Why should Medical Societies increasingly attend to their Specialist Title exams and why should medical professionals obtain it?

Medical societies must maintain high standards of competence and quality when awarding specialist titles, defining the certification criteria, taking into account the needs and realities of the health system and medical practice.

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.

Results of the Last 5 Years (2018-2022) of the Specialist Title Exam of The Brazilian College of Surgeons.

The article discusses the evolution of the Brazilian College of Surgeons (CBC) specialist title exam, highlighting the importance of evaluating not only theoretical knowledge, but also the practical skills and ethical behavior of candidates. The test was instituted in 1971, initially with only the written phase, and later included the oral practical test, starting with the 13th edition in 1988. In 2022, the assessment process was improved by including the use of simulated stations in the practical test, with the aim of assessing practical and communication skills, as well as clinical reasoning, in order to guarantee excellence in the assessment of surgeons training. The aim of this study is to demonstrate the performance of candidates in the last five years of the Specialist Title Test and to compare the performance results between the different surgical training groups of the candidates. The results obtained by candidates from the various categories enrolled in the test in the 2018 to 2022 editions were analyzed. There was a clear and statistically significant difference between doctors who had completed three years of residency recognized by the Ministry of Education in relation to the other categories of candidates for the Specialist Title..

Anatomical and developmental aspects of iatrogenic injury to the right recurrent laryngeal nerve in surgical resections of substernal goiter.

Thyroid surgery is the primary treatment for substernal goiters, and iatrogenic injury to the recurrent laryngeal nerve (RNL) is always a risk. The literature suggests that iatrogenic lesions of the RNL post resection of substernal goiter are not equally distributed, being more frequent on the right recurrent laryngeal nerve (R-RLN) in comparison to the left recurrent laryngeal nerve (L-RLN). The relative paucity of basic anatomical and clinical reportages on R-RLN iatrogenic injuries and on the developmental factors that may help explain its higher incidence justifies this study's undertaking. Here we compare incidence of right versus left iatrogenic injuries to the RLN in surgical resections of substernal goiters and discuss the anatomical and embryological factors involved. This report is part of a larger retrospective observational cohort study of 239 patients surgically treated for substernal goiter in the Gaffrée and Guinle University Hospital, Rio de Janeiro, from 2006 to 2018. From 239 patients, 13 presented with iatrogenic RLN injury, one patient presented bilateral lesion, totalling 15 iatrogenic lesions. Our analysis showed that the R-RLN seems to be anatomically more vulnerable to injury due to the embryological underpinnings addressed in this review, R-RLN = 64.29% (n = 9) and L-RLN = 35.71% (n = 5). Pathological factors like malignancy and size of the mass are relevant issues to be considered. The knowledge of anatomical landmarks and embryological development of the thyroid and associated structures can improve our understanding and teaching of surgical anatomy, thus helping prevent and reduce the number of iatrogenic injuries on right RLNs.

Management of acute appendicitis during the COVID-19 pandemic: Views of two Brazilian surgical societies.

Acute appendicitis (AA) is a frequent cause of abdominal pain requiring surgical treatment. During the COVID-19 pandemic, surgical societies considered other therapeutic options due to uncertainties in the evolution of the disease. The purpose of this study is to assess the treatment of AA by members of two Brazilian surgical societies in this period. A common questionnaire was sent in 2020. There were 382 responses. Most surgeons had more than 15 years of profession (68.3%) and treated more than five cases per month (44.8%). About 72.5% would indicate chest CT to investigate COVID-19 in patients with AA. For those patients sustaining uncomplicated AA, without COVID-19, 60.2% would indicate laparoscopic appendectomy (VLA), followed by open appendectomy (OA) (31.7%) and non-operative management (NOM) (1.3%). For those with mild COVID-19, OA was suggested by 51.0%, followed by VLA (29.6%) and NOM (6.0%). For those with severe COVID-19, OA was proposed by 35.3%, followed by NOM (19.9%) and VLA (18.6%). For patients with periappendiceal abscesses, without COVID-19, VLA was suggested by 54.2%, followed by OA (33.2%) and NOM (4.4%). For those with mild COVID-19, OA was proposed in 49.5%, followed by VLA (29.3%) and NOM (8.9%). In those with severe COVID-19, OA was proposed in 36.6%, followed by NOM (25.1%) and VLA (17.3%). This information, based on two recognized Brazilian surgical societies, can help the surgeon to select the best approach individually.

