Submitted by Caroline Xavier (caroline.xavier@pucrs.br) on 2017-09-13T12:24:35Z No. of bitstreams: 1 DIS_PATRICIA_ARIANE_GUEDES_PARCIAL.pdf: 3965418 bytes, checksum: 2706b87cf2c984ce569ea0dbf88ce595 (MD5) / Made available in DSpace on 2017-09-13T12:24:35Z (GMT). No. of bitstreams: 1 DIS_PATRICIA_ARIANE_GUEDES_PARCIAL.pdf: 3965418 bytes, checksum: 2706b87cf2c984ce569ea0dbf88ce595 (MD5) Previous issue date: 2017-06-30 / The consequences of obesity and overweight can be analyzed by matters of mental and physical health, quality of life and social impacts. When this condition is already instated, it is necessary to act with treatments that bring benefits. The goal of the present dissertation is to report an intervention based on the Acceptance and Commitment Therapy (ACT), as well as identifying the results on the Psychological Flexibility in people with obesity or overweight. In order to achieve that, the inclusion criteria were being between 18 and 59 years of age, presenting a BMI 25 or above, and having studied at least eight years, The exclusion criteria were the presence of diagnosis of Borderline Personality Disorder, Bipolar Mood Disorders (in active episode), Depressive Disorder (in active episode) and Substance Abuse Disorders. Instruments used: Depression, Anxiety and Stress Scale (DASS-21), Binge Eating Scale (BES), Acceptance and Action Questionnaire II (AAQ-II), Acceptance and Action Questionnaire for Weight (AAQ-W), Values of Life Questionnaire (VLQ), Cognitive Fusion Questionnaire - Body Image (CFQ-BI) and Mindful Eating Questionnaire (MEQ). They were applied in three moments: before the intervention, right after the intervention, and five months after the intervention. The present study was done with 39 subjects, ages between 21 and 58, with an average of 40.9. The majority of the participants was single (35.7%) and had a college degree, either completed or not (66.7%). The participants presented a BMI between 25.3 and 51.6, with an average of 34.2 (considered obesity). In section I an experience account with patient illustrations was done. The intensive intervention presented aspects connected to ACT concepts such as experiential acceptance, cognitive defusion, Mindfulness, among others, as well as the use of Matrix diagram and the texting of messages in the weeks following. In section 2 the effects of intensive intervention on psychological flexibility, eating compulsion, depression, anxiety and stress symptoms. Of the 478 people who were interested in participating on the intervention, 181 underwent triage. Of those, 39 participated on the intervention and 29 returned for the segment evaluation. As far as results, a significant difference was found in the increase of experiential acceptance (AAQ?II F10,92; p<0,001; AAQ?W F14,94; p<0,001), in the development of cognitive defusion (CFQ F10,96; p<0,001; CFQ-BI F24,45; p<0,001), increase of consciousness and attention in the eating process (MEQ t=-3,75; p=0,001) and there was no significant difference in the importance of life values and how much they can be applicable in actions (VLQ). There was an expressive reduction on eating compulsion related symptoms. Even though they?re preliminary, the results appear to be promising to for the increase in Psychological Flexibility. / As consequ?ncias da obesidade e sobrepeso podem ser analisadas a partir das quest?es de sa?de f?sica, mental, de qualidade de vida e impactos sociais. Quando essa condi??o j? est? instaurada, ? necess?rio atuar a partir de tratamentos que tragam benef?cios. Objetiva-se nessa disserta??o relatar uma interven??o intensiva baseada na Terapia de Aceita??o e Compromisso (ACT), assim como, identificar os resultados na Flexibilidade Psicol?gica em pessoas com sobrepeso e obesidade. Para tanto, os crit?rios de inclus?o foram ter idade entre 18 e 59 anos, apresentar IMC maior ou igual a 25 e ter escolaridade m?nima de oito anos de estudo. J? os crit?rios de exclus?o foram presen?a de diagn?sticos de Transtorno da Personalidade Borderline, Transtornos do Humor Bipolar (em epis?dio ativo), Transtorno Depressivo (em epis?dio ativo) e Transtornos de Uso de Subst?ncias. Instrumentos utilizados: Escala de Depress?o Ansiedade e Estresse (DASS-21), Escala de Compuls?o Alimentar Peri?dica (ECAP), Question?rio de Aceita??o e A??o II (AAQ-II), Question?rio de Aceita??o e A??o para o Peso (AAQ-W), Question?rio de Valores de Vida (VLQ), Question?rio de Fus?o Cognitiva (CFQ), Question?rio de Fus?o Cognitiva ? Imagem Corporal (CFQ-BI) e Mindful Eating Questionnaire (MEQ). Eles foram aplicados em tr?s tempos: antes da interven??o, logo ap?s a interven??o e cinco meses depois da interven??o. O presente estudo foi realizado com 39 indiv?duos, com idades entre 21 e 58 anos, com m?dia de 40,9. A maioria dos participantes era solteiro(a) (35,7%) e tinha Ensino Superior, entre incompleto e completo (66,7%). Os participantes apresentaram IMC entre 25,3 e 51,6, com m?dia 34,2 (considerado obesidade). Na se??o 1 foi realizado um relato de experi?ncia associando com depoimentos dos pacientes. A interven??o intensiva apresentou aspectos ligados a conceitos da ACT tais como aceita??o experiencial, desfus?o cognitiva, Mindfulness, entre outros, assim como o uso do diagrama Matriz e o envio de mensagens de texto nas semanas seguintes. Na se??o 2 foi investigado os efeitos da interven??o intensiva nas medidas de flexibilidade psicol?gica, compuls?o alimentar, sintomas de depress?o, de ansiedade e de estresse. Das 478 pessoas que demonstraram interesse em participar da interven??o, 181 foram triadas. Dessas, 39 pessoas participaram da interven??o e 29 retornaram para a avalia??o de seguimento. Como resultados, encontrou-se diferen?a significativa no aumento da aceita??o experiencial (AAQ?II F10,92; p<0,001; AAQ?W F14,94; p<0,001), no desenvolvimento da desfus?o cognitiva (CFQ F10,96; p<0,001; CFQ-BI F24,45; p<0,001), aumento da consci?ncia e aten??o no processo de comer (MEQ t=-3,75; p=0,001) e n?o houve diferen?a expressiva na import?ncia aos valores na vida e o quanto eles s?o aplic?veis em a??es (VLQ). Houve uma redu??o significativa de sintomas ligados ? compuls?o alimentar. Ainda que preliminares, os resultados parecem promissores para o aumento da Flexibilidade Psicol?gica.

Submitted by PPG Psicologia (psicologia-pg@pucrs.br) on 2018-05-17T18:50:07Z No. of bitstreams: 1 LUCAS_ANDRE_SCHUSTER_DE_SOUZA_DIS.pdf: 2165020 bytes, checksum: 83c14e87e569f3c0b94891c827f07ed3 (MD5) / Rejected by Caroline Xavier (caroline.xavier@pucrs.br), reason: Devolvido devido ao t?tulo da folha de rosto (p?gina 2) estar diferente do t?tulo da capa, ficha catalogr?fica e publica??o depositada. on 2018-05-30T17:58:52Z (GMT) / Submitted by PPG Psicologia (psicologia-pg@pucrs.br) on 2018-06-13T13:42:00Z No. of bitstreams: 1 LUCAS_ANDRE_SCHUSTER_DE_SOUZA_DIS.pdf: 2261551 bytes, checksum: 6d2ae6206b912e63a5477cc83923cef8 (MD5) / Approved for entry into archive by Sheila Dias (sheila.dias@pucrs.br) on 2018-06-25T11:34:35Z (GMT) No. of bitstreams: 1 LUCAS_ANDRE_SCHUSTER_DE_SOUZA_DIS.pdf: 2261551 bytes, checksum: 6d2ae6206b912e63a5477cc83923cef8 (MD5) / Made available in DSpace on 2018-06-25T11:54:40Z (GMT). No. of bitstreams: 1 LUCAS_ANDRE_SCHUSTER_DE_SOUZA_DIS.pdf: 2261551 bytes, checksum: 6d2ae6206b912e63a5477cc83923cef8 (MD5) Previous issue date: 2018-03-08 / Introduction: Obesity is a complex and multifactorial condition that represents a risk factor for several other health problems and reductions in quality of life. The high prevalence and growing incidence of obesity in the world makes it necessary to identify the predisposing factors and effective intervention strategies for its treatment. One of the most important aspects in the treatment of obesity is the promotion of more adaptive eating behaviors and the reduction of problematic eating behaviors. It is currently recognized that emotional regulation is an important element in the etiological equation and maintenance of problematic eating behaviors in obesity and in some eating disorders related to obesity, especially binge eating. Dialectical Behavioral Therapy (DBT) is a behavioral therapeutic approach whose effectiveness has been demonstrated for a wide range of psychopathological conditions in which difficulties with emotional regulation are present. Although there are already several studies demonstrating DBT's efficacy in the context of eating disorders and obesity, in Brazil, research with DBT is still scarce and there are no empirical studies to date about its application