7.8-115)

23.1 (9.1-101)

n=18

n=15

13.2 (1.8-33.8)

6.08 (1.96-23.4)

n=18

n=15

0.08 (0.03-0.57)

0.16 (0.04-0.51)

mean (SD) CRP (mg/L) md (P25-P75) mPINI md (P25-P75) INI md (P25-P75)

0.021**

p

Yes

Albumin (g/dL)

P

1.000***

0.820**

0.106**

0.151* 0.708# 0.532# 0.605#

* Student’s t test; ** Pearson’s Chi-square test; Fisher’s exact test; # Mann Whitney test. BMI= body mass index; %WL= percentage of weight loss; PG-SGA= Patient-Generated Subjective Global Assessment; GPS= Glasgow Prognostic Score; mPNI= modified Prognostic Nutritional Index; NLR= Neutrophil/Lymphocyte ratio; CRP= C-Reactive Protein; mPINI= modified Prognostic Inflammatory-Nutritional Index; INI= Inflammatory Nutritional Index; SD= Standard Deviation; md= median.

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Fruchtenicht Inflammatory and nutritional statuses of patients submitted to resection of gastrointestinal tumors

7

The NLR was the marker that most correlated

patients with GIT tumors, where PG-SGA detected 83%

with death. Significantly higher NLR values were found

of malnutrition and BMI was able to detect malnutrition

in death cases (p=0.033), when comparing patients who died (median 5.12) with those who did not (median 2.95). After multivariate analysis, however, NLR did not remain statistically significant as a predictor of mortality (p=0.139). In the multivariate analysis assessing factors independently associated with death, tumor staging (p=0.001) and albumin (p=0.004) were the only independent predictors of mortality (Table 4).

in only 40% of the patients16. In another study conducted with 51 patients with advanced colorectal cancer, PG-SGA was able to detect 56% of malnourished patients or at nutritional risk, whereas BMI was not a sensitive measure according to the authors17. Although BMI is a commonly used measure in the evaluation of nutritional status, including surgical and oncological patients, these results demonstrate that BMI cannot be relied upon to evaluate malnutrition, because it is not an appropriate tool to differentiate body

Table 4. Multivariate Analysis through the Poisson regression model to evaluate factors independently associated with death.

Variables

were not statistically significant in the multivariate analysis

Multivariate Model (n=26) RR (95% CI)

components16,18. In the present study, the results for BMI to assess independent factors associated with PG-SGA

p

Staging

malnutrition (RR 0.98, 95% CI 0.93-1.04, p=0.491). Due to the inadequacy of several methods for evaluating nutritional status when used alone, studies

IV

5.02 (1.86-13.6)

Other

0.001

have been undertaken with the objective of combining the evaluation measures, such as anthropometric,

1.0

laboratory and subjective tools, in order to increase the

BMI Classification Malnutrition

1.04 (0.54-1.99)

0.907

Eutrophy

0.93 (0.43-1.99)

0.843

Overweight

1.0

sensitivity and specificity of the methods, which would allow to evaluate and to draw nutritional strategies more suitable for these patients18. Recently,

studies

have

demonstrated

an

important association between nutritional depletion and

PG-SGA A

inflammation in cancer patients4-6,14,16,17,19-22, including

1.0

B/C

1.01 (0.57-1.80)

0.969

Albumin

0.48 (0.29-0.79)

0.004

NLR

1.05 (0.98-1.13)

0.139

BMI= body mass index; PG-SGA= Patient-Generated Subjective Global Assessment; NLR= Neutrophil/Lymphocyte ratio; RR= Relative Risk; CI= confidence interval.

GIT tumors. Since cancer patients are in a constant state of inflammation, and considering the role of this systemic inflammation in progressive weight loss and muscle mass, cancer cachexia can be identified by the presence and alteration of certain inflammatory markers5-7. In our study, several inflammatory markers were altered, especially in patients with high weight loss and malnourished, demonstrating that, as marker values were inadequate, inflammation was worse and %WL was higher. Lima et

DISCUSSION

al.16 and Costa et al.19 evaluated the association between %WL and different inflammatory markers in patients with

Malnutrition was highly prevalent in the patients included in this study. According to the global subjective assessment (PG-SGA), 76% of the patients were malnourished or at risk of malnutrition (categories B and C), whereas BMI detected less than a quarter of undernourished patients. A similar result was found in a previous study (n=30) that evaluated preoperatively

GIT tumors, and found a positive association between %WL and different markers, including mPINI (p<0.05 and p=0.002, respectively). However, few studies focused on the association between inflammatory markers and methods of nutritional assessment. In addition, other studies that evaluated such associations did not do so in populations solely of patients with GIT tumors, which

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Fruchtenicht Inflammatory and nutritional statuses of patients submitted to resection of gastrointestinal tumors

8

may compromise the comparison and extrapolation of

GIT tumors (n=30) conducted by Lima et al.16 in which

the data6,14.

patients considered to be undernourished by the global

markers of inflammatory response and predictors of prognosis in surgical procedures23, and the association between these markers and nutritional status has been previously assessed14,22. A recent Asian study of 64 patients with esophageal cancer found a strong association between nutritional status by PG-SGA and performance scores. However, such association was weak in relation to prognostic scores such as GPS22. On the other hand, in a study including patients with advanced tumors (n=114), the authors found that 60% of the patients who were malnourished by the PG-SGA presented high mGPS when compared with well-nourished ones (p=0.046). Although in our study 79% of malnourished patients had high mGPS compared with well-nourished individuals, this difference was not significant. The same occurs with NLR, since the authors found a significant association between the PG-SGA categories with this inflammatory marker, which we did not observe, and that can be justified by the inclusion, in our study, only patients with GIT tumors, or even by the size of the sample14. When we compared the PG-SGA with the inflammatory markers, only INI, mPINI and albumin were significantly associated with the subjective evaluation categories. The Inflammatory-Nutritional Index (INI) was developed with the purpose of investigating the relationship between the inflammatory state and the

Both mGPS and NLR have been proposed as

subjective assessment had significantly higher values of mPINI (p=0.014), as well as lower values of albumin (p=0.017) compared with well-nourished ones. CRP is an important marker of systemic inflammatory response expressed by some tumor cells. Elevated CRP values have been demonstrated as a reliable marker of malignancy potential and of predicted prognosis in several solid tumors24. Some studies found a positive association between altered CRP levels and weight loss in patients with GIT tumors16,19,25. In this study, despite the altered CRP values in most cases, the association between CRP, malnutrition and mortality was not observed, mainly due to its high variability or due to the small number of subgroups. On the other hand, in a study conducted by Read et al.17 with patients with advanced colorectal cancer, they initially found a positive correlation between PG-SGA and CRP (r=0.430; p=0.003). However, when two outliers were excluded, the association did not remain significant (r=0.278, p=0.065). Although initially proposed as a marker for the nutritional status of patients with GIT neoplasms, mPNI is likely to reflect the degree of systemic inflammation that affects cancer patients. Pinato et al.26 suggested the need to correlate mPNI with nutritional assessment instruments widely used in cancer patients, such as PG-SGA, with the aim of improving the results. This

nutritional status. In the present study, malnourished patients had significantly lower INI values when compared with well-nourished ones, a result similar to that reported in a study conducted by Alberici et al.6. We also assessed the CRP/albumin ratio (mPINI), considered an alternative for the simplification of the original formula of the Inflammatory and Nutritional Prognostic Index (PINI) to determine the association between the nutritional status and the systemic inflammatory response in patients with gastrointestinal cancer16,19. In our study, the PG-SGA scores were significantly associated with mPINI and albumin, demonstrating that malnourished patients had a high risk of complications and lower albumin values when compared with well-nourished individuals. This was similar to that shown in the study including patients with

study performed this association and, although the mPNI values were abnormal in the sample, especially in malnourished patients, this association was not statistically significant. As expected, we evidenced high mortality in patients with gastrointestinal tumors at more advanced stages of the disease, similarly to a previous study in esophageal cancer (n=141), in which tumor staging (TNM) was independently associated with worse prognosis in the multivariate analysis (p<0,0001)27. Inflammatory markers have been used to estimate the long-term prognosis, such as overall survival and diseasefree survival in cancer patients, and have been shown to be effective predictors of prognosis in patients with GIT tumors, including esophagus, stomach, pancreas, and colon15,23,28-30. However, the literature is scarce regarding

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Fruchtenicht Inflammatory and nutritional statuses of patients submitted to resection of gastrointestinal tumors

9

the use of these markers as predictors of short-term

nutritional assessment, because its results are influenced

outcomes and morbidity and mortality, and the results

by non-nutritional factors6,7.

are still contradictory27,31-34. Hypoalbuminemia is a consequence of systemic inflammation and is associated with a worse prognosis in cancer patients35. With the exception of albumin, no other inflammatory marker in our study was a predictor of mortality in the multivariate analysis. Poziomyck et al.34 reported a similar result in gastric cancer patients (n=44), in whom albumin was highly capable of predicting 30day mortality (p=0.026). Albumin has been widely used as a measure of nutritional and inflammatory statuses of cancer patients. Altered preoperative albumin levels have proven to be a better predictor of postoperative mortality for various types of cancer, including GIT tumors. However, this marker is not a reliable indicator of

and systemic inflammation in patients with GIT cancer submitted to surgical resection. The results showed a significant association between nutritional status and inflammatory markers, evidenced by the worse PG-SGA scores and percentage of weight loss, in addition to the high inflammatory response. Regarding mortality, only albumin and tumor staging were independently related to death in the population. Because of the lack of studies associating inflammatory markers with nutritional assessment methods, such as PG-SGA for example, and studies evaluating the use of these markers for mortality outcomes, more research is needed to better compare and discuss such results adequately.

