INTRODUÇÃO: Cerca de 20% da população é portadora de colelitíase, sendo esta afecção a principal causa abdominal de internação hospitalar em países desenvolvidos. Considerando-se que somente nos Estados Unidos são realizadas cerca 700.000 colecistectomias a cada ano, pode-se estimar a importância do problema para a saúde pública. A diminuição do número de incisões tem o potencial de reduzir o trauma cirúrgico e oferecer melhor resultado estético. OBJETIVOS: Descrever técnica de colecistectomia laparoscópica com duas incisões (CL2i) utilizando apenas material convencional, sem aumentar complicações, nem tempo operatório, oferecendo a mesma segurança da colecistectomia videolaparoscópica convencional. MÉTODO: Série prospectiva de casos consecutivos, comparada a outra série histórica de casos operados pela técnica laparoscópica convencional (CLC). A CL2i foi realizada com 3 portais em 2 incisões, sendo dois na incisão umbilical e outro no epigástrio. Foram operados 72 pacientes (36 em cada grupo) pelo mesmo cirurgião. RESULTADOS: Não houve diferença estatística entre os grupos quanto sexo, média de idade, índice de massa corpórea (IMC) e tempo de internação. Os procedimentos foram classificados pelo cirurgião de acordo com o grau de dificuldade e não houve diferença entre as séries (p < 0,05). Ocorreram complicações menores em 5,6% (n = 2) procedimentos em cada grupo. Não houve diferença entre as médias de tempo operatório (p= 0,989), que foram de 49 (IC95% 42 a 56) min na CLC e 40 (IC95% 35 a 44) min na CL2i. Não houve necessidade de portais adicionais em nenhum caso, nem de conversão para cirurgia aberta. CONCLUSÕES: A técnica de colecistectomia laparoscópica com duas incisões (CL2i) é factível, segura e com bom resultado estético, permitindo operar utilizando apenas instrumental laparoscópico convencional, sem aumentar tempo operatório ou risco de complicações / INTRODUCTION: About 20% of the population has cholelithiasis and this is the main abdominal cause of hospitalization in developed countries. Considering that only in the United States about 700,000 cholecystectomies are done each year, it is possible to estimate the importance of the problem for public health. Decreasing the number of incisions can reduce surgical trauma and offer better aesthetic results. OBJECTIVE: To describe a two-incision laparoscopic cholecystectomy technique (TILC) using only conventional material, without increasing complications, nor operative time, offering the same safety as conventional laparoscopic cholecystectomy. METHOD: A consecutive and prospective case series, compared to another historical series operated by conventional laparoscopy cholecystectomy (LC). The TILC was performed with 3 trocars in 2 incisions, two trocars in umbilical incision and one in epigastrium. A total of 72 patients were operated on by the same surgeon (36 in each group). RESULTS: There were no significant differences between groups for gender, mean age, body mass index (BMI) or length of hospital stay. The procedures were classified by the surgeon according to surgical difficulty and there was no difference between the series (p < 0.05). There were minor complications in 5.6% (n = 2) procedures in each group. There were no differences between means of operative time (p = 0.989), which were 49 (95% CI 42 to 56) min in LC and 40 (CI 95% 35 to 44) min in TILC. There was no need for additional portals in any case, nor for conversion to open surgery. CONCLUSIONS: Two-incision laparoscopic cholecystectomy (TILC) is feasible, safe and with good aesthetic result, using the same instruments of LC, without increasing operative time or complications

O objetivo deste estudo foi avaliar e comparar a reparação tecidual após incisões com os lasers de CO2 e de diodo, bisturi elétrico e convencional em língua e pele de 30 ratos Wistar. Incisões de 5 mm de comprimento por 2 mm de profundidade na pele, e de 2,5 mm de comprimento por 1 mm de profundidade na língua, foram feitas nestes tecidos, e os animais sacrificados nos intervalos de zero, 24, 48, 72 horas, 7 e 14 dias após as intervenções. Cortes histológicos foram obtidos das incisões e submetidos a 3 tipos de análises: quantificação do dano tecidual, de mastócitos e da densidade de colágeno tipo I. Os dados foram submetidos à análise estatística pelo teste ANOVA de Kruskal-Wallis e pelo teste de comparações múltiplas de Turkey-Kramer, com nível de significância estabelecida para P < 0,05. Os resultados mostraram que o dano tecidual na