to eating disorders. Considering this scenario, two studies were proposed to identify the effectiveness and maintenance of the effects of a group intervention based on the training of TCD Skills for obese people. Goals: To verify the maintenance of effects on problematic and adaptive eating behaviors after a group intervention based on Dialectic Behavioral Therapy for obese people, and to explore relevant aspects of the participants' experience with the intervention. Method: sequential quantitative and qualitative design, using self-report measures and semi-directed interviews. On the quantitative stage, self-report measures of problematic eating behaviors (Binge Eating Scale - BES, Emotional Eating Scale - EES) and adaptive (Mindful Eating Eating Questionnaire - MEQ, Intuitive Eating Scale 2 - IES-2) were used. An intention-to-treat analysis (n = 121) was used with all participants who were assigned for the intervention. Measures were taken at pretest, post-test and 3 and 8 months follow-up. Descriptive analyzes and hierarchical linear modeling were used to verify the effectiveness and stability of the effects of the intervention. In the qualitative phase, semi-directed interviews were conducted with 3 participants who concluded the intervention, focusing on the experience with the intervention, perceived effects, 31 facilitators and difficulties with the participation and implementation of the strategies developed in the treatment. The interviews were analyzed by four researchers, using inductive thematic analysis. Results: There was a significant reduction in problematic eating behaviors after the intervention, with stable results at the three-month follow-up and slight return towards baseline at 8-month follow-up. As for adaptive eating behavior, there was improvement after the intervention, which was maintained at three months follow-up and tended to return to baseline at 8 months follow-up. Analysis of the interviews revealed that participants identified improvements in various aspects of their life after the intervention, especially in interpersonal functioning and in the ability to regulate their own behavior. They point the identification with other group members and the presence of a supportive family and social environment as facilitators of participation in the intervention. Experiences of anxiety and aversive emotions during the group and difficulty in maintaining skills practice outside the sessions were pointed out as obstacles to the effectiveness of the intervention. Discussion: Quantitative results are consistent with other literature findings on DBT interventions in the context of eating disorders and demonstrate that a brief intervention based on DBT and adapted to the Brazilian context may be effective in reducing problematic eating behaviors and promoting more adaptive behaviors in the short and medium term for obese people, however they are not conclusive as to the maintenance of these changes for 8 months or longer. Data from the qualitative study replicated in part other findings in the literature on DBT for people with emotional dysregulation and borderline personality disorder, stressing the importance that clinicians be attentive to aversive emotional experiences during the group and provide support as well as identify opportunities for application of the skills during the group sessions. In addition, the perception of improvement in interpersonal relationships reflects the importance of the interpersonal dimension in obesity and binge eating, highlighting the strong relationship between interpersonal aspects and emotional responses to which maladaptive coping strategies such as overeating may follow. / Introdu??o: A obesidade ? uma condi??o complexa e multifatorial que representa um fator de risco para diversos outros problemas de sa?de e preju?zos ? qualidade de vida. A elevada preval?ncia e crescimento da quantidade de casos de obesidade no mundo, torna necess?rio que se identifiquem os fatores predisponentes e estrat?gias de interven??o eficazes para seu tratamento. Um dos aspectos mais importantes no tratamento da obesidade consiste na promo??o de comportamentos alimentares mais adaptativos e redu??o dos comportamentos alimentares problem?ticos. Reconhece-se atualmente que