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CONTENTS / SUMÁRIO Rev Col Bras Cir 2017; 44(3)

E DITORI AL A cirurgia e a internet Surgery and the internet Felipe Carvalho Victer ............................................................................................................................................................................ 220

O R IGINAL ARTIC L ES Preditores de mortalidade em pacientes com fratura de pelve por trauma contuso Mortality predictors in patients with pelvic fractures from blunt trauma Wagner Oséas Corrêa; Vinícius Guilherme Rocha Batista; Erisvaldo Ferreira Cavalcante Júnior; Michael Pereira Fernandes; Rafael Fortes; Gabriela Zamunaro Lopes Ruiz; Carla Jorge Machado; Mario Pastore Neto................................................................................................ 222 Avaliação do tratamento da sepse com glutamina via enteral em ratos Evaluation of sepsis treatment with enteral glutamine in rats Isadora Moscardini Fabiani; Sérgio Luiz Rocha ......................................................................................................................................... 231 Herniorrafia inguinal convencional com tela autofixante versus videolaparoscópica totalmente extraperitoneal com tela de polipropileno: resultados no pós-operatório precoce Conventional inguinal hernia repair with self-fixating mesh versus totally extraperitoneal laparoscopic repair with polypropylene mesh: early postoperative results José Antonio Cunha-e-Silva; Flávio Malcher Martins de Oliveira; Antonio Felipe Santa Maria Coquillard Ayres; Antonio Carlos Ribeiro Garrido Iglesias .................................................................................................................................................................................................. 238 Análise retrospectiva de 103 casos de lesão diafragmática operados em um centro de trauma Retrospective analysis of 103 diaphragmatic injuries in patients operated in a trauma center Lucas Figueiredo Cardoso; Marcus Vinícius Capanema Gonçalves; Carla Jorge Machado; Vivian Resende; Michael Pereira Fernandes; Mario Pastore-Neto; Renato Gomes Campanati; Guilherme Victor Oliveira Pimenta Reis ...................................................................................... 245 Prevalência do câncer de vesícula biliar em pacientes submetidos à colecistectomia: experiência do Hospital de Clínicas da Faculdade de Ciências Médicas da Universidade Estadual de Campinas – UNICAMP Prevalence of gallbladder cancer In patients submitted to cholecystectomy: experience of the University Hospital, Faculty of Medical Sciences, State University of Campinas – UNICAMP Márcio Apodaca-Rueda; Everton Cazzo; Rita Barbosa De-Carvalho; Elinton Adami Chaim.......................................................................... 252 Preditores de mortalidade em pacientes submetidos à nefrectomia por carcinoma de células renais não metastático em um centro de referência no Nordeste Brasileiro Predictors of mortality in patients submitted to nephrectomy for non-metastatic renal cell carcinoma at a referral center in Northeastern Brazil Marcus Vinicius Silva Araújo Gurgel; Josualdo Alves Júnior; Guilherme Bruno Fontes Vieira; Felipe de Castro Dantas Sales; Marcos Venício Alves Lima ................................................................................................................................................................................................................... 257 Paratireoidectomia na doença renal crônica: efeitos no ganho de peso e na melhora da qualidade de vida Parathyroidectomy in chronic kidney disease: effects on weight gain and on quality of life improvement Henyse Gomes Valente-Da-Silva; Maria Cristina Araújo Maya; Annie Seixas Moreira ........................................................................................ 263 Cuidados perioperatórios em cirurgia bariátrica no contexto do projeto ACERTO: realidade e o imaginário de cirurgiões em um hospital de Cuiabá Perioperative care in bariatric surgery in the context of the ACERTO project: reality versus surgeons assumptions in a Cuiabá hospital Jacqueline Jéssica De-Marchi; Mardem Machado De-Souza; Alberto Bicudo Salomão; José Eduardo de Aguilar Nascimento; Anyelle Almada Selleti; Erik de-Albuquerque; Katia Bezerra Veloso Mendes ...................................................................................................................... 270 Hemorroidopexia por grampeamento parcial: aspectos clínicos e impacto sob a fisiologia anorretal Partial stapled hemorrhoidopexy: clinical aspects and impact on anorectal physiology Marllus Braga Soares; Marcos Bettini Pitombo; Francisco Lopes Paulo; Paulo Cezar de Castro Júnior; Júlia Resende Schlinz; Annibal Amorim Júnior; Karin Guterres Lohmann Hamada ................................................................................................................................................ 278

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O R IG I NAL ARTIC LES Incidência e fatores de complicações pulmonares pós-operatórias em pacientes submetidos à cirurgias de tórax e abdome Incidence and risk factors for postoperative pulmonary complications in patients undergoing thoracic and abdominal surgeries Ana Carolina de Ávila; Romero Fenili ...................................................................................................................................................... 284

R E VIEW ARTICLES Estenose de carótida extracraniana: revisão baseada em evidências Extracranial carotid stenosis: evidence based review Carolina Dutra Queiroz Flumignan; Ronald Luiz Gomes Flumignan; Túlio Pinho Navarro ............................................................................... 293

L E ARNI NG Modelo de programa de treinamento em cirurgia robótica e resultados iniciais Model of a training program in robotic surgery and its initial results Fernando Athayde Veloso Madureira; José Luís Souza Varela; Delta Madureira Filho; Luis Alfredo Vieira D`Almeida; Fábio Athayde Veloso Madureira; Alexandre Miranda Duarte; Otávio Pires Vaz; José Reinan Ramos ................................................................................................ 302

T E CHNICAL NOTE Resultados preliminares do tratamento de insuficiência venosa grave com termoablação da veia safena magna por técnica endovascular com laser de diodo 980nm desenvolvido no Brasil, associado à escleroterapia com polidocanol Preliminary results of severe venous insufficiency treatment with thermal ablation of the great saphenous vein by endovascular technique with laser diode 980nm developed in Brazil, associated with sclerotherapy with polidocanol Matheus Bertanha; Marcone Lima Sobreira; Paula Angelelli Bueno Camargo; Rafael Elias Farres Pimenta; Jamil Victor Oliveira Mariúba; Regina Moura; Vanderlei Salvador Bagnato; Winston Bonetti Yoshida ........................................................................................................ 308

Rev. Col. Bras. Cir.

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p 220 / 313

mai/jun

2017


Cirurgiões

Revista do Colégio Brasileiro de

EDITOR

Órgão Oficial do Colégio Brasileiro Brasileiro de Cirurgiões Cirurgiões ASSOCIATE EDITORS

CONSELHO DE REVISORES - NOVA GESTÃO - 2016

Guilherme Pinto Bravo Neto Associate Professor, EDITOR Department of Surgery, Faculty of Medicine, Federal Guilherme Pinto Bravo Neto University of Rio de JaneiroTCBC - Rio de Janeiro UFRJ - Rio de Janeiro RJ - Brazil.

FELIPE CARVALHO VICTER TCBC-RJ –EDITORES PHYSICIAN, UNIVERSITY HOSPITAL PEDRO ASSOCIADOS ERNESTO, STATE UNIVERSITY OF RIO DE JANEIRO – UERJ, RIO DE JFANEIRO , ARVALHO RJ, BRAZIL ELIPE C V.ICTER RODRIGO M ARTINEZ TCBC-RJ TCBC-RJ - ASSOCIATE PROFESSOR, DEPARTMENT OF ODRIGO ARTINEZ SURGERY, FACULTY OF MREDICINE , FM EDERAL UNIVERSITY OF TCBC-RJ DE JANEIRO, RJ, BRAZIL. RIO DE JANEIRO – UFRJ, RIO FERNANDO EON BRAULIOPONCE PONCEDELLEON PEREIRA DE C ASTRO FERNANDO ACBC- RJ – PHYSICIAN , U NIVERSITY HOSPITAL AsCBC-RJ CLEMENTINO FRAGA FILHO, FEDERAL UNIVERSITY OF RIO DE JANEIRO – UFRJ, RIO DE JANEIRO, RJ, BRAZIL

LIBRARIAN

Lenita Penido Xavier CRB-RJ 4808

ASSISTENTE DE PUBLICAÇÕES MARIA RUTH MONTEIRO WRITING ASSISTANT David da Silva Ferreira Júnior

ASSISTENTE DE REDAÇÃO DAVID

DA

S ILVA FERREIRA JÚNIOR

GRAPHIC DESIGN

João Maurício Carneiro Rodrigues

JORNALISTA RESPONSÁVEL Mtb 18.552 JOÃO M AURÍCIO CARNEIRO RODRIGUES Mtb 18.552

COPYHOLDERS COUNCIL ADVISORY BOARD ABRÃO RAPOPORT - ECBC- SP - HELIOPOLIS HOSPITAL - SÃO PAULO - SP - BR JOSÉ LUIZ BRAGA DE AQUINO - TCBC-SP - FACULTY OF MEDICAL SCIENCES - PUCMAURICIO GONÇALVES RUBINSTEIN, TCBC-RJ ABRAO RAPOPORT – ECBC-SP- HOSPHEL- SP-BR EDMUND CHADA BARACAT – TCBC – SP- UNIFESP-BR ALDO DA CUNHA MEDEIROS - ECBC- RN - FEDERAL UNIVERSITY OF RIO GRANDE DO CAMPINAS - SP - BR NORTE - NATAL - RN - BR JOSÉ MARCUSUNIFESP-BR RASO EULÁLIOMAURO - TCBC-RJ - FEDERAL OF RIO DE JANEIRO DE SOUZA LEITE UNIVERSITY PINHO – TCBC-SC - HOSPITAL ALBERTO SCHANAIDER – TCBC-RJ - UFRJ-BR EDNA FRASSON DE SOUZA MONTERO – TCBC-SPALEXANDRE FERREIRA OLIVEIRA - TCBC- MG - FEDERAL UNIVERSITY OF JUIZ DE - RIO DE JANEIRO - RJ - BR MUNICIPAL SÃO SC-BR ALDO -DA CUNHA MEDEIROSTCBC-RN-UFRN-BR EDUARDO HARUO SAITO, TCBC-RJ JULIO CESAR BEITLER - TCBC-RJ FORA JUIZ DE FORA - MG - BR - ESTÁCIO DEJOSÉSÁ UNIVERSITY - RIO DE JANEIRO - RJ - BR ALVARO ANTONIO BANDEIRA FERRAZ - TCBC-PE - FEDERAL UNIVERSITY OF JÚLIO CEZAR UILI COELHO - TCBC-PR - FEDERAL UNIVERSITY OF PARANÁ - CURITIBA - BR LUIZ ANTONIO MODOLIN, ECBC-SP ALESSANDRO BERSCH FABIO XERFAN NAHAS – TCBC-SP –UNIFESP-BR PERNAMBUCO - RECIFEOSVALDT - PE - BR– TCBC-RS- UFRGS-BR KATIA SHEYLA MALTA PURIMMIGUEL - POSITIVO UNIVERSITY - CURITIBA - PR - BR ANA CRISTINA GOUVEIA MAGALHÃES FEDERAL UNIVERSITY OF RIO DE JANEIRO EYER DE JESUS - TCBC-RJ NELSON ADAMI ANDREOLLO – TCBC-SP - UNICAMP-SP-BR ALEXANDRE FERREIRA OLIVEIRA, TCBC-MG FERNANDO QUINTANILHA RIBEIROLISIEUX – SP- FCMSC-SP-BR RIO DE JANEIRO - RJ - BR FLUMINENSE FEDERAL UNIVERSITY - NITERÓI - RJ - BR ANDY PETROIANU - TCBC-MG - FEDERAL UNIVERSITY OFFLAVIO MINASDANIEL GERAIS - BELOTOMASICH,TCBC-PR LUIZ CARLOS VON BAHTEN - TCBC-PR FEDERAL UNIVERSITY OF PARANÁ - CURITIBA - BR NELSON -ALFRED SMITH ALEXANDRE PIASSI PASSOS, TCBC-MG SAAVEDRA HORIZONTE - MG - BR LUIZ GUSTAVO DE OLIVEIRA E SILVA - TCBC-RJ - IPANEMA FEDERAL HOSPITAL / NELSON -FONTANA ÁLVARO ANTONIO – TCBC-PE - UFPE-BR FREDERICO SILVEIRA TCBC-RJ ANGELITA HABR BANDEIRA - GAMA - FERRAZ TCBC-SP - UNIVERSITY OF SÃO PAULO - SÃO AVELLAR PAULO - SP - BR LUCAS, MINISTRY OF HEALTH - RIO DE JANEIRO RJ - BR MARGARIDO – TCBC-SP - USP-BR ANTONIO CARLOS VALEZI - TCBC-PR - STATE UNIVERSITY OF LONDRINA LUIZ GUSTAVO PERISSÉ - FEDERAL UNIVERSITY OF RIO DE JANEIRO - RIO DE JANEIRO - RJ - BR OSVALDO MALAFAIA – TCBC-PR- UFPR-BR ANA CRISTINA GOUVEIA MAGALHÃES, UFRJ-RJ GASPAR DE JESUS LOPES FILHO –TCBC-SP – UNIFESP LONDRINA - PR - BR LUIZ RONALDO ALBERTI - FEDERAL UNIVERSITY OF MINAS GERAIS - BELO HORIZONTE ANTONIO CLAUDIO JAMEL COELHO UNIVERSITY /MINISTRY - MG - BR PAULO FRANCISCO GUERREIRO CARDOSO – ACBC-RS- FFFCMPA-BR ANDY PETROIANUTCBC-MG - UFMG-BR- TCBC-RJ - GAMA FILHO GIOVANNI ANTONIO MARSICO, TCBC-RJ OF HEALTH - RIO DE JANEIRO - RJ - BR MANOEL XIMENES NETO - ECBC-DF - UNIVERSITY OF BRASÍLIA - BRASÍLIA - DF - BR PAULO GONÇALVES DE OLIVEIRA – TCBC-DFUNB-DF-BR ANGELITA HABR-GAMA – TCBC-SPUSP-BR - FACULTY OF MEDICAL GIULIANO ANCELMO- BENTO,ACBC-RJ ANTONIO JOSÉ GONÇALVES - TCBC-SP SCIENCES SÃO MANUEL DOMINGOS DA CRUZ GONÇALVES - ECBCRJ - FEDERAL UNIVERSITY OF RIO PAULO HOLY HOME - SÃO PAULO - SP - BR DE JANEIRO - RIO DE JANEIRO - RJ - BR RICARDO ANTONIO CORREIA LIMA, TCBC-RJ ANTONIO CARLOS VALEZI, TCBC-PR GUSTAVO PEREIRA FRAGA – TCBC-SPUNICAMP BR ANTONIO NOCCHI KALIL - TCBC-RS - FEDERAL UNIVERSITY OF HEALTH SCIENCES OF MARCOS ALPOIN FREIRE - TCBC-RJ - FEDERAL UNIVERSITY OF RIO DE JANEIRO - RIO DE PORTO ALEGRE - PORTO ALEGRE - RSTCBC-RJ - BR JANEIRO - RJ - BR RENATO ABRANTES LUNA, TCBC-RJ ANTONIO CLAUDIO JAMEL COELHO. HAMILTON PETRY DE SOUZA – TCBC-RSPUCRS-BR ARLINDO MONTEIRO DE CARVALHO JR. - TCBC-PB - FEDERAL UNIVERSITY OF PARAÍBA MARIA DE LOURDES P. BIONDO SIMÕES - TCBC-PR - PONTIFICAL CATHOLIC UNIVERSITY -ANTONIO JOÃO PESSOA - PB - BR OF PARANÁ JOSÉ GONÇALVES – TCBC-SP - FCMSCSP-BR JOÃO GILBERTO MAKSOUD- ECBC-SPUSP-BR - CURITIBA - PR - BRRENATO MIRANDA DE MELO, TCBC-GO ARTHUR BELARMINO GARRIDO JUNIOR - TCBC-SP - UNIVERSITY OF SÃO PAULO - SÃO MAURICIO GONÇALVES RUBINSTEIN - TCBC-RJ - FEDERAL UNIVERSITY OF RIO DE RICACHENEVSKY GURSKI – TCBC-RS- UFRGS-BR ANTONIO NOCCHI KALIL – TCBC-RS - UFCSPA-BR JOSÉ EDUARDO DE AGUILAR-NASCIMENTO – TCBC–MTPAULO - BR. JANEIRO - RIO DE UFMT-BR JANEIRO - RJRICHARD - BR CARLOS ANSELMO LIMA - TCBC - FEDERAL UNIVERSITY OF SERGIPE - ARACAJU - SE - BR MAURO DE SOUZA LEITE PINHO - TCBC-SC- UNIVERSITY OF THE JOINVILLE REGION ROBERTO SAAD JR., TCBC-SP ARLINDO MONTEIRO DE CARVALHO JR., TCBC-PB JÚLIO CEZAR UILI COELHO- TCBC-PR - UFPR-BR DANILO NAGIB SOLOMON PAUL - ECBC-ES - SUPERIOR SCHOOL OF SCIENCES - JOINVILLE - SC- BR VITÓRIA HOMEGARRIDO OF MERCY - VITÓRIA - ES --BRAZIL MIGUEL LUIZ ANTONIO MODOLIN - ECBC-SP - FACULTY OF MEDICINE RODOLFO ACATAUASSU NUNES, TCBC-RJ - UNIVERSITY OF ARTHUR HOLY BELARMINO JUNIOR – TCBC-SP USP-BR LISIEUX EYER DE JESUS- TCBC-RJ- UFF-BR DAYSE COUTINHO VALENTE - TCBC-RJ - FERNANDO LUIZ BARROSO INSTITUTE - RIO SAO PAULO - SP - BR RODRIGO ALTENFELDER SILVA – TCBC-SP-OFFCMSC-SP-BR AUGUSTO – TCBC-MG- UFU-BR LUIZ CARLOS VON BAHTEN- TCBC-PRUFPR-BR DE JANEIRODIOGO - RJ - FILHO BR NELSON ADAMI ANDREOLLO - TCBC-SP - STATE UNIVERSITY CAMPINAS DIOGO FRANCO - TCBC-RJ - FEDERAL UNIVERSITY OF RIO DE JANEIRO - RIO DE CAMPINAS - SP - BR ROGERIO APARECIDO DEDIVITIS, TCBC-SP CARLOS ANSELMO LIMA, TCBC-RJ LUIZ GUSTAVO DE OLIVEIRA E SILVA, TCBC-RJ JANEIRO - RJ - BR NELSON ALFRED SMITH - FEDERAL UNIVERSITY OF RIO DE JANEIRO - RIO DE JANEIRO - RJ - BR DJALMA JOSE FAGUNDES - SANTOS, ECBC-SPTCBC-RJ - FEDERAL UNIVERSITY SÃO PAULO - SÃO OSVALDO MALAFAIA - ECBC-PR - FEDERAL UNIVERSITY PARANÁUFGO-BR - CURITIBA - PR - BR RUFFO DE FREITAS JÚNIOR-OF TCBC-GOCARLOS EDUARDO RODRIGUES LUIZOF GUSTAVO PERISSÉ PAULO - SP - BR PAULO FRANCISCO GUERREIRO CARDOSO - ACBC-RS - FEDERAL FACULTTY OF MEDICAL EDMUND CHADA BARACAT SÃO PAULO - SÃO SCIENCES FOUNDATION OF PORTO - PORTO ALEGRE - RS - BR RUIALEGRE HADDAD – TCBC-RJUFRJ-BR CLEBER DARIO KRUEL – TCBC-RS- - TCBC-SP UFRGS-B - FEDERAL UNIVERSITY LUIZ OF RONALDO ALBERTI PAULO - SP - BR PAULO GONÇALVES DE OLIVEIRA - TCBC-DF - UNIVERSITY OF BRASÍLIA - BRASÍLIA SILVIA CRISTINE SOLDÁ- TCBC-SP- FCMSC-SP-BR DANILOFRASSON NAGIB SALOMÃO PAULO – TCBC-ESEMESCAM-BR. LUIZ EDNA DE SOUZA MONTERO - TCBC-SP - FEDERAL MANOEL UNIVERSITY OFFERREIRA SÃO PAULO - DF - BR - SÃO PAULO - SP - BR RICARDO ANTONIO CORREIA LIMA - TCBC-RJ - FEDERAL UNIVERSITY OF THE STATE SIZENANDO VIEIRA STARLING, TCBC-MG DAYSE COUTINHO VALENTE, TCBC-RJ MANOEL XIMENES NETO- ECBC-DF - UNB-DF-BR EDUARDO HARUO SAITO - TCBC-RJ - STATE UNIVERSITY OF RIO DE JANEIRO - RIO DE OF RIO DE JANEIRO - RIO DE JANEIRO - RJ - BR JANEIRO - RJ - BR– TCBC-RJ- UFRJ-BR RENATO– TCBC-RJABRANTES LUNA - TALITA TCBC-RJ - RIO DE JANEIRO STATE UFRJ-BR EMPLOYEES FEDERAL ROMERO FRANCOECBC-RJDIOGO FRANCO MANUEL DOMINGOS DA CRUZ GONÇALVES UFRJ-BR ELIZABETH GOMES DOS SANTOS - TCBC-RJ - FEDERAL UNIVERSITY OF RIO DE JANEIRO HOSPITAL - RIO DE JANEIRO - RJ - BR ERNESTO COELHO MARCELO DE PAULA LOUREIRO, TCBC-PR -DJALMA RIO DE JANEIRO - RJ - BR NETO,ACBC-RJ RENATO MIRANDA DE MELO THALES - TCBC-PAULO GO - BATISTA, FEDERALTCBC-PE UNIVERSITY OF GOIÁS - GOIÂNIA FABIO XERFAN NAHAS - TCBC-SP - FEDERAL UNIVERSITY OF SÃO PAULO - SÃO PAULO - GO - BR WILSON CINTRA TCBC-SP MARIA DE LOURDES P. BIONDO SIMOES – TCBC-PR – PUCPR-BR -DJALMA SP - BR JOSE FAGUNDES – TCBC-SP- UNIFESP-BR ROBERTO SAAD JR. - TCBC-SP - FACULTY OFJR., MEDICAL SCIENCES OF THE SÃO PAULO FLAVIO DANIEL SAAVEDRA TOMASICH - TCBC-PR - CLINICS HOSPITAL - FEDERAL HOLY HOME - SÃO PAULO - SP WILLIAM - BR ABRÃO SAAD- ECBC-SP- USP -BR UNIVERSITY OF PARANÁ - CURITIBA - PR - BR RODRIGO ALTENFELDER SILVA - TCBC-SP - FACULTY OF MEDICAL SCIENCES OF THE FREDERICO AVELLAR SILVEIRA LUCAS - TCBC-RJ - NATIONAL CANCER INSTITUTE - RIO SÃO PAULO HOLY HOME - SÃO PAULO - SP - BR DE JANEIRO - RJ - BR ROGERIO APARECIDO DEDIVITIS - TCBC-SP - UNIVERSITY OF SÃO PAULO - SÃO FERNANDO ATHAYDE VELOSO MADUREIRA - TCBC-RJ - FEDERAL UNIVERSITY OF THE PAULO - BR ARNULF THIEDE DIETZOF GOIÁS - GOIÂNIA CONSULTANTS STATE OF RIO DE JANEIRO - RIOEDITORS DE JANEIRO - RJ - BR. RUFFO DE FREITAS JÚNIOR - ULRICH TCBC-GO - ANDREAS FEDERAL UNIVERSITY GASPAR DE JESUS LOPES FILHO - TCBC-SP - FEDERAL UNIVERSITY OF SÃO - University - GO - BRof Würzburg Department of PAULO Surgery, Department of Surgery I, University of Würzburg, SÃO PAULO - SP - BR SOLDÁ - TCBC-SP - FACULTY OF MEDICAL SCIENCES OF THE SÃO Hospital, OberdürrbacherSILVIA Str. CRISTINE 6, D-97080 Medical School, Würzburg, Germany GIOVANNI ANTONIODA MARSICO TCBC-RJ - ANDARAÍ FEDERAL HOSPITAL /MINISTRY PAULO HOLY HOME - SÃO PAULO - SP - BR ALCINO LÁZARO SILVA, -ECBC-MG Würzburg, Germany OF HEALTH - RIO DE JANEIRO - RJ - BR SILVIO HENRIQUES DA CUNHA NETO - FEDERAL UNIVERSITY OF RIO DE JANEIRO - RIO ANTONIOANCELMO PELOSI DE MOURA LEITE, ECBC-SP GIULIANO BENTO - ACBC-RJ - UNIVERSITY OF THE STATE OF RIO DE DE JANEIRO - RJ - BR WEDER JANEIRO - RIO DE JANEIRO - RJ - BR VIEIRA STARLING W. - TCBC-MG - JOHN XXIII HOSPITAL - BELO HORIZONTE DARIO BIROLINI, ECBC-SP MURRAY BRENNAN IZENANDO GUSTAVO PEREIRA FRAGA - TCBC-SP - STATE UNIVERSITY OF CAMPINAS - CAMPINAS - MG - BR Klinikdirektor- UniversitätsSpital Zürich, HeCBC Department of Surgery, Memorial -FARES SP - BR RAHAL, ECBC-SP TALITA ROMEROSloanFRANCO - ECBC-RJ - FEDERAL UNIVERSITY OF RIO DE JANEIRO - RIO Switzerland HAMILTON PETRY DE SOUZA - ECBC-RS - PONTIFICAL CATHOLIC UNIVERSITY RIO DE JANEIRO - RJUSA - BR Kettering CancerOFCenter, New York NY, FERNANDO LUIZ BARROSO, GRANDE DO SUL - PORTO ALEGRE ECBC-RJ - RS - BR TÉRCIO DE CAMPOS - TCBC- SP - FACULTY OF MEDICAL SCIENCES OF THE SÃO PAULO JOÃO MAKSOUD - ECBC-SP - UNIVERSITY OF SÃO PAULO - SÃO PAULO - BR. HOLY HOME - SÃO PAULO - SP - BR ISAC GILBERTO JORGE FILHO, TCBC-SP CLAUDE DESCHAMPS H.UNIVERSITY FUCHS OF JOSÉ EDUARDO DE AGUILAR NASCIMENTO - TCBC- MT KARL - FEDERAL THALES PAULO BATISTA - TCBCPE - PERNAMBUCO HEALTH FACULTY / PROFESSOR IVO H.GROSSO J. CAMPOS PITANGUY, TCBC-RJ MATO - CUIABÁ - MT - BR FERNANDO FIGUEIRA INSTITUTE OF INTEGRAL MEDICINE - RECIFE - PE - BR M.D The Mayo Clinic, MN,USA Markus-Krankenhaus Frankfurter DiakonieJOSÉ EDUARDO FERREIRA MANSO - TCBC-RJ - FEDERAL UNIVERSITY OF RIO DE JANEIRO WILSON CINTRA JR. - TCBC-SP - UNIVERSITY OF PAULO - SÃO PAULO - SP - BR MARCOS F. MORAES, ECBC-RJ Kliniken, Wilhelm-Epstein-Straße 4, 60435 - RIO DE JANEIRO - RJ - BR WILLIAM ABRÃO SAAD - ECBC-SP - UNIVERSITY OF SÃO PAULO - SÃO PAULO - SP - BR

SAUL GOLDENBERG, ECBC-SP

Frankfurt am Main


NATIONAL CONSULTANTS

INTERNATIONAL CONSULTANTS

EDITORES DA REVISTA DO CBC

ALCINO LÁZARO DA SILVA, ECBC-MG - Federal University of Minas Gerais.

ARNULF THIEDE - Department of Surgery, University of Würzburg

ALUIZIO SOARES DE SOUZA RODRIGUES, ECBC-RJ - Federal University of

Hospital, Oberdürrbacher Str. 6, D-97080 Würzburg, Germany

1967 - 1969 JÚLIO SANDERSON

1973 - 1979 HUMBERTO BARRETO

1983 - 1985 1992 - 1999 CLAUDE DESCHAMPS - M.D - The Mayo Clinic, MN,USA JOSÉ LUIZ XAVIER PACHECO MERISA GARRIDO

Rio de Janeiro-UFRJ-Rio de Janeiro-RJ.

ANTONIO PELOSI DE MOURA LEITE, ECBC-SP - Cardiovascular Diseases Institute of São José do Rio Preto-SP

EDUARDO PARRA-DAVILA - Florida Hospital Celebration Health - 400

Celebration Pl, Kissimmee, FL 34747, USA. 1986 - 1991 2000 - 2001 Sanchinarro Madrid MARCOS EMILIO MORAESDE VICENTE LÓPEZ – Hospital JOSÉ ANTÓNIO GOMES DE SOUZA

1969 - 1971 JOSÉ HILÁRIO

1980 - 1982 EVANDRO FREIRE

FERNANDO LUIZ BARROSO, ECBC-RIO DE JANEIRO - Ipanema County

KARL H. FUCHS - Markus-Krankenhaus Frankfurter Diakonie-Kliniken,

Hospital-RJ.

2006-2015

Wilhelm- Epstein-Straße 4, 60435 Frankfurt am Main

DARIO BIROLINI, ECBC-SP - Faculty of Medicine, University of Paulo.

2002 - 2005

FERNANDO PAES LEME, ECBC-RIO DE JANEIRO - Faculty of INTO BRAVO NETO JOSÉ E DUARDO FERREIRA MANSO GUILHERME PMANOEL

MURRAY BRENNAN - HeCBC Department of Surgery, Memorial Sloan-

Medicine of Campos-RJ.

Kettering Cancer Center, New York NY, USA

ISAC JORGE I, TCBC-SP - Ribeirão Preto University (UNAERP)

ULRICH ANDREAS DIETZ - Department of Surgery I, University of

MARCOS F. MORAES, ECBC-RJ - Gama Filho University-RJ.

Würzburg, Medical School, Würzburg, Germany

SAUL GOLDENBERG, ECBC-SP - Federal University of São Paulo- Paulista

W. WEDER - Klinikdirektor-UniversitätsSpital Zürich, Switzerland

School of Medicina. A REVISTA DO COLÉGIO BRASILEIRO DE CIRURGIÕES é inde ada no Latinde , Lilacs e Scielo, Scopus, Medline PubMed, DOAJ,

Free Medical Journals e enviada bimestralmente a todos os membros do CBC, aos seus assinantes, a entidades médicas, bibliotecas, hospitais, e centros de estudos, publica ões com as uais mantém permuta, e aos seus anunciantes.

EDITORS OF THE JOURNAL OF THE BRAZILIAN COLLEGE OF SURGEONS 1967 - 1969 JÚLIO SANDERSON

1973 - 1979 HUMBERTO BARRETO

1983 - 1985 JOSÉ LUIZ XAVIER PACHECO

1992 - 1999 MERISA GARRIDO

1969 - 1971 JOSÉ HILÁRIO

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V

Convenção Latinoamericana de Hérnia

19 a 21 abril de 2018 Foz do Iguaçu - Brasil Realização

www.cbhernia.com.br Apoio

Save the date! Patrocinadores

Federación Latinoamericana de Hernia Federação Latinoamericana de Hernia

Organização e Viagens

GROUP


A SOBRACIL lança mais uma edição do Programa Jovem Cirurgião, focado no treinamento para residentes e cirurgiões iniciantes em videocirurgia, com programação completa em conhecimentos e habilidades básicas para iniciação no método minimamente invasivo.

Inscrições abertas COORDENADORES

Dr. Cláudio Moura Dr. Thiers Soares

Patrocinador

www.programajovemcirurgiao.com.br O objetivo do programa é dar o treinamento necessário para o aprendizado e disseminação da técnica minimamente invasiva (videocirurgia básica), com conteúdo teórico-prático (prática em simuladores), para que um número cada vez maior de cirurgiões possa usá-la em benefício dos seus pacientes.


D O I : 10.1590/

Editorial

0100- 6912017003014

Surgery and the internet A cirurgia e a internet FELIPE CARVALHO VICTER, TCBC-RJ1.

T

he internet, a few years ago, has become the initial tool for search of update or review articles. Initially used only as a bibliographic reference, it required a subsequent excursion to the libraries in search of the physical journals for reading. More recently, however, most journals, including the Journal of the Brazilian College of Surgeons (Revista do Colégio Brasileiro de Cirurgiões), make their content available online and thus reach an even larger number of readers, not only in the health area. Our daily medical practices, such as work, study, and even the physician-patient relationship, have been influenced by the internet. It is common for patients to arrive in the clinic with a list of questions, generated after research on their disease. Also on the internet, many patients seek out the professionals who best fit their profile, without the traditional indications of another doctor, of other patients or of acquaintances. On the other hand, in the search for patients, some doctors turn their lives into reality shows and post every step of their activities carried out throughout the day, with emphasis on classes, congresses, courses and other activities related to their clinical practice. At times, they go beyond common sense and expose situations capable of generating false hopes to the public, with unattainable promises or success results that are not usual for certain diseases. It was in this sense that the Federal Medical Council issued the resolution number 1974/2011 to guide and avoid abuses of medical dissemination in the various media1. Interestingly, however, the patients themselves organize into discussion groups of clinical cases or blogs specific for certain diseases. And the interesting thing is that some of these blogs are run by patients who discuss the “best” medical conducts for the cases

in question, based on personal experiences and, of course, the information on the internet. Videolaparoscopy, on its turn, brought not only the inherent benefit of the method to the patient, but also the ease of reliably recording the performed surgery. Initially this record was made in VHS tapes that, besides occupying great physical space, had a laborious and delayed edition. Perhaps because of this editing difficulty, there were a limited number of recorded procedures, and these were displayed in the crowded video exhibition rooms of the surgery congresses. Continuously, the evolution of computers and video editing software took place, which resulted in the simplification of the processes, with even better results for the viewer. At the same time, access to high-speed internet and video-sharing platforms became popular and allowed doctors to exchange experiences from the visualization of their procedures, also granting patients access to these surgical videos. It is in this context that the relation of the surgeon with the internet became even more integrated, since besides the academic articles research, the surgeon was able to update his expertise with videos of the surgeries he intends to perform. And this practice became commonplace not only by the resident before operating his first cholecystectomy, tutored by his preceptor, but also by experienced surgeons, to refine some technical detail of their practice. It is no wonder that several papers on the subject are being published in different journals, in which they seek to analyze the influence of the Internet, not only on already trained surgeons, but also on training ones2,3. No matter how detailed the description of a surgical technique is, it does not compare with video recording. As highlighted by O’Leary et al in their

1 - Pedro Ernesto University Hospital, Federal University of the State of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro State, Brazil. Rev. Col. Bras. Cir. 2017; 44(3): 220-221


Victer Surgery and the internet

221

singular article, the use of the internet as a teaching tool provides easy access, good cost-effectiveness and the possibility of independent learning4. Also in this article, they reviewed the YouTube and iTunes releases of their institution’s Surgery Department sessions, which garnered a considerable number of views, distributed globally. Video posting sites can be viewed by countless people who directly post their comments. Unfortunately, even in the restricted access groups, there is eventually a certain lack of commitment to reality, both for the comments and for the videos themselves, stimulated perhaps by the impersonality

REFERENCES 1. Conselho Federal de Medicina (Brasil). Resolução no. 1974, de 14 de julho de 2011. Estabelece os critérios norteadores da propaganda em Medicina, conceituando os anúncios, a divulgação de assuntos médicos, o sensacionalismo, a autopromoção e as proibições referentes à matéria. Diário Oficial da União 19 ago 2011; Seção 1. Disponível em: http://www.portalmedico.org.br/resolucoes/ CFM/2011/1974_2011.htm

created by the internet. The ease of these postings also allows releasing of materials without scientific rigor, often incorrectly disseminated to the public. The use of the internet cannot be ignored by the surgeon, who has the opportunity to improve with this tool. It is in this scenario that the Brazilian College of Surgeons and other specialized societies promote actions to provide their members with resources that really aim at technical and scientific improvement. And it is with this intention that I hope, more and more, that the seals of the Specialty Societies are stamped on sites that truly have commitment with ethics and with continued medical education. 2. Jayakumar N, Brunckhorst O, Dasgupta P, Khan MS, Ahmed K. e-Learning in surgical education: a systematic review; J Surg Educ. 2015;72(6):1145-57. 3. Maertens H, Madani A, Landry T, Vermassen F, Van Herzeele I, Aggarwal R. Systematic review of e-learning for surgical training. Br J Surg. 2016;103(11):1428-37. 4. O’Leary DP, Corrigan MA, McHugh SM, Hill AD, Redmond HP. From theater to the world wide web-a new online era for surgical education. J Surg Educ. 2012;69(4):483-6.

Rev. Col. Bras. Cir. 2017; 44(3): 220-221


D O I : 10.1590/

Original Article

0100- 6912017003001

Mortality predictors in patients with pelvic fractures from blunt trauma Preditores de mortalidade em pacientes com fratura de pelve por trauma contuso WAGNER OSÉAS CORRÊA1; VINÍCIUS GUILHERME ROCHA BATISTA1; ERISVALDO FERREIRA CAVALCANTE JÚNIOR1; MICHAEL PEREIRA FERNANDES1; RAFAEL FORTES1; GABRIELA ZAMUNARO LOPES RUIZ2; CARLA JORGE MACHADO3; MARIO PASTORE NETO1. A B S T R A C T Objective: to analyze the association of mortality with sociodemographic and clinical variables, as well as lesions and complication in patients with pelvic trauma due to blunt trauma. Methods: we conducted a retrospective, observational study with five-year trauma record data. Death was considered as the main stratification variable for the analyzes. We used the Student t test to compare means, the Chi-Square or Fisher exact test for proportions, and the Wilcoxon-Mann Whitney test for medians. We analyzed the independent factors using a logistic regression model with penalized likelihood, based on the Wald tests, the Akaike Information Criterion (AIC) and the Schwarz Bayesian Information Criterion (BIC). Results: of the 28 patients with blunt trauma fracture, 23 (82.1%) were men; 16 (57.1%) were, in average, 38.8 years old (±17.3). There were 98 lesions or fractures in the 28 patients. As for severity, seven people had Injury Severity Score higher than 24 (25%). The mean hospital stay was 26.8 days (±22.4). Fifteen patients (53.6%) had ICU admission. Mortality was 21.4%. The analysis showed that age 50 years or more and presence of coagulopathy were factors independently associated with death. Conclusion: pelvic fractures can have high mortality. In this study, mortality was higher than that described in the literature. Age above 50 years and the presence of coagulopathy are risk factors in this population. Keywords: Wounds and Injuries. Pelvis. Multiple Trauma. General Surgery.

INTRODUCTION

P

elvic fractures usually result from high energy trauma. In about 90% of the cases, there are other associated lesions, the prognosis relating mainly to the severity of these injuries1-4. The mortality in patients with pelvic fracture ranges from 4% to 15% in different studies. Mortality is usually associated with multiple traumas and bleeding. Some risk factors – such as advanced age or shock at admission, defined by a systolic pressure lower than 90mmHg – were positively associated with death. In addition, the Injury Severity Score (ISS), a measure of body surface accumulated traumas, is directly related to increased mortality5. After the primary approach of a patient with pelvic trauma based on Advanced Trauma Life Support (ATLS), a complete skeletal muscle assessment should be performed, looking for symmetry, rotation or shortening of lower limbs, in addition to skin

thorough exam in search for injuries. The genital region deserves careful investigation, especially when there is local bleeding, including sensory, motor, and reflex neurological examination. Most pelvic fractures do not pose specific treatment challenges, are stable and do not carry a greater chance of retroperitoneal bleeding. However, in patients with complex and unstable fractures, retroperitoneal hemorrhage may be lethal3,4. Early fixation of the pelvis is essential to avoid pain, chronic deformities and to facilitate mobilization. Even with anatomical preservation, common late complications are pain and sexual dysfunction. In addition, neurological impairment has been shown to be a sign of poor prognosis regardless of the type of injury. For a better approach to the patient, the type of fracture should be elucidated by stress assessment of the pelvis while the patient is anesthetized 7. The objective of the present study was to analyze the association between death and

1 - Federal University of Minas Gerais, Risoleta Tolentino Neves Hospital, Belo Horizonte, Minas Gerais State, Brazil. 2 - Federal University of Minas Gerais, Medical School, Belo Horizonte, Minas Gerais State, Brazil. 3 - Federal University of Minas Gerais, Department of Preventive and Social Medicine, Belo Horizonte, Minas Gerais State, Brazil. Rev. Col. Bras. Cir. 2017; 44(3): 222-230


Corrêa Mortality predictors in patients with pelvic fractures from blunt trauma

sociodemographic and clinical variables, injuries and complications in patients with blunt pelvic trauma attended at a reference center for trauma.

METHODS We conducted a retrospective, observational study, using the trauma registry database of the General Surgery and Trauma Service of the Risoleta Tolentino Neves Hospital – FUNDEP/UFMG (Collector® System Maryland USA) and the electronic records of all patients admitted to the hospital who were victims of Trauma with pelvic fractures, admitted from 2010 to 2014. The main variable of interest and stratification of the study was the occurrence of death among patients. The other variables analyzed were gender, age, Use of FAST (Focused Assessment with Sonography in Trauma), Laparotomy, ISS (Injury Severity Score) categorized according to severity levels8, need of external fixator, time (in days) of hospital admission, need for ICU admission and Time (in days) in the ICU (Intensive Care Unit). We also identified the patients’ fractures, injuries and complications. We also recorded the mean arterial blood pressure and the mean heart rate at admission, and the presence of bleeding at admission and discharge for all patients. To verify if the variables of interest were associated with mortality, we used the Student’s t test for continuous variables (mean, standard deviation and coefficient of variation) with Gaussian (normal) distribution. For categorical variables, we used the Chi-square test (when one of the categories of analysis had less than five elements) or the Fisher’s test (more than four categories. We also computed the following statistics for the continuous variables: median, interquartile range (25th percentile subtracted from the 75th percentile), maximum and minimum values. For comparison of medians, was performed a Wilcoxon-Mann Whitney test. It was also of interest to evaluate the independent factors associated with death. Considering that we observed the phenomenon of quasi-separation in the data, that is, some variables predicted almost completely the outcome, we used

223

the logistic model with penalized likelihood, which allows estimating with more stability the odds ratios and overcomes the limitation of the traditional logistic model that works with convergences based on likelihood ratios9. We generated a multivariate regression model to quantify the relationships between one or more factors of interest and mortality. The multivariate analysis was initiated only with the variables that presented p<0.20 in the univariate analysis, as follows: after obtaining the first model, the variables were sequentially withdrawn, according to the significance presented by the Wald test. The significance level adopted for this test was 10%. In case of doubt about which variable to remove, the models were maintained for further analysis by two information criteria: Akaike Information Criterion (AIC) and Schwarz Bayesian Information Criterion (BIC). The model chosen was the one with the lowest AIC and the lowest BIC, since lower values of AIC and BIC indicated a better fit of the model10. The obtained estimator was the odds ratio (OR) of death (compared to survival). We considered values of p<0.10 and obtained 95% confidence intervals.

RESULTS We identified 28 patients with pelvic fracture after blunt trauma, with the following admission characteristics: 23 (82.1%) were men; 16 (57.1%) were less than 40 years old; mean and median age were 38.8 years (standard deviation 17.3) and 36 years (interquartile range 20), respectively. The mean systolic blood pressure at admission was above 90mmHg and the mean heart rate at admission at 96bpm (66-132). Seventeen patients underwent FAST (Focused Assessment Sonography for Trauma) on admission, six (21.4%) with evidence of intraperitoneal bleeding. There were 98 lesions or fractures in the 28 patients. Pelvic abdominal fracture, pneumothorax, external pelvic fracture and fracture of costal arches occurred in 19 (67.9%), 11 (39.3%), ten (35.7%) and seven (25.0%) patients respectively. Hemothorax, pulmonary contusion and liver injury had five (17.9%) occurrences each.

