Orientador: Orlando Petrucci Junior / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-18T18:24:11Z (GMT). No. of bitstreams: 1 Severino_ElaineSorayaBarbosadeOliveira_D.pdf: 8406293 bytes, checksum: bc2a25ec83eb02498875fd5f899eb087 (MD5) Previous issue date: 2011 / Resumo: Introdução: A doença cardíaca reumática é a principal causa de doença valvar mitral no Brasil. A superioridade da plastia mitral na regurgitação mitral de etiologia degenerativa já tem sido demonstrada por vários estudos, mas ainda há poucos avaliando os resultados da plastia mitral na doença reumática. Objetivo: O objetivo foi avaliar fatores preditivos de risco para reoperação e mortalidade tardia em população de pacientes reumáticos submetidos à plastia da valva mitral. Material e Método: Este é um estudo retrospectivo. Variáveis clínicas, ecocardiográficas e técnicas cirúrgicas foram anotadas. Foram avaliados apenas pacientes submetidos a reparo da valva mitral exclusivamente, ou em conjunto com plastia da valva tricuspide. Para a análise de reoperação e sobrevida foram utilizadas curvas de Kaplan-Meier. Para a análise univariada das variáveis contínuas foi utilizado o teste t de Student ou Mann-Whitney dependendo do tipo de distribuição da amostra. Para as variáveis discretas foi utilizado o teste do Qui-quadrado. Resultados: Um total de 116 pacientes foram incluídos. O tempo de seguimento médio foi de 58,02 ± 45,33 meses. A idade média dos pacientes foi de 31,19 ± 12,72 anos. No pré-operatório 54,8% dos pacientes estavam em classe funcional I, 24,7% em classe II, 17,2% III e 3,2% em classe funcional IV. Não houve reoperação por sangramento na primeira cirurgia. A taxa de reoperação tardia foi de 12,9% (15 pacientes). A mortalidade cardíaca foi de 5,2% e a geral de 7,8% durante o seguimento tardio. A hipertensão pulmonar no pós-operatório esteve associada ao óbito (P<0,01). Na análise univariada os fatores preditivos de reoperação no pré-operatório foram: medida do átrio esquerdo (P=0,03) e o diâmetro diastólico do ventrículo esquerdo (P=0,01). Durante o seguimento os fatores preditivos de reoperação foram: medida do átrio esquerdo (P<0,01), diâmetro diastólico do ventrículo esquerdo (P<0,01) e a pressão sistólica da artéria pulmonar (P=0,02). Na análise de Kaplan-Meier a variável pré-operatório preditiva de reoperação foi o diâmetro diastólico do ventrículo esquerdo (P=0,01). No seguimento as variáveis preditivas de reoperação foram: a presença de hipertensão pulmonar (P=0,02), presença de insuficiência cardíaca (P<0,01) e a insuficiência mitral (P<0,01). Quanto às técnicas de plastia utilizadas a anuloplastia mitral exclusiva e a anuloplastia tricuspide mostraram maior ocorrência de reoperação (P<0,01 para ambas). A ocorrência de reoperação não esteve associada a menor probabilidade de sobrevida. Conclusão: Os pacientes submetidos a reparo da valva mitral tem fatores preditivos de reoperação no pré e no pós-operatório. Estes pacientes devem ser seguidos de forma mais cautelosa. O reparo da valva mitral e seguro em pacientes reumáticos e com boa sobrevida a longo prazo / Abstract: Introduction: Rheumatic heart valve disease is the most frequent cause of mitral valve disease in Brazil. The advantage of mitral valve repair over mitral valve replacement in degenerative mitral regurgitation has already been demonstrated by several studies, but there are few studies evaluating the early and late outcomes of in rheumatic mitral valve repair . Objective: Our aim was to assess predictive risk factors for mitral reoperation and late mortality in a population of rheumatic patients who underwent mitral valve repair. Methods: This is a retrospective study. Clinical, echocardiographic and surgical techniques were noted. For the analysis of reoperation and survival rates were used Kaplan-Meier curve. For the univariate analysis of continuous variables the Student t test or Mann-Whitney test were used where appropriated. For discrete variables the chisquare test was used. Results: One hundred and sixteen patients were included. The average follow-up was 58.02 ± 45.33 months. The mean age was 31.19 ± 12.72 years. At the preoperative time 54.8% of patients were in functional class I, 24.7% in class II, 17.2% class III, and 3.2% in class IV. There were no reoperations due to bleeding in the early postoperative time. The reoperation rate was 12.9% (15 patients) due to mitral valve degeneration after initial repair within the late follow-up. Cardiac mortality was 5.2% and all causes of death was 7.8% during the same period. The presence of pulmonary hypertension at the late follow-up was associated with death (P<0,01). In the univariate analysis, the risk factors for reoperation in the preoperative time were: left atrium dimension (P = 0.03) and left ventricular end diastolic diameter (P = 0.01). During the late follow-up period, predictive factors for reoperation were: left atrium dimension (P <0.01), left ventricular diastolic diameter (P <0.01) and pulmonary artery systolic pressure (P = 0.02). Kaplan-Meier curve analysis showed the left ventricular diastolic diameter (P = 0.01) associated with reoperation. During the late follow-up, the predictors for reoperation were: the presence of pulmonary hypertension (P = 0.02), congestive heart failure (P <0.01) and mitral regurgitation (P <0.01). Analyzing the techniques used in the initial mitral valve repair annuloplasty exclusively and tricuspid annuloplasty showed a higher incidence of reoperation (P <0.01 in both situations). The reoperation event did not decrease the probability of survival within the follow up period. Conclusion: There are predictors of reoperation in the pre- and postoperative time in patients who underwent rheumatic mitral valve repair. These patients should be followed more cautiously. The rheumatic mitral valve repair is safe and shows good long-term survival / Doutorado / Fisiopatologia Cirúrgica / Doutor em Ciências

