text:
!"" #$%&" !
Seja Membro Acadêmico da maior associação cirúrgica da América Latina
O Colégio Brasileiro de Cirurgiões cria categoria especial para acadêmicos de medicina VISITE O SITE DO CBC: www.cbc.org.br • Confira as inúmeras atividades e serviços para sua formação e desenvolvimento. • Pré-requisitos para ser Membro Acadêmico do CBC Informe-se também na Secretaria Geral do CBC Tel.: (21) 2138-0653/0654 Sede: Rua Visconde de Silva, 52 - 3º andar Botafogo - Rio de Janeiro - CEP: 22271-092
0QSPHSBNBDJFOUรmDP KรFTUรEJTQPOรWFMOPTJUF XXXDCIFSOJBDPNCS
&XUWDQR ]XZ\Yffb
)HGHUDFLyQ/DWLQRDPHULFDQDGH+HUQLD )HGHUDomR/DWLQRDPHULFDQDGH+HUQLD
B EFNBJP EF ;nfeKd_c[Z 9kh_j_XW%FH
1SJODJQBJTUFNBT ย 0GVUVSPรBHPSBo$PNPBUFDOPMPHJBFTUรNVEBOEPB
*/5&3/"$*0/"*4 $0/7*%"%04
BCBOEPOBOEPPCJTUVSJ ย &OEPNFUSJPTFQSPGVOEBDPNBDPNFUJNFOUPJOUFTUJOBM ย "OBUPNJBSFUSPQFSJUPOFBMBQMJDBEBรDJSVSHJBMBQBSPTDรQJDB ย %FSJWBยกรFTVSJOรSJBTJOUSBDPSQรSFBTRVBJTPTEFTBmPT
6RFLHGDGH%UDVLOHLUDGH &LUXUJLD %DULiWULFD H 0HWDEyOLFD
2UJDQL]DomR H9LDJHQV
Órgão Oficial do Colégio Brasileiro de Cirurgiões EDITOR Guilherme Pinto Bravo Neto TCBC-RJ Associate Professor, Department of Surgery, Faculdade de Medicina, Universidade Federal do Rio de Janeiro-UFRJ-Rio de Janeiro-RJ-Brasil.
LIBRARIAN Lenita Penido Xavier
WRITING ASSISTANT David S. Ferreira Júnior
GRAPHIC DESIGN HG Design Digital Ltda.
RESPONSIBLE JOURNALIST João Maurício Carneiro Rodrigues
ADVISORY BOARD ABRÃO RAPOPORT - ECBC-SP - Hospital Heliópolis - São Paulo - SP - BR ALDO DA CUNHA MEDEIROS - ECBC-RN - Universidade Federal do Rio Grande do Norte – Natal – RN - BR ALEXANDRE FERREIRA OLIVEIRA - TCBC-PE - Universidade Federal de Pernambuco – Recife – PE - BR ÁLVARO ANTONIO BANDEIRA FERRAZ - TCBC-PE - Universidade Federal de Pernambuco – Recife – PE - BR ANA CRISTINA GOUVEIA MAGALHÃES - Universidade Federal do Rio de Janeiro- Rio de Janeiro- RJ – BR ANDY PETROIANU - TCBC-MG – Universidade Federal de Minas Gerais – Belo Horizonte – MG - BR ANTONIO CARLOS VALEZI - TCBC-PR – Universidade Estadual de Londrina - Londrina - PR – BR ANTONIO JOSÉ GONÇALVES - TCBC-SP – Faculdade de Ciências Médicas da Santa Casa de São Paulo- São Paulo - SP - BR ARLINDO MONTEIRO DE CARVALHO JR. - TCBC-PB - Universidade Federal da Paraíba João Pessoa - PB - BR CARLOS ALBERTO PORCHAT - TCBC-RJ - Hospital Clementino Fraga Filho da Universidade Federal do Rio de Janeiro - RJ - BR CARLOS ANSELMO LIMA - TCBC-SE- Universidade Federal de Sergipe – Aracaju - SE - BR CARLOS DELROY - Universidade Federal de São Paulo - São Paulo - SP - BR DAYSE COUTINHO VALENTE - TCBC-RJ- Instituto Fernando Luiz Barroso – Rio de Janeiro - RJ - BR DIOGO FRANCO - TCBC-RJ - Universidade Federal do Rio de Janeiro- Rio de Janeiro – RJ - BR DJALMA JOSE FAGUNDES - ECBC-SP - Universidade Federal de São Paulo – São Paulo – SP – BR EDMUND CHADA BARACAT - TCBC – SP - Universidade Federal de São Paulo – São Paulo – SP – BR EDNA FRASSON DE SOUZA MONTERO - TCBC-SP- Universidade Federal de São Paulo – São Paulo – SP – BR EDUARDO CREMA - TCBC-MG - Universidade Federal do Triângulo Mineiro - Uberaba MG - BR EDUARDO HARUO SAITO - TCBC-RJ- Universidade do Estado do Rio de Janeiro – Rio de Janeiro - RJ - BR ELIZABETH GOMES DOS SANTOS - TCBC-RJ - Universidade Federal do Rio de Janeiro – Rio de Janeiro – RJ - BR FÁTIMA CARNEIRO FERNANDES - Universidade Federal do Rio de Janeiro - Rio de Janeiro - RJ - BR FLÁVIO DANIEL SAAVEDRA TOMASICH - TCBC-PR – Hospital de Clínicas da Universidade Federal do Paraná – Curitiba –PR- BR FLÁVIO MALCHER M. DE OLIVEIRA - TCBC-RJ - Hospital Universitário Gaffrée e Guinle - Rio de Janeiro - RJ - BR FREDERICO AVELLAR SILVEIRA LUCAS - TCBC-RJ - Instituto Nacional do Câncer – Rio de Janeiro - RJ - BR GIULIANO ANCELMO BENTO - ACBC- RJ – Universidade do Estado do Rio de Janeiro – Rio de Janeiro – RJ – BR GUSTAVO PEREIRA FRAGA - TCBC-SP - Universidade Estadual de Campinas – Campinas - SP – BR HAMILTON PETRY DE SOUZA - ECBC-RS - Pontifícia Universidade Católica do Rio Grande do Sul – Porto Alegre - RS – BR HAROLDO VIEIRA DE MORAES Jr. - Universidade Federal do Rio de Janeiro - Rio de Janeiro - RJ - BR HENRI CHAPLIN RIVOIRE - TCBC-RS -Universidade Federal do Rio Grande do Sul - Porto Alegre - RS - BR HENRIQUE MURAD - ECBC-RJ - Universidade Federal do Rio de Janeiro - Rio de Janeiro - RJ - BR JOSÉ ANACLETO DUTRA RESENDE Jr. - Hospital Universitário Pedro Ernesto-UERJ - Rio de Janeiro - RJ - BR JOSÉ EDUARDO DE AGUILAR NASCIMENTO - TCBC-MT-Universidade Federal de Mato Grosso – Cuiabá – MT –BR JOSÉ EDUARDO FERREIRA MANSO - TCBC-RJ – Universidade Federal do Rio de Janeiro – Rio de Janeiro – RJ – BR JOSÉ LUIZ BRAGA DE AQUINO - TCBC-SP - Faculdade de Ciências Médicas - PUC Campinas - SP - BR JOSÉ MARCUS RASO EULÁLIO - TCBC-RJ – Universidade Federal do Rio de Janeiro – Rio de Janeiro – RJ – BR JOSÉ MAURO DA SILVA RODRIGUES - TCBC-SP - Pontifícia Universidade Católica de São
Paulo - São Paulo - SP - BRA JOSÉ WILSON NOLETO - Universidade Federal da Paraíba - João Pessoa - PB - BR JULIO CESAR BEITLER - TCBC-RJ – Universidade Estácio de Sá – Rio de Janeiro - RJ - BR JÚLIO CEZAR UILI COELHO - TCBC-PR – Universidade Federal do Paraná – Curitiba - PR – BR KATIA SHEYLA MALTA PURIM - Universidade Positivo - Curitiba - PR - BR LEONEL DOS SANTOS PEREIRA - Universidade Federal do Rio de Janeiro - Rio de Janeiro - RJ - BR LISIEUX EYER DE JESUS - TCBC-RJ- Universidade Federal Fluminense – Niterói – RJ – BR LUIZ CARLOS DUARTE DE MIRANDA - ACBC-RJ - Universidade Federal do Rio de Janeiro - Rio de Janeiro - RJ - BR LUIZ CARLOS VON BAHTEN - TCBC-PR- Universidade Federal do Paraná – Curitiba - PR – BR LUIZ GUSTAVO DE OLIVEIRA E SILVA - TCBC-RJ- Hospital Federal de Ipanema/Ministério da Saúde- Rio de Janeiro - RJ - BR LUIZ RONALDO ALBERTI - Universidade Federal de Minas Gerais – Belo Horizonte – MG –BR MANOEL XIMENES NETO - ECBC-DF –Universidade de Brasília – Brasília - DF - BR MANUEL DOMINGOS DA CRUZ GONÇALVES - ECBC-RJ- Universidade Federal do Rio de Janeiro- Rio de Janeiro –RJ – BR MARCOS ALPOIN FREIRE - TCBC-RJ- Universidade Federal do Rio de Janeiro- Rio de Janeiro – RJ – BR MARIA APARECIDA DE ALBUQUERQUE CAVALCANTE - Universidade Federal do Rio de Janeiro - Rio de Janeiro - RJ - BR MARIA DE LOURDES P. BIONDO SIMÕES - TCBC-PR – Pontifícia Universidade Católica do Paraná – Curitiba – PR - BR MARCELO AUGUSTO F. RIBEIRO JR. - TCBC-SP - Universidade de Santo Amaro- UNISA - São Paulo - SP - BR MAURÍCIO AUGUSTO S. MAGALHÃES COSTA - TCBC-RJ - Sociedade Brasileira de Mastologia - Rio de Janeiro - RJ - BR MAURO ANTÔNIO C. GUIMARÃES FILHO - Hospital Moinho dos Ventos - Porto Alegre - RS- BR MAURO DE SOUZA LEITE PINHO - TCBC-SC – Universidade da Região de Joinville – Joinville - SC - BR NELSON ADAMI ANDREOLLO - TCBC-SP – Universidade Estadual de Campinas Campinas - SP - BR NELSON ALFRED SMITH - Universidade Federal do Rio de Janeiro- Rio de Janeiro – RJ – BR NELSON FONTANA MARGARIDO – TCBC-SP – Universidade de São Paulo – São Paulo – SP – BR ORLANDO JORGE MARTINS TORRES - TCBC-MA - Universidade Federal do Maranhão - São Luís - MA - BR OSVALDO MALAFAIA - ECBC-PR- Universidade Federal do Paraná – Curitiba –PR- BR PAULO FRANCISCO GUERREIRO CARDOSO - ACBC-RS- Fundação Faculdade Federal de Ciências Médicas de Porto Alegre – Porto Alegre – RS - BR PAULO GONÇALVES DE OLIVEIRA - TCBC-DF - Universidade de Brasília – Brasília - DF - BR RENATO ABRANTES LUNA - TCBC-RJ - Hospital Federal dos Servidores do Estado do Rio de Janeiro - Rio de Janeiro - RJ - BR RICARDO ANTONIO CORREIA LIMA - TCBC-RJ – Universidade Federal do Estado do Rio de Janeiro- Rio de Janeiro – RJ – BR RICARDO VITOR COHEN - TCBC-SP - Hospital Alemão Oswaldo Cruz - São Paulo - SP - BR ROBERTO CAMPOS MEIRELLES - TCBC-RJ - Universidade do Estado do Rio de Janeiro - Rio de Janeiro - RJ - BR RODRIGO ALTENFELDER SILVA - TCBC-SP - Faculdade de Ciências Médicas da Santa Casa de São Paulo - São Paulo - SP-BR RODRIGO FELIPPE RAMOS - TCBC - RJ - Universidade Federal Fluminense - Niterói - RJ - BR ROGERIO APARECIDO DEDIVITIS - TCBC-SP - Universidade de São Paulo - São Paulo SP - BR RUFFO DE FREITAS JÚNIOR - TCBC-GO - Universidade Federal de Goiás - Goiânia – GO – BR SILVIA CRISTINE SOLDÁ - TCBC-SP- Faculdade de Ciências Médicas da Santa Casa de São Paulo- São Paulo - SP - BR SILVIO HENRIQUES DA CUNHA NETO – TCBC- RJ - Universidade Federal do Rio de Janeiro- Rio de Janeiro – RJ – BR SIZENANDO VIEIRA STARLING - TCBC-MG - Hospital João XXIII - Belo Horizonte - MG - BR THALES PAULO BATISTA - TCBC-PE- Faculdade Pernambucana de Saúde/ Instituto de Medicina Integral Professor Fernando Figueira - Recife - PE - BR VIVIAN RESENDE - TCBC-MG - Universidade Federal de Minas Gerais - Belo Horizonte MG - BR WILSON CINTRA JR. - TCBC-SP-Universidade de São Paulo- São Paulo- SP - BR
NATIONAL CONSULTANTS ALCINO LÁZARO DA SILVA, ECBC-MG - Universidade Federal de Minas Gerais - MG ALUIZIO SOARES DE SOUZA RODRIGUES, ECBC-RJ - Universidade Federal do Rio de Janeiro - UFRJ - RJ ANTONIO PELOSI DE MOURA LEITE, ECBC-SP - Instituto de Moléstias Cardiovasculares de São José do Rio Preto - SP DARIO BIROLINI, ECBC-SP - Faculdade de Medicina da Universidade de São Paulo - SP EUGÊNIO AMÉRICO BUENO FERREIRA, ECBC-SP - Faculdade de Medicina de Jundiaí - SP FERNANDO LUIZ BARROSO, ECBC-RJ - Hospital Municipal de Ipanema - RJ. FERNANDO MANOEL PAES LEME, ECBC-RJ - Faculdade de Medicina de Campos - RJ GASPAR DE JESUS LOPES FILHO, TCBC-SP - Universidade Federal de São Paulo - SP GUILHERME EURICO BASTOS DA CUNHA, ECBC-RJ - Universidade Federal Fluminense - RJ HELÁDIO FEITOSA DE CASTRO FILHO, TCBC-CE Universidade Federal do Ceará - CE ISAC JORGE FILHO, TCBC-SP - Universidade de Ribeirão Preto - SP. JOSÉ REINAN RAMOS, TCBC-RJ - Hospital Vitória-RJ LUIZ GUILHERME BARROSO ROMANO, ECBC-RJ MARCOS F. MORAES, ECBC-RJ - Universidade Gama Filho-RJ
ORLANDO MARQUES VIEIRA, ECBC-RJ - Universidade Federal do Rio de Janeiro-RJ ROBERTO SAAD JR., TCBC-SP - Faculdade de Ciências Médicas da Santa Casa de São Paulo-SP SAMIR RASSLAN, ECBC-SP - Faculdade de Medicina da Universidade de São Paulo-SP SAUL GOLDENBERG, ECBC-SP - Universidade Federal de São Paulo- Escola Paulista de Medicina - SP
INTERNATIONAL CONSULTANTS ARNULF THIEDE - Department of Surgery, University of Würzburg Hospital, Oberdürrbacher Str. 6, D-97080 Würzburg, Germany CLAUDE DESCHAMPS - M.D - The Mayo Clinic, MN,USA EDUARDO PARRA-DAVILA - Florida Hospital Celebration Health - 400 Celebration Pl, Kissimmee, FL 34747, USA. EMILIO DE VICENTE LÓPEZ – Sanchinarro Hospital, Madrid, Spain KARL H. FUCHS - Markus-Krankenhaus Frankfurter Diakonie-Kliniken, Wilhelm- Epstein-Straße 4, 60435 Frankfurt am Main MURRAY BRENNAN - HeCBC Department of Surgery, Memorial SloanKettering Cancer Center, New York NY, USA ULRICH ANDREAS DIETZ - Department of Surgery I, University of Würzburg, Medical School, Würzburg, Germany W. WEDER - Klinikdirektor-UniversitätsSpital Zürich, Switzerland
THE JOURNAL OF THE BRAZILIAN COLLEGE OF SURGEONS is indexed in Latindex, Lilacs and Scielo, Scopus, Medline / PubMed, DOAJ, Free Medical Journals, and sent every two months to all members of the CBC, to its subscribers, to medical institutions, libraries, hospitals and study centers, to publications with which it keeps exchange and to its advertisers.
PUBLISHING, SUBSCRIPTIONS and ADMINISTRATION Rua Visconde de Silva, 52 - 3º andar - Botafogo - 22271-092 - Rio de Janeiro - RJ - Brasil Tel.: + 55 21 2138-0659; Fax: + 55 21 2286-2595; E-mail: firstname.lastname@example.com http//www.cbc.org.br PRINTING AND FINISHING Gráfica e Editora Prensa Ltda Rua João Alvares, 27 Saúde - Rio de Janeiro - RJ Tel.: (21) 2253-8343
International Standard Serial Number ISSN 0100-6991
GRAPHIC DESIGN Artur Farias
GRAPHIC DESIGN – COVER Libertta Comunicação JOURNAL OF THE BRAZILIAN COLLEGE OF SURGEONS
Indexed in Latindex, Lilacs and Scielo, Scopus, Medline/PubMed, DOAJ and Free Medical Journals
Original Article
Splenic implant preservation after conservation in lactated Ringer´s solution Preservação de implante esplênico autógeno após conservação em solução de Ringer-lactato ARGOS SOARES VIDIGAL3.
A B S T R A C T Objective: to evaluate the morphology and function of autogenous splenic tissue implanted in the greater omentum, 24 hours after storage in Ringer-lactate solution. Methods: we divided 35 male rats into seven groups (n=5): Group 1: no splenectomy; Group 2: total splenectomy without implant; Group 3: total splenectomy and immediate autogenous implant; Group 4: total splenectomy, preservation of the spleen in Ringer-lactate at room temperature, then sliced and implanted; Group 5: total splenectomy, spleen sliced and preserved in Ringer-lactate at room temperature before implantation; Group 6: total splenectomy with preservation of the spleen in Ringerlactate at 4°C and then sliced and implanted; Group 7: total splenectomy and the spleen sliced for preservation in Ringer-lactate at 4°C before implantation. After 90 days, we performed scintigraphic studies with Tc99m-colloidal tin (liver, lung, spleen or implant and clot), haematological exams (erythrogram, leucometry, platelets), biochemical dosages (protein electrophoresis) and anatomopathological studies. Results: regeneration of autogenous splenic implants occurred in the animals of the groups with preservation of the spleen at 4ºC. The uptake of colloidal tin was higher in groups 1, 3, 6 and 7 compared with the others. There was no difference in hematimetric values in the seven groups. Protein electrophoresis showed a decrease in the gamma fraction in the group of splenectomized animals in relation to the operated groups. Conclusion: the splenic tissue preserved in Ringer-lactate solution at 4ºC maintains its morphological structure and allows functional recovery after being implanted on the greater omentum. Keywords: Spleen. Implants, Experimental. Trauma and Stressor Related Disorders. Organ Preservation.
immunoglobulins and other opsonins. It removes altered erythrocytes, anomalous particles and microorganisms
he damage control surgery consists of immediate interruption of bleeding and contamination due to severe trauma, followed by temporary closure of the body cavity and general stabilization of the patient. After 24 to 72 hours, a new operation is performed to repair the sustained damage1-5. Total splenectomy has been used as a treatment for severe splenic lesions in this situation. Despite saving the patient's life, this procedure results in complications related to the asplenic state. To avoid this adversity, total removal of the spleen has been replaced by conservative treatments such as partial or subtotal splenectomy and autogenous implants6-10. The spleen is responsible for 30% of the function of the mononuclear phagocytic system11 and participates in the synthesis of complement factors,
from the circulation11-13. The first autogenous splenic implants are attributed to Griffini and Tizzioni (1883), who performed them in dogs. In men, in surgery to treat splenic trauma, it began to be used in 1896. Petroianu14,15, from 1985, began to perform splenic autogenous implants in the greater omentum in patients with various affections, such as portal hypertension, myeloid hepatosplenomegaly, Gaucher's disease, leukemia, severe splenic pain and trauma15-18. The results of this procedure proved the effectiveness of the implants in preserving the functions of the spleen. The aim of this study was to evaluate the morphological and functional preservation of the autogenous splenic tissue implanted on the day after
1 - Department of Surgery, Medical School, Federal University of Minas Gerais, (UFMG), Belo Horizonte, MG, Brazil. 2 - Department of Clinical and Toxicological Analysis (Radioisotope Laboratory), Faculty of Pharmacy (UFMG), Belo Horizonte, MG, Brazil. 3 - Department of Pathological Anatomy, Medical School (UFMG), Belo Horizonte, MG, Brazil. Rev Col Bras Cir. 2018; 45(1):e1346
Matos Filho Splenic implant preservation after conservation in lactated Ringer´s solution
removal of the spleen after its conservation in Ringer-
lactate solution. After 24 hours, the abdominal cavity was
lactate solution.
reopened at the sutured site and the autogenous implants were performed using the same technique described for
Group 3.
This work was approved by the Ethics
99mTc-labeled colloidal tin solution (110MBq/3mCi) was
Committee on Animal Experimentation of the Federal
injected into the rats' tail vein after anesthesia. After 20
University of Minas Gerais (UFMG), protocol 265/2008.
minutes, the whole rat was studies in a gamma camera.
After the 90-day follow-up period, 1.0ml of
We randomly assigned 35 adult male rats
After a median laparotomy, 3.0ml of blood were collected
(Rattus norvegicus albinus) of the Holtzman lineage to
from the abdominal vena cava for hematological study.
seven groups (n=5): Group 1- no splenectomy; Group
This blood was collected in an EDTA flask, for erythrogram,
2- total splenectomy; Group 3- total splenectomy and
fractional leucometry and platelet dosage. Another blood
implantation of autogenous splenic tissue in the greater
sample was collected in a vial without anticoagulant, to
omentum, immediately after spleen removal; Group 4-
evaluate albumin and gamma fraction, using the protein
total splenectomy, preserving the entire spleen in Ringer-
electrophoresis method.
lactate solution at room temperature for 24 hours. The
The spleen or implants, the liver, the lungs and
spleen was then sliced and implanted over the greater
a blood clot were then removed. Each of these structures
omentum; Group 5- total splenectomy and spleen slicing,
was placed in a 20ml plastic beaker and inserted into the
with preservation in lactated Ringer's solution at room
collimator of the gamma camera to measure the uptake
temperature for 24 hours, then implantation of the
of the radiopharmaceutical into each tissue and its blood
splenic slices in the greater omentum; Group 6- total
remnant. After the scintigraphic study, the implants
splenectomy, preserving the whole spleen in Ringer-
were fixed in 10% buffered saline formaldehyde for later
lactate solution at 4°C for 24 hours, then the spleen was
histological evaluation.
sliced and implanted on the greater omentum; Group 7-
The analysis of the phagocytic function,
total splenectomy and spleen slicing, with preservation
through the colloidal tin uptake by the scintigraphic
in lactated Ringer's solution at 4°C for 24 hours, then
method, was estimated by the radioactive counts per
implantation of the splenic slices in the greater omentum.
gram of tissue. Each sample was weighed immediately
We grouped the rats into cages, one for each
upon its withdrawal. Taking into account the weight of
group. All received common chow for rats and water ad
liver, spleen or implant samples, lung and blood clot, the
libitum. No procedure was performed in Group 1. In groups
radioactivity of the sample was calculated by counting the
2 to 7, after anesthesia with an association of ketamine
per minute (cpm) of uptake per gram (g) of tissue19-21.
hydrochloride (50mg/kg) and xylazine hydrochloride (5mg/
For the purpose of calculation, the sum of the
kg) intramuscularly, total splenectomy was performed by
radioactivities of liver, splenic, lung and blood clot samples
means of a supraumbilical median laparotomy. In Group
from the same animal was considered as equivalent to
3, the spleen was transversely sliced into five segments,
100% of the radioactivity injected into it. To calculate
three of which were sutured immediately over the greater
the percentage of uptake of each tissue, we used the
omentum, with a continuous 6-0 prolene suture. At the
following formula21: % = (cpm/g da the sample x 100) /
end of this suture, the omentum was folded over to cover
cpm/g of all samples.
the splenic segments. After reviewing the abdominal
Data were presented as mean and standard
cavity and hemostasis, the abdominal wall was closed in
error of the mean. We used the Kolmogorov-Smirnov
two planes using 2-0 silk monofilament sutures.
normality test, followed by the Bartlett test, to compare
In animals from groups 4, 5, 6 and 7 the
hematimetric and immune values and the percentage
removed spleen, whole or sliced according to the group,
collected by the mononuclear phagocytic system of the
was placed in a 25ml Becker flask containing Ringer-
liver, spleen or implants, lungs and clot of the different
Rev Col Bras Cir. 2018; 45(1):e1346
Matos Filho Splenic implant preservation after conservation in lactated Ringer´s solution
groups. When the data displayed a normal distribution
In the group with preservation of the whole
and same variance, we performed the parametric analysis
spleen in Ringer-lactate solution at 4ºC for 24 hours
of variance (ANOVA), followed by the Tukey-Kramer multiple comparison test. When the values did not present a normal distribution, we performed the KruskalWallis test, followed by the Dunn-Bonferroni multiple comparison test. We considered the results significant for a probability of significance higher than 95% (p<0.05).
(Group 6) and in the group with preservation of the sliced spleen in Ringer-lactate solution at 4ºC for 24 hours (Group 7), the scintigraphy showed clear images of the implants (Figures 2A and 2B). The omentum with the implants were removed for scintigraphic imaging due to the overlap of the liver.
RESULTS All rats tolerated anesthesia well and evolved satisfactorily, with rapid postanesthetic recovery and apparently normal motor activity. Splenectomy was performed without intraoperative complications in all animals. All rats survived 90 days. In the reoperations after 90 days, we observed no intra-abdominal collections. In all animals of groups 4 and 5 we observed no splenic implants in the omentum. In groups 6 and 7 we found splenic implants with normal appearance (Figure 1).
Figure 1. Macroscopic appearance of the implants (arrows) on the greater omentum
In the group in which total splenectomy was complemented with autogenous splenic implant in the greater omentum immediately after spleen removal (Group 3), scintigraphy showed clear images of the liver and splenic implants. However, there was no image of splenic implants in groups with preservation of spleen in Ringer-lactate solution at room temperature (Groups 4 and 5).
Figure 2. Scintigraphic image of the implants.
The relative uptake (percentage) of the radiopharmaceutical was greater in the splenic tissue of Group 1 (without splenectomy), Group 3 (immediate autogenous implant), Groups 6 and 7 (autogenous implants after preservation of the spleen in Ringer-lactate solution at 4ºC) (p=0.0003). In the other groups (2, 4 and 5) there was no record of splenic tissue (Figure 3).
Figure 3. Uptake according to organ or tissue * p=0.0003 (Krustal-Wallis) – 1>2=4=5 (Dunn-Bonferroni); ** p=0.0271 (ANOVA) – 2=4>1(Tukey-Kramer).
Scintigraphic comparison of the tissues of the phagocytic mononuclear system indicated increased liver uptake in all groups, followed by the spleen (in the group where it was preserved) and then lung (p=0.0271) (Figure 3). When comparing the presence of the radiopharmaceutical in the circulating blood (clot), there was no difference between groups (p=0.3155).
Rev Col Bras Cir. 2018; 45(1):e1346
Matos Filho Splenic implant preservation after conservation in lactated Ringer´s solution
Table 1 shows the comparison of erythrogram,
group of animals with autogenous implantation of splenic
hemoglobin and hematocrit levels between groups after
fragments preserved at room temperature in relation to all
90 days. The mean leukocyte count increased in the
other groups after 90 days of operation (p=0.0235).
Table 1. Results of the laboratory tests by group.
Study Red blood Hemoglobin Hematocrit Leukocytes (g/dl) (%) (x103/dl) Group cells (x106/dl)
Platelets (x103/dl)
Protein Albumin electrophoresis protein Gamma electrophoresis Fraction (g/dl) (g/dl)
15.54 0.20 49.56±0.97 5.21±1.40 555.20±35.07
9.76±0.38 15.86±0.67 51.18±2.18 6.90±0.98 583.20±98.76
9.49±0.14 15.90±0.27 49.55±0.88 6.46±0.70 744.75±55.45
9.47±0.18 15.38±0.18 47.90±0.87 7.91±1.46 700.20±78.98
9.16±0.31 14.53±0.96 45.05±3.08 15.89±4.48 756.00±129.40
8.86±0.19 14.86±0.24 46.14±1.00 10.09±2.19 625.00±46.26
8.42±0.56 13.86±1.09 42.76±3.46 13.63±2.94 615.80± 7.27
1- No splenectomy; 2- Splenectomy; 3- Total splenectomy with autogenous implant in the same operative procedure; 4- Total splenectomy with preservation of whole spleen in Ringer-lactate solution at room temperature and autogenous implant after 24 hours; 5- Total splenectomy with preservation of the sliced spleen in Ringer-lactate solution at room temperature and autogenous implant after 24 hours; 6- Total splenectomy with preservation of whole spleen in Ringer-lactate solution at 4ºC and autogenous implant after 24 hours; 7- Total splenectomy with preservation of the sliced spleen in Ringer-lactate solution at 4ºC and autogenous implant after 24 hours.
Autogenous implants of groups 3, 6 and 7 presented the same histological pattern (Figure 4), all without difference from the normal spleen aspect (Group 1).
DISCUSSION The spleen has several functions essential to the organism. In this organ, lymphocytes and monocytes are formed and phagocytosis of foreign particles, parasites, bacteria, fungi and viruses11,13 is responsible for 30% of the function of the mononuclear phagocytic system. The spleen also participates in the synthesis of complement factors and immunoglobulins. It differs from lymph nodes by receiving antigens from blood rather than from lymph. In addition to being essential to the body's defense system, the spleen removes altered erythrocytes and anomalous particles from the interior of circulating cells, such as the Howell-Jolly, Heintz and Pappenheimer corpuscles. This clearance is performed by splenic cord macrophages through direct phagocytosis, without the need for opsonization12-14.
Figure 4. Histological appearance of implants. White pulp (B), red pulp (V) and central artery (arrow).
Splenic lesions resulting from abdominal trauma are treated in most cases without operation due to the recognition of the importance of its immune function and
Rev Col Bras Cir. 2018; 45(1):e1346
Matos Filho Splenic implant preservation after conservation in lactated Ringer´s solution
the adverse effects resulting from asplenia. Even when
when the implants are of larger size or are not covered
surgical intervention is necessary, the options have been
by the greater omentum to avoid adhesions with the
preservation of the organ, with splenic sutures, vascular
intestine or other abdominal structure.
ligations, application of topical hemostatic agents, partial
Pister & Leon Pachter30 reviewed spleen
splenectomies and subtotal splenectomies. In cases
implants in humans and animals but failed to demonstrate
where complete removal of the spleen is unavoidable, the
a reduction in morbidity and mortality rates related to
autogenous splenic tissue implant is the alternative14-22.
subsequent bacterial infections. Other studies have shown
The conduct of the splenic trauma should
that there is a need for at least 25% of the amount of
consider the patient as a whole, in its physiological and
tissue in a normal spleen to preserve all its functions25,29-32.
comorbid aspects. Decisions are differentiated in adults
The experience of the present research group with splenic
and children. In pediatric trauma, it is recommended at
implants for portal hypertension, Gaucher's disease, and
level 2B that the spleen should be preserved even partially,
myeloid metaplasia, as well as in the presence of chronic
and non-operative treatment should be attempted even
lymphocytic leukemia, have shown absence of abnormal
in patients with associated traumatic spinal cord or brain
particles in blood samples, suggesting that phagocytosis
injury. In adults, splenectomy is indicated in the non-
function is present in the implanted splenic tissue14-18.
operative treatment failure, and this is still practiced in
The Ringer-lactate solution is a low-cost
24% to 35% of the patients, where only 1% to 6% of
physiological solution available in most surgical wards. This
patients are submitted to spleenorraphy. In this group,
study showed that this solution was sufficient to preserve
when traumatic brain injury or associated spinal cord
the vitality of the splenic tissue at low temperatures.
injury is present, splenectomy is indicated .
Still remains the doubt about the best temperature to
Splenic autoimplantation was described mainly 14
preserve the splenic tissue, although the temperature of
after splenectomy due to severe trauma . This operation is
4°C in a common refrigerator is adequate to maintain its
based on splenosis, that is, the spontaneous implantation
vitality. In animals in which the implant was performed
of spleen fragments in any part of the body, mainly in the
after preservation in Ringer-lactate at 4°C (groups 6 and
abdomen, after severe splenic injury. The splenic tissue is
7), the scintigraphic examination was not different from
able to maintain its vitality anywhere in the body in which
those with implants performed immediately after spleen
it is implanted. Experimental studies have indicated that
removal (Group 2). This confirms the good clearance
the best place to implant splenic fragments is the greater
function present on the day after spleen removal.
omentum. This choice is due not only to the rich omentum
According to the indications of this experimental
blood supply, but to the fact that its blood drains into the
study, it is pertinent to suppose that in cases of severe
liver through the portal system, which is also the natural
trauma with indication of total splenectomy, the removed
spleen drainage. This may be particularly useful in terms
spleen can be preserved in refrigerated Ringer-lactate
of splenic functions and production of immunoglobulins,
solution to maintain its vitality, and be used as an
complements and metabolic substances
autogenous implant, in the greater omentum, during the
The literature shows some complications
reoperation to repair the damage. This procedure, which
of splenic implants, such as hemorrhage, intestinal
lasts less than five minutes, can restore splenic functions
obstruction or perforation. These complications occur
and prevent asplenia complications.
Rev Col Bras Cir. 2018; 45(1):e1346
Matos Filho Splenic implant preservation after conservation in lactated Ringer´s solution
R E S U M O Objetivo: avaliar morfologia e função de tecido esplênico autógeno, implantado no omento maior, 24 horas após conservação em solução de Ringer-lactato. Métodos: foram estudados 35 ratos machos, distribuídos em sete grupos (n=5): Grupo 1: sem esplenectomia; Grupo 2: esplenectomia total sem implante; Grupo 3: esplenectomia total e implante autógeno imediato; Grupo 4: esplenectomia total, preservação do baço em Ringer-lactato à temperatura ambiente, em seguida, fatiado e implantado; Grupo 5: esplenectomia total, baço fatiado e preservado em Ringer-lactato à temperatura ambiente antes de ser implantado; Grupo 6: esplenectomia total com preservação do baço em Ringer-lactato a 4°C e, em seguida, fatiado e implantado; Grupo 7: esplenectomia total e baço fatiado, para preservação em Ringer-lactato a 4°C antes de ser implantado. Após 90 dias, realizaram-se estudos cintilográficos com estanho coloidalTc99m (fígado, pulmão, baço ou implante e coágulo), hematológicos (eritrograma, leucometria, plaquetas), bioquímicos (eletroforese de proteínas) e anatomopatológicos. Resultados: ocorreu regeneração dos implantes esplênicos autógenos nos animais dos grupos com preservação do baço a 4ºC. A captação de estanho coloidal foi superior nos grupos 1, 3, 6 e 7 em relação aos demais. Não houve diferença nos valores hematimétricos nos sete grupos. A eletroforese de proteínas mostrou diminuição da fração gama no grupo de animais esplenectomizados em relação aos grupos operados. Conclusão: o tecido esplênico conservado em solução de Ringer-lactato à temperatura de 4ºC mantém sua estrutura morfológica e permite a recuperação funcional após ser implantado sobre o omento maior. Descritores: Baço. Implantes Experimentais. Redução do Dano. Preservação de Órgãos.
complications: a prospective multicenter study. J Trauma Acute Care Surg. 2012;72(1):229-34.
1. Waibel BH, Rotondo MM. Damage control surgery: it's evolution over the last 20 years. Rev Col Bras Cir. 2012;39(4):314-21. 2. Chovanes J, Cannon JW, Nunez TC. The evolution of damage control surgery. Surg Clin North Am. 2012; 92(4):859-75. 3. Normando GR JR. [Damage control surgery and Latin America's contributions to it]. Rev Col Bras Cir. 2011;38(1):1-2. Portuguese. 4. Duchesne JC, McSwain NE Jr, Cotton BA, Hunt JP, Dellavolpe J, Lafaro K, et al. Damage control resuscitation: the new face of damage control. J Trauma. 2010;69(4):976-90. 5. Edelmuth RCl, Buscariolli YS, Ribeiro MA Jr. Cirurgia para controle de danos: estado atual. Rev Col Bras Cir. 2013;40:142-151. 6. Beuran M, Gheju I, Venter MD, Marian RC, Smarandache R. Non-operative management of splenic trauma. J Med Life. 2012;5(1):47-58. 7. Liu PP, Liu HT, Hsieh TM, Huang CY, Ko SF. Nonsurgical management of delayed splenic rupture after blunt trauma. J Trauma Acute Care. Surg. 2012;72(4):101923. 8. Skattum J, Naess PA, Gaarder C.Non-operative management and immune function after splenic injury. Br J Surg. 2012; 99 Suppl 1:59-65. 9. Demetriades D, Scalea TM, Degiannis E, Barmparas G, Konstantinidis A, Massahis J, et al. Blunt splenic
10. Renzulli P, Gross T, Schnüriger B, Schoepfer AM, Inderbitzin D, Exadaktylos AK, et al. Management of blunt injuries to the spleen. Br J Surg. 2010;97(11):1696-703. 11. Llende
Immunobiological consequences of splenectomy: a review. J Surg Res. 1986;40(1):85-94. 12. Müftüo lu TM1, Köksal N, Ozkutlu D. Evaluation
rats after partial splenectomy. J Am Coll Surg. 2000;191(6):668-71. 13. Lynch AM, Kapila R. Overwhelming postsplenectomy infection. Infect Dis North Am. 1986;10(4):693-707. 14. Petroianu A, Simal CJR, Barbosa AJA. Assessment of phagocytic funtion in remnants of subtotal splenectomy and in autologous spleen implantation. Med Sci Res. 1993;21:715-7. 15. Resende
Autotransplantation for treatment of severe splenic lesions. Emerg Radiol. 2002;9(4):208-12. 16. Resende V, Petroianu A. Funções do remanescente esplênico após esplenectomia subtotal ou autoimplantes esplênicos para tratamento de lesões graves do baço humano. Rev Med Minas Gerais. 2001;11(1):59. 17. Marques RG, Petroianu A, Coelho JM, Portela MC. Regeneration of splenic autotransplants. Ann Hematol. 2002;81(11):622-6.
Rev Col Bras Cir. 2018; 45(1):e1346
Matos Filho Splenic implant preservation after conservation in lactated Ringer´s solution
18. Petroianu A, Petroianu LP. Splenic autotransplantation
27. Clayer M, Drew P, Leong A, Jamieson GG. The
for treatment of portal hypertension. Can J Surg.
vascular supply of splenic autotransplants. J Surg
Res. 1992;53(5):475-84.
19. Petroianu A, Simal CJRS. Shifts in the reticuloendothelial system uptake pattern induced by carbon colloid in the rat. Med Sci Res. 1993;21:311-2. 20. Marques RG, Petroianu A, de Oliveira MB, BernardoFilho M, Boasquevisque EM, Portela MC. Bacterial clearance after total splenectomy and splenic autotransplantation in rats. Appl Radiat Isot. 2002;57(6):767-71. 21. Marques RG, Petroianu A, Coelho JMCO, Portela MC. Morfologia e função fagocitária de implante esplênico autógeno regenerado em ratos. Acta Cir Bras. 2004;19(6):642-8. 22. Silva RG, Petroianu A, Silva MG, Diniz SOF, Cardoso VN. Influência das operações sobre o baço na distribuição da Escherichia coli no sistema mononuclear fagocitário. Rev Col Bras Cir. 2003;30(1):65-71. 23. Coccolini F, Montori G, Catena F, Kluger Y, Biffl W, Moore EE, et al. Splenic trauma: WSES classification and guidelines for adult and pediatric patients. World J Emerg Surg. 2017;12:40. 24. Livingston CD, Levine BA, Sirinek KR. Site of splenic autotransplantation effects protection from sepsis. Am J Surg. 1983;146(6):734-7. 25. Alvarez FE, Greco RS. Regeneration of the spleen after ectopic implantation and partial splenectomy.
28. Iinuma H, Okinaga K, Sato S, Tomioka M, Matsumoto K. Optimal site and amount of splenic tissue for autotransplantation. J Surg Res. 1992;53(2):109-16. 29. Weber T1, Hanisch E, Baum RP, Seufert RM. Late results of heterotopic autotransplantation of splenic tissue into the greater omentum. World J Surg. 1998; 22(8):883-9. 30. Pisters PW, Pachter HL. Autologous splenic transplantation for splenic trauma. Ann Surg. 1994;219(3):225-35. 31. Drew PA, Clayer MT, Jamieson GG. The value of splenic autotransplantation. Arch Surg. 1990;125(9):1224. 32. Witte CL, Witte MH. Enlargement of splenic implants. Surgery. 1995;117(3):357.
Received in: 03/08/2017 Accepted for publication: 17/09/2017 Conflict of interest: none. Source of funding: none. Mailing address: Argos Soares de Matos Filho E-mail: email@example.com / firstname.lastname@example.com
Arch Surg. 1980;115(6):772-5. 26. Cooney DR, Dearth JC, Swanson SE, Dewanjee MK, Telander RL. Relative merits of partial splenectomy, splenic reimmplantation, and immunization in preventing postsplenectomy infection. Surgery. 1979;86(4):561-9.
Rev Col Bras Cir. 2018; 45(1):e1346
Original Article
Glucose level evaluation in monopedicled rectus abdominis myocutaneous flap after venous occlusion: experimental study in rats Avaliação do nĂvel glicĂŞmico em retalho miocutâneo do reto abdominal monopediculado apĂłs oclusĂŁo venosa: estudo experimental em ratos. GUSTAVO LEVACOV BERLIM1; ANTĂ"NIO CARLOS PINTO OLIVEIRA2; CIRO PAZ PORTINHO2; EMERSON MORELLO1; CAROLINA BARBI LINHARES3; MARCUS VINICIUS MARTINS COLLARES1 A B S T R A C T Objective: to validate an experimental model for the measurement of glycemic levels in surgical flaps with the use of common glucometers, and to analyze the diagnostic criteria for hypoperfusion of such flaps. Methods: we performed vertical myocutaneous rectus abdominis flaps with upper pedicles bilaterally in 20 male Wistar rats, divided into two groups: with and without venous occlusion of the pedicle. We measured glucose levels in the flaps and in the systemic circulation with standard glucometers. We tested the accuracy of alternative diagnostic criteria for the detection of hypoperfusion. Results: from 15 minutes of venous occlusion on, there was a significant reduction in glucose levels measured in the congested flap (p<0.001). Using a minimum difference of 20mg/dl in the glycemic levels between the flap and systemic blood, 30 minutes after occlusion, as a diagnostic criterion, the sensitivity was 100% (95% CI 83.99-100%) and specificity of 90% (95% CI 69.90-97.21%) for the diagnosis of flap congestion. Conclusion: It is possible to measure glucose levels in vertical myocutaneous rectus abdominis flaps of Wistar rats, perfused or congested, using a common glucometer. The diagnostic criteria that compare the glucose levels in the flaps with the systemic ones were more accurate in the evaluation of tissue perfusion. Keywords: Models, Animal. Glucose. Perfusion. Surgical Flaps. Diagnosis.
measurement methods are costly and require the use of special equipment14,15,17-20. The common glucometer,
ne of the most common complications of flap surgery is the occlusion of the pedicle vessels with subsequent necrosis of the flap, which occurs in 3% to 7% of cases, even with advanced surgical techniques1-8. Therefore, perfusion monitoring is essential, since early reoperation is the best option to recover a low perfusion flap, the diagnosis of which is usually made through clinical evaluation of the flap by a member of the surgical team2,4-8. Many methods have been tested with the aim of obtaining the early diagnosis of hypoperfusion, also capable of allowing an objective evaluation by other, non-specialist professionals. Among these evaluations are temperature measurement, Doppler flowmetry, transcutaneous oximetry, and tissue glucose and metabolic levels6,7,9-16. The latter are highly efficient in the evaluation of flap perfusion, although some
which uses a drop of blood, is a low-cost method for measuring glucose and is readily available in most hospital units. It is an easy, fast, objective and inexpensive method to measure glycemic levels. Although glycemic levels are a widely accepted way of monitoring flaps, there is no consensus as to the appropriate levels for the diagnosis of hypoperfusion. Sitzman et al.19 observed that the rate of reduction of glycemic levels is more accurate in the diagnosis of hypoperfusion than one isolated glucose measurement. The objective of this study is to validate an experimental model that uses a common glucometer to measure glucose in a vertical rectus abdominis myocutaneous (VRAM) flap in Wistar rats. We also tested the accuracy of diagnostic criteria that compare glucose levels in flaps with systemic levels.