Rev. Col. Bras. Cir. 2017; 44(3): 222-230


CorrĂŞa Mortality predictors in patients with pelvic fractures from blunt trauma

224

Table 1. Mortality among patients with pelvic blunt trauma according to selected variables.

Variable Gender (n,%) Male Female Age (categories) (n; %) Up to 39 years 40 to 49 years 50 years or more Age (years) Mean (Sd) Median (IQR) Minimum; Maximum Use of FAST (n,%) Yes No Laparotomy (n,%) Yes No ISS (categories) (n; %) < 15 (mild) 15 to 24 (moderate) > 24 (severe or very severe) ISS (continuous) Mean (Sd) Median (IQR) Minimum; Maximum Pelvic External Fixator (n,%) Yes No Hospital stay (in days) Mean (Sd) Median (IQR) Minimum; Maximum Hospital stay (ranges) (n,%) 1 to 7 days From 8 to 21 days More than 22 days Admission to ICU (n; %) Yes No Time in ICU (in days) Mean (Sd) Median (IQR) Minimum; Maximum Time in the ICU (range) (n,%) No day From 1 to 7 days More than 7 days

Survival (n=22; 78.6%)

Death (n=6; 21.4%)

Total (n=28; 100.0%)

18 (78.3) 4 (80.0)

4 (21.7) 1 (20.0)

23 (100.0) 5 (100.0)

0.715

14 (87.5) 5 (100.0) 3 (42.9)

2 (12.5) 0 (0.0) 4 (57.4)

16 (100.0) 5 (100.0) 7 (100.0)

0.034 **

34.3 (11.9) 36 (15) 12; 58

55.5 (24.5) 57 (30) 27; 86

38.8 (17.3) 36 (20.5) 12; 86

0.088 * 0.064 *

9 (81.8) 13 (76.5)

2 (18.2) 4 (23.5)

17 (100.0) 11 (100.0)

0.561

6 (66.7) 16 (84.2)

3 (33.3) 3 (15.8)

9 (100.0) 19 (100.0)

0.352

8 (88.9) 9 (81.8) 4 (57.1)

1 (11.1) 2 (18.2) 3 (42.9)

9 (100.0) 11 (100.0) 7 (1000)

0.369

18.6 (9.8) 18 (10) 5; 41

25.3 (11.5) 23 (18) 23; 42

20.1 (10.4) 18 (16) 5; 42

0.167 0.218

5 (100.0) 17 (73.9)

0 (0.0) 6 (26.1)

5 (100.0) 23 (100.0)

0.198

30.8 (22.6) 26 (36) 1; 72

12.2 (15.5) 6 (17) 1; 41

26.8 (22.4) 21 (35) 1; 72

0.070 * 0.031 **

3 (50.0) 6 (75.0) 13 (92.9)

3 (50.0) 2 (25.0) 1 (7.1)

6 (100.0) 8 (100.0) 14 (100.0)

0.099 *

11 (84.6) 11 (73.3)

2 (15.4) 4 (16.7)

13 (100.0) 15 (100.0)

0.655

5.8 (7.8) 1 (11) 0; 28

8.3 (10.2) 4 (18) 0; 24

6.4 (8.2) 3 (12) 0; 28

0.516 0.555

11 (84.6) 4 (66.7) 7 (77.8)

2 (15.4) 2 (33.3) 2 (22.2)

13 (100.0) 6 (100.0) 9 (100.0)

0.836

* p<0.10; ** p<0.05

Rev. Col. Bras. Cir. 2017; 44(3): 222-230

p value


CorrĂŞa Mortality predictors in patients with pelvic fractures from blunt trauma

225

Table 2. Absolute figures and percentages of injuries in patients with blunt trauma and pelvic fracture.

Survival (n=22; 78.6%)

Death (n=6; 21.4%)

Total (n=28; 100.0%)

p value

Abdominal pelvic fracture

15 (78.9)

4 (21.1)

19 (100.0)

0.650

Pneumothorax

9 (81.8)

2 (18.2)

11 (100.0)

0.561

External Pelvis Fracture

7 (70.0)

3 (30.0)

10 (100.0)

0.358

Rib Fracture

5 (71.4)

2 (28.6)

7 (100.0)

0.622

Hemopneumothorax

4 (80.0)

1 (20.0)

5 (100.0)

0.715

Pulmonary Contusion

1 (50.0)

1 (50.0)

5 (100.0)

0.389

Liver injury

4 (80.0)

1 (20.0)

5 (100.0)

0.715

Fracture of Vertebrae

2 (50.0)

2 (50.0)

4 (100.0)

0.191

Large vessels Injury

2 (50.0)

2 (50.0)

4 (100.0)

0.191

Bladder Injury

4 (100.0)

0 (0.0)

4 (100.0)

0.549

Spleen Injury

2 (50.0)

2 (50.0)

4 (100.0)

0.191

Renal Injury

3 (100.0)

0 (0.0)

3 (100.0)

0.471

Femur Fracture

3 (75.0)

1 (25.0)

3 (100.0)

0.999

Tibia Fracture

2 (66.7)

1 (33.3)

3 (100.0)

0.530

Colon Injury

1 (50.0)

1 (50.0)

2 (100.0)

0.389

Calcaneus Fracture

2 (100.0)

0 (0.0)

2 (100.0)

0.999

Skull Fracture

1 (100.0)

0 (0.0)

1 (100.0)

0.786

Maxillofacial Fracture

1 (100.0)

0 (0.0)

1 (100.0)

0.786

Sternum Fracture

1 (100.0)

0 (0.0)

1 (100.0)

0.786

Small intestine Injury

1 (100.0)

0 (0.0)

1 (100.0)

0.786

Urethral Injury

1 (100.0)

0 (20.0)

1 (100.0)

0.786

Vaginal Injury

1 (100.0)

0 (0.0)

1 (100.0)

0.786

Clavicle Fracture

1 (100.0)

0 (0.0)

1 (100.0)

0.786

Humerus Fracture

1 (100.0)

1 (0.0)

1 (100.0)

0.999

Total (of fractures and injuries)

74 (75.5)

24 (24.5)

98 (100.0)

Fractures and injuries (n,%)

According to the Young-Burgess classification used to determine the type of pelvic ring fracture, the fracture mechanism was by lateral compression (LC) of type I in 13 patients (46.4%), type II in five (17.9%) and type III in one (3.6%); by anteroposterior compression (APC) of type I in two (7.14%) and type II in five (17.86%); and by combination of APC II and vertical shear (VS) in two (7.14%).

Regarding severity, seven patients had an ISS greater than 24, that is, a severe score (25%). Mean and median ISS were 20.1 (standard deviation 10.3) and 18 (interquartile range 16), respectively. At the end of admission, seven patients (25%) had intraperitoneal bleeding, seven just extraperitoneal bleeding and five intra and extraperitoneal. Nine (32.1%) patients required

Rev. Col. Bras. Cir. 2017; 44(3): 222-230


CorrĂŞa Mortality predictors in patients with pelvic fractures from blunt trauma

226

Table 3. Absolute figures and percentages of complications in patients with blunt trauma and pelvic fracture, according to survival and death.

Survival (n=22; 78.6%)

Death (n=6; 21.4%)

Total (n=28; 100.0%)

p value

Rhabdomyolysis

7 (63.6)

4 (36.4)

11 (100.0)

0.174

Surgical wound infection

8 (80.0)

2 (20.0)

10 (100.0)

0.642

Sepsis

3 (50.0)

3 (50.0)

6 (100.0)

0.091 *

Decubitus ulcer

5 (100.0)

0 (0.0)

5 (100.0)

0.268

Shock

3 (100.0)

2 (40.0)

5 (100.0)

0.285

Renal Insufficiency

1 (25.0)

3 (75.0)

4 (100.0)

0.022 **

Acute Respiratory Infection

2 (66.7)

1 (33.3)

3 (100.0)

0.530

Coagulopathy

0 (0.0)

3 (100.0)

3 (100.0)

0.006 ***

Pneumonia

3 (100.0)

0 (0.0)

3 (100.0)

0.470

Pseudomembranous Colitis

3 (100.0)

0 (0.0)

3 (100.0)

0.470

0 (0.0)

2 (100.0)

2 (100.0)

0.040 **

1 (100.0)

0 (0.0)

1 (100.0)

0.786

Central Veins Thrombosis

0 (0.0)

1 (100.0)

1 (100.0)

0.214

Mesenteric Ischemia

0 (0.0)

1 (100.0)

1 (100.0)

0.214

Unnoticed Injury

1 (100.0)

0 (0.0)

1 (100.0)

0.786

Cardiac Arrest

1 (100.0)

0 (0.0)

1 (100.0)

0.786

0 (0.0)

1 (100.0)

1 (100.0)

0.214

Residual pneumothorax

1 (100.0)

0 (0.0)

1 (100.0)

0.786

Another abscess

1 (100.0)

0 (0.0)

1 (100.0)

0.786

Empyema

1 (100.0)

0 (0.0)

1 (100.0)

0.786

Intestinal bleeding

0 (0.0)

1 (100.0)

1 (100.0)

0.214

Total complications

44 (64.7)

24 (35.3)

68 (100.0)

Complication (n; %)

Compartment Syndrome Deep Vein Thrombosis

Hemothorax

* p<0.10; ** p<0.05; *** p<0.001.

laparotomy and six (21.4%) underwent chest drainage. Five (17.9%) patients required an external fixator to stabilize the pelvis. None of the patients was treated by hemodynamics. The length of hospital stay varied from one to 72 days, with an average of 26.8 (standard deviation

22.4) and the median 21 (interquartile range 35). The length of stay in the Intensive Care Unit (ICU) ranged from zero to 28 days, with a mean of 6.4 days (standard deviation 8.2) and median three (interquartile range 19 days). Fifteen patients (53.6%) had ICU admission. Among the complications during hospitalization, 68 occurred for the 28 patients. The

Rev. Col. Bras. Cir. 2017; 44(3): 222-230


CorrĂŞa Mortality predictors in patients with pelvic fractures from blunt trauma

227

Table 4. Factors independently associated with death in patients with blunt trauma and pelvic fracture.

Or (95%) Variables

Model 1

Model 2

Model 3

Model 4

Up to 39 years

1.0

1.0

1.0

1.0

40 to 49 years

0.5 (0.1; 13)

2.6 (0.1; 143)

0.9 (0.1; 24)

2.6 (0.1; 148)

7.5 (1.1; 52) **

1.1 (1.1; 676) **

9.1 (0.95; 87) *

28.3 (1.2; 692) **

No

1.0

1.0

Yes

0.96 (0.01; 91)

27 (0.7; 1000) *

Age

50 years or more Compartment Syndrome

Coagulopathy No

1.0

1.0

Yes

83 (1.2; 5917) **

140 (22; 8857) **

Information statistics AIC

28.3

25.9

27.1

21.5

BIC

32.2

32.4

30.3

26.7

* p<0.10; ** p<0.05.

highest frequencies observed were 11 (39.2%) patients with rhabdomyolysis, 10 (35.7%) with surgical wound infection, six (21.5%) with sepsis, five (17.9%) with septic shock, four (14.3%) with acute renal failure, three (10.7%) with respiratory insufficiency, three (10.7%) with pneumonia, three (10.7%) with coagulopathy and three (10.7%) with pseudomenbranous colitis. There were six deaths (21.4%). Table 1 indicates that there were statistically significant differences between the survivors and those who died in relation to the following characteristics: age group (p=0.034), with a much higher mortality among those aged 50 years or over compared with all the 28 patients (57.4% and 21.4%, respectively); mean hospital stay (p=0.031), this being shorter among those who died compared with the hospitalization time of all patients (six versus 21 days). We further highlight the borderline significance of the findings of mean (p=0.088) and median (p=0.064) age, which were more than ten years lower among the survivors compared with those who died, the mean hospital stay (p=0.070), which was 12.2 days among

those who died and 30.8 days among survivors, and, following this result, the mortality progressively lower as the number of hospitalization days advanced (p=0.099). Regarding the differential mortality due to thoracic injuries, there was no significant finding or at the threshold of statistical significance (Table 2). As for the differential complications (Table 3), mortality was higher in the cases of compartment syndrome (p=0.040), renal insufficiency (p=0.022) and coagulopathy (p=0.006). Death was also more frequent among those who progressed with sepsis, with a borderline significance (p=0.091). Table 4 shows the results of the logistic models predictive of death. We observed that the best model, with lower AIC and BIC, was Model 4, after comparing models 2 and 3, for which the AIC indicated that the best model would be 2 (if compared to 1 and 3) and The BIC indicated that the best would be Model 3 (if compared with 1 and 3). In fact, Model 4 indicated that age was a factor independently associated with death: the chance of death in patients aged 50 years or older was

Rev. Col. Bras. Cir. 2017; 44(3): 222-230


CorrĂŞa Mortality predictors in patients with pelvic fractures from blunt trauma

228

Figure 1 - Odds ratios associated with mortality (Model 4)

28.3 times the chance of death among patients under 40 years of age (p<0.05). In Model 4, the presence of coagulopathy was independently associated with death (OR=140, p<0.05, Figure 1)

DISCUSSION Pelvic fractures are serious injuries and can lead to early and late death1-4. This study corroborates these findings, having found mortality greater than 20%. This incidence is a very high vis-Ă -vis the literature on patients with pelvic fractures due to blunt trauma. Mortality ranged from 4% to 15% according to to recent studies2,5. The majority of the patients were young adults, aged less than 40 years. Survivors were not only significantly younger, but age was also independently associated with death. This finding was analyzed in this study in a detailed way and the most robust predictive model was the one that took into account the presence of coagulopathy and compartment syndrome. After obtaining this model, we included variables for the number of lesions or fractures and for the number of complications, and there was no improvement in the predictive capacity of death measured by the information statistics proposed here (AIC and BIC). Advanced age is a factor that contributes to higher mortality among trauma patients11. However, little is known about the effects that cause this variation of risk according to age. Patients with the same ISS levels have a higher risk of dying if they are older12. Biologic fragility, which is associated with a

reduction of the homeostatic reserve and a decrease in resistance to stressors, increases with age13. This study adds to what is already known when indicating that coagulopathy, in addition to age, was independently associated with death. A review of coagulopathy, which is a condition that develops in large bleeds, and constitutes the inability to produce adequate hemostasis in response to tissue injury, indicated that this condition is the main cause of death in the first 24 hours of treatment of victims of trauma14. Multiple factors contribute to the development of coagulopathy in trauma, the main ones being hemodilution, metabolic acidosis and hypothermia. To prevent and treat this condition, the main measure is to control bleeding quickly and immediately through surgery. The correction of hypothermia and acidosis, as well as the rational use of blood components, should always be sought to obtain the maximum therapy effectiveness and avoid possible complications14. We should also note that coagulopathy is associated with the compartment syndrome, being a predictor, thus predating abdominal compartment syndrome (ACS). ACS is a serious complication caused by the exaggerated increase in intra-abdominal pressure (IAP) associated with the failure of at least one abdominal organ. Intraabdominal hypertension (IAH), defined as IAP values above 12mmHg, is what causes ACS15. Long before the symptomatic manifestation of ACS, the harmful effects of IAH appear and are not restricted to the abdomen, also affecting the chest and skull16. Patients with IAH were 11 times more likely to develop abdominal complications than those who did not present with IAH or ACS17. Thus, coagulopathy is part of the lethal triad (hypotension, coagulopathy and acidosis)18, a vicious cycle that, if uninterrupted, leads to death quickly, requiring rapid and effective bleeding control techniques to interrupt the triad. Pelvic fracture due to trauma is a severe condition that poses serious risks to life. The mortality found in the study was more than 20%, that is, even higher than what is usually described in the literature. This study resulted in the direct relationship of age and the presence of coagulopathy as independent predictors of mortality.

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Corrêa Mortality predictors in patients with pelvic fractures from blunt trauma

229

R E S U M O Objetivo: analisar a associação de mortalidade com variáveis sociodemográficas, clínicas, lesões e complicações em pacientes com trauma de pelve decorrente de trauma contuso. Métodos: estudo retrospectivo e observacional com dados de registro de trauma obtidos durante cinco anos. O óbito foi a variável de estratificação das análises. Para verificar se as variáveis de interesse tinham associação com o óbito, foi realizado o teste t de Student e teste do Qui-quadrado (ou Fisher) e Wilcoxon-Mann Whitney . Os fatores independentemente associados ao óbito foram analisados por modelo logístico binomial, e com base nos testes de Wald e por Critérios de Informação de Akaike (AIC) e Bayesiano de Schwarz (BIC). Resultados: dos 28 pacientes com fratura de pelve por trauma contuso, 23 (82,1%) eram homens; 16 (57,1%) com média de idade de 38,8 anos (desvio padrão 17,3). Houve 98 lesões ou fraturas nos 28 pacientes. Quanto à gravidade, sete pacientes tiveram Injury Severity Score superior a 24 (25%). O tempo de internação hospitalar médio foi 26,8 dias (DP=22,4). Quinze pacientes (53,6%) tiveram internação em UTI. A incidência de óbito foi de 21,4%. A análise mostrou que idade igual ou maior do que 50 anos e presença de coagulopatia foram fatores independentemente associados ao óbito. Conclusão: as fraturas de pelve podem ter mortalidade elevada. Neste estudo a mortalidade foi superior ao que é descrito na literatura. A idade acima de 50 anos e a coagulopatia se revelaram fatores de risco nessa população. Descritores: Ferimentos e Lesões. Pelve. Traumatismo Múltiplo. Cirurgia Geral.

REFERENCES 1. Parreira JG, Haddad L, Rasslan S. Lesões abdominais nos traumatizados com fraturas de bacia. Rev Col Bras Cir. 2002;29(3):153-60. 2. Cordts Filho RM, Parreira JG, Perlingeiro JAG, Soldá SC, Campos T, Assef JC. Fratura de pelve: um marcador de gravidade em trauma. Rev Col Bras Cir. 2011;38(5):310-6 3. Godinho M, Garcia DFV, Parreira JG, Fraga GP, Nascimento B, Rizoli C. Tratamento da hemorragia da fratura pélvica em doente instável hemodinamicamente. Rev Col Bras Cir. 2012;39(3):238-42. 4. Parreira JG, Kanamori LR, Valinoto GCJ, Perlingeiro JA. Giannini SSC, Assef JC. Análise comparativa dos fatores preditivos de morte em vítimas de trauma fechado com fraturas pélvicas. Rev Col Bras Cir. 2014;41(4): 285-91. 5. Vaidya R, Scott AN, Tonnos F, Hudson I, Martin AJ, Sethi A. Patients with pelvic fractures from blunt trauma. What is the cause of mortality and when? Am J Surg. 2016;211(3):495-500. 6. Langford JR, Burgess AR, Liporace FA, Haidukewych GJ. Pelvic fractures: part 1. Evaluation, classification, and resuscitation. J Am Acad Orthop Surg. 2013;21(8):448-57. 7. Langford JR, Burgess AR, Liporace FA, Haidukewych GJ. Pelvic fractures: part 2. Contemporary indications and techniques for definitive surgical management. J Am Acad Orthop Surg. 2013;21(8):458-68.

8. Rezende R, Avanzi O. Importância do índice anatômico de gravidade do trauma no manejo de fraturas toracolombares do tipo explosão. Rev Col Bras Cir. 2009;36(1):9-13. 9. Gonçalves JM. Soluções para o problema de separação quase completa em regressão logística [dissertação]. Belo Horizonte (MG): Universidade Federal de Minas Gerais; 2008. 10. Menezes GRO, Torres RA, Sarmento, JLR, Rodrigues, MT, Brito LF, Lopes PS, et al. Modelos de regressão aleatória na avaliação da produção de leite em cabras da raça Saanen. R Bras Zootec. 2011;40(7):1526-32. 11. Calland JF, Xin W, Stukenborg GJ. Effects of leading mortality risk factors among trauma patients vary by age. J Trauma Acute Care Surg. 2013:75(3): 501-5. 12. Caterino JM, Valasek T, Werman HA. Identification of an age cutoff for increased mortality in patients with elderly trauma. Am J Emerg Med. 2010; 28(2):151-8. 13. Green P, Woglom AE, Genereux P, Daneault B, Paradis JM, Schnell S, et al. The impact of frailty status on survival after transcatheter aortic valve replacement in older adults with severe aortic stenosis: a single-center experience. JACC Cardiovasc Interv. 2012;5(9):974-81. 14. Nascimento Jr B, Scarpelini S, Rizoli S. Coagulopatia no trauma. Medicina (Ribeirão Preto). 2007;40(4):509-17. 15. Malbrain ML, Cheatham ML, Kirkpatrick A,

Rev. Col. Bras. Cir. 2017; 44(3): 222-230


Corrêa Mortality predictors in patients with pelvic fractures from blunt trauma

230

Sugrue M, Parr M, De Waele J, et al. Results from the International Conference of Experts on Intra-abdominal Hypertension and Abdominal Compartment Syndrome. I. Definitions. Intensive Care Med. 2006;32(11):1722-32. 16. Falcão ALE, Oliveira DG. Hipertensão intraabdominal associada à lesão pulmonar aguda: efeitos sobre a pressão intracraniana. Rev Bras Ter Intensiva. 2011;23(2):117-9. 17. Pereira BMT, Fraga GP. Síndrome compartimental abdominal. In: Colégio Brasileiro de Cirurgiões. Programa de Atualização em Cirurgia (PROACI). Porto Alegre: Artmed/Panamerica; 2013. p.53-73.

18. Gerecht R. The lethal triad. Hypothermia, acidosis & coagulopathy create a deadly cycle for trauma patients. JEMS. 2014;39(4):56-60. Received in: 04/01/2017 Accepted for publication: 12/02/2017 Conflict of interest: none. Source of funding: none. Mailing address: Carla Jorge Machado E-mail: carlajmachado@gmail.com carlajm@ufmg.br

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D O I : 10.1590/

0100- 691201

Original Article

7003002

Evaluation of sepsis treatment with enteral glutamine in rats Avaliação do tratamento da sepse com glutamina via enteral em ratos ISADORA MOSCARDINI FABIANI1; SÉRGIO LUIZ ROCHA, TCBC-PR1. A B S T R A C T Objective: to analyze the influence of glutamine on morphological and histological changes observed in the ileum, lung, kidney and liver of Wistar rats subjected to sepsis. Methods: we induced sepsis by cecal ligature and puncture. We divided the animals in two groups: group A, control, with five animals, and group B, experience, with ten animals that received enteral glutamine two days before sepsis induction. We used histological analysis to rank the injury according to a score dependent on the injury severity and the affected organ. The sum of values assigned to each animal resulted in a final grade. We assessed the villi in the ileum, microgoticular steatosis in the liver, interstitial pneumonitis in the lungs, and vacuolation of the proximal convoluted tubules in the kidneys. Results: cell lysis and destruction of the villi of the ileum were more intense in the control group when compared with animals receiving glutamine. In the kidney, we found more pronounced vacuolization in the proximal convoluted tubules in the control group compared with animals receiving glutamine. Both microgoticular steatosis and interstitial pneumonitis were similar between groups. Conclusion: administration of enteral glutamine prior to sepsis preserved the histological structure. Keywords: Sepsis. Glutamine. Peritonitis. Rats.

INTRODUCTION

systemic arterial hypotension, which remains even after volume resuscitation requiring vasoactive drugs to

S

epsis is the main responsible for death of patients in

maintain a Mean Arterial Pressure (MAP) >90mmHg4.

Intensive Care Units worldwide1. The increase in its

A series of animal models5 are used to

incidence, morbidity and mortality is due to the advances

simulate signs and laboratory findings of sepsis in

in the diagnosis and therapeutics of medicine, which

humans. Induction of sepsis can be done by intravenous

allows the treatment of increasingly severe patients2. In

or intraperitoneal administration of living bacteria or

1991, the American College of Chest Phisicians and the

microbial components, or by models of bowel injury with

Society of Critical Care Medicine established definitions for

subsequent release of microbial flora6. It is important to

the diagnosis of the inflammatory response to infection.

note that rodents are, in general, the animals of choice

Such concepts, in addition to allowing researchers to

for preclinical evaluations. They, however, have good

compare results, facilitated an early diagnosis, as well

resistance to endotoxins, limited vascular accesses,

as the determination of the appropriate prognosis and

blood volume and a cardiocirculatory physiology that is

treatment for each patient2,3.

significantly different from that of humans5.

Systemic inflammatory response syndrome

The systemic response in sepsis is due to the

(SIRS) is a generalized reaction of the organism to non-

activation of the body’s immune system with the release of

necessarily infectious agents, such as trauma, ischemia,

cytokines, the TNF-alpha being the main proinflammatory

burns, hemorrhage, among others. Sepsis, on the other

mediator7. The inflammatory process, in turn, leads to an

hand, is the SIRS caused by infection, which can only be

extensive release of glutamine from its main reservoir,

presumed. A worsening of the sepsis causing organic

the skeletal muscle. Although its synthesis is enhanced,

dysfunction or tissue hypoperfusion is defined as severe

there is still a depletion in its intracellular concentration.

sepsis. Septic shock, finally, is sepsis concomitant with

Even with the great release of this amino acid, there is

1 - Pontifical Catholic University of Paraná, Operative Technique, Curitiba, Paraná State, Brazil. Rev. Col. Bras. Cir. 2017; 44(3): 231-237


Fabiani Evaluation of sepsis treatment with enteral glutamine in rats

232

no increase in its serum concentration, demonstrating

by cecalligature and puncture (CLP); and group B –

its high uptake by the other organs, mainly by the liver

experiment (n=10), which received 0.5g/Kg/day of

and cells of the immune system. That is, the availability of

Resource Glutamine powder, 48 hours prior to sepsis

glutamine may limit essential cellular activities .

induction also by CLP. Before to the procedures, were

8

Studies have shown that various cell types,

anesthetized the animals with intraperitoneally ketamine

such as lymphocytes, macrophages and enterocytes, have

hydrochloride solutions (80 ml/kg) and 2% xilasin (10ml/

increased proliferation as well as improved structural

kg). After anesthetic induction, we performed tricotomy

and physiological maintenance when in culture media

of the operative region and fixated the animal on the

containing glutamine . It is known to modulate cellular

operative tablein supine position. After skin antisepsis

immune function and the production of Cytokines, so

with polyvinylpyrrolidone solution (PVPI), we started a

that, in critical states, its deficiency is associated with

3cm laparotomy at the midline. After exposure of the

impaired immune response and increased susceptibility

cecum, we emptied it of feces by external compression,

to infection, since the exacerbated release of pro-

ligated it with 3-0 cotton suture 1cm distal to the ileo-

inflammatory molecules results in increased intestinal

cecal valve, without occluding the intestinal transit, and

permeability .

performed two transfixing punctures with a 40x12mm

9

10

The

intestinal

epithelial

cells

have

their

needle. Then, we re-inserted the cecum into the

proliferation, migration, differentiation and apoptosis

abdominal cavity and the sutured abdominal incision

affected by the organism’snutritional state. Glutamine

with 3-0 silk. After 48 hours, we euthanizedthe animals

acts as a trophic agent for the enterocytes, maintains the

with intraperitoneal Thiopental Sodium at a dose of

integrity of the mucosa and, therefore, decreases the

180mg/kg, until the animal had cardiorespiratory arrest.

chance of breakage of the intestinal barrier . Therefore, it

Then we harvested the right lung, right kidney, liver and

prevents bacterial translocation, preventing the spread of

proximal and distal ileum for histological analysis. We

microorganisms . It is thus evident that administration of

used hematoxylin-eosin (HE) staining for the organs’

glutamine may be useful in the treatment of sepsis, but its

histological analysis.

10

7,9

dose, means and time of administration are not yet defined.

For subsequent biostatistics, were classified the

The objective of this study is to analyze the

lesions according to a score in which we attributed 0to

response of sepsis induced by cecum ligation and

absent lesions, 1 to mild lesions and value 2 to severe

puncture in rats previously treated with enteral glutamine,

ones. The lesions in the ileum were multiplied by 3, the

by evaluating intestinal, renal, hepatic and pulmonary

ones in the kidneys by 2, and the lesions in the lung and

histological changes.

liver, by 1. In the ileum were evaluated hypoxia signs, in the liver, microgoticular steatosis, in the lung, interstitial

METHODS

pneumonitis, and in the kidney, the vacuolization of the proximal convoluted tubules. The sum of all values

The present study was based on the project

attributed to each animal resulted in its final grade.

“Therapeutic Interventions in Experimental Sepsis”, of

For the total score of each animalwe used the

Prof. Dr. Sérgio Luiz Rocha. The project was submitted

following formula: Organ X Injury Severity = Injury Value;

to the Ethics Committee on Animal Use (CEUA) of

Sum of Injury Values = Animal Score.

PUCPR and was approved in 2014 under Protocol 893A.

We described theanimals’ total scores by averagesand standard deviations, medians, minimum and

We used 15 Wistar rats, weighing between

maximum values. We used the non-parametric Mann-

250 and 350 grams. We allocated the animals to two

Whitney test to compare the groups in relation to the final

groups: Group A – control (n=5), submitted to sepsis

score. Values of p<0.05 indicated statistical significance.

Rev. Col. Bras. Cir. 2017; 44(3): 231-237


Fabiani Evaluation of sepsis treatment with enteral glutamine in rats

233

Figure 1. Histological analysis of the Ileus (20X magnification).

A) with glutamine;

B) without glutamine.

RESULTS

observations, it was possible to assign scores to each of the animals taking into account the organs in which there was

In the histological evaluation, we found cell lysis and villi destruction in the control group to be

a greater difference between the groups and the severity of the respective lesions found (Table 1).

significantly more intense compared with animals receiving

Since one animal from the control group and one

previousglutamine supplementation (Figure 1). Among the

animal from the experiment group diedduring the research,

other organs observed, the kidney presented the second

we reached the final scores presented in table 2, with the

greater difference between groups. Proximal convoluted

experiment group clearly showing lower scores. In the

tubule vacuolation was significantly more pronounced

biostatistical analysis by the Mann-Whitney non-parametric

in the control group compared with animals receiving

test, we tested the null hypothesis that the results of the score

glutamine (Figure 2). In the liver, the microgoticular

are equal in both groups, versus the alternative hypothesis

steatosis and, in the lungs, the interstitial pneumonitis

of different results. The result of the statistical test indicated

observed were similar between the groups. With these

the rejection of the null hypothesis (p=0.008). Thus, we

Figure 2. Histological analysis of the kidney (20X magnification).

A) with glutamine;

B) without glutamine. Rev. Col. Bras. Cir. 2017; 44(3): 231-237


Fabiani Evaluation of sepsis treatment with enteral glutamine in rats

234 Table 1. Values of lesions according to the affected organ and the degree observed.

Site of injury/degree of injury

Ileum (3)

Rim (2)

Liver (1)

Lung (1)

Absent (0)

0

0

0

0

Discrete (1)

3

2

1

1

Severe (2)

6

4

2

2

can state that there is a significant difference between the

that intense release of glutamine from skeletal muscle

control and experiment groups regarding the score.

and lungs takes place. The intestine, strangely enough, absorbs it less and less, while the liver and the immune

DISCUSSION

system become its main consumers13. Glutamine plays a central role in the immune

The model used for the induction of sepsis in

system cells, being a precursor of nucleotides and other

the present study was the cecum ligature and puncture,

molecules and contributing to the modulation of the

widely used in the study of sepsis, since its main

function of macrophages and leukocytes, by reducing the

advantage is its rapid performance and low cost. Because

concentration of cytokines13.

sepsis is caused by a surgical procedure, there is no need

This amino acid is a key element for the

to culture or count bacteria to cause sepsis. In addition,

proliferation of intestinal epithelial cells and may be an

this model represents the contamination by mixed flora,

essential substance for intestinal homeostasis during

presenting important similarity with cases of appendicitis

catabolic states. Glutamine-depleted enterocytes have

and perforated diverticulitis. The main disadvantage of

been shown to gradually atrophy and sustain decrease

this method is the difficulty of controlling the severity of

in epithelial proliferation. If these enterocytes have

the induced sepsis. In studies using small rodents, this

their glutamine levels reestablished, signaling of the

problem can be solved by searching for a larger sample5.

mammalian target of rapamycin (mTOR) protein occurs,

Another issue to be raised regarding sepsis

in order to regain the proliferation and regeneration of

induction models is that the natural history observed

the affected mucosa14.

in laboratory animals will often be distinct from that of

mTOR is a key mediator in the union of

humans. In humans, the main cause of death from sepsis

glutamine metabolism and intestinal cell activation. It

is multiple organ dysfunction, whereas in animal models

ensures cell growth only at the right moment, ie when

death may occur within the first 6-12 hours and may not

the cell has all the necessary nutrients15. It promotes

correspond to clinically observed outcomes. In addition,

growth in response to the presence of nutrients (amino

the agents to be researched are usually administered

acids and nitrogen), which leads to the activation of

before or shortly after the occurrence of sepsis induction,

mTOR on the surface of lysosomes. Recently, it has been

a condition that is difficult to apply in the daily clinic5.

discovered that the communication between amino acid

Glutamine is a non-essential amino acid that

levels and mTOR is done by means of a complex called

plays a key role in the biosynthesis of cellular metabolites

Npr2Complex. When nutrients are available, mTOR is

(nucleotides, glutathione and NAD+), which stimulate cell

activated so that glutamine can be used for biosynthesis.

proliferation11. It is a limiting factor for the production

In cases of nutrient depletion, mTOR remains inactive11.

of proteins necessary for the inflammatory response and

In addition to its immune function, glutamine

is essential for the synthesis of glutathione (antioxidant

is the preferred energetic source of enterocytes and its

molecule)12. When sepsis affectsan organism, the

depletion eventually affects the cellularity of the intestinal

metabolism of glutamine in each organ is altered, so

mucosa, contributing to alterations in the barrier function

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Fabiani Evaluation of sepsis treatment with enteral glutamine in rats

235

Table 2. Final scores of each animal.

Control Group

Group Experiment

Number of mouse

Score

Number of mouse

Score

10

12

3

4

11

9

4

7

12

12

5

7

16

Died

6

10

17

12

7

7

8

Died

9

7

13

7

14

9

15

7

of the digestive epithelium, resulting in predisposition

Although the antioxidant effects observed by

to bacterial translocation and, consequently, to sepsis.

the parenteral route are not clearly demonstrated in the

Thus, the supplementation of this amino acid can

enteral use, its intestinal trophic effects justify the use

interfere in the following processes: (I) increasing the

of glutamine in severely burned and polytraumatized

synthesis of glutathione, potentiating the antioxidant

patients, since it reduces the incidence of bacteremia, but

defenses; (II) maintaining the integrity of the intestinal

its use for septic patients is still subject to debate. The

mucosa, since it is an important energy source for

recommended dose of glutamine for such patients by

enterocytes; (III) enhancing the synthesis of inflammatory

the Federal Council of Medicine is 0.3 to 0.5 g/kg/day of

responseprotein, attenuating the inflammatory process;

supplemental glutamine divided into two or three doses.

and (IV) preserving the immune function, serving as an

Recent studies, however, suggest that better effects can

energy source for lymphocytes and cytokineprecursors .

be achieved at higher doses, from 0.5 to 0.7 g/kg/day17.

Findings about regulatory functions and the

As enteral glutamine is safe and improves gastrointestinal

contribution of glutamine to the body in stressful situations

tolerance, we opted for using 0.5 g/kg/day, a dose that

become more and more frequent. For septic patients,

is safe and shows greater efficacy for intestinal trophic

most studies involve the use of parenteral glutamine in

actions, an evaluation that our study aimed at.

12

the form of a dipeptide (because it is more soluble and

A randomized study published in the New

more stable). When glutamine is administered enterally,

England Journal of Medicine, in 2013, has raised a number

the observed benefits are not the same. This is due to

of doubts in the use of glutamine and has further associated

the first-pass metabolism in the enterocyte and liver, in

it with an increased mortality of critically ill patients with

which it serves as an energy source or precursor to other

multiple organ failure. The authors themselves pointed out

amino acids. Therefore, the mode of administration may

as possible cause of these results the use of a high dosage

be decisive in obtaining systemic effects. In the present

of glutamine, 30 grams per day, higher than the maximum

study, we used the enteral route precisely because it had

already used in studies up to that time18.

a more targeted action on the intestinal mucosa, allowing

In our histological analysis, we found different

histological evaluation of its action and efficacy in relation

lesion degrees between the glutamine group and the

to bacterial translocation .

control group. Sepsis is associated with tissue oxygenation

16

Rev. Col. Bras. Cir. 2017; 44(3): 231-237


Fabiani Evaluation of sepsis treatment with enteral glutamine in rats

236

abnormalities, which may arise due to inadequate oxygen

acute renal injury in sepsis, which results from a decrease

distribution at microregional levels. This tends to cause

in oxygen levels, inducing apoptosis, damage to tubular

tissue damage and, later, multiple organ dysfunction .

epithelial cells, and tubular necrosis if the condition is

19

We observed a morphology suggestive of early

prolonged. Pinto et al.20, when histologically evaluating

ischemic lesions in the animals’small intestines, which were

kidneys of adult rats submitted to sepsis induction by

more severe in the ones that did not receive glutamine.

cecum ligation and puncture, observed edema, diffuse

Sepsis and septic shock cause a significant decrease in

interstitial inflammatory infiltrate, flattened tubular cells

systemic vascular resistance and a redistribution of blood

with lumen dilation and bare basement membrane in the

flow out of the splanchnic circulation, compromising the

cortical region. They concluded that acute renal injury

mucosa, which, in association with the hypermetabolic

caused by sepsis results from an association of renal

state characteristic of sepsis, makes small intestine villi the

vasoconstriction of hemodynamic and inflammatory

main target of the ischemic lesion. Due to hypoperfusion

origin, characterized by endothelium damage and

of the region, there is also depletion in the extraction

hemodynamic

and utilization of nutrients, mainly amino acids such as

mediators and generation of reactive oxygen species by

glutamine. The latter is decreased in sepsis or endotoxemia,

tubular cells.

dysfunction,

increased

inflammatory

and may cause local metabolic changes and contribute

We did not assess vital signs and other dynamic

to mucosal atrophy. There are also changes in the red

patterns in the present study. However, previous enteral

blood cell density, as well as in its average passage speed

glutamine supplementation ameliorates the histologically

through the capillaries, increasing the development of

observed lesions in villi of the small intestine and renal

areas of hypoxia and cellular injury .

cortex in sepsis-induced animals.

19

The kidneys were the organs in which

Further studies are needed to define the best

we observed the second largest variation of tissue

dose to be used enterally and whether this is in fact

involvement between the groups. In them, we found

beneficial in terms of mortality, since the animals were

vacuolation of the proximal tubules. Although numerous

sacrificed, not allowing such a comparison. There is still

studies have already been proposed to try to elucidate

much to elucidate about sepsis’causative mechanisms

the induction of acute kidney injury by sepsis, the exact

and possible treatments12,18,19.

mechanism of sepsis has not yet been elucidated. Among

We conclude that rats receiving enteral

the possibilities are vasodilatation that induces glomerular

glutamine for 48 hours and then submitted to sepsis

hypoperfusion, inflammation, oxidative lesions and

by ligature and cecal puncture presented significant

tubular dysfunction. What is known is that renal tissue

preservation of the intestinal wall and kidney structure.

ischemia and reperfusion represent the main cause of

In the lungs and liver, there was no significant difference.

R E S U M O Objetivo: analisar a influência da glutamina nas alterações morfo-histológicas observadas em íleo, pulmão, rim e fígado de ratos Wistar submetidos à sepse. Métodos: a sepse foi induzida por meio de ligadura e punção do ceco. Os animais foram divididos em dois grupos: grupo A, controle, com cinco animais, e grupo B, experimento, com dez animais que utilizaram previamente glutamina por dois dias por via enteral. Na análise histológica, classificou-se as lesões de acordo com um escore cujo valor atribuído dependia da gravidade da lesão e do órgão acometido. A somatória dos valores atribuídos a cada animal resultou em sua nota final. No íleo, avaliaram-se as vilosidades; no fígado, esteatose microgoticular; no pulmão, pneumonite intersticial; e no rim, vacuolização dos túbulos contorcidos proximais. Resultados: a lise celular e a destruição das vilosidades no íleo do grupo controle foram mais intensas em relação aos animais que receberam glutamina. No rim, verificou-se vacuolização mais acentuada dos túbulos contorcidos proximais no grupo controle em relação aos animais que receberam glutamina. Tanto a esteatose microgoticular como a pneumonite intersticial mostraram-se semelhantes em ambos os grupos. Conclusão: o uso de glutamina via enteral previamente à sepse na dose de 0,5 g/kg/dia preservou de maneira significativa a estrutura histológica do intestino delgado e os rins em ratos. Descritores: Sepse. Glutamina. Peritonite. Ratos.

Rev. Col. Bras. Cir. 2017; 44(3): 231-237


Fabiani Evaluation of sepsis treatment with enteral glutamine in rats

237

REFERENCES 1. Andrade J, Júnior LS, David CM, Hatum R, Souza PCSP, Japiassú A, et al. Sepse Brasil: estudo epidemiológico da sepse em Unidades de Terapia Intensiva brasileiras. Rev Bras Ter Intensiva. 2006;18(1):9-17. 2. Carvalho PRA, Trotta EA. Avanços no diagnóstico e tratamento da sepse. J Pediatr (Rio J). 2003;79(Suppl 2):S195-S204. 3. Salles MJC, Sprovieri SRS, Bedrikow R, Pereira AC, Cardenuto SL, Azevedo PRC, et al. Síndrome da resposta inflamatória sistêmica/sepse – revisão e estudo da terminologia e fisiopatologia. Rev Ass Med Bras. 1999;45(1):86-92. 4. Martins HS, Brandão Neto RA, Scalabrini Neto A, Valesco IT. Emergências clínicas: abordagem prática. 8a ed. São Paulo: Manole; 2013. 5. Garrido AG, Figueiredo LFP, Silva MR. Experimental models of sepsis and septic shock: an overview. Acta Cir Bras. 2004;19(2):82-8. 6. Benjamim CF. Atualização sobre mediadores e modelos experimentais de sepse. Medicina, Ribeirão Preto. 2001;34(1):18-26. 7. Kesici S, Turkmen UA, Kesici U, Altan A, Polat E. Effects of enteral and parenteral glutamine on intestinal mucosa and on levels of blood glutamine, tumor necrosis factor-alpha, and interleukin-10 in an experimental sepsis model. Saudi Med J. 2012;33(3):262-71. 8. Karinch AM, Pan M, Lin CM, Strange R, Souba WW. Glutamine metabolism in sepsis and infection. J Nutr. 2001;131(9):2535S-8S. 9. Cruzat VF, Petry ER, Tirapegui J. Glutamina: aspectos bioquímicos, metabólicos, moleculares e suplementação. Rev Bras Med Esporte. 2009;15(5):392-7. 10. Santos RGC. A ação da glutamina no processo de translocação bacteriana em modelo experimental de obstrução intestinal em camundongos [dissertação]. Belo Horizonte (MG): Universidade Federal de Minas Gerais; 2007. 11. Laxman S, Sutter BM, Shi L, Tu BP. Npr2 regulates cellular utilization of glutamine for biosynthesis of nitrogen-containing metabolites through TORC1. Sci Signal. 2015;7(356):ra120. 12. Pacífico SL, Leite HP, Carvalho WB. A suplementação de glutamina é benéfica em crianças com doenças graves? Rev Nutr. 2005;18(1):95-104.

