published_or_final_version / abstract / Medicine / Master / Doctor of Medicine

Dissertação (mestrado) - Universidade Federal de Santa Catarina, Centro de Ciências da Saúde. / Made available in DSpace on 2012-10-17T12:19:35Z (GMT). No. of bitstreams: 0Bitstream added on 2014-09-25T19:23:58Z : No. of bitstreams: 1 170789.pdf: 19642286 bytes, checksum: 9524d54ee3758c77930c7b3cbf84d713 (MD5) / A musculatura lisa presente no saco herniário de hérnias inguinais do tipo indireta de pacientes adultos do sexo masculino foi estudada quanto a prevalência em seus três terços e a relação com o tempo, lado e tamanho da hérnia, bem como a idade do paciente e seu índice de massa corpórea, visando descobrir situações que tornem o saco herniário mais ou menos apto para sua utilização como reforço da parede posterior. Ocorreram diferenças histológicas significavas apenas em sacos herniários muito pequenos, que não apresentaram musculatura lisa. Concluímos que todos os sacos herniários de hérnias inguinais do tipo indireta podem ser utilizados no estudo da validade da técnica proposta por Lázaro da Silva.

Einleitung: In Zeiten des digitalen Fortschritts und wachsender Speicherkapazitäten wird es möglich, immer größere Datenmengen zu verarbeiten. Gleichzeitig besteht der Wunsch, aus diesen Daten neue Informationen im Sinne des „Information retrieval“ zu gewinnen. PaDaWaN ist ein parametrisierbares Data Warehouse Framework zur effizienten Abfrage und Auswertung homogener und heterogener Datenbestände, das 2011 an der Universität Würzburg entwickelt wurde. Methoden: Zur Validierung des Data Warehouses in der Viszeralchirurgie wurden die automatisiert generierten Daten aus PaDaWaN mit den manuell erhobenen Registerdaten des EuraHS Registers verglichen. Eingeschlossen wurden Patienten mit der Diagnose einer inzisionalen oder primär ventralen Hernie (n=510). Hierfür wurden Informationen zu Diagnosen, Operationen und die intraoperativ verwendeten Materialien aus strukturierten und unstrukturierten Datenquellen des CIS ausgelesen. Das Maß der Übereinstimmung wurde mittels Cohens Kappa-Koeffizienten berechnet (IBM SPSS Statistics 24). Ergebnisse: Im Rahmen der Studie konnten Diskrepanzen zwischen strukturierten Datenquellen (ICD-10 Codes, OPS Codes) und unstrukturierten Datenquallen (Arztbriefe, Operationsberichte) aufgedeckt werden. Unstimmigkeiten in der ICD-10 Klassifikation für primär ventrale und inzisionale Hernien führten zu einer deutlichen Unterschätzung der inzisionalen umbilikalen Hernien. Sehr gute Übereinstimmungen wurden in den Kategorien Netzimplantation in IPOM-Technik, Underlay- und Sublay-Position erreicht. Faktoren, die die Konkordanz der Datensätze beeinflussten, waren: Erfassung von Vordiagnosen, Voroperationen, mangelndes Erkennen von Negierungen und die Verwendung mehrerer Netze während einer Operation. Klassifikationen wie die "Dietz-Klassifikation" konnten automatisch erkannt und in ihre Bestandteile zerlegt werden. Fazit: Durch die Etablierung von Data Warehousing als Plattform für die klinische Forschung können Daten in Zukunft schneller strukturiert und generiert werden. Durch die dynamische tägliche automatisierte Datenaktualisierung kann das klinische Personal Behandlungskonzepte und Ergebnisse schneller validieren und bewerten. Darüber hinaus können Empfehlungen für zukünftige medizinische Dokumentation gegeben werden, um die Informationsextraktion von PaDaWaN zu verbessern. Die Ergebnisse dieser Studie zeigen deutliche Diskrepanzen zwischen strukturierten und unstrukturierten Datenquellen. Vorhandene Register und Daten des CIS können zukünftig im Sinne einer internen Validierung verifiziert und damit manuelle Dokumentationsfehler nachhaltig aufgedeckt werden. / Introduction: Since technology is advancing and storage capacities are growing, it is possible to process larger amounts of data. Meanwhile, there is the desire to generate useful knowledge from this aggregated data, which is not found explicitly or cannot be identified at once in the data. PaDaWaN is a parameterizable data warehouse framework for an efficient query and evaluation of homogeneous as well as heterogeneous data sets, which was developed at the University of Würzburg in 2011. Methods: To validate the data warehouse in visceral surgery, automatically generated data from PaDaWaN was compared with manually collected registry data from the EuraHS registry. Patients with a diagnosis of incisional or primary ventral hernia (n=510) were included. For this purpose, information on diagnoses, operations and the materials used intraoperatively were extracted from structured and unstructured data sources of the CIS. Concordance between the information obtained from the different data sources (regarding the exactly same patients) was calculated using the kappa coefficient (IBM SPSS Statistics 24). Results: Applying these methods, discrepancies between ICD-10 codes and medical reports were found. Relying on ICD-10 codes resulted in a marked underestimation of incisional umbilical hernias due to inconsistencies in the ICD 10 classification for primary ventral and incisional hernias. Very good concordance was achieved in the categories mesh implantation in IPOM technique, underlay and sublay position. Factors that influenced the concordance of the data sets were: Recording of prediagnoses, preoperations, inability to recognize negations, and the use of multiple meshes in the