Efeitos da carboxiterapia na integração de enxertos condrocutâneos em coelhos

Dissertação (mestrado)—Universidade de Brasília, Faculdade de Medicina, Programa de Pós-Graduação em Ciências Médicas, 2012.O enxerto condrocutâneo é uma boa opção para reconstrução, principalmente da asa nasal. Um dos fatores que limita o uso deste enxerto é o seu diâmetro máximo em torno de 1,5 cm. A carboxiterapia é o uso terapêutico do gás carbônico por via subcutânea e tem sido usada para melhorar a perfusão tecidual, aumentar o fluxo sanguíneo e acelerar a cicatrização. A necessidade de tratamentos que aumentassem as chances de pega dos enxertos compostos e a divulgação da carboxiterapia como medida que aumenta a microcirculação e a oxigenação, podendo facilitar a integração dos enxertos levaram à proposição deste trabalho. O objetivo deste trabalho é estudar os possíveis efeitos da carboxiterapia na integração de enxertos condrocutäneos em coelhos. Foi feito um estudo experimental utilizando 20 coelhos que foram distribuídos em um grupo submetido a carboxiterapia e outro à infiltração de solução cloreto de sódio a 0,9%. Em cada orelha foi feito um enxerto circular de 1,5 cm ou 2 cm de diâmetro. Foram analisadas a evolução clínica dos animais, a pega dos enxertos, a quantidade e o tipo de colágeno por histomorfometria, a histopatologia incluindo a neovascularização, fibroblastos, células mononucleares, hiperplasia epitelial, folículos pilosos viáveis, necrose da cartilagem e ulceração da pele. O grupo submetido a carboxiterapia teve um ganho de peso significativamente menor que os animais do grupo submetido à infiltração de solução salina (p=0,038). Na análise do enxerto, não foram observadas diferenças histopatológicas entre os grupos. A carboxiterapia não influenciou a pega dos enxertos de 1,5 cm ou 2 cm, p = 0.567 e 0.777, respectivamente. Houve aumento da quantidade de colágeno nos enxertos de 2 cm nos coelhos submetidos a carboxiterapia (p=0,003). O efeito da carboxiterapia não foi significativamente diferente da infusão de solução salina na integração de enxertos condrocutâneos realizados em orelhas de coelhos. _______________________________________________________________________________________ ABSTRACTChondrocutaneous graft is an effective option for reconstruction, especially of the nasal alae. The limiting factor for its use is the maximum diameter of 1.5 cm. Carboxitherapy comprises subcutaneous use of carbon dioxide aming to improve tissue perfusion, increase blood flow and speed healing. The need for a treatment strategy to increase composite graft survival and the possibility of improving microcirculation and oxygenation with the use of carbon dioxide therapy that could make survival of larger grafts possible led us to this study. The objective was to evaluate the effect of carboxytherapy in auricular composite grafts. An experimental study was conducted using 20 rabbits randomly assigned to a treatment group of carbon dioxide therapy or a control group of sodium chloride solution at 0,9%. In each ear a circular graft with a 1,5 cm or 2 cm of diameter was amputated and reattached. The animals underwent carbon dioxide therapy or saline solution injection four times during the experiment. We analyzed clinical evolution of animals, grafts survival, the amount and type of collagen by histomorphometry, histopathology including neovascularization, collagen, fibroblasts, mononuclear cells, epithelial hyperplasia, viable hair follicles, necrosis of cartilage and skin ulceration. The treated group had a significantly lower weight gain than control group (p=0,038). Histopathology of grafted area was not significantly different between groups. Carboxytherapy didn’t influence graft survival rate for 1.5cm or 2 cm grafts, p = 0.567 and 0.777 respectively. There was an increase in amount of collagen in 2 cm grafts submitted to carbon dioxide therapy (p=0,003). Carboxytherapy was not significantly different from saline infusion on auricular composite graft survival

Resultado estético e qualidade de vida após mastectomia e reconstrução mamária para tratamento de câncer de mama