13. Garrett-Cox RG, Stefanutti G, Booth C, Klein NJ, Pierro A, Eaton S. Glutamine decreases inflammation in infant rat endotoxemia. J Pediatr Surg.2009;44(3):523-9. 14. Moore SR, Guedes MM, Costa TB, Vallance J, Maier EA, Betz KJ, et al. Glutamine and alanyl-glutamine promote crypt expansion and mTOR signaling in murine enteroids. Am J Physiol Gastrointest Liver Physiol. 2015:308(10):G831-9. 15. Efeyan A, Zoncu R, Sabatini D. Amino acids and mTORC1: from lysosomes to disease. Trends Mol Med. 2012;18(9):524-33. 16. Associação de Medicina Intensiva Brasileira, Sociedade Brasileira de Infectologia, Sociedade Brasileira de Nutrição Parenteral e Enteral, Instituto Latino Americano de Sepse. Diretrizes clínicas na saúde suplementar. Sepse: nutrição. São Paulo: AMB/ANS; 2011. 17. Sociedade Brasileira de Nutrição Parenteral e Enteral; Associação Brasileira de Nutrologia. Projeto diretrizes. Terapia nutricional no paciente grave. São Paulo: AMB/CFM; 2011. 18. Heyland D, Muscedere J, Wischmeyer PE, Cook D, Jones G, Albert M, et al. A randomized trial of glutamine and antioxidants in critically ill patients. N Engl J Med. 2013;368(16):1489-97. 19. Tramonte R, Carvalho ROM, Farias DC, Serafim JDM, Ortellado DK, d’Acampora AJ. Alterações da mucosa intestinal em ratos: estudo morfométrico em três diferentes tratamentos após indução experimental de sepse abdominal aguda. Acta Cir Bras. 2004;19(2):120-5. 20. Pinto CF, Watanabe M, da Fonseca CD, Ogata CI, Vattimo Mde F. [The sepsis as cause of acute kidney injury: an experimental model]. Rev Esc Enferm USP. 2012;46(spe):86-90. Portuguese. Received in: 03/11/2016 Accepted for publication: 22/12/2016 Conflict of interest: none. Source of funding: none. Mailing address: Isadora Moscardini Fabiani E-mail: isadoramf94@gmail.com

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D O I : 10.1590/

Original Article

0100- 6912017003003

Conventional inguinal hernia repair with self-fixating mesh versus totally extraperitoneal laparoscopic repair with polypropylene mesh: early postoperative results Herniorrafia inguinal convencional com tela autofixante versus videolaparoscópica totalmente extraperitoneal com tela de polipropileno: resultados no pós-operatório precoce JOSÉ ANTONIO CUNHA-E-SILVA1; FLÁVIO MALCHER MARTINS DE OLIVEIRA, TCBC-RJ1; ANTONIO FELIPE SANTA MARIA COQUILLARD AYRES, TCBC-RJ1; ANTONIO CARLOS RIBEIRO GARRIDO IGLESIAS, TCBC-RJ1. A B S T R A C T Objective: to evaluate the early postoperative results of inguinal hernia repair by the conventional technique with self-fixating mesh versus laparoscopic totally extraperitoneal repair with polypropylene mesh. We compared pain, surgical time and early complications. Methods: this is a prospective, case-series study of 80 consecutive patients treated in the surgical clinic of the Gaffrée e Guinle University Hospital (HUGG). We included patients with unilateral inguinal hernia, not relapsed and operated only on an elective basis. We divided patients into two groups of 40 patients each, SF group (conventional technique using self-fixating mesh) and LP group (laparoscopic technique with polypropylene mesh). We followed patients up until the 45th postoperative day. Results: of the 80 patients, 98.7% were male and the majority had indirect right inguinal hernias (Nyhus II). There was no difference between the groups studied in respect to pain and operative time. However, more complications occurred (seroma and hematoma) in the open surgery group. Conclusion: both operations have proved feasible, safe and with minimal postoperative pain and a low operating time. Keywords: Hernia, Inguinal. Laparoscopy. Visual Analog Scale. Herniorrhaphy.

INTRODUCTION

recovery time5,10. Minimally invasive techniques can be performed either totally extraperitoneally (TEP) or through

C

urrently herniorrhaphy is the most performed

transabdominal preperitoneal (TAPP) access.

surgical procedure in the world . More than

Technological advances have also allowed the

800,000 patients undergo the procedure annually in the

development of different types of surgical mesh, such

United States (USA) . In Brazil, according to data from

as with resorbable material, self-fixating adhesives, low

the Ministry of Health, approximately 115,598 inguinal

weight and fixation with fibrin glue3,11,12. This large arsenal

herniorrhaphies were performed between January 2014

of available material, associated with a wide variety of

and June 2015 .

techniques (open or laparoscopic), raises questions about

1-5

1,2

6

Since 1887, when Bassini published her first 7

the gold standard for the treatment of inguinal hernia.

knowledge about the surgical repair of hernias of the

In view of the high incidence of this disease in

inguinal region, several operations have been described

the world, and lack of consensus on the best procedure

for the surgical treatment of this disease . Of the

or mesh5,13, the aim of this study was to compare the early

techniques of open repair, the Lichtenstein procedure8,

postoperative period results between two techniques

with fixation of polypropylene mesh for a tension-free

of herniorrhaphy, especially in relation to pain, surgical

repair, is the one in greater use currently . Laparoscopic

time and early complications. The first one represents

herniorrhaphy, on its turn, has been gaining strength

a classic technique, however, using a new type of

lately, as it causes less pain and shorter postoperative

surgical mesh, namely inguinal herniorrhaphy based on

3

3,9

1 - Gaffrée e Guinle University Hospital (UNIRIO), Rio de Janeiro, Rio de Janeiro State, Brazil. Rev. Col. Bras. Cir. 2017; 44(3): 238-244


Cunha-e-Silva Conventional inguinal hernia repair with self-fixating mesh versus totally extraperitoneal laparoscopic repair with polypropylene mesh: early postoperative results

239

the repair of Lichtenstein with the use of a self-fixating

cases where there was great destruction of the inguinal

mesh. The second applies a technique represented by

canal’s posterior wall, we performed reconstruction of

minimally invasive access, but with the use of the classic

the floor with separate stitches of polyglactin 910.

polypropylene mesh (totally extraperitoneal laparoscopic Totally extraperitoneal laparoscopic hernioplasty

inguinal herniorrhaphy using the polypropylene mesh).

(VL group):

METHODS

Under general anesthesia, we made a 10-mm infra-umbilical incision, through which we incised the

This is a case series study performed at the

anterior sheath of the rectus abdominis muscle ipsilateral

Surgery Clinic A of the Gaffrée e Guinle University

to the location of the hernia. After lateral removal of the

Hospital (HUGG) from August 2011 to August 2014.

musculature to expose the preperitoneal space, we inserted

We defined sampling by convenience in the formation of

a 10-mm trocar with CO2 insufflation at 8-10 mmHg for

groups. In total, we divided 80 patients into two groups

the pre-pneumoperitoneum. With the introduction of 30o

of 40 individuals each: SF group, represented by those

optics by this initial trocar and the dissection of the midline

submitted to open herniorrhaphy using a self-fixating

to the anterior superior iliac spine, it was possible to create

mesh, and VL group, referring to the patients operated

a pre-peritoneal “work space” filled with CO2. We inserted

by video-laparoscopy.

two other 5-mm trocarsin the midline under direct vision,

Inclusion criteria were patients older than 18

which allowed the dissection and correction of the hernia

years with unilateral inguinal hernia and operated on

defect. We positioned a 15x10cm polypropylene mesh,

electively. Exclusion criteria comprised incarcerated and

without any fixation, in this space. Once we removed the

relapsed hernias, patients using systemic steroids, those

pre-penumoperitoneum, the mesh remained confined to

with complaints or evidence of prostatism, and those

the dissected bed19.

who refused to participate in the survey.

Postoperative analgesia was similar between

Several surgeons, all with previous experience

groups and was restricted to the administration of non-

in minimally invasive surgery and members of the clinical

steroidal anti-inflammatory drugs (intravenous tenoxicam

body of HUGG’s Surgery Clinic A, participated in the

20mg 12/12 hours). Rescue analgesia was performed,

operations. All patients received antibiotic prophylaxis

when necessary, with intravenous dipyrone 1g in up to six

with 1g of Cephalothin intravenously, 30 minutes before

daily administrations. We evaluated postoperative pain in

the incision.

two moments: the first (T1) six hours after the end of the operation, and the second (T2), at the time of hospital

Conventional Inguinal Hernioplasty (SF group):

discharge. We estimated pain with the visual analogue

Under spinal anesthesia with sedation and

scale (VAS), considering values from 0 to 2 as mild pain

following the basic principles of the Lichtenstein technique ,

intensity, from 3 to 6 as moderate intensity, and from 7

we used a self-fixating mesh for tension-free repair of the

to 10, as severe pain14,19.

8

hernia. The self-fixating mesh is a low molecular weight

Other variables evaluated in this study were

mesh, having a number of small, absorbable hooks on

gender, age, laterality, Nyhus classification, operative time

one of its faces, therefore dispensing with any additional

and operative complication rate. We followed the patients

attachment. These are made of polylactic acids that

for an average of 45 days from the operation, and performed

degrade as soon as their integration with the underlying

two revision visits: the first in the 15th postoperative day, and

connective tissue occurs14-18. In this study, this we placed

the second, 30 days after the first revision.

mesh on the posterior wall of the inguinal canal, passing

The study was approved by the HUGG Ethics in

the pubis, the ileopubic tract and the joint tendon. In

Research Committee (protocol CAAE 02697412.3.0000.5258)

Rev. Col. Bras. Cir. 2017; 44(3): 238-244


240

Cunha-e-Silva Conventional inguinal hernia repair with self-fixating mesh versus totally extraperitoneal laparoscopic repair with polypropylene mesh: early postoperative results

and the included patients agreed to participate in the study

Nyhus IIIa (25%) when compared to the VL group (45%).

after signing an Informed Consent Form.

On the other hand, in the Nyhus IIIb classification, the

We calculated the difference between the

SF group had a higher value (17.5%) when compared to

relative frequencies of the variables of interest using the

the VL group (5%). However, both differences were not

chi-square test and the Fisher’s exact test (two-sided), and

statistically significant (Table 1).

the differences of means with the student’s t-test. We

Regarding pain stratification, there was no

used the Excel 2010 software and the SPSS 17.0 (Statistical

significant difference between the groups in both moments

Package for Social Science - Chicago, IL, 2008) for the

evaluated. The evaluation of pain revealed that, in T1,

analysis. Statistical significance was considered at p<0.05.

67.5% of the SF group and 60% of the VL group had mild pain; Moderate pain occurred in 30% of the SF group

RESULTS

and 37.5% of the VL group; And 2.5% of both groups classified pain as intense. In T2, at the time of hospital

Regarding the clinical-epidemiological data, the

discharge the results were identical: 75% classified as

majority of patients were male (98.7%). The age ranged

having mild intensity pain (values 0-2 for EVA) and 25%

from 18 to 90 years, and the values were similar in the

with moderate intensity pain (values 3-6 for EVA) (Table 2).

two groups evaluated, as shown in Table 1. The right

However, as for the need of rescue analgesia, 17 patients

inguinal hernia was more frequent and responded by

from the SF group requested it at least once, whereas in

67.5% of the cases (54 patients), displaying homogeneity

the VL group only nine patients had this need (Table 2).

between groups (SF group= 65% and VL group= 70%)

Regarding operative time, there was no

(Table 1). As to the Nyhus classification, we observed a

difference with statistical significance between the

predominance of indirect hernias, 53.7% of them being

studied groups (Table 2); In both groups 87.5% of the

classified as Nyhus II (43 cases), followed by Nyhus IIIa

operations were performed in up to 50 minutes.

(n=28, 35%) and finally Nyhus IIIb (9, 11.3%). The SF

There was no death among the patients

group presented a lower number of cases classified as

studied. The observed complications all occurred in the

Table 1. General characteristics, classification and laterality according to surgical groups.

SF Group n=40 (%)

VL Group n=40 (%)

p value (<0.05)

1 (2.5)

0 (0.0)

39 (97.5)

40 (100.0)

0.98

56.9 ± 15.7

55.8 ± 15.2

0.76

Right

26 (65.0)

28 (70.0)

Left

14 (35.0)

12 (30.0)

Nyhus II

23 (57.5)

20 (50.0)

Nyhus IIIa

10 (25.0)

18 (45.0)

Nyhus IIIb

7 (17.5)

2 (5.0)

Gender Female Male Age (descriptive measures) Average ± SD* Laterality

0.81

Classification

* SD: standard deviation. Rev. Col. Bras. Cir. 2017; 44(3): 238-244

0.07


Cunha-e-Silva Conventional inguinal hernia repair with self-fixating mesh versus totally extraperitoneal laparoscopic repair with polypropylene mesh: early postoperative results

241

Table 2. Assessment of pain, surgical complications and operative time according to surgical groups.

SF Group n = 40 (%)

VL Group n = 40 (%)

p value (< 0.05)

Mild

27 (67.5)

24 (60.0)

0.91

Moderate

12 (30.0)

15 (37.5)

1 (2.5)

1 (2.5)

Mild

30 (75.0)

30 (75.0)

Moderate

10 (25.0)

10 (25.0)

0 (0.0)

0 (0.0)

0

23 (57.5)

31 (77.5)

1

13 (32.5)

9 (22.5)

2

4 (10.0)

0 (0.0)

20-49

35 (87.5)

35 (87.5)

= 50

5 (12.5)

5 (12.5)

33 (82.5) 5 (12.5)

40 (100.0) 0 (0.0)

Hematoma

2 (5.0)

0 (0.0)

Surgical wound infection

0 (0.0)

0 (0.0)

Pain-T1 *

Severe Pain-T2 **

Severe

0.98

Rescue analgesia 0.17

Operative time (min.) 0.98

Surgical complications Without complications Seroma

0.02

* six hours after the procedure; **on hospital discharge

SF group, in those patients whose operative time was

economic impact. Thus, it is fundamental to choose a

over 50 minutes, so that five patients (12.5%) presented

technique that, in addition to a low rate of relapse and

seroma and two others (5%) had hematoma, a result that

complications, is associated with a faster recovery, with

showed a statistical significance (p=0.02).

an early resumption of labor activities5,20,21. In our study, there was a predominance of

DISCUSSION

male patients, most of whom present with hernia Nyhus type II3,19,22,23. The most frequent topography was to the

In addition to the medical aspect related to

right, which is expected due to the delay in atrophy of

the high incidence of inguinal hernias, there is a relevant

the peritoneal-vaginal conduit on this side, associated to

economic aspect in the treatment of this disease. It is

the tamponade exerted by the sigmoid colon on the left

estimated that the 800,000 inguinal herniorrhaphies

inguinal canal.

performed in the USA carries about ten million unworked days per year

Although we know the difficulty of measuring

. Although this cost is difficult to

postoperative pain due to its subjective nature, we used two

estimate, it is obviously a huge expense and with great

methods to quantify it: the numerical scale of pain and the

5,20

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Cunha-e-Silva Conventional inguinal hernia repair with self-fixating mesh versus totally extraperitoneal laparoscopic repair with polypropylene mesh: early postoperative results

242

patient’s need for rescue analgesia1,6,8,11,12,14,15,19. Although

not an increasing factor of the operative time. Although

there was no difference between the groups regarding

in some series laparoscopic access is associated with

the pain scale, with 97.5% of the patients reporting mild

longer surgery duration5,10, it is known that the surgeon’s

to moderate pain and only one patient with severe pain in

experience is inversely proportional to the operative time

both groups, we noticed that the patients in the SF group

in laparoscopic herniorrhaphy26-28. In the present study,

requested more doses of analgesics than in the VL group,

surgeons with expertise in the method performed the

although this fact is also devoid of statistical significance.

laparoscopic procedures, which justifies the low operative

The analysis of pain behavior between the two

time. We observed no intraoperative complications in both

groups is difficult because three factors are directly involved:

techniques and there was no conversion to conventional

the different techniques used (open vs. laparoscopic), the

surgery when using the minimally invasive technique.

different meshes used and the non-fixation of the mesh.

No “severe complication” occurred in the

In the same way that laparoscopic repair seems to be

immediate or late postoperative period, but we observed

associated with less postoperative pain

local “small complications” in seven cases of the SF

, the use of the

5,10

self-fixating mesh also confers this benefit

. Perhaps

group, represented by seroma and hematoma, as

these points were balanced against reducing pain in the

reported in table 2. All of them were resolved with non-

two groups analyzed. Non-fixation of the mesh is also to

surgical treatment and there were no cases of surgical

be emphasized, since some series indicate that the non-

wound infection. However, we should note that all these

use of sutures or staples is related to less postoperative

“small complications” occurred in the group submitted to

pain

. However, these are still the subject of debate,

open surgery with more than 50 minutes duration. Thus,

requiring studies that are more robust. Esteban et al

it is worth asking whether there is a direct relationship

3

conducted a prospective study with 90 patients submitted

between a higher risk of local complications in patients

to Lichtenstein herniorrhaphy with self-fixating mesh versus

undergoing

classic polypropylene mesh (and fixed with monofilament

laparoscopy exerts any protective factor and whether the

suture) and did not find difference between the groups.

self-fixating mesh may have influenced this process. It is

3,17

24,25

Regarding operative time, we divided the analysis into two groups: surgical time <50min and

long-lasting

open

surgery,

whether

not possible to establish this relationship with the data obtained, and further studies are necessary.

surgical time ≥ 50 min. We observed that time was

In conclusion, although it is still not possible

identical between the two groups, so that 87.5% of the

to determine which gold standard technique (best cost-

patients were operated in less than 50 minutes. In addition

effectiveness) to be routinely employed in the repair of inguinal

to the use of the self-fixating mesh being responsible for

hernias, we observed that the two operations performed

the reduction of surgical time, as already verified by some

were feasible, safe and related to minimal postoperative pain

series

and to low surgical time in experienced hands.

3,17

, we emphasize that laparoscopic repair was R E S U M O

Objetivo: avaliar o resultado no pós-operatório precoce do tratamento da hérnia inguinal pela técnica convencional com tela autofixante versus videolaparoscópica totalmente extraperitoneal com uso da tela de polipropileno. Foram comparados, sobretudo, dor, tempo cirúrgico e complicações precoces. Métodos: estudo prospectivo, de série de casos, realizado na Clínica Cirúrgica A, do Hospital Universitário Gaffrée e Guinle (HUGG), no qual 80 casos consecutivos foram estudados. Apenas pacientes com hérnia inguinal unilateral, não recidivada e operadas em caráter eletivo foram incluídas no estudo. Os pacientes foram divididos em dois grupos, de 40 pacientes cada; grupo AF (técnica convencional com uso de tela autofixante) e grupo VL (técnica videolaparoscópica com uso de tela de polipropileno). Os pacientes foram acompanhados até o 45o dia de pós-operatório. Resultados: dos 80 pacientes operados no estudo, 98,7% pertenciam ao sexo masculino e a maioria era portadora de hérnia inguinal direita indireta (Nyhus II). Não houve diferença entre os grupos estudados no que diz respeito à dor e tempo operatório. No entanto, ocorreram mais complicações (seroma e hematoma) no grupo da cirurgia aberta. Conclusão: as duas operações realizadas se mostraram factíveis, seguras e estão relacionadas à mínima dor pós operatório e a um baixo tempo cirúrgico. Descritores: Hérnia Inguinal. Laparoscopia. Escala Visual Analógica. Herniorrafia.

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Cunha-e-Silva Conventional inguinal hernia repair with self-fixating mesh versus totally extraperitoneal laparoscopic repair with polypropylene mesh: early postoperative results

REFERENCES

243

hernia: outcome and cost. BMJ. 1998; 317(7151):10310. Erratum in: BMJ. 1998;317(7159):631.

1. Paajanen H, Varjo R. Ten-year audit of Lichtenstein

13. Millikan KW, Deziel JD. The management of hernia.

hernioplasty under local anaesthesia performed by

Considerations in cost effectiveness. Surg Clin North

surgical residents. BMC Surg. 2010;10:24.

Am. 1996;76(1):105-16.

2. Cheek CM, Black NA, Devlin HB, Kingsnorth AN, Taylor

14. García Ureña MÁ, Hidalgo M, Feliu X, Velasco MÁ,

RS, Watkin DF. Groin Hernia Surgery: a systematic

Revuelta S, Gutiérrez R, et al. Multicentric observational

review. Ann R Coll Surg Engl. 1998;80 Suppl1:S1-80.

study of pain after the use of a self-gripping lightweight

3. Bruna Esteban M, Cantos Pallarés M, Sánchez De Rojas

mesh. Hernia. 2015;15(5):511-5.

EA. Utilización de mallas autoadhesivas em la henioplastia

15. Hollinsky C, Kolbe T, Walter I, Joachim A, Sandberg

frente a la técnica convencional. Resultados de un estudio

S, Koch T, et al. Comparison of a new self-gripping

prospectivo y aleatorizado. Cir Esp. 2010;88(4):253-8.

mesh with other fixation methods for laparoscopic

4. Goo TT, Lawenko M, Cheah WK, Tan C, Lomanto D.

hernia repair in a rat model. J Am Coll Surg.

Endoscopic total extraperitoneal repair of recurrent inguinal hernia: a 5-year review. Hernia. 2010;14(5):477-80.

2009;208(6):1107-14. 16. Wang Y, Zhang X. Short-term results of open

5. Hamza Y, Gabr E, Hammadi H, Khalil R. Four-arm

inguinal hernia repair with self-gripping Parietex

randomized trial comparing laparoscopic and open

ProGrip mesh in China: a retrospective study of 90

hernia repairs. Int J Surg. 2010; 8(1):25-8.

cases. Asian J Surg. 2016;39(4):218-24.

6. Millikan KW, Deziel DJ. The management of hernia.

17. Chastan P. Tension-free open hernia repair using

Considerations in cost effectiveness. Surg Clin North

an innovative self-gripping semi-resorbable mesh.

Am.1996;76(1):105-16.

Hernia. 2009;13(2):137-42.

7. Bassini E. sulla cura radicale dell’ernia inguinale. Ach

mesh for the Lichtenstein procedure--a prestudy.

Soc Ital Chir. 1887;4:380-6. 8. Lichtenstein IL, Shulman AG, Amid PK, Montllor MM. The tension free hernioplasty.

18. Kapischke M, Schulze H, Caliebe A. Self-fixating

Am J Surg.

Langenbecks Arch Surg. 2010; 395(4):317-22. 19. Goo TT, Lawenko M, Cheah WK, Tan C, Lomanto D. Endoscopic total extraperitoneal repair of

1989;157(2):188-93. 9. Kingsnorth AN, Porter CS, Bennett DH, Walker AJ, Hyland ME, Sodergren S. Lichtenstein patch or Perfix

recurrent inguinal hernia: a 5-year review. Hernia. 2010;14(5):477-80.

plug-and-patch in inguinal hernia: a prospective

20. Johansson B, Hallerbäck B, Glise H, Anesten B,

double-blind randomized controlled trial of short-

Smedberg S, Román J. Laparoscopic mesh versus

term outcome. Surgery. 2000;127(3):276-83.

open preperitoneal mesh versus conventional

10. Dirksen CD, Beets GL, Go PM, Geisler FE, Baeten CG,

technique for inguinal hernia repair: a randomized

Kootstra G. Bassini repair compared with laparoscopic

multicenter trial (SCUR Hernia Repair Study). Ann

repair for primary inguinal hernia: a randomised

Surg. 1999;230(2):225-31.

controlled trial. Eur J Surg. 1998;164(6):439-47. 11. Lawrence K, McWhinnie D, Goodwin A, Doll H, Gordon A, Gray A, et al. Randomised controlled trial of laparoscopic versus open repair of inguinal hernia: early results. BMJ. 1995;311(7011):981-5. 12. Wellwood J, Sculpher MJ, Stoker D, Nicholls GJ, Geddes

21. Memon MA, Fitzgibbons RJ Jr. Assessing risks, costs, and benefits of laparoscopic hernia repair. Annu Rev Med. 1998;49:95-109. 22. Falci F. Reconstrução do assoalho profundo na reparação da hérnia inguinal direta. Rev Col Bras Cir. 1989;26(6):264-9.

C, Whitehead A, et al. Randomised controlled trial

23. Nyhus LM, Pollak R, Bombeck CT, Donahue PE.

of laparoscopic versus open mesh repair for inguinal

The preperitoneal approach and prosthetic buttress

Rev. Col. Bras. Cir. 2017; 44(3): 238-244


244

Cunha-e-Silva Conventional inguinal hernia repair with self-fixating mesh versus totally extraperitoneal laparoscopic repair with polypropylene mesh: early postoperative results

repair for recurrent hernia. The evolution of a technique. Ann Surg. 1998;208(6):733-7.

27. Champault GG, Rizk N, Catheline JM, Turner R, Boutelier P. Inguinal hernia repair: totally

24. Canonico S, Benevento R, Perna Guerniero R,

preperitoneal laparoscopic approach versus Stoppa

Sciaudone G, Pellino G, Santoriello A, Selvaggi F.

operation: randomized trial of 100 cases. Surg

Sutureless fixation with fibrin glue of lightweight

Laparosc Endosc. 1997;7(6):445-50.

mesh in open inguinal hernia repair: effect on

28. Edwards CC 2nd, Bailey RW. Laparoscopic hernia

postoperative pain: a double-blind, randomized

repair: the learning curve. Surg Laparosc Endosc

trial versus standard heavyweight mesh. Surgery.

Percutan Tech. 2000;10(3):149-53.

2013;153(1):126-30. 25. Canonico S, Santoriello A, Campitiello F, Fattopace

Received in: 26/09/2016

A, Corte AD, Sordelli I, Benevento R. Mesh fixation

Accepted for publication: 19/01/2017

with human fibrin glue (Tissucol) in open tension-

Conflict of interest: none.

free inguinal hernia repair: a preliminary report.

Source of funding: none.

Hernia. 2005;9(4):330-3. 26. Liem MS, van Steensel CJ, Boelhouwer RU, Weidema

Mailing address:

WF, Clevers GJ, Meijer WS, et al. The learning curve

JosĂŠ Antonio Cunha-e-Silva

for totally extraperitoneal laparoscopic inguinal

E-mail: joseantoniocunha@yahoo.com.br

hernia repair. Am J Surg. 1996;171(2):281-5.

joseantoniocunha1984@outlook.com

Rev. Col. Bras. Cir. 2017; 44(3): 238-244


D O I : 10.1590/

0100- 691201

Original Article

7003004

Retrospective analysis of 103 diaphragmatic injuries in patients operated in a trauma center Análise retrospectiva de 103 casos de lesão diafragmática operados em um centro de trauma LUCAS FIGUEIREDO CARDOSO2; MARCUS VINÍCIUS CAPANEMA GONÇALVES2; CARLA JORGE MACHADO1; VIVIAN RESENDE, TCBC-MG1; MICHAEL PEREIRA FERNANDES2; MARIO PASTORE-NETO2; RENATO GOMES CAMPANATI1; GUILHERME VICTOR OLIVEIRA PIMENTA REIS1 A B S T R A C T Objective: to analyze the factors associated with death in patients with diaphragmatic injury treated at a trauma reference hospital. Methods: we conducted a retrospective study of patients with diaphragm injury attended at the Risoleta Tolentino Neves Hospital of the Federal University of Minas Gerais, between January 2010 and December 2014. We used The Collector® database of trauma records (MD, USA). We gathered data on demographics, location of the diaphragmatic lesion, site and number of associated lesions, type of therapeutic approach, complications and Injury Severity Score (ISS). The variable of interest was the occurrence of death. Results: we identified 103 patients and mortality was 16.5%. Penetrating lesions occurred in 98% of patients. Univariate analysis showed a mortality higher in patients whose treatment was non-operative, without closing of the defect (p=0.023), and lower in patients submitted to diaphragmatic suturing (p<0.001). The increase in the number of lesions was associated with an increase in mortality (p=0.048). In multivariate analysis, ISS>24 (OR=4.0, p=0.029) and diaphragmatic suturing (OR=0.76, p<0.001) were associated with mortality. Conclusion: The findings indicate that the traumatic rupture of the diaphragm rarely presents as an isolated lesion, being frequently associated with injuries of other organs, especially the liver and hollow viscera. Mortality was higher among those with ISS>24. Keywords: Diaphragm. Wounds and Injuries. Death.

INTRODUCTION

All thoracic-abdominal penetrating lesions are at increased risk for diaphragmatic rupture1,4. These

T

raumatic rupture of the diaphragm is present in

tend to be smaller, potentially more dangerous because

1% to 7% of victims of blunt thoraco-abdominal

of the risk of going unnoticed and progressing with

trauma and in 10% to 15% of patients with penetrating

diaphragmatic hernia and strangulation in a later stage.

trauma. However, the true incidence is unknown due to

Larger ruptures are more likely to result inintra-abdominal

the presence of undiagnosed lesions1-3. In blunt trauma,

organs herniating into the thoraxin the acute phase, and

there is a sudden increase in abdominal pressure that

the diagnosis is easier both on the left and on the right

may lead to rupture of the muscular or membranous

due to the possibility of following the lesion trajectory

portion of the diaphragm, especially when the trauma

and the observation of contiguous lesions6,9.

is associated with great impact energy2-5. Most of

In trauma acute phase, the clinical examination

these lesions occur in the posterolateral aspect of the

hardly contributes to the diagnosis, and the injury can easily

left side, an area of weakness originating from the

go unnoticed in the primary evaluation, at a frequency

pleuroperitoneal membrane. The right side is more

ranging from 7% to 66%2,5,6,10. Computed tomography

resistant and is partially protected by the liver1,4,6.

with multidetectors (MDCT) is the method of choice

Penetrating injuries may occur by stabbing or gunshot

for stable patients and has sensitivity and specificity of

wounds7. High-velocity projectiles determine wide,

87% and 72 to 100%, respectively, being more sensitive

lateral shock waves and temporary cavities, which are

for detection on the left side11. The visualization of the

sometimes difficult to perceive externally8.

diaphragm discontinuity depends on the contrast with

1 - Federal University of Minas Gerais, Belo Horizonte, Minas Gerais State, Brazil. 2 - Risoleta Tolentino Neves Hospital, Belo Horizonte, Minas Gerais State, Brazil. Rev. Col. Bras. Cir. 2017; 44(3): 245-251


Cardoso Retrospective analysis of 103 diaphragmatic injuries in patients operated in a trauma center

246

the adipose tissue, being more difficult on the right side,

therapeutic approach (chest drainage, transdiaphragmatic

since the liver is iso-attenuating with the diaphragm . The

lavage, suturing, nonoperative treatment) and complications

current tendency regarding the nonoperative treatment

(empyema, pneumonia). We used the Injury Severity Score

of intra-abdominal organs blunt lesions can result in a

(ISS) with cutoff of 25, above which we considered the

greater diagnosis delay, the diagnosis by imagingbeing

trauma be severe or very severe. The outcome response

essential to guarantee adequate surgical repair .

of interest was the occurrence of death. For univariate

8

2,6

Due to the high incidence of associated intra-

analysis, we computed averages and proportions and used

abdominal lesions, the primary approach is preferably

the Student’s t-test, Chi-square test and Fisher’s test. To

performed by laparotomy, which is a gold standard

identify predictive factors for the patients’ outcome, we

for the identification of diaphragmatic injuries after

used the factors that were significant at a level of 10%

penetrating trauma5,12. Thoracoscopy has been proposed

(p<0.10) in the univariate analysis. Such factors then formed

as a safe method for evaluating the diaphragm when the

an initial multivariate model, in which we sequentially

diagnosis has not been confirmed and laparotomy is not

excluded the factors whose level of significance were not

necessary, with sensitivity and specificity close to 100%,

below 5% (p<0.05) at the Wald test. The multiple binary

the limiting factors being the presence of hemodynamic

logistic regression analysis used was the one with penalized

instability and the need for general anesthesia .

likelihood, as has already been used in other studies in

9

diaphragmatictraumatic

the area of trauma surgery. In the regression analysis, we

rupture is generally good with immediate treatment, but

reported 95% confidence intervals. We analyzed the data

late diagnosis is associated with increased morbidity and

with the Stata for Mac software, version 12.

The

prognosis

of

mortality, due to herniation of intra-abdominal organs to

The study was approved by the Ethics

the chestand strangulation, with respiratory compromise

inResearch Committee of UFMG and Risoleta Tolentino

and death ranging from 30 to 60%

Neves Hospital and submitted to Plataforma Brasil (CAAE:

.

4,6,9

The objective of this study was to identify the

44349515.5.0000.5149).

injuries related to traumatic rupture of the diaphragm and the factors associated with mortality in patients attended

RESULTS

at a trauma reference hospital in Belo Horizonte, Minas Gerais, Brazil, over a period of five years.

We analyzed 103 patient records in which the presence of traumatic diaphragm injury was identified

METHODS

between January 2010 and December 2014, of which 93 (90.3%) were male, aged 15 to 58 years (mean

This is a retrospective, case-series, descriptive and

and median of 28.3 and 26, respectively, and standard

analytical study. Wesearched the trauma records database

deviation, 25th and 75th percentiles 9.9, 20 and 35,

(Collector®, MD, USA) of the Risoleta Tolentino Neves

respectively). The trauma mechanism was predominantly

Hospital to identify patients diagnosed with traumatic

penetrating (n=101; 98.1%), being blunt in only two cases

diaphragmatic injury admitted between January 1, 2010

(1.9%). The diaphragmatic injuries were on the left, on the

and December 31, 2014. The Risoleta Tolentino Neves

right and bilateral in 56 (54.4%), 39 (37.9%) and seven

Hospital is a tertiary center of reference in emergency and

(6.7%) patients, respectively. In only two cases (1.9%), the

trauma surgery in the city of Belo Horizonte (MG).

diaphragmaticlesion was isolated, being more commonly

The diagnosis was based on the data obtained

associated with injuries of one or more organs (Tables

after the surgical procedure. Information on sex and age,

1 and 2). The mean and median ISS were 18.8 and 18,

location of the diaphragmatic injuries (right, left, bilateral),

respectively, and the standard deviation, 25th and 75th

associated lesions (liver, spleen or hollow viscus), number of

percentiles were equal to 6.7, 13 and 25, respectively. The

associated lesions (none, one, two, three or more), type of

ISS ranged from a minimum of eight to a maximum of 36.

Rev. Col. Bras. Cir. 2017; 44(3): 245-251


Cardoso Retrospective analysis of 103 diaphragmatic injuries in patients operated in a trauma center

Table 1. Presence of multiple injuries associated with diaphragmatic injury.

247

Table 2. Associated Injuries.

Number of associated injuries

Number and percentage (%) of patients

Organ

Number and percentage (%) of patients

0

2 (1.9)

Liver

58 (56.3)

1

54 (52.4)

Spleen

33 (32.0)

2

39 (37.9)

3 or more

8 (7.8)

Hollow viscera (stomach, intestine, colon)

65 (63.1)

Regarding the approach, 86 (83.5%) patients

DISCUSSION

had the diaphragmatic lesion sutured versus 13 (12.6%) who did not have the lesion repaired, due eitherto lack

In the present study, the mortality of patients

of identification or to a damage control context. Four

with diaphragmatic lesions was 16.5%, 15.8%

patients (3.9%) died during surgery. Only one patient

of which were patients with penetrating trauma.

who did not undergo diaphragmatic repair needed to

Penetrating trauma accounted for more than 98%

be reopened on the fifth postoperative day due to a

of the sample. One can cite, as possible reasons for

thoraco-biliary fistula. Thoracic drainage was performed

this high proportion of penetrating trauma, the high

in 82 patients (79.6%), and transdiaphragmatic pleural

frequency of undiagnosed diaphragmatic lesions and

lavage, in 13 (12.6%). The complications identified were

the increasing mortality rate related to firearm injuries

pneumonia (n=8, 7.8%), empyema (n=5, 4.9%) and

in our country13-15.

thoraco-biliary fistula (n=1, 0.9%). There were 17 deaths in the period (16.5%).

The findings on mortality are in agreement with other studies evaluating blunt and penetrating

Table 3 shows the univariate analysis and

trauma, which found incidence of death varying from

indicates the percentage of survivors and deaths of

7.8% to 32.1%3,4,16-19. These same studies found

patients according to each characteristic evaluated.

mortalities ranging from 4% to 20.1% for penetrating

The highest number of lesions was associated with

trauma3,4,16,17,19.

higher mortality, and the percentage of deaths among

As observed in other studies4,7,16,17, mortality

those without lesions was nil. We observed that the

was also associated with the presence of associated

mortality gradually increased with the increase in

lesions. We observed a clear and sustained dose-response

the number of lesions and among those with three

relationship in the univariate analysis: when there was

or more lesions, it reached 37.5%. Mortality was

no other lesion associated with the diaphragmatic one,

lower among patients who underwent diaphragm

mortality was zero, increasing to 11.1% (one lesion),

suturing (p<0.001) and higher among those who

20.5% (two lesions) and 37.5% (three or more lesions).

did not (p=0.023). Finally, mortality was higher

However, in the multivariate analysis, we observed no

among patients with ISS equal to or higher than 25

independent effect of the number of lesions, and this

(p=0.058), although with a threshold significance

result is not surprising, since, in the presence of ISS equal

(p<0.10) (Table 3).

to or greater than 25 â&#x20AC;&#x201C; an indicator of severe or very

The final model found that there was a negative and independent association between death and having

severe trauma13 â&#x20AC;&#x201C; injuries would not be expected to have an independent effect on death.

undergone diaphragmatic repair (OR=0.76, 95% CI

Fair et al.4 identified 3,773 patients with traumatic

0.67-0.87, p<0.001). The ISS was equal to or higher than

diaphragmatic injuries in the year 2012, after analyzing

25 as an independent risk factor associated with death

833,309 records from the National Trauma Database of

(OR=4.02, 95% CI, 1.15-14.0, p=0.029).

the American College of Surgeons (NTDB).They observed Rev. Col. Bras. Cir. 2017; 44(3): 245-251


248

Cardoso Retrospective analysis of 103 diaphragmatic injuries in patients operated in a trauma center

Table 3. Outcome-related factors of patients with diaphragmatic injury.

Survivors

Deaths

Total

p value

27.6 (9.2)

31.8 (12.4)

28.3 (9.9)

0.199

Male

78 (83.9)

15 (16.1)

93 (100.0)

Female

8 (80.0)

2 (20.0)

10 (100.0)

Blunt

1 (50.0)

1 (50.0)

2 (100.0)

Penetrating

85 (84.2)

16 (15.8)

101 (100.0)

Left

47 (83.9)

9 (16.1)

56 (100.0)

Right

32 (82.0)

7 (18.0)

39 (100.0)

Bilateral

6 (85.3)

1 (14.3)

7 (100.0)

Liver

46 (79.3)

12 (20.7)

58 (100.0)

0.151

Spleen

33 (81.8)

6 (18.2)

33 (100.0)

0.753

Hollow viscera

52 (80.0)

13 (20.0)

65 (100.0)

0.165

No

2 (100.0)

0 (0.0)

2

1

48 (88.9)

6 (11.1)

54

2

31 (79.5)

8 (20.5)

39

3

5 (62.5)

3 (37.5)

8

Suture

79 (90.8)

8 (9.2)

87 (100.0)

<0.001

No suture

8 (61.5)

5 (38.5)

13 (100.0)

0.023

Thoracic drainage

69 (84.1)

13 (15.9)

82 (100.0)

0.473

LPT**

11 (84.6)

2 (15.4)

13 (100.0)

0.999

ISS (average; standard deviation)

18.4 (6.3)

20.7 (8.1)

18.8 (6.7)

0.133

ISS > 24 (n,%)

21 (72.4)

8 (27.6)

29 (100.0)

0.058

Pneumonia

8 (100.0)

0 (0.0)

8 (100.0)

0.223

Empyema

5 (100.0)

0 (0.0)

5 (100.0)

0.588

Age (average; standard deviation) Gender (n,%)

0.069

Trauma (n,%) 0.304

Side (n,%)

0.999

Injury associated with (n,%)*

Number of associated lesions (n,%)

0.048

Type of treatment

Complications (n,%)5

* p values calculated on the basis of a comparison of patients with each injury/treatment/ISS/complication with patients without that (a) injury/ treatment/ISS/specific complication; ** Transdiaphragmatic pleural lavage Rev. Col. Bras. Cir. 2017; 44(3): 245-251


Cardoso Retrospective analysis of 103 diaphragmatic injuries in patients operated in a trauma center

249

that patients with blunt trauma had a greater association

one in repaired cases (9.2%), thoracic drainage (15.9%),

of injuries in the thoracic aorta, lungs, spleen and bladder,

and transdiaphragmatic pleural lavage (15.4%). In

whereas in penetrating trauma there was a greater frequency

the multivariate analysis, diaphragm suturing was an

of lesions of hollow viscera, hemothorax, pancreas and liver.

independent predictor of survival, and mortality among

In the present study, the data of mostly penetrating traumas

those undergoing suturing was 24% lower than among

are concordant with these findings, since the majority were

those without it (OR=0.76), regardless of whether the

hollow viscera and liver.

trauma was severe or not. Perhaps in this finding lies the

Since nonoperative treatment of blunt or

greatest contribution of the present study.

penetrating thoraco-abdominal injuries has increased,

Despite the evidence contained in the data

there is evidence that the additional use of techniques

presented, we advise caution. This study does not allow

such as laparoscopy and thoracoscopy is necessary

inferring if suturing the diaphragm or not implies lower

to prevent important lesions from go unnoticed

.

mortality and morbidity, because as the diaphragmatic

Currently, the idea that laparoscopy is associated with an

injury itself is not the cause of death, this cause is

increased risk of complications is considered outdated,

much related to the number of visceral lesions. The

since exploratory laparoscopy can avoid delays in more

diaphragmatic injury in the acute phase cannot by itself

resolutive treatments .

be considered a cause of death, whether sutured or not.

4,19,17

20

Once the diagnosis has been made, the

As limitations to this work, we can mention

nonoperative approach to diaphragmatic rupture is

that it is a retrospective analysis, with a database based

not recommended. Surgical treatment can be done

only on records coming from the surgical act, therefore

by laparotomy, thoracotomy or by the combination

not contemplating patients submitted to nonoperative

of both, traditionally with the use of non-absorbable

treatment. The small number of cases in which

sutures

. The surgical correction of a diaphragmatic

transdiaphragmatic pleural lavage was performed also did

rupture is simple if performed immediately, this being the

not allow for a relevant association with the outcome or

main justification for the operative approach.

other possible complications, and further studies are needed

9,16,19,21

However, there is controversy. Experimental animal studies have observed the occurrence of

to establish its importance in cases of diaphragmatic injuries associated with gastro-biliary-enteric contamination.

spontaneous scarring in a percentage of diaphragmatic

We conclude that the traumatic rupture of the

injuries, especially when small and located on the

diaphragm rarely presents as an isolated lesion, being

right side .Nevertheless, in our univariate analysis,

commonly associated with injuries in other organs, mainly

mortality was significantly associated with cases without

liver and hollow viscera. Mortality was higher among

diaphragmatic suture repair, higher (38.5%) than the

those with ISS equal to or higher than 25.