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.

Why should Medical Societies increasingly attend to their Specialist Title exams and why should medical professionals obtain it? / Por que as Sociedades Médicas devem cada vez mais cuidar de suas provas de Título de Especialista e porque os profissionais médicos devem obtê-lo?

ABSTRACT Medical societies must maintain high standards of competence and quality when awarding specialist titles, defining the certification criteria, taking into account the needs and realities of the health system and medical practice.

RESUMO As Sociedades Médicas devem manter padrões elevados de competência e qualidade na concessão dos Títulos de Especialista, com definição dos critérios de certificação, considerando as necessidades e realidades do sistema de saúde e da prática médica.

Safety and quality in surgery: surgeons' perception in Brazil. / Segurança e qualidade em cirurgia: a percepção de cirurgiões no Brasil.

OBJECTIVE: to evaluate the perception of surgeons, members of the Brazilian College of Surgeons (CBC), on safety and quality issues in surgery, based on projects of Brazilian Ministry of Health (MS), CBC, World Health Organization (WHO), and American College of Surgeons (ACS). METHODS: a questionnaire based on WHO, CBC, and ACS initiatives was sent to all active and non-active CBC members, using Survey Monkey, in March 2018. RESULTS: out of 7,100 members, 171 professionals answered the questionnaire. Out of these, the majority (63.2%) declared to perform general surgery, 88.9% indicated knowing the project called Safe Surgery developed by MS, 73.1%, the CBC manual, and 14.6%, the ACS Strong for Surgery. Among those who indicated knowing the MS project, 73.1% said that they were accustomed to use it as a routine, and, among those who indicated knowing the CBC manual, 46.2% said that they were accustomed to use it. Most of the surgeons (81.3%) indicated that they had experienced severe surgical failures, being failures related to surgical material (49.7%) and presence of foreign bodies (8.2%) the most common ones. There were distinct opinions on who was responsible for checking over the checklist. CONCLUSION: the importance of safety and quality in surgery is well known by surgeons, but the practice is varied. Serious adverse events had been experienced by many surgeons, mainly related to surgical material and foreign bodies. The concept of interdisciplinarity did not seem to be common practice. Data indicated the need to develop education projects and the obligation of audits.

OBJETIVO: avaliar a percepção dos cirurgiões, membros do Colégio Brasileiro de Cirurgiões (CBC), sobre temas de segurança e qualidade em cirurgia, com base em Projetos do Ministério da Saúde (MS), do CBC, da Organização Mundial de Saúde (OMS) e do Colégio Americano de Cirurgiões (ACS). MÉTODOS: questionário com base nas iniciativas da OMS, do CBC e do ACS foi enviado pelo Survey Monkey a todos os sócios, ativos e não ativos, do CBC em março de 2018. RESULTADOS: responderam ao questionário 171 profissionais dentre os 7.100 sócios. Desses, a maioria (63,2%) declarou praticar Cirurgia Geral, 88,9% indicaram conhecer o Projeto Cirurgia Segura do MS, 73,1%, o Manual do CBC e 14,6%, o Strong for Surgery do ACS. Entre os que conhecem o Projeto do MS, 73,1% disseram usá-lo como rotina e, entre os que conhecem o Manual do CBC, 46,2% usam-no. A maior parte dos cirurgiões (81,3%) indicou que já vivenciou falha cirúrgica grave, sendo aquelas relacionadas com material cirúrgico (49,7%) e presença de corpos estranhos (8,2%), isoladamente, as mais comuns. Houve opiniões distintas sobre a responsabilidade de conferência do checklist. CONCLUSÃO: a importância da segurança e qualidade em cirurgia é conhecida pelos cirurgiões, mas a prática é variada. Eventos adversos graves foram vivenciados por muitos cirurgiões, principalmente relacionados com material cirúrgico e corpos estranhos. O conceito de interdisciplinaridade parece não ser prática comum. Os dados indicam a necessidade de desenvolver projetos de educação e a obrigatoriedade de auditorias.

