CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior / Aproximadamente metade dos pacientes constipados apresenta sintomas de evacuaÃÃo obstruÃda, sendo o anismus uma das principais causas. O objetivo à demonstrar uma nova tÃcnica utilizando a ultra-sonografia anorretal tridimensional dinÃmica (USD-3D) para o diagnÃstico do anismus e comparando os resultados com a eletromanometria anorretal. Foram utilizadas neste estudo prospectivo e comparativo 70 mulheres adultas com sintomas de evacuaÃÃo obstruÃda provenientes do ServiÃo de Coloproctologia do Hospital UniversitÃrio Walter CantÃdio da Universidade Federal do CearÃ, no perÃodo entre maio de 2005 a agosto de 2006. A idade variou de 23-79, na mÃdia de 48.72 anos. Todas as pacientes foram inicialmente submetidas à eletromanometria anorretal e, a partir dos resultados, divididas em grupo I, constituÃdo por 40 pacientes normais apresentando relaxamento da musculatura esfincteriana estriada ao esforÃo evacuatÃrio e grupo II com as 30 pacientes restantes com diagnÃstico de anismus. Em seguida, as pacientes de ambos os grupos foram submetidas à ultra-sonografia anorretal tridimensional dinÃmica. A tÃcnica consistiu em dois escaneamentos e as imagens estÃticas e dinÃmicas foram devidamente analisadas nos planos axial e longitudinal, observando-se as posiÃÃes do mÃsculo PR entre o repouso e o esforÃo evacuatÃrio. Visando quantificar de forma objetiva os movimentos do mÃsculo PR, foi desenvolvido no plano longitudinal mediano um Ãngulo constituÃdo por uma linha traÃada paralela à borda interna do PR ( 1.5cm ) com uma outra linha vertical, longitudinal ao eixo do canal anal. Esse Ãngulo à calculado no repouso e no esforÃo evacuatÃrio, sendo a mÃdia no repouso de 88.37   4.05 no grupo I e de 89.13   5.73 no grupo II. NÃo houve diferenÃa significativa entre os dois grupos no repouso ( p=0.51 ). A mÃdia do Ãngulo no esforÃo evacuatÃrio no grupo I foi de 98.19   1.18 e no grupo II, de 84.94   1.31, ocorrendo diferenÃa estatisticamente significante entre os dois grupos ( p<0.001 ). A ultra-sonografia anorretal tridimensional dinÃmica demonstrou resultados concordantes com a eletromanometria anorretal em 92,86 % com relaÃÃo ao diagnÃstico de anismus em pacientes com sintomas de evacuaÃÃo obstruÃda. Conclui-se que a tÃcnica de ultra-sonografia anorretal dinÃmica apresentada neste estudo pode ser considerada eficaz no diagnÃstico do anismus e com a vantagem de demonstrar simultaneamente a conformaÃÃo anatÃmica dos mÃsculos esfincterianos. . / Aproximadamente metade dos pacientes constipados apresenta sintomas de evacuaÃÃo obstruÃda, sendo o anismus uma das principais causas. O objetivo à demonstrar uma nova tÃcnica utilizando a ultra-sonografia anorretal tridimensional dinÃmica (USD-3D) para o diagnÃstico do anismus e comparando os resultados com a eletromanometria anorretal. Foram utilizadas neste estudo prospectivo e comparativo 70 mulheres adultas com sintomas de evacuaÃÃo obstruÃda provenientes do ServiÃo de Coloproctologia do Hospital UniversitÃrio Walter CantÃdio da Universidade Federal do CearÃ, no perÃodo entre maio de 2005 a agosto de 2006. A idade variou de 23-79, na mÃdia de 48.72 anos. Todas as pacientes foram inicialmente submetidas à eletromanometria anorretal e, a partir dos resultados, divididas em grupo I, constituÃdo por 40 pacientes normais apresentando relaxamento da musculatura esfincteriana estriada ao esforÃo evacuatÃrio e grupo II com as 30 pacientes restantes com diagnÃstico de anismus. Em seguida, as pacientes de ambos os grupos foram submetidas à ultra-sonografia anorretal tridimensional dinÃmica. A tÃcnica consistiu em dois escaneamentos e as imagens estÃticas e dinÃmicas foram devidamente analisadas nos planos axial e longitudinal, observando-se as posiÃÃes do mÃsculo PR entre o repouso e o esforÃo evacuatÃrio. Visando quantificar de forma objetiva os movimentos do mÃsculo PR, foi desenvolvido no plano longitudinal mediano um Ãngulo