22

R E S U M O Objetivo: analisar os fatores associados ao óbito em pacientes com lesão diafragmática atendidos em hospital de referência para o trauma. Métodos: estudo retrospectivo de pacientes com lesão do diafragma atendidos no Hospital Risoleta Tolentino Neves da Universidade Federal de Minas Gerais entre janeiro de 2010 e dezembro de 2014. Foi utilizado o Banco de Registros de Trauma Collector® (MD, USA). Utilizaram-se dados demográficos, localização da lesão diafragmática, lesões associadas de outros órgãos, número de lesões associadas, tipo de abordagem terapêutica, complicações e o escore de gravidade Injury Severity Score (ISS). A variável de interesse foi a ocorrência de óbito. Resultados: foram identificados 103 pacientes e a incidência de óbito foi de 16,5%. Lesões penetrantes ocorreram em 98% dos pacientes. Em análise univariada a mortalidade foi maior em pacientes cujo tratamento foi não operatório, sem rafia (p=0,023), e menor em pacientes submetidos à rafia diafragmática (p<0,001). O aumento do número de lesões associou-se ao aumento da incidência de óbitos (p=0,048). Em análise multivariada, ISS>24 (OR=4,0; p=0,029) e rafia do diafragma (OR=0,76; p<0,001) associaram-se à mortalidade. Conclusão: os achados indicam que a ruptura traumática do diafragma raramente se apresenta como lesão isolada, estando associada frequentemente à lesão de outros órgãos, especialmente fígado e vísceras ocas. Pode-se afirmar que a mortalidade foi mais elevada entre aqueles com ISS>24. Descritores: Diafragma. Ferimentos e Lesões. Morte.

Rev. Col. Bras. Cir. 2017; 44(3): 245-251


Cardoso Retrospective analysis of 103 diaphragmatic injuries in patients operated in a trauma center

250

REFERENCES

11. Melo ASA, Moreira LBM, Damato SD, Martins EML, Marchiori E. Ruptura traumática do diafragma:

1. Scharff JR, Naunheim KS. Traumatic diaphragmatic

aspectos na tomografia computadorizada. Radiol Bras. 2002;35(6):341-4.

injuries. Thorac Surg Clin. 2007;17(1):81-5. 2. Kuo IM, Liao CH, Hsin MC, Kang SC, Wang SY,

12. Freeman RK, Al-Dossari G, Hutcheson KA, Huber L,

Ooyang CH, et al. Blunt diaphragmatic rupture--a rare

Jessen ME, Meyer DM, et al. Indications for using

but challenging entity in thoracoabdominal trauma.

video-assisted thoracoscopic surgery to diagnose

Am J Emerg Med. 2012;30(6):919-24.

diaphragmatic injuries after penetrating chest

3. Okada

M,

Adachi

H,

Kamesaki

M,

Mikami

trauma. Ann Thorac Surg. 2001;72(2):342-7.

M, Ookura Y, Yamakawa J, et al. Traumatic

13. Ties JS, Peschman JR, Moreno A, Mathiason

diaphragmatic injury: experience from a tertiary

MA, Kallies KJ, Martin RF, et al. Evolution in the

emergency medical center. Gen Thorac Cardiovasc

management of traumatic diaphragmatic injuries:

Surg. 2012;60(10):649-54.

a multicenter review. J Trauma Acute Care Surg.

4. Fair KA, Gordon NT, Barbosa RR, Rowell SE, Watters

2013;76(4):1024-8.

JM, Schreiber MA. Traumatic diaphragmatic injury in

14. Rezende R, Avanzi O. Importância do Índice

the American College of Surgeons National Trauma

Anatômico de Gravidade do Trauma no manejo das

Data Bank: a new examination of a rare diagnosis. Am

fraturas toracolombares do tipo explosão. Rev Col

J Surg. 2015;209(5):864-69.

Bras Cir. 2009;36(1) 9-13.

5. van der Werken C, Lubbers EJ, Goris RJ. Rupture of

15. Abreu EMS, Machado CJ, Pastore Neto M, Rezende

the diaphragm by blunt trauma as a marker of injury

Neto JB, Sanches MD. Impacto de um protocolo de

severity. Injury 1983;15(3):149-52

cuidados a pacientes com trauma torácico drenado.

6. Panda A, Kumar A, Gamanagatti S, Patil A, Kumar

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

S, Gupta A. Traumatic diaphragmatic injury: a

16. Trindade RFC, Costa FAMM, Silva PPAC, Caminiti

review of CT signs and the difference between

GB, Santos CB. Map of homicides by firearms: profile

blunt and penetrating injury. Diagn Interv Radiol.

of the victims and the assaults. Rev Esc Enferm USP.

2014;20(2):121-8.

2015;49(5):748-52. EAP.

17. Zellweger R, Navsaria PH, Hess F, Omoshoro-Jones J,

Ferimento por arma branca: perfil epidemiológico

Kahn D, Nicol A. Transdiaphragmatic pleural lavage

dos atendimentos em um pronto socorro. Rev Rene.

in penetrating thoracoabdominal trauma. Br J Surg.

2011;12(4):669-77.

2004;91(12):1619-23.

7. Zandomenighi

RC,

Mouro

DL,

Martins

8. Medeiros GA. Ferimentos penetrantes de tórax. In:

18. Saad JúniorR, Gonçalves R. Toda lesão do diafragma

Sociedade Brasileira de Cirurgia Torácica. Tópicos de

por ferimento penetrante deve ser suturada? Rev

atualização em cirurgia torácica [Internet].Disponível

Col Bras Cir. 2012;39(3):222-5.

em: http://itarget.com.br/newclients/sbct/wp-content/ uploads/2015/03/ferimentos_penetrantes_torax.pdf 9. Dirican A, Yilmaz M, Unal B, Piskin T, Ersan V, Yilmaz S. Acute traumatic diaphragmatic ruptures: a retrospective study of 48 cases. Surg Today.

on managing diaphragmatic rupture in blunt trauma: a review of 208 consecutive cases. Can J Surg. 2009;52(3):177-81. 20. Mandriolli M, Inaba K, Piccinini A, Biscardi A, Sartelli M, Agresta F, et al. Advances in laparoscopy for acute

2011;41(10):1352-6. 10. Beigi AA, Masoudpour H, Sehhat S, Khademi EF. Prognostic factors and outcome of traumatic diaphragmatic rupture. Ulus Travma Acil Cerrahi Derg. 2010;16(3):215-9.

19. Chughtai T, Ali S, Sharkey P, Lins M, Rizoli S. Update

care surgery and trauma. World J Gastroenterol. 2016;22(2):668-80. 21. Zarour AM, El-Menyar A, Al-Thani H, Scalea TM, Chiu WC. Presentations and outcomes in

Rev. Col. Bras. Cir. 2017; 44(3): 245-251


Cardoso Retrospective analysis of 103 diaphragmatic injuries in patients operated in a trauma center

patients with traumatic diaphragmatic injury: a

Received in: 27/12/2016

15-year experience. J Trauma Acute Care Surg.

Accepted for publication: 02/02/2017

2013;74(6):1392-8.

Conflict of interest: none.

22. Caiel BA, Scapulatempo Neto C, Souza JĂşnior AS,

Source of funding: none.

Saad JĂşnior R. Analysis of natural history of the diaphragmatic injury on the right in mice. Rev Col

Mailing address:

Bras Cir. 2015;42(6):386-92.

Carla Jorge Machado E-mail: carlajmachado@gmail.com / carlajm@ufmg.br

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Original Article

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Prevalence of gallbladder cancer In patients submitted to cholecystectomy: experience of the University Hospital, Faculty of Medical Sciences, State University of Campinas – UNICAMP Prevalência do câncer de vesícula biliar em pacientes submetidos à colecistectomia: experiência do Hospital de Clínicas da Faculdade de Ciências Médicas da Universidade Estadual de Campinas – UNICAMP MÁRCIO APODACA-RUEDA1; EVERTON CAZZO2; RITA BARBOSA DE-CARVALHO2; ELINTON ADAMI CHAIM, TCBC-SP2. A B S T R A C T Objective: to evaluate the prevalence of gallbladder carcinoma in patients submitted to cholecystectomy for chronic cholecystitis at the University Hospital of the State University of Campinas. Methods: we conducted a retrospective prevalence study through the analysis of histological specimens from January 2010 to May 2015. Results: we analyzed 893 patient reports. Emergency cholecystectomies amounted to 144, and elective ones, 749 (16.2% and 83.8%, respectively). Regarding gender, 72.8% were female and 27.2% male. Gallbladder adenocarcinoma occurred in 12 patients (1.3%) and non-Hodgkin’s lymphoma in one (0.1%). In patients with cancer, seven (53.8%) were associated with cholelithiasis and two (15.3%) with gallbladder polyps. Conclusion: prevalence results of gallbladder adenocarcinoma in this study were similar to those of Western studies and the main risk factor was cholelithiasis, followed by the presence of gallbladder polyps. Keywords: Gallbladder Neoplasms. Cholelithiasis. Gallstones. Prevalence

INTRODUCTION

G

allbladder cancer (GBC) is a rare condition and ranks fifth in neoplasms of the gastrointestinal tract. However, it is the most frequent malignant neoplasm that affects the bile ducts1. The most common histological type is adenocarcinoma, representing approximately 90% of the cases and classified as papillary, tubular and mucinous. The frequency of the other histological types (anaplastic, squamous and adenosquamous carcinoma) is extremely low2. GBC affects patients older than 60 years. The incidence in women is greater when compared to male patients in the approximate ratio of 3:13,4. Among its risk factors, the most common are cholecystolithiasis, followed by the presence of polyps in the gallbladder and the gallbladder in porcelain. Several studies have demonstrated that the infection of the bile ducts with Salmonella sp. and Helicobacter pylori would be related to the increased incidence of the disease. The genetic component is also an important risk factor for the development of this neoplasm6-8.

The incidence of GBC is variable when analyzed in different geographic regions and in certain ethnic groups. It is low in Western countries such as the United States, where it affects 0.9 women and 0.5 men per 100,000 inhabitants. The United Kingdom also has a similar incidence. However, indigenous populations of the US, Hispanic American countries like Mexico, Chile, Peru, northern Argentina and Bolivia, Ecuador, Colombia, some Eastern European countries like Poland and Slovakia and in Asia, Japan, India and Pakistan, have a high incidence of GBC9. Due to the disease’s characteristics, the lack of specificity of the clinical picture and, fundamentally, its late diagnosis, the prognosis of gallbladder cancer is poor10. In the vast majority of cases, the diagnosis comes late and in advanced stages, thus compromising treatment results and consequently increasing morbidity and mortality11. It is estimated that 85% of patients die one year after being diagnosed12. In Brazil, there are no population studies analyzing the incidence of gallbladder cancer. There

1 - State University of Campinas, Department of Surgery, Faculty of Medical Sciences, Campinas, São Paulo State, Brazil. 2 - Pontifical Catholic University of Campinas, Faculty of Medicine, Campinas, São Paulo State, Brazil. Rev. Col. Bras. Cir. 2017; 44(3): 252-256


Apodaca-Rueda Prevalence of gallbladder cancer In patients submitted to cholecystectomy: experience of the University Hospital, Faculty of Medical Sciences...

Table 1 - Gallbladder neoplasms’ histological types.

Histological type

N

%

Adenocarcinoma

12

92.3

Non-Hodgkin’s Lymphoma

1

7.7

Total

13

100

are, however, some studies of regional prevalence and incidental diagnosis, with different results when compared with each other13-17. Therefore, the real incidence of gallbladder cancer in our country remains unknown. The objective of this study is to analyze the prevalence of gallbladder cancer in patients undergoing cholecystectomy, as well as risk factors associated with GBC, in the Clinics Hospital of the Faculty of Medical Sciences of the State University of Campinas – UNICAMP.

METHODS We conducted a cross-sectional, descriptive study, with retrospective data collection. We reviewed the reports of histopathological specimens from patients submitted to elective or emergency cholecystectomy and sent to the Department of Pathology of the Clinics Hospital, UNICAMP, from January 2010 to May 2015. In reports with diagnosis of gallbladder neoplasia, we performed an analysis of the medical record in the medical archive service. This project was approved by the Ethics in Research Committee and is registered in the “Plataforma Brasil” under the CAAE number 48103614.6.0000.5404. We collected the data in protocol sheets and organized them into Excel spreadsheets. We performed the statistical analysis with the software SPSS Statistics 20.0. We present quantitative variables as mean ± standard deviation, and qualitative variables, as frequency and percentage.

to the gender, 650 (72.8%) were female and 243 (27.2%), male. Upon analyzes of the histopathology reports of the surgical specimens, we found that 13 (1.4%) had a diagnosis of gallbladder neoplasia. Regarding histological type, 12 (92.3%) patients had gallbladder adenocarcinoma, and one (7.7%), non-Hodgkin’s lymphoma (Table 1). The study group had a mean age of 60.23 years, with a variability of 35 to 85 (median age 59 years and standard deviation 12.93). As for gender, 10 (77%) patients were women, and three (23%), men (Table 2). The analysis of the clinical presentation of such patients in the preoperative period showed that seven (53.84%) had moderate abdominal pain located in the right hypochondrium; two patients (15,38) presented with nonspecific dyspeptic condition; another two (15.38%) in addition to complaints of abdominal pain, had jaundice and coluria; one patient (7.7%) was admitted to the emergency room with acute cholangitis; and one patient (7.7%) was asymptomatic. Regarding the preoperative ultrasonographic findings, four patients (30.8%) had a diagnosis of cholecystolithiasis, and two (15.4%), of polyps in the gallbladder. In four (30.8%), there was suspicion of gallbladder neoplasia. Finally, three other patients (23%) were suspected of having gallbladder neoplasia and cholecystolithiasis. In the study group, seven Table 2 - General characteristics of the studied population.

Variable

During the study period, 893 cholecystectomies were performed. Of these, 749 (83.8%) were elective and 144 (16.2%) were emergency ones. According

N° (%)

Gender Female

650 (72.8)

Male

243 (27.2)

Histopathology Inflammatory cholecystopathy Neoplasm

RESULTS

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Age Total * M = median, ** SD = standard deviation.

Rev. Col. Bras. Cir. 2017; 44(3): 252-256

880 (98.6) 13 (1.4) M* 59 (35-85). SD** ±12.93 893 (100)


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Apodaca-Rueda Prevalence of gallbladder cancer In patients submitted to cholecystectomy: experience of the University Hospital, Faculty of Medical Sciences...

patients had a suspicion of gallbladder cancer in the preoperative period, corresponding to 53.84%. However, six patients (46.16%) had their diagnosis confirmed only after the histopathological analysis of the surgical specimen. All surgeries of the studied group were performed in an elective manner.

DISCUSSION Bile duct neoplasms are rare conditions that in most cases originate from the biliary lining epithelium, being classified according to their location in intrahepatic, extrahepatic and of the gallbladder, the latter being the most common. The predominant histological type is adenocarcinoma18,19. In the present study, only one patient (7.7%) presented a different histological type. Because of its late diagnosis and the tumor biological behavior, GBC continues to display poor prognosis and low long-term survival20,21. The incidental diagnosis of GBC has apparently increased, ranging from 0.3% to 2% of cholecystectomies due to cholecystolithiasis22. In our series, all patients were treated electively. In two patients, the approach was laparoscopic, and in eleven, laparotomic. In seven patients (53.84%), there was a diagnostic suspicion of neoplasia still in the preoperative period. I four of these, cholecystectomy was performed with regional lymphadenectomy associated with resection of the extrahepatic biliary tract with Roux-en-Y biliodigestive anastomosis. Three of them, in addition to the aforementioned procedures, were submitted to wedge resection of the gallbladder’s hepatic bed. In six patients (46.16%), the diagnosis was defined after a histopathological study of specimens from patients undergoing cholecystectomy due to cholecystolithiasis. Of these, five had mucosalrestricted neoplasia (carcinoma in situ) and one had a diagnosis of non-Hodgkin’s lymphoma, being referred to the Oncology service for adjuvant therapy. The incidental diagnosis in patients electively submitted to cholecystectomy due to cholecystolithiasis in this sample was 0.67%, similar to those published in other Western countries23-25. Recently, Martins-Filho

et al., in a study of the population of the State of Pernambuco, reported prevalence for incidental GBC of 0.34% 26. Gallbladder cancer affects patients over 50 years of age at approximately 90% of the time, and female. In our study, 77% of the patients were female, with a mean of 60.23 years of age. Of these, 84% were older than 50 years. Due to the lack of specificity of the clinical picture and the absence of symptoms suggestive of the disease in the early stages, the diagnosis of GBC is most often reached late and at an advanced stage. This invariably compromises prognosis, increases treatment morbidity and decreases long-term survival, of 5% when analyzed in a global manner. In this study, in 53.8% of cases the disease was advanced at the time of surgery. Among the symptoms these patients usually present with, abdominal pain localized mainly in the right hypochondrium, of continuous character, associated to the weight loss, are the most frequent. The presence of cholestatic symptoms usually suggests advanced disease. In this study, abdominal pain was present in all of those in whom the neoplasia was suspected in the preoperative period, followed by the presence of dyspeptic symptoms in 15.38%. In three patients, cholestatic symptoms were predominant. The incidence of this neoplasia varies according to the region studied. Hispanic-American populations have a high incidence. In our continent, it is noteworthy the high incidence in countries such as Chile, 25/100,000 women and 9/100,000 men, and in Native American of the New Mexico, of 14.5/100,000. In Europe, Poland shows an incidence of 14/100,000. In Asia, India has 10/100,000 and Japan, 7/100,000, figures very different from those published in Western populations. This population variability of the disease reinforces the theory of the genetic component in the disease’s etiology. In our country, there are no population studies assessing GBC incidence. The few that exist analyzed the disease’s prevalence in certain regions of the country or the incidental diagnosis of this neoplasia. Jukemura et al.15, studying 475 patients who underwent cholecystectomy due to cholecystolithiasis

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Apodaca-Rueda Prevalence of gallbladder cancer In patients submitted to cholecystectomy: experience of the University Hospital, Faculty of Medical Sciences...

in São Paulo, found incidental GBC in 1.68%. Weston et al.16 showed an incidental diagnosis of the disease of 0.012% in a study carried out in a population of the State of Rio Grande do Sul. Torres et al.17, in a study similar to ours, found a prevalence of 2.3% in patients from São Luiz, Sate of Maranhão. The difference between the values in the different population samples studied once again suggests the importance of the ethnic-genetic component of the neoplasia. It is possible to infer that the intermediate prevalence of 1.4% found in our sample is explained by the miscegenation characteristics of the Campinas population, similar to that of the city of São Paulo. Among the risk factors associated with gallbladder cancer, the most important is cholecystolithiasis, which is present in more than 70% of the time. In our country, Ziliotto Jr et al.27 found an association of chronic cholecystolithiasis and gallbladder neoplasia in 40.9% of the cases. Carneiro et al.14, in 1994, found a 68% association. Ours was 53%. Another risk factor related to GBC is the presence of gallbladder adenomatous polyps, considered pre-neoplastic lesions

255

for the development of the disease, representing 30.8% of cases and being directly related to their size. In our sample, 15.4% had a diagnosis of gallbladder polyp at the ultrasound examination, which was confirmed in the histopathological study. Other risk factors such as porcelain gallbladder, anatomical anomalies of the biliary tract, Salmonella sp. and Helicobacter pylori infection, and genetic alterations, were not studied in our series. The main limitation of this study is its retrospective design, which negatively influences the quality of data available. In addition, since the global incidence of GBC is low, the small absolute number of patients affected by it also makes it difficult to perform deeper analyzes. On the other hand, the availability of a large absolute number of histopathological specimens, in a study carried out in a regional and state reference service, partially attenuates this limitation. Due to Brazil’s continental dimensions and ethnic diversity, there is a need for multicenter studies with larger population samples including the different geographic regions, to determine the real incidence of gallbladder cancer in our country.

R E S U M O Objetivo: estudar a prevalência do câncer de vesícula biliar em pacientes submetidos à colecistectomia no Hospital de Clínicas da Universidade Estadual de Campinas. Métodos: estudo de prevalência retrospectivo a partir da análise de laudos de espécimes histopatológicos de pacientes submetidos à colecistectomia, no período de janeiro de 2010 a maio de 2015. Resultados: foram analisados 893 laudos de pacientes submetidos à colecistectomia, dos quais 144 de urgência e 749 eletivas (16,2% e 83,8%, respectivamente). Segundo o sexo, 72,8% correspondiam ao feminino e 27,2%, ao masculino. Em 12 pacientes (1,3%) foi evidenciado o diagnóstico de adenocarcinoma de vesícula biliar e, em um (0,1%), o diagnóstico de linfoma não Hodgkin. Dos 13 pacientes com neoplasia, sete (53,8%) apresentaram colecistolitíase associada. Em dois doentes (15,3%) foi constatado pólipo de vesícula biliar. Sete (53,8%) doentes foram operados com a hipótese diagnóstica de neoplasia de vesícula biliar. Conclusão: a prevalência do adenocarcinoma de vesícula biliar no presente estudo foi semelhante à dos estudos ocidentais e o principal fator de risco foi a colecistolitíase, seguido pela presença de pólipos de vesícula biliar. Descritores: Neoplasias da Vesícula Biliar. Colecistolitíase. Cálculos Biliares. Prevalência.

REFERENCES 1. Siegel R, Naishadham D, Jemal A. Cancer statistics, 2013. CA Cancer J Clin. 2013;63(1):11-30. 2. Gallbladder. In: Edge S, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A, editors. AJCC Cancer staging manual. 7th ed. New York: Springer; 2010. p. 211-7. 3. Castro FA, Koshiol J, Hsing AW, Devesa SS. Biliary tract cancer incidence in the United States Demographic and temporal variations by anatomic site. Int J Cancer. 2013;133(7):1664-71.

4. Devor EJ, Buechley RW. Gallbladder cancer in Hispanic New Mexicans: I. General population, 1957-1977. Cancer. 1980;45(7):1705-12. 5. Strom BL, Soloway RD, Rios-Dalenz JL, RodriguezMartinez HA, West SL, Kinman JL, et al. Risk factors for gallbladder cancer and international collaborative case-control study. Cancer. 1995;76(10):1747-56. 6. Albores-Saavedra J, Alcántra-Vazquez A, Cruz-Ortiz H, Herrera- Goepfert R. The precursor lesions of invasive gallbladder carcinoma. Hyperplasia, atypical hyperplasia and carcinoma in situ. Cancer. 1980;45(5):919-27.

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Apodaca-Rueda Prevalence of gallbladder cancer In patients submitted to cholecystectomy: experience of the University Hospital, Faculty of Medical Sciences...

7. Wernberg JA, Lucarelli DD. Gallbladder cancer .Surg Clin N Am. 2014; 94(2):343-60. 8. Serra I, Calvo A, Báez S, Yamamoto M, Endoh K, Aranda W. Risk factors for gallbladder cancer. An international collaborative case control study. Cancer. 1996;78(7):1515-7. 9. Randi G, Franceschi S, La Vecchia C. Gallbladder cancer worldwide: geographical distribution and risk factors. Int J Cancer. 2006;118(7):1591-602. 10. De Aretxabala X, Roa IS, Burgos LA, Araya JC, Villaseca MA, Silva JA. Curative resection in potentially resectable tumours of the gallbladder. Eur J Surg. 1997;163(6):419-26. 11. Perpetuo MD, Valdivieso M, Heilbrun LK, Nelson RS, Connor T, Bodey GP. Natural history study of gallbladder cancer: a review of 36 years experience at M.D. Anderson Hospital and Tumor Institute. Cancer. 1978;42(1):330-5. 12. Hawkins WG, DeMatteo RP, Jarnagin WR, BenPorat L, Blumgart LH, Fong Y. Jaundice predicts advanced disease and early mortality in patients with gallbladder cancer. Ann Surg Oncol. 2004;11(3):310-5. 13. Conci FM, Zanette M, Paviani MS, Tesch TP. Carcinoma de vesícula biliar: incidência em 10 anos. Rev Cient AMECS. 1993;2(2):133-6. 14. Carneiro PCA, Oliveira DP, Sales Filho R, Ferreira MAM. Colelitíase e câncer primário da vesícula biliar. Rev Bras Cancerol. 1994;40(2):87-90. 15. Jukemura J, Leite KRM, Machado MCC, Montagnini AL, Penteado S, Abdo EE, et al. Frequency of incidental gallbladder carcinoma in Brazil. Arq Bras Cir Dig. 1997;12(1/2):10-3. 16. Weston AC, De Carli LA, Fuhrmeister CA, Tang M, Cerato MM, Ting HY, et al. Achado ocasional de carcinoma de vesícula biliar. Rev Bras Cancerol. 1997;43(4):269-71. 17. Torres OJM, Caldas LRA, Azevedo RP, Palácio RL, Rodrigues MLS, Lopes JAC. Colelitíase e câncer de vesícula biliar. Rev Col Bras Cir. 2002;29(2):88-91. 18. Ishak G, Ribeiro FS, Dias EM, Bahia LAC, Costa DS, Assumpção PP. Câncer de vesícula biliar: experiência de 10 anos em um hospital de referência da Amazônia. Rev Col Bras Cir. 2011;38(2):100-4.

19. Randi G, Malvezzi M, Levi F, Ferlay J, Negri E, Franceschi S, et al. Epidemiology of biliary tract cancers: an update. Ann Oncol. 2009;20(1):146-59. 20. Pais-Costa SR, Farah JFM, Artigiani-Neto R, Franco MIF, Martins SJ, Golderberg A. Adenocarcinoma da vesícula biliar: avaliação dos fatores 25(1):13-9. 21. Fong Y, Jarnagin W, Blumgart LH. Gallbladder cancer: comparison of patients presenting initially for definitive operation with those presenting after prior noncurative intervention. Ann Surg. 2000;232(4):557-69. 22. Daines WP, Rajagopalan V, Grossbard ML, Kozuch P. Gallbladder and biliary tract carcinoma: a comprehensive update. Part 2. Oncology (Williston Park). 2004;18(8):1049-59; discussion 1060, 1065-6, 1068. 23. Varshney S, Butturini G, Gupta R. Incidental carcinoma of the gallbladder. Eur J Surg Oncol. 2002;28(1):4-10. 24. Zhang WJ, Xu GF, Zou XP, Wang WB, Yu JC, Wu GZ, et al. Incidental gallbladder carcinoma diagnosed during or after laparoscopic cholecystectomy. World J Surg. 2009;33(12):2651-6. 25. Kwon AH, Imamura A, Kitade H, Kamiyama Y. Unsuspected gallbladder cancer diagnosed during or after laparoscopic cholecystectomy. J Surg Oncol. 2008;97(3):241-5. 26. Martins-Filho ED, Batista TP, Kreimer F, Martins AC, Iwanaga TC, Leão CS. Prevalence of incidental gallbladder cancer in a tertiary-care hospital from Pernambuco, Brazil. Arq Gastroenterol. 2015;52(3):247-9. 27. Ziliotto Jr A, Kunzle JE, Sgarbi EC. Carcinoma primário de vesícula biliar. Rev Bras Cancerol. 1985;31(2):103-6. Received in: 17/10/2016 Accepted for publication: 27/12/2016 Conflict of interest: none. Source of funding: none. Mailing address: Elinton Adami Chaim E-mail: chaim@hc.unicamp.br / apodaca.r@hotmail.com

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7003006

Predictors of mortality in patients submitted to nephrectomy for non-metastatic renal cell carcinoma at a referral center in Northeastern Brazil Preditores de mortalidade em pacientes submetidos à nefrectomia por carcinoma de células renais não metastático em um centro de referência no Nordeste Brasileiro MARCUS VINICIUS SILVA ARAÚJO GURGEL, ACBC-CE1; JOSUALDO ALVES JÚNIOR2; GUILHERME BRUNO FONTES VIEIRA2; FELIPE DE CASTRO DANTAS SALES2; MARCOS VENÍCIO ALVES LIMA1. A B S T R A C T Objective: to identify predictors of mortality in patients submitted to nephrectomy for non-metastatic renal cancer. Methods: we conducted a retrospective cohort study based on the records of patients with renal cancer submitted to radical or partial nephrectomy at the Ceará Cancer Institute. Results: we studied 117 patients, with mean and median age of 59.14 and 59 years, respectively. The male gender was slightly predominant. The right kidney was most frequently affected (64%). The most common histopathological diagnosis was clear-cell carcinoma (77%). Stage pT1 and Fuhrman grade II were predominant. The only predictive variables of overall survival were pathological stage (pT) and lymph node involvement. Conclusion: pathological stage (pT) and lymph node involvement are important prognostic factors in patients undergoing nephrectomy for non-metastatic renal cancer. Keywords: Kidney Neoplasms. Nephrectomy. Carcinoma, Renal Cell. Survival. Prognosis.

INTRODUCTION

K

idney cancer accounts for approximately 3.8% of all neoplasms reported annually in the United States, where in 2014 the estimated figures were 63,920 new cases and 13,860 deaths. It is the seventh most common malignant neoplasm in men, with an incidence of 4%, and the eighth most common in women, with an incidence of 3%1,2. In both genders, it is the eighth most diagnosed annually malignant neoplasm and the thirteenth in causes of cancer death, also being the second most common type of cancer of the urinary tract1,2. Renal carcinoma is considered the most lethal of urological neoplasms3. Its incidence is continually increasing worldwide. In the United States, for example, the incidence of new cases rose from ten to 15 cases per 100,000 inhabitants per year in the last 20 years4. In Brazil, the described incidence – considering the high rates of national underreporting – varies from seven to ten cases per 100,000 inhabitants per year in more

developed areas, with lower rates in less developed regions5. According to the first National Study on Kidney Cancer in Brazil, the disease is more common in men (59%) and Caucasians (79%), with a mean age of 59 years6. The clear cell variant is the most common subtype, accounting for 75% of renal cell carcinomas (RCC). Based on morphological, histochemical and cytogenetic aspects, renal carcinoma does not constitute a single neoplasm, but a group comprising four main tumor subtypes: clear cells, papillary type I, papillary type II and chromophobe, with incidence of 75%, 5%, 10% and 5%, respectively. Among these, clear-cell RCC is the one that displays the most aggressive behavior7. There is great heterogeneity in renal cancer regarding both age, histological subtype, degree of differentiation or staging. This fact justifies the great clinical importance of this disease and the search for knowledge for a better clinical and surgical approach. About 75% of renal cancer cases occur in individuals

1 - Haroldo Juaçaba Hospital, Cancer Institute of Ceará, Surgical Oncology, Fortaleza, Ceará State, Brazil. 2 - State University of Ceará, Fortaleza, Ceará State, Brazil. Rev. Col. Bras. Cir. 2017; 44(3): 257-262


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Gurgel Predictors of mortality in patients submitted to nephrectomy for non-metastatic renal cell carcinoma at a referral center in Northeastern Brazil

over 60 years of age2,8. The disease is more common in men at a 3:2 ratio2,8. Several clinical and pathological variables have been studied for the prediction of overall survival, including the presence of symptoms at diagnosis, hematuria, flank pain, palpable abdominal mass, anemia, hypercalcemia, hypoalbuminemia, thrombocytosis, as well as gender, age, tumor laterality, size (pT), histological type, grade, angiolymphatic invasion, presence of tumor necrosis, sarcomatoid differentiation and lymph node involvement9,10. This study aims to identify prognostic factors for patients with non-metastatic RCC undergoing nephrectomy, so that they serve as predictive variables of mortality.

METHODS This is a retrospective cohort study, which used data obtained from review of medical records of patients with RCC who underwent radical or partial nephrectomy at the CearĂĄ Cancer Institute from January 1999 to December 2010. As exclusion criteria, we adopted the identification of metastasis at the time of diagnosis or within six months thereafter, as well as the presence of a second primary tumor. The independent variables analyzed were gender, age, tumor laterality, histological subtype, degree of differentiation (Fuhrman), tumor size, presence of tumor necrosis, lymph node involvement, and angiolymphatic invasion. Lymphadenectomy was performed only in patients who had lymph nodes suspected of metastatic involvement in the preoperative period (through imaging tests) or during the intraoperative period (if there were changes in the abdominal cavity inventory). Surgeons followed the National Comprehensive Cancer Network (NCCN) recommendations for primary lymphadenectomy. Patients who did not undergo lymphadenectomy were considered pNx, that is, no lymph node histology was available. We used the TNM 7th Edition (2009) as reference. After surgery, all patients were followed regularly according to their staging. The majority were submitted to a semiannual consultation with serum creatinine dosage, in addition to chest X-rays and

computed tomography of the abdomen. Recurrence was defined as the appearance of suspicious and growing lesions at typical sites of disease progression (retroperitoneal or mediastinal lymph nodes, liver, lungs, bones, brain, adrenals and contralateral kidney) or atypical sites with diagnostic biopsy. We calculated the survival time as the time interval between the surgery and the last known follow-up. We used overall survival as the dependent variable. We tabulated, stored and processed data with the statistical program Statistical Package for Social Science (SPSS) Version 18.0 for Windows. We assessed survival using the Kaplan-Meier method and carried out comparisons with the Log-Rank test. We adopted a significance level of 5%. This work was submitted and approved by the Ethics in Research Committee of the Cancer Institute of CearĂĄ, under the number 026/2011.

RESULTS From an initial sample of 160 patients with RCC, we excluded 23 patients with metastatic tumor at the time of diagnosis or within six months after diagnosis, and 20 patients who had another primary cancer before or after RCC diagnosis. We selected 117 patients for analysis. Follow-up averaged 47.9 months, ranging from one to 158. The overall survival rate in this period was 41.1%. There were 26 deaths at the end of follow-up. Regarding the clinical condition, macroscopic hematuria was present in 42.7% of the patients (50), followed by abdominal pain in 32.4% (38), palpable abdominal mass in 31.6% (37), low back pain in 24.7% (29), cachexia or weight loss in 20.5% (24), anorexia or hyporexia in 4.2% (5), fever in 3.4% (4) and increase in abdominal volume in 2.5 % (3). Only 8.5% (10) of the patients were asymptomatic at the time of diagnosis. The classic clinical triad represented by macroscopic hematuria, palpable abdominal mass and abdominal pain occurred in only 14.53% (17) of the patients. The patientsâ&#x20AC;&#x2122; age at diagnosis ranged from 19 to 85 years, with a median of 59. The majority received the diagnosis after 45 years of age. This group

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259

Table 1. Outcome versus surgical technique.

Type of Nephrectomy Conventional Final status

Partial nephrectomy

Laparoscopic

Radical nephrectomy

Partial nephrectomy

Total

Radical nephrectomy

Total

N

N%

N

N%

N

N%

N

N%

N

N%

N

N%

Alive

7

8.6%

74

91.4%

81

100%

1

10.0%

9

90.0%

10

100%

Dead

0

0.0%

25

100.0%

25

100%

0

0.0%

1

100.0%

1

100%

Total

7

6.6%

99

93.4%

106

100%

1

9.1%

10

90.9%

11

100%

of patients did not display a greater overall mortality (Figure 1). The male gender represented 53.8% (63) and the female, 46.1% (54). The right kidney was the most affected, with 63.2% (74) of the cases. A bilateral tumor was present in 1.7% (2) of patients. For unilateral tumors, radical nephrectomy was performed in 93% (107) of the cases, and partial nephrectomy, in 6.9% (8). The bilateral tumors were treated with radical left nephrectomy and right partial nephrectomy (2). The laparoscopic route was used in 9.4% (11) of the cases, represented by five pT1A stage tumors and six pT1B lesions (Table 1). Unilateral tumors (115) had the following characteristics: clear cell carcinoma (89 – 77.3%), chromophilic carcinoma (16 – 13.9%), chromophobic carcinoma (8 – 6.9%) and mixed carcinoma (2 – 1.7%). Stages: pT1A in 16.5% (19), pT1B in 25.2% (29), pT2 in 33.0% (38), pT3A in 20.0% (23) and pT3B in 5,2% – we did not observepT3C or pT4 stages. Grade was GI in 21 patients (21.6%), GII in 59 (60.8%) and GIII

and GIV in 17 (17.5%) – we highlight the absence of this data (Gx) in 18 patients (15, 6%); Angiolymphatic invasion was present in 12.1% (14); Tumor mass necrosis occurred in 55.6% (64); 3.4% (4) of the cases had sarcomatoid differentiation. As for the bilateral tumors (2), all showed clear cell histology, both in the right and left kidney. One of the patients presented with stages pT2 and pT1A, and the other, pT4 and pT1A. One displayed GIV grade and contralateral GI grade, and the other, GII and contralateral GI. There wereno angiolymphatic invasion or sarcomatoid differentiation. Tumor mass necrosis was present in only one lesion on the left with pT4/GII stage. Lymph node involvement in patients with unilateral tumors (115) was present (pN1) in 8.7% (10) of the cases; it was absent (pN0 – 32) or could not be assessed (pNx – 73) in 91.30% (105). In patients with bilateral tumors (2), no lymphadenectomy was initially performed, since they were clinically negative.

Figure 1. Probability of survival in patients with non-metastatic renal cell carcinoma, according to age.

Figure 2. Probability of survival in patients with non-metastatic renal cell carcinoma, according to the pathological stage (T).

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Gurgel Predictors of mortality in patients submitted to nephrectomy for non-metastatic renal cell carcinoma at a referral center in Northeastern Brazil

Figure 3. Probability of survival in patients with non-metastatic renal cell carcinoma, according to lymph node involvement.

Pathological staging (pT) and lymph node involvement (N+) were variables that presented significant statistical significance when related to overall survival in univariate analyzes. The histological grade, angiolymphatic invasion, presence of tumor necrosis and tumor laterality were also studied variables related to overall survival in univariate analyzes, but without statistical significance. (Figures 2, 3, 4 and 5).

DISCUSSION The incidence of renal cancer, unlike other genitourinary tumors, is increasing11. This may be partly explained by the greater use of imaging methods such as magnetic resonance, computed tomography and ultrasound11. In our sample, only 8.55 % (10) of the patients were asymptomatic at the time of diagnosis. However, not only localized disease but also advanced disease is increasingly prevalent. The mortality rate continues to increase, suggesting that the elevation of incidence is not merely driven by better detection of early tumors12. Although international studies indicate that up to 60% of renal carcinomas are coincidentally diagnosed by imaging tests still in the asymptomatic phase13,14, our sample of patients from a Brazilian Northeastern state showed that 91.5% (107/117) of the patients had symptoms at the time of diagnosis. This is a very relevant data and reflects the reality of the population studied, typical of a referral hospital in the public health care through the Unified Health System

Figure 4. Overall survival of patients with non-metastatic renal cell carcinomain months.

(SUS), characterized by attending patients from regions with scarce access to medical care, notably in the case of neoplastic disease. Possibly, therefore, about 58.2% of patients had tumor size greater than 7 cm (pT2) or invasion of renal vein/inferior vena cava or adrenal gland, limited to the Gerota (pT3). This fact may justify the large number of symptomatic patients at diagnosis and the high rate of radical nephrectomies, certainly influencing mortality on this sample. There is no consensus regarding age being associated with an increased risk of mortality in RCC patients. According to Lee et al.15, young patients are more likely to have non-clear cell tumors, with the greater possibility of recurrence and lower overall survival. On the other hand, Cai et al.16, in a study that included 1,147 patients undergoing unilateral RCC nephrectomies (T1 to T2 N0 and M0), concluded that age above 45 years is associated with a higher incidence of cancer-specific mortality in localized RCC. In our study, the majority of patients received diagnosis after 45 years of age and this group did display a greater overall mortality (Figure 1). Grivas et al.17, in a study of clinical and pathological prognostic factors of renal cell carcinoma, concluded that the pathological stage and Fuhrman grade are strongly associated with survival. Besides that, in localized disease, such factors can be used in the follow-up to identify high-risk patients who could be the target of adjuvant therapy studies. In that study, as

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Gurgel Predictors of mortality in patients submitted to nephrectomy for non-metastatic renal cell carcinoma at a referral center in Northeastern Brazil

Figure 5. Probability of survival versus histological grade.

in ours, gender was not a predictor of survival. Ornellas et al.18 studied prognostic factors in renal cell carcinoma in 227 patients and found that the histological subtype, tumor necrosis, Fuhrman’s grade and angiolymphatic

261

invasion were predictive factors of survival, a fact that was not reproducible in our sample. In the evaluation of lymph node involvement as an independent survival predictor, Zhuang-fei et al.10 stated that T1-3M0 patients with N (+) have a worse prognosis, being an independent predictor of cancerspecific and disease-free survival. They also showed that Fuhrman’s grade and T stage are also predictors of cancerspecific survival. It is noteworthy that they considered Nx the cases in which no initial lymphadenectomy was performed, since they did not present lymph node enlargement at imaging or perioperative examination. Our study demonstrated that staging (pT – p=0.013) and lymph node involvement (N+ – p<0.001) were significantly associated with a higher overall mortality rate in univariate analysis in patients with non-metastatic RCC who underwent radical or partial nephrectomy. We also verified that 91.5% (107/117) of patients had symptoms at the time of diagnosis.

R E S U M O Objetivo: identificar fatores prognósticos envolvidos no carcinoma de células renais não metastático. Métodos: estudo tipo coorte retrospectivo, utilizando dados obtidos em revisão de prontuários de pacientes portadores de carcinoma de células renais, submetidos à nefrectomia radical ou parcial, no Instituto do Câncer do Ceará. Resultados: foram estudados 117 pacientes com média de idade de 59,14 anos e mediana de 59 anos. Não houve predominância de sexo, o rim direito foi o mais acometido (64%) e o tipo histopatológico mais comum foi o carcinoma de células claras (77%). Predominou o estádio pT1 e o grau GII. Das variáveis analisadas, apenas o estadiamento patológico (pT) e o acometimento linfonodal revelaram-se preditoras de sobrevida global. Conclusão: o estadiamento patológico (pT) e o acometimento de linfonodos regionais são fatores prognósticos importantes em pacientes portadores de carcinoma de células renais não metastáticos submetidos a nefrectomia. Descritores: Neoplasias Renais. Nefrectomia. Carcinoma de Células Renais. Sobrevida. Prognóstico.

REFERENCES 1. National Cancer Institute [Internet]. Kidney (renal cell) cancer. 2015 [cited 2015 Feb 23]. Available from: www.cancer.gov/cancertopics/types/kidney 2. Setiawan VW, Stram DO, Nomura AM, Kolonel LN, Henderson BE. Risk factors for renal cell cancer: the multiethnic cohort. Am J Epidemiol. 2007;166(8):932-40. 3. Siegel R, Naishadham D, Jemal A. Cancer statistics, 2013. CA Cancer J Clin. 2013;63(1):11-30. 4. Surveillance Epidemiology and End Results (SEER) [Internet]. Age adjusted SEER incidence rates by cancer site, all ages, all races, both sexes – 1992-

5.

6.

7.

8. 9.