Results of the Last 5 Years (2018-2022) of the Specialist Title Exam of The Brazilian College of Surgeons / Avaliação dos resultados dos últimos 5 anos (2018-2022) da prova do Título de Especialista do Colégio Brasileiro de Cirurgiões

ABSTRACT The article discusses the evolution of the Brazilian College of Surgeons (CBC) specialist title exam, highlighting the importance of evaluating not only theoretical knowledge, but also the practical skills and ethical behavior of candidates. The test was instituted in 1971, initially with only the written phase, and later included the oral practical test, starting with the 13th edition in 1988. In 2022, the assessment process was improved by including the use of simulated stations in the practical test, with the aim of assessing practical and communication skills, as well as clinical reasoning, in order to guarantee excellence in the assessment of surgeons training. The aim of this study is to demonstrate the performance of candidates in the last five years of the Specialist Title Test and to compare the performance results between the different surgical training groups of the candidates. The results obtained by candidates from the various categories enrolled in the test in the 2018 to 2022 editions were analyzed. There was a clear and statistically significant difference between doctors who had completed three years of residency recognized by the Ministry of Education in relation to the other categories of candidates for the Specialist Title..

RESUMO O artigo aborda a evolução da prova de título de especialista do Colégio Brasileiro de Cirurgiões (CBC), destacando a importância de avaliar não apenas o conhecimento teórico, mas também as habilidades práticas e o comportamento ético dos candidatos. A prova foi instituída em 1971, inicialmente com apenas a fase escrita, e posteriormente foi incluída a prova prática oral, a partir da 13ª edição em 1988. Em 2022, foi aprimorado o processo de avaliação, incluindo na prova prática o uso de estações simuladas, visando avaliar habilidades práticas e de comunicação, além do raciocínio clínico, buscando garantir a excelência da avaliação da formação dos cirurgiões. O objetivo deste estudo é demonstrar o desempenho dos candidatos nos últimos cinco anos da Prova de Título de Especialista e comparar os resultados dos desempenhos entre os diferentes grupos de formação cirúrgica dos candidatos. Foram analisados os resultados obtidos pelos candidatos das diversas categorias inscritas na prova nas edições de 2018 a 2022. Ficou evidente e estatisticamente significativa a diferença entre os médicos que fizeram três anos de residência reconhecida pelo MEC em relação aos demais categorias de candidatos ao Título de Especialista.

ANTIBIOTIC PROPHYLAXIS IN LAPAROSCOPIC CHOLECISTECTOMY: IS IT WORTH DOING?

Background: Elective laparoscopic cholecystectomy has very low risk for infectious complications, ranging the infection rate from 0.4% to 1.1%. Many surgeons still use routine antibiotic prophylaxis. Aim: Evaluate the real impact of antibiotic prophylaxis in elective laparoscopic cholecystectomies in low risk patients. Method: Prospective, randomized and double-blind study. Were evaluated 100 patients that underwent elective laparoscopic cholecystectomy divided in two groups: group A (n=50), patients that received prophylaxis using intravenous Cephazolin (2 g) during anesthetic induction and group B (n=50), patients that didn't receive any antibiotic prophylaxis. The outcome evaluated were infeccious complications at surgical site. The patients were reviewed seven and 30 days after surgery. Results: There was incidence of 2% in infection complications in group A and 2% in group B. There was no statistical significant difference of infectious complications (p=0,05) between the groups. The groups were homogeneous and comparable. Conclusion: The use of the antibiotic prophylaxis in laparoscopic cholecystectomy in low risk patients doesn't provide any significant benefit in the decrease of surgical wound infection.

Racional: A colecistectomia laparoscópica eletiva apresenta risco muito baixo para complicações infecciosas, com média de infecção entre 0,4% a 1,1%. Muitos cirurgiões ainda utilizam de rotina profilaxia antibiótica. Objetivo: Avaliar a real necessidade de profilaxia antibiótica em colecistectomias laparoscópicas eletivas em pacientes de baixo risco para infecção do sítio cirúrgico. Método: Estudo prospectivo, randomizado e duplo-cego, em pacientes submetidos à colecistectomia laparoscópica eletiva, envolvendo 100 pacientes em dois grupos: A (n=50), que receberam profilaxia com cefazolina 2 g intravenoso na indução anestésica; B (n=50), não foi utilizado antibiótico. O desfecho avaliado foi presença de complicações infecciosas de sítio cirúrgico. Os pacientes foram revisados em sete e 30 dias no pós-operatório. Resultados: As taxas de complicações infecciosas foi de 2% no grupo A e de também 2% no grupo B. Não houve diferença estatisticamente significativa (p>0,05) entre os grupos que foram homogêneos e comparáveis. Conclusão: A antibioticoprofilaxia na colecistectomia laparoscópica em pacientes de baixo risco não apresenta nenhum benefício significativo na redução da incidência de infecção do sítio cirúrgico.

