Introdução / Objetivos: O prognóstico do adenocarcinoma ampular pode ser influenciado por fatores como estadiamento e variáveis histopatológicas, como o padrão intestinal ou pancreatobiliar. O diagnóstico do padrão histopatológico pode ser auxiliado pela expressão de citoqueratinas, CK, 7 e 20 e do gene homeobox CDX2. O objetivo do estudo foi analisar associações entre características histopatológicas e sobrevida, e entre padrão histopatológico e expressão de CK7, CK20 e CDX2. Método: Estudo de coorte retrospectivo desenvolvido no Hospital de Clínicas de Porto Alegre entre 2000 e 2011. Foram avaliados dados histopatológicos, estadiamento pTNM, padrão histopatológico e expressão imunoistoquímica e sobrevida. Resultados: A amostra constou de 65 carcinomas ampulares (n = 65). Foi observado padrão intestinal em 46, pancreatobiliar em 16 e outros em três. Sobrevida em cinco anos após duodenopancreatectomia (n = 47) foi de 27%. Associaram-se à menor sobrevida na análise univariada: dois ou mais linfonodos metastáticos, razão de linfonodos, RL, maior ou igual a 20%; estágio IIB em relação a inferiores; tumor de alto grau; invasão linfovascular. Na análise multivariada, metástase linfonodal e RL ≥ 20% influenciaram sobrevida. Conclusões: O pior prognóstico foi associado à metástase linfonodal. Não foi observada associação entre padrão histopatológico e expressão imunoistoquímica. / Background / Objectives: The prognosis of patients with ampullary adenocarcinomas can be influenced by such factors as pTNM stage and histopathological variables, such as intestinal or pancreatobiliary patterns. The characterization of these patterns can be facilitated by the expression of cytokeratins 7 (CK7) and 20 (CK20) and caudal-related homeobox gene 2 (CDX2). The aim of the present study was to analyze the association between the histopathological characteristics and the survival of patients with ampullary adenocarcinomas, as well as the association between the histopathological patterns and CK7, CK20 and CDX2 expression. Methods: This retrospective cohort study was performed at the Clinics Hospital of Porto Alegre between 2000 and 2011 and examined the histopathological data, pTNM stage, histopathological patterns, immunohistochemical expression patterns and survival of patients with ampullary adenocarcinomas. Results: The sample patient population consisted of 65 ampullary carcinomas. Of these carcinoma samples, an intestinal pattern was observed for 46, a pancreatobiliary pattern was observed for 16 and other patterns were observed 3 of the samples. The 5-year survival rate for patients following pancreaticoduodenectomy (n = 47) was 27%. From the univariate analysis, the following variables were associated with shorter survival times: the presence of 2 or more metastatic lymph nodes; positive lymph node ratio (LR) ≥ 20%; stage IIB or greater; high-grade tumors; and lymphovascular invasion. From the multivariate analysis, lymph node metastases and a LR ≥ 20% were shown to influence survival significantly. Conclusions: Lymph node metastases were associated with poor patient prognoses, although no association was found between the histopathological pattern and immunohistochemical expression.

Introdução: Complicações respiratórias são comuns no pós-operatório de cirurgias abdominais. Identificar os fatores de risco para tal possibilita à equipe de saúde adotar medidas protetivas, a fim de reduzir a chance de complicações e suas implicações. Objetivo: Identificar fatores de risco para complicações respiratórias no pós-operatório de cirurgias abdominais. Metodologia: Estudo de coorte retrospectivo realizado por busca em prontuário eletrônico de indivíduos adultos submetidos à cirurgia abdominal no período de Janeiro a Julho de 2016. Os dados foram analisados através do software estatístico SPSS 20.0. Para teste de normalidade foi utilizado Shapiro-Wilk, para comparação entre grupos teste de X² e t-test, para cálculo de razão de chance foi utilizada regressão logística multivariada. Considerou-se significativo p<0,05. Resultados: No período estudado foram realizadas 1586 cirurgias, sendo os pacientes 55,7% do sexo feminino com idade média de 52,12±16,56 anos. Após a cirurgia, 17,7% dos pacientes apresentaram alguma complicação respiratória; sendo a mais prevalente atelectasia. Identificou-se como fator de risco independente para o surgimento de complicações respiratórias a realização de cirurgia aberta, cirurgia de emergência, presença de pneumopatia crônica, ASA≥3, incisão supraumbilical, IMC≤21kg/m², tabagismo, idade e tempo de cirurgia. Os indivíduos que apresentaram complicações respiratórias permaneceram mais tempo hospitalizados e apresentaram maior mortalidade. Conclusão: Cirurgias abdominais realizadas por laparoscopia estão relacionadas a um menor risco de complicações respiratórias, enquanto que a presença de pneumopatia crônica é o principal fator de risco entre comorbidades. Complicações respiratórias elevam o tempo de internação e a mortalidade. / Introduction: Postoperative respiratory complications are common after abdominal surgeries. Identify risk factors helps the health team to adopt protective measures in order to reduce the chance of complications and its implications. Objective: Identify risk factors for postoperative respiratory complications after abdominal surgeries. Methodology: A retrospective cohort study was carried out by searching electronic medical records of adult subjects submitted to abdominal surgery from January to July 2016. Data were analyzed using statistical software SPSS 20.0. For