Cirurgia endoscópica em tumores nasosinusais: experiência do IPOLFG

Introdução: Os tumores nasais são, classicamente, abordados pela via externa mas recentemente tem-se optado, também, pela via endoscópica. No entanto, em tumores localmente avançados, poderá não ser possível a remoção completa. Material e métodos: Foram analisados os processos clínicos dos 14 doentes com tumor das fossas nasais removido por via endoscópica no IPOLFG entre 2005 e 2012. Resultados: Dos 14 doentes, 8 apresentavam tumor maligno e 5 tumor benigno. Não houve preponderância de nenhum tipo histológico. 7 doentes realizaram RT adjuvante e 1 foi submetido a esvaziamento ganglionar cervical ipsilateral. Foram registadas 2 complicações cirúrgicas: 1 fístula de LCR e 1 complicação minor. Apenas 2 doentes recidivaram, recorrendo-se à via externa em 1. Conclusões: A abordagem de tumores nasais por via endoscópica é uma opção eficaz mas é necessária uma correta avaliação da extensão tumoral para decisão da via cirúrgica a utilizar, para remoção completa e obtenção de margens livres.

An investigation of the clinical utility of preoperative cardiopulmonary exercise testing in patients undergoing major pancreatic surgery

Pancreaticoduodenectomy with or without adjuvant chemotherapy remains the only modality of possible cure in patients with cancer involving the head of the pancreas and the periampullary region. While mortality rates after pancreaticoduodenectomy have improved considerably over the course of the last century, morbidity remains high. Patient selection is of paramount importance in ensuring that major surgery is offered to individuals who will most benefit from a pancreaticoduodenectomy. Moreover, identifying preoperative risk factors provides potential targets for prehabilitation and optimisation of the patient's physiology before undertaking surgery. In addition to this, early identification of patients who are likely to develop postoperative complications allows for better allocation of critical care resources and more aggressive management high risk patients. Cardiopulmonary exercise testing is becoming an increasingly popular tool in the preoperative risk assessment of the surgical patient. However, very little work has been done to investigate the role of cardiopulmonary exercise testing in predicting complications after pancreaticoduodenectomy. The impact of jaundice, systemic inflammation and other preoperative clinicopathological characteristics on cardiopulmonary exercise physiology has not been studied in detail before in this cohort of patients. The overall aim of the thesis was to examine the relationships between preoperative clinico-pathological characteristics including cardiopulmonary exercise physiology, obstructive jaundice, body composition and systemic inflammation and complications and the post-surgical systemic inflammatory response in patients undergoing pancreaticoduodenectomy. Chapter 1 reviews the existing literature on preoperative cardiopulmonary exercise testing, the impact of obstructive jaundice, perioperative systemic inflammation and the importance of body composition in determining outcomes in patients undergoing major surgery with particular reference to pancreatic surgery. Chapter 2 reports on the role of cardiopulmonary exercise testing in predicting postoperative complications after pancreaticoduodenectomy. The results demonstrate that patients with V˙O2AT less than 10 ml/kg/min are more likely to develop a postoperative pancreatic fistula, stay longer in hospital and less likely to receive adjuvant therapy. These results emphasise the importance of aerobic fitness to recover from the operative stress of major surgery without significant morbidity. Cardiopulmonary exercise testing may prove useful in selecting patients for intensive prehabilitation programmes as well as for other optimisation measures to prepare them for major surgery. Chapter 3 evaluates the relationship between cardiopulmonary exercise physiology and other clinicopathological characteristics of the patient. A detailed analysis of cardiopulmonary exercise test parameters in jaundiced versus non-jaundiced patients demonstrates that obstructive jaundice does not impair cardiopulmonary exercise physiology. This further supports emerging evidence in contemporary literature that jaundiced patients can proceed directly to surgery without preoperative biliary drainage. The results of this study also show an interesting inverse relationship between body mass index and anaerobic threshold which is analysed in more detail in Chapter 4. Chapter 4 examines the relationship between preoperative cardiopulmonary exercise physiology and body composition in depth. All parameters measured at cardiopulmonary exercise test are compared against body composition and body mass index. The results of this chapter report that the current method of reporting V˙O2, both at peak exercise and anaerobic threshold, is biased against obese subjects and advises caution in the interpretation of cardiopulmonary exercise test results in patients with a high BMI. This is particularly important as current evidence in literature suggests that postoperative outcomes in obese subjects are comparable to non-obese subjects while cardiopulmonary exercise test results are also abnormally low in this very same cohort of patients. Chapter 5 analyses the relationship between preoperative clinico-pathological characteristics including systemic inflammation and the magnitude of the postoperative systemic inflammatory response. Obstructive jaundice appears to have an immunosuppressive effect while elevated preoperative CRP and hypoalbuminemia appear to have opposite effects with hypoalbuminemia resulting in a lower response while elevated CRP in the absence of hypoalbuminemia resulted in a greater postoperative systemic inflammatory response. Chapter 6 evaluates the role of the early postoperative systemic inflammatory response in predicting complications after pancreaticoduodenectomy and aims to establish clinically relevant thresholds for C-Reactive Protein for the prediction of complications. The results of this chapter demonstrate that CRP levels as early as the second postoperative day are associated with complications. While post-operative CRP was useful in the prediction of infective complications, this was the case only in patients who did not develop a post-operative pancreatic fistula. The predictive ability of inflammatory markers for infectious complications was blunted in patients with a pancreatic fistula. Chapter 7 summarises the findings of this thesis, their place in current literature and future directions. The results of this thesis add to the current knowledge regarding the complex pathophysiological abnormalities in patients undergoing pancreaticoduodenectomy, with specific emphasis on the interaction between cardiopulmonary exercise physiology, obstructive jaundice, systemic inflammation and postoperative outcomes. The work presented in this thesis lays the foundations for further studies aimed at improving outcomes after pancreaticoduodenectomy through the development of individualised, goal-directed therapies that are initiated well before this morbid yet necessary operation is performed.

