<p>UVOD. Bilijarna kalkuloza je najče&scaron;će oboljenje hepatobilijarnog sistema, a holecistektomija predstavlja jedan od najče&scaron;će izvođenih operativnih zahvata. Laparoskopska holecistektomija je danas zlatni standard lečenja holelitijaze. Laparoskopska holecistektomija je pokazala pobolj&scaron;anje u klinički značajnim ishodima kao &scaron;to su skraćenje operativnog vremena, kraća hospitalizacija, smanjenje jačine i trajanja postoperativnog bola i brži povratak dnevnim i radnim aktivnostima. Postoperativna bol i vreme potpunog oporavka ostaju dva glavna problema posle nekomplikovane laparoskopske holecistektomije koje bi trebalo pobolj&scaron;ati. Bol koji je povezan sa laparoskopskom holecistektomijom je kompleksan i multifaktorijalan. On nastaje o&scaron;tećenjem tkiva, disekcijom i uklanjanjem žučne kesice iz svoje lože, stimulacijom periportalnih nerava, iritacijom dijafragme, mehaničkim i hemijskim interakcijama gasa i pneumoperitoneuma, incizijama portova. Istraživanja su označila parijetalni i visceralni bol kao dva glavna mehanizma nastanka bola kod laparoskopske holecistektomije. Bol se ne može meriti nego proceniti jer je subjektivni osećaj. Pokazalo se potrebnim da se na čvr&scaron;ćim naučnim osnovama da odgovor na pitanje da li je moguće blokirati parijetalni i visceralni bol posle laparoskopske holecistektomije u akutnoj fazi. CILJEVI. Cilj studije je da uporedi standardnu analgeziju (ne-opioidnu) (grupa O) sa davanjem parijetalne blokade (grupa P), ili davanjem visceralne blokade (grupa V), ili sa obe date blokade (grupa P+V). Primarni ishodi studije su bolesnikov procenjeni bol pre operacije i posle operacije na 1, 2, 4, 6, 12, 24, 48 sati i 7. dana. Sekundarni ishodi studije su bolesnikova procenjena mučnina na 1,2,4,6,12 sati i bolesnikova procenjena mobilnost 1. 2. i 7. dan. HIPOTEZA. Blokada postoperativnog visceralnog bola i blokada postoperativnog parijetalnog bola posle laparoskopske holecistektomije putem intraperitonealne lokalne infiltracije anestetikom i putem lokalne infiltracije anestetikom pristupnih laparoskopskih portova može značajno smanjiti rani postoperativni bol. MATERIJAL I METODE. Ova prospektivna, randomizirana jednostruko slepa studija je započela septembra 2014. godine i trajala je do januara 2016. godine. Istraživanje je sprovedeno na Klinici za abdominalnu, endokrinu i transplantacionu hirurgiju i Urgentnom centru Kliničkog centra Vojvodine u Novom Sadu kod bolesnika operisanih metodom laparoskopske holecistektomije. Rad je podeljen u nekoliko celina. 1. Procena veličine uzorka; 2. Procena podobnosti za studiju; 3. Anketiranje i uključivanje u studiju; 4. Razvrstavanje u grupe i operativni rad; 5. Period postoperativnog praćenja; 6. Statistička obrada i pisanje rada.<br />1. Procena veličine uzorka. Studija je realizovana podelom bolesnika u 4 grupe. Neophodni broj bolesnika je izračunat uzimajući podatke iz pilot istraživanja slične studije iz 2012. godine. Veličina uzorka je računata za primarni ishod studije&nbsp; (bolesnikov procenjen bol sa NAS) na pretpostavci da treba biti 20% smanjenja bola u prvom postoperativnom satu, uz verovatnoću Tip 1 gre&scaron;ke &alpha;=0.05 i Tipa 2 gre&scaron;ke &beta;=0.10 da postigne adekvatnu statističku snagu oko 80% i da otkrije 20% razlike u srednjoj vrednosti procenjenog bola jedan sat nakon laparoskopske&nbsp; holecistektomije. Procenjeni broj ispitanika po grupama prema zadatim kriterijumima je bio (P+V=65; P=68; V=68; O=65). Studija je započela uključivanjem prvog bolesnika u studiju a zavr&scaron;ena ispunjenim periodom praćenja sve dok poslednji bolesnik nije doneo upitnike o bolu, mučnini i kretanju. 2. Procena podobnosti za studiju. U periodu studije ukupan broj holecistektomiranih bolesnika je bio 1024 (440 klasično i 584 laparoskopski). Samo pogodni bolesnici su anketirani (584) i pročitali su informacioni list o istraživanju. Uključivanje ili procena podobnosti bolesnika za studiju sprovedena je na osnovu uključnih i isključnih kriterijuma. U studiju nije uključeno ukupno 226 bolesnika. Od tog broja 82 bolesnika je odbilo učestvovati u studiji a 144 bolesnika nije ispunilo uključne postavljene kriterijume. Svojim potpisom potvrdilo je uče&scaron;će u studiji 358 bolesnika. 3. Anketiranje i uključivanje u studiju. Nakon prijema bolesnika u bolnicu ispitivači su uzimali anamnezu i bolesnicima je ponuđen informacioni list i informisani pristanak. Nakon čitanja informacije, potpisivanja informisanog pristanka i zadovoljavanja&nbsp; uključnih i isključnih kriterijuma 358 bolesnika je uključeno u studiju. Obavljena je preoperativna priprema i ispitivači su popunili deo podataka u individualnom listu. 4. Razvrstavanje u grupe i operativni rad. Neposredno preoperativno od strane nezavisne osobe neuključene u studiju napravljena je randomizacija izabranih (n=358) u studijske grupe tablicama slučajnog izbora, tako da bolesnici nisu znali kojoj grupi pripadaju, dok su operater i osoblje to znali na početku operacije (jednostruko slepa studija). Nakon randomizacije i operacije bolesnici pripadaju jednoj od sledeće 4 grupe: Kontrolna grupa O=89, u kojoj su bolesnici sa urađenom laparoskopskom&nbsp; holecistektomijom bez visceralne blokade anestetikom i bez parijetalne blokade anestetikom. Eksperimentalna grupa P=88, u kojoj su bolesnici sa urađenom laparoskopskom holecistektomijom bez visceralne blokade anestetikom i sa parijetalnom blokadom anestetikom. Eksperimentalna grupa V=92, u kojoj su bolesnici sa urađenom laparoskopskom holecistektomijom sa visceralnom blokadom anestetikom i bez parijetalne blokade anestetikom. Eksperimentalna grupa P+V=89, u kojoj će biti bolesnici sa urađenom laparoskopskom holecistektomijom sa visceralnom blokadom anestetikom i sa parijetalnom blokadom anestetikom. Primenjivan je uobičajni, standardni protokol anestezije za laparoskopske operacije kod svih ispitanika. Svim bolesnicima plasirana je orogastrična sonda koja se nakon operacije odstranjivala. Kod&nbsp; bolesnika kod kojih je primenjivan lokalni anestetik neposredno pre početka operacije pravio se rastvor lokalnog anestetika (Marcaine&reg; 0,25%). Bolesnici su otpu&scaron;teni sa bolničkog lečenja prvog postoperativnog dana, pod uslovom da nisu imali komplikacija. 5. Postoperativno praćenje i ispunjavanje upitnika. Po dolasku na odeljenje&nbsp; bolesnicima je odmah uključivana ista analgezija. Tokom ispunjavanja informisanog pristanka, bolesnici su dobili upitnik na kojoj će sami procenjivati nivo bola, mučnine i kretanja tokom ležanja u bolnici i vremena praćenja od 7 dana kući. Bolesnici su dolazili na unapred zakazane postoperativne kontrole 7 do 10 dana posle operacije i donosili ispunjene upitnike. Otpu&scaron;teno je i za praćenje ostalo n=302 laparoskopski operisanih bolesnika a isključeno iz studije n=20 bolesnika. 6. Statistička obrada i pisanje rada. Ukupno je analizirano 274 listića operisanih bolesnika: u Grupi P+V =67; u Grupi P =70; u Grupi V =70 i u Grupi O =67. Od osnovnih deskriptivnih statističkih parametara za kvalitativnu i kvantitativnu procenu dobijenih rezultata su kori&scaron;ćeni apsolutni brojevi, relativni brojevi, mediana, mod, aritmetička sredina i standardna devijacija (SD). Obrada podataka se vr&scaron;ila&nbsp; osnovnim i naprednim statističkim metodama i programima. Rezultati su prikazani tabelarno i grafički. REZULTATI. Demografski podaci. Ukupno je bilo 188 žena i 86 mu&scaron;karaca, u odnosu 2,2 : 1. Prosečna starost cele grupe je bila 52,1 &plusmn; 15,72 godine. Ukupno je bilo 179 zaposlenih i 95 nezaposlenih. Ukupno je bilo 45 ispitanika sa osnovnim obrazovanjem, 153 ispitanika sa srednjim obrazovanjem i 76 ispitanika sa visokim obrazovanjem. Ukupno je bilo 186 nepu&scaron;ača i 88 pu&scaron;ača. Prosečna vrednost BMI cele grupe je bila 27,24 &plusmn; 4,21 kg/m2. Prosečna vrednost ASA u celoj grupi je bila 2,03 (mediana=2, mod=2). Ne postoji statistički značajna razlika između posmatranih grupa u odnosu na posmatrane parametre. Laboratorijski podaci. Postoji statistički značajna razlika u vrednosti leukocita između posmatranih grupa (p=0,039), u vrednosti uree između posmatranih grupa (p=0,040). Ne postoji statistički značajna razlika u vrednosti eritrocita, trombocita, hemoglobina, &Scaron;UK-a, kreatinina i bilirubina posmatranih grupa. Operativni i postoperativni podaci. Ne postoji statistički značajna razlika u količini upotrebljenog Fentanila između posmatranih