This diploma thesis develops methodology of arsenic speciation analysis by selective hydride generation with cryotrapping and atomic absorption spectrometry. Using this technique it is possible to determine toxicologically important forms of arsenic, i.e arsenites, arsenates and their mono-, di-, and trimethylated forms at concentration levels below 0,1 ng.ml-1 . The first part of the thesis is focused on testing tubular membrane gas dryers with nafion membrane for drying gaseous phase containing generated hydrides. The suitability for arsenic speciation analysis was investigated and transport losses of individual arsenic species were found. The second part describes mild digestion procedures suitable for arsenic speciation analysis in tissues. Two procedures were compared, acid digestion in phosphoric acid and more recent alkalic digestion by tetramethylammonium hydroxide. Digestion procedures were tested on certified reference material DOLT - 4 (Dogfish Liver) and chicken liver matrix. Key words: Tubular nafion membrane dryers, Arsenic speciation analysis, Digestion, Phosphoric acid, Tetramethylammonium hydroxide, Chicken liver, CRM DOLT - 4, Hydride generation, Atomic absorption spectrometry

Este estudo teve por objetivo avaliar o hábito intestinal e os fatores de risco para incontinência anal (IA) em adultos da população geral, residentes na área urbana da cidade de Londrina - PR. Estudo epidemiológico de base populacional, de corte transversal, realizado após a aprovação do Comitê de Ética da Escola de Enfermagem da Universidade de São Paulo. Dois mil cento e sessenta e dois indivíduos, com idade igual ou superior a 18 anos, condições físicas e mentais adequadas e que aceitaram a participar do estudo, compuseram a amostra, estabelecida a partir de amostragem estratificada por conglomerado, constituídos pelas ruas sorteadas aleatoriamente dentro dos 390 setores censitários do município. Todos os residentes nos domicílios das ruas sorteadas, que atenderam aos critérios de inclusão foram entrevistados utilizando-se dois instrumentos: Dados demográficos e o Hábito intestinal na comunidade (adaptado e validado para a língua portuguesa por Domansky e Santos, 2007). Os dados foram submetidos aos testes de Qui-Quadrado e Exato de Fischer. O predomínio foi do sexo feminino (1203 / 56%); média etária de 40,6±16,4; brancos (1591/74%); união estável (1290 / 60%); 9 a 12 anos de estudo (784/ 36%); 37% pessoas sem ocupação definida; 44% tinham remuneração entre 2 e 3,9 SM; 38% com renda per capita entre 0,6 a 1 salário mínimo. Para o padrão intestinal normal (1.875/87%; p<,0001), predominância de uma evacuação por dia (1.133/52%; p<0,0001), entre as mulheres (968/52%; p<0,0001); os brancos (1591/85%; p<0,0001), ausência de esforço evacuatório (1956/90%), exonerações de fezes macias (1379/64%), esvaziamento retal completo (1938/90%). Padrão intestinal constipado (261/12,1%), entre mulheres (219/84%), esforço evacuatório (99/41,8%), fezes endurecidas (176/67%); esvaziamento retal incompleto (99/38%). Padrão intestinal diarréico (26/1,2%), sem esforço evacuatório (26/100%) fezes líquidas e amolecidas (5/19%), esvaziamento retal completo (16/61%). A prevalência das doenças anorretais, foi de 53 (2%) abscessos, 22 (1%) fístulas, 81 (3%) fissuras, 20(1%) prolapsos retais, 30 (1%) traumas anais; 229 (11%) doença hemorroidária, 58 (3%) cirurgias anorretais, para todas o predomínio foi feminino. O histórico de parto e ginecológico: 886 (74%) tiveram partos, 709 (73%) com padrão intestinal normal; 432 (49%) entre 31 e 50 anos; 168 (14%) tiveram um parto normal; destas 33 (3%) tiveram laceração anal pós-parto que necessitou de intervenção cirúrgica; porém mantiveram o padrão intestinal normal (25/75%); 109 (9%) fizeram histerectomia (109 /9%), 90 (90%) padrão intestinal normal e menos de um por cento tiveram retocele e quatro (50%) eram constipadas. Os fatores de risco para incontinência anal: 35 (2%) radioterapia pélvica, 133 (6%) diabetes mellitus, 330 (15%) doenças ou distúrbios do sistema nervoso, 291 (13%) lesão na coluna espinhal e 29 (1%) relataram o acidente vascular encefálico (AVE), para todos os fatores houve predomínio do padrão intestinal normal, predomínio feminino para distúrbios do sistema nervoso e AVE. Este estudo permitiu conhecer o hábito intestinal da população geral de uma cidade no norte do Paraná, os fatores de risco para IA que estão expostos, cooperando para a elucidação do tema entre a população, ampliando os conhecimentos daqueles que atuam na área, e colaborando para o desenvolvimento de programas de prevenção ou diagnóstico precoce das doenças intestinais / The objective of this study was to evaluate the bowel habits and anal incontinence (AI) risk factors in adults living in the urban area of Londrina, PR, Brazil. This population-based, transversal epidemiological study was carried out after being approved by the University of São Paulo Nursing School Ethics Committee. Population sample established from a stratified sampling procedure by a conglomerate constituted of streets taken randomly from 390 county census sectors, included 2162 individuals , 18 years old and over, in adequate physical and mental conditions, who accepted to participate in the study. All residents in the selected streets who met the inclusion criteria established by the study were interviewed, using two instruments: Demographic data and the Bowel function in the community (adapted and validated for the Portuguese language by Domansky and Santos, 2007). Data were submitted to Chi-square and Fischer exact tests. There was a predominance of female subjects (1203/56%); ages 40,6 ± 16,4; white (1591/74%); with a stable relationship (1290/60%), with 9 to 12 years of formal education ( 784/36%), subjects without a defined job (37%) with salaries around 2 to 3,9 / minimum wage (44%) and per capita income between 0,6 to one/minimum wage (38%). As for normal intestinal pattern (1.875/87%; p<0,0001), there was the predominance of one bowel movement per day (1.133/52%; p<0,0001), among women (968/52%; p<0,0001); whites (1591/85%; p<0,0001), absence of defecation strain (1956/90%), soft feces (1379/64%), total rectal emptying (1938/90%). Constipated intestinal pattern (261/12,1%), among women (219/84%), defecation strain (99/41,8%), hard feces (176/67%); incomplete rectal emptying (99/38%). Diarrheic intestinal pattern (26/1,2%), no defecation strain (26/100%) liquid and soft feces (5/19%), total rectal emptying (16/61%). Prevalence of anorectal diseases was 53 (2%) abscesses, 22 (1%) fistules, 81 (3%) fissures, 20(1%) rectal prolapse, 30 (1%) anal traumas; 229 (11%) hemorrhoidal disease 58 (3%) ; anorectal surgeries, mainly among females. Gynecological and delivery history, 886 (74%) had deliveries, 709 (73%) with normal intestinal pattern; 432 (49%) between 31 and 50 years old; 168 (14%) had normal deliveries; 33 (3%) with postpartum laceration that needed surgical intervention; however, they maintained a normal intestinal pattern (25/75%); 109 (9%) had hysterectomy (109 /9%), 90 (90%) normal intestinal pattern and less than one percent had rectocele and four (50%) were constipated. Anal incontinence risk factors, 35 (2%) pelvic radiotherapy, 133 (6%) diabetes mellitus, 330 (15%) nervous systems diseases and dysfunctions, 291 (13%) spinal cord lesion and 29 (1%) reported having had an encephalic vascular stroke. In all factors there was the predominance of the normal intestinal pattern; however, females presented more nervous system dysfunctions and encephalic vascular strokes. This study reports on the bowel habits of a general population in a city in Northern Paraná, and the AI risk factors they are exposed to, bringing more information about the topic to the population and to those who work in the area , helping develop prevention programs or early diagnoses of intestinal diseases

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.

