Efficacy of Synbiotics to Reduce Symptoms and Rectal Inflammatory Response in Acute Radiation Proctitis: A Randomized, Double-Blind, Placebo-Controlled Pilot Trial.

Purpose: Evaluate whether the daily intake of synbiotics improves symptoms and rectal/systemic inflammatory response in patients with radiation-induced acute proctitis.Methods and Materials: Twenty patients who underwent three-dimensional conformal radiotherapy for prostate cancer were randomized to intake either a synbiotic powder containing Lactobacillus reuteri (108 CFU) and soluble fiber (4.3 g) or placebo. EORTC QLQ-PRT23 questionnaire was applied before the beginning of radiotherapy and after the fifth, sixth, and seventh weeks of treatment, and the sum of both the complete (proctitis symptoms plus quality of life) and partial (proctitis symptoms) scores were compared. Fecal calprotectin was measured at Day 0 and in the fourth week of treatment, and serum C-reactive protein/albumin ratio were measured in the fourth week of treatment.Results: Both the complete and partial questionnaire score (median and range) were higher in the fifth and sixth weeks in the placebo group; there was a higher increase in fecal calprotectin in the placebo group and no difference comparing CRP/albumin ratio.Conclusions: Synbiotics reduce proctitis symptoms and improve quality of life by preventing rectal inflammation during radiotherapy for prostate cancer.

RESIDUAL GASTRIC VOLUME IN MORBIDLY OBESE DIABETICS AFTER AN OVERNIGHT FASTING OR 3 HOURS OF A CARBOHYDRATE-ENRICHED SUPPLEMENT: A RANDOMIZED CROSSOVER PILOT STUDY.

BACKGROUND: To reduce the risk of regurgitation during anesthesia for elective procedures, residual gastric volumes (RGV) have traditionally been minimized by overnight fasting. Prolonged preoperative fasting presents some adverse consequences and has been abandoned for most surgical procedures, except for obese and/or diabetic patients. AIMS: The aim of this study was to assess the RGV in morbidly obese diabetic patients after traditional or abbreviated fasting. METHODS: This study was approved by the Ethics Committee for Research with Human Beings from the Federal University of Mato Grosso, under number 179.017/2012. This is a prospective, randomized, and crossover design study in eight morbidly obese type II diabetic patients. RGV was measured endoscopically after either traditional overnight fasting of at least 8 hours, or after abbreviated fasting of 6 hours for solids and 3 hours for a drink containing water plus 25 g (12.5%) of maltodextrin. Data were expressed as mean and range and differences were compared with paired t-tests at p<0.05. RESULTS: The study population had a mean age of 41.5 years (28-53), weight of 135 kg (113-196), body mass index of 48.2 kg/m2 (40-62.4), and type II diabetes for 4.5 years (1-10). The RGV after abbreviated fasting was 21.5 ml (5-40) vs 26.3 ml (7-65) after traditional fasting. This difference was not significant (p=0.82). CONCLUSIONS: Gastric emptying in morbidly obese diabetic patients is similar after either traditional or abbreviated fasting with a carbohydrate drink.

PERIOPERATIVE CARE IN DIGESTIVE SURGERY: THE ERAS AND ACERTO PROTOCOLS - BRAZILIAN COLLEGE OF DIGESTIVE SURGERY POSITION PAPER.

BACKGROUND: The concept introduced by protocols of enhanced recovery after surgery modifies perioperative traditional care in digestive surgery. The integration of these modern recommendations components during the perioperative period is of great importance to ensure fewer postoperative complications, reduced length of hospital stay, and decreased surgical costs. AIMS: To emphasize the most important points of a multimodal perioperative care protocol. METHODS: Careful analysis of each recommendation of both ERAS and ACERTO protocols, justifying their inclusion in the multimodal care recommended for digestive surgery patients. RESULTS: Enhanced recovery programs (ERPs) such as ERAS and ACERTO protocols are a cornerstone in modern perioperative care. Nutritional therapy is fundamental in digestive surgery, and thus, both preoperative and postoperative nutrition care are key to ensuring fewer postoperative complications and reducing the length of hospital stay. The concept of prehabilitation is another key element in ERPs. The handling of crystalloid fluids in a perfect balance is vital. Fluid overload can delay the recovery of patients and increase postoperative complications. Abbreviation of preoperative fasting for two hours before anesthesia is now accepted by various guidelines of both surgical and anesthesiology societies. Combined with early postoperative refeeding, these prescriptions are not only safe but can also enhance the recovery of patients undergoing digestive procedures. CONCLUSIONS: This position paper from the Brazilian College of Digestive Surgery strongly emphasizes that the implementation of ERPs in digestive surgery represents a paradigm shift in perioperative care, transcending traditional practices and embracing an intelligent approach to patient well-being.

COST-EFFECTIVENESS OF THE USE OF ACERTO PROTOCOL IN MAJOR DIGESTIVE SURGERY.