Prevalence of Barrett Esophagus in Adolescents and Young Adults With Esophageal Atresia

International audience

Does prenatal diagnosis modify neonatal treatment and early outcome of children with esophageal atresia?

International audience

Le diagnostic anténatal modifie-t-il la prise en charge néonatale et le devenir à 1 an des enfants suivis pour atrésie de l’œsophage de type III ?

International audience

Nivelación dialectal: aspectos metodológicos y teóricos para el estudio de la convergencia lingüística a través de un caso concreto: los inmigrantes de Riogordo y Colmenar en Málaga

Convergencia y divergencia dialectales en los núcleos rurales Redes sociales Actitudes individuales y construcción de estilos personales Existe una tendencia bien conocida en las lenguas hacia la convergencia entre las variedades vernáculas regionales con las prestigiosas y de mayor estatus, propias de los núcleos urbanos y centros culturales. En las comunidades rurales, sin embargo, es más frecuente que tenga lugar una resistencia a la convergencia con el estándar y que se refuerce el uso de los rasgos vernáculos. Lo que ocurre es que el estudio de los procesos de convergencia en los centros urbanos está bien representado en la bibliografía y, sin embargo, son escasos los trabajos que se han ocupado de estudiar las tendencias divergentes en núcleos poblacionales más pequeños y en zonas rurales. De ahí que esta tesis pretenda dar respuesta a ese choque de tendencias convergentes y divergentes que tiene lugar en el ámbito rural. El estudio se centra en dos localidades de la provincia de Málaga, Colmenar y Riogordo, porque ambas reúnen las características idóneas para arrojar un poco de luz sobre este tipo de procesos de contacto dialectal: están cerca de la capital y bien comunicadas con el núcleo urbano, pero a la vez tienen una identidad muy marcada, lo que las convierte en un laboratorio ideal para investigar por qué sus habitantes se inclinan por una u otra variante impulsando, de esta manera, tendencias de convergencia o bien de divergencia con el estándar. Para crear el corpus en el que se basa esta investigación se establecieron cuotas de afijación uniforme basadas en tres variables de preestratificación: sexo, edad y nivel de instrucción. Las casillas de las cuotas se fueron completando por medio del procedimiento de bola de nieve. Para investigar los procesos de divergencia dialectal se han escogido tres variables dependientes, la fricativa velar /x/, la palatal africada /ʧ/ y las líquidas /r/ y /l/ en la distensión silábica. Son buenos indicios para estudiar las tendencias que aquí interesan y, por otra parte, su presencia en la bibliografía sociolingüística no está tan bien representada como la de, por ejemplo, el proceso de escisión de /θs/ en dos unidades, mate y estridente, o su variación en la coda silábica. En el capítulo correspondiente a la variación social se estudia la correlación entre variables dependientes y de preestratificación y también se presta atención a la influencia que ejercen otras variables de postestratificación, como el modo de vida y el grado de formalidad de la situación, porque aportan información relevante sobre la atribución de prestigio patente o encubierto en las localidades rurales. En relación con la variación reticular, se revisa de qué manera interactúan el rango de la red, el sexo y el nivel de estudios de los contactos con las variables dependientes, pues son estos precisamente los indicadores que más fuerza explicativa tienen en la muestra analizada. También interesa conocer qué influencia ejerce en los usos lingüísticos de los hablantes el grado de aceptación de los valores urbanos o su apego a las costumbres locales y su mentalidad rural. Con tal fin se ha construido una Escala de Orientación Urbana, ESORURB, que mide la interacción entre usos lingüísticos y mentalidad del hablante. La tesis se cierra con un estudio de la variación individual