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京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第22349号 / 医博第4590号 / 新制||医||1042(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 木村 剛, 教授 椛島 健治, 教授 妻木 範行 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Magister Chirurgiae Dentium (MChD) / Introduction: Defects in the mandible and maxilla have various etiological factors. These include trauma, inflammatory diseases or pathology such as benign and malignant tumours. Patients that are exposed to these factors are often left with compromised function and aesthetics which could have a deleterious effects on the patients’ quality of life if not adequately restored with reconstructive surgery (Goh et al. 2008). Reconstruction should aim to allow rehabilitation of normal stomatognathic function, facial contour and aesthetics, obliteration of dead space left after ablation, and the need to examine the area for recurrence (Kim and Ghali 2011). The fibula free flap has become the gold standard for maxillofacial reconstruction. This flap offers various advantages that makes it suitable, especially for reconstructing defects of the mandible (Anne-Gaelle et al. 2011). The success of rehabilitation of these patients should however also take into consideration the patient’s ability to use a dental prosthesis (conventional or implant retained) post-operatively. This remains challenging (Kramer and Dempf 2005). The effective placement of a dental prosthesis relies on the basic principles of retention, stability and support. With the altered anatomy caused by the graft, placement of dental implants is used to enhance retention and stability. Quality of life (QoL) is a measure of a patient’s satisfaction with their current situation in regards to function and other factors compared to a perceived or expected ideal. The subjective component linked to quality of life means that it could vary from one locality to another, and therefore gathering data that will establish a baseline for these patients that have undergone tumour ablative surgeries. This could be invaluable to healthcare practitioners that operate in this specific field.

A transferência de retalhos livres e o reimplante de tecidos têm em comum a exposição dos tecidos à isquemia e tempos de reperfusão variáveis, que são importantes na determinação dos danos celulares estruturais e ultraestruturais, às vezes irreversíveis. O tempo de isquemia dificilmente pode ser controlado no período pré ou transoperatório, mas pode-se tentar prevenir ou diminuir as alterações celulares com soluções preservadoras, como, por exemplo, a da Universidade de Wisconsin, amplamente utilizada na prática clínica dos transplantes de tecidos. Porém a disponibilidade e o custo alto destas soluções dificultam seu uso rotineiro nos centros cirúrgicos. O presente trabalho propõe a utilização de solução de preservação (Solução Plástica-USP) que pode ser facilmente preparada com medicamentos accessíveis e baixo custo; a eficiência desta solução foi comparada com a da solução de Wisconsin. Os resultados demonstraram que não existe diferencia significativa entre a solução Plástica-USP, comparável à solução de Wisconsin; conferindo, ambas, um maior nível de proteção celular sobre os controles; beneficiando significativamente os resultados, e diminuindo assim os riscos de perdas do transplante a baixo custo / The free flaps transfer and reimplantation of tissue has in common the exposure of the tissue to ischemia and different time of reperfusion which are important for the determination of the extent of the cellular injury, being sometimes irreversible. In the pre and trans-surgical procedure the control of the ischemic period is difficult. Although efforts are made to prevent and decrease cellular changes using preservative solution, such as University of Wisconsin (UW) used in routine transplant of organs. The availability and high cost of this solution some time is one problem. The present study was made in a rat model that we have been reported in others works, we proposed the utilization of a preservation solution that we called Plastic Surgery-USP solution (PS-USP); witch can be easily prepared with accessible and low cost drugs. The efficiency of this PS-USP solution was compared to UW; our result showed that there is not significative difference in the protective effects of the PS-USP and UW solutions; both solutions were efficient considering cellular protection to ischemia/reperfusion injury, decreasing the risks of flap lost, with low cost and easy disposition

No description available.