the normality test, Shapiro-Wilk was used to compare groups of categorical variables. X² test was used and for continuous variables, t test for independent variables and multivariate logistic regression was used to calculate odds ratios. Significant p<0.05 was considered. Results: During the study period, 1586 surgeries were performed, 55.7% female patients with a mean age of 52.12±16.56 years. After surgery, 17.7% of the patients presented one or more respiratory complications; the most common was atelectasis. Independent risk factors identified were open surgery, emergency surgery, chronic lung disease, ASA≥3, supraumbilical incision, BMI≤21kg/m², smoking, age and surgery time. Subjects with respiratory complications presented higher length of stay and mortality. Conclusion: Abdominal surgeries performed by laparoscopy are related to a lower risk of respiratory complications, while the presence of chronic lung disease is the main risk factor among comorbidities. Respiratory complications increase length of hospital stay and mortality.

Introduction: Obesity and type 2 diabetes mellitus (hereinafter referred to as DM2T) are called the greatest epidemic of the 21st century. Its occurrence is on the rise not only in the Czech Republic but all around the world. Overweight and obesity are the key factors in developing DM2T, they are affecting the occurrence of the disease in men in 64 % and 77 % in women. Based on the observations, nearly 60 % of the population in the Czech Republic are considered obese or overweight. Bariatric/Metabolic surgery is one of the most effective treatments of the DM2T. Objectives: The objective of this thesis is to describe and analyze the effect of each bariatric surgery on the patients of 3rd Internal Clinic of Endocrinology and Metabolism, General University Hospital and 1st Medical Faculty, Charles University in Prague within the first two years post-surgery. The same time period is observed to monitor the DM2T compensation depending on the type of bariatric surgery. Methodology: 128 patients were observed (including 52 patients diagnosed with DM2T), that underwent the bariatric surgery. The data were gathered from the medical records in the hospital's information system Medea. These data were further analyzed, processed and assessed in Microsoft Excel and also together with the agency STEM/MARK a.s....

Introdução / Objetivos: O prognóstico do adenocarcinoma ampular pode ser influenciado por fatores como estadiamento e variáveis histopatológicas, como o padrão intestinal ou pancreatobiliar. O diagnóstico do padrão histopatológico pode ser auxiliado pela expressão de citoqueratinas, CK, 7 e 20 e do gene homeobox CDX2. O objetivo do estudo foi analisar associações entre características histopatológicas e sobrevida, e entre padrão histopatológico e expressão de CK7, CK20 e CDX2. Método: Estudo de coorte retrospectivo desenvolvido no Hospital de Clínicas de Porto Alegre entre 2000 e 2011. Foram avaliados dados histopatológicos, estadiamento pTNM, padrão histopatológico e expressão imunoistoquímica e sobrevida. Resultados: A amostra constou de 65 carcinomas ampulares (n = 65). Foi observado padrão intestinal em 46, pancreatobiliar em 16 e outros em três. Sobrevida em cinco anos após duodenopancreatectomia (n = 47) foi de 27%. Associaram-se à menor sobrevida na análise univariada: dois ou mais linfonodos metastáticos, razão de linfonodos, RL, maior ou igual a 20%; estágio IIB em relação a inferiores; tumor de alto grau; invasão linfovascular. Na análise multivariada, metástase linfonodal e RL ≥ 20% influenciaram sobrevida. Conclusões: O pior prognóstico foi associado à metástase linfonodal. Não foi observada associação entre padrão histopatológico e expressão imunoistoquímica. / Background / Objectives: The prognosis of patients with ampullary adenocarcinomas can be influenced by such factors as pTNM stage and histopathological variables, such as intestinal or pancreatobiliary patterns. The characterization of these patterns can be facilitated by the expression of cytokeratins 7 (CK7) and 20 (CK20) and caudal-related homeobox gene 2 (CDX2). The aim of the present study was to analyze the association between the histopathological characteristics and the survival of patients with ampullary adenocarcinomas, as well as the association between the histopathological patterns and CK7, CK20 and CDX2 expression. Methods: This retrospective cohort study was performed at the Clinics Hospital of Porto Alegre between 2000 and 2011 and examined the histopathological data, pTNM stage, histopathological patterns, immunohistochemical expression patterns and survival of patients with ampullary adenocarcinomas. Results: The sample patient population consisted of 65 ampullary carcinomas. Of these carcinoma samples, an intestinal pattern was observed for 46, a pancreatobiliary pattern was observed for 16 and other patterns were observed 3 of the samples. The 5-year survival rate for patients following pancreaticoduodenectomy (n = 47) was 27%. From the univariate analysis, the following variables were associated with shorter survival times: the presence of 2 or more metastatic lymph nodes; positive lymph node ratio (LR) ≥ 20%; stage IIB or greater; high-grade tumors; and lymphovascular invasion. From the multivariate analysis, lymph node metastases and a LR ≥ 20% were shown to influence survival significantly. Conclusions: Lymph node metastases were associated with poor patient prognoses, although no association was found between the histopathological pattern and immunohistochemical expression.