Tese (doutorado)—Universidade de Brasília, Faculdade de Medicina, Programa de Pós-Graduação em Ciências Médicas, 2017.INTRODUÇÃO: Nos últimos 16 anos, foi observado um aumento de 35% nos casos de reconstrução mamária nos Estados Unidos, aumentando o interesse em relação à satisfação e à qualidade de vida relacionada à reconstrução mamária. O objetivo deste estudo é avaliar a qualidade de vida e o resultado estético das pacientes submetidas a diferentes técnicas de reconstrução mamária para o tratamento do câncer de mama. MÉTODOS: Foi realizada a análise retrospectiva dos dados demográficos e características clínicas das pacientes submetidas a reconstrução mamária entre 2009 e 2011 na Cleveland Clinic – OH. A qualidade de vida foi avaliada por meio de questionários pré e pós-operatórios de qualidade de vida relacionada a reconstrução mamária, o BreastQ. O resultado estético foi avaliado por meio de análise de fotografias com a utilização de uma escala multi-parâmetro específica para a avaliação da estética da mama. As pacientes que responderam a versão pré-operatória do questionário foram agrupadas entre o grupo que buscava a reconstrução imediata e o grupo que buscava a reconstrução tardia. Os questionários pósoperatórios foram analisados quanto a: tipo de reconstrução (somente implante ou tecido autólogo com ou sem implante); necessidade ou não de radioterapia; presença da placa aréolo papilar (PAP); presença de complicações pós-operatórias e lateralidade. A satisfação com as mamas relatada pelas pacientes foi comparada à avaliação do resultado estético atribuída por profissionais/estudantes da área médica por meio de fotografias de pós-operatório. Foram realizadas análises univariada e multivariada dos dados e p <0,05 foi considerado estatisticamente significativo. RESULTADOS: Ao todo, 153 pacientes responderam o questionário pré-operatório: 141 para a reconstrução imediata e 13 para reconstrução tardia. As pacientes que buscavam a reconstrução imediata apresentaram maior satisfação com as mamas (63,3±22,7 vs. 31,6±18,9; p<0,01), bem-estar psicossocial (73,1±16,8 vs. 53,2±17; p<0,01), bem-estar físico – tórax (61,6±14,2 vs. 66,4±14,1; p<0,03) e bem-estar sexual (58,9±21,5 vs. 31,1±14,1; p<0,01), comparado à reconstrução tardia. Um total de 261 questionários pós-operatórios foram avaliados. Entre as pacientes que responderam os questionários, 147 tiveram suas fotografias avaliadas. A satisfação com as mamas foi maior na reconstrução autóloga (67,5±21,6 vs. 60,4±21,4; p=0,018), quando comparada ao implante. Pacientes submetidas à radioterapia relataram menor satisfação com as mamas (60,1±22,1 vs. 65,4±21,3; p=0,03), menor satisfação com o tratamento (61,3±24,0 vs. 69,4±22,4; p=0,008), menor bem-estar psicossocial (65,9±20,9 vs. 74,2±21,4; p=0,001), menor bem-estar sexual (45,4±22,9 vs. 53,5±24,1; p=0,034) e menor bem-estar físico (72,0±16,5 vs 78,6±16,5; p=0,002), camparadas às pacientes nãoirradiadas. A reconstrução bilateral apresentou maior satisfação com as mamas (66,6±18,9 vs 60,0±24,1; p= 0,028) e com o tratamento (69,4±22,2 vs 63,3±24,2; p=0,035), comparada à unilateral. A presença de complicações pós-operatórias está relacionada a um menor bem–estar físico (73,8±16,4 vs 80,4±16,8; p=0,003). Reoperações devido a complicações estão relacionadas a menor bem-estar psicossocial (67,0±21,8 vs 73,4±21,1; p=0,02) e físico (72,3±16,4 vs 78,3±16,6; p=0,01), em relação às pacientes sem complicações. O resultado estético global foi superior