same procedure. Classifications such as the “Dietz classification” could be automatically recognized and separated into their components. Conclusion: By establishing Data Warehousing as a clinical research platform, data can be structured and generated faster in the future. The dynamic daily automated data update enables clinical staff to validate and evaluate treatment concepts and results more easily. Furthermore, recommendations for future medical reports can be given in order to improve information extraction of Data Warehousing. The results also show that depending on the intention of data collection, there is a great discrepancy between data regarding the very same patient. Existing registers and data of the CIS can be verified in the sense of an internal validation and thus manual documentation errors can be detected sustainably.

INTRODUCTION Internal abdominal hernias are infrequent but an increasing cause of bowel obstruction still often underdiagnosed. Among adults its usual causes are congenital anomalies of intestinal rotation, postsurgical iatrogenic, trauma or infection diseases. PRESENTATION OF CASE We report the case of a 63-year-old woman with history of chronic constipation. The patient was hospitalized for two days with acute abdominal pain, abdominal distension and inability to eliminate flatus. The X-ray and abdominal computerized tomography scan (CT scan) showed signs of intestinal obstruction. Exploratory laparotomy performed revealed a trans-mesenteric hernia containing part of the transverse colon. The intestine was viable and resection was not necessary. Only the hernia was repaired. DISCUSSION Internal trans-mesenteric hernia constitutes a rare type of internal abdominal hernia, corresponding from 0.2 to 0.9% of bowel obstructions. This type carries a high risk of strangulation and even small hernias can be fatal. This complication is specially related to trans-mesenteric hernias as it tends to volvulize. Unfortunately, the clinical diagnosis is rather difficult. CONCLUSION Trans-mesenteric internal abdominal hernia may be asymptomatic for many years because of its nonspecific symptoms. The role of imaging test is relevant but still does not avoid the necessity of exploratory surgery when clinical features are uncertain. / Revisión por pares

Background Surgery has traditionally been considered more expensive than many other health care interventions and with little impact on the burden of disease in a global perspective. One of the reasons behind this misconception is that the effects of surgical conditions and their treatment have not been factored into the equation. Cost-effectiveness analyses of surgical interventions have largely been missing. An estimated 20 million herniorrhaphies are carried out annually but over 200 million people suffer from groin hernias. Herniorrhaphy is one of the most commonly performed surgical procedures also in Low and Middle Income Countries (LMIC). However, the surgical repair method is not the same due to financial constraints. In high income countries a synthetic mesh is used and has reduced the risk of recurrence. This 125 USD mesh is too costly for the majority in LMIC. Mosquito mesh, which is cheaper but very similar to commercial meshes, is used in several settings but outcomes need to be investigated more extensively before this practice can be recommended in routine surgical service. The Aims of this thesis were to define the prevalence of groin hernia, to relate it to the surgical capacity, outcomes and costs of surgery in eastern Uganda and to investigate the feasibility and difference in cost and cost-effectiveness of replacing a commercial mesh with a mosquito mesh in groin hernia surgery. Methods Three studies (1-3) were carried out in eastern Uganda. 1: A cross sectional study investigating the prevalence of groin hernia in adult males in the Health and Demographic Surveillance Site (HDSS) in Iganga and Mayuge districts. 2: A facility based study with prospective data collection of all surgeries undertaken in the two hospitals providing surgery for the HDSS population. 3: A double blinded, randomised controlled trial comparing the outcomes of using a mosquito mesh relative using a commercial mesh in groin hernia surgery. Results 1: the prevalence of untreated groin hernia among the study participants was 6.6%. 2: the rate of groin hernia surgery was 17 per 100 000 population. Thus, less than 1% of the estimated number of cases of groin hernia in the catchment area of the two hospitals are operated per year. A herniorrhaphy costs around 60 USD to perform. This corresponds to a third of the cost of TB treatment and a 15th of the cost of HIV/AIDS treatment per year in Uganda. 3: No significant differences in terms of recurrence rates, post operative and chronic complications and patient satisfaction were demonstrated between the patients operated using the mosquito mesh and the commercial mesh. Cost-effectiveness was very high for both materials but total cost in the mosquito mesh group was 124 USD lower per surgery than in the commercial mesh group. Conclusion There is a vast unmet need for groin hernia surgery. Cost of surgery compares favourably with other health care interventions prioritised by the international organisations and funders. A superior technique can be used in groin hernia surgery at low cost, with high cost-effectiveness in a Low Income Country.