1 - Federal University of Rio Grande do Sul (UFRGS), Post-Graduate Program in Surgical Sciences, Medical School, Porto Alegre, RS, Brazil. 2 - Porto Alegre Clinics Hospital (HCPA), Plastic Surgery Service, Porto Alegre, RS, Brazil. 3 - Federal University of Rio Grande do Sul (UFRGS), Medical School, Porto Alegre, RS, Brazil. Rev Col Bras Cir. 2018; 45(1):e1276
Berlim Glucose level evaluation in monopedicled rectus abdominis myocutaneous flap after venous occlusion: experimental study in rats
METHODS We conducted an experimental, comparative and controlled study, approved by the Ethics Committee on the Use of Animals, of the Group of Research and Graduate Studies of the Porto Alegre Clinics Hospital, under number 130448. The sample size was calculated based on the results of an earlier study by Sitzman et al.19. Considering
Figure 1. a) Marked flaps. b) Dissected flaps. c) Dissected superior epigastric vein. d) Ligated and divided upper epigastric vein.
a significance level of 5% and a power of 80% to detect a difference of 150mg/dL of glucose between the groups, with the same standard deviation obtained 15 minutes after the intervention in the aforementioned study, the sample size was estimated in 16 rats (32 flaps). In order to avoid any losses and impairment of the statistical analysis, we decided to include four more animals. We selected 20 male Wistar rats at four months of age and weighing between 400 and 500 g, divided into two groups: intervention group (n=20), with ligation of the superior epigastric vein of the flap, and control group (n=20), without ligation of the superior epigastric vein. The animals received tramadol hydrochloride (5mg/kg)
inhalation anesthesia with isoflurane vaporized in 100% oxygen. The doses specified in the institution's protocol are 100ml/min for induction and 30ml/min for maintenance of anesthesia. We placed the rats in dorsal decubitus on thermal plates and performed abdominal trichotomy. We dissected bilateral VRAM flaps, as previously described21-24. The flaps were pediculated exclusively by the superior epigastric vessels, which are the dominant pedicle of the rectus abdominis muscle in rats22,23. The abdominal cavity was protected with a plastic field to reduce heat loss and dryness of the viscera. We dissected the pedicle containing the upper epigastric vessels with microsurgical instruments and under five-times magnification. We chose
We measured interstitial glucose in the flaps every 15 minutes, from time zero (before ligation and division of the superior epigastric vein) to 60 minutes, through the puncture of a vein located in the posterior aspect of the flap. We also measured glycemia at the same time intervals in the rats' caudal vein (systemic control, n=20). We measured glucose levels with the MediSense Optimum glucometer. We performed euthanasia at the end of the experiment with isoflurane overdose, capable of inducing cardiac arrest, followed by exanguination. We followed all biosafety regulations, as well as the ethical aspects relevant to animal research. We performed statistical analysis using a model of generalized estimating equation25, comparing measurement times and groups (congestive flap, control flap and systemic control) and the interaction between measurement times and groups. We expressed glycemic levels as mean ¹ standard deviation. For diagnostic analysis, we used the Receiver Operating Characteristic (ROC) curve to determine cutoff points. For these points, we calculated the sensitivity and specificity values, as well as their 95% confidence intervals (95% CI). We considered values of p less than 5% as significant. We performed calculations using the SPSS v.22 and WinPEPI v.11.39 softwares.
the side on which we ligated and divided the epigastric vein based on a previously defined random sequence.
This sequence was generated at www.sealedenvelope. com. We dissected the vascular pedicle of the control flap and kept it intact (Figure 1).
Systemic glucose remained stable throughout the experiment in all animals. Glycemic levels fell rapidly after venous occlusion in the intervention group and remained stable in the control group. From 15 minutes
Rev Col Bras Cir. 2018; 45(1):e1276
Berlim Glucose level evaluation in monopedicled rectus abdominis myocutaneous flap after venous occlusion: experimental study in rats
after venous occlusion on, the glycemic levels of the
From the ROC curves, we determined the cutoff
intervention group flaps were significantly lower than
points. Using glycemic levels in the flap as a diagnostic
those of the control and systemic blood flaps (Figure 2).
test with a cutoff value of 153 mg/dl, the sensitivity was 90% (95% CI 69.90-97.21%) and 85% specificity (95% CI 63.96-94.76%). Using the difference between flap and systemic glucose levels with a cutoff value of 20mg/dl, the sensitivity was 100% (95% CI 83.89-100.00%) and the specificity of 90% (95% CI 69.90-97.21%). Using the relationship between the flap and systemic glucose levels with a cutoff value of 0.8773, the sensitivity was 95% (95% CI 76.39-99.11%) and the specificity was 90% (95% CI 69.90-97.21%).
Figure 2. Mean glucose levels.
We performed an intragroup analysis to compare glycemic levels prior to venous occlusion (zero time) with those of subsequent measurement times. We found significant differences only in the intervention group. To assess the diagnostic criteria for congestion, we used glycemic values of 30 minutes after venous occlusion, because at that moment the levels began to stabilize in the flaps submitted to the intervention. We calculated three ROC curves: glycemic levels, the difference between the flap and systemic glucose levels (measured value in the flap minus that measured in the tail) and the relationship between the flap and systemic glucose levels (value measured in the flap divided by the value measured in the tail). The areas under the curve were, respectively, 0.925, 0.975 and 0.980 (Figure 3).
The measurement of glycemic levels in VRAM flaps of Wistar rats was possible using a common glucometer, as well as the detection of a drop in glycemic levels in congested flaps. The results were comparable to those obtained by Sitzman et al.19, who used an implantable glucometer. However, glucometers are readily available in all hospital units. During the study, we observed that there was little, if any, bleeding in the cutaneous lesions. To obtain a drop of blood for the measurement of glucose level in the flap, we performed a puncture injury on a vein on the posterior aspect of the flap. The results obtained in this study are comparable to those observed in previous ones that measured the glycemic levels of the flaps using implantable glucometers19 or microdialysis14,15,17,18,20. We identified no previous experimental studies with glucose dosage by glucometers, this aspect being the novelty of this work. This validates the present experimental model as an alternative to those who used implantable meters14. In most clinical studies, glycemic values in the flap are used alone for monitoring. In this study, criteria using comparative glucose levels were more accurate than the isolated use of glycemic levels in the diagnosis of flap congestion. This higher precision can be observed by the sensitivity and specificity values and the ROC curve, in which the comparative criteria presented a larger area under the curve. In a series of 33 flaps, Hara et al.26 used
Figure 3. ROC curve.
glucometers to monitor postoperative glucose levels. Rev Col Bras Cir. 2018; 45(1):e1276
Berlim Glucose level evaluation in monopedicled rectus abdominis myocutaneous flap after venous occlusion: experimental study in rats
A cut-off value of 62mg/dL was established for the
that they do not work in ischemic flaps, which receives less
diagnosis of vascular obstruction in the pedicle, resulting
blood and therefore will not bleed. As a result, a needle
in a sensitivity of 88% and a specificity of 82%. Using the same cutoff value, Bashir et al.27 obtained a sensitivity of 90% and a specificity of 78% in a prospective study with 127 flaps. In a French multicenter study, Henault et al.28 evaluated free flaps in 37 patients. Tissue levels of glucose and lactate and hypoperfusion were measured using cutoff values of 69.37mg/dL for glucose and 57.66mg/ dL for lactate. Based on these criteria, they obtained a sensitivity of 98.5% and a specificity of 99.5%, and hypoperfusion was diagnosed approximately 5.4 hours prior to diagnosis based on the clinical evaluation. Akita et al.29 conducted a study comparing tissue oximetry and tissue glucose levels in flaps. For both evaluations, they used indices comparing the values obtained in the flaps with those obtained in another nonoperated site of the body. In that study, both evaluations were efficient, but tissue oximetry provided an earlier diagnosis. The main limitation in the use of glucometers is
puncture wound on the flap will not produce the drop of blood needed to measure glycemic levels. If a drop of blood is produced in the ischemic flap, it comes from the retrograde venous blood flow, which will not reflect the glycemic levels in the flap15,19,20. It could also be considered a limitation of this study to not follow the animals for a longer period to verify the clinical outcome in the flaps studied. However, as the flaps were pediculated exclusively by the superior epigastric vessels, it is reasonable to assume that all the flaps in the intervention group would undergo complete necrosis. We conclude that tissue glucose levels of perfused and congested VRAM flaps in Wistar rats can be adequately measured with a common glucometer. Comparison of glucose levels of the flap with the systemic ones appears to be more accurate in the diagnosis of congestion than the isolated flap levels.
R E S U M O Objetivo: validar um modelo experimental para mensuração de níveis glicêmicos em retalhos cirúrgicos com a utilização de glicosímetros comuns, e analisar os critérios diagnósticos para hipoperfusão destes retalhos. Métodos: foram realizados retalhos miocutâneos verticais de reto abdominal com pedículos superiores, bilateralmente, em 20 ratos Wistar machos, divididos em dois grupos: com e sem oclusão venosa do pedículo. Os níveis de glicose foram mensurados nos retalhos e na circulação sistêmica com glicosímetros comuns. A acurácia de critérios diagnósticos alternativos foi testada para a detecção de hipoperfusão. Resultados: a partir de 15 minutos de oclusão venosa, houve uma redução significativa dos níveis de glicose medidos no retalho congesto (p<0,001). Utilizando como critério diagnóstico uma diferença mínima de 20mg/dl nos níveis glicêmicos do retalho e do sangue sistêmico, 30 minutos após a oclusão, a sensibilidade foi de 100% (intervalo de confiança de 95% - 83,99 a 100%) e especificidade de 90% (intervalo de confiança de 95% - 69,90 a 97,21%) para o diagnóstico de congestão do retalho. Conclusão: os resultados demonstraram que é possível medir níveis de glicose em retalhos miocutâneos verticais de reto abdominal de ratos Wistar, perfundidos ou congestos, utilizando um glicosímetro comum. Os critérios diagnósticos que comparam os níveis de glicose nos retalhos com os níveis sistêmicos foram mais precisos na avaliação da perfusão tecidual. Descritores: Modelos Animais. Perfusão. Retalhos Cirúrgicos. Glucose. Diagnóstico.
REFERENCES 1. Glicksman A, Ferder M, Casale P, Posner J, Kim R, Strauch B. 1457 years of microsurgical experience. Plast Reconstr Surg. 1997;100(2):355-63. 2. Bui DT, Cordeiro PG, Hu QY, Disa JJ, Pusic A, Mehrara BJ. Free flap reexploration: indications, treatment, and outcomes in 1193 free flaps. Plast Reconstr Surg. 2007;119(7):2092-100.
3. Gill PS, Hunt JP, Guerra AB, Dellacroce FJ, Sullivan SK, Boraski J, et al. A 10-year retrospective review of 758 DIEP flaps for breast reconstruction. Plast Reconstr Surg. 2004;113(4):1153-60. 4. Kroll SS, Schusterman MA, Reece GP, Miller MJ, Evans GR, Robb GL, et al. Timing of pedicle thrombosis and flap loss after free-tissue transfer. Plast Reconstr Surg. 1996;98(7):1230-3.
Rev Col Bras Cir. 2018; 45(1):e1276
Berlim Glucose level evaluation in monopedicled rectus abdominis myocutaneous flap after venous occlusion: experimental study in rats
5. Brown JS, Devine JC, Magennis P, Sillifant P, Rogers
pyruvate response in an experimental model of
SN, Vaughan ED. Factors that influence the outcome
microvascular flap ischemia and reperfusion: a
of salvage in free tissue transfer. Br J Oral Maxillofac
microdialysis study. Microsurgery. 2004;24(3):22331.
Surg. 2003;41(1):16-20. 6. Jallali N, Ridha H, Butler PE. Postoperative monitoring
16. Jyränki J, Suominen S, Vuola J, Bäck L. Microdialysis
of free flaps in UK plastic surgery units. Microsurgery.
in clinical practice: monitoring intraoral free flaps.
Ann Plast Surg. 2006;56(4):387-93.
7. Disa JJ, Cordeiro PG, Hidalgo DA. Efficacy of
17. Röjdmark J, Ungerstedt J, Blomqvist L, Ungerstedt
conventional monitoring techniques in free tissue
U, Hedén P. Comparing metabolism during ischemia
transfer: an 11-year experience in 750 consecutive
and reperfusion in free flaps of different tissue
cases. Plast Reconstr Surg. 1999;104(1):97-101.
composition. Eur J Plast Surg. 2002;24(7):349-55.
8. Chubb D, Rozen WM, Whitaker IS, Acosta R, Grinsell
18. Röjdmark J, Hedén P, Ungerstedt U. Microdialysis
D, Ashton MW. The efficacy of clinical assessment in
- a new technique for free flap surveillance:
the postoperative monitoring of free flaps: a review
methodological description. Eur J Plast Surg.
of 1140 consecutive cases. Plast Reconstr Surg.
1998;21(7):344-8. 19. Sitzman TJ, Hanson SE, King TW, Gutowski KA.
2010;125(4):1157-66. 9. Kraemer R, Lorenzen J, Knobloch K, Papst S, Kabbani
Detection of flap venous and arterial occlusion using
M, Koennecker S, et al. Free flap microcirculatory
interstitial glucose monitoring in a rodent model.
monitoring correlates to free flap temperature assessment.
Plast Reconstr Surg. 2010;126(1):71-9. 20. Röjdmark J, Hedén P, Ungerstedt U. Comparison of flap ischemia induced by arterial or venous occlusion
2011;64(10):1353-8. 10. Kind GM, Buntic RF, Buncke GM, Cooper TM, Siko PP, Buncke HJ Jr. The effect of an implantable
in pigs with the aid of microdialysis. Eur J Plast Surg. 2000;23(5):278-82.
Doppler probe on the salvage of microvascular tissue
21. Dunn RM, Mancoll J. Flap models in the rat: a review
transplants. Plast Reconstr Surg. 1998;101(5):1268-
and reappraisal. Plast Reconstr Surg. 1992;90(2):319-
73; discussion 1274-5.
11. Gimbel ML, Rollins MD, Fukaya E, Hopf HW.
22. Ozgentas HE, Shenaq S, Spira M. Development of
a TRAM flap model in the rat and study of vascular
compromise in a rabbit skin flap model. Plast
dominance. Plast Reconstr Surg. 1994;94(7):1012-
Reconstr Surg. 2009;124(3):796-803.
7; 1025-6 discussion.
12. Keller A. A new diagnostic algorithm for early prediction
23. Hallock GG, Rice DC. Physiologic superiority of the anatomic dominant pedicle of the TRAM flap in a rat
microsurgical flaps using tissue oxygen saturation
model. Plast Reconstr Surg. 1995;96(1):111-8.
measurements. Ann Plast Surg. 2009;62(5):538-43.
24. Dunn RM, Huff W, Mancoll J. The rat rectus
13. Russell JA, Conforti ML, Connor NP, Hartig
abdominis myocutaneous flap: a true myocutaneous
GK. Cutaneous tissue flap viability following
flap model. Ann Plast Surg. 1993;31(4):352-7.
partial venous obstruction. Plast Reconstr Surg.
25. Guimarães LS, Hirakata VN. Uso do Modelo de
2006;117(7):2259-66; discussion 2267-8.
Equações de Estimativas Generalizadas na análise de
14. Contaldo C, Plock J, Djonov V, Leunig M, Banic A,
dados longitudinais. Rev HCPA. 2012;32(4):503-11.
Erni D. The influence of trauma and ischemia on
26. Hara H, Mihara M, Iida T, Narushima M, Todokoro
carbohydrate metabolites monitored in hamster flap
T, Yamamoto T, et al. Blood glucose measurement
tissue. Anesth Analg. 2005;100(3):817-22.
for flap monitoring to salvage flaps from venous
15. Setälä LP, Korvenoja EM, Härmä MA, Alhava EM, Uusaro AV, Tenhunen JJ. Glucose, lactate, and
Rev Col Bras Cir. 2018; 45(1):e1276
Berlim Glucose level evaluation in monopedicled rectus abdominis myocutaneous flap after venous occlusion: experimental study in rats
27. Bashir MM, Tayyab Z, Afzal S, Khan FA. Diagnostic accuracy of blood glucose measurements in detecting venous compromise in flaps. J Craniofac Surg. 2015;26(5):1492-4. 28. Henault B, Pluvy I, Pauchot J, Sinna R, LabruèreChazal C, Zwetyenga N. Capillary measurement of lactate and glucose for free flap monitoring. Ann Chir Plast Esthet. 2014;59(1):15-21. 29. Akita S, Mitsukawa N, Tokumoto H, Kubota Y, Kuriyama M, Sasahara Y, et al. Regional Oxygen Saturation Index: a novel criterion for free flap assessment using tissue oximetry. Plast Reconstr Surg. 2016;138(3):510e-8e.
Received in: 03/08/2017 Accepted for publication: 17/09/2017 Conflict of interest: none. Source of funding: Research and Events Incentive Fund (FIPE) of the Porto Alegre Clinics Hospital (number: 130448). Mailing address: Gustavo Levacov Berlim E-mail: firstname.lastname@example.com / firstname.lastname@example.com
Rev Col Bras Cir. 2018; 45(1):e1276
Original Article
The applicability of POSSUM and P-POSSUM scores as predictors of morbidity and mortality in colorectal surgery Aplicação dos escores POSSUM e P-POSSUM como preditores de morbimortalidade em cirurgia colorretal MARIA EMÍLIA CARVALHO-E-CARVALHO1; FÁBIO LOPES VINÍCIUS PIRES-RODRIGUES1.
A B S T R A C T Objective: to apply the POSSUM and P-POSSUM scores as a tool to predict morbidity and mortality in colorectal surgery. Methods: we conducted a prospective cohort study of 551 patients submitted to colorectal surgery in a colorectal surgery tertiary referral hospital in Brazil. We grouped patients into pre-established risk categories for comparison between expected and observed morbidity and mortality rates by the POSSUM and P-POSSUM scores. Results: in the POSSUM morbidity analysis, the overall expected morbidity was significantly higher than that observed (39.2% vs. 15.6%). The same occurred with patients grouped in categories II (28.9% x 10.5) and III (64.6% x 24.5%). In category I, the expected and observed morbidities were similar (13.7% x 9.1%). Regarding the evaluation of mortality, it was statistically higher than that observed in category III patients and in the total number of patients (11.3% vs. 5.6%). In categories I and II, we observed the same pattern of category III, but without statistical significance. When evaluating mortality by the P-POSSUM score, the overall expected and observed mortality was similar (5.8% x 5.6%). Of the 31 patients who died, 20.2% underwent emergency procedures and sepsis was the main cause of death. Conclusion: the P-POSSUM score was an accurate tool to predict mortality and could be safely used in this population profile, unlike the POSSUM score. Keywords: Indicators of Morbidity and Mortality. Colorectal Surgery. Mortality. Morbidity
comparing the results within the institution over time or performing a cross-sectional comparative analysis with
eriodic auditing of a surgical service is essential to perform a critical evaluation and to gain quality. For this purpose, scores are used to predict postoperative morbidity and mortality. The result of this audit allows for better individual risk prediction, therapeutic planning and resource allocation, and comparison among populations of different geographic areas, with lower risk of failure1-4. Several predictors of morbidity and mortality are available (ASA, APACHE, SAPS II). However, the POSSUM (Physiologic and Operative Severity Score for the Study of Mortality and Morbidity) has been commonly recommended as appropriate for surgical practice2,4-6. The POSSUM model, first described in 1991 by Copeland et al.4, originally used 62 variables, 48 physiological and 14 surgical. After multivariate analysis techniques, these numbers were reduced to 12 physiological variables and six surgical. The system seeks to predict morbidity and mortality in the first 30 postoperative days and allows
other institutions2,4. In the evaluation of morbidity, predetermined postoperative complications are considered, subdivided into infectious (subcutaneous infection, abdominal abscess, anastomotic fistula, pneumonia and sepsis) and non-infectious (cardiac events and pulmonary thromboembolism)4. This method of outcome evaluation was applied to a large number of patients, but it was observed that the system overestimated mortality, especially for low risk patients. Therefore, the P-POSSUM score (Portsmouth Physiologic and Operative Severity Score for the Study of Mortality and Morbidity) was developed, which, despite using the same variables, is able to reduce the overestimation calculated by POSSUM3,7. The P-POSSUM is calculated by adding a regression equation to the POSSUM calculation. The Coloproctology Clinic of the Felício Rocho Hospital adopted the POSSUM/P-POSSUM system in
1 - Felício Rocho Hospital, Coloproctology Clinic, Belo Horizonte, MG, Brazil.
Rev Col Bras Cir. 2018; 45(1):e1347
Carvalho-e-Carvalho The applicability of POSSUM and P-POSSUM scores as predictors of morbidity and mortality in colorectal surgery
January 2011. The objective of this study was to evaluate
follow-up, specific for each disease, including data on
the use of the POSSUM system as a tool to predict morbidity
postoperative morbidity and mortality, and later stored
and mortality in colorectal surgery by comparing expected and observed POSSUM and P-POSSUM values.
in the database maintained by the Coloproctology Clinic. After the surgical procedure, the patient's POSSUM and P-POSSUM were calculated through a risk calculator using the mathematical equation of the POSSUM system,
created in Microsoft Excel format. In the service database, A prospective study, conducted by the Coloproctology Clinic of the Hospital Felício Rocho-BHMG - Brazil, followed Brazilian governmental standards for human research and was approved by the institution's ethics and research committee (CEP), under number 43647815.1.0000.5125.
we entered the demographic data, the data referring to
There were 551 patients undergoing colorectal surgeries enrolled between January 2011 and June 2014. The medical staff filled the protocols for clinical
of mortality by POSSUM and P-POSSUM, we grouped
the surgical procedure and the respective POSSUM and P-POSSUM values. For analysis of morbidity, we divided the 551 patients into three morbidity categories estimated by POSSUM, validated in previous studies8. For the analysis the patients into three and four categories of estimated mortality, respectively (Table 1).
Table 1. Categories of morbidity and mortality.
POSSUM Mortality
P-POSSUM Mortality
For statistical analysis, we calculated the mean
Table 2 . Surgical procedure.
and standard deviation (SD) of the expected morbidity
Patients (n)
and mortality. We also computed the confidence interval (95% CI) of each category for analysis of morbidity and mortality, allowing comparison between the observed and expected findings. We considered a p-value <0.05 as statistically significant. We performed statistical analysis
Gender Female (%)
314 (57%)
Male (%)
237 (43%)
Surgical Approach
using the SPSS Statistics for Windows, version 19.0 (IBM
Laparoscopic (%)
257 (46.6%)
Open (%)
294 (53.4%)
Conversion (%)
17 (6.6%)
Surgical mode
With respect to procedures' modality, 83% (457) of the patients were submitted to elective procedures and
Urgency (%)
94 (17.1%)
Elective (%)
457 (82.9%)
Deaths (n)
31 (5.6%)
(46.6%) patients underwent laparoscopic procedures,
Urgency (%)
19 (20.2%)
with a conversion rate of 6.6% (Table 2).
Elective (%)
12 (2.62%)
17% to emergency ones. Two hundred and fifty-seven
Rev Col Bras Cir. 2018; 45(1):e1347
Carvalho-e-Carvalho The applicability of POSSUM and P-POSSUM scores as predictors of morbidity and mortality in colorectal surgery
In the POSSUM morbidity analysis, the total
predicted one when evaluating general morbidity and in
expected morbidity was 39.2%, 13.7% being in category
categories II and III (p<0.05). The morbidity of category I
I, 28.9% in category II and 64.6% in category III. Table 3 shows that the observed morbidity was lower than the
patients was lower than the expected, but not statistically significant (p>0.05).
Table 3 . POSSUM morbidity.
In the evaluation of mortality by the POSSUM score, as shown in table 4, the observed general mortality rate (5.6%) and that of category III patients (15%) was significantly lower than the expected by the POSSSUM
system (p<0.05). In the analysis of categories I and II, we observed a lower than expected mortality, but without statistical significance (I: 0.8% vs. 3%; II: 1.6% vs. 6.9%, p>0.05).
Table 4 . POSSUM mortality.
When evaluating mortality by the P-POSSUM, the expected general mortality was not different from the observed one (5.8% vs 5.6%, p>0.05). Table 5 shows
that in the separate analysis of each of the four separately, there was no difference between the expected and the observed mortality.
Table 5 . P-POSSUM mortality.
The overall mortality rate was 5.62%. Of the patients who died, 19 did after emergency surgery, and 12, after elective procedures, a mortality rate of 20.2%
and 2.62%, respectively. Sepsis was the main cause of death in 67.7% of the patients.
Rev Col Bras Cir. 2018; 45(1):e1347
Carvalho-e-Carvalho The applicability of POSSUM and P-POSSUM scores as predictors of morbidity and mortality in colorectal surgery
The POSSUM and P-POSSUM scores were developed based on several surgical procedures. Although
Postoperative morbidity and mortality rates are objective measures of outcomes that can be used to modify behavior and assess the quality of care. Previous studies have evidenced the important role of the POSSUM system as a predictor of postoperative morbidity and mortality5,9,10. A systematic review of the literature that evaluated POSSUM and its variants in patients undergoing surgery for colorectal cancer showed that the POSSUM score was able to predict morbidity in a reliable way and the P-POSSUM was the most accurate predictor of mortality, even when compared with CR-POSSUM1. In their prospective study, Chatterjee et al.10 evaluated 50 patients with perforating peritonitis. The POSSUM score was a good indicator of postoperative outcome, but the limitations of the study were the sample size and the reliability evaluation of the use of the score in highrisk patients and emergency procedures, preventing its extrapolation to the low-risk population. Oomen et al.11 compared the different POSSUM scores in 241 patients submitted to resections for sigmoid tumor or diverticular disease, and did not observe any difference in mortality, showing no mortality predictors specific to each disease. In the present study, the POSSUM score was able to predict morbidity and mortality with accuracy only in patients with low risk of complications and mortality. In patients with a high risk of morbidity and mortality, there was an overestimation, making the tool flawed and inadequate to evaluate this population profile. On the other hand, P-POSSUM was able to predict morbidity and mortality in a reliable manner when performed by category or general mortality, showing to be a safe and accurate index. With regard to deaths, the rates observed are in line with the data in the literature. Of the thirtyone deaths, the majority were secondary to emergency procedures and in patients who had high morbidity. The implementation of a results evaluation system to analyze the mortality rate as the P-POSSUM in our service was of great value, as it allowed risk stratification. Thus, it was possible to evaluate the results in a timely manner, clearly identifying the situations in need of resources to improve quality. In addition, it allowed the implementation of corrective measures in specific groups aimed at improving results, with targeted interventions.
studies have shown the value of the POSSUM score in colorectal cancer surgery1,12, Tekkis et al.13 developed the CR-POSSUM (Colorectal Possum) variation, which uses fewer parameters, facilitating calculation and decreasing variations. The CR-POSSUM evaluates the physiological variables age, cardiovascular system, systolic pressure, pulse rate, hemoglobin and urea, and the surgical variables peritoneal contamination, malignancy status and surgery size. A study comparing POSSUM and CRPOSSUM as predictors of mortality in 120 patients who underwent surgical resection for colorectal cancer showed that P-POSSUM, despite a non-significant overestimation of mortality in 25%, may be used to predict mortality. However, when compared to CR-POSSUM, this variant was more accurate14. Two other prospective studies evaluated the use of the POSSUM score to predict morbidity and mortality in colorectal surgeries in 304 and 899 patients15,16. In both studies, only CR-POSSUM was accurate in predicting
mortality in the first study and underestimated the risk of dying after surgery in the other16. Corroborating with these findings, Constantinides et al.17, when evaluating the POSSUM score in 324 patients with complicated diverticulitis, found that CR-POSSUM was able to predict the results more reliable than P-POSSUM. Our study has as limitations the selected sample. Since it is a high complexity reference hospital, it deals with patients with more complex clinical conditions and, consequently, they are expected to have a greater potential for complications and associated deaths. P-POSSUM proved to be an accurate tool for this high-risk population and it is not possible to safely extrapolate its use to low-risk patients. Data collection by more than one service surgeon was another limiting factor in the study, as it allows subjective data used in the calculation of the score, such as estimated blood loss, to be interpreted differently, leading to variations in the final score result. The analysis of the population in a stratified manner, by age and by disease, although previously described without a statistical difference in diseasespecific morbidity and mortality12, could allow a thorough evaluation, especially with regard to morbidity, enabling
Rev Col Bras Cir. 2018; 45(1):e1347
Carvalho-e-Carvalho The applicability of POSSUM and P-POSSUM scores as predictors of morbidity and mortality in colorectal surgery
the implementation of targeted interventions.
more adequate to the profile of the population studied,
The evaluation of the P-POSSUM in a population of low risk is necessary to validate it as suitable for use in a generalized way in the patients submitted to colorectal surgeries in the institution. Regarding morbidity, further studies are needed to validate a score that accurately predicts morbidity in both low and high-risk patients. As seen previously seen14-16, the use of CR-POSSUM may be
but other studies are necessary to validate its adoption. The data presented show that the P-POSSUM score was able to accurately predict mortality, but the population evaluated was composed of high-risk patients. This score can be safely used in this specific population, allowing for improvements in the postoperative routines and in performing internal audit with regard to mortality.
R E S U M O Objetivo: aplicar os escores POSSUM e P-POSSUM como ferramenta para predizer morbimortalidade em cirurgia colorretal. Métodos: estudo de coorte prospectivo de 551 pacientes submetidos à cirurgia colorretal em um hospital terciário de referência em cirurgia colorretal no Brasil. Os pacientes foram agrupados em categorias de risco pré-estabelecidas para comparação entre as taxas de morbimortalidade esperada e observada pelo POSSUM e P-POSSUM. Resultados: na análise de morbidade pelo POSSUM, a morbidade geral esperada foi significativamente maior que a observada (39,2% x 15,6%). O mesmo ocorreu com os pacientes agrupados na categoria II (28,9% x 10,5) e na categoria III (64,6% x 24,5%). Na categoria I, a morbidade esperada e observada foi semelhante (13,7% x 9,1%). Com relação à avaliação da mortalidade, esta foi estatisticamente maior do que a observada, nos pacientes da categoria III, e no total dos pacientes (11,3% x 5,6%). Nas categorias I e II observou-se o mesmo padrão da categoria III, porém sem significância estatística. Ao avaliar a mortalidade pelo escore P-POSSUM, a mortalidade geral esperada e observada foi semelhante (5,8% x 5,6%). Dos 31 pacientes que morreram, 20,2% foram submetidos a procedimentos de urgência e a sepse foi a principal causa. Conclusão: o escore P-POSSUM foi uma ferramenta acurada para predizer mortalidade podendo ser utilizado com segurança neste perfil populacional, ao contrário do escore POSSUM. Descritores: Indicadores de Morbimortalidade. Cirurgia Colorretal. Mortalidade. Morbidade.
LM, Trotter GA, et al. Operative mortality rates among surgeons: comparison of POSSUM and p-POSSUM
1. Richards CH, Leitch FE, Horgan PG, McMillan DC. A systematic review of POSSUM and its related models as predictors of post-operative mortality and morbidity in patients undergoing surgery for colorectal cancer. J Gastrointest Surg. 2010;14(10):1511-20. 2. Copeland GP. The POSSUM system of surgical audit. Arch Surg. 2002;137(11):15-9. 3. Prytherch DR, Whiteley MS, Higgins B, Weaver PC, Prout WG, Powell SJ. POSSUM and Portsmouth POSSUM for predicting mortality. Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity. Br J Surg. 1998;85(9):1217-20. 4. Copeland GP, Jones D, Walters M. POSSUM: a scoring system for surgical audit. Br J Surg. 1991;78(3):355-60. 5. Hong S, Wang S, Xu G, Liu J. Evaluation of the POSSUM, p-POSSUM, o-POSSUM, and APACHE II scoring systems in predicting postoperative mortality and morbidity in gastric cancer patients. Asian J Surg. 2017;40(2):89-94. Epub 2015 Sep 26. 6. Tekkis PP, Kocher HM, Bentley AJ, Cullen PT, South
scoring systems in gastrointestinal surgery. Dis Colon Rectum. 2000;43(11):1528-32. 7. Whiteley MS, Prytherch DR, Higgins B, Weaver PC, Prout WG. An evaluation of the POSSUM surgical scoring system. Br J Surg. 1996;83(6):812-5. 8. Ren L, Upadhyay AM, Wang L, Li L, Lu J, Fu W. Mortality rate prediction by Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM), Portsmouth POSSUM and Colorectal POSSUM and the development of new scoring systems in Chinese colorectal cancer patients. Am J Surg. 2009;198(1):31-8. 9. Wang H, Wang H, Chen T, Liang X, Song Y, Wang J. Evaluation of the POSSUM, P-POSSUM and E-PASS scores in the surgical treatment of hilar cholangiocarcinoma. World J Surg Oncol. 2014;12:191. 10. Chatterjee AS, Renganathan DN. POSSUM: a scoring system for perforative peritonitis. J Clin Diagn Res. 2015;9(4):PC05-9.
Rev Col Bras Cir. 2018; 45(1):e1347
Carvalho-e-Carvalho The applicability of POSSUM and P-POSSUM scores as predictors of morbidity and mortality in colorectal surgery
11. Oomen JL, Cuesta MA, Engel AF. Comparison of
post-operative mortality in patients undergoing
outcome of POSSUM, p-POSSUM, and cr-POSSUM
colorectal surgery using P-POSSUM and CR-POSSUM
scoring after elective resection of the sigmoid colon for carcinoma or complicated diverticular disease. Scand J Gastroenterol. 2007;42(7):841-7. Cheung H, Poon JT, Law WL. The impact of POSSUM score on the long-term outcome of patients with rectal cancer. Colorectal Dis. 2013;15(9):1171-6. Tekkis PP, Prytherch DR, Kocher HM, Senapati A, Poloniecki JD, Stamatakis JD, et al. Development of a dedicated risk-adjustment scoring system for colorectal surgery (colorectal POSSUM). Br J Surg. 2004;91(9):1174-82. Horzic M, Kopljar M, Cupurdija K, Bielen DV, Vergles D, Lackovic Z. Comparison of P-POSSUM and CrPOSSUM scores in patients undergoing colorectal cancer resection. Arch Surg. 2007;142(11):1043-8. Bromage SJ, Cunliffe WJ. Validation of the CRPOSSUM risk-adjusted scoring system for major colorectal cancer surgery in a single center. Dis Colon Rectum. 2007;50(2):192-6. Leung E, Ferjani AM, Stellard N, Wong LS. Predicting
scores: a prospective study. Int J Colorectal Dis. 2009;24(12):1459-64. 17. Constantinides VA, Tekkis PP, Senapati A; Association of Coloproctology of Great Britain and Ireland. Comparison of POSSUM scoring systems and the surgical risk scale in patients undergoing surgery for complicated diverticular disease. Dis Colon Rectum. 2006;49(9):1322-31.
Received in: 11/07/2017 Accepted for publication: 21/09/2017 Conflict of interest: none. Source of funding: none. Mailing address: Maria EmĂlia Carvalho e Carvalho E-mail: firstname.lastname@example.com
Rev Col Bras Cir. 2018; 45(1):e1347
Original Article
Profile of patients with Fournier's gangrene and their clinical evolution Perfil dos pacientes com gangrena de Fournier e sua evolução clínica DJONEY RAFAEL DOS-SANTOS1; ULISSES LUIZ TASCA ROMAN1; ANDRÉ PEREIRA WESTPHALEN, TCBC-PR1; KELI LOVISON2; FERNANDO ANTONIO C. SPENCER NETO, TCBC-PR1 A B S T R A C T Objective: to analyze the profile of patients with Fournier's gangrene treated in a public tertiary hospital in western Paraná State. Methods: we conducted a cross-sectional, retrospective and descriptive study of patients with Fournier's gangrene treated between January 2012 and November 2016. Results: there were 40 patients with Fournier's gangrene treated in the period, 29 (72.5%) men and 11 (27.5%) women. The mean age was 51.7±16.3 years. The mean time of disease progression, from the initial symptom to hospitalization, was 10.5±1.2 days. All patients had clinical signs such as pain, bulging, erythema, among others, and 38 (95%) had associated comorbidities, the most common being type 2 diabetes mellitus and systemic arterial hypertension. The majority (30 patients - 75%) had perianal abscess as the probable etiology. All patients were submitted to antibiotic therapy and surgical treatment, with a mean of 1.8±1.1 surgeries per patient. Nine (22.5%) patients died. There was a strong correlation between the presence of sepsis on admission and mortality. Conclusion: Fournier's gangrene patients in this series had a long disease duration and a high prevalence of comorbidities, with a high mortality rate. Keywords: Fournier Gangrene. Fasciitis, Necrotizing /epidemiology.
problem, considering its incidence, prevalence, mortality and the high costs of treatment and rehabilitation8.
ournier's Gangrene (FG) is a severe infectious disease of soft tissues, of fast progression, that affects the genital region and adjacent areas, characterized by intense tissue destruction, involving the subcutaneous and the fascia. This is a necrotizing fasciitis of the perineal region, also known as scrotal gangrene, synergistic necrotizing cellulitis, synergic gangrene, idiopathic gangrene and fulminant gangrene1,2. If not treated early, it can progress to sepsis and multiple organ failure3,4. Thus, early diagnosis along with appropriate and aggressive treatment are determinant factors in patients' prognosis. It occurs predominantly in males, between the third and sixth decades of life, with associated comorbidities such as renal and hepatic diseases, immunosuppression, acquired human immunodeficiency syndrome (AIDS), chronic diseases such as diabetes mellitus (DM), malnutrition, among others5,6. It displays high mortality rates, ranging from 13 to 30.8% in Brazil1,6,7. It represents a public health
In view of the severity and scarcity of data of the population that presents FG in Brazil, we sought to analyze the profile of the patients, their treatment and clinical evolution in a university hospital in western Paraná State.
METHODS This research project was approved by the Ethics Committee of the State University of Western Paraná (UNIOESTE) on the campus of Cascavel/PR under the number 56997516.1.0000.0107. This is a crosssectional, retrospective and descriptive study based on analysis of physical and electronic records of FG patients treated at the University Hospital of Western Paraná HUOP/Cascavel - PR, from January 2012 to November 2016. We included patients diagnosed with FG
1 - State University of Western Paraná, Cascavel, PR, Brazil. 2 - University of São Paulo, Ribeirão Preto, SP, Brazil.
Rev Col Bras Cir. 2018; 45(1):e1430
dos-Santos Profile of patients with Fournier's gangrene and their clinical evolution
hospitalized at HUOP from January 2012 to November
days, and nine patients (22.5%) presented signs of sepsis
2016 and over 18 years of age. We inputted data from
at admission. Table 2 describes the main comorbidities.
physical and electronic records in a data collection form with information on demography, clinical and laboratory presentation, treatment instituted, evolution, complications and mortality. We tested numerical variables for normality with the Shapiro-Wilk test and, since they displayed normal distribution, we presented them in mean and standard deviation. For the proposed correlations according to the objective of the study, we used the Pearson R test, 0.9 (positive or negative) being considered a very strong correlation, 0.7 to 0.9, a strong correlation, and 0.5 to 0.7, a moderate correlation. For the qualitative variables, we performed frequency distributions and presented them in absolute numbers and percentage. The software used the was SPSS® Version 22.0. The information obtained from the medical records was presented through tables.
Only two patients did not report comorbidities.
RESULTS The sample consisted of 40 patients, 29 (72.5%) males and 11 (27.5%) females. The mean age was 51.7±16.3 years. The mean length of hospital stay was 19.6±14.7 days. Table 1 shows the main clinical signs.
Table 1. Main clinical signs in patients with FG.
Main clinical signs
Number of patients (%)
26 (65%)
26 (65%)
14 (35%)
10 (25%)
9 (22.5%)
Purulent collection
9 (22.5%)
7 (17.5%)
Fever Tissue necrosis
6 (15%) 5 (12.5%)
The mean time of disease progression, from the initial symptom to the hospitalization, was 10.5±1.2
Table 2. Major comorbidities in patients with FG.
Major comorbidities
Number of patients (%)
Diabetes mellitus type II
28 (70%)
Arterial hypertension
14 (35%)
Heart disease
6 (15%)
3 (7.5%)
3 (7.5%)
Prostate disease
2 (5%)
Stenosis of urethra
1 (2.5%)
1 (2.5%)
The probable etiology of FG was identified in all patients. Thirty (75%) individuals had history and examination compatible with perianal abscess, four (10%) trauma, three (7.5%) perineal surgeries, two (5%) urological diseases and one (2.5%) animal bite. All patients underwent antibiotic therapy and surgical debridement, in addition to concomitant treatment of comorbidities. We performed 72 surgical procedures, with a mean of 1.8±1.1 procedures per patient. Of these, four patients (10%) underwent colostomy to control fecal contamination and two (5%) were submitted to cystostomy. In seven (17.5%) patients, reconstruction surgeries were performed in the same hospitalization, after infection control. Eight (20%) patients remained hospitalized at the Intensive Care Unit (ICU). Nine (22.5%) patients died. All had signs and symptoms of sepsis on admission (r=0.93**). The remaining patients were discharged and were followed up at the HUOP outpatient clinic. There was no correlation between sepsis presence at admission with time of disease evolution, age or presence of comorbidities. There was no correlation between diabetes and the presence of perianal abscess as a probable FG etiology. Table 3 shows the correlation between age, disease duration, comorbidities, ICU stay, perianal abscess as etiology and number of surgeries per patient with mortality.
Rev Col Bras Cir. 2018; 45(1):e1430
dos-Santos Profile of patients with Fournier's gangrene and their clinical evolution
underlying fascia13,14. According to Santos2, signs and
Table 3. Factors associated with FG mortality.
Mortality (r)
symptoms such as local discomfort with painful sensation,
Age (years)
elevated fever, malaise, sweating, edema apparently
Disease evolution time (days)
without injury, erythema and blistering can be found,
Presence of comorbidities
corroborating the findings of the present study.
