Theses / Dissertations 2015



Author: Melissa Mitsue Makita Arantes Marinho
Original Title: Evaluation of rabbit cervical sympathetic nerve injury by clipping: Titanium X polymer clips

Introduction: surgical treatment of hyperidrosis has become a widely used procedure with the advent of video - surgery since 1990. The sympathetic nervous block by clipping the sympathetic nerve is considered a reversal operation because of the theoretical possibility of removal of the clipif the patient develops intolerable side effects, such as compensatory sweating. The question of reversibility remains controversial, and many variables can be involved in the recovery or not of the lesion. The material used in the procedure could be a contributing factor. Purpose: to study the macro and microscopic evaluation of the damage caused by titanium versus polymeric clamping of cervical sympathetic nerve in rabbits, quantifying the collagen in the lesions. Methods: twenty rabbits were divided into two groups of ten, doing in group 1 (titanium) clipping of the right cervical sympathetic nerve with titanium clamp while in group 2 (polymer) were used polymeric clamp. All rabbits were induced to death on the seventh Day after surgery. The macroscopic variables were: consequences of nerve lesion, clip appearance, presence of infection and adhesions around the nerve. Microscopy used hematoxylin-eosin staining to evaluate the stages and the degree of inflammation and necrosis, and Picrosirius Red staining to quantify collagen. Mann-Whitney test was used for comparisons of collagen types I and III between groups. Fischer exact test analyzed the macroscopic variables, the degree of inflammation and necrosis. Results: the presence of severe adhesions was significantly higher in the titanium group (p< 0,0001). There was no nerve discontinuity of injury in both groups, as well as significant differences in the type of inflammation , but the intensity was significantly higher in the titanium group (p < 0.0001). There was no significant difference between the groups in terms of collagen deposition nerves. Conclusions: clamping of cervical nerve with titanium clips showed more adhesion and significantly higher inflammatory process than with polymeric clip, while collagen deposition was similar in both groups.

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Author: Cassio Zini
Original Title: Knee arthroscopic visibility alterations in obese and non-obese patients

Introduction: the pneumatic tourniquet has been used for over a century to reduce intraoperative blood loss and improve the visual field of the surgeon. However, orthopedic surgery society expressed concern about the use of tourniquet and potential risks. Arthroscopic meniscectomy is traditionally regarded as low-morbidity procedure with fast postoperative recovery. The relevance of tourniquet use in this procedure remains undefined, as well as its influence in the postoperative period. Obesity is a chronic disease characterized by excess body fat and has become the most prevalent public health problem worldwide, in both the developed and the developing and is a multifactorial process that involves environmental and genetic factors. Orthopedic surgeons need to know the impact of obesity on surgical interventions and the influence of BMI on the outcome of arthroscopy for partial meniscectomy. Objective: compare the surgical time and the visualization of arthroscopic field in partial meniscectomy in obese and non-obese patients with and without tourniquet. Patients and methods: this study was conducted at Center Sports Traumatology and Arthroscopy (CTEA) of the Hospital Vita Curitiba and Medical Research Institute (IPEM) of the Evangelical Paraná College (FEPAR) and approved by the Research Ethics Committee of the Society Evangelical Beneficent from Curitiba. 60 patients were selected. Among them, a total of 30 obese and 30 non-obese patients who underwent arthoscopy partial meniscectomy with or without pneumatic tourniquet, following it safe use guideline. The arthroscopic surgical procedures were recorded and later analyzed. Results: the study included 60 patients divided into 4 groups: 15 obese patients without use of tourniquet, 15 obese patients with the use of the tourniquet, 15 nonobese patients without use of tourniquet and 15 nonobese patients with the use of the tourniquet. 48 men and 12 women participated in the study, the average age was 42.9 years ranging from 18 to 70 years. BMI 21:56 to 40.14 kg / m2. Surgical time ranged from 10:40 to 65.20 minutes and the average time of surgery was 21.34 minutes. The distribution of visibility of the surgical field according to the classification was used: Class 1 - 38/60 (63.3%); Class 2 - 13/60 (21.6%); Class 3 - 6/60 (10%); Class 4 - 3/60 (5%). Conclusion: the comparison of surgical time and visualization of arthroscopic field in partial meniscectomy with and without tourniquet in obese and non-obese patients there was no significant difference between groups.

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Author: Gilberto Laurino Almeida
Original Title: EORTC Risk Model to Predict Progression in Patients With Non-Muscle-Invasive Bladder Cancer: Is It Safe to Use in Clinical Practice?

