Implante primário de lente-intraocular para o tratamento da catarata congênita e do desenvolvimento

Pós-graduação em Pesquisa e Desenvolvimento (Biotecnologia Médica) - FMB

Considerações acerca do preparo ortodôntico direcionado à cirurgia ortognática

This work aims at contributing to increase and improve the communication between orthodontists and maxillofacial surgeons, reviewing and discussing the principles of diagnosis and orthodontic movement specific to patients with surgical indication. It describes the elective points in the conduct of the orthodontist so that their decisions could lead to an individualized and appropriate planning, striving for excellence in terms of outcomes for the surgical-orthodontic treatment of dentofacial discrepancies.

Are Complications Associated With the Repiphysis(®) Expandable Distal Femoral Prosthesis Acceptable for Its Continued Use?

BACKGROUND: Reconstruction of the distal femur after resection for malignant bone tumors in skeletally immature children is challenging. The use of megaprostheses has become increasingly popular in this patient group since the introduction of custom-made, expandable devices that do not require surgery for lengthening, such as the Repiphysis(®) Limb Salvage System. Early reports on the device were positive but more recently, a high complication rate and associated bone loss have been reported. QUESTIONS/PURPOSES: We asked: (1) what are the clinical outcomes using the Musculoskeletal Tumor Society (MSTS) scoring system after 5-year minimum followup in patients treated with this prosthesis at one center; (2) what are the problems and complications associated with the lengthening procedures of this implant; and (3) what are the specific concerns associated with revision of this implant? METHODS: At our institute, between 2002 and 2007, the Repiphysis(®) expandable prosthesis was implanted in 15 children (mean age, 8 years; range, 6-11 years) after distal femoral resection for malignant bone tumors. During this time, the general indication for use of this implant was resection of the distal femur for localized malignant bone tumors in pediatric patients. Alternative techniques used for this indication were modular prosthetic reconstruction, massive (osteoarticular or intercalary) allograft reconstruction, or rotationplasty. Age and tumor extension were the main factors to decide on the surgical indication. Of the 15 patients who had this prosthesis implanted during reconstruction surgery, five died with the implant in situ or underwent amputation before 5 years followup and the remaining 10 were evaluated at a minimum of 5 years (mean, 104 months; range, 78-140 months). No patients were lost to followup. These 10 patients were long-term survivors and underwent the lengthening program. They were included in our study analysis. The first seven lengthening procedures were attempted in an outpatient setting; however, owing to pain and burning sensations experienced by the patients, the procedures failed to achieve the desired lengthening. Therefore, other procedures were performed with the patients under general anesthesia. We reviewed clinical data at index surgery for all 15 patients. We further analyzed the lengthening procedures, implant survival, radiographic and functional results, for the 10 long-term survivors. Functional results were assessed according to the MSTS scoring system. Complications were classified according to the International Society of Limb Salvage (ISOLS) classification system. RESULTS: Nine of the 10 survivors underwent revision of the implant for mechanical failure. They had a mean MSTS score of 64% (range, 47%-87%) before revision surgery. At final followup the 10 long-term surviving patients had an average MSTS score of 81% (range, 53%-97%). In total, we obtained an average lengthening of 39 mm per patient (range, 17-67 mm). Exact expansion of the implant was unpredictable and difficult to control. Nine of 10 of the long-term surviving patients underwent revision surgery of the prosthesis-eight for implant breakage and one for stem loosening. At revision surgery, six patients had another type of expandable prosthesis implanted and three had an adult-type megaprosthesis implanted. In five cases, segmental bone grafts were used during revision surgery to compensate for loss of bone stock. CONCLUSIONS: We could not comfortably expand the Repiphysis(®) prosthesis in an outpatient setting because of pain experienced by the patients during the lengthening procedures. Furthermore, use of the prosthesis was associated with frequent failures related to implant breakage and stem loosening. Revisions of these procedures were complex and difficult. We no longer use this prosthesis and caution others against the use of this particular prosthesis design. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Are Complications Associated With the Repiphysis(®) Expandable Distal Femoral Prosthesis Acceptable for Its Continued Use?