constituÃdo por uma linha traÃada paralela à borda interna do PR ( 1.5cm ) com uma outra linha vertical, longitudinal ao eixo do canal anal. Esse Ãngulo à calculado no repouso e no esforÃo evacuatÃrio, sendo a mÃdia no repouso de 88.37   4.05 no grupo I e de 89.13   5.73 no grupo II. NÃo houve diferenÃa significativa entre os dois grupos no repouso ( p=0.51 ). A mÃdia do Ãngulo no esforÃo evacuatÃrio no grupo I foi de 98.19   1.18 e no grupo II, de 84.94   1.31, ocorrendo diferenÃa estatisticamente significante entre os dois grupos ( p<0.001 ). A ultra-sonografia anorretal tridimensional dinÃmica demonstrou resultados concordantes com a eletromanometria anorretal em 92,86 % com relaÃÃo ao diagnÃstico de anismus em pacientes com sintomas de evacuaÃÃo obstruÃda. Conclui-se que a tÃcnica de ultra-sonografia anorretal dinÃmica apresentada neste estudo pode ser considerada eficaz no diagnÃstico do anismus e com a vantagem de demonstrar simultaneamente a conformaÃÃo anatÃmica dos mÃsculos esfincterianos. . / Aproximadamente metade dos pacientes constipados apresenta sintomas de evacuaÃÃo obstruÃda, sendo o anismus uma das principais causas. O objetivo à demonstrar uma nova tÃcnica utilizando a ultra-sonografia anorretal tridimensional dinÃmica (USD-3D) para o diagnÃstico do anismus e comparando os resultados com a eletromanometria anorretal. Foram utilizadas neste estudo prospectivo e comparativo 70 mulheres adultas com sintomas de evacuaÃÃo obstruÃda provenientes do ServiÃo de Coloproctologia do Hospital UniversitÃrio Walter CantÃdio da Universidade Federal do CearÃ, no perÃodo entre maio de 2005 a agosto de 2006. A idade variou de 23-79, na mÃdia de 48.72 anos. Todas as pacientes foram inicialmente submetidas à eletromanometria anorretal e, a partir dos resultados, divididas em grupo I, constituÃdo por 40 pacientes normais apresentando relaxamento da musculatura esfincteriana estriada ao esforÃo evacuatÃrio e grupo II com as 30 pacientes restantes com diagnÃstico de anismus. Em seguida, as pacientes de ambos os grupos foram submetidas à ultra-sonografia anorretal tridimensional dinÃmica. A tÃcnica consistiu em dois escaneamentos e as imagens estÃticas e dinÃmicas foram devidamente analisadas nos planos axial e longitudinal, observando-se as posiÃÃes do mÃsculo PR entre o repouso e o esforÃo evacuatÃrio. Visando quantificar de forma objetiva os movimentos do mÃsculo PR, foi desenvolvido no plano longitudinal mediano um Ãngulo constituÃdo por uma linha traÃada paralela à borda interna do PR ( 1.5cm ) com uma outra linha vertical, longitudinal ao eixo do canal anal. Esse Ãngulo à calculado no repouso e no esforÃo evacuatÃrio, sendo a mÃdia no repouso de 88.37   4.05 no grupo I e de 89.13   5.73 no grupo II. NÃo houve diferenÃa significativa entre os dois grupos no repouso ( p=0.51 ). A mÃdia do Ãngulo no esforÃo evacuatÃrio no grupo I foi de 98.19   1.18 e no grupo II, de 84.94   1.31, ocorrendo diferenÃa estatisticamente significante entre os dois grupos ( p<0.001 ). A ultra-sonografia anorretal tridimensional dinÃmica demonstrou resultados concordantes com a eletromanometria anorretal em 92,86 % com relaÃÃo ao diagnÃstico de anismus em pacientes com sintomas de evacuaÃÃo obstruÃda. Conclui-se que a tÃcnica de ultra-sonografia anorretal dinÃmica apresentada neste estudo pode ser considerada eficaz no diagnÃstico do anismus e com a vantagem de demonstrar simultaneamente a conformaÃÃo anatÃmica dos mÃsculos esfincterianos. . / Approximately half of the constipated patients shows symptoms of obstructed defecation and anismus is one of the main causes. The aim of this study is to demonstrate a new technique using dynamic three-dimensional anorectal ultrasonography for diagnosis of anismus and compare the results with anorectal manometry. This prospective and comparative study was carried out by seventy women with symptoms of obstructed defecation selected from the Colorectal Unit of the Walter CantÃdio