Redução do risco de complicações em cirurgia colorretal com cuidados peri-operatórios recomendados pelo Projeto ACERTO : estudo multicêntrico

Abstract

The application of perioperative care multimodal protocol have resulted in significant improvement in surgery's results, remarkably, shorter hospital stay, reduction of global complications and deaths. However, there is a wide variety of conducts in multimodal protocols, with different times of application, which generates a particular interest to investigate what the components of a multimodal protocol would be the most responsible for positive results that have been observed. OBJECT: Investigate in patients submitted to large elective colorectal operations in two university hospitals of thecity of Cuiabá-MT, between epidemiologic factors, clinical factors, and conducts of multimodal protocol ACERTO, which be have as independent risk variables for theresults of: time of postoperative hospital stay, incidence of surgical site infection, anastomotic fistula, pneumoniaatelectasis and mortality. METHODS: Cohort study including patients submitted to elective open surgery, with colon resection and/or rectum, primary anastomosis or terminal colostomy closure with realization of colorectal anastomosis (Hartmann's procedure). RESULTS: 234 patients were analyzed and submitted to 84 (35.9%) Hartmann's colostomy reconstructions, 39 (16.7%) right coloncolectomy, 39 (16.7%) left coloncolectomy and 72 (30.8%) anterior rectum resection. In the logistic regression model, maintained relation to length of hospital stay postoperative ≥7days rectal surgery (OR=2,93 IC95=1,43- 6,02; p=0,03) and presence of the NNIS risk index (OR=5,25 IC95=2,15-12,86). Preoperative fasting ≤4h (OR=0,250 IC95=0,114-0,551) and intravenous volume of crystalloid infused ≤30ml/kg/day (OR=0,290 IC95=0,119-0,706) formed protective factors against ≥7 days postoperative hospitalization. The risk of postoperative infection was 4x greater in malnourished (IC95=1,98-8,20); 8.5x higher in rectal surgery (IC95=3,42-21,08) and 4.58x higher in the presence of NNIS risk factor (IC95=1,75-11,97). The duration of preoperative fasting ≤4h was a protective factor, reducing by 81.3% the risk of surgical site infection. By multivariate analysis, increased risk of anastomotic fistula occurred for malnutrition (OR=2,87 IC95=1,36-6,05; p=0,006), rectal surgery (OR=8,23 IC95=3,12-21,74; p<0,0001) and presence of NNIS risk factor (OR=6,14 OR=2,09-18,05; p=0,001). Time preoperative fasting ≤4h (OR=0,11 IC95=0,05-0,25; p<0,0001) constituted a protective factor for the occurrence of fistulas. Factors significantly associated with pneumonia-atelectasis were cancer diagnosis (OR = 4.82 OR = 2.03 -11.47, p <0.0001) and rectal surgery(OR=3,07 IC95=1,18-7,74; p=0,022), while the time of preoperative fasting ≤4h (OR=0,10 IC95=0,04-0,24; p<0,0001) and intravenous volume of crystalloid infused ≤30ml/kg/day (OR=0,36 IC95=0,13-0,97, p=0,044) shown to be protective factors for pneumonia-atelectasis. Cancer diagnosis was associated with an increased risk of death 9x (OR= 9,04 IC95=1,60-50,89). In this study, the duration of preoperative fasting ≤4h (OR=0,05 IC95= 0,01-0,23) and intravenous volume of crystalloid infused ≤30ml/kg/day (OR=0,14 IC95=0,02-0,97) constituted protective factors for mortality. CONCLUSION: In this series of patients were independent risk factors for prolonged postoperative hospitalization: surgeries involving the rectum, presence of NNIS risk factor, time of preoperative fasting exceeding 4h and intravenous crystalloid fluidtherapy exceeding 30ml/kg/day for the first 48 hours of postoperative. Malnutrition, rectal surgery, NNIS risk factor and time of preoperative fasting exceeding 4h were independent risk factors for surgical site infection and anastomotic fistula. By multivariate analysis, risk factors for pneumonia-atelectasis were: rectum surgeries, time of preoperative fasting exceeding 4h and intravenous crystalloid fluidtherapy exceeding 30ml/kg/day and cancer diagnosis. Cancer diagnosis, prolonged preoperative fasting and intravenous crystalloid fluidtherapy exceeding 30ml/kg/day represented independent risk factors for postoperative death.