We found a high prevalence of malnutrition

R E S U M O Objetivo: avaliar a associação entre o estado nutricional e inflamatório em pacientes com câncer do trato gastrointestinal submetidos à ressecção cirúrgica e identificar variáveis preditoras de mortalidade nestes pacientes. Métodos: estudo prospectivo de 41 pacientes com câncer do trato gastrointestinal submetidos à cirurgia entre outubro de 2012 e dezembro de 2014. O estado nutricional foi avaliado por métodos subjetivos e objetivos. A resposta inflamatória e o prognóstico foram avaliados através do Escore Prognóstico de Glasgow modificado (mGPS), razão Neutrófilo/Linfócito (NLR), Índice Nutricional Prognóstico de Onodera (mPNI), Índice Inflamatório Nutricional (INI) e razão Proteína C-reativa/Albumina (mPINI). Resultados: metade dos pacientes estava desnutrida e 27% apresentavam-se em risco nutricional. Associação positiva foi encontrada entre percentual de perda de peso (%PP) e os marcadores NLR (p=0,047), mPINI (p=0,014) e INI (p=0,015) e os níveis séricos de albumina (p=0,015), INI (p=0,026) e mPINI (p=0,026) se associaram significativamente às categorias da ASG-PPP. Na análise multivariada, a albumina foi o único marcador inflamatório independentemente relacionado ao óbito (p=0,004). Conclusão: marcadores inflamatórios foram significativamente associados com a desnutrição, demonstrando que quanto maior a resposta inflamatória, piores foram os escores da ASG-PPP (B e C) e maior o %PP nesses pacientes. No entanto, mais estudos, com o objetivo de melhorar resultados cirúrgicos e determinar o papel desses marcadores como preditores de mortalidade são necessários. Descritores: Neoplasias Gastrointestinais. Estado Nutricional. Inflamação. Mortalidade.

REFERENCES 1. Ferlay J, Soerjomataram I, Dikshit R, Eser S, Mathers C, Rebelo M, et al. Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer. 2015;136(5):E35986. 2. Silva MPN. Síndrome da anorexia-caquexia em portadores de câncer. Rev Bras Cancerol. 2006;52(1):59-7.

3. Nourissat A, Mille D, Delaroche G, Jacquin JP, Vergnon JM, Fournel P, et al. Estimation of the risk for nutritional state degradation in patients with cancer: development of a screening tool based on results from a cross-sectional survey. Ann Oncol. 2007;18(11):1882-6. 4. McMillan DC. Systemic inflammation, nutritional status and survival in patients with cancer. Curr Opin Clin Nutr Metab Care. 2009;12(3):223-6. 5. Silva JB, Maurício SF, Bering T, Correia MI. The

Rev Col Bras Cir. 2018; 45(2):e1614


10

6.

7.

8.

9.

10.

11. 12. 13.

14.

15.

16.

Fruchtenicht Inflammatory and nutritional statuses of patients submitted to resection of gastrointestinal tumors

relationship between nutritional status and the

17. Read JA, Choy ST, Beale PJ, Clarke SJ. Evaluation

Glasgow prognostic score in patients with cancer

of nutritional and inflammatory status of advanced

of the esophagus and stomach. Nutr Cancer. 2013;65(1):25-33. Alberici Pastore C, Paiva Orlandi S, González MC. Association between an inflammatory-nutritional index and nutritional status in cancer patients. Nutr Hosp. 2013;28(1):188-93. Barbosa-Silva MC. Subjective and objective nutritional assessment methods: what do they really assess? Curr Opin Clin Nutr Metab Care. 2008;11(3):248-54. ASPEN Board of Directors and the Clinical Guidelines Task Force. Guidelines for the use of parenteral and enteral nutrition in adults and pediatrics patients. Erratum in: J Parenter Enter Nutr. 2002;26(1 Suppl):1SA-138SA. Sobin LH, Compton CC. TNM seventh edition: what’s new, what’s changed: communication from the International Union Against Cancer and the American Joint Committee on Cancer. Cancer. 2010;116(22):5336-9. Ottery FD. Definition of standardized nutritional assessment and interventional pathways in oncology. Nutrition. 1996;12(1 Suppl):S15-9. World Health Organization. Obesity: preventing and managing the global epidemic. Geneva: WHO; 1997. Lipschitz DA. Screening for nutrition status in the elderly. Prim Care. 1994;21(1):55-67. Blackburn GL, Bristian BR, Maini BS, Schlamm HT, Smith MF. Nutritional and metabolic assessment of the hospitalized patient. JPEN J Parenter Enteral Nutr. 1977;1(1):11-22. Tan CS, Read JA, Phan VH, Beale PJ, Peat JK, Clarke SJ. The relationship between nutritional status, inflammatory markers and survival in patients with advanced cancer: a prospective cohort study. Support Care Cancer. 2015;23(2):385-91. Eo WK, Chang HJ, Suh J, Ahn J, Shin J, Hur JY, et al. The prognostic nutritional index predicts survival and identifies aggressiveness of gastric cancer. Nutr Cancer. 2015;67(8):1260-7. Lima KVG, Maio R. Nutritional status, systemic inflammation and prognosis of patients with gastrointestinal cancer. Nutr Hosp. 2012;27(3):70714.

colorectal cancer patients and its correlation with survival. Nutr Cancer. 2006;55(1):78-85. Poziomyck AK, Fruchtenicht AV, Kabke GB, Volkweis BS, Antoniazzi JL, Moreira LF. Reliability of nutritional assessment in patients with gastrointestinal tumors. Rev Col Bras Cir. 2016;43(3):189-97. Costa MD, Vieira de Melo CY, Amorim AC, Cipriano Torres O, Dos Santos AC. Association between nutritional status, inflammatory condition, and prognostic indexes with postoperative complications and clinical outcome of patients with gastrointestinal neoplasia. Nutr Cancer. 2016;68(7):1108-14. Maurício SF, da Silva JB, Bering T, Correia MI. Relationship between nutritional status and the Glasgow Prognostic Score in patients with colorectal cancer. Nutrition. 2013;29(4):625-9. Daniele A, Divella R, Abbate I, Casamassima A, Garrisi VM, Savino E, et al. Assessment of nutritional and inflammatory status to determine the prevalence of malnutrition in patients undergoing surgery for colorectal carcinoma. Anticancer Res. 2017;37(3):1281-7. Quyen TC, Angkatavanich J, Thuan TV, Xuan VV, Tuyen LD, Tu DA. Nutrition assessment and its relationship with performance and Glasgow prognostic scores in Vietnamese patients with esophageal cancer. Asia Pac J Clin Nutr. 2017;26(1):49-58. Maeda K, Shibutani M, Otani H, Nagahara H, Ikeya T, Iseki Y, et al. Inflammation-based factors and prognosis in patients with colorectal cancer. World J Gastrointest Oncol. 2015;7(8):111-7. Crumley AB, McMillan DC, McKernan M, Going JJ, Shearer CJ, Stuart RC. An elevated C-reactive protein concentration, prior to surgery, predicts poor cancer-specific survival in patients under- going resection for gastro-oesophageal cancer. Br J Cancer. 2006;94(11):1568-71. Deans DA, Tan BH, Wigmore SJ, Ross JA, de Beaux AC, Paterson-Brown S, et al. The influence of systemic inflammation, dietary intake and stage of disease on rate of weight loss in patients with gastrooesophageal cancer. Br J Cancer. 2009;100(1):63-9. Pinato DJ, North BV, Sharma R. A novel, externally

18.

19.

20.

21.

22.

23.

24.

25.

26.

Rev Col Bras Cir. 2018; 45(2):e1614


Fruchtenicht Inflammatory and nutritional statuses of patients submitted to resection of gastrointestinal tumors

11

validated inflammation-based prognostic algorithm in

33. Rashid F, Waraich N, Bhatti I, Saha S, Khan RN,

hepatocellular carcinoma: the prognostic nutritional

Ahmed J, et al. A pre-operative elevated neutrophil:

index (PNI). Br J Cancer. 2012;106(8):1439-45. 27. Hirahara N, Matsubara T, Hayashi H, Takai K, Fujii Y, Tajima Y. Impact of inflammation-based prognostic score on survival after curative thoracoscopic esophagectomy for esophageal cancer. Eur J Surg Oncol. 2015;41(10):1308-15. 28. Proctor MJ, Morrison DS, Talwar D, Balmer SM, O Reilly DS, Foulis AK, et al. An inflammation-based prognostic score (mGPS) predicts cancer survival independent of tumour site: a Glasgow inflammation outcome study. Br J Cancer. 2011;104(4):726-34. 29. La Torre M, Nigri G, Cavallini M, Mercantini P, Ziparo V, Ramacciato G. The Glasgow prognostic score as a predictor of survival in patients with potentially resectable pancreatic adenocarcinoma. Ann Surg Oncol. 2012;19(9):2917-23. 30. Sun K, Chen S, Xu J, Li G, He Y. The prognostic significance of the prognostic nutritional index in cancer: a systematic review and meta-analysis. J Cancer Res Clin Oncol. 2014;140(9):1537-49. 31. Walsh SM, Casey S, Kennedy R, Ravi N, Reynolds JV. Does the modified Glasgow Prognostic Score (mGPS) have a prognostic role in esophageal cancer? J Surg Oncol. 2016;113(7):732-7. 32. Jaramillo-Reta KY, Velรกzquez-Dohorn ME, MedinaFranco H. Neutrophil to lymphocyte ratio as predictor of surgical mortality and survival in complex surgery

lymphocyte ratio does not predict survival from oesophageal cancer resection. World J Surg Oncol. 2010;8:1. 34. Poziomyck AK, Cavazzola LT, Coelho LJ, Lameu EB, Weston AC, Moreira LF. Nutritional assessment methods as predictors of postoperative mortality in gastric cancer patients submitted to gastrectomy. Rev Col Bras Cir. 2017;44(5):482-90. 35. Hirashima K, Watanabe M, Shigaki H, Imamura Y, Ida S, Iwatsuki M, et al. Prognostic significance of the modified Glasgow prognostic score in elderly patients with gastric cancer. J Gastroenterol. 2014;49(6):1040-6.

Received in: 30/01/2018 Accepted for publication: 13/03/2018 Conflict of interest: none. Source of funding: FIPE HCPA, Research Fund and Post-Graduate Program in Surgical Sciences, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil. Mailing address: Luis Fernando Moreira E-mail: lufmoreira@hcpa.edu.br / anavaleria.1012@hotmail.com

of the upper gastrointestinal tract. Rev Invest Clin. 2015;67(2):117-21.

