Abstract
ABSTRACTBackground:Perioperative care multimodal protocol significantly improve outcome in surgery. Aim:To investigate risk factors to various endpoints in patients submitted to elective colorectal operations under the ACERTO protocol. Methods:Cohort study analyzing through a logistic regression model able to assess independent risk factors for morbidity and mortality, patients submitted to elective open colon and/or rectum resection and primary anastomosis who were either exposed or non-exposed to demographic, clinical, and ACERTO interventions. Results:Two hundred thirty four patients were analyzed and submitted to 156 (66.7%) rectal and 78 (33.3%) colonic procedures. The length of hospital postoperative stay (LOS) ≥ 7 days was related to rectal surgery and high NNIS risk index; preoperative fasting ≤4 h (OR=0.250; CI95=0.114-0.551) and intravenous volume of crystalloid infused > 30ml/kg/day (OR=0.290; CI95=0.119-0.706). The risk of postoperative site infection (SSI) was approximately four times greater in malnourished; eight in rectal surgery and four in high NNIS index. The duration of preoperative fasting ≤4 h was a protective factor by reducing by 81.3% the risk of surgical site infection (SSI). An increased risk for anastomotic fistula was found in malnutrition, rectal surgery and high NNIS index. Conversely, preoperative fasting ≤4 h (OR=0.11; CI95=0.05-0.25; p<0.0001) decreased the risk of fistula. Factors associated with pneumonia-atelectasis were cancer and rectal surgery, while preoperative fasting ≤ 4 h (OR=0.10; CI95=0.04-0.24; p<0.0001) and intravenous crystalloid ≤ 30 ml/kg/day (OR=0.36; CI95=0.13-0.97, p=0.044) shown to decrease the risk. Mortality was lower with preoperative fasting ≤4 h and intravenous crystalloids infused ≤30 ml/kg/day. Conclusion:This study allows to conclude that rectal procedures, high NNIS index, preoperative fasting higher than 4 h and intravenous fluids greater than 30 ml/kg/day during the first 48 h after surgery are independent risk factors for: 1) prolonged LOS; 2) surgical site infection and anastomotic fistula associated with malnutrition; 3) postoperative pneumonia-atelectasis; and 4) postoperative mortality.
Highlights
From the last decade on, the use of multimodal protocols of perioperative care have been established as a core part of the routine in various health services in the world[18]
As ERAS (Enhanced Recovery After Surgery)[25,26,28], the ACERTO protocol is based in a solid reference of studies that have shown the benefit of the evidence applied to surgery can positively alter results such as early recovery of organ function, reduced days of hospitalization, decrease postoperative complications and death . 3,6,9 In a large prospective study with 5,974 elective patients, the same authors compared outcomes before and after the implementation of the ACERTO protocol
We have proposed to investigate the impact of the main strategies advocated by the ACERTO protocol for postoperative enhanced recovery in the morbimortality after colorectal surgery
Summary
From the last decade on, the use of multimodal protocols of perioperative care have been established as a core part of the routine in various health services in the world[18]. The reported a significant improvement of various endpoints such as decrease length of hospital stay (LOS), less need of blood products, and reduced postoperative infections, overall complications and deaths[9] In colorectal surgery these findings are confirmed by various recent controlled randomized trials[17,20] and metaanalyses[19,31] even in studies with the use of videolaparoscopy[21,24]. Both in the ACERTO project and ERAS protocol there is a large range of routines in different moments for prescriptions and it is particular interest in investigating which component of one multimodal protocol such as the ACERTO is most associated with the observed beneficial effects This answer could help for the definitions of better clinical strategies of implementation of programs of enhancing recovery and be the basics for decision policies to be adopt aiming at optimization of postoperative recovery[12,23]. The aim of this study was to investigate risk factors for various endpoints in patients submitted to elective colorectal procedures within the ACERTO protocol
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