Submitted by Biblioteca do Instituto Biomédico BIB (uffbib@gmail.com) on 2017-06-05T17:54:30Z No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) JULIANA RIBEIRO PAES.pdf: 6034146 bytes, checksum: 58c9838023389c0b9dc754e1a8382dcb (MD5) / Made available in DSpace on 2017-06-05T17:54:30Z (GMT). No. of bitstreams: 2 license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) JULIANA RIBEIRO PAES.pdf: 6034146 bytes, checksum: 58c9838023389c0b9dc754e1a8382dcb (MD5) / Fundação Carlos Chagas Filho de Amparo à Pesquisa do Estado do Rio de Janeiro. / Há evidências de que profissionais de saúde apresentem menor reatividade emocional ao visualizarem cenas envolvendo dor e que o traço de empatia tenha um papel crítico na reatividade emocional. O objetivo deste estudo foi investigar a reatividade emocional a imagens de procedimentos cirúrgicos. No experimento 1, estudantes (52 de Enfermagem e 48 de Serviço Social, todas mulheres) avaliaram imagens de procedimentos cirúrgicos (relato avaliativo) quanto à agradabilidade e ativação. No experimento 2, estudantes de enfermagem (N= 27) visualizaram 4 blocos de 20 imagens: procedimentos cirúrgicos, mutilados e 2 blocos neutros pareados, enquanto sua atividade eletrocardiográfica era registrada. O traço de empatia foi medido nos dois experimentos. No Experimento 1, a valência média para as imagens de procedimentos cirúrgicos no grupo de Enfermagem (M = 4,57, DP = 1,02) foi maior do que no grupo de Serviço Social (M = 3,31, DP = 1,05). Além disso, a maioria das estudantes de Enfermagem (65,4%) escolheu "neutro" como a palavra que melhor descrevia o que sentiam ao ver as fotos de cirurgia. No grupo de Serviço Social, o nojo (54,2%) foi a emoção mais escolhida. No experimento 2, observou-se que a curva de resposta cardíaca (desacelerativa) para as imagens de mutilados diferiu da curva neutra pareada desde o ponto 4 (2s de visualização) até o ponto 12 (6s). Já a curva para as imagens de procedimentos cirúrgicos diferiu da curva neutra pareada somente do ponto 6 (3s) até o ponto 9 (4500 ms), sugerindo uma resposta cardíaca atenuada e/ou recuperação da bradicardia. Observou-se uma correlação entre o traço de empatia e a magnitude da desaceleração cardíaca, com níveis mais altos de empatia associados à maior amplitude da desaceleração no bloco de procedimentos cirúrgicos. Em conjunto, os dados mostram a importância da relevância ocupacional das imagens em sua avaliação subjetiva e impacto cardiovascular. / There is evidence that health professionals are less emotionally reactive when viewing scenes involving pain and that the empathy trait plays a critical role in emotional reactivity. The objective of this study was to investigate the emotional reactivity to images of surgical procedures. In the experiment 1, students (52 Nursing and 48 Social Work students, all women) evaluated images of surgical procedures (self-report) regarding the pleasantness and arousal. In the experiment 2, nursing students (N = 27) visualized 4 blocks of 20 images: surgical procedures, mutilated and 2 paired neutral blocks, while their electrocardiographic activity was recorded. The empathy trait was measured in both experiments. In Experiment 1, the mean valence for surgical procedures images in the Nursing group (M = 4.57, SD = 1.02) was higher than in the Social Work group (M = 3.31, SD = 1, 05). In addition, the majority of Nursing students (65.4%) chose "neutral" as the word that best described what they felt when they saw the surgery photos. In the Social Work group, disgust (54.2%) was the most chosen emotion. In experiment 2, it was observed that the cardiac (decelerating) response curve for the mutilated images differed from the paired neutral curve from point 4 (visualization in 2s) to point 12 (6s). The curve for the images of surgical procedures differed from the neutral paired curve only from point 6 (3s) to point 9 (4500 ms), suggesting an attenuated cardiac response and/or bradycardia recovery. A correlation was observed between the empathy trait and the magnitude of the cardiac deceleration, with higher levels of empathy associated with the greater amplitude of the deceleration in the surgical procedures block. Together, the data shows the importance of the occupational relevance of the images in their subjective evaluation and cardiovascular impact.