2009. [cited 2015 Feb 23]. Available from: http:// seer.cancer.gov/faststats Wünsch-Filho V. Insights on diagnosis, prognosis and screening of renal cell carcinoma. Sao Paulo Med J. 2002;120(6):163-4. Nardi AC, Zequi SC, Clark OA, Almeida JC, Glina S. Epidemiologic characteristics of renal cell carcinoma in Brazil. Int Braz J Urol.;36(2):151-7. Linehan WM, Walther MM, Zbar B. The genetic basis of cancer of the kidney. J Urol. 2003;170(6 Pt 1):2163-72. Jemal A, Siegel R, Xu J, Ward E. Cancer statistics, 2010. CA Cancer J Clin. 2010;60(5):277-300. Yap NY, Ng KL, Ong TA, Pailoor J, Gobe GC, Ooi

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CC, et al. Clinical prognostic factors and survival outcome in renal cell carcinoma patients--a malaysian single centre perspective. Asian Pac J Cancer Prev. 2013;14(12):7497-500. 10. Chen Z, Wu P, Zheng SB, Zhang P, Tan WL, Mao XM. Patient outcome and prognostic factors of renal cell carcinoma in clinical stage T(1-3)N(1-2) M(0): a single-institution analysis. Nan Fang Yi Ke Da Xue Xue Bao. 2011;31(5):749-54. 11. Kouba E, Smith A, McRackan D, Wallen EM, Pruthi RS. Watchful waiting for solid renal masses: insight into the natural history and results of delayed intervention. J Urol. 2007;177(2):466-70. 12. Chow WH, Devesa SS, Warren JL, Fraumeni JF Jr. Rising incidence of renal cell cancer in the United States. JAMA. 1999;281(17):1628-31. 13. Heidenreich A, Ravery V; European Society of Oncological Urology. Preoperative imaging in renal cell cancer. World J Urol. 2004;22(5):30715. 14. Cohen HT, McGovern FJ. Renal-cell carcinoma. N Engl J Med. 2005;353(23):2477-90. 15. Lee LS, Yuen JSP, Sim HG. Renal cell carcinoma in young patients is associated with poorer prognosis. Ann Acad Med Singapore. 2011;40(9):401-6.

16. Cai M, Wei J, Zhang Z, Zhao H, Qiu Y, Fang Y, et al. Impact of age on the cancer-specific survival of patients with localized renal cell carcinoma: martingale residual and competing risks analysis. PLoS One. 2012;7(10):e48489. 17. Grivas N, Kafarakis V, Tsimaris I, Raptis P, Hastazeris K, Stavropoulos NE. Clinico-pathological prognostic factors of renal cell carcinoma: a 15year review from a single center in Greece. Urol Ann. 2014;6(2):116-21. 18. Ornellas AA, Andrade DM, Ornellas P, Wisnescky A, Schwindt AB. Prognostic factors in renal cell carcinoma: analysis of 227 patients treated at the Brazilian National Cancer Institute. Int Braz J Urol. 2012;38(2):185-94. Received in: 18/12/2016 Accepted for publication: 02/02/2017 Conflict of interest: none. Source of funding: none. Mailing address: Marcus Vinicius Silva AraĂşjo Gurgel E-mail: vinicius.gurgel@hotmail.com marvinonco@gmail.com

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D O I : 10.1590/

0100- 691201

Original Article

7003007

Parathyroidectomy in chronic kidney disease: effects on weight gain and on quality of life improvement Paratireoidectomia na doença renal crônica: efeitos no ganho de peso e na melhora da qualidade de vida HENYSE GOMES VALENTE-DA-SILVA1; MARIA CRISTINA ARAÚJO MAYA, TCBC-RJ1; ANNIE SEIXAS MOREIRA1. A B S T R A C T Objective: to evaluate the benefit of parathyroidectomy in patients on hemodialysis, regarding nutritional and biochemical statuses, body composition and the health-related quality of life. Methods: this is a longitudinal study involving 28 hemodialysis adult patients with severe secondary hyperparathyroidism evaluated before and one year after surgery. Inclusion criteria: parathyroid hormone levels exceeding ten times the upper normal range and end-stage renal disease in hemodialysis program. We used the body mass index to classify the nutritional status and the biodynamics analyzer to evaluate the body composition. Biochemical analysis included markers of lipid and bone metabolism. We assessed quality of life with the SF36 (Short Form Health Survey) questionnaire. All individuals underwent total parathyroidectomy with a forearm implant. Results: there were significant gains in body weight (61.7 vs 66.0 kg, p<0.001), body cell mass (22.0 vs 24.5 kg/ m2, p=0.05) and quality of life (p=0.001) after surgery. With respect to bone metabolism, intact PTH, calcium, phosphorus and alkaline phosphatase all stabilized and there were improvements in biochemical parameters such as albumin and hemoglobin. Conclusion: parathyroidectomy improves hemodialysis patient survival and is associated with weight and bone cell mass gain and improvement in health-related quality of life. Keywords: Parathyroidectomy. Kidney Failure, Chronic. Survival. Quality of Life. Nutrition Assessment.

INTRODUCTION

C

hronic kidney disease (CKD) has gained importance worldwide, since the morbidity profile of chronic noncommunicable diseases has changed. With the change, challenges have come due to its economic and social implications1. CKD is characterized by the presence of renal morphofunctional changes for a minimum period of three months, whose severity varies with the reduction of renal function, and may lead to death if left untreated2. Substitutive therapies such as hemodialysis, peritoneal dialysis and renal transplantation become essential when loss of renal function is incompatible with life. Several basic diseases, whose prevalence is increasing each year, can lead to CKD, among them obesity, diabetes mellitus, systemic arterial hypertension and glomerulonephritis3,4. Reduced renal function leads to several adaptive changes involving serum levels of calcium, phosphorus, and regulatory hormones, such as parathyroid hormone (PTH) and 1,25-hydroxy-vitamin D1. Metabolic changes

due to renal failure result not only in bone mineral disease with its effects on the skeleton generating pain, deformities and incapacity due to changes in remodeling and errors in bone mineralization, but they are associated with high mortality mainly due to cardiovascular disease5-7. Regarding bone mineral disease, secondary hyperparathyroidism (HPT) is characterized by elevated levels of PTH, usually greater than 800 pg/mL, associated with bone lesions, increased resting energy expenditure (REE) and worsening of quality of life2,7. Increased REE leads to weight loss and decreases survival. However, overweight and/or obesity, heavily studied as a risk factor for cardiovascular disease3 and decreased survival, may be a protective factor in this case8. The worsening of quality of life is due to all these factors, and for its evaluation, we use the Short Form Health Survey 36 (SF-36), a questionnaire that evaluates eight physical and mental domains9. When quality of life becomes much compromised, the deformities are important and the bone pain intractable, surgery becomes the best option. In

1 - University of the State of Rio de Janeiro (UERJ), Rio de Janeiro, Rio de Janeiro State, Brazil. Rev. Col. Bras. Cir. 2017; 44(3): 263-269


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general, total parathyroidectomy with a forearm implant has been an excellent therapeutic option, reversing these negative factors10. The objective of this study was to evaluate the benefit of parathyroidectomy (PTx) on quality of life, body weight, biochemical and metabolic parameters in dialytic chronic renal disease.

METHODS We carried out a longitudinal study involving 28 adults with CKD who underwent a three-timesweekly hemodialysis program with severe HPT and uncontrolled PTH levels (>1000 pg/mL), and fulfilled the criteria for parathyroidectomy (PTx). All were evaluated before surgery, when they signed an informed consent, and one year after surgery, between the years of 20102012, at the Pedro Ernesto University Hospital, UERJ. Inclusion criteria were serum PTH levels equal to or greater than ten times the upper normality limit, inability to respond to oral medications and one or more of the following: persistent hypercalcemia despite interruption of calcium and calcitriol or after kidney transplantation; Calcium-phosphorus product >70mg/ dL; bone pain that did not respond to oral treatment; pathological fractures; bone deformities; ectopic calcification; disabling arthritis or periarthritis; tendon rupture; intractable pruritus; or presence of brown tumor11. We excluded subjects with previous hospitalization within three months before the start of this study, with active inflammatory disease or infection, and in use of steroid and/or immunosuppressive agents. The evaluation before and one year after surgery included anthropometry, body composition analysis by electrical bioimpedance (BIA), biochemical parameters and quality of life by the SF 36. The study was approved by the Ethics in Research Committee of the Pedro Ernesto University Hospital, under the number 2551-030. Anthropometry We measured weight and height for evaluation of the body mass index (BMI), using the classification of nutritional status proposed by the World

Health Organization (WHO)3, based on BMI = Kg/m2, namely: underweight <18.5 kg/m2; Eutrophy 18.5 to 24.9 kg/m2; Overweight 25 to 29.9 kg/m2; Obesity â&#x2030;Ľ30 kg/m2. The evaluation was performed after the hemodialysis session, with the patients wearing light clothes and without shoes. Analysis of Body Composition by Electric Bioimpedance (BIA)12 We used a Biodynamics 310E, version 4.0 analyzer. We placed the electrodes in the standard position, on the side not accessible for hemodialysis. We analyzed: lean mass (LM), fat mass (FM), phase angle (PA) and body cell mass (BCM). Cell mass included evaluation of muscle (60%) and organs (20%), as well as cells and tissues. The loss of BCM is a strong marker of mortality13. We performed the examination the day after the hemodialysis session. Biochemical parameters We collected blood samples after 12 hours of fasting for the analysis of triglycerides, total cholesterol and HDL-cholesterol by automated methods using commercial kits. The LDL-cholesterol level was calculated by the Friedewaldâ&#x20AC;&#x2122;s14. The following were considered as altered: triglycerides above 150mg/dL; HDL-cholesterol below 40mg/dL for men and below 50mg/dL for women; LDL-cholesterol greater than 130mg/dL and total cholesterol greater than 200mg/dL. For the analysis of bone metabolism, we used the colorimetric method to study total alkaline phosphatase, calcium and phosphorus, and the chemo-luminescence to assess intact PTH (iPTH). We considered normal intervals, respectively: 50-250 U/L, 8.6-10.0 mg/dL, 2.5-4.8 mg/dL and 10-65 pg/ml. For evaluation of nutritional status, we used the colorimetric method to measure hemoglobin and albumin. Levels below 3.5g/dL for albumin and below 12.8g/L for men and 11.3g/L for women for hemoglobin were markers of poor nutritional status. Assessment of Quality of Life We evaluated quality of life with a validated Brazilian version of the SF-36, which measures eight health domains related to quality of life (QOL)15.

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Valente-Da-Silva Parathyroidectomy in chronic kidney disease: effects on weight gain and on quality of life improvement

We compared the QOL at the time of the study with the QOL one year before the evaluation. The calculation procedures of the scores followed the recommendations of the SF-36 developers. Each component was analyzed individually as the average of a predefined sum of questions, ranging from 0 to 3 or from 0 to 5, depending on the number of possible answers. Each response was linearly transformed to 0 to 100, the higher scores indicating better QOL. The eight domains of the SF-36 are: functional capacity (ten items), physical aspects (four items), pain (two items), general health status (five items), emotional aspects (three items) and mental health (five items), and two summary measures - PC (physical component) and MC (mental component). Statistical analysis We used the Statistical Software for Social Sciences (SPSS) version 20 and the Stata 12 for data analysis. We expressed the frequency distributions of socio-demographic characteristics and anthropometric measurements as percentages (%). We investigated the normality of the variables with the Kolmogorov-Smirnov test. We compared the mean ± standard deviation (SD) of the anthropometric, biochemical, body composition, and quality of life values before and one year after parathyroidectomy using the Student t-test or the Wilcoxon Signed Ranks test. In all cases, we considered p values of less than 0.05 as statistically significant.

RESULTS The most frequent clinical manifestations were pain, bone high uptake and pruritus. PTx had a positive and significant effect on pruritus reduction (p=0.04), reducing its prevalence from 50% to 22%. The other clinical manifestations also had a significant reduction after surgery. Table 1 shows the baseline characteristics of the 28-people study group. There was a change in nutritional status after PTx. The prevalence of overweight increased from 31% to 39% (p=0.001) and low weight decreased from 12% to 4% (p=0.343). Surgery did not determine modification in body composition, except for the increase in BCM. Before surgery, the phase

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angle (PA) varied from 2.9 to 7.1°, BCM= 11.2 to 45.6 kg, LM= 25.9 to 71.7 kg and FM= 1.5 to 42.9 kg. After PTx the variations were as follows: PA= 2.9 to 9.0°, BCM= 12.3 to 50.3 kg, LM= 28.5 to 89.2 kg and FM= 1.5 to 46.0 kg. Table 2 shows the mean ± standard deviation of body composition, SF-36 and biochemical values. Table 1 - Baseline Characteristics of the 28 subjects studied: data presented in percentages or mean ± standard deviation.

Basic Features Male (%)

Average +-dp or% 39.3

Age (years)

43.7 +-9.9

2

BMI (Kg/m )

23.7 ± 4.8

Time of disease (years)

10.7 +-4.6

Smoking (%)

17.9

Alcoholism (%)

3.6

Non-Caucasian (%)

32.1

Causes of kidney disease (%) Systemic hypertension

75.0

Diabetes mellitus

3.7

Glomerulonephritis

7.1

Polycystic Kidney

7.1

Other

7.1

Secondary manifestations of hyperparathyroidism (%) Pain

96.4

High bone uptake

78.6

Pruritus

50.0

Bone resorption

32.7

Deformities

32.1

Ectopic calcification

25.0

Calcium/Phosphate ratio > 70

25.0

Arthritis

21.4

Nutritional Status (%) Low Weight

3.6

Eutrophic

53.6

Overweight/obese

42.8

BMI= body mass index.

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When analyzing only the individuals who gained weight, we observed that this variation was mainly in the fat mass (delta= 37%, p<0.05), a little less intense but present in BCM (16%, p=0, 03), and had no effect on lean mass. The proportion of subjects with low albumin was 33% before surgery and 26% after surgery. The procedure also significantly reduced the prevalence of anemia. Before, 91% of the patients had reduced hemoglobin and after, only 38% (p=0.02). Regarding lipid profile, before the surgery,

50% had triglycerides above the reference values, 44% had low HDL-cholesterol levels and more than 20% had elevated total cholesterol. Despite weight gain, the lipid profile did not change significantly after surgery except for the increase in LDL-cholesterol. However, despite this increase, the levels observed both before and after PTx remained within normal values. Surgery had an important effect in the reduction of bone remodeling and, consequently, in the prevention of future fractures.

Table 2 - Characteristics of body composition, biochemical parameters and quality of life (SF-36) before and after PTx: mean ± standard deviation.

General parameters

Pre-PTx

Post-PTx

p

Weight (Kg)

61.7 +-18.5

66.0 ± 20.3

< 0.001

BMI (Kg/m )

23.7 ± 4.8

+ 25.1-5.8

< 0.001

LM (Kg)

46.8 +-2.3

47.2 +-2.9

ns

FM (Kg)

16.8 ± 1.9

19.7 +-1.7

ns

BCM (Kg)

22.0 +-7.4

24.5 +-9.1

0.05

PA (degree)

5.4 +-0.5

6.2 +-0.6

ns

2290.7 +-734.5

215.5 +-90.8

0.000

Calcium (mg/dl)

10.0 +-1.3

8.19 +-1.1

0.000

Phosphorus (mg/dl)

5.6 +-1.5

3.83 +/-1.2

0.000

1548.1 +-1257.4

362.35 +-128.5

0.000

Albumin (g/dL)

6.7 +-0.9

7.3 +-0.9

0.06

Hematocrit (%)

32.5 +-5.3

36.8 +-1.5

0.05

Hemoglobin (g%)

10.7 +-1.7

12.1 +-2.2

0.02

Total cholesterol (mg/dL)

160.1 +-41.9

166.0 +-40.6

NS

HDL-cholesterol (mg/dL)

44.1 +-13.2

42.3 +-13.7

NS

LDL-cholesterol (mg/dL)

65.3 +-14.1

91.8 +-11.5

0.004

Triglycerides (mg/dL)

166.8 +-83

174.2 +-25.9

NS

Functional capacity

19.3 +-22.1

53.0 +-30.7

0.001

Physical aspects

12.5 +-29.3

52.7 +-43.7

0.001

Pain

29.3 +-23.2

+ 70.2-27.1

0.001

General health

43.8 +-19.3

61.1 +-21.6

0.001

Vitality

45.7 +-41.9

+ 58.9-18.9

0.001

Social aspects

53.8 +-18.7

75.9 +-24.3

0.001

Emotional aspects

15.5 +-33.3

72.6 +-41.6

0.001

Mental health

53.8 +-18.7

+ 60.6-19.7

0.259

Body Composition (BIA) 2

Biochemical Parameters Intact PTH (pg/ml)

Alkaline phosphatase (U/l)

SF-36

BMI= body mass index; LM= lean body mass; FM= fat mass; BCM= body cell mass; PA= the Phase angle. Rev. Col. Bras. Cir. 2017; 44(3): 263-269


Valente-Da-Silva Parathyroidectomy in chronic kidney disease: effects on weight gain and on quality of life improvement

There was also a positive effect of surgery on QOL. Both the functional capacity and the emotional, vitality and pain aspects, which were important pre-PTx complaints, had a significant reduction, contributing to the improvement of quality of life and satisfaction with the surgical procedure.

DISCUSSION The most relevant results of surgery in this study were: a) improvement of nutritional status, b) weight gain, and c) improvement in quality of life. The data are in accordance with a recent study showing the importance of parathyroid resection in CKD patients with advanced disease17. In large population studies, overweight, low body cell mass and phase angle have shown to increase morbidity and mortality18,19. However, in patients with end-stage renal disease, an â&#x20AC;&#x153;obesity paradoxâ&#x20AC;? has been consistently reported: High BMI is associated with lower all-cause mortality19. The present study showed a gain after PTx, predominantly a change in fat mass. The explanation for this effect would be related to a reduction of PTH20 associated with a more liberal diet and better quality of life. Still in relation to body composition, this study showed a BCM increase after PTx that could be explained by some factors already described: 1) Reduction of serum phosphate: phosphate has a toxic cellular effect, reducing the lean and total body masses21; 2) Reduction of bone pain: Pain can reduce mobility and contribute to the reduction of BCM, resulting in lower survival; 3) Increased food intake: the improvement in the general state of health favors a higher food intake, with a gain of fat mass, but also with a higher protein intake22. Although some patients had their albumin levels increased after surgery, this difference did not have statistical robustness, probably due to the small number of individuals studied. We can infer from this observation that even patients with more adequate levels of postoperative serum albumin require a proper nutritional follow-up, since hypoalbuminemia is associated with higher morbidity and mortality in chronic kidney disease23.

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Surgery had a positive effect on hemoglobin levels. Anemia in CKD is difficult to manage, especially when associated with hyperparathyroidism. The reduction of iPTH and phosphate levels, combined with an improvement in the Ca:P ratio, contribute to the control of anemia and may be associated with a reduction in bone marrow fibrosis and systemic inflammation. The evaluation of lipids in the pre-dialysis serum may underestimate the true lipemic levels, since before the hemodialysis (HD) sessions the individuals have greater weight (due to a greater amount of free water), impairing results and hindering therapeutic management24. In this study, we did not identify prePTx elevated lipids and justified the increase in LDLcholesterol after surgery by other factors, other than nutritional or metabolic, such as oxidative stress, inflammation and possible endothelial dysfunction, as described by Nitta25. According to that author, LDL-cholesterol cannot be used as a good marker of cardiovascular risk in CKD. The poor quality of life was evident before surgery, not directly related to the duration of the disease, as demonstrated26,27. However, the procedure had an important beneficial effect, which can be explained by the reduction of the toxic effects of PTH, causing multiple organ damage and exuberant symptomatology28. These improvements validate the indication of parathyroidectomy as early as possible in CKD29,30. The present study has some limitations that include the low number of participants, due to the financial difficulties of a public hospital, and the lack of information about the body weight gain after PTx. However, it demonstrates the importance of surgery being performed as early as possible, considering all the presented advantages, and that there is concern about the excessive gain of body weight, which can become a predictor of greater cardiovascular risk in end-stage renal disease. We conclude that parathyroidectomy with forearm implantation (PTx), performed in patients with end-stage renal disease in hemodialysis regimen and with severe hyperparathyroidism, is associated with weight gain, increased body cell mass and improved quality of life.

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R E S U M O Objetivo: avaliar o benefício de paratireoidectomia em pacientes submetidos à hemodiálise, em relação ao estado nutricional e bioquímico, composição corporal e a qualidade de vida. Métodos: estudo longitudinal envolvendo 28 adultos em programa de hemodiálise, com hiperparatireoidismo secundário grave, avaliados antes e um ano após a cirurgia. Critérios de inclusão: níveis de paratormônio dez vezes superior ao valor de referencia e doença renal crônica em programa de hemodiálise. O índice de massa corporal foi utilizado para classificação do estado nutricional. A bioimpedância elétrica para avaliação da composição corporal. A análise bioquímica incluiu dosagem de lipídios e marcadores do metabolismo ósseo. A qualidade de vida foi avaliada pelo questionário SF36 (Short Form Health Survey). Todos os pacientes foram submetidos à paratireoidectomia total com implante em antebraço. Resultados: houve ganho significativo de peso corporal (61,7 vs 66,0 kg; p<0,001), da massa celular corporal (22,0 vs 24,5 kg/m2; p=0,05) e da qualidade de vida (p=0,001) após a cirurgia. Com relação ao metabolismo ósseo, PTH intacto, cálcio, fósforo e fosfatase alcalina, se estabilizaram e houve melhora em parâmetros bioquímicos, tais como albumina e hemoglobina. Conclusão: a paratireoidectomia melhora a sobrevida em pacientes de hemodiálise e está associada a aumento de peso, ganho de massa óssea e melhoria na qualidade de vida. Descritores: Paratireoidectomia. Insuficiência Renal Crônica. Sobrevida. Qualidade de Vida. Avaliação Nutricional.

REFERENCES 1. Williams AW. Health policy, disparities, and the kidney. Adv Chronic Kidney Dis. 2015;22(1):54-9. 2. United States Renal Data System. 2014 USRDS annual data report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2014. 3. World Health Organization (WHO). Obesity: Preventing and Managing the Global Epidemic. WHO Technical Report Series 894. Geneva: WHO; 2000. 4. Tomich GM, Milhomem BM, Araújo CS, Sousa PPS, Coelho TA, Ginani GF, et al. Hiperparatireoidismo secundário à doença renal crônica em pacientes em diálise no Pará-Brasil. Semina Ciên Biol Saúde. 2015;36(2):67-74. 5. Nasuto M, Pansini V, Cortel B, Guglielmi G, Cotten A. Renal failure: a modern semiology for an old disease. Semin Musculoskelet Radiol. 2016;20(4):353-68. 6. Hruska KA, Sugatani T, Agapova O, Fang Y. The chronic kidney disease - Mineral bone disorder (CKD-MBD): advances in pathophysiology. Bone. 2017;pii:8756-3282(17):30023-6. 7. Cuppari L, Carvalho AB, Avesani CM, Kamimura MA, Lobão RRS, Draibe AS. Increased resting energy expenditure in Hemodialysis patients with severe hyperparathyroidism. J Am Soc Nephrol. 2004;15(11):2933-9. 8. Kalantar-Zadeh K, Kopple JD. Obesity paradox in patients on maintenance dialysis. Contrib Nephrol. 2006;151:57-69.

9. Yarlas AS, White MK, Yang M, Saris-Baglama RN, Bech PG, Christensen T. Measuring the health status burden in hemodialysis patients using the SF36 health survey. Qual Life Res. 2011;20(3):383-9. 10. Ma TL, Hung PH, Jong IC, Hiao CY, Hsu YH, Chiang PC, Guo HR, Hung KY. Parathyroidectomy Is Associated with Reduced Mortality in Hemodialysis Patients with Secondary Hyperparathyroidism. BioMed Res Int. 2015;2015:639587. 11. Lacativa PGS, Patrício Filho PJM, Gonçalves MDC, Farias MLF. Indicações de paratireoidectomia no hiperparatireoidismo secundário à insuficiência renal crônica. Arq Bras Endocrinol Metab. 2003;47(6):644-53. 12. Chertow GM, Lazarus JM, Lew NL, Ma L, Lowrie EG. Bioimpedance norms for the hemodialysis population. Kidney Int. 1997;52(6):1617-21. 13. Chua A, Xiang L, Chow PY, Xu H, Shen L, Lee E, et al. Quantifying acute changes in volume and nutritional status during hemodialysis using bioimpedance analysis. Nephrology. 2012;17(8):695-702. 14. Friedewald WT, Levy RI, Fredrickson DS. Estimation of concentration of low-density lipoprotein cholesterol in plasma, without use of preparative ultracentrifuge. Clin Chem. 1972;18(6):499-502. 15. Ciconelli RM. Tradução para o português e validação do questionário genérico de avaliação de qualidade de vida “medical outcomes study 36-item short-form health survey” (SF-36)” [dissertação]. São Paulo: UNIFESP; 1997. 16. Ware Jr JE, Snow KK, Kosinski MA, Gandek B. SF36 health survey: manual & interpretation guide. 6th ed. Boston: The Health Institute, New England Medical Center; 2002.

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17. Khajehdehe P, Ali M, Al-Gebory F, Henry G, Bastani B. The effects of parathyroidectomy on nutritional and biochemical status of hemodialysis patients with severe secondary hyperparathyroidism. J Ren Nutr. 1999;9(4):186-91. 18. Segall L, Moscalu M, Hogas S, Mititiuc I, Nistor I, Veisa G, et al. Protein-energy wasting, as well as overweight and obesity, is a long-term risk factor for mortality in chronic hemodialysis patients. Int Urol Nephrol. 2014;46(3):615-21. 19. Park J, Ahmadi SF, Streja E, Molnar MZ, Flegal KM, Gillen D, et al. Obesity paradox in end-stage kidney disease patients. Prog Cardiovasc Dis. 2014;56(4):415-25. 20. HjelmesÌth J, Hofsø D, Aasheim ET, Jenssen T, Moan J, Hager H, et al. Parathyroid hormone, but not vitamin D, is associated with the metabolic syndrome in morbidly obese women and men: a cross-sectional study. Cardiovasc Diabetol. 2009;8:7. 21. Ohnishi M, Razzaque MS. Dietary and genetic evidence for phosphate toxicity accelerating mammalian aging. FASEB J. 2010;24(9):3562-71. 22. Peters BS, Jorgetti V, Martini LA. Body composition changes in haemodialysis patients with secondary hyperparathyroidism after parathyroidectomy measured by conventional and vector bioimpedance analysis. Br J Nutr. 2006;95(2):353-7. 23. Zeier M. Risk of mortality in patients with endstage renal disease: the role of malnutrition and possible therapeutic implications. Horm Res. 2002;58 Suppl 3:30-4. 24. Ueno T, Doi S, Nakashima A, Yokoyama Y, Doi T, Kawai T, et al. The serum lipids levels may

25.

26.

27.

28. 29.

30.

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be underestimated in patients on hemodialysis. Intern Med. 2015;54(8):887-94. Nitta K. Clinical assessment and management of dyslipidemia in patients with chronic kidney disease. Clin Exp Nephrol. 2012;16(4):522-9. Malindretos P, Sarafidis P, Lazaridis A, Nikolaidis A. A study of the association of higher parathormone levels with health-related quality of life in hemodialysis patients. Clin Nephrol. 2012;77(3):196-203. Johansen KL, Chertow GM. Chronic kidney disease mineral bone disorder and health-related quality of life among incident end-stage renaldisease patients. J Ren Nutr. 2007;17(5):305-13. Rodriguez M, Lorenzo V. Parathyroid hormone, a uremic toxin. Sem Dial. 2009;22(4):363-8. Edwards ME, Rotramel A, Beyer T, Gaffud MJ, Djuricin G, Loviscek K, et al. Improvement in the health-related quality-of-life symptoms of hyperparathyroidism is durable on long-term follow-up. Surgery. 2006;140(4):655-63. Cheng SP, Lee JJ, Liu TP, Yang TL, Chen HH, Wu CJ, et al. Parathyroidectomy improves symptomatology and quality of life in patients with secondary hyperparathyroidism. Surgery. 2014;155(2):320-8.

Received in: 15/12/2016 Accepted for publication: 16/02/2017 Conflict of interest: none. Source of funding: none. Mailing address: Henyse Gomes Valente-da-Silva E-mail: henyse@uol.com.br / anniebello@gmail.com

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D O I : 10.1590/

Original Article

0100- 6912017003009

Perioperative care in bariatric surgery in the context of the ACERTO project: reality versus surgeons assumptions in a Cuiabá hospital Cuidados perioperatórios em cirurgia bariátrica no contexto do projeto ACERTO: realidade e o imaginário de cirurgiões em um hospital de Cuiabá JACQUELINE JÉSSICA DE-MARCHI, ACBC-MT1; MARDEM MACHADO DE-SOUZA, TCBC-MT1; ALBERTO BICUDO SALOMÃO, TCBC-MT1; JOSÉ EDUARDO DE AGUILAR NASCIMENTO, TCBC-MT1; ANYELLE ALMADA SELLETI2; ERIK DE-ALBUQUERQUE3; KATIA BEZERRA VELOSO MENDES4. A B S T R A C T Objective: to assess the level of knowledge among bariatric surgeons, about the recommendations of the ACERTO Project, correlating their assumptions on their perioperative prescriptions and the reality, according to the patients charts. Method: we conducted a prospective, longitudinal, observational study comparing the assumptions of bariatric surgeons obtained through responses on a specific questionnaire with the reality found in clinical data from the hospital records. We analyzed the following variables: preoperative fasting, early postoperative feeding, intravenous hydration, perioperative antibiotic prophylaxis, use of abdominal drains, type of analgesia, and prophylaxis of nausea and vomiting. We confronted the responses of seven surgeons with data from 200 records of patients undergoing gastroplasty for morbid obesity. Results: all interviewed surgeons knew the ACERTO Project. Five (72%) responded that they followed the protocol thoroughly. The median time of preoperative fasting found in the records was higher than the reported by the surgeons (p<0.05). Early postoperative feeding was prescribed for 96.5% of cases. The median volume of intravenous fluids prescribed in the first 24 hours was 4000ml, which was consistent with the interviews. There were no differences between the response in the questionnaire and the findings in the hospital records in relation to antibiotic prophylaxis, use of catheters and drains, analgesia and prophylaxis of nausea and vomiting. Conclusion: the ACERTO Project was well practiced among the surveyed surgeons. There was a good correlation between their assumptions and the reality in perioperative care of patients undergoing bariatric surgery. However, there was a significant difference in preoperative fasting time. Keywords: Bariatric Surgery. Postoperative Care. Intraoperative Care. Evidence-Based Medicine.

INTRODUCTION

E

vidence-based medicine (EBM) translates into the practice of medicine in a context of clinical and integrated experience, with the ability to critically analyze and apply scientific information in a rational way, with the aim of improving the quality of medical care1,2. In this context, translational medicine is a discipline that studies how to accelerate the discoveries of medicine in the laboratory and clinical fields in fast application of medical practice to improve medical or surgical treatment results3. According to Lean et al.4, it is a process that starts from EBM towards sustainable solutions to community health problems. Evidence-based protocols and guidelines are mechanisms that should be implemented in the medical routine, since they reduce morbidity and mortality5. Standardization of clinical practice,

making it safer, is a challenge, since physicians often do not apply it6,7. The ACERTO Project (Portuguese acronym for Total Postoperative Recovery Acceleration)8 is an educational multimodal protocol (Figure 1) designed to accelerate patients’ postoperative recovery, based on the ERAS (Enhanced Recovery After Surgery)9 European program already existing and grounded in the EBM paradigm. Although the ACERTO Project has been widely disseminated for ten years, there is a need for data on its incorporation into perioperative care routines. It is believed that there is a mismatch between what one assumes to have prescribe and what is prescribed, that is, between the “real” and the “imaginary”. The preoperative fasting time, for example, may be greater in audits than one might imagine from the medical prescription in Brazil10. Several factors

1 - University of Mato Grosso, Cuiabá, Mato Grosso State, Brazil. 2 - University of Várzea Grande, Várzea Grande, Mato Grosso State, Brazil. 3 - University of Cuiabá, Cuiabá, Mato Grosso State, Brazil. 4 - Mato Grosso Cancer Hospital, Cuiabá, Mato Grosso State, Brazil. Rev. Col. Bras. Cir. 2017; 44(3): 270-277


De-Marchi Perioperative care in bariatric surgery in the context of the ACERTO project: reality versus surgeons assumptions in a Cuiabá hospital

Figure 1. Main conducts addressed in the ACERTO Project.

Source: www.periop.com.br

may contribute to the fact that the recommended guidelines are not actually performed. At present, the number of surgical procedures for morbid obesity has increased significantly. These are procedures involving resections and anastomoses of the stomach and small intestine. The use of the ACERTO Project11 or the ERAS protocol12 has shown that they are safe in bariatric surgery and can reduce hospitalization time. Recently, a new guideline of the ERAS has recommended the application of the multimodal protocol in this type of procedure13. This study is important as it investigates the use of the routines of the ACERTO project between surgeons who perform bariatric surgery. Thus, the objective of this study was to verify the degree of knowledge among bariatric surgeons about the recommendations of the ACERTO Project, correlating their assumptions about their prescriptions and what really occurred through patients’ records.

METHODS The study was approved by the Ethics in Research Committee of the Júlio Muller University Hospital, according to protocol number 031470/2016. It is a prospective, longitudinal, observational study, using the medical questionnaire and analysis of prospective clinical data of patients’ charts submitted to bariatric laparoscopic procedures. We collected the data until the day of patients’ discharge.

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We interviewed seven surgeons with a structured questionnaire (Table 1) and gathered clinical data from medical records of 200 consecutive patients, aged between 18 and 70 years, of both genders, operated at the São Mateus Hospital and Maternity (HMSM), a private service in Cuiabá, MT, from May 1 to July 1, 2016. Data collection was authorized by the HMSM ethics committee. All patients underwent general anesthesia and were submitted to the Rouxen-Y vertical gastric bypass technique. We excluded patients who underwent open surgery, reoperations, and procedures with severe intraoperative complications, such as cardiac arrest, irreversible shock and severe intraoperative bleeding. The variables analyzed were preoperative fasting time, early postoperative feeding, perioperative venous hydration volume, antibiotic prophylaxis, use of catheters and drains, analgesia and prophylaxis of postoperative (PO) nausea and vomiting. To estimate the preoperative fasting time, in the immediate postoperative period or on the first postoperative day, we asked all patients how long their fast lasted before the onset of anesthesia. We defined as “assumption” the perception gathered from the response of the interviewed surgeons about their conduct in perioperative care, and “reality”, the data found in the medical records on these same conducts. We then correlated the answers to the medical questionnaire (assumptions) with the medical records’ data (reality). We grouped and entered the data into spreadsheets using the EXCEL® 365 software and later exported them for the SPSS 17.0 program for descriptive and analytical analysis. We used the nonparametric Mann-Whitney test for comparisons of continuous or ordinal variables, considering a significance level of 5%. We expressed continuous data as mean and standard deviation or median and inter-quartile range.

RESULTS All the surgeons were male, with a mean age of 42 years (36 to 55) and 18 years (12 to 32) average training after graduation. All of them attended Medical

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De-Marchi Perioperative care in bariatric surgery in the context of the ACERTO project: reality versus surgeons assumptions in a Cuiabรก hospital

Table 1. Medical questionnaire items and the data file.

Medical questionnaire

Chart data collection sheet

Time of preoperative fasting commonly prescribed for solids and liquids?

Preoperative fasting time observed for solids and liquids

How and when to prescribe postoperative feeding?

Date (day of PO) on which feeding initiated

Which crystalloid fluid prescribes in post-op?

Crystalloid fluid that was prescribed in the PO

Which volume prescribes per day and when suspends it?

Prescribed volume

Prescribes prophylactic antibiotic? (which?)

Antibiotic

Knows and uses the CCIH Protocol?

Time of antibiotic regimen start

Days of intravenous hydration in PO

Antibiotic usage time in PO Uses nasogastric and bladder catheter and abdominal drains?

Use of drains and nasogastric and bladder catheter

Which drug prescribes for analgesia?

Medication used for analgesia in PO

Prescribes prophylaxis for nausea and vomiting? Which medication?

Medication used for prophylaxis of nausea and vomiting

Knows the ACERTO project?

Note on the use of the routines of the ACERTO Protocol in PO prescriptions

Uses the ACERTTO project partially or totally?

Residency in General Surgery and six had a Specialist Degree issued by some surgical society in Brazil. Among them, two (28%) reported that they used the ACERTO protocol partially, and five (72%), fully. Regarding the analysis of the medical records (n=200), no deaths were recorded. Of the total, 187 patients (93.5%) were discharged on the first postoperative day. Twelve patients were discharged on the second postoperative day and one patient presented lobar pneumonia, remaining hospitalized for seven days for antibiotic therapy, without abdominal complications. Preoperative fasting and early feeding Five surgeons responded that they advised their patients to remain on an eight-hour fasting for solid foods. Regarding fasting for fluids, all said they recommended on average three hours before the procedure. No surgeon said to prescribe carbohydrate

drinks two to three hours before surgery. All responded that they early refed their patients, on average eight hours postoperatively. However, in the medical records we observed that the median time of preoperative fasting was 12 hours (eight to 21) for solid foods and ten hours (two to 18) for clear liquids. Only 23 cases (11.5%) were operated on with preoperative fasting for clear liquids less than six hours. Postoperative feeding occurred in 96.5% (n=193) of cases in the first 24 hours. In six cases (3%), the diet was prescribed on the first postoperative day and in one (0.5%) case on the second. Figure 2 shows the comparison of data from the medical records and the questionnaire regarding preoperative fasting. Perioperative intravenous fluids According to the questionnaire, the fluid used by all surgeons in the postoperative period

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De-Marchi Perioperative care in bariatric surgery in the context of the ACERTO project: reality versus surgeons assumptions in a CuiabĂĄ hospital

Figure 2. Average time of fasting for solids and liquids (p<0.05 to solid foods and liquids).

p<0.05 in both comparisons between the questionnaire and medical charts, for both solid and liquid foods.

was the combination of 5% glucose and saline. The charts revealed that this combination was the most commonly used intravenous fluid (190 cases, 95%), followed by saline (seven cases, 3.5%) and lactated ringer (two cases, 1%). One patient (0.5%) received only 5% glucose. Patients received a median of 1,000 ml (5004,000) intraoperatively. In the immediate postoperative period, surgeons prescribed a median of 4,000ml (1,000 to 7,000). Only thirteen patients (6.5%) received intravenous fluids on the first postoperative day, with a median of 3,000ml (1,000 to 4,000). Only one patient received 1,500ml of crystalloid fluid on the second postoperative day. Surgeons reported having prescribed a median of 3,000ml (2,500 to 4,000 ml) per day in the immediate postoperative period. Regarding the criteria for the suspension of venous hydration: 58% (n=4) reported discontinuation on discharge, 14% (n=1) used maintenance hydration (while the patient was taking intravenous medications) and 28% suspended

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the serum when they offered solid foods to patients. Table 2 shows the comparison of the assumed intravenous fluid prescription and the reality observed in 200 hospital records. Only 3.5% and 0.5% of the patients received intravenous fluids on the first and second PO days, respectively. In the statistical analysis, we observed a significant difference (p=0.01) between the amount described above and the amount observed in the medical record for fluid prescribing in the immediate postoperative period (Figure 3). Three surgeons (42.8%) reported not to prescribe intravenous fluids on the first postoperative day and the remainder admitted to prescribe an amount of fluid between 1,500 and 3,500 ml. Only one surgeon reported prescribing fluids on the second postoperative day (3,000ml). Antibiotic prophylaxis All surgeons answered that they use antibiotic prophylaxis, and cefazolin is the antibiotic of choice, as recommended by the Hospital Infection Control Committee (CCIH). Five surgeons kept the antibiotic for 24 hours, and the other two for 48 hours. Four surgeons were familiar with the CCIH protocol of the hospital where they work (58%), and reported to use it, while three (42%) said they did not know. Data from the medical records revealed that 199 patients (99.5%) received antibiotic prophylaxis at the time of anesthetic induction and one in the immediate postoperative period (0.5%). The majority of cases (196, 98%) received antibiotics for 24 hours, three (1.5%), for 48 hours and one (0.5%), for more than 48 hours. The most commonly prescribed

Table 2. Median volume of IV fluids prescribed in the PO (p=0.01 between questionnaire and medical charts).

Medical questionnaire Median and variation (ml/day)

Patientsâ&#x20AC;&#x2122; charts Median and variation (ml/day)

3,000 (2,500-4,000)

4,000 (1,000-7,000)

1st PO day

1,500 (0-3,500)*

0 (0-4,000)**

2nd PO day

0 (0-3,000) #

0 (0-1,500) ##

Postoperative day Immediate PO

* Three surgeons responded that did not prescribed IV fluids in first PO. ** 187 patients did not receive fluids in the first PO day. Only seven (3.5%) cases were given fluids ranging from 1,000 to 4,000 ml/day. # Only one surgeon reported prescribing fluids in the second PO day. Others reported that the patient would already be discharged, without IV fluids. ## Only one (0.5%) patients received 1,500ml in second PO day. The remaining 199 (99.5%) were discharged and did not receive IV fluids. Rev. Col. Bras. Cir. 2017; 44(3): 270-277


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De-Marchi Perioperative care in bariatric surgery in the context of the ACERTO project: reality versus surgeons assumptions in a CuiabĂĄ hospital

Figure 3. Median volume of intravenous fluids in the immediate PO (p=0.01 for the comparison of the questionnaire and medical charts).

antibiotic was cefazolin (197 cases, 98.5%). One patient (0.5%) received ciprofloxacin and two (1%) received ceftriaxone. Abdominal drains, nasogastric catheter and bladder catheter Most surgeons (72%) said they never use abdominal drains in this type of operation. In contrast, 28% reported the rare use of abdominal drains, in cases of reoperations due to complications. In these situations, the drain chosen by the surgeons in the questionnaire was that of Blake. No surgeon routinely used nasogastric and bladder catheters. The review of medical records found that no patient had a nasogastric or bladder catheter after the end of surgery. Four (2%) patients had the insertion of a Blake drain. Prophylaxis of nausea and vomiting and postoperative analgesia All surgeons reported that they use dipyrone and tramadol in combination with anti-inflammatory drugs: five (72%) use ketoprofen, and two (28%), tenoxicam. Regarding prophylaxis of nausea and vomiting, 86% (six surgeons) said they prescribed, five (72%) used ondansetron and one (14%) used dimenhydrin. In the medical records, all patients received analgesic medication, dipyrone and tramadol being the most frequent (195 cases, 97.5%), followed by dipyrone alone in five (2.5%) cases. One hundred and ninety-six patients (98%) received prophylaxis of nausea and vomiting, 194 patients ondansetron and two, dimenhydrin.