a regula??o emocional ? um elemento de grande import?ncia na equa??o etiol?gica e na manuten??o dos comportamentos alimentares problem?ticos na obesidade e em alguns transtornos alimentares correlatos da obesidade, em especial a compuls?o alimentar. A Terapia Comportamental Dial?tica (TCD) ? uma abordagem terap?utica de base comportamental cuja efic?cia vem sendo demonstrada para uma ampla gama de condi??es psicopatol?gicas nas quais est?o presentes dificuldades com a regula??o emocional. Apesar de j? haver diversos estudos demonstrando efic?cia da TCD no contexto dos transtornos alimentares e da obesidade, no Brasil, ainda ? escassa a investiga??o com aplica??es da TCD, e inexistente no caso de estudos emp?ricos sobre sua aplica??o a dist?rbios relacionados ao comportamento alimentar. Em face de tal cen?rio, prop?s-se a realiza??o de dois estudos com objetivo de identificar a efetividade e manuten??o dos efeitos de uma interven??o em grupo baseada no treinamento de Habilidades da TCD para pessoas obesas. Objetivos: verificar manuten??o dos efeitos sobre comportamentos alimentares problem?ticos e adaptativos ap?s uma interven??o em grupo baseada na Terapia Comportamental Dial?tica para pessoas obesas, e explorar aspectos relevantes da experi?ncia dos participantes com a interven??o. M?todo: desenho sequencial quantitativo e qualitativo, utilizando medidas de autorrelato e entrevista semidirigida. Na etapa quantitativa, utilizaram-se medidas de autorrelato de comportamentos alimentares problem?ticos (Escala de Compuls?o Alimentar Peri?dica - ECAP; Emotional Eating Scale - EES) e adaptativos (Mindful Eating Questionnaire - MEQ; Intuitive Eating Scale 2 - IES-2). Utilizou-se uma an?lise intention-to-treat (n=121) com participantes 28 selecionados para a interven??o. Foram realizadas medidas de pr?-teste, p?s-teste e seguimento de 3 e de 8 meses ap?s a interven??o. An?lises descritivas e modelagem linear hier?rquica foram utilizadas para verificar a efetividade e estabilidade dos efeitos da interven??o. Na fase qualitativa, entrevistas semidirigidas foram conduzidas com 3 participantes que conclu?ram a interven??o, enfocando a experi?ncia com a interven??o, efeitos percebidos, facilitadores e dificuldades com a participa??o e implementa??o das estrat?gias desenvolvidas no tratamento. As entrevistas foram analisadas por quatro pesquisadores, utilizando o procedimento de an?lise tem?tica indutiva. Resultados: verificou-se uma redu??o significativa nos comportamentos alimentares problem?ticos logo ap?s a interven??o, com resultados est?veis no seguimento de tr?s meses e levemente elevados no seguimento de 8 meses. Quanto ao comportamento alimentar adaptativo, houve melhora logo ap?s a interven??o, com resultados tamb?m est?veis aos tr?s meses de seguimento e tendendo a retornar aos valores iniciais aos 8 meses de seguimento. As entrevistas revelaram que os participantes identificaram melhoras em diversos aspectos de sua vida ap?s a interven??o, especialmente no funcionamento interpessoal e na capacidade de regular o pr?prio comportamento. Apontam a identifica??o com outros membros do grupo e a presen?a de um ambiente familiar e social suportivo como facilitadores da participa??o na interven??o. Experi?ncias de ansiedade e emo??es aversivas durante o grupo e dificuldade de manter a pr?tica das habilidades fora das sess?es foram apontadas como obst?culos para a efetividade da interven??o. Discuss?o: os resultados quantitativos s?o coerentes com outros achados da literatura sobre interven??es de TCD no contexto de dist?rbios da alimenta??o, e demonstram que uma interven??o breve baseada na TCD e adaptada ao contexto brasileiro pode ser efetiva para reduzir comportamentos alimentares problem?ticos e promover comportamentos mais adaptativos em curto e m?dio prazo, no entanto n?o s?o conclusivos quanto ? manuten??o em prazos superiores a 8 meses. Os dados do estudo qualitativo replicaram em parte outros achados da literatura sobre a TCD para pessoas com desregula??o emocional e transtorno limite de personalidade, ressaltando a import?ncia de que os cl?nicos estejam atentos ?s experi?ncias emocionais aversivas durante o grupo, oferecendo suporte e identificando oportunidades de aplica??o das habilidades treinadas durante o o pr?prio grupo. 29 Ademais, a percep??o de melhora nas rela??es interpessoais reflete a import?ncia da dimens?o interpessoal na problem?tica da obesidade e da compuls?o alimentar, dando realce ? forte rela??o entre aspectos interpessoais e respostas emocionais ?s quais podem se seguir estrat?gias maladaptativas de enfrentamento como a sobreingesta de alimentos.