OBJECTIVE: Hospital costs in surgery constitute a burden for the health system in all over the world. Multimodal protocols such as the ACERTO project enhance postoperative recovery. The aim of this study was to analyze the hospital costs in patients undergoing major digestive surgical procedures with or without the perioperative care strategies proposed by the ACERTO project. METHODS: Retrospective data from elective patients undergoing major digestive surgical procedures in a university hospital between January 2002 and December 2011 were collected. The investigation involved two phases: between January 2002 and December 2005, covering cases admitted before the implementation of the ACERTO protocol (pre-ACERTO period), and cases operated between January 2006 and December 2011, after implementation (ACERTO period). The primary outcome was the comparison of hospital costs between the two periods. As secondary end point, we compared length of stay (LOS), postoperative complications, surgical-site infection (SSI) rate, and mortality. RESULTS: We analyzed 381 patients (239 of the pre-ACERTO period and 142 of the ACERTO period) who underwent major procedures on the gastrointestinal tract. Patients operated after within the ACERTO protocol postoperative LOS had a median of 3 days shorter (p=0.001) when compared with pre-ACERTO period [median (IQR): 10 (12) days vs. 13 (12) days]. Mortality was similar between the two periods. Postoperative complications risk, however, was 29% greater (RR: 1.29; 95%CI 1.11-1.50) in the pre-ACERTO period (p=0.002). SSI risk was also greater in pre-ACERTO period (RR: 1.33; 95%CI 1.14-1.50). Costs (mean and SE) per patients were R$24,562.84 (1,349.33) before the implementation and R$19,912.81 (1,459.89) after the ACERTO protocol (p=0.02). CONCLUSION: The implementation of the ACERTO project in this University Hospital reduced the hospital costs in major digestive procedures. Moreover, the implementation of this modern perioperative care strategy also reduced postoperative complications, SSI risks, and LOS.

ACERTO Project - 15 years changing perioperative care in Brazil.

The ACERTO project is a multimodal perioperative care protocol. Implemented in 2005, the project in the last 15 years has disseminated the idea of a modern perioperative care protocol, based on evidence and with interdisciplinary team work. Dozens of published studies, using the protocol, have shown benefits such as reduced hospital stay, postoperative complications and hospital costs. Disseminated in Brazil, the project is supported by the Brazilian College of Surgeons and the Brazilian Society of Parenteral and Enteral Nutrition, among others. This article compiles publications by the authors who belong to the CNPq research group "Acerto em Nutrição e Cirurgia", refers to the experience of other national authors in various surgical specialties, and finally outlines the evolution of the ACERTO project in the timeline.

Hypophosphatemia and risk of refeeding syndrome in critically ill patients before and after nutritional therapy.

OBJECTIVE: To investigate the prevalence of hypophosphatemia as a marker of refeeding syndrome (RFS) before and after the start of nutritional therapy (NT) in critically ill patients. METHODS: Retrospective cohort study including 917 adult patients admitted at the intensive care unit (ICU) of a tertiary hospital in Cuiabá-MT/Brasil. We assessed the frequency of hypophosphatemia (phosphorus <2.5mg/dl) as a risk marker for RFS. Serum phosphorus levels were measured and compared at admission (P1) and after the start of NT (P2). RESULTS: We observed a significant increase (36.3%) of hypophosphatemia and, consequently, a greater risk of RFS from P1 to P2 (25.6 vs 34.9%; p<0.001). After the start of NT, malnourished patients had a greater fall of serum phosphorus. Patients receiving NT had an approximately 1.5 times greater risk of developing RFS (OR= 1.44 95%CI 1.10-1,89; p= 0.01) when compared to those who received an oral diet. Parenteral nutrition was more associated with hypophosphatemia than either enteral nutrition (p=0,001) or parenteral nutrition supplemented with enteral nutrition (p=0,002). CONCLUSION: The frequency of critically ill patients with hypophosphatemia and at risk for RFS on admission is high and this risk increases after the start of NT, especially in malnourished patients and those receiving parenteral nutrition.

Perioperative care in digestive surgery: the eras and acerto protocols - brazilian college of digestive surgery position paper / Cuidados perioperatórios em cirurgia digestiva: protocolos eras e acerto - posicionamento do colégio brasileiro de cirurgia digestiva

ABSTRACT BACKGROUND: The concept introduced by protocols of enhanced recovery after surgery modifies perioperative traditional care in digestive surgery. The integration of these modern recommendations components during the perioperative period is of great importance to ensure fewer postoperative complications, reduced length of hospital stay, and decreased surgical costs. AIMS: To emphasize the most important points of a multimodal perioperative care protocol. METHODS: Careful analysis of each recommendation of both ERAS and ACERTO protocols, justifying their inclusion in the multimodal care recommended for digestive surgery patients. RESULTS: Enhanced recovery programs (ERPs) such as ERAS and ACERTO protocols are a cornerstone in modern perioperative care. Nutritional therapy is fundamental in digestive surgery, and thus, both preoperative and postoperative nutrition care are key to ensuring fewer postoperative complications and reducing the length of hospital stay. The concept of prehabilitation is another key element in ERPs. The handling of crystalloid fluids in a perfect balance is vital. Fluid overload can delay the recovery of patients and increase postoperative complications. Abbreviation of preoperative fasting for two hours before anesthesia is now accepted by various guidelines of both surgical and anesthesiology societies. Combined with early postoperative refeeding, these prescriptions are not only safe but can also enhance the recovery of patients undergoing digestive procedures. CONCLUSIONS: This position paper from the Brazilian College of Digestive Surgery strongly emphasizes that the implementation of ERPs in digestive surgery represents a paradigm shift in perioperative care, transcending traditional practices and embracing an intelligent approach to patient well-being.

