Avaliação da Função Intestinal e da Qualidade de Vida de Pacientes com Endometriose Pélvica Profunda Submetidas à Ressecção Colorretal / Evaluation of Intestinal Function and Quality of Life in Patients with Deep Pelvic Endometriosis Undergoing Colorectal Resection

Objetivo: Identificar fatores relacionados à ocorrência de disfunção intestinal e de impacto negativo na Qualidade de vida (QV) de mulheres submetidas à ressecção segmentar (RS) ou em disco (RD) por endometriose intestinal. Método: Estudo retrospectivo com mulheres submetidas à RS ou RD para tratamento de endometriose intestinal,com registro medico consecutivo, em hospital terciário (Biocor, Instituto) por equipe multidiciplinar no período 2008-2018. Os critérios de inclusão foram: anastomose até 15cm da margem anal, confirmação histológica de endometrioses intestinal, seguimento pós-operatório mínimo de 12 meses,sem cirurgia colorretal anterior e assinatura do termo de consentimento. Foram excluídas aquelas com doença inflamatória intestinal ou com doença sistêmica ou outra condição patológica grave capaz de comprometer a qualidade de vida. Foram utilizados questionários validados para avaliar a função intestinal Low Anterior Resection Syndrome Score (LARS score) e qualidade de vida (Short ­ Form Health Survey SF ­ 36). Dados clínicos cirúrgicos e sócio-demográficos foram também registrados. Variáveis que poderiam estar relacionadas à disfunção intestinal foram investigadas. A análise de associação das variáveis do estudo com a variável resposta LARS foi feita pela regressão logística e o p<0.05 foi considerado como significativo. O estudo foi aprovado pelo comitês de ética local. Resultados: Foram estudadas 144 mulheres com idade média 34 anos, sendo a dor a principal indicação cirúrgica (n=130;90,3%), seguida de infertilidade (n=74; 51,4%) todas as cirurgias forma por videolaparoscopia e realizadas pelo mesmo coloprotctologista sendo a RS realizada em 91 pacientes (63,2%), enquanto 53 (35,8%) foram submetidas a RD.A incidência de LARS foi de 42,36% (61pacientes) sendo 20,8% LARS leve e 21,5% de LARS grave. Não houve diferença significativa na incidência de LARS entre pacientes submetidos a RS 47% e RD 34% (p=0,120) Na análise das variáveis do questionário LARS escore, as pacientes que foram submetidas a RD apresentaram constipação, e quanto às submetidas a RS, um pequeno grupo apresentou frequência evacuatória de 4 a 7 vezes ao dia (p=0,011), e o restante de 1 a 3 vezes. As únicas variáveis responsáveis pela ocorrência de LARS foram: histerectomia prévia ou concomitante (OR 2,94 95% IC 1,24;6,97, p=0,014), distância a anastomose ≤ 5 cm e RS associada a distância a anastomose ≤ 5 cm da margem anal (OR 4,22 95% IC 1,70;10,50 p=0,002). A ocorrênca de LARS em pacientes submetidas a RS foi maior naquela com anastomose ≤ 5 cm da margem anal (37,6% versus 6,2% p < 0,001), sendo também significativamente maior quando comparada com RD (p=0,006). As pacientes, apresentaram boa QV, independente da técnica cirúrgica utilizada com todos os domínios acima de 60. Em relação a QV versus LARS, as pacientes que apresentaram LARS tiveram impacto significativo nos domínios aspectos emocional p=0,006) e saúde mental (p=0,011) comparado aos sem LARS. A taxa de morbidade geral foi de 10,3% sendo 6,3% complicações menores e 4,2% maiores, segundo classificação de Clavien-Dindo. As complicações não impactaram a QV e nem o LARS escore (p=0,655). Conclusão: Pacientes submetidas a cirurgia para tratamento da endometriose desenvolveram disfunção intestinal independente da técnica cirúrgica, com impacto na QV nos domínios aspectos emocional e saúde mental. A realização da histerectomia e anastomose baixa associada a RS aumentaram significamente o risco de disfunção intestinal.