University Hospital of the Federal University of the CearÃ, between may 2005 and august 2006. The mean age was 48 years old (range 23 â 79). All the patients were initially submitted to anorectal manometry and then, depending on the results, separated into two groups. Group I, consisting of forty patients with normal results and presenting anal striated muscles relaxation during straining and group II with the thirty remaining patients with diagnosis of anismus. Subsequently, the patients from both groups were submitted to dynamic three-dimensional anorectal ultrasonography. The method consisted of two automatic scans at rest and during straining. Then, both images were analyzed in the axial and longitudinal planes in order to identify the PR movements. The technique consisted to determine an angle between a line traced parallel to the internal edge of the PR ( 1.5cm ) with another vertical and perpendicular line with the anal canal axis. This angle is calculated at rest and during straining and the average resting angle size was 88.37   4.05 in group I and 89.13   5.73 in group II, without significant difference between them ( p=0.51 ). The mean angle size during straining was of 98.19   1.18 in group I and 84.94   1.31 in group II, showing significant statistical difference ( p<0.001 ). Thus, the dynamic three-dimensional anorectal ultrasonography showed the same results of the anal manometry in 92.86 % of the patients regarding anismus diagnosis in patients with symptoms of obstructed defecation. As a conclusion, the dynamic ultrasonography technique showed to be considered efficient for anismus diagnosis, with the advantage to simultaneously demonstrate the anatomical conformation of the anal canal. / Approximately half of the constipated patients shows symptoms of obstructed defecation and anismus is one of the main causes. The aim of this study is to demonstrate a new technique using dynamic three-dimensional anorectal ultrasonography for diagnosis of anismus and compare the results with anorectal manometry. This prospective and comparative study was carried out by seventy women with symptoms of obstructed defecation selected from the Colorectal Unit of the Walter CantÃdio University Hospital of the Federal University of the CearÃ, between may 2005 and august 2006. The mean age was 48 years old (range 23 â 79). All the patients were initially submitted to anorectal manometry and then, depending on the results, separated into two groups. Group I, consisting of forty patients with normal results and presenting anal striated muscles relaxation during straining and group II with the thirty remaining patients with diagnosis of anismus. Subsequently, the patients from both groups were submitted to dynamic three-dimensional anorectal ultrasonography. The method consisted of two automatic scans at rest and during straining. Then, both images were analyzed in the axial and longitudinal planes in order to identify the PR movements. The technique consisted to determine an angle between a line traced parallel to the internal edge of the PR ( 1.5cm ) with another vertical and perpendicular line with the anal canal axis. This angle is calculated at rest and during straining and the average resting angle size was 88.37   4.05 in group I and 89.13   5.73 in group II, without significant difference between them ( p=0.51 ). The mean angle size during straining was of 98.19   1.18 in group I and 84.94   1.31 in group II, showing significant statistical difference ( p<0.001 ). Thus, the dynamic three-dimensional anorectal ultrasonography showed the same results of the anal manometry in 92.86 % of the patients regarding anismus diagnosis in patients with symptoms of obstructed defecation. As a conclusion, the dynamic ultrasonography technique showed to be considered efficient for anismus diagnosis, with the advantage to simultaneously demonstrate the anatomical conformation of the anal canal. / Approximately half