na reconstrução autóloga, comparada ao implante (3,5±0,8 vs. 3,0±0,9; p=0,001); na ausência da radioterapia, comparado às mamas irradiadas (3,4±0,8 vs. 3,0±0,9; p=0,016); na presença da PAP, comparado às mamas sem a PAP (3,3±0,9 vs. 3,0±0,8; p=0,023). Na análise multivariada, a reconstrução autóloga e a bilateralidade influenciaram positivamente a satisfação com as mamas; enquanto a radioterapia, o número de cirurgias e o tempo decorrido entre a reconstrução e o questionário influenciaram negativamente. O resultado estético global foi influenciado positivamente pela reconstrução autóloga e negativamente pelo risco anestésico (ASA), radioterapia e número de cirurgias por paciente. Foi observada uma correlação entre o resultado estético avaliado e a satisfação com as mamas (r=0,329; p<0,001). CONCLUSÃO: A qualidade de vida e o resultado estético das pacientes submetidas a reconstrução mamária são positivamente influenciados pelo uso de tecido autólogo associado ou não a implantes mamários e pela bilateralidade da reconstrução. Fatores que influenciaram negativamente incluem: o uso da radioterapia, um maior número de cirurgias necessárias para a reconstrução, a realização de reoperações devido a complicações, maior índice de massa corporal e um maior tempo decorrido entre a reconstrução e o questionário. A qualidade de vida relatada pelas pacientes nos demais módulos do BreastQ também influencia na satisfação com as mamas. Tanto as pacientes quanto os profissionais avaliam melhor a reconstrução com tecido autólogo. No entanto, as pacientes tendem a avaliar melhor que os profissionais a reconstrução realizada com o uso exclusivo de implantes, enquanto os profissionais da área médica reconstrução autóloga quando comparados avaliam melhor a às pacientes.INTRODUCTION: Over the past 16 years, there has been a 35% increase in breast reconstruction in the United States, increasing the interest in satisfaction and quality of life after to breast reconstruction. The aim of this study is to evaluate the quality of life and aesthetic outcome of patients submitted to different breast reconstruction techniques for the treatment of breast cancer. METHODS: Retrospective analysis of demographic data and clinical characteristics of patients undergoing breast reconstruction between 2009 and 2011 at Cleveland Clinic – OH was performed. Quality of life related to breast reconstruction was assessed using pre and post-operative quality of life questionnaires, the BreastQ. The aesthetic result was evaluated by means of photographic analysis using a specific multi-parameter scale for the evaluation of breast aesthetics. The patients who answered the preoperative version of the questionnaire were grouped between the group that sought immediate reconstruction and the group that sought the delayed reconstruction. The postoperative questionnaires were analyzed for: type of reconstruction (implant only or autologous tissue with or without implant); need for radiation therapy; presence of nipple-areolar complex (NAC); presence of postoperative complications; and laterality. Patient-reported breast satisfaction was compared to the aesthetic result graded by medical professionals / students through postoperative photographs. Univariate and multivariate data analyzes were performed and p <0.05 was considered statistically significant. RESULTS: A total of 153 patients answered the preoperative questionnaire: 141 for immediate reconstruction and 13 for delayed. Patients who