Rev Col Bras Cir. 2018; 45(2):e1614


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Original Article

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Perception of body image by patients undergoing bariatric surgery Percepção da imagem corporal em pacientes submetidos à cirurgia bariátrica ROSANA MARIA RESENDE LACERDA1; CHRISTIANE RAMOS CASTANHA2; ALESSANDRA RAMOS CASTANHA2; JOSEMBERG MARINS CAMPOS, TCBC-PE1; ÁLVARO ANTÔNIO BANDEIRA FERRAZ, TCBC-PE1; LUCIO VILAR1 A B S T R A C T Objective: to investigate changes in body image perception in patients undergoing bariatric surgery, evaluating the accuracy/inaccuracy in body size estimation and satisfaction/dissatisfaction with own body after surgery. Methods: we performed a survey at the General Surgery outpatient clinic of the Clinics Hospital of the Federal University of Pernambuco. Thirty-six patients aged 18 years and older undergoing bariatric surgery participated. We carried out cross-sectional and quantitative studies using the Silhouetted Figures Scale. Results: in the descriptive analysis of the distortion and dissatisfaction score of the patients with the body image, the mean distortion was positive (6.43kg/m²), indicating that most people see themselves greater than they really are. On the other hand, in the dissatisfaction, we found a negative mean (-6.91kg/m²), indicating that the majority of the patients evaluated had a “BMI” lower than the current one (that is, a smaller silhouette). Regarding satisfaction with silhouette size, only 11.8% of women liked the post-surgical result, while among men there was 50% satisfaction. Conclusion: Although bariatric surgery significantly reduced BMI, the patients presented, for the most part, dissatisfaction with body weight, perceiving it greater than it actually was, thus characterizing a perceptual inaccuracy. Keywords: Perception. Body image. Patient Satisfaction. Body Mass Index. Bariatric Surgery.

INTRODUCTION

relevant in cases of eating disorders, since in abnormal eating behavior the perception of body weight may be

I

n addition to physical burdens, obesity has a

a more determining factor than the objective reality of

psychological impact that can reflect on body image

its appearance7.

disorders, low self-esteem, anxiety, depression, and

Bariatric surgery (BS) leads to several changes

a social impact that negatively reflects on professional

in weight and body contours. However, the body image

life and interpersonal relationships1. In this context,

will not always immediately follow these adjustments.

undergoing weight loss treatments may not only be

Psychological alterations may require a longer time of

related to the need or desire for physical health, but also

symbolic elaboration, a perception of obese body image

psychological and social one , since massive weight loss

persisting even with significant and expected weight loss.

has effects, for example, on the alteration of body image

Perceptual restructuring tends to be slower than rapid

perception and self-esteem3.

and massive weight loss4,8. This rapid and massive weight

2

Body image is a multidimensional construct

loss after BS can concomitantly lead to the recovery of

that involves cognitive, cultural, and physiological

self-esteem and cause dissatisfaction of the body image,

aspects. It concerns the perception and feeling one

due to either inadequate perceptual restructuring or to

has in relation to one’s own body. Distortions in body

direct consequences of surgery itself, such as sagging

image generally promote a feeling of rejection or

skin in the breasts and in the abdomen, in addition to

dissatisfaction4-6. The study of body image is extremely

extensive scars3.

1 - Federal University of Pernambuco, Department of Surgery and Clinical Medicine, Recife, PE, Brazil. 2 - Federal University of Pernambuco, Department of Psychology, Recife, PE, Brazil. Rev Col Bras Cir. 2018; 45(2):e1793


Lacerda Perception of body image by patients undergoing bariatric surgery

2

Some authors state that dissatisfaction with

To analyze the data, we built a dataset in a

body image can lead to behaviors harmful to health,

Microsoft Excel spreadsheet, which was exported to the

such as adherence to inappropriate diets, as well as the

Statistical Package for the Social Sciences (SPSS), version

emergence of psychopathologies such as anorexia, bulimia

18, where we performed the analysis. We described the

and body dysmorphia. These are aggravated in patients

anthropometric data with mean, standard deviation,

submitted to BS, since it can hinder adherence to the new

median, minimum and maximum. We also constructed

habits required, resulting in negative consequences, such

the degree of distortion through the difference of the

as weight regain, nutritional deficiencies and even the risk

BMI chosen by the patients and the actual BMI. For

9,10

of death

. In this sense, self-perception and satisfaction

the construction of the degree of dissatisfaction, we

with body image are fundamental for self-acceptance,

calculated the difference between the desired BMI and

and justifies the importance of the study of body image

the current BMI. We used the Kolmogorov-Smirnov test to

11

assess the normality of the distortion and dissatisfaction

This research sought to investigate changes

scores. In cases showing normality of the score, we used

in body image perception in patients submitted to BS,

the Student’s t-test for independent samples and the

evaluating the accuracy/inaccuracy in body size estimation

ANOVA test to compare two or three and more groups,

and body satisfaction/dissatisfaction after surgery.

respectively. To compare the dissatisfaction score with

perception after bariatric surgery .

the distortion score, we used the Student’s t-test for

METHODS

paired samples. We drew all conclusions considering the level of significance of 5%. We used a 95% truth force

We performed the research at the Outpatient

(p=0.05).

Clinic of General Surgery of the Clinics Hospital of UFPE

The study was approved by the Ethics in

(HC-UFPE). We carried out cross-sectional and quantitative

Research Committee of the Health Sciences Center

studies. Participants were 36 patients of both genders,

(CCS) of the Federal University of Pernambuco (CAAE:

aged between 22 and 63 years, who underwent surgery for

26602314.7.0000.5208).

a maximum of seven years. The Silhouetted Figures Scale (SFS) was composed of silhouettes of both sexes and Body

RESULTS

Mass Index (BMI) averages varying from 12.5 to 47.5 kg/ m². We presented the patients the SFS cards in ascending

Table 1 shows the descriptive analysis of the

order (from thinnest figure to largest) and asked them to

patient’s anthropometric data. The average weight before

choose: a) the card that represented the silhouette of their

surgery was 115.94kg, with a standard deviation (SD) of

current body; b) the card that represented the silhouette

19.56kg. The mean weight after surgery was 79.53kg,

of a body that they would like to have.

with SD 21kg. Mean height was 159cm.

Table 1. Distribution of anthropometric data.

Variable

Mean

SD

Minimum

Median

Maximum

Before

115.94

19.56

82.00

110.00

166.00

After

79.53

16.78

51.90

76.00

119.00

159

0.07

149

158

181

Weight (KG)

Height (cm)

Before BS, we divided patients into two categories, obesity grades II and III, with the predominance of the latter, which affected 82.4% of the patients. After

the surgical procedure, the majority of patients presented grade I obesity (35.3%), followed by overweight (29.4%), normal weight (14.7%), grade II obesity (11.8%), and

Rev Col Bras Cir. 2018; 45(2):e1793


Lacerda Perception of body image by patients undergoing bariatric surgery

3

grade III obesity (8.8%).

bigger than they really are. On the other hand, in the

Table 2 shows the descriptive analysis of patients’ distortion score and dissatisfaction of with body image. The mean distortion was positive (6.43kg/ m²), indicating that most people see themselves

dissatisfaction, we found a negative mean (-6.91kg/m²), indicating that the majority of the patients evaluated had a “BMI goal” lower than the current one (that is, a smaller silhouette).

Table 2. Characterization of distortion and dissatisfaction.

Variable

Mean

SD

Minimum

Median

Maximum

Distortion

6.43

5.14

-4.57

6.61

17.63

Dissatisfaction

-6.91

6.40

-30.00

-5.00

5.00

p-value¹ < 0.001

¹ Student’s t-test for paired samples (If p-value <0.05, Distortion differs from the Dissatisfaction).

In the female group, the mean value of the

male group this percentage was 50%. As for satisfaction

current BMI was 37.86kg/m² (±6.22), while the mean

with silhouette size, only 11.8% of women liked the

desired BMI was 30.88kg/m² (±4.64). In men, the current

post-surgical result, while among men there was 50%

BMI mean was 35.0kg/m² (±0) and the desired BMI was

satisfaction. Table 3 shows the descriptive analysis of the

30kg/m² (±7.07). As for image distortion according to gender,

dissatisfaction score and body image distortion according

87.5% of women presented overestimation (that is, they

to gender. We observed that both in the female and in

saw themselves bigger than they really were), while the

the male groups the mean dissatisfaction was negative

male group showed 100% overestimation. Therefore, we

(-7.03kg/m2 and -5.0kg/m², respectively), indicating

found no significant relationship between gender and

that they wanted to have a smaller silhouette. For the

image overestimation.

distortion, we found positive mean score values (6.60kg/

Regarding dissatisfaction with body image

m² for females and 3.72kg/m² for males), indicating

according to gender, we found that 85.3% of the women

that patients of both genders overestimated their body

wished to decrease the size of the silhouette, while in the

image.

Table 3. Descriptive analysis of the dissatisfaction score and distortion of body image according to gender.

Gender Female Male

Variable

n

Mean

SD

Minimum

Median

Maximum

Dissatisfaction

32

-7.03

6.46

-30.00

-5.00

5.00

Distortion

32

6.60

5.20

-4.57

6.80

17.63

Dissatisfaction

2

-5.00

7.07

-10.00

-5.00

0.00

Distortion

2

3.72

4.11

0.81

3.72

6.63

Table 4 presents the descriptive analysis of the body image dissatisfaction and distortion score according to postoperative time. There was a higher mean level of dissatisfaction with body image in the group of patients submitted to surgery up to six months (-9.50kg/m² ±3.26), followed by the group within 12 and 24 months (-7.71kg/

m² ±5.59) and the one over 24 months (-6.67kg/m² ±9.10). For the body image distortion, we found a higher mean score in the group of patients with 12 to 24 months postoperative (7.42kg/m² ±5.10), followed by the group with six to 12 months (7.06kg/m² ±4.72) and more than 24 months postoperatively (5.94kg/m² ±6.56).

Rev Col Bras Cir. 2018; 45(2):e1793


Lacerda Perception of body image by patients undergoing bariatric surgery

4

Table 4. Descriptive analysis of the dissatisfaction score and distortion of body image the according to the patient’s postoperative period.