Permanence in ICU
0.57 *
Etiology: perianal abscess
Number of surgeries per patient
The surgical procedure is indispensable2,15 and consists
0.93 **
of extensive debridement of devitalized tissues, often
Sepsis admission * Moderate Correlation; ** Strong correlation.
antibiotics are used, covering gram-positive and gramnegative aerobic microorganisms, as well as anaerobes.
demanding multiple reassessments. Patients not submitted to this procedure have a mortality rate of 100%1,16. All patients underwent clinical treatment with antibiotic
therapy and surgical debridement as the initial treatment line.
This study showed that all patients had local symptoms, associated comorbidities, long disease time before hospital admission and perianal abscess as the most common etiology. Knowledge of these factors may lead to earlier recognition of patients at risk, with an earlier diagnosis and reduction of associated morbidity and mortality. FG is a necrotizing fasciitis that originates in the perineal region and can extend to the abdominal and thoracic wall. It can originate in the scrotum and penis in men, and in the vulva and in the groin in women9,10. It can also be associated with injuries, burns, abrasions, lacerations, bruises, animal bites, insect bites, subcutaneous and intravenous injections2. In our study, the FG etiology was predominantly associated with perianal abscess and with late or inadequate treatment. It is possible that early diagnosis, associated with an immediate surgical approach, could prevent some of these patients from progressing to FG. In Brazil, the disease has a high prevalence in the male gender (10:1), but can also affect women and children6,11. It can affect all age groups, with an average around 50 years12. In this study, 72.5% were males and 27.5% females, and in both genders, the mean age was 51 years. With regard to its pathophysiology, bacterial infection leads to an obliterating endarteritis, followed by ischemia and thrombosis of the subcutaneous vessels, resulting in necrosis of the skin and impairment of the
In a study performed by Dornelas et al.1, reconstructive procedure was used in 23 patients, with simple and efficient techniques for each case or area, after effective infection control. Thus, small tissue losses were treated with border-to-edge suture or autogenous skin grafting. In our study, seven (17.5%) patients underwent reconstructive surgery, mainly by primary repair, aiming at reducing the raw surface, facilitating dressings and early discharge. Since we have observed no adverse effects in the reconstructive surgeries, we have considered it in our service as part of the therapeutic flowchart of these patients, although there is a lack of definitive evidence of benefit. In this study, the mean hospitalization time was over 19 days and 22.5% of the patients died. There was a strong correlation between sepsis on admission and mortality. Despite all the current therapeutic advances, FG continues to present prolonged hospitalization and high mortality rates17,18. We could verify that the majority of patients diagnosed with FG treated in a tertiary public service of Western ParanĂĄ have late diagnosis and comorbidities, particularly type-II diabetes, with perianal abscess as an etiological factor. These patients had long hospitalization and high mortality. These data suggest the need for improvements in the emergency services, for the early diagnosis and treatment of the disease and to reduce its morbidity and mortality.
Rev Col Bras Cir. 2018; 45(1):e1430
dos-Santos Profile of patients with Fournier's gangrene and their clinical evolution
R E S U M O Objetivo: analisar o perfil dos pacientes com gangrena de Fournier tratados em um hospital público terciário do oeste do Paraná. Métodos: estudo transversal, retrospectivo e descritivo de pacientes portadores de gangrena de Fournier atendidos no período de janeiro de 2012 a novembro de 2016. Resultados: foram tratados 40 pacientes com gangrena de Fournier no período: 29 (72,5%) homens e 11 (27,5%) mulheres. A média de idade foi de 51,7±16,3 anos. A média de tempo de evolução da doença, do sintoma inicial até a internação, foi de 10,5±1,2 dias. Todos os pacientes apresentaram algum sinal clínico como dor, abaulamento, eritema, entre outros, e 38 (95%) tinham comorbidades associadas, sendo as mais comuns diabetes mellitus tipo 2 e hipertensão arterial sistêmica. A maioria (30 pacientes - 75%) apresentava como etiologia provável abscesso perianal. Todos os pacientes foram submetidos à antibioticoterapia e tratamento cirúrgico com média de 1,8±1,1 cirurgias por paciente. Nove (22,5%) pacientes morreram. Houve forte correlação entre a presença de sepse na admissão e mortalidade. Conclusão: pacientes portadores de gangrena de Fournier, nesta casuística, apresentavam longo tempo de doença e elevada prevalência de comorbidades com alto índice de mortalidade. Descritores: Gangrena de Fournier. Fasciíte Necrosante/epidemiologia.
epidemiology and outcomes in the general US
population. Urol Int. 2016;9(3)7:249-59. 1. Dornelas MT, Correa MPD, Barra FML, Corrêa LD, Silva
10. Rocha ST, Castelan Filho JB, Petry MS, Bernardi
EC, Dornelas GV, et al. Fournier's syndrome: a 10-year
RM, Bueno GB, Warmling CZ. Experiência inicial da
evaluation study. Rev Bras Cir Plást. 2012;27(4):600-4.
terapia hiperbárica na síndrome de Fournier em um
2. Santos EI, Vale ALVV, Reis ICPM, Neves PB, Pontes CM,
hospital de referência no sul catarinense. ACM Arq
Camara SGC. Brazilian scientific evidence on Fournier's
Catarin Med. 2012;41(4):71-6. 11. Abreu RAA, Leal Filho JMM, Corrêa M, Coimbra
gangrene. Rev Rene. 2014;15(6):1047-55. 3. Ramirez B, Cavalheiro CS, Campioni FC, Solla MF,
RAA, Figueiras ALM, Speranzini MB. [Fournier's
Franco RL, Minata MK. Síndrome de Fournier. Rev Fac
gangrene: study of 32 patients – from diagnosis
Ciênc Med Sorocaba. 2014;16 Supl:1-6.
to reconstruction]. GED Gastroenterol Endosc Dig.
4. Ward L, Eisenson D, Fils JL. Fournier's gangrene of the penis in a 12-year-old patient secondary to phimosis. R
2014;33(2):45-51. Portuguese. 12. 12.Safioleas M, Stamatakos M, Mouzopoulos G, Diaba A, Kontonzoglou K, Papachirstodoulou A.
I Med J. 2016;99(12):45-6. 5. Rocha DM, Bezerra SMG, Nogueira LT, Viana MCBR, Benício CDAV, Santos RR, et al. Scientific evidences on therapeutic methods in treatment of Fournier's
Fournier´s gangrene: exists and it is still lethal. Int Urol Nephrol. 2006;38(3-4):653-7. 13. Shyam DC, Rapsang AM. Founier´s gangrene. Surgeon. 2013;11(4):222-32.
gangrene. Int Arch Med. 2016;9(251):1-9. 6. Benjelloun el B, Souiki T, Yakla N, Ousaddean A, Mazaz
14. Roje Z, Matik D, Lindrenjak D, Dokuzovic S, Vardovic J.
K, Louchi A, et al. Fournier's gangrene: our experience
Necrotizing fasciitis: literature review of contemporary
with 50 patients and analysis of factors affecting
strategies for diagnosing and management with
mortality. World J Emerg Surg. 2013;8(1):13.
three case reports: torso, abdominal wall, upper and
7. Corrêa Neto IJF, Sia ON, Rolim AS, Souza RFL, Watté
lower limbs. World J Emerg Surg. 2011;6(1):46.
HH, Robles L. Clinical outcomes of Fournier's gangrene
15. Kaufmann JA, Ramponi D. Recognition of risk factors
from a tertiary. J Coloproctol (Rio J.). 2012;32(4):407-
and prognostic indicators in Fournier's gangrene. Crit
Care Nurs Q. 2015;38(2):143-53.
8. Sroczy ski M, Sebastian M, Rudinicki J, Sebastian E
S, Agrawal AK. A complex approach to the treatment of Fournier's gangrene. Adv Clin Exp Med.
16. Eke N. Fournier's gangrene: a review of 1726 cases. Br J Surg. 2000;87(3):718-28. 17. Torremadé Barreda J, Millán Scheiding M, Suárez Fernández C, Cuadrado Campaña JM, Rodríguez
2013;22(1):407-10. 9. Sorensen MD, Krieger JN. Fournier's gangrene:
Aguilera J, Franco Miranda E, et al. Gangrena de
Rev Col Bras Cir. 2018; 45(1):e1430
dos-Santos Profile of patients with Fournier's gangrene and their clinical evolution
Fournier. Estudio retrospectivo de 41 casos. Cir Esp. 2010;87(4):218-23. 18. Candelária PAP, Klug WA, Capelhuchnik P, Fang CB. Síndrome de Fournier: análise dos fatores de mortalidade. Rev Bras Colo-proctol. 2009;29(2):197202. Received in: 17/08/2017 Accepted for publication: 05/10/2017 Conflict of interest: none. Source of funding: none. Mailing address: Djoney Rafael dos-Santos E-mail: email@example.com / firstname.lastname@example.com
Rev Col Bras Cir. 2018; 45(1):e1430
Original Article
Intragastric balloons in high-risk obese patients in a Brazilian center: initial experience Balões intragástricos em obesos de alto risco em um centro brasileiro: experiência inicial ALANA COSTA BORGES1; PAULO CÉSAR ALMEIDA3; STELLA M. T. FURLANI2; MARCELO DE SOUSA CURY4; SHANTANU GAUR5
A B S T R A C T Objective: to assess the short-term efficacy, tolerance and complications in high-risk morbidly obese patients treated with an intragastric balloon as a bridge for surgery. Methods: we conducted a post-hoc analysis study in a Brazilian teaching hospital from 2010 to 2014, with 23 adult patients with a BMI of 48kg/m2, who received a single intragastric air or liquid balloon. We defined efficacy as 10% excess weight loss, and complications, as adverse events consequent to the intragastric balloon diagnosed after the initial accommodative period. We expressed the anthropometric results as means ± standard deviation, comparing the groups with paired T / Student's T tests, when appropriate, with p<0.05 considered statistically significant. Results: the balloons were effective in 91.3% of the patients, remained in situ for an average of 5.5 months and most of them (65.2%) were air-filled, with a mean excess weight loss of 23.7kg±9.7 (excess weight loss 21.7%±8.9) and mean BMI reduction of 8.3kg/m2±3.3. Complications (17.3%) included abdominal discomfort, balloon deflation and late intolerance, without severe cases. Most of the participants (82.7%) did not experience adverse effects. We removed the intragastric balloons in time, without intercurrences, and 52.2% of these patients underwent bariatric surgery within one month. Conclusion: in our center, intragastric balloons can be successfully used as an initial weight loss procedure, with good tolerance and acceptable complications rates. Keywords: Gastric Balloon. Risk. Obesity, Morbid. Bariatric Surgery.
lead to a substantial reduction in the national economic burden imposed by obesity6.
besity is an international health problem, with high morbidity and mortality1. Worldwide, more than two million people die annually due to obesity or overweight2. The higher the body mass index (BMI), the greater the risk of comorbidities2. Overall, mean BMI has increased by 0.4kg/m2 per decade3. In Brazil, obesity affects 17.5% of the population and the prevalence of morbid obesity (BMI³40kg/m2) increased by more than 255% since 1970s4,5. Health spending rises in direct proportion to the BMI as well. In 2011, Brazilian morbid obesity costs (US$ 64.2 million) corresponded to 23.8% of all expenses related to obesity (US$ 269.6 million)2. Theoretically, a decrease of only 1% in the mean BMI can potentially
Extreme obesity is associated with a large decrease in life expectancy when compared to that of normal weight individuals, and the main causes of death are heart disease, cancer and diabetes. When calculating the years of life lost, the numbers are worrisome: in the BMI range of 40-45 kg/m2, mean survival decreases by 6.5 years, of 50-55 kg/m2, in 9.8 years, and in the range of 55-60 kg/m2, in 13.7 years7. High-risk morbid obese individuals are usually defined by superobesity (SO), BMI=50kg/m2, associated with males, age >45 years and presence of severe comorbidities. Such a population represents a challenge in bariatric surgery due to technical difficulties, high mortality rates, and perioperative morbidity, which reach
1 - Zilda Arns Hospital and Maternity, Digestive Endoscopy Department, Fortaleza, CE, Brazil. 2 - César Cals General Hospital, Digestive Endoscopy Department, Fortaleza, CE, Brazil. 3 - State University of Ceará, Biostatistics, Health Sciences Center, Fortaleza, CE, Brazil. 4 - SCOPE Endoscopy Unit, Digestive Endoscopy, Campo Grande, MS, Brazil. 5 - Allurion Technologies, Wellesley, MA, USA. Rev Col Bras Cir. 2018; 45(1):e1448
Borges Intragastric balloons in high-risk obese patients in a Brazilian center: initial experience
12% and 40%, respectively, in the early postoperative 8
period . In fact, the 30-day mortality risk increases exponentially according to the number of comorbidities in these patients: 0-1 comorbidities: 0.03%; 2-3
In this study, our objective is to identify the short-term efficacy of IGB in the treatment of high-risk morbid obesity patients in a bridge-to-surgery strategy, assessing their tolerance and complications at our center.
comorbidities; 0,16%; and 4 comorbidities: 7,4 %9. To minimize this risk, a significant loss of
preoperative weight is essential. Currently, the viable strategies to achieve it are hypocaloric diet, medications, hospitalization and Intragastric Balloon (IGB)8,10. However, the low calorie diet has a considerable circumvention rate, most anti-obesity drugs have been withdrawn from the market due to systemic side effects and hospitalization for an intensive program in a controlled environment is excessively onerous10. Thus, IGB have been widely used as a bridge for bariatric surgery in high-risk superobese patients. Generally, the established goal is 10% excess weight loss (10% EWL)10, with positive effects on postoperative risk, technical complexity and shorter surgical times due to a decrease in the volume of the liver and adipose, subcutaneous and visceral tissues11, and may improve the results of surgery after one year12. The degree of risk reduction seems to relate to the degree of weight loss, and patients with higher BMIs probably benefit more13. In six months, IGB generally reach the goal of 10% EWL or more, providing greater control of obesity-related diseases and improvement in metabolic profile, without compensatory increase of appetite hormones10,14-16. In fact, it is considered a safe procedure with few complications. Serious events are exceptional17. Perforation, the most feared, can occur in the stomach (0.2%) or more rarely in the esophagus, subsequent to implantation or endoscopic extraction18-20. Intestinal obstruction is estimated at 0.2%18. The main adverse effect is vomiting, especially in the first days postprocedure21. Additionally, there are reports of esophagitis and gastritis diagnosed after its removal22. Absolute contraindications to the use of IGB are previous gastric surgery, large hiatal hernias (³5cm), pregnancy, potential hemorrhagic lesions in the upper gastrointestinal tract, coagulation disorders and severe liver diseases. Relative contraindications include previous abdominal surgery, esophagitis, Crohn's disease and psychiatric disorders23.
This is a post-hoc study-analysis from June 2010 to June 2014, at a public hospital in Fortaleza-CE. The institutional Ethics Committee approved the research protocol (Number 831,224), with written consent of the patients and the hospital for access to medical records. Participants included high-risk, morbidly obese adult patients who were refractory to conservative treatment, were involved in the weight loss program, and underwent IGB insertion as a bridge to bariatric surgery. We excluded individuals with BMI<48kg/m2 or with balloon contraindications. Each patient received a single balloon, which could be filled with 500cc of air or 500-700 cc of liquid. Until October 2012, we implanted air IGB, and liquid ones thereafter, due to changes in the availability of these devices in the hospital. The insertion of IGB occurred with conscious sedation assisted by an anesthesiologist and removal under general anesthesia under direct endoscopic control, using gastroscopes and standard accessories (needle catheter, grasping clamps and polypectomy loops). We performed a routine upper digestive endoscopy before IGB implantation. The preoperative weight loss protocol consisted of multidisciplinary outpatient follow-up (with surgeons, internists, nutritionists, psychologists and psychiatrists), IGB implantation, hypocaloric diet (1000 cal/day) and physical activities. In addition, there were regular consultations with the bariatric endoscopist for assessment of efficacy and tolerance, weekly in the first month post-procedure, fortnightly in the second month, and monthly thereafter. We prescribed proton pump inhibitors during the IGB permanence, associated with antiemetics and analgesics during the first two weeks. All patients had their weight monitored before IGB implantation, at each follow-up visit and at extraction. Using standard methods of weight loss quantification24, such as Ideal weight corresponding to BMI 25kg/m2 and % EWL, we defined the efficacy as at least 10% EWL.
Rev Col Bras Cir. 2018; 45(1):e1448
Borges Intragastric balloons in high-risk obese patients in a Brazilian center: initial experience
and expressed results as mean ± standard deviation. We
effects attributable to IGB diagnosed after two weeks
used the paired T and Student's T tests, as appropriate,
of insertion, identified during the outpatient follow-up.
for comparison between groups. We set the statistical significance at p<0.05.
In our experience, nausea, vomiting and abdominal pain are very common in such a period, consequent to gastric
accommodation to the foreign body, and easily treated with oral medication. Therefore, we did not consider such complications in this study. The studied variables included IGB type, length of stay, associated complications, % EWL, weight variation and BMI. We used used SPSS 20 to process the data,
Twenty-three patients received IGB and their characteristics are shown in table 1. The main comorbidities at the beginning of treatment were hypertension, sleep apnea syndrome and diabetes.
Table 1. Characteristics of high-risk patients with morbid obesity treated with IGB as bridge to bariatric surgery.
Age (years) 19-67 Gender
Number of Comorbidities
Practice of physical activity
IGB Type
SD: standard deviation.
The IGB stayed for an average time of 5.5 months and most of them (65.2%) were air-filled, with a mean weight loss of 23.6kg (21.7% EWL), with maximum 41kg (35.8% EWL). BMI reduced on average 8.3kg/
m2. All anthropometric parameters, before and after IGB, displayed statistically significant differences, with p<0.0001. Table 2 shows such results.
Rev Col Bras Cir. 2018; 45(1):e1448
Borges Intragastric balloons in high-risk obese patients in a Brazilian center: initial experience
Table 2. Anthropometric parameters in high-risk, morbidly obese individuals before and after the use of the IGB.
Weight (kg) (mean±SD) EW (kg) (mean±SD)
175.3±33.1 [122-238] 112.0±26.0 [73.6-168.4]
151.6±31.0 [97-214] 88.3±24.9 [48-136.1]
BMI (kg/m2) (mean±SD)
61.7±7.5 [48-78.6]
53.4±7.8 [40.6-68.6]
Weight loss results
p <0.0001 <0.0001 <0.0001
BMI reduction (kg/m2) (mean±SD)
8.3±3.3 [1.5-14.0]
Weight loss (kg) (mean±SD)
23.7±9.7 [4.3-41]
% EWL (mean±SD) IGB time (months) (mean±SD)
21.7±8.9 [3.5-35.8] 5.5±1.4 [1-7]
SD: standard deviation; EW: excess weight; EWL: excess weight loss.
The effectiveness of the balloons in our center was 91.3%. All, except for two participants, were
Table 3. Intragastric balloon complications in high-risk, morbidly obese patients.
first failure occurred in a female patient who, despite a
Abdominal discomfort
time with IGB of seven months, reached only 3.5% EWL
IGB deflation/obstruction
(4.3kg) and a BMI variation of 1.5kg/m . She did not
Late intolerance/dehydration
adhere to the prescription of physical activity, nor to the
No complications
low-calorie diet. The other failure occurred in a man with
clinically successful, exceeding the 10% EWL target. The
satisfactory adherence to the combined treatment during the six months. However, he obtained 9% EWL (13.5kg) and a BMI reduction of 4.0kg/m2. Given our small sample, the comparison tests performed did not reach statistical significance. However, there was a tendency for better EWL results in older patients, in the 40-67 years age range (23.1% EWL vs. 20.3% EWL, p=0.465), who were physically active (22.3% EWL vs. 21.3% EWL, p=0.820) and with more comorbidities (24.6% EWL vs. 22.05% EWL, p=0.842). There was no difference between the two types of balloons in relation to the final weight parameters. As described in table 3, our complication rate was 17.3%, including abdominal discomfort (8.7%), balloon deflation with migration (4.3%), and late intolerance with severe dehydration (4.3%).
Cases of abdominal discomfort were mild, patients were treated conservatively and experienced gradual symptom resolution. On the other hand, the patient with balloon deflation had migration to the small intestine and obstruction, being submitted to surgery for removal of the device. Interestingly, the IGB had remained in situ during the six-month period. One late intolerance occurred after one month of fluid IGB use and the patient developed intense and refractory vomiting, aggravated by dehydration and acute renal failure. Treatment included hospitalization and balloon extraction. Bariatric surgery was performed during the same admission, after normalization of clinical parameters. Nevertheless, 18.9% EWL (20kg) was achieved preoperatively. In 82.7% of patients, there were no complications and their IGBs were extracted when
Rev Col Bras Cir. 2018; 45(1):e1448
Borges Intragastric balloons in high-risk obese patients in a Brazilian center: initial experience
programmed, without any technical difficulties described
up and the motivation of the participants contributed
by endoscopists. The majority of patients (52.2%)
to these results. In addition, correlating with a national
underwent bariatric surgery (Roux-en-Y gastric bypass) within one month after balloon extraction. The remainder were submitted to surgery after this interval, following the schedule of bariatric surgeons.
multicenter study that described a mean BMI decrease of 8.5kg/m2 and 26.1kg EWL (23.5% EWL) in the superobese sample38. Our numbers are quite similar. The weight loss results were excellent in 21 of the 23 patients (91.3% efficacy), with an average treatment duration of 5.5 months. Recently, Gaur et al.39 have shown that IGB appear to be more effective in the first trimester of therapy, with mean results corresponding to 80% of the total amount lost. Current research has not explored the monthly kinetics of weight loss. However, this may represent a justification for shifting the sixmonth treatment paradigm. This study showed a trend towards greater weight loss in older patients, exercise practitioners and patients with more comorbidities. Physical activity plays an important role in bariatric patients' care, with recent evidence demonstrating that higher levels of pre and postoperative activity are associated with greater weight loss40. Elderly patients with severe comorbidities such as diabetes have a high probability of weight loss41. Our overall complication rate was 17.3%. The literature cites a range of possible complications: intolerance with early removal (up to 6.3%), deflation and migration (1.6-28.9%), abdominal pain (5.8-11.6%), nausea and vomiting (up to 18%), minor side effects (0.2-1.27%) and some rare reports of fatalities (0.07%)23,30,39,42. In our study, we observed a 4.3% rate (one participant) of late intolerance, resolved upon device removal. Many authors consider vomiting intrinsic to balloon use, especially in the early stages. Its appearance occurs within hours, persisting for a few days after placement, as a consequence of the natural adaptation of the stomach to the foreign body43. Thus, intolerance is characterized by vomiting that persists for longer periods, usually associated with abdominal discomfort. These unpleasant symptoms can lead to patient dissatisfaction or lack of motivation to continue therapy. At the same time, patients who do not experience these symptoms may refuse to follow dietary modifications, culminating in weight loss below the expected level43. However, when intense enough (hyperemesis), vomiting may trigger a dangerous sequence of electrolyte imbalance/ dehydration/ renal failure, characterizing the indication
DISCUSSION There are several studies of IGBs with heterogeneity in BMI the selection criteria. Most of them define the lower limit of BMI at 40kg/m2, with weight losses ranging from 17 to 21kg16,25-28. Much of the published data refers to Orbera's IGB, while there is a relative paucity of articles on Heliosphere29, a 30g silicone-coated polymer with two layers interconnected by a valve, unlike most liquid IGBs, which are also made of silicone but weigh 500-600 g23,30. The Medicone IGB, which used in this study, requires further investigation, with little clinical data so far. Experiments with the Heliosphere (air IGB) report weight losses of around 17kg. Its tolerance, efficacy and final results are equivalent to those of Orbera in a small series of cases30-35, a finding that was also demonstrated in two controlled studies comparing both IGB, where there was no significant difference in the weight loss final parameters36,37. Likewise, our cohort did not find statistical difference between the two balloons in the final anthropometric parameters. However, technical problems with air IGB are repeatedly emphasized in the studies: considerable rates of spontaneous deflation, difficult removal due to valve size, longer extraction times, patient discomfort, laborious passage through the cardia or lower pharynx, and occasional need for more complex procedures such as rigid esophagoscopy or surgery30,31,33,36,37. Unlike the international literature, our endoscopists did not describe any technical challenges in the withdrawal and we believe that the reason was the previous extensive experience of the team with the use of IGB. Compared with previous data, we reported greater weight loss, with a mean of 23.6kg (21.7% EWL), a maximum of 41kg (35.8% EWL) and a mean BMI decrease of 8.3kg/m2. We believe that the greater initial weight, our multidisciplinary program with regular follow-
Rev Col Bras Cir. 2018; 45(1):e1448
Borges Intragastric balloons in high-risk obese patients in a Brazilian center: initial experience
for IGB withdrawal if refractory to conservative
damage, such as erosions on the silicone surface43.
treatment43,44. This chain of events happened in our
Diagnosing a leakage of liquid IGB is relatively simple,
patient, leading the authors to opt for the early removal of IGB. On the other hand, our two participants (8.7%) with abdominal discomfort evolved successfully with conservative treatment. We had one case (4.3%) of spontaneous IGB deflation, complicated by intestinal migration and obstruction. Deflation is a well-known phenomenon, common to all existing types of balloons. The only postulated risk factor is implant permanence exceeding the recommended withdrawal date, with greater susceptibility to device dysfunction and leakage39. The longer it remains in situ, the greater the likelihood of
given the urine of bluish coloration, because of the excretion of methylene blue. However, diagnosing the spontaneous rupture of an air IGB is a challenge, since it is usually an asymptomatic process. Frequently, one can only detect subsequent complications, such as mechanical ileus or perforations45. In conclusion, the current efficacy of intragastric balloons in high-risk obese patients at our center is 91.3%, with clinical success and satisfactory tolerance. Our complication profile is within published rates. Intragastric balloons can be used effectively, in association with diet, as a bridge to surgery in our center.
R E S U M O Objetivo: identificar a eficácia em curto prazo, a tolerância e as complicações em obesos mórbidos de alto risco, tratados com balão intragástrico como ponte para cirurgia. Métodos: estudo de análise post-hoc em um hospital acadêmico brasileiro durante o período de 2010 a 2014, de 23 pacientes adultos com IMC de 48kg/m2 que receberam um único balão intragástrico de ar ou líquido. Eficácia foi definida como perda de excesso de peso de 10%, e complicações como eventos adversos consequentes ao balão intragástrico diagnosticados após o período acomodativo inicial. Expressaram-se os resultados antropométricos com média ± desvio padrão, comparando os grupos com testes T Pareado / T de Student, quando apropriado, com p<0,05 considerado estatisticamente significante. Resultados: os balões foram efetivos em 91,3% dos pacientes, permaneceram in situ por em média 5,5 meses e a maioria deles (65,2%) era de ar, com perda média de excesso peso de 23,7kg±9,7 (perda de excesso de peso de 21,7%±8,9) e redução média de IMC de 8,3kg/m2±3,3. As complicações (17,3%) compreenderam desconforto abdominal, deflação do balão e intolerância tardia, sem casos graves. A maioria dos participantes (82,7%) não experimentou efeitos adversos, seus balões intragástricos foram extraídos em tempo, sem intercorrências e 52,2% desses pacientes submeteram-se à cirurgia bariátrica no intervalo de um mês. Conclusão: no nosso centro, balões intragástricos podem ser usados com sucesso como procedimento inicial de perda ponderal, com boa tolerância e taxas aceitáveis de complicações. Descritores: Balão Gástrico. Risco. Obesidade Mórbida. Cirurgia Bariátrica.
REFERENCES 1. ASGE Standards of Practice Committee, Anderson MA, Gan SI, Fanelli RD, Baron TH, Banerjee S, Cash BD, Dominitz JA, Harrison ME, Ikenberry SO, Jagannath SB, Lichtenstein DR, Shen B, Lee KK, Van Guilder T, Stewart LE. Role of endoscopy in the bariatric surgery patient. Gastrointest Endosc. 2008;68(1):1-10. 2. Oliveira ML, Santos LM, da Silva EN. Direct healthcare cost of obesity in Brazil: an application of the cost-ofillness method from the perspective of the public health system in 2011. PLoS ONE. 2015;10(4):e0121160. 3. Sturm H, Hattori A. Morbid obesity rates continue
to rise rapidly in the United States. Int J Obes (Lond). 2013;37(6):889-91. 4. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Vigitel Brasil 2013: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília: Ministério da Saúde; 2014. 5. Santos LM, de Oliveira IV, Peters LR, Conde WL. Trends in morbid obesity and in bariatric surgeries covered by the Brazilian public health system. Obes Surg. 2010;20(7):943-8. 6. Rtveladze K, Marsh T, Webber L, Kilpi F, Levy D, Conde W, et al. Health and economic burden of obesity in Brazil. PLoS One. 2013;8(7):e68785.
Rev Col Bras Cir. 2018; 45(1):e1448
Borges Intragastric balloons in high-risk obese patients in a Brazilian center: initial experience
7. Kitahara CM, Flint AJ, Berrington de Gonzalez AB, Bernstein L, Brotzman M, MacInns RJ, et al. Association
balloon for obesity. Cochrane Database Syst Rev. 2007;(1):CD004931.
between class III obesity (BMI of 40-59 kg/m2) and mortality: a pooled analysis of 20 prospective studies. PLoS Med. 2014;11(7):e1001673. Spyropoulos C, Katsakoulis E, Mead N, Vagenas K, Kalfarentzos F. Intragastric balloon for highrisk super-obese patients: a prospective analysis of efficacy. Surg Obes Relat Dis. 2007;3(1):78-83. Khan MA, Grinberg R, Johnson S, Afthinos JN, Gibbs KE. Perioperative risk factors for 30-day mortality after bariatric surgery: is functional status important? Surg Endosc. 2013;27(5):1772-7. Santo MA, Riccioppo D, Pajecki D, Cleva R, Kawamoto F, Cecconello I. Preoperative weight loss in superobese patients: study of the rate of weight loss and its effects on surgical morbidity. Clinics (Sao Paulo). 2014;69(12):828-34. Collins J, McCloskey C, Titchner R, Goodpaster B, Hoffman M, Hauser D, et al. Preoperative weight loss in high-risk superobese bariatric patients: a computed tomography-based analysis. Surg Obes Relat Dis. 2011;7(4):480-5. Giordano S, Victorzon M. The impact of preoperative weight loss before laparoscopic gastric bypass. Obes Surg. 2014;24(5):669-74. Anderin C, Gustafsson UO, Heijbel N, Thorell A. Weight loss before bariatric surgery and postoperative complications: data from the Scandinavian Obesity
18. Dumonceau JM. Evidence-based review of the BioEnterics intragastric balloon for weight loss. Obes Surg. 2008;18(12):1611-7. 19. Koutelidakis I, Dragoumis D, Papaziogas B, Patsas A, Katsougianopoulos A, Atmatzidis S, et al. Gastric perforation and death after the insertion of an intragastric balloon. Obes Surg. 2009;19(3):393-6. 20. Ruiz D, Vranas K, Robinson DA, Salvatore L, Turner JW, Adsati T. Esophageal perforation after gastric balloon extraction. Obes Surg. 2009;19(2):257-60. 21. Imaz I, Martínez-Cervell C, García-Álvarez EE, SendraGutiérrez JM, González-Enríquez J. Safety and effectiveness of the intragastric balloons for obesity. A meta-analysis. Obes Surg. 2008;18(7):841-6. 22. Mathus-Vliegen EM, Tytgat GN, VeldhuyzenOffermans EA. Intragastric balloons in the treatment of super-morbid obesity. Double-blind, shamcontrolled, crossover evaluation of 500-milliliter balloon. Gastroenterology. 1990;99(2):362-9. 23. Swidnicka-Siergiejko A, Wróblewski E, Dabrowski A. Endoscopic treatment of obesity. Can J Gastroenterol. 2011;25(11):627-33. 24. Baltasar A, Perez N, Serra C, Bou R, Bengochea M, Borrás F. Weight loss reporting: predicted body mass index after bariatric surgery. Obes Surg. 2011;21(3):367-72. 25. Mathus-Vliegen EM, Alders PR, Chuttani R,
Registry (SOReg). Ann Surg. 2015;261(5):909-13. Fuller NR, Lau NS, Denyer G, Caterson ID. An intragastric balloon produces large weight losses in the absence of change in ghrelin or peptide YY. Clin Obes. 2013;3(6):172-9. Forlano R, Ippolito AM, Iacobellis A, Merla A, Valvano MR, Niro G, et al. Effect of the BioEnterics intragastric balloon on weight, insulin resistance and liver steatosis in obese patients. Gastrointest Endosc. 2010;71(6):927-33. Carvalho MR, Jorge Z, Nobre E, Dias T, CortezPinho H, Machado MV, et al. [Intragastric balloon in the treatment of morbid obesity]. Acta Med Port. 2011;24(4):489-98. Portuguese. Fernandes M, Atallah AN, Soares BG, Humberto S, Guimarães S, Matos D, et al. Intragastric
Scherpenisse J. Outcomes of intragastric balloon placements in a private practice setting. Endoscopy. 2015;47(4):302-7. 26. Doldi SB, Micheletto G, Perrini MN, Librenti MC, Rella S. Treatment of morbid obesity with intragastric balloon in association with diet. Obes Surg. 2002;12(4):583-7. 27. Almeida N, Gomes D, Gonçalves C, Gregório C, Brito D, Campos JC, et al. [Intragastric balloon in the grave forms of obesity]. J Port Gastroenterol. 2006; 13(5):220-5. Portuguese. 28. Bispo M, Ferreira da Silva MJ, Bana T, Seves I, Couto G, Peixe P, et al. [Intragastric balloon in the treatment of obesity: evaluation of efficacy, safety and tolerability]. GE J Port Gastroenterol. 2008;15(3):1039. Portuguese.
Rev Col Bras Cir. 2018; 45(1):e1448
Borges Intragastric balloons in high-risk obese patients in a Brazilian center: initial experience
29. Tsesmeli N, Coumaros D. Review of endoscopic devices for weight reduction: old and new balloons
and implantable prostheses. Endoscopy. 2009; 41(12):1082-9. Martínez Olmos MÁ, Cancer E, Bretón I, Álvarez V, Abilés V, Abilés J, Peláez N, Mellado C, Mazure RA, Culebras JM; Grupo de Trabajo OBESMINVA de la SENPE. [Intragastric balloon: a review concerning alternative balloons compared to the classical ones (Bioenterics)]. Nutr Hosp. 2015;31(1):84-91. Spanish. Forestieri P, De Palma GD, Formato A, Giuliano ME, Monda A, Pilone V, et al. Heliosphere Bag in the treatment of severe obesity: preliminary experience. Obes Surg. 2006;16(5):635-7. Sciumè C, Geraci G, Pisello F, Arnone E, Mortillaro M, Modica G. [Role of intragastric air filled balloon (Heliosphere Bag) in severe obesity. Personal experience]. Ann Ital Chir. 2009;80(2):113-7. Italian. Trande P, Mussetto A, Mirante VG, De Martinis E, Olivetti G, Conigliaro RL, et al. Efficacy, tolerance and safety of the new intragastric air-filled balloon (Heliosphere Bag) for obesity: the experience of 17 cases. Obes Surg. 2010;20(9):1227-30. Lecumberri E, Krekshi W, Matía P, Hermida C, de la Torre NG, Cabrerizo L, et al. Effectiveness and safety of air-filled baloon Heliosphere BAG® in 82 consecutive obese patients. Obes Surg. 2011;21(10):1508-12. Giuricin M, Nagliati C, Palmisano S, Simeth C, Urban F, Buri L, et al. Short- and long-term efficacy of intragastric air-filled balloon (Heliosphere® BAG) among obese patients. Obes Surg. 2012;22(11):1686-9. De Castro ML, Morales MJ, Del Campo V, Pineda JR, Pena E, Sierra JM, et al. Efficacy, safety and tolerance of two types of intragastric balloons placed in obese subjects: a double-blind comparative study. Obes Surg. 2010;20(12):1642-6. Giardiello C, Borrelli A, Silvestri E, Antognozzi V, Iodice G, Lorenzo M. Air-filled vs water-filled intragastric balloon: a prospective randomized study. Obes Surg. 2012;22(12):1916-9. Sallet JA, Marchesini JB, Paiva DS, Komoto K, Pizani CE, Ribeiro ML, et al. Brazilian multicenter study of the intragastric balloon. Obes Surg. 2004;14(7):991-8. Gaur S, Levy S, Mathus-Vliegen L, Chuttani R. Balancing risk and reward: a critical review of the
intragastric balloon for weight loss. Gastrointest Endosc. 2015;81(6):1330-6. 40. King WC, Bond DS. The importance of preoperative and postoperative physical activity counseling in bariatric surgery. Exerc Sport Sci Rev. 2013;41(1):2635. 41. Calderón-Larrañaga A, Hernández-Olivan P, González-Rubio F, Gimeno-Feliu LA, Poblador-Plou B, Prados-Torres A. Multimorbidity and weight loss in obese primary care patients: longitudinal study based on electronic healthcare records. BMJ Open. 2015;5(3):e006227. 42. ASGE Technology Committee, Kethu SR, Banerjee S, Barth BA, Desilets DJ, Kaul V, Pedrosa MC, Pfau PR, Pleskow DK, Tokar JL, Wang A, Song LM, Rodriguez SA. Endoluminal bariatric techniques. Gastrointest Endosc. 2012;76(1):1-7. 43. Mitura K, Garnysz K. Tolerance of intragastric balloon and patient's satisfaction in obesity treatment. Wideochir Inne Tech Maloinwazyjne. 2015;10(3):445-9. 44. Milone M, Maietta P, Bianco P, Pisapia A, Gaudioso D, Coretti G, et al. An early onset of acute renal failure in a young woman with obesity and infertility who underwent gastric balloon positioning. A case report. G Chir. 2014;35(3/4):73-4. 45. Drozdowski R, Wyle o M, Fr czek M, Hevelke W
P, Giaro M, Soba ski P. Small bowel necrosis as a consequence of spontaneous deflation and migration of an air-filled intragastric balloon - a potentially life-threatening complication. Wideochir Inne Tech Maloinwazyjne. 2014;9(2):292-6. Y
Received in: 23/08/2017 Accepted for publication: 28/09/2017 Conflict of interest: none. Source of funding: none. Mailing address: Alana Costa Borges E-mail: firstname.lastname@example.com / firstname.lastname@example.com
Rev Col Bras Cir. 2018; 45(1):e1448
Original Article
Damage control surgery: are we losing control over indications? Cirurgia de controle de danos: estamos perdendo controle das indicações? SILVÂNIA KLUG PIMENTEL, TCBC-PR1; TULIO RUCINSKI1; MELINA PAULA NATHAN HARMUCH KOHL1
A B S T R A C T Objective: to analyze the surgeons' subjective indications for damage control surgery, correlating with objective data about the patients' physiological state at the time the surgery was chosen. Methods: we carried out a prospective study between January 2016 and February 2017, with 46 trauma victims who were submitted to damage control surgery. After each surgery, we applied a questionnaire to the attending surgeon, addressing the motivations for choosing the procedure. We collected data in the medical records to assess hemodynamic conditions, systolic blood pressure and heart rate on arrival at the emergency room (grade III or IV shock on arrival at the emergency room would partially justify the choice). We considered elevation of serum lactate level, prolonged prothrombin time and blood pH below 7.2 as laboratory indicators of worse prognosis, objectively corroborating the subjective choice of the procedure. Results: the main indications for damage control surgery were hemodynamic instability (47.8%) and high complexity lesions (30.4%). Hemodynamic and laboratory changes corroborated the choice in 65.2% of patients, regardless of the time; 23.9% presented hemodynamic changes compatible with degree III and IV shock, but without laboratory alterations; 4.3% had only laboratory abnormalities and 6.5% had no alterations at all. Conclusion: in the majority of cases, there was early indication for damage control surgery, based mainly on hemodynamic status and severity of lesions, and in 65.2%, the decision was compatible with alterations in objective hemodynamic and laboratory data. Keywords: Trauma centers. General surgery. Advanced Trauma Life Support Care. Wounds and Injuries. Laparotomy.
severely injured patients, DCS is associated with serious complications, such as enteric fistulas, readmissions,
atients sustaining severe trauma suffer from physiological and metabolic changes that often culminate in the dreaded "lethal triad" (metabolic acidosis, hypothermia and coagulopathy)1. Attempts to treat all lesions in the same procedure were already ineffective and became prohibitive due to high perioperative mortality rates. In the mid-1980s, a three-step approach aimed at controlling fatal injuries: control of bleeding and contamination of the abdominal cavity, stabilization of the patient and return to the operating room for definitive repair of all lesions. The improvement in survival in this group of patients established the concept of damage control surgery (DCS) as the procedure of choice in patients with multiple lesions of high complexity2. Despite being the procedure of choice for
multiple surgical interventions and reduction of quality of life3-6. To date, there is no defined standard for its indication, and it is necessary to weigh risk and benefit in emergency situations7. In 2012, it was shown that the use of temporary abdominal closure in patients with less severe lesions led to an increase in morbidity8. Thus, there are variations in the indications of a procedure that is not free from complications and raises the concern about possible unnecessary indications9. DCS is associated with a high mortality rate of 35%, possibly related to the severity of the patients state who undergo the procedure10. Patients with severe metabolic acidosis - blood pH lower than 7.2 - have 60%higher rates of hemorrhage secondary to coagulopathy11. Increasing serum lactate levels associated
1 - Hospital do Trabalhador, Federal University of Paraná, Curitiba, PR, Brazil.
Rev Col Bras Cir. 2018; 45(1):e1474
Pimentel Damage control surgery: are we losing control over indications?
with decreases in systolic blood pressure (SBP) also
long thereafter the surgeon would indicate reoperation,
significantly aggravate the mortality rate – levels above
regardless of whether it actually happened or not.
4,0mg/dL associated with SBP between 70 and 90 mmHg
We also collected objective data in the charts to
present a mortality rate of approximately 30% . Initial
assess patients' general physiological status. We selected
prothrombin (PT) activity time (longer than 14 seconds) in
systolic blood pressure (SBP) and heart rate (HR) to
polytrauma patients is considered an isolated predictor of
evaluate the hemodynamic condition. For assessment of
mortality, with a 35% higher risk of death13.
the metabolic state, we chose blood pH, lactate and PT (all
Our Service is a reference in trauma care in a
correlated with worse prognosis). We obtained the data
capital city with high crime and automobile accidents
upon arrival of the patient to the ER, and they reflected
rates, with frequent indication of DCS. The objective of
the possible development of the triad of death. Arterial
this study was to evaluate whether the indications of
blood gas sampling is routinely performed in severe
this technique were consistent with the severity of the
patients upon arrival at our institution.
patients selected and to analyze whether or not there
The choice for DCS is often subjective. We considered changes in HR and SBP compatible with
was over-reporting indication.
grade III or IV hypovolemic shock as partial criteria for DCS choice. The procedure indication was justified if the
patient also had at least one of the following laboratory
We conducted a prospective study at the Hospital do Trabalhador, a reference center for trauma care in Curitiba, State of Paraná (PR), and metropolitan region. The study included 46 patients admitted between January 2016 and February 2017, victims of penetrating or closed trauma, who underwent DCS. There was no intervention in the management of these patients. The study was approved by the Ethics Committee of the Hospital do Trabalhador under the number 50805415.0.0000.5225.
criteria: serum lactate level above 4,0mmol/L (reference value 0.5-2.2) when SBP was above 90mmHg or 2.5mg/dL if associated with SBP lower than 90mmHg; presence of severe metabolic acidosis, with blood pH below 7.2; or PT over 14 seconds. The hemodynamic instability associated with alterations in laboratory tests would justify the choice, since hemorrhage is the cause of the lethal triad, and when associated with the laboratory abnormalities described above, the prognosis worsens. There
associated with the procedure or late mortality.