según las aportaciones de los trabajos de la tercera ola. Para el análisis se ha escogido a una integrante de una de las redes sociales que sobresale entre su grupo de edad (la segunda generación) y estudios (sociolecto superior) por el alto porcentaje de formas estigmatizadas que emplea. El objetivo del capítulo es detectar qué valor confiere esta hablante a las variantes vernáculas, estudiando los temas de conversación que favorecen su aparición y los marcos discursivos que sirven de contexto. A partir de estos datos se establecen dos estilos conversacionales concretos asociados al empleo de las variantes, y que ella adopta de forma consciente para mostrarse ante los demás y construir una imagen concreta de sí misma.

Using autologous platelet-rich plasma for the treatment of complex fistulas

Objective: This study aims to demonstrate the effectiveness and safety of autologous fibrin gel rich in platelet growth factors for the treatment of complex perianal fistulas. Material and methods: Prospective epidemiological study. Patients with complex perianal fistula or perianal fistula mere alteration of continence are included. identification of both holes and the journey, curettage of it and instillation of Vivostat PRF® in the way it is done to observe excess material by OFE. The variables analyzed were: age, sex, use of prior Seton clinic prevalent type of fistula, postoperative complications, fistula closure and impaired quality of life using the SF-36 test (v2). Results: From January 2011 to May 2013 have involved 23 patients, 12 men and 11 women, with an average age of 49 years and a minimum follow-up of 12 months. Two dropped out. 17 patients had low transsphincteric fistulas, 2 and 2 high transsphincteric intersphincteric with impaired continence. The most common symptom is the discharge. Twelve patients had a loose seton (62%), of which nine cured. Of all the patients we have operated the success rate is 62%. No patient developed incontinence after treatment. Only two reported a worse quality of life after surgery. Conclusion: This study demonstrates that there is a clear benefit to the use of Vivostat PRF® as a treatment for complex perianal fistulas. It is a highly reproducible technique with acceptable results and does not produce impairment of continence.

Self-expanding metal stents in postoperative esophageal leaks

Background: Postoperative esophageal leaks have a high morbidity and mortality. Self-expanding metal stents (SEMS) have been used as an alternative to re-operation. Aim: Evaluating predictors of success of SEMS in postoperative esophageal leaks. Methods: Retrospective study of patients with postoperative esophageal leaks referred for SEMS placement in a reference center during a period of 3 years. Technical success was defined as closure of the leak in barium swallow at 15 days. Clinical success was considered as endoscopic and/or radiographic confirmation of closure after stent removal. Results: Thirteen patients placed SEMS. Median follow-up was 58 days. Leaks had a median size of 20 mm. Time between surgery and SEMS placement was 20 days. One patient died 2 days after SEMS placement and one had worsening of the fistula after SEMS expansion. Time till stent migration was 9 days. Technical success was achieved in 9 of 11 patients, with clinical success without recurrence in 5 patients. All leaks with less than 20 mm were solved endoscopically. Technical and clinical success was higher when time between surgery and SEMS placement was lower, even though without statistical significance (respectively, p = 0.228 and 0.374). In the 8 patients who died during follow-up, median survival was 59 days. Conclusions: Technical success of SEMS was higher than 80%; however, due to high morbidity and mortality, only 45% of patients had their stent removed. Lower time from diagnosis to SEMS placement and leak size less than 20 mm may be associated with better results.