BACKGROUND: Reconstruction of the distal femur after resection for malignant bone tumors in skeletally immature children is challenging. The use of megaprostheses has become increasingly popular in this patient group since the introduction of custom-made, expandable devices that do not require surgery for lengthening, such as the Repiphysis(®) Limb Salvage System. Early reports on the device were positive but more recently, a high complication rate and associated bone loss have been reported. QUESTIONS/PURPOSES: We asked: (1) what are the clinical outcomes using the Musculoskeletal Tumor Society (MSTS) scoring system after 5-year minimum followup in patients treated with this prosthesis at one center; (2) what are the problems and complications associated with the lengthening procedures of this implant; and (3) what are the specific concerns associated with revision of this implant? METHODS: At our institute, between 2002 and 2007, the Repiphysis(®) expandable prosthesis was implanted in 15 children (mean age, 8 years; range, 6-11 years) after distal femoral resection for malignant bone tumors. During this time, the general indication for use of this implant was resection of the distal femur for localized malignant bone tumors in pediatric patients. Alternative techniques used for this indication were modular prosthetic reconstruction, massive (osteoarticular or intercalary) allograft reconstruction, or rotationplasty. Age and tumor extension were the main factors to decide on the surgical indication. Of the 15 patients who had this prosthesis implanted during reconstruction surgery, five died with the implant in situ or underwent amputation before 5 years followup and the remaining 10 were evaluated at a minimum of 5 years (mean, 104 months; range, 78-140 months). No patients were lost to followup. These 10 patients were long-term survivors and underwent the lengthening program. They were included in our study analysis. The first seven lengthening procedures were attempted in an outpatient setting; however, owing to pain and burning sensations experienced by the patients, the procedures failed to achieve the desired lengthening. Therefore, other procedures were performed with the patients under general anesthesia. We reviewed clinical data at index surgery for all 15 patients. We further analyzed the lengthening procedures, implant survival, radiographic and functional results, for the 10 long-term survivors. Functional results were assessed according to the MSTS scoring system. Complications were classified according to the International Society of Limb Salvage (ISOLS) classification system. RESULTS: Nine of the 10 survivors underwent revision of the implant for mechanical failure. They had a mean MSTS score of 64% (range, 47%-87%) before revision surgery. At final followup the 10 long-term surviving patients had an average MSTS score of 81% (range, 53%-97%). In total, we obtained an average lengthening of 39 mm per patient (range, 17-67 mm). Exact expansion of the implant was unpredictable and difficult to control. Nine of 10 of the long-term surviving patients underwent revision surgery of the prosthesis-eight for implant breakage and one for stem loosening. At revision surgery, six patients had another type of expandable prosthesis implanted and three had an adult-type megaprosthesis implanted. In five cases, segmental bone grafts were used during revision surgery to compensate for loss of bone stock. CONCLUSIONS: We could not comfortably expand the Repiphysis(®) prosthesis in an outpatient setting because of pain experienced by the patients during the lengthening procedures. Furthermore, use of the prosthesis was associated with frequent failures related to implant breakage and stem loosening. Revisions of these procedures were complex and difficult. We no longer use this prosthesis and caution others against the use of this particular prosthesis design. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Studio pancreatic cystic follow-up, an international collaboration (PACYFIC study). Valutazione prospettica della sorveglianza delle cisti pancreatiche basato sulla consensus Europea sui tumori cistici del pancreas.