grupa. Postoji statistički značajna razlika u dužini trajanja operacije između posmatranih grupa (p=0,003), u trajanju postavljenog abdominalnog drena između posmatranih grupa (p=0,024), u trajanju hospitalizacije između posmatranih grupa (p=0,027), u broju dana do povratka uobičajenim aktivnostima između posmatranih grupa (p=0,000), u broju uzetih tableta između posmatranih grupa (p=0,000). Prosečna ocena zadovoljstva bolesnika posle operacije u celoj grupi je bila 8,80 (mediana=9; mod=10). Najbolju ocenu zadovoljstva bolesnika posle operacije je imala grupa P+V. Procena bola, mučnine i kretanja. Postoji statistički značajna razlika između posmatranih grupa u proceni jačine bola pre operacije (p=0,003). Postoji statistički značajna razlika između posmatranih grupa u proceni jačine bola 1h posle operacije (najbolju procenu bola je imala grupa P+V); u proceni jačine bola 2h posle operacije (najbolju procenu bola je imala grupa P+V); u proceni jačine bola 4h posle operacije (najbolju procenu bola je imala grupa P); u proceni jačine bola 6h posle operacije (najbolju procenu bola je imala grupa P+V); u proceni jačine bola 12h posle operacije (najbolju procenu bola je imala grupa P+V); u proceni jačine bola 24h posle operacije (najbolju procenu bola je imala grupa P+V); u proceni jačine bola 48h posle operacije (najbolju procenu bola je imala grupa P) i u proceni jačine bola 7 dana posle operacije (najbolju procenu bola je imala grupa P). Procenjena bol se pojačava otprilike 2,5 sata posle operacije sa vrhom 3 sata posle operacije, a smanjuje se na istu vrednost kao 2. sata posle operacije, otprilike 5. sata posle operacije. U vremenskim intervalima 1, 2. i 7. postoperativni dan postoji značajno pobolj&scaron;anje u postoperativnoj mobilnosti bolesnika. U vremenskim intervalima 1, 2, 4, 6 i 12 sati postoji značajno pobolj&scaron;anje u procenjenoj vrednosti mučnine bolesnika. Korelacije. Statistički značajna pozitivna korelacija ocene bola posle 1. sata, posle 2. sata, posle 6. sata, posle 12. sata je utvrđena sa brojem uzetih tableta (p=0,000), kao i procene mučnine (p=0,000). Statistički značajna pozitivna korelacija procene bola posle 4. sata je utvrđena sa brojem uzetih tableta (p=0,006), kao i aktivnosti (p=0,014). Statistički značajna korelacija procene bola posle 24. sata je utvrđena sa brojem uzetih tableta (p=0,000; pozitivna) i trajanjem operacije (p=0,028; negativna). Statistički značajna pozitivna korelacija procene bola posle 48. sata i posle 7 dana je utvrđena sa brojem uzetih tableta (p=0,000). ZAKLJUČCI: Primena lokalnog anestetika datog na bilo koji način značajno smanjuje bol posle laparoskopske holecistektomije. Primena lokalnog anestetika datog i&nbsp; portalno i visceralno (P+V) značajno smanjuje bol u odnosu na samo portalnu (P) ili visceralnu (V) primenu u vremenskim intervalima 2, 6, 12 sat posle laparoskopske holecistektomije. Portalna (P) primena sa ili bez visceralne (V) primene lokalnog anestetika značajno smanjuje bol u vremenskim intervalima 1, 4, 24, 48 sati i 7 dana posle laparoskopske holecistektomije. Najbolje kretanje je bilo u grupi P+V posle laparoskopske holecistektomije. Najbolje smanjenje procenjene mučnine je bilo u grupi P posle laparoskopske holecistektomije. Najraniji povratak uobičajenim aktivnostima zabeležen je u grupi P+V. Najbolja ocena zadovoljstva bolesnika hirur&scaron;kim lečenjem bila je u grupi P+V. Postoperativna bol ima najznačajniju pozitivnu korelaciju sa procenjenom mučninom i brojem tableta uzetih od momenta otpusta do prve kontrole bolesnika.</p> / <p>INTRODUCTION: Biliary calculosis is the most frequent disease of the hepatobiliary system, and cholecystectomy is one of the most frequently performed surgical procedures. Today laparoscopic cholecystectomy represents the golden standard in treating cholelithiasis. Laparoscopic cholecystectomy showed improvement in the clinically significant outcomes, such as: reducing the duration of the surgery, shorter hospital stay, reducing the intensity and duration of postoperative pain and faster return to normal daily and working activities. Postoperative pain and the time of full recovery remain the two major problems after a non-complicated laparoscopic cholecystectomy and they should be improved. The pain related to laparoscopic cholecystectomy is complex and multi-factorial in origin. The pain occurs due to damaged tissues, dissection and removal of gallbladder from its cavity, stimulation of periportal nerves, irritation of the diaphragm, mechanical and chemical interaction of gases and pneumoperitoneum and port incisions. Researches have denoted parietal and visceral pains as two major mechanisms in occurrence of pain in laparoscopic cholecystectomy. Pain cannot be measured, but estimated, as it is a subjective feeling. It was considered necessary to find the answer, based on solid scientific evidence, if it was possible to block parietal and visceral pain after laparoscopic cholecystectomy in its acute phase. OBJECTIVES: The aim of this study is to compare standard, non-opioid, analgesia (group O) with applying parietal blockade (group P), or visceral blockade (group V), or compare with both applied blockades (group P+V). The primary outcomes of the study are the patient&acute;s estimated pain before surgery and 1, 2, 4, 6, 12, 24, 48 hours and 7th day after the surgery. The secondary outcomes of this study are the patient&acute;s estimated nausea level during 1, 2, 4, 6, 12 hours, along with the patient&acute;s estimated mobility 1st, 2nd and 7th day, postoperatively. HYPOTHESIS. Blockade of postoperative visceral pain and blockade of postoperative parietal pain following laparoscopic cholecystectomy, applying intraperitoneal local infiltration with anesthetic and also by local infiltration with anesthetic through accessible laparoscopic ports, can significantly reduce early postoperative pain. MATERIAL AND METHODS: This prospectively randomized single-blinded study started in September 2014 and lasted up to January 2016. The research was carried out at the Clinic for Abdominal, Endocrine and Transplantation Surgery and Emergency Center, Clinical Center of Vojvodina in Novi Sad and it involved patients who underwent laparoscopic cholecystectomy. This study has been divided into several units. 1. Assessment of sample size; 2. Assessment of eligibility for the study; 3. Survey and inclusion in the study; 4. Group formation and operational work; 5. Period of postoperative follow-up; 6. Statistical processing and writing the paper.1. Assessment of sample size. The study was realized by dividing the patients into 4 groups. The number of patients necessary was determined based on the data taken as pilot study from a similar study from 2012. Sample size was calculated for the primary outcome of the study (patient&acute;s estimated pain with NAS) based on the assumption that a pain reduction of 20% should occur during the first postoperative hour, with the probability of Type 1 error &alpha;=0.05 and Type 2 error &beta;=0.10 to reach the adequate statistical power of about 80%, and to reveal 20% difference in the average value of the estimated pain one hour after the laparoscopic cholecystectomy. The assessed number of respondents in groups according to the set criteria was (P+V =65;P =68;V =68; O =65). The study started when the first patient was included and it ended with the complete follow-up period when the last patient handed in the survey about pain, nausea and mobility. 2. Assessment of eligibility for the study. During the study the number of patients undergoing surgery applying the method of cholecystectomy was 1024 (440 classical and 584 laparoscopic). Only the suitable patients were surveyed (584) and given to read the information leaflet about the study. Inclusion and assessment of patients&acute; eligibility was performed on the basis of inclusion and exclusion criteria. A total of 226 patients was not included in the study. Out of that number 82 patients refused to participate in the study and 144 did not fulfill the inclusive criteria set. By signing 358 patients confirmed their participation in the study. 