Colorectal Trauma: From Incidence to Definitive Treatment of Patients Treated in a Tertiary Hospital in the Federal District

Abstract

Introduction

Colorectal trauma presents a significant clinical challenge due to its complexity and high morbidity. Although well-documented in international literature, data on its incidence and management in Brazil—particularly in the Federal District—remain scarce.

Objective

To determine the incidence, causes, and treatment approaches of colorectal trauma in patients treated at a tertiary hospital in Brasília, Brazil, over a five-year period. Methods: This retrospective cohort study analyzed medical records of patients aged ≥18 years diagnosed with colorectal trauma and treated at the Regional Hospital of Taguatinga from January 2020 to January 2025. Data on demographics, mechanisms and types of injury, injury severity, and treatment were collected. Statistical analysis included descriptive and inferential tests with a significance level set at p < 0.05.

Results

A total of 40 patients was included. The majority were male (82.05%) with a mean age of 32.39 ± 10.04 years. Most injuries (92.5%) were due to penetrating trauma, especially gunshot wounds (50%) and stab wounds (42.5%). The transverse colon was the most frequently affected site (37.5%). Transfixing injuries were the most common type (51.72%). The mean Injury Severity Score (ISS) was 45.31 ± 25.06. Primary repair was the most common surgical approach (47.37%), followed by resection with anastomosis (26.32%) and colostomy (10.53%). A significant association between gender and trauma mechanism was observed (p = 0.026), with men more often suffering firearm injuries and women more likely to experience blunt trauma.

Conclusion

Findings align with global trends, highlighting the predominance of penetrating trauma and a shift toward conservative surgical approaches like primary repair. The results underscore the need for public health strategies targeting firearm-related violence and emphasize the importance of national guidelines adapted to the Brazilian context.

Keywords

colorectal surgery - penetrating injuries - trauma severity indices

Introduction

Colorectal trauma, which involves injuries to the colon and rectum, is a significant medical problem due to its potential for serious complications and high mortality rates.[1] The treatment of these injuries has evolved with advances in surgical techniques and perioperative care. However, the optimal approach remains a matter of debate, influenced by factors such as the mechanism of injury, patient demographics, and healthcare context.[2]

In Brazil, there is extensive data on colorectal cancer, but specific information on colorectal trauma is scarce. This is even more evident when we consider the context of Brasília, which is home to a large tertiary hospital, such as the Hospital Regional de Taguatinga. Thus, understanding the incidence, causes, and treatment outcomes in this context is essential to improve patient care and develop evidence-based clinical guidelines adapted to our region.[3]

Colorectal trauma can result from blunt or penetrating mechanisms.[4] Penetrating injuries, commonly caused by gunshots or stab wounds, are more prevalent in urban areas with high rates of violence. On the other hand, blunt injuries, typically from traffic accidents or falls, are more common in other contexts.[1] The treatment of these injuries has changed over time, with historical practices such as routine fecal diversion giving way to more conservative approaches such as primary repair or resection and anastomosis, depending on the extent of the injury and the stability of the patient.[4]

In Brazil, abdominal trauma is a significant public health problem, with studies indicating that traffic accidents and violence are the main causes. For example, a 2018 study highlighted that 21% of trauma patients admitted to an ICU in southern Brazil had abdominal trauma, with traffic accidents accounting for 60.4% of cases.[3]

Regarding treatment, it is observed that international literature provides guidelines. For example, a 2017 review noted that colorectal injuries occur in approximately half of patients with penetrating injuries to hollow organs, with treatment strategies ranging from primary repair to diversion, depending on severity.[1] Another 2011 study highlighted ongoing controversies, such as the preference for colostomy diversion versus primary repair, particularly in destructive injuries.[2]

The aim of this study was to determine the incidence and causes of colorectal trauma in patients admitted to a tertiary hospital in the Federal District of Brazil and to evaluate current treatment strategies, including surgical interventions such as primary repair, resection and anastomosis, or diversion.

Methodology

Study Design

This research adopted a retrospective cohort study design, analyzing medical records of patients admitted with colorectal trauma. This approach allowed for a comprehensive review of historical data to identify patterns and outcomes without influencing current clinical practice.

Setting and Study Period

The study was conducted at the Regional Hospital of Taguatinga, a tertiary care facility in Brasília, Brazil, known for its extensive trauma and emergency services. The study's data collection period comprised data from January 1, 2020, to January 31, 2025, providing a five-year window to capture enough cases for analysis.