RESUMO RACIONAL: O conceito introduzido pelos protocolos de recuperação após a cirurgia modifica os cuidados perioperatórios tradicionais em cirurgia digestiva. A integração desses componentes modernos de recomendações, durante o período perioperatório, é de grande importância para garantir menos complicações pós-operatórias, redução do tempo de internação hospitalar e diminuição dos custos cirúrgicos. OBJETIVOS: Enfatizar os pontos mais importantes de um protocolo multimodal de cuidados perioperatórios. MÉTODOS: Análise criteriosa de cada recomendação dos protocolos ERAS e ACERTO, justificando sua inclusão no atendimento multimodal recomendado para pacientes de cirurgia digestiva. RESULTADOS: Os programas de recuperação avançada (PRAs), tais como os protocolos ERAS e ACERTO, são a base dos cuidados perioperatórios modernos. A terapia nutricional é de grande importância na cirurgia digestiva e, portanto, tanto os cuidados nutricionais pré-operatórios, quanto pós-operatórios são fundamentais para garantir menos complicações pós-operatórias e reduzir o tempo de internação hospitalar. O conceito de pré-habilitação é outro elemento-chave nos PRAs. O manuseio de fluidos cristalóides em perfeito equilíbrio é vital. A sobrecarga de fluidos pode atrasar a recuperação dos pacientes e aumentar as complicações pós-operatórias. A abreviação do jejum pré-operatório para duas horas antes da anestesia é agora aceita por diversas diretrizes das sociedades cirúrgicas e de anestesiologia. Combinadas com a realimentação pós-operatória precoce, essas prescrições não são apenas seguras, mas também podem melhorar a recuperação de pacientes submetidos a procedimentos digestivos. CONCLUSÕES: Este posicionamento do Colégio Brasileiro de Cirurgia Digestiva enfatiza fortemente que a implementação de PRAs em cirurgia digestive, representa uma mudança de paradigma no cuidado perioperatório, transcendendo as práticas tradicionais e adotando uma abordagem inteligente para o bem-estar do paciente.

Residual gastric volume in morbidly obese diabetics after an overnight fasting or 3 hours of a carbohydrate-enriched supplement: a randomized crossover pilot study / Volume gástrico residual em diabéticos obesos mórbidos após jejum noturno ou 3 horas de suplemento enriquecido com carboidratos: um estudo piloto cruzado randomizado

ABSTRACT BACKGROUND: To reduce the risk of regurgitation during anesthesia for elective procedures, residual gastric volumes (RGV) have traditionally been minimized by overnight fasting. Prolonged preoperative fasting presents some adverse consequences and has been abandoned for most surgical procedures, except for obese and/or diabetic patients. AIMS: The aim of this study was to assess the RGV in morbidly obese diabetic patients after traditional or abbreviated fasting. METHODS: This study was approved by the Ethics Committee for Research with Human Beings from the Federal University of Mato Grosso, under number 179.017/2012. This is a prospective, randomized, and crossover design study in eight morbidly obese type II diabetic patients. RGV was measured endoscopically after either traditional overnight fasting of at least 8 hours, or after abbreviated fasting of 6 hours for solids and 3 hours for a drink containing water plus 25 g (12.5%) of maltodextrin. Data were expressed as mean and range and differences were compared with paired t-tests at p<0.05. RESULTS: The study population had a mean age of 41.5 years (28-53), weight of 135 kg (113-196), body mass index of 48.2 kg/m2 (40-62.4), and type II diabetes for 4.5 years (1-10). The RGV after abbreviated fasting was 21.5 ml (5-40) vs 26.3 ml (7-65) after traditional fasting. This difference was not significant (p=0.82). CONCLUSIONS: Gastric emptying in morbidly obese diabetic patients is similar after either traditional or abbreviated fasting with a carbohydrate drink.

