Implementation of Enhanced Recovery After Colorectal Surgery (Eras) Protocol: Initial Results of the First Brazilian Experience

Background:Colorectal cancer has a higher incidence in the rectum and sigmoid. However, with the expansion of the diagnosis of superficial lesions interest in the diagnosis and in the role they play in colorectal carcinogenesis has increased. Aim:To verify the behavior of superficial lesions of the colon and rectum, comparing the pathological and endoscopic findings, below and above 65 years. Methods:Cross-sectional study with prospective evaluation of standard protocol, where 200 patients with colorectal superficial lesions were evaluated; they were submitted to colonoscopy and mucosectomy of these lesions. They were divided in two age groups, below and above 65 years. Results: One hundred-and-eight were women (54%) and 92 men (46%). Most colon lesions were localized in the right colon (95%) and the remaining (5%) in the rectum. In endoscopy, 77.20% were granular lesions in patients under 65 years and 77.90% above. Colon histology showed low grade intraepithelial neoplasia, being 69.79% in patients under and 73.70% in above 65 years. In rectum, above 65 years the incidence of high-grade intraepithelial neoplasia was higher (66.70%). Conclusion:The superficial colorectal lesions have been more endoscopically diagnosed today, and the highest incidence is the granular type, both in the colon and rectum, regardless of age. Regardless the age, histologically colon lesions were more as low grade intraepithelial neoplasia. In rectum, there was distinction for both age groups, being more frequent high grade intraepithelial neoplasia in patients over 65 years.

Section: Introductionmentioning

confidence: 99%

Is Superficial Colorectal Lesions With Low and High Grades Intraepithelial Neoplasms More Prevalent in Older Above 65 Years?

diger¹,

Kubrusly

Nassif

et al. 2019

“…Initially, descriptive statistics of continuous variables were made, that is, the minimum, maximum, median, mean and standard deviation were estimated, then they were evaluated for normal distribution using the lilliefors test and as they presented normal distribution, they were assessed by the parametric Student's t test. Then, to assess the association of sociodemographic and clinic-surgical variables in relation to the INTRODUCTION T he ACERTO project (ACEleration of Postoperative Total Recovery) is based on the ERAS protocol (Enhanced Recovery After Surgery) in which care is guided by daily goals based on evidence-based medicine 21,24,25 . The implementation of this form of care has shown a significant reduction in postoperative complications and reduced the length of hospital stay by 30-50%, and today it is adopted in more than 20 countries as the ideal form of surgical assistance 12 .…”

Section: Discussionmentioning

confidence: 99%

“…The ACERTO project (ACEleration of Postoperative Total Recovery) is based on the ERAS protocol (Enhanced Recovery After Surgery) in which care is guided by daily goals based on evidence-based medicine 21 , 24 , 25 . The implementation of this form of care has shown a significant reduction in postoperative complications and reduced the length of hospital stay by 30-50%, and today it is adopted in more than 20 countries as the ideal form of surgical assistance 12 .…”

Section: Introductionmentioning

confidence: 99%

Acerto Project: Impact on Assistance of a Public Emergency Hospital

Sampaio

Leal

et al. 2020

Background: In Brazil, the goal-based approach was named Project ACERTO and has obtained good results when applied in elective surgeries with shorter hospitalization time, earlier return to activities without increased morbidity and mortality. Aim: To analyze the impact of ACERTO on emergency surgery care. Methods: An intervention study was performed at a trauma hospital. Were compared 452 patients undergoing emergency surgery and followed up by the general surgery service from October to December 2018 (pre-ACERTO, n=243) and from March to June 2019 (post-ACERTO, n=209). Dietary reintroduction, volume of infused postoperative venous hydration, duration of use of catheters, probes and drains, postoperative analgesia, prevention of postoperative vomiting, early mobilization and physiotherapy were evaluated. Results: After the ACERTO implantation there was earlier reintroduction of the diet, the earlier optimal caloric intake, earlier venous hydration withdrawal, higher postoperative analgesia prescription, postoperative vomiting prophylaxis and higher physiotherapy and mobilization prescription were achieved early in all (p<0.01); in the multivariate analysis there was no change in the complication rates observed before and after ACERTO (10.7% vs. 7.7% (p=0.268) and there was a decrease in the length of hospitalization after ACERTO (8,5 vs. 6,1 dias (p=0.008). Conclusion: The implementation of the ACERTO project decreased the length of hospital stay, improved medical care provided without increasing the rates of complications evaluated.

“…This was named Projeto ACERTO (acronym in portuguese for “Aceleração da Recuperação Total” no Pós-Operatório - Enhancing total postoperative recovery). 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.…”

Section: Introductionmentioning

confidence: 99%

Factors Related to the Reduction of the Risk of Complications in Colorectal Surgery Within Perioperative Care Recommended by the Acerto Protocol

Bicudo-Salomão

Salomão

Cuerva

et al. 2019

Background: 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.