Management of acute appendicitis during the COVID-19 pandemic: Views of two Brazilian surgical societies / Análise descritiva do tratamento dos doentes com apendicite aguda durante a pandemia de COVID-19: A visão dos cirurgiões de duas sociedades nacionais

ABSTRACT Acute appendicitis (AA) is a frequent cause of abdominal pain requiring surgical treatment. During the COVID-19 pandemic, surgical societies considered other therapeutic options due to uncertainties in the evolution of the disease. The purpose of this study is to assess the treatment of AA by members of two Brazilian surgical societies in this period. A common questionnaire was sent in 2020. There were 382 responses. Most surgeons had more than 15 years of profession (68.3%) and treated more than five cases per month (44.8%). About 72.5% would indicate chest CT to investigate COVID-19 in patients with AA. For those patients sustaining uncomplicated AA, without COVID-19, 60.2% would indicate laparoscopic appendectomy (VLA), followed by open appendectomy (OA) (31.7%) and non-operative management (NOM) (1.3%). For those with mild COVID-19, OA was suggested by 51.0%, followed by VLA (29.6%) and NOM (6.0%). For those with severe COVID-19, OA was proposed by 35.3%, followed by NOM (19.9%) and VLA (18.6%). For patients with periappendiceal abscesses, without COVID-19, VLA was suggested by 54.2%, followed by OA (33.2%) and NOM (4.4%). For those with mild COVID-19, OA was proposed in 49.5%, followed by VLA (29.3%) and NOM (8.9%). In those with severe COVID-19, OA was proposed in 36.6%, followed by NOM (25.1%) and VLA (17.3%). This information, based on two recognized Brazilian surgical societies, can help the surgeon to select the best approach individually.

RESUMO A apendicite aguda (AA) é causa frequente de abdome agudo cirúrgico. Durante a pandemia de COVID-19, devido às incertezas na evolução da doença, sociedades consideraram outras opções terapêuticas. Nosso objetivo é descrever o tratamento da AA por membros do CBC e SBAIT neste período. O questionário foi enviado em 2020. Houve 382 respostas. A maioria dos profissionais tinha mais de 15 anos de profissão (68,3%) e atendia mais de cinco casos por mês (44,8%). Cerca de 72,5% realizariam TC de tórax para investigação de COVID-19 em pacientes com AA. Nos com AA não complicada, sem COVID-19, 60,2% optariam pela apendicectomia videolaparoscópica (AVL), seguido de apendicectomia aberta (AAB) (31,7%) e tratamento não operatório (TNO) (1,3%). Nos com COVID-19 leve, AAB foi proposta por 51,0%, seguido da AVL (29,6%) e TNO (6,0%). Nos com COVID-19 grave, a AAB foi proposta por 35,3%, seguido de TNO (19,9%) e AVL (18,6%). Nos com AA complicadas com abscesso, sem COVID-19, AVL foi sugerida por 54,2%, seguida da AAB (33,2%) e TNO (4,4%). Nos com COVID-19 leve, a AAB foi proposta em 49,5%, seguidos da AVL (29,3%) e TNO (8,9%). Nos com COVID-19 grave, a AAB foi proposta em 36,6%, seguido de TNO (25,1%) e AVL (17,3%). Estas são opções de cirurgiões de duas sociedades cirúrgicas reconhecidas e podem auxiliar o colega que está na linha de frente a definir a melhor conduta individualmente.

ORGANIC INFLAMMATORY RESPONSE TO REDUCED PREOPERATIVE FASTING TIME, WITH A CARBOHYDRATE AND PROTEIN ENRICHED SOLUTION; A RANDOMIZED TRIAL.

BACKGROUND: this study aims to assess the organic inflammatory response of the video laparoscopic cholecystectomy, with abbreviation of the preoperative fasting to 2h using a carbohydrate and protein enriched solution. METHODS: this is a randomized, prospective study with patients divided into the following 2 groups: group A, conventional fasting and group B, 2h abbreviated fasting with oral ingestion of a carbohydrate and protein solution. Serum glucose, insulin, interleukin 1, and TNF-α were mesasured before ingestion of the solution, during induction of anesthesia, and 4 h after the end of surgery. RESULTS: thirty-eight patients completed the study without presenting pulmonary complications associated with bronchoaspiration. The postoperative HOMA-IR variance was greater in group A (p = 0.001). CONCLUSION: the abbreviation of preoperative fasting for 2 h, using carbohydrate and protein enriched solutions, is safe, reduces insulin resistance, and does not increase the risk of bronchoaspiration.