RESUMO RACIONAL: Para reduzir o risco de regurgitação durante a anestesia para procedimentos eletivos, os volumes gástricos residuais (VRG) têm sido tradicionalmente minimizados com jejum noturno. O jejum pré-operatório prolongado tem algumas consequências adversas e tem sido abandonado para a maioria dos procedimentos cirúrgicos, com exceção de pacientes obesos e/ou diabéticos. OBJETIVOS: O objetivo deste estudo foi avaliar o VRG em pacientes diabéticos obesos mórbidos após jejum tradicional ou abreviado. MÉTODOS: Este estudo foi aprovado pelo Comitê de Ética em Pesquisa com Seres Humanos da Universidade Federal de Mato Grosso, sob o número 179.017/2012. Este é um projeto prospectivo, randomizado e cruzado em 8 pacientes diabéticos tipo II com obesidade mórbida. O VRG foi medido endoscopicamente após jejum noturno tradicional (pelo menos 8 horas) ou após jejum abreviado (6 horas para sólidos e 3 horas para uma bebida contendo água mais 25 g (12,5%) de maltodextrina). Os dados são expressos como média e variação e as diferenças foram comparadas com testes t pareados em p<0,05. RESULTADOS: A população estudada tinha 41,5 (28-53) anos de idade, peso médio de 135 (113-196) kg, índice de massa corporal (IMC) de 48,2 (40-62,4) kg/m2 e diabetes tipo II de 4,5 (1-10) anos. O VRG após o jejum abreviado foi de 21,5 (5-40) ml versus 26,3 (7-65) ml após o jejum tradicional. Essa diferença não foi significativa (p=0,82). CONCLUSÕES: O esvaziamento gástrico em pacientes diabéticos obesos mórbidos é semelhante após jejum tradicional ou abreviado com uma bebida com carboidrato.

Cost-effectiveness of the use of acerto protocol in major digestive surgery / Custo-efetividade do uso do protocolo acerto em cirurgia digestiva de grande porte

ABSTRACT - BACKGROUND: Hospital costs in surgery constitute a burden for the health system in all over the world. Multimodal protocols such as the ACERTO project enhance postoperative recovery. OBJECTIVE: The aim of this study was to analyze the hospital costs in patients undergoing major digestive surgical procedures with or without the perioperative care strategies proposed by the ACERTO project. METHODS: Retrospective data from elective patients undergoing major digestive surgical procedures in a university hospital between January 2002 and December 2011 were collected. The investigation involved two phases: between January 2002 and December 2005, covering cases admitted before the implementation of the ACERTO protocol (pre-ACERTO period), and cases operated between January 2006 and December 2011, after implementation (ACERTO period). The primary outcome was the comparison of hospital costs between the two periods. As secondary end point, we compared length of stay (LOS), postoperative complications, surgical-site infection (SSI) rate, and mortality. RESULTS: We analyzed 381 patients (239 of the pre-ACERTO period and 142 of the ACERTO period) who underwent major procedures on the gastrointestinal tract. Patients operated after within the ACERTO protocol postoperative LOS had a median of 3 days shorter (p=0.001) when compared with pre-ACERTO period [median (IQR): 10 (12) days vs. 13 (12) days]. Mortality was similar between the two periods. Postoperative complications risk, however, was 29% greater (RR: 1.29; 95%CI 1.11-1.50) in the pre-ACERTO period (p=0.002). SSI risk was also greater in pre-ACERTO period (RR: 1.33; 95%CI 1.14-1.50). Costs (mean and SE) per patients were R$24,562.84 (1,349.33) before the implementation and R$19,912.81 (1,459.89) after the ACERTO protocol (p=0.02). CONCLUSION: The implementation of the ACERTO project in this University Hospital reduced the hospital costs in major digestive procedures. Moreover, the implementation of this modern perioperative care strategy also reduced postoperative complications, SSI risks, and LOS.

RESUMO - RACIONAL: Custos hospitalares em cirurgia constituem um peso para o sistema de saúde. Protocolos multimodais como o projeto ACERTO aceleram a recuperação pós-operatória. OBJETIVO: O objetivo deste estudo foi o de analisar custos hospitalares em pacientes submetidos a procedimentos cirúrgicos de grande porte no aparelho digestivo com ou sem as estratégias de cuidados perioperatórios proposta pelo projeto ACERTO. MÉTODOS: Foram coletados dados retrospectivos de pacientes eletivos submetidos a procedimentos cirúrgicos de grande porte no aparelho digestivo em um Hospital Universitário entre Janeiro de 2002 e Dezembro de 2011. O estudo envolveu duas fases: Entre Janeiro de 2002 a Dezembro 2005 envolvendo casos internados antes da implementação do protocolo ACERTO (período pré-ACERTO) e casos operados entre Janeiro de 2006 a Dezembro de 2011, após a implementação (período ACERTO). O desfecho primário foi a comparação de custos hospitalares entre os dois períodos. Como desfechos secundários, comparou-se o tempo de internação (LOS), complicações pós-operatórias, taxa de infecção de sitio cirúrgico (ISS) e a mortalidade. RESULTADOS: Foram analisados 381 pacientes (239 do período pré-ACERTO e 142 do período ACERTO) submetidos a procedimento cirúrgicos de grande porte no trato gastrointestinal. Pacientes operados dentro do protocolo ACERTO apresentaram mediana (IQR) mediana de tempo de internação três dias menor (p=0.001) quando comparados ao período pré-ACERTO (mediana (IQR): 10 (12) vs. 13 (12) dias). A mortalidade foi similar entre os dois períodos. Entretanto, o risco de complicações pós-operatórias foi 29% maior (RR: 1.29; IC95%: 1.11 - 1.50) no período pré-ACERTO (p=0.002). O risco de SSI também foi maior no período pré-ACERTO (RR: 1.33; 95%CI: 1.14-1.50). Custos (media e SE) per paciente foram de R$ 24562,84 (1349,33) antes da implementação e R$ 19912,81 (1459,89) após o protocolo ACERTO (p=0.02). CONCLUSÕES: A implementação do projeto ACERTO neste hospital universitário reduziu custos hospitalares em cirurgias digestivas de grande porte. Além disso, a prescrição de estratégias modernas de cuidados perioperatórios também reduziu riscos de complicações pós-operatórias e de SSI e o tempo de internação.