sought immediate reconstruction had higher satisfaction with breasts (63.3 ± 22.7 vs. 31,6 ± 18.9; p <0.01), higher psychosocial well-being (73.1 ± 16.8 vs. 53.2 ± 17; p <0.01), higher physical – thorax well-being (61.6 ± 14.2 vs. 66.4 ± 14.1; p <0.03), and sexual wellbeing (58.9 ± 21.5 Vs. 31.1 ± 14.1; p <0.01) compared to delayed reconstruction. A total of 261 post-operative questionnaires were evaluated. Among the patients who answered the questionnaires, 147 had their photographs graded. Breast satisfaction was higher in the autologous reconstruction (67.5 ± 21.6 vs. 60.4 ± 21.4; p = 0.018) when compared to implant. Radiated patients reported lower satisfaction with breasts (60.1 ± 22.1 vs. 65.4 ± 21.3; p = 0.03), lower satisfaction with the treatment (61.3 ± 24.0 vs. 69.4 ± 22.4; p = 0.008), lower psychosocial well-being (65.9 ± 20.9 vs. 74.2 ± 21.4; p = 0.001), lower sexual well-being (45.4 ± 22.9 vs. 53.5 ± 24.1; p = 0.034) and lower physical wellbeing (72.0 ± 16.5 vs. 78.6 ± 16.5; p = 0.002), compared to non-radiated patients. Bilateral reconstruction patients presented higher satisfaction with breasts (66.6 ± 18.9 vs 60.0 ± 24.1; p = 0.028) and with treatment (69.4 ± 22.2 vs 63.3 ± 24.2; P = 0.035), compared to unilateral. The presence of postoperative complications is related to lower physical well-being (73.8 ± 16.4 vs 80.4 ± 16.8; p = 0.003). Reoperations due to complications are related to lower psychosocial (67.0 ± 21.8 vs 73.4 ± 21.1; p = 0.02) and physical well-being (72.3 ± 16.4 vs 78.3 ± 16.6; p = 0.01), in relation to patients without complications. The overall aesthetic result was higher in the following groups: autologous reconstruction compared to the implant (3.5 ± 0.8 vs. 3.0 ± 0.9; p = 0.001); in the absence of radiation therapy, compared to non-radiated (3.4 ± 0.8 vs. 3.0 ± 0.9; p = 0.016); and in the presence of NAC, compared to breasts without NAC (3.3 ± 0.9 vs. 3.0 ± 0.8; p = 0.023). In the multivariate analysis, autologous reconstruction and bilaterality positively influenced the satisfaction with breasts; whereas the radiation therapy, the number of surgeries, and the time elapsed between the reconstruction and the questionnaire negatively influenced satisfaction with breasts. The overall aesthetic result was positively influenced by autologous reconstruction and negatively influenced by higher anesthetic risk (ASA), radiation therapy, and number of surgeries per patient. A correlation was observed between the aesthetic result evaluated and the satisfaction with breasts (r = 0.329, p <0.001). CONCLUSION: The quality of life and aesthetic outcome of breast reconstruction patients are positively influenced by the use of autologous tissue associated or not with breast implants, and bilateral reconstruction. Factors that negatively influenced include: the use of radiation therapy, a bigger number of surgeries required for the reconstruction, reoperations due to complications, a higher body mass index and a longer time elapsed between reconstruction and the questionnaire. The patient-reported quality of life in other domains of the BreastQ also influences the satisfaction with breasts. Both patients and practitioners better evaluate autologous tissue reconstruction. However, the patients tend to evaluate better than the professionals the reconstruction performed with the exclusive use of implants, while the medical professionals evaluate better the autologous reconstruction, compared to the patients’ evaluation