Introdução: Complicações respiratórias são comuns no pós-operatório de cirurgias abdominais. Identificar os fatores de risco para tal possibilita à equipe de saúde adotar medidas protetivas, a fim de reduzir a chance de complicações e suas implicações. Objetivo: Identificar fatores de risco para complicações respiratórias no pós-operatório de cirurgias abdominais. Metodologia: Estudo de coorte retrospectivo realizado por busca em prontuário eletrônico de indivíduos adultos submetidos à cirurgia abdominal no período de Janeiro a Julho de 2016. Os dados foram analisados através do software estatístico SPSS 20.0. Para teste de normalidade foi utilizado Shapiro-Wilk, para comparação entre grupos teste de X² e t-test, para cálculo de razão de chance foi utilizada regressão logística multivariada. Considerou-se significativo p<0,05. Resultados: No período estudado foram realizadas 1586 cirurgias, sendo os pacientes 55,7% do sexo feminino com idade média de 52,12±16,56 anos. Após a cirurgia, 17,7% dos pacientes apresentaram alguma complicação respiratória; sendo a mais prevalente atelectasia. Identificou-se como fator de risco independente para o surgimento de complicações respiratórias a realização de cirurgia aberta, cirurgia de emergência, presença de pneumopatia crônica, ASA≥3, incisão supraumbilical, IMC≤21kg/m², tabagismo, idade e tempo de cirurgia. Os indivíduos que apresentaram complicações respiratórias permaneceram mais tempo hospitalizados e apresentaram maior mortalidade. Conclusão: Cirurgias abdominais realizadas por laparoscopia estão relacionadas a um menor risco de complicações respiratórias, enquanto que a presença de pneumopatia crônica é o principal fator de risco entre comorbidades. Complicações respiratórias elevam o tempo de internação e a mortalidade. / Introduction: Postoperative respiratory complications are common after abdominal surgeries. Identify risk factors helps the health team to adopt protective measures in order to reduce the chance of complications and its implications. Objective: Identify risk factors for postoperative respiratory complications after abdominal surgeries. Methodology: A retrospective cohort study was carried out by searching electronic medical records of adult subjects submitted to abdominal surgery from January to July 2016. Data were analyzed using statistical software SPSS 20.0. For the normality test, Shapiro-Wilk was used to compare groups of categorical variables. X² test was used and for continuous variables, t test for independent variables and multivariate logistic regression was used to calculate odds ratios. Significant p<0.05 was considered. Results: During the study period, 1586 surgeries were performed, 55.7% female patients with a mean age of 52.12±16.56 years. After surgery, 17.7% of the patients presented one or more respiratory complications; the most common was atelectasis. Independent risk factors identified were open surgery, emergency surgery, chronic lung disease, ASA≥3, supraumbilical incision, BMI≤21kg/m², smoking, age and surgery time. Subjects with respiratory complications presented higher length of stay and mortality. Conclusion: Abdominal surgeries performed by laparoscopy are related to a lower risk of respiratory complications, while the presence of chronic lung disease is the main risk factor among comorbidities. Respiratory complications increase length of hospital stay and mortality.

Glycaemic control in critically ill patients has been a topic of considerable attention for the past 20 years. In literature and at scientific meetings, there have been ongoing debates regarding the efficacy of glycaemic control in these patients with frequently entirely opposite opinions. These range from a strict invasive approach with target glycaemia 4-6 mmol/l to a liberal approach tolerating even values higher than 12 mmol/l. In the preview of this PhD thesis we have analysed so far published literature and describe the reasons for this inconsistency. According to the results of recent studies, the most significant efficacy of tight glycaemic control has been observed in cardiac surgical patients. If we consider the concept of tight glycaemic control as efficient strategy, there are three important questions remaining unanswered as follow. Does the specific algorithm-protocol play a key part in the concept of tight glycaemic control alongside the knowledge and skills of nursing staff in safe and efficient blood glucose control? What is the ideal timing of starting the strategy of tight glycaemic control (TGC) in cardiac surgical patient? And is there any benefit in outcome respect to mortality or morbidity? Do we have any more safe and efficient option or add-on to standard perioperative...