Introducción: El objetivo de este estudio es la evaluación de la respuesta inflamatoria orgánica a la colecistectomía laparoscópica mediante vídeo con una reducción del tiempo de ayuno preoperatorio a 2h y empleando una solución enriquecida con carbohidratos y proteínas. Métodos: Se trata de un estudio aleatorizado, prospectivo con pacientes divididos en los dos grupos siguientes: grupo A, ayuno convencional y grupo B, ayuno abreviado de 2h con ingesta oral de una solución enriquecida con carbohidratos y proteínas. Antes de la ingesta de la solución, se hicieron mediciones de glucosa sérica, insulina, interleucina 1y TNF-α; también se realizaron mediciones durante la inducción de la anestesia y 4h después de la intervención quirúrgica. Resultados: Treinta y ocho pacientes completaron el estudio sin presentar complicaciones pulmonares relacionadas con el broncoaspirado. La varianza HOMA-IR postoperatoria fue superior en el grupo A (p = 0,001). Conclusión: La reducción del tiempo de ayuno preoperatorio a 2h, empleando soluciones enriquecidas con carbohidratos y proteínas, es segura, reduce la resistencia a la insulina, y no aumenta el riesgo de broncoaspirado.

Comparative study of the different degrees of risk of gastrointestinal stromal tumor.

OBJECTIVE: To evaluate the applicability of the main categories of risk and morphological factors in the prognosis of gastrointestinal stromal tumors. METHODS: we retrospectively studied fifty-four cases of GIST, assessing the main prognostic factors of this neoplasis: risk levels, topography, size, mitotic index, necrosis, histological subtype and immunophenotype. We also verified their association and the reduction of overall survival. RESULTS: Univariate analysis showed that tumors with mitoses number greater than 5 per 50CGA (high-power fields), the presence of necrosis and a high risk for both the systems proposed by Fletcher and Miettinen had a significant association with reduced survival (p = 0.00001, 0.0056, 0.03 and 0.009, respectively). The remaining analyzed factors (size, histological subtype, topography and immunophenotype) had no such association. Multivariate analysis (Jacard index) showed that the Miettinen degree of risk was the one that best correlated with prognosis. CONCLUSION: the risk criteria of Fletcher and Miettinen are important in assessing the prognosis of patients with gastrointestinal stromal tumors, especially the latter, which adds to the mitotic index and the presence of tumor necrosis.

Actual preoperative fasting time in Brazilian hospitals: the BIGFAST multicenter study.

BACKGROUND: Prolonged fasting increases organic response to trauma. This multicenter study investigated the gap between the prescribed and the actual preoperative fasting times in Brazilian hospitals and factors associated with this gap. METHODS: Patients (18-90-years-old) who underwent elective operations between August 2011 and September 2012 were included in the study. The actual and prescribed times for fasting were collected and correlated with sex, age, surgical disease (malignancies or benign disease), operation type, American Society of Anesthesiologists score, type of hospital (public or private), and nutritional status. RESULTS: A total of 3,715 patients (58.1% females) with a median age of 49 (18-94) years from 16 Brazilian hospitals entered the study. The median (range) preoperative fasting time was 12 (2-216) hours, and fasting time was longer (P<0.001) in hospitals using a traditional fasting protocol (13 [6-216] hours) than in others that had adopted new guidelines (8 [2-48] hours). Almost 80% (n=2,962) of the patients were operated on after 8 or more hours of fasting and 46.2% (n=1,718) after more than 12 hours. Prolonged fasting was not associated with physical score, age, sex, type of surgery, or type of hospital. Patients operated on due to a benign disease had an extended duration of preoperative fasting. CONCLUSION: Actual preoperative fasting time is significantly longer than prescribed fasting time in Brazilian hospitals. Most of these hospitals still adopt traditional rather than modern fasting guidelines. All patients are at risk of long periods of fasting, especially those in hospitals that follow traditional practices.