Introdução: A laceração obstétrica do esfíncter anal (LOEA) está associado com incontinência anal. A episiotomia foi proposta como uma forma de proteção do esfíncter anal no parto, especialmente a episiotomia mediolateral; entretanto, diversos estudos mostraram que o uso de rotina da episiotomia não reduz o risco de LOEA. Objetivo: Este estudo tem por objetivo analisar se a redução na taxa de episiotomia em hospital escola no Brasil foi associada a um aumento na incidência de lacerações obstétricas do esfíncter anal, além de fatores associados a elas. Métodos: Estudo observacional, transversal e retrospectivo, realizado no Hospital de Clínicas de Porto Alegre, Rio Grande do Sul, Brasil. Foram incluídos todos os partos vaginais de gestações únicas, apresentação cefálica, a partir de 34 semanas de idade gestacional, realizados em 2011-2012 (uso liberal da episiotomia) e 2015-2016 (uso restrito da episiotomia), e comparados em relação a taxa de episiotomia mediolateral e de LOEA. Resultados: foram analisados 4268 partos (2043 no período de 2011-2012, 2225 de 2015-2016), foram analisados 2043 partos. A taxa de episiotomia reduziu de 59.4% para 44.2% (p≤0.0001). No período 2011-2012, ocorreram 10 lacerações obstétricas do esfíncter anal em 2043 partos (0.48%), enquanto que no período 2015-2016, ocorreram 31 lacerações em 2225 partos (1.39%). Houve interação quando comparado os dois períodos em relação a realização de episiotomia e a ocorrência de LOEA (p≤0.0001). A episiotomia foi fortemente associada a não ocorrência de LOEA em 2011-2012 (59.5%), enquanto que não ter episiotomia foi associado ao grupo com (67.7%) e sem LOEA (55.7%) em 2015-2016. Fatores associados a LOEA foram indução do parto e distócia de ombro. Conclusão: Houve um aumento na taxa de lacerações do esfíncter anal com a diminuição da taxa de episiotomia. A episiotomia de rotina foi prote / Introduction: Obstetric anal sphincter tear (OAST) is associated with anal incontinence. Episiotomy was proposed as a form of protection of the anal sphincter at delivery, especially mediolateral episiotomy; however, several studies have shown that routine use of episiotomy does not reduce the risk of OAST. Objective: This study aims to analyse whether the reduction in the rate of episiotomy in a school hospital in Brazil was associated with an increase in the incidence of obstetric lacerations of the anal sphincter, in addition to associated factors. Methods: Observational, cross-sectional and retrospective study, conducted at Hospital de Clínicas, Porto Alegre, Rio Grande do Sul, Brazil. We included all vaginal deliveries of single pregnancies, cephalic presentation, from 34 weeks of gestational age, performed in 2011-2012 (liberal episiotomy) and 2015- 2016 (restricted episiotomy), and compared in relation to the rate of mediolateral episiotomy and OAST. Results: 4268 births were analysed (2043 in 2011-2012 and 2225 in 2015-2016). The episiotomy rate decreased from 59.4% to 44.2% (p≤0.0001). In 2011-2012, there were 10 obstetric anal sphincter lacerations in 2043 births (0.48%), while in the period 2015-2016 there were 31 lacerations in 2225 births (1.39%). There was interaction when comparing the two periods in relation to the episiotomy and the occurrence of OAST (p≤0.0001). Episiotomy was strongly related to 2011-2012 group with no OAST (59.5%), while not having an episiotomy was related to both OAST (67.7%) and no OAST (55.7%) group in 2015-2016. Factors associated with OAST were labor induction and shoulder dystocia. Conclusion: There was an increase in the rate of lacerations of the anal sphincter with a decrease in the rate of episiotomy. Routine episiotomy was protective.