3. Survey and inclusion in the study. After admitting the patients to hospital the surveyors took their anamnesis and the patients were offered an information leaflet and informed consent. Following the reading of the information leaflet, signing the informed consent and satisfying the criteria for inclusion and exclusion, 358 patients were included in the study. Preoperative preparations were performed and the surveyors filled in some of the data on the individual list. 4. Group formation and operational work. Prior to the surgery an independent person not included in the study carried out the randomisation of the patients chosen (n=358) into study groups by random selection tables. The patients did not know which group they belonged to, while it became known to the surgeon and the operation stuff at the beginning of the surgery (singleblinded study). After randomization and surgery the patients belonged to one of the following groups: Control group O=89 of patients with performed laparoscopic cholecystectomy without visceral blockade by anesthetic and without parietal blockade by anesthetic. Experimental group P=88 of patients with performed laparoscopic cholecystectomy without visceral blockade by anesthetic but with parietal blockade by anesthetic. Experimental group V=92 of patients with performed laparoscopic cholecystectomy with visceral blockade by anesthetic but without parietal blockade by anesthetic. Experimental group P+V=89 of patients with performed laparoscopic cholecystectomy with visceral blockade by anesthetic and with parietal blockade by anesthetic. The standard protocol of anesthesia for laparoscopic cholecystectomy was applied to all patients. An orogastric tube used during the surgery, was removed after it. In patients with applied local anesthetic immediately before surgery a solution of local anesthetic was made (Marcaine&reg; 0,25%). The patients were discharged from hospital the first postoperative day, provided that no complications occurred. 5. Postoperative follow-up and completing the questionnaire. When admitted to the ward the patients were given the same kind of analgesia. While completing the informed consent the patients were given a questionnaire for estimating their pain level, nausea and mobility during their stay in hospital and during the 7-day follow-up period at home. The patients were required to come for 7 and 10-day postoperative check-ups by appointment and then they handed in the questionnaires. n=302 patients with performed laparoscopic cholecystectomy were released and designated for follow-up, and n=20 patients were excluded from the study. 6. Statistical processing and writing the paper. In total 274 operated patients&acute; slips were analysed, by groups as follows: in Group P+V =67; in Group P =70; in Group V =70 and in Group O =67. From the basic descriptive statistical parametres for qualitative and quantitative assessment of results obtained, absolute numbers, relative numbers, the median, mode, arithmetic mean and standard deviation (SD) were used. Data processing was carried out using basic and advanced statistical methods and programmes. The results are presented in tabular and graphical manner. RESULTS. Demographic data. In total there were 188 women and 86 men, in proportion 2,2 : 1. The average age of the whole group was 52,1 &plusmn; 15,72 years. In total there were 179 employed and 95 unemployed persons. In total there were 45 surveyed patients with primary education, 153 surveyed patients with secondary education and 76 surveyed patients with higher education. In total there were 186 nonsmokers and 88 smokers. The mean BMI value of the whole group was 27,24 &plusmn; 4,21 kg/m2. The mean value of ASA of the whole group was 2,03 (the median=2, mode=2). There is no significant difference among the groups observed considering the observed parametres. Laboratory data. There is a statistically significant difference in the value of leukocytes among the observed groups (p=0,039), and in the value of urea among the observed groups (p=0,040). There is no statistically significant difference in the value of the erythrocyte, platelets, hemoglobin, blood glucose, creatinine and bilirubin of the&nbsp; observed groups. Operative and postoperative data. There is no statistically significant difference in the amount of Fentanyl&reg; applied among the observed groups. There is statistically significant difference in the length of the surgery among the observed groups (p=0,003), in the duration of the positioning of abdominal drainage among the observed groups (p=0,024), in the duration of hospital stay among the observed groups (p=0,027), in the number of days until getting back to regular activities among the observed groups&nbsp; (p=0,000), in the number of taken pills among the observed groups (p=0,000). The patients&acute; average satisfaction grade after surgery in the whole group was 8,80 (the median=9; mode=10). Group P+V had the best patient&lsquo;s satisfaction grade after the surgery. Assessment of pain, nausea and mobility. There is statistically significant difference in the estimation of pain intensity before surgery among the observed groups (p=0,003). There is statistically significant difference in the estimation of pain intensity 1 hour after surgery among the observed groups (P+V having the best estimated pain); in the estimation of pain intensity 2 hours after&nbsp; surgery (P+V having the best estimated pain); in the estimation of pain intensity 4 hours after surgery (P having the best estimated pain); in the estimation of pain intensity 6 hours after surgery (P+V having the best estimated pain); in the estimation of pain intensity 12 hours after surgery (P+V having the best estimated pain); in the estimation of pain intensity 24 hours after surgery (P+V having the best estimated pain); in the estimation of pain intensity 48 hours after surgery (P having the best estimated pain) also in the estimation of pain intensity 7 days after surgery (P having the best estimated pain). The estimated pain intensifies at about 2,5 hours after surgery and peaks 3 hours after surgery, and decreases to the same level as it was during 2nd hour after surgery approximately during 5th hour after surgery. There is considerable improvement in mobility of patients in the time interval 1st, 2nd and 7th postoperative days. There is considerable improvement in estimated nausea level of patients in the time interval 1, 2, 4, 6 and 12 hours. Correlations. Statistically significant positive correlation in estimated pain after 1st hour, after 2nd hour, after 6th hour and after 12th hour was determined by the number of tablets taken (p=0,000), just like the estimated nausea level (p=0,000). Statistically significant positive correlation in estimated pain after 4th hour was determined by the number of tablets taken (p=0,006), just like the activities (p=0,014). Statistically significant positive correlation in estimated pain after 24th hour was determined by the number of tablets taken (p=0,000; positive), and by the duration of the surgery (p=0,028; negative). Statistically significant positive correlation in estimated pain after 48th hour and after 7 days was determined by the number of tablets taken (p=0,000). CONCLUSIONS: The application of local anesthetic, regardless of how it was applied, considerably reduces pain after laparoscopic cholecystectomy. The application of local anesthetic by port or viscerally (P+V) considerably reduces pain compared to only by port (P) or only visceral (V) application in the time intervals of 2, 6, and 12 hours after laparoscopic cholecystectomy. The application of local anesthetic by port (P), with or without visceral (V), considerably reduces pain in the time intervals of 1, 4, 24, and 48 hours and 7 days after laparoscopic cholecystectomy. The best mobility was shown by group P+V after laparoscopic cholecystectomy. Estimated nausea was most reduced in group P after laparoscopic cholecystectomy. Group P+V presented the earliest return to regular activities. The best patients&acute; satisfaction grade with surgical treatment was shown by group P+V. Postoperative pain is most considerably positively correlated with the estimated nausea and pills taken, from the moment of patient&acute;s release from hospital to the first check-up.<br />&nbsp;</p>