Segurança e qualidade em cirurgia: a percepção de cirurgiões no Brasil / Safety and quality in surgery: surgeons' perception in Brazil

RESUMO Objetivo: avaliar a percepção dos cirurgiões, membros do Colégio Brasileiro de Cirurgiões (CBC), sobre temas de segurança e qualidade em cirurgia, com base em Projetos do Ministério da Saúde (MS), do CBC, da Organização Mundial de Saúde (OMS) e do Colégio Americano de Cirurgiões (ACS). Métodos: questionário com base nas iniciativas da OMS, do CBC e do ACS foi enviado pelo Survey Monkey a todos os sócios, ativos e não ativos, do CBC em março de 2018. Resultados: responderam ao questionário 171 profissionais dentre os 7.100 sócios. Desses, a maioria (63,2%) declarou praticar Cirurgia Geral, 88,9% indicaram conhecer o Projeto Cirurgia Segura do MS, 73,1%, o Manual do CBC e 14,6%, o Strong for Surgery do ACS. Entre os que conhecem o Projeto do MS, 73,1% disseram usá-lo como rotina e, entre os que conhecem o Manual do CBC, 46,2% usam-no. A maior parte dos cirurgiões (81,3%) indicou que já vivenciou falha cirúrgica grave, sendo aquelas relacionadas com material cirúrgico (49,7%) e presença de corpos estranhos (8,2%), isoladamente, as mais comuns. Houve opiniões distintas sobre a responsabilidade de conferência do checklist. Conclusão: a importância da segurança e qualidade em cirurgia é conhecida pelos cirurgiões, mas a prática é variada. Eventos adversos graves foram vivenciados por muitos cirurgiões, principalmente relacionados com material cirúrgico e corpos estranhos. O conceito de interdisciplinaridade parece não ser prática comum. Os dados indicam a necessidade de desenvolver projetos de educação e a obrigatoriedade de auditorias.

ABSTRACT Objective: to evaluate the perception of surgeons, members of the Brazilian College of Surgeons (CBC), on safety and quality issues in surgery, based on projects of Brazilian Ministry of Health (MS), CBC, World Health Organization (WHO), and American College of Surgeons (ACS). Methods: a questionnaire based on WHO, CBC, and ACS initiatives was sent to all active and non-active CBC members, using Survey Monkey, in March 2018. Results: out of 7,100 members, 171 professionals answered the questionnaire. Out of these, the majority (63.2%) declared to perform general surgery, 88.9% indicated knowing the project called Safe Surgery developed by MS, 73.1%, the CBC manual, and 14.6%, the ACS Strong for Surgery. Among those who indicated knowing the MS project, 73.1% said that they were accustomed to use it as a routine, and, among those who indicated knowing the CBC manual, 46.2% said that they were accustomed to use it. Most of the surgeons (81.3%) indicated that they had experienced severe surgical failures, being failures related to surgical material (49.7%) and presence of foreign bodies (8.2%) the most common ones. There were distinct opinions on who was responsible for checking over the checklist. Conclusion: the importance of safety and quality in surgery is well known by surgeons, but the practice is varied. Serious adverse events had been experienced by many surgeons, mainly related to surgical material and foreign bodies. The concept of interdisciplinarity did not seem to be common practice. Data indicated the need to develop education projects and the obligation of audits.

ACERTO guidelines of perioperative nutritional interventions in elective general surgery / Diretriz ACERTO de intervenções nutricionais no perioperatório em cirurgia geral eletiva

ABSTRACT 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.

RESUMO Objetivo: apresentar recomendações, baseadas no Projeto ACERTO (Aceleração da Recuperação Total Pós-Operatória) e sustentada por evidências, relativas aos cuidados nutricionais perioperatórios em procedimentos eletivos em Cirurgia Geral. Métodos: revisão da literatura pertinente entre 2006 e 2016, com base em busca realizada nas principais bases de dados, com o intuito de responder a perguntas norteadoras previamente formuladas por especialistas, dentro de cada temática desta diretriz. Foram selecionados alguns estudos de coorte, mas, preferencialmente, foram utilizados estudos aleatórios controlados, revisões sistemáticas e meta-análises. Cada pergunta norteadora de recomendação foi contextualizada de modo a determinar a qualidade da evidência e a força desta recomendação (GRADE). Este material foi enviado aos autores utilizando um questionário aberto on-line. Após o recebimento das respostas, formalizou-se o consenso para cada recomendação desta diretriz. Resultados: o nível de evidência e o grau de recomendação para cada item é apresentado em forma de texto, seguido de resumo da evidência encontrada. Conclusão: esta diretriz traduz as recomendações do grupo de especialistas do Colégio Brasileiro de Cirurgiões, da Sociedade Brasileira de Nutrição Parenteral e Enteral e do Projeto ACERTO para intervenções nutricionais no período perioperatório em Cirurgia Geral eletiva. A prescrição dessas recomendações pode acelerar a recuperação pós-operatória de pacientes submetidos a operações eletivas em cirurgia geral, com diminuição de morbidade, do tempo de internação e de reinternações e, consequentemente, dos custos.