Inclusion and Exclusion Criteria

Patients aged 18 years or older at the time of admission, admitted with a diagnosis of colorectal trauma, identified using ICD-10 codes for colon and rectum injuries, who underwent treatment for the injury at the hospital, including surgical or non-surgical management, were included.

Patients with incomplete medical records, where key data such as demographics, injury details, or outcomes were missing, patients who were only observed and not treated for colorectal trauma, such as those with minor injuries not requiring intervention, and patients with colorectal injuries secondary to surgical procedures or other iatrogenic causes were excluded.

Data Collection

Data was collected through a systematic review of the hospital's medical records and trauma registry. The following variables were extracted:

• Demographic Data: Age and sex.

• Mechanism of Injury: Classification as blunt or penetrating.

• Clinical Presentation: Vital signs (e.g., blood pressure, heart rate), symptoms (e.g., abdominal pain, rectal bleeding), Injury Severity Score (ISS), and physical examination findings (e.g., tenderness, distension).

• Type of Injury: Location (colon or rectum), grade of injury using the Organ Injury Scale (e.g., nondestructive versus destructive), and extent of damage (e.g., perforation, laceration).

• Treatment: Type of intervention, including surgical procedures (primary repair, resection and anastomosis, diversion with colostomy), non-surgical management (e.g., antibiotics, observation), and timing of intervention (e.g., damage control surgery).

Data collection was performed by trained research assistants, with double-entry verification to ensure accuracy. Patient confidentiality was maintained by de-identifying all records before analysis.

Statistical Analysis

Descriptive statistics were used to summarize patient characteristics, injury details, and treatment methods. Categorical variables, such as sex, injury mechanism, and treatment type, were presented as frequencies and percentages. Continuous variables, such as age, were summarized using means and standard deviations for normally distributed data, or medians and interquartile ranges for non-normally distributed data.

Inferential statistics were used to compare different groups and identify factors associated with each type of injury. In all analyses, a significance level <0.05 was considered, and all data were analyzed using STATA 17 (StataCorp LLC, College Station, USA).

Ethical Considerations

The study adhered to the principles of the Declaration of Helsinki and obtained approval from the ethics committee of the Fundação de Ensino e Pesquisa em Ciências da Saúde (FEPECS) (CAAE: 86166924.0.0000.5553).

RESULTS

A total of 40 patients diagnosed with colorectal trauma were included in the study ([Table 1]). The mean age of the patients was 32.39 ± 10.04 years, with a predominance of male patients (82.05%, n = 32) compared with females (17.95%, n = 7). The distribution of cases over the study period showed that the highest incidence occurred in 2020 (40%), followed by 2021 and 2022 (15% each), 2023 (10%), and 2024 (20%).