of the constipated patients shows symptoms of obstructed defecation and anismus is one of the main causes. The aim of this study is to demonstrate a new technique using dynamic three-dimensional anorectal ultrasonography for diagnosis of anismus and compare the results with anorectal manometry. This prospective and comparative study was carried out by seventy women with symptoms of obstructed defecation selected from the Colorectal Unit of the Walter CantÃdio University Hospital of the Federal University of the CearÃ, between may 2005 and august 2006. The mean age was 48 years old (range 23 â 79). All the patients were initially submitted to anorectal manometry and then, depending on the results, separated into two groups. Group I, consisting of forty patients with normal results and presenting anal striated muscles relaxation during straining and group II with the thirty remaining patients with diagnosis of anismus. Subsequently, the patients from both groups were submitted to dynamic three-dimensional anorectal ultrasonography. The method consisted of two automatic scans at rest and during straining. Then, both images were analyzed in the axial and longitudinal planes in order to identify the PR movements. The technique consisted to determine an angle between a line traced parallel to the internal edge of the PR ( 1.5cm ) with another vertical and perpendicular line with the anal canal axis. This angle is calculated at rest and during straining and the average resting angle size was 88.37   4.05 in group I and 89.13   5.73 in group II, without significant difference between them ( p=0.51 ). The mean angle size during straining was of 98.19   1.18 in group I and 84.94   1.31 in group II, showing significant statistical difference ( p<0.001 ). Thus, the dynamic three-dimensional anorectal ultrasonography showed the same results of the anal manometry in 92.86 % of the patients regarding anismus diagnosis in patients with symptoms of obstructed defecation. As a conclusion, the dynamic ultrasonography technique showed to be considered efficient for anismus diagnosis, with the advantage to simultaneously demonstrate the anatomical conformation of the anal canal.

Aspiration of gastric content and delayed or failed intubation are the leading causes of anesthesia-related mortality and morbidity. In the recovery period, airway obstruction with subsequent hypoxia is a relatively common cause of morbidity, and is highly associated to the amount of opioids administered, especially in obese patients. The overall aim of this thesis was to study these risk factors for airway complications and postoperative hypoxia in obese patients, and to evaluate possible strategies for their prevention. In Study I, intubation times and incidence of failed intubation in obese patients were compared between direct laryngoscopy and videolaryngoscopy with the Stortz® C-MAC™. In Studies II and III, the effect of esmolol vs. remifentanil on the esophageal junction, and the possible analgesic properties of low-dose esmolol vs. placebo were evaluated using high-resolution manometry and the cold pressor test, respectively. Finally, in Study IV, the possible opioid-sparing effect of esmolol after laparoscopic gastric bypass surgery was evaluated. The use of videlaryngoscopy did not shorten intubation times, however appeared to reduce the incidence of failed intubation. Our results also show that esmolol has a favorable profile, compared to remifentanil, with regard to the protection against passive regurgitation and aspiration of gastric content. No analgesic effect of low-dose esmolol was however demonstrated. The intraoperative administration of esmolol instead of remifentanil also did not reduce the requirement of morphine for treatment of post-operative pain. The use of Stortz® C-MAC™ may be recommended for intubation of obese patients. Further studies are however required to clarify the possible role of esmolol in anesthesia.

