Orientador: Márcia Rita Fernandes Machado / Banca: Bruno Watanabe Minto / Banca: Sheila Canevese Rahal / Resumo: Na busca de material biológico alternativo para a realização de implantes, objetivou-se com o presente estudo avaliar comparativamente a implantação do peritônio de paca, uma nova opção de biomaterial, conservado em solução supersaturada de açúcar a 300% e conservado em glicerina a 98% na parede abdominal de ratos wistar. Foram utilizados 60 ratos, machos, da linhagem Wistar pesando entre 150 e 200 gramas organizados nos seguintes grupos experimentais: grupo controle (GI), grupo peritônio conservado em solução supersaturada de açúcar a 300% (GII) e grupo peritônio conservado em glicerina a 98% (GIII), cada um com 20 animais. Os grupos GII e GIII receberam o enxerto de peritônio da paca conservado em solução de açúcar 300% e glicerina 98% respectivamente, e o grupo GI não recebeu a membrana. Cinco ratos de cada grupo foram submetidos à eutanásia em quatro momentos distintos: sete, 15, 30 e 60 dias de pós-operatórios para avaliações clínicas, macroscópicas, histológicas e estereológicas da interface implante-tecido nativo. Apesar de reações adversas observadas em 57,5% dos animais do grupo GII e GIII, em 95% dos animais destes grupos houve boa cicatrização da membrana. Na análise histológica, verificou-se a presença de grande infiltrado inflamatório nos períodos iniciais (sete e 15 dias) e grande presença de tecido conjuntivo nos momentos finais (30 e 60 dias). Mediante análise estereológica verificou-se que o número de células mononucleares diminuiu no decorrer dos momentos de avaliação. Concluiu-se que o peritônio da paca como membrana biológica conservado nos meios estudados pode ser utilizado com segurança na parede abdominal de ratos; ainda, que sua conservação em solução supersaturada de açúcar a 300% permitiu melhor maleabilidade no ato cirúrgico e também que a conservação em glicerina a 98% possibilitou, microscopicamente, menor resposta inflamatória / Abstract: In the search for alternative biological material to perform implants, this study aimed to compare the implantation of paca peritoneum, a new option biomaterial, preserved in supersaturated sugar solution 300% and preserved in glycerin 98% in the abdominal wall of Wistar rats. A total of 60 male rats of Wistar strain weighing between 150 and 200 grams housed into three diferent experimental groups: control group (GI), peritoneum preserved in supersaturated sugar solution 300% group (GII) and peritoneum preserved in glycerin 98% group (GIII), with 20 animals each one. The GII and GIII received the paca peritoneum graft preserved in sugar solution 300% and glycerin 98%, respectively and the group GI did not receive any membrane. Five rats from each group were euthanized at four different times: seven, 15, 30 and 60 days post-surgery to macroscopic, microscopic and stereological evaluations in graft-native tissue interface. Despite the adverse reactions observed in 57,5% of GII and GIII, there was good healing of the membrane in 95% of the animals of these groups. On histological examination, there was a large presence of inflammatory infiltrates in the initial periods (seven and 15 days) and large presence of connective tissue in the final stages (30 and 60). By stereology, it was found that the number of mononuclear cells decreased throughout the evaluation times. It was concluded that the paca peritoneum as biological membrane preserved as presented in this study can be used safely in the abdominal wall of rats, the preservation in supersaturated sugar solution 300% allowed better flexibility during surgery and conservation in glycerin 98% allowed, microscopically, less inflammatory response / Mestre

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第20665号 / 医博第4275号 / 新制||医||1024(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 羽賀 博典, 教授 横出 正之, 教授 瀬原 淳子 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