Postoperative Period Up to 6 months 6 to 12 months 12 to 24 months Over 24 months

Variable

n

Mean

SD

Minimum

Median

Maximum

Dissatisfaction

5

-9.50

3.26

-12.50

-10.00

-5.00

Distortion

5

3.94

3.03

-0.58

5.06

6.59

Dissatisfaction

8

-4.38

5.47

-10.00

-6.25

5.00

Distortion

8

7.06

4.72

-0.14

7.38

12.54

Dissatisfaction

12

-7.71

5.59

-17.50

-5.00

0.00

Distortion

12

7.42

5.10

-3.81

7.22

14.86

Dissatisfaction

9

-6.67

9.10

-30.00

-5.00

0.00

Distortion

9

5.94

6.56

-4.57

5.69

17.63

DISCUSSION

into the current patterns12. Among the studies that corroborate the results

Data showed that, regardless of gender, there

of the present one, that is, those in which the majority of

was a distortion of body image (6.43kg/m² ± 5.14). As

the participants tended to overestimate body size, we can

the value of the distortion was positive, this indicates a

cite the research with 50 women who had undergone BS,

tendency to overestimate the body image, that is, the

which demonstrated that patients had expected weight

majority of the participants of the research saw themselves

loss and improved obesity-associated comorbidities, as

bigger than they really are. These data corroborate,

well as improved symptoms of anxiety and depression12.

in part, the existing literature, since studies point to

However, they still had body image disturbances and

divergent conclusions regarding the distortion of body

62% of them overestimated their actual body size on an

image in obese individuals, who can either underestimate

average of 3.9kg/m² and were dissatisfied with their own

or overestimate body size.

image, wishing to weigh less. Some authors affirm that the

In a study with 100 patients of both genders

patients have the belief that BS will be the solution of their

submitted to BS, Rezende10 observed a tendency to

problems. When they perceive that this is not the case, “a

underestimation of body image, with negative distortion

search for a dreamed and idealized body begins, which

values both in men and in women (-0.94kg/m² ±6.88

most of the times does not materialize. In that moment,

and -0.77kg/m² ±6.45, respectively), thus showing that

deviation of self-image, frustration and depression arise”13.

the majority of the participants perceived themselves

A factor that can lead to overestimation is the incidence of

thinner than they really were. Underestimation can

obesity during childhood. The earlier obesity ensues, the

occur because of the difficulty in estimating body size

greater the incidence of preoccupation with body image

after rapid weight loss. Another factor that can lead to

and a threefold higher chance of overestimating body size

inaccuracy of body weight reckoning is the desire to move

when compared with normal adults14.

away from stereotypes that usually accompany obese

We found a negative dissatisfaction mean

life, such as laziness, lack of self-control and will power.

(-6.91kg/m² ±6.40), indicating that most patients have

These stereotypes generate psychic suffering, whether

a “goal” of having a lower BMI than the current one,

conscious or unconscious, and can lead individuals to

that is, they want to have a smaller silhouette. A study

underestimate their body sizes, functioning as a defense

of 50 women in BS pre- and postoperative (four months)

mechanism, through denial of a body that does not fit

periods, using three instruments, among them the

Rev Col Bras Cir. 2018; 45(2):e1793


Lacerda Perception of body image by patients undergoing bariatric surgery

5

Silhouettes Figure Scale, demonstrated that all patients

a perceptual inaccuracy, since they perceived a mean

were dissatisfied with body image, on average, a BMI of

BMI of 37.71kg/m², that is, a larger silhouette than

12

10.3kg/m² less than they thought they had .

they actually possessed, leading to a greater degree of

BS is effective in weight loss, which reduces

dissatisfaction, suffering, and anguish.

depreciation of body image, brings more disposition to

Sarwer et al.21 affirm that the subjective

the working life and allows a better resourcefulness in the

perception about self-image may even be more important

physical, social and sexual activities, thus increasing the

than the objective reality itself of its appearance. In this

self-esteem as a whole, causing a positive impact in the

context, the analysis of the data of the present research

15,16

patient’s psychosocial behavior

. On the other hand,

is that, regardless of the actual BMI being close to the

the negative evaluation of the body image itself can

desired BMI, what really matters is how the patients

worsen the prognosis, compromising treatment success,

perceive their bodies and, in this case, the perception

12

is distorted, increased. Cordás et al.18 state that this

understanding that it does not end with BS . A study conducted by Segura et al.17 with 50

distortion may be influenced by some factors, and that

individuals (36 women and 14 men) with a mean age

one of them is the age at which the obesity picture

of 43.82 (±12.2) years and a mean postoperative time

began. The authors argue that the earlier it is, the more

of 34.8 months (±22.0) indicated that BMI showed a

difficult it will be to adapt to this new body, over which

direct relationship between body image and level of

often individuals continue to project an image of a fat

satisfaction with weight. These data are in line with

body with which they have always identified, even having

those found in the present study, as well as in others

lost weight.

performed by several authors, which observed that it is

We observed that, as effective as BS might have

not BMI that will necessarily establish the relationship

been, as evidenced by the BMI and weight loss indexes, as

between body image and satisfaction level, but with

well as by the proximity of the mean values of the actual and

the self-image of perceived obesity, that is, through a

desired BMI, it is evident the difficulty of the investigated

subjective evaluation, not related to the actual weight

patients in perceiving not only the improvement in body

20

contour, but how much this improvement was so close

state that BS patients who can improve in psychological

to what they would wish to possess. This difficulty occurs

aspects such as changes in self-esteem, body image,

due to perceptual inaccuracy, through the distortion of

depression and mood, tend to have an adaptation to this

the subjective body perception.

of the individual

18-20

. Still in this sense, Palmeira et al.

new body in a more positive way, as well as being able to

After BS, there are weight loss and changes in

maintain weight reduction in the long run because they

body contours that happen rapidly. Often the individual

feel more motivated.

cannot psychologically assimilate this new body image,

In view of the above, it is important to

and a perception of an obese body can remain, until

work with patients who remain dissatisfied with their

the perceptive, cognitive restructuring can occur in an

body image after BS, in an attempt to understand

effective way, bringing the actual weight closer to what

the intrinsic and extrinsic factors that are negatively

the individual perceives to have at that moment4,8. Still in

influencing it, so that they can re-evaluate this new

this sense, Branco et al.11 affirm that self-acceptance is

body positively. When analyzing the mean of the actual

directly related to the way in which one perceives oneself

BMI (collected in the chart), the perceived (indicated

and how satisfied one is with one’s own body image. The

on the silhouette scale) and the desired one (also

dissatisfaction with body image in patients submitted

indicated in the silhouette scale), we observed that

to BS can negatively affect self-esteem, interpersonal

despite the actual BMI (31.21kg/m²) was quite close

relationships, cause anxiety and depression, may also

to the desired one (30.83kg/m²), the participants had

hamper the necessary adaptation related to adherence

Rev Col Bras Cir. 2018; 45(2):e1793


Lacerda Perception of body image by patients undergoing bariatric surgery

6

to medical and nutritional recommendations, and lead

When analyzing the body image dissatisfaction

to weight regain, nutritional deficiencies and, in more

and distortion score according to the postoperative

9

serious cases, the risk of death .

period, there was a higher level of dissatisfaction in

When analyzing the distribution of patients’

the group of patients submitted to BS up to six months

dissatisfaction with body image according to gender, we

(-9.50kg/m² ±3.26) followed by the group in the 12 to

noticed that women have a higher dissatisfaction index.

24 months postoperative period (-7.71kg/m² ±5.59)

Regarding the size of the silhouette, 85.3% of women

and the one over 24 months (-6.67kg/m² ±9.10). As

wanted it smaller, while in the men’s group this percentage

for distortion, we found the highest mean score in the

was 50%. Regarding satisfaction with silhouette size, only

group of patients within 12 to 24 postoperative months

11.8% of women liked the postoperative result, while

(7.06kg/m² ±4.72). The highest index of dissatisfaction

men presented a 50% satisfaction index. The difference

in the group of up to six months can be explained by

found between genders in regard to dissatisfaction may

the fact that the postoperative time was not enough

be based on gender issues, in which, culturally, there is

for the desired weight loss. Regarding groups of 12 to

the cult of thinness as an acceptable/desirable aesthetic

24 months and over 24 months, it can be explained by

pattern and this is a factor that affects women much

the expected weight regain from the second year after

more, because they suffer a much greater charge of

surgery on22.

society in relation to their body. In addition, men tend

These negative feelings, which arise over

to seek the BS’s appeal motivated much more by the

time, are also accompanied by the increase in weight

limitations that obesity brings in daily activities than by

that comes with the years of surgery. In this way, there

10

aesthetic reasons per se. Rezende conducted a survey of

is need for a multidisciplinary follow-up after BS, with

85 women and 15 men and found more homogeneous

the participation of professionals from the medical,

data when comparing these two groups. In both genders,

psychological, nutritional and physical educator areas,

80% of the participants wished to decrease their

thus providing a better adaptation to a permanent habit

silhouette and, in the comparison regarding silhouette

change and maintenance of surgical results22.

satisfaction after BS, 15% of the women and 20% of the

We conclude that although BS had a significant

men were satisfied. Despite finding a smaller difference

decrease in BMI, the patients presented, for the most part,

between the two groups, the author also found a slightly

dissatisfaction with body weight, perceiving it greater

lower index of satisfaction with the postoperative result

than it actually was, thus characterizing a perceptual

among women.

inaccuracy.

R E S U M O Objetivo: investigar as mudanças sofridas na percepção da imagem corporal em pacientes submetidos à cirurgia bariátrica, avaliando a acurácia/inacurácia na estimativa do tamanho corporal e a satisfação/insatisfação com os corpos após a cirurgia. Métodos: pesquisa foi realizada no ambulatório de Cirurgia Geral do Hospital das Clínicas da Universidade Federal de Pernambuco. Participaram 36 pacientes com idade a partir de 18 anos submetidos à cirurgia bariátrica. Foram realizados estudos transversal e quantitativo com a utilização da Escala de Figuras de Silhuetas. Resultados: na análise descritiva do escore de distorção e insatisfação dos pacientes com a imagem corporal, percebeu-se que a média da distorção foi positiva (média= 6,43kg/m²), indicando que a maioria das pessoas se vê maior do que realmente é. Em contrapartida, na insatisfação foi encontrada uma média negativa (média= -6,91kg/m²), indicando que a maioria dos pacientes avaliados tem como “meta” um IMC menor do que aquele apontado como atual (ou seja, gostaria de ter uma silhueta menor). Quanto à satisfação com o tamanho da silhueta, apenas 11,8% das mulheres gostaram do resultado pós-cirúrgico, enquanto que entre os homens houve 50% de satisfação. Conclusão: embora a cirurgia bariátrica tenha diminuído significativamente o IMC, os pacientes apresentaram, em sua maioria, insatisfação com o peso corporal, percebendo-o maior do que realmente era, caracterizandose, assim, uma inacurácia perceptiva. Descritores: Percepção. Imagem Corporal. Satisfação do Paciente. Índice de Massa Corporal. Cirurgia Bariátrica.