L'hydrolyse de LiH à température ambiante et sous faible pression de vapeur d'eau (PH2O < 10 hPa) est d’abord étudiée par thermogravimétrie McBain et spectroscopie infrarouge in situ sur de faibles masses d’échantillon. Puis, afin de se rapprocher des conditions industrielles, l’hydrolyse de LiH est étudiée sur des masses plus importantes, par manométrie en système fermé (PH2O variable) et ouvert (PH2O constante) avec de l'eau lourde. Les produits de la réaction sont caractérisés par diffraction des rayons X et spectroscopie IRTF. Les premières séries d'expériences montrent que le mécanisme se déroule dans un premier temps par la croissance de la couche d’oxyde de lithium Li2O. Puis, quand la couche d’oxyde est suffisamment épaisse, la réaction d’hydrolyse se poursuit par la formation de l’hydroxyde de lithium LiOH pour finir avec la formation de l’hydroxyde de lithium monohydraté LiOH,H2O. La couche externe de Li2O/LiOH formerait une barrière protectrice à la surface de LiH. De plus, grâce à la seconde série d'expériences, il est montré pour la première fois que la réaction d'hydrolyse se déroule en deux étapes : d'abord l'eau est adsorbée à la surface de LiH puis la réaction d'hydrolyse commence. La vitesse de réaction est toutefois extrêmement faible et seule une très petite quantité de LiH est transformée. La cinétique est bien prédite par le modèle du coeur rétrécissant limitée par la diffusion à travers la couche de Li2O et/ou LiOD entourant les particules de LiH. Pour une application pratique, il est conclu que si la poudre de LiH est stockée plusieurs années sous atmosphère contrôlée ou dans un récipient étanche où la pression de vapeur d'eau est inférieure à 0,04 hPa, il n'y a pas de risque majeur de produire LiOH. / The hydrolysis of LiH at room temperature and under low water vapor pressure (PH2O < 10 hPa) is investigated by thermogravimetry and FTIR spectroscopy with low sample mass. Then, to be closer to industrial conditions, hydrolysis of LiH is studied by manometry either in closed (adjustable PH2O) or open (constant PH2O) system using larger amounts of sample and heavy water. Products of the reaction are characterized by X-ray diffraction and FTIR spectroscopy. The first set of experiments show that the mechanism of hydrolysis starts with the formation of lithium oxide Li2O. Then, when the oxide layer is sufficiently thick, the hydrolysis reaction is followed by the formation of lithium hydroxide LiOH and afterwards with the formation of lithium hydroxide monohydrate LiOH, H2O. Besides, the Li2O/LiOH outer layer forms a protective barrier on the surface of LiH. The second set of experiments clearly highlights for the first time that the hydrolysis reaction occurs in two steps: first water is adsorbed on the LiH surface and then the hydrolysis reaction starts. The reaction rate is however extremely low and only a very small fraction of LiH is hydrolysed. The kinetic can be well predicted by the shrinking-core model limited by the diffusion through the external ash layer (Li2O and/or LiOH). For practical application, it is concluded that if the LiH powder is stored for several years under a controlled atmosphere or in a sealed container where the vapor water pressure is less than 0.04 hPa, there is no major risk of LiOH formation.

The diploma thesis aims to describe the functional disorders of the upper gastrointestinal tract with an emphasis on gastroesophageal reflux disease. The theoretical part describes the anatomy, pathophysiology, etiology of GERD and treatment options. In the practical part is measured postural reactivity of the diaphragm in the selected 15 probands with GERD. We measured the postural reactivity of the diaphragm using high resolution manometry in various postural situations: lying on the back with flexion of lower limbs above the surface, standing and standing on the AIREX mat, for standing patients, we used weights of 3,6 and 9 kilos inside and outside the center of gravity. Patients also completed the GERD Health-Related Quality of Life questionnaire. The measurements confirmed an increase in resting pressure in all positions except standing, which correlated with the highest occurrence of reflux episodes in standing. The results were compared with a healthy control group. The activation of the crural part of the diaphragm was the same in both groups. We found in patients with GERD decreased coordination, delayed and influent activation of the crural diaphragm. The most significant increase in pressure in GERD patients occurred in the postural position of the flexed lower limbs and in standing...

Background: Achalasia is a primary esophageal motility disorder that can be classified into three types (I-III) based on high-resolution manometry (HRM). Exact pathogenesis is unknown, but immune-mediated processes and genetic predisposition play a role, which is supported by finding of a genetic risk variant (rs28688207 insertion) in HLA-DQB1 gene that is strongly associated with achalasia. Per-oral endoscopic myotomy (POEM) has become a standard treatment for achalasia, but the long-term efficacy, safety and impact on esophageal physiology are not fully understood. The aims of our studies were to perform the first genotype-phenotype analysis investigating the frequency of rs28688207 accross three HRM types of achalasia, to evaluate the efficacy and safety of POEM and to assess the post-POEM esophageal motility patterns. Patients and methods: These were three retrospective studies of prospectively collected data. Genotyping of the rs2868827 insertion was performed using real-time PCR in 347 patients from Czech Republic (n = 163), Germany (n = 114), Greece (n = 70). The efficacy and safety of POEM were evaluated in 133 patients treated in our center. The post-POEM esophageal motility was assessed using the Chicago Classification in 237 patients in whom HRM was performed prior to and after POEM....