DISCUSSION We achieved the objectives drawn to answer the project question. The findings showed that all surgeons in the service knew the foundations of the ACERTO Project and applied them partially or totally. In addition, there was a high percentage of agreement between the surgeonsâ&#x20AC;&#x2122; assumptions and the reality of medical records. These postoperative results were adequate to the concept of acceleration of the postoperative recovery contained in the multimodal protocols, with a reduced number of hospitalization days, no mortality and low postoperative morbidity. These considerations are quite relevant, since bariatric surgery involves gastrointestinal resections and anastomosis. Traditionally, patients with gastric resection followed by anastomosis have received excessive volume of intravenous infusion for several days14. In bariatric surgery, this excessive volume is prescribed because of the fear of rhabdomyolysis15. There are indications in the literature of aggressive hydration in Bariatric patients starting at the anesthetic act, with volume ranging from four to five liters of crystalloid fluids for two to three hours of operation16. However, in a comparative study in the obese patient, the adoption of a more restricted regime (15ml/kg versus 40ml/kg) showed no difference in the incidence of postoperative rhabdomyolysis17. Boldt18, in 2006, published a review of venous hydration regimens in the postoperative period of abdominal surgery and concluded that patients undergoing postoperative restraint fluid therapy had fewer cardiovascular and pulmonary complications and postoperative ileus. Our results showed that the interviewed surgeons assimilated the concept of a more restricted fluid therapy defended by the Project in Bariatric Surgery11, which reflected in the observations of the 200 procedures performed. There was little disagreement between the assumed and the injected volume. In general, as for the population of obese patients, the prescribed volume, and mainly the number of days in intravenous fluid therapy, were adequate and within the recommendations of the ACERTO protocol. This

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scenario was observed not only by the surgeons in the postoperative period, but also by the anesthesiologists during the perioperative one, since the mean fluids were 1,000 ml per operation. This probably reflects the improved education of the HMSM anesthetic team, which for many years has been accompanying and implanting the ACERTO Project in Brazil. Many of the anesthesiologists in this group are authors of chapters and scientific articles in national and international journals19,20. However, there was still a preference of surgeons for the combination of 5% glucose and saline. According to recent guidelines of the ERAS group, the British intravenous fluid protocol (GIFTASUP) and the recommendations of the ACERTO Project, the most recommended intravenous fluids are the most balanced and chlorine-free solutions, such as simple or lactated ringer21. Traditionally, oral feeding after gastric surgery is prescribed after the second postoperative day, thus leading, as a possible complication, to postoperative ileus. This delay in refeeding results in an increase in hospitalization days and consequently hospital costs. Late feeding associated with increased venous hydration in the postoperative period may be a cause of prolonged ileus. Lukey et al.22, in 2003, showed that postoperative ileus costs can reach US$ 750 million per year due to the procedures involved and the number of hospitalization days. In this current series, the vast majority of patients, even with digestive anastomosis, received food on the same day of the operation, according to modern multimodal protocols such as the ERAS or the ACERTO Project11. At present, several guidelines of anesthesia societies recommend fasting of two hours for liquids with carbohydrates23-25. A recent guideline of the ERAS group recommends this prescription also for obese patients undergoing gastroplasty. However, when we examine the data regarding the assumptions and the reality of preoperative fasting prescription, we perceive a disagreement between what surgeons think they do and what the research patients received. In fact, there was a two-hour increase in fasting for solids and five hours for liquids between the data from the

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medical questionnaire and the data contained in the patients’ charts. This is relevant and allows affirming that there is still a need for greater attention and emphasis on the prescription and the conduction of correct preoperative fasting. These data are not new, and several studies have previously shown a large gap between prescribed fasting and fasting observed in the preoperative period. The multicenter BIGFAST study, performed in 17 Brazilian hospitals, showed that almost 50% of patients with six to eight hours of prescribed fasting really fasted for more than 12 hours before surgery. Even in hospitals where preoperative fasting is already performed according to the ACERTO Project, this interval exists, although it is not too long. A study in the HUJM showed that abbreviated fasting of two hours for clear liquids preoperatively in the medical prescription extended to four to five hours in the observed reality26. One possible explanation for the data we found is that due attention has not yet been given to preoperative fasting and perhaps an adequate protocol for patient orientation does not exist. Regarding the other mentioned perioperative care, we found a good agreement between the medical questionnaire and the hospital records regarding analgesia, use of catheters and drains, and prophylaxis of nausea or vomiting. These data show a perfect synchrony between the interviewed surgeons’ assumptions and the reality of the prescription found in the medical records. In general, the recommendations of the ACERTO Project were followed in this series of 200 patients. Most likely, the results are due to the wide surgical experience of the researched team, with more than ten years of surgical practice. In addition, many of them come from the HUJM, where in their graduation and/or post-graduation they got in touch with the ACERTO Project. In conclusion, we can say that the concepts of the ACERTO Project were known in the researched environment and were associated with good results in the postoperative period. With the exception of preoperative fasting, the assumptions and the reality in perioperative care in bariatric surgery were close in the HMSM.

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R E S U M O Objetivo: verificar o grau de conhecimento entre cirurgiões, sobre as recomendações do Projeto ACERTO em cirurgia bariátrica, correlacionando o “imaginário”, sobre suas prescrições, e a “realidade”, através de dados de prontuários de seus pacientes. Métodos: estudo observacional longitudinal prospectivo comparativo entre o “imaginário” dos cirurgiões, obtido através de respostas de questionário sobre condutas recomendadas pelo ACERTO e a análise de dados clínicos “reais” encontrados em prontuários de pacientes submetidos à cirurgia bariátrica. Foram analisados: jejum pré-operatório, realimentação precoce, hidratação venosa perioperatória, antibioticoprofilaxia, uso de sondas e drenos, analgesia e profilaxia de náuseas e vômitos. Foram confrontadas as respostas de sete cirurgiões e dados de 200 prontuários médicos. Resultados: todos os cirurgiões entrevistados conheciam o Projeto ACERTO. Cinco (72%) responderam que seguiam o protocolo completamente. O tempo mediano de jejum pré-operatório foi maior do que o relatado pelos cirurgiões (p<0,05). Os pacientes receberam realimentação precoce em 96,5% dos casos. O volume mediano de fluidos prescritos nas primeiras 24 horas foi 4000ml, condizente com a entrevista. Em relação à antibioticoprofilaxia, uso de sondas e drenos, analgesia e prevenção de náuseas e vômitos, não houve diferença entre o respondido e o constatado nos prontuários. Conclusão: o Projeto ACERTO era bem praticado entre os cirurgiões pesquisados, havendo boa correlação entre o “imaginário” e “realidade” dos cuidados perioperatórios prescritos em pacientes submetidos à cirurgia bariátrica. Descritores: Cirurgia Bariátrica. Cuidados Pós-Operatórios. Cuidados Intraoperatórios. Medicina Baseada em Evidências.

REFERENCES 1.

2.

3.

4. 5.

6.

7.

8.

9.

Evidence-Based Medicine Working Group. Evidence-based medicine. A new approach to teaching the practice of medicine. JAMA. 1992;268(17):2420-5. Lopes AA. Raciocínio clínico e tomada de decisões em medicina: um curso integrando medicina interna e epidemiologia. Rev Bras Educ Med. 1991;15(1-3):8-10. Wang X. A new vision of definition, commentary, and understanding in clinical and translational medicine. Clin Transl Med. 2012;1(1):5. Lean ME, Mann JI, Hoek JA, Elliot RM, Schofield G. Translational research. BMJ. 2008;337:a863. Polanczyk CA. Aplicando protocolos na doença cardiovascular. Arq Bras Cardiol. 2004;82(4):3078. Uchoa SA, Camargo Jr KR. Os protocolos e a decisão médica: medicina baseada em vivências e ou evidências? Ciên Saúde Coletiva. 2010;15(4):2241-9. Sutherland J, Ganous T. The medical informatics challenge in surgery. In: Satava RM, Gaspari A, Di Lorenzo N, editors. Emerging technologies in surgery. New York: Springer; 2007. p. 57-71. Aguilar-Nascimento JE, Caporossi C, Salomão AB. Acerto: acelerando a recuperação total pósoperatória. 3a ed. Rio de Janeiro: Rubio; 2016. Ljungqvist O. ERAS--enhanced recovery after surgery. J Visc Surg. 2011;148(3):e157-9.

10. Aguilar-Nascimento JE, Dias ALA, DockNascimento DB, Correia MI, Campos AC, PortariFilho PE, et al. Actual preoperative fasting time in Brazilian hospitals: the BIGFAST multicenter study. Ther Clin Risk Manag. 2014;10(1):107-12. 11. Pimenta GP, Capellan DA, Aguilar-Nascimento JE. Sleeve gastrectomy with or without a multimodal perioperative care. a randomized pilot study. Obes Surg. 2015;25(9):1639-46. 12. Lemanu DP, Singh PP, Berridge K, Burr M, Birch C, Babor R, et al. Randomized clinical trial of enhanced recovery versus standard care after laparoscopic sleeve gastrectomy. Br J Surg. 2013;100(4):482-9. 13. Thorell A, MacCormick AD, Awad S, Reynolds N, Roulin D, Demartines N, et al. Guidelines for perioperative care in bariatric surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations. World J Surg. 2016;40(9):2065-83. 14. Thiele RH, Rea KM, Turrentine FE, Friel CM, Hassinger TE, McMurry TL, et al. Standardization of care: impact of an enhanced recovery protocol on length of stay, complications, and direct costs after colorectal surgery. J Am Coll Surg. 2015;220(4):430-43. 15. de Menezes Ettinger JE, dos Santos Filho PV, Azaro E, Melo CA, Fahel E, Batista PB. Prevention of rhabdomyolysis in bariatric surgery. Obes Surg. 2005;15(6):874-9. 16. Ogunnaike BO, Jones SB, Jones DB, Provost D, Whitten CW. Anesthetic considerations for

Rev. Col. Bras. Cir. 2017; 44(3): 270-277


De-Marchi Perioperative care in bariatric surgery in the context of the ACERTO project: reality versus surgeons assumptions in a Cuiabá hospital

17.

18.

19.

20.

21.

22.

23.

bariatric surgery. Anesth Analg. 2002;95(6):1793805. Wool DB, Lemmens HJ, Brodsky JB, Solomon H, Chong KP, Morton JM. Intraoperative fluid replacement and postoperative creatine phosphokinase levels in laparoscopic bariatric patients. Obes Surg. 2010;20(6):698-701. Boldt J. Fluid management of patients undergoing abdominal surgery--more questions than answers. Eur J Anaesthesiol. 2006;23(8):631-40. Benevides ML, Oliveira SS, de Aguilar-Nascimento JE. The combination of haloperidol, dexamethasone, and ondansetron for prevention of postoperative nausea and vomiting in laparoscopic sleeve gastrectomy: a randomized double-blind trial. Obes Surg. 2013;23(9):1389-96. Oliveira KG, Balsan M, Oliveira SS, AguilarNascimento JE. A abreviação do jejum préoperatório para duas horas com carboidratos aumenta o risco anestésico? Rev Bras Anestesiol. 2009;59(5):577-84. Powell-Tuck J, Gosling P, Lobo DN, Allison SP, Carlson GL, Gore M, et al. Summary of the British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients (GIFTASUP): for comment. J Intensive Care Soc. 2009;10(1):13-5. Luckey A, Livingston E, Taché Y. Mechanisms and treatment of postoperative ileus. Arch Surg. 2003;138(2):206-14. Mortensen K, Nilsson M, Slim K, Schäfer M, Mariette C, Braga M, et al. Consensus guidelines for enhanced recovery after gastrectomy: Enhanced Recovery

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After Surgery (ERAS®) Society recommendations. Br J Surg. 2014;101(10):1209-29. 24. Smith I, Kranke P, Murat I, Smith A, O’Sullivan G, S reide E, et al. Perioperative fasting in adults and children: guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol. 2011;28(8):556-69. 25. American Society of Anesthesiologists Committee. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters. Anesthesiology. 2011;114(3):495-511. 26. de Aguilar-Nascimento JE, Bicudo-Salomão A, Caporossi C, Silva R de M, Cardoso EA, Santos TP. Acerto pós-operatório: avaliação dos resultados da implantação de um protocolo multidisciplinar de cuidados peri-operatórios em cirurgia geral. Rev Col Bras Cir. 2006;33(3):181-8. Received in: 15/12/2016 Accepted for publication: 02/03/2017 Conflict of interest: none. Source of funding: none. Mailing address: Jacqueline Jéssica De-Marchi E-mail: je.nascimentocba@gmail.com jac_marchi@hotmail.com

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Partial stapled hemorrhoidopexy: clinical aspects and impact on anorectal physiology Hemorroidopexia por grampeamento parcial: aspectos clínicos e impacto sob a fisiologia anorretal MARLLUS BRAGA SOARES, TCBC-RJ1,2; MARCOS BETTINI PITOMBO, TCBC-RJ1; FRANCISCO LOPES PAULO1; PAULO CEZAR JÚLIA RESENDE SCHLINZ, ASCBC-RJ1; ANNIBAL AMORIM JÚNIOR1; KARIN GUTERRES LOHMANN HAMADA , ACBC-RJ1.

DE

CASTRO JÚNIOR1;

A B S T R A C T Objective: to evaluate the impact of partial stapled hemorrhoidopexy on anorectal physiology, the complications related to this surgical technique, pain, postoperative bleeding and recurrence of hemorrhoidal disease one year after surgery. Methods: this is a prospective, descriptive study in consecutive patients with mixed or internal hemorrhoidal disease, the internal component being classified as grade III or IV, undergoing partial stapled hemorrhoidopexy. Results: we studied 17 patients, 82% of them with internal hemorrhoids grade III and 18% grade IV. The mean operative time was 09:09 minutes (07:03 to 12:13). The median pain in the immediate postoperative period evaluated by the numerical pain scale was one (0 to 7). The median time to return to work was nine days (4 to 19). No patient had anal stenosis and 76% were satisfied with the surgery 90 days postoperatively. When comparing the preoperative manometry data with that measured 90 days after surgery, none of the variables studied showed statistically significant difference. There was no recurrence of hemorrhoidal disease with one year of postoperative follow-up. Conclusion: partial stapled hemorrhoidopexy showed no impact on anorectal physiology, presenting low levels of complications and postoperative pain, without recurrence of hemorrhoidal disease in one year of follow-up. Keywords: Hemorrhoids. Hemorrhoidectomy. Surgical Staplers. Surgical Stapling.

INTRODUCTION

H

emorrhoidal disease affects millions of people around the world, and represents a medical and socioeconomic problem. It is estimated that 58% of the US population have hemorrhoids at 40 years of age1 and approximately 10 to 20% of patients with symptomatic hemorrhoidal disease will need surgery2. The surgical treatment for hemorrhoidal disease has undergone multiple modifications in recent times and the general trend went from total to partial excision of the anoderma excision. Hemorrhoidectomy using the MilliganMorgan technique is the most widely used technique in our country, being considered the most effective surgical technique for the treatment of hemorrhoidal disease3. However, this technique is still associated with significant postoperative pain due to trauma to the sensitive tissue of the anal canal. Since the initial description of the circumferential-stapled hemorrhoidopexy by Longo et

al.4, in 1998, some modifications of the technique have been addressed and presented. Circumferential-stapled hemorrhoidopexy is characterized by circumferential resection of the lower rectal mucosa. Such a technique has become widely accepted as an alternative to the Milligan-Morgan hemorrhoidectomy in the treatment of third and fourth degree hemorrhoids. Studies developed over the last decade concluded that the technique of circumferentialstapled hemorrhoidopexy is effective in the treatment of hemorrhoidal prolapse5-7, but fecal urgency in the early postoperative period and anal stenosis occur in 41% and 6% of cases, respectively7. These complications appear to be a result of total stapling in the lower rectum. Partial stapled hemorrhoidopexy surgery (PSH) has as a differential proposal the partial resection of the structures of the anal canal, resembling, in a way, traditional techniques of hemorrhoidectomy, which also preserve parts of the anal canal. This, when compared to circumferential stapled hemorrhoids,

1 - University of the State of Rio de Janeiro (UERJ), Rio de Janeiro, Rio de Janeiro State, Brazil. 2 - São José do Avaí Hospital, Itaperuna, Rio de Janeiro State, Brazil. Rev. Col. Bras. Cir. 2017; 44(3): 278-283


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seems to have the advantage of reducing fecal urgency rates and postoperative stenosis8. The present study aims to evaluate the clinical and anorectal physiological impacts generated by PSH.

METHODS We carried out a prospective, descriptive study in consecutive patients with hemorrhoidal disease of the mixed or internal type, the internal component being classified as grade III or IV, submitted to PSH. The aim of this study was to evaluate the impact on anorectal physiology by comparing anorectal manometry data performed in the preoperative period with those of the postoperative outpatient follow-up of 30, 60 and 90 postoperative days. We also evaluated outcomes related to complications of the surgical technique, postoperative pain and bleeding, and recurrence of hemorrhoidal disease after one year of surgery. External hemorrhoids and presence of anal plicoma were not exclusion criteria. We excluded patients with concomitant anorectal disease (fistula, fissure, abscess, inflammatory bowel disease, polyps or rectal cancer), acute hemorrhoidal thrombosis, coagulopathy or anticoagulant therapy, previous history of colon, rectum and anus cancer or pelvic cancer. We enrolled those who fulfilled the inclusion criteria, had no exclusion criteria and agreed to participate in the study through a specific informed consent form, previously approved by the Ethics in Research Committee of the Pedro Ernesto University Hospital of the State University of Rio de Janeiro (protocol n# CAAE: 21418413.1.0000.5259). Partial stapled hemorroidopexy was performed with the patient in ventral decubitus, in a pocketknife position, and was initiated by transanal anuscope accommodation to expose the pectine line. We then introduced the fenestrated three-window anuscope into the anal canal, observing the volume of prolapsed hemorrhoidal tissue. We performed an “in pouch” suture of the prolapsed structures and introduced the circular stapler. We than fired the stapler, resecting the prolapsed tissues through the anuscope windows and “refixing” the mucosa previously removed from the anatomical position in

Figure 1. Partial stapled hemorrhoidopexy.

the anal canal and lower rectus (Figure 1). The postoperative follow-up period was divided into immediate postoperative (24 hours after surgery) and outpatient follow-up (7, 30, 60 and 90 days, and one postoperative year). We evaluated the clinical aspects by numerical pain scale (NPS), date of first bowel movement, return to work activities, presence of postoperative bleeding, patient satisfaction with surgery and recurrence of hemorrhoidal disease. The postoperative pain evaluation was performed using a numerical scale of pain ranging from zero to 10, 10 referring to disabling pain and 0, to absence of pain. We evaluated the anorectal functional aspects by computerized anorectal manometry in the preoperative period and at 30, 60 and 90 days after surgery. We assessed resting pressures and voluntary contraction of the anal canal, anal canal length, volume required to induce anal sensitivity, maximal rectal capacity, and recto-anal inhibitory reflex. We performed the computerized anorectal manometry with a water column catheter of eight radial channels. We used boxplot graphs with the median, 10, 25, 75 and 90 percentiles and minimum and maximum values to demonstrate the statistical results. For those variables with normal distribution, we presented the results in column graphs (mean ± standard deviation). We presented the comparison between the four moments for each variable with the Anova Oneway test (Mauchly test obeying the criterion of sphericity) with Grennhouse-Geisser correction. To compare

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Figure 2. Computerized anorectal manometry: resting pressure, anal contraction pressure and sensitivity induction volume in the preoperative period and at 30, 60 and 90 postoperative days.

the moments in the preoperative period with 90 postoperative days, we used the paired Wilcoxon test. We considered values for p<0.05 statistically significant.

RESULTS We conducted the study over a two-year period with 17 patients undergoing PSH surgery. All selected

patients completed a one-year follow-up. The mean age was 53.5 years and 76% were women. In 82% of the cases, the main complaint was hematochezia, and in 18%, anal prolapse. Eleven patients (65%) had external hemorrhoids associated with anal plicoma. All cases had three hemorrhoidal cushions. Fourteen patients (82%) had grade III internal hemorrhoids and three (18%), grade IV. Four patients (24%) had chronic intestinal constipation. The average operative time was 9:09 minutes (07:03 to 12:13). In 24% of the procedures there were technical difficulties related to the use of the three-window anuscope. In seven surgeries (41%) there was bleeding after stapling of the hemorrhoidal cushions. We controlled all bleedings due to stapling of hemorrhoidal cushions with 3-0 polygalacturin sutures. There was no resection of anal plicoma or hemorrhoidectomy of the external cushion.

Figure 3. Computerized anorectal manometry: anal canal length and maximum rectal volume in the preoperative period and at 30, 60 and 90 postoperative days. Rev. Col. Bras. Cir. 2017; 44(3): 278-283


Soares Partial stapled hemorrhoidopexy: clinical aspects and impact on anorectal physiology

The median pain in the immediate postoperative period (IPO) was one (NPS 0 to 7). Eleven patients (65%) presented bleeding in the IPO. Two patients (12%) presented urinary retention, requiring bladder catheterization for relief. The median time between surgery and first bowel movement was six days (2 to 12). The median pain during the first bowel movement was three (NPS 1 to 4). The median return to work after surgery was nine days (4 to 19). Postoperative pain medians with seven, 30, 60 and 90 postoperative days were, respectively, 5, 3, 2 and 1. Four patients (24%) presented hematochezia with seven days of PO. One patient had hematochezia with 30 days of PO. There were no cases of hematochezia after 30 days of PO. On the seventh and 30th days, five patients (29%) presented urgency upon bowel movement. In the 60th and 90th, two of the five patients (12%) had a fecal urgency complaint. On return after one year, no patient maintained a fecal urgency complaint. No patient had anal canal stenosis. Eleven patients (65%) were satisfied with the surgery after 90 postoperative days. With one year of OP, two patients (12%) were not satisfied. After oneyear follow-up, no patient presented recurrence of hemorrhoidal disease. Regarding the computerized anorectal manometry data, 15 patients had a recto-anal inhibitory reflex at the preoperative examination, which did not change in any patient during the 30, 60 and 90-day manometric evaluations after surgery. The variables resting anal pressure, voluntary contraction anal pressure and volume require to induce anal sensitivity did not present statistical significance for altered anorectal physiology (p>0.05) when compared between postoperative periods, or when comparing the manometry at 90 days postoperative with the preoperative one (Figure 2). The anal canal length and maximum rectal volume had a normal distribution, so we presented the results in column graphs (mean Âą standard deviation), and they also did not present statistical significance for alteration of anorectal physiology (p>0.05) when comparing the postoperative periods with each other, or when

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comparing manometry of 90 postoperative days with the preoperative one (Figure 3).

DISCUSSION Due to lower postoperative pain rates, stapled techniques for hemorrhoidal treatment became widely diffused5-9. PSH surgery was developed based on Thomsonâ&#x20AC;&#x2122;s theory regarding the arrangement of hemorrhoidal cushions and prolapse of the anal canal mucosa10. The great differential of this technique refers to the use of one, two or three-window anuscopes, which provide prolapse only of those enlarged hemorrhoidal cushions, generating stapling of only the excess hemorrhoidal tissue and creating bridges of normal mucosa between the stapled tissue. We performed all PSH surgeries with threewindow anuscope. We opted to create data that could later allow the comparison of PSH with the MilliganMorgan technique, in which three is resection of the hemorrhoidal cushions. In the surgical procedure, the main technical difficulty was related to the introduction of the three-window anuscope (four patients) due to the disproportion between the diameter of the anuscope and the anal canal, generating perianal lacerations and anal bleeding. The numeric scale of postoperative pain remained at low levels both in the immediate postoperative and in the outpatient follow-up. No patient had disabling pain and most had an early return to work activities. It is worth mentioning that this benefit does not seem to be directly related to PSH, but rather to the fact that it is a stapled surgical technique, such as circumferential-stapled hemorrhoidopexy, which does not generate anoderma lesions. The high bleeding rates in the IPO (65% of the cases) are probably related to the applied questionnaire, since any blood residue in the surgical dressing was considered bleeding in the IPO. However, the seven-day PO (24%) hematochezia index was almost twice that of the PSH literature and almost four times higher than that for the Milligan-Morgan hemorrhoidectomy, but no bleeding occurred with clinical repercussion in the sample11-14.

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The two patients that presented with fecal urgency with 90 days started this complaint after 30 days of follow-up. However, after one year, none of these patients maintained a fecal urgency complaint. The anorectal manometry of these patients demonstrated a significant reduction in the rectal sensitivity threshold and a reduced maximum rectal capacity with 90 days postoperatively. Because of the small number of patients, the presence of these two patients with fecal urgency provided greater fecal urgency rates related to PSH, than those found in the literature (11% versus 0.8% to 3%)8,10,14. In no case, we resected the anal plicoma or performed hemorrhoidectomy of the external hemorrhoidal cushion, since such conduct is associated with a possible increase in postoperative pain. Four patients (24%) were not satisfied with the surgery with 90 days of OP: two due to the presence of fecal urgency and another two due to the presence of a remnant anal plicoma. At one year, no patient maintained a fecal urgency complaint, and only those patients who presented with anal plicoma reported dissatisfaction, providing levels of postoperative satisfaction similar to those in the literature (88% versus 95% to 97%)8,9,11,15,16. As for the manometric parameters, we found no statistical significance in relation to anorectal physiology in any of the variables studied when compared the postoperative periods with each other or with the preoperative period. However, there was a difference in the distribution of the anal canal length and anal sensitivity induction volume in the preoperative and postoperative anorectal manometry (Figure 2 and 3).

The length of the anal canal is affected by the excision and fixation of the hemorrhoidal cushions in the anal canal, generating a sustained reduction of the same in the three postoperative anorectal manometric assessments. The anal sensitivity induction volume is determined by the first rectal sensation (gas or feces) after insufflation of the balloon at the distal end of the anorectal manometry catheter. We observed that in the preoperative manometry the distribution of the patients regarding the anal sensitivity induction volume occurred between 40 and 60 ml. Ninety days after surgery, the induction of anal sensitivity occurred with 30 to 40 ml. This fact was probably generated by local surgical trauma associated with scarring and possible presence of fibrosis. Even so, none of these changes had any real impact with clinical repercussion on anorectal physiology. To date, no group in South America has studied the clinical impacts and anorectal physiology of PSH. None of the studies available in the literature on this surgical technique had used computerized anorectal manometry to demonstrate the impacts of PSH on anorectal physiology, and our group was pioneer in using it to evaluate the method. Despite the limitations of the descriptive single-site, limited-sample study, the data provided demonstrate that PSH may be a good treatment option for hemorrhoidal disease. Due to the easy technical execution, low levels of intra and postoperative complications, and sustained results after one year of follow-up, this study authorizes us to include hemorrhoidopexy by partial stapling in the arsenal of hemorrhoidal disease treatment.

R E S U M O Objetivo: avaliar o impacto na fisiologia anorretal da hemorroidopexia por grampeamento parcial, das complicações relacionadas à técnica cirúrgica, dor e sangramento pós-operatório e recidiva de doença hemorroidária após um ano de cirurgia. Métodos: estudo prospectivo, descritivo, em pacientes consecutivos, portadores de doença hemorroidária do tipo mista ou interna, com componente interno classificado como grau III ou IV, submetidos à hemorroidopexia por grampeamento parcial. Resultados: foram estudados 17 pacientes, dos quais 82% apresentavam hemorroidas internas grau III, e 18% grau IV. A média de tempo operatório foi de 09:09 minutos (07:03 a 12:13 minutos). A mediana de dor no pós-operatório imediato avaliada pela escala numérica de dor foi de 1 (0 a 7). A mediana de retorno ao trabalho foi de nove dias (4 a 19). Nenhum paciente apresentou estenose de canal anal e 76% ficaram satisfeitos com a cirurgia com 90 dias de pós-operatório. Comparando-se os dados manométricos pré-operatórios e após 90 dias, nenhuma das variáveis avaliadas apresentou diferença com significância estatística. Não houve recidiva da doença hemorroidária com um ano de acompanhamento pós-operatório. Conclusão: a hemorroidopexia por grampeamento parcial não demonstrou impacto na fisiologia anorretal, apresentando baixos níveis de complicações e de dor pós-operatória, e sem recidivas após um ano de acompanhamento. Descritores: Hemorroidas. Hemorroidectomia. Grampeadores Cirúrgicos. Grampeamento Cirúrgico.

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REFERENCES 1. Cohen Z. Symposium on outpatient anorectal procedures. Alternatives to surgical haemorrhoidectomy. Can J Surg. 1985;28(3):230-1. 2. Goligher JC. Surgery of the anus rectum and colon 4th ed. London: Springer; 1980. 3. Milligan ET, Morgan CN, Jones LE, Officer R. Surgical anatomy of the anal canal and the operative treatment of hemorrhoids. Lancet. 1937; 2:1119-24. 4. Longo A. Treatment of hemorrhoidal disease by reduction of mucosa and hemorrhoidal prolapse with a circular suturing device: a new procedure. Proceedings of the 6th World Congress of Endoscopic Surgery; 1998 May 31 - Jun 6; Rome, Italy. p. 3. 5. Hetzer FH, Demartines N, Handschin AE, Clavien PA. Stapled vs excision hemorrhoidectomy: longterm results of a prospective randomized trial. Arch Surg. 2002;137(3):337-40. 6. Mehigan BJ, Monson JR, Hartley JE. Stapling procedure for haemorrhoids versus Milligan-Morgan haemorrhoidectomy: randomised controlled trial. Lancet. 2000;355(9206):782-5. 7. Shalaby R, Desoky A. Randomized clinical trial of stapled versus Milligan-Morgan haemorrhoidectomy. Br J Surg. 2001;88(8):1049-53. 8. Khubchandani IT. Lin HC, Ren DL, He QL, Peng H, Xie SK, Su D, Wang XX. Partial stapled hemorrhoidopexy versus circular stapled hemorrhoidopexy for grade III-IV prolapsing hemorrhoids: a two-year prospective controlled study. Tech Coloproctol. 2012;16(5):345; discussion 347-8. 9. Lin HC, He QL, Ren DL, Peng H, Xie SK, Su D, et al. Partial stapled hemorrhoidopexy: a minimally

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invasive technique for hemorrhoids. Surg Today. 2012;42(9):868-75. 10. Haas PA, Fox TA Jr, Haas GP. The pathogenesis of hemorrhoids. Dis Colon Rectum. 1984;27(7):442-50. 11. Wang ZG, Zhang Y, Zeng XD, Zhang TH, Zhu QD, Liu DL, et al. Clinical observations on the treatment of prolapsing hemorrhoids with tissue selecting therapy. World J Gastroenterol. 2015;21(8):2490-6. 12. Bleday R, Pena JP, Rothenberger DA, Goldberg SM, Buls JG. Symptomatic hemorrhoids: current incidence and complications of operative therapy. Dis Colon Rectum. 1992;35(5):477-81. 13. Denis J, Dubois N, Ganansia R, du PuyMontbrun T, Lemarchand N. Hemorrhoidectomy: Hospital Leopold Bellan procedure. Int Surg. 1989;74(3):152-3. 14. Eu KW, Seow-Choen F, Goh HS. Comparison of emergency and elective haemorrhoidectomy. Br J Surg. 1994;81(2):308-10. 15. He P, Liu N. Treatment of mixed hemorrhoids with TST: a clinical report of 300 cases. J Colorect Anal Surg. 2011;17(3):175-6. 16. Naldini G, Martellucci J, Talento P, Caviglia A, Moraldi L, Rossi M. New approach to large haemorrhoidal prolapse: double stapled haemorrhoidopexy. Int J Colorectal Dis. 2009;24(12):1383-7. Received in: 17/11/2016 Accepted for publication: 19/01/2017 Conflict of interest: none. Source of funding: none. Mailing address: Marllus Braga Soares E-mail: marllusbsoares@hotmail.com soaresmarllus@gmail.com

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Incidence and risk factors for postoperative pulmonary complications in patients undergoing thoracic and abdominal surgeries Incidência e fatores de complicações pulmonares pós-operatórias em pacientes submetidos à cirurgias de tórax e abdome ANA CAROLINA DE ÁVILA1; ROMERO FENILI1. A B S T R A C T Objective: to determine the incidence of postoperative pulmonary complications in patients undergoing abdominal and thoracic surgery and investigate the risk factors for their occurrence. Methods: we conducted a prospective, observational and analytical study with all the patients undergoing thoracic and abdominal surgeries at the Santo Antônio Hospital in Blumenau, SC. We collected data from medical records and structured interviews with patients, regarding the characteristics of patients and procedures. The outcome variable was the occurrence of postoperative pulmonary complications in the medical record. Results: we studied 314 patients, 65.6% female, with an average age of 46.61 years. Of the sample, 51.6% was ASA II, 55.7% of the surgeries were performed by laparoscopy or thoracoscopy, 85.4% were in the abdomen, and 61.5% were potentially contaminated and of medium-scale procedures. The average time of surgery was 126.65 minutes and the average length of hospital stay was 2.59 days. The incidence of postoperative pulmonary complications was 11.5%. The most common complications were respiratory failure, pleural effusion and pneumonia. The most important risk factor were diabetes, hospitalization for more than five days and the presence of pulmonary disease. Patients operated by laparoscopy or thoracoscopy had fewer complications. Conclusion: postoperative pulmonary complications are frequent and factors associated with greatest risk were diabetes, prolonged hospitalization and presence of previous lung disease. Keywords: Postoperative Complications. Respiratory Tract Diseases. Risk Factors.

INTRODUCTION

D

espite advances in perioperative care, postoperative complications continue to affect the recovery of surgical patients1. Among surgical complications, pulmonary ones are the second most common type, following the complications related to surgical site infection2. They can be defined as conditions that compromise the respiratory tract and that may adversely influence the patient’s clinical condition after surgery. They increase perioperative mortality and are the main cause of postoperative morbidity and mortality in both cardiothoracic and noncardiothoracic surgeries. They also contribute to the increase of the hospitalization time and the re-hospitalization rates, raising the financial expenses with health care2,3. The incidence can vary from 2% to 40% according to risk factors of the patient or those of the surgical procedure. Postoperative pulmonary complications (PPC) include respiratory insufficiency,

pneumonia, tracheal re-intubation within 48 hours or tracheal intubation for more than 48 hours due to the maintenance of mechanical ventilation due to acute respiratory failure, atelectasis, bronchospasm, exacerbation of chronic obstructive pulmonary disease (COPD), pneumothorax and pleural effusion³. PPCs are more common in thoracic and abdominal surgeries, with incidence varying from 12 to 70%4. Risk factors for PPC are congestive heart failure, surgical risk classification by the American Society of Anesthesiologists (ASA) II or greater, functional dependence and advanced age, reduction of peripheral oxygen saturation, respiratory infection in the month preceding the surgical procedure, anemia (hemoglobin= 10g/dL), surgical incision near the diaphragm, surgery long duration and emergency surgery5. In this sense, the objective of this study was to study postoperative pulmonary complications to assess their incidence submitted to chest and abdominal

1 - Regional University of Blumenau, Department of Medicine, Blumenau, Santa Catarina State, Brazil. Rev. Col. Bras. Cir. 2017; 44(3): 284-292


Ávila Incidence and risk factors for postoperative pulmonary complications in patients undergoing thoracic and abdominal surgeries

surgeries and identify the main factors involved in their occurrence.

METHODS This is a prospective, observational, analytical study, which used, as data collection tools, the electronic charts and previously structured interviews with patients submitted to chest and abdominal surgeries at the Blumenau Santo Antônio Hospital – SC – in a period of five months (August 2015 to December 2015). Inclusion criteria were patients older than 18 years who underwent chest and/or abdominal surgery during the period of data collection. Intraoperative death, due to any cause, was considered an exclusion criterion. All participants signed a Free and Informed Consent Form and the Ethics in Research Committee of Santo Antônio Hospital approved the research project under the protocol number 44656215.6.0000.5359. We collected data regarding age, gender, presence or absence of lung disease prior to the surgical procedure, smoking, weight and height for calculation of Body Mass Index (BMI), diabetes mellitus, systemic arterial hypertension, neoplastic disease and other comorbidities, data that were present in the patient’s electronic medical records or reported by them during the structured interview. Regarding the surgical procedure, was collected information on the procedure time, anatomical site (thorax and/or abdomen), ASA classification of surgical risk, degree of contamination (clean, potentially contaminated, contaminated, infected), procedure extension (minor, midsize, major), days of hospitalization after the procedure and type of surgical access, whether by video or not. The outcome variable was the occurrence of PPCs recorded in the electronic patient record, through which the patients were monitored daily. We searched for pneumonia, tracheobronchitis, atelectasis, respiratory failure, prolonged tracheal intubation, bronchospasm, pulmonary embolism, pulmonary edema and pneumothorax or pleural

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effusion. The criteria used to determine the presence and classification of postoperative pulmonary complications were those established by Silva et al.4. We tabulated the collected data in the Microsoft Office Excel® program and later analyzed them through descriptive and inferential statistics. We present the characteristics of the participants in tabular form, as absolute and relative frequencies, with the respective 95% confidence intervals. For continuous variables, we calculated central (mean) and dispersion (standard deviation) trends. We studied the association between the outcome variable and the risk factors, which involved patient characteristics and surgical procedure, using the chi-square biostatistical test. We accepted a significance level of p<0.05. We included the factors that presented p<0.05 at the chi-square test in a logistic regression analysis with the aid of the EpiInfo® program, and expressed the results with the odds ratio.

RESULTS There were 314 patients participating in the study. Table 1 shows the sample characteristics. Table 2 shows the sample characteristics regarding the surgical procedure. Postoperative pulmonary complications are presented in table 3 in descending order of frequency. Table 4 describes the chi-square test statistically significant associations between variables related to the sample characteristics or to the surgical procedure and the PPC outcome variable. The variables: arterial hypertension, gender, surgical site, smoking and age were not significantly associated with the occurrence or not of PPC. The result of the multivariate logistic regression analysis of the evaluated factors and the occurrence of PPC, presented in table 5, revealed some more strongly associated risk and protection factors. During the study, there were seven deaths in the postoperative period, among which only one patient did not present PPC directly. Deaths were attributed to septic shock, cardiorespiratory arrest and multiple organ failure. This study was not able to

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Table 1. Characteristics of the sample.

Descriptive characteristics

n (%)

95% CI

Male

108 (34.4%)

(29.14-39.65)

Female

206 (65.6%)

(60.35-70.86)

No

178 (56.7%)

(51.21-62.17)

Yes

47 (15%)

(11.02-18.91)

86 (27.4%)

(22.46-32.32)

1 (0.3%)

(0-0.94)

No

265 (84.4%)

(80.38-88.41)

Yes

47 (15%)

(11.02-18.91)

Not informed

2 (0.6%)

(0-1.52)

No

210 (66.9%)

(61.67-72.08)

Yes

102 (32.5%)

(27.3-37.66)

2 (0.6%)

(0-1.52)

No

194 (61.8%)

(56.41-67.16)

Yes

118 (37.6%)

(32.22-42.94)

2 (0.6%)

(0-1.52)

Yes

51 (16.2%)

(12.16-20.32)

No

261 (83.1%)

(78.98-87.26)

Mean ± SD

95% CI

Age (Years)

(46.61 ± 15.98)

(44.85-48.38)

Weight (Kg)

(77.25 ± 23.09)

(74.69-79.81)

Height (cm)

(165.12 ± 12.03)

(166.45-163.78)

BMI (Kg/m ²)

(29.16 ± 15.69)

(27.42-30.9)

Gender

Smoking

Ex-smokers Not informed DM

SAH

Not informed Comorbidities

Not informed Previous lung disease

Quantitative characteristics

CI= confidence interval; SD= standard deviation; DM= diabetes mellitus; SAH= systemic arterial hypertension; BMI= body mass index.

evaluate whether or not these deaths were associated with postoperative pulmonary complications.

DISCUSSION In this study, patients submitted to chest and abdominal surgeries had a PPC incidence of 11.5%, higher than that found by the American College of Surgeons (5.8%) after abdominal surgeries². Two large studies, the ARISCAT (Assess Respiratory Risk in Surgical Patients in Catalonia)6 and the PERISCOPE (Prospective

Evaluation of a Risk Score for Postoperative Pulmonary Complications in Europe)7, that evaluated the risk factors for the occurrence of postoperative pulmonary complications in non-cardiac surgeries, presented complication rates of 5% and 7.9%, respectively. There was no statistically significant difference when surgery was performed on the thorax or abdomen. Although the incidence of PPCs in this study may appear to be high compared to the ARISCAT, PERISCOPE and American College of Surgeons studies, we should note that these studies were not performed

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Table 2. Characteristics related to the surgical procedure.

Characteristics ASA I II III IV V Video surgery No Yes Surgical site Abdomen Chest Thorax and Abdomen Degree of contamination Clean Potentially contaminated Contaminated Infected Size of surgery Minor Medium Major Special Pulmonary complications Yes No Surgery time (min) Length of stay (days)

n

95% CI

83 (26.4%) 162 (51.6%) 66 (21%) 3 (1%) 0

(21.56-31.31) (46.06-57.12) (16.51-25.53) (0-2.03) 0

139 (44.3%) 175 (55.7%)

(38.77-49.76) (50.24-61.23)

268 (85.4%) 44 (14%) 2 (0.6%)

(81.44-89.26) (10.17-17.85) (0-1.52)

84 (26.8%) 193 (61.5%) 34 (10.8%) 3 (1%)

(21.86-31.65) (56.08-66.85) (7.39-14.26) (0-2.03)

14 (4.5%) 193 (61.5%) 106 (33.8%) 1 (0.3%)

(2.18-6.74) (56.08-66.85) (28.53-38.99) (0-0.94)

36 (11.5%) 278 (88.5%) Mean ± SD 126.65 ± 95.92 Mean ± SD 2.59 ± 3.93

(7.94-14.99) (85.01 92.06-) 95% CI 116.04-137.26 95% CI 2.15-3.02

CI= confidence interval; SD= standard deviation.

specifically in patients undergoing chest and abdominal surgeries, but only in the abdomen (American College of Surgeons) and non-cardiac surgeries (ARISCAT and PERISCOPE). PPC are more common in thoracic and abdominal surgeries, and the incidence was 18.2% in a study performed by a group from Porto Alegre (RS)4. In the ARISCAT study, the main complications reported were pulmonary infection (24%), respiratory insufficiency (4.7%) and pleural effusion (3.1%), compatible with the results of this sample, respectively 9.2%, 1.3 % and 1.3%.

In this study, we recorded only clinically significant pleural effusions, reaching 1.3% of the sample. However, we believe that the percentage of pleural effusion in the postoperative period is higher when also considering the clinically non-important ones. A group from São Paulo found a high rate of pleural effusion in the postoperative period (70.3%) through ultrasound examinations in a study that aimed to attest the sensitivity of this exam8. Conditions such as systemic arterial hypertension, heart disease and diabetes mellitus have

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Table 3. Postoperative pulmonary complications.