Rev Col Bras Cir. 2018; 45(2):e1793


Lacerda Perception of body image by patients undergoing bariatric surgery

REFERÊNCIAS

7

2006;33(6):292-6. 12. Oliveira MP, Siqueira EJ, Alvarez GS, Laitano FF, Pires

1. de Zwaan M, Enderle J, Wagner S, Mühlhans B,

FKS, Martins PDE. Aspectos psicológicos do paciente

Ditzen B, Gefeller O, et al. Anxiety and depression

pós-bariátrico. Arq Catarinen Med. 2012;41(Supl

in bariatric surgery patients: a prospective, followup study using structured clinical interviews. J Affect

1):173-5. 13. Fandiño JN, Apolinário JC. Avaliação psiquiátrica da cirurgia bariátrica. In: Nunes MA, Appolinário

Disord 2011;133(1-2):61-8. 2. Almeida GAN, Santos JE, Pasian SR, Loureiro SR.

JC, Galvão AL, Coutinho W, editores. Transtornos

Percepção de tamanho e forma corporal de mulheres:

alimentares e obesidade. Porto Alegre: Artmed;

estudo exploratório. Psicol Estud. 2005;10(1):27-35.

2006. p. 365-54.

3. Castro MR. Imagem corporal de mulheres submetidas

14. Ceneviva R, Silva GA, Viegas MM, Sankarankutty

à cirurgia bariátrica [dissertação]. Juiz de Fora (MG):

AK, Chueire FB. Cirurgia bariátrica e apneia do sono.

Universidade Federal de Juiz de Fora; 2009.

Medicina (Ribeirão Preto). 2006;39(2):235-45.

4. Tavares MCGF. Imagem corporal: conceito e desenvolvimento. São Paulo: Manole; 2003. 5. Adami F, Fernandes TC, Frainer DES, Oliveira FR. Aspectos da construção e desenvolvimento da imagem corporal e implicações na educação

15. Castanha CR. Avaliação da qualidade de vida, perda de peso e comorbidades de pacientes submetidos à cirurgia bariátrica [dissertação]. Recife (PE): Universidade Federal de Pernambuco; 2017. 16. Boscatto

EC,

Gomes

MA,

Duarte

MFS.

física. Rev Digit [Internet]. 2005 [citado 2017 Nov

Comportamentos ativos e percepção da saúde em

13];83(10):[cerca de 1 p]. Disponível em: http://www.

obesos submetidos à cirurgia bariátrica. Rev Bras

efdeportes.com/efd83/imagem.htm

Atividade Fís Saúde. 2012;16(1):43-7.

6. Friedman MA, Brownell KD. Psychological correlates

17. Segura DCA, Corral JP, Wozniak SD, Scaravonatto

of obesity: moving to the next research generation.

A, Vandresen EP. Análise da imagem corporal e

Psychol Bull. 1995;117(1):3-20.

satisfação com o peso em indivíduos submetidos à

7. Nunes MA, Olinto MTA, Barros FC, Camey S. Influência da percepção do peso e do índice de massa corporal nos comportamentos alimentares anormais.

cirurgia bariátrica. Rev Pesqui Saúde. 2016;17(3):1704. 18. Cordás TA. Participação do psiquiatra e do psicólogo na fase perioperatória: a participação do psiquiatra.

Rev Bras Psiquiatr. 2001;23(1):21-7. 8. Pruzinsky T, Edgerton M. Body-image change in cosmetic plastic surgery. In: Cash TF, Pruzinsky T,

In: Garrido Jr AB, editor. Cirurgia da obesidade. São Paulo: Atheneu; 2002. p. 71-4.

editors. Body images: development, deviance, and

19. Barros LM, Moreira RAN, Frota NM, Caetano JA.

change. New York: Guilford Press; 1990. p. 190–

Mudanças na qualidade de vida após a cirurgia

236.

bariátrica. Rev Enferm UFPE online. 2013;7(5):1365-

9. McCabe MP, Ricciardelli LA. Body image dissatisfaction among males across the lifespan: a review of past

75. 20. Palmeira AL, Branco TL, Martins SC, Minderico CS,

literature. J Psychosom Res. 2004;56(6):675-85.

Silva MN, Vieira PN, et al. Change in body image

10. Rezende FF. Percepção da imagem corporal, resiliência

and psychological well-being during behavioral

e estratégias de coping em pacientes submetidos à

obesity treatment: associations with weight loss and

cirurgia bariátrica [dissertação]. Ribeirão Preto (SP):

maintenance. Body Image. 2010;7(3):187-93. 21. Sarwer DB, Wadden TA, Foster GD. Assessment

Universidade de São Paulo; 2011. 11. Branco LM, Hilário MOE, Cintra IP. Percepção e

of body image dissatisfaction in obese women:

satisfação corporal em adolescentes e a relação

specificity, severity, and clinical significance. J Consult

com seu estado nutricional. Rev Psiquiatr Clin.

Clin Psychol. 1998;66(4):651-4.

Rev Col Bras Cir. 2018; 45(2):e1793


Lacerda Perception of body image by patients undergoing bariatric surgery

8

22. Franques ARM, Arenales-Loli MS. Novos corpos,

Mailing address:

novas realidades: reflex천es sobre o p처s-operat처rio da

Rosana Maria Resende Lacerda

cirurgia da obesidade. S찾o Paulo: Vetor; 2011.

E-mail: lacerda.rosana@yahoo.com.br / alessandra_castanha@yahoo.com.br

Received on: 01/02/2018 Accepted for publication: 13/03/2018 Conflict of interest: None. Funding source: CAPES Masters Scholarship.

Rev Col Bras Cir. 2018; 45(2):e1793


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Review Article

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Fecal microbiota transplantation in the treatment of Clostridium difficile infection: state of the art and literature review Transplante de microbiota fecal no tratamento da infecção por Clostridium difficile: estado da arte e revisão de literatura BRUNO AMANTINI MESSIAS, TCBC-SP2; BÁRBARA FREITAS FRANCHI1; PEDRO HENRIQUE PONTES1; DANIEL ÁTILA DE ANDRADE MEDEIROS BARBOSA1; CÉSAR AUGUSTO SANITA VIANA1

A B S T R A C T Clostridium difficile infection is a common complication following intestinal dysbiosis caused by abusive antibiotic use. It presents medical importance due to the high rates of recurrence and morbidity. Fecal microbiota transplantation is an effective alternative for the treatment of recurrent and refractory C. difficile infection and consists of introducing the intestinal microbiota from a healthy donor into a patient with this infection. The exact physiological mechanism by which fecal microbiota transplantation alters the intestinal microbiota is not well established, but it is clear that it restores the diversity and structure of the microbiota by promoting increased resistance to colonization by C. difficile. Several routes of transplant administration are being studied and used according to the advantages presented. All forms of application had a high cure rate, and the colonoscopic route was the most used. No relevant complications and adverse events have been documented, and the cost-effectiveness over conventional treatment has proven advantageous. Despite its efficacy, it is not commonly used as initial therapy, and more studies are needed to establish this therapy as the first option in case of refractory and recurrent Clostridium difficileinfection. Keywords: Fecal Microbiota Transplantation. Clostridium difficile. Enterocolitis, Pseudomembranous. Anti-BacterialAgents.

INTRODUCTION

2000, an increase in cases of severe C. difficile infection was reported, with a high mortality rate. This increase

C

lostridium difficileis an obligate anaerobic gram-

in the mortality rate is mainly due to the involvement

positive bacillus that is part of the intestinal

of the elderly and the increase in the use of antibiotics

1

microbiota, both in man and in other animals . It was first

of the fluoroquinolones class. The epidemic arose from

isolated in 1935 and so named because of the difficulties

the appearance of a hypervirulent strain, which is highly

encountered in achieving its culture. In 1978, it was

resistant to the antibiotics most commonly used in the

identified as the main agent causing pseudomembranous

hospital environment, the NAP1/BI/0274.

colitis, the sigmoid and rectum being the main sites of 2

Infection caused by C. difficile is the most

involvement . The main virulence factors are its exotoxins,

common form of nosocomial diarrhea associated with the

enterotoxin A and cytotoxin B. They are responsible for

use of antibiotics in elderly, hospitalized patients. Most

the destruction of the intestinal epithelium and mucosal

infected hospitalized patients are asymptomatic carriers

injury3.

and serve as a silent reservoir for continued dissemination In recent years, there has been a dramatic

in the hospital setting5. The transmission of C. difficile

change in the epidemiology of the infection caused by

occurs through the fecal-oral route, person-to-person,

Clostridium difficile. It is currently considered a global

through fomites and instruments of hospital furniture.

public health problem. At the beginning of the year

Bacterial spores remain in the environment for extended

1 - Medical School, São Camilo University Center, São Paulo, SP, Brazil. 2 - General Surgery Service, Carapicuíba General Hospital, Carapicuíba, SP, Brazil. Rev Col Bras Cir. 2018; 45(2):e1609


Messias Fecal microbiota transplantation in the treatment of Clostridium difficile infection: state of the art and literature review

2

periods and resist most available disinfectants6.

diarrhea with several episodes a day (>3 bowel

The main risk factors are age greater than

movements/day), abdominal pain that improves after

65 years, use of laxatives, proton pump inhibitors or histamine, chemotherapy, gastrointestinal surgeries, prolonged hospitalization and especially the use of antibiotics. Historically, clindamycin, cephalosporins, penicillins and more recently fluoroquinolones, are the antibiotics most implicated in this infection7. However, any antibiotic may predispose to C. difficile colonization, including metronidazole and vancomycin, first-line treatment medications for its treatment8. The typical clinical picture is of watery

evacuation, low fever and leukocytosis. More severe cases may evolve with toxic megacolon and intestinal perforation, thereby greatly increasing the mortality rate. Complications include hypoalbuminemia, 7 dehydration, and malnutrition . Diagnosis rests on the clinical presentation (presence of diarrhea or ileus) and microbiological detection of C. difficile in the feces (detection of toxins A and B by PCR or coproculture)3. To choose the correct treatment, it is important to classify the severity of the disease (Table 1)9.