This thesis focuses on the characterization of rhythmic activity in the colon of healthy subjects and patients diagnosed with refractory constipation; this activity is mediated by pacemaker cells in the gastrointestinal system, the Interstitial cells of Cajal (ICC). The myogenic activity described are the cyclic motor patterns (CMP) and haustral activity; characterization of these motor patterns in healthy subjects provided control values for the subsequent comparison in patients. Frequency analysis of CMP revealed a novel high-frequency activity (7-15cpm) unrelated to the breathing artefact. Three categories of cyclic motor patterns were observed: (1) CMP following mass peristaltic events (HAPW); (2) those that occur in isolation of other colonic motor patterns (HAPW) in the colon; and (3) low-frequency (2-6cpm), prominently retrograde rhythmic activity in the rectum. CMP were scarcely present in majority of the patients; however, elevated retrograde CMP in the distal colon and rectum in some patients plays a role in retarding flow of colonic content. A detailed characterization of haustral activity (comprised of 2 boundaries and the activity within a haustrum) is reported for the first time using high-resolution colonic manometry. Furthermore, we find that over expression of haustral boundary activity in patients serves as a disproportionate hindrance in colonic transit. An in-depth methodology is developed for the identification and subsequent analysis of haustral activity and CMP; this provides transparency in the data acquisition and analysis. Lastly, a sphincter at the rectosigmoid junction, sphincter of O’Beirne is presented in a patient case report. The persistent presence and paradoxical contractions of this sphincter served to impede flow colonic content, an important factor contributing to the pathophysiology of severe refractory constipation. / Thesis / Master of Science (MSc) / Colonic manometry tests and measures strength and coordination of colonic muscles contractions. This tool was used to understand the rhythmic colonic motor patterns and their contribution to motility in healthy subjects and patients with constipation. Rhythmic activity in the gut is mediated by pacemaker cells, Interstitial cells of Cajal (ICC). We present a detailed characterization of ICC-mediated rhythmic activity that (1) occurs in the small pouches making up the colon (haustra) and (2) is greater than 5cm along the length of the colon (cyclic motor patterns-CMP).CMP possess high-frequency activity (7-15cpm), in addition to activity observed in the low-frequency range (2-6cpm). Activity in the haustra, or haustral activity, is comprised of 2 boundaries with activity within these bounds (intra-haustral activity); the overexpression in patients serves to retard flow of colonic content. Sphincter of O’Beirne is the last haustral boundary at the rectosigmoid junction; its persistent presence was characterized in a patient with refractory constipation.