Introduzione Nel 2014 è stato proposto un protocollo di studio riguardante la sorveglianza delle lesioni cistiche del pancreas (intese come IPMN) e denominato PACYFIC Study. Obiettivi Obiettivo primario era di stabilire l’impatto di un programma di sorveglianza in termini di pazienti arruolati e pazienti con indicazione chirurgica. Obiettivi secondari erano: 1) stabilire l’impatto dei fattori demografici, clinici, radiologici e della strategia di sorveglianza sull’indicazione chirurgica, sulla capacità individuare le lesioni maligne, sulla sopravvivenza. Materiali e Metodi Lo studio su cui si è basata la raccolta dei dati è uno studio di tipo prospettico, di coorte, multicentrico, internazionale. Lo studio ha incluso gli individui con una IPMN, di nuova o pregressa diagnosi, che giustifichi una sorveglianza o il trattamento chirurgico. I dati clinici, demografici, radiologici e chirurgici sono stati raccolti in un database prospettico. Le variabili discrete sono state espresse come frequenza e percentuale. Le continue come medie e deviazioni standard o mediane e range interquartile (IQR). Per l’analisi statistica sono stati utilizzati il test di Fischer, il test del Chi quadro, il test di Spearman, il test di Student. L’analisi multivariata è stata eseguita utilizzando la regressione logistica espressa come Odds Ratio e intervallo di confidenza al 95 %. Per la sopravvivenza è stato utilizzato il metodo di Kaplan-Meier. L’analisi multivariata sulle sopravvivenze è stata eseguita mediante la regressione di Cox. Risultati Il protocollo di sorveglianza ha permesso l'arruolamento di 516 pazienti. 53 pazienti hanno raggiunto l'indicazione chirurgica. La sopravvivenza globale della coorte è stata di 326.8± 9.1 mesi. I fattori predittivi la sopravvivenza sono risultati età (OR 1.07, P-value<0.001), sesso (OR 1.82, P-value=0.006), ittero, noduli murali (OR 4.84, P-value=0.018 e OR 2.19, P-value=0.016), chirurgia (OR 0.46, P-value 0.038). Conclusioni L'introduzione del protocollo di sorveglianza ha portato ad un aumento di identificazione di lesioni e ha avuto impatto sulla sopravvivenza

Neuropathy after herniorrhaphy: indication for surgical treatment and outcome.

BACKGROUND: Chronic neuropathy after hernia repair is a neglected problem as very few patients are referred for surgical treatment. The aim of the present study was to assess the outcome of standardized surgical revision for neuropathic pain after hernia repair. METHODS: In a prospective cohort study we evaluated all patients admitted to our tertiary referral center for surgical treatment of persistent neuropathic pain after primary herniorrhaphy between 2001 and 2006. Diagnosis of neuropathic pain was based on clinical findings and a positive Tinel's sign. Postoperative pain was evaluated by a visual analogue scale (VAS) and a pain questionnaire up to 12 months after revision surgery. RESULTS: Forty-three consecutive patients (39 male, median age 35 years) underwent surgical revision, mesh removal, and radical neurectomy. The median operative time was 58 min (range: 45-95 min). Histological examination revealed nerve entrapment, complete transection, or traumatic neuroma in all patients. The ilioinguinal nerve was affected in 35 patients (81%); the iliohypogastric nerve, in 10 patients (23%). Overall pain (median VAS) decreased permanently after surgery within a follow-up period of 12 months (preoperative 74 [range: 53-87] months versus 0 [range: 0-34] months; p<0.0001). CONCLUSIONS: The results of this cohort study suggest that surgical mesh removal with ilioinguinal and iliohypogastric neurectomy is a successful treatment in patients with neuropathic pain after hernia repair.

Le reflux gastro-oesophagien: l'apport de l'endoscopie dans l'indication opératoire et les contrôles postopératoires [Gastroesophageal reflux: importance of endoscopy in surgical indications and postoperative control].

Endoscopy constitutes an important investigation in the presence of a gastro-oesophageal reflux. The primary intention is to exclude the possibility of an organic pathology, for example cancer, which has not been demonstrated by other investigative procedures. Accordingly it must provide a detailed exploration of the whole superior digestive tract, from the mouth to the duodenum. Secondly, endoscopy must establish the consequence of the reflux on the mucosa of the lower oesophagus both by a macroscopic and a detailed microscopic description. Peptic lesions are classified according to 4 degrees of severity. The difficulty in evaluating the very early lesions (1st degree) and the advanced stages (4th degree) necessitates systematic biopsies of the lesions. The erythroplasic type of carcinoma in situ can present the same endoscopic changes as a 1st degree peptic lesion, whereas the exclusion of an adenocarcinoma constitutes the major preoccupation at the time of endoscopy of a 4th degree oesophagitis.