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Hintergrund: Der Einsatz minimal invasiver Techniken in der onkologischen Chirurgie wird wegen der Berichte über Trokarmetastasen kontrovers diskutiert. Die Pathogenese von Inzisionsmetastasen und intraperitonealem Tumorwachstum ist bisher nicht bekannt. Als mögliche Ursachen kommen bei Einsatz der laparoskopischen Chirurgie auch Einflüsse von Gas und Druck auf das Peritoneum in Betracht. Dabei könnte eine peritoneale Inflammation die Adhäsion und das Wachstum von Tumorzellen begünstigen. Wir untersuchten den Einfluss eines CO2- und Helium- Pneumoperitoneums auf die Morphologie des Rattenperitoneums. Methoden: Bei insgesamt 50 Ratten (BD IX) erfolgte die intraabdominelle Injektion von Tumorzellen (DHB/TRb) und im Anschluß für 30 min der Aufbau eines CO2-oder Helium-Pneumoperitoneums mit einem Druck von 15 mm Hg. Nach definierten Zeitpunkten (2, 12, 24, 48 und 96h) wurden die Tiere geopfert und Proben des Peritoneums rasterelektronenmikroskopisch auf inflammatorische Veränderungen untersucht. Bei den Kontrolltieren wurde keine Pneumoperitoneum aufgebaut. Ergebnisse: Bei allen Kontrolltieren war das Peritoneum frei von entzündlichen Veränderungen. Sowohl in der CO2 als auch in der Helium-Gruppe lagen bei 21 von 25 Tieren ebenfalls keine entzündlichen Veränderungen vor. Lediglich bei vier Tieren jeder Gruppe fanden sich Alterationen des Mesothel, die auf eine Inflammation hindeuteten. Tumorzellen wurden in insgesamt sechs Tieren nachgewiesen. In keinem Fall kam es zu einem nodulären oder diffusen intraperitonealen Tumorwachstum. Schlussfolgerung: Morphologisch zeigt das Rattenperitoneum nach Tumorzellinjektion und CO2- bzw. Helium- Pneumoperitoneum keine Veränderungen, die ein intraperitoneales Tumorwachstum begünstigen könnten. Alterationen des Peritoneums infolge eines Pneumoperitoneums scheinen daher nicht die Ursache für das Auftreten von Metastasen nach minimal-invasiven Operationen zu sein. / Objective: Laparoscopic surgery in patients with cancer has been discussed controversially because of the susceptibility of laparoscopic incisions for metastatic tumour growth. The mechanisms of port-site metastases and intraperitoneal tumour growth are still unknown. One reason might be the influence of insufflation gas and pressure on the peritoneum. A structural damage of the mesothelial layer due to the pneumoperitoneum might facilitate tumour cell adhesion and growth. We have examined the influence of CO2- and helium- pneumoperitoneum on the morphology of the peritoneum. Methods: A total of 50 rats (BD IX) received colon carcinoma (DHB/TRb) cells intraperitoneally and CO2 or Helium were used for insufflation at a pressure of 15 mm Hg for 30 minutes. After different time periods (2, 12, 24, 48 and 96h) rats were killed and the peritoneum was examined by scanning electron microscopy. Controls were without pneumoperitoneum. The peritoneum was examined by scanning electron microscopy. Results: Controls and most of the rats with pneumoperitoneum showed no peritoneal alterations. In 4 animals of each group inflammatory alterations of the peritoneum such as bulging and retraction of mesothelial cells were observed at different time points. Tumour cells adherent to the peritoneum were found in a total of 6 animals. Peritoneal carcinomatosis, tumour nodules or infiltration of the peritoneum by tumour cells were not observed. Conclusions: Our study demonstrates that the morphologic integrity of the rat peritoneum is not disturbed when CO2 or helium are used for insufflation combined with the intraperitoneal injection of carcinoma cells. Pneumoperitoneum therefore is probably not the condition causing peritoneal changes that favour intraperitoneal tumour growth.