京都大学 / 新制・課程博士 / 博士(医学) / 甲第24472号 / 医博第4914号 / 新制||医||1062(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 今中 雄一, 教授 山本 洋介, 教授 小濱 和貴 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Traumatic diaphragmatic hernia (TDH) is a known complication in patients with abdominal injuries. Delayed TDH, which presents long after the traumatic event, is a rare subset and is often missed upon initial presentation. We discuss a case involving a 15-year-old female who presented with persistent nausea, vomiting, and epigastric pain and was subsequently diagnosed with TDH via chest x-ray, later confirmed by CT scan. Further investigation of the patient's history revealed a motor vehicle accident one year prior in which the patient sustained an injury to the left chest. A chest x-ray at that time did not show signs of a diaphragmatic hernia. Surgical evaluation of the diaphragmatic defect further supported previous trauma as the mechanism of injury. Our patient's presentation is particularly interesting considering the lack of TDH reported in the pediatric population, as well as the presenting complaints being primarily gastrointestinal rather than respiratory.

A hernia frequently complicates abdominal stoma formation. The aetiology of parastomal herniation is claimed to be multi-factorial but currently only age and trephine diameter have been shown to independently predict its development. Open or laparoscopic repair of a symptomatic parastomal hernia is frequently challenging and is associated with unsatisfactory recurrence rates. As a result, many affected patients are managed non-operatively. Prevention of parastomal herniation by prophylactic mesh reinforcement of the stoma site is a new strategy that may reduce its incidence. Manual mesh implantation, however, is thought to increase the operating time and is considered cumbersome, particularly in laparoscopic surgery. As a result, routine reinforcement of the stoma site is not currently standard practice within the National Health Service. Thus, there is a need for a simple and quick technique for stoma formation which avoids creating an oversized defect and simultaneously reinforces the trephine with mesh. The aims of this thesis included: (i) understanding the aetiopathogenesis of parastomal herniation, assessing its impact on patients’ quality of life and examining the outcomes associated with current therapeutic strategies in order to find novel therapies that may lead to its prevention; (ii) assessing the safety, reproducibility and efficacy of the Stapled Mesh stomA Reinforcement Technique (SMART) in preventing parastomal herniation and (iii) investigating the contribution of the rectus abdominis muscle to the development of herniation. A detailed literature review of PubMed and Medline databases confirmed that stoma formation through the rectus muscle is complicated by parastomal herniation in 50%-80% of 4 cases. Surgeons have underestimated its impact on patients’ quality of life. There is no conclusive evidence that alternative techniques (e.g. extraperitoneal, lateral rectus abdominis positioned stoma) are superior. Open and laparoscopic parastomal hernia repair have similar recurrence rates up to 50%. Prophylactic reinforcement of the stoma trephine with mesh in the sublay or subperitoneal position is safe and appears to reduce the herniation rate but it is difficult laparoscopically and does not address the issue of trephine size when a defect <25mm is associated with a reduced herniation risk. The Stapled Mesh stomA Reinforcement Technique (SMART) obviates the technical issues associated with routine stoma formation and reinforcement. In a pilot study with patients at high risk for herniation, SMART was found to be safe and reproducible and reduced the herniation rate to 18%. Preliminary results of the international multicentre randomised controlled trial in all patients undergoing permanent stoma formation show that SMART reduces the herniation rate compared to the standard technique, without added morbidity and minimal impact on the operating time. A radiological study assessing the contribution of the rectus abdominis muscle into the development of parastomal herniation showed that the abdominal musculature undergoes postoperative changes consistent with atrophy with postoperative muscle density being higher in patients without parastomal herniation. In conclusion, at this moment in time, prophylactic mesh reinforcement should be offered to all patients undergoing elective permanent stoma formation. The SMART procedure has the potential to change current surgical practice. The contribution of the rectus muscle to the development of herniation warrants further research since improving muscle repair and regeneration may result in therapeutic benefits.