Introduction: Functional motility disorders of the colon are poorly defined. Hence, patients with chronic colonic motor dysfunction are treated or undergo surgery without proper diagnosis. Most colonic motility assessment centers around the largest propagating motor pattern in the colon- the High Amplitude Propagating Pressure Wave (HAPW). However, there is no consensus regarding a definition of this important motor pattern. Additionally, no consideration is given to other aspects of colonic motility such as colo-ano-rectal coordination and control by the autonomic nervous system (ANS). The aim of this thesis was to improve understanding of HAPWs and other features of colonic motility in health and constipation, understand how autonomic dysfunction is related to observations in patients, and evaluate the effect of neuromodulation of the ANS. Methods: Motility was assessed in healthy volunteers and patients using water-perfused High Resolution Colonic Manometry (HRCM). To assess the association between ANS and colonic motor activity Heart Rate Variability (HRV) was measured in patients. Spatiotemporal maps were created using HRCM to analyse and quantify colonic motor activity following baseline, and interventions which included proximal balloon distention, meal, and rectal bisacodyl. Low-Level Light Therapy (LLLT) was also applied during HRCM as a method of neuromodulation, to observe its effect on colonic motility. Results: Normal HAPWs are those which have an amplitude of more than 50 mmHg and belong to one of 3 categories: proximally originating, proximal continuing, and transverse/descending. The best intervention sequence to generate these during HRCM assessment is baseline, proximal balloon distention, meal, rectal bisacodyl. Based on their responses to these interventions and the type of HAPWs present, patients could be classified into strong responder, weak responder and non-responder groups. Overall, patients in the strong responder group were most similar to healthy volunteers both with regard to motility and ANS control. Conversely, the weak and non-responders had showed decreased or no motility with decreased parasympathetic input and occasionally sympathetic inhibition. Additionally, other features of motility such as the sphincter of O'Beirne, and lack of colo-ano-rectal coordination were found to lead to constipation even in presence of normal HAPWs. LLLT shows promise in initiating colonic motor activity through neuromodulation of the sacral defecation center. Conclusions: HAPWs can be defined into one of three categories and used to categorize patients based on their HAPW response to different interventions. However, other aspects of colonic motility such as the colo-ano-rectal coordination and autonomic nervous system control of colonic motility should be taken into consideration in diagnosis of constipation, as they can point towards more non-invasive treatment methods such as neuromodulation using LLLT. / Thesis / Master of Science in Medical Sciences (MSMS)

No description available.

The esophageal sphincters constitute the anatomical protection against pulmonary aspiration. The aim of this thesis was to study the esophageal sphincters and how they are affected by different components of emergency anesthesia using high-resolution solid-state manometry. The effect of propofol (0.3 mg/kg) was studied in young and elderly volunteers. Propofol can be given as an anxiolytic agent for manometric studies of the lower esophageal sphincter (LES) without affecting the results. However, propofol is not recommended for studies of the upper esophageal sphincter (UES). The effects of cricoid pressure (CP) and peripheral pain were studied in awake volunteers, with and without remifentanil infusion (5 ng/ml). Pain did not affect pressure in the LES, but CP or remifentanil induced a significant decrease in LES pressure. However, neither CP nor remifentanil affected the barrier pressure (LES-intra gastric pressure). When CP was applied during ongoing remifentanil infusion, no further decrease in LES pressure was measured. CP induced high pressures in the area of the UES independent of remifentanil infusion, indicating that CP is effective in preventing gastroesophageal regurgitation. Barrier pressure was also studied in anesthetized patients after rocuronium (0.6 mg/kg) administration and no decrease was measured. In addition, alfentanil (20 μ/kg) added during anesthesia induction with propofol did not decrease the barrier pressure. In conclusion, CP seems to be effective in preventing regurgitation and does not affect barrier pressure. Muscle relaxation with rocuronium does not risk gastro-esophageal integrity. In addition, opioids can be integrated, even during emergency anethesia, without increasing the risk for pulmonary aspiration.