<p>Акутни панкреатитис је ензиматско инфламаторно оболење панкреаса, са инциденцијом око 17/100000 становника. Најчешћи етиолошки чиниоци који се везују за ово стање су билијарна калкулоза (45%) и конзумација алкохолних пића (35%). Ређи узроци су одређени лекови, хипертриглицеридемија, хиперкалијемија, траума, урођени чиниоци, и идиопатски панкреатитис (20%). По међународној Атланској (Atlanta) класификацији, акутни панкреатитис се може манифестовати у умереној, умерено тешкој и тешкој форми. Умерене форме панкреатитиса се јављају у 80%, карактеришу се едемом органа и имају благ и краткотрајан клинички ток, са стопом морталитета од 1%. Основни циљ лечења болесника са акутним панкреатитисом у прва 24 сата хоспитализације јесте олакшавање тегоба, утврђивање узрока панкреатитиса и процена тежине обољења. Акутни панкреатитис билијарне етиологије узрокован је калкулозом жучне кесе и/ или жучних путева. Препоручени третман билијарне калкулозе, у циљу превенције поновног атака умерене форме билијарног панкреатитиса , подразумева уклањање жучне кесе лапароскопском холецистектомијом са интраоперативном холангиографијом. Уколико се дијагностикује калкулоза жучних канала ради се ендоскопска ретроградна холангиопанкреатографија (ЕРЦП) са ендоскопском папилотомијом (ЕПТ) и уклањем__ калкулуса и детритуса уз жучних водова, са циљем обезбеђивања нормалног протока жучи у дванаестопалачно црево. Циљ овог истраживања је оптимализација редоследа примене ЛХ и ЕРЦП са ЕПТ, идентификацијом предикционих показатеља холедохолитијазе, ради скраћења дужине хоспитализације болесника са умереном формом акутног билијарног панкреатитиса. У спроведеној проспективној анамнестичкој студији, учествовало је 100 болесника лечених од умерене форме акутног билијарног панкреатитиса, у Ургентном центру Клиничког центра Војводине, од 2011. до 2015.године, од којих је код 80 урађена само ЛХ, а код 20 ЛХ и ЕРЦП са ЕПТ. Анализом клиничких, ултразвучних и лабораторијских налаза, идентификовано је 5 статистички значајних предиктора холедохолитијазе; директни и укупни билирубин, алкална фосфатаза (АФ), гама глутирил транспепдидаза (гама ГТ) и це реактивни протеин (ЦРП), на основу којих је омогућено креирање математичког модела за предикцију холедохолитијазе, коришћењем теорије потпорних вектора (СВМ). Установљено је да патолошки налази ових параметара значајно указују на холедохолитијазу, те да је ЛХ препоручена као метода првог избора, код болесника код којих налази предиктора холедохолитијазе нису патолошки. Овако лечени болесници су имали значајно краће време хоспитализације. Поред тога, уколико се интраоперативном холангиографијом (ИОХ) при ЛХ установи холедохолитијаза, ЕРЦП са ЕПТ се може урадити без одлагања.</p> / <p>Akutni pankreatitis je enzimatsko inflamatorno obolenje pankreasa, sa incidencijom oko 17/100000 stanovnika. Najčešći etiološki činioci koji se vezuju za ovo stanje su bilijarna kalkuloza (45%) i konzumacija alkoholnih pića (35%). Ređi uzroci su određeni lekovi, hipertrigliceridemija, hiperkalijemija, trauma, urođeni činioci, i idiopatski pankreatitis (20%). Po međunarodnoj Atlanskoj (Atlanta) klasifikaciji, akutni pankreatitis se može manifestovati u umerenoj, umereno teškoj i teškoj formi. Umerene forme pankreatitisa se javljaju u 80%, karakterišu se edemom organa i imaju blag i kratkotrajan klinički tok, sa stopom mortaliteta od 1%. Osnovni cilj lečenja bolesnika sa akutnim pankreatitisom u prva 24 sata hospitalizacije jeste olakšavanje tegoba, utvrđivanje uzroka pankreatitisa i procena težine oboljenja. Akutni pankreatitis bilijarne etiologije uzrokovan je kalkulozom žučne kese i/ ili žučnih puteva. Preporučeni tretman bilijarne kalkuloze, u cilju prevencije ponovnog ataka umerene forme bilijarnog pankreatitisa , podrazumeva uklanjanje žučne kese laparoskopskom holecistektomijom sa intraoperativnom holangiografijom. Ukoliko se dijagnostikuje kalkuloza žučnih kanala radi se endoskopska retrogradna holangiopankreatografija (ERCP) sa endoskopskom papilotomijom (EPT) i uklanjem__ kalkulusa i detritusa uz žučnih vodova, sa ciljem obezbeđivanja normalnog protoka žuči u dvanaestopalačno crevo. Cilj ovog istraživanja je optimalizacija redosleda primene LH i ERCP sa EPT, identifikacijom predikcionih pokazatelja holedoholitijaze, radi skraćenja dužine hospitalizacije bolesnika sa umerenom formom akutnog bilijarnog pankreatitisa. U sprovedenoj prospektivnoj anamnestičkoj studiji, učestvovalo je 100 bolesnika lečenih od umerene forme akutnog bilijarnog pankreatitisa, u Urgentnom centru Kliničkog centra Vojvodine, od 2011. do 2015.godine, od kojih je kod 80 urađena samo LH, a kod 20 LH i ERCP sa EPT. Analizom kliničkih, ultrazvučnih i laboratorijskih nalaza, identifikovano je 5 statistički značajnih prediktora holedoholitijaze; direktni i ukupni bilirubin, alkalna fosfataza (AF), gama glutiril transpepdidaza (gama GT) i ce reaktivni protein (CRP), na osnovu kojih je omogućeno kreiranje matematičkog modela za predikciju holedoholitijaze, korišćenjem teorije potpornih vektora (SVM). Ustanovljeno je da patološki nalazi ovih parametara značajno ukazuju na holedoholitijazu, te da je LH preporučena kao metoda prvog izbora, kod bolesnika kod kojih nalazi prediktora holedoholitijaze nisu patološki. Ovako lečeni bolesnici su imali značajno kraće vreme hospitalizacije. Pored toga, ukoliko se intraoperativnom holangiografijom (IOH) pri LH ustanovi holedoholitijaza, ERCP sa EPT se može uraditi bez odlaganja.</p> / <p>Acute pancreatitis is an enzymatic inflammatory disease of the pancreas, with an incidence of around 17/100000 inhabitants. The most common etiological factors that are associated with this condition are biliary calculi (45%) and consumption of alcoholic beverages (35%). Less common causes include certain medications, hypertriglyceridemia, hyperkalemia, trauma, congenital factors and idiopathic pancreatitis (20%). According to the Atlanta International classification, acute pancreatitis can be manifested in a moderate, moderately severe and severe forms. Moderate forms of pancreatitis occur in 80%, characterized by pancreatic edema and have mild and short clinical course, with a mortality rate of 1%. The main goal of treatment of patients with acute pancreatitis in the first 24 hours of hospitalization is to facilitate complaints, determining the cause of pancreatitis and assessment of severity of the disease. Acute biliary pancreatitis is caused by calculosis of the gallbladder and / or bile ducts. The recommended treatment of biliary calculi, in order to prevent repeated attacks of moderate biliary pancreatitis, involves the removal of the gallbladder thru laparoscopic cholecystectomy with intraoperative cholangiography. If presence of bile duct calculi is established, an endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic papillotomy (EPT) and removes stones and detritus along the bile ducts is indicated, with the aim of ensuring the normal flow of bile into the duodenum. The aim of this study is the optimization of the order of application LH and ERCP with EPT, the identification of predictable indicators of choledocholithiasis, in order to shorten the length of hospitalization of patients with a moderate form of acute biliary pancreatitis. We conducted prospective case control study, with 100 patients involved, treated for moderate forms of acute biliary pancreatitis in the Emergency Center of the Clinical Center of Vojvodina, from 2011 to 2015, of which 80 made only with LH and 20 with LH at and ERCP with EPT . The analysis of clinical, ultrasound and laboratory findings identified 5 significant predictors of choledocholithiasis; direct and total bilirubin, alkaline phosphatase (AF), gamma glutiril transpepdidase (gamma GT) and C reactive protein (CRP), under which enabled the creation of a mathematical model for predicting choledocholithiasis, using the Support vector machines (SVM). It was found that pathological findings of these parameters indicate a significant choledocholithiasis, and LH is recommended as the first choice in patients in whom there are not present pathological predictors of choledocholithiasis. Thus treated patients had a significantly shorter hospital stay. In addition, if the intraoperative cholangiography (IOH) during LH show choledocholithiasis, ERCP with the EPT can be done without delay.</p>