Congenital diaphragmatic hernia (CDH) is a potentially fatal condition found in neonates where embryological defects in the diaphragm negatively impact fetal maturation and growth. The defect allows contents below the diaphragm to potentially migrate into the thoracic cavity during development, which could lead to secondary complication including pulmonary hypertension and left ventricular hypoplasia. CDH tends to have a high neonate mortality rate in congruence with the severity of the condition. Several risk factors for CDH include accompanying chromosomal abnormalities and the anatomical positions of organs in the fetus. Diagnosis is typically found with an ultrasound (US) in utero. There have been several studies in order to better understand the pathology of the disease and new techniques to try and alleviate the cases prenatally, however the risks involved with these procedures may outweigh the benefits. The standard practice for neonates that qualify for postnatal treatment is the use of extracorporeal membrane oxygenation (ECMO) postnatally, to facilitate oxygenated blood to the fetus via a bio-mechanical device. Recent treatment techniques that have revolutionized care for CDH include a delayed surgical intervention in order to reduce the risk of developing a pulmonary ailment such as pulmonary hypertension and/or lung hypoplasia. Interventions with inhaled nitric oxide have also been shown to relegate a similar outcome to those with ECMO intervention. Despite the advancements in knowledge, treatment, and technology, the mortality rate for CDH still hovers around 50% on average, yet that percentage can increase or decrease depending on the severity of the condition and any genetic abnormalities associated with it. Overall, while there have been great strides in treatment and understanding of CDH, additional research is necessary in order to provide the utmost care for future generations of CDH patients.

Introducción:El uso del abdordage preperitoneal en la cirugía de la hernia inguinal es conocido des de hace tiempo. Wantz, siguiendo los principios de Stoppa introdujo la malla con la finalidad de encontrar la técnica ideal de la malla. Otro aspecto importante en la cirugía de la hernia inguinal es el seguimiento de los pacientes. El examen clínico en las consultas externas puede ser impracticable en hospitales terciarios con áreas de influencia sobre grandes grupos poblacionales.El objetivo del presente estudio es analizar los parámetros de la calidad a largo plazo de la cirugía de la hernia inguinal y la utilidad de un cuestionario postal con visita selectiva combinado con llamada telefónica en el seguimiento.Método:Se han incluido los pacientes intervenidos por una hernia inguinal mediante un abordaje preperitoneal y de forma ambulatoria en el Servicio de Cirugía General de un hospital terciario, entre el 1/1/1999 y el 31/12/2003.El cuestionario con seis preguntas con la opción de contestación si o no: ¿era la primera vez que le operaban la hernia?, ¿era del lado derecho, lado izquierdo o los dos a la vez?, ¿ha notado de nuevo un bulto en la zona operada?, ¿ha tenido dolor en la zona operada pasado un mes de la intervención?, ¿le continua doliendo en la actualidad la zona operada?, ¿esta satisfecho con la cirugía que se realizó?Resultados: Un total de 841 pacientes (72.9%) devolvieron el cuestionario después de tres envios (512 después del primero, 205 después del segundo y 124 después del tercero). El cuestionario con respuesta positiva se halló en 152 pacientes (18.1%) y con respuesta negativa en 689 pacientes (81.9%). De los 152 pacientes que respondieron "si" a alguna de las preguntas sobre dolor en la actualidad y/o recurrencia, 91 no quisieron ser visitados en consultas externas, 24 no se pudieron contactar por teléfono, y 37 quisieron ser visitados. De los 312 pacientes que no respondieron el cuestionario postal, 8 habían fallecido, 124 no quisieron ser visitados y 180 no se localizaron. La tasa de recurrencia hallada fue de 2.7% y la de dolor crónico de 5.9%.Conclusiones:1.La tasa de recidiva herniaria en nuestra serie puede oscilar entre el 4,3% y el 0,12% según como se tomen los criterios de recidiva y como se escoja la muestra de control.2.El dolor crónico postcirugía no se ha presentado y sólo se ha encontrado un 7,3% de parestesias y molestias inespecíficas en la región operada.3.El 95,2% de los pacientes que han respondido al cuestionario postal han manifestando estar satisfechos con la