pele das incisões realizadas com lasers e bisturi elétrico foi significativamente maior do que o do bisturi convencional (P < 0,05). Quanto às incisões na língua, houve diferença significante de menor dano tecidual resultante da incisão do bisturi convencional comparado com o das incisões realizadas com laser de CO2 2 W, laser de diodo 4 W e bisturi elétrico (P < 0,05). A quantificação de mastócitos mostrou diferenças estatísticas entre as incisões realizadas com bisturi convencional em relação às outras incisões (lasers e bisturi elétrico), principalmente nas 48 e 72h, tanto na pele quanto na língua. Quanto à quantificação de colágeno, apenas no 7º dia houve diferença estatisticamente significante, ocorrendo maior quantidade de colágeno tipo I somente na incisão com bisturi convencional comparada com a do bisturi elétrico (P < 0.05). No 14º dia, os dados morfométricos de colágeno foram semelhantes em todas as técnicas utilizadas. Concluímos que no período final analisado do processo reparacional, os dados morfométricos foram semelhantes em todas as técnicas utilizadas, apesar das diferenças ocorridas quanto ao dano tecidual, quantificação de mastócitos e colágeno tipo I no início do processo. Em princípio, dentro de um mesmo padrão de incisão, todos os instrumentos cirúrgicos geraram um processo reparacional semelhante, variações entre eles podem estar associadas às características do tecido, como foi observado entre a pele e mucosa. / The aim of this study was to quantify and compare the healing process after incision with CO2 (2 W e 4 W) and diode lasers (2 W and 4 W), electrosurgery (2 W) and scalpel in the skin and tongue of Wistar rats (30 animals were used). One incision of each technique (6 in total) of 5 mm long and 2 mm deep was made in the dorsal skin and dorsal tongue. The animals were sacrificed at zero, 24, 48, 72 hours, 7 and 14 days after incisions. Histological sections were made from the wound areas and subjected to analyses of area of tissue damage, quantification of mast cells and density of collagen type I. The data were submitted to the ANOVA of Kruskal-Wallis and compared by Turkey-Kramer. The level of significance was set at 5% (P < 0.05). The results showed difference concerning area of tissue damage, occurring significant statistically difference between the incisions with scalpel compared with those of other techniques (lasers and electrosurgery) in skin (P < 0.05). On the tongue, there was statistical difference, with less tissue damage on scalpel incision compared with that of CO2 (2 W) and diode lasers (4 W) and electrosurgery incisions (P < 0.05). The quantification of mast in the incisions showed statistical differences between the incisions, especially in 48 and 72h, both on the skin and tongue. Concerning the collagen quantification, statistical difference was found only in 7 th day, the collagen types I was only more evident on scalpel incision than with the electrosurgery (P < 0.05). In 14 th day, the morphometric data were similar in all types of incisions. Based on these results, it is possible to conclude that at the end of the analyzed period, the morphometric data were similar in all techniques, even though there were differences concerning tissue damage, quantification of masts cell and collagen type I at the beginning of the process. Additionally, the healing process proceeds similarly in all this technique as long as the incisions are made in a similar pattern; variations may occur depending on the type of the tissue, as was shown here between the skin and tongue.

京都大学 / 0048 / 新制・課程博士 / 博士(工学) / 甲第22052号 / 工博第4633号 / 新制||工||1722(附属図書館) / 京都大学大学院工学研究科都市社会工学専攻 / (主査)教授 角 哲也, 准教授 Sameh Kantoush, 准教授 竹門 康弘 / 学位規則第4条第1項該当 / Doctor of Philosophy (Engineering) / Kyoto University / DFAM

En chirurgie vasculaire, l’accès à l’artère fémorale, qu’il soit par une incision chirurgicale ou par une approche percutanée, est très fréquemment utilisé pour une multitude d’interventions vasculaires ou endovasculaires; pour des pontages divers, le traitement d’occlusions artérielles, la réparation d’anévrismes et la pose d’endoprothèses. L’objectif général de ce projet de recherche est de faciliter et réduire les risques des approches de l’artère fémorale par une meilleure compréhension anatomique du triangle fémoral. La méthodologie a été réalisée grâce à l’utilisation de cadavres spécialement embaumés par la méthode développée par Walter Thiel. Les résultats présentés dans ce mémoire ont permis de proposer