Os materiais de uso único (MUU) são utilizados há décadas na assistência à saúde. Inicialmente produzidos com a finalidade de prontamente disponibilizar os materiais para uso na assistência a saúde e ao mesmo tempo diminuir a sobrecarga com o trabalho inerente ao reprocessamento dos materiais. Com o passar do tempo, principalmente por questões financeiras, estes passaram a ser reutilizados. A partir de então diversos questionamentos têm sido suscitados a respeito do risco de transmissão de infecção pelo reuso destes artigos em decorrência da dificuldade para de limpeza, desinfecção e esterilização seguras destes. Os materiais utilizados para as cirurgias vídeo-laparoscópicas encontram-se entre os MUU de preço considerável e complexidade importante em relação às dificuldades para limpeza, devido à sua conformação com espaços internos inacessíveis e impossibilidade de desmonte. Isto posto, as pinças grasper, dissector, tesoura, agulha de Veress, sistema de sonda de eletrocirurgia (ou aspirador e irrigador) e sua respectiva haste, instrumentais básicos nos procedimentos de vídeo-cirurgia-laparoscópica, foram o objeto desta investigação com o propósito de avaliar a eficácia da esterilidade destes acessórios de uso único após contaminação artificial desafio e comparar os resultados dos testes de esterilidade dos MUU com os dos materiais equivalentes reprocessáveis – denominados neste estudo como grupo controle. Tratou-se de uma pesquisa experimental, laboratorial e comparativa. O inóculo utilizado para a contaminação artificial dos instrumentais de uso único constituiu-se de suspensão de esporos bacterianos do Bacillus atrophaeus var. niger e de sangue de carneiro desfibrinado esterilizado. Para o grupo controle o microrganismo eleito foi o Geobacillus stearothermophilus acrescido também de sangue de carneiro desfibrinado. Antes de proceder aos experimentos validou-se a metodologia analítica em duas fases: fase 1 - realizada a contagem de U.F.C. em três unidades de cada um dos materiais dos grupos experimental e controle após a contaminação artificial antecedendo a limpeza; fase 2 - realizada a contagem de U.F.C. em três unidades de cada um dos materiais dos grupos experimental e controle após a contaminação artificial e procedimento de limpeza. Desta forma, assegurada a recuperação dos contaminantes em todas as amostras da primeira fase e a diminuição do bioburden inicial após a limpeza dos instrumentais na 2ª fase, deu-se prosseguimento aos experimentos. Os materiais laparoscópicos foram intencionalmente contaminados com o inóculo desafio e submetidos após ao protocolo teste para validação que consistiu da seguinte seqüência: limpeza automatizada em lavadora ultra-sônica com retrofluxo com auxílio do detergente enzimático, limpeza manual complementar com serpilhos e irrigação dos lumens dos instrumentais com água sob pressão. Por fim, foi realizado o enxágüe com água destilada esterilizada, secagem com ar comprimido medicinal, acondicionamento em embalagem de papel grau cirúrgico e filme e submetidos a esterilização em Óxido de Etileno 12/88 (materiais de uso único) e em autoclave (materiais de aço inoxidável). Os materiais esterilizados foram inoculados diretamente nos meios de cultura de caseína soja e incubados por 20 dias quando foi feita a leitura final dos resultados das culturas. Os resultados encontrados foram 100% negativos para a recuperação dos microrganismos contaminantes nos 2 grupos - experimental e controle. Estes achados permitiram concluir que o reprocessamento dos materiais de uso único foi validado em relação à esterilidade permitindo chegar a um protocolo de reprocessamento / Single use devices (SUD) have been used in healthcare for decades. They were initially produced for making them readily available for use in healthcare and at the same time lower the inherent workload for device reprocessing. After time, mainly for financial reasons, they became reused. Since then, several questioning has been raised regarding to the risk of infection transmission by reusing these devices due to their difficulty of safe cleaning, disinfection and sterilization. Devices used for videosurgeries are among the SUD of considerable price and important complexity due to cleaning difficulties, because of their adjustments in inaccessible inner spaces and impossibility of taking them out into pieces. Thus, grasper calipers, dissecting forceps, scissors, Veress insuflation needle, electrosurgery probe system (or suction and irrigation tubes) and its respective dissector cannula, basic devices in videosurgery laparoscopic procedures were all the subject of investigation aimed to evaluate the effectiveness of sterility of these single use products after challenged artificial contamination and comparing the results of sterility tests of SUD to their equivalent reprocessed devices – named in this study as control group. It’s a comparative, laboratory experimental research. The inoculum used for artificial contamination of single use devices was the suspension of Bacillus atrophaeus var. niger bacteria spores and sterilized defibrinated sheep blood. For the control group, the elected strain was Geobacillus stearothermophilus adding also the defibrinated sheep blood. Before carrying out the experiments, the analytical methodology was validated in two phases: phase 1 – counting the colony formation units in three units of each one of the devices from the experimental and control groups after the artificial contamination and cleaning procedures. This way, assured the contaminant recovery in all samples of the 1st phase and the reduction of initial bioburden after device cleaning in the 2nd phase, it was carried on the experiments. The laparoscopic devices were intentionally contaminated with challenged inoculum and submitted after the trial test to validation that was consisted of the following sequence: cleaning in automated narrow-lumen cleaner with enzymatic detergent, complementary manual cleaning with brush and lumen washing of devices with water under pressure. At last, it was made rinsing with sterile distillated water, drying with medical compressed air, packing in surgical paper and film wrapping and submitted to sterilization in ethylene oxide 12/88 (single use devices) and in autoclave (stainless steel devices). The sterilized devices were contaminated directly in the casein soy media and incubated for 20 days when it was made the final reading of media results. The outcomes found were 100% negative for recovering of contamination strains in the 2 groups – the experimental and the control. These findings permitted us to conclude that single use device reprocessing was validated regarding to sterility allowing us to get a reprocessing guideline

Trotz Inkrafttretens des ersten gesamtdeutschen Transplantationsgesetzes im Dezember 1997 steigt die Anzahl terminal niereninsuffizienter Patienten auf der Warteliste, ebenso wie die Wartezeit auf eine Nierentransplantation (NTX). Verschiedene Programme existieren, um der Organknappheit zu begegnen. Im Eurotransplant Senior Programm (ESP) werden seit 1999 Nieren älterer verstorbener Spender (65+) an ältere Empfänger (65+) unabhängig von der Gewebeübereinstimmung auf lokaler Ebene übertragen. Unsere Studien konnten zeigen, dass die Transplantat- und Empfängerüberlebensraten sich nicht von denen nach Transplantation jüngerer Spendernieren in alte Empfänger unterscheiden. Transplantatverlust im ESP tritt meist als Tod mit funktionierendem Transplantat auf. Dies ist die Folge vermehrt vorkommender Komorbiditäten in dieser Empfängergruppe und unterstreicht die Notwendigkeit einer intensiven prä-operativen Evaluation sowie engmaschigen Nachsorge. Zudem konnten wir zeigen, dass die Grundannahme einer verminderten Immunkompetenz älterer Empfänger nicht zutrifft. Eine Änderung der Allokationsregeln von Eurotransplant wird deshalb diskutiert, die auch im ESP die Gewebetypisierung berücksichtigt. Der Anteil der Lebendnierenspende (LNTX) in Deutschland hat sich in den vergangenen Jahren auf ca. 19% verdreifacht. An unserer Klinik macht sie ca. 30% der durchgeführten NTX aus. Zudem wird an unserer Klinik deutschlandweit die laparoskopische Spendernierenentnahme am häufigsten durchgeführt. Folge einer hier durchgeführten prospektiven Studie zur präoperativen Bildgebung der renalen Gefäßarchitektur des Spenders ist der Verzicht auf invasive Methoden. In weiteren Untersuchungen konnten wir zeigen, dass die Akzeptanz von Lebendspendern mit erweiterten Spenderkriterien gute Möglichkeiten bieten NTX-Programme zu intensivieren. In einer Lebensqualitätsstudie untersuchten wir erstmalig für den deutschen Sprachraum die postoperativen Verläufe von Lebendnierenspendern und konnten neben einer grundsätzlichen Zufriedenheit auch besondere Bedürfnisse aufdecken. Verschiedene Studien zur