Die Idealvorstellung eines vollständig digitalisierten Behandlungsalltags rückt mit fortschreitender technologischer und informationeller Entwicklung stetig näher an die Realität. Zu Beginn bestand lediglich die Möglichkeit einer elektronischen Patientenakte, hinzu kamen vielfältige Möglichkeiten der digitalen Bildgebung und wurden schließlich um das Ziel eines vollständigen digitalen Workflows ergänzt. Die Planung der interdisziplinären kieferorthopädischen / kieferchirurgischen Versorgung von Patienten mit Lippen-Kiefer-Gaumen-Spalten (LKGS) wird momentan noch hauptsächlich analog durchgeführt. Eine volldigitalisierte Behandlungsplanung und –freigabe unter intersektoraler Einbeziehung aller beteiligten Behandler findet nicht statt. Neu entwickelte, digitale kieferorthopädische und –chirurgische Produkte, welche bis vor ein paar Jahren noch nicht denkbar waren, unterstützen den digitalen Workflow maßgeblich. 3D-Scanner und 3D-Fotoaufnahmen erstellen digitale Modelle, deren Daten zur Integration in den digitalen Workflow durch Softwareprozesse verarbeitet werden müssen. Um einen einfachen und strukturierten Zugriff auf die gesamten 3D Daten zu gewährleisten, ist die Idee entstanden, die anfallenden Daten und Unterlagen zu digitalisieren und in einer für diesen Zweck entwickelten Datenbank zu speichern und zu bearbeiten. Die konsequente Verwendung von digitalen 3D-Analysen und der Verzicht auf die aufwändige Erstellung der Diagnostik- und Therapieplanung aus einer Kombination von Gipsmodellen und 2D-Daten (z.B. Röntgenbilder) führen zu einer fundamentalen und richtungsweisenden Veränderung des Behandlungsplanungsprozesses. Räumlich und monetär aufwendige Bearbeitungsprozesse werden eingespart und Behandlungspläne können rascher erstellt werden, da sich alle notwendigen Unterlagen gebündelt in einem System wiederfinden. Weiterhin wird die Strahlenbelastung der Patienten wesentlich verringert, da eine Doppeldiagnostik durch mehrmaliges Anfertigen von Röntgenaufnahmen, DVTs und CTs in verschiedenen Abteilungen vermieden wird. Die Kommunikation, der Austausch und die konsiliarische Zusammenarbeit zwischen den Behandlern erfolgt unter Verwendung der europaweit ersten offenen, überregionalen telemedizinischen Plattform zur Verbesserung der medizinischen Versorgung – CCS TELEHEALTH OSTSACHSEN (THOS). [... aus der Einleitung]

Background: In reconstructive surgery, loss of a microvascular free flap due to perfusion disorders, especially thrombosis, is a serious complication. In recent years, viscoelastic testing (VET) has become increasingly important in point-of-care (POC) anticoagulation monitoring. This paper describes a protocol for enhanced anticoagulation monitoring during maxillofacial flap surgery. Objective: The aim of the study will be to evaluate, in a controlled setting, the predictive value of POC devices for the type of flap perfusion disorders due to thrombosis or bleeding. VET, Platelet monitoring (PM) and standard laboratory tests (SLT) are comparatively examined. Methods/Design: This study is an investigator-initiated prospective trial in 100 patients undergoing maxillofacial surgery. Patients who undergo reconstructive surgery using microvascular-free flaps will be consecutively enrolled in the study. All patients provide blood samples for VET, PM and SLT at defined time points. The primary outcome is defined as free flap loss during the hospital stay. Statistical analyses will be performed using t-tests, including the Bonferroni adjustment for multiple comparisons. Discussion: This study will help clarify whether VET can improve individualized patient care in reconstruction surgery. A better understanding of coagulation in relation to flap perfusion disorders may allow real-time adaption of antithrombotic strategies and potentially prevent flap complications.