Objective: To identify factors related to the occurrence of bowel dysfunction and negative impact on the Quality of life (QoL) of women undergoing segmental (SR) or disc resection (RD) for intestinal endometriosis. Method: This was a retrospective study with women undergoing RS or RD for the treatment of intestinal endometriosis,with consecutive medical record, in a tertiary hospital (Biocor, Instituto) by a multidisciplinary team from 2008 to 2018. Inclusion criteria were: anastomosis up to 15 cm above anal margin histological confirmation of intestinal endometriosis, minimum postoperative follow-up of 12 months,no previous colorectal surgery and signature of the consent form. Those with inflammatory bowel disease or with systemic disease or other serious pathological condition affecting quality of life were excluded. Validated questionnaires were used to assess bowel function: (Low Anterior Resection Syndrome Score (LARS score) and quality of life (Short ­ Form Health Survey SF ­ 36). Clinical, surgical and socio-demographic data were also recorded. Variables that could be related to bowel dysfunction were investigated. Statistical analysis included logistic regression to study the association of the study variables with the response variable LARS and p<0.05 w considered significant. The study was approved by the local ethics committee.Results: 144 women with an average age of 34 years were studied, with pain being the main indication for surgery (n= 130;90.3%), followed by infertility (n=74; 51.4%). All surgeries were laparoscopies performed by the same coloproctologist: RS was performed in 91 patients (63.2%), while 53 (35.8%) were submitted to DR. The incidence of LARS was 42.36% (n=61) with 20.8% classified as mild and 21. 5% severe. There was no significant difference in the incidence of LARS between patients who underwent either RS (47%) or RD (34%) (p=0.120). As for those submitted to RS, a small group presented evacuation frequency from 4 to 7 times a day (p=0.011), and the rest from 1 to 3 times. The only variables responsible for the occurrence of LARS were: previous or concomitant hysterectomy (OR 2.94 95% CI 1.24;6.97, p=0.014), distance to anastomosis ≤ 5 cm and RS associated with distance to anastomosis ≤ 5 cm from the anal margin (OR 4.22 95% CI 1.70; 10.50 p=0.002). The occurrence of LARS in patients undergoing RS was higher in those with anastomosis ≤ 5 cm from the anal margin (37.6% versus 6.2%; p < 0.001), being also significantly higher when compared to DR (p = 0.006). Patients, in general, had good QoL, regardless of the surgical technique used, with all domains above 60. Regarding QoL versus LARS, patients who had LARS had a significant impact on the emotional aspects (p=0.006) and mental health domains (p=0.011) compared to those without LARS. The overall morbidity rate was 10.3%, with 6.3% minor complications and 4.2% major complications, according to the Clavien-Dindo classification. Complications did not impact QoL nor the LARS score (p= 0.655). Conclusion: Patients undergoing surgery for endometriosis developed bowel dysfunction regardless of the surgical technique, with an impact on QoL in the emotional aspects and mental health domains. Hysterectomy and anastomosis ≤ 5 cm with RS significantly increase the risk of bowel dysfunction.

Resecciones colorrectales laparoscópicas en una comunidad rural / Laparoscopic colorectal resections in a rural community

Antecedentes: La cirugía laparoscópica colorrectal continúa en camino de convertirse en el abordaje de elección para el tratamiento de la patología colorrectal benigna y maligna. Sin embargo, su aplicabilidad aún es baja y está mayormente limitada a grandes centros urbanos. Objetivo: analizar la factibilidad de un programa de cirugía laparoscópica colorrectal en un centro de comunidad rural. Como objetivo secundario, comparar los resultados con la cirugía abierta convencional Material y métodos: se analizó una base de datos prospectiva de todos los pacientes operados de forma electiva y consecutiva entre junio de 2012 y diciembre de 2016. Se empleó un criterio de alta estandarizado. Los pacientes fueron divididos en dos grupos según la cirugía fuese laparoscópica (grupo A) o convencional (grupo B). El análisis de variables se realizó con los métodos de Chi cuadrado y T-test según corresponda. Resultados: se realizaron 129 resecciones colorrectales con una proporción de varones del 60% y una mediana de edad de 64 años. El 83% pertenecía a comunidades vecinas. Hubo un 35% de pacientes ASA I, 56% ASA II y 9% ASA III. La distancia promedio del lugar de residencia fue 75 km con una superficie de distribución de 24 000 km2. La mediana de internación fue de 4 días. La aplicabilidad de la laparoscopia fue del 74% con una tasa de conversión del 6%. Ambos grupos fueron similares en términos de sexo, IMC, diagnóstico, ASA, proporción de ASA III-IV, antecedentes clínicos y quirúrgicos, así como también distancia de su lugar de residencia. El grupo A presentó una media de edad menor que el grupo B (61 años vs. 69 años; p < 0,01). No se observaron diferencias en términos de tipo de cirugía y tiempo operatorio. La morbilidad posoperatoria fue 18% y la tasa de readmisión fue del 4%, sin diferencias entre grupos. Conclusiones: la cirugía laparoscópica colorrectal puede ser realizada en un centro rural con bajo índice de readmisión y complicaciones y resultados comparables a los de la cirugía abierta convencional.