Laparoskopie in der LNTX, Handhabung und Optimierung dieses neuen Verfahrens sowie dessen Anwendbarkeit bei anatomischen Besonderheiten konnten zeigen, dass diese Methode ein sicheres Verfahren darstellt. Anhand unserer Erfahrungen in der LNTX haben wir zudem Empfehlungen zur Evaluation und Nachbetreuung von Lebendnierenspendern erarbeitet. Insgesamt sind das ESP und die LNTX, hier besonders die laparoskopische Spendernierenentnahme, effektive Konzepte zur Erweiterung der Nierentransplantationsprogramme. / Despite the implementation of a transplantation law in 1997 the number of patients with end-stage renal disease in Germany is rising, as is the waiting time for a kidney transplantation (KTX). Different programs exist to counterbalance organ shortage. The Eurotransplant Senior Programm (ESP), initiated in 1999, allocates kidneys of deceased donors aged 65 and older (65+) irrespective of tissue matching locally to recipients 65+. Our studies revealed that graft- and patient survival in this program are comparable to that after transplantation of young donor-kidneys in old recipients. Graft loss is mostly due to recipient death, which is a consequence of the co-morbidities of the recipient. Meticulous evaluation and intensified follow-up in this recipient-group are most important. Furthermore, despite the assumption of a reduced immunologic response of old recipients we could show that they are very well immunocompetent. Therefore, a change in allocation rules at Eurotransplant is discussed, possibly involving HLA-matches in the ESP. Living donor kidney transplantation (LDKTX) has increased three-fold over the last years and features about 19% of all hat KTX in Germany. In our department LDKTX features about 30% of all KTX and our department also performs the most laparoscopic explantations of living kidney donors in Germany. With regard to the preoperative donor evaluation we could show in a prospective study that non-invasive methods for renal vessel imaging are better than the standard invasive approach. Further research proved that applying extended donor criteria renders good results for graft and recipient and thus is a viable option to increase LDKTX. In the first German study on donors Quality of Life we mostly found satisfied donors and also could detect specific donor demands. For the laparoscopic approach we performed different studies on the technique, its improvement and peculiarities, proving that laparoscopic organ retrieval is a safe method in LDKTX. ESP and LDKTX, especially the laparoscopic organ retrieval, are effective concepts to increase the number of kidney transplantations.

近年来，血管类疾病已经成为人类健康的第一杀手。每年有成百上千万人死于血管疾病。血管介入术是一种非常有前景的血管类疾病的治疗手段。血管介入术是一种微创手术，它已经被广泛的用于治疗中风，血管狭窄，血管瘤等疾病。相对于传统的开放式手术，它具有风险低，恢复快，住院时间短等优点。该疗法通常在透视影像的引导下由导管和导线在血管内协同完成手术过程。因为介入术的复杂性和特殊性，作为介入手术医生的必要技能，掌握手术中手眼协同，各种手术器具的使用和复杂细致的手术流程无疑是一个巨大的挑战。因此，迫切地需要一种高效、安全的训练系统。相对于传统的训练方法，基于虚拟现实技术的训练系统是一种非常好的训练手段。 / 为了建立一套高仿真的介入手术训练模拟器，首先，我们要为病人的血管网重建三维模型。我们提出了一种自动的提取中心线的方法，用来从分割好的CTA/MRA体数据中获取病人血管网的中心线。基于改进的平行传递算法，沿着这些中心线，生成了一系列连续的标架。根据这些标架，我们构造了血管的横截面，并在此基础上生成了光滑连续的三维血管模型。 / 其次，作为血管介入术中最基础和最重要的手术器械，我们为导管和导线建立了物理模型。我们提出了一种基于最小势能原理的可变形的模型用于模拟导管和导线对于受力的反应。我们还提出了一个快速并且稳定的多网格算法来保证模拟的真实性和严格的实时交互要求。另外，我们做了几组实验。通过这些实验，验证了多网格算法在稳定性、实时性、模拟的真实性等方面满足了我们对于训练用模拟系统的要求。 / 再次，为了模拟血管栓塞术的手术过程，我们提出了一种模拟线圈填充血管瘤的过程的新方法。通过加总线圈弯曲变形的弹性势能、血管瘤变形的弹性势能以及外力做的功，我们建立了在血管栓塞术的环境下的总势能模型。为了求解这个模型，我们提出了一个基于有限元方法的求解器。从而模拟了线圈在介入医生的操作下慢慢的进入血管瘤，并缠绕起来的过程。 / 另外，我们提出了一个分层圆柱网格模型（LCGM）用于模拟在血管网中血流的运动。这一模型在几何上和拓扑结构上都非常适合我们的应用。我们将血液在血管中的流动近似为一维的层流，并用一组线性等式描述了血管网中流速与血压的关系。通过求解这一线性系统，得到了在分层圆柱网格模型下血流的速度场。依据这个血流的速度场，我们采用平流-扩散模型来模拟造影剂在血管中的传播的过程。 / Vascular diseases have been becoming the number one cause of death worldwide in recent years. Millions of people were killed by vascular diseases each year. An increasingly promising therapy for treating vascular diseases is Vascular Interventional Radiology (VIR). VIR is a minimally invasive surgery (MIS) procedure, which has been widely used to cure stroke, angiostenosis, aneurysm and etc. A low risk, an accelerated recovery and a shorter stay in hospital are important advantages over the traditional vascular surgery. This therapy is performed by a guidewire-catheter combination inside the blood vessels under the guidance of the fluoroscopic imaging. Because of the complexity and particularity of these procedures, it is a great challenge to master hand-eye coordination, instrument manipulation and procedure protocols for each radiologist mandatory. An efficient and safe training system is needed urgently. In contrast to these traditional training methods, virtual reality (VR) based simulation systems is a pretty good surrogate. / In order to build a high fidelity interventional simulator for physician training, firstly, we reconstructed the three dimensional (3D) model for the vascular network of the patients. An method of automatic skeleton extraction was proposed to acquire the centerline of the vascular network from the segmented volume data from CTA/MRA. A series of continuing frames were generated along with the centerline based on improved parallel transporting method. According to these frames we built the crossections of the vessels and further the 3D vascular model with the smooth meshes. / Secondly, as the most basic and important instruments in the VIR procedure, the catheter and guidewire were modeled and simulated physically. We developed a deformable model to simulate complicated behaviors of guidewires and catheters based on the principle of minimum total potential energy. A fast and stable multigrid solver was proposed to ensure both realistic simulation and real time interaction. A series of experiments were conducted to evaluate our multigrid solver in terms of stability, time performance, the capability of simulating catheter behaviors and the realism of catheter deformation. / Thirdly, to simulate the procedure of embolization, we proposed a novel method to simulate the motion of coil and their interactions with the aneurysm. We formulated the total potential energy in the embolization circumstance by summing up the elastic energy deriving from the bending of coils, the potential energy due to the deformation of the aneurysm and the work by the external forces. A novel FEM-based approach was proposed to simulate the deformation of coils. And the motion of coils and their responses to every input from the interventional radiologist can be calculated globally. / Fourthly, we proposed our Layered Cylindrical Gird Model (LCGM) for simulating blood flow in vascular network, which is pretty suitable for sampling the vascular network geometrically and topologically. The blood flow in vessels was regarded as 1D laminar flow and formulated into a set of linear equations based on the Poiseuille law to describe the relationship between the speed of flow and the pressure. Solving those equations, we got the velocity fields in the blood flow. In terms of the velocity fields, an advection-diffusion model was adopted to simulate the propagation of contrast agent with the blood flow. / Finally, all above techniques and procedures were implemented and integrated into a simulation system for training the medical students to acquire the endovascular skill, and an empirical study was also designed based on a typical selective catheteriza- tion procedure to assess the feasibility and effectiveness of the proposed system. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / 最后，我们将所有以上提到的技术和方法集成到模拟系统中用于训练医学院的学生，并使他们获得血管介入术的技能。并且，我们基于一个典型的导管插入术过程，使用经验分析的方法对模拟系统的可用性和效率进行了评估。 / Li, Shun. / Thesis (Ph.D.)--Chinese University of Hong Kong, 2012. / Includes bibliographical references (leaves 105-116). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Abstracts in also Chinese. / Abstract --- p.i / Acknowledgement --- p.vi / Chapter 1 --- Introduction --- p.1 / Chapter 2 --- Vascular Modeling --- p.14 / Chapter 2.1 --- Introduction and Related Work --- p.14 / Chapter 2.2 --- Vascular Skeleton Graph Construction --- p.15 / Chapter 2.2.1 --- Chamfer distance transform and Dijkstra's shortest-path algorithm --- p.17 / Chapter 2.2.2 --- End vertices retrieval --- p.19 / Chapter 2.2.3 --- The algorithm of vascular skeleton extraction --- p.21 / Chapter 2.3 --- Vascular Modeling --- p.21 / Chapter 2.3.1 --- Tubular Model --- p.21 / Chapter 2.3.2 --- Bifurcation Model --- p.23 / Chapter 3 --- Catheter Simulation --- p.28 / Chapter 3.1 --- Introduction and Related Works --- p.28 / Chapter 3.2 --- Catheter Simulation --- p.31 / Chapter 3.2.1 --- Kirchhoff Theory of Elastic Rod --- p.32 / Chapter 3.2.2 --- Problem Formulation --- p.34 / Chapter 3.2.3 --- The Multigrid Iterative Solver --- p.38 / Chapter 3.3 --- Collision detection --- p.45 / Chapter 3.4 --- Validation of the Catheter Simulation Method --- p.47 / Chapter 3.4.1 --- Stability --- p.49 / Chapter 3.4.2 --- Time Performance --- p.50 / Chapter 3.4.3 --- Preservation of Curved Tip --- p.51 / Chapter 3.4.4 --- The realism of catheter deformation --- p.53 / Chapter 4 --- Coil Embolization Simulation --- p.59 / Chapter 4.1 --- Introduction and Related Work --- p.59 / Chapter 4.2 --- Methodology --- p.61 / Chapter 4.2.1 --- Total potential energy of a coil --- p.61 / Chapter 4.2.2 --- The FEM-based numeric solver for interactive coil simulation --- p.61 / Chapter 5 --- Angiography Simulation --- p.70 / Chapter 5.1 --- Introduction and related works --- p.70 / Chapter 5.2 --- The Equations of Fluid --- p.72 / Chapter 5.3 --- Layered Cylindrical Gird Model --- p.73 / Chapter 5.4 --- Numerical Method --- p.76 / Chapter 5.4.1 --- Evaluation of the velocity field of blood flow --- p.76 / Chapter 5.4.2 --- Evaluation of the density field --- p.78 / Chapter 5.5 --- Results --- p.81 / Chapter 6 --- System Implementation and Evaluation --- p.84 / Chapter 6.1 --- Introduction and Related Work --- p.84 / Chapter 6.2 --- System Construction --- p.85 / Chapter 6.3 --- Empirical Study of the Training System --- p.89 / Chapter 7 --- Conclusion and Discussion --- p.98 / Chapter 7.1 --- Geometric Modeling of Vasculature --- p.99 / Chapter 7.2 --- Catheterization Simulation --- p.99 / Chapter 7.3 --- Embolization Simulation --- p.100 / Chapter 7.4 --- Angiography Simulation --- p.101 / Chapter 7.5 --- System and Evaluation --- p.102 / Publication List --- p.103 / Bibliography --- p.105

Ο στόχος αυτής της εργασίας είναι να αποκτήσουμε μία βασική γνώση όλων των διαφορετικών σχεδιαστικών παραμέτρων που πρέπει να εξεταστούν για να είναι εφικτή η κατασκευή και ο έλεγχος ενός πολυαρθρωτού εργαλείου. Επιπλέον, όλες οι αναλυτικές μέθοδοι ελέγχου που βασίζονται στις ιδιαιτερότητες των SMA παρουσιάζονται λεπτομερώς, ώστε να παραχθεί μία ικανοποιητική λύση βασιζόμενη στις μεταβολές κατάστασης των κραμάτων και του συγκεκριμένου βραχίονα. Με άλλα λόγια, μία πλήρης γνώση του πώς σχεδιάζουμε, κατασκευάζουμε, προσομοιώνουμε, ελέγχουμε και απεικονίζουμε ένα λειτουργικό μικροσκοπικό πολυαρθρωτό βραχίονα, με τένοντες βασισμένους σε SMA για ελάχιστα επεμβατική χειρουργική είναι ο στόχος της παρούσας εργασίας. / The purpose of this work is to acquire a fundamental knowledge of all the different design parameters, which must be evaluated in order to be able to fabricate and control a multi-DOF manipulator. Moreover, all the analytical control techniques based on the particularities of the shape memory alloys will be shown in details, in order to provide an efficient solution based on the variations of the alloys and the specific manipulator. In other words, the knowhow of building, evaluating, controlling and displaying a functional tiny multi- DOF SMA-based manipulator for minimally invasive surgery is the purpose of this work.

Os materiais de uso único (MUU) são utilizados há décadas na assistência à saúde. Inicialmente produzidos com a finalidade de prontamente disponibilizar os materiais para uso na assistência a saúde e ao mesmo tempo diminuir a sobrecarga com o trabalho inerente ao reprocessamento dos materiais. Com o passar do tempo, principalmente por questões financeiras, estes passaram a ser reutilizados. A partir de então diversos questionamentos têm sido suscitados a respeito do risco de transmissão de infecção pelo reuso destes artigos em decorrência da dificuldade para de limpeza, desinfecção e esterilização seguras destes. Os materiais utilizados para as cirurgias vídeo-laparoscópicas encontram-se entre os MUU de preço considerável e complexidade importante em relação às dificuldades para limpeza, devido à sua conformação com espaços internos inacessíveis e impossibilidade de desmonte. Isto posto, as pinças grasper, dissector, tesoura, agulha de Veress, sistema de sonda de eletrocirurgia (ou aspirador e irrigador) e sua respectiva haste, instrumentais básicos nos procedimentos de vídeo-cirurgia-laparoscópica, foram o objeto desta investigação com o propósito de avaliar a eficácia da esterilidade destes acessórios de uso único após contaminação artificial desafio e comparar os resultados dos testes de esterilidade dos MUU com os dos materiais equivalentes reprocessáveis – denominados neste estudo como grupo controle. Tratou-se de uma pesquisa experimental, laboratorial e comparativa. O inóculo utilizado para a contaminação artificial dos instrumentais de uso único constituiu-se de suspensão de esporos bacterianos do Bacillus atrophaeus var. niger e de sangue de carneiro desfibrinado esterilizado. Para o grupo controle o microrganismo eleito foi o Geobacillus stearothermophilus acrescido também de sangue de carneiro desfibrinado. Antes de proceder aos experimentos validou-se a metodologia analítica em duas fases: fase 1 - realizada a contagem de U.F.C. em três unidades de cada um dos materiais dos grupos experimental e controle após a contaminação artificial antecedendo a limpeza; fase 2 - realizada a contagem de U.F.C. em três unidades de cada um dos materiais dos grupos experimental e controle após a contaminação artificial e procedimento de limpeza. Desta forma, assegurada a recuperação dos contaminantes em todas as amostras da primeira fase e a diminuição do bioburden inicial após a limpeza dos instrumentais na 2ª fase, deu-se prosseguimento aos experimentos. Os materiais laparoscópicos foram intencionalmente contaminados com o inóculo desafio e submetidos após ao protocolo teste para validação que consistiu da seguinte seqüência: limpeza automatizada em lavadora ultra-sônica com retrofluxo com auxílio do detergente enzimático, limpeza manual complementar com serpilhos e irrigação dos lumens dos instrumentais com água sob pressão. Por fim, foi realizado o enxágüe com água destilada esterilizada, secagem com ar comprimido medicinal, acondicionamento em embalagem de papel grau cirúrgico e filme e submetidos a esterilização em Óxido de Etileno 12/88 (materiais de uso único) e em autoclave (materiais de aço inoxidável). Os materiais esterilizados foram inoculados diretamente nos meios de cultura de caseína soja e incubados por 20 dias quando foi feita a leitura final dos resultados das culturas. Os resultados encontrados foram 100% negativos para a recuperação dos microrganismos contaminantes nos 2 grupos - experimental e controle. Estes achados permitiram concluir que o reprocessamento dos materiais de uso único foi validado em relação à esterilidade permitindo chegar a um protocolo de reprocessamento / Single use devices (SUD) have been used in healthcare for decades. They were initially produced for making them readily available for use in healthcare and at the same time lower the inherent workload for device reprocessing. After time, mainly for financial reasons, they became reused. Since then, several questioning has been raised regarding to the risk of infection transmission by reusing these devices due to their difficulty of safe cleaning, disinfection and sterilization. Devices used for videosurgeries are among the SUD of considerable price and important complexity due to cleaning difficulties, because of their adjustments in inaccessible inner spaces and impossibility of taking them out into pieces. Thus, grasper calipers, dissecting forceps, scissors, Veress insuflation needle, electrosurgery probe system (or suction and irrigation tubes) and its respective dissector cannula, basic devices in videosurgery laparoscopic procedures were all the subject of investigation aimed to evaluate the effectiveness of sterility of these single use products after challenged artificial contamination and comparing the results of sterility tests of SUD to their equivalent reprocessed devices – named in this study as control group. It’s a comparative, laboratory experimental research. The inoculum used for artificial contamination of single use devices was the suspension of Bacillus atrophaeus var. niger bacteria spores and sterilized defibrinated sheep blood. For the control group, the elected