First case reported of Bouveret's syndrome associated to duodenal and biliary perforation to retroperitoneum

We present the case of a 69 year old woman with a history of cholecystitis, who consulted for severe abdominal pain, nausea and vomiting. Abdominal CT showed duodenal obstruction caused by a gallstone, cholecystoduodenal fistula and pneumobilia, what is known as Bouveret's syndrome, a rare form of gallstone ileus. Additionally, she presented free duodenal and vesicular perforation to retroperitoneum at the same level of the cholecystoduodenal transit point. The patient underwent a difficult cholecystectomy, enterolithotomy, repair of the duodenal defect, extensive washing and drainage of the retroperitoneum. The postoperative course was uneventful except for a laparotomy infection.

Odontometric analysis of molars for sex determination

Aim: To investigate the existence of sexual dimorphism between the first and second permanent molars. Methods: A cross-sectional, observational, blind study using comparative and statistical descriptive procedures. The sample included 50 pairs of plaster casts from undergraduate dental students (25 men/25 women) from the Federal University of Paraíba, João Pessoa/PB, Brazil, aged 20-26 years. Odontometric measurements of first and second maxillary/mandibular, right/left permanent molars were performed. Mesiodistal (MD) and buccolingual/palatal (BL/BP) widths and the distance between the lingual cusps of corresponding molars in opposite quadrants, were measured. The data were analyzed by Student’s t test and ANOVA with Bonferroni (p≤0.05). Results: The crowns of all first molars were statistically larger in men than in women (p<0.05). Maxillary and mandibular left second molars (#27 and #37) did not differ in their MD widths (p=0.66, p=0.75), whereas mandibular left and right second molars (#37 and #47) showed statistically different BL widths (p=0.007 and p=0.008). As to the distance between the lingual cusps, only the first left-to-right mandibular molars (#36-46) showed no sex dimorphism (p=0.107). Conclusions: Molars are larger in males than in females. Individually, first molars demonstrated higher evidence of sex distinction than second molars.

Fratura traumática do osso temporal : diagnóstico, sequelas e tratamento

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2014

Estenosis esofágica. Aplicación de una técnica quirúrgica. Caso clínico

Se presenta el caso clínico de un paciente que presenta estenosis esofágica tras ingesta de caústicos, con disfagia a líquidos por lo que se realizó esofagectomía transhiatal con técnica de tubo gástrico como alternativa para reemplazo esofágico con ascenso mediastinal y yeyunostomía de alimentación, luego del procedimiento presenta fístula a nivel de la anastomosis proximal cervical y derrame pleural que se drena mediante avenamiento pleural bilateral, se maneja de manera conservadora sin desfuncionalización la fistula cervical mediante dren semirígido, con cierre espontaneo y se da de alta al paciente luego de tolerar dieta

Cambios corticales en los dientes anteriores superiores e inferiores con Brackets convencionales, Damon y biofuncional QR en pacientes de trece a veinte y cuatro años