Of benign tumors and colorectal cancer. However, its use is low and limited to large urban centers. Objective: The aim of this study was to analyze the feasibility of a laparoscopic colorectal surgery program in a rural community center. The secondary outcome was to compare these results with those of conventional open surgery. Material and methods: We analyzed a prospective data base of all the patients undergoing scheduled and consecutive surgery between June 2012 and December 2016. A standardized discharge criterion was used. The patients were divided into two groups: laparoscopic surgery (group A) and conventional surgery (group B). The variables were analyzed with the chi-square test or Student's t test, as applicable. Results: A total of 129 colorectal resections were performed; median age was 64 years, 60% were men and 83% belonged to neighbor communities. The ASA physical status classification system was grade 1 in 35% of the patients, grade 2 in 56% and grade 3 in 9%. The average distance between patients' place of residence was of 75 km comprising an area of 24,000 km2. Patients were hospitalized for a median of 4 days. The applicability of laparoscopy was 74% with a conversion rate of 6%. There were no significant differences in sex, BMI, diagnosis, ASA grade, proportion of ASA grade 3-4 patients, clinical history, previous surgeries and distance from the place of residency. Compared to group B, patients in group A were younger (61.6 years vs. 69 years; p < 0.01). There were no differences in terms of type of surgery and surgery duration. Postoperative morbidity was 18% and the readmission rate was 4%, with no differences between the groups. Conclusions: Laparoscopic colorectal surgery can be performed in a rural center with low readmission rate and complications; these results are similar to those of conventional open surgery.

Variación de la temperatura central durante la cirugía colorrectal laparoscópica / Cangas in central temperature during laparoscopic colorectal surgery

Introducción: La hipotermia es una complicación que se produce con frecuencia en el posoperatorio de la cirugía laparoscópica. Múltiples factores potencian la disminución de la temperatura corporal por efecto directo del gas. Objetivo: Determinar las variaciones de la temperatura corporal en la intervención colorrectal laparoscópica y su influencia en la hipotermia intraoperatoria. Métodos: Se realizó un estudio descriptivo, longitudinal y prospectivo en pacientes con anestesia general para procedimiento laparoscópico colorrectal electivo con el propósito de identificar la incidencia y variaciones de la temperatura corporal. El estudio se realizó en el hospital Hermanos Ameijeiras entre enero de 2014 y enero de 2017. Resultados: De los 88 pacientes, 78,4 por ciento tenían entre 51 y 60 años. El sexo masculino, los pacientes con sobrepeso y la clasificación ASA II presentaron mayor frecuencia. La temperatura basal media fue de 36,4 oC. Luego de 30 min disminuyó a 35,5 oC, a la hora 35,4 oC, a 90 min 35,1 oC y al finalizar 34,9 oC. Del total, presentaron hipotermia intraoperatoria no intencionada 78,4 por ciento. En ninguno se constató hipotermia severa. El tiempo quirúrgico promedio fue de 183,1 min. Se verificaron 49 complicaciones asociadas a hipotermia. Conclusiones: Se identificaron las variaciones de la temperatura corporal en la intervención colorrectal laparoscópica y la tendencia de generar hipotermia durante el procedimiento quirúrgico(AU)

Introduction: Hypothermia is a complication that frequently occurs in the postoperative period of laparoscopic surgery. Multiple factors boost the decrease in body temperature due to the direct effect of gas. Objective: To determine the variations in body temperature in laparoscopic colorectal surgery and its influence on intraoperative hypothermia. Methods: A descriptive, longitudinal and prospective study was carried out with patients, using general anesthesia for elective laparoscopic colorectal procedures and with the purpose of identifying the incidence and variations of body temperature. The study was carried out at the Hermanos Ameijeiras Hospital, between January 2014 and January 2017. Results: Among the 88 patients, 78.4 percent were at ages 51-60 years. Male sex, overweight patients and ASA-II classification were more frequent. The average basal temperature was 36.4ºC. After 30 min, it decreased to 35.5ºC; after one hour, to 35.4 ºC; after 90 min, 35.1ºC; and at the end, to 34.9 ºC. From the total, 78.4 percent presented unintentional intraoperative hypothermia. None of them had severe hypothermia. The average surgical time was 183.1 min. There were 49 complications associated with hypothermia. Conclusions: Variations in body temperature were identified in the laparoscopic colorectal intervention, as well as the tendency to generate hypothermia during the surgical procedure(AU)

Analgesia peridural con anestésicos locales en la implementación del protocolo de recuperación precoz tras la cirugía colorrectal / Peridural analgesia with local anesthetics in the implementations of the early recovery protocol after correctable surgery