Residual gastric volume evaluation with ultrasonography after ingestion of carbohydrate- or carbohydrate plus glutamine-enriched beverages: a randomized, crossover clinical trial with healthy volunteers.

BACKGROUND: - Abbreviation of preoperative fasting to 2 hours with maltodextrin (CHO)-enriched beverage is a safe procedure and may enhance postoperative recovery. Addition of glutamine (GLN) to CHO beverages may include potential benefits to the metabolism. However, by adding a nitrogenous source to CHO beverages, gastric emptying may be delayed and increase the risk of bronchoaspiration during anesthesia. OBJECTIVE: - In this study of safety, we aimed at investigating the residual gastric volume (RGV) 2 hours after the intake of either CHO beverage alone or CHO beverage combined with GLN. METHODS: - We performed a randomized, crossover clinical trial. We assessed RGV by means of abdominal ultrasonography (US) in 20 healthy volunteers (10 males and 10 females) after an overnight fast of 8 hours. Then, they were randomized to receive 600 mL (400 mL immediately after US followed by another 200 mL 2 hours afterwards) of either CHO (12.5% maltodextrin) or CHO-GLN (12.5% maltodextrin plus 15 g GLN). Two sequential US evaluations were done at 120 and 180 minutes after ingestion of the second dose. The interval of time between ingestion of the two types of beverages was 2 weeks. RESULTS: - The mean (SD) RGV observed after 8 hours fasting (13.56±13.25 mL) did not statistically differ (P>0.05) from the RGV observed after ingesting CHO beverage at both 120 (16.32±11.78 mL) and 180 minutes (14.60±10.39 mL). The RGV obtained at 120 (15.63±18.83 mL) and 180 (13.65±10.27 mL) minutes after CHO-GLN beverage also was not significantly different from the fasting condition. CONCLUSION: - The RGV at 120 and 180 minutes after ingestion of CHO beverage combined with GLN is similar to that observed after an overnight fast.

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.

[Nutritional risk in surgery evaluated by body mass index adjusted or not to elderly patients]. / Risco nutricional em cirurgia avaliado pelo índice de massa corporal ajustado ou não para pacientes idosos.

BACKGROUND: Standard body mass index cut-off points for malnutrition are routinely used for adults independently of their age. The hypothesis of this study was that a cut-off point higher than the usual for the diagnosis of malnutrition might be more precise to access the nutritional risk of aged surgical patients. AIM: To evaluate the morbimortality in aged surgical patients and its association with nutritional status assessed by body mass index using either the standard and a higher cut-off point for malnutrition. PATIENTS AND METHODS: All patients admitted for operative procedures (n = 1,912) were allocated to either two groups: <65 years (n = 1,627) or >65 years old (n = 285). The body mass index was used to access the nutritional status. Two different cut-off points for malnutrition (18.5 or 24 kg/m(2)) were used in the group of older patients. Endpoints of the study were length of stay, morbidity and mortality. RESULTS: Length of stay was higher in patients over 65 years (6 [1-75] days vs. 4 [1-137] days). Both postoperative complications (37/285; 13.0% vs. 109/1627; 6.7%; OR 2.1; IC95% 1.40-3.09) and deaths (15/285; 5.3% vs. 34/1627; 2.1%; OR 2.6; IC95% 1.40-4.84) were most common in the older group. Using a higher cut-off (24 kg/m(2)), the length of stay (8 [1-75] days vs. 4 [1-43] days), postoperative complications (28/152; 18.4% versus 9/133; 6.8%; OR 3,1; IC95% 1.41-6.86) and re-operations (16/152; 10.5% versus 3/133; 2.2%; OR 5.1; IC95% 1.45-17.91) were greater in malnourished patients. However these correlations were not statistically significant with the cut-off point for malnutrition in 18.5 kg/m(2). CONCLUSIONS: Morbimortality is higher in surgical patients over 65 years old. In these, the cut-off point set in 24 kg/m(2) was most associated with the occurrence of postoperative complications, re-operations and length of stay.

Enhanced muscle strength with carbohydrate supplement two hours before open cholecystectomy: a randomized, double-blind study.