After each surgery, we applied a questionnaire
We made the descriptive statistical analysis
of three simple questions to the surgeon in charge. We
of the data collected in this study by means of relative
conducted the interviews via cell phone text messages or
frequency, absolute frequency, mean and median. For
in person. The first question was about the time when
inferential statistical analysis, we used the Kuskall-Wallis
the surgeon opted for DCS, the options being before
test: we grouped patients according to the moment of
the patient's arrival at the emergency room (ER), as soon
DCS choice, and evaluated if the groups were composed
as the patient arrived at the ER, at the beginning of
of different populations based on the laboratory and
the procedure, after worsening of the condition during
hemodynamic variables of each patient – pH, lactate,
surgery, or at another time (in this case, the surgeon
systolic blood pressure, HR and PT.
would specify the moment of choice). The second question addressed the reason for the DCS indication,
and the options were hemodynamic state of difficult control, lesions of high complexity, lesions of multiple
The mean age was 34.2 years ± 17.4, and
intestinal loops, cardiorespiratory arrest, cardiac or large
97.8% (n=45) were males. The mechanisms of trauma
vessel lesions, or another reason (in this case, the surgeon
were gunshot wound in 60.9% (n=28), stabbing wound
would specify the reason). The third question asked how
in 10.9% (n=5), trampling in 8.7% (n=3), auto-auto
Rev Col Bras Cir. 2018; 45(1):e1474
Pimentel Damage control surgery: are we losing control over indications?
collision in 6.5% (n=3), fall from height in 4.3% (n=2)
via cell phone text messages (n=44). Regarding the
and motorcycle accident in 2.2% (n=1). The survival rate
answers to the first question, 4.3% of the surgeons (n=2)
was 80.4% (n=37), with nine deaths. The majority of the
took the decision to control the damage before the patient
cases, 65% (n=30), were attended between Friday and
arrived at the ER, 26.1% (n=12) opted for it as soon as the
Sunday, and the most prevalent time range between 18h
patient reached the ER, 56.5% (n=26) decided early in the
and 23:59h, with 43.4% (n=20) of cases.
surgery, and 10.8% (n=5) decided upon worsening of the
We applied most of the questionnaires, 95.6%,
condition during surgery (Table 1).
Table 1. Average results of laboratory tests according to the time of DCS choice.
Moment of choice
Before reaching the ER
Upon arrival at the ER
At the beginning of surgery
After worsening during surgery
In another moment
ER: Emergency Room; SBP: systolic blood pressure, in mmHg; HR: heart rate, in beats per minute; Lactate level, in serum mmol/L; PT: prothrombin time activity, in seconds.
Regarding the reason that led to DCS: in 47.8% (n=22) of the cases it was the hemodynamic state of difficult control; in 30.4% (n=14), lesions of high complexity; in 8.7% (n=4), multiple lesions of intestinal
loops; 2.2% (n=1), cardiorespiratory arrest; in 2.2% (n=1), cardiac or large vessel lesions; and in 8.7% (n=4), other reasons (Table 2).
Table 2. Average results of laboratory tests according to the reason for DCS.
Hemodynamic state of difficult control
Highly complex lesions
Multiple lesions in the intestinal loops
Cardiopulmonary arrest
Heart or great vessels injuries
SBP: systolic blood pressure, in mmHg; HR: heart rate, in beats per minute; Lactate level, in serum mmol/L; PT: prothrombin time activity, in seconds.
In the third question, 78.3% (n=36) of the surgeons answered that they would indicate reoperation between 24 and 48 hours, 17.4% (n=8) after 48 hours and 4.3% (n=2) between 12 and 24 hours, and none would indicate before 12 hours. The Kuskall-Wallis test
showed no differences between the groups of patients divided by the time of DCS choice, although the results displayed different medians. The sample was, therefore, homogeneous (p>0.05). The same occurred by grouping the patients according to question 2 (reason for the
Rev Col Bras Cir. 2018; 45(1):e1474
Pimentel Damage control surgery: are we losing control over indications?
choice), except in the patient whose indication was
associated with worse prognosis and higher mortality
cardiorespiratory arrest.
Since the patients constituted a homogeneous
The less altered laboratory test was PT, with
sample according to the moment of choice and pre-
abnormality in only 26% of the patients. The main hypothesis for the late widening of PT is the fact that the coagulation factors are altered only after the installation of metabolic acidosis and hypothermia. Another possible explanation might be the influence of early volume replacement, with plasma infusion and coagulation factors. Perhaps the use of thromboelastography (TEG) would better evaluate coagulopathy, since it can assess all phases of coagulation16. However, this test is not available at the hospital where the study was performed.
established criteria, we considered that hemodynamic and laboratory changes that corroborated the choice for DCS were present in 65.2% (n=30) of patients, regardless of the moment of choice. Eleven (23.9%) presented hemodynamic changes compatible with grade III and IV shock, but without laboratory abnormalities, 4.3% (n=2) presented only laboratory abnormalities, and 6.5% (n=3), none. Eighteen (39.1%) reoperations occurred at the time indicated by the surgeon in the third question. In 10.8% (n=5), reoperation occurred before the expected time, in 30.4% (n=14), after, and the remaining 19.5% (n=9) patients died before reoperation.
DISCUSSION The epidemiological profile of the cases reinforces what we already know: the greatest cause of death in young men is trauma, which is illustrated by the fact that practically all victims are male and most are of working age and at increased exposure to alcohol, illicit drugs and violent behavior. Another fact, also known and proven by our work, is represented by the majority of visits occurring on weekends and at night or dawn, when exposure to risk situations is also more prevalent14. Most of the traumas were penetrating injuries, predominantly by gunshots. Curitiba is in fact a metropolis with high homicide rates due to this mechanism of trauma and within the national average15. We did not analyze whether the morbimortality of the victims of penetrating trauma was different from that of blunt trauma. The use of text messages facilitated the application of questionnaires and the recording of responses. Regarding responses, we noticed that most decisions for damage control were early, based mainly on the hemodynamic instability and the severity of the lesions. In the general average, the victims had signs of hypovolemic shock, since they were hypotensive and tachycardic. The mean serum lactate level was 4.94mmol/L and the mean pH was 7.04. These changes combined are
Hemodynamic and laboratory changes that justified DCS occurred in 65.2% of all patients, a result that answers our first question: "did this group really need damage control or could it have undergone only repair surgery?� The second question was whether the remaining 34.8% of the patients needed DCS, since 23.9% presented only hemodynamic changes, 4.3% had only laboratory abnormalities, and 6.5% had no alterations. An important point that could justify the choice for damage control in these cases is that our study was cross-sectional and we collected the data from the examinations made on arrival at the emergency room. This group of patients could therefore be starting to develop the lethal triad. Another justification in favor of DCS is that the choice relies not only on laboratory data, but also on the severity of the lesions or the mechanism of the trauma. The overall mortality of our patients was 19.6%, lower than the 28-35% reported in the literature. This is another corroboration of the choice for DCS. The literature also cites that the lower the physiological changes, the better the DCS prognosis, which could justify the choice in patients with only hypovolemic shock. However, doubt remains whether they could have undergone repair in a single procedure. We should not rule out the possibility of over-reporting in the 6.5% without any alterations. The DCS should be used to reduce the chances of death by the lethal triad. The general profile of the cases studied were very serious patients, with signs of hypovolemic shock, a significant increase in serum lactate levels, and a decrease in pH. This set of data pointed to a higher risk of death.
Rev Col Bras Cir. 2018; 45(1):e1474
Pimentel Damage control surgery: are we losing control over indications?
Based on the previously mentioned criteria
means that in most cases the damage control surgery was
used to assess hemodynamic and metabolic status, we
properly indicated. The low mortality rate also ratifies the
observed that among the patients studied, 65.21% presented changes correlated with worse prognosis. This
choice for this strategy.
R E S U M O Objetivo: analisar as indicações subjetivas, por parte do cirurgião, para cirurgia de controle de danos, correlacionando com dados objetivos sobre o estado fisiológico do paciente, no momento em que a cirurgia foi escolhida. Métodos: estudo prospectivo realizado entre janeiro de 2016 e fevereiro de 2017, de 46 pacientes vítimas de traumas e submetidos à cirurgia de controle de danos. Após cada cirurgia era aplicado um questionário ao cirurgião responsável, abordando as motivações para a escolha do procedimento. Foram coletados dados nos prontuários para avaliar as condições hemodinâmicas, pressão arterial sistólica e frequência cardíaca na chegada ao pronto socorro (choque grau III ou IV na chegada ao pronto socorro justificaria parcialmente a escolha). Elevação do nível sérico de lactato, tempo de protrombina alargado e pH abaixo de 7,2 foram usados como indicadores laboratoriais de pior prognóstico, corroborando objetivamente com a escolha subjetiva pela cirurgia de controle de danos. Resultados: as principais indicações para cirurgia de controle de danos foram instabilidade hemodinâmica (47,8%) e lesões de alta complexidade (30,4%). Alterações hemodinâmicas e laboratoriais corroboraram a escolha em 65,2% dos pacientes, independente do momento; 23,9% apresentaram alterações hemodinâmicas compatíveis com choque grau III e IV, porém sem alterações laboratoriais; 4,3% apresentavam somente as alterações laboratoriais e 6,5% estavam sem alteração alguma. Conclusão: na maioria dos casos optou-se precocemente pela cirurgia de controle de danos, baseando-se principalmente no estado hemodinâmico e gravidade das lesões, sendo que em 65,2% a decisão foi compatível com alterações de dados objetivos do estado hemodinâmico e laboratoriais. Descritores: Centros de Traumatologia. Cirurgia Geral. Cuidados de Suporte Avançado de Vida no Trauma. Ferimentos e Lesões. Laparotomia.
study. J Trauma Acute Care Surg. 2013;74(1):11320; discussion 1120-2.
1. Burch JM, Ortiz VB, Richardson RJ, Martin RR, Mattox KL, Jordan GL Jr. Abbreviated laparotomy and planned reoperation for critically injured patients. Ann Surg.1992;215(5):476-84. 2. Rotondo MF, Schwab CW, McGonigal MD, Phillips GR 3rd, Fruchterman TM, Kauder DR, et al. "Damage control": an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma. 1993;35(3):375-82; discussion 382-3. 3. Cheatham ML, Safcsak K, Llerena LE, Morrow CE Jr, Block EF. Long-term physical, mental, and functional consequences of abdominal decompression. J Trauma. 2004;56(2):237-41; discussion 241-2. 4. Dubose JJ, Scalea TM, Holcomb JB, Shrestha B, Okoye O, Inaba K, Bee TK, Fabian TC, Whelan J, Ivatury RR; AAST Open Abdomen Study Group. Open abdominal management after damage-control laparotomy for trauma: a prospective observational American Association for the Surgery of Trauma multicenter
5. Cheatham ML, Safcsak K. Longterm impact of abdominal decompression: a prospective comparative analysis. J Am Coll Surg. 2008;207(4):573-9. 6. Sutton E, Bochicchio GV, Bochicchio K, Rodriguez ED, Henry S, Joshi M, et al. Long term impact of damage control surgery: a preliminary prospective study. J Trauma. 2006;61(4):831-4; discussion 835-6. 7. Flin R, Youngson G, Yule S. How do surgeons make intraoperative decisions? Qual Saf Health Care. 2007;16(3):235-9. 8. Schreiber MA. The beginning of the end for damage control surgery. Br J Surg. 2012;99 Suppl 1:10-1. 9. Martin MJ, Hatch Q, Cotton B, Holcomb J. The use of temporary abdominal closure in low-risk trauma patients: helpful or harmful? J Trauma Acute Care Surg. 2012;72(3):601-6; discussion 606-8. 10. Stone HH, Strom PR, Mullins RJ. Management of the major coagulopathy with on set during laparotomy. Ann Surg. 1983;197(5):532-5.
Rev Col Bras Cir. 2018; 45(1):e1474
Pimentel Damage control surgery: are we losing control over indications?
11. Aoki N, Wall MJ, Demsar J, Zupan B, Granchi T,
FLACSO/CEBELA; 2016. Available from: http://
Schreiber MA, et al. Predictive model for survival at
the conclusion of a damage control laparotomy. Am J Surg. 2000;180(6):540- 4; discussion 544-5. Odom SR, Howell MD, Silva GS, Nielsen VM, Gupta A, Shapiro NI, et al. Lactate clearance as a predictor of mortality in trauma patients. J Trauma Acute Care Surg. 2013;74(4):999-1004. MacLeod JB, Lynn M, McKenney MG, Cohn SM, Murtha M. Early coagulopathy predicts mortality in trauma. J Trauma. 2003;55(1):39-44. Lima SO, Cabral FLD, Pinto Neto AF, Mesquita FNB, Feitosa MFG, Santana VR de. Avaliação epidemiológica das vítimas de trauma abdominal submetidas ao tratamento cirúrgico. Rev Col Bras Cir. 2012;39(4):302-6. Waiselfsz JJ. Mapa da violência 2016. Homicídios por armas de fogo no Brasil. PDF file. Rio de Janeiro:
armas_web.pdf 16. Nascimento Jr B, Scarpelini S, Rizoli S. Coagulopatia no trauma. Medicina, Ribeirão Preto. 2007;40(4):509-17.
Received in: 03/09/2017 Accepted for publication: 26/10/2017 Conflict of interest: none. Source of funding: none. Mailing address: Tulio Rucinski E-mail: email@example.com / firstname.lastname@example.com
Rev Col Bras Cir. 2018; 45(1):e1474
Original Article
The role of computerized tomography in penetrating abdominal trauma O papel da tomografia no trauma abdominal penetrante EDUARDO LOPES MARTINS FILHO1; MELISSA MELLO MAZEPA1; CAMILA ROGINSKI GUETTER, ACCBC-PR1; SILVÂNIA KLUG PIMENTEL, TCBC-PR1,2
A B S T R A C T Objective: to evaluate the role of abdominal computed tomography in the management of penetrating abdominal trauma. Methods: we conducted a historical cohort study of patients treated for penetrating trauma in the anterior abdomen, dorsum or thoracoabdominal transition, that were submitted to a computed tomography carried out on admission. We evaluated the location of the wound and the presence of tomographic findings, and the management of these patients as for nonoperative treatment or laparotomy. We calculated the sensitivity and specificity of computed tomography according to the evolution of the nonoperative treatment or the surgical findings. Results: we selected 61 patients, 31 with trauma to the anterior abdomen and 30 to the dorsum or thoracoabdominal transition. The mortality rate was 6.5% (n=4), all in the late postoperative period. Eleven patients with trauma to the anterior abdomen were submitted to nonoperative treatment, and 20, to laparotomy. Of the 30 patients with trauma to the dorsum or thoracoabdominal transition, 23 underwent nonoperative treatment and seven, laparotomy. There were three nonoperative treatment failures. In penetrating trauma of the anterior abdomen, the sensitivity of computed tomography was 94.1% and the negative predictive value was 93.3%. In dorsal or thoracoabdominal transition lesions, the sensitivity was 90% and the negative predictive value was 95.5%. In both groups, the specificity and the positive predictive value were 100%. Conclusion: the accuracy of computed tomography was adequate to guide the management of stable patients who could be treated conservatively, avoiding mandatory surgery in 34 patients and reducing the morbidity and mortality of non-therapeutic laparotomies. Keywords: Tomography. Abdominal Injuries. Sensitivity and Specificity. Conservative Treatment. Multiple Trauma.
towards a more judicious treatment6. Bearing
he change in management of penetrating abdominal
instability, peritonitis, evisceration and impalement are
trauma over time is remarkable. During the late
formal indications for surgical exploration7, currently
nineteenth and early twentieth centuries, nonoperative
nonoperative treatment (NOT) can be performed in
treatment of abdominal injuries was the norm, since
selected stable patients who do not present these signs8.
laparotomies were associated with a prohibitive rate of
In order to target patients to this form of treatment,
mortality . Due to paradigm shifts, with the development
imaging tests, particularly abdominal tomography (CT),
of asepsis and anesthetic techniques, patients who
are essential9. Although the time required for the CT
suffer from penetrating abdominal trauma have been
exam is a risk factor for higher mortality in patients
mandatorily operated . However, it was observed that
with severe abdominal injuries10, the careful selection
non-therapeutic laparotomies doubled hospitalization
of those who can undergo abdominal CT may be a safe
time and significantly increased patients' morbidity . Thus,
way of directing management in penetrating trauma11.
victims of stabbing injuries were managed conservatively
Our institution (Hospital do Trabalhador – UFPR) has
in selected cases , and gunshot wounds, until recently 5
a mandatory indication of laparotomy , also has a shift
accumulated considerable experience in the selective management of penetrating abdominal trauma, but
1 - Federal University of Paraná, Curitiba, PR, Brazil. 2 - Hospital do Trabalhador, General Surgery Service, Curitiba, PR, Brazil.
Rev Col Bras Cir. 2018; 45(1):e1348
Martins Filho The role of computerized tomography in penetrating abdominal trauma
there are still few studies that evaluate the accuracy of the
anatomical location of the entry wounds, the abdominal
tomography in this scenario.
tomography findings, the type of treatment performed
Thus, the objective of this study is to evaluate the
(surgical or nonoperative), the main surgical indications,
role of abdominal CT in victims of penetrating abdominal
the exploratory laparotomies findings and the treatment
trauma and to see if the accuracy of tomography in this
outcome. Due to the anatomical differences, we divided
population is adequate to determine the treatment of the
the patients into two groups according to the location
of the penetrating wound: anterior abdomen group and dorsum/TAT group.
We considered, as positive abdomen CT findings, the abdominal trajectory of the projectile, peritoneal cavity
We conducted a historical cohort study at the
violation, lesions of large vascular structures, solid viscera,
Hospital do Trabalhador, a reference center for trauma
diaphragm, urether or bladder, and the presence of free
care in Curitiba-PR and its metropolitan region. We
fluid in the abdominal cavity and/or pneumoperitoneum13.
included patients admitted between January 2014 and
Those that did not present these findings were negative
June 2015, victims of penetrating trauma to the anterior
CT scans.
abdomen, dorsum and thoracoabdominal transition (TAT)
We calculated sensitivity, specificity, accuracy,
who underwent abdominal CT at admission. Thus, we
positive predictive value and negative predictive value
guaranteed the selection of stable patients. Therefore,
by comparing the CT findings with the surgical findings
we analyzed 1837 records of abdominal tomography and
in exploratory laparotomies or with the nonoperative
cross-checked the data using the records of assaults and
treatment (NOT) outcome, depending on the management
homicides of the social work sector of the Hospital do
to which the patient was submitted. Thus, true positives
Trabalhador, to identify victims of penetrating abdominal
were patients with surgical findings consistent with those
trauma due to stabbing injuries (SI) and gunshot
of CT or patients who performed NOT for lesions seen on CT
wounds (GSW). We excluded patients without trauma
and had a favorable evolution. True negatives cases were
to the anterior abdomen, dorsum or TAT, patients with
those with no CT findings who had a favorable evolution
multiple entry wounds, and patients with missing data
of NOT or who underwent exploratory laparotomies
on the medical chart. The total number of individuals
without findings, ie, non-therapeutic laparotomy (NTL).
who underwent abdominal CT for penetrating trauma
False positives happened when CT showed lesions but
was 128. Of these, we excluded 37 because they did
the surgical findings were not consistent with them, and
not present trauma to the anterior abdomen, dorsum
false negatives, when NOT failed or when laparotomy was
or thoracoabdominal transition. Of the 91 remaining
clinically indicated and presented findings different from
patients, we excluded 30 (32.96%) because they did not
CT ones. We considered NOT failure as hypotension or
present sufficient data in the medical records.
hematocrit decrease without explanation and evolution to
For purposes of anatomical division, we
diffuse peritonitis14.
considered the anterior abdomen the region delimited by
The study was approved by the Ethics
the xiphoid process and the costal borders superiorly, the
Committee of the Hospital do Trabalhador under the
axillary lines medium laterally, and the lower symphysis
number 45397615.0.0000.5225.
pubis. We defined thoracoabdominal transition as the area between the nipple line and the costal borders. We
considered the dorsum as the region between the infrascapular line superiorly, the iliac crests inferiorly, and the 12
We included 61 patients in the study, of whom 88.52% (n=54) were male. Their mean age was 26.8Âą9.38
median axillary lines laterally . We evaluated the epidemiological data, the
years. The mechanisms of trauma were gunshot wounds
Rev Col Bras Cir. 2018; 45(1):e1348
Martins Filho The role of computerized tomography in penetrating abdominal trauma
in 59.01% (n=36) and stabbing injuries in 40.99%
injuries to the anterior abdomen in 50.82% (n=31) of the
(n=25). There were four deaths in this cohort, two due
patients, and injuries to the dorsum or TAT in 49.18%
to hemodynamic instability in the postoperative period,
(n=30). We observed positive tomographic findings in
and two late ones because of pulmonary and abdominal
51.61% (n=16) of patients with trauma to the anterior
sepsis. The mortality rate found was, therefore, 6.55%,
abdomen and 30% (n=9) of patients with dorsum/TAT
all of them being victims of gunshot wounds. We found
trauma (Table 1).
Table 1. Epidemiological data and trauma mechanism.
Anterior abdomen (n = 31)
Dorsum/TAT (n = 30)
Total n = 61
28 (90.3)
26 (86.7)
54 (88.5)
27.8 (± 9.4)
25.7 (± 9.2)
26.8 (± 9.4)
Gunshot wound
20 (64.5)
16 (53.3)
36 (59)
Stabbing injury
11 (35.5)
14 (46.7)
25 (41)
Variable Male (%) Average age (± SD) Mechanism of trauma (%)
SD: standard deviation; TAT: thoracoabdominal transition.
The most common positive findings in patients with trauma to the anterior abdomen were lesions in solid viscera associated with free fluid or pneumoperitoneum (22.58%), free fluid associated with pneumoperitoneum (19.35%), free liquid alone (6.45%) and isolated lesion of solid viscera (3.23%). In this group, 48.39% of the CT scans
had negative findings. In the patients with trauma to the dorsum/TAT, 20% were lesions in solid viscera with free fluid or pneumoperitoneum, 3.33% pneumoperitoneum, and in 3.33%, isolated solid viscera lesions. In this group, 70% of the CT scans had negative findings (Table 2).
Table 2. Tomographic findings in penetrating abdominal trauma.
Anterior abdomen (n=31)
Dorsum/TAT (n=30)
2 (6.45)
1 (3.34)
Isolated solid viscera injury
1 (3.23)
1 (3.33)
Free liquid and pneumoperitoneum
6 (19.35)
Solid viscera injury with free fluid or pneumoperitoneum
7 (22.58)
7 (20)
Negative scan
15 (48.39)
21 (70)
Variable (%) Free fluid Pneumoperitoneum
TAT: thoracoabdominal transition.
The CT findings in patients submitted to NOT
can be seen in table 3.
Rev Col Bras Cir. 2018; 45(1):e1348
Martins Filho The role of computerized tomography in penetrating abdominal trauma
4 Table 3. Tomographic findings in patients undergoing NOT.
Variable (%)
Anterior abdomen (n=11)
Dorsum/TAT (n=23)
1 (9.09%)
1 (4.34%)
3 (13.04%)
10 (90.91%)
19 (82.60%)
Isolated solid viscera injury Solid viscera injury and free fluid Negative scan TAT: thoracoabdominal transition.
Among the CT scans of the patients with trauma to the anterior abdomen, were found 16 true positive exams, 14 true negatives and one false negative due to a grade I lesion of the ileum not seen on the tomography. Among patients with dorsum/TAT trauma, there were nine true positives, 20 true negatives and one false negative, the latter due to the presence of a grade III lesion in jejunum.
For patients with anterior abdominal trauma, CT sensitivity was 94.1%, specificity was 100%, and accuracy was 96.7%. The positive predictive value was 100% and the negative predictive value was 93.3%. For patients with dorsum/TAT trauma, the CT's sensitivity was 90%, the specificity was 100%, and the accuracy was 96.6%. The positive predictive value was 100% and the negative predictive value, 95.52% (Table 4).
Table 4. Accuracy of CT in penetrating abdominal trauma victims.
Anterior abdomen
CT: computed tomography; PPV: positive predictive value; NPV: negative predictive value; TAT: thoracic abdominal transition.
found in this study, both in anterior abdomen trauma (PPV=100% and NPV=93.3%) and in the dorsum or TAT
The results presented accompany the current trend
penetrating abdominal trauma, using imaging resources in hemodynamically stable patients and allowing the selection 15
of patients for NOT, which, in addition to reducing costs ,
(PPV=100% and PPV=95.5%), are consistent with other works13,17 and show that CT is reliable for the definition of therapeutic management. It is predicted that trauma in the anterior abdomen presents a higher rate of abdominal viscera
is associated with lower morbidity and mortality . Among
lesions and, therefore, will tend to be more surgical.
the available exams, abdominal tomography has become
Among the victims of trauma in this topography (n=31)
essential , being a rapid examination and providing the
who presented positive findings (n=16), only one was
surgeon in the emergency room with the security of
submitted to NOT due to a grade III hepatic lesion,
determining whether surgical treatment is necessary
with favorable evolution. The others (n=15) underwent
or not. The high positive and negative predictive values
laparotomies, all therapeutic. Among the patients whose
Rev Col Bras Cir. 2018; 45(1):e1348
Martins Filho The role of computerized tomography in penetrating abdominal trauma
tomography did not show signs of lesions (n=15), ten were submitted to NOT, with only one failure due to an ileum degree I lesion. The other five patients underwent laparotomies for indications other than the tomographic findings, one being therapeutic for a grade I lesion in ileum, and four were non-therapeutic. Thus, the sensitivity and specificity of tomography to define the management of penetrating trauma in the anterior abdomen proved to be reliable, as in the literature data12,13. In patients with dorsum/TAT trauma, there is usually greater diagnostic doubt18, since the back musculature is a much greater obstacle than that of the anterior abdominal wall, so that the abdominal cavity not always get penetrated, thus leading to a smaller incidence of intraabdominal lesions19. Considering this diagnostic challenge, we observed that 70% (n=21) of patients with trauma in this topography did not present tomographic findings. Among them, 19 underwent NOT with favorable evolution and two underwent laparotomies due to failure, one being non-therapeutic because of the presence of a stable retroperitoneal hematoma in zone II, with no need for surgical approach20, and one for a jejunum grade III lesion. Among the nine other patients with positive CT findings, four were due to trauma to the liver or kidney, allowing NOT and avoiding non-therapeutic laparotomies. Five patients underwent laparotomy, all being therapeutic. Thus, tomography was also reliable in patients with penetrating trauma to the dorsum or TAT. We emphasize that, in TAT lesions, tomography is essential for the possibility of successfully targeting NOT from liver lesions21,22.
The time required to perform a CT scan is associated with a higher mortality rate in patients who require surgical treatment10. With this in mind, we observed that our sample had a mortality rate of 6.5% (four patients). This rate was consistent with the literature data6. However, no death occurred during the CT scan, immediately after it or because of NOT failure. All deaths occurred in the late postoperative period due to septic or hemodynamic decompensation. Thus, tomography at admission would hardly be related to the cause of these deaths. The literature shows an unnecessary rate of laparotomies, ranging from 4.0% to 14%14,19. Overall, if mandatory laparotomies were performed for penetrating abdominal trauma in this study of 61 patients, 39 (63.9%) would have undergone nontherapeutic laparotomies. With selective abdominal computed tomography and NOT targeting, this number was reduced to five (8.2%) patients, avoiding 34 unnecessary laparotomies. The use of abdominal CT in the presence of hemodynamic stability and lack of mandatory indications for laparotomy (peritonitis, evisceration or impalement) clearly reduced morbidity in victims of penetrating abdominal trauma. Abdominal CT is an examination that, when indicated in a judicious manner, can be performed safely in patients with penetrating abdominal trauma. This study demonstrates an adequate sensitivity and specificity of the method for detecting traumatic lesions, which allows less aggressive treatments to be performed safely, reducing the morbidity and mortality to which these patients would be exposed to if mandatory laparotomies were performed.
Rev Col Bras Cir. 2018; 45(1):e1348
Martins Filho The role of computerized tomography in penetrating abdominal trauma
R E S U M O Objetivo: avaliar o papel da tomografia computadorizada de abdome no manejo do trauma abdominal penetrante. Métodos: estudo de coorte histórico de pacientes tratados por trauma penetrante em abdome anterior, dorso ou transição tóraco-abdominal que realizaram tomografia computadorizada à admissão. Avaliou-se a localização do ferimento e a presença de achados tomográficos, e o manejo desses pacientes quanto ao tratamento não operatório ou laparotomia. A sensibilidade e especificidade da tomografia computadorizada foram calculadas de acordo com a evolução do tratamento não operatório ou com os achados cirúrgicos. Resultados: foram selecionados 61 pacientes, 31 com trauma em abdome anterior e 30 em dorso ou transição tóraco-abdominal. A taxa de mortalidade foi de 6,5% (n=4), todos no pós-operatório tardio. Onze pacientes com trauma em abdome anterior foram submetidos a tratamento não operatório e 20 à laparotomia. Dos 30 pacientes com trauma em dorso ou transição tóraco-abdominal, 23 realizaram tratamento não operatório e sete foram submetidos à laparotomia. Houve três falhas do tratamento não operatório. Em traumas penetrantes do abdome anterior, a sensibilidade da TC foi de 94,1% e o valor preditivo negativo, 93,3%. Em lesões de dorso ou transição tóraco-abdominal, a sensibilidade foi de 90%, e o valor preditivo negativo foi de 95,5%. Em ambos os grupos, a especificidade e o valor preditivo positivo foram de 100%. Conclusão: a acurácia da tomografia computadorizada foi adequada para direcionar o manejo de pacientes estáveis que puderam ser tratados de forma conservadora, evitando cirurgia mandatória em 34 pacientes e reduzindo a morbimortalidade de laparotomias não terapêuticas. Descritores: Tomografia. Traumatismos Abdominais. Sensibilidade e Especificidade. Tratamento Conservador. Traumatismo Múltiplo.
in a prospective single-center study. Ann Surg. 2015;261(4):760-4.
1. Loria FL. Historical aspects of penetrating wounds of the abdomen. Surg Gynecol Obstet. 1948;87(6):52149. 2. Moore EE, Moore JB, Van Duzer-Moore S, Thompson JS. Mandatory laparotomy for gunshot wounds penetrating the abdomen. Am J Surg. 1980;140(6):847-51. 3. Nance FC, Wennar MH, Johnson LW, Ingram JC Jr, Cohn I Jr. Surgical judgment in the management of penetrating wounds of the abdomen: experience with 2212 patients. Ann Surg [Internet]. 1974 May [cited 2016 Oct 12];179(5):639-46. Available from: http:// www.ncbi.nlm.nih.gov/pmc/articles/PMC1356042/ 4. Shaftan GW. Indications for operation in abdominal trauma. The Am J Surg [Internet]. 1960 May [cited 2016 Oct 12];99(5):657-64. Available from: http://linkinghub.elsevier.com/retrieve/ pii/0002961060900106 5. Martin RS, Meredith JW. Management of acute trauma. In: Sabiston D. C. Textbook of Surgery. Durham, North Carolina: Elsevier, 2016. p. 407-48. 6. Navsaria PH, Nicol AJ, Edu S, Gandhi R, Ball CG. Selective nonoperative management in 1106 patients with abdominal gunshot wounds: conclusions on safety, efficacy, and the role of selective CT imaging
7. Biffl WL, Leppaniemi A. Management guidelines for penetrating abdominal trauma. World J Surg. 2015;39(6):1373-80. 8. Demetriades D, Velmahos G, Cornwell E 3rd, Berne TV, Cober S, Bhasin PS, et al. Selective nonoperative management of gunshot wounds of the anterior abdomen. Arch Surg. 1997;132(2):178-83 . 9. Jansen JO, Inaba K, Resnick S, Fraga GP, Starling SV, Rizoli SB, et al. Selective non-operative management of abdominal gunshot wounds: survey of practice. Injury. 2013;44(5):639-44. 10. Neal MD, Peitzman AB, Forsythe RM, Marshall GT, Rosengart MR, Alarcon LH, et al. Over reliance on computed tomography imaging in patients with severe abdominal injury: is the delay worth the risk? J Trauma. 2011;70(2):278-84. 11. Ginzburg E, Carrillo EH, Kopelman T, McKenney MG, Kirton OC, Shatz DV, et al. The role of computed tomography in selective management of gunshot wounds to the abdomen and flank. J Trauma. 1998;45(6):1005-9. 12. Velmahos GC, Constantinou C, Tillou A, Brown CV, Salim A, Demetriades D. Abdominal computed tomographic scan for patients with gunshot wounds to the abdomen selected for nonoperative
Rev Col Bras Cir. 2018; 45(1):e1348
Martins Filho The role of computerized tomography in penetrating abdominal trauma
discussion 1160-1.
20. Wang F, Wang F. The diagnosis and treatment of traumatic retroperitoneal hematoma. Pak J Med Sci
13. Ramirez RM, Cureton EL, Ereso AQ, Kwan RO, Dozier KC, Sadjadi J, et al. Single-contrast computed tomography for the triage of patients with penetrating torso trauma. J Trauma. 2009;67(3):583-8. 14. Velmahos GC, Demetriades D, Toutouzas KG, Sarkisyan G, Chan LS, Ishak R, et al. Selective nonoperative management in 1,856 patients with abdominal gunshot wounds: should routine laparotomy still be the standard of care? Ann Surg. 2001;234(3):395-402; discussion 402-3. 15. Kim R, Navsaria P, Myer L, Nicol A. Selective nonoperative management of abdominal gunshot wounds: a cost analysis [abstract]. South Afr J Surg. 2009;47;21. 16. Hasaniya N, Demetriades D, Stephens A, Dubrowskiz R, Berne T. Early morbidity and mortality of nontherapeutic operations for penetrating trauma. Am Surg. 1994;60(10):744-7. 17. Dreizin D, Munera F. Multidetector CT for penetrating torso trauma: State of the Art. Radiology. 2015;277(2):338-55. 18. Berg RJ, Karamanos E, Inaba K, Okoye O, Teixeira PG, Demetriades D. The persistent diagnostic challenge of thoracoabdominal stab wounds. J Trauma Acute Care Surg. 2014;76(2):418-23. 19. Velmahos GC, Demetriades D, Foianini E, Tatevossian R, Cornwell EE, Asensio J, et al. A selective approach to the management of gunshot wounds to the back. Am J Surg. 1997;174(3):342-6.
[Internet]. 2013 Apr [cited 2016 Oct 14];29(2):5736. Available from: http://www.ncbi.nlm.nih.gov/ pmc/articles/PMC3809226/ 21. Starling SV, Rodrigues BL, Martins MP, da Silva MSA, Drumond DA. Non operative management of gunshot wounds on the right thoracoabdomen. Rev Col Bras Cir. 2012;39(4):286-94. 22. Starling SV, Azevedo CI, Santana AV, Rodrigues BL, Drumond DA. Isolated liver gunshot injuries: nonoperative management is feasible? Rev Col Bras Cir [Internet]. 2015 Aug [cited 2017 Oct 10];42(4):238-43. Available from: http://www. scielo.br/scielo.php?script=sci_abstract&pid=S010069912015000500238&lng=en&nrm=iso&tlng=en
Received in: 07/08/2017 Accepted for publication: 02/11/2017 Conflict of interest: none. Source of funding: none. Mailing address: Eduardo Lopes Martins Filho E-mail: email@example.com / email@example.com
Rev Col Bras Cir. 2018; 45(1):e1348
Original Article
Basic ultrasound training assessment in the initial abdominal trauma screening Avaliação de treinamento básico em ultrassom na triagem inicial do trauma abdominal LUAN GERALDO OCAÑA OLIVEIRA1, DEBORA TAGLIARI1, MARIANA JULIATO BECKER1, THIAGO ADAME1, JOSÉ CRUVINEL NETO, TCBC-SP1, FERNANDO ANTÔNIO CAMPELO SPENCER NETTO, TCBC-PR1 A B S T R A C T Objective: to verify the efficiency and usefulness of basic ultrasound training in trauma (FAST - Focused Assessment with Sonography in Trauma) for emergency physicians in the primary evaluation of abdominal trauma. Methods: a longitudinal and observational study was carried out from 2015 to 2017, with 11 emergency physicians from Hospital Universitário do Oeste do Paraná, submitted to ultrasound training in emergency and trauma (USET® - SBAIT). FAST results started to be collected two months after the course. These were compared with a composite score of complementary exams and surgical findings. Information was stored in a Microsoft Excel program database and submitted to statistical analysis. Results: FAST was performed in 120 patients. In the study, 38.4% of the assessed patients had a shock index ³0.9. The composite score detected 40 patients with free peritoneal fluid, whereas FAST detected 27 cases. The method sensitivity was 67.5%, specificity was 98.7%, the positive predictive value was 96.4%, the negative predictive value was 85.39% and accuracy was 88%. All those with a positive FAST had a shock index ³0.9. Fifteen patients with positive FAST and signs of instability were immediately submitted to surgery. Conclusions: the basic training of emergency physicians in FAST showed efficiency and usefulness in abdominal trauma assessment. Due to its low cost and easy implementation, this modality should be considered as a screening strategy for patients with abdominal trauma in health systems. Descriptors: Ultrasonography. Training/ultrasonics. Multiple Trauma. Abdominal Injuries. Point-of-Care Systems. Advanced Trauma Life Support Care.
of multiple trauma patients, replacing the peritoneal lavage method in the assessment of abdominal trauma,
rauma is the main cause of mortality and morbidity in Brazil and worldwide, predominantly affecting the population aged <45 years1-3. Due to its high incidence and years of potential life lost, it constitutes a public health problem, at national and international levels1,3. Aiming to improve the initial screening of trauma patients, more than two decades ago the use of ultrasound (Focused Assessment with Sonography in Trauma - FAST) was incorporated into the initial assessment of trauma victims, under the approval of the American College of Surgeons, through the Advanced Trauma Life Support (ATLS) program1,4-6. This evaluation tool resulted in a change in the diagnostic management
particularly in unstable patients4,7,8. Physical examination in multiple trauma patients may be made difficult by the presence of several lesions, as well as the possibility of low level of consciousness level, shock of unknown etiology, central nervous system lesions and other clinical manifestations that make diagnosis difficult at the clinical examination only1. FAST consists of a non-invasive ultrasound examination that can be quickly performed by the patient's bedside, aiming to clarify specific clinical issues, regardless of the trauma mechanism that affected the patient1,3,4,7,8. Regarding FAST accuracy in the assessment of abdominal trauma, the sensitivity is 62% to 94% and the specificity is greater
1 - Universidade Estadual do Oeste do Paraná, Serviço de Cirurgia Geral, Cascavel, PR, Brasil.
Rev Col Bras Cir. 2018; 45(1):e1556
Oliveira Basic ultrasound training assessment in the initial abdominal trauma screening
than 96% in skilled hands1,4.
follow-up of the cases during the study. The inclusion
In this context, FAST has the objective of
criteria comprised all patients with clinical suspicion of
detecting the presence of free peritoneal fluid (FPF)
abdominal trauma, blunt or penetrating, submitted to
in the primary assessment of patients victims of acute
FAST at their initial evaluation.
abdominal trauma . The examination is performed in
Additional information was obtained from
the right upper quadrant (RUQ), called the hepatorenal
the patients' physical and electronic medical records.
space or Morrison's pouch, in the left upper quadrant
Demographic data (date, identification, gender, age, type
(LUQ) and in presence of free peritoneal fluid1,3,4,6,7.
of trauma, time since the trauma, vital signs at admission),
The aim of this study was to verify the efficiency
FAST results (time of exams, ultrasound findings), results
of the basic training in emergency ultrasonography and
of complementary examinations in the abdominal
trauma (USET®), of emergency physicians in the detection
assessment and procedures performed on the patients
of free peritoneal fluid in trauma patients, by measuring
(laparotomy and its findings) were collected.
the sensitivity, specificity, predictive values, accuracy and
FAST reports were compared with a composite
likelihood ratios. The method usefulness was assessed
score consisting of complementary exams (computed
by clinical decision-making based on FAST and clinical
tomography - CT) and clinical and surgical findings.
The composite score was used as the gold standard for comparison between the FAST examination results and
the evaluation of training efficiency. The analysis of medical records was used to verify
The project was approved by the Institutional
possible changes in clinical or surgical management related
Research Ethics Committee of Plataforma Brasil under
to the use of FAST, such as the use of complementary
number: 53225215.2.0000.0107. This is a longitudinal,
exams or immediate surgery. This criterion was used to
observational study carried out at Hospital Universitário
assess the method usefulness. The information was stored in a Microsoft Excel
do Oeste do Paraná - HUOP. With the availability of a LOGIC C5 Premium
database and submitted to statistical analysis. The results
ultrasound device for the HUOP emergency room in
of quantitative and qualitative variables were described by
September 2015, the institution provided training to
means, absolute values, percentages, predictive values,
the hospital physicians, with a 10-hour basic course
sensitivity, specificity, accuracy and likelihood ratios.
in emergency and trauma ultrasound (USET®) by the
Fisher's exact test was used to verify the strength of
Brazilian Society for the Integral Care of Trauma Patients
associations, as appropriate.
(SBAIT - Sociedade Brasileira de Atendimento Integral ao Traumatizado). This training was voluntary and paid for
by the physicians interested in taking it. Eleven emergency physicians (a total of 31 physicians working at emergency
During the study period, 559 patients with
at the time) received the training. After the training, the
suspected abdominal trauma were admitted and FAST
emergency physicians started to use FAST according to its
was performed in 120 patients. The patients' mean age
respective indications.
was 35 years, with a prevalence of males. Most received
After two months, data on FAST examination
prehospital care and there was a greater prevalence of
performed from 12/2015 to 04/2017 were collected. After
blunt trauma (Table 1). Three patients were excluded from
FAST performance, the examiners voluntarily notified the
the analysis, as they had inconclusive tests (two patients
authors, through electronic media, allowing an early
identified as obese).
Rev Col Bras Cir. 2018; 45(1):e1556
Oliveira Basic ultrasound training assessment in the initial abdominal trauma screening
Table 1. Demographic data of the total number of patients assessed in the study.
Variable Mean age (years) Male gender (%) Prehospital care (%) Tachycardia * (%) BP<70 mmHg ** (%) Blunt trauma (%) SI*** ³ 0.9 (%)
Values 35.6 75.6 94 30 22 74.2 37.5
p<0.0001). Fifteen patients, of 27 with positive FAST and SI³0.9, were immediately submitted to surgery for bleeding treatment, without undergoing additional tests. All patients with positive FAST (27) underwent CT or surgery in comparison to 13 (15%) patients with negative FAST for FPF (p<0.0001).
*Tachycardia: HR>100 beats/min; **BP: Blood pressure ***SI: Shock index.