Table 1 Data extraction from medical records and surgical records

Description of the injury[a]	Description of treatment[a]
Two perforations of ∼1 cm in transverse colon covered by fibrin, necrosis in transverse colon close to splenic flexure	Transverse colon colectomy using linear stapler and a load, burying the left colon
Perforation in mesentery of transverse colon without signs of colon perforation	−
Sigmoid injury	Hartman
Small perforation of transverse colon	Raphia of injuries in a single plane
Injury of descending colon of ∼1 cm	Primary raphia in two planes of the injury
Injury in proximal third of transverse colon	Raphia of transverse colon injury
Transfixing injury of splenic angle of colon	Angulectomy with primary barcelona anastomosis. Right hemicolectomy due to the extension of the injuries, with release of mesocolon and lateral ileotransverse anastomosis in barcelona
Laceration in transverse colon in its middle third with injury of more than 50% of the circumference of the loop	Raphia
Small perforation in the cecum, less than 1 cm	-
Two perforations in the ascending colon of ∼2 cm	Section of the mesocolon up to the proximal transverse colon, section of mesentery up to 10 cm after the ileocecal valve and construction of ileotransverse anastomosis in barcelona
Transfixing injury in the transverse colon affecting ∼40% of the circumference in the anti-mesenteric edge, perserved vascularization	Raphia in continuous stitches
Injury of ⅔ of the circumference of the transverse colon, 15 cm from the hepatic angle	Anastomosis of the transverse colon injuries
Transfixing injury in the sigmoid colon of ∼2 cm, transfixing injury in the mesosigmoid measuring 3 cm	Raphia of the injuries
Injury of ∼4 cm in the antimesenteric edge of the middle sigmoid	Raphia of the sigmoid and mesosigmoid
5 mm perforation in the wall anterior sigmoid	Raphia perforation of the sigmoid
Transfixing injury of the middle third of the sigmoid	Sigmoidostomy in handle, with opening in topography of initial transfixing injury
Two transfixing injuries in the distal transverse colon and ascending colon close to the hepatic angle	Raphia of colonic injuries
Laceration of the anterior wall of the right colon, ∼3 cm	Right ileocolectomy with construction of ileostomy and double-mouth transverse mucosal fistula, exteriorized in left iliac fossa
Injury of 70% of the circumference of the transverse colon at the hepatic angle	Clamping of the right colon with intestinal clamper, closure of the transverse colon from the injury close to the hepatic angle and right colectomy followed by construction of ileostomy
Transfixing injury of the transverse colon, transfixing injury of the mesosigmoid with pre-sacral hematoma	Exploration of mesosigmoid and drainage of mesorrectum, debridement of transverse injury and preparation for diversion in the hypochondrium left (patient with multiple perforations in the gluteus, injury of the mesosigmoid and high rectum) maturation of colostomy in transverse loop
Injury of the mesocolon	Closure of laceration in the mesocolon with prolene 3.0 in x-stitch
Transfixing injury of the descending mesocolon	Closure of the gaps in the mesocolon with prolene 4.0
Perforation in the ascending colon of 2 cm diameter 5 cm from the ileocecal valve	Debridement of the edges of intestinal perforations and raphia in heineke mikulicz
Transfixing injury of transverse colon	Debridement of transfixing wound in the transverse colon, with raphia of the same with continuous stitches
Perforation in transverse of ∼2 cm	Transverse raphia of the transverse colon
Two puncture injuries in the middle third of the descending colon, followed by a lacerant injury, compromising more than 50% of the descending colon wall, with ∼3 cm in extension	Resection of injured edge proximal of descent and distal edge, injured part of ∼5 cm was removed, manual end-to-end raphia of the descending vein with approximation of the meso in the descending and thin veins
Injury of ∼1 cm in the descending colon over the anterior taenia, injury of ∼1 cm in the hepatic angle of the colon, this being transfixing, measuring ∼1 cm, associated with wall hematoma and drainage of contents enteric to the cavity	Raphia of the injuries
Perforation in the posterior meso of sigmoid, without injury to the vessel or intestinal loop, transfixing injury in the meso of transverse	Ligating of the injured meso of the transverse vein, approximation of the meso of the sigmoid with vicryl 0 in simple stitches
Injury in the ascending colon	−
Presence of injury in the transverse colon	Raphia of colon injury with continuous stitches
Two perforative injuries of 2 cm each in the sigmoid	Suture of sigmoid perforations in overhead stitches
Transfixing injury in the right colon, less than 5 mm	Colorrhaphy, enterorraphy and appendixectomy
Injury in the transverse mesocolon and transverse colon	Suture of transverse mesocolon injury
Presence of blast injury in the transverse mesocolon, with ischemia affecting ∼10 cm of the transverse colon, close to the hepatic angle	Right hemicolectomy and ileocolon anastomosis in barcelona with stapler
Transfixing injury in the transverse colon in the proximal third to the hepatic angleat the mesenteric edge of ∼2 cm	Debridement of the edge of the lesion in the transverse colon and raphia with vycril 3.0 in continuous stitches without a plane
Transfixing injury of the cecum, right colon and ileo-terminal	Resection of segment of terminal ileum and ascending colon, and end-to-end anastomosis of ileum with transverse colon in continuous stitches
Presence of hematoma in the meso of the transverse colon	Raphia of transverse mesocolon
Transfixing injury in the transverse colon with mesocolic hematoma	Enterectomy colonic segmental, around 10 cm in transverse colon including transfixing lesion, with construction of end-to-end anastomosis in a single plane
Transfixing perforation in the colon at the splene angle with extravasation of fecaloid content into the abdominal cavity	Revitalization of the edges of a colon lesion and primary survey
Transfixing injury in the transverse colon	Resection of perforative segment in transverse colon, with colo-cololic anastomosis in a single plane

^a All descriptions are exactly as they were in the medical records and surgical records.