In the past, patients with peritoneal surface malignancy were considered incurable and were only offered palliative treatments. However, in a substantial number of patients, disease progression that is isolated to peritoneum may occur. It has been realised that elimination of peritoneal surface tumours may have an impact on the survival of these cancer patients, in whom a prominent cause of death is peritoneal carcinomatosis. The focus of this PhD. thesis is on the combined treatment of cytoreductive surgery and perioperative intrapersonal chemotherapy for diffuse malignant peritoneal mesothelioma, pseudomyxoma peritonei, colorectal peritoneal carcinomatosis and resectable gastric cancer. Section one describes the major principles of management for peritoneal surface malignancy, covering the historical perspectives, the treatment rationales and the learning curve associated with the combined procedure. Section two is devoted to peritoneal mesothelioma, in trying to examine this disease from its clinical, radiologic and histopathologic aspects. A radiologic classification and a histopathologic staging system for this disease are proposed. In section three, the results of the combined treatment for pseudomyxoma peritonei are presented, including a systematic review of the literature, a case series of 50 patients from our Australian centre and a treatment failure analysis of 402 patients from the Washington Cancer Institute. These studies suggest that a disease-free state is important for long-term survival for patients with pseudomyxoma peritonei. In section four, the current evidence on the combined treatment for colorectaI peritoneal carcinomatosis is demonstrated by conducting a systematic review of the literature and survival and perioperative outcome analyses of two separate patient cohorts. These results suggest that the combined treatment is associated with an improved survival, as compared with historical controls. In the last section, a metaanalysis of the randomised controlled trials on adjuvant intraperitoneal chemotherapy for resectable gastric cancer shows that a significant improvement in survival is associated with hyperthermic intraoperative intraperitoneal chemotherapy alone or in combination with early postoperative intraperitoneal chemotherapy.

Purpose Extended resections in hepatopancreatobiliary (HPB) surgery frequently require vascular resection to obtain tumor clearance. The use of alloplastic grafts may increase postoperative morbidity due to septic or thrombotic complications. The use of suitable autologous venous interponates (internal jugular vein, great saphenous vein) is frequently associated with additional incisions. The aim of this study was to report on our experience with venous reconstruction using the introperative easily available parietal peritoneum, focusing on key technical aspects. Methods All patients who underwent HPB resections with venous reconstruction using peritoneal patches at our department between January 2017 and November 2021 were included in this retrospective analysis with median follow-up of 2 months (IQR: 1–8 months). We focused on technical aspects of the procedure and evaluated vascular patency and perioperative morbidity. Results Parietal peritoneum patches (PPPs) were applied for reconstruction of the inferior vena cava (IVC) (13 patients) and portal vein (PV) (4 patients) during major hepatic (n = 14) or pancreatic (n = 2) resections. There were no cases of postoperative bleeding due to anastomotic leakage. Following PV reconstruction, two patients showed postoperative vascular stenosis after severe pancreatitis with postoperative pancreatic fistula and bile leakage, respectively. In patients with reconstruction of the IVC, no relevant perioperative vascular complications occurred. Conclusions The use of a peritoneal patch for reconstruction of the IVC in HPB surgery is a feasible, effective, and low-cost alternative to alloplastic, xenogenous, or venous grafts. The graft can be easily harvested and tailored to the required size. More evidence is still needed to confirm the safety of this procedure for the portal vein regarding long-term results.