Made available in DSpace on 2016-01-26T12:51:37Z (GMT). No. of bitstreams: 1 nelsoncolombini_tese.pdf: 1052278 bytes, checksum: 65caf5c2304f80f9167fa51d736325f5 (MD5) Previous issue date: 2010-03-22 / To describe the results obtained by the Maxillo Mandibular Advancement (MMA), associated to a glossectomy of Medium Line (GML) to CO2 Laser in the surgical treatment of Obstructive Sleep Apnea-Hypoapnea Syndrome (ASOSH), from moderate to severe, with adequate analysis of macroscstruture e microstructure of the sleep. Casuistics and Method: In the period from February 2005 to December 2008, 22 sequencial patients with ASOSH, from moderate to severe, with or without maxillary mandibular bone alterations, were selected. These patients were submitted to MMP plus GML using a CO2 laser. All patients underwent clinical, polissonographic and cephalometric evaluations. The polissonographic parameters used were: IAH, MD, Minimum SAT O2% < measured in minutes, sleep stages N1, N2, N3 and REM, preoperative and postoperative. The cephalometric parameters used were: SNA, SNB, PAS, PP2 PP2, preoperative and postoperative. Results: Evaluation of eventual differences in the preoperative and postoperative moments were investigated with the appropriate statistical tools. The surgical treatment proved to be effective in 8, out of 22 of the cases (36.36%), according to international criteria of normality. On the other hand, in these patients the IAH was not the best parameter to evaluate the therapeutic success. The MD (68.18% of improvement), stage N3 (59.09% of improvement) and Minimum SAT O2% < 90 measured in minutes (81.81% of improvement) demonstrated that they were the best instruments for characterizing the laboratorial control of the disease. Discussion: The MMA has expanded the dimensions of the pharynx and the hypopharynx. The GLM was associated in order to maximize the VAS, improve the stability of the dental occlusion, as well as the function of the temporomandibular joint, reducing the morbidity of the procedure. A postoperative evaluation with polysomnography showed improvements of the parameters in both macro and microarchitecture of the sleep (in relation to preoperative findings), besides proving that the IAH is not the best parameter for a postoperative evaluation (this applies to the patients of this series). Conclusions: The surgical treatment performed with MMA, associated to the GLM with CO2 laser was effective to treat patients with from ASOSH : - The improvement using the most accepted parameter by the international community (IAH < 5/ hour) was 8 out of the 22 (36.36%); - The IAH was not the best instrument to evaluate the control of the disease; - Were MD, stage N3 and Minimum SAT O2% < 90 measured in minutes showed that they are good indicators of the control of the disease (postoperative moment); - The Minimum SAT O2% < 90 measured in minutes was the best parameter in the evaluation of the surgical treatment (18/22 or 81.81%). / Descrever os resultados obtidos pelo Avanço Maxilo- Mandibular (AMM) associados à Glossectomia de Linha Média (GLM) a Laser CO2 no tratamento cirúrgico da Síndrome da Apnéia/Hipopnéia Obstrutiva do Sono (SAHOS) moderada e severa, usando instrumentos estatísticos que avaliem a arquiquetura do sono quanto à macro e micro estrutura para adequada e real avaliação dos resultados obtidos pelo tratamento proposto. Casuística e Método: No período de fevereiro de 2005 a dezembro de 2008 foram selecionados 22 pacientes seqüenciais portadores de SAHOS moderada e severa, com ou sem alterações esqueléticas maxilo-mandibulares. Estes pacientes foram submetidos à AMM, mais GLM com laser de CO2. Todos pacientes tiveram avaliação clínica, polissonográfica e cefalométrica. Os parâmetros polissonográficos utilizados foram: IAH, MD, SAT O2 % Mínima < 90 medida em minutos, estágios do sono N1, N2, N3 e REM, pré e pósoperatório. Os parâmetros cefalométricos utilizados foram: SNA, SNB, PAS, PP2 PP2 pré e pós-operatório. Resultados: Avaliação de eventuais diferenças nos momentos pré e pós-operatório foram investigadas com ferramenta estatística apropriada. O tratamento cirúrgico mostrou-se eficaz em 8/22 (36,36%) dos casos, segundo critérios internacionais de normalidade. Por outro lado nestes pacientes o IAH não foi o melhor parâmetro para avaliar sucesso terapêutico. MD (68,18% melhora), estágio N3 (59,09% de melhora) e SAT O2% Mínima < 90 medida em minutos (81,81% de melhora) mostraram-se melhores instrumentos para caracterizar controle laboratorial da enfermidade.Discussão: O AMM ampliou as dimensões da faringe e hipofaringe. A GLM foi associada para maximizar a VAS, aumentar a estabilidade da oclusão dentária e função da articulação têmporo-mandibular, reduzindo a morbidade do procedimento. Avaliação pós-operatória com polissonografia demonstrou melhora de parâmetros de macro e micro-arquitetura do sono (em relação aos achados pré-operatórios), além de comprovar não ser o IAH o melhor parâmetro para avaliação pós-operatória (isto para os pacientes desta série). Conclusões: O tratamento cirúrgico com AMM associado à GLM com laser de CO2 foi eficaz para tratar pacientes com SAHOS: A melhora utilizando o parâmetro mais aceito pela comunidade internacional (IAH < 5/hora) foi de 8/22 (36,36%); IAH não foi o melhor instrumento para avaliação do controle da enfermidade; MD, estágio N3 e SAT O2% Mínima < 90 medida em minutos mostraram-se bons indicadores de controle da enfermidade (momento pósoperatório); SAT O2% Mínima < 90 medida em minutos foi o melhor parâmetro na avaliação do tratamento cirúrgico (18/22 ou 81,81%).