INTRODUÇÃO: As reconstruções com tecidos combinados e bem vascularizados permitem a melhor reabilitação para defeitos extensos em cabeça e pescoço. O padrão-ouro tem sido as transferências microcirúrgicas de tecidos. Porém, há pacientes em que não há vasos receptores cervicais adequados para os transplantes de tecidos livres devido à múltiplas recidivas, ressecções e reconstruções; linfadenectomias cervicais; fístulas e infecções; e o tratamento com radioterapia. Com o aprimoramento do controle oncológico, pacientes nestas circunstâncias são cada vez mais frequentes e há poucas alternativas para reconstrução. OBJETIVO: Descrever a dissecação anatômica de um retalho osteomiocutâneo combinado, pediculado nos vasos torácicos internos, para reconstrução de defeitos complexos em cabeça e pescoço. MÉTODO: Retalhos osteomiocutâneos contendo 6ª e 7ª costelas e músculo reto abdominal foram dissecados bilateralmente em 35 cadáveres, 26 do sexo masculino e 9 do sexo feminino. Estudou-se a vascularização cutânea do abdome superior pelas perfurantes da artéria epigástrica superior superficial (SSEA); e os padrões de vascularização do 6º e 7º arcos costais e músculo reto abdominal a partir dos vasos torácicos internos, musculofrênicos e intercostais. O arco de rotação para segmento cefálico com ponto pivô na margem inferior da primeira costela foi avaliado. RESULTADOS: Foram dissecadas 114 perfurantes SSEA, 62 à direita e 52 à esquerda, com calibre arterial médio homogêneo de 0,68 mm. A maior frequência de perfurantes encontradas foi no grupo de 0,5 a 1,0 mm, com 60 (52,7%) ocorrências. Não houve diferença estatisticamente significativa para localização e calibre em relação ao lado. Também não houve correlação dos calibres com localização, idade, peso e altura dos cadáveres. Sessenta e dois retalhos osteomiocutâneos com pedículo nos vasos torácicos internos, 6° e 7° arcos costais e músculo reto abdominal foram divididos em 3 tipos de acordo com o padrão de vascularização do sexto arco costal. O tipo 1, em que a vascularização da sexta costela é pela artéria musculofrênica, foi o mais frequente, com 46 (74,2%) ocorrências. Dez pedículos vasculares diferentes para os componentes do retalho foram individualizados e medidos bilateralmente. Apenas quatro foram significativamente maiores nos homens e, dois, maiores à direita. Os calibres de todos os pedículos arteriais foram homogêneos em relação ao sexo e ao lado. O comprimento do pedículo para o componente ósseo do retalho variou de 18,5 a 21,6 cm, alcançando mandíbula e maxila em todos as dissecações. Já o componente miocutâneo do reto abdominal atingiu occipício em todos os casos e levou os vasos epigástricos profundos inferiores para possível anastomose vascular. Cinco pacientes foram operados em 2 anos com adequada integração dos retalhos e recuperação do contorno e função mandibulares. CONCLUSÃO: Em todas as dissecações de cadáver as perfurantes SSEA estiveram presentes bilateralmente com calibre maior que 0,3 mm; os retalhos osteomiocutâneos pediculados nos vasos torácicos internos foram constantes e alcançaram o segmento cefálico. Os pacientes operados recuperaram forma e função mandibulares. Este retalho pode ser uma alternativa para reconstruções secundárias em cabeça e pescoço / INTRODUCTION: The use of combined well-vascularized flaps offers better results and rehabilitation for complex head and neck defects. Microsurgical reconstructions are the gold standard. However, there are patients with vessel-depleted necks from multiple recurrences and resections, failed reconstructions, neck dissections, infections, fistulas and radiotherapy, which impair adequate free tissue transfers. With better oncologic therapies, these patients have become more common and lack reconstructive options. OBJECT: To describe a combined ostemyocutaneous pedicled flap based on the internal mammary artery for complex head and neck reconstructions. METHOD: Osteomyocutaneous flaps with 6th and 7th ribs and the rectus abdominis muscle were dissected bilaterally on 35 cadavers, 26 male and 9 female. We studied the upper abdominal irrigation through isolation of the superficial superior epigastric artery perforators (SSEA) and the vascular pedicles to the 6th and 7th ribs, and the rectus abdominis muscle arising from the internal mammary, the musculophrenic and the intercostal arteries. The arc of rotation of the flap to the cephalic segment was tested with the pivot point on the lower margin of the first rib. RESULTS: We dissected 114 SSEA, 62 on the right side and 52 on the left. They had an homogeneous mean arterial diameter of 0,68 mm. Sixty perforators (52,7%) were on the group that ranged from 0,5 to 1,0 mm. After statistical analysis, there were no differences in relation to the side as for location and caliber of the perforators. Neither there was any relation of the