Complication

n (%)

95% CI

Respiratory failure

29 (9.2%)

(6.03-12.44)

Pleural effusion

4 (1.3%)

(0.03-2.51)

Pneumonia

4 (1.3%)

(0.03-2.51)

3 (1%)

(0-2.03)

Bronchospasm

2 (0.6%)

(0-1.52)

Tracheobronchitis

2 (0.6%)

(0-1.52)

Pulmonary edema

2 (0.6%)

(0-1.52)

Pneumothorax

1 (0.3%)

(0-0.94)

Atelectasis

1 (0.3%)

(0-0.94)

Pulmonary embolism

1 (0.3%)

(0-0.94)

Prolonged intubation

3 (1%)

(0-2.03)

Prolonged mechanical ventilation

CI= confidence interval.

previously been described in association with a higher risk for PPC4. Specifically on diabetes, one study identified the relationship between elevated glycated hemoglobin levels and the increased risk of developing postoperative complications, even with glycated hemoglobin levels lower than those established for the diagnosis of diabetes mellitus9. The diabetic patients in this sample had a nearly five-fold increased risk of presenting this outcome, emphasizing the metabolic control prior to the surgical procedure as an important factor in the prevention of PPC. The presence of COPD is a commonly identified risk factor for PCP, being one of the most cited, with a risk greater than 18%, and varying with disease severity5. This factor was significantly associated with PPC in this study. However, when treated and controlled prior to the surgical procedure, COPD patients have the same incidence of PPCs as healthy subjects4, as is also expected to occur with diabetes. The extremes of nutritional status, malnutrition and obesity, also have an influence on the risk of PPC development. In this study, although the univariate analysis was significant, the multivariate analysis no longer was. In malnourished patients, low serum albumin is an established risk for PPC because it is associated with changes in pulmonary dynamics and functioning of the respiratory muscles, and is related to

higher rates of pneumonia. On the other hand, obese patients present physiological changes such as decreased ventilation-perfusion ratio due to under-ventilation and to high tissue perfusion. They also present a decrease in pulmonary complacency and chest movement secondary to the accumulation of adipose tissue in the thoracic wall5 and abdominal cavity, hampering the diaphragmatic mobility10. In addition, obese patients are more difficult to mobilize during the postoperative period, which implies greater risk of deep venous thrombosis and, consequently, pulmonary thromboembolism5. The ASA risk classification was also associated with the development of PPC. According to the study conducted by Silva et al.4, ASA II patients have an increased risk of PPC. Surgical time is also important, and when greater than three hours, was associated with a higher occurrence of PPC. Likewise, the greater the surgical size, the greater the risk for PPC11. Patients submitted to video surgeries (laparoscopic or thoracoscopic) presented lower PPC rates when compared with those submitted to conventional open procedures. We cannot state that video surgeries act as protective factors because it was not possible to measure the risks involved in the different procedures performed by video or open. However, it is known that patients submitted to

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Table 4. Association of factors with pulmonary complications through the Chi-square test.

Factors

Postoperative pulmonary complications

Total

p

Yes

No

Diabetes Yes No

11 (31.4%) 24 (68.6%)

36 (13%) 241 (87%)

47 (15.1%) 265 (84.9%)

0.0041

Surgery by video No Yes

30 (83.3%) 6 (16.7%)

109 (39.2%) 169 (60.8%)

139 (44.3%) 175 (55.7%)

0.0000

Presence of neoplasm No Yes

21 (58.3%) 15 (41.7%)

214 (77%) 64 (23%)

235 (74.8%) 79 (25.2%)

0.0153

Previous lung disease No Yes

20 (57.1%) 15 (42.9%)

241 (87%) 36 (13%)

261 (83.7%) 51 (16%)

0.0000

BMI Low weight Normal weight Overweight Obesity I Obesity II Obesity III

6 (16.7%) 12 (33.3%) 7 (19.4%) 4 (11.1%) 7 (19.4%) 0 (0%)

14 (5.1%) 114 (41.3%) 89 (32.2%) 33 (12%) 25 (9.1%) 1 (0.4%)

20 (6.4%) 126 (40.4%) 96 (30.8%) 37 (11.9%) 32 (10.3%) 1 (0.3%)

Surgical risk classification WING I II III IV V

3 (8.3%) 15 (41.7%) 15 (41.7%) 3 (8.3%) 0 (0%)

80 (28.8%) 147 (52.9%) 51 (18.3%) 0 (0%) 0 (0%)

83 (26.4%) 162 (51.6%) 66 (21%) 3 (1%) 0 (0%)

Degree of contamination Clean Potentially contaminated Contaminated Infected

8 (22.2%) 20 (55.6%) 6 (16.7%) 2 (5.6%)

76 (27.3%) 173 (62.2%) 28 (10.1%) 1 (0.4%)

84 (26.8%) 193 (61.5%) 34 (10.8%) 3 (1%)

Surgical size Minor Medium Major

1 (2.8%) 10 (27.8%) 25 (69.4%)

13 (4.7%) 183 (66.1%) 81 (29.2%)

14 (4.5%) 193 (61.7%) 106 (33.9%)

Surgical time Up to 3 hours Greater than or equal to 3 hours

24 (66.7%) 12 (33.3%)

246 (88.5%) 32 (11.5%)

270 (86%) 44 (14%)

Inpatient days Up to 1 day 2 to 5 days More than 5 days

6 (16.7%) 18 (50%) 12 (33.3%)

168 (60.4%) 92 (33.1%) 18 (6.5%)

174 (55.4%) 110 (35%) 30 (9.6%)

BMI= body mass index. Rev. Col. Bras. Cir. 2017; 44(3): 284-292

0.0300

0.0000

0.0127

0.0000

0.0004

0.0000


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Table 5. Results of the multivariate analysis (logistic regression) of the factors assessed and the occurrence of PPC

Factors

Or

95% CI

Z-Statistic

p

Hospitalization for more than 5 days

7.2507

(2.54 -20.65)

3.7087

0.0002

Diabetes

4.8299

(1.87 -12.43)

3.2637

0.0011

Previous lung disease

5.5381

(2.28 -13.41)

3.7932

0.0001

Video surgery

0.1949

( -0.53 0.07)

-3.1796

0.0015

Infected surgery

9.3066

(0.63 -137.18)

1.6250

0.1042

Or= Odds Ratio; CI= confidence interval; Z= statistics generated by logistic regression analysis; p= value of significance.

video-surgeries present smaller incisions, less systemic inflammatory responses, reduced postoperative pain and better pulmonary function, which emphasizes the option for this type of surgical access5. The degree of contamination was also associated with a higher occurrence of PPC in this study, and patients submitted to infected surgeries had a ninefold greater risk of developing such complications. The presence of neoplastic disease was associated with the occurrence of PPC. This association can be explained by the fact that these patients present severe disease, often with anorexia-cachexia syndrome (ACS). This syndrome is characterized by intense consumption, with consequent involuntary weight loss, malnutrition and physiological, metabolic and immunological changes. Malnutrition is often very prevalent in cancer patients and is associated with greater risks of postoperative infection and increased morbidity and mortality12. Length of hospitalization greater than five days was strongly associated with the occurrence of PPC. However, we cannot say whether it is the longer hospitalization time that predisposes the occurrence of complications due to the decrease in mobility, the greater exposure to microbial agents, or the patients who present complications remain hospitalized for a longer time precisely to treat such complications. PPCs, in general, prolong the length of hospital stay, increase the consumption of hospital resources and may lead to patientsâ&#x20AC;&#x2122; death13. We found no relation between age and the occurrence of PPCs, though we expected this association. The physiological aging of the respiratory

system leads to a decrease in the elasticity of the parenchyma and pulmonary complacency, in the strength of the muscles involved in respiration, and a decrease in the alveolar surface and cilia of the respiratory tract. These changes may lead to poor coughing and increased respiratory work, with increased dependence on the diaphragm. There is also a decrease in oxygen partial pressure and an increase in the dead space, which decrease the pulmonary ventilation-perfusion ratio. These factors, associated with some postoperative conditions such as immobility and the use of narcotics, generally lead to a high probability of atelectasis and pulmonary aspiration, with the development of pneumonia14. Another factor that was also expected to be a risk for the occurrence of PPC but was not significantly associated with this type of complication in this study was smoking. Smokers also present physiological changes that may alter the responses to surgical procedures, contributing to the increase in postoperative morbidity due to the high risk of developing respiratory, cardiovascular and healing complications15. One of the main alterations implicated in smoking is damage to the cilia of the tracheobronchial mucosa and increased mucus production with high consistency, in addition to an increased susceptibility to alveolar collapse, leading to a higher chance of infection in the lower airways and prolonged mechanical ventilation5. We conclude that postoperative pulmonary complications were frequent in our study and are associated with higher morbidity and mortality. Identifying risk factors predisposing to this outcome may help in the elaboration of prevention strategies.

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R E S U M O Objetivos: avaliar a incidência de complicações pulmonares pós-operatórias em pacientes submetidos à cirurgias de tórax e abdome e os principais fatores envolvidos. Métodos: estudo analítico observacional prospectivo dos pacientes submetidos à cirurgias de tórax e abdome no Hospital Santo Antônio de Blumenau, SC. Os dados foram coletados dos prontuários eletrônicos e através de entrevistas estruturadas com os pacientes. Foram avaliados dados relativos às características dos pacientes e da cirurgia. A variável de desfecho foi a ocorrência de complicações pulmonares pós-operatórias. Resultados: foram estudados 314 pacientes, 65,6% do sexo feminino, com média de idade de 46,61 anos, 51,6% classificados como ASA II. Cirurgias por vídeo foram realizadas em 55,7% dos casos, abdominais em 85,4% e 61,5% dos procedimentos foram classificados como potencialmente contaminadas e de porte médio. O tempo médio de cirurgia foi de 126,65 minutos e os pacientes ficaram internados em média por 2,59 dias. A incidência de complicações pulmonares pós-operatórias foi de 11,5%. As complicações mais comuns foram a insuficiência respiratória, o derrame pleural e a pneumonia. Os fatores de risco mais importantes para estas complicações foram diabetes, internação hospitalar por mais de cinco dias e presença de doença pulmonar prévia. Os pacientes submetidos às cirurgias por vídeo apresentaram menor incidência de complicações. Conclusão: as complicações pulmonares pós-operatórias são frequentes e os fatores associados a maior risco foram diabetes, internação prolongada e presença de doença pulmonar prévia. Descritores: Complicações Pós-Operatórias. Doenças Respiratórias. Fatores de Risco.

REFERENCES 1. Calvache JA, Guzmán EL, Gómez Buitrago LM, García Torres C, Torres M, Buitrago G, et al. Manual de práctica clínica basado en la evidencia: manejo de complicaciones posquirúrgicas. Rev Colomb Anestesiol. 2015;43(1):51-60. 2. Yang CK, Teng A, Lee DY, Rose K. Pulmonary complications after major abdominal surgery: National Surgical Quality Improvement Program analysis. J Surg Res. 2015;198(2):441-9. 3. Langeron O, Carreira S, Ie Saché F, Raux M. Postoperative pulmonary complications updating. Ann Fr Anesth Reanim. 2014;33(7-8):480-3. 4. Silva DR, Gazzana MB, Knorst MM. Valor dos achados clínicos e da avaliação funcional pulmonar pré-operatórios como preditores das complicações pulmonares pós-operatórias. Rev Assoc Med Bras. 2010;56(5):551-7. 5. Taylor A, DeBoard Z, Gauvin JM. Prevention of postoperative pulmonary complications. Surg Clin North Am. 2015;95(2):237-54. 6. Canet J, Gallart L, Gomar C, Paluzie G, Vallès J, Castillo J, Sabaté S, Mazo V, Briones Z, Sanchis J; ARISCAT Group. Prediction of postoperative pulmonary complications in a populationbased surgical cohort. Anesthesiology. 2010;113(6):1338-50. 7. Mazo V, Sabaté S, Canet J, Gallart L, de Abreu MG, Belda J, et al. Prospective external

validation of a predictive score for postoperative pulmonary complications. Anesthesiology. 2014;121(2):219-31. 8. Rossi LA, Bromberg SH. Estudo prospectivo do derrame pleural pós-cirurgia abdominal e dos fatores de risco associados: avaliação por ultrasonografia. Radiol Bras. 2005;38(2):101-6. 9. Stenberg E, Szabo E, Näslund I; Scandinavian Obesity Surgery Registry Study Group. Is glycosylated hemoglobin A1 c associated with increased risk for severe early postoperative complications in nondiabetics after laparoscopic gastric bypass? Surg Obes Relat Dis. 2014;10(5):801-5. 10. Melo SMA, Melo VA, Menezes Filho RS, Santos FA. Efeitos do aumento progressivo do peso corporal na função pulmonar em seis grupos de índice de massa corpórea. Rev Assoc Med Bras. 2011;57(5):509-515. 11. Zraier S, Haouache H, Dhonneur G. Which preoperative respiratory evaluation? Ann Fr Anesth Reanim. 2014;33(7-8):453-6. 12. Silva MPN. Síndrome da anorexia-caquexia em portadores de câncer. Rev Bras Cancerol. 2006;52(1):59-77. 13. Martins CGG, Denari SDC, Montagnini AL. Comprometimento da força muscular respiratória no pósoperatório de cirurgia abdominal em pacientes oncológicos. Arq Med ABC. 2007;32(Supl.2):S26-9. 14. Sanguineti VA, Wild JR, Fain MJ. Management of

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postoperative complications: general approach. Clin Geriatr Med. 2014;30(2):261-70. 15. Cavichio BV, Pompeo DA, Oller GAS, Rossi LA. Tempo de cessação do tabagismo para a prevenção de complicações na cicatrização de feridas cirúrgicas. Rev Esc Enferm USP. 2014;48(1):174-80. Received in: 08/01/2017 Accepted for publication: 30/03/2017 Conflict of interest: none.

Source of funding: This study was sponsored by the Scientific Initiation Scholarship for the author Ana Carolina de Avila, Medical School graduate at the Regional University of Blumenau. The grant was provided by the National Council for Scientific and Technological Development (CNPq). Mailing address: Ana Carolina de Ávila E-mail: anacdeavila@gmail.com anacarolinadeavila@hotmail.com

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D O I : 10.1590/

0100- 691201

Review Article

7003012

Extracranial carotid stenosis: evidence based review Estenose de carótida extracraniana: revisão baseada em evidências CAROLINA DUTRA QUEIROZ FLUMIGNAN1; RONALD LUIZ GOMES FLUMIGNAN1; TÚLIO PINHO NAVARRO2. A B S T R A C T Extracranial cerebrovascular disease is one of the most important causes of death and disability worldwide and its treatment is based on clinical and surgical strategies, the latter being performed by conventional or endovascular techniques. The management of stenosis of the carotid bifurcation is mainly aimed at preventing stroke and has been the subject of extensive investigation. The role of clinical treatment has been re-emphasized, but carotid endarterectomy remains the first-line treatment for symptomatic patients with 50% to 99% stenosis and for asymptomatic patients with 60% to 99% stenosis. Stent angioplasty is reserved for symptomatic patients with stenosis of 50% to 99% and at high risk for open surgery due to anatomical or clinical reasons. Currently, the endovascular procedure is not recommended for asymptomatic patients who are able to undergo conventional surgical treatment. Brazil presents a trend similar to that of other countries in North America and Europe, keeping endarterectomy as the main indication for the treatment of carotid stenosis and reserving the endovascular procedure for cases in which there are contraindications for the first intervention. However, we must improve our results by reducing complications, notably the overall mortality rate. Keywords: Carotid Stenosis. Carotid Artery Diseases. Endarterectomy, Carotid. Angioplasty, Balloon. Stents.

INTRODUCTION

I

n the last decades, Brazil has changed its profile of morbidity and mortality, and chronic diseases have been among the main causes of death and disability. Stroke is among the most relevant chronic diseases and is one of the main reasons for hospitalization and death, causing disability in the vast majority of patients, be it total or partial1. Apart from this, only the presence of carotid stenosis would already be related to significant cognitive decline2. In addition, stroke is the third leading cause of death in the United States and Europe, losing only for coronary artery disease and cancer3-5. In Brazil, cerebrovascular diseases registered 160,621 hospitalizations in 2009, according to public data from the Unified Health System, Ministry of Health1. The mortality rate was 51.8 per 100,000 inhabitants and the age group older than 80 years was responsible for almost 35% of the 99,174 deaths1. According to Lessa et al.6, about 250,000 strokes occur each year in Brazil, of which 85% are ischemic in nature. The ischemic etiology, with the participation of extracranial carotid stenosis in its etiopathogeny, is

present in at least 80% of cases, also in countries of North America and Europe3,4,7. Similar to the USA, in Brazil the proportional mortality rate for cerebrovascular diseases has decreased in the last 32 years8. However, the absolute number of deaths due to cerebrovascular diseases in Brazil has remained relatively constant, around 21 thousand deaths per year between 2008 and 20139. This rate means about one death every 25 minutes over the five-year period9. Such behavior may be influenced by the change in the structure of the national age pyramid, with the population aging and consequent increase in the life expectancy of the Brazilian of around 30 years, that is, from 45.5 years to 75.5 years in the period from 1945 to 201510. Globally, cerebrovascular disease accounts for more than five million deaths per year (1 in 10) and approximately 3% of total health expenditure4. In the European Union, about 21 billion euros were spent in 2003 with care for cerebral ischemia. From 2005 to 2050, the estimated cost of stroke to the US economy is estimated at $ 2.2 trillion4. In the face of a global scale health problem, with significant associated costs,

1 - Federal University of São Paulo, Paulista School of Medicine, São Paulo, São Paulo State, Brazil. 2 - Federal University of Minas Gerais, Faculty of Medicine, Belo Horizonte, Minas Gerais State, Brazil. Rev. Col. Bras. Cir. 2017; 44(3): 293-301


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there is a need for advances in stroke prevention and consequences. Given the relevance of the theme, we carried out this review to compile the highest quality evidence about it. The aim is to discuss the current therapeutic options for extracranial carotid artery stenosis.

METHODS We performed an electronic search using the DeCS terms (Health Sciences Keywords) in Portuguese (Carotid Stenosis, Carotid Artery Diseases, Carotid Endarterectomy, Balloon Angioplasty and Stents) in the LILACS (Latin American and Caribbean Literature In Health Sciences) and IBECS (Spanish Bibliographic Index of Health Sciences) databases, both through the electronic site (lilacs.bvsalud.org/). We also performed a search with the MeSH (Medical Subject Headings) terms or their English correspondents (Carotid Stenosis, Carotid Artery Diseases, Endarterectomy, Carotid, Angioplasty, Balloon, Stents) in the Medline database via Pubmed (https://www.ncbi.nlm.nih.gov/ pubmed/) and in the Cochrane database (http://www. cochranelibrary.com/). We stratified the results of these searches according to the Oxford levels of evidence11,12 to prioritize the highest quality levels for each clinical question (incidence, treatment, etc.). Finally, we search the DATASUS9 publicly accessible website for mortality data according to the International Classification of Diseases, Tenth Edition, ICD-10, for the cerebrovascular disease group, and for endarterectomy and stent angioplasty procedures. We tabulated the findings per year and gender, and we converted the information on financial data into US dollars according to the average annual Brazilian currency quotation. Clinical condition Extracranial carotid stenosis requiring surgical correction may occur in two different scenarios: in the asymptomatic population7 and in the symptomatic one5. In the latter case, the symptoms most related to carotid injury are stroke, transient ischemic attack (TIA), and the fleeting amaurosis in ipsilateral brain territories3,5.

Asymptomatic carotid stenosis can be divided into: 1) lesions with hemodynamic impairment (stenosis greater than 50%); and 2) ulcerated/irregular lesions, with increased risk of embolization, regardless of hemodynamic changes. Such asymptomatic stenoses are the potential cause of future strokes and can be identified with noninvasive tests13. However, natural history is not linear, displaying variable and controversial forms. Some prospective, randomized studies have been conducted to determine the efficacy of carotid endarterectomy in asymptomatic patients. The European clinical trial CASANOVA did not show benefits of endarterectomy versus clinical treatment but, unfortunately, in its evaluation it presented serious methodological problems14. The Asymptomatic Carotid Atherosclerosis Study (ACAS) is the largest study ever performed for completely asymptomatic carotid lesions. It presents evidence that the surgical treatment of asymptomatic lesions with stenosis superior to 60% by arteriography is better than only the clinical treatment, with decrease in morbidity and mortality in the surgical group. More recently, another European clinical trial, the Asymptomatic Carotid Surgery Trial (ACST)16 included 3,120 patients with more than 60% stenosis (NASCET method17). According to this study, asymptomatic patients under 75 years of age, males and stenosis superior to 60% are indications for surgery. The benefit is unclear for patients over 75 years and for women16. As for TIA, which is defined as a neurological impairment not lasting for more than 24 hours, many affected patients never get to the hospital, so inpatient studies are not a true reflection of the disease. The best studies in this regard are conducted in specific communities, such as Rochester, Minnesota, USA18,19. In this population, the incidence of TIA was 31 patients per 100,000 inhabitants per year at all ages, with an increase in incidence related to advanced age. TIA was also seen more frequently in men than in women of the same age group: 1.3 men for each woman. In those studies18,19, the predisposing factors for stroke after TIA were age, transient ischemia, hypertension and heart disease.

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However, there are conflicting data when studying the natural history of TIA, mainly due to the lack of definition of the baseline damage to the study population. If the individuals studied have predominantly critical lesions with ulcerated plaques, they probably have subsequent stroke rates greater than individuals with less severe lesions do. Currently, TIA are classified as small strokes, with lesions better identified by more accurate imaging methods20. Grigg et al.21 correlated TIA with heart attacks and cerebral atrophy. Therefore, TIAs should be seen not as a benign disease, but as a sign that something worse may be coming. Thus, the ideal would be to approach carotid lesions before permanent clinical damage. However, only about 15% of patients with stroke had a previous TIA, a scenario that highlights the role of screening of asymptomatic carotid lesions3. Indications for treatment Characterization of cerebrovascular ischemic signs and symptoms is important in determining treatment and prognosis. Most patients with extracranial carotid artery stenosis are asymptomatic and have their diagnosis through the identification of lesions on imaging tests such as vascular echography with Doppler22. Indications for treatment are made after imaging of the carotid bifurcation, which may be (1) for the neurologically symptomatic patient or (2) for the neurologically asymptomatic patient. Image acquisition of the cervical carotid artery is recommended in all patients with symptoms of ischemia in the carotid territory. In addition, there are two basic indications for the screening of asymptomatic patients: 1) patients with evidence of clinically significant peripheral vascular disease, regardless of age, and 2) potential high-risk groups, who may benefit from screening for asymptomatic stenosis. It is important to note that screening is not recommended in the presence of an isolated cervical murmur without other risk factors. Potential high-risk groups include: 1) patients with peripheral arterial disease, regardless of age; or 2) patients 65 years of age or older who have one or more of the

following risk factors: carotid artery disease, smoking or hypercholesterolemia. In general, the more risk factors are present, the greater the benefit of screening3. A Brazilian study found a prevalence of 84% of carotid stenosis in patients who already had peripheral arterial disease. In this same sample, carotid stenosis greater than 50% was present in 40% of patients and stenosis greater than 70% in 17% of them22. The treatment of extracranial carotid stenosis is usually composed of two strategies: clinical or surgical. The latter is performed by conventional or endovascular techniques. Conventional surgical treatment is commonly performed by carotid endarterectomy (CEA), and the endovascular, by carotid angioplasty with stent (CAS). The management of carotid bifurcation stenosis is particularly performed for the prevention of stroke and has been the subject of extensive research. The greatest predictor of risk of a future stroke is the presence of recent ipsilateral neurological symptoms and not only the degree of carotid stenosis. The NASCET and ECST studies have shown that the risk of stroke is greater in the first month after an initial event and this neurological risk approaches the same risk of an asymptomatic patient six months after an event17,23. The role of clinical treatment has been reemphasized for the treatment of carotid disease3. A national reference document prepared by the Brazilian Society of Angiology and Vascular Surgery is in the production phase and should also highlight the importance of the best medical practice (BMP)24. This BMP includes control of hypertension, smoking, reduction of cholesterol levels and use of antiplatelet agents. In clinical decision-making for treatment, the systematic review is considered the best scientific evidence available because it refers to all the best randomized clinical trials on a particular subject25. A Cochrane systematic review5 on CEA for symptomatic carotid stenosis with 35,000 patient-years of followup (included NASCET17, ECST23 and VACSP26) reported that the benefit of surgery was greater in men, in patients aged 75 years or older, and in randomized

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patients within two weeks of their last ischemic event. This benefit fell rapidly with increasing the interval after the onset of ischemia. CEA was of some benefit between 50% and 69% of symptomatic stenosis and highly beneficial for stenosis between 70% and 99% without subocclusion. The benefits in patients with carotid subocclusion were marginal in the short term and uncertain in the long one. These results are generalizable only for patients operated by surgeons with low complication rates (less than 7% risk for stroke and death). The benefits of endarterectomy depend not only on the degree of carotid stenosis, but may also vary according to other factors, including the time between the neurological event and the CEA27. The Committee of the American Society for Vascular Surgery3 recommends CEA as the firstline treatment for symptomatic patients with stenosis between 50% and 99% and for asymptomatic patients with stenosis between 60% and 99%. The risk of perioperative stroke and death in asymptomatic patients should be less than 3% to ensure benefit for the patient. CAS should be reserved for symptomatic patients with stenosis of 50% to 99% and high risk for CEA due to anatomical or clinical reasons. CAS is not recommended for asymptomatic patients who can undergo conventional surgical treatment3. Asymptomatic patients at high risk for intervention or less than three years of life expectancy should be considered for clinical treatment (BMP) as the first line therapy. Another Cochrane systematic review7 with a total of 5,223 patients included in three randomized controlled trials (ACAS15, ACST16 and VA28) found that, despite a perioperative stroke rate or death of 3%, CEA reduced the risk of ipsilateral stroke and any cerebral ischemic event by about 30% over three years in asymptomatic patients with carotid artery stenosis (greater than 50% in the VA and greater than 60% in the ACAS and ACST trials). However, the absolute risk reduction was small (approximately 1% per year during the first few years of follow-up in the two largest and most recent trials), but could be larger if there was a longer follow-up.

Similar to these global results, the Brazilian view is more careful, especially concerning the results for asymptomatic patients. It is believed that CEA and CAS should be done only in reference centers with minimal perioperative risks (<3% for asymptomatic individuals and <7% for symptomatic ones). This would ensure better patient outcomes. Until some time ago, in Brazil and other major world centers, CAS was believed to be a good therapeutic option for asymptomatic patients29. However, it is now known that CAS has limited indications for symptomatic patients, and is not currently recommended for asymptomatic patients that can undergo CEA3,30. Surgical results Few operations are as studied in scientific circles as CEA. In 2005, 135,701 carotid interventions were performed in the USA. Of these, 122,986 (92%) were in asymptomatic patients (91% CEA and 9% CAS), while in the UK only 20% were in asymptomatic individuals32. The main paradox of this intervention is the fact that it is intended to prevent long-term stroke, but in the course of its execution, it may be directly responsible for the occurrence of the same event in a small proportion of patients. Therefore, the intervention is justified only if the morbidity and mortality associated with it are significantly lower than one can expect with the clinical treatment alone. The endovascular Balloon transluminal angioplasty and stent insertion may be a useful alternative to carotid endarterectomy in the treatment of atherosclerotic carotid artery stenosis33. Bonati et al.30 published a Cochrane systematic review in 2012 that evaluated the benefits and risks of CAS in comparison with CEA or with clinical treatment alone in patients with symptomatic or asymptomatic carotid stenosis. They used 16 randomized clinical trials involving 7,572 patients. CAS was associated with a greater risk than the CEA for the outcomes death, myocardial infarction or any stroke, occurring between randomization and 30 days after treatment, in patients with symptomatic carotid stenosis and

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Figure 1. Brazilian mortality by procedure (% per year).

CEA= carotid endarterectomy; CAS= carotid angioplasty with stent.

standard surgical risk. The rate of death or disabling/ major stroke did not differ significantly between treatments. In patients with asymptomatic carotid stenosis, the effects of treatment on primary safety and on combined safety and efficacy results were similar to symptomatic patients, but differences between treatments were not statistically significant. They concluded that endovascular treatment is associated with an increased risk of perioperative stroke or death compared with endarterectomy. However, this excess risk seems to be limited to patients older than 70 years. The long-term efficacy of endovascular treatment and the risk of restenosis are unclear and require longer follow-up of existing studies. Further studies are needed to determine the best treatment for asymptomatic carotid stenosis. The Brazilian gross procedure-related mortality rate from 2008 to 2013 was 2.42% for CEA and 2.14% for CAS, according to DATASUS data9. See figure 1 for the evolution of mortality by type of surgery per year4. These results differ from the reality found in places such as USA, Canada and Europe. The risk of perioperative mortality in the CREST study ranged from a 0.3% for CEA and 0.7% for CAS34-36. In Brazil, not only are the mortality rates for both types of treatment higher, but also the inequalities in the risk of death between the two surgical modalities are not reproduced.

Figure 2. Average cost of procedures for carotid stenosis (US dollars per year).

CEA= carotid endarterectomy; CAS= carotid angioplasty with stent.

Economic aspects In Brazil, from 2008 to 2013, there was an absolute number of 7,461 CEA and 783 CAS performed9. Expenses for all procedures were US$ 10,533,233.41 for CEA and US$ 1,648,300.65 for CAS. The average cost and length of stay for the procedure was US$ 1,357.09 / nine days for CEA and US$ 2,086.57 / five days for CAS, but the professional who performed the surgery received only an average of 23.61% (US$ 333.14) and 13.03% (US$ 273.31) of this amount, respectively. See figure 2 for the annual evolution of the average costs in this period, by type of surgery. We verified that 36.2% (US$ 645,570.10) of the total spent in each surgical procedure corresponds to the cost of the intensive care unit after CEA and 11% (US$ 30,645.78) after CAS. The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST)35, conducted in the USA, showed that the initial cost with CAS is higher, costing an average of US$ 1,025 more per patient when compared with CEA, which corroborates Brazilian data. The reimbursement to the Unified Health System (SUS) in Brazil, created by article 32 of Law 9,656/1998 and regulated by the norms of the National Health Agency, is the legal obligation of private health insurance providers in order to restore the expenses of the SUS with any beneficiaries of services that are covered by private plans37. However, the public health services do not obtain financial return in some of these cases, reducing

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available resources and impairing the service to the user in general. According to DATASUS9, each CAS in 2014 was reimbursed at US$ 1,213, while only one stent in this same region at the same time cost about US$ 3,428. We should also remember that the direct cost of treatment is not the only one impacting the patient’s life, his/her family and society as a whole, especially regarding stroke, which is the leading cause of disability in the world. Thera are also the costs with complementary treatments or for assistance to the patients with some sequelae4.

DISCUSSION Brazil has a trend similar to that of other countries in North America and Europe in some respects, maintaining CEA as the main indication for the treatment of carotid stenosis, CAS being reserved for cases in which there are contraindications for the first intervention. However, national results still need to be improved, including complications related to the surgical procedure. Perhaps the execution of these procedures in centers of reference, preferably or even exclusively, favors better results38,39. The causes of perioperative complications in carotid revascularization depend on a series of factors such as previous clinical conditions, intensive support and the surgical technique40,41. The postoperative carotid thrombosis, or the thromboembolism initiated at the site of the arteriotomy, remains a cause of perioperative stroke and is often related to technical defects in the arterial reconstruction procedure. In the endovascular technique,

this is minimized by the routine use of protective brain mechanisms, such as filters, reverse flow systems or shunts, and by post-procedure angiographic control in the same intervention30. Other devices have been used to improve surgical outcomes of large vascular centers around the world. Cerebral electroencephalography, transcranial Doppler, cerebral electromagnetic flow measurement, and revascularization (either CEA or CAS) with local anesthesia and awaken patient for serial neurological examination are some of the techniques used41. An attractive alternative has been Intraoperative imaging in carotid endarterectomy, as it is usually done in the endovascular technique38,40,41. However, catheter angiography and digital subtraction add risks and costs that would otherwise not exist in the classical endarterectomy technique, such as contrast nephrotoxicity, surgical intervention (arterial puncture), and the use of ionizing radiation38,40,41. Thus, in endarterectomy, mapping with vascular Doppler echography seems to play a relevant role, since it would avoid these additional risks. This intraoperative control in endarterectomy is not a routine of all services and its real effects are being discussed38-41. Despite the overall reduction in the proportional mortality rate for age of cerebrovascular diseases, stroke continues to be the leading cause of disability in the modern world and a major cause of death. Its outcomes represent a great socioeconomic commitment to the patient, family members and the population in general. Efforts to prevent baseline illness should be accompanied by a medical team committed to improving their treatment outcomes in order to provide the best in medical evidence and care to their patients.

R E S U M O A doença vascular cerebral extracraniana é uma das mais importantes causas de morte e de incapacidade em todo o mundo e seu tratamento se baseia em estratégias clínica e cirúrgica, sendo que esta última pode ser feita pelas técnicas convencional ou endovascular. O manejo da estenose da bifurcação carotídea visa principalmente a prevenir o acidente vascular cerebral e tem sido objeto de extensa investigação. O papel do tratamento clínico tem sido re-enfatizado, mas a endarterectomia de carótida permanece como o tratamento de primeira linha para pacientes sintomáticos com estenose de 50% a 99% e, para pacientes assintomáticos, com estenose de 60% a 99%. A angioplastia com stent é reservada para pacientes sintomáticos, com estenose de 50% a 99% e com risco elevado para a cirurgia aberta, por motivos anatômicos ou clínicos. Atualmente, o procedimento endovascular não é recomendado para pacientes assintomáticos que tenham condições de serem submetidos ao tratamento cirúrgico convencional. O Brasil apresenta tendência semelhante à de outros países da América do Norte e Europa, observando a manutenção da endarterectomia como a principal indicação para o tratamento da estenose carotídea e reservando o procedimento endovascular para casos em que há contraindicações para a primeira intervenção. Todavia, temos de melhorar os nossos resultados, reduzindo as complicações, notadamente a taxa de mortalidade geral. Descritores: Estenose das Carótidas. Doenças das Artérias Carótidas. Endarterectomia das Carótidas. Angioplastia com Balão. Stents.

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REFERENCES 1. Almeida SRM. Análise epidemiológica do Acidente Vascular Cerebral no Brasil. Rev Neurocienc. 2012;20(4):481-2. 2. Oliveira GP, Guillaumon AT, Brito IB, Lima JMT, Benvindo SC, Cendes F. The impact of carotid revascularization on cognitive function. J Vasc Bras. 2014;13(2):116-22. 3. Ricotta JJ, Aburahma A, Ascher E, Eskandari M, Faries P, Lal BK; Society for Vascular Surgery. Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease. J Vasc Surg. 2011;54(3):e1-31. 4. Flynn RW, MacWalter RS, Doney AS. The cost of cerebral ischaemia. Neuropharmacology. 2008;55(3):250-6. 5. Rerkasem K, Rothwell PM. Carotid endarterectomy for symptomatic carotid stenosis. Cochrane Database Syst Rev. 2011;(4):CD001081. 6. Lessa I. Epidemiologia das doenças cerebrovasculares no Brasil. Rev Soc Cardiol do Estado de São Paulo. 1999;9(4):509-18. 7. Chambers BR, Donnan GA. Carotid endarterectomy for asymptomatic carotid stenosis. Cochrane Database Syst Rev. 2005;(4):CD001923. 8. Villela PB, Klein CH, Oliveira GM. Trends in mortality from cerebrovascular and hypertensive diseases in Brazil between 1980 and 2012. Arq Bras Cardiol. 2016;107(1):26-32. 9. Brasil. Ministério da Saúde do Brasil. DATASUS. Informações de saúde [Internet].Brasília (DF): Ministério da Saúde; [citado 2017 Mar 1]. Disponível em: http://www2.datasus.gov.br/DATASUS/index. php?area=02 10. Brasil. Governo Federal. Portal Brasil. Expectativa de vida no Brasil sobe para 75,5 anos em 2015 [Internet]. Brasília (DF): Portal Brasil; 2016 [citado 2017 Mar 8]. Dsiponível em: http://www.brasil. gov.br/governo/2016/12/expectativa-de-vida-nobrasil-sobe-para-75-5-anos-em-2015 11. Howick J, Chalmers I, Glasziou P, Greenhalgh T, Heneghan C, Liberati A, et al. Explanation of the

12.

13.

14.

15.

16.

17.

18.

2011 Oxford Centre for Evidence-Based Medicine (OCEBM) Levels of Evidence (Background Document) [Internet]. 2011 [cited 2016 Mar 3]. Available from: http://www.cebm.net/index.aspx?o=5653 OCEBM Levels of Evidence Working Group. The Oxford Levels of Evidence 2. Oxford Centre for Evidence-Based Medicine. [Internet]. 2011 [cited 2016 Mar 3]. Available from: http://www.cebm. net/index.aspx?o=5653 Nicolaides AN, Kakkos SK, Griffin M, Sabetai M, Dhanjil S, Thomas DJ, Geroulakos G, Georgiou N, Francis S, Ioannidou E, Doré CJ; Asymptomatic Carotid Stenosis and Risk of Stroke (ACSRS) Study Group. Effect of image normalization on carotid plaque classification and the risk of ipsilateral hemispheric ischemic events: results from the asymptomatic carotid stenosis and risk of stroke study. Vascular. 2005;13(4):211-21. Carotid surgery versus medical therapy in asymptomatic carotid stenosis. The CASANOVA Study Group. Stroke. 1991;22(10):1229-35. Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. JAMA. 1995;273(18):1421-8. Halliday A, Mansfield A, Marro J, Peto C, Peto R, Potter J, et al. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet. 2004;363(9420):1491-502. North American Symptomatic Carotid Endarterectomy Trial Collaborators, Barnett HJM, Taylor DW, Haynes RB, Sackett DL, Peerless SJ, Ferguson GG, Fox AJ, Rankin RN, Hachinski VC, Wiebers DO, Eliasziw M. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med. 1991;325(7):445-53. Matsumoto N, Whisnant JP, Kurland LT, Okazaki H. Natural history of stroke in Rochester, Minnesota, 1955 through 1969: an extension of a previous study, 1945 through 1954. Stroke. 1973;4(1):20-9.

Rev. Col. Bras. Cir. 2017; 44(3): 293-301


Flumignan Extracranial carotid stenosis: evidence based review

300

19. Whisnant JP, Fitzgibbons JP, Kurland LT, Sayre GP. Natural history of stroke in Rochester, Minnesota, 1945 through 1954. Stroke. 1971;2(1):11-22. 20. Thompson JE, Patman RD, Talkington CM. Asymptomatic carotid bruit: long term outcome of patients having endarterectomy compared with unoperated controls. Ann Surg. 1978;188(3):308-16. 21. Grigg MJ, Papadakis K, Nicolaides AN, Al-Kutoubi A, Williams MA, Deacon DF, et al. The significance of cerebral infarction and atrophy in patients with amaurosis fugax and transient ischemic attacks in relation to internal carotid artery stenosis: a preliminary report. J Vasc Surg. 1988;7(2):215-22. 22. Bez LG, Navarro TP. Study of carotid disease in patients with peripheral artery disease. Rev Col Bras Cir. 2014;41(5):311-8. 23. MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis. European Carotid Surgery Trialists’ Collaborative Group. Lancet. 1991;337(8752):1235-43. 24. Nobre MRC, Bernardo WM. Diretrizes AMB/CFM. Rev Assoc Médica Bras. 2002;48(4):290-290. 25. Cook DJ, Mulrow CD, Haynes RB. Systematic reviews: synthesis of best evidence for clinical decisions. Ann Intern Med. 1997;126(5):376-80. 26. Wilson SE, Mayberg MR, Yatsu F, Weiss DG. Crescendo transient ischemic attacks: a surgical imperative. Veterans Affairs trialists. J Vasc Surg. 1993;17(2):249-55; discussion 255-6. 27. Vasconcelos V, Cassola N, da Silva EM, BaptistaSilva JC. Immediate versus delayed treatment for recently symptomatic carotid artery stenosis. Cochrane Database Syst Rev. 2016;9:CD011401. 28. Hobson RW 2nd, Weiss DG, Fields WS, Goldstone J, Moore WS, Towne JB, et al. Efficacy of carotid endarterectomy for asymptomatic carotid stenosis. The Veterans Affairs Cooperative Study Group. N Engl J Med. 1993;328(4):221-7. 29. Bosiers M, Kleinsorge GHD, Deloose K, Navarro TP. Carotid artery surgery: back to the future. J Vasc Bras. 2011;10(1):44-9. 30. Bonati LH, Lyrer P, Ederle J, Featherstone R,

31.

32.

33.

34.

35.

36.

37.

Brown MM. Percutaneous transluminal balloon angioplasty and stenting for carotid artery stenosis. Cochrane Database Syst Rev. 2012;(9):CD000515. McPhee JT, Schanzer A, Messina LM, Eslami MH. Carotid artery stenting has increased rates of postprocedure stroke, death, and resource utilization than does carotid endarterectomy in the United States, 2005. J Vasc Surg. 2008;48(6):1442-50, 1450.e1. Waton S, Johal A, Groene O, Cromwell D, Mitchell D, Loftus I. UK Carotid Endarterectomy Audit. Round 5 [Internet]. London: The Royal College of Surgeons of England, October 2013. [cited 2017 Mar 2]. Available from: https://www.vascularsociety.org.uk/_userfiles/ pages/files/Document%20Library/UK-CarotidEndarterectomy-Audit-Round-5-Report.pdf Campos BAG, Pereira Filho WC. Estenose de carótida extracraniana. Arq Bras Cardiol. 2004;83(6):528-32. Brott TG, Hobson RW 2nd, Howard G, Roubin GS, Clark WM, Brooks W, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med. 2010;363(1):11-23. Mantese VA, Timaran CH, Chiu D, Begg RJ, Brott TG; CREST Investigators. The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST): stenting versus carotid endarterectomy for carotid disease. Stroke. 2010;41(10 Suppl):S31-4. Vilain KR, Magnuson EA, Li H, Clark WM, Begg RJ, Sam AD 2nd, Sternbergh WC 3rd, Weaver FA, Gray WA, Voeks JH, Brott TG, Cohen DJ; CREST Investigators. Costs and cost-effectiveness of carotid stenting versus endarterectomy for patients at standard surgical risk: results from the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST). Stroke. 2012;43(9):2408-16. Agência Nacional de Saúde Suplementar. Ressarcimento ao SUS [Internet]. Rio de Janeiro: ANS; [cited 2017 Mar 2]. Available from: http:// www.ans.gov.br/planos-de-saude-e-operadoras/ espaco-da-operadora/18-planos-de-saude-

Rev. Col. Bras. Cir. 2017; 44(3): 293-301


Flumignan Extracranial carotid stenosis: evidence based review

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e-operadoras/espaco-da-operadora/263ressarcimento-ao-sus 38. Burnett MG, Stein SC, Sonnad SS, Zager EL. Costeffectiveness of intraoperative imaging in carotid endarterectomy. Neurosurgery. 2005;57(3):478-85. 39. Ascher E, Markevich N, Kallakuri S, Schutzer RW, Hingorani AP. Intraoperative carotid artery duplex scanning in a modern series of 650 consecutive primary endarterectomy procedures. J Vasc Surg. 2004;39(2):416-20. 40. Parsa P, Hodgkiss-Harlow K, Bandyk DF. Interpretation of intraoperative arterial duplex ultrasound testing. Semin Vasc Surg. 2013;26(23):105-10.