Submitted by Fabíola Silva (fabiola.silva@famerp.br) on 2016-09-15T14:48:20Z No. of bitstreams: 1 robertoluizkaiserjr_tese.pdf: 4752393 bytes, checksum: ce4cfccd0a448075485500eb792cb826 (MD5) / Made available in DSpace on 2016-09-15T14:48:20Z (GMT). No. of bitstreams: 1 robertoluizkaiserjr_tese.pdf: 4752393 bytes, checksum: ce4cfccd0a448075485500eb792cb826 (MD5) Previous issue date: 2014-10-06 / Introduction: Fecal incontinence is defined as the recurrent uncontrolled passage of stool for at least 1 month's duration in an individual with a age of at least 4 years. If conservative management fails or surgical intervention is not indicated, biofeedback therapy may be considered. Objective: To assess the influence of sphincter defect in the response to biofeedback in patients with fecal incontinence, considering manometry, electromyography and incontinence score. Patients and Methods: A total of 242 patients with fecal incontinence (mean age: 70.5 ± 14.0 years; range 10 to 100 years) underwent biofeedback were studied. Patients were evaluated using anorectal physiology tests and Cleveland Clinic Florida Fecal Incontinence score (CCF-FI) before and after biofeedback. Manometry including resting and squeeze pressures was performed before biofeedback. Electromyographic activity at resting and squeeze before and after biofeedback was recorded. Defects in the internal and external anal sphincters were detected by endoanal ultrasound. Results of physiologic tests and CCF-FI score before and after biofeedback were compared with one-sample t test (or Wilcoxon test as appropriate). A two independent sample t test (or Kruskal-Wallis test as appropriate) was used for comparison between groups with and without defect. Results: Among the 242 patients with fecal incontinence, 143(59.1%) underwent ultrasonography whose anatomical alterations in the sphincter were detected in 43(30.1%) individuals. Before biofeedback, there was no significant difference between resting and squeeze pressures in patients with and without sphincter defect. Electromyography before and after biofeedback in patients with and without sphincter defect showed no significant difference. Of the 66 individuals who responded to CCF-FI score before biofeedback, there was decrease in 45(68.2%), no alteration in 18(27.3%) and increase in 3(4.5%). Comparison between score before and after biofeedback of individuals with and without sphincter defect revealed no significant difference. After mean time of 6.1 years, of the 54 patients who responded to CCF-FI, 31(57.4%) reduced the score, 4(7.4%) remained unaltered and 19(35.2%) increased. Before and after this mean time, fecal incontinence score of patients with and without sphincter defect demonstrated a significant difference (P = 0.021) and the score in patients with defect was higher than those with no defect. Conclusions: Sphincter defect did not influenced in the response to biofeedback in patients with fecal incontinence. Manometry before biofeedback revealed that individuals with and without sphincter defect showed sufficient muscle conditions for indication of this therapy. Increase of electromyographic activity at squeeze after biofeedback indicated a satisfactory response of the sphincter musculature, independent of the presence or absence of defect. Regarding fecal incontinence score, there was a clinical improvement in most patients both immediately after biofeedback as after mean time of 6.1 years. Presence or absence of sphincter defect did not alter significantly the clinical outcome following biofeedback, however after 6.1 years better results were obtained in those with no defect. / Introdução: Incontinência fecal é definida como perda recorrente e incontrolável de material fecal por pelo menos 1 mês em um indivíduo com no mínimo 4 anos de idade. Se o tratamento conservador falha ou a correção cirúrgica não é indicada, o biofeedback pode ser opção viável. Objetivo: Avaliar a influência do defeito esfincteriano na resposta ao biofeedback em pacientes com incontinência fecal, considerando-se aspectos manométricos, eletromiográficos e referentes ao grau de incontinência. Casuística e Método: Foram estudados 242 pacientes com incontinência fecal, cuja idade variou de 10 a 100 anos (70,5 ± 14,0 anos), submetidos ao biofeedback. Pacientes foram avaliados segundo testes de fisiologia anorretal e escore de incontinência fecal (CCF-IF) antes e após biofeedback. Na manometria anorretal foram mensuradas pressões de repouso e contração antes do biofeedback. Na eletroneuromiografia anal foi medida atividade elétrica nas fases repouso e contração antes e após biofeedback. Defeitos nos esfíncteres interno e externo foram detectados por meio de ultrassonografia endoanal. Para comparação dos resultados dos testes fisiológicos e escore CCF-IF antes e após biofeedback foram utilizados testes t uniamostral ou Wilcoxon. Nas comparações entre grupos com e sem defeito foram aplicados testes t para duas amostras independentes ou Kruskal-Wallis. Resultados: Do total de 242 pacientes com incontinência fecal, 143(59,1%) realizaram ultrassonografia, sendo detectadas alterações no esfíncter em 43(30,1%). Não houve diferença significativa entre valores da pressão em repouso e contração em pacientes com e sem defeito esfincteriano antes do biofeedback. Na eletromiografia o resultado da comparação antes e após biofeedback em pacientes com e sem defeito esfincteriano não foi significativo. Dos 66 pacientes que responderam ao escore CCF-IF antes do biofeedback, 45(68,2%) reduziram o escore, 18(27,3%) permaneceram inalterados e 3(4,5%) aumentaram. Comparando-se esse escore antes e após biofeedback de pacientes com e sem defeito esfincteriano, não houve diferença significativa. Após tempo médio de 6,1 anos, dos 54 pacientes que responderam ao CCF-IF, 31(57,4%) reduziram o escore, 4(7,4%) permaneceram inalterados e 19(35,2%) aumentaram. Analisando escore antes e após esse tempo médio de pacientes com e sem defeito esfincteriano, a diferença foi significativa (P = 0,021), sendo o escore em pacientes com defeito maior em relação àqueles sem defeito. Conclusões: Não houve influência do defeito esfincteriano na resposta ao BF em pacientes com incontinência fecal. Achados manométricos antes do biofeedback revelaram que pacientes com e sem defeito esfincteriano apresentaram condições musculares suficientes para indicação desse tipo de tratamento. Na eletromiografia o aumento da atividade elétrica na fase de contração após biofeedback indicou resposta satisfatória da musculatura esfincteriana, independente da presença ou ausência de defeito esfincteriano. Na avaliação do grau de incontinência fecal, houve melhora clínica na maioria dos pacientes tanto imediatamente após biofeedback como após tempo médio de 6,1 anos. Presença ou não de defeito esfincteriano não alterou significativamente a melhora clínica após biofeedback, porém após 6,1 anos resultados melhores foram obtidos naqueles sem defeito esfincteriano.