Os macrófagos (M<font face=\"Symbol\">&#934;s) compõem uma população celular altamente heterogênea, e são extensivamente adotados como ferramenta experimental, em especial os M<font face=\"Symbol\">&#934;s peritoneais murinos. O objetivo desse trabalho foi revisitar o peritônio dando ênfase à heterogeneidade dos M<font face=\"Symbol\">&#934;s. Duas populações distintas compõem os M<font face=\"Symbol\">&#934; peritoneais residentes: LPM (Large Peritoneal Macrophage) e SPM (Small Peritoneal Macrophage). Todas as condições proporcionadas in vivo resultam no desaparecimento de LPM, aumento de SPM e influxo de monócitos. Em paralelo, ocorre uma diminuição na marcação para <font face=\"Symbol\">b-galactosidase (marcador de senescência) e um aumento na produção de Óxido Nítrico (NO) e na frequência de células F4/80+IL-12+ após a subseqüente estimulação com LPS e IFN-<font face=\"Symbol\">g, que parece ser às custas da SPM. Além disso, parece haver uma especialização onde LPM assume um perfil M2 após inoculação de zimosan, e SPM um perfil M1 após reestimulo com LPS ou IFN-<font face=\"Symbol\">g.Esses dados sugerem que renovação celular que ocorre no peritônio após estimulação, parece ser benéfica para a resposta celular frente a estímulos infecciosos. / Macrophages (M<font face=\"Symbol\">&#934;) are a heterogeneous population extensively adopted as experimental model, especially peritoneal M<font face=\"Symbol\">&#934;. Then, the aim of this work was to revisit peritoneal cavity looking for M<font face=\"Symbol\">&#934; heterogeneity. Peritoneal M<font face=\"Symbol\">&#934; comprise two distinct subpopulations: LPM (Large Peritoneal Macrophage) and SPM (Small Peritoneal Macrophage). The different conditions proporcioned in vivo, resulted in the disappearance of LPM and the accumulation of SPM and monocytes. In parallel, adherent cells isolated from stimulated mice displayed reduced staining for <font face=\"Symbol\">b-galactosidase (senescence marker). Further, an increase in nitric oxide (NO) production and IL-12-producing cells frequency was observed in response to LPS/FN-<font face=\"Symbol\">g re-stimulation. In addition, there was a specialization of activation profile marked by a M2 activation profile after zymosan administered in vivo assumed by LPM, and SPM showed a bias to M1 after re-stimulation with LPS/IFN-<font face=\"Symbol\">g. Then, the substitution of LPM by a robust SPM and monocytes in response to infectious stimuli greatly improves peritoneal effector activity.

A artrite induzida por pristane (PIA) em camundongos HIII (resistentes) e LIII (suscetíveis) foi usada para estudar mecanismos inflamatórios e imunes atuantes na fase pré-clínica da doença, os quais são pouco conhecidos. Estudos anteriores mostraram diferenças significativas na produção de citocinas nos animais HIII e LIII na fase pré-clínica da PIA, sugerindo forte influênica no fenótipo de PIA. A PIA foi induzida apenas por via intraperitoneal nos animais LIII, com intensa infiltração de neutrófilos, linfócitos, monócitos e macrófagos, altos níveis de IL-12p40 e maior expressão de genes de citocinas inflamatórias após a injeção de pristane. Por outro lado, na linhagem HIII houve aumento de eosinófilos e neutrófilos, mas redução de monócitos e linfócitos. Não observamos diferenças nos níveis de TNF-<font face=\"Symbol\">&#945;, IFN-<font face=\"Symbol\">g, IL-12p70, IL-17, IL-10. Concluímos que a intensidade e o tipo de resposta inflamatória na fase inicial da PIA podem ser mecanismos envolvidos na diferença de resistência/ susceptibilidade entre as linhagens HIII e LIII. / Pristane-induced arthritis (PIA) in HIII (resistant) and LIII (susceptible) mice was used in this work to characterize the cellular and molecular alterations of the pre-clinical phase of the disease, of which little is known. Previous reports showed significant differences in cytokine production of HIII and LIII mice in the pre-clinical phase of PIA, suggesting a strong influence on PIA phenotype. PIA was induced only by the intraperitoneal route in LIII animals, which showed intense infiltration of neutrophils, lymphocytes, monocytes and macrophages, with high levels of IL-12p40 after pristane injection. Inflammatory cytokine genes were also upregulated in LIII mice. On the other hand, HIII strain had increased eosinophils and neutrophils, but reduced monocytes and lymphocytes. No significant differences were found in TNF-<font face=\"Symbol\">&#945;, IFN-<font face=\"Symbol\">g, IL-12p70, IL-17, IL-10 levels. We conclude that the intensity and type of inflammatory response in the initial phase of PIA may be different mechanisms involved in resistance / susceptibility between HIII and LIII mice.

