Alberto Bicudo Salomão

Clinical benefits after the implementation of a multimodal perioperative protocol in elderly patients

CONTEXT Multimodal protocol of perioperative care may enhance recovery after surgery. Based on evidence these new routines of perioperative care changed conventional prescriptions in surgery. OBJECTIVE To evaluate the results of a multimodal protocol (ACERTO protocol) in elderly patients. METHODS Non-randomized historical cohort study was performed at the surgical ward of a tertiary university hospital. One hundred seventeen patients aged 60 and older were submitted to elective abdominal operations under either conventional (n = 42; conventional group, January 2004-June 2005) or a fast-track perioperative protocol named ACERTO (n = 75; ACERTO group, July 2005-December 2007). Main endpoints were preoperative fasting time, postoperative day of re-feeding, volume of intravenous fluids, length of hospital stay and morbidity. RESULTS The implantation of the ACERTO protocol was followed by a decrease in both preoperative fasting (15 [8-20] vs 4 [2-20] hours, P<0.001) and postoperative day of refeeding (1st [1st-10th] vs 0 [0-5th] PO day; P<0.01), and intravenous fluids (10.7 [2.5-57.5] vs 2.5 [0.5-82] L, P<0.001). The changing of protocols reduced the mean length of hospital stay by 4 days (6[1-43] vs 2[1-97] days; P = 0.002) and surgical site infection rate by 85.7% (19%; 8/42 vs 2.7%; 2/75, P<0.001; relative risk = 1.20; 95% confidence interval = 1.03-1.39). Per-protocol analysis showed that hospital stay in major operations diminished only in patients who completed the protocol (P<0.01). CONCLUSION The implementation of multidisciplinary routines of the ACERTO protocol diminished both hospitalization and surgical site infection in elderly patients submitted to abdominal operations.

Perioperative administration of probiotics: effects on immune response, anastomotic resistance and colonic mucosal trophism

PURPOSE To investigate the effects of perioperative administration of diet containing probiotics on the immune response, anastomotic resistance, and colonic mucosal trophism in rats underwent left-sided colonic anastomosis. METHODS Sixty adults Wistar rats were randomized to two groups (A and B) with 30 animals each to receive or not a diet supplemented with probiotics (Streptococcus thermophilus e Lactobacillus helveticus) during pre- and postoperative period. They underwent laparotomy followed by left colon section and immediate anastomosis. Groups of 15 animals were killed either on the 4th (groups A1 and B1) or 7th PO (groups A2 and B2) days. The outcome variables were serum proteins, albumin, globulins and IgA, length and weight of the colon, mucosal weight, DNA content and anastomotic bursting pressure. RESULTS Colonic weight was greater in probiotic group compared to controls (1.69+/-0.34 g vs 1.48+/-0.26 g; p<0.05). Total serum proteins and globulin were higher in probiotic animals (proteins = 7.05+/-0.97 g/dl vs 6.57+/-0.66 g/dl e globulins = 5.1+/-0.62 g/dl vs 4.68+/-1.1 g/dl; p<0.05). Serum IgA increased from basal to post-operative days only in the probiotic group (p<0.01). CONCLUSIONS Perioperative probiotics enhanced the immune response and colonic weight. Probiotics failed to increase anastomotic resistance.

Intraluminal injection of short chain fatty acids diminishes intestinal mucosa injury in experimental ischemia-reperfusion

PURPOSE Investigated the effect of intraluminal short-chain fatty acids (SCFA) on the intestinal mucosa in the presence of ischemia-reperfusion injury (IRI). METHODS Six blind sacs of the small bowel (3 at the jejunum and 3 at the ileum) were created in ten Wistar rats. The lateral sacs of both bowel regions were subjected to IRI (15/15 minutes) while the medial sacs were let free to receive blood supply. In the lateral sacs, it was injected either a solution containing SCFA (butyrate, propionate and acetate) or pure saline at the bowel lumen. No fluid was injected in the medial sacs. RESULTS Both at the jejunum and at the ileum the score of the mucosal injury was higher in saline than in control sacs. SCFA treated sacs showed lesser score at the ileum (p = 0.03) but were not significantly different at the jejunum (p = 0.83) when compared with saline sacs. It was found a significant greater number of neutrophils (p < 0.01) in the sacs treated with saline than in the other two sacs in both regions. CONCLUSION SCFA protect the distal small bowel mucosa and diminishes infiltration of neutrophils to the gut lamina propria in IRI.