41. Weinstein S, Mabray MC, Aslam R, Hope T, Yee J, Owens C. Intraoperative sonography during carotid endarterectomy: normal appearance and spectrum of complications. J Ultrasound Med. 2015;34(5):885-94. Received in: 26/01/2016 Accepted for publication: 20/03/2017 Conflict of interest: none. Source of funding: none. Mailing address: Ronald Luiz Gomes Flumignan E-mail: flumignan@gmail.com

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D O I : 10.1590/

Learning

0100- 6912017003013

Model of a training program in robotic surgery and its initial results Modelo de programa de treinamento em cirurgia robótica e resultados iniciais FERNANDO ATHAYDE VELOSO MADUREIRA, TCBC-RJ1,2; JOSÉ LUÍS SOUZA VARELA, TCBC-RJ1; DELTA MADUREIRA FILHO, ECBC-RJ1; LUIS ALFREDO VIEIRA D`ALMEIDA1; FÁBIO ATHAYDE VELOSO MADUREIRA, TCBC-RJ1; ALEXANDRE MIRANDA DUARTE, TCBC-RJ1; OTÁVIO PIRES VAZ1; JOSÉ REINAN RAMOS, TCBC-RJ1. A B S T R A C T Objective: to describe the implementation of a training program in robotic surgery and to point the General Surgery procedures that can be performed with advantages using the robotic platform. Methods: we conducted a retrospective analysis of data collected prospectively from the robotic surgery group in General and Colo-Retal Surgery at the Samaritan Hospital (Rio de Janeiro, Brazil), from October 2012 to December 2015. We describe the training stages and particularities. Results: two hundred and ninety three robotic operations were performed in general surgery: 108 procedures for morbid obesity, 59 colorectal surgeries, 55 procedures in the esophago-gastric transition area, 16 cholecystectomies, 27 abdominal wall hernioplasties, 13 inguinal hernioplasties, two gastrectomies with D2 lymphadenectomy, one vagotomy, two diaphragmatic hernioplasties, four liver surgeries, two adrenalectomies, two splenectomies, one pancreatectomy and one bilio-digestive anastomosis. The complication rate was 2.4%, with no major complications. Conclusion: the robotic surgery program of the Samaritan Hospital was safely implemented and with initial results better than the ones described in the current literature. There seems to be benefits in using the robotic platform in super-obese patients, re-operations of obesity surgery and hiatus hernias, giant and paraesophageal hiatus hernias, ventral hernias with multiple defects and rectal resections. Keywords: Robotic Surgical Procedures. Inservice Training. Learning Curve. Laparoscopy. General Surgery.

INTRODUCTION

S

ince the 1990s, the laparoscopic approach has been gaining ground in relation to open surgery, mainly after the evolution of technique and materials. It is minimally invasive character and has the advantages of lower postoperative pain, faster return to labor activities, lower rates of wall infection and incisional hernias, and a better cosmetic appearance1. Since the early 2000s, the robotic platform has been used to assist operations. The Da Vinci Surgical System platform has been the most active and most studied robotic system2,3. This system consists of a tower with four robotic arms, one of them with an installed high-resolution 3D camera and the other three to couple with various instruments such as graspers, scissors, clip applicators, needle holders, among others1-3. Robotic surgery is on course to be the new revolution in modern surgery, combining all

the benefits of minimally invasive surgery with the advantage of image stability, three dimensions (3D), and the mobility of intracorporeal instrumentation, mainly in operative fields of more restricted spaces3. In the first years of the robotic access route, prostate surgery was the most cost-effective4. With the passage of years and dilution of implantation costs, other procedures are beginning to prove adequate: operations in super obese individuals, esophageal procedures, low rectal resections, enlarged hysterectomies with pelvic lymphadenectomy, surgery to treat endometriosis and others. The main criticism of this new access route is still the high cost per procedure. In first world countries the surgeries by robot and the number of implanted systems grow at a fast pace3-5. Normally, during training, surgeons are tutored for a short time and in few cases, which increases the learning curve and leads to questionable results in terms of complications and morbidity6.

1 - Samaritan Hospital, Robotic Surgery Group, Rio de Janeiro, Rio de Janeiro State, Brazil. 2 - Gaffrée Guinle University Hospital, Federal University of the State of Rio de Janeiro (UNIRIO), Rio de Janeiro, Rio de Janeiro State, Brazil. Rev. Col. Bras. Cir. 2017; 44(3): 302-307


Madureira Model of a training program in robotic surgery and its initial results

Concurrently, a parallel industry of legal suits against medical malpractice grows, trying to explore unsuccessful cases. Two questions need to be asked: how to implement this new system, with training that exploits the advantages of robotic surgery, but in a safe way for the patient and the Institution, and which procedures in General Surgery have the cost / benefit ratio adequate for Brazil. The purpose of this study is to describe the implementation of a successful training program in robotic surgery and to present the initial results of the series of operations in General Surgery using the robotic platform.

METHODS This is a retrospective analysis of a prospectively collected database of patients operated from October 2012 to December 2015 at the robotic surgical training program of the General and Colorectal Surgery group of the Samaritan Hospital (Rio de Janeiro, RJ, Brazil). The Study was submitted to the Ethics in Research Committee of the Gaffré & Guinle University Hospital, UNIRIO, and carried out in accordance with its recommendations. When the Robotic Surgery program was implemented, the Da Vinci Si operating system was chosen and a training plan was drawn up for eight general surgeons and five urologists. Initially, the mandatory training required by the manufacturer of the Da Vinci robotic system, the Intuitive Surgical, consisted of four steps: 1) digital training on the Intuitive Company’s website with a focus on the robot’s operation, its components and main functions; 2) training on the Mimic simulator to gain proficiency in performance and dexterity exercises; 3) training in the dry laboratory, with exercises in the surgical robot itself, using models (performed abroad in different places according to the choice of Intuitive Surgical); and 4) training in cadavers or live animals at Intuitive Surgical training centers in the United States of America as the last step prior to human operations. Surgeons who passed these steps

303

received a certification from the company, and from that moment on, they were able to use the robot in human operations with the supervision of more experienced surgeons (proctors). In the program conducted at the Samaritan Hospital, in addition to the training proposed by the manufacturer of the Da Vinci system, an agreement was made with the Robotic Surgery Service of the Celebration Hospital, in Orlando, United States. Proctors from that hospital were present in the first 20 operations of each training surgeon for possible assistance or even substitution. Surgeons were divided into two specialties: Urology and General Surgery, with specific proctors in each. Training surgeons worked in pairs: one on the console and another as an assistant next to the patient, the proctor always being present in the operating room. All other service surgeons who were not operating were committed to attending the surgeries scheduled for that training round. Five to six surgeries were scheduled for each training stage and divided in two days, each month. For the Urology group, the instructors were the professors Dr. Vipul Patel and Dr. Keneth Palmer. For the General Surgery group, the instructors were the professors Dr. Eduardo Parra D’Ávila and Dr. Keith Kim. After the 20 cases performed, the training surgeons were evaluated by the proctor and, if considered fit, were allowed to operate with the robot without mentoring. The patients chosen to be operated on in the robotics program came from each surgeon’s office and were selected by the surgeon with prior consent from the proctor and Hospital Director. Surgeries with a greater degree of technical difficulty were previously discussed in the Service and submitted to the proctor authorization. The patients undergoing the procedures were informed about the new technology that would be employed and signed an informed consent form at the time of admission. We analyzed the type of operation, complications, length of hospital stay, morbidity and mortality only in the General Surgery operations.

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304 Table 1 - Robotic Operations, reoperations and complications.

Procedure

n

Reoperations

Complications

Bariatric Surgery

108

0

1 Hematoma in mesentery in the first trocar insertion

Rectosigmoidectomy

44

2

2 Early small bowel obstruction; anastomotic dehiscence

Hiatus hernia

43

0

2 Punctate esophagus perforation, recognized and treated during the procedure; Pneumothorax requiring drainage

Cholecystectomy

16

0

0

Ventral Hernia

27

0

0

Inguinal Hernia

13

0

0

Achalasia

12

0

1 Punctate esophageal mucosa perforation, recognized and treated during surgery

Right colectomy

9

1

1 Bowel obstruction

Milles Procedure

4

0

0

Adrenalectomy

2

0

0

Gastrectomy D2

2

0

0

Splenectomy

2

0

0

Liver Surgery

4

0

0

Pancreatectomy

1

0

0

Bilio-Digestive Anastomosis

1

1

1 Choleperitoneum that was drained

RESULTS

DISCUSSION

A total of 293 robotic operations were performed in General Surgery. Table 1 shows the most performed operations. A total of 108 surgeries were performed for morbid obesity, 59 colorectal surgeries, 55 surgeries in the gastro-esophageal transition, 16 cholecystectomies, 27 abdominal wall hernioplasties, two gastrectomies with D2 lymphadenectomy, one vagotomy, two diaphragmatic hernioplasties, four liver surgeries, two adrenalectomies, two splenectomies, one pancreatectomy and one biliodigestive surgery. The total morbidity rate was 2.4%, with no major complications (Table 1). We reoperated 1.4% of the patients. The length of hospital stay is shown in table 2. There were no deaths.

Robotics comes from the word ROBOT, the Czech word for â&#x20AC;&#x153;forced labor.â&#x20AC;? The term ROBOT was used for the first time in history by the Czech Karel Capek, in a play of 1921 in the city of Prague. Leonardo Da Vinci was responsible for the first project of a humanoid automaton in 1495, with drawings of a knight able to sit, move his arms, head and jaw2. Table 2 - Mean time of hospitalization of the main procedures.

Procedures Bariatric Hiatus hernia Rectosigmoidectomy Ventral hernias Achalasia

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Average length of stay 2.2 days 1.6 days 3.4 days 1.4 days 1.6 days


Madureira Model of a training program in robotic surgery and its initial results

By concept, robots were created to facilitate human life. They have application in the domestic use to facilitate daily tasks, in the military use to carry out risky tasks, in the industrial use to perform automated tasks aiming at the increase of productivity and the reduction of costs, and in medicine, supporting tasks of the elderly and disabled, replacing members and organs and participating in surgeries, making them more precise. The robots participate in telemedicine with the concepts of telepresence and telecolaboration, with the possibility of performing surgeries at a distance and with the aid of a more experienced surgeon assisting in the procedure and aiming at a better final result. The initial concept of robotics in surgery began in the 1980s and involved the idea of performing an operation at a location far from where the surgeon was. This possibility attracted the American military, who began the development of robots aimed at performing surgeries on the battlefield, through remote control by the doctor. Between the late 1990s and the early 21st century, surgical robots have been improved. The first system for robotic surgery was AESOP, represented by a mechanical arm that held the laparoscopic optics and could be controlled by the surgeon with pedals or voice command. In 1995, the same company developed the Zeus robot, which had three arms, two to handle the instruments and a third to operate the camera2. With the development of Da Vinci, this became the most complete active robotic system, since it evolved from Improvements of its antecedents. The Da Vinci system is connected to a command console that receives the images generated by the 3D camera and emits the movements of the surgeon’s hand in a joystick for the robotic arms with the coupled instruments, allowing wide and precise movements in the surgery, with high performance2. Robotic surgery has a number of advantages over laparotomic and laparoscopic surgery, incorporating all the positive aspects of a minimally invasive surgery and supplanting it in terms of ergonomics, operative field control, high resolution image in three dimensions (3D), freedom of movement

305

of the instruments, reduction of tremors, performance of risky tasks for the surgeon (exposure to radiation, for example), greater autonomy of the surgeon with the lesser use of auxiliaries and, especially, precision1. Nowadays we still face some disadvantages in the use of robotic surgery, especially in terms of costs and lack of tactile feedback, which in our opinion, with the popularization of this type of surgical approach and the technological advances already underway by the manufacturing industry, tend to be resolved quickly, as have been the difficulty of accessing multiple quadrants, performing irrigation, suctioning and stapling and the sealing of large blood vessels. In planning the deployment of a new technology, in the case of the Da Vinci Si robotic system, the challenge was to train a group of surgeons with the greatest efficiency, the least complications and costs appropriate to the national reality, understanding that this access route was not widespread in Brazil, unlike the USA and Europe, and that its implementation would also imply new concepts and community acceptance6,7. By the end of 2012, surgeons were usually tutored briefly and in a few cases. During training, five cases were required for the surgeon to be “cleared” to operate. This may have been one of the reasons for a high learning curve and early questionable results in terms of complications and morbidity in programs implemented in the early and mid 2000s6,7. The strategy adopted was to associate with the group of surgeons at Celebration Hospital in Orlando, United States, in the person of its head, Dr. Vipul Patel, a renowned urological surgeon and holder of the world’s largest experience in the treatment of prostate cancer by robotic surgery. The objective of this agreement was to incorporate the experience acquired by that success group, minimizing complications, unnecessary costs and reaching the outlined objectives more quickly8-13. The profile of chosen surgeons took into account extensive experience in laparoscopic surgery and they were given freedom to choose the procedures. The recommendation was that they focus on operations with which they were familiar to reach better performance and accelerate learning on the new

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Madureira Model of a training program in robotic surgery and its initial results

306

platform. The chosen group consisted of younger and more experienced surgeons. At first, what seemed to be a reason for difficulty, proved very correct, since the generations were complementary, exchanging experiences and gaining aptitude. The requirement that all training surgeons be present in the operations of others has greatly accelerated the group’s experience. Although each has done 20 to 35 operations, they were present in about 200 cases of other colleagues. After performing 20 operations and if considered fit by the program proctors, the surgeons were allowed to operate with the robot without mentoring. Some were elected to act as internal proctors in the program and thereby replicate the knowledge in other services that were starting in Rio de Janeiro and other states in Brazil. In a rational way and with considerable investment, the most complete Robotic Surgery training system has been safely and efficiently implemented. With around 300 patients operated in three years, with a very low rate of complications and reoperations and no deaths, this new service is credited as a very successful model and ready for new challenges14,15. Rocha et al.11 reported that the methodology adopted in radical resection of the prostate (even with the surgeons in training), produced early results similar to groups that had already been established. In Europe and especially in the USA, robotic technology has been well developed since the early 2000s, where there are more than 1,300 surgical robots installed. Thus, the discussion about training and deployment of the robotic access route has already been made in the residency programs11-13,16-19. It is

also important to note that not all types of surgeries performed during training have met the criteria found in the literature for the advantageous use of the robotic platform. Lower complexity surgeries were performed to fit the aptitude of the surgeon who presented the greatest difficulty at the beginning of the experiment (learning curve) to be able to operate with the required safety for the patient3. With the experience gained from performing various operations, it seems promising to use the robotic platform instead of laparoscopic and open surgery in the following procedures: bariatric surgery in super-obese patients and bariatric reoperations, due to the technical and ergonomic challenges these patients impose; giant hiatus hernias, para-esophageal hernias and their reoperations; low rectal cancer, especially in the narrow pelvis; achalasia surgery; pancreatectomies; complicated diverticulitis, with multiple adhesions and fistulas; lymphadenectomies in general; abdominal wall surgeries mainly in the ventral ones with multiple defects, large defects and in obese patients; and lumbotomy eventrations3. The continuity of the experience acquired by the group in the coming years tends to align with the medical literature in this field and a larger number of patients treated should validate this trend favorable to the treatment performed on the robotic platform of the conditions mentioned herein. The modernization of the robot used in this study, as well as new models that will soon enter the market, tend to democratize the use of this fabulous technology and further facilitate the surgeon’s work for the patient’s benefit.

R E S U M O Objetivo: descrever a implantação de um programa de treinamento em cirurgia robótica e apontar as operações em Cirurgia Geral que podem ser feitas com vantagens utilizando a plataforma robótica. Métodos: estudo prospectivo do Grupo de Cirurgia Robótica em Cirurgia Geral e Colorretal do Hospital Samaritano (Rio de Janeiro, Brasil), de outubro de 2012 a dezembro 2015. São descritas as etapas do treinamento e particularidades. Resultados: no período do estudo foram realizadas 293 operações robóticas em Cirurgia Geral: 108 cirurgias para obesidade mórbida, 59 colorretais, 55 cirurgias na área da transição esôfago-gástrica, 16 colecistectomias, 27 hérnias da parede abdominal, 13 hernioplastias inguinais, duas gastrectomias com linfadenectomia à D2, uma vagotomia, duas hernioplastias diafragmáticas, quatro cirurgias hepáticas, duas adrenalectomias, duas esplenectomias, uma pancreatectomia, uma anastomose biliodigestiva. O índice de complicações foi de 2,4% sem complicações maiores. Conclusão: o Programa de Cirurgia Robótica do Hospital Samaritano foi implementado de forma segura e com resultados iniciais acima da literatura. Parece haver benefício em se utilizar a plataforma robótica nos super obesos, nas reoperações de cirurgia de obesidade e de hérnias de hiato, hérnias de hiato gigantes e para-esofágicas, hérnias ventrais com múltiplos defeitos e ressecções baixas de reto. Descritores: Procedimentos Cirúrgicos Robóticos. Capacitação em Serviço. Curva de Aprendizado. Laparoscopia. Cirurgia Geral.

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Madureira Model of a training program in robotic surgery and its initial results

REFERENCES 1. Barbash GI, Glied SA. New technology and health care costs--the case of robot-assisted surgery. N Engl J Med. 2010;363;(8):701-4. 2. Pugin F, Bucher P, Morel P. History of robotic surgery: From AESOP® and ZEUS® to da Vinci ®. J Visc Surg. 2011;148(5Suppl):e3-8. 3. Szold A, Bergamaschi R, Broeders I, Dankelman J, Forgione A, Langø T, et al. European Association of Endoscopic Surgeons (EAES) consensus statement on the use of robotics in general surgery. Surg Endosc. 2015;29(2):253-88. 4. Montorsi F, Wilson TG, Rosen RC, Ahlering TE, Artibani W, Carroll PR, et al. Best practices in robot-assisted radical prostatectomy: recommendations of the Pasadena Consensus Panel. Eur Urol. 2012;.62(3):368-81. 5. Chitwood WR Jr, Nifong LW, Chapman WH, Felger JE, Bailey BM, Ballint T, et al. Robotic surgical training in an academic institution. Ann Surg. 2001;234(4):475-84; discussion 484-6. 6. Lee JY, Mucksavage P, Sundaram CP, McDougall E. Best practices for robotic surgery training and credentialing. J Urol. 2011;185(4):1191-7. 7. Davis D, O’Brien MAT, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A. Impact of formal continuing medical education. Do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA. 1999;282(9):867-74. 8. Patel VR. Essential elements to the establishment and design of a successful robotic surgery programme. Int J Med Robot. 2006;2(1):28-35. 9. Rocco B, Lorusso A, Coelho RF, Palmer KJ, Patel VR. Building a robotic program. Scan J Surg. 2009;98(2):72-5 10. Murphy D, Bjartell A, Ficarra V, Graefen M, Haese A, Montironi R, et al. Downsides of robot-assisted laparoscopic radical prostatectomy: limitations and complications. Eur Urol. 2010;57(5):735-46. 11. Zorn KC, Gantam G, Shalhav AL, Clayman RV, Ahlering TE, Albala DM, et al. Training, credentialing, proctoring and medicolegal risks of robotic urological surgery: recommendation of the Society of Urologic Robotic Surgeons. J Urol. 2009;182(3):1126-32.

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12. Rocha R, Fiorelli RK, Buogo G, Rubistein M, Mattos RM, Frota R, et al. Robotic-assisted laparoscopic prostatectomy (RALP): a new way to training. J Robot Surg. 2016;10(1):19-25. 13. Gomes PP, Willis RE, Van Sickle KR. Development of a virtual reality robotic surgical curriculum using the Da Vinci Si surgical system. Surg Endosc.2015;29(8):2171-9. 14. Passerotti CC, Franco F, Bissoli JC, Tiseo B, Oliveira CM, Buchalla CA, et al. Comparison of the learning curves and frustration level in performing laparoscopic and robotic training skills by experts and novices. Int Urol Nephrol. 2015;47(7):1075-84. 15. Dulan G, Rege RV, Hogg DC, Gilbert-Fisher KM, Arain NA, Tesfay ST, et al. Developing a comprehensive, proficiency-based training program for robotic surgery. Surgery. 2012;152(3):477-88. 16. Donias HW, Karamanoukian RL, Glick PL, Bergsland J, Karamanoukian HL. Survey of resident training in robotic surgery. Am Surg. 2002;68(2):177-81. 17. Geller EJ, Schuler KM, Boggess JF. Robotic surgical training program in gynecology: how to train residents and fellows. J Minim Invasive Gynecol. 2011;18(2):224-9. 18. Moles JJ, Connelly PE, Sarti EE, Baredes S. Establishing a training program for residents in robotic surgery. Laryngoscope. 2009;119(10):1927-31. 19. Dulan G, Rege RV, Hogg DC, Gilbert-Fisher KK, Tesfay ST, Scott DJ. Content and face validity of a comprehensive robotic skills training program for general surgery, urology, and gynecology. Am J Surg. 2012;203(4):535-9. 20. Patel HR, Linares A, Joseph JV. Robotic and laparoscopic surgery: cost and training. Surg Oncol. 2009;18(3):242-6. Received in: 23/11/2016 Accepted for publication: 27/01/2017 Conflict of interest: none. Source of funding: none. Mailing address: Fernando Athayde Veloso Madureira E-mail: drfmadureira@hotmail.com drfmadureira@gmail.com

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D O I : 10.1590/

Technical Note

0100- 6912017003008

Preliminary results of severe venous insufficiency treatment with thermal ablation of the great saphenous vein by endovascular technique with laser diode 980nm developed in Brazil, associated with sclerotherapy with polidocanol Resultados preliminares do tratamento de insuficiência venosa grave com termoablação da veia safena magna por técnica endovascular com laser de diodo 980nm desenvolvido no Brasil, associado à escleroterapia com polidocanol MATHEUS BERTANHA1; MARCONE LIMA SOBREIRA1; PAULA ANGELELLI BUENO CAMARGO1; RAFAEL ELIAS FARRES PIMENTA1; JAMIL VICTOR OLIVEIRA MARIÚBA1; REGINA MOURA1; VANDERLEI SALVADOR BAGNATO1; WINSTON BONETTI YOSHIDA1. A B S T R A C T The endovenous laser ablation (EVLA) of the insufficient saphenous vein has similar results to open conventional surgery, but less morbidity. The echo-guided polidocanol foam sclerotherapy technique has been used for the same purpose. The combined techniques may play a role for more severe diseases, such as those with varicose ulcers. An EVLA device (called VELAS) has been developed in the Optics and Photonics Research Center of USP-São Carlos in agreement with FMB-UNESP. In this study, we present the preliminary results of the VELAS device (MMO 980nm diode) in patients with chronic venous ulcer, associated with echo-guided polidocanol foam sclerotherapy for the treatment of varicosities. Primary outcomes were healing time of the venous ulcer, occlusion of the treated veins and treatment-related adverse events. We included 12 patients with insufficient saphenous vein and chronic venous ulcer. Initially, we treated all of them with thermoablation of the insufficient saphenous vein (VELAS), on an outpatient basis, with local anesthesia. After one week of the procedure, we sclerosed the varicosities with polidocanol foam (Tessari technique). The national VELAS device was easily handled. Total venous occlusion occurred in 83.3% of the patients (in seven days) and the association of the techniques was responsible for a wound healing rate of 83.3%, with no adverse events. Keywords: Laser Therapy. Laser Coagulation. Varicose veins. Varicose Ulcer. Venous Insufficiency.

INTRODUCTION

T

he conventional treatment of lower limbs varicose veins consists of surgical removal of insufficient veins. Among the procedures for this condition, when there is insufficiency of the great saphenous vein (GSV), phlebectomy is the recommended treatment and has been performed for decades with relative safety and efficacy1,2. In addition to the conventional method, the sclerosing treatment with polidocanol foam by the Tessari technique3, generally used when there is some contraindication to the surgical procedure, is a useful alternative. More recently, endovascular treatments for varicose veins have been available. These techniques have achieved great popularity, especially in firstworld countries, because they are less invasive and

involve fewer anesthesia-related risks. These include photothermolysis and photocoagulation, which can be performed with a laser or a radiofrequency device, respectively4-7. However, non-invasive surgery equipment for varicose veins is imported and costly, making it difficult to popularize its use in patients treated by the Brazilian Unified Health System (SUS). In view of the need to reduce costs for the incorporation of this technique by SUS, a new MMO 980nm diode laser equipment (endovascular laser ablation – EVLA) was developed and made available for evaluation of efficacy and safety, as result of a national research involving USP and UNESP, and received the trade name VELAS. The complementation of the thermoablation with sclerosis with polidocanol is scarce in the literature. In this work, we present the preliminary

1 - Botucatu Medical School – FMB-UNESP, Botucatu, São Paulo State, Brazil. Rev. Col. Bras. Cir. 2017; 44(3): 308-313


Bertanha Preliminary results of severe venous insufficiency treatment with thermal ablation of the great saphenous vein by endovascular technique ...

results obtained in 13 surgeries performed in patients with great saphenous vein (GSV) or lesser saphenous vein (LSV) severe insufficiency with active chronic venous ulcer in the lower limb (CEAP 6). We performed a treatment session with 1% polidocanol and air microsurgery sclerotherapy using the Tessari technique in an echo-guided fashion to treat the residual varices one week after the laser treatment, when necessary. Ethics The equipment was approved for use in patients, as part of a clinical research protocol, after numerous electronic and physical tests, as well as extensive performance regulation initially in corpses’ parts (veins) and also pre-clinical tests in experimental animals (rabbits), the equivalence with imported devices being demonstrated. This project was submitted to, and approved by, the Ethics in Research Committee (CEP) of the Botucatu Medical School (FMB-UNESP), with protocol number 3240/2009. We thoroughly oriented all the patients and provided them with all information regarding the procedures to be performed before they signed the Informed Consent Form (TCLE). Inclusion and exclusion criteria We included consecutive patients of the FMBUNESP Clinics Hospital, in an outpatient follow-up, of both genders, older than 18 years, with chronic venous insufficiency and active chronic venous ulcers (CEAP classification 6). Exclusion criteria were patients less than 18 years of age, history of deep vein thrombosis (DVT) or post thrombotic syndrome, use of anticoagulants, varicose veins classified as CEAP 5 or less, previous total great and lesser saphenectomy in the affected limb, ulcers with signs of active infection, concomitant peripheral arterial disease, pregnancy or puerperium, active cellulites or erysipelas, signs of active mycoses, personal history of alcohol or drug abuse, clinically decompensated comorbidities, disagreement with the research terms, ulcer healing occurring before the procedure, and refusal to sign the Informed Consent Form.

309

The equipment The endovascular venous laser ablation (EVLA) device, VELAS, was developed through an agreement between the Optics and Photonics Research Center of the Physics Institute of São Carlos – USP – and the FMB-UNESP (Process 1084/2007). A 980nm diode laser equipment was built, with regulation of power, time of pulsed or continuous energy exposure and accompanied by a 600 micron optical fiber, protection goggles, hand-piece and carrying case. Operative technique The procedures were performed in a standardized way, under local anesthesia with 20ml of 2% Xylocaine without vasoconstrictor plus 20ml of 0.5% isobaric bupivacaine, diluted in 200ml of cold saline solution (0.9%), injected with a 27G spinal anesthesia needle, guided by a portable Ultrasound (US) instrument, aiming to anesthetize the GSV (or LSV) pathway. We anesthetized the inguinal region (or the popliteal fossa in the one case of LSV treatment) with the same solution, to dissect and ligate the saphenous arc. This was sectioned and doubly ligated with unabsorbable suture. We then proceeded to the retrograde introduction of a 0.035” x 260mm stiff hydrophilic guidewire through the sectioned saphenous vein to the distal third of the leg in an echoguided fashion. We inserted a Levine number six probe (with cut tip) over the guide wire. We echographycally performed an additional intumescence inside the saphenous compartment with ice-cold 0.9% saline. After removing the guide wire, we introduced the laser fiber optic into the Levine, making a retrograde movement with the probe for exposing the optical fiber. We calibrated the laser at 15W, with continuous shooting, with thermoablation application speed of 3mm/s, with optical fiber of 600 microns. The laser was fired in a distal to proximal direction in the saphenous vein, and we repeated the firing until we noticed the ultrasonographic obliteration of the more calibrous veins. The procedures took approximately an hour and a half, a time spent, for the most part, for anesthesia and intumescence. We did not surgically treat

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Bertanha Preliminary results of severe venous insufficiency treatment with thermal ablation of the great saphenous vein by endovascular technique ...

310

Table 1. Epidemiological data and results.

Patient

Age (years)

Gender

Saphenous vein diameter (cm)

Saphenous vein

Foam in varicose veins

DVT

PO Infection

Saphenous vein occlusion (7 days)

Ulcer healed after one year

Healing time (months)

Saphenous vein occlusion (1 year)

(7 days)

MLSG

50

F

1.65

Greater

Yes

No

No

Yes

Yes

7

Yes

CCZ

58

F

1.37

Greater

No

No

No

Yes

Yes

2

Yes

JS

53

F

1.42

Greater

Yes

No

No

Yes

Yes

0.5

Yes

TFFG

57

F

1.7

Greater

Yes

No

Yes

Yes

Yes

6

Partial

JVS

64

M

0.49

Greater

Yes

No

No

Yes

No

-

Yes

MLBG

64

F

1.35

Greater

Yes

No

No

Yes

Yes

12

Partial

VS

71

M

1.27

Greater

No

No

No

Yes

Yes

4

Yes

MBL

50

F

1.05

Greater

No

No

No

Yes

Yes

1.5

Partial

CSLG

43

F

0.38

Lesser

Yes

No

No

Yes

No

-

Yes

ESP

47

F

1.34

Greater

No

No

No

Yes

Yes

3

Yes

JBP

50

M

1.6

Greater

Yes

No

No

Partial

Yes

0.5

Partial

AGM

41

F

1.39

Greater

Yes

No

No

Partial

Yes

0.75

Partial

8/12

12/12

1/12

10/12

10/12

Total Average (~)

3M 9F

~ 3.7

11 GSV ~ 1.27

~ 54

1 LSV

(~111 days)

7/12

M: male; F: female; ~: average.

additional varicosities at the same operative time. After ablation of the GSV or LSV, we sutured the inguinal or popliteal fossa incision by planes. We applied a semi-compressive and inelastic dressing throughout the operated limb. We observed the patients for four hours before discharge, and advised them to maintain relative rest until the following day.

the patients from the outpatient clinic and followed them up every six months in a returning clinic. We performed a further US examination after one year of treatment to assess the maintenance of obliteration of the treated vein, as well as clinical data.

Follow-up We instructed the patients to return to the clinic one week after surgery. In this return, we made an US examination to evaluate the occlusion or not of the treated vein and the patency of the deep venous system. We then treated varicose veins of the saphenous system with 10ml solution containing 2ml of 1% Polidocanol and 8ml of ambient air in the form of foam by the Tessari technique, a volume fractionated by the caliber and length of the varicosities, when necessary. The patients had biweekly returns in an outpatient clinic for dressings to follow the wound healing, or in other periods as determined by the attending physician. After wound healing, we discharged

In the period from February 2014 to June 2015, we treated 30 consecutive patients with active chronic venous ulcer of difficult treatment in the vascular dressing outpatient clinic of our service, of whom 12 could be included and treated by the EVLA method with the new laser device VELAS (Table 1). We excluded 18 patients (preoperative ulcer closure, withdrawal, absence of significant saphenous vein changes in the US, signs of involvement of the deep venous system by prior DVT or concomitant arterial disease). Among the 12 patients selected, ten had a saphenous vein with a greater caliber than 1.0cm (Table 1). There was no inclusion restriction due to the saphenous vein caliber.

RESULTS

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Bertanha Preliminary results of severe venous insufficiency treatment with thermal ablation of the great saphenous vein by endovascular technique ...

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Figure 1. Venous ulcers: A, C, E â&#x20AC;&#x201C; pretreatment; B, D, F â&#x20AC;&#x201C; posttreatment.

Regarding laser treatment, there were no hospital complications (burns, bleeding, cardiovascular events or DVT). Eleven patients had GSV treatment, and only one, LSV. All patients reported improved clinical symptoms one week after surgery. At the end of the seven-day follow-up period, one patient had an infection characterized as erysipela, which was treated with an oral antibiotic (Amoxicillin 875mg + Clavulanate 125mg b.i.d.) for seven days, with success. In eight patients (67%), we carried out the complementary treatment of varicosities with sclerotherapy with 1% polidocanol by the Tessari technique. Also at the one week return, ten patients presented total obliteration of the treated saphenous vein (83.3%) and two presented partial occlusion, predominantly present in small segments of the vein where they were more dilated (Table 1).

The mean time of total ulcer healing was 3.7 months (0.5 to 12), which occurred in ten patients (83.3%) (Figure 1). Two patients (16.7%) did not have complete healing of the venous ulcers in the follow-up period, both presenting a decrease in the perimeter and depth of the ulcers. One had reflux of the proximal deep venous system (femoral vein) not associated with known prior DVT and received LSV treatment. The other did not show complete healing with one year of follow-up despite the treatments performed. At the one-year follow-up, 58.3% of the treated patients sustained obliteration of the treated vein, and the remaining patients remained with partial occlusion with recanalized segments, but all of them maintained the clinical improvements obtained with the treatment (Table 1).

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Bertanha Preliminary results of severe venous insufficiency treatment with thermal ablation of the great saphenous vein by endovascular technique ...

DISCUSSION The equipment tested included safety requirements (goggles, safety switches, etc.), as well a LED light on the tip of the fiber optics, which facilitated the monitoring of its progression inside the vessel by transillumination through the skin. The VELAS laser displayed good performance and ease of handling, mainly because it has a practical Touch-Screen panel, friendly programming and easy adjustment and access by the auxiliary team. The laser emission occurred safely, as previously calibrated and tested by the engineers. This laser device has a frequency of 980nm and is quite effective in venous ablation; equipment with a higher frequency (1470nm) report to have a higher affinity for water8. The use of this VELAS laser device with retrograde ablation technique was sufficiently capable of promoting the closure of most treated veins in the evaluation in seven days, similar to what is found in the literature9,10. At points of caliber of less than 1cm, it promoted permanent vein fibrosis. However, since the selected patients had greater venous insufficiency, the treated veins exceeded the maximum recommended diameter of 1cm in some segments (mean larger diameter of 1.27cm). Thus, as expected, there was not fibrosis of the entire course of the treated vein, and some patients presented segment phlebitis and partial recanalization in the one-year follow-up. In these cases, the ligation of the saphenous arc in all cases contributed to prevent embolization. In any case, three patients presented partial recanalization of segments

initially considered obliterated in the follow-up of one year. According to the literature, these recanalizations usually occur in segments of veins with a caliber greater than 1cm, a fact corroborated by this study11,12. Sclerotherapy performed with 1% polidocanol by the Tessari technique for varicosities of the GSV or LSV was effective in promoting their obliteration in the one-year follow-up (80%). In this sense, thermoablation supplemented by sclerosis with polidocanol may be a less invasive and efficient alternative, often serving as rescue for more complicated cases. This association of techniques is an unusual procedure and the preliminary results were promising, leading to future research with a greater number of cases. The mean wound healing time was 3.7 months, which was considered precocious compared with the time they remained open. No patient presented any type of major complication associated with both methods. This study suggests that the techniques employed complemented each other in promoting patients’ clinical improvement, besides increasing the chances of ulcer healing13,14. We conclude that the VELAS laser apparatus was easy to handle, showed good performance and similar safety to imported equipment. Ambulatory thermoablation in association with complementary sclerotherapy with echogenic polidocanol foam was an unusual and promising technique for the treatment of patients with severe venous insufficiency, with good clinical success rates. Studies with more cases will be necessary to confirm these findings.

R E S U M O A termoablação endovascular das veias safenas insuficientes com laser é descrita como uma técnica menos invasiva, com resultados semelhantes à cirurgia convencional, porém, com efeitos adversos menos frequentes. A técnica de escleroterapia com espuma de polidocanol ecoguiada vem sendo empregada com a mesma finalidade. A combinação de técnicas pode representar uma alternativa para pacientes mais graves, como os portadores de úlcera varicosa. Um equipamento de laser (denominado VELAS) foi desenvolvido no Centro de Pesquisas em Ótica e Fotônica da USP-São Carlos em convênio com a FMB-UNESP para termoablação endoluminal da veia safena insuficiente. Neste estudo apresentamos os resultados preliminares do uso do aparelho de laser VELAS (diodo MMO 980nm) na termoablação endovascular de veias safenas insuficientes, em portadores de úlcera venosa crônica, associado à complementação com espuma de polidocanol para o tratamento de varicosidades, após uma semana. Os desfechos analisados foram o tempo de cicatrização da úlcera venosa, oclusão das veias tratadas e eventos adversos relacionados aos tratamentos. Foram incluídos 12 pacientes portadores de insuficiência de veia safena e úlcera venosa crônica que aceitaram participar do projeto. Todos foram tratados em regime ambulatorial, com anestesia local e termoablação da veia safena insuficiente (VELAS). Após uma semana da cirurgia, as varicosidades foram esclerosadas com polidocanol espuma (técnica de Tessari). O equipamento laser VELAS nacional apresentou fácil manuseio, oclusão venosa total em 83,3% dos pacientes (em sete dias) e a associação das técnicas foi responsável por uma taxa de cicatrização de feridas de 83,3%, sem ocorrência de eventos adversos. Descritores: Terapia a Laser. Fotocoagulação a Laser. Varizes. Úlcera Varicosa. Insuficiência Venosa.

Rev. Col. Bras. Cir. 2017; 44(3): 308-313


Bertanha Preliminary results of severe venous insufficiency treatment with thermal ablation of the great saphenous vein by endovascular technique ...

REFERENCES 1. Nicolaides A, Kakkos S, Eklof B, Perrin M, Nelzen O, Neglen P, et al. Management of chronic venous disorders of the lower limbs - guidelines according to scientific evidence. Int Angiol. 2014;33(2):87-208. 2. Darwood RJ, Theivacumar N, Dellagrammaticas D, Mavor AID, Gough MJ. Randomized clinical trial comparing endovenous laser ablation with surgery for the treatment of primary great saphenous varicose veins. Br J Surg. 2008;95(3):294-301. 3. Breu FX, Guggenbichler S, Wollmann JC. 2nd European Consensus Meeting on Foam Sclerotherapy 2006. Tegernsee. Germany. VASA. 2008;37 Suppl 71:1-29. 4. Rasmussen LH, Lawaetz M, Bjoern L, Vennits B, Blemings A, Eklof B. Randomized clinical trial comparing endovenous laser ablation, radiofrequency ablation, foam sclerotherapy and surgical stripping for great saphenous varicose veins. Br J Surg. 2011;98(8):1079-87. 5. Araújo M, Velasco FCG. Physical methods used to promote occlusion of varicose veins of the lower limbs. J Vasc Bras. 2006;5(2):139-46. 6. Medeiros CAF. Comparação entre o laser endovenoso e a fleboextração total da veia safena interna: resultados em médio prazo. J Vasc Bras. 2006;5(4):277-87. 7. Goldman MP, Amiry S. Closure of the greater saphenous vein with endoluminal radiofrequency thermal heating of the vein wall in combination with ambulatory phlebectomy: 50 patients with more than 6-month follow-up. Dermatol Surg. 2002;28(1):29-31. 8. Kim HS, Nwankwo IJ, Hong K, McElgunn PS. Lower energy endovenous laser ablation of the great saphenous vein with 980 nm diode laser in continuous mode. Cardiovasc Intervent Radiol. 2006;29(1):64-9.

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9. Sullivan LP, Quach G, Chapman T. Retrograde mechanico-chemical endovenous ablation of infrageniculate great saphenous vein for persistent venous stasis ulcers. Phlebology. 2014;29(10):654-7. 10. Abdul-Haqq R, Almaroof B, Chen BL, Panneton JM, Parent FN. Endovenous laser ablation of great saphenous vein and perforator veins improves venous stasis ulcer healing. Ann Vasc Surg. 2013;27(7):932-9. 11. Chaar CI, Hirsch SA, Cwenar MT, Rhee RY, Chaer RA, Abu Hamad G, et al. Expanding the role of endovenous laser therapy: results in large diameter saphenous, small saphenous, and anterior accessory veins. Ann Vasc Surg. 2011;25(5):656-61. 12. Theivacumar NS, Gough MJ. Endovenous laser ablation (EVLA) to treat recurrent varicose veins. Eur J Vasc Endovasc Surg. 2011;41(5):691-6. 13. Biemans AA, Kockaert M, Akkersdijk GP, van den Bos RR, Maeseneer MG, Cuypers P, et al. Comparing endovenous laser ablation, foam sclerotherapy, and conventional surgery for great saphenous varicose veins. J Vasc Surg. 2013;58(3):727-34. 14. Tang JC, Marston WA, Kirsner RS. Wound Healing Society (WHS) venous ulcer treatment guidelines: what’s new in five years? Wound Repair Regen. 2012;20(5):619-37. Received in: 26/12/2016 Accepted for publication: 09/03/2017 Conflict of interest: none. Source of funding: none. Mailing address: Matheus Bertanha E-mail: matheus.fameca@ig.com.br matheusbertanha@fmb.unesp.br

Rev. Col. Bras. Cir. 2017; 44(3): 308-313


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 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. The Advisory Board (in charge of the peer-review) receives the text anonymously and decides for its 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. I must contain at most 15 pages and 45 references. • 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, which can be accessed through the Brazilian College of Surgeons’ website (www.cbc.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).

FORM AND STYLE • Text: The textual form of the manuscripts submitted for publication must be original and submitted in digital form (Word – .doc), double spacing and arial font, size 12. The images should be sent separately, in JPG, GIF or TIF formats, with the insertion site referred in the text. Articles should be concise and written in Portuguese, English or Spanish. Abbreviations must be in the lowest number possible and limited to the terms mentioned repeatedly, as long as they do not hamper the text understanding, and must be defined in their first appearance. • References: Must be predominantly of works published in the last five years, not forgetting to include national authors and journals, 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 ICMJEwww.icmje.org – CIERM RevColBras 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 AND FIGURES (maximum of six) Tables and figures 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. 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. Authors who wish to publish colored figures in their articles can do so at a cost of R$ 650.00 for a figure per page. Additional figures on the same page will cost R$ 150.00 each. The payment will be effected a through bank payment slip, sent to the lead author when the article is aproved for publication. 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 interest, compliant with the 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 grant the copyright and 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 they 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) 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. 6) 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. 7) works already published or simultaneously submitted for evaluation in other periodicals will not be accepted. 8) Due to the journal’s high publication costs, starting with issue 1/2017, each approved article will have a cost of R$ 1,000.00 (one thousand reais) for the authors. If the lead author is a solvent 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 CBC Journal of Case Reports 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: http://www.revistadocbc.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”, which, however, went on to be published without due regularity. From 1974 on, the journal began to be published bi-monthly, on a regular basis, to the present day. In these more than 40 years of uninterrupted publication, the Journal of the CBC gained importance and scope. With standards and criteria for selection and publication of scientific articles in the area of General and specialist Surgery, including “peer review”, the Journal of the CBC falls along the lines of the main international journals and has an Editorial Board that evaluates the merits for publication of submitted manuscripts. With indexing in SciELO and Medline/Pubmed, the Journal of the Brazilian College of Surgeons gained greater visibility, greater importance and greater coverage in its primary purpose of science dissemination. The abbreviation for your title is Rev. Col. Bras. CIR., which should be used in bibliographies, footnotes and in references and bibliographic legends.

DOAJ NOTE 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 APCs In view of the high cost for publication of the journal, from the issue 1/2017 on, every approved article will cost R$ 1000.00 (1000 reais) for the authors.

Indexing sources Latindex LILACS Scopus DOAJ Free Medical Journals MEDLINE/PUBMED

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 (from the Magazine 1/2017 on)


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