Approximately one in four men will have surgery for ingunial hernia in their lifetime. In Sweden, 16 000 procedures are performed each year. To investigate the possible link between handling of nerves and sensory disturbance, 97 groins in 92 patients were examined one year after inguinal hernia surgery. Sensory disturbances were found to be common after open surgery (29 %), but were not seen after the laparoscopic procedures. No significant relationship between sensory disturbance and handling of nerves or pain was seen. The risk for recurrence has been significantly reduced due to the use of prosthetic meshes, but continued surveillance of this important outcome will always be necessary. In that context, the time frame in which recurrence develops in relation to possible risk factors can help our understanding of the underlying mechanisms. To explore such temporal relationships, 142,578 patients were included in a register study. A relative over-risk for early recurrence was seen after suture repair, laparoscopic repair, after postoperative complications, and after surgery for previous recurrence. Corticosteroids are known to decrease pain and nausea after several surgical procedures. In a randomised trial on open hernia surgery, 398 patients were randomised to treatment with 12 mg of betamethasone or placebo. Decreased levels of pain were seen on the day of surgery, the next day and after one month. No difference was seen on days 2-7 and after one year. Nausea was not common and did not differ between the groups. Reoperation is sometimes performed to correct a presumed structural defect thought to cause the long-term pain. In order to evaluate the result of such treatment, 111 cases were analysed based on register data, questionnaires and medical records. Sixty-two per-cent of the patients reported an improvement compared to before the reoperation, but a high level of pain remaining (42 %), and impaired quality of life was seen. There was no clear advantage for any surgical intervention over the other.

published_or_final_version / abstract / Orthopaedics and Traumatology / Doctoral / Doctor of Philosophy

published_or_final_version / Orthopaedics and Traumatology / Master / Master of Philosophy

Bariatric surgery is an effective procedure type for morbidly obese patients when all else fails. Because obesity is a chronic disease, prolonged assessment and understanding of the credibility of procedure types and their effects on bariatric surgery outcomes are essential, yet current evidence shows decreasing utilization of one of the dominant procedure types. To better compare outcomes of procedure type, this research was designed to control for volume, hospital size, age, gender, season, month, year, and ethnicity. The goal of the study was to compare the outcomes of laparoscopic adjustable gastric banding (LAGB) and laparoscopic sleeve gastrectomy (LSG) bariatric surgery using the epidemiologic triad model. This study was a retrospective cross-sectional review of Nationwide Inpatient Sample (NIS) from 2009 to 2014. Univariate and multivariate logistic regression were conducted to analyze the data. This study was based on a secondary analysis previously collected from NIS data. A convenience sample of 73,086 patients who underwent bariatric surgery using ICD-9 diagnosis and procedure codes was used. Multiple logistic regression analysis indicated that LAGB (odds ratio [OR] =.043) and LSG (OR =.030) were positively associated with in-hospital mortality. Similarly, LAGB (OR =.041) and LSG (OR =.425) were positively correlated to length of stay (LOS). Finally, LAGB (OR = .461) and LSG (OR = .480) was positively related to reoperation. LAGB, when compared to LSG for LOS, had a substantial advantage over biliopancreatic diversion. The LOS findings may contribute to patients' value proposition, including cost reduction for third party insurance payers and for the community.