Trauma is the third cause of death in the Brazilian population and the main one in individuals under 40 years of age2. In the present study, the age
The composite score (CS) detected 40 patients with free peritoneal fluid (FPF) according to the following distribution of detection methods: CT: 17; CT + surgery: 8; surgery: 15. FAST detected 27 cases of FPF. Among these, one patient with blunt trauma had a false positive (FP) case. When reviewing the abdominal CT, nine patients had less than 400mL of free fluid in the peritoneal cavity, all of them negative by FAST. The values obtained by the USET® of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy (A), positive likelihood ratio (PLR) and negative likelihood ratio (NLR) for all patients with FPF and for those with a significant amount of free peritoneal fluid (SAFPF>400mL) are shown in table 2.
group was consistent, with a higher prevalence of blunt trauma and male individuals. The accurate and rapid diagnosis of abdominal bleeding can be difficult, particularly in blunt trauma cases1,4. In the present study, it was demonstrated that the training of emergency physicians through a basic ultrasound course and the device availability in the emergency room was sufficient to obtain examinations with sensitivity and specificity values similar to those of skilled professionals (>100 FAST exams)1,4. The examination was particularly useful in patients with evidence of FPF (positive FAST) and hemodynamic instability (IC³0.9), allowing the decisionmaking to perform surgery immediately, based on the initial abdominal assessment. Only 21% of patients admitted with severe trauma had FAST examination performed at the
Table 2. Association of FAST in the assessment of all patients with free peritoneal fluid (FPF) x significant amount of FPF (SAFPF)
Variable Sensitivity Specificity Accuracy Positive predictive value Negative predictive value PLR* NLR**
All FPF 67.5 98.7 88 96.4 85.4 49.7 0.33
admission. This may be due to some factors: a) only 1/3 of the attending physicians took the training course and
were able to perform the examination; b) our emergency room, as well as several others of the Brazilian Unified Health System (Sistema Único de Saúde do Brasil - SUS), often treats an excessive number of patients, making it difficult to transport the ultrasound device to the bed of the patient that needs to be examined or even the nonavailability of an electrical outlet for the device connection;
*PLR: Positive Likelihood Ratio; **NLR: Negative Likelihood Ratio.
c) eventual notification failures to the follow-up team regarding the examination performance. However, it 9
Forty-five patients (38.4%) had a shock index (SI) ³0.9 on admission. All patients (27) with a positive FAST had SI³0.9. There was an association between SI³0.9 and the presence of positive CS or positive FAST (both
could be expected that it would be used in patients with greater possibility of positivity at the initial phase of the method introduction, in this case, unstable patients with evident abdominal trauma. Therefore, a selection bias
Rev Col Bras Cir. 2018; 45(1):e1556
Oliveira Basic ultrasound training assessment in the initial abdominal trauma screening
cannot be ruled out for patients with greater possibility of
However, there is limitation of its use in patients with
a positive examination. This possible bias does not exclude
hemodynamic instability due to the treatment urgency of
the method assessment validity, since the hypothesis was tested with a reasonable number of patients, with varied results. Regarding inconclusive exams, two patients were obese, which made the examination technically unfeasible, and technical difficulty was reported by the professional performing the examination in one patient. The literature reports that the diagnostic performance of FAST depends on several factors, including clinical adjustment, professional skill, equipment and patient condition1,4,10-12. It is known that obesity is a limiting factor for the ultrasound performance1,4. Another bias that may have contributed to the inconclusive results is the fact that most of the errors that occur during the learning period are related to inadequate depth and gain13. Shock index (SI) is an indicator calculated by the ratio of heart rate to systolic blood pressure (SI=HR/ SBP) and has been used as a mortality predictor at the admission of a trauma patient, being potentially useful for the identification of patients requiring massive blood transfusion9. Trauma patients with SI³0.9 have a higher mortality and are at higher risk of being submitted to massive blood transfusion9. In the present study, 45 (38.4%) of the patients submitted to FAST had a SI³0.9. This demonstrates that more than one third of the patients were potentially severe cases in terms of hemodynamic stability, with a higher mortality rate than
these patients1,4,6. The sensitivity and specificity of FAST for FPF assessment may vary according to the professional's skill from 62% to 96% and from 94% to 99.7%, respectively4. The present study demonstrated that, with basic formal training (USET®-SBAIT), in the short term, professionals with little or no experience can obtain results similar to results of previous studies regarding sensitivity and specificity. Therefore, a lower learning curve can be inferred, if compared to studies showing that at least 100 examinations are required to acquire proficiency with the method1,10-12. Thus, FAST showed to be a method with a rapid learning curve and easy to use as a propaedeutic tool in the initial assessment of abdominal trauma. Regarding the limitations of FAST in the assessment of abdominal trauma, loss of sensitivity is possible in cases of pneumoperitoneum, obesity and small amount of FPF (<400mL)1. Of the 13 false-negative cases, nine were due to small amounts of FPF, detected only by CT. It has been previously demonstrated that FPF>600mL is easily observable on FAST examination. The detection of amounts between 400mL and 600mL depends on the professional's skill and values below 400mL are difficult to visualize1,4. In this context, if we disregard these nine patients with a small amount of FPF, the sensitivity of FAST increases from 67.5% to 87% and the accuracy from 88% to 95.7%. In general, patients
patients with a lower SI. All patients with FPF in FAST (27) and 29 (72.5%) in the CS had a CI³0.9 at admission, with a strong statistical association. This demonstrates the strong association of abdominal bleeding with hemodynamic instability and suggests the distinct method usefulness in the most severe patients, contributing to the rapid establishment of appropriate therapy for these patients. The composite score (CS) used in the study consisted of the abdominal CT, clinical and surgical findings. This composition represents the choice parameter as a tool for comparison with FAST to obtain predictive values, sensitivity, specificity, accuracy and likelihood ratios. Among the CS variables, the abdominal CT corresponds to the gold standard to detect FPF1,4,6.
with FPF<400mL do not have an indication for emergency surgical intervention and show good evolution when submitted to non-surgical treatment1. In this study, all patients with a small amount of FPF in the CT evaluation received conservative management and showed good evolution. FAST is a rapid, low-cost examination that can result in valuable prognostic information in patients who are hemodynamically stable or not14,15. Therefore, in hemodynamically stable patients, the method is potentially useful both for the initial screening and to rationalize the use of health resources, reducing the number of requested abdominal CTs and potentially avoiding a hospital transfer for specialized assessment14,15. In the present study, there was a statistically significant
Rev Col Bras Cir. 2018; 45(1):e1556
Oliveira Basic ultrasound training assessment in the initial abdominal trauma screening
reduction in the use of abdominal CT in patients with
reason for the shock (unstable with negative FAST); c)
negative FAST. Although the test result may have
require further evaluation through complementary tests
influenced this decision, it is likely that other conditions such as the trauma mechanism and clinical conditions have influenced this decision. However, in a developing country such as Brazil, with a low availability of resources in the SUS (Sistema Único de Saúde, in English: Unified Health System) health units, FAST can be a potentially useful tool to facilitate patient screening and rationalize the use of resources in trauma patients. In cases of hemodynamic instability, FAST can quickly identify FPF and, consequently, reduce the time of referral for emergency surgery15. In this study, 15 patients had this benefit, being submitted to emergency laparotomy soon after the positive FAST, confirming the abdominal location of the bleeding. Since FAST is a relatively simple, fast, lowcost examination with a short learning curve, the basic training of professionals and the availability of ultrasound equipment to assess acute abdominal trauma can have a positive impact on the treatment and survival of trauma patients. This examination can help in therapeutic decision-making in patients who: a) require immediate surgical intervention (unstable with positive FAST); b) require urgent investigation to detect another
(stable with positive FAST); d) have indication of clinical observation and serial evaluations (stable with negative FAST). Its systematic use in the care of trauma patients can rationalize and reduce the use of human and material resources in health systems, in addition to providing early and significant information to physicians, which will potentially reduce the risk of complications and deaths in this group of patients. Therefore, the basic training in emergency and trauma ultrasound administered to emergency physicians with no previous experience with the method, demonstrated to be efficient in their training to perform FAST in the initial screening of abdominal trauma, considering the obtained results with moderate sensitivity, high accuracy and high specificity. The method was particularly useful for trauma patients with evidence of hemodynamic instability and positive FAST, allowing immediate access to surgical treatment. The training simplicity and FAST applicability suggest that the universalization of FAST access in health systems can lead to the rationalization of resource utilization, as well as improvement of clinical outcomes in trauma patients.
R E S U M O Objetivo: verificar a eficiência e a utilidade do treinamento básico em ultrassom no trauma (Focused Assessment with Sonography in Trauma - FAST) para emergencistas, na avaliação primária do trauma abdominal. Métodos: estudo longitudinal, observacional, realizado durante o período de 2015 a 2017, com 11 emergencistas do Hospital Universitário do Oeste do Paraná, submetidos ao treinamento em ultrassom na emergência e trauma (USET® - SBAIT). Resultados dos FAST começaram ser coletados dois meses após o curso. Estes foram comparados com escore composto de exames complementares e achados cirúrgicos. Informações foram armazenadas em banco de dados do programa Microsoft Excel® e submetidas à análise estatística. Resultados: foram realizados FAST em 120 pacientes. No estudo, 38,4% dos pacientes avaliados apresentavam índice de choque ³0,9. O escore composto detectou 40 pacientes com líquido livre peritoneal. FAST detectou 27 casos de líquido livre peritoneal. A sensibilidade do método foi de 67,5%, a especificidade de 98,7%, o valor preditivo positivo de 96,4%, o valor preditivo negativo de 85,39% e a acurácia foi de 88%. Todos que tiveram FAST positivo apresentavam índice de choque ³0,9. Quinze pacientes com FAST positivo e sinais de instabilidade foram conduzidos imediatamente para cirurgia. Conclusões: o treinamento básico de emergencistas em FAST demonstrou eficiência e utilidade mediata na avaliação do trauma abdominal. Por seu baixo custo e facilidade de implantação, esta modalidade deve ser considerada como estratégia de triagem de pacientes com trauma abdominal nos sistemas de saúde. Descritores: Ultrassonografia. Capacitação/ultrassom. Traumatismo Múltiplo. Traumatismos Abdominais. Sistemas Automatizados de Assistência Junto ao Leito. Cuidados de Suporte Avançado de Vida no Trauma.
Rev Col Bras Cir. 2018; 45(1):e1556
Oliveira Basic ultrasound training assessment in the initial abdominal trauma screening
2015;2(5):574-82. 11. Ziesmann MT, Park J, Unger BJ, Kirkpatrick AW,
1. Williams SR, Perera P, Gharahbaghian L. The FAST and E-FAST in 2013: trauma ultrasonography: overview, practical techniques, controversies, and new frontiers. Crit Care Clin. 2014;30(1):119-50. 2. Brasil. Ministério da Saúde. Datasus. Indicadores de Saúde. [Internet]. [acessado em 05 set 2017]. Disponível em: http://tabnet.datasus.gov.br/cgi/ tabcgi.exe?sim/cnv/ext10uf.def. 3. Flato UAP, Guimarães HP, Lopes RD, Valiatti JL, Flato EMS, Lorenzo RG. Utilização do FAST-Estendido (EFAST-Extended Focused Assessment with Sonography for Trauma) em terapia intensiva. Rev Bras Ter Intensiva. 2010;22(3):291-9. 4. Savatmongkorngul S, Wongwaisayawan S, Kaewlai R. Focused assessment with sonography for trauma: current perspectives. Open Access Emerg Med. 2017;9:57-62. 5. American College of Surgeons. ATLS: Advanced Trauma Life Support: student course manual. 9th ed. Chicago (IL): American College of Surgeons; 2012. 6. Richards JR, McGahan JP. Focused Assessment with Sonography in Trauma (FAST) in 2017: what radiologists can learn. Radiology. 2017;283(1):30-48. 7. Wongwaisayawan S, Suwannanon R, Prachanukool T, Sricharoen P, Saksobhavivat N, Kaewlai R. Trauma ultrasound. Ultrasound Med Biol. 2015;41(10):2543-61. 8. Ghafouri HB, Zare M, Bazrafshan A, Modirian E, Farahmand S, Abazarian N. Diagnostic accuracy of emergency-performed focused assessment with sonography for trauma (FAST) in blunt abdominal trauma. Electronic Physician. 2016;8(9):2950-3. 9. Allgöwer M, Burri C. ["Shock-index"]. Dtsch Med Wochenschr [Internet]. 1967;92(43):1947-50. [cited 2017 set 12]. Available from: https://www.mdcalc. com/shock-index#evidence. German. 10. Blehar DJ, Barton B, Gaspari RJ. Learning curves in emergency ultrasound education. Acad Emerg Med.
Vergis A, Logsetty S, et al. Validation of the quality of ultrasound imaging and competence (QUICK) score as an objective assessment tool for the FAST examination. J Trauma Acute Care Surg. 2015;78(5):1008-13. Ziesmann MT, Park J, Unger B, Kirkpatrick AW, Vergis A, Pham C, et al. Validation of hand motion analysis as an objective assessment tool for the Focused Assessment with Sonography for Trauma examination. J Trauma Acute Care Surg. 2015;79(4):631-7. Jang T, Kryder G, Sineff S, Naunheim R, Aubin C, Kaji AH. The technical errors of physicians learning to perform focused assessment with sonography in trauma. Acad Emerg Med. 2012;19(1):98-101. Dammers D, El Moumni M, Hoogland II, Veeger N, ter Avest E. Should we perform a FAST exam in haemodynamically stable patients presenting after blunt abdominal injury: a retrospective cohort study. Scan J Trauma Resusc Emerg Med. 2017;25(1):1. doi: 10.1186/s13049-016-0342-0. Lane BH. Evidence for cost-effectiveness of ultrasound in evaluation of blunt trauma patients. Emerg Care J. 2016;12(2):63-6.
Received in: 07/08/2017 Accepted for publication: 02/11/2017 Conflict of interest: none. Source of funding: none. Mailing address: Luan Geraldo Ocaña Oliveira E-mail: email@example.com / email@example.com
Rev Col Bras Cir. 2018; 45(1):e1556
Original Article
Scrotal reconstruction with superomedial fasciocutaneous thigh flap Reconstrução escrotal com retalho fasciocutâneo superomedial da coxa DANIEL FRANCISCO MELLO, TCBC-SP1; AMERICO HELENE JÚNIOR1
A B S T R A C T Objective: to describe the use of a superomedial fasciocutaneous thigh flap for scrotal reconstruction in open areas secondary to the surgical treatment of perineal necrotizing fasciitis (Fournier's gangrene). Methods: retrospective analysis of cases treated at the Plastic Surgery Service of Santa Casa de Misericórdia, São Paulo, from 2009 to 2015. Results: fifteen patients underwent scrotal reconstruction using the proposed flap. The mean age was 48.9 years (28 to 66). Skin loss estimates in the scrotal region ranged from 60 to 100%. Definitive reconstruction was performed on average 30.6 days (22 to 44) after the initial surgical treatment. The mean surgical time was 76 minutes (65 to 90) to obtain the flaps, bilateral in all cases. Flap size ranged from 10cm to 13cm in the longitudinal direction and 8cm to 10cm in the cross-sectional direction. The complication rate was 26.6% (four cases), related to the occurrence of segmental and partial dehiscence. Conclusion: the superomedial fasciocutaneous flap of thigh is a reliable and versatile option for the reconstruction of open areas in the scrotal region, showing adequate esthetic and functional results. Keywords: Scrotum. Skin. Wounds and Injuries. Wound Closure Techniques. Fournier Gangrene.
ones (24%), followed by anorectal (21%) and urological (19%) cases.
erineal necrotizing fasciitis, also called Fournier's gangrene, was first described in 1883. It has high rates of morbidity and mortality. Treatment is predominantly surgical, including extensive and early drainage and debridement, associated with volume replacement and
broad-spectrum intravenous antibiotic therapy. The process etiology is identified in approximately 70% to 90% of cases, and may be related to dermatological, urological and colorectal diseases or surgical procedures – including surgical complications of hemorrhoidectomy, orchiectomy, herniorrhaphy, vasectomy and postectomy1,2. The association with diabetes mellitus (DM) is frequent, with rates ranging from 20 to 60% in the literature3. Eke1, in a systematic review including 1726 cases from 1950 to 1999, reports etiology identification in more than 90% of the cases, with dermatological infections being the most frequent
The male gender is more frequently affected, and skin loss in the scrotal and perineal region is very common. The participation of the plastic surgeon is necessary to carry out the reconstruction, after clinical stabilization of the patient. The scrotal reconstruction should
characteristics, as much as possible. The ideal procedure includes performing a one-time reconstruction with adequate skin and subcutaneous thickness, resistant to traction and movements, with minimal sequelae to the donor area, which can maintain the thermoregulation of the testicles and shows the natural ptosis of the scrotal region.4,5 The choice of technique depends on factors related to the defect itself, such as size and location, as well as preferences of the surgical team and the patient. Multiple techniques have been described, and there
1 - Irmandade da Santa Casa de Misericórdia de São Paulo, Discipline of Plastic Surgery, São Paulo, SP, Brazil.
Rev Col Bras Cir. 2018; 45(1):e1389
Mello Scrotal reconstruction with superomedial fasciocutaneous thigh flap
is not a single one that can be considered ideal or even applicable to all cases4,5. This study aims to describe the use of the superomedial fasciocutaneous thigh flap (SMFCTF) for scrotal reconstruction in open areas secondary to the surgical treatment of perineal necrotizing fasciitis.
METHODS Retrospective photographic
analysis of
medical submitted
and to
surgical treatment of Fournier's gangrene and scrotal
Figure 1. Postoperative period: 28 days of debridement.
reconstruction with SMFCTF, in the period between 2009 and 2015, at Central Hospital of Irmandade da Santa Casa de Misericórdia de São Paulo. Mean age, presence of comorbidities, etiology, associated penile involvement and use of ostomies were analyzed. Estimates of scrotal skin loss were calculated as relative percentages. The number of debridement procedures and time to start the reconstruction were evaluated. Regarding the flap itself, the dimensions and complications found were evaluated. The number of total surgical procedures related to the reconstruction and length of hospital stay were also analyzed. To perform the SMFCTF, the patient was
Figure 2. Bilateral demarcation of the flaps.
positioned in the lithotomy position, with abduction and partial flexion of the lower limbs under spinal block. Resection of fibrotic-scar tissue and excessive granulation was performed in the entire affected region - perineum, testes and funiculi (Figures 1 and 2). The open area was measured to facilitate flap demarcation. A transposition flap (90o) of the superomedial region of the thigh was used, with dissection in the fasciocutaneous plane and evidencing the gracilis muscle throughout the bed, without direct handling. The suture was made by flap planes in the midline and base of the penis, as well as in the thigh and perineum. The donor area was submitted to primary closure, by planes, in all cases. There was no need to use aspiration drainage (Figures 3 to 6).
Figure 3. Dissected and mobilized flaps.
Rev Col Bras Cir. 2018; 45(1):e1389
Mello Scrotal reconstruction with superomedial fasciocutaneous thigh flap
ten patients (66.7%), with DM being the most frequent one. The process etiology was identified in ten cases (66.7%), being mainly skin infections and anorectal abscesses. Penile skin involvement was observed in six patients (40%). Ostomies were performed in five cases, mainly in those who had initial treatment in another service and who were transferred to our institution for reconstruction. Estimates of skin loss at the scrotal region ranged from 60 to 100%. In the initial stage of the surgical treatment, a mean of 1.33 debridement procedures was performed per patient, being one procedure performed in ten patients and two in five. Definitive reconstruction was performed on average 30.6 days (22 to 44) after the initial treatment. The mean surgical time for reconstruction with the SMFCTF was 76 minutes (65 to 90). The flaps were bilateral in all cases. Flap size ranged from 10cm to 13cm in the longitudinal direction and from 8cm to 10cm in the cross-sectional direction. The number of reconstruction procedures was 1.4 surgeries/patient. One procedure was performed in nine patients, two in four patients and three in two patients. Sequential treatment was an option in cases with abdominal or perineal region involvement, with sutures or skin grafting being performed. We also chose to perform skin grafting on the penile body in an isolated surgical procedure, when necessary. Complications were observed in four cases (26.6%), associated with three occurrences of segmental dehiscence (less than 2cm) and one area of epitheliolysis, also localized. These situations were treated in a conservative and non-surgical manner. The total hospital length of stay was on average 39.1 days (26 to 54).
Figure 4. Detailed view of the vascular pedicle.
Figure 5. Medially transposed flaps.
Figure 6. Thirty days postoperatively.
RESULTS Fifteen patients with a mean age of 48.9 years (28 to 66) were assessed. Comorbidities were identified in
Scrotal skin loss may be secondary to trauma, oncological surgeries and infections6. An important technical aspect for the reconstruction is the granulation tissue resection that is incarcerating the funiculus, testis and perineal region7. In this way, the actual defect is evaluated to program the suitable size(s) of the flap(s). Ostomies should be avoided whenever possible, and are usually indicated in cases of anorectal lesions (perforations or fistulas), as well as sphincter lesions8.
Rev Col Bras Cir. 2018; 45(1):e1389
Mello Scrotal reconstruction with superomedial fasciocutaneous thigh flap
Candelária et al.3 did not demonstrate an advantage of
al.11 describe the use of the gracilis myofasciocutaneous
this procedure in survival rates. The use of rectal catheters
flap in V-Y advancement of the entire medial aspect of the
may help in the acute phase of treatment, but should not be used for prolonged periods8. Negative pressure therapy is an option in the wound preparation phase after complete debridement of the devitalized tissues6,9. We emphasize the need for additional care for the adaptation of the adhesive films to the perineal contours and the adequate isolation of the perianal region, which is also an indication for rectal catheters in the patients that were not submitted to an ostomy. The following are technical options described for scrotal reconstruction: (1) secondary wound healing, (2) primary synthesis, (3) skin grafting, (4) residual scrotal myocutaneous flap, (5) local and locoregional cutaneous flaps, (6) locoregional and distant fasciocutaneous flaps, and (7) locoregional and distant myocutaneous flaps. In general, the literature reports 50% of scrotal skin loss as the limit for the indication of simpler reconstruction techniques. In these smaller losses, myocutaneous advancement flaps of the residual scrotum or primary suture are usually recommended. For losses > 50%, the indication should be for skin grafting or locoregional or even distant flaps2,4-6. Franco et al.7 describe the use of locoregional flaps for losses > 2/3. The transposition of the testes to the subcutaneous tissue of the upper thigh region is an option for temporary protection. Alterations in spermatogenesis,
thigh. Muscle flaps are described associated with partial skin grafting. The gracilis and rectus abdominis flaps (VRAM) were used by Ellabban and Towsend10. Balbinot et al.2 highlight the functional aspect of the sequel after the removal of each of these muscles, with the gracilis being associated with potential alterations in lower-limb abduction. The resulting volume of the added musculature is a significant limitation. Fasciocutaneous flaps of the posterior thigh region, with a pedicle based on the inferior gluteal artery may be an option. However, it is necessary to modify the patient's position during the intraoperative period (initial ventral decubitus, changing to the lithotomy position), with the flap thickness also being a limiting factor. Chen et al.9 describe the use of island flaps, based on perforators of the medial thigh region, in addition to cases using the anterolateral pedicle flap of the thigh (ALT). Yu et al.14 also describe the use of ALT. The use of SMFCTF was initially described by Hirshowitz et al.15 as a "probably" arterial flap using a different demarcation, following the medial thigh curvature. The vascular supply from branches of the external pudendal artery, anterior branch of the obturator artery and branches of the medial femoral circumflex artery were described. Our choice to use bilateral flaps is based on some aspects: smaller flaps can be used, with easier and
secondary to increased local temperature, have been described, as well as cases of testicular atrophy and chronic pain. The secondary psychological alterations should also be considered10-13. We did not have any cases treated with this technique, which, in our opinion, should not be used. Tissue expansion performed at two different moments is described by Khan et al.6 as an option. They also mention the performance of rapid intraoperative expansion. Partial skin grafting is advocated by several authors, such as Tan et al.8 and Maguina et al13, with the suture being normally performed between the testes, initially. Special care is needed to fix the grafts for proper integration. The tunica vaginalis should be present and with favorable granulation tissue. Mopuri et al.4 describe the use of transposition fasciocutaneous flaps, with a posteroinferior basis. Hsu et
simpler closure of the donor areas, as well as the creation of a median raphe. These aspects are also highlighted by Maguina et al.12. The demarcation we used, with a triangular and predominantly longitudinal donor area, is similar to that used by Balbinot2, Ferreira5 and Maguina12. Regarding the advantages of the SMFCTF, one can consider that, normally, the donor area is not affected, the thickness of the skin and subcutaneous tissue can be considered adequate, the reconstruction can be performed in a single stage for the scrotal defects without changing the patient's position on the surgical table. Mauro16 points out that this flap is technically simple, rarely shows ischemia, and provides excellent esthetic results. As a disadvantage, one can consider the limitation of the cross-sectional diameter and the skin elasticity of the medial thigh region. Maguina et al.12 also consider the
Rev Col Bras Cir. 2018; 45(1):e1389
Mello Scrotal reconstruction with superomedial fasciocutaneous thigh flap
potential technical difficulty due to the thickness of the
the scrotal region, showing adequate functional and
subcutaneous tissue in obese patients.
esthetic results. It has been observed that the use of this
We can conclude that SMFCTF is a reliable and versatile option for the reconstruction of open areas in
flap is not technically difficult or time-consuming, and does not result in significant sequelae to the donor area.
R E S U M O Objetivo: descrever a utilização do retalho fasciocutâneo superomedial da coxa para a reconstrução escrotal em áreas cruentas secundárias ao tratamento cirúrgico da fasceíte necrosante do períneo (gangrena de Fournier). Métodos: análise retrospectiva de casos atendidos no Serviço de Cirurgia Plástica da Irmandade da Santa Casa de Misericórdia de São Paulo, no período de 2009 a 2015. Resultados: quinze pacientes foram submetidos à reconstrução escrotal utilizando o retalho proposto. A média de idade foi de 48,9 anos (28 a 66). A estimativa de perda cutânea da região escrotal variou de 60 a 100 %. A reconstrução definitiva foi realizada em média 30,6 dias (22 a 44) após o tratamento cirúrgico inicial. O tempo cirúrgico médio foi de 76 minutos (65 a 90) para a realização dos retalhos, bilaterais em todos os casos. O tamanho dos retalhos variou de 10cm a 13cm no sentido longitudinal por 8cm a 10cm no sentido transverso. O índice de complicações observado foi de 26,6% (quatro casos), referentes à ocorrência de deiscências segmentares e parciais. Conclusão: o retalho fasciocutâneo superomedial da coxa é uma opção confiável e versátil para a reconstrução de áreas cruentas na região escrotal, apresentando resultados estéticos e funcionais adequados. Descritores: Escroto. Pele. Ferimentos e Lesões. Técnicas de Fechamento de Ferimentos. Gangrena de Fournier
necrosante. Rev Bras Cir Plast. 2010;25(2):349-54. 8. Tan BK, Rasheed MZ, Wu WT. Scrotal reconstruction
1. Eke N. Fournier's gangrene: a review of 1726 cases. Br J Surg. 2000;87(6):718-28. 2. Balbinot P, Ascenço ASK, Nasser IJG, Berri DT, Maluf Jr I, Lopes MC, et al. Síndrome de Fournier: reconstrução de bolsa testicular com retalho fasciocutâneo de região interna de coxa. Rev Bras Cir Plást. 2015;30(2):32934. 3. Candelária PAP, Klug WA, Capelhuchnik P, Fang
CB. Síndrome de Fournier: análise dos fatores de mortalidade. Rev Bras Coloproct. 2009;29(2):197202. Mopuri N, O'Connor EF, Iwuagwu FC. Scrotal reconstruction with modified pudendal thigh flaps. J Plast Reconstr Aesthet Surg. 2016;69(2):278-83. Ferreira PC, Reis JC, Amarante JM, Silva AC, Pinho CJ, Oliveira IC, et al. Fournier's Gangrene: a review of 43 reconstructive cases. Plast Reconst Surg. 2007;119(1):175-84. Khan Q, Knight RJW, Goodwin-Walters A. Scrotal reconstruction: a review and a proposed algorithm. Eur J Plast Surg. 2013;36(7):399-406. Franco D, Rodrigues C, Tavares Filho JM, Imoto F, Franco T. Reconstrução do escroto após fascite
by testicular apposition and wrap-around skin grafting. J Plast Reconst Aesthet Surg. 2011;64(7):944-8. 9. Chen SY, Fu JP, Chen TM, Chen SG. Reconstruction of scrotal and perineal defects in Fournier's gangrene. J Plast Reconst Aesthet Surg. 2011;64(4):528-34. 10. Ellabban MG, Towsend PL. Single-stage muscle flap reconstruction of major scrotal defects: report of two cases. Br J Plast Surg. 2003;56(5):489-93. 11. Hsu H, Lin CM, Sun TB, Cheng LF, Chien SH. Unilateral gracilis myofasciocutaneous advancement flap for single stage reconstruction of scrotal and perineal defects. J Plast Reconst Aesthet Surg. 2007;60(9):1055-9. 12. Maguina P, Paulius KL, Kale S, Kalimuthu R. Medial thigh fasciocutaneous flaps for reconstruction of the scrotum following Fournier gangrene. Plast Reconst Surg. 2010;125(1):28e-30e. 13. Maguina P, Palmieri TL, Greenhalgh DG. Split thickness skin grafting for recreation of the scrotum following Fournier's gangrene. Burns. 2003;29(8):857-62. 14. Yu P, Sanger JR, Matloub HS, Gosain A, Larson D. Anterolateral thigh fasciocutaneous island flaps in
Rev Col Bras Cir. 2018; 45(1):e1389
Mello Scrotal reconstruction with superomedial fasciocutaneous thigh flap
perineoscrotal reconstruction. Plast Reconstr Surg. 2002;109(2):610-6. 15. Hirshowitz B, Moscona R, Kaufman T, Pnini A. One-stage reconstruction of the scrotum following Fournier's syndrome using a probable arterial flap. Plast Reconst Surg. 1980;66(4):608-12. 16. Mauro V. Retalho fáscio-cutâneo da região interna de coxa para reconstrução escrotal na síndrome de Fournier - relato de caso. Rev Bras Cir Plast.
Received in: 01/09/2017 Accepted for publication: 23/11/2017 Conflict of interest: none. Source of funding: none. Mailing address: Daniel Francisco Mello E-mail: email@example.com / firstname.lastname@example.com
Rev Col Bras Cir. 2018; 45(1):e1389
Original Article
Comparison between different methods of breast implant volume choice and degree of postoperative satisfaction Comparação entre diferentes métodos de escolha de volume de implantes mamários e o grau de satisfação pós-operatório RAFAEL DAIBERT DE SOUZA MOTTA1; ANA CLAUDIA WECK ROXO1; FABIO XERFAN NAHAS1; FERNANDO SERRA-GUIMARÃES1 A B S T R A C T Objectives: to assess the degree of patient satisfaction after undergoing breast augmentation and compare three different, easy, inexpensive and universal methods of preoperative choice of breast implant volume. Methods: a prospective study was carried out at University Hospital Pedro Ernesto of State University of Rio de Janeiro, in 94 women from Rio de Janeiro, aged 18 to 49 years, submitted to breast augmentation mammaplasty with breast implant due to hypomastia. All implants were textured, with a round base and high projection and were introduced into the retroglandular space through an inframammary access. The patients were divided into three groups: Control, Silicone and MamaSize®, with 44, 25 and 25 patients, respectively. Satisfaction questionnaires were applied in the pre and postoperative periods by the same evaluator, through the visual analogue scale, in which '0' meant very unsatisfied and '100' very satisfied for the four variables: shape, size, symmetry and consistency. The degree of satisfaction with the surgical scar was also assessed in the postoperative period. Results: when the preoperative and postoperative satisfaction levels were compared, there was a difference in all variables for the three groups, with statistical significance. However, when the postoperative data were compared with each other, there was no significant difference. The degree of satisfaction with the surgical scar was high. Conclusion: the augmentation mammaplasty with breast implant had a high index of satisfaction among patients. However, there was no difference in the degree of satisfaction in the postoperative period between the three methodologies of breast volume measurement. Keywords: Mammaplasty. Patient Satisfaction. Plastic Surgery. Breast Implants. Size Perception.
was the second in the world in esthetic plastic surgery in 2016, there have been few studies that evaluated this
ugmentation mammaplasty is currently the most often performed cosmetic surgery worldwide1. In Brazil, it is the second most often performed esthetic plastic surgery, corresponding to 13.64% of procedures1. Thus, complication rates, which are relatively low, become high in absolute numbers. There are many articles in the literature on the subject, however, most of them are retrospective or multicenter studies that do not focus on the choice of breast volume. Additionally, when they describe the choice of implant, they do so through a single methodology, without any prospective comparisons between the other existing methods2-7. The population evaluated in these studies generally consists of women from the northern hemisphere, where culture and customs closely correlate with the aspirations and perspectives about the surgery2,3,7-10. Although Brazil
cultural issue in the country1. The choice of breast implant size is one of several variables that must be determined prior to the surgical procedure. Guiding the patient is important in situations where reoperation is mandatory, such as when a late seroma is evidenced, for instance11. On the other hand, breast implant change, which is currently one of the main causes of reoperation, should also be discussed with the patient, and needs to be reduced, through a more complete preoperative approach3,6,9,12. Few studies have been performed in which the patient actively participates in the choice of breast implant volume and evaluates her degree of satisfaction in the postoperative period. Therefore, it is necessary to assess an easy, inexpensive and universal model of breast implant volume measurement, which involves the
1 - State University of Rio de Janeiro, Postgraduate Program in Pathophysiology and Surgical Sciences, Rio de Janeiro, RJ, Brazil.
Rev Col Bras Cir. 2018; 45(1):e1345
Motta Comparison between different methods of breast implant volume choice and degree of postoperative satisfaction
patient's decision power, together with the surgeon, and
and the available volume to be placed: 170=175mL,
with excellent postoperative results.
220=215mL, 240=235mL, 260=255mL, 290=285mL, 300=305mL, 330=325 mL, 360=355 mL.
This study aims at assessing the degree of satisfaction of patients submitted to augmentation mammaplasty, as well as to compare three different, easy, inexpensive and universal methods of preoperative choice of breast implant volume.
METHODS This was a prospective study, carried out at the University Hospital Pedro Ernesto of the State University of Rio de Janeiro (UERJ), with 94 women from Rio de Janeiro, aged between 18 and 49 years, submitted to augmentation mammaplasty due to hypomastia. The non-inclusion factors were: patients under 18 years of age, those with indication for mastopexy, smokers, patients with psychiatric disorders, those with a prior history of breast surgery and those with systemic diseases. The exclusion factors were: breastfeeding or pregnancy during the study, failure to perform the preoperative study and loss of postoperative follow-up. The
retroglandular space through an inframammary access. Patients were systematically divided into three groups, for convenience: Control Group with 44 patients, MamaSize® Experimental Group with 25 patients and Silicone Experimental Group with 25 patients. All implants were textured, with a round base and high projection. In the control group, breast implants were chosen through anthropometric measurements13. By
Figure 1. MamaSize® Mold
measuring the basis and thickness of the patient's breast parenchyma, the silicone implant basis is calculated. Subsequently, the product that corresponds to that base is chosen. In the MamaSize® Experiment group, the implants were chosen according to the MamaSize®14 meter, where the mold is placed behind a bra without a cup, in front of a full-length mirror (Figure 1). The intersection between the mold of the patient's breast size (vertical axis) and that chosen by the patient (horizontal axis) shows the volume to be placed (Figure 1). Aiming to be similar to silicone molds, the following correlation was made between the volume chosen through MamaSize®
In the Experimental Silicone Group, the following volume molds were used: 175mL, 195mL, 215mL, 235mL, 255mL, 285mL, 305 mL, 325mL and 355mL. The patient chose the volume using the breast implant measurer that reproduced them in their shapes and dimensions, using a bra without a cup, in front of a full-length mirror. After the choice, new tests with volumes were performed, one above and one below the chosen one, for the ratification of the decision. Satisfaction questionnaires were applied in the pre- and postoperative periods by the same evaluator, using a visual analogue scale (Figure 2), where 0 meant
Rev Col Bras Cir. 2018; 45(1):e1345
Motta Comparison between different methods of breast implant volume choice and degree of postoperative satisfaction
very unsatisfied and 100 meant very satisfied for the four
scar, only the postoperative period was evaluated15,16.
variables: shape, size, symmetry, and consistency. For the
Figure 2. Visual Analog Scale and Questionnaire
and analytical case-control one, has a convenience sample, in which the definition of cases and controls is systematized. We analyzed 25 cases as Silicone, 25 cases as MamaSize® and 44 cases as Control. The first analysis used descriptive statistics. Frequency, relative frequency and 95% confidence intervals were used to depict the variables in descriptive tables, aiming to understand the groups' profile in relation to the performed research. All variables were tested in relation to their normality, i.e., to verify whether they come from a population with normal distribution, using the Shapiro-Wilks test. To verify whether
used, in which p-value <0.05 was considered significant for the analyses. The computer programs Microsoft Excel 2010 and Software R, version 3.3.1 (R Core Team 2015, Vienna, Austria) were used for data organization, creation of tables/charts and statistical analysis. The study was submitted to Plataforma Brasil, under CAAE number 13986513.2.0000.5259 version 1, and was approved on 05/21/2013, under Opinion Number 285716. All patients signed the free and informed consent form for the surgical procedure and for the study participation.
the anthropometric variables and the research variables were from the same population, regardless of the group
(Silicone, MamaSize and Control), the ANOVA statistical test was used, or Kruskal-Wallis test, when the data were not from the Normal population. To verify the existence of significant changes during the follow-up period, the t test was used, or the Wilcoxon test, when the data are not from the Normal population. For the assessment of the statistical tests, a significance level of 0.05 (5%) was
The mean values of the patients' age, BMI and mammary basis did not show statistical difference between the three groups. The mean age of the groups was 28 years, the mean BMI was 21.91 (kg/m²) and the mean value of the mammary basis was 11.62cm. The results of the mean implant volume, when statistically evaluated,
Rev Col Bras Cir. 2018; 45(1):e1345
Motta Comparison between different methods of breast implant volume choice and degree of postoperative satisfaction
showed no difference between them: MamaSize® Group:
statistical difference. However, when the groups were
284,04mL; Implant Group: 280.83mL; Control Group:
compared between them regarding the four variables
287.85mL (p-value: 0.6761). Table 1 shows the comparison of the variables shape, size, symmetry and consistency in the preoperative and postoperative periods (12th month), showing a
in the 12th postoperative month, there was no statistical difference. When comparing the patients' scores for the scar variable between the 1st and 12th month in all three groups, no statistical significance was observed.
Table 1. Comparison of the Control, Silicone and MamaSize® groups in the preoperative and postoperative periods (12th month).
PERIODS GROUP VARIABLES Shape
Control Silicone MamaSize® Control Silicone MamaSize® Control Silicone MamaSize® Control Silicone MamaSize®
Preoperative 38.07 (30.25-46.86) 37.60 (25.67-49.53) 42.00 (31.54-52.46) 21.82 (16.61-28.13) 22.40 (13.30-31.50) 19.20 (10.87-27.53) 68.07 (58.38-79.25) 62.80 (48.28-77.32) 62.16 (48.81-75.51) 52.73 (43.11-63.21) 63.20 (49.52-76.88) 58.80 (46.00-71.60)
12th postoperative Month 98.29 (96.78-99.80) 96.40 (93.77-99.03) 97.60 (95.13-100.07) 95.00 (91.56-98.44) 93.40 (89.79-97.01) 87.60 (80.77-94.47) 90.92 (86.25-95.59) 92.80 (87.40-98.62) 95.20 (90.72-99.68) 97.50 (94.81-100.19) 94.00 (89.38-98.62) 98.80 (96.99-100.61)
P-value <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 0.0012 0.0020 0.0002 <0.0001 0.0003 <0.0001
Figure 3 shows the preoperative and the 12th month postoperative aspects of a patient, in the control group, with a 285mL implant. Figure 4 shows a patient in the preoperative and in the 12th month postoperative periods, with a 285mL implant, and the methodology of choice with the silicone mold in the Silicone group. Figure 5 shows a patient in the preoperative and in the 12th month postoperative periods, with a 285mL implant, and the methodology of choice with the MamaSize® mold.
Figure 3. Control group: preoperative (A); postoperative (B).
Figure 4. Silicone Group: Preoperative (A), 12th month (B), Mold (C).
Rev Col Bras Cir. 2018; 45(1):e1345
Motta Comparison between different methods of breast implant volume choice and degree of postoperative satisfaction
evaluation by the patients, if they use these different preoperative methods discussed in the literature? As satisfaction is closely related to the patient's expectations, and these vary according to the local culture, we believe that the Brazilian patients should be studied. Therefore, this study was then created, which utilized three easy, inexpensive methodologies widely used in the literature to compare the degree of patient satisfaction in the preand postoperative periods. The sample results confirm the stereotype of these patients: they are young, with a mean age of 28 years and normal BMI, whose main dissatisfaction is breast size. The mean mammary basis was 11.62cm, with an anticipated implant volume of approximately 285mL. Therefore, anthropometrically similar patients were studied and compared. When patient satisfaction was evaluated before and one year after the surgery, there was a significant Figure 5. MamaSize® group: preoperative (A), 12th month (B), MamaSize® (C).
increase in the degree of satisfaction in all groups, with statistical significance. This fact supports studies in the literature that show the excellent results of this intervention2,3,5. However, when comparing the degree of satisfaction in the postoperative evaluation between the
three studied groups, there was no statistical difference, Because it is the second most often performed esthetic plastic surgery in Brazil and the first in the USA, augmentation mammaplasty reoperation rates due to volume exchange, which would firstly be relatively low (1.9% to 5.4%)9,12, are significantly higher in absolute numbers. Therefore, predicting this volume and, thus, avoiding reoperations, in addition to adding less morbidity to the patient, would avoid an expense that, in the US for instance, is around US$.5770.00 per reoperation9,12. The literature shows that up to 20% of patients in the postoperative period of breast augmentation surgery complain of breast volume, although not all of them want to reoperate17. There are articles that study preoperative types of breast implant volume measurement. However, despite showing good results, no studies were found comparing them prospectively4,5,13,14,17-19. Thus, what would be the measurement methodology of preoperative breast implant volume with the lowest cost and the best benefit? Is there any difference in the postoperative
which shows that the method used to choose the implants does not interfere with the degree of satisfaction. The scar is an important variable to be explained to the patient in the preoperative consultation, considering the change in location according to one's culture: in the USA and Brazil, inframammary scars are more common; in China the axillary scar is more frequent6,8,9. In our study, in the 1st, 6th and 12th months, the evaluation mean was higher than 85. Additionally, there was no statistical difference when comparing the periods. This confirms the patients' acceptance of the scar, even in the first postoperative month. The choice made through anthropometric measures has been the routine in our service for several years. On the other hand, methods that directly include the patient in this choice have proved equally effective and can facilitate decision-making, as well as the sharing of the choice responsibility. This is likely to reduce reoperation rates for breast volume dissatisfaction after a few years. On the other hand, it does not reduce
Rev Col Bras Cir. 2018; 45(1):e1345
Motta Comparison between different methods of breast implant volume choice and degree of postoperative satisfaction
mandatory reoperation rates in rare complications such
and a dissatisfaction degree with the final result of around
as a late seroma. Therefore, guiding patients about all
25% has already been verified20.
risks inherent to the procedure is essential11. New third-dimensional preoperative measurement techniques have been introduced in the market. These are devices with high added value, requiring company-specific software and hardware4. On the other hand, these devices are still under evaluation,
augmentation mammaplasty with breast implant has a high index of satisfaction among the patients, but there was no difference in satisfaction in the postoperative period between the three breast volume measurement methods.