Regarding the mechanism of injury, penetrating trauma accounted for the majority of cases, with gunshot wounds (GSW) represented 50% (n = 20) and stab wounds (SW) accounted for 42.5% (n = 17). Blunt trauma (BT) was the least frequent mechanism, responsible for only 7.5% (n = 3) of cases.

Analysis of injury location revealed that the colon was the most frequently affected site, with injuries distributed as follows: transverse colon (37.5%, n = 15), sigmoid colon (17.5%, n = 7), ascending colon (15%, n = 6), mesocolon (12.5%, n = 5), descending colon (7.5%, n = 3), cecum (5%, n = 2), and splenic flexure (5%, n = 2).

The most prevalent type of injury was transfixation, observed in 51.72% (n = 15) of cases, followed by perforation (31.03%, n = 9), lacerations (10.34%, n = 3), hematoma (3.45%, n = 1), and blast injuries (3.45%, n = 1). The number of injuries per patient varied, with most cases presenting one lesion (75%, n = 30) and two lesions in 25% (n = 10) of cases. [Table 2] contains a description of the intraoperative findings and the treatment of each patient, as described in the medical records and surgical records.

Table 2 Data systematization

Year	Age	Gender	Mechanism of injury	Site of injury	Type of injury	Number of injuries	Injury Severity Score (ISS)
2024	37	M	SW	Transverse colon	Perforation	2	9
2024	25	M	SW	Mesocolon	Perforation	1	1
2024	35	M	BT	Sigmoid	−	1	41
2024	35	M	SW	Transverse colon	Perforation	1	1
2024	33	M	SW	Descending colon	−	1	17
2024	32	M	GSW	Transverse colon	−	1	9
2024	37	M	SW	Splenic flexure of colon	−	1	25
2024	44	M	GSW	Transverse colon	Laceration	1	9
2023	32	M	SW	Cecum	Perforation	1	4
2023	23	M	GSW	Ascending colon	Perforation	2	41
2023	22	M	SW	Transverse colon	Transfixation	1	9
2023	49	M	GSW	Transverse colon	−	1	75
2022	29	M	SW	Sigmoid	Transfixation	2	66
2022	46	M	SW	Sigmoid	−	1	41
2022	34	M	SW	Sigmoid	Perforation	1	1
2022	27	M	GSW	Sigmoid	Transfixation	1	41
2022	18	M	GSW	Ascending colon and transverse colon	Transfixation	2	75
2022	28	F	BT	Ascending colon	Laceration	1	9
2021	54	F	SW	Transverse colon	−	1	41
2021	22	22	GSW	Transverse colon and sigmoid	Transfixation	2	75
2021	21	F	BT	Mesocolon	−	1	75
2021	41	M	GSW	Mesocolon	Transfixation	1	75
2021	24	F	GSW	Ascending colon	Perforation	1	9
2021	30	M	GSW	Transverse colon	Transfixation	1	9
2020	39	F	SW	Transverse colon	Perforation	1	41
2020	29	M	SW	Descending colon	Laceration	2	75
2020	32	F	SW	Descending colon	Transfixation	2	41
2020	58	F	SW	Mesocolon	Transfixation	2	75
2020	32	M	SW	Ascending colon	−	1	9
2020	22	M	GSW	Colon transverse	−	1	9
2020	21	M	GSW	Sigmoid	Perforation	2	−
2020	27	M	GSW	Ascending colon	Transfixation	1	75
2020	41	M	GSW	Transverse colon and mesocolon	−	2	−
2020	19	M	GSW	Transverse colon	Blast injury	1	41
2020	20	M	SW	Transverse colon	Transfixation	1	41
2020	26	M	GSW	Cecum	Transfixation	1	41
2020	23	M	GSW	Mesocolon	Hematoma	1	−
2020	38	M	GSW	Transverse colon	Transfixation	1	41
2020	48	M	GSW	Splenic flexure of colon	Transfixation	1	41
2020	43	M	GSW	Transverse colon	Transfixation	1	75

BT: Blunt trauma; F: Female; GSW: Gunshot wound; M: Male; SW: Stab wound.