The effect of carbon dioxide therapy on composite graft survival

PURPOSE: To investigate the effect of carboxytherapy in auricular composite grafts in rabbits. METHODS: An experimental study was conducted using 20 rabbits randomly assigned to a treatment group of carboxytherapy or a control group of saline solution. In each ear, a circular graft with 1.5 cm or 2 cm of diameter was amputated and reattached. Animals underwent carbon dioxide or saline injection four times during the experiment. We analyzed clinical evolution of the animals, grafts survival, histopathology features and histomorphometry of collagen. RESULTS:The treated group had a significantly lower weight gain (p=0.038). Histopathology was not significantly different between groups. There was an increase in amount of collagen in 2 cm grafts submitted to carbon dioxide therapy (p=0.003). Carboxytherapy didn't influence graft survival rate for 1.5 cm grafts or 2 cm grafts (p=0.567 and p=0.777, respectively). CONCLUSIONS:Carbon dioxide therapy increased the amount of collagen in 2 cm grafts. CO2 was not significantly different from saline infusion on composite grafts survival, but this study suggests that there is a mechanical effect caused by distension which favored graft survival

Effects of carbon dioxide therapy on the healing of acute skin wounds induced on the back of rats

PURPOSE: To evaluate the healing effect of carbon dioxide therapy on skin wounds induced on the back of rats. METHODS: Sixteen rats underwent excision of a round dermal-epidermal dorsal skin flap of 2.5 cm in diameter. The animals were divided into two groups, as follows: carbon dioxide group - subcutaneous injections of carbon dioxide on the day of operation and at three, six and nine days postoperatively; control group - no postoperative wound treatment. Wounds were photographed on the day of operation and at six and 14 days postoperatively for analysis of wound area and major diameter. All animals were euthanized on day 14 after surgery. The dorsal skin and the underlying muscle layer containing the wound were resected for histopathological analysis. RESULTS: There was no statistically significant difference between groups in the percentage of wound closure, in histopathological findings, or in the reduction of wound area and major diameter at 14 days postoperatively. CONCLUSION: Under the experimental conditions in which this study was conducted, carbon dioxide therapy had no effects on the healing of acute skin wounds in rats

Correlation between bursting pressure and breaking strength in colonic anastomosis

PURPOSE: To investigate the correlation between bursting pressure and breaking strength on the 7th postoperative day following left colonic anastomosis in rats. METHODS: Seventy rats were randomly divided into seven groups of ten animals each. All of the animals underwent segmental resection of the left colon and end-to-end anastomosis. The animals in groups I to VI underwent surgical laparoscopies with pneumoperitoneums using carbon dioxide or helium at pressures of 5, 12 or 20 mmHg. In Group VII, open laparotomy was performed. The animals were reoperated on postoperative day 7 to measure the bursting pressure and the breaking strength of the anastomosis. RESULTS: The anastomosis bursting pressure in 70 animals was 193.10±55.56 mmHg. There was no significant difference between the groups (p=0.786). The breaking strength of the anastomosis was 0.26±0.12 N. There was no significant difference between the groups (p=0.356). Pearson's correlation test showed a low correlation (r=0.231) lacking statistical significance (p=0.054). CONCLUSION: There was no correlation between the bursting pressure and breaking strength of left colonic anastomoses in rats on the 7th postoperative day

A new proposal for laparoscopic left colectomy in a rat model

PURPOSE: To evaluate the feasibility and safety of a new technique for laparoscopic segmental colectomy and primary anastomosis in the left colon of rats. METHODS: Thirty rats were randomly assigned to three groups of ten animals each. All animals underwent segmental resection of the left colon and end-to-end anastomosis. In Group I, the animals underwent laparoscopic surgery with carbon dioxide pneumoperitoneum at a pressure of 5 mmHg. In Group II, the animals underwent pneumoperitoneum with carbon dioxide at a pressure of 12 mmHg. In Group III, the control group, the animals underwent open surgery. All animals were reopened on the 7th postoperative day and were evaluated for peritonitis, abscesses, anastomotic dehiscence and bowel obstruction, and the anastomosis bursting pressure was measured. RESULTS: No obstructions, peritonitis or abscesses were found in any of the animals. An animal in Group I exhibited a blocked anastomosis leakage. The average anastomosis bursting pressure in the 30 animals was 187.02 ± 68.35 mmHg. There was no significant difference in the anastomosis bursting pressure among the groups (p = 0.503) CONCLUSION: The laparoscopic experimental model was feasible and safe for segmental colectomy and anastomosis of the left colon in rats

Effects of carbon dioxide therapy on the healing of acute skin wounds induced on the back of rats

PURPOSE: To evaluate the healing effect of carbon dioxide therapy on skin wounds induced on the back of rats. METHODS: Sixteen rats underwent excision of a round dermal-epidermal dorsal skin flap of 2.5 cm in diameter. The animals were divided into two groups, as follows: carbon dioxide group - subcutaneous injections of carbon dioxide on the day of operation and at three, six and nine days postoperatively; control group - no postoperative wound treatment. Wounds were photographed on the day of operation and at six and 14 days postoperatively for analysis of wound area and major diameter. All animals were euthanized on day 14 after surgery. The dorsal skin and the underlying muscle layer containing the wound were resected for histopathological analysis. RESULTS: There was no statistically significant difference between groups in the percentage of wound closure, in histopathological findings, or in the reduction of wound area and major diameter at 14 days postoperatively. CONCLUSION: Under the experimental conditions in which this study was conducted, carbon dioxide therapy had no effects on the healing of acute skin wounds in rats