Our study allowed us to conclude that
R E S U M O Objetivos: avaliar o grau de satisfação de pacientes submetidas à mamoplastia de aumento e comparar três métodos diferentes, fáceis, baratos e universais, de escolha pré-operatória de volume de implante mamário. Métodos: estudo prospectivo, realizado no Hospital Universitário Pedro Ernesto da Universidade do Estado do Rio de Janeiro, em 94 mulheres naturais do Rio de Janeiro, com idades entre 18 e 49 anos, e submetidas à cirurgia de mamoplastia de aumento com implante, por hipomastia. Todos os implantes eram texturizados, com base redonda e projeção alta e foram introduzidos na loja retroglandular, por via inframamária. As pacientes foram divididas em três grupos: Controle, Silicone e MamaSize®, com 44, 25 e 25 pacientes, respectivamente. Foram realizados questionários de satisfação nos períodos pré e pós-operatórios pelo mesmo avaliador, através de escala analógico-visual, em que 0 significava muito insatisfeita e 100 significava muito satisfeita para as quatro variáveis: forma, tamanho, simetria e consistência. No período pós-operatório avaliou-se também o grau de satisfação com a cicatriz cirúrgica. Resultado: quando comparados os graus de satisfação do pré-operatório com os do pós-operatório, houve diferença em todas as variáveis dos três grupos, com significância estatística. Entretanto, quando comparados os dados dos pós-operatórios entre si, não houve diferença significativa. O grau de satisfação com a cicatriz cirúrgica foi elevado. Conclusão: a mamoplastia de aumento com implante teve um grande índice de satisfação entre as pacientes. No entanto, não houve diferença no grau de satisfação no período pós-operatório entre as três metodologias de mensuração de volume mamário. Descritores: Mamoplastia. Satisfação do Paciente. Cirurgia Plástica. Implantes de Mama. Percepção de Tamanho.
REFERENCES 1. isaps.org [Internet]. New York: The International Society of Aesthetic Plastic Surgery (ISAPS); c2017 [cited 2017 June 27] Available from: http://www.isaps.org/Media/ Default/Current%20News/GlobalStatistics2016.pdf. 2. Saariniemi KM, Helle MH, Salmi AM, Peltoniemi HH, Charpentier P, Kuokknen HO. The Effects of Aesthetic Breast Augmentation on Quality of Life, Psychological Distress, and Eating Disorder Symptoms: A Prospective Study. Aesthetic Plast Surg 2012;36(5):1090-5. 3. Handel N, Cordray T, Gutierrez J, Jensen JA. A LongTerm Study of Outcomes, Complications, and Patient Satisfaction with Breast Implants. Plast Reconstr Surg. 2006;117(3):757-67. 4. Epstein MD, Scheflan M. Three-dimensional Imaging and Simulation in Breast Augmentation: What is the current state of the art? Clin Plastic Surg. 2015;42(4):437-50.
5. Hidalgo DA, Spector JA. Preoperative Sizing in Breast Augmentation. Plast Reconstr Surg. 2010;125(6):17817. 6. Psillakis JM, Facchina PH, Kharmandayan P, Trillo L, Canzi WC, Aguiar HR. Review of 1,447 Breast Augmentation Patients Using PERTHESE Silicone Implants. Aesthetic Plast Surg. 2010;34(1):11-5. 7. Spear SL, Murphy DK, Slicton A, Walker PS, Inamed Silicone Breast Implant U.S. Study Group. Inamed Silicone Breast Implant Core Study Results at 6 Years. Plast Reconstr Surg. 2007;120(7 Suppl. 1):S8-16. 8. Sun J, Liu C, Mu D, Wang K, Zhu S, He Y, Luan J. Chinese Women's Preferences and Concerns regarding Incision Location for Breast Augmentation Surgery: A Survey of 216 Patients. Aesthetic Plast Surg. 2015;39(2):214-26. 9. Somogyi RB, Brown MH. Outcomes in Primary Breast Augmentation: A Single Surgeon's Review of 1539 Consecutive Cases. Plast Reconstr Surg. 2015;135(1):87-97.
Rev Col Bras Cir. 2018; 45(1):e1345
Motta Comparison between different methods of breast implant volume choice and degree of postoperative satisfaction
10. Zelken J, Cheng MH. Asian Breast Augmentation: A Systematic Review. Plast Reconstr Surg Glob Open. 2015;3(11):e555. 11. Franco T, Franco D. Seroma tardio após implantes mamários de silicone: três formas diferentes de apresentação, evolução e conduta. Rev Bras Cir Plást. 2013;28(2):247-52. 12. Schmitt WP, Eichhorn MG, Ford RD. Potential cost of breast augmentation mammaplasty. J Plast Reconstr Aesthet Surg. 2016;69(1):55-60. 13. Tebbetts JB. A system for breast implant selection based on patient tissue characteristics and implant-soft tissue dynamics. Plast Reconstr Surg. 2002;109(4):1396-409. 14. França ALF, Scevola MCO, Fachin SD, França PF, França NC. Mamasize: A new auxiliary instrument in the planning of enlargement mammaplasty. Rev Soc Bras Cir Plást. 2005;20(4):204-6. 15. Nahas FX, Solia D, Ferreira LM, Novo NF. The Use of Tissue Adhesive for Skin Closure in Body Contouring Surgery. Aesthetic Plast Surg. 2004;28(3):165-9. 16. Quinn JV, Drzewiecki AE, Stiell IG, Elmslie TJ. Appearance Scales To Measure Cosmetic Outcomes Of Healed Lacerations. Am J Emerg Med. 1995;13(2): 229-31. 17. Adams WP Jr, Small KH. The Process of Breast Augmentation with Special Focus on Patient
Education, Patient Selection and Implant Selection. Clin Plastic Surg. 2015;42(4):413-26. 18. Dionyssiou DD, Demiri EC, Davison JA. A simple method for determining the breast implant size in augmentation mammaplasty. Aesthetic Plast Surg. 2005;29(6):571-3. 19. Pechter EA. A new method for determining bra size and predicting postaugmentation breast size. Plast Reconstr Surg. 1998;102(4):1259-65. 20. Cruz NI. Patient satisfaction with 3D simulation of breast augmentation surgery. P R Health Sci J. 2015;34(2):108.
Received in: 26/07/2017 Accepted for publication: 23/11/2017 Conflict of interest: none. Source of funding: none. Mailing address: Rafael Daibert de Souza Motta E-mail: email@example.com / firstname.lastname@example.com
Rev Col Bras Cir. 2018; 45(1):e1345
Original Article
Criopreserved ovarian tissue transplantation and bone restoration metabolism in castrated rats Transplante de tecido ovariano criopreservado e restauração do metabolismo ósseo em ratas castradas LÍGIA HELENA FERREIRA MELO E SILVA1; JOÃO MARCOS DE MENESES E SILVA1; MAHMOUD SALAMA6; LUIZ GONZAGA PORTO PINHEIRO, ECBC-CE2; FRANCIELE OSMARINI LUNARDI3; PAULO GOBERLÂNIO BARROS DA SILVA1; CARLOS GUSTAVO HIRTH1; IGOR FREITAS DE LUCENA4; GLAUCO JORGE DA COSTA GOMES5; JOSÉ ALBERTO DIAS LEITE1 A B S T R A C T Objectives: to evaluate estradiol levels and autotransplantation heated ovarian tissue effects, after vitrification, on rats bone metabolism previously oophorectomized bilaterally. Methods: experimental study with 27 rats aged 11 to 12 weeks and weighing 200g to 300g, submitted to bilateral oophorectomy and ovarian tissue cryopreservation for subsequent reimplantation. Animals were divided into two groups, A and B, with 8 and 19 rats, respectively. Autotransplantation occurred in two periods according to castration time: after one week, in group A, and after one month in group B. Serum estradiol measurements and ovary and tibia histological analysis were performed before and after oophorectomy period (early or late) and one month after reimplantation. Results: in groups A and B, tibia median cortical thickness was 0.463±0.14mm (mean±SD) at the baseline, 0.360±0.14mm after oophorectomy and 0.445±0.17mm one month after reimplantation p<0.005). Trabecular means were 0.050±0.08mm (mean±SD) at baseline, 0.022±0.08mm after oophorectomy and 0.049±0.032mm one month after replantation (p<0.005). There was no statistical difference in estradiol variation between the two study groups (p=0.819). Conclusion: cryopreserved ovarian tissue transplantation restored bone parameters, and these results suggest that ovarian reimplantation in women may have the same beneficial effects on bone metabolism. Keywords: Menopause. Osteoporosis, Postmenopausal. Estrogens. Primary Ovarian Insufficiency. Tissue Transplantation. Cryopreservation.
cryopreservation and ovarian tissue autotransplantation varian aging and cytotoxic treatments are the most
can be used to restore fertility in cancer patients, in
common causes to women fertility loss. According
patients who do not respond adequately to conventional
to recent reports, 700.000 women in the United States
treatments and in those with premature ovarian failure6,7.
and 300.000 women in Brazil are diagnosed with cancer
Although experimental, cryopreservation and ovarian
each year. Approximately 8% of these women are under
tissue autotransplantation resulted in more than 86
40 years of age and are at risk for fertility loss after
healthy babies birth all over the world8 with approximately
aggressive gonadotoxic anticancer treatments. Many
25% live birth rate per transplantation5.
strategies were developed to prevent fertility loss in young
One of the consequences of natural or induced
women and girls undergoing these treatments, which
ovarian failure is osteoporosis, characterized by bone
significantly increase survival rates for most cancers .
mass and mineral density loss, thus increasing fractures
Several options are available, such as cryopreservation of
risk. Osteoporosis is an important complication of old age
embryos, oocytes and ovarian tissue, and ovarian tissue
in women and is strongly associated with sex hormones
deficiency, but it can also be caused by alcoholism or
1 - Federal University of Ceará, Fortaleza, CE, Brazil. 2 - Maternity School Assis Chateaubriand, Fortaleza, CE, Brazil. 3 - State University of Ceará, Fortaleza, CE, Brazil. 4 - School of Medicine Unichristus, Fortaleza, CE, Brazil. 5 - Hospital São Carlos, Fortaleza, CE, Brazil. 6 - Cologne University, Cologne – Germany. Rev Col Bras Cir. 2018; 45(1): ¬
Silva Criopreserved ovarian tissue transplantation and bone restoration metabolism in castrated rats
corticosteroids high doses treatment.9 In the United
with 90% power for the test and 0.05 significance
States, osteoporosis causes approximately two million
level, considering 0.2 (20%) maximum deviation
fractures annually, including 547,000 vertebral fractures,
0.5 (50)%) expected difference between groups (d), the
300,000 hip fractures and 135,000 pelvic fractures
sample calculation must be 4.36 animals, that is, five
To study agents capable of preserving bone
animals per group, rounded to next whole number. In
metabolism and preventing osteoporosis, several animal
our study, we used the minimum number of eight rats
models have been used. According to Food and Drug
in group A, respecting this rule with safety margin. The
Administration (FDA) guidelines, bone metabolism
animals were divided into two groups, A and B, with eight
studies based on rat models should include proximal
and 19 rats, respectively.
tibia, distal femur or lumbar vertebrae evaluations .
Bilateral oophorectomy was performed and
Oophorectomized mouse provides an excellent preclinical
extracted ovaries were cryopreserved by vitrification.
animal model that accurately reveals human skeleton
important clinical features under hypoestrogenism and
oophorectomized rats, one week (group A) or one month
can be used to evaluate responses to therapeutic agents .
(group B) after oophorectomy. Serum estradiol and tibia
The specific development of osteopenia/
bone tissue histological analysis were performed prior
spongy osteoporosis site in oophorectomized rats is one
to oophorectomy (baseline parameters), at the end of
of the most reproducible biological responses in skeletal
surgical castration period (surgical castration) and one
research14. After oophorectomy, rapid loss of spongy
month after transplantation (recovery parameters).
bone mass and bone strength occurs, followed by a loss slower rate to reach, finally, a bone mass stable phase
Ovarian and bone tissue collection
after 90 days. These bone loss characteristics mimic bone changes after oophorectomy or menopause in humans15.
After two hours fasting (to reduce drugs amount
Our study aim was to evaluate estradiol levels
needed), abdominal area trichotomy and antisepsis with
and heated ovarian tissue autotransplantation effects,
Chlorhexidine solution was performed. The animals were
after vitrification, on bone metabolism in rats previously
anesthetized with ketamine/xylazine (40mg/kg or 5mg/
oophorectomized bilaterally.
kg, respectively) intraperitoneal injection in the right lower abdominal quadrant, according to Federation of
Associations of Laboratory Animal Science guidelines16. In full anesthetic effect, 10ml at 0.9% physiological saline for
This study included 27 Wistar rats (Rattus
hydration effect was injected into the subcutaneous region
norvegicus) aged 11 to 12 weeks and weighing 200g
of the animal´s back. We proceeded then to laparotomy,
to 300g. In this period there was hormonal maturation
with pelvic organs exposure and bilateral oophorectomy.
and end of growth of distal tibial plate, that happens
The ovaries were dissected, in order to remove all the
after three months of age . Animals were housed in
fat, and sliced in an approximate 2mm size3. One ovary
individual cages in a controlled environment (circadian
was immediately submitted to histological analysis, while
cycle, 22±2°C, constant humidity and food and water
the other was cryopreserved by vitrification (n=27). The
ad libitum). All experimental protocols were reviewed
abdominal wall was sutured with 5-0 nylon in two planes
and approved by the Animal Research Ethics Committee
(peritoneum-aponeurotic planes and skin).
of Federal University of Ceará, and filed under number 79/2012.
Then, bone tissue biopsy of the left posterior leg proximal tibia was also performed. For this, after
antisepsis and trichotomy of rat left thigh inner part, a
performed in adult rats. For an experimental model
1.5cm incision in length was made removing easily the
Rev Col Bras Cir. 2018; 45(1): À
Silva Criopreserved ovarian tissue transplantation and bone restoration metabolism in castrated rats
skin around the thigh. Once the deep musculature was
was subjected to a three to five minutes bath in solutions
exposed, it was set aside for bone exposure of the anterior
containing minimal essential medium plus 10% fetal calf
proximal part, about 5mm from the insertion of the tibia.
serum and decreasing concentrations of sucrose (0.5M,
The bone biopsy was performed with a 2mm diameter
0.25M and 0.0M).
helical drill coupled to a mini-drill (3i Implant Innovations Inc., Palm Beach Gardens, FL, USA), with 12,000rpm
Ovarian tissue autotransplantation
rotation and a constant irrigation with saline solution. The drill was positioned vertically and in perpendicular
To compare surgical castration early and late
position to the bone longitudinal axis to penetrate the
effects, rats randomly divided into groups A and B,
cortex, reaching the deep medullary canal, but without
underwent vitrified ovarian tissue autotransplantation,
reaching contralateral side. Next, skin was sutured with
performed at the greater omentum, one week after
3-0 nylon at equidistant points.
bilateral oophorectomy in group A (n = 8) and one month
On first postoperative day, acetaminophen
after bilateral oophorectomy in group B (n=19). One
120mg/kg and codeine 60mg/kg were orally administered
month after ovarian autotransplantation in both groups
for analgesia.
(A and B), abdominal cavity was opened and transplanted ovaries were identified, evaluated macroscopically and
Ovarian tissue vitrification and heating
removed. The animals were then submitted to euthanasia with lethal doses of previously used anesthetic.
Ovarian fragments vitrification and subsequent heating were carried out according to protocol described
Estradiol Determination
by Silva et al. . In most cases, the ovaries were initially balanced in HEPES (2-[4-(2-hydroxyethyl)-piperazin-1-yl]-
ethanesulfonic acid) containing 10% (v/v) ethylene glycol
both groups in several moments: before bilateral
and 10% (v/v) DMSO (dimethylsulfoxide) for 20 minutes
at room temperature (23°C to 26°C) and then immersed
autotransplantation (surgical castration) and one month
in vitrification solution containing 17% (v/v) ethylene
after autotransplantation (reimplantation). According
glycol, 17% (v/v) DMSO and 0.75M sucrose in HEPES for
to our laboratory protocol, 2ml of blood were taken
three minutes. Ovaries were transferred individually with
from retro-orbital plexus using a heparinized capillary
a minimal vitrification solution to a metal bucket surface
hematocrit tube. After blood centrifugation at 2500rpm
floating in liquid nitrogen. Vitrified ovaries were stored
for 15 minutes, plasma was collected and stored in
in liquid nitrogen (-196°C) for 30 to 60 minutes. Using
a freezer for later use in hormonal assay. Enzymatic
refrigerated forceps, samples were placed in refrigerators
immunoabsorption assay kits (Diagnostics Biochem
containing liquid nitrogen.
Canada Inc., assay sensitivity, 10ng/ml) were used to
To thaw the ovarian cortex, cryotubes were
quantitatively measure serum estrogen levels.
removed from Dewar vessel and maintained at room temperature for two minutes, followed by immersion in
Tibias histological analysis
a 37°C water bath for two minutes. A slight and gentle stirring was carried out. Cryotubes contents were rapidly
In both groups, tibial biopsies were collected
emptied into culture plates with Leibovitz L-15 medium,
before bilateral oophorectomy (baseline), immediately
and washed three times with fresh medium to remove
before autotransplantation (surgical castration) and
residual cryoprotectant prior to replantation, according
one month after autotransplantation (reimplantation).
to a protocol adapted from Lunardi et al. . Each sample
Tibia biopsy samples were fixed in 10% neutral
Rev Col Bras Cir. 2018; 45(1): Ä
Silva Criopreserved ovarian tissue transplantation and bone restoration metabolism in castrated rats
buffered formaldehyde and decalcified in EDTA solution
not of corpus luteum (CL).
(ethylenediamine tetraacetic acid) for two weeks. After decalcification, specimens were subjected to routine histological
Statistical analysis
Subsequently, 5µm paraffin sections from tibia metaphysis
Statistical analyzes were blind and performed
were dewaxed and stained with hematoxylin and eosin
by specialists. Findings were analyzed using ANOVA and
for optical microscopy examination . Trabecular and
t-tests of paired samples. Degrees of freedom and statistical
cortical thickness, Havers channel diameter, osteoclast
significance level were defined in n-1 and 5% (p<0.05),
and osteoblast counts and the presence of osteoid were
respectively. Rosner21 table was used for reference. Study
variables were dichotomous (presence/absence). Data
The methodology used was: a) trabecular
were analyzed with Fisher exact test, using GraphPad
cortical thickness and Havers channels
Prism 5.0 and expressed as absolute frequencies and
diameter direct measurements using
microscope and
percentages. Statistical significance level was established
millimetric rule; b) Osteoblast and osteoclast count in
at 5% (p<0.05). For all the variables studied, each animal
Neubauer chamber 30x70mm and 4mm thickness using
was its control, to avoid possible errors with previous
zig-zag technique; c) Simple detection of osteoid presence
diseases in the animal. Therefore, samples were taken
or absence.
before starting the procedures.
Ovaries histological analysis RESULTS In
submitted to histological analysis immediately after
Plasma estradiol level
oophorectomy and immediately after euthanasia, to evaluate histological changes in ovaries captured with
There was no statistically significant difference
transplanted vitrification. Ovarian tissue samples were
between estradiol levels variation in the two study groups
fixed in 10% paraformaldehyde and incorporated in
(p=0.819). In animals with early menopause, despite the
paraffin. The 8µm sections were prepared for staining
variation between baseline levels (25.6±0.8ng/dL) and
with hematoxylin and eosin. The sections were analyzed
those of the immediate postoperative period (19.0±1.1ng/
under a light microscope coupled to an image acquisition
dL) and those of the one-month postoperative period
system (LAZ 3.5, LEICA - DM1000 models). Qualitative
(25.6±3.9ng/dL), there was no significant difference
follicle and histological evaluations were performed using
between the three estradiol analysis moments (p=0.140).
conventional classifications20.
The late menopausal group, however, presented a
To carry out this protocol, morphometry and
significant reduction in estradiol levels between the
histometry following parameters were used: a) Follicles
preoperative period (28.0±1.1ng/dL) and the immediate
number count per sample, through normal primordial
postoperative period (19.7±1.6ng/dL), with recovery of
follicles quantification, defined as those that had a well-
normal levels one month after surgery (25.8±0.5ng/dL)
defined cavity containing an oocyte with a nucleus and
atretic primordial follicles quantification, that is, those that presented granulosa cells in degenerative process
Ovarian graft
and, often, with apparent oocyte degeneration, with eosinophilic ooplasm, contraction and chromatin clumps
In 81.5% of animals (group A: n=7/8, 87%, group
formation or wrinkled nuclear membrane; b) Presence or
B: n=15/19, 78.9%, p=0.080), the graft was successful
Rev Col Bras Cir. 2018; 45(1): È
Silva Criopreserved ovarian tissue transplantation and bone restoration metabolism in castrated rats
(presence of follicles). In general, approximately 40.7% of
oophorectomy and 0.0448±0.032mm in the month
grafts presented atheromatous follicles, 27.3% exhibited
following ovarian autotransplantation (p<0.005) (Figure
atretic and primordial follicles and 13.5% presented
2). Paired t-test, adopting as value of freedom the value (n-1) and having as "p" (probability) the value of 0.05, receives value of 1.812. As in our calculations we found the value of 0.472, we concluded that p was not significant.
primordial follicles and corpus luteum. No ovarian graft was found in remaining 18.3%: only inflammatory and scar tissue and/or fibrosis were found in these animals.
Bone parameters Cortical bone In general, tibia average cortical thickness was 0.463±0.14mm at the baseline, 0.354±0.14mm after the oophorectomy, and 0.446±0.17mm in the month following ovarian autotransplantation (p<0.005) (Figure 1). Paired t test, adopting as a degree of freedom the value (n-1) and taking as "p" (probability) 0.005 value, receives 2,977 value. As in our calculations we found 5.28 value, we conclude that p<0.005. Figure 2. Tibia trabecular thickness (mm) (p<0.005). Blue: basal; Green: castration; Orange: reimplantation.
Figure 1. Tibia cortical thickness (mm) (p<0.005). Blue: basal; Green: castration; Orange: reimplantation.
Trabecular bone In addition, mean trabecular thickness was 0.051±0.08mm at baseline, 0.021±0.08mm after
In cortical bone, before oophorectomy, during metaphyseal-diaphysis transition we observed soft tissue and bone, osteoblasts and osteocytes borders in compact spaces. Osteoblasts border was absent in group A, one week after oophorectomy. One month after autotransplantation, there was absence of trabeculae (Figure 3). In group B, 30 days after oophorectomy, we observed extensive, occasionally empty channels (without osteocytes) and osteoblast foci. However, one month after ovarian autotransplantation, we observed cortical bone formation containing a border of osteoblasts, channels and large gaps containing osteocytes (Figure 4). We found an osteoblasts border and hematopoietic matrix in trabecular bone before oophorectomy.
Figure 3. Cortical bone histology (HE 100x)- Group A. A) Basal; B) Post-oophorectomy; C) Post-reimplantation. Rev Col Bras Cir. 2018; 45(1): Ì
Silva Criopreserved ovarian tissue transplantation and bone restoration metabolism in castrated rats
Figure 4. Cortical bone histology (HE 100x)- Group B. A) Basal; B) Post-oophorectomy; C) Post-reimplantation.
Subsequently, group A demonstrated trabecula irregularity, one week after oophorectomy. We observed a hematopoietic matrix one month after ovarian autotransplantation (Figure 5). In group B, one month after oophorectomy, we observed extensive channels and gaps occasionally empty (i.e., without osteocytes) and osteoblasts foci. However, one month after ovarian autotransplantation, we observed trabecular bone formation containing osteoblasts border, channels and large gaps containing osteocytes (Figure 6).
thickness and osteoblast counts, but these changes were not significant (p>0.05).
DISCUSSION Ovarian
autotransplantation in young women with cancer can prevent or reduce early osteoporosis and premature ovarian failure induced by gonadotoxic drugs. Using the terms "cryopreservation", "bone health", "menopause" and "bone metabolism" in research in PubMed, Lilacs and Cochrane database, we did not found published studies on cryopreserved ovarian tissue autotransplantation effects in bone metabolism. The studies with animal models for osteopenia and osteoporosis, show that, in models of oophorectomized rats, bone loss is gradual and irreversible, being clearly measurable from the first weeks14. In this study, rats were oophorectomized
Figure 5. Trabecular bone histology (HE 100x)- Group A. A) Basal; B) Post-oophorectomy; C) Post-reimplantation.
bilaterally and their ovaries were cryopreserved via vitrification. Bone and tibial tissue biopsy samples were analyzed one week (group A) or one month (group B) after ovarian autotransplantation. Graft was successful in most rats. In both groups, compared to baseline levels, post-autotransplantation ovarian estradiol levels increased in almost half of the animals, suggesting successful transplantation and endocrine ovarian function recovery. In addition, average bones cortical thickness one month after ovarian autotransplantation was similar to that at baseline. In addition, bones cortical thickness
Figure 6. Trabecular bone histology (HE 100x)- Group B. A) Basal; B) Post-oophorectomy; C) Post-reimplantation.
at baseline was similar to the month after ovarian autotransplantation.
When comparing transplant time, group A presented slightly improved cortical thickness, trabecular
general, bone quality measurements worsened after
Rev Col Bras Cir. 2018; 45(1): Ð
Silva Criopreserved ovarian tissue transplantation and bone restoration metabolism in castrated rats
bilateral oophorectomy and improved after ovarian
increase in bone osteoclasts resorption associated with
autotransplantation, suggesting that ovarian tissue grafts
estrogen deficiency. Estrogen-deficient animal models
had effect on bone metabolism. This effect was evident for cortical thickness, trabecular thickness and osteoblast count. However, no alterations were observed in osteoids deposition. There was significant improvement in cortical and trabecular thickness. These results demonstrate that oophorectomy and consequent decrease in ovaries estradiol production have a potential role in reducing osseous parameters values in these animals. After ovaries re-implantation with vitrified heating, we observed sexual hormone production restoration (estrogen) in these animals. Hormonal production restoration, in turn, resulted in a significant improvement in bone parameters values of these animals. However, we were unable to accurately measure follicle-stimulating hormone levels (FSH) because the kits used were not sensitive enough to detect variations in FSH levels; thus, all the results were the same. Our findings suggest that cryopreserved ovarian tissue autotransplantation can restore hormonal function and normalize bone metabolism in rats. Some studies have already provided changes evidence in bone metabolism after ovarian hormones loss due to oophorectomy. Although these studies clearly showed a direct relationship between hormone absence duration and decreased bone parameters, resulting in osteopenia and osteoporosis, they did not investigate hormonal effects on bone metabolism after cryopreserved ovaries reimplantation. Menopause can represent up to 30% to 40% of a woman's life and produces sequelae such as postmenopausal demineralization (i.e., osteoporosis), cardiovascular diseases increased risk, cognitive deficiencies, quality of life and sexual desire loss22. These findings suggest that cryopreserved ovarian tissue autotransplantation can restore hormonal function and normalize bone metabolism in castrated rats. Bone quality is monitored clinically by measuring bone mineral density. However, additional information, especially histological parameters, are necessary to accurately determine bone fragility and susceptibility to fractures23. Connection between sex hormones and bone metabolism is well documented. Therefore, postmenopausal osteoporosis is mainly attributable to
and humans studies showed reduced osteocytes viability in postmenopausal osteoporosis. As estrogen improves mature osteoclasts apoptosis, osteoclasts life is prolonged as estrogen levels decrease23. Estrogen showed doubling or tripling osteoclast apoptosis rate in vitro and in vivo24. In direct contrast to its pro-apoptotic effect on osteoclasts, estrogen exerts an antiapoptotic effect on osteocytes. In other words, estrogen loss compromises osteocytes viability. In an immunohistochemical study that evaluated activated caspase-3 as an apoptosis marker in adult oophorectomized mice, estrogen loss increased osteocytes apoptosis, which is necessary to activate osteoclastic resorption25. Traditionally, symptoms related to menopause were treated with hormone therapy (HT). However, the publication of Women's Health Initiative (WHI) report in California, in 2002, indicated an association between HT and an increased breast cancer risk, which convinced many women to interrupt or reduce TH posology. Although several authors have subsequently shown that TH does not significantly increase breast cancer risk and cardiovascular disease, confidence in TH has not been fully restored. When HT is limited to menopause transition period (4 to 5 years), it often simply delays the onset of symptoms26. Therefore, prolonged menopause women (for example, 30 years) are susceptible to feel symptoms independently of therapy22. Recently, Satpathy et al. 27 described what they believed to be an osteoporosis epidemic and called for new strategies for osteoporosis long-term prevention. Ten years earlier, a meta-analysis found a 27% overall reduction in vertebral fractures among estrogen users. In addition, WHI estrogen-progestin study (2002) reported 33%, 29%, 35% and 24% reductions in the incidence of hip, arm/pulse, vertebral and total fractures, respectively, among women, assigned to estrogen plus progestin compared to those attributed to placebo during 5.6 years evaluation period. However, despite exogenous hormonal therapy temporary efficacy, cryopreservation and ovarian tissue autotransplantation are gaining ground as an alternative method to delay menopause28. Ovarian tissue cryopreservation was developed more than two decades ago. This technique preserves the
Rev Col Bras Cir. 2018; 45(1): Ô
Silva Criopreserved ovarian tissue transplantation and bone restoration metabolism in castrated rats
large endogenous reserve of ovarian follicles that would
can be saved from degeneration and continue to grow
otherwise pass through atresia and is now used for fertility
and secrete sexual hormones32.
preservation for women facing gonadotoxic, potentially sterilizing treatments and can also be used to postpone menopause27,29. A technological developments review in cryopreservation and storage techniques for ovarian tissue has recently been published30. Ovarian tissue can be cryopreserved when the woman is still young, and then transplanted, after menopause, to restore ovarian functions28. Ovaries of a newborn girl contain approximately two million follicles, present in resting follicles. This follicle store protects fertility and menstrual cycles from puberty to menopause. Regardless of age, a series of resting follicles are continually stimulated to grow, but only one follicle is selected for ovulation during each cycle29. On average, women ovulate approximately 400 to 500 times from puberty to menopause, and as a result, 99.9% of follicles degenerate. Many of these "wasted follicles" have development capacity (for sex steroids secretion), but they cannot contain oocytes suitable for reproduction31. As demonstrated by assisted reproduction, these follicles
significantly with an ovary loss. A woman with an ovary will produce approximately 20% fewer mature oocytes compared to a woman with both ovaries after ovarian stimulation, indicating that follicle atresia in remaining ovary is reduced and more follicles survive pre-ovulatory stage33. In healthy women, an ovary loss advances menopause onset age for only one year due to the huge follicles excess. In other words, normal women experience little or no effect on fertility or menopause onset age after ovarian tissue removal when young. We can conclude with our study that cryopreservation and ovarian tissue autotransplantation help bone quality improvement in castrated rats. Despite expressive variation in hormone levels in groups subjected to different periods of surgical castration, there was no statistically significant difference between estradiol levels variation. There is bone histological effects reversal derived from estradiol deprivation after cryopreserved ovarian tissue autotransplantation.
R E S U M O Objetivos: avaliar os níveis de estradiol e os efeitos do autotransplante de tecido ovariano aquecido, após vitrificação, no metabolismo ósseo de ratas previamente ooforectomizadas bilateralmente. Métodos: trabalho experimental com 27 ratas com idades entre 11 e 12 semanas e pesando 200g a 300g, submetidas à ooforectomia bilateral e criopreservação de tecido ovariano para posterior reimplante. Os animais foram divididos em dois grupos, A e B, com oito e 19 ratas, respectivamente. O autotransplante ocorreu em dois períodos de acordo com o tempo de castração: após uma semana, no grupo A, e após um mês no grupo B. Mensurações de estradiol sérico e análise histológica de ovário e tíbia foram feitos antes e após o período de ooforectomia (precoce ou tardio) e um mês após o reimplante. Resultados: nos grupos A e B, as espessuras corticais médias da tíbia foram 0,463±0,14mm (média±DP) na linha de base, 0,360±0,14mm após ooforectomia e 0,445±0,17mm em um mês após o reimplante (p<0,005). As médias trabeculares foram 0,050±0,08mm (média±DP) na linha de base, 0,022±0,08mm após ooforectomia e 0,049±0,032mm em um mês após o reimplante (p<0,005). Não houve diferença estatística entre a variação do estradiol entre os dois grupos de estudo (p=0,819). Conclusão: o transplante de tecido ovariano criopreservado restabeleceu os parâmetros ósseos, e estes resultados sugerem que a reimplantação ovariana em mulheres pode apresentar os mesmos efeitos benéficos sobre o metabolismo ósseo. Descritores: Menopausa. Osteoporose Pós-Menopausa. Estrogênios. Insuficiência Ovariana Primária.
AJ, Partridge AH, Quinn G, Wallace WH, Oktay K; American Society of Clinical Oncology. Fertility
1. Romao RL, Lorenzo AJ. Fertility preservation options for children and adolescents with cancer. Can Urol Assoc J. 2017;11(1-2Suppl1):S97-S102. 2. Loren AW, Mangu PB, Beck LN, Brennan L, Magdalinski
preservation for patients with cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 2013;31(19):2500-10. 3. Koch J, Ledger W. Ovarian stimulation protocols
Rev Col Bras Cir. 2018; 45(1): Ø
Silva Criopreserved ovarian tissue transplantation and bone restoration metabolism in castrated rats
for onco-fertility patients. J Assist Reprod Genet.
osteopenia and osteoporosis. J Musculoskelet
Neuronal Interact. 2001;1(3):193-207.
4. Bortoletto P, Confino R, Smith BM, Woodruff TK, Pavone ME. Practices and attitudes regarding women undergoing fertility preservation: a survey of the National Physicians Cooperative. J Adolesc Young Adult Oncol. 2017;6(3):444-9. 5. Salama M, Winkler K, Murach KF, Seeber B, Ziehr SC, Wildt L. Female fertility loss and preservation: threats and opportunities. Ann Oncol. 2013;24(3):598-608. 6. Kawamura K, Cheng Y, Sun YP, Zhai J, Diaz-Garcia C, Simon C, et al. Ovary transplantation: to activate or not to activate. Hum Reprod. 2015;30(11):2457-60. 7. Donnez J, Dolmans MM. Ovarian cortex transplantation: 60 reported live births brings the success and worldwide expansion of the technique towards routine clinical practice. J Assist Reprod Genet. 2015;32(8):1167-70. 8. Jensen AK, Macklon KT, Fedder J, Ernst E, Humaidan P, Andersen CY. 86 successful births and 9 ongoing pregnancies worldwide in women transplanted with frozen-thawed ovarian tissue: focus on birth and perinatal outcome in 40 of these children. J Assist Reprod Genet. 2017;34(3):325-36. Erratum in: J Assist Reprod Genet. 2017;34(3):337. 9. Anderson RA, Cameron DA. Pretreatment serum antimüllerian hormone predicts long-term ovarian function and bone mass after chemotherapy for early breast cancer. J Clin Endocrinol Metab. 2011;96(5):1336-43. 10. Hsu WL, Chen CY, Tsauo JY, Yang RS. Balance control in elderly people with osteoporosis. J Formos Med Assoc. 2014;113(6):334-9. 11. Xiong Q, Tang P, Gao Y, Zhang L, Ge W. Proteomic analysis of estrogen-mediated signal transduction in osteoclasts formation. Biomed Res Int. 2015;2015:596789. 12. Thompson DD, Simmons HA, Pirie CM, Ke HZ. FDA Guidelines and animal models for osteoporosis. Bone. 1995;17(4 Suppl):125S-33S. 13. Lane NE, Haupt D, Kimmel DB, Modin G, Kinney JH. Early estrogen replacement therapy reverses the rapid loss of trabecular bone volume and prevents further deterioration of connectivity in the rat. J Bone Miner Res. 1999;14(2):206-14. 14. Jee WS, Yao W. Overview: animal models of
15. Kalu DN. The ovariectomized rat model of postmenopausal bone loss. Bone Miner. 1991;15(3):175-91. 16. Guillen J. FELASA guidelines and recommendations. J Am Assoc Lab Anim Sci. 2012;51(3):311-21. 17. Silva JM, Pinheiro LG, Leite JA, Melo LH, Lunardi FO, Barbosa Filho RC, et al. Histological study of rat ovaries cryopreserved by vitrification or slow freezing and reimplanted in the early or late postmenopausal stage. Acta Cir Bras. 2014;29(5):299-305. 18. Lunardi FO, Chaves RN, de Lima LF, Araújo VR, Brito IR, Souza CE, et al. Vitrified sheep isolated secondary follicles are able to grow and form antrum after a short period of in vitro culture. Cell Tissue Res. 2015;362(1):241-51. 19. Malluche HH, Faugere MC. Atlas of Mineralized Bone Histology. 1st ed. Basel: Karger; 1986. 20. Bancroft JD, Gamble, editors. Theory and practice of histological techniques. 6th ed. Philadelphia (PA): Elsevier, Churchill Livingstone; 2008. 21. Rosner B. Fundamentals of Biostatistics. 7th ed. Boston: Brooks/ Cole Engage Learning; 2010. 22. Lobo RA, Davis SR, De Villiers TJ, Gompel A, Henderson VW, Hodis HN, et al. Prevention of diseases after menopause. Climacteric. 2014;17(5):540-56. 23. McCreadie BR, Goldstein SA. Biomechanics of fracture: is bone mineral density sufficient to assess risk? J Bone Miner Res. 2000;15(12):2305-8. 24. Parfitt AM, Mundy GR, Roodman GD, Hughes DE, Boyce BF. A new model for the regulation of bone resorption, with particular reference to the effects of bisphosphonates. J Bone Miner Res. 1996;11(2):1509. 25. Hughes DE, Dai A, Tiffee JC, Li HH, Mundy GR, Boyce BF. Estrogen promotes apoptosis of murine osteoclasts mediated by TGF-beta. Nat Med. 1996;2(10):1132-6. 26. Emerton KB, Hu B, Woo AA, Sinofsky A, Hernandez C, Majeska RJ, et al. Osteocyte apoptosis and control of bone resorption following ovariectomy in mice. Bone. 2010;46(3):577-83. 27. Satpathy S, Patra A, Ahirwar B. Experimental techniques for screening of antiosteoporotic activity
Rev Col Bras Cir. 2018; 45(1): Ü
Silva Criopreserved ovarian tissue transplantation and bone restoration metabolism in castrated rats
in postmenopausal osteoporosis. J Complement
hormone supplementation timing strategies in older
Integr Med. 2015;12(4):251-66.
women undergoing ovarian stimulation. Reprod
28. Andersen CY, Kristensen SG. Novel use of the ovarian follicular pool to postpone menopause and delay osteoporosis. Reprod Biomed Online. 2015; 31(2):128-31. 29. Hovatta O, Silye R, Abir R, Krausz T, Winston RM. Extracellular matrix improves survival of both stored and fresh human primordial and primary ovarian follicles in long-term culture. Hum Reprod. 1997;12(5):1032-6. 30. Rodriguez-Wallberg KA, Oktay K. Recent advances in oocyte and ovarian tissue cryopreservation and transplantation. Best Pract Res Clin Obstet Gynaecol. 2012;26(3):391-405. 31. Gosden RG. Low temperature storage and grafting of human ovarian tissue. Mol Cell Endocrinol. 2000;163(1-2):125-9. 32. Behre HM, Howles CM, Longobardi S; PERSIST Study Investigators. Randomized trial comparing luteinizing
Biomed Online. 2015;31(3):339-46. 33. Pelosi E, Simonsick E, Forabosco A, Garcia-Ortiz JE, Schlessinger D. Dynamics of the ovarian reserve and impact of genetic and epidemiological factors on age of menopause. Biol Reprod. 2015;92(5):130.
Received in: 30/10/2017 Accepted for publication: 30/11/2017 Conflict of interest: none. Source of funding: none. Mailing address: Lígia Helena Ferreira Melo e Silva E-mail: firstname.lastname@example.com / email@example.com
Rev Col Bras Cir. 2018; 45(1): à
Original Article
Comparative study of systemic early postoperative inflammatory response among elderly and non-elderly patients undergoing laparoscopic cholecystectomy Estudo comparativo da resposta inflamatória sistêmica no pós-operatório precoce entre pacientes idosos e não idosos submetidos à colecistectomia vídeolaparoscópica LUCIANA FIALHO1; JOSÉ ANTONIO CUNHA-E-SILVA1; ANTONIO FELIPE SANTA-MARIA, TCBC-RJ1; FERNANDO ATHAYDE MADUREIRA1; ANTONIO CARLOS IGLESIAS, TCBC-RJ1 A B S T R A C T Objective: to evaluate and compare the early postoperative period systemic inflammatory response between elderly and non-elderly patients submitted to laparoscopic cholecystectomy, mainly performing a quantitative analysis of interleukin-6 (IL-6), a marker of inflammatory activity systemic. Methods: we compared a series of cases over a period of six months at the Gaffrée and Guinle University Hospital of the Federal University of the State of Rio de Janeiro, involving 60 patients submitted to elective laparoscopic cholecystectomy. We used nonprobabilistic sampling for convenience, selecting, from the inclusion criteria, the first 30 patients aged 18-60 years, who comprised group I, and 30 patients with age equal to or greater than 60 years, who formed group II. Results: the 60 patients involved were followed for at least 30 days after surgery and there were no complications. There was no conversion to open surgery. The values of the medians found in the IL-6 dosages for the preoperative period, three hours after the procedure and 24 hours after surgery were, respectively, 3.1 vs. 4.7 pg/ ml, 7.3 vs. 14.1 pg/ml and 4.4 vs 13.3 pg/ml. Conclusion: Elderly patients were more responsive to surgical trauma and had elevated IL-6 levels for a longer period than the non-elderly group. Keywords: Cholecystectomy, Laparoscopic. Systemic Inflammatory Response Syndrome. Interleukin-6.
standard treatment for biliary lithiasis, and the laparoscopic procedure has been proven to be associated with a faster
razil has been presenting a process of rapid and intense population aging. In the USA, the population aged 65 or over was 8.1% in 2000 and reached 12.4% in 2015. The estimate for 2020 is that about 88.5 million (20.2%) of Americans are 65 or older1. In Brazil, it is estimated that the elderly population reaches the order of 30 million in 20202. Consequently, the number of elderly patients who undergo surgical procedures has increased considerably3,4. Cholelithiasis is the most common abdominal surgical disease in these individuals5 and several studies describe the increase of cholecystectomies in octagenarians6-8. The high prevalence of cholelithiasis makes cholecystectomy one of the most performed surgical procedures in the world9,10. With the advent of minimally invasive surgery, laparoscopic cholecystectomy has become the gold
recovery and lower systemic inflammatory response11,12. Several population studies have shown that the incidence of cholelithiasis and acute cholecystitis increases with age. The prevalence of cholelithiasis is 9.3% for the general population, 21.4% for individuals between 60 and 69 years of age, and 27.5% for individuals aged 70 years or older5. Some studies have shown that biliary lithiasis behaves particularly in the elderly population, since there is an approximation of incidence between the genders, a higher incidence of choledocholithiasis and other complicated forms of the disease (cholecystitis, pancreatitis, biliary fistulas), a higher incidence of gallbladder cancer and higher mortality associated with emergency surgery6,13-15. Other studies demonstrate a higher morbidity in
1 - Federal University of the State of Rio de Janeiro, Digestive System Surgery - Rio de Janeiro - RJ – Brazil Rev Col Bras Cir. 2018; 45(1):e1586
Fialho Comparative study of systemic early postoperative inflammatory response among elderly and non-elderly patients undergoing laparoscopic cholecystectomy
cholecystectomy in the elderly population (especially
greater, who formed group II.
above 80 years). These individuals present higher
In all the patients studied, we collected blood
complication rates, higher rates of conversion to open surgery and longer hospital stays7,16,17. There is no single reason to explain the greater surgical morbidity found in the elderly population. Probably this cause is multifactorial. Some series have shown that the large number of comorbidities present in this population, associated with low cardiopulmonary reserve, negatively influence postoperative recovery7,18. Moreover, other authors have already demonstrated differences in the systemic inflammatory response between young and old individuals in certain situations19,20. The objective of this study was to evaluate and compare the systemic inflammatory response between elderly and non-elderly patients submitted to elective laparoscopic cholecystectomy.
samples for the quantitative analysis of interleukin-6 (IL-6), a marker of systemic inflammatory activity. This collection occurred in three different moments: in the anesthetic induction, three hours and 24 hours after the end of the procedure. Other parameters studied were plasma leukometry (measured before and after surgery), surgical time (started at the time of the first incision and finished after the last cutaneous suture), presence of comorbidities, body mass index (BMI), variation in pre and post-operative platelet counts and C-reactive protein (CRP) measured 24 hours after the surgical procedure. All patients underwent general anesthesia, without epidural block and without the use of corticoids or opioids. We constructed tables to describe the measures of central tendency (mean and median) and dispersion (minimum and maximum values, amplitude, percentiles and standard deviation) of the continuous quantitative variables. We evaluated the difference between means with the Student's t-test for independent samples, the One-way ANOVA test for comparison of variances for paired samples, the Wilcoxon test for comparison between medians of paired samples, and the Mann-Whitney test to compare medians of unpaired samples. We used the Excel 2016 software and the statistical package SPSS 21.0 (Statistical Package for Social Science - Chicago, IL, 2008) for the analysis. Statistical significance was considered at p<0.05. This work was approved by the HUGG Ethics Committee, protocol number 03297312800005258, and all the patients involved in the present study signed the informed consent form.