des solutions en réponse à des problèmes cliniques en chirurgie vasculaire. Dans un premier temps, l’étude de la vascularisation cutanée du triangle fémoral a mené à proposer de nouvelles incisions chirurgicales afin de limiter la dévascularisation cutanée des plaies et ainsi réduire les problèmes de cicatrisation observés. Ensuite, nous avons validé l’identification radiographique et échographique de l’artère fémorale à son croisement avec le ligament inguinal afin de faciliter l’identification d’un site de ponction artérielle adéquat. Enfin, nous avons développé une méthode échographique simple qui facilite l’approche percutanée de l’artère fémorale, même chez les patients obèses. Les retombées de ce projet de recherche sont multiples pour les cliniciens, l’étude fournit une meilleure compréhension anatomique tridimensionnelle du triangle fémoral et les techniques proposées dans ce mémoire pourront apporter une amélioration de la pratique chirurgicale et faciliter le travail des médecins. Toutefois, ces propositions devront maintenant être validées en clinique. / In vascular surgery, access to the femoral artery is frequently used either through a surgical incision of the groin or by a percutaneous approach in a wide variety of vascular and endovascular procedures; for multiple bypasses, treatment of arterial occlusions, aneurysms repair and placement of various stents. The general purpose of this study is to facilitate and reduces the risks of both the surgical and the percutaneous approaches of the femoral artery through a better anatomical understanding of the femoral triangle. The methodology was conducted on specifically embalmed cadavers according to the method developed by Walter Thiel. The results presented in this memory allowed us to propose solutions to clinical problems in vascular surgery. First, the study of the cutaneous vascularisation of the femoral triangle led to suggest new surgical approaches in order to reduce lesions of the cutaneous arteries and the potential devascularization of the borders of the wound yielding a better postoperative outcome. Then, we validated the radiographic and ultrasonographic position and identification of the inguinal ligament and the proximal femoral artery to facilitate the identification of a safe arterial puncture site. Moreover, we developed a simple method for ultrasound-guided arterial puncture, suitable for obese patients, to facilitate the percutaneous approach of the femoral artery. The benefits of this research project are multiple for clinicians, the study provides a better tridimensional anatomic understanding of the femoral triangle and the techniques proposed will lead to an improved surgical practice and facilitate the work of doctors. However, our work and propositions still need to be validated clinically.

Ce travail de thèse est divisé en deux parties. La première porte sur l'acquisition d'un nouvel enregistrement paléosismologique en Mer de Marmara. Différentes méthodes ont été utilisées afin d'identifier et de caractériser les perturbations sédimentaires associées aux tremblements de terre dans les carottes étudiées. Nous avons cherché à acquérir une compréhension spatio-temporelle des distributions des séismes en mer pour aboutir à une meilleure compréhension du comportement de la Faille Nord Anatolienne sur le long terme. Nous avons par ailleurs cherché à corréler les données de sismicité historique avec de nouvelles données paléosismologiques. Les événements sédimentaires associés aux séismes ont été caractérisés en combinant l'imagerie aux rayons X, des mesures de susceptibilité magnétique, de granulométrie et de composition géochimique. Les données des compositions élémentaires nous ont permis de tracer au travers des différents bassins les changements environnementaux et anthropiques ayant lieu dans la région. L’obtention d’une chronologie robuste dans les carottes a également été recherchée en combinant des datations carbone 14 et des données de 210Pb et 137Cs afin de relier les sismoturbidites à la sismicité historique. Les variations d'aimantation au travers des carottes ont été mesurées dans le but initial de contraindre par une méthode indépendante l'âge des sédiments échantillonnés. Les variations des propriétés magnétiques ont mis en évidence une chute d'aimantation importante que nous avons reliée à des dépôts sapropéliques.La deuxième partie porte sur l’étude géomorphologique du décalage de la rivière Kizilirmak le long du segment central de la Faille