Introduction: The non-muscle invasive urothelial cancer (NMIBC) represents 85% of all bladder tumors. Although a heterogeneous biologic behavior, recurrence and progression are typical to these tumors. The stratification in risk groups of recurrence and progression has been determinant to choose adequate treatment and define prognosis of these patients, and the EORTEC risk tables has been widely used in clinical practice for this goal. Objective: Validate the EORTEC risk tables and its applicability in patients with NMIBC from the south of Brazil. Methods: Two hundred and five patients with NMIBC submitted to trans-urethral bladder resection were analyzed. The six parameters analyzed were: histologic grading, pathologic stage, size and number of tumors, previous recurrence rate and concomitant carcinoma in situ. The time for first recurrence (TFR), time for progression (TFP), risk score and probabilities of recurrence and progression were calculated for each patient and compared to the probabilities obtained from EORTEC risk tables. To external validation, the C-index was calculated and accuracy of EORTEC risk tables was analyzed. Results: The pathologic stage Ta was presented in 91 patients and T1 in 114. Ninety-seven patients had solitary tumor, sixty-four had 2 to 5 lesions and forty-four had more than 5 lesions. One hundred and three patients had tumors smaller than 3 centimeters and one hundred had bigger than 3 centimeters.  Concomitant carcinoma in situ was observed in 21 patients. Histologic grading G1 and G2 were presented in 95 patients, and the G3 in 110. Intravesical therapy was utilized in 105 patients. Recurrence was observed in 117 patients and the mean TFR was 14,2 ± 7,3 months; progression was observed in 43 patients and mean TFP was 26,9 ± 15,2 months. The C-index for recurrence was 0,72 for 1 year and 0,7 for 5 years, and for progression was 0,86 for 1 year and 0,78 for 5 years. The recurrence risk was 28,8% in 1 year and 57,1% in 5 years, independently of the scoring risk. The progression risk was 3,4% in 1 year and 19,1% in 5 years, independently of the scoring risk. In our population, the EORTEC risk tables overestimated the risk of recurrence in 1 year and underestimated in 5 years, and for progression the risk was overestimated in 1 and 5 years. Conclusion: The external validation of the EORTEC risk tables in south Brazilian population with NMIBC was satisfactory and should be stimulated to predict recurrence and progression.

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Author: Eduardo Nascimento Silva
Original Title: Histological evaluation of capsules formed by silicon implants coated with polyurethane foam and with a textured surface in rats

Introduction: The biggest late complication due to mammaplasty is capsular contracture. The incidence is approximately 10% for textured implant and around 1% for polyurethane-coated implants. Any process in which the cause is unknown treatment remains speculative and multimodal. This is the challenge of capsular contracture. Objectives: To analyze the intensity of: the foreign body reaction, the formation of granulation tissue,the presence of myofibroblasts, the neoangiogenesis and the synovial metaplasia in capsules formed around silicone implants in both groups; To assess whether the polyurethane group presents a thicker capsule than the textured group; To assess the total areas and percentage of the collagen type I and III in both groups. Methods: We used 64 albino female rats, Wistar, which were divided into two groups (polyurethane foam and textured surface) with32 animalseach.The capsuleswere analyzed bystaining hematoxylin-eosin, Masson’s trichromeacid and picrosiriusredat30, 50, 70 and 90 days. To compare the two groups, within each subgroup, the test was considered nonparametric Mann-Whitney. To compare the different subgroups, within each type of group, it was considered nonparametric Kruskal-Wallis. Comparisons between the groups and subgroups, for dichotomous qualitative variables, were made using Fisher's exact test. P-values<0.05 were considered statistically significant. Results: Theforeign body reaction was bigger in the polyurethane group thanit was in thetextured group (30 days p=0.0001; 50 days p=0.002; 70 p=0.001 days and 90 days p=0.0002). The formation of granulation tissue was more noticeablein the polyurethane group compared tothe textured group (30 days p=0.0001; 50 days p=0.002; 70 days p=0.0002 and 90 days p=0.0002). The presence of myofibroblasts was more intense in the polyurethane group thanthe textured group (30 days p=0.0001; 50 days p=0.015; 70 days p=0.007 and 90 days p=0.0002). With regardto the neoangiogenesis and synovial metaplasia, there was no statistical difference between the groups.The polyurethane group showed: a thicker capsule (30 days p=0.001; 50 days p=0.006, p=0.00170 days and 90 days p=0.001); a smaller total area of type I collagen (30 days p=0.046; 50 days p=0.045, p=0.021 70 days and 90 days p=0.037); a smaller percentage area of type I collagen (30 days p=0.036; 50 days p=0.011, p=0.02170 days and 90 days p=0.028) and a larger percentage area oftype III collagen (30 days p=0.036; 50 days p=0.011; p=0.021 70 days and90 days p=0.028). Conclusions:The polyurethane-coated implants induced a bigger foreign body reaction, a noticeable formation of the granulation tissue and a higher intensity of myofibroblasts. With regard tothe neoangiogenesis and synovial metaplasia, there was no difference between groups. In allsubgroupsevaluated,the polyurethane group showed a thicker capsule, a smaller totaland percentagearea of type I collagenand a higher percentage area of type III collagen.

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