METHODS This is a case series study, conducted over a six-month period, at the GaffrĂŠe and Guinle University Hospital (HUGG), involving 60 patients submitted to elective laparoscopic cholecystectomy. The criteria used for surgical indication were the clinical history (biliary lithiasis or symptomatic polyp) and ultrasonographic findings, such as microcalculi, a calculus greater than or equal to 3cm, a polyp associated with biliary calculus and a polyp greater than or equal to 1cm in asymptomatic patients. Inclusion criteria were: age equal to or greater than 18 years, any gender, uncomplicated cholelithiasis, patients without comorbidities (ASA-I) or with clinically compensated comorbidities (ASA-II). Exclusion criteria were: need for conversion to open surgery, intraoperative finding of complicated biliary lithiasis (acute cholecystitis, choledocholithiasis and acute pancreatitis), use of immunosuppressive drugs (corticosteroids and immunomodulators), acquired immunodeficiency syndrome, malignant disease in activity, and those who did not sign the informed consent form. We used non-probabilistic sampling for convenience, selecting, according to the inclusion criteria, the first 30 patients aged 18-60 years, who comprised group I, and the first 30 patients with age 60 years or
RESULTS We followed all 60 patients for at least 30 days after the end of surgery. There were no complications or death in this period. No case required conversion to open surgery or insertion of an extra trocar. Regarding gender, six individuals from group I were male (20%), and in group II, five (16.7%). The majority of the participants, therefore, were female, 80 and 83.3%, respectively (Table 1).
Rev Col Bras Cir. 2018; 45(1):e1586
Fialho Comparative study of systemic early postoperative inflammatory response among elderly and non-elderly patients undergoing laparoscopic cholecystectomy
Comparison of body mass index (BMI) revealed
Table 1. Patients undergoing cholecystectomy by gender and age group.
I n
20.0% 5 16.7%
24 80.0% 25 83.3%
30 100% 30 100%
* Chi-square test.
Regarding surgical risk (Table 2), 66.7% of the individuals in group I were ASA 1, and in group II, 80% of the individuals were classified as ASA 2. Thus, we verified that the greater the age, the greater the number of comorbidities. Table 2. Patients undergoing cholecystectomy by ASA and age group.
I n
20 66.7%
10 33.3%
30 100%
< 0.001
a similar mean between groups, 23.1kg/m2 in group I and 23.2kg/m2 in group II. The mean duration of the cholecystectomies was approximately one hour for both groups, thus confirming that the surgical time was very close between the two groups, with a mean of 68.3 minutes for group I and 68.1 for group II. The mean values of C-reactive protein (CRP) measured 24 hours after the surgical procedure were 6.3 for group I and 1.4 for group II, but the standard deviation showed a high variability between observations (Table 3). Regarding preoperative and postoperative leukometry, the mean had similar results. Group I had 6,581.9/mm³ versus 6,678.1/mm³ in group II; and in the postoperative period, 11,246.1/mm³ versus 10,864.3/mm³ for groups I and II, respectively. The mean platelet analysis present the same similarity. In the preoperative period, the values were 266.9 thousand/mm³ in group I versus 260.5 thousand/ mm³ in group II, and in the postoperative period they were 255.9 thousand/mm³ versus 241.3 thousand / mm³ for groups I and II, respectively (Table 3).
* Chi-square test.
Table 3. Patients' epidemiological and laboratory profile.
18-59 years (n=30) Mean (SD)
³60 years (n=30) Mean (SD)
p value*
44.3 (12.6)
67.8 (7.6)
< 0.001
23.1 (3.3)
23.2 (2.1)
6,581.9 (1540.5)
6,678.1 (1739.5)
11,246.1 (3756.7)
10,864.3 (2285.1)
266.9 (61.3)
260.5 (64.4)
255.9 (78.5)
241.3 (66.8)
C-Reactive Protein
6.3 (18.1)
1.4 (1.8)
Surgery time
68.3 (27.3)
68.1 (23.4)
SD: Standard Deviation; * Student t Test comparison of means (independent samples).
As for Interleukin 6 (IL-6), the comparison within each group showed that, in the three moments analyzed (preoperative, three hours after surgery and 24 hours after surgery), its median values in group I were, 3.1, 7.3
and 4.4 pg/ml, respectively, and in group II, 4.7, 14.1 and 13.3 pg/ml, respectively, both with statistically significant differences (Table 4 ).
Rev Col Bras Cir. 2018; 45(1):e1586
Fialho Comparative study of systemic early postoperative inflammatory response among elderly and non-elderly patients undergoing laparoscopic cholecystectomy
Table 4. IL-6 levels at the preoperative time and at three and 24 hours after the procedure.
Group I Preop Mean (SD) 25 Percentile
3 hours
Group II
24 hours p value
3 hours
24 hours
p value
7.3 (10.4) 19.4 (34.6) 26.6 (67.1) 0.24 * 17.7 (32.3) 54.5 (124.3) 24.3 (44.1)
0.15 *
75 Percentile MinimumMaximum Amplitude
-50.0 2.0 2.5 -174.0 1.8 -332.7 48
-138.0 41.5 2.7 -684.4 2.1 -223.8
x x
Preop: preoperative time; SD: Standard deviation; * One-way ANOVA comparison of variances (paired samples). ** Wilcoxon test comparison between medians (samples paired by posts).
Regarding comparison between groups, the median values of IL-6 were 3.1 x 4.7 pg/ml in the preoperative period, 7.3 x 14.1 pg/ml three hours after the
procedure, and 4.4 x 13.3 pg/ml at the 24th postoperative hour. Only the medians of three and 24 hours showed statistically significant differences (Table 5).
Table 5. Comparison between the IL6 dosage times, preoperative, three hours and 24 hours.
p value
Group I Group II Average [SD*] Median
3 hours
p value
Group I Group II 0.10** 0.67***
24 hours
p value
Group I Group II 0.14** <0.01***
0.87** <0.001***
* SD: Standard deviation; ** Student's t-Test comparison of means (independent samples); *** Mann-Whitney test comparison of medians (paired samples).
increasing the production of interleukin-625. It has been clearly demonstrated in several studies12,24,25 that IL-6 can
Tissue injury triggers a systemic inflammatory response , which is influenced by several factors, such as tissue injury volume and trauma intensity. This has already been described when comparing open cholecystectomy with laparoscopic one, the latter with an attenuated inflammatory response, probably due to less associated tissue damage11,22,23. Tissue injury from surgical trauma activates different cellular elements responsible for the immune response, like macrophages, neutrophils and natural killer (NK). Once activated, these cells initiate the production of cytokines, such as interleukin-6, which directly participates in the systemic inflammatory response24. Riese et al. demonstrated that during abdominal surgeries the peritoneum reacts rapidly, 21
be used as an inflammatory marker, since its levels are elevated early in the face of tissue damage. Therefore, the dosages of interleukin-6 and C-reactive protein have been used by several authors as a method of choice for the evaluation and comparison of the systemic inflammatory response in different groups26,27. Like IL-6, C-reactive protein can also be used as a marker of inflammation2. Of the group of patients studied, we observed a predominance of the female gender, remembering that gallstones are more prevalent in females5,9. Regarding surgical risk, we found a predominance of individuals with comorbidities in group II. However, we included only patients with controlled comorbidities in this study, to minimize their effects on the behavior of inflammatory
Rev Col Bras Cir. 2018; 45(1):e1586
Fialho Comparative study of systemic early postoperative inflammatory response among elderly and non-elderly patients undergoing laparoscopic cholecystectomy
markers. We also analyzed the two groups regarding
more sustained in this same group II.
body mass index (BMI) and operative time, since the
In summary, it is possible to suggest that the
higher BMI could represent greater technical difficulty and longer surgical time. Therefore, we verified that the means of BMI and operative times were very close between the two groups, emphasizing the homogeneity of the sample. Several studies26,27 used IL-6 as the main marker of inflammatory response after surgical trauma. In the results shown in tables 4 and 5, it is possible to note that both groups responded to surgical trauma with elevation of IL-6. In the younger population this initial variation was lower than in the elderly. When comparing the median values of IL-6 dosages of the young and elderly groups in three and 24 hours after surgery, we observed statistically significant differences (p<0.01 and p<0.001, respectively). By analyzing the results, we can suggest that there is an initial major inflammatory response in the elderly group, since there was a more exacerbated IL-6 release in this group, with a statistically significant difference between the medians. And we also observed that the inflammatory response is
elderly patients have a more exacerbated response to surgical trauma and had this inflammation maintained for a longer period, unlike the younger ones, who responded to the surgical trauma with a lower release of IL-6 and a faster normalization of its levels. Although CRP was widely used to track inflammatory response in clinical practice, this marker was not sensitive to detect differences in the inflammatory response between the groups (young and old) undergoing a minimally invasive procedure, unlike IL-6, which is a more sensitive marker. Leukometry also behaved similarly between groups I and II. Its initial dosage did not present a significant statistical difference, neither a significant variation between the groups in the postoperative period. In view of our results, the elderly patient has a more exacerbated response to the surgical trauma of laparoscopic cholecystectomy, an inflammatory response that is maintained for a longer period.
R E S U M O Objetivo: avaliar e comparar a resposta inflamatória sistêmica no pós-operatório precoce de pacientes idosos e não idosos submetidos à colecistectomia vídeo-laparoscópica, realizando, sobretudo, análise quantitativa de interleucina-6 (IL-6), que representa um marcador de atividade inflamatória sistêmica. Métodos: estudo de série de casos, comparativo, realizado num período de seis meses, no Hospital Universitário Gaffrée e Guinle da Universidade Federal do Estado do Rio de Janeiro, envolvendo 60 pacientes com indicação de colecistectomia laparoscópica eletiva. Amostragem não probabilística por conveniência foi utilizada, selecionando, a partir dos critérios de inclusão, os primeiros 30 pacientes com idades entre 18 e 60 anos, que compuseram o grupo I e os 30 pacientes com idade igual ou maior que 60 anos, que formaram o grupo II. Resultados: os 60 pacientes envolvidos foram acompanhados por no mínimo 30 dias após o término da cirurgia e não houve complicações. Não houve conversão para cirurgia aberta. Os valores das medianas encontrados nas dosagens da IL-6, nos grupos I e II, para cada momento analisado (pré-operatório, três horas após e 24 horas após) foram, respectivamente: 3,1 x 4,7 pg/ml no pré-operatório, 7,3 x 14,1 pg/ml após três horas do procedimento e 4,4 x 13,3 pg/ml na 24a hora do pós-operatório. Conclusão: pacientes idosos responderam de forma mais exacerbada ao trauma cirúrgico e apresentaram elevação dos níveis de IL-6 por um período maior do que o grupo de não idosos. Descritores: Colecistectomia Laparoscópica. Síndrome de Resposta Inflamatória Sistêmica. Interleucina-6.
Júnior AM. Tratamento cirúrgico da litíase vesicular no idoso: análise dos resultados imediatos da
1. Halaweish I, Alam HB. Changing demographics of the American population. Surg Clin N Am. 2015;95(1):110. 2. Rego RE, Campos T, Moricz A, Silva RA, Pacheco
colecistectomia aberta e laparoscópica. Rev Assoc Med Bras. 2003;49(3):293-9. 3. Uecker J, Adams M, Skipper K, Dunn E. Cholecystitis in the octagenarian: is laparoscopic cholecystectomy
Rev Col Bras Cir. 2018; 45(1):e1586
Fialho Comparative study of systemic early postoperative inflammatory response among elderly and non-elderly patients undergoing laparoscopic cholecystectomy
the best approach? Am Surg. 2001;67(7):637-40. 4. Lujan JA, Sanchez-Bueno F, Parrilla P, Robles R, Torralba JA, Gonzalez-Costea R. Laparoscopic vs. open cholecystectomy in patients aged 65 and older. Surg Laparosc Endosc. 1998;8(3):208-10. 5. Coelho JC, Bonilha R, Pitaki SA, Cordeiro RM, Salvalaggio PR, Bonin EA, et al. Prevalence of gallstones in a Brazilian population. Int Surg.1999;84:25-8. 6. González González JJ, Sanz Alvarez L, Graña López JL, Bermejo Abajo G, Navarrete Guijosa F, Martínez Rodríguez E. Litiasis biliar en pacientes mayores de 80 años. ¿cirugía o tratamiento conservador? Rev Esp Enferm Dig. 1997;89(3):196-205. 7. Maxwell JG, Tyler BA, Maxwell BG, Brinker CC, Covington DL. Laparoscopic cholecystectomy in octagenarians. Am Surg. 1998;64(9):826-31; discussion 831-2. 8. Maxwell JG, Tyler BA, Rutledge R, Brinker CC, Maxwell BG, Covington DL, et al. Cholecystectomy in patients aged 80 and older. Ann Surg. 1998;176(6):627-31. 9. Kuy S, Sosa JA, Roman SA, Desai R, Rosenthal RA. Age matters: a study of clinical and economic outcomes following cholecystectomy in elderly Americans. Am J Surg. 2011;201(6):789-96. 10.Festi D, Dormi A, Capodicasa S, Staniscia T, Attili AF, Loria P, et al. Incidence of gallstone disease in Italy: results from a multicenter population-based Italian study (the MICOL Project). World J Gastroenterol. 2008;14(34):5282-9. 11.Glaser F, Sannwald GA, Buhr HJ, Kuntz C, Mayer H, Klee F, et al. General stress response to convencional and laparsocopic cholecystectomy. Ann Surg. 1995;221(4):372-80. 12. Biffi WL, Moore EE, Moore FA, Peterson VM. Interleukin-6 in the injured patient. Marker of injury or mediator of inflammation? Ann Surg. 1996;224(5):647-64. 13. Kahng KU, Roslyn JJ. Surgical issues for the elderly patients with hepatobiliary disease. Surg Clin North Am. 1994;74(2):345-73. 14. Magnuson TH, Ratner LE, Zenilman ME, Bender JS. Laparoscopic cholecystectomy: applicability in the geriatric population. Am Surg. 1997;63(1):91-5. 15. Casaroli AA, Bevilacqua RG, Rasslan S. Análise multivariada dos fatores de risco no tratamento
cirúrgico da colecistite aguda no idoso. Rev Col Bras Cir. 1996;23(1):1-7. 16. Yetkin G, Uludag M, Oba S, Citgez B, Paksoy I. Laparoscopic cholecystectomy in elderly patients. JSLS. 2009;13(4):587-91. 17. Kirshtein B, Bayme M, Bolotin A, Mizrahi S, Lantsberg L. Laparoscopy cholecystectomy for acute cholecystitis in the elderly: is it safe? Surg Laparosc Endosc Percutan Tech. 2008;18(4):334-9. 18. Hazzan D, Geron N, Golijanin D, Reissman P, Shiloni E. Laparoscopic cholecystectomy in octagenarians. Surg Endosc. 2003;17(5):713-76. 19. Pawelec G, Adibzadeh M, Pohla H, Schauadt K. Immunosenescence: ageing of the imune system. Immunol Today. 1995;16(9):420-2. 20. O'Mahony L, Holland J, Jackson J, Feighery C, Hennessy TP, Mealy K. Quantitative intracellular cytokine measurement: age-related changes in proinflammatory cytokine production. Clin Exp Immunol. 1998;113(2):213-9. 21. Marks J, Tacchino R, Roberts K, Onders R, Denoto G, Paraskeva P, et al. Prospective randomized controlled trial of traditional laparoscopic cholecystectomy versus single-incision laparoscopic cholecystectomy: report of preliminary data. Am J Surg. 2011;201(3):369-72; discussion 372-3. 22. Vittimberga FJ Jr, Foley DP, Meyers WC, Callery MP. Laparoscopy surgery and the systemic immune response. Ann Surg. 1998;227(3):326-34. 23. Bruce DM, Smith M, Walker CB, Heys SD, Binnie NR, Gough DB, et al. Minimal access surgery for cholelithiasis induces an attenuated acute phase response. Am J Surg. 1999;178(3):232-4. 24. Decker D, Tolba R, Springer W, Lauschke H, Hirner A, von Ruecker A. Abdominal surgical interventions: local and systemic consequences for the immune system--a prospective study on elective gastrointestinal surgery. J Surg Res. 2005;126(1):128. 25. Riese J, Schoolmann S, Beyer A, Denzel C, Hohenberger W, Haupt W. Production of IL-6 and MCP1 by the human peritoneum in vivo during major abdominal surgery. Shock. 2000;14(2):91-4. 26. Luna RA, Nogueira DB, Varela PS, Rodrigues Neto Ede O, Norton MJ, Ribeiro Ldo C, et al. A prospective,
Rev Col Bras Cir. 2018; 45(1):e1586
Fialho Comparative study of systemic early postoperative inflammatory response among elderly and non-elderly patients undergoing laparoscopic cholecystectomy
randomized comparison of pain, inflammatory
Received in: 03/11/2017
Accepted for publication: 14/12/2017
single-port and laparoscopic cholecystectomy. Surg Endosc. 2013;27(4):1254-9. 27. Madureira FA, Manso JE, Madureira Filho D, Iglesias AC. Inflammation in laparoscopic single-site surgery versus laparoscopic cholecystectomy. Surg Innov. 2013;21(3):263-6.
Conflict of interest: none. Source of funding: none. Mailing address: Antonio Carlos Iglesias E-mail: firstname.lastname@example.com / email@example.com
Rev Col Bras Cir. 2018; 45(1):e1586
Review Article
Resuscitative endovascular balloon occlusion of the aorta (REBOA): an updated review Oclusão ressuscitativa por meio de balão endovascular da aorta (REBOA): revisão atualizada MARCELO AUGUSTO FONTENELLE RIBEIRO JÚNIOR, TCBC-SP1; MEGAN BRENNER2; ALEXANDER T. M. NGUYEN3; CÉLIA Y. D. FENG3; RAÍSSA REIS DE-MOURA1; VINICIUS C. RODRIGUES1; RENATA L. PRADO1 A B S T R A C T In a current scenario where trauma injury and its consequences account for 9% of the worlds causes of death, the management of noncompressible torso hemorrhage can be problematic. With the improvement of medicine, the approach of these patients must be accurate and immediate so that the consequences may be minimal. Therefore, aiming the ideal method, studies have led to the development of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). This procedure has been used at select trauma centers as a resuscitative adjunct for trauma patients with non-compressible torso hemorrhage. Although the use of this technique is increasing, its effectiveness is still not clear. This article aims, through a detailed review, to inform an updated view about this procedure, its technique, variations, benefits, limitations and future. Keywords: Radiology, Interventional. Multiple Trauma. Abdomen. Shock, Hemorrhagic.
occurred in the acute stages of injury; 36% of patients found or declared deceased at the scene of injury had
very year more than five million people die around the world from traumatic injury and its consequences1. This accounts for 9% of worldwide mortality; greater than the combined deaths caused by HIV/AIDS, malaria and tuberculosis1. In 2015, 214,000 Americans died from traumatic causes2. Whilst hemorrhage is the second highest cause of trauma death (30-40% of trauma deaths), it is also the most preventable cause3,4. Fatalities caused by traumatic hemorrhage most commonly
exsanguinated and the majority of exsanguinations once admitted to hospital occurred in the first 48 hours of admission4. Traumatic hemorrhage can be subdivided into compressible and non-compressible, with the former type being easier to control and carrying less risk of mortality5,6. Non-compressible hemorrhage of the torso (NCTH) is defined using the criteria in table 1 and is considerably harder to control, with an overall mortality of up to 44.6%5.
Table 1. Non-compressible torso hemorrhage, which consists of one of the anatomic criteria PLUS the physiological criterium. Adapted from Kisat et al.5.
Anatomic criteria
Physiological criterium
1. Pulmonary injury (massive haemothorax, pulmonary vascular injury) 2. Solid organ injury = grade 4 (liver, kidney, spleen) 3. Named axial torso vessel
Systolic blood <90mmHg
4. Pelvic fracture with ring disruption
1 - Santo Amaro University, Discipline of General Surgery and Trauma, São Paulo, SP, Brazil. 2 - University of Maryland, RA Cowley Shock Trauma Center, Baltimore, MD, USA. 3 - University of New South Wales, School of Medicine, Sydney, New South Wales, Australia. Rev Col Bras Cir. 2018; 45(1):e1709
Ribeiro Júnior Resuscitative endovascular balloon occlusion of the aorta (REBOA): an updated review
The current management of NCTH is highly
flow distal to the balloon and significantly decreases any
invasive; laparotomy is used to cause hemostasis in intra-
non-compressible intrathoracic/intra-abdominal bleeding.
abdominal hemorrhage, while patients who present or
Due to the risk of ischemia-reperfusion injury, which will be discussed later in the review, it is a temporary maneuver in the emergency department to prepare the patient for a surgical procedure11,12. As an alternative to conventional resuscitative thoracotomy, REBOA has been shown to preserve myocardial and cerebral tissue perfusion in a less invasive fashion13. Its aims are to maintain cerebral and coronary circulation and temporarily control arterial hemorrhage from the injured organ via occlusion using balloon inflation of the aortic lumen14. The use of REBOA begins with patient selection. It is indicated for use in any patient presenting with hypotension (SBP<90mmHg) after trauma who proves to be a partial responder or non-responder to fluids and/ or blood components, as per the Advanced Trauma Life Support guidelines. Widened mediastinum, evidence of hemorrhage above the potential balloon landing site or a penetrating thoracic injury are contraindications to its use. Currently in USA, traumatic brain injuries are no longer a contraindication to the method15. Any physician adept at the Seldinger's 16 technique can perform a REBOA catheter insertion at the patient's bedside. Common femoral artery access is obtained via the insertion of a femoral arterial introducer, varying in size from 7Fr to 14Fr, depending on the particular device used16. The site at which femoral access
progress to refractory haemorrhagic shock are subjected to open thoracotomy with cross-clamping of the aorta to resuscitate the cardiovascular system7. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is an improving technique involving expansion of an endovascular balloon to provide haemorrhagic control. It is less invasive than emergency department thoracotomy (EDT), but only one prospective study has been completed that compared the clinical use of open thoracotomy and REBOA8. The results from this study are optimistic. After the procedure, REBOA patients regained a higher mean systolic blood pressure compared to patients undergoing open thoracotomy (90.0±52.9mmHg vs. 64.6±61.1mmHg, p=0.029). Importantly, there was no significant difference in overall mortality between the two techniques (REBOA, 71.7% vs. open, 83.8%; p=0.120)8. According to Qasim et al.7, the REBOA technique had its origins during the Korean War, and its progress to civilian use is linked to its use in the military. A retrospective study of the UK Joint Theatre Trauma Registry found that roughly 20% of combat casualties might have been treated with REBOA9. Recently, one of the first prospective cohort studies comparing REBOA with open methods of endovascular occlusion (i.e. EDT) has been completed with promising results on patient mortality, as explained above8. As REBOA becomes increasingly used in major
is obtained is shown in figure 1.
trauma centers in the United States and worldwide, extensive research and training will need to be conducted in this area to ensure that the method is reliable and well suited to its indications10. This review provides an update on the current literature and context surrounding REBOA. We also review the technique itself, its indications and uses, benefits and limitations, identifying areas for future research.
TECHNIQUE REBOA involves rapidly placing a flexible catheter into the femoral artery, manoeuvring it into the aorta and inflating a balloon at its tip. This prevents blood
Figure 1. Femoral access to insertion of REBOA.
Rev Col Bras Cir. 2018; 45(1):e1709
Ribeiro Júnior Resuscitative endovascular balloon occlusion of the aorta (REBOA): an updated review
Recent advances, particularly the development of balloon catheters deliverable via smaller 7Fr sheaths have led to new enthusiasm for this technique for trauma patients. However, although it has now become commercially available, the evidence of efficacy is limited17. Common femoral artery cannulation can be accomplished via surgical cut-down, a blind percutaneous approach, or most recently, with the use of bedside ultrasound. Ultrasound guidance access should be considered the standard of care whenever feasible, since its use affords placement precision, effectively identifies aberrant femoral anatomy and mitigates the risk of arterial injury. It is also an alternative for achieving femoral access in patients with severe hypotension or with no palpable pulse to guide needle insertion18. Access has been found to be the rate-limiting step of REBOA and therefore is a critical skillset to perform the procedure. The choice of REBOA device to be used dictates subsequent upsizing of the 5Fr sheath. A micropuncture with this size of sheath is done in order to reduce the risk of hematoma or vessel injury if initial placement is imprecise19. The use of a smaller introducer catheter results in a more gradual enlargement of the arteriotomy with sheath upsizing, particularly important in vessels with atherosclerotic disease. There are several types of balloon for use in the REBOA, but the balloon more commonly selected is the ER REBOA, which is 7Fr compatible. It possesses an atraumatic flexible tip, has an arterial monitoring port proximal to the balloon that can be used to accurately measure pre-occlusion blood pressure as well as arterial response to REBOA, and external markings on the catheter that facilitate placement and were specifically designed for trauma applications18,20. Other alternative balloons include the Coda®, the Reliant® and the Berenstein®20. After insertion of the femoral artery sheath, a REBOA catheter is placed into the aorta and aortic occlusion is performed. The placement of the balloon catheter in the aorta should be decided prior to insertion, and the levels of the aorta, chosen according to figure 221. These levels are usually set according to the three zone classifications: Zone I (thoracic aorta, from the left subclavian artery to the celiac artery), Zone II (between celiac and renal arteries), and Zone III (infra-renal placement)22, and depend on the site(s) of hemorrhage.
Figure 2. Illustration of the zone classification for REBOA location.
The aortic zone for occlusion is selected based on the primary assessment: Zone I is usually the choice for the placement in patients with suspected intra-abdominal hemorrhage, while Zone III is chosen in patients with hemorrhage from a confirmed pelvic fracture23. REBOA catheter positioning is confirmed by portable chest or abdominal radiography in the Emergency Room23. To inflate the balloon, a solution of sterile saline and iodinated contrast can be used. The balloon should be inflated until the blood pressure is augmented and contralateral femoral pulse is stopped; currently, the volumes used are approximately 8 mL for Zone I and 3mL for Zone III20. The physician should be careful not to over-inflate the balloon, as over-inflation will rupture the balloon or the blood vessel20. Balloon inflation
Rev Col Bras Cir. 2018; 45(1):e1709
Ribeiro Júnior Resuscitative endovascular balloon occlusion of the aorta (REBOA): an updated review
should be guided by fluoroscopy, if available at the ER
used at select trauma centers as a resuscitative adjunct
area, by the hemodynamic response and/or by the loss
for trauma patients with life-threatening NCTH25. The
of the contralateral pulse. It is possible to verify the balloon position using x-ray or fluoroscopy (the x-ray is the preferred method, due to the availability in the resuscitation areas)24. After balloon inflation, the patient should be taken to the operating room or angiography suite, where the necessary procedure will be done. Once specific vascular control or definitive hemorrhage control has been obtained, balloon deflation and sheath removal should be performed19. At this stage, health care professionals should be prepared for instances of new bleeding. Metabolic consequences may also appear due to significant reperfusion effect and the surgical team must ensure all necessary support for a possible reintervention. Some vascular repair may be necessary after sheath removal22. When REBOA is no longer required, the deflated balloon may be removed from the sheath. The sheath's removal depends on its size and how it was introduced. If the introducer sheath was placed by open arterial cutdown, then open surgical repair of the arterial access site is necessary. The femoral artery proximal and distal to the sheath entry site should be exposed to allow control. Proximally, this may require dissection of 2cm to 3cm underneath the inguinal ligament when the sheath removal is performed via standard cutdown18,20. However, if the sheath used has a smaller caliber (i.e. 7Fr) and was placed percutaneously, the sheath may be removed and direct pressure held at the arterial site, above the skin puncture site. Full occlusive direct pressure is applied for ten minutes, with gradual decrease in pressure every five minutes for a total of 30 minutes20. Lastly, restoration of flow through the arterial segment should be confirmed using manual palpation for pulses distally and continuous wave doppler of both the artery and more distal extremity. If there is any uncertainty of flow, it is recommended to perform an angiogram, and immediate intervention if any abnormalities are noted20.
intervention can be performed with a full occlusion of the aorta, which is known as complete REBOA (cREBOA), with a partial occlusion (pREBOA) or with an intermittent occlusion (iREBOA)11,26. Although the use of REBOA in clinical practice is increasing, animal data suggests that prolonged occlusion of the aorta is associated with ischemia-reperfusion injury and potentially an increased risk of death27. The profound distal ischemia means that there is a maximal duration of use for REBOA that cannot be extended11. Periods of occlusion exceeding 40 minutes can result in irreversible organ injury and death. Additionally, supraphysiologic increases in blood pressure proximal to the occlusion balloon during cREBOA can contribute to cardiac failure and exacerbation of traumatic brain injury26. These limitations have led to the development of pREBOA, whereby the balloon is deflated slightly, allowing a degree of flow beyond the balloon27; and iREBOA, in which the balloon is fully deflated for brief periods of reperfusion11. The refinement of the technique attempts to minimize distal ischemia and extend the duration of REBOA27. Several clinical reports suggest that partial aortic flow restoration via partial aortic occlusion may serve to mitigate the adverse effects of aortic occlusion on both proximal and distal vascular beds, whilst aiming to limit ongoing hemorrhage in the bleeding patient. Generally, these researchers and clinicians have described this therapeutic strategy as pREBOA. However, the application known as pREBOA has been heterogeneous and the methodology to perform it remains ill-defined28. An alternative approach to mitigate the consequences of sustained aortic occlusion is the concept of iREBOA. Intermittent REBOA represents the cyclical full inflation and full deflation of a balloon catheter in the management of physiologically deranged patients. This represents a binary approach to resuscitation, where aortic occlusion is repeatedly toggled from "on" to "off" to minimize the ischemic burden to downstream tissues. As with pREBOA, the application of iREBOA remains illdefined, with similar challenges regarding quantification, data capturing and reporting28. Although these techniques are still under
VARIATIONS OF REBOA USE Developed from the convergence of trauma and endovascular surgery, REBOA has increasingly been
Rev Col Bras Cir. 2018; 45(1):e1709
Ribeiro Júnior Resuscitative endovascular balloon occlusion of the aorta (REBOA): an updated review
analysis, some studies demonstrate that pREBOA
underwent REBOA for NCTH (n=48), none of the patients
maintained normal physiology better than cREBOA,
experienced significant vascular complications that
minimized the systemic impact of distal organ ischemia, and reduced hemodynamic instability, allowing longer periods of intervention26. Studies have also shown that iREBOA increased the tolerable duration of the aorta occlusion beyond 80 minutes without ischemic complications11. Currently, whilst the consensus on which technique is superior remains unclear, in a study conducted in 2017 examining the preferences of surgeons before and after the 2017 Endovascular and Hybrid Trauma and Bleeding Management Symposium, the vast majority of participants favored partial REBOA over intermittent REBOA (81,6% preferred partial REBOA)29. Innovation in the development and employment of endovascular resuscitative adjuncts continues at an impressive pace. The evolution of devices and concepts involved in these efforts will inevitably lead to a growing lexicon of endovascular intervention for resuscitation28.
required amputations18. Time required for aortic occlusion was also significantly shorter than EDT (p=0.003), with a retrospective review performed by Romagnoli et al. finding a median time of 245 seconds required for occlusion after arterial access was obtained34. In an animal study conducted on porcine models of hemorrhagic shock, REBOA resulted in lower serum lactate levels, less acidosis, lower pCO2 levels and required smaller volumes of fluid and norepinephrine when compared to thoracotomy and occlusion by clamp35.
BENEFITS REBOA is recognized as a minimally invasive and lower risk procedure in comparison to EDT, particularly in minimizing potential exposure to bloodborne pathogens30. When compared to open procedures for aortic occlusion, such as EDT, REBOA was found to more consistently achieve hemodynamic stability (47,8% vs. 27,9%, p=0.014), defined as SBP>90mmHg for more than five minutes8. Furthermore, there was no significant difference found in mortality rates between both procedures8. Whilst originally adopted as a technique of aortic occlusion for controlling NCTH, after being shown as effective in pelvic hemorrhage, studies have demonstrated the usefulness of intra-aortic balloon occlusion in cases such as an emergency Caesarean hysterectomy in a pregnant Jehovah's Witness patient31, major upper gastrointestinal bleeding in patients with Crohn's disease32, restoring maternal blood in postpartum hemorrhage, and ruptured abdominal aortic aneurysm33. Additionally, complications related to use of REBOA are uncommon. In a retrospective review conducted over five years of all patients in the US that
LIMITATIONS Whilst REBOA lowers risks of contamination for the patient, the minimally invasive nature of the procedure reduces exposure to the torso, a disadvantage when emergency procedures such as relieving pericardial tamponade, tension pneumothorax or performing an open chest cardiac massage are required36 Reported complications related to the use of REBOA has been minimal. However, there have been cases of lower limb ischemia and external iliac artery injury reported37. Lower limb ischemia for prolonged periods can result in irreversible damage due to limited reperfusion. Furthermore, prolonged periods of hypertension caused by REBOA can lead to cardiovascular complications, due to the increased afterload on the left ventricle of the heart38. In a 7-year retrospective study conducted in Tokyo, Japan, of all patients (n=24), there were three reports of complications, two cases of lower limb ischemia and one case of external iliac artery injury, all of which required lower limb amputation37. Complications may also arise during the balloon deflation, such as release of inflammatory mediators, complement, ROS, embolism, metabolic acidosis and hemorrhage to the affected area that had previously attained hemostasis35. However, variables such as approach to treatment of the patient, technique used and management strategies which vary across different health institutions globally, can largely affect the complications that REBOA has on its patients39. This must be addressed in future, in order to minimise such complications.
Rev Col Bras Cir. 2018; 45(1):e1709
Ribeiro Júnior Resuscitative endovascular balloon occlusion of the aorta (REBOA): an updated review
the use of resuscitative balloon technology in occlusion of the inferior vena cava, known as REBOVC. In a novel
REBOA has vast potential in the future as an adjunct to other trauma and resuscitative techniques and perhaps even in replacing EDT in some emergency scenarios. However, further studies must be conducted in order to establish the benefits of this procedure, as well as its optimal indications7. Large multicenter prospective studies on trauma patients should be performed, evaluating the efficacy and complications of REBOA39. Transdisciplinary training, such as through the established Endovascular Skills for Trauma and Resuscitative Surgery (ESTAR) and Basic Endovascular Skills for Trauma (BEST) courses40, must be expanded in future and made more accessible to providers, to ensure knowledge of REBOA is adequate to allow subsequent practice of the technology. Currently, new developments to the technology of REBOA are emerging. The use of smaller 7Fr introducer arterial sheaths for REBOA have been hypothesized to be a safer alternative to the currently used larger sheaths41. New techniques such as the use of the mid-sternum landmark instead off fluoroscopic image guidance for deployment of the balloon, have been investigated as a safe alternative to facilitate situations where fluoroscopic imaging is not available42. Furthermore, a new smaller profile, fluoroscopy-free ER-REBOA catheter, has been developed by Pryor Medical36. Recently, there has been emerging data of
animal study conducted by Reynolds et al.43, REBOVC prolonged time to death and significantly reduced blood loss in swine liver models, when compared to no control of the suprahepatic inferior vena cava. This has immense potential for use in emergency situations such as retrohepatic inferior vena cava injuries, where it is difficult to appropriately expose and isolate the vasculature43. Finally, to minimize complications and lower mortality rates of the use of REBOA, a uniform management strategy or clinical guideline must be established and used to allow for optimal utilisation of this technology36.
CONCLUSION REBOA is an emergent and innovative technique that is increasingly being recognized and performed by health care providers in trauma centers internationally. Its minimally invasive technique has continually been developed and modified over the past few years, utilizing new technology to decrease complications and maximize benefits. However, for continual expansion and use of REBOA in future, further research and training must be conducted to ensure adequate knowledge and warranted safety of the procedure as a resuscitative technique.
R E S U M O Em um cenário atual onde a lesão traumática e suas consequências representam 9% das causas de morte no mundo, o manejo da hemorragia não compressível do tronco pode ser problemático. Com a melhoria da medicina, a abordagem desses pacientes deve ser precisa e imediata, para que as consequências possam ser mínimas. Portanto, visando o método ideal de manejo, estudos levaram ao desenvolvimento da técnica de oclusão ressuscitativa por balão endovascular da aorta (Resuscitative Endovascular Balloon Occlusion of the Aorta – REBOA). Este procedimento foi utilizado em centros de trauma selecionados como um complemento durante a reanimação para pacientes vítimas de trauma com hemorragia não compressível do tronco. Embora o uso dessa técnica esteja aumentando, sua eficácia ainda não é clara. Este artigo objetiva, por meio de uma revisão detalhada, trazer uma visão atualizada sobre este procedimento, sua técnica, variações, benefícios, limitações e futuro. Descritores: Radiologia Intervencionista. Traumatismo Múltiplo. Abdome. Choque Hemorrágico.
Rev Col Bras Cir. 2018; 45(1):e1709
Ribeiro Júnior Resuscitative endovascular balloon occlusion of the aorta (REBOA): an updated review
torso hemorrhage patients. World J Emerg Surg. 2017;12(1):30.
1. World Health Organization. Injuries and violence: the facts 2014. Geneva: WHO; 2014. 2. Murphy SL, Xu J, Kochanek KD, Curtin SC, Arias E. Deaths: final data for 2015. Natl Vital Stat Rep. 2017;66(6):1-75. 3. Kauvar DS, Lefering R, Wade CE. Impact of hemorrhage on trauma outcome: an overview of epidemiology, clinical presentations, and therapeutic considerations. J Trauma. 2006;60(6 Suppl):S3-11. 4. Kauvar DS, Wade CE. The epidemiology and modern management of traumatic hemorrhage: US and international perspectives. J Crit Care. 2005;9 Suppl 5:S1-9. 5. Kisat M, Morrison JJ, Hashmi ZG, Efron DT, Rasmussen TE, Haider AH. Epidemiology and outcomes of non-compressible torso hemorrhage. J Surg Res. 2013;184(1):414-21. 6. Kragh JF Jr, Littrel ML, Jones JA, Walters TJ, Baer DG, Wade CE, et al. Battle casualty survival with emergency tourniquet use to stop limb bleeding. J Emerg Med. 2011;41(6):590-7. 7. Qasim Z, Brenner M, Menaker J, Scalea T. Resuscitative endovascular balloon occlusion of the aorta. Resuscitation. 2015;96:275-9. 8. Dubose JJ, Scalea TM, Brenner M, Skiada D, Inaba K, Cannon J, Moore L, Holcomb J, Turay D, Arbabi CN, Kirkpatrick A, Xiao J, Skarupa D, Poulin N; AAST AORTA Study Group. The AAST prospective Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry: data on contemporary utilization and outcomes of aortic occlusion and resuscitative balloon occlusion of the aorta (REBOA). J Trauma Acute Care Surg. 2016;81(3):409-19. 9. Morrison JJ, Ross JD, Rasmussen TE, Midwinter MJ, Jansen JO. Resuscitative endovascular balloon occlusion of the aorta: a gap analysis of severely injured UK combat casualties. Shock. 2014;41(5):38893. 10. Manzano Nunez R, Naranjo MP, Foianini E, Ferrada P, Rincon E, García-Perdomo HA, et al. A meta-analysis of resuscitative endovascular balloon occlusion of the aorta (REBOA) or open aortic cross-clamping by resuscitative thoracotomy in non-compressible
11. Johnson MA, Davidson AJ, Russo RM, Ferencz SE, Gotlib O, Rasmussen TE, et al. Small changes, big effects: the hemodynamics of partial and complete aortic occlusion to inform next generation resuscitation techniques and technologies. J Trauma Acute Care Surg. 2017;82(6):1106-11. 12. Aso S, Matsui H, Fushimi K, Yasunaga H. Resuscitative endovascular balloon occlusion of the aorta or resuscitative thoracotomy with aortic clamping for noncompressible torso hemorrhage: a retrospective nationwide study. J Trauma Acute Care. 2017;82(5):910-4. 13. Weltz AS, Harris DG, O'Neill NA, O'Meara LB, Brenner ML, Diaz JJ. The use of resuscitative endovascular balloon occlusion of the aorta to control hemorrhagic shock during video-assisted retroperitoneal debridement or infected necrotizing pancreatitis. Int J Surg Case Rep. 2015;13:15-8. 14. Gamberini E, Coccolini F, Tamagnini B, Martino C, Albarello V, Benni M, et al. Resuscitative Endovascular Balloon Occlusion of the Aorta in trauma: a systematic review of the literature. World J Emerg Surg. 2017;12:42. 15. Okada A, Nakamoto O, Komori M, Arimoto H, Rinka H, Nakamura H. Resuscitative endovascular balloon occlusion of the aorta as an adjunct for hemorrhagic shock due to uterine rupture: a case report. Clin Case Rep. 2017;5(10):1565-8. 16. Daley J, Morrison JJ, Sather J, Hile L. The role of resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct to ACLS in non-traumatic cardiac arrest. Am J Emerg Med. 2017;35(5):731-6. 17. Doucet J, Coimbra R. REBOA: is it ready for prime time? J Vasc Bras. 2017;16(1):1-3. 18. Taylor RJ 3rd, Harvin JA, Martin C, Holcomb JB, Moore LJ. Vascular complications from resuscitative endovascular balloon occlusion of the aorta: life over limb? J Trauma Acute Care Surg. 2017;83(1 Suppl 1):S120-S3. 19. DuBose JJ. How I do it: partial resuscitative endovascular balloon occlusion of the aorta (P-REBOA). J Trauma Acute Care Surg. 2017;83(1):197-9. 20. Joint Trauma System Clinical Practice Guideline.
Rev Col Bras Cir. 2018; 45(1):e1709
Ribeiro Júnior Resuscitative endovascular balloon occlusion of the aorta (REBOA): an updated review
Resuscitative Endovascular Balloon Occlusion of the
29. DeSoucy E, Loja M, Davidson AJ, Faulconer ER,
Aorta (REBOA) for Hemorrhagic Shock (CPG ID: 38).