strain was Geobacillus stearothermophilus adding also the defibrinated sheep blood. Before carrying out the experiments, the analytical methodology was validated in two phases: phase 1 – counting the colony formation units in three units of each one of the devices from the experimental and control groups after the artificial contamination and cleaning procedures. This way, assured the contaminant recovery in all samples of the 1st phase and the reduction of initial bioburden after device cleaning in the 2nd phase, it was carried on the experiments. The laparoscopic devices were intentionally contaminated with challenged inoculum and submitted after the trial test to validation that was consisted of the following sequence: cleaning in automated narrow-lumen cleaner with enzymatic detergent, complementary manual cleaning with brush and lumen washing of devices with water under pressure. At last, it was made rinsing with sterile distillated water, drying with medical compressed air, packing in surgical paper and film wrapping and submitted to sterilization in ethylene oxide 12/88 (single use devices) and in autoclave (stainless steel devices). The sterilized devices were contaminated directly in the casein soy media and incubated for 20 days when it was made the final reading of media results. The outcomes found were 100% negative for recovering of contamination strains in the 2 groups – the experimental and the control. These findings permitted us to conclude that single use device reprocessing was validated regarding to sterility allowing us to get a reprocessing guideline

Cette thèse a pour objectif la conception de méthodes pour la reconnaissance automatique des activités chirurgicales. Cette reconnaissance est un élément clé pour le développement de systèmes réactifs au contexte clinique et pour des applications comme l’assistance automatique lors de chirurgies complexes. Nous abordons ce problème en utilisant des méthodes de Vision puisque l’utilisation de caméras permet de percevoir l’environnement sans perturber la chirurgie. Deux types de vidéos sont utilisées : des vidéos laparoscopiques et des vidéos multi-vues RGBD. Nous avons d’abord étudié les résultats obtenus avec les méthodes de l’état de l’art, puis nous avons proposé des nouvelles approches basées sur le « Deep learning ». Nous avons aussi généré de larges jeux de données constitués d’enregistrements de chirurgies. Les résultats montrent que nos méthodes permettent d’obtenir des meilleures performances pour la reconnaissance automatique d’activités chirurgicales que l’état de l’art. / The main objective of this thesis is to address the problem of activity recognition in the operating room (OR). Activity recognition is an essential component in the development of context-aware systems, which will allow various applications, such as automated assistance during difficult procedures. Here, we focus on vision-based approaches since cameras are a common source of information to observe the OR without disrupting the surgical workflow. Specifically, we propose to use two complementary video types: laparoscopic and OR-scene RGBD videos. We investigate how state-of-the-art computer vision approaches perform on these videos and propose novel approaches, consisting of deep learning approaches, to carry out the tasks. To evaluate our proposed approaches, we generate large datasets of recordings of real surgeries. The results demonstrate that the proposed approaches outperform the state-of-the-art methods in performing surgical activity recognition on these new datasets.

Teleoperation systems have been used in the operating rooms for more than a decade. However, the lack of force feedback in commercially available systems still raises safety issues and forbids surgical gestures like palpation. Although force feedback has already been implemented in experimental setups, a systematic methodology is still lacking to design the control laws.<p><p>The approach developed in this thesis is a contribution towards such a systematic<p>methodology: it combines the use of disturbance observers with the use of a structured fixed-order controller. This approach is validated by experiments performed on a one degree of freedom teleoperation system. A physical model of this system is proposed and validated experimentally.<p><p>Disturbance observers allow to compensate friction, which is responsible for performance degradation in teleoperation. Contrary to alternative approaches,they are based on a model of the frictionless mechanical system. This allows to compensate friction with a time varying behavior, which occurs in laparoscopy.<p><p>Parametric uncertainties in this model may lead to an unstable closed-loop. A kind of "separation principle" is provided to decouple the design of the closed-loop system from the design of the observer. It relies on a modified problem statement and on the use of available robust design and analysis tools.<p><p>A new metric is proposed to evaluate the performance of friction compensation systems experimentally. This metric evaluates the ability of a compensation system to linearize a motion system, irrespective of the task and as a function of frequency. The observer-based friction compensation is evaluated with respect to this new metric and to a task-based metric. It correctly attenuates the friction in the bandwidth of interest and significantly improves position and force tracking during a palpation task.<p><p>Structured fixed-order controllers are optimized numerically to achieve robust closed-loop performance despite modeling uncertainty. The structure is chosen among classical teleoperation structures. An efficient algorithm is selected and implemented to design such a controller, which is evaluated for a palpation task. It is compared to a full-order unstructured controller, representative of the design approach that has been used in the teleoperation literature up to now. The comparison highlights the advantages of our new approach: order-reduction steps and counter-intuitive behaviors are avoided. <p><p>A structured fixed-order controller combined with a disturbance observer is implemented during a needle insertion experiment and allowed to obtain excellent performance. / Doctorat en Sciences de l'ingénieur / info:eu-repo/semantics/nonPublished

Abstract Morbid obesity is the most rapidly increasing health threat of developed countries, and the costs caused by it are already higher than those of smoking. In an increasing number of developing countries both starvation and morbid obesity are increasing simultaneously. Obesity in children and adolescents is also increasing rapidly. Conservative treatment almost invariably fails when treating morbid obesity. Results of pharmacotherapy have been disappointing after great expectations. Laparoscopic gastric banding has been used in the treatment of morbid obesity since 1993. The method was first used mostly in Europe. In the USA either an open or laparoscopic gastric bypass have been the most common methods of surgery. The aim of this study was to investigate the operation results of 280 patients operated in Vaasa Central Hospital during the 11 years after March 1996. Of these patients, 123 have been followed at least 5 years. The results have been analyzed with BAROS that measures the quality of life. Quality of life was measured prospectively 1 year after surgery with the 15D questionnaire that is validated in the Finnish population. The effect of gastric banding in esophageal motility and reflux was studied prospectively in 31 patients. Late results were analyzed in 123 patients 11 years after the first operation. Mean excess weight loss (EWL) was 56% in patients who had their band in place 7 years after surgery, and 46% in all patients. There was no mortality related to the operation, and there was only one serious complication. Disease-specific quality of life improved in 78.8% of the patients in 28 months of follow-up. Health-related quality of life was significantly improved 12 months after surgery, but improvement was not connected to the amount of weight loss. The band inhibited reflux 19 months after surgery. Complications, failures, and reoperations increase with longer follow-up. Weight loss is moderate 9 years after a gastric banding operation, and in carefully selected patients this operation is still a good option in the treatment of morbid obesity.