Table 1. Classification of Clostridium difficile based on disease severity.

Category

Clinical signs and laboratory

Associated risk Factors

Mild to

Diarrhea with signs of systemic infection, leukocytosis <15.000/ml or serum creatinine<1.5x baseline.

Use of antibiotics, prior hospitalization, long hospitalization, use of Proton pump inhibitors, chemotherapy, chronic kidney disease and presence of nasogastric catheter.

Moderate

Severe

Severe complicated

Recurrent

Systemic signs of infection and/or Leukocytosis Âł15.000/ml or serum creatinine Age, infection by the BI/NAP1/027 strain Âł1.5x the premorbid level Systemic signs of infection including hypotension, Ileus or megacolon.

Same as sever, plus recent surgery, history of inflammatory bowel disease and treatment with intravenous immunoglobulin.

Age Âł65 years old, concomitant use of antibiotics, presence of significant Recurrence in up to eight weeks of the end of comorbidity, use of Proton pump the full treatment inhibitors and initial increase of disease severity.

Source: Adapted from Bagdasarian N, Rao K, Malani p. Diagnosis and Treatment of Clostridium difficile in Adults: A Systematic Review. JAMA. 2015:313(4):398-4089.

Most studies and guidelines establish the therapeutic regimens based on the clinical picture, severity, risk of recurrence and complications. The two most

commonly used drugs are metronidazole and vancomycin. Table 2 illustrates the scheme currently used10.

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Table 2. Treatment of Infection by Clostridium difficile..

Episode

Therapy

Initial episode and first recurrence

Mild-moderate infection: metronidazole 500mg PO 3 times daily for 10–14 days or fidaxomicin* 200mg twice daily for 10–14 days Severe infection: vancomycin** 125mg PO 4 times daily for 10–14 days Severe complicated infection: metronidazole 500mg IV 3 times daily and vancomycin** 500mg PO 4 times daily for 10–14 days

Second recurrence

Pulsed and tapered doses of vancomycin 125mg 4 times daily for 14 days 125mg 2 times daily for 7 days 125mg once daily for 7 days 125mg once every 2 days for 8 days (total 4 doses) 125mg once every 3 days for 15 days (total 5 doses)

Third or more recurrences

Vancomycin 125mg PO 4 times daily for 14 days, followed by rifaximin 400mg twice daily or fidaxomicin 200mg twice daily for 14 days Fecal microbiota transplantation

Source: Adapted from Burke KE, Lamont JT. Clostridium difficile infection: the Worldwide disease. Gut Liver. 2014; 8(1):1-6.10 * In Brazil, Fidaxomicina is not commercialised. oral formulation, ** in Brazil Vancomycin capsules are not available in. It is recommended to break the ampule and orally administer the antibiotic in its venous presentation. There is no evidence of difference in outcome between the two formulations. PO: orally; IV: intravenous.

In Brazil, there are few studies on C. difficile

In search of a more effective and appropriate

infection, generally attributed to the difficulty of access

treatment for recurrent and refractory episodes, the

to the tests for detecting the bacteria, mainly in the public

researchers resumed a Chinese practice dating to the

health system, thus being an underdiagnosed disease in

fourth century, known as Fecal Microbiota Transplantation

11

our country .

(FMT). Although very old, FMT was first reported

In a recent guideline of the European Society of

Clinical

Microbiology

and

Infectious

scientifically in 1958, when it was successfully used in

Diseases

the treatment of four patients with pseudomembranous

(ESCMID) , the authors maintained the recommendation

colitis. Despite its apparent efficacy, FMT began to be

for metronidazole as the first-line medication, and

widely studied and incorporated into clinical practice only

vancomycin, as a second option. Fidaxomycin (Fid)

in the last ten years13.

12

was added as a therapeutic option, but with the same

FMT consists of introducing the intestinal

degree of recommendation as vancomycin. In the US, Fid

microbiota from a healthy donor into a patient with C.

is also accepted as atreatment option. This drug is not

difficile infection to restore his/her microbiota14. Numerous

yet marketed in Brazil11. Precarious response to standard

case reports, retrospective studies and randomized clinical

oral vancomycin or metronidazole treatment leads to

trials have demonstrated the benefits of FMT in patients

high recurrence rates, around 30%. After two or more

with severe or recurrent C. difficile infection. The cure

episodes of C. difficile infection, the estimated recurrence

rates can reach 100% in some works, but with an average

12

risk with antimicrobial therapy increases to 60% .

rate of 87 to 90% in the more than 500 cases described

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Messias Fecal microbiota transplantation in the treatment of Clostridium difficile infection: state of the art and literature review

4

in the literature15.

observed the reduction of intestinal microbiota diversity

The donor for this type of treatment is usually

one year after the FMT in comparison to the healthy

a familiar or known one that goes through a thorough

donor microbiota and its increase in relation to the pre-

investigation for several pathogensbefore selection for

FMTmicrobiota. They found thatthe microbiota increased

16

the transplant . The routes of administration of FMT may

soon after the treatment and it remained stable during

benasojejunal, nasogastric, endoscopic, through enemas

the first year after transplantation17.

or colonoscopy. The choice of route depends on the

In relation to the colonizing organisms, only

feasibility of the site, the experience of the physician and

the Firmicutes and Proteobacteria phyla presented

4

significant changes. Inside the Firmicutes are the bacteria

the safety offered to the patient . The objective of this work is to characterize and

of the order Clostridiales. This bacterial order is scarce

discuss the main forms of FMT application, its indications,

in the microbiota of patients with C. difficile infection

existing barriers and efficacy when used as a therapeutic

(12.8%), and high in donors (70%). After the FMT, there

alternative for Clostridium difficile infection.

was a significant increase of this bacterium (55%) in the receptors. Clostridium difficile belongs to this order, but

METHODS

in a healthy microbiota, it should not be present orbe in very low concentration. In patients with acute infection,

For the preparation of this review, we searched

the nonpathogenic Clostridiales species are in reduced

for articles in the electronic databases PubMed, Lilacs and

concentration, thus facilitating colonization by C.

in the SciELO portal. The research consisted of the following

difficile17. In the same study, they observed the protective

descriptors:

pseudomembranous”

effect to the mucosa by butyrate producing bacteria

“OR” “Clostridium difficile”, “AND” “fecal microbiota

against C. difficile colonization. The reduced number of

transplantation”. The search was limited to studies in

such bacteria in the microbiota of patients with recurrent

humans older than 19 years and published in English and

C. difficile infection may be one of the reasons for

Portuguese in the last five years.

frequent recurrences.

“Enterocolitis,

Two independent researchers reviewed the

Another study analyzed the fecal composition

texts in their entirety and selected the ones that had

of the microbiota and bile acids of 12 patients with

the most evidence on the subject, excluding those that

recurrent C. difficile infection before and after FMT.

were not in agreement with the objective and/or that

They observed that the use of antibiotics exterminates

touched on the proposed subject. We also included the

part of the microbiota responsible for the metabolization

bibliographic references of the selected articles.

of primary into secondary bile acids in the intestines. Secondary bile acids are responsible for the inhibition of

RESULTS AND DISCUSSION

C. difficile germination and colonization in the intestinal mucosa and their absence facilitates the infectious

The imbalance of the intestinal microbiota,

process. FMT causes rapid restoration of the primary bile

called dysbiosis, plays a crucial role in the pathophysiology

acids metabolizing microbiota, normalizing the amount

of C. difficile infection. During the last decade, the

of secondary bile acids available, thus suggesting the

importance of the intestinal microbiota has gained

reason for transplant efficacy18.

relevance, it being considered an organ4. A longitudinal

In 2010, members of several specialized

study analyzed the intestinal microbiota of FMT donors

medical societies formed a working group with the aim

and recipients one week after the procedure and again

of developing a consensus on treatment15. As described

after one year. All patients submitted to treatment

by the working group, the main indications for treatment

were considered cured of C. difficile infection. They also

with FMT are:

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Messias Fecal microbiota transplantation in the treatment of Clostridium difficile infection: state of the art and literature review

5

1. Recurrent C. difficile infection:

are no differences, we can consider the donor eligible at

A) Three or more episodes of mild to moderate

any age provided that he/she had screening performed

C. difficile infection and failure of a six to eight week

correctly and does not present contraindications to the

cycle with vancomycin, with or without an alternative

donation20.

antibiotic, i.e.,rifaximin, nitazoxanide or fidaxomycin.

The preparation of the material is not yet

B) At least two episodes of C. difficile infection

uniform and different studies aim to find the best option

resulting in hospitalization and associated with significant

for the patient. In general, the material should be diluted,

morbidity.

homogenized (using blender, manual work, or other

2. Moderate C. difficile infection not responding

method) and filtered when necessary (eg, gauze, coffee

to standard therapy (vancomycin or fidaxomicin) for at

filter, plain filter) into a form that can be administered.

least one week.

This processed material can be either infused directly into

3. Severe C. difficile infection (even fulminant) without response to standard therapy after 48 hours The 2013 C. difficile treatment guidelines of the American College of Gastroenterology also recommend

the gastrointestinal tract, or be centrifuged, placed into gelatin capsules and swallowed. Several series of studies have described freezing of fecal microbiota for its use at another time15.

FMT as a therapeutic alternative for recurrent cases of C.