cirugía. Cuando se aplica el cuestionario SF-36, todos presentan unas puntuaciones medias superiores a 60 en cualquiera de sus dimensiones.4.El abordaje preperitoneal en régimen de Cirugía Mayor Ambulatoria es una buena técnica en nuestro ámbito.5.El uso de un cuestionario postal nos ha determinado una respuesta del 72,9%. Esto nos hace concluir que es una modalidad muy útil para la obtención de datos cuando se pretenden realizar estudios de calidad y de control del procedimiento.6.El uso del cuestionario postal con visita selectiva no ha aportado datos significativos para control sucesivo de un paciente.7.Una vez evaluada la calidad de la técnica y establecidos unos resultados a partir de un cuestionario postal, la utilización de un protocolo para el seguimiento no aporta ningún resultado añadido que lo justifique a menos que se modifique la técnica o el equipo.8.Al paciente intervenido consideramos que se le ha de proponer una única visita postoperatoria, donde a parte de hacer el control posquirúrgico pertinente, hay que informarle de que su hernia operada no necesita más controles. / Background:The open preperitoneal surgery for hernia repair is known since ages. Wantz, following Stoppa principles introduced the mesh trying to find, with this way, the ideal hernia repair technique. In the other hand, follow-up of the patient who have had a hernia repair is still an important problem nowadays for the general Surgeon. Classical follow-up with the patient are nearly impossible when the amount of patients is very high, and also, because of the low recurrence rate. This is the reason why we decided to evaluate the quality control parameters in hernia surgery (recurrence and pain) and also to assessed the usefulness of a short postal questionnaire and selective clinical examination combined with repeat mailing and telephone reminders for quality assessment in hernia surgery.Method: All patients (n = 1153) who underwent tension-free hernioplasty through an open preperitoneal approach between 1999 and 2003 received a 6-item questionnaire with a covering letter and a stamped addressed enveloped. Non-responders received two successive new questionnaires and a telephone call. Concerning to the questionnaire, we asked the patients to answer 6 questions: 1-Was it your first hernia surgery procedure? 2-You were operated of the right, left or both hernia? 3-After a month since surgery, have you had a lump in the groin? 4-After a month since surgery, have you had pain in the groin? 5-Do you still have pain in the groin? 6-Are you satisfied with the surgery?Results:A total of 841 (72.9%) patients returned questionnaires after three reminders (512 after the first mailing, 205 after the second, and 124 after the third). Positive questionnaire answers were documented for 152 (18.1%) repairs and negative answers for 689 (81.9%). Of the 152 patients who answered "yes" to either of the questions regarding recurrence and/or current pain, 91 declined clinical appointment, 24 could not be contacted by phone, and 37 underwent physical examination. Of the 312 patients who did not return the questionnaire, 8 had died, 124 were not willing to be visited, and 180 could not be localised. The recurrence rate was 2.7% and the chronic pain rate 5.9%.Conclusions:1. Recurrence is estimated to be between 4.3% and 0,12% depending recurrence criteria and patients selection.2. Chronic pain has not been reported and 7.3% of patient refer paresthesias and unspecific pain.3. In our study, patients are satisfied with surgery (95.2%), SF-36 shows good results and our surgery quality in terms of satisfaction and recurrence is acceptable.4. Low recurrence rate, no chronic pain and few paresthesias added to a high number of patients satisfied allows us to say that preperitoneal technique in Ambulatory Surgery is a good option in our area.5. The use of a postal questionnaire in our area could be a useful way to obtain information when a quality control of the surgery is done.6. The use of a postal questionnaire in our area with selective physical examination, has not added significant data for the control of patients.7. Once evaluated the quality of the technique and established some results about the postal questionnaire, unless the technique or the team changes, the use of a protocol is not required.8. The patient who underwent a surgery of inguinal hernia, has to be visited only once after operation and inform him that his hernia does not need more examinations.