Nord Anatolienne. À cet endroit, trois terrasses préservées le long de deux bassins en pull-apart incisés par la rivière Kizilirmak ont été cartographiées. Les résultats principaux de cette étude ont été de contraindre par la méthode des isotopes cosmogéniques 10Be, 26Al et 36Cl l'âge de ces terrasses. Les datations montrent que la terrasse la plus basse est âgée de 6 ka, que la deuxième terrasses est âgée de 50 ka et que la troisième a un âge de 80 ka. Cette dernière montre une contribution importante d'âges jeunes liée à l'érosion du bassin versant situé au-dessus d'elle. Les résultats montrent une origine climatique des terrasses et ont permis d'estimer une vitesse d'incision de la rivière de l'ordre de 3 mm/an depuis le début de l'Holocène. / This PhD work is divided in two parts. The first part focuses on obtaining a new paleoseismological record of earthquakes in the Marmara Sea (West of Turkey) using different analysis to pinpoint and characterize earthquake-related sedimentary disturbance in the studied cores. We seek to provide a spatio-temporal understanding of earthquakes in the Marmara Sea allowing greater insight into long-term fault behaviour and seismic interaction by integrating historical and new paleosismological data (recurrence rate in the Sea of Marmara). We characterized earthquake-related sedimentary events by combining X-ray imagery, magnetic susceptibility, granulometry and XRF (chemical analyses) measurements. Geochemistry data also allowed us to trace between basin anthropogenic and environmental changes occurring in the Marmara Sea. We also aim at establishing a reliable and robust chronology of the cores combining radiocarbon dating (bulk sedimentation, foraminifers, shelves), 210Pb and 137Cs data to connect seismoturbidites to historical seismicity. Magnetic variations were also recorded in the cores to obtain a time constrain for the cores. The down-core changes in magnetic properties suggest taking into account possible delays in the acquisition of magnetization and have been correlated to lower sapropelic layers in the Marmara Sea.The second part deals with geomorphology and tectonic in the central part of the North Anatolian Fault situated in Turkey. There, three terraces preserved in two pull-apart and incised by the longest river in Turkey (the Kizilirmak River) are mapped. The main results of this work are several constraints on the ages of the terraces using 10Be, 26Al and 36Cl cosmogenic dating methods. The obtained in situ cosmogenic 36Cl exposure ages calculated are 6 ka for the lowest terrace, 50ka for the middle terrace, and 80ka for the highest terrace in the areas preserved from erosion. The highest terrace shows a contribution of younger ages due to erosion of the nearby limestone catchment. The obtained results imply a climatic origin of the terraces, and a mean incision rate of about 3 mm/yr since the early Holocene along the Kizilirmak River.

Ce dossier d'habilitation à diriger des recherches dresse un bilan de mon activité de recherche effectuée depuis l'obtention de ma thèse de doctorat, d'abord au Research School of Earth Sciences de l'Australian National University (1995-1997) et depuis 1998 au Laboratoire de Géodynamique des Chaînes Alpines de l'Université Joseph Fourier. Il présente également le projet scientifique que j'envisage de poursuivre dans les années à venir. Je présente dans la première partie mon Curriculum Vitae avec un bilan succinct des thèmes de recherche que j'ai développés, mon activité d'encadrement de jeunes chercheurs et d'enseignement, ainsi qu'une liste de mes publications et conférences. La deuxième partie propose quelques éléments de réflexion sur les relations entre tectonique, érosion et l'évolution du relief à long terme. Après une introduction générale, je dresse le bilan de ma contribution sur ce terrain, en ce qui concerne le développement et l'utilisation de modèles numériques des processus de surface pour étudier l'évolution du relief, ainsi que dans l'acquisition de données thermochronologiques pour contraindre les taux de dénudation. La troisième et dernière partie de ce mémoire présente mon projet de recherche, axé sur le développement des modèles numériques des processus de surface et la mise en œuvre de nouvelles bases de données permettant d'appréhender l'évolution du relief. Afin de permettre une plus grande accessibilité pour tous les membres du jury d'habilitation, les deuxième et troisième parties de ce dossier seront rédigées en anglais.