As there is no clear consensus on how to best

difficile infection that did not respond to a vancomycin

prepare the fecal material,the routes of administration are

19

quite varied and include the upper gastrointestinal tract

treatment regimen . The evidence supporting FMT for treatment

(by endoscopy, nasogastric or nasojejunal catheter or by

of severe and complicated disease (toxic megacolon) is

ingestion of pills)21-24 and the lower gastrointestinal tract

less extensive and has fewer published clinical cases, but

(by colonoscopy in the proximal colon, by enema and

case reports suggest that it can be safe and effective even

rectosigmoidoscopy in the distal colon, or a combined

in critically ill patients. Patients with severe C. difficile

approach)5,25-34. Clinical trials were conducted comparing

infection are at greater risk of negative outcomes, and

the various forms of FMT application, their results,

deciding between FMT and surgery or other therapeutic

advantages and disadvantages. The important thing

modality should prompt caution15.

is that all the forms studied were more efficient than

An essential aspect of FMT success is the

the treatment with antibiotics15. The enema pathway

identification of a healthy donor. Several medical

presented a high rate of resolution of symptoms. However,

societies provide guidelines for donor selection. Most

in most cases it was necessary to repeat the procedure

do not stipulate an age limit; however, the vast majority

several times until obtaining the clinicalimprovement.

of those selected are between 18 and 60 years old. The

Infection severity was a decisive factor for the outcome.

donor may be a long-term intimate partner, friend or

More severe cases were more refractory to treatment. No

20

unrelated volunteer . A single prospective study makes

adverse effects were observed, the application is simple

considerations about the characteristics of the donor

and, according to some reports, can be carried out by the

and the different compositions of its fecal microbiota. It

patient in the home environment29.

concludes that the human intestinal microbiota undergoes

The nasogastric route is effective and safe for

changes with the passage of years, with a decrease in the

patients with contraindications to the colonoscopic route

number of firmicutes and actinobacteria, and an increase

and it is well accepted, even though patients with advanced

in the amount of bacterioides, besides a reduction of

age are somewhat disgusted. The biggest concern is the

global diversity. Despite these changes, no clinically

vomiting and aspiration of the infused contents12. In the

significant changes were found in the results of FMT

only Brazilian study on FMT, ten patients underwent the

20

performed with samples of different ages . Since there

treatment with oral enteroscopy with 90% healing rate.

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Messias Fecal microbiota transplantation in the treatment of Clostridium difficile infection: state of the art and literature review

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It is believed that the enteroscopic route is also an option

other means of administration, but with a longer time

to be considered for patients with contraindications to

to clinical improvement. The advantages of the method

other forms of application. Due to the need for sedation,

are easy storage, low cost, proven efficacy, few adverse

the physical and moral discomfort of nasogastric infusion

effects, easy administration, patientâ&#x20AC;&#x2122;s comfort, non-

12

invasiveness and safety for critically ill patients. The only

of fecal material is avoided . The colonoscopic route is the most used and has the advantage of allowing direct visualization of the

contraindication is the inability to swallow, increasing the risk of bronchoaspiration21,23.

affected area, infusion of large volume of fecal material

Freezing the samples allows donor screening in

and better retention than the enema. The preparation

advance and ease of storage allows donor investigation

and the need for sedation are detrimental in highly

for possible incubated viral infections. A clinical trial of

debilitated patients, in addition to the risk of perforation

232 patients with recurrence or refractoriness to standard

when the mucosa has abundant inflammation. The risk

treatment divided the sample into two groups, one with

of perforation can be minimized by the endoscopistâ&#x20AC;&#x2122;s

108 patients who received the frozen transplant, and

5

another with 111 patients who received the fresh enema

experience and skill . Considering how best to completely restore

transplant. The results showed no clinical difference

the microbiota of the entire gastrointestinal tract, a

between the two forms of preparation, both having a

prospective study selected 27 patients with recurrent

good resolution rate. Considering the advantages of

C. difficile infection to receive FMT by combined route

providing frozen/cooled FMT, its use is a considerable

(enteroscopy and colonoscopy). All the patients selected

option in this scenario31.

had a reduction in the number of bowel movements

In

recent

years

there

have

been

few

and dissipation of C. difficile toxins in the fecal sample

published case reports regarding the efficacy of FMT in

after only one infusion. The mean resolution time was

immunocompromised patients. At the beginning of the

three days. The authors suggest a high resolution rate

century, this population had been excluded from major

when the procedure is performed by combined route.

clinical trials because of the lack of knowledge and fear

One setback of the study was the high cost due to the

of the complications of this new form of treatment,

use of the two techniques, but its high curative potential

especially in relation to possible bacterial translocation in a context of depression of intestinal mucosal defenses35,36.

33

renders excellent cost-effectiveness . In the analysis of the results the authors

The economic impact of Clostridium difficile

concluded that the infusion of feces below the angle of

infection in Brazil was not estimated due to the difficulty

Treitz can reduce the degradation of the microbiota by

of establishing the diagnosis and lack of documentation.

gastric acid and pancreatic enzymes, and that intrajejunal

In the United States, it is estimated that each year C.

administration can promote a contact of beneficial bacteria

difficile infection costs the government between US$ 1

with the surface of the intestinal mucosa till the cecum.

billion and US 3.6 billions. These high costs are the results

The technique allows the infusion of a large volume of

of hospitalizations, drug costs, and post-treatment care37.

fecal material, without rapid elimination through the

Recent studies compared the different forms of treatment

rectum, besides reducing the risk of aspiration and oral

of recurrent Clostridium difficile infection with FMT. In

33

all studies, FMT was more cost-effective and clinically

regurgitation . Two studies performed the preparation of

efficient than treatment with metronidazole, vancomycin,

FMT frozen capsules, and administered in patients

and fidaxomicin (not available in Brazil)38. A French study

with recurrent C. difficile infection with preserved

compared the cost-effectiveness of FMT via colonoscopy,

swallowing. Both studies had a curing rate close to

duodenal and enema to treatment with vancomycin and

90%. Oral capsules have a resolution rate similar to the

fidaxomicin. The authors concluded that FMT in all forms

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Messias Fecal microbiota transplantation in the treatment of Clostridium difficile infection: state of the art and literature review

7

is more cost-effective than the other treatments and that

of elucidating the reason for the low prescription of FMT,

there is a better cost-effectiveness for the colonoscopic

another similar study, now turned to the medical class,

route than for the others. The enema has a characteristic

applied 139 questionnaires on the technique, in which

of resolution of the infection and cost very close to the

65% of the physicians answered that they would not

colonoscopic route, and because it is safer for the patients,

indicate FMT. The main justification was to ignore the

the authors concluded that it is the recommended route

indication and to believe in the disgust of the patient or

39

in the work performed .

the fact that there is no adequate protocol and logistics

Only one study compared FMT (via colonoscopy)

in the workplace44.

as a form of initial treatment of Clostridium difficile infection to the other primary regimens (metronidazole

CONCLUSIONS

and vancomycin). FMT was more expensive and more effective than metronidazole, and cheaper and more

Fecal microbiota transplantation (FMT) is a

effective than vancomycin. Thus, it practically excluded

proven technique, with low costs when compared to

vancomycin as a therapeutic option for the initial

conventional treatment, and with few adverse effects.

40

treatment of the infection . No articles were found that

Refractory and severe cases are the main indications of

assessed the cost of the ingestion of FMT capsules and the

FMT. All forms of application had a high cure rate, and

feces cryopreservation technique, which could provide

the colonoscopic route was the most used.

data regarding the financial costs of the procedure in relation to already consolidated treatments.

In view of the severity of Clostridium difficile infection, it is not surprising that patients consider FMT

Adverse reactions to FMT are rare. Most describe

as an alternative treatment. Education and patient

a feeling of gastrointestinal discomfort that presents

involvement in the decision-making process are crucial

resolution in up to 12 hours. There are few reports on the

factors for acceptance of the technique. It is perceptible

subject, but none directly attributed the complications

through research that the physician has great influence

presented to transplantation. Most of the patients who

in the choice of treatment to be performed and, if

had adverse effects had previous bowel disease, such as

prescribed, there is a high probability of acceptance.

inflammatory bowel disease or diverticulitis41,42.

The lack of indication rests on the prejudice towards the

Despite the proven efficacy of FMT, there is still

procedure.

little clinical recommendation. One study focused on this

The lack of regulation and institutional

issue and found that up to 94% of patients would be

protocols leads to insecurity and is a barrier that needs

willing to accept FMT as a treatment if it was prescribed by

to be overcome. The adequate use of this technique will

their doctor, and that there is a predisposition for patients

only be feasible through the disclosure of its effectiveness,

to accept the colonoscopic method; the odorless pill was

knowledge of the administration routes and acceptance

43

the first choice . With this finding and with the objective

of health professionals.

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Messias Fecal microbiota transplantation in the treatment of Clostridium difficile infection: state of the art and literature review

8

R E S U M O A infecção por Clostridium difficile é uma complicação comum após a disbiose intestinal ocasionada pelo uso abusivo de antibióticos. Apresenta elevada importância médica devido às altas taxas de recorrência e morbidade. O transplante de microbiota fecal é uma alternativa eficaz para o tratamento da infecção recorrente e refratária pelo C. difficile e consiste na introdução da microbiota intestinal de um doador saudável em um paciente portador desta infecção. O mecanismo fisiológico exato pelo qual o transplante de microbiota fecal altera a microbiota intestinal não está tão bem estabelecido, mas é evidente que restaura a diversidade e a estrutura da microbiota promovendo aumento da resistência à colonização pelo C. difficile. Diversas vias de administração do transplante estão sendo estudadas e utilizadas de acordo com as vantagens apresentadas. Todas as formas de aplicação apresentaram elevada taxa de cura, sendo a via colonoscópica a mais utilizada. Não foram documentados complicações e efeitos adversos relevantes, e seu custo benefício em relação ao tratamento convencional se mostrou vantajoso. Apesar da sua eficácia é pouco utilizado como terapia inicial, sendo necessários mais estudos para firmar essa terapêutica como primeira opção no caso de infecção por Clostridium difficile refratária e recorrente. Descritores: Transplante de Microbiota Fecal. Clostridium difficile. Enterocolite Pseudomembranosa. Antibacterianos.

REFERENCES 1. Rocha MFG, Sidrim JJC, Lima AAO. O Clostridium difficile como agente indutor de diarréia inflamatória. Rev Soc Bras Med Trop. 1999;32(1):47-52. 2. Cookson B. Hypervirulent strains of Clostridium difficile. Postg Med J. 2007;83(979):291-5. 3. Zanella Terrier MC, Simonet ML, Bichard P, Frossard JL. Recurrent Clostridium difficile infections: the importance of the intestinal microbiota. World J Gastroenterol. 2014;20(23):7416-23. 4. Korman TM. Diagnosis and management of Clostridium difficile infection. Semin Respir Crit Care Med. 2015;36(1):31-43. 5. Cammarota G, Masucci L, Ianiro G, Bibbò S, Dinoi G, Costamagna G, et al. Randomised clinical trial: faecal microbiota transplantation by colonoscopy vs. vancomycin for the treatment of recurrent Clostridium difficile infection. Aliment Pharmacol Ther. 2015;41(9):835-43. 6. Blondeau JM. What have we learned about antimicrobial use and the risks for Clostridium difficileassociated diarrhoea? J Antimicrob Chemother. 2009;63(2):238-42. 7. Silva Júnior M. Recentes mudanças da infecção por Clostridium difficile. Einstein. 2012;10(1):105-9. 8. Efron PA, Mazuski JE. Clostridium difficile colitis. Surg Clin North Am. 2009;89(2):483-500. 9. Bagdasarian N, Rao K, Malani PN. Diagnosis and treatment of Clostridium difficile in adults: a systematic review. JAMA. 2015;313(4):398-408. 10. Burke KE, Lamont JT. Clostridium difficile infection: a worldwide disease. Gut Liver. 2014;8(1):1-6 11. Pereira NG. Infecção pelo Clostridium difficile. JBM. 2014;102(5):27-49. 12. Ganc AJ, Ganc RL, Reimão SM, Frisoli JA Jr, Pasternak

13.