A transferência de retalhos livres e o reimplante de tecidos têm em comum a exposição dos tecidos à isquemia e tempos de reperfusão variáveis, que são importantes na determinação dos danos celulares estruturais e ultraestruturais, às vezes irreversíveis. O tempo de isquemia dificilmente pode ser controlado no período pré ou transoperatório, mas pode-se tentar prevenir ou diminuir as alterações celulares com soluções preservadoras, como, por exemplo, a da Universidade de Wisconsin, amplamente utilizada na prática clínica dos transplantes de tecidos. Porém a disponibilidade e o custo alto destas soluções dificultam seu uso rotineiro nos centros cirúrgicos. O presente trabalho propõe a utilização de solução de preservação (Solução Plástica-USP) que pode ser facilmente preparada com medicamentos accessíveis e baixo custo; a eficiência desta solução foi comparada com a da solução de Wisconsin. Os resultados demonstraram que não existe diferencia significativa entre a solução Plástica-USP, comparável à solução de Wisconsin; conferindo, ambas, um maior nível de proteção celular sobre os controles; beneficiando significativamente os resultados, e diminuindo assim os riscos de perdas do transplante a baixo custo / The free flaps transfer and reimplantation of tissue has in common the exposure of the tissue to ischemia and different time of reperfusion which are important for the determination of the extent of the cellular injury, being sometimes irreversible. In the pre and trans-surgical procedure the control of the ischemic period is difficult. Although efforts are made to prevent and decrease cellular changes using preservative solution, such as University of Wisconsin (UW) used in routine transplant of organs. The availability and high cost of this solution some time is one problem. The present study was made in a rat model that we have been reported in others works, we proposed the utilization of a preservation solution that we called Plastic Surgery-USP solution (PS-USP); witch can be easily prepared with accessible and low cost drugs. The efficiency of this PS-USP solution was compared to UW; our result showed that there is not significative difference in the protective effects of the PS-USP and UW solutions; both solutions were efficient considering cellular protection to ischemia/reperfusion injury, decreasing the risks of flap lost, with low cost and easy disposition

Postoperative delirium (POD) is an acute and serious complication following extended surgery. The aim of this study was to identify possible risk factors and scores associated with POD in patients undergoing reconstructive head and neck surgery. A collective of 225 patients was retrospectively evaluated after receiving reconstructive surgery in the head and neck region, between 2013 to 2018. The incidence of POD was examined with regards to distinct patient-specific clinical as well as perioperative parameters. Uni- and multivariate statistics were performed for data analysis. POD occurred in 49 patients (21.8%) and was strongly associated with an increased age-adjusted Charlson Comorbidity Index (ACCI) and a prolonged stay in the ICU (p = 0.009 and p = 0.000, respectively). Analogous, binary logistic regression analysis revealed time in the ICU (p < 0.001), an increased ACCI (p = 0.022) and a Nutritional Risk Screening (NRS) score 6= 0 (p = 0.005) as significant predictors for a diagnosis of POD. In contrast, the extent of reconstructive surgery in terms of parameters such as type of transplant or duration of surgery did not correlate with the occurrence of POD. The extension of reconstructive interventions in the head and neck region is not decisive for the development of postoperative delirium, whereas patient-specific parameters such as age and comorbidities, as well as nutritional parameters, represent predictors of POD occurrence.