A basin analysis was conducted at the Conway Flat coast (Marlborough Fault Zone, South Island, New Zealand) to investigate the interaction of regional and local structure in a transpressional plate boundary and its control on basin formation. A multi-tiered approach has been employed involving: (i) detailed analysis of sedimentary deposits; (ii) geomorphic mapping of terraces, fault traces and lineaments; (iii) dating of deposits by 14C and OSL and (iv) the integration of data to form a basin-synthesis in a sequence stratigraphy framework. A complex thrust fault zone (the Hawkswood Thrust Fault Zone), originating at the hinge of the thrust-cored Hawkswood anticline, is interpreted to be a result of west-dipping thrust faults joining at depth with the Hundalee Fault and propagating eastwards. The faults uplift and dissect alluvial fans to form terraces along the Conway Flat coast that provide the necessary relief to form the fan deltas. These terrace/fan surfaces are ~9 km long and ~3 km wide, composite features, with their upper parts representing sub-aerial alluvial fans. These grade into delta plains of Quaternary Gilbert-style fan deltas. Uplift and incision have created excellent 3D views of the underlying Gilbert-style fan delta complexes from topsets to prodelta deposits. Erosive contacts between the Medina, Rafa, Ngaroma and modern Conway fan delta deposits, coupled with changes in terrace elevations allow an understanding of the development of multiple inset terraces along the Conway Flat coast. These terraces are divided into five stages of evolution based on variations in sedimentary facies and geomorphic mapping: Stage I involves the uplift of the Hawkswood Range and subsequent increased sedimentation rate such that alluvial fans prograded to the sea to form the Medina fan delta Terrace. Stage II began with a period of incision, from lowering sea level or changes in the uplift and sedimentation rate and continued with the deposition of the Dawn and Upham fan deltas. Stage III starts with the incision of the Rafa Terrace and deposition of aggradational terraces in the upper reaches. Stage IV initiated by a period of incision followed by deposition of estuarine facies at ~8ka and Stage V began with a period of incision and continues today with the infilling of the incised valley by the modern fan delta of the Conway River and its continued progradation. New dates from within the Gilbert-type fan deltas along the Conway Flat coast are presented, using OSL and 14C dating techniques. Faulting at the Conway Flat coast began ~ 94 ka, based on the development of the Medina Terrace fan delta with uplift rates ~1.38~1.42 m/ka. The interplay of tectonics and sea level fluctuations continued as the ~79 ka Rafa Terrace fan deltas were created, with uplift rates calculated at ~1.39 m/ka. Detailed 14C ages from paleoforest (~8.4-~6.4 ka) in the Ngaroma Terrace and from the mouths of smaller streams have established uplift rates during the Holocene ~1-3 m/ka, depending on sea level.

Ce travail de thèse a porté sur l’étude de littoraux sous l’influence de deux grands deltas, l’Amazone et le Mékong, avec un focus sur les plages et cheniers de Guyane intégrant le système de dispersion vaseuse de l’Amazone, et sur les liens entre la déstabilisation du littoral du delta du Mékong et les changements morpho-bathymétriques des chenaux deltaïques sous influence anthropique croissante. L’étude de la plage de Montjoly en Guyane a été conduite en combinant une approche innovante de photogrammétrie aéroportée SfM (Structure from Motion), des mesures hydrodynamiques, bathymétriques, et la modélisation de la propagation des houles à travers cette bathymétrie. Les résultats obtenus montrent le potentiel considérable de la technique de photogrammétrie SfM pour l’étude géomorphologique des plages, et confirment un modèle de rotation de la plage sous l'influence de banc de vase. Le suivi du second site d’étude, un chenier en recul sur un ancien polder rizicole vaseux, au travers d'une analyse multi décennale d’images satellites et des mesures de terrain, a démontré très finement les taux (atteignant 160 m par an) et mécanismes de recul du substrat vaseux en lien avec sa rhéologie.L’analyse de l'évolution de la bathymétrie des chenaux deltaïques du Mékong sur une décennie (1998 et 2008), conduite à travers une méthode sous SIG, a permis de quantifier une perte nette de 200 millions de m3 de sédiments et un approfondissement de chenaux ne relevant pas de processus naturels mais d'extraction de granulats.Ces prélèvements importants de sédiments ont des répercussions importantes sur les apports de sédiments au littoral du delta qui montre des taux d’érosion importants. / This thesis is a geomorphic study of two separate sites associated with two large deltas: the Amazon and the Mekong, with a focus on a beach and chenier in French Guiana integrated into the mud dispersal system of the Amazon, and on the links between destabilization of the Mekong delta shoreline and morpho-bathymetric changes in the deltaic channels under increasing human influence.The study of Montjoly beach in French Guiana was carried out using a combination of an innovative approach in SfM (Structure from Motion) airborne photogrammetry, hydrodynamic and bathymetric measurements, and wave propagation modelling over the nearshore bathymetry. The results show the strong potential of SfM photogrammetry in high-resolution morphometric and sediment budget surveys of sandy beach, and confirm a previously proposed model of beach rotation under mud-bank influence.The second field site in French Guiana, a retreating chenier over a muddy abandoned polder formerly a rice fields, work based on a multi-decadal analysis of satellite images combined with short-term field topographic and hydrodynamic measurements highlighted high rates of chenier migration (up to 160 m a year) and retreat mechanisms over the muddy substrate due to its rheology.A GIS-based analysis of bathymetric changes in the deltaic channels of the Mekong over a 10-year period (1998 to 2008) enabled the quantification of a net loss of 200 million m3 of sediments and an increase in the mean depth of the channels, which appears as unnatural and due to sand mining.These important sediment extractions have serious repercussions on sediment supply to the Mekong delta coast, which shows important rates of erosion.