14.

15.

16.

17.

18.

19.

J. Transplante de microbiota fecal por enteroscopia alta para o tratamento da diarreia causada por Clostridium difficile. Einstein. 2015;13(2):338-9. Rossen NG, MacDonald JK, de Vries EM, D’Haens GR, De Vos WM, Zoetendal EG, et al. Fecal microbiota transplantation as novel therapy in gastroenterology: a systematic review. World J Gastroenterol. 2015; 21(17):5359-71. Gough E, Shaikh H, Manges AR. Systematic review of intestinal microbiota transplantation (fecal bacteriotherapy) for recurrent Clostridium difficile infection. Clin Infect Dis. 2011;53(10):9941002. Kelly CR, Kahn S, Kashyap P, Laine L, Rubin D, Atreja A, et al. Update on Fecal Microbiota Transplantation 2015: indications, methodologies, mechanisms and outlook. Gastroenterology. 2015;149(1):223-37. Broecker F, Kube M, Klumpp J, Schuppler M, Biedermann L, Hecht J, et al. Analysis of the intestinal microbiome of recovered Clostridium difficile patient after fecal transplantation. Digestion. 2013;88(4):243-51. Song Y, Garg S, Girotra M, Maddox C, Von Rosenvinge EC, Dutta A, et al. Microbiota dynamics in patients treated with fecal microbiota transplantation for recurrent Clostridium difficile infection. PloS One. 2013;8(11):1-11. Weingarden AR, Chen C, Bobr A, Yao D, Lu Y, Nelson VM, et al. Microbiota transplantation restores normal fecal bile acid composition in recurrent Clostridium difficile infection. Am J Physiol Gastrointest Liver Physiol. 2014;306(4):G310-9. Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH, et al. Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. Am J Gastroenterol. 2013;108(4):478-98.

Rev Col Bras Cir. 2018; 45(2):e1609


Messias Fecal microbiota transplantation in the treatment of Clostridium difficile infection: state of the art and literature review

20. Anand R, Song Y, Garg S, Girotra M, Sinha A, Sivaraman A, et al. Effect of aging on the composition of fecal microbiota in donors for FMT and its impact on clinical outcomes. Dig Dis Sci. 2017;62(4):1002-8. 21. Hirsch BE, Saraiya N, Poeth K, Schwartz RM, Epstein ME, Honig G. Effectiveness of fecal-derived microbiota transfer using orally administered capsules for recurrent Clostridium difficile infection. BMC Infect Dis. 2015;15:191. 22. Staley C, Hamilton MJ, Vaughn BP, Graiziger CT, Newman KM, Kabage AJ, et al. Successful resolution of recurrent Clostridium difficile infection using freeze- dried, encapsulated fecal microbiota; pragmatic cohort study. Am J Gastroenterol. 2017;112(6):940-7. 23. Youngster I, Russell GH, Pindar C, Ziv-Baran T, Sauk J, Hohmann EL. Oral, capsulized, frozen fecal microbiota transplantation for relapsing Clostridium difficile infection. JAMA. 2014;312(17):1172-8. 24. Youngster I, Sauk J, Pindar C, Wilson RG, Kaplan JL, Smith MB, et al. Fecal Microbiota Transplant for relapsing Clostridium difficile infection using a frozen inoculum from unrelated donors: a randomized, open-label, controlled pilot study. Clin Infect Dis. 2014;58(11):1515-22. 25. Khan MA, Sofi AA, Ahmad U, Alaradi O, Kahn AR, Hammad T, et al. Efficacy and safety of, and patient satisfaction with, colonoscopic-administered fecal microbiota transplantation in relapsing and refractory community- and hospital-acquired Clostridium difficile infection. Can J Gastroenterol Hepatol. 2014;28(8):434-8. 26. van Nood E, Vrieze A, Nieuwdorp M, Fuentes S, Zoetendal EG, de Vos WM, et al. Duodenal infusion of donor feces for recurrent Clostridium difficile. N Engl J Med. 2013;368(5):407-15. 27. Satokari R, Mattila E, Kainulainen V, Arkkila PE. Simple faecal preparation and efficacy of frozen inoculum in faecal microbiota transplantation for recurrent Clostridium difficile infection--an observational cohort study. Aliment Pharmacol Ther. 2015;41(1):46-53. 28. Allegretti JR, Korzenik JR, Hamilton MJ. Fecal microbiota transplantation via colonoscopy for recurrent C. difficile infection. J Vis Exp. 2014;(94):52154. 29. Lee CH, Belanger JE, Kassam Z, Smieja M, Higgins D, Broukhanski G, et al. The outcome and long-term follow-up of 94 patients with recurrent and refractory Clostridium difficile infection using single to multiple fecal microbiota transplantation via retention enema. Eur J Clin Microbiol Infect Dis. 2014;33(8):1425-8. 30. Lee CH, Steiner T, Petrof EO, Smieja M, Roscoe D, Nematallah A, et al. Frozen vs fresh fecal microbiota

31.

32.

33.

34.

35.

36.

37.

38.

39.

40.

41.

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transplantation and clinical resolution of diarrhea in patients with recurrent clostridium difficile infection: a randomised clinical study. JAMA. 2016;315(2):1429. Hamilton MJ, Weingarden AR, Sadowsky MJ, Khoruts A. Standardized frozen preparation for transplantation of fecal microbiota for recurrent Clostridium difficile infection. Am J Gastroenterol. 2012;107(5):761-7. Costello SP, Conlon MA, Vuaran MS, RobertsThomson IC, Andrews JM. Faecal microbiota transplant for recurrent Clostridium difficile infection using long-term frozen stool is effective: clinical efficacy and bacterial viability data. Aliment Pharmacol Ther. 2015;42(8):1011-8. Dutta SK, Girotra M, Garg S, Dutta A, von Rosenvinge EC, Maddox C, et al. Efficacy of combined jejunal fecal microbiota transplantation for recurrent Clostridium difficile infection. Clin Gastroenterol Hepatol. 2014;12(9):1572-6. Brandt LJ, Aroniadis OC, Mellow M, Kanatzar A, Kelly C, Park T, et al. Long-term follow-up of colonoscopic fecal microbiota transplant for recurrent Clostridium difficile infection. Am J Gastroenterol 2012; 107(7):1079-87. Di Bella S, Gouliouris T, Petrosillo N. Fecal microbiota transplantation (FMT) for Clostridium difficile infection: focus on immunocompromised patiens. J Infect Chemother. 2015;21(4):230-7. Kelly CR, Ihunnah C, Fischer M, Khoruts A, Surawicz C, Afzali A, et al. Fecal microbiota transplant for treatment of Clostridium difficile infection in immunocompromised patients. Am J Gastroenterol. 2014;109(7):1065-71. Mergenhagen KA, Wojciechowski AL, Paladino JA. A review of the economics of treating Clostridium difficile infection. Pharmacoeconomics 2014;32(7):639-50. Konijeti GG, Sauk J, Shrime MG, Gupta M, Ananthakrishnan NA. Cost-effectiveness of competing strategies for management of recurrent Clostridium difficile infection: a decision analysis. Clin Infect Dis. 2014;58(11):1507-14. Baro E, Galperine T, Denies F, Lannoy D, Lenne X, Odou P, et al. Cost-effectiveness analysis of five competing strategies for the management of multiple recurrent commuity-onset Clostridium difficile infection in France. PloS One. 2017;12(1):e0170258. Varier RU, Biltaji E, Smith KJ, Roberts MS, Kyle Jensen M, LaFleur J, et al. Cost-effectiveness analysis of fecal microbiota transplantation for recurrent Clostridium difficile infection. Infect Control Hosp Epidemiol. 2015;36(4):438-44. De Leon LM, Watson JB, Kelly CR. Transient flare of

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ulcerative colitis after fecal microbiota transplantation for recurrent Clostridium difficile infection. Clin Gastroenterol Hepatol. 2013;11(8):1036-8. 42. Mandalia A, Kraft CS, Dhere T. Diverticulitis after fecal microbiota transplant for C. difficile infection. Am J Gastroenterol. 2014;109(12):1956-7. 43. Zipursky JS, Sidorsky TL, Freedman CA, Sidorsky MN, Kirkland KB. Patient attitudes toward the use of fecal microbiota transplantation in the treatment of recurrent Clostridium difficile infection. Clin Infect Dis. 2012;55(12):1652-8. 44. Zipursky JS, Sidorsky TI, Freedman CA, Sidorsky MN, Kirkland KB. Physician attitudes toward the use of fecal microbiota transplantation for the treatment of recurrent Clostridium difficile infection. Can J Gastroenterol Hepatol. 2014;28(6):319-24.

Received in: 03/12/2017 Accepted for publication: 25/01/2018 Conflict of interest: none. Source of funding: none. Mailing address: Bรกrbara Freitas Franchi E-mail: med.barbarafranchi@gmail.com / bruno22med@hotmail.com

Rev Col Bras Cir. 2018; 45(2):e1609


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

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

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

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


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

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

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

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

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

Indexing sources · · · · · · ·

Latindex LILACS Scopus DOAJ Free Medical Journals MEDLINE/PUBMED SciELO

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

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


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Revista do Colégio Brasileiro de Cirurgiões - volume 45 - inglês  

A Revista do CBC é indexada ao Scielo e possui classificação da CAPES Qualis B1

Revista do Colégio Brasileiro de Cirurgiões - volume 45 - inglês  

A Revista do CBC é indexada ao Scielo e possui classificação da CAPES Qualis B1