Antibiotic prophylaxis in laparoscopic cholecistectomy: is it worth doing? / Profilaxia antibiótica na colecistectomia laparoscópica: vale a pena fazer?

ABSTRACT Background: Elective laparoscopic cholecystectomy has very low risk for infectious complications, ranging the infection rate from 0.4% to 1.1%. Many surgeons still use routine antibiotic prophylaxis Aim: Evaluate the real impact of antibiotic prophylaxis in elective laparoscopic cholecystectomies in low risk patients. Method: Prospective, randomized and double-blind study. Were evaluated 100 patients that underwent elective laparoscopic cholecystectomy divided in two groups: group A (n=50), patients that received prophylaxis using intravenous Cephazolin (2 g) during anesthetic induction and group B (n=50), patients that didn't receive any antibiotic prophylaxis. The outcome evaluated were infeccious complications at surgical site. The patients were reviewed seven and 30 days after surgery. Results: There was incidence of 2% in infection complications in group A and 2% in group B. There was no statistical significant difference of infectious complications (p=0,05) between the groups. The groups were homogeneous and comparable. Conclusion: The use of the antibiotic prophylaxis in laparoscopic cholecystectomy in low risk patients doesn't provide any significant benefit in the decrease of surgical wound infection.

RESUMO Racional: A colecistectomia laparoscópica eletiva apresenta risco muito baixo para complicações infecciosas, com média de infecção entre 0,4% a 1,1%. Muitos cirurgiões ainda utilizam de rotina profilaxia antibiótica Objetivo: Avaliar a real necessidade de profilaxia antibiótica em colecistectomias laparoscópicas eletivas em pacientes de baixo risco para infecção do sítio cirúrgico. Método: Estudo prospectivo, randomizado e duplo-cego, em pacientes submetidos à colecistectomia laparoscópica eletiva, envolvendo 100 pacientes em dois grupos: A (n=50), que receberam profilaxia com cefazolina 2 g intravenoso na indução anestésica; B (n=50), não foi utilizado antibiótico. O desfecho avaliado foi presença de complicações infecciosas de sítio cirúrgico. Os pacientes foram revisados em sete e 30 dias no pós-operatório. Resultados: As taxas de complicações infecciosas foi de 2% no grupo A e de também 2% no grupo B. Não houve diferença estatisticamente significativa (p>0,05) entre os grupos que foram homogêneos e comparáveis. Conclusão: A antibioticoprofilaxia na colecistectomia laparoscópica em pacientes de baixo risco não apresenta nenhum benefício significativo na redução da incidência de infecção do sítio cirúrgico.

Organic inflammatory response to reduced preoperative fasting time, with a carbohydrate and protein enriched solution; a randomized trial / La respuesta orgánica inflamatoria en la reducción del tiempo de ayuno preoperatorio con una solución enriquecida con carbohidratos y proteínas; un estudio aleatorizado

Background: this study aims to assess the organic inflammatory response of the video laparoscopic cholecystectomy, with abbreviation of the preoperative fasting to 2h using a carbohydrate and protein enriched solution. Methods: this is a randomized, prospective study with patients divided into the following 2 groups: group A, conventional fasting and group B, 2h abbreviated fasting with oral ingestion of a carbohydrate and protein solution. Serum glucose, insulin, interleukin 1, and TNF-α were mesasured before ingestion of the solution, during induction of anesthesia, and 4 h after the end of surgery. Results: thirty-eight patients completed the study without presenting pulmonary complications associated with bronchoaspiration. The postoperative HOMA-IR variance was greater in group A (p = 0.001). Conclusion: the abbreviation of preoperative fasting for 2 h, using carbohydrate and protein enriched solutions, is safe, reduces insulin resistance, and does not increase the risk of bronchoaspiration (AU)