OBJECTIVE: to investigate the effects of preoperative fasting abbreviation with oral supplementation with carbohydrate in the evolution of grip strength in patients undergoing cholecystectomy by laparotomy. METHODS: we conducted a clinical, randomizeddouble blind study with adult female patients, aged 18-60 years. Patients were divided into two groups: Control Group, with fasting prescription 6-8h until the time of operation; and Intervention Group, which received prescription of fasting for solids 6-8h before surgery, but ingested an oral supplement containing 12.5% carbohydrate, six (400ml) and two (200ml) hours before theprocedure. The handgrip strength was measured in both hands in both groups, at patient's admission (6h before surgery), the immediate pre-operative time (1h before surgery) and 12-18h postoperatively. RESULTS: we analyzed 27 patients, 14 in the intervention group and 13 in the control group. There was no mortality. The handgrip strength (mean [standard deviation]) was significantly higher in the intervention group in the three periods studied, in at least one hand: preoperatively in the dominant hand (27.8 [2.6] vs 24.1 [3.7] kg; p=0.04), in the immediate preoperative in both hands, and postoperatively in the non-dominant hand (28.5 [3.0] vs 21.3 [5.9] kg; p=0.01). CONCLUSION: the abbreviation of preoperative fasting to two hours with drink containing carbohydrate improves muscle function in the perioperative period.

Acerto Project - 15 years changing perioperative care in Brazil / Projeto Acerto - 15 anos modificando cuidados perioperatórios no Brasil

ABSTRACT The ACERTO project is a multimodal perioperative care protocol. Implemented in 2005, the project in the last 15 years has disseminated the idea of a modern perioperative care protocol, based on evidence and with interdisciplinary team work. Dozens of published studies, using the protocol, have shown benefits such as reduced hospital stay, postoperative complications and hospital costs. Disseminated in Brazil, the project is supported by the Brazilian College of Surgeons and the Brazilian Society of Parenteral and Enteral Nutrition, among others. This article compiles publications by the authors who belong to the CNPq research group "Acerto em Nutrição e Cirurgia", refers to the experience of other national authors in various surgical specialties, and finally outlines the evolution of the ACERTO project in the timeline.

RESUMO O projeto ACERTO é um protocolo multimodal de cuidados perioperatórios. Implementado em 2005, o projeto, nos últimos 15 anos, tem disseminado a ideia de moderno protocolo de cuidados perioperatórios baseados em evidência e com atuação interprofissional. Dezenas de estudos publicados com o uso do protocolo têm mostrado benefícios como redução do tempo de internação, complicações pós-operatórias e custos hospitalares. Disseminado pelo Brasil, o projeto tem apoio do Colégio Brasileiro de Cirurgiões e da Sociedade Brasileira de Nutrição Parenteral e Enteral, entre outros. Este artigo compila publicações dos autores que compõem o grupo de pesquisa do CNPq "Acerto em Nutrição e Cirurgia", cita a experiência de outros autores nacionais em diversas especialidades cirúrgica e finalmente, delineia a evolução do projeto ACERTO ao longo da linha do tempo.

Benefits of maltodextrin intake 2 hours before cholecystectomy by laparotomy in respiratory function and functional capacity: a prospective randomized clinical trial.

OBJECTIVE: To evaluate the change in respiratory function and functional capacity according to the type of preoperative fasting. METHODS: Randomized prospective clinical trial, with 92 female patients undergoing cholecystectomy by laparotomy with conventional or 2 hours shortened fasting. The variables measured were the peak expiratory flow, forced expiratory volume in the first second, forced vital capacity, dominant handgrip strength, and non-dominant handgrip strength. Evaluations were performed 2 hours before induction of anesthesia and 24 hours after the operation. RESULTS: The two groups were similar in preoperative evaluations regarding demographic and clinical characteristics, as well as for all variables. However, postoperatively the group with shortened fasting had higher values than the group with conventional fasting for lung function tests peak expiratory flow (128.7±62.5 versus 115.7±59.9; p=0.040), forced expiratory volume in the first second (1.5±0.6 versus 1.2±0.5; p=0.040), forced vital capacity (2.3±1.1 versus 1.8±0.9; p=0.021), and for muscle function tests dominant handgrip strength (24.9±6.8 versus 18.4±7.7; p=0.001) and non-dominant handgrip strength (22.9±6.3 versus 17.0±7.8; p=0.0002). In the intragroup evaluation, there was a decrease in preoperative compared with postoperative values, except for dominant handgrip strength (25.2±6.7 versus 24.9±6.8; p=0.692), in the shortened fasting group. CONCLUSION: Abbreviation of preoperative fasting time with ingestion of maltodextrin solution is beneficial to pulmonary function and preserves dominant handgrip strength.

Hypophosphatemia and risk of refeeding syndrome in critically ill patients before and after nutritional therapy

Summary OBJECTIVE: To investigate the prevalence of hypophosphatemia as a marker of refeeding syndrome (RFS) before and after the start of nutritional therapy (NT) in critically ill patients. METHODS: Retrospective cohort study including 917 adult patients admitted at the intensive care unit (ICU) of a tertiary hospital in Cuiabá-MT/Brasil. We assessed the frequency of hypophosphatemia (phosphorus <2.5mg/dl) as a risk marker for RFS. Serum phosphorus levels were measured and compared at admission (P1) and after the start of NT (P2). RESULTS: We observed a significant increase (36.3%) of hypophosphatemia and, consequently, a greater risk of RFS from P1 to P2 (25.6 vs 34.9%; p<0.001). After the start of NT, malnourished patients had a greater fall of serum phosphorus. Patients receiving NT had an approximately 1.5 times greater risk of developing RFS (OR= 1.44 95%CI 1.10-1,89; p= 0.01) when compared to those who received an oral diet. Parenteral nutrition was more associated with hypophosphatemia than either enteral nutrition (p=0,001) or parenteral nutrition supplemented with enteral nutrition (p=0,002). CONCLUSION: The frequency of critically ill patients with hypophosphatemia and at risk for RFS on admission is high and this risk increases after the start of NT, especially in malnourished patients and those receiving parenteral nutrition.