In terms of injury severity, the ISS was calculated for all patients based on the lesions described ([Table 2]). The ISS values ranged from a minimum of 1 to the maximum score of 75, which indicates unsurvivable trauma severity. The mean ISS among the patients was 45.31 ± 25.06, reflecting a wide variation in trauma severity across the cohort ([Table 3]). These findings highlight the substantial burden of injury among the patients studied, emphasizing that a significant proportion sustained multiple critical injuries, with several cases reaching the highest possible ISS due to the combination of major vascular trauma, colon perforations, and severe fractures.

Table 3 Descriptive analysis of collected data

Year of case, number (%):
2020	16 (40)
2021	6 (15)
2022	6 (15)
2023	4 (10)
2024	8 (20)
Age, mean ± standard deviation in years	32,39 ± 10,04
Sex, number (%):
Male	32 (82)
Female	7 (18)
Mechanism of injury, number (%):
Blunt trauma	3 (7,5)
Stab wound	17 (42,5)
Gunshot wound	20 (50)
Lesion site, number (%):
Mesocolon	5 (12,5)
Cecum	2 (5)
Ascending colon	6 (15)
Transverse colon	15 (37,5)
Splenic flexure	2 (5)
Descending colon	3 (7,5)
Sigmoid	7 (17,5)
Injury type, number (%):
Hematoma	1 (3,45)
Laceration	3 (10,34)
Perforation	9 (31,03)
Transfixation	15 (51,72)
Blast injury	1 (3,45)
Number of injuries, number (%):
One	30 (75)
Two	10 (25)
Injury severity score, mean ± standard deviation	45,31 ± 25,06
Treatment of injuries, number (%):
Debridement of injuries	1 (2,63)
Raphia/ligature of mesocolon/mesenterium	5 (13,16)
Primary raphia of injuries in the colon	18 (47,37)
Segmental resection with anastomosis	10 (26,32)
Segmental resection and ostomy	4 (10,53)

Comparative analysis between genders showed a statistically significant association between gender and injury mechanism (Pearson Chi-Square = 7.2705, p = 0.026 | [Fig. 1]). Male patients had a significantly higher probability of suffering GSW, representing 94.74% of these cases, while women were most often affected by BT (66.67%). This suggests a gender -related difference in exposure to different types of trauma, with men being more vulnerable to firearm -related injuries and women more common to suffer injuries to blunt forces.

Fig. 1 Comparative analysis between genders showed a statistically significant association between gender and injury mechanism (Pearson Chi-Square = 7.2705, p = 0.026).

Further analysis of treatment modalities showed that primary repair of the colon was the most commonly performed surgical intervention (47.37%, n = 18), followed by resection and anastomosis (26.32%, n = 10), ligation of mesocolon/mesentery (13.16%, n = 5), resection with ostomy (10.53%, n = 4), and debridement of lesions (2.63%, n = 1). The detailed distribution of injury mechanisms, locations, and treatment approaches is summarized in [Table 3].

Discussion

This study aims to fill a critical gap in the literature by providing detailed insights into colorectal trauma in a tertiary hospital setting in Brazil. The findings are expected to highlight the incidence, treatment practices, and outcomes, potentially revealing regional variations and informing clinical guidelines. An unexpected challenge identified during the research process was the lack of specific incidence data for the Federal District, necessitating reliance on broader national estimates and international comparisons.

The study findings indicate that most cases (92.5%) resulted from penetrating trauma, with gunshot wounds being the most common mechanism (50%). This aligns with international studies showing that penetrating trauma is the leading cause of colorectal injuries, particularly in urban settings with high violence rates.[5] [6] Penetrating injuries account for more than 80% of colorectal traumas in the United States, with gunshot wounds being the most lethal.[7]

In Brazil, data on colorectal trauma are scarce, but studies suggest that urban violence and traffic accidents are the primary determinants of abdominal trauma in general.[8] [9] The predominance of young males (82.05%) among the cases in the study reflects the classic trauma victim profile, as described in the literature, where young men are more exposed to violence and accidents.

The analysis revealed that the colon was the most frequently affected structure, with the transverse colon being the most common site (37.5%). This is consistent with previous studies indicating that the transverse colon is more vulnerable to penetrating injuries due to its anatomical position.[1] [10] [11] Additionally, the high rate of transfixing (51.72%) and perforating (31.03%) injuries confirms the severity of penetrating trauma.

According to the American Association for the Surgery of Trauma (AAST) criteria, destructive injuries typically require resection and anastomosis or stoma formation.[12] In the analyzed study, only 10.53% of patients underwent colostomy, suggesting a trend toward more conservative approaches, such as primary repair.