Simon MA, Russo RM, et al. Practice preferences
using resuscitative endovascular balloon occlusion of the aorta for traumatic injury before and after the 2017 EndoVascular and Hybrid Trauma and Bleeding Management Symposium. JEVTM. 2017;1(1):13-21. Codner PA, Brasel KJ. Emergency Department Thoracotomy: an update. Curr Trauma Rep. 2015;1(4):212-8. Russo RM, Girda E, Kennedy V, Humphries MD. Two lives, one REBOA: hemorrhage control for urgent cesarean hysterectomy in a Jehovah's Witness with placenta percreta. J Trauma Acute Care Surg. 2017;83(3):551-3. Karkos CD, Bruce IA, Lambert ME. Use of the intra-aortic balloon pump to stop gastrointestinal bleeding. Ann Emerg Med. 2001;38(3):328-31. Nordon IM, Hinchliffe RJ, Loftus IM, Thompson MM. Pathophysiology and epidemiology of abdominal aortic aneurysms. Nat Rev Cardiol. 2011;8(2):92102. Romagnoli A, Teeter W, Pasley J, Hu P, Hoehn M, Stein D, et al. Time to aortic occlusion: It's all about access. J Trauma Acute Care Surg. 2017;83(6):11614. White JM, Cannon JW, Stannard A, Markov NP, Spencer JR, Rasmussen TE. Endovascular balloon occlusion of the aorta is superior to resuscitative thoracotomy with aortic clamping in a porcine model
21. Lee J, Kim K, Jo YH, Lee JH, Kim J, Chung H, et al. Use of resuscitative endovascular balloon occlusion of the aorta in a patient with gastrointestinal bleeding. Clin Exp Emerg Med. 2016;3(1):55-8. 22. Ordoñez CA, Manzano-Nunez R, del Valle AM, Rodriguez F, Burbano P, Naranjo MP, et al. Uso actual del balón de resucitación aórtico endovascular (REBOA) en trauma. Rev Colomb Anestesiol. 2017;45(Suppl 2):30-8. 23. Tsurukiri J, Akamine I, Sato T, Sakurai M, Okumura E, Moriya M, et al. Resuscitative endovascular balloon occlusion of the aorta for uncontrolled haemorrahgic shock as an adjunct to haemostatic procedures in the acute care setting. Scand J Trauma Resusc Emerg Med. 2016;24:13. Erratum in: Scand J Trauma Resusc Emerg Med. 2016;24(1):72. 24. Okada Y, Narumiya H, Ishi W, Iiduka R. Anatomical landmarks for safely implementing resuscitative balloon occlusion of the aorta (REBOA) in zone 1 without fluoroscopy. Scand J Trauma Resusc Emerg Med. 2017;25(63):1-5. 25. Johnson MA, Neff LP, Williams TK, DuBose JJ; EVAC Study Group. Partial resuscitative balloon occlusion of the aorta (P-REBOA): Clinical technique and rationale. J Trauma Acute Care Surg. 2016;81(5 Suppl 2 Proceedings of the 2015 Military Health System Research Symposium):S133-7. 26. Russo RM, Neff LP, Lamb CM, Cannon JW, Galante JM, Clement NF, et al. Partial Resuscitative Endovascular Balloon Occlusion of the Aorta in Swine Model of Hemorrhagic Shock. J Am Coll Sur. 2016;223(2):359-68. 27. Madurska MJ, Jansen JO, Reva VA, Mirghani M, Morrison JJ. The compatibility of computed tomography scanning and partial REBOA: a large animal pilot study. J Trauma Acute Care Surg. 2017;83(3):557-61. 28. Williams TK, Johnson A, Neff L, Hörer TM, Moore L, Brenner M, et al. "What's in a Name?" A Consensus Proposal for a Common Nomenclature in the Endovascular Resuscitative Management and REBOA Literature. JEVTM. 2017;1(1):9-12.
of hemorrhagic shock. Surgery. 2011;150(3):400-9. 36. Belenkiy SM, Batchinsky AI, Rasmussen TE, Cancio LC. Resuscitative endovascular balloon occlusion of the aorta for hemorrhage control: Past, present, and future. J Trauma Acute Care Surg. 2015;79(4 Suppl 2):S236-42. 37. Saito N, Matsumoto H, Yagi T, Hara Y, Hayashida K, Motomura T, et al. Evaluation of the safety and feasibility of resuscitative endovascular balloon occlusion of the aorta. J Trauma Acute Care Surg. 2015;78(5):897-903. 38. Sridhar S, Gumbert SD, Stephens C, Moore LJ, Pivalizza EG. Resuscitative Endovascular Balloon Occlusion of the Aorta: principles, initial clinical experience, and considerations for the anesthesiologist. Anesth Analg. 2017;125(3):884-90.
Rev Col Bras Cir. 2018; 45(1):e1709
Ribeiro Júnior Resuscitative endovascular balloon occlusion of the aorta (REBOA): an updated review
39. Costantini TW, Coimbra R, Holcomb JB, Podbielski
TE, Smith J, Mendelsberg R, et al. Emergent non-
JM, Catalano R, Blackburn A, Scalea TM, Stein DM,
image-guided resuscitative endovascular balloon
Williams L, Conflitti J, Keeney S, Suleiman G, Zhou T, Sperry J, Skiada D, Inaba K, Williams BH, Minei JP, Privette A, Mackersie RC, Robinson BR, Moore FO; AAST Pelvic Fracture Study Group. Current management of hemorrhage from severe pelvic fractures: results of an American Association for the Surgery of Trauma multi-institutional trial. J Trauma Acute Care Surg. 2016;80(5):717-23. 40. Keller BA, Salcedo ES, Williams TK, Neff LP, Carden AJ, Li Y, et al. Design of a cost-effective, hemodynamically adjustable model for resuscitative endovascular balloon occlusion of the aorta (REBOA) simulation. J Trauma Acute Care Surg. 2016;81(3):606-11. 41. Teeter WA, Matsumoto J, Idoguchi K, Kon Y, Orita T, Funabiki T, et al. Smaller introducer sheaths for REBOA may be associated with fewer complications. J Trauma Acute Care Surg. 2016;81(6):1039-45. 42. Linnebur M, Inaba K, Haltmeier T, Rasmussen
occlusion of the aorta (REBOA) catheter placement: a cadaver-based study. J Trauma Acute Care Surg. 2016;81(3):453-7. 43. Reynolds CL, Celio AC, Bridges LC, Mosquera C, O'Connell B, Bard MR, et al. REBOA for the IVC? Resuscitative balloon occlusion of the inferior vena cava (REBOVC) to abate massive hemorrhage in retro-hepatic vena cava injuries. J Trauma Acute Care Surg. 2017;83(6):1041-6.
Received in: 04/01/2018 Accepted for publication: 16/01/2018 Conflict of interest: none. Source of funding: none. Mailing address: Marcelo Augusto Fontenelle Ribeiro Júnior E-mail: email@example.com / email@example.com
Rev Col Bras Cir. 2018; 45(1):e1709
The experience of an Academic League: the positive impact on knowledge about trauma and emergency A experiência de uma Liga Acadêmica: impacto positivo no conhecimento sobre trauma e emergência LUCIANA THURLER TEDESCHI1; LUIZ PAULO JUNQUEIRA RIGOLON1; FLà VIO ALMEIDA KLEIN1; VALÉRIA TRONCOSO BALTAR2.
A B S T R A C T Objective: to evaluate the knowledge growth of the members of the Trauma, Resuscitation and Emergency League in comparison with a nonparticipating group, with similar characteristics, at the Fluminense Federal University. Methods: we evaluated 50 league members and 50 non-members (control group) through questionnaires applied at the beginning and end of a school year. We used a generalized linear model, with interaction effect between groups and tests (multiple comparisons with Bonferroni correction). We included the following control variables: gender, period, age, and attendance to some other course on a similar topic. Results: there was an increase of 22 percentage points (p<0.001) for the group with more than 75% presence in the League compared with the eight points in the control group (p<0.05). There was no statistically significant growth for the group with less than 75% presence. Conclusion: the growth of knowledge was significantly higher in the group that assiduously participated in the League, which reinforces its importance in complementing the traditional content of medical courses. Keywords: Teaching. Education, Medical. Students, Medical. Emergencies. Traumatology.
he number of medical schools in Brazil has steadily increased, with an average of approximately 19,000
physicians graduating each year1. Currently, the country has 279 public and private universities, behind only 381 schools in India, the country with the first position in the world ranking and with population six times greater than the Brazilian1. The maintenance of teaching quality is fundamental and, even more relevant, when it comes to learning about trauma and emergency, due to the occupation of shifts in emergency rooms by newly graduated doctors2. According to data from the Mortality Information System (SIM), there were 152,135 deaths from external causes in Brazil in 20153. This number represents the third leading cause of death in the country in the same year, behind only mortality due to diseases of the circulatory system and neoplasias3. The investments in trauma in Brazil are approximately R$.300,00 per capita per year,
with costs that reach R$.100,000.00 in serious victims4. Additionally, the social impact of accidents and violence can be verified by the 30% increase in the Potential Years of Life Lost (PYLL) observed in the last decades. This tendency is not accompanied by the index of death due to natural causes, which, on the contrary, is in decline. Clinical emergencies also imply direct and indirect costs with consultations, procedures, hospitalizations and loss of productivity. Urgency expenditures are about three times higher than the ones of elective hospitalizations, intensive care units and professional services5. Despite the relevance of the theme, in almost all Brazilian universities, there are no programs for teaching trauma and medical emergencies in the curricular matrix of the medical courses2. In order to change this reality, in a still incipient way, in 2013, Law 12,871 was enacted, which, in article 4o , item I, establishes a workload of at least 30% of the undergraduate medical internship in Primary Care and Emergency facilities of tthe Brazilian Unified Health System (SUS)6. As a complementary methodology, a relevant portion of this content has
1 - Fluminense Federal University, Faculty of Medicine, NiterĂłi, RJ, Brazil. 2 - Fluminense Federal University, Department of Epidemiology and Biostatistics, NiterĂłi, RJ, Brazil.
Rev Col Bras Cir. 2018; 45(1):e1482
Tedeschi The experience of an Academic League: the positive impact on knowledge about trauma and emergency
been contemplated by extracurricular activities such as Academic Leagues. The Leagues are formed by students of courses in the area of health, coordinated by professionals associated with the institution or the teaching hospital7 and governed by their own statute. They basically offer structures that cover the tripod teaching, research and extension, through seminars, classes, discussions, presentations of clinical cases, practical activities, contact with patients, internships, publications of articles, among others. The leagues are maintained by a self-sustaining financial system in which courses and workshops are provided and funds are raised from corporate sponsorship and university scholarships. They are entities that have been gradually gaining space in the university environment because of their potential contribution to teaching8. However, the leagues' impact on cognitive development, on the pedagogical function within institutions, and on students' academic performance is poorly studied9,10. The League of Trauma, Resuscitation and Emergency (LiTRE) is a project of the Fluminense Federal University (UFF), in association with the Department of General and Specialized Surgery of the Faculty of Medicine, composed of medical graduates and other courses in the health area, and professionals of the institution itself and the health network of Niterói. LiTRE came up with the mission of stimulating the study of clinical emergencies and trauma, aiming at the better training of students and the quality of attending to society. It is formed by 50 students, admitted through a selective process, structured from theoretical lectures in a symposium offered with invited speakers from renowned institutions. Its board of directors consists mainly of those members who stood out during the year. It promotes theoretical-practical classes, given every two weeks in the prehospital, emergency and intra-hospital areas; provides internships that aim to bring participants closer to medical activity and to patients; encourages scientific research and work; and holds events focused on the population. The objective of the present study was to evaluate the effect of the activities offered by the League of Trauma, Resuscitation and Emergency on the knowledge acquired by its participants, when compared with a control group. Specifically, we intended to quantitatively verify the effectiveness of the content developed by LiTRE over one year.
METHODS We conducted a prospective study with two groups balanced by academic period. The exposure variable was the participation in the LiTRE activities, and we carried out the evaluation in two moments: at the beginning of the activities of the League and at their conclusion, for the exposed sample, corresponding to the months of May 2016 and March 2017, respectively. For the group not exposed to the league's activities in that period, we performed two tests in the same periods of the league members group. We invited participants to respond to a questionnaire created by the board members, composed of 20 multiple-choice questions developed according to the programmatic content demonstrated during the course, so that each questionnaire differs according to the category of the participant (pre-hospital, emergency, in-hospital). The different topics addressed during the weekly theoretical-practical classes in each segment justify the different questionnaires, to relativize the degree of achievement according to the category of the course and period for non-members. Among the contents evaluated in the questionnaires are fundamental issues to medical training, such as basic and advanced life support, burns, drowning, disasters and accidents with multiple victims, trauma, ischemic and hemorrhagic stroke, shock, sepsis, acute coronary syndrome, disorders of hydroelectrolytic and acid-base balance, access to airways, electrical and cardioversion therapies, post-resuscitation care and sedation. The board members responsible for each respective area applied the questionnaires after specific training to standardize data collection. Students were not notified that the tests were the same in both applications and the questions were not commented or corrected to avoid anticipation of the second test over the first. Variables related to age, gender, attendance in classes, period (semester) of Medicine course, and previous participation in another trauma/emergency course/activity were also collected. Initially, the sample comprised 112 medical students at the Fluminense Federal University, with a response frequency of 89.3%, so that at the end of the study, 100 questionnaires were answered by pre-hospital students, between the 3rd and the 5th period, emergency
Rev Col Bras Cir. 2018; 45(1):e1482
Tedeschi The experience of an Academic League: the positive impact on knowledge about trauma and emergency
students, between the 5th and 7th periods and the intra-
between the interaction groups were corrected by the
hospital hospital, between the 7th and 10th periods.
Bonferroni method. The analyzes were performed in the
We excluded from the study all students participating in the league who dropped out and/or refused to answer the questionnaire. We formed the control group with students with the same criteria of number of participants and academic period, chosen by random draw. Due to the large frequency variation in classes for students who participated in the course, we reclassified the league members in groups with <50%, between 50-75% and with >75% attendance in classes. We carried out a descriptive analysis of the data, with the basic characteristics of the sample. The scores were converted in percentage points from 0 to 100 according to the proportion of correctness in both tests. We used a generalized linear model (GLM) to evaluate the mean scores in the first (P1) and second (P2) tests in each of the four groups (control, attendance <50%, between 50 and 75% and >75%) with effect of groups and tests, and an interaction between groups and tests, controlling for gender, period, age and some other course on a similar theme. The multiple comparisons of the average scores
Statistical Package for Social Sciences (SPSS version 21) for Windows. A significance level of 5% was considered in all analyzes. Participation
responses were anonymous. UFF's Ethics in Research Committee approved this study and all participants signed informed consent forms (CAAE: 55267216.1.0000.5243).
RESULTS The study sample consisted of 56 students belonging to the control group and 44 LiTRE members. The mean age was 22.87 years (Standard Deviation 2.93), with 80% concentrated between 20 and 24 years. Of the sample, 57% were women. The majority of the participants did not perform any previous trauma or emergency course (n=71). At the beginning of the study, students were between the 3rd and 10th periods of medical graduation, mainly in the second and third years (Table 1).
Table 1. Characteristics of control and LiTRE groups and frequency of attendance to the League' activities.
Control (n=56; 56%) Attended any other course No in the same area? Yes Gender
UFF Medical School Year
Age group
LiTRE LiTRE LiTRE Total =75% 50%-75% =50% (n=100) (n=19; 19%) (n=8; 8%) (n=17; 17%)
39 (69.6%)
14 (73.7%)
4 (50.0%)
14 (82.4%)
17 (30.4%)
5 (26.3%)
4 (50.0%)
3 (17.6%)
32 (57.1%)
12 (63.2%)
5 (62.5%)
8 (47.1%)
24 (42.9%)
7 (36.8%)
3 (37.5%)
9 (52.9%)
2nd year
17 (30.4%)
12 (63.2%)
2 (25%)
2 (11.8%)
3rd year
24 (42.9%)
5 (26.3%)
0 (0%)
13 (76.5%)
4th year
11 (19.6%)
1 (5.3%)
5 (62.5%)
2 (11.8%)
5th year
4 (7.1%)
1 (5.3%)
1 (12.5%)
0 (0%)
Pre/hospital 18 (32.1%)
14 (73.7%)
2 (25%)
2 (11.8%)
23 (41.1%)
4 (21.1%)
0 (0%)
14 (82.4%)
15 (26.8%)
1 (5.3%)
6 (75%)
1 (5.9%)
< 20
1 (1.8%)
2 (10.5%)
0 (0%)
0 (0%)
47 (83.9%)
13 (68.4%)
6 (75%)
14 (82.4%)
6 (10.7%)
3 (15.8%)
1 (12.5%)
3 (17.6%)
2 (3.6%)
1 (5.3%)
1 (12.5%)
0 (0%)
LiTRE: League of Trauma, Resuscitation and Emergency Rev Col Bras Cir. 2018; 45(1):e1482
Tedeschi The experience of an Academic League: the positive impact on knowledge about trauma and emergency
Considering the league and control groups, we observed that the mean score in both tests is higher for the league group. In addition, we observed a proportional increase in both groups (p-value of the non-significant interaction, p=0.081). Figure 1 shows the respective groups' means in the two moments and the 95% confidence intervals.
Table 2. Averages and standard deviations for the percentage scores in the first and final tests for the control groups and the three subgroups of league members.
Test 1
Test 2
51.4 ± 1.93
59.4 ± 1.95
LiTRE =50%
64.9 ± 2.66
74.8 ± 3.04
LiTRE 50-75%
65.8 ± 3.83
68.4 ± 2.76
LiTRE =75%
58.9 ± 3.13
81.6 ± 3.55
* GLM model controlling for gender, age, school year, and attendance in another course. Effects of groups (p£0.001), tests (p<0.001) and interaction of groups and tests (p<0.001).
By controlling for gender, school year, age and other courses in the area, the GLM model showed an interaction effect between the groups and the two tests (Table 2). We then carried out multiple comparisons Figure 1. Means and respective 95% confidence intervals for the scores of the control and LiTRE groups between tests 1 and 2.
between groups and Bonferroni-corrected tests (Table 3).
When reclassifying the league members according to attendance, the average score in the first test for the control group was 51.4% (SD 3.8%); for league members with less than 50% attendance, it was 64.9% (SD 5.2%); for attendance between 50 and 75%, of 65.8% (SD 7.5%); and with more than 75% attendance, the mean percentage score was 58.9% (SD 6.1%) (Table 2). After the classes and activities, or during the course of a school year for non-members, the average scores for the respective groups were 59.4% (SD 3.8%) for the control group, 74.8% (SD 6.0%) for the attendance less than 50%, 68.4% (SD 5.4%) for the subgroup with 50 and 75% attendance, and of 81.6% (SD 7.0%) for more than 75% attendance (Table 2).
(Table 2) from the first to the second test for the control
For example, the increase of eight mean percentage points group was statistically significant, p=0.003 (Table 3). The groups of league members with less than 50% and with 50 to 75% attendance obtained, respectively, 9.9% and 2.6% increase in the score, without statistical significance (p=0.121 and p=0.999, respectively). However, the average 22.7 percentage points increase of the league members with more than 75% participation had p<0.001 (Figure 2). The difference of 7.5 percentage points in the first test between the control group and LiTRE with more than 75% attendance was not significant (p=0.668), both being equal at the beginning of the research.
Table 3. Results of p-values of multiple comparisons of interaction between groups and tests, with Bonferroni correction.
p values corrected by Bonferroni Control LiTRE =50% LiTRE 50-75% LiTRE =75%
Control Test 1
Test 1 Test 2
Test 1
Test 2
LiTRE =50%
Test 2
Test 1
<0.001* <0.001*
Test 1
Test 2
Test 2
0.001* <0.001* 0.018* <0.001*
Test 1
Test 2
Test 1
Test 2
<0.001* <0.001*
LiTRE =75% Test 1
Test 2
LiTRE 50-75%
* Statistically Significant. Rev Col Bras Cir. 2018; 45(1):e1482
<0.001* <0.001 *
Tedeschi The experience of an Academic League: the positive impact on knowledge about trauma and emergency
working in Brazil, only 85 are graduates of some of the scarce twelve residency programs in Emergency Medicine in the country13. In this research, after a year of undergraduate education
curriculum, we found a performance improvement in eight percentage points on the second test in relation to the first one in the control group. The numbers suggest, however, that only this structure as an isolated way of providing knowledge is inferior when dimensioned in the face of the new modalities of development of skills, competencies and formal content. The main result found in this study concerns the increase of more than 22 Figure 2. Means and respective 95% confidence intervals for the scores of the four groups, the control one and the three LiTRE attendance subgroups, between tests 1 and 2.
points, almost three times higher than the control, for the segment of the LiTRE with attendance greater than 75%, considered by as a minimum to guarantee effective learning. The variables gender, age, school period and
participation in other courses (such as the Nucleus of
A considerable part of medical students presents a large gap in the concepts of trauma and emergency, although it is a matter of extreme relevance to the health professional2. The low average percentages found in the survey, between 51 and 66 points, for both groups, control and LiTRE, in the first test application, are in agreement with this scenario. Trauma is the leading cause of death in
Teaching and Research in Emergency and Pre-hospital Care, offered by the university, among others) were controlled, so that the increase was related to learning in the league, save for some other confounding factor not accounted for. The strong association of attendance in LiTRE with the significant increase of the groups' grades, to the detriment of those under conventional methodology, evidences the need of supplementary formation of future professionals. This circumstance
individuals of up to 40 years of age in the Brazilian
provides a differential between medical students who
population and involves, in addition to costs in excess of
seek extracurricular activities in relation to those who do
R$ 9 billion, important social issues11. According to the
not14. In similar studies, the results are also positive for
Pan American Health Organization and the World Health
students who participate in complementary activities,
Organization, 5.8 million people die from trauma each year
presenting a better learning curve and mastery of the
worldwide, 32% more than the combined deaths from
endemic diseases due to malaria, AIDS and tuberculosis12.
In addition to the importance of promoting the
Medical emergencies are similarly notorious for their
knowledge of the participants, as evidenced by the increase
characteristics that require thought, diagnosis and acute
in test score, analyzes on the subject demonstrate other
treatment. Time, in these circumstances, is essential to
benefits of extracurricular activities, such as integration
improve patients' prognosis. In order to develop this
with colleagues, supplementation of the course, feeling
agility in attendance and perform good conducts, it is
of well-being, attendance to professional inquiries and
necessary for the medical student to have the consolidated
greater contact with society, promoting health and social
theoretical contents. Poor teaching of the subject is an
transformation, expansion of critical sense and scientific
issue that needs to be deepened, especially when coupled
with the still precarious institutionalization of residence
The perception of the relevance of these and
programs in regulated areas in 2015 and the current
other complementary structures, in consonance with the
health situation in the country. Of the 409,267 physicians
idealization of the "parallel" and "informal" curriculum,
Rev Col Bras Cir. 2018; 45(1):e1482
Tedeschi The experience of an Academic League: the positive impact on knowledge about trauma and emergency
leads to ponder the need of integration and transposition
how to act in daily emergencies to the population of
of the extracurricular activities to the traditional education
Niterói, and to youth and adolescents in public schools.
programs. However, some factors can be pointed out as
Over more than six years of the project, we estimate
obstacles to this process, such as difficulty of integration
that about 3000 people have received the information
between disciplines and between theory and practice,
for rapid recognition and activation of the medical
strenuous workload of the usual curriculum with little
service. In addition, basic life support courses are offered
time available for extracurricular activities, lack of political
throughout the year in partnerships with the social pre-
desire or material difficulties, such as a lack of physical
college entrance examination and the academic directory
structure and practice rooms,` lack of trained and
of the university. In the scientific segment, the league
available teachers, and high cost of laboratory skills and
enables research for publications and presentations at
mannequins for simulated training
. Most of these
conferences and reviews on topics of relevance in its blog.
the abscence of financial and research
All these aspects reinforce evidence of the fundamental
investments destined to the teaching of trauma and
presence of the leagues for medical and human formation
emergency, so that they are, therefore, delegated to
and for the development of the skills and competences
extracurricular activities such as academic leagues and
necessary to attend to both traumatic and non-traumatic
mentoring. Currently, projects such as "Situation of
points reflect
emergency and emergency education in undergraduate
The study had some limitations. The first one
courses in medicine", developed by the Brazilian
concerns the sample size of the interest group, ie the
Association of Medical Education (ABEM), have tried
students in the league. It was not possible, for reasons
to articulate the inclusion of this content in the current
of structure and management of the practical activities,
programs through strategies of gradual and phased
to increase the number of members during the research
teaching of the thematic . In the first years, the students
year so that the sample size would be larger. This fact may
are inserted in programs of prevention of accidents, first
be an explanation for the lack of statistical significance
aid and basic life support; in the following years, they
of score increase in groups with less than 75% of
are exposed to content and skills training in clinical
attendance, the number of students in this category
medicine, pediatrics, gynecology-obstetrics and general
possibly being insufficient for analysis. Another topic was
surgery based on courses such as Advanced Trauma
the difficulty of making classes in the league exclusive
Life Support®, PreHospital Trauma Life Support® and
to members, so that the control group did not attend
Advanced Cardiovascular Life Support®; and finally, they
them, which could generate bias in the study. Finally, the
experience the practice in prehospital care, in medical
literature lacks well-defined variables that could influence
the learning of these students and, therefore, were not
regulation, and in-hospital emergency care . Specifically, LiTRE complements the current curriculum of the UFF course, which does not have a
included in the study, such as internships and presence in practice scenarios.
compulsory discipline focused on theoretical teaching
In conclusion, the present study demonstrated
of trauma and emergency. In addition, it aids in the
the improvement of the academic performance in trauma
practical teaching of this content through simulations,
and emergency of the students participating in the
considering that the university hospital faces difficulties,
LiTRE. The increase in knowledge was evident, especially
since its emergence sector functions as a referencing
when compared with a similar sample. The presence of
system, that is, there is no care by free demand, so that
complementary methods to the formal curriculum has
the experiences of trauma and emergency situations
proved important to increase the learning of medical
become limited. LiTRE also has programs to approach
students. LiTRE has been successfully pursuing strategies
the population. Under projects entitled "LiTRE Saúde"
to improve its techniques and, consequently, to change
and "LiTRE Educa", students offer specific training on
the students' domain content deficit landscape.
Rev Col Bras Cir. 2018; 45(1):e1482
Tedeschi The experience of an Academic League: the positive impact on knowledge about trauma and emergency
R E S U M O Objetivo: avaliar o crescimento do conhecimento dos integrantes da Liga de Trauma, Reanimação e Emergência em comparação com um grupo não participante, de características semelhantes, na Universidade Federal Fluminense. Métodos: foram avaliados 50 ligantes e 50 não ligantes (grupo controle), através de questionários aplicados no início e no fim de um ano letivo. Foi utilizado um modelo linear generalizado, com efeito de interação entre grupos e provas (comparações múltiplas com correção de Bonferroni). Foram incluídas como variáveis de controle: sexo, período, idade e realização de algum outro curso sobre tema similar. Resultados: observou-se um incremento de 22 pontos percentuais (p<0,001) para o grupo com mais de 75% de presença na Liga em comparação aos oito pontos do grupo controle (p<0,05). Não houve crescimento com significância estatística para o grupo com menos de 75% de presença. Conclusão: o crescimento de conhecimento foi significativamente maior no grupo assiduamente participante da Liga, o que reforça sua importância na complementação do conteúdo tradicional dos cursos de medicina. Descritores: Ensino. Educação Médica. Estudantes de Medicina. Emergências. Traumatologia.
(DF): Associação Brasileira de Economia da Saúde – ABrES; 2013. Acessado 2016 Aug 6. Disponível em:
1. Escolas Médicas do Brasil. Estudo comparativo mundial de escolas por país [Internet]. 2010. Acessado 2016 nov 19. Disponível em: http://www. escolasmedicas.com.br/intern2.php 2. Fraga GP, Pereira Jr GA, Fontes CER. A situação do ensino de urgência e emergência nos cursos de graduação de medicina no Brasil e as recomendações para a matriz curricular. In: Lampert JB, Bicudo AM, editores. 10 anos das Diretrizes Curriculares Nacionais dos cursos de graduação em Medicina. Rio de Janeiro: Associação Brasileira de Educação Médica; 2014. p. 41-56. Acessado 2016 Nov 23. Disponível em: http://abem-educmed.org.br/ wp-content/uploads/2016/06/Projetos_ABEM_ Diretrizes_Curriculares_Cap3.pdf 3. Brasil. Ministério da Saúde. DATASUS. Óbitos por causas externas segundo Unidade da Federação [Internet]. Brasília (DF): Ministério da Saúde; 2011 [citado 2016 Aug 1]. Disponível em: http://tabnet. datasus.gov.br/cgi/tabcgi.exe?sim/cnv/obt10uf.def 4. Sociedade Brasileira de Atendimento Integral ao Traumatizado; Sociedade Brasileira de Ortopedia e Traumatologia; Associação de Medicina Intensiva Brasileira; Sociedade Brasileira de Pediatra; Sociedade Brasileira de Neurocirurgia; Sociedade Brasileira de Anestesiologia; Colégio Brasileiro de Cirurgiões. Projeto trauma 2005-2025: sociedade, violência e trauma [Internet]. 2005. Acessado 2016 Aug 3. Disponível em: http://lateme.webnode.com.br/news/ projeto-trauma-2005-2025/ 5. Barros JV, Dias RD. Impacto das internações de Urgência e Emergência no financiamento do Sistema Único de Saúde (SUS) no Brasil [Internet]. Brasília
http://abresbrasil.org.br/sites/default/files/avaliacao_ trabalho_10_impacto_das_internacoes_jacson.pdf 6. Brasil. Presidência da República, Casa Civil, Subchefia para Assuntos Jurídicos. Lei no 12.871 de 22 de outubro de 2013. Institui o Programa Mais Médicos, altera as Leis no 8.745, de 9 de dezembro de 1993, e no 6.932, de 7 de julho de 1981, e dá outras providências [Internet]. Brasília (DF); 2013. Acessado 2016 Aug 15. Available from: http://www.planalto. gov.br/ccivil_03/_ato2011-2014/2013/lei/l12871.htm 7. Monteiro LLF, Cunha MS, Oliveira WL, Bandeira NG, Menezes JV. Ligas acadêmicas: o que há de positivo? Experiência de implantação da Liga Baiana de Cirurgia Plástica. Rev Bras Cir Plástica. 2008;23(3):158-61. 8. Pego-Fernandes PM, Mariani AW. Medical teaching beyond graduation: undergraduate study groups. Sao Paulo Med J. 2010;128(5):257-8. 9. Torres AR, De Oliveira GM, Yamamoto FM, Lima MCP. Ligas Acadêmicas e formação médica: contribuições e desafios. Interface (Botucatu). 2008;12(27):713-20. 10. Peres CM, Andrade AS, Garcia SB. Atividades extracurriculares:
necessárias ao currículo. Rev Bras Educ Med. 2007;31(3):203-11. 11. Sociedade Brasileira de Atendimento integrado ao Traumatizado. Projeto de Atenção Nacional ao Trauma. 2014. Disponível em: http://www.sbait.org. br/projeto_trauma.php. 12. Organização Pan-America de Saúde; Organização Mundial de Saúde. Traumas matam mais que as três grandes endemias: malária, tuberculose e AIDS. Brasília (DF): OPAS/OMS; 2010. Disponível em: http:// www.paho.org/bra/index.php?option=com_conte.
Rev Col Bras Cir. 2018; 45(1):e1482
Tedeschi The experience of an Academic League: the positive impact on knowledge about trauma and emergency
13. Sociedade Brasileira de Atendimento Integrado ao
e organização do trabalho em saúde: nada é
Traumatizado. Medicina de Emergência passa a
indiferente no processo de luta para a consolidação
ser especialidade no Brasil [Internet]. SBAIT News. 2015; Available from: https://sbaitbrasil.wordpress. com/2015/10/15/medicina-de-emergencia-passa-aser-especialidade-no-brasil/ Costa BEP, Hentschke MR, Silva ACC, Barros A, Salerno M, Poli-de-Figueiredo CE, et al. Reflexões sobre a importância do currículo informal do estudante de medicina. Sci Med (Porto Alegre). 2012;22(3):162-8. Simões RL, Bermudes FAM, Andrade HS, Barcelos FM, Rossoni BP, Miguel GPS, et al. Trauma leagues: an alternative way to teach trauma surgery to medical students. Rev Col Bras Cir. 2014;41(4):297-302. Ramalho AS, Silva FD, Kronemberger TB, Pose RA, Torres MLA, Carmona MJC, et al. Ensino de anestesiologia durante a graduação por meio de uma liga acadêmica: qual o impacto no aprendizado dos alunos? Rev Bras Anestesiol. 2012;62(1):63-73. Feuerwerker L. Modelos tecnoassistenciais, gestão
do SUS. Interface (Botucatu). 2005;9(18):489-506. 18. Maia JA. O currículo no ensino superior em saúde. In: Batista NA, Batista SH, orgs. Docência em saúde: temas e experiências São Paulo; SENAC; 2004. p.101-33. 19. Fraga GP, Quintas ML, Abib SCV. Trauma and emergency: is the unified health system (SUS) the solution in Brazil? Rev Col Bras Cir. 2014;41(4):232-3. Received in: 06/09/2017 Accepted for publication: 26/10/2017 Conflict of interest: none. Source of funding: none. Mailing address: Luciana Thurler Tedeschi E-mail: firstname.lastname@example.com
Rev Col Bras Cir. 2018; 45(1):e1482
INSTRUCTIONS FOR AUTHORS SCOPE AND POLITICS The Journal of the Brazilian College of Surgeons (CBC), an official division of the CBC, is published bimonthly in one annual volume, and proposes the dissemination of articles of all surgical specialties, contributing to its teaching, development and national integration. Articles published in the Journal of the Brazilian College of Surgeons follow the uniform requirements recommended by the International Committee of Medical Journals Editors (ICMJE – www.icmje.org), and are submitted to a double blind peer review. The journal of the Brazilian College of surgeons supports the policies for registration of clinical trials of the World Health Organization (WHO) and the ICMJE, recognizing the importance of these initiatives for the record and international dissemination of information on clinical studies in open access. Thus, it will only accept for publication the clinical research articles that have received an identification number on a clinical trial registry validated by the criteria established by WHO and ICMJE. The identification number must be registered at the end of the abstract. Between three and five members of the Editorial Board, anonymous to the authors, receive the texts, also anonymously, and decide for their publication. In the event of conflict of opinions, the Director of publications will evaluate the need for a new appraisal. Rejected articles are returned to authors. Only the works within the journal's publication standards will be submitted to evaluation. Approved articles may sustain editorial-type alterations, provided that they do not alter the merit of the work. GENERAL INFORMATION The Journal of the Brazilian College of Surgeons evaluates articles for publication in Portuguese (Brazilian authors) and English (foreign authors) that follow the rules for manuscripts submitted to biomedical journals prepared and published by the International Committee of Medical Journal Editors (ICMJE – www.icmje.org) [CIERM Rev Col Bras Cir. 2008; 35 (6): 425-41, or article on the website of the journal (www.revistadocbc.org.br)] with the following characteristics: • Editorial: Is the initial article of an issue, generally about a current subject, requested by the Editor to the author of recognized technical and scientific capacity. • Original Article: Is the full account of clinical or experimental research, with positive or negative results. It must consist of Abstract, Introduction, Methods, Results, Discussion and References, the latter limited to a maximum of 35, aiming to the inclusion, whenever possible, of articles from national authors and national journals. The title should be written in Portuguese and English, and should contain the maximum of information with the minimum of words, without abbreviations. It must be accompanied by the complete name(s) of author(s) followed by the name(s) of the institution(s) where the work was performed. If multicenter, Arabic numerals must indicate the provenance of each of the authors in relation to the listed institutions. Authors should send along with their names only one title and one that best represents their academic activity. The Abstract should have a maximum of 250 words and be structured as follows: objective, methods, results, conclusions and keywords in the form referred to by DeCS (http://decs.bvs.br ). • Review article: The Editorial Board encourages the publication of matters of great interest to the surgical specialties containing synthetic analysis and relevant criticism and not merely a chronological description of literature. I must contain an introduction with description of the reasons that led to the writing of the article, the search criteria, followed by text ordered in titles and subheadings according to the complexity of the subject, and unstructured abstract. When applicable, at the end there may be conclusions and opinions of authors summarizing the review contents. • Letters to the Editor: Scientific Comments or controversy regarding articles published in the journal of the CBC. In general, such letters are sent to the principal author of the article to response and both letters are published in the same journal issue, no replica being allowed. • Scientific Communication: Content that deals with the form of presentation of scientific communication, investigating the problems and proposing solutions. Due to its features, this section can be multidisciplinary, receiving contributions from doctors, surgeons and non-surgeons and other professionals from various areas. It must have an unstructured Abstract, Keywords and free text. • Technical Note: Information about a particular operation or procedure of importance in surgical practice. The original must not exceed six pages including pictures and references if necessary. It must have an unstructured Abstract, Keywords and free text. • Education: Freeform content that addresses the teaching of surgery, both in graduate and post-graduate levels. Unstructured abstract. • Bioethics in surgery: Discussion of bioethical aspects in surgery. The content should address bioethical dilemmas in the performance of surgical activity. Freeform. Unstructured abstract. • Case reports: May be submitted for evaluation and the approved reports will be published, mainly in electronic journal of case reports, the Journal of Case Reports of the Brazilian College of Surgeons which can be accessed through the Brazilian College of Surgeons' website (www.cbc.org.br) or directly at www.relatosdocbc.org.br. ARTICLE SUBMISSION Sending articles for the Journal of the Brazilian College of Surgeons can only be done through the online platform for submission of scientific papers, which can be accessed through the Brazilian College of Surgeons' website (www.cbc.org.br) or directly at www.rcbc.gnpapers.com.br.
FORM AND STYLE • Text: Manuscripts submitted for review by the Journal of the Brazilian College of Surgeons must be unpublished and should not be evaluated in whole or in part by another scientific journal. Images should be forwarded separately from the text, and in accordance with the instructions on the online submission platform. Articles should be concise, not exceeding 2500 words. The abbreviations should be as few as possible, limited to the terms mentioned repetitively, as long as they do not hinder the understanding of the text, and should be defined from the first use. • References: Must be predominantly of works published in the last five years, restricted to those cited in the text, in order of citation, numbered consecutively and presented according to the Vancouver format (rules for manuscripts submitted to Biomedical Journals ICMJE- www.icmje.org – CIERM Rev Col Bras Cir. 2008; 35 (6): 425-41-www. revistadocbc.org.br). Annals of congresses and personal communications will not be accepted as references. Citations of books and theses should be discouraged. The authors of the article are responsible for the accuracy of the references. • Acknowledgements: Should be made to people who importantly contributed to the work's realization. TABLES (maximum of six) Tables should be numbered with Arabic numerals, with captions on the top containing one or two sentences, and explanations of symbols at the bottom. Cite the tables in the text in numerical order including only information necessary for understanding of important points of the text. The data presented should not be repeated in graphs. Tables should follow the above-mentioned Vancouver standards. Tables must be typed in the body of the text, and never sent as figures. FIGURES (maximum of six) Figures are all the photos, graphics, paintings and drawings. All figures must be referred to in the text, being numbered consecutively by Arabic numbers and accompanied by descriptive captions. Histological images should contain in the legends the histological technique used and the degree of magnification. All figures should be submitted separately at the end of the manuscript.
MANDATORY CONDITIONS (READ CAREFULLY) It is expressed that, with the electronic submission, the author (s) agree (s) with the following assumptions: 1) that there is no conflict of interests, compliant with the Brazilian Federal Council of Medicine (CFM) resolution No. 1595/2000 that prevents the publication of works and materials with promotional purposes of products and/or medical devices; 2) that one must cite the funding source, if any; 3) that the work was submitted to the respective Ethics in Research Committee which approved it, providing the aproval number in the text; 4) that all authors authorize that the article suffer changes in the submitted text to be standardized in the language format of the Journal, which can result in removal of redundancies, as well as tables and/ or figures that are deemed unnecessary to understanding the text, provided that it does not change its meaning. If there are disagreements of the authors about these assumptions, they should write a letter leaving explicit the point at which they disagree, which will be appraised by the Editor, who will decide whether the article can be forwarded for publication or returned to the authors. 5) that the authors are allowed to hold the copyright of their published work without restrictions. 6) that if there is conflict of interest, it should be quoted with the text: "the author (s) (provide names) received financial support of the private company (provide name) for this study". When there is a research foment funding source, it must also be cited. 7) that the responsibility for concepts or statements issued on articles and announcements published in the Journal of the Brazilian College of Surgeons is entirely up to the author (s) and advertisers. 8) that works already published or simultaneously submitted for evaluation in other periodicals will not be accepted. 9) that each approved article will have a cost of R$ 1,000.00 (one thousand reais) for the authors. If the lead author is a member of the Brazilian College of Surgeons, there will be a 50% discount on the article's fee. Case Reports, approved for publication in the Journal of Case Reports of the Brazilian College of Surgeons are exempt from charges.
CONTACT: 2016-Brazilian College of Surgeons Rua Visconde de Silva, 52-3the floor 22271-090-Rio de Janeiro-RJ-Brazil Tel: + 55 21 2138-0659 Fax: + 55 21-2286 2595 Address for submission of manuscripts: E-mail: firstname.lastname@example.com
ABOUT THE JOURNAL Basic information Objectives: To disseminate scientific works of the surgical area of medicine that contribute to its teaching and development. History: The publication and dissemination of scientific activities of its members is one of the aims of medical societies. The Brazilian College of Surgeons (Colégio Brasileiro de Cirurgiões – CBC), founded in 1929, already in its first statute provided for the issuance of the "Bulletin of the Brazilian College of Surgeons" as its official division, whose starting number was published in January 1930. In 1967, the National Directory of CBC changed its name to "Journal of the Brazilian College of Surgeons". From 1974 on, the journal began to be published bi-monthly, on a regular basis, to the present day. The abbreviation for its title is Rev Col Bras Cir, which should be used in bibliographies, footnotes and in references and bibliographic legends.
Creative Commons The journal of the Brazilian College of Surgeons is licensed with a 4.0 International , non-commercial, Creative Commons Attribution. This license lets others remix, adapt and create from your work, for non-commercial purposes. Although the new works have to assign proper credit and may not be used for commercial purposes, users do not have to license these derivative works under the same terms.
Free access policy This journal provides free and immediate access to its content, following the principle that providing free scientific knowledge to the public provides greater democratization of world knowledge.
About APC (Article Processing Charges) In view of the high costs for publication of the journal, from the issue 1/2017 on, every approved article started to have a cost of R$ 1000.00 (1000 reais) for the authors. Articles in which the lead author is a member of the CBC will have a discount of 50% of the publication fee.
Anti-Plagiarism Policy The Journal of the Brazilian College of Surgeons uses the iThenticate program to identify plagiarism in articles submitted for publication.
Indexing sources · · · · · · ·
Latindex LILACS Scopus DOAJ Free Medical Journals MEDLINE/PUBMED SciELO
Intellectual property All journal content, except where otherwise stated, is licensed under a Creative Commons License of type CC-BY attribution.
Sponsors The Journal of the Brazilian College of Surgeons is sponsored by CBC through: · Annuity of its associated members · Money from advertisers · Article publication fee
!"#$%%& '