Objetivo: Avaliar a segurança e eficácia da injeção transesfincteriana de silicone para o tratamento da incontinência anal, assim como correlacionar os resultados clínicos, ultra-sonográficos e manométricos. Métodos: Pacientes incontinentes foram submetidos à manometria e ultra-sonografia anorretal, índice de incontinência (II) e instrumento de qualidade de vida (FIQL), antes e após injeção do silicone (PTQ) sob anestesia local e profilaxia antibiótica. Os critérios de inclusão foram: incontinência anal, lesão isolada ou múltipla do músculo esfíncter interno do ânus, associada ou não à lesão isolada, em um quadrante, do músculo esfíncter externo do ânus. O instrumento FIQL utilizado inclui quatro domínios: estilo de vida, comportamento,depressão e constrangimento.Os parâmetros da manometria foram: pressão média de repouso (PMR), pressão média (PMCV) e máxima (PmaxCV) de contração voluntária, zona de alta pressão (ZAP) e índice de assimetria (IA). Após três meses de tratamento, os pacientes foram reavaliados através do II, FIQL, manometria e ultra-sonografia anorretal. Um grupo controle composto por 10 homens e 10 mulheres continentes e sem história prévia de cirurgia anorretal foi submetido à manometria após consentimento informado. Resultados: Foram estudados 35 pacientes, 28 mulheres e sete homens com idade média de 60,3 (19-80) anos, antes e após injeção do silicone anal. As complicações observadas incluíram dois hematomas (5,7%), um abscesso anal (2,8%), dor anal em dois pacientes (5,7%) e dificuldade evacuatória em um paciente (2,8%). Notou-se uma melhora do índice médio de incontinência de 11,3 para 4,3 (p < 0,001). Houve melhora de todos os domínios estudados no instumento FIQL (p<0,0001). Pacientes incontinentes apresentaram hipotonia esfincteriana quando comparados aos controles (p < 0,05). As pressões esfincterianas antes e após injeção foram respectivamente: PMR (29,4 mmHg x 35,1 mmHg; p = 0,07), PMCV (68,6 mmHg x 75,9 mmHg; p = 0,20) e PmaxCV (102,2 mmHg x 127,0 mmHg; p = 0,11). Houve aumento médio da ZAP de 1,0 para 1,7 cm (p = 0,002) Em relação aos resultados da manometria: o IA aos 3 e 2 cm apresentou redução significativa após injeção do silicone (p < 0.05 e 0,002). A ultra-sonografia de canal anal demonstrou a presença do silicone nos sítios de injeção em todos os pacientes. Conclusão: Em casos selecionados, a injeção transesfincteriana de silicone é um método seguro e proporciona uma melhora do quadro de incontinência anal, observada pela mudança significativa dos parâmetros de qualidade de vida e índice de incontinência. O provável mecanismo de ação pelo qual o agente estudado melhora o quadro de incontinência parece relacionar-se à correção da assimetria esfincteriana e aumento do comprimento da zona de alta pressão. / Aim: To evaluate safety and efficacy of trans-sphincteric silicone injection for the treatment of anal incontinence and to assess correlation between clinical and physiological results. Methods: Incontinent patients prospectively selected by clinical and physiological evaluation underwent trans-sphincteric silicone injection (PTQ) under local anesthesia. Eight channel manometry with asymmetry index and anal ultrasound were performed before and after injections. Incontinence scale (IS) and quality of life instrument (FIQL scale) were applied before and after injection.Inclusion criteria were: anal incontinence, isolated or multiple injury of the internal anal sphincter associated or not to small, restricted, external anal sphincter defect. FIQL scale included four domains: life-style, behavior, depression and embarrassment. Manometry evaluation included mean resting pressure (MRP), mean squeeze pressure (MSP), maximal squeeze pressure (MaxSP), high-pressure zone (HPZ) and asymmetry index (AI). After 3 months of treatment the patients had been reevaluated through the IS, FIQL scale, manometry and ultrasound. A controlled group of 20 healthy volunteers (10 men and 10 women) underwent anal manometry. Results: 35 patients (28 women and seven men) with a mean age of 60.3 (19-80) years were evaluated. Complications observed were two anal hematomas (5,7%), one perianal abscess (2.8%), two patients complained of anal pain (5,7%) and one patient required assistance for defecation (2,8%). Mean incontinence score improved significantly after injection: 11, 3 to 4,3 (p < 0.001). Significant improvement in the FIQL scale was noticed in all domains (p < 0.0001). Incontinent patients had significantly lower anal pressures when compared to controls (p < 0.05). Manometric pressures before and after injection did not change: MRP (29,4 mmHg x 35,1 mmHg; p = 0.07), MSP (68,6 mmHg x 75,9 mmHg; p = 0.20) e MaxSP (102.2 mmHg x 127.0 mmHg; p = 0.11) The HPZ changed from 1 to 1,7 cm after injection (p = 0.002) AI at 3 and 2 cm showed a significantly change (p < 0.05 and p = 0.001, respectively). Ultrasound images demonstrated the presence of silicone in all sites of injection. Conclusion: In selected cases, trans-sphincteric silicone injection is an effective treatment for anal incontinence, as significant changes in quality of life and incontinence scales can be observed. The mechanism of action for which the studied agent improves anal incontinence seems to be related to improvement in the asymmetry index as well as a change in the HPZ.