arterial calibers to the location, age, weight and height of the cadavers. Sixty-two internal mammary artery pedicled osteomyocutaneous flaps, that carried the 6th and 7th ribs and the rectus abdominis muscle, were divided in 3 types depending on the vascular pattern to the 6th costal arch. Type 1, where the pedicle to the 6th rib branches from the musculophrenic artery, was the most frequent and dissected in 46 flaps (74,2%). Ten different vascular pedicles to the components of the flap were isolated and measured bilaterally. Only four of them were significantly longer in males and, two, were longer on the right side. The arterial diameters were also homogeneous in relation to the side and sex. The pedicle length to the osseous component of the flap varied from 18,5 to 21,6 cm, which allowed to reach mandible and maxilla in all dissections. The myocutaneous component of the rectus abdominis muscle reached the occipitum in all cases and carried along the deep inferior epigastric vessels for vascular anastomosis if needed. Five patients were operated in 2 years with adequate flap integration and recovery of the mandible contour and function. CONCLUSION: In all cadaveric dissections SSEA perforators were bilaterally present with a caliber bigger than 0,3 mm; internal mammary artery osteomyocutaneous pedicled flaps were constant and reached the cephalic segment. The operated patients recovered mandibular form and function. This flap can be an alternative for secondary head and neck reconstructions

INTRODUÇÃO: As reconstruções com tecidos combinados e bem vascularizados permitem a melhor reabilitação para defeitos extensos em cabeça e pescoço. O padrão-ouro tem sido as transferências microcirúrgicas de tecidos. Porém, há pacientes em que não há vasos receptores cervicais adequados para os transplantes de tecidos livres devido à múltiplas recidivas, ressecções e reconstruções; linfadenectomias cervicais; fístulas e infecções; e o tratamento com radioterapia. Com o aprimoramento do controle oncológico, pacientes nestas circunstâncias são cada vez mais frequentes e há poucas alternativas para reconstrução. OBJETIVO: Descrever a dissecação anatômica de um retalho osteomiocutâneo combinado, pediculado nos vasos torácicos internos, para reconstrução de defeitos complexos em cabeça e pescoço. MÉTODO: Retalhos osteomiocutâneos contendo 6ª e 7ª costelas e músculo reto abdominal foram dissecados bilateralmente em 35 cadáveres, 26 do sexo masculino e 9 do sexo feminino. Estudou-se a vascularização cutânea do abdome superior pelas perfurantes da artéria epigástrica superior superficial (SSEA); e os padrões de vascularização do 6º e 7º arcos costais e músculo reto abdominal a partir dos vasos torácicos internos, musculofrênicos e intercostais. O arco de rotação para segmento cefálico com ponto pivô na margem inferior da primeira costela foi avaliado. RESULTADOS: Foram dissecadas 114 perfurantes SSEA, 62 à direita e 52 à esquerda, com calibre arterial médio homogêneo de 0,68 mm. A maior frequência de perfurantes encontradas foi no grupo de 0,5 a 1,0 mm, com 60 (52,7%) ocorrências. Não houve diferença estatisticamente significativa para localização e calibre em relação ao lado. Também não houve correlação dos calibres com localização, idade, peso e altura dos cadáveres. Sessenta e dois retalhos osteomiocutâneos com pedículo nos vasos torácicos internos, 6° e 7° arcos costais e músculo reto abdominal foram divididos em 3 tipos de acordo com o padrão de vascularização do sexto arco costal. O tipo 1, em que a vascularização da sexta costela é pela artéria musculofrênica, foi o mais frequente, com 46 (74,2%) ocorrências. Dez pedículos vasculares diferentes para os componentes do retalho foram individualizados e medidos bilateralmente. Apenas quatro foram significativamente maiores nos homens e, dois, maiores à direita. Os calibres de todos os pedículos arteriais foram homogêneos em relação ao sexo e ao lado. O comprimento do pedículo para o componente ósseo do retalho variou de 18,5 a 21,6 cm, alcançando mandíbula e maxila em todos as dissecações. Já o componente miocutâneo do reto abdominal atingiu occipício em todos os casos e levou os vasos epigástricos profundos inferiores para possível anastomose vascular. Cinco pacientes foram operados em 2 anos com adequada integração dos retalhos e recuperação do contorno e função mandibulares. CONCLUSÃO: Em todas as dissecações de cadáver as perfurantes SSEA estiveram presentes bilateralmente com calibre maior que 0,3 mm; os retalhos osteomiocutâneos pediculados nos vasos torácicos internos foram constantes e alcançaram o segmento cefálico. Os pacientes operados recuperaram forma e função mandibulares. Este retalho pode ser uma alternativa para reconstruções secundárias em cabeça e pescoço / INTRODUCTION: The use of combined well-vascularized flaps offers better results