Evaluation of the indication for surgical extraction of third molars according to the oral surgeon and the primary care dentist. Experience in the Master of Oral Surgery and Implantology at Barcelona University Dental School

Introduction: Third molar extraction is the most frequent procedure in oral surgery. The present study evaluates the indication of third molar extraction as established by the primary care dentist (PCD) and the oral surgeon, and compares the justification for extraction with the principal reason for patient consultation. Patients and method: A descriptive study was made of 319 patients subjected to surgical removal of a third molar in the context of the Master of Oral Surgery and Implantology (Barcelona University Dental School, Barcelona, Spain) between July 2004 and March 2005. The following parameters were evaluated: sex, age, molar, type of impaction, position according to the classifications of Pell and Gregory and of Winter, and the reasons justifying extraction. Results: The lower third molars were the most commonly extracted molars (73.7%). A total of 69.6% of the teeth were covered by soft tissues only. Fifty-six percent of the lower molars corresponded to Pell and Gregory Class IIB, while 42.1% were in the vertical position. The most common reason for patient reference to our Service of Oral Surgery on the part of the PCD was prophylactic removal (51.0% versus 46.1% in the case of the oral surgeon). Discussion and conclusions. Our results show prophylaxis to be the principal indication of third molar extraction, followed by orthodontic reasons. Regarding third molars with associated clinical symptoms or signs, infectious disease-including pericoronitis- was the pathology most often observed by the oral surgeon, followed by caries. This order of frequency was seen to invert in the case of third molars referred for extraction by the PCD. A vertical position predominated among the third molars with associated pathology

Clinical and surgical evaluation of the indication of postoperative antibiotic prescription in third molar surgery

Objective. The aim of this study was to evaluate the need for antibiotic prescription in third molar surgery. Study design. A double-blind randomized study was carried out with 71 patients from CODONT (Dentistry Center of the Police of Sao Paulo). Amoxicillin, clindamycin, or no medication was administered for 7 days immediately after surgery. The participants evaluated the presence of pain, edema, interincisal distance (ID), presence of infection, Pell and Gregory classification, rescue analgesia, osteotomy, and odontosection. Results. There was no difference (P < .05) between antibiotics and control over the surgery duration, dose, visual analog scale (VAS), ID, and edema, yet significant differences were seen over time for VAS, edema, and ID. Conclusions. Antibiotic prescription should not be indicated in all clinical conditions, yet it is necessary to correctly evaluate factors such as systemic condition of the patient, skill of the operator, and contamination of the surgical environment. (Oral Surg Oral Med Oral Pathol Oral Radiol 2012; 114(suppl 5):S26-S31)

What Is The Best Indication For Single-incision Ophira Mini Sling? Insights From A 2-year Follow-up International Multicentric Study.

The Ophira Mini Sling System involves anchoring a midurethral, low-tension tape to the obturator internus muscles bilaterally at the level of the tendinous arc. Success rates in different subsets of patients are still to be defined. This work aims to identify which factors influence the 2-year outcomes of this treatment. Analysis was based on data from a multicenter study. Endpoints for analysis included objective measurements: 1-h pad-weight (PWT), and cough stress test (CST), and questionnaires: International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) and Urinary Distress Inventory (UDI)-6. A logistic regression analysis evaluated possible risk factors for failure. In all, 124 female patients with stress urinary incontinence (SUI) underwent treatment with the Ophira procedure. All patients completed 1 year of follow-up, and 95 complied with the 2-year evaluation. Longitudinal analysis showed no significant differences between results at 1 and 2 years. The 2-year overall objective results were 81 (85.3%) patients dry, six (6.3%) improved, and eight (8.4%) incontinent. A multivariate analysis revealed that previous anti-incontinence surgery was the only factor that significantly influenced surgical outcomes. Two years after treatment, women with previous failed surgeries had an odds ratio (OR) for treatment failure (based on PWT) of 4.0 [95% confidence interval (CI) 1.02-15.57). The Ophira procedure is an effective option for SUI treatment, with durable good results. Previous surgeries were identified as the only significant risk factor, though previously operated patients showed an acceptable success rate.

Good surgical outcome in discordant ictal EEG-MRI unilateral mesial temporal sclerosis patients