The study identified that primary repair was the most common approach (47.37%), followed by resection with anastomosis (26.32%) and colostomy (10.53%). This is in line with the latest recommendations, which suggest that primary repair is safe in many cases, provided there is no severe fecal contamination and the patient is hemodynamically stable.[11]

Historically, colostomy was widely used to prevent complications such as fistulas and infections. However, recent studies suggest that morbidity associated with stomas may outweigh the benefits, particularly in young and healthy patients. A study by Zelga et al. (2021) indicated that colostomy complication rates can reach 40%, including stenosis and infections.[13] Furthermore, recent guidelines emphasize the importance of damage control surgery, particularly in unstable patients, where temporary closure and delayed reanastomosis may be safer.[11]

Damage control surgery (DCS) was performed in patients with hemodynamic instability and severe intra-abdominal injuries. The role of DCS in colorectal trauma is well established, particularly in cases of significant hemorrhage and peritoneal contamination. Our study findings align with Oosthuizen et al (2021), who emphasize that a staged approach with temporary abdominal closure and subsequent definitive repair improves survival in critically ill trauma patients.[14]

Another relevant finding was the analysis of the Injury Severity Score (ISS), which ranged from 1 to 75, with a mean of 45.31 ± 25.06, indicating significant variability in trauma severity. Given that 92.5% of the cases were due to penetrating trauma—often associated with major vascular injuries and fractures, the ISS proved essential in guiding clinical decisions. High ISS values were frequently observed in patients requiring damage control surgery, reinforcing its utility in assessing overall trauma burden and the need for aggressive interventions, as highlighted by Oosthuizen et al. (2021).[14] The routine calculation of ISS is recommended, as it helps stratify severity, support therapeutic choices, and optimize trauma care in high-complexity settings.[14]

The analysis revealed a statistically significant association between gender and trauma mechanism (p = 0.026), where men were more affected by GSW (94.74%), while women had a higher incidence of blunt trauma (66.67%). This difference can be explained by the fact that young men are more frequently exposed to firearm-related violence, while women are more susceptible to falls and physical assaults without weapons.[4] [6]

The study findings reinforce the need for preventive strategies, particularly concerning firearm-related violence, which was the leading cause of colorectal trauma. Additionally, the surgical management demonstrated a more conservative approach, aligned with global trends.

However, there are gaps in the Brazilian literature on colorectal trauma, particularly in specific regions such as the Federal District. Multicenter studies could provide more robust data on the epidemiology and outcomes of these patients.

Limitations of our study include its retrospective nature and the single-center setting, which may affect the generalizability of our results. Additionally, long-term functional outcomes of patients with rectal injuries remain an area for further investigation.

Conclusion

Comparison with current literature confirms that the study findings are consistent with global trends in colorectal trauma management. The increasing use of primary repair and the reduced dependence on colostomy reflect changes in modern surgical guidelines. However, the high incidence of penetrating trauma highlights the need for public safety policies to reduce firearm-related violence.

These conclusions underscore the importance of national guidelines adapted to the Brazilian reality, as well as the need for longitudinal studies to assess the long-term outcomes of different treatment methods.

Colorectal trauma remains a significant surgical challenge, requiring a multidisciplinary approach for optimal management. The findings of our study align with existing literature regarding incidence, mechanisms of injury, and treatment strategies. In this discussion, we compare our results with contemporary studies and highlight key aspects of colorectal trauma management.

Conflict of interests

The authors have no conflict of interests to declare.

Contributions of the Authors

Conceptualization: Sarmento IMG and Rezende Júnior DdC.

Data curation: Sarmento IMG and Coelho AFMeS.

Formal analysis: Sarmento IMG.

Investigation: Sarmento IMG and Bedin B.

Methodology: Sarmento IMG.

Project administration: Sarmento IMG.

Supervision: Rezende Júnior DdC.

Validation: Sarmento IMG and Rezende Júnior DdC.

Visualization: Sarmento IMG and Rezende Júnior DdC.

Writing – original draft: Sarmento IMG, Coelho AFMeS, Bedin B

Writing – review & editing: Sarmento IMG and Rezende Júnior DdC.

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Publication History

Received: 16 June 2025

Accepted: 10 November 2025

Article published online:
29 December 2025