Diss. (sammanfattning) Linköping : Univ., 2001. / Härtill 6 uppsatser.

Diss. (sammanfattning) Linköping : Univ., 2003. / Härtill 5 uppsatser.

Orientador: Orlando Petrucci Junior / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-11T21:17:28Z (GMT). No. of bitstreams: 1 Oliveira_PedroPauloMartinsde_D.pdf: 3207291 bytes, checksum: 643cd7870725684beed7998d60351274 (MD5) Previous issue date: 2008 / Resumo: Introdução: Reoperações representam cerca de 20% das cirurgias cardíacas, quase na totalidade com esternotomia, onde há a formação de aderências entre o coração, esterno e estruturas adjacentes. Lesões das câmaras cardíacas e grandes vasos pela serra esternal ou na dissecção dessas estruturas resultam em aumento da morbimortalidade e do sangramento perioperatório. Vários autores propuseram o uso de substitutos pericárdicos biológicos e sintéticos na tentativa de diminuir o risco de acidentes nas reoperações, porém sem resultados consistentes em longo prazo. A membrana de poli (álcool vinílico) - PVAl reticulado formam um hidrogel bastante estudado como biomaterial, com boa biocompatibilidade e características favoráveis ao seu emprego como substituto pericárdico. Objetivo: Caracterizar a membrana de PVAl quanto à capacidade de absorção de água, calcificação e citotoxidade e estudar o comportamento biológico da mesma como substituto pericárdico. Metodologia: Foram utilizadas amostras da membrana de PVAl reticulada por irradiação e realizados ensaios de citotoxicidade em culturas de células VERO, da capacidade de absorção de água e de calcificação após o implante in vivo. Ratos da Raça Wistar foram divididos em quatro grupos: Grupo controle - pericardiotomia. Grupo Talco - colocação de talco sobre o epicárdio. Grupo PVAl - colocada membrana de PVAl circundando o coração. Grupo PVAl + Talco - colocado talco sobre o epicárdio e a membrana de PVAl circundando o coração. Após oito semanas foi realizada análise macroscópica e histológica dos corações. Avaliação estatística foi realizada com análise de variância (ANOVA) e teste de Dunnett com significância p<0,05. Resultados: A membrana de PVAl não apresentou citotoxicidade, sua capacidade de absorção de água foi de 42,4 ± 0,89% e mostrou valor médio de 0,00422± 0,00256% de cálcio da massa total do material analisado. Na análise macroscópica observou-se maior aderência no grupo Talco. Na análise histológica o grupo PVAl + Talco apresentou maior espessura epicárdica. Os grupos T e PVAl + Talco apresentaram maior número de células inflamatórias. Conclusão: A membrana não é citotóxica, apresentou boa capacidade de hidratação, a absorção de cálcio foi desprezível, não induziu formação de aderências pericárdicas, não provocou aumento da espessura epicárdica e não induziu aumento de migração de células de resposta inflamatória para o epicárdio, mostrando-se interessante para a aplicação desejada. / Abstract: Background: Cardiac surgery reoperations represent around 20% of all surgical procedures. The main incision is sternotomy and after the first operation there are adherences joining the heart, sternum and neighboring structures. Cardiac chambers and great vessels lesions caused by sternal saw increase morbidity and mortality as well as perioperatory bleeding. Several authors had tried pericardial replacement with biological or synthetic materials in order to decrease risks at reoperations, however with no significant results on long term. Polyvinyl alcohol (PVAl) is a well-known hydrogel, with good biocompatibility and favorable properties as a pericardium replacement. Objective: Describe the biological PVAl behavior as a pericardial replacement. Methodology: PVAl samples were reticulated by radiation. Cytotoxicity direct and indirect tests with VERO cells were performed. We tested absorption water capability and in vivo calcification. Wistar rats were divided in four groups: Control - pericardium abrasion; Talc - talc insertion surrounding the heart; PVAl membrane - PVAl surrounding the heart; PVAl + talc - talc and PVAl membrane insertion surrounding the heart. All animals were kept for 8 weeks and euthanized for study. Macroscopic and microscopic analyses were performed. Statistical analyses were performed with ANOVA and Dunnett post test. Results: The PVAl membrane showed no cytotoxicity. The water absorption capability was 42,4 ± 0,89%. The calcification test showed only 0.00422± 0.00256% of calcium in the total mass of analyzed material. Macroscopic analysis showed higher adherences in the talc group. Histological analysis showed higher epicardium thickness in the PVAl + talc group, higher inflammatory cells in the talcum and PVAl + talc groups. Conclusion: The PVAl membrane hasn't cytotoxicity. It has good water absorption capability and calcification was insubstantial. The membrane showed neither adherences formation nor inflammatory response ...Note: The complete abstract is available with the full electronic digital thesis or dissertations. / Doutorado / Pesquisa Experimental / Doutor em Cirurgia