Submitted by Automa??o e Estat?stica (sst@bczm.ufrn.br) on 2016-03-09T22:56:26Z No. of bitstreams: 1 ClarissaNesiVenzon_DISSERT.pdf: 2129281 bytes, checksum: 8bd476fcced3f9ebacf23659cc288b48 (MD5) / Approved for entry into archive by Arlan Eloi Leite Silva (eloihistoriador@yahoo.com.br) on 2016-03-10T23:32:29Z (GMT) No. of bitstreams: 1 ClarissaNesiVenzon_DISSERT.pdf: 2129281 bytes, checksum: 8bd476fcced3f9ebacf23659cc288b48 (MD5) / Made available in DSpace on 2016-03-10T23:32:29Z (GMT). No. of bitstreams: 1 ClarissaNesiVenzon_DISSERT.pdf: 2129281 bytes, checksum: 8bd476fcced3f9ebacf23659cc288b48 (MD5) Previous issue date: 2013-09-19 / A Obesidade ? uma doen?a cr?nica de etiologia multifatorial que se caracteriza por excesso de gordura corp?rea, cujo grau varia de acordo com o ?ndice de Massa Corporal (IMC=m2 /kg). A obesidade grave ? caracterizada por IMC>40, frequentemente associada a altera??es cl?nicas end?crino-metab?licas ou mec?nicas e transtornos psicol?gicos; o quadro de Compuls?o Alimentar Peri?dica (CAP) tem alta incid?ncia nesta popula??o. A cirurgia Bari?trica vem sendo o tratamento de escolha para a obesidade grave, por apresentar r?pido emagrecimento e melhora nas condi??es cl?nicas. T?m-se verificado aumento de peso ap?s dois anos de cirurgia em 20% a 30% dos casos. O objetivo geral desta pesquisa ? avaliar caracter?sticas psicol?gicas e comportamentais entre obesos graves submetidos ? Cirurgia Bari?trica do tipo Bypass G?strico h? pelo menos 24 meses. Foram investigados aspectos espec?ficos como, (1) caracter?sticas do funcionamento personalidade e presen?a de transtornos cl?nicos e de personalidade; (2) a incid?ncia de CAP e sua rela??o com perda de peso; (3) a diferen?a entre os grupos em rela??o aos acompanhamentos p?s-cir?rgicos; atividade f?sica, acompanhamento psicol?gico e nutricional. M?todo: 40 adultos (homens e mulheres), com idades entre 23 a 60 anos, submetidos ? cirurgia bari?trica h? pelo menos 24 meses, na cidade de Natal-RN, foram divididos em dois grupos com n= 20, Grupo de Ganho, com perda < 50% do peso excedente inicial, e o Grupo de Perda, com perda >50%. O protocolo de pesquisa foi composto por question?rio biossociodemogr?fico, o m?todo de Rorschach ? Sistema Compreensivo (SC); Invent?rio de Personalidade de Millon (MCMI-III); e Escala de Compuls?o Alimentar Peri?dica (ECAP). Atrav?s do m?todo de Rorschach foram evidenciadas diferen?as significativas entre os dois grupos, relacionadas aos tipos vivenciais (EB), maior presen?a de EB Extratensivo no Grupo Ganho e Intratensivo no Grupo de Perda; e ao descontrole na express?o dos afetos, com eleva??o de respostas de Cor Pura no Grupo Ganho. Em rela??o ? popula??o normativa do SC, a amostra como um todo apresentou maior tend?ncia a experienciar sofrimento ps?quico, auto percep??o denegrida, autocr?tica excessiva, distor??es perceptivas, vulnerabilidade a desenvolver transtornos afetivos e eleva??o da pontua??o na Constela??o de Suic?dio. O MCMI-III indicou maior incid?ncia de transtornos cl?nicos e de personalidade no Grupo Ganho: Transtorno Depressivo e Esquizot?pico, Ansiedade, Distimia, Depress?o Maior; Transtorno do Pensamento, Bipolar- Man?aco e Transtornos de Estresse P?s-Traum?tico. Os resultados da ECAP indicaram diferen?a significativa, com eleva??o de CAP no Grupo de Ganho como tamb?m, entre a gravidade de CAP e presen?a de transtornos cl?nicos e de personalidade. Em rela??o aos acompanhamentos foi encontrada diferen?a significativa no quesito atividade f?sica com mediana elevada no Grupo de Perda. Os grupos ainda se diferenciaram em rela??o ao peso inicial e tempo p?scir?rgico, indicando que quanto maior o peso inicial e tempo percorrido maior o aumento de peso p?s-cir?rgico. Os resultados ainda revelam que os participantes com mais de 3 anos de tempo cirurgia, apresentam eleva??o na presen?a de Transtornos Cl?nicos de Transtorno Depressivo Maior; Transtorno