and rehabilitation for complex head and neck defects. Microsurgical reconstructions are the gold standard. However, there are patients with vessel-depleted necks from multiple recurrences and resections, failed reconstructions, neck dissections, infections, fistulas and radiotherapy, which impair adequate free tissue transfers. With better oncologic therapies, these patients have become more common and lack reconstructive options. OBJECT: To describe a combined ostemyocutaneous pedicled flap based on the internal mammary artery for complex head and neck reconstructions. METHOD: Osteomyocutaneous flaps with 6th and 7th ribs and the rectus abdominis muscle were dissected bilaterally on 35 cadavers, 26 male and 9 female. We studied the upper abdominal irrigation through isolation of the superficial superior epigastric artery perforators (SSEA) and the vascular pedicles to the 6th and 7th ribs, and the rectus abdominis muscle arising from the internal mammary, the musculophrenic and the intercostal arteries. The arc of rotation of the flap to the cephalic segment was tested with the pivot point on the lower margin of the first rib. RESULTS: We dissected 114 SSEA, 62 on the right side and 52 on the left. They had an homogeneous mean arterial diameter of 0,68 mm. Sixty perforators (52,7%) were on the group that ranged from 0,5 to 1,0 mm. After statistical analysis, there were no differences in relation to the side as for location and caliber of the perforators. Neither there was any relation of the arterial calibers to the location, age, weight and height of the cadavers. Sixty-two internal mammary artery pedicled osteomyocutaneous flaps, that carried the 6th and 7th ribs and the rectus abdominis muscle, were divided in 3 types depending on the vascular pattern to the 6th costal arch. Type 1, where the pedicle to the 6th rib branches from the musculophrenic artery, was the most frequent and dissected in 46 flaps (74,2%). Ten different vascular pedicles to the components of the flap were isolated and measured bilaterally. Only four of them were significantly longer in males and, two, were longer on the right side. The arterial diameters were also homogeneous in relation to the side and sex. The pedicle length to the osseous component of the flap varied from 18,5 to 21,6 cm, which allowed to reach mandible and maxilla in all dissections. The myocutaneous component of the rectus abdominis muscle reached the occipitum in all cases and carried along the deep inferior epigastric vessels for vascular anastomosis if needed. Five patients were operated in 2 years with adequate flap integration and recovery of the mandible contour and function. CONCLUSION: In all cadaveric dissections SSEA perforators were bilaterally present with a caliber bigger than 0,3 mm; internal mammary artery osteomyocutaneous pedicled flaps were constant and reached the cephalic segment. The operated patients recovered mandibular form and function. This flap can be an alternative for secondary head and neck reconstructions

Les fentes labio-palatines (FLP) sont la malformation cranio-faciale congénitale la plus fréquente. D'origine multifactorielle, elles sont la conséquence d'un défaut de fusion des bourgeons faciaux.Objectif et MéthodologieL'objectif de ce travail a été d'étudier la place des gènes de l'angiogenèse dans le cadre de la piste étiologique des FL/P. La méthodologie de ce travail comportait 3 étapes :- Une analyse systématique et exhaustive des gènes impliqués dans les FL/P comprenant les gènes identifiés mais aussi les gènes potentiellement impliqués.- Une analyse rétrospective des explorations génétiques des FL/P opérées au CHU de Reims entre 2003 et 2009.- La mise en place d'une analyse prospective (2009-2012, AOL) :- Génomique constitutionnelle par CGH Array- In situ au niveau des berges des fentes issues de déchets opératoires des chirurgies primaires des FL/P comprenant :Le développement d'un protocole de culture cellulaire de fibroblastesUne analyse anatomopathologiqueEt surtout le développement d'un modèle d'étude in vivo chez l'enfant d'analyse d'expression des gènes de l'angiogenèse.RésultatsL'analyse systématique des gènes impliqués dans les FL/P a mis en évidence 95 gènes dont plus d'une dizaine sont connus comme liés aux mécanismes d'angiogenèse (facteurs de croissance et protéases). Ces derniers sont en interaction entre eux mais aussi avec 18 autres gènes impliqués eux aussi dans les FL/P. Ainsi au total 1/3 des gènes d'intérêt sont soit des gènes de l'angiogenèse soit en lien avec eux.L'étude rétrospective nous a permis de mettre en exergue certaines formes cliniques originales qui ont été étudiées et publiées sous un angle « étiologique ».L'étude prospective nous a permis, après obtention des consentements, d'inclure 72 patients (30 FLP, 24FL, 18FP) opérés au CHU de Reims entre 2009 et 2012 d'une