Orientador: Márcia Rita Fernandes Machado / Banca: Antonio Carlos Alessi / Banca: Sheila Canevese Rahal / Resumo: Neste estudo, implantou-se peritônio bovino ou biomembrana de látex natural em defeito (1,5 x 1,5 cm) induzido na parede ventral da bexiga de coelhos, com o intuito de se avaliar o processo de reparação tecidual no que se refere à biocompatibilidade, capacidade de reparação e possíveis complicações. Utilizaram-se 36 coelhos, albinos, raça Nova Zelândia Branco, adultos, machos inteiros, divididos em grupos experimentais: grupo Biomembrana (GB), grupo peritônio bovino (GP) e grupo controle (GC), cada um com 12 animais. Aos sete, 14, 30 e 60 dias de pós-operatório, os animais foram eutanasiados mediante o emprego de uma dose elevada de tiopental sódico para avaliações macroscópica e histopatológica da interface do implante com o tecido nativo. Macroscopicamente, em ambos os grupos (GB, GP e GC), observaramse, em todos os períodos, aderências de estruturas adjacentes ao local do implante, presença de cálculos e ausência de sinais de rejeição. No grupo biomembrana, aos 30 e 60 dias de pós-operatório, constatou-se a presença do biocompósito solto na luz vesical. Sob microscopia de luz, aos sete dias verificaram-se intensa reação inflamatória, neovascularização e presença de fibroblastos proliferados. Aos 14 dias não havia epitélio, porém observaram-se escassos feixes musculares, intensa neovascularização, fibroblastos e infiltrado inflamatório. No grupo GP, aos 30 dias de observação, o implante estava presente, havia fibroblastos, feixes de fibras musculares, moderada população inflamatórias e ausência de epitélio e de lâmina própria. No grupo GB, neste mesmo período, todas as camadas vesicais estavam reconstituídas. Em ambos os grupos, aos 60 dias de pós-operatório, todas as camadas vesicais encontravam-se reparadas e a membrana peritônio bovino não foi observada. No grupo GC, em todos os tempos de avaliação verificou-se integridade... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: In this study, bovine peritoneum or biomembrane of natural latex were utilized to replace a section of ventral face of the bladder of rabbits, with purpose of evaluation of the tissue repair process in regard of its biocompatility, scar formation ability and possible complications. Thirty-six New Zealand rabbits, adult and entire males were divided in three experimental groups: biomembrane group (GB), bovine peritoneum group (GP) and control group (GC), each one with 12 animals. The animals were euthanized at seven, 14, 30 and 60 days post operative, by use of an elevated dosage of sodium tiopental, followed by macroscopic and histopathological analysis of the implant interface with the native tissue. Macroscopically, in both groups (GB, GP and GC), it was observed, in all time periods, structure adherence to the implant site, presence of calculi and absence of rejection signs. In the GB group, since 30 until 60 days of post operative, it was evidenced the presence of the biomembrane inside the bladder. Under light microscopy, at seven days, there were intense inflammatory reaction, new vessels and proliferated fibroblasts. In 14 days, there was no urotelium, however it saw muscle fibers, intense inflammatory cells, new vessels and fibroblasts. In the GP group, at 30 days the implant was still present, there were fibroblasts, muscle fibers, moderate population of inflammatory cells and absence of urotelium and sheath. In the GB group, in the same time period, all the vesical layers were reconstituted. In both groups, at 60 days of post operative, bladder wall was repaired and the bovine peritoneum membrane was not observed. In the GC group, all the evaluation times, integrity of the vesical wall was verified... (Complete abstract click electronic access below) / Mestre

Bibliography: leaves 111-137.