Introducción: El objetivo de este estudio es la evaluación de la respuesta inflamatoria orgánica a la colecistectomía laparoscópica mediante vídeo con una reducción del tiempo de ayuno preoperatorio a 2h y empleando una solución enriquecida con carbohidratos y proteínas. Métodos: Se trata de un estudio aleatorizado, prospectivo con pacientes divididos en los dos grupos siguientes: grupo A, ayuno convencional y grupo B, ayuno abreviado de 2h con ingesta oral de una solución enriquecida con carbohidratos y proteínas. Antes de la ingesta de la solución, se hicieron mediciones de glucosa sérica, insulina, interleucina 1y TNF-α; también se realizaron mediciones durante la inducción de la anestesia y 4h después de la intervención quirúrgica. Resultados: Treinta y ocho pacientes completaron el estudio sin presentar complicaciones pulmonares relacionadas con el broncoaspirado. La varianza HOMA-IR postoperatoria fue superior en el grupo A (p = 0,001). Conclusión: La reducción del tiempo de ayuno preoperatorio a 2h, empleando soluciones enriquecidas con carbohidratos y proteínas, es segura, reduce la resistencia a la insulina, y no aumenta el riesgo de broncoaspirado (AU)

Comparative study of the different degrees of risk of gastrointestinal stromal tumor / Estudo comparativo dos diferentes graus de risco no tumor estromal gastrointestinal

OBJECTIVE: To evaluate the applicability of the main categories of risk and morphological factors in the prognosis of gastrointestinal stromal tumors. METHODS: we retrospectively studied fifty-four cases of GIST, assessing the main prognostic factors of this neoplasis: risk levels, topography, size, mitotic index, necrosis, histological subtype and immunophenotype. We also verified their association and the reduction of overall survival. RESULTS: Univariate analysis showed that tumors with mitoses number greater than 5 per 50CGA (high-power fields), the presence of necrosis and a high risk for both the systems proposed by Fletcher and Miettinen had a significant association with reduced survival (p = 0.00001, 0.0056, 0.03 and 0.009, respectively). The remaining analyzed factors (size, histological subtype, topography and immunophenotype) had no such association. Multivariate analysis (Jacard index) showed that the Miettinen degree of risk was the one that best correlated with prognosis. CONCLUSION: the risk criteria of Fletcher and Miettinen are important in assessing the prognosis of patients with gastrointestinal stromal tumors, especially the latter, which adds to the mitotic index and the presence of tumor necrosis.

OBJETIVO: Avaliar a aplicabilidade das principais categorias de risco e de fatores morfológicos no prognóstico tumor estromal gastrointestinal. MÉTODOS: cinquenta e quatro casos de GIST foram estudados retrospectivamente considerando-se os principais fatores prognósticos da neoplasia: graus de risco, topografia, tamanho, índice mitótico, necrose, subtipo histológico e imunofenótipo. Foi também verificada a sua associação e a redução da sobrevida global dos pacientes. RESULTADOS: a análise univariada mostrou que os tumores com número de mitoses maior que 5/50CGA (campos de grande aumento), a presença de necrose, de alto risco tanto para os sistemas propostos por Fletcher, quanto para Miettinen tiveram associação significativa com redução da sobrevida (p=0,00001, 0,0056, 0,03 e 0,009, respectivamente). Enquanto que os demais fatores analisados (tamanho, subtipo histológico, topografia e imunofenótipo) não tiveram tal associação. A análise multivariada (índice de Jacard) demonstrou que o grau de risco de Miettinen foi aquele que melhor se relacionou com o prognóstico. CONCLUSÃO: os critérios de risco de Fletcher e de Miettinen são importantes na avaliação do prognóstico de pacientes com tumor estromal gastrointestinal, principalmente este último, que se soma ao índice mitótico e a necrose tumoral.

Prevention and treatment of postoperative nausea and vomiting. / Prevenção e tratamento de náuseas e vômitos no período pós-operatório.

Postoperative nausea and vomiting are common and can be prevented. Complications of this condition cause higher rates of morbidity and mortality. A review of literature was carried out on MEDLINE, with focus on controlled clinical trials. Pathophysiology is complex, with many afferent and efferent pathways, and its comprehension facilitate the choice of medication. Risk factors are presented, with a stratified score of chance to develop postoperative nausea and vomiting. An algorithm for identification of higher risk patients was elaborated and classified the level of prevention/treatment recommended to avoid excessive use of drugs and their side effects. Postoperative nausea and vomiting must be prevented, because of the involved complications and discomfort for patients. A systematic approach with analysis of preoperative risk factors and prescription of medication can be effective for prevention.