En el mercado existen varios sistemas de tratamiento en ortodoncia, los cuales deben ser estudiados para evitar que causen alteraciones en el periodonto, especialmente en los procesos alveolares corticales, por lo que el objetivo de este estudio fue conocer los cambios óseos alveolares, sean reabsorciones, aposiciones o ningún cambio óseo. Para realizar el estudio, se tomó como muestra tres sistemas de tratamiento: Sistema de Autoligado Damon, Sistema Biofuncional QR y Sistemas Convencionales Roth y MBT, estos brackets se aplicaron en 18 pacientes (seis de cada sistema), los cuales fueron sometidos a una tomografía antes del tratamiento y otra después de finalizada la etapa de alineación y nivelación. En los estudios tomográficos se realizaron trazados para medir en milímetros las corticales alveolares vestibulares, palatina y lingual, de los seis dientes anteriores superiores e inferiores, siendo la muestra total de 216 dientes. Para obtener los resultados del estudio, se ingresaron los datos recolectados en una hoja de cálculo Excel y procesados estadísticamente mediante el software SPSS versión 22, con las pruebas ANOVA y Tukey, obteniendo como resultados en el promedio de reabsorción ósea total p= 0,05 y con el Sistema Biofuncional QR una significancia de p= 0,025, en este último se demostró la presencia de aposición en la cortical lingual mandibular. Se concluyó que todos los sistemas de tratamiento causan reabsorciones óseas, siendo el Sistema Damon el de mayor reabsorción, seguido del Sistema convencional y luego el Sistema Biofuncional QR, produciendo este último una aposición estadísticamente significante. En los dientes anterosuperiores no existieron cambios óseos significativos y en los dientes anteroinferiores las mayores reabsorciones fueron en las piezas 42 y 32 y aposición en la pieza 41

Evaluation of Onlay Island Flap Technique in Shallow Urethral Plate Hypospadiasis

Background: Hypospadias is one of the most common congenital genital anomalies in males that necessitates to be operated early in infancy (when 6 to 9 months old). On the other hand, hypospadias is a challenging field of pediatric urology with multiple reconstruction techniques. A perfect hypospadias repair is supposed to return urethral continuity with sufficient caliber, eradicate phallus curvature, and supply an acceptable appearance with low complications. Objectives: This study aimed to evaluate the outcomes of using onlay island flap technique in the repair of hypospadias with shallow urethral plate. Patients and Methods: In this prospective study within June 2012 to December 2013, we performed onlay island flap procedure to repair hypospadias with shallow urethral plate measuring less than 6 millimeter. This technique was selected for all types of hypospadiasis except subcoronal type. Nesbit’s dorsal plication procedure was established for chordee. In cases with very small glans, urethroplasty was performed without glansplasty. Results: Twenty three patients with mean age of 30 (range 10 - 60) months underwent onlay island flap repair; all had a shallow urethral plate < 6 mm, 3 had a very small glans, and 18 had chordee. Meatus was located in distal shaft in 5 cases, mid shaft in 8, proximal in 6 and penoscrotal type in 4 patients. Chordee was corrected with Nesbit’s dorsal plication in 16 cases. Complications were: meatal stenosis in 2 cases and urethrocutaneous fistula in 2 patients, all of which were repaired surgically. Mean follow up time was 13 (3 - 20) months. All cases that had glansplasty have excellent esthetic appearance. Conclusions: This technique offers acceptable results regarding meatal stenosis, urethrocutaneous fistula and esthetic outcome.

Expansão rápida da maxila

O presente trabalho tem como objetivo estudar a técnica da Expansão Rápida da Maxila, comparando os tipos de aparelhos recomendados consoante as diferentes propriedades, vantagens e desvantagens associadas. Quando pensamos em um padrão normal para a oclusão temos em mente uma correta relação entre as bases apicais em que a arcada maxilar deverá englobar a arcada mandibular permitindo o equilíbrio entre ambas. Quando ocorre uma redução das dimensões transversais da maxila nos vemos diante de atresias, entre elas uma anomalia de má oclusão bastante frequente na nossa clínica, a mordida cruzada posterior. Quando isto acontece o profissional precisa buscar uma correção da conformação do arco através da expansão rápida da maxila abrindo a sutura palatina mediana por meio de aparelhos expansores fixos tais como o de Haas (dento-muco-suportado) ou os classificados como dento-suportados como o Hyrax ou o disjuntor de McNamara, na dentição decídua, mista ou permanente e até mesmo em pacientes adultos com protocolos diferenciados para cada faixa etária. Caso o indivíduo apresente uma calcificação óssea avançada da sutura mediana deve ser encaminhado para a expansão rápida da maxila cirurgicamente assistida.