Introducción: la implementación de un protocolo de recuperación posoperatoria precoz, garantiza menor morbilidad, estancia posoperatoria corta y satisfacción de los pacientes. Objetivos: evaluar la utilidad de la analgesia epidural dentro de un protocolo de recuperación precoz en cirugía colorrectal laparoscópica. Método: se realizó un estudio observacional descriptivo prospectivo y longitudinal con el objetivo de evaluar la utilidad de la analgesia epidural dentro de un protocolo de recuperación precoz en cirugía colorrectal laparoscópica en pacientes intervenidos en el Hospital Clínico Quirúrgico Hermanos Ameijeiras en el período de mayo 2014-diciembre 2016. La muestra quedó conformada por 97 pacientes intervenidos de cirugía colorrectal laparoscópica con estado físico II-III según la ASA, de cualquier género, programados para cirugía electiva colorrectal laparoscópica incluidos en el protocolo. Resultados: La media de la edad fue de 70 años y predominó el sexo masculino. La analgesia obtenida fue eficaz, se logró ausencia de dolor tanto en reposo como en movimiento en todos los momentos de medición en más del 50 por ciento de los pacientes y cuando apareció el dolor este fue considerado leve. Los requerimientos de analgesia de rescate fueron de 24,7 por ciento. Las complicaciones fueron escasas. Los temblores y la hipotensión aparecieron en 11,3 y 9,3 por ciento, respectivamente. La estadía fue menor de tres días en más de la mitad de los pacientes. Conclusiones: la implementación de un protocolo de recuperación posoperatoria precoz incrementa la eficacia y la eficiencia en la atención perioperatoria(AU)

Introduction: The implementation of an early postoperative recovery protocol guarantees lower morbidity, short postoperative stay, and patient satisfaction. Objectives: To evaluate the usefulness of epidural analgesia within an early recovery protocol in laparoscopic colorectal surgery. Method: A prospective and longitudinal descriptive and observational study was carried out with the objective of evaluating the usefulness of epidural analgesia within an early recovery protocol in laparoscopic colorectal surgery in patients operated at Hermanos Ameijeiras Surgical-Clinical Hospital in the period from May 2014 to December 2016. The sample consisted of 97 patients who underwent laparoscopic colorectal surgery with physical status II-III according to the ASA, of any gender, scheduled for elective laparoscopic colorectal surgery included in the protocol. Results: The average age was 70 years and the male sex predominated. The analgesia obtained was effective, absence of pain was achieved both at rest and in movement at all measurement times in more than 50 percent of patients and, when pain appeared, it was considered mild. The requirements for rescue analgesia were 24.7 percent. The complications were minimal. Tremors and hypotension appeared in 11.3 percent and 9.3 percent of cases, respectively. Hospital stay was less than three days in more than half of the patients. Conclusions: The implementation of an early postoperative recovery protocol increases the effectiveness and efficiency in perioperative care(AU)

Tasa de reingreso no programado en cirugía colorrectal electiva / Hospital readmission rates in complex colorrectal surgery

Background: Non programmed hospital readmission rates are a quality indicator of colorectal surgery. Aim: To analyze the causes of readmission of patients subjected to surgical procedures including intestinal anastomoses. Material and Methods: Analysis of a database of patients subjected to elective intestinal anastomoses in a period of 10 years. All non-programmed readmissions that occurred within 30 days after patient discharge were analyzed. Results: Overall non-programmed readmission rate was 7 percent and it was due to medical causes in 55 percent of patients. Nine percent of readmitted patients required a new surgical intervention. The figure among patients readmitted due to surgical causes, was 20 percent. Sixty one percent of patients were admitted at less than six days after discharge and 84 percent at less than 10 days. A non-programmed readmission duplicated the total hospitalization lapse and triplicated the rates of new surgical procedures. Conclusions: In this series of patients, the only predictor of a non-programmed readmission was the need for reoperation during the first admission.

Antecedentes: La readmisión no programada de un paciente operado es un evento frecuente en la práctica quirúrgica y se considera un indicador de calidad de la atención. El objetivo de este estudio es revisar las causas relevantes de reingreso en nuestro medio, establecer una tasa (TR) que permita una comparación prospectiva de los resultados y, eventualmente, identificar factores de riesgo modificables. Pacientes y Método: Se incluyen todos los pacientes sometidos a cirugía mayor electiva con una anastomosis intestinal en un período de 10 años. Se define como readmisión la re-hospitalización no planificada en el período de 30 días a contar del alta del paciente categorizada como causa médica o quirúrgica. Para el análisis estadístico se empleó el test de regresión logística. Resultados: La TR en la serie fue 7 por ciento (56/791), el 55 por ciento son por causa médica. La tasa de re-operación global durante el reingreso fue 9 por ciento (5/56), cifra que se eleva al 20 por ciento (5/25) en el grupo con alguna causa quirúrgica de re-admisión. El 61 por ciento de los pacientes reingresan antes de los 6 días del egreso y el 84 por ciento antes de los diez días. Un reingreso no planificado duplica el tiempo total de hospitalización (9 vs 19 días; p = 0,001) y casi triplica la tasa de reoperación (p = 0,001). Conclusión: En nuestra serie el único factor de riesgo de un reingreso fue el antecedente de una reoperación durante la cirugía índice. La TR es un indicador complejo y los factores predictivos de una re-hospitalización son motivo de controversia.