Intestinal intraluminal injection of glutamine increases trolox total equivalent antioxidant capacity (TEAC) in hepatic ischemia-reperfusion

PURPOSE To evaluate the effects of intraluminal injection of glutamine on the serum trolox equivalent antioxidant capacity in an experimental model of ischemia-reperfusion of the liver observing the applicability of modifications on the original assay method. METHODS Thirty Wistar rats underwent laparotomy to perform a 20 cm blind sac of small bowel and occlusion of the hepatic hilo for 30 minutes and reperfusion for 5 minutes. Into the gut sac it was injected glutamine (glutamine group, n=10) or distilled water (control group, n=10). Ten other animals (sham group) underwent laparotomy without artery occlusion. Blood samples were collected for trolox equivalent antioxidant capacity assays in different temperature conditions, reagent quantities and time for spectrophotometer readings. RESULTS Total antioxidant capacity was significantly greater in glutamine group than in both control group (1.60[1.55-1.77] vs 1.44[1.27-1.53]) and sham group (1.60[1.55-1.77] vs 1.48[1.45-1.59]). CONCLUSION Glutamine enhanced serum antioxidant capacity. The assay technique consistently reflected the changes in the antioxidant defenses in this experimental model.

Effect of glutamine on the total antioxidant system of rats subjected to renal ischemia and reperfusion

PURPOSE To evaluate the protective effects of glutamine administered before renal ischemia-reperfusion on plasma antioxidant protection, and lung and renal tissue injury. METHODS 33 rats underwent right nephrectomy. On the eighth postoperative day, animals were randomized into three groups (n=11): glutamine, control and sham. Each group of animals received, by gavage, a particular diet for 7 days. On day 14 following nephrectomy, the animals were subjected to left renal ischemia-reperfusion. After this, blood samples were collected and the animals were killed. At necropsy the kidney and lung were removed for histology. RESULTS The levels of total antioxidant capacity were higher in the glutamine group and control group compared with the sham group. The levels of glutathione peroxidase in both the sham and glutamine groups were higher when compared with the control group (p<0.05). The level of superoxide dismutase in the sham group was clearly higher than that in the glutamine and control groups. Histological examination showed no differences between the three groups. CONCLUSION Prior intake of glutamine improves total antioxidant capacity and increases glutathione peroxidase levels in rats subjected to renal ischemia-reperfusion.

Cuidados perioperatórios em cirurgia bariátrica no contexto do projeto ACERTO: realidade e o imaginário de cirurgiões em um hospital de Cuiabá

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.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.

ACERTO guidelines of perioperative nutritional interventions in elective general surgery

OBJECTIVE to present recommendations based on the ACERTO Project (Acceleration of Total Post-Operative Recovery) and supported by evidence related to perioperative nutritional care in General Surgery elective procedures. METHODS review of relevant literature from 2006 to 2016, based on a search conducted in the main databases, with the purpose of answering guiding questions previously formulated by specialists, within each theme of this guideline. We preferably used randomized controlled trials, systematic reviews and meta-analyzes but also selected some cohort studies. We contextualized each recommendation-guiding question to determine the quality of the evidence and the strength of this recommendation (GRADE). This material was sent to authors using an open online questionnaire. After receiving the answers, we formalized the consensus for each recommendation of this guideline. RESULTS the level of evidence and the degree of recommendation for each item is presented in text form, followed by a summary of the evidence found. CONCLUSION this guideline reflects the recommendations of the group of specialists of the Brazilian College of Surgeons, the Brazilian Society of Parenteral and Enteral Nutrition and the ACERTO Project for nutritional interventions in the perioperative period of Elective General Surgery. The prescription of these recommendations can accelerate the postoperative recovery of patients submitted to elective general surgery, with decrease in morbidity, length of stay and rehospitalization, and consequently, of costs.

Modificações morfométricas e do conteúdo protéico na obstrução experimental do cólon esquerdo

BACKGROUND: The colonic response to obstruction is poorly understood. The aim of this study was to investigate the colonic morphology and the variation of collagen and protein content during the development of a left-sided colonic obstruction. METHOD: 36 Wistar rats underwent a ligature obstruction of the left colon. Groups of 6 animals were killed immediately (0h; control group) or after 6, 12, 24, 48 and 72hs after the obstruction. The length and weight of the colon were registered as well as the colonic diameter in four segments: at 1cm above and below the ligature, at the splenic flexure and at the ceccum. Biopsies of these sites, containing all layers of the colon, were assayed for hydroxyproline and protein concentration. RESULTS: The colonic length decreased from 6 to 24hs after obstruction, returning to normal values after 48hs. Proximally to the ligature, a significant increase of the diameter was observed at 1cm above the ligature after 6hs, at the splenic flexure, after 12hs, and at the ceccum, 24hs later. Colonic weight was higher after 48hs (4,6 ± 0,5g vs. 3,4 ± 1,1g; p < 0,05). Below the ligature there was no variation in the weight of the specimens, neither in the hydroxyproline nor in the protein concentrations. Above the ligature however, the specimens became significantly heavier after 6hs and higher in hydroxyproline centent after 24hs. Protein content diminished in all proximal sites. CONCLUSIONS: The obstructed colon initially contracts and then progressively enlarges, dilates, and becomes heavier. After obstruction, colonic protein concentration progressively diminishes, although the hydroxyproline content transitorily increases.