RESUMO OBJETIVO: Determinar a frequência de hipofosfatemia como marcador da síndrome de realimentação (SR) antes e após o início da TN em pacientes críticos. MÉTODOS: Coorte retrospectiva realizada com 917 pacientes adultos de um hospital terciário em Cuiabá-MT. Foi determinada a frequência de hipofosfatemia (fósforo <2,5 mg/dl) como marcador de risco de SR, para valores de fósforo sérico da admissão (P1) e após o início da TN (P2). RESULTADOS: Foi observado um aumento significativo (36,3%) da hipofosfatemia entre P1 e P2 e, consequentemente, do risco de SR (25,6% vs 34,9%; p<0,001) com o início da TN. Após o início da TN, pacientes desnutridos apresentaram maior queda do fósforo sérico. Os pacientes com TN apresentaram aproximadamente 1,5 vez mais chance de desenvolver hipofosfatemia e risco de SR (OR=1,44 IC95% 1,10-1,89; p=0,01) quando comparado aos com dieta oral. Nutrição parenteral foi mais associada à hipofosfatemia versus nutrição enteral (p=0,001) e nutrição enteral suplementada com parenteral (p=0,002). CONCLUSÃO: A frequência de pacientes críticos com hipofosfatemia e em risco de SR é alta e esse risco aumenta após o início da TN, especialmente nos desnutridos e naqueles recebendo nutrição parenteral.

[Comparison between resection and primary anastomosis and staged resection in obstructing adenocarcinoma of the left colon]. / Comparação entre ressecçã o com anastomose primária e ressecção em estágios nos tumores obstrutivos do cólon esquerdo.

BACKGROUND: The surgical option to deal with obstruction of the left side of the large bowel is still controversial. OBJECTIVE: To report the experience of our group in the treatment of malignant left-sided colonic obstruction focusing on the immediate results using either one-stage resection and primary anastomoses or staged resection. PATIENTS/METHODS: Twenty-three patients (median age = 52 (39-84) years; 10 males and 13 females) with potentially resectable obstructed adenocarcinomas of the left colon entered the study. The patients were submitted to different surgical procedure: 14 (60,9%) underwent one stage colonic resection (intra-operative lavage of colon (n = 10) or subtotal colectomy (n = 4); resection and primary anastomoses group) and 9 patients (39,1%) underwent staged resection (Hartmann's operation (n = 4) or loop colostomy (n = 5); staged resection group). RESULTS: Two patients (8,7%) died. All were from the staged resection group. Four patients (44,4%) of staged resection group did not complete the treatment with the closing of the colostomy. The incidence of complications was 28,6% in resection and primary anastomoses group (4/14) and 66,7% in staged resection group (6/9). Hospital stay was 15 (9-45) in staged resection patients and 8 (6-20) in resection and primary anastomoses group. There was one case (7,1%) of anastomotic dehiscence in resection and primary anastomoses group and two cases (22,2%) in staged resection group. CONCLUSIONS: The treatment of obstruction of left colon in one stage is safe and may be indicated for the management of the majority of cases.

Enteral nutrition in critical patients; should the administration be continuous or intermittent?

UNLABELLED: Enteral nutrition therapy (ENT) is an essential part in the management of critically ill patients, having a significant impact on these patients' clinical results. It can be administered on a continuous or intermittent basis using an infusion pump. There is a discussion on which of these techniques has the best performance, involving a number of factors such as nausea, diarrhea, and particularly the relationship between diet volume and the ratio of programed calories to calories effectively supplied to the critical patients. OBJECTIVES: To compare the forms of continuous or intermittent infusion of enteral nutrition, using as primary outcome the level of estimated caloric needs daily supplied. METHODS: Observational prospective randomized clinical study carried out in an intensive care unit on 41 patients divided into two groups, of intermittent (ENT during 18 hours with a 6-hour nocturnal pause), or continuous (ENT during 24 hours continuously) administration. The secondary outcome variables measured in this study were bowel evacuation, distension, emesis, with the primary outcome variable being the relationship between infusion volume and the estimated-to-supplied ratio of caloric needs. The rejection index of the null hypothesis was established at 5% for all the tests. RESULTS: Most of the patients received more than 60% infusion of enteral diet over the 5 days of study (p = 1.0), with no difference regarding the provision of caloric needs. No statistically significant difference between groups was found in the variables vomiting, abdominal distension or diarrhea. CONCLUSION: The administration modalities of continuous or intermittent enteral nutrition are similar in which regards the comparison of the variables included in this study.