Orientador: Nelson Adami Andreollo / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-27T00:10:08Z (GMT). No. of bitstreams: 1 Brandalise_Andre_D.pdf: 14069828 bytes, checksum: d178e5d4a6b617f687e38a9c3855f1b7 (MD5) Previous issue date: 2015 / Resumo: Introdução: o tratamento cirúrgico da doença do refluxo gastroesofágico através da fundoplicatura realizada por videolaparoscopia apresenta bons resultados a longo prazo e é amplamente aceita como alternativa à manutenção do tratamento medicamentoso. Entretanto, a abordagem cirúrgica aos pacientes portadores de grandes hérnias de hiato ainda é motivo de discordância entre os especialistas. O uso de prótese para reforçar a hiatoplastia é proposta por alguns e descartada por outros, especialmente por temor de complicações relacionadas à prótese. Objetivo: realizar uma análise dos resultados a longo prazo do uso de próteses para reforço da hiatoplastia em pacientes com grandes hérnias de hiato tratadas por videolaparoscopia. Método: realizamos análise retrospectivo com 78 pacientes operados entre janeiro de 2000 e fevereiro de 2011 que eram portadores de grandes hérnias e que foram tratados através de cirurgia videolaparoscópica com emprego de próteses para reforço da hiatoplastia. Foram incluídos no estudo pacientes com tamanho do hiato superior a 5 cm de diâmetro, em hérnias primárias ou recidivadas. As próteses estudadas foram: polipropileno ¿ em modelo de implantação original, desenvolvido em nosso serviço ¿ e biológica absorvível. O acompanhamento foi realizado através de entrevista clínica e exames complementares ¿ endoscopia digestiva alta e/ou radiografias contrastadas de esôfago, estômago e duodeno. Resultados: observou-se maior presença de pacientes do sexo feminino (69%). A idade variou de 33 a 83 anos. A média de idade nos pacientes com hérnias primárias foi 64,7 anos, enquanto que nas hérnias recidivadas, foi de 52,3 anos. Essa diferença foi estatisticamente significante (p=0,0001). O tempo de seguimento médio foi de 45,8 meses para hérnias primárias e 61,4 meses para as recidivadas. (p=0,09). Na entrevista, 64 pacientes (82,0%) permaneciam assintomáticos, 7 (9,0%) queixavam-se de refluxo, 3 (3,9%) apresentavam disfagia e 4 (5,2%) relataram problemas com gases. Foram realizados exames complementares em 68 pacientes (87,2%). Destes 54 (79,4%) apresentavam exames normais, enquanto 14 (20,6%) apresentavam recidiva (da hérnia ou de esofagite). No grupo de hérnia primária ocorreram recidivas em seis pacientes (13%) e no grupo de hérnias recidivadas, oito (36,4%) apresentaram nova recorrência e essa diferença foi estatisticamente significante (p=0,05). Segundo o tipo de prótese, nos pacientes em que foi empregada a prótese de polipropileno, 13,5% apresentavam recidiva anatômica enquanto que na prótese biológica este valor foi de 31,2%, mas essa diferença observada não atingiu nível de significância estatística (p=0,13). Não foram observadas complicações relacionadas à prótese. Conclusão: O uso de prótese de polipropileno, segundo o modelo apresentado, é seguro a longo prazo e tem baixos índices de recidiva a longo prazo. A prótese biológica apresentou maiores índices de recidiva. Nas hérnias de hiato recidivas, os índices de recidiva são maiores que nas hérnias primárias / Abstract: Introduction: the surgical treatment of gastroesophageal reflux disease by laparoscopic fundoplication has good long-term results and is widely accepted as an alternative to the maintenance of medical treatment. However, surgical approach to patients with large hiatal hernias still causes disagreement among the experts. The use of prosthesis to enhance hiatus is proposed by some and dismissed by others, especially for fear of complications related to the prosthesis. Objective: To perform an analysis of long-term results of the use of prostheses for strengthening hiatoplasty in patients with large hernias treated by laparoscopy. Method: We performed a retrospective analysis of 78 patients operated between January 2000 and February 2011 with large hernias treated by laparoscopic surgery with the use of prostheses for strengthening hiatoplasty. The study included patients with hiatos larger than 5 cm in diameter, in primary or recurrent hernias. The prostheses were: polypropylene - in original model of implementation, developed in our service - and absorbable biological. The monitoring was performed by clinical interview and objective tests - endoscopy and / or barium contrast x-rays of esophagus, stomach and duodenum. Results: there was a higher presence of female patients (69%). The age ranged 33-83 years. The mean age of the patients was 64.7 years in primary hernias, whereas in the recurrent hernias, was 52.3 years. This difference was statistically significant (p = 0.0001). The mean follow-up was 45.8 months for primary hernias and 61.4 months for recurrent. (p = 0.09). In the interview, 64 patients (82.0%) remained asymptomatic, 7 (9.0%) complained of reflux, 3 (3.9%) had dysphagia and 4 (5.2%) reported problems with gas. Objective tests were performed in 68 patients (87.2%). Of these 54 (79.4%) had normal results, while 14 (20.6%) had recurrence (hernia or esophagitis). In the primary hernia group relapses occurred in six patients (13%) and in the recurrent hernia group, eight (36.4%) had recurred and this difference was statistically significant (p = 0.05). According to the type of prosthesis, in patients in whom we used the polypropylene prosthesis, 13.5% had anatomic recurrence while on the biological prosthesis this value was 31.2%, but this difference did not reach statistical significance level (p = 0.13). There were no complications related to the prosthesis. Conclusion: The use of polypropylene mesh, according to the presented model, is safe in the long term and have low recurrence rates. The biological prostheses showed higher recurrence rates. In patientes with recurrent hernias, the recurrence rates are higher than in primary hernias / Doutorado / Fisiopatologia Cirúrgica / Doutor em Ciências