Somatoforme; Distimia. Tais resultados corroboram conclus?es de estudos sobre a rela??o entre CAP p?s-cir?rgico e novo ganho de peso, como tamb?m acerca de maior incid?ncia de transtornos cl?nicos na popula??o obesa grave. Conclui-se que o processo cir?rgico ? apenas uma faceta do tratamento da obesidade grave, e que o acompanhamento p?s-cir?rgico deve receber maior aten??o e ocorrer em longo prazo para a manuten??o n?o s? dos resultados cir?rgicos, como da melhoria da qualidade de vida dos pacientes. / Obesity is a chronic disease that has multi-factorial aetiology, characterized by high degree of body fat; the degree of obesity will vary according to the Body Mass Index (BMI=m2 /kg). The severe degree of obesity is characterized by BMI>40 and it is regularly associated to endocrine-metabolic or mechanic clinical alterations, and to psychological disorders. Binge Eating (BE) results were overly high for this population. The Bariatric Surgery has been the treatment chosen by those diagnosed with severe obesity as this intervention provides prompt outcomes for loss of weight and clinical improvement conditions. However, recent research has acquiesced that after two years between 20% and 30% of people subject to this intervention gained weight. The main objective of this research is to assess the psychological and behavioral characteristics of those diagnosed with severe obesity that have been subject to Gastric Bypass Surgery in the past 24 months. Specific aspects were investigated: (1) characteristics of different personalities and diagnose of clinic and personality disorders; (2) BE and its relation with loss of weight; (2) the difference between the groups regarding post-surgery care, e.g. physical activity, psychological and dietician input. Method: 40 adults (women and men) aged 23 and 60 year-old who went through a bariatric surgery in the past 24 months, in the city of Natal-RN (Brazil); they were assembled in two groups n=20, Gain group displaying loss of < 50% of their initial surplus of weight, and the Loss group displaying loss of >50%. The research protocol is made of a socio-demographic questionnaire and 3 psychometric instruments: Rorschach ? Comprehensive System; Millon Personality Inventory (MCMI-III); and the Binge Eating Scale (Escala de Compuls?o Alimentar Peri?dica (ECAP). Through Rorschach significant differences between these groups were verified according to the kind of personality (EB) - more EB Extratensivo in Gain group and Intratensivo in Loss group ? and the lack of control to express affect, increasing the answer for Color Pure at Group I. Concerning the people standardization, the sample as a whole tends to show psychic pain, denigrated selfperception, high levels of self-criticism, distorted perceptions, vulnerability to develop mood disorders and high scores regarding Suicide. MCMI-III results showed more clinic and personality disorders in Group I: Depressive Disorder and Schizotypal, Anxiety, Dysthymia, Major Depressive Disorder; Thought Disorder, Bipolar- Manic and Posttraumatic Stress Disorder. In relation to ECAP, the results indicated significant differences, showing increased BE results in Gain group. There were found significant differences between BE severity and the presence of clinic and personality disorders. Concerning the post-surgery care, the observed differences are statistically significant regarding physical activities with median-increased differences in Loss group. There is a difference between the initial weight and the time post-surgery, indicating that the higher the initial weight and the time after the surgery the higher the re-gain of weight post-surgery. Finally, the results show that the participants with more than 3 years of surgery will have Clinic and Major Depressive Disorders; Somatoform Disorder; Dysthymia. These results confirm prior studies related to BE post-surgery and re-gain of weight as well as the proneness of clinic disorders in severe obesity people. That means the results reinforce that the surgery process is a facet of the severe obesity treatment. The post-surgery process needs to be the main focus of attention and have a long-term input to sustain the care of the surgery results and the quality of life of the patients.