Purpose:Video electroencephalography (vEEG) monitoring of patients with unilateral mesial temporal sclerosis (uMTS) may show concordant or discordant seizure onset in relation to magnetic resonance imaging (MRI) evidence of MTS. Contralateral seizure usually leads to an indication of invasive monitoring. Contralateral seizure onset on invasive monitoring may contraindicate surgery. We evaluated long-term outcome after anteromesial temporal lobectomy (AMTL) in a consecutive series of uMTS patients with concordant and discordant vEEG findings, uniformly submitted to AMTL on the MRI evidence of MTS side without invasive monitoring. Methods:We compared surgical outcome of all uMTS patients undergoing vEEG monitoring between January 1999 and April 2005 in our service. Discordant cases were defined by at least one seizure onset contralateral to the MRI evidence of MTS. Good surgical outcome was considered as Engel`s class I. We also evaluated ictal SPECT concordance to ictal EEG and surgical outcome. Results:Fifty-four patients had concordant (C) and 22 had discordant (D) scalp EEG and MRI. Surgical outcome was similar in both groups (C = 74% versus D = 86%). Duration of follow-up was comparable in both groups: C = 56.1 +/- 20.7 months versus D = 59.8 +/- 21.2 months (p = 0.83, nonsignificant). Discordant single-photon emission computed tomography (SPECT) results did not influence surgical outcome. Discussion:Surgical outcome was not influenced by contralateral vEEG seizure onset or contralateral increased flow on ictal SPECT. Although vEEG monitoring should still be performed in these patients, to rule out psychogenic seizures and extratemporal seizure onset, a potentially risky procedure such as invasive monitoring may not only not be indicated in this patient population, but may also lead to patients erroneously being denied surgery.

Infective endocarditis: surgical therapy

OBJECTIVE: To assess the major causes of surgical morbidity and mortality in patients with infective endocarditis operated upon in a regional cardiology center. METHODS: Thirty-four patients underwent surgical treatment for infective endocarditis. Their ages ranged from 20 to 68 years (mean of 40.6) and 79% were males. Their NYHA functional classes were as follows: IV - 19 (55.8%) patients; III - 12 (35.2%) patients; II - 3 (8.8%) patients. Blood cultures were positive in only 32% of the cases. Eight patients had already undergone previous cardiac surgery, whose major indication (82.3%) was heart failure refractory to clinical treatment. RESULTS: Four (11.7%) patients died at the hospital. Follow-up was complete in 26 (86%) patients. Five (14.7%) patients died later, 12, 36, 48, 60, and 89 months after hospital discharge. Of the 21 patients being currently followed up, 1 is in NYHA functional class III, and 5 in NYHA functional class II. CONCLUSION: A high degree of clinical suspicion, at an early diagnosis, and indication of surgical treatment prior to deterioration of left ventricular function and installation of generalized sepsis may improve prognosis.

Approches chirurgicales "palliatives" de l'épilepsie ["Palliative" surgical procedures in refractory epilepsy]

In some patients with refractory epilepsy, no resective surgery of the epileptogenic zone can be offered. This is the case when for instance the epileptogenic zone is located in an eloquent region (motor, language or visual) or when there are several epileptogenic zones. When disabling seizures persist despite the medical treatment, several surgical procedures can be proposed with the aim of decreasing the seizure frequency. Among these procedures, we review briefly here vagus nerve stimulation, the various brain stimulations procedures, multiples subpial transsections, and the corpus callosotomy. For each procedure, we will discuss its indication and outcome.

Perioperative nutrition is still a surgical orphan: results of a Swiss-Austrian survey.

Background/Objectives:There is strong evidence for the beneficial effects of perioperative nutrition in patients undergoing major surgery. We aimed to evaluate implementation of current guidelines in Switzerland and Austria.Subjects/Methods:A survey was conducted in 173 Swiss and Austrian surgical departments. We inquired about nutritional screening, perioperative nutrition and estimated clinical significance.Results:The overall response rate was 55%, having 69% (54/78) responders in Switzerland and 44% (42/95) in Austria. Most centres were aware of reduced complications (80%) and shorter hospital stay (59%). However, only 20% of them implemented routine nutritional screening. Non-compliance was because of financial (49%) and logistic restrictions (33%). Screening was mainly performed in the outpatient's clinic (52%) or during admission (54%). The nutritional risk score was applied by 14% only; instead, various clinical (78%) and laboratory parameters (56%) were used. Indication for perioperative nutrition was based on preoperative screening in 49%. Although 23% used preoperative nutrition, 68% applied nutritional support pre- and postoperatively. Preoperative nutritional treatment ranged from 3 days (33%), to 5 (31%) and even 7 days (20%).Conclusions:Although malnutrition is a well-recognised risk factor for poor post-operative outcome, surgeons remain reluctant to implement routine screening and nutritional support according to evidence-based guidelines.