La terapia con nutrición enteral (TNE), una parte esencial del manejo de los pacientes críticos, tiene un impacto significativo en los resultados clínicos de estos pacientes. La TNE puede administrarse de forma continua o intermitente utilizando una bomba de infusión. Existe una discusión sobre cuál de estas dos técnicas tiene un mejor rendimiento, lo que implica una serie de factores como náuseas, diarrea y especialmente la relación entre el volumen de la dieta y la proporción entre calorías que se programan y las que realmente se proporcionan efectivamente a los pacientes críticos. Objetivos: Comparar las formas continua e intermitente de infusión de nutrición enteral, utilizando un nivel de necesidades calóricas estimadas suministradas diariamente como resultado principal. Métodos: Estudio clínico prospectivo y observacional, de distribución aleatoria, de 41 pacientes en una unidad de cuidados intensivos (UCI), divididos en dos grupos, intermitente (TNE durante 18 horas con una pausa nocturna de 6 horas) o continua (TNE durante 24 horas de forma continua). Evaluamos como variables secundarias de resultados la evacuación, distención, emesis y como variable principal de resultado la relación entre el volumen de infusión y el cociente entre necesidades calóricas estimadas a suministradas. Se estableció el índice de rechazo de la hipótesis nula en el 5% para todos los tests. Resultados: La mayoría de los pacientes recibieron > 60% de la infusión de la dieta enteral a lo largo de los 5 días del estudio (p = 1,0), sin observarse diferencias en la provisión de las necesidades calóricas. No se observaron diferencias estadísticamente significativas entre los grupos con respecto a las variables vómitos, distensión abdominal o diarrea. Conclusión: Las modalidades intermitente o continua de administración de la nutrición enteral son similares en lo que respecta a la comparación de las variables de este estudio.

Efficacy of synbiotics to reduce acute radiation proctitis symptoms and improve quality of life: a randomized, double-blind, placebo-controlled pilot trial.

PURPOSE: To evaluate whether the daily intake of synbiotics interferes in radiation-induced acute proctitis symptoms and in quality of life in patients with prostate cancer. METHODS AND MATERIALS: Twenty patients who underwent 3-dimensional conformal radiation therapy for prostate cancer were randomized to intake either a synbiotic powder containing Lactobacillus reuteri 10(8) colony-forming units and 4.3 g of soluble fiber (Nestlé) or placebo. The questionnaire EORTC QLQ-PRT23 was applied before the beginning of radiation therapy and in every week for the first 4 weeks of treatment. The sum of both the complete (proctitis symptoms plus quality of life) and partial (proctitis symptoms) scores of the EORTC QLQ-PRT23 (European Organization for Research and Treatment of Cancer Quality of Life Module for Proctitis-23 items) questionnaire were the main endpoints. RESULTS: This pilot study showed that the complete questionnaire score (median [range]) was higher in the second (23 [21-30] vs 26.5 [22-34], P<.05) and third (23 [21-32] vs 27.5 [24-33], P<.01) weeks in the placebo group. Proctitis symptoms were highest scored in the placebo group in both the second (19.5 [16-25]) and third (19 [17-24]) weeks than in the synbiotic group (week 2: 16.5 [15-20], P<.05; week 3: 17 [15-23], P<.01). In both scores the placebo group had a significantly higher result (P<.01) than the synbiotic group (repeated-measures analysis of variance). CONCLUSIONS: Synbiotics reduce proctitis symptoms and improve quality of life in radiation-induced acute proctitis during radiation therapy for prostate cancer.

Gastric residual volume by magnetic ressonance after intake of maltodextrin and glutamine: a randomized double-blind, crossover study.

CONTEXT: The addition of glutamine in preoperative drinks may enhance the benefits of carbohydrate alone. OBJECTIVES: To evaluate the gastric residual volume after the intake of a beverage containing carbohydrate plus glutamine. METHODS: Eleven healthy volunteers (24-30 years-old) were randomized in a crossover fashion to intake 400 mL (4h before) and 200 mL (2h before) of a beverage containing either 12.5% maltodextrin (carbohydrate group) or 12.5% maltodextrin plus 15 g of glutamine (glutamine group) in two different moments 7 days apart. Magnetic ressonance was performed to measure the gastric residual volume (mL) 120 and 180 minutes after the last ingestion. RESULTS: Gastric residual volume similar to basal condition was found after 2h and 3h of the intake of beverages. There was no difference in the mean ±SD GRV (mL) found at 120 minutes (carbohydrate group: 22.9±16.6 and glutamine group: 19.7±10.7) and at 180 minutes (carbohydrate group: 21.5±24.1 and glutamine group: 15.1±10.1) between the two drinks. CONCLUSIONS: Gastric emptying is efficient, and occurs in up to two hours after the intake of a beverage containing either carbohydrate alone or carbohydrate associated with glutamine. The addition of glutamine to carbohydrate-enriched drink seems to be safe for the use up to 2h before an operation.