chirurgie primaire.Nous présentons :- nos résultats anatomopathologiques, et génétiques (CGH Array)- notre protocole de culture cellulaire- nos réflexions, notre cheminement aboutissant à la création du modèle d'étude d'analyse d'expression des gènes de l'angiogenèseDiscussionLa littérature a bien mis en avant une implication des phénomènes angiogéniques dans la constitution des FL/P par le biais des facteurs de croissance (TGFβ, PDGF C et Ra, FGF, TGFA, FGFR1, FGFR2 ; VEGF) et des protéases (MMP/TIMP2). L'ensemble de nos manipulations in situ nous permet aujourd'hui de disposer du matériel nécessaire pour l'étude de l'expression des facteurs impliqués dans l'angiogenèse sur les berges des fentes.Parallèlement, l'étude génomique constitutionnelle en CGH Array a permis de retrouver des variations non-connues comme polymorphiques chez 62% de nos patients. Des études familiales vont compléter notre travail. Elles permettront de savoir si ces CNV sont héritées ou De Novo et ainsi de préciser leur caractère bénin ou pathologique. L'identification chez un de nos patients d'une amplification, même de petite taille, du gène SKI (gène lié à la voie des TGFβ) nous encourage dans la poursuite de nos recherches d'anomalies constitutionnelles des gènes de l'angiogenèse dans les FL/PLa CGH array est une technique qui nous a paru particulièrement utile et fiable en terme de « scanning » et de dépistage.En conclusion, en pratique clinique, la découverte des anomalies préalablement certainement sous estimées par les cliniciens doit nous mener à une nouvelle réflexion sur le conseil génétique et sur l'utilité dans l'avenir d'un dépistage plus systématique. / Cleft lip and palate (CLP) are the most common congenital craniofacial malformation. They have a multifactorial etiology and are the consequence of incomplete fusion of the facial buds.Objective and MethodologyThe objective of this work was to study the role of the genes of angiogenesis in the framework of studying the etiology of CL/P. Our methodological approach included 3 steps:- Systematic and thorough analysis of the genes involved in CL/P including identified genes but also genes that could be potentially involved.- A retrospective analysis of the operated clefts at the University Hospital of Reims between 2003 and 2009.- Implementation of a prospective analysis (2009-2012, AOL):- Constitutional genomic study by CGH Array- In situ with tissue specimens extracted from surgically excised cleft edges including:The development of a protocol for fibroblast cell culturesHistopathological analysisAnd above all the development of an in vivo study model in children for analyzing the expression of genes of angiogenesis.ResultsThe systemic analysis of genes involved in cleft lip palate unveiled 95 genes including about ten that are known to be related to angiogenesis mechanisms (growth factor and proteases). These genes interact between themselves but also with 18 other genes also involved in CL/P. In all, 1/3 of relevant genes are either angiogenesis-related genes or in direct relation with them.The retrospective study permitted to underline the some original clinical forms that were studied and published under an « etiological » angle.The prospective study included 72 patients (30 CLP, 24CL, 18CP), for whom we obtained informed signed consents, operated at the University Hospital of Reims between 2009 and 2012 for primary cleft surgery.We present:- Our histopathological and genetic results (CGH Array)- Our cell culture protocol (submitted for publication)- Our approaches and thought process behind the design of a study model for analyzing expression profiling of angiogenic genesDiscussionThe literature has highlighted the role of angiogenesis in the formation of cleft lip/palate via growth factors (TGFβ, PDGF C and Ra, FGF, TGFA, FGFR1, FGFR2, VEGF) and proteases (MMP/TIMP2). All our manipulations in situ have yielded the necessary material, i.e. edges of resected clefts, to study the expression of factors involved in cleft angiogenesis.In parallel, the constitutional genomic study in CGH Array enabled to uncover abnormalities in 62% of our patients. Family studies will complete our work. They will help to refine if these CNV are inherited or de novo and thus indicate their benign or pathological nature. In one of our patients, the identification of the SKI gene (related to the TGFβ pathway) encourages us to continue our research of genetic abnormalities of angiogenic genes involved in cleft lip/palate. CGH array appeared to be a very useful and reliable method in terms of scanning and screening.In conclusion, in clinical practice, the discovery of abnormalities which were probably underestimated by clinicians before, leads us to rethink the issue of genetic counseling and the relevance of a more systematic screening for these abnormalities in the future.