<p>In this thesis, occurrence of heterotopic ossification (HO) following total hip arthroplasty (THA) was studied. Preventive effects and complications with non-steroidal anti-inflammatory drugs (NSAIDs) were analyzed. Experimental investigations on bone formation were employed to gain insight to the mechanism of NSAIDs action on bone.</p><p>(I). Fifty-six patients with bilateral THAs were analyzed. We found a strong correlation between HO on the two sides. Incidence and grade of HO were higher in men than in women.</p><p>(II). Sixty-nine patients with bilateral THAs who had been treated with NSAIDs after one or both THAs were analyzed for HO. Widespread HO occurred in untreated THAs, but in none of the treated THAs.</p><p>(III). A consecutive series of THAs were analyzed for HO. No widespread HO occurred in patients treated with NSAIDs for 21 days. In contrast, widespread HO occurred in 23% of patients not treated.</p><p>(IV). A randomized, double-blind, prospective study on 144 patients was performed to determine the efficacy and minimum treatment time with Ibuprofen for prophylaxis of HO after THA. Treatment with Ibuprofen was effective for preventing HO and a treatment time of 8 days was sufficient.</p><p>(V). A ten-year follow-up examination was performed on the patients from study IV. Thirteen patients had been revised. All but one belonged to groups treated with Ibuprofen. However, the prosthetic survival time was not statistically different for patients treated with NSAIDs compared to the control group. Eighty-four more patients underwent radiographic examination10 years after THA. Nine loose prostheses were found. These were equally distributed between NSAIDs-treated and non-treated THAs. When combining complications (revisions and radiographic loosening) no significant effects could be verified.</p><p>(VI). Experimental induction of heterotopic new bone with demineralized allogeneic bone matrix (DABM) and with bone autografts, was used in rats to study effects of NSAIDs on new bone formation. Indomethacin inhibited net bone formation in DABMs and in orthotopic fractured bone. In contrast, a net mineral loss occurred in autografts, but neither mineral content nor ⁴⁵Ca incorporation was affected by Indomethacin treatment. The amount of bone formed per mg implanted DABM was linearly correlated to implant size.</p>