Abstract Free flap surgery (FFS) is used for the reconstruction of head and neck defects after tumor resection. Compared to many other cancers requiring operative care, postoperative complications are frequent and the long-term outcome is poor in this patient group. The impact of postoperative complications on outcome, quality of life (QOL) and causes of death has not been well studied. The aim of this thesis was to study the factors associated with postoperative complications after FFS for cancer of the head and neck, as well as the impact of complications on QOL and long-term outcomes. The thesis includes one prospective and three retrospective studies. The study population was 146 head and neck patients undergoing FFS in Oulu University Hospital from 2008 to 2016. The impact of goal-directed fluid management using SVV (stroke volume variation) analysis on postoperative outcome was evaluated retrospectively. It led to a significant reduction in intraoperative fluid administration (6070 ml vs. 8185 ml) and length of stay (LOS) in hospital (11.5 vs. 14.0 days) but had no impact on the rate of postoperative complications. Postoperative complications were recorded in 60% of the patients and were related to alcohol abuse, complicated intraoperative course and fibular flap surgery. The patients with late complications (occurring after the fourth postoperative day) had higher mortality compared to those without. The QOL of 53 patients undergoing operations during 2013-2016 was evaluated using four questionnaires. Patients with medical complications (n=12, 22.6%) had significantly lower QOL in most domains of RAND-36 but QOL for those without complications was comparable to the general population. A total of 62/146 patients (42.5%) died by the end of 2016, and in 72.6% of cases the cause of death was the primary disease. In multivariate analysis male gender, low BMI, ASA above 2 and late medical complications were indicative for long-term mortality. In conclusion, postoperative complications have an impact on outcome after FFS for cancer of the head and neck in terms of QOL and long-term mortality. Patient-related factors were associated with unfavorable outcomes when intraoperative factors did not have as significant a role. Prevention of medical complications and adequate patient selection are essential when aiming to improve outcome after FFS. / Tiivistelmä Mikrovaskulaarikielekkeitä käytetään korjaamaan kasvaimen poiston vuoksi syntyneitä kudospuutoksia pään ja kaulan alueen syöpäpotilailla. Näihin toimenpiteisiin liittyy merkittävä komplikaatioriski ja myös itse syövän pitkäaikaisennuste on huono. Komplikaatioiden vaikutusta toipumisvaiheen elämänlaatuun ja kuolleisuuteen ei ole tutkittu. Tämän väitöskirjatyön tavoitteena oli selvittää tekijöitä, jotka liittyvät leikkauksen jälkeisiin komplikaatioihin, ja niiden merkitystä potilaiden elämänlaatuun ja pitkäaikaisennusteeseen. Tutkimuskokonaisuus koostuu kolmesta retrospektiivisestä tutkimuksesta ja yhdestä prospektiivisesta haastattelututkimuksesta. Tutkimukseen kuului 146 vuosina 2008–2016 Oulun yliopistollisessa sairaalassa leikattua pään ja kaulan alueen syöpäpotilasta. Tutkimuksessa selvitettiin tavoiteohjatun nestehoidon vaikutusta välittömään toipumisvaiheeseen, mutta tällä ei todettu olevan vaikutusta komplikaatioiden ilmaantumiseen. Sen sijaan potilaiden saama nestemäärä väheni merkitsevästi (6070 ml vs. 8185 ml) ja sairaalahoitojakson pituus lyheni (11,5 päivää vs. 14 päivää). Komplikaatioita todettiin 60 % leikkauksista ja useimmin komplikaation sai potilas, jolla oli alkoholin liikakäyttöä, ongelmia toimenpiteen aikana ja luullinen siirre. Neljännen leikkauksen jälkeisen päivän jälkeen ilmenneisiin komplikaatioihin liittyi korkeampi pitkäaikaiskuolleisuus. Elämänlaatu arvioitiin 53 potilaalta, jotka oli leikattu vuosina 2013–2016. Ei-kirurgisia komplikaatioita esiintyi 12 potilaalla ja heidän raportoimansa elämänlaatu oli merkitsevästi alentunut verrattuna muihin potilaisiin. Ilman komplikaatioita toipuneiden elämänlaatu oli verrattavissa väestöarvoihin. 42,5 % leikatuista potilaista oli kuollut vuoden 2016 loppuun mennessä ja 72,6 % heistä kuolema johtui hoidetusta syövästä. Monimuuttujamallissa pitkäaikaiskuolleisuuden riskitekijöitä olivat miessukupuoli, matala BMI, ASA-luokka yli 2 sekä todetut ei-kirurgiset komplikaatiot. Yhteenvetona voidaan todeta, että komplikaatioilla on merkitystä toipumisvaiheen elämänlaatuun ja pitkäaikaiskuolleisuuteen tässä potilasryhmässä. Potilaslähtöiset tekijät vaikuttavat merkittävästi komplikaatioiden ilmaantumiseen ja myös huonoon ennusteeseen. Ei-kirurgisten komplikaatioiden estäminen kuten myös oikea potilasvalinta ovat keskeisessä asemassa, kun tämän potilasryhmän hoidon tuloksia halutaan parantaa.

No description available.

This study explores the effects of surgical reconstruction and nerve repair on sensorimotor function and quality of life (QOL) for patients with base of tongue (BOT) cancer compared to healthy, age-matched adults. Sensations were tested on the anterior two-thirds of the oral tongue for two-point discrimination, light touch, taste, temperature, form and texture on 30 patients with BOT reconstruction with radial forearm free-flap and on 30 controls. Results indicated sensation for the unaffected tongue side and affected side with lingual nerve intact was comparable to controls, with poorer sensory outcomes for nerve repair. However, lingual nerves repaired with reanastomosis provided superior results to cable-grafting and severed nerves. Patients had decreased motor function only when the hypoglossal and lingual nerves were affected. Patients' QOL responses on the UW-QOL and EORTC QLQ-H&N35 revealed involvement of lingual and hypoglossal nerves resulted in poorer QOL outcomes. QOL interviews revealed additional problematic issues in this population not identified by standardized questionnaires. / Speech-Language Pathology