Factors Related to the Reduction of the Risk of Complications in Colorectal Surgery Within Perioperative Care Recommended by the Acerto Protocol

Abstract

Background: Perioperative care multimodal protocol significantly improve outcome in surgery. Aim: To investigate risk factors to various endpoints in patients submitted to elective colorectal operations under the ACERTO protocol. Methods: Cohort study analyzing through a logistic regression model able to assess independent risk factors for morbidity and mortality, patients submitted to elective open colon and/or rectum resection and primary anastomosis who were either exposed or non-exposed to demographic, clinical, and ACERTO interventions. Results: Two hundred thirty four patients were analyzed and submitted to 156 (66.7%) rectal and 78 (33.3%) colonic procedures. The length of hospital postoperative stay (LOS) ≥ 7 days was related to rectal surgery and high NNIS risk index; preoperative fasting ≤4 h (OR=0.250; CI95=0.114-0.551) and intravenous volume of crystalloid infused > 30ml/kg/day (OR=0.290; CI95=0.119-0.706). The risk of postoperative site infection (SSI) was approximately four times greater in malnourished; eight in rectal surgery and four in high NNIS index. The duration of preoperative fasting ≤4 h was a protective factor by reducing by 81.3% the risk of surgical site infection (SSI). An increased risk for anastomotic fistula was found in malnutrition, rectal surgery and high NNIS index. Conversely, preoperative fasting ≤4 h (OR=0.11; CI95=0.05-0.25; p<0.0001) decreased the risk of fistula. Factors associated with pneumonia-atelectasis were cancer and rectal surgery, while preoperative fasting ≤ 4 h (OR=0.10; CI95=0.04-0.24; p<0.0001) and intravenous crystalloid ≤ 30 ml/kg/day (OR=0.36; CI95=0.13-0.97, p=0.044) shown to decrease the risk. Mortality was lower with preoperative fasting ≤4 h and intravenous crystalloids infused ≤30 ml/kg/day. Conclusion: This study allows to conclude that rectal procedures, high NNIS index, preoperative fasting higher than 4 h and intravenous fluids greater than 30 ml/kg/day during the first 48 h after surgery are independent risk factors for: 1) prolonged LOS; 2) surgical site infection and anastomotic fistula associated with malnutrition; 3) postoperative pneumonia-atelectasis; and 4) postoperative mortality.

ACERTO Project - 15 years changing perioperative care in Brazil

“…Since its inception, the use of the ACERTO protocol has accelerated the postoperative recovery of patients both undergoing medium-sized procedures 34,35 and major ones, involving resections of the upper 36 and lower 37,38 gastrointestinal tract. All this, associated with several publications in abbreviation of preoperative fasting, including studies on safety and benefits [39][40][41][42][43][44][45][46][47] and on perioperative intravenous fluid prescription 29,48,49 , increased the visibility of the ACERTO project.…”

“…All this, associated with several publications in abbreviation of preoperative fasting, including studies on safety and benefits [39][40][41][42][43][44][45][46][47] and on perioperative intravenous fluid prescription 29,48,49 , increased the visibility of the ACERTO project. In fact, in any patient undergoing an operative procedure, prolonged fasting in the preoperative period decreases the functionality (strength) of the patients in the postoperative period 50 , increases insulin resistance 38 and acute phase inflammation 51 . Thus, elderly 52 , oncological 18 , orthopedic 53,54 patients, and those undergoing myocardial revascularization 55,56 were subgroups of surgical patients in which the ACERTO Project has shown significant results improvements.…”

Risco Nutricional versus Risco de Sarcopenia Associado a Complicações Pós-Operatórias e Mortalidade em Pacientes Oncológicos Submetidos a Cirurgias de Grande Porte

“…Consideraram-se complicações infecciosas: presença de pneumonia, infecção no sítio cirúrgico, deiscências de anastomose ou parede, infecção do trato urinário e sepse. Todas as definições de complicações infecciosas foram citadas em outros artigos publicados pelo mesmo grupo 20,21 . As complicações foram também classificadas pelos critérios de Clavien-Dindo 22 .…”

“…Ainda, a metade dos pacientes era de idosos. Contudo, em virtude da expressiva quantidade de operações de grande porte, que ocorrem entre os pacientes oncológicos, o rastreio nutricional é determinante para a redução da morbidade operatória e dos custos com o paciente cirúrgico 16,21 .…”

Association between preoperative potential sarcopenia and survival of cancer patients undergoing major surgical procedures

“…We considered infectious complications the presence of pneumonia, infection at the surgical site, dehiscence of anastomosis or abdominal wall, urinary tract infection, and sepsis. All definitions of infectious complications were cited in other articles published by the same group 23,24 . We also classified complications by the Clavien-Dindo criteria 25 .…”