<p>Patients with idiopathic anal fistula (n=85) were compared with 215 control subjects, matched for age and sex, through a 180-item questionnaire. Obesity, smoking, constipation and bowel symptoms associated with IBS were more common in the patients.</p><p>Endoanal ultrasound (EUS) and magnetic resonance imaging (MRI) were compared in the preoperative evaluation of anal fistula in 23 patients. For classifying the primary tract, EUS and surgical findings agreed in 14 cases, and MRI and surgery for 11: for identifying an internal opening, the corresponding figures were 17 and 10.</p><p>Healing and sphincter function were studied in 42 patients operated with fistula excision and closure of the internal opening. Twenty-three patients healed primarily and another 10 after one re-operation, whereas nine required further surgery until healed. Anal resting pressure was reduced after three and 12 months, and squeeze pressure after 12 months.</p><p>Eighty-three patients were randomised to surgery with or without application of gentamicin-collagen underneath the flap: 26/42 of patients randomised to gentamicin-collagen healed primarily compared with 21/41 of patients randomised to surgery only (n.s).</p><p>Micro perfusion in the flap was studied by laser Doppler flowmetry during surgery in 16 patients. No correlation was seen between change in blood flow during surgery and non-healing/recurrence of the fistula.</p><p>In conclusion, obesity, functional bowel symptoms and possibly smoking are more common in patients with idiopathic anal fistula than in the general population. Endoanal ultrasound is a useful tool in the preoperative evaluation of anal fistula. Advancement flap repair has a reasonably high primary recurrence rate and healing is not significantly improved by local application of gentamicin-collagen: impaired intraoperative blood perfusion of the flap is an unlikely reason for non-healing. A decrease in continence occurs also after this kind of surgery, probably due to an impaired internal anal sphincter function.</p>

Patients with idiopathic anal fistula (n=85) were compared with 215 control subjects, matched for age and sex, through a 180-item questionnaire. Obesity, smoking, constipation and bowel symptoms associated with IBS were more common in the patients. Endoanal ultrasound (EUS) and magnetic resonance imaging (MRI) were compared in the preoperative evaluation of anal fistula in 23 patients. For classifying the primary tract, EUS and surgical findings agreed in 14 cases, and MRI and surgery for 11: for identifying an internal opening, the corresponding figures were 17 and 10. Healing and sphincter function were studied in 42 patients operated with fistula excision and closure of the internal opening. Twenty-three patients healed primarily and another 10 after one re-operation, whereas nine required further surgery until healed. Anal resting pressure was reduced after three and 12 months, and squeeze pressure after 12 months. Eighty-three patients were randomised to surgery with or without application of gentamicin-collagen underneath the flap: 26/42 of patients randomised to gentamicin-collagen healed primarily compared with 21/41 of patients randomised to surgery only (n.s). Micro perfusion in the flap was studied by laser Doppler flowmetry during surgery in 16 patients. No correlation was seen between change in blood flow during surgery and non-healing/recurrence of the fistula. In conclusion, obesity, functional bowel symptoms and possibly smoking are more common in patients with idiopathic anal fistula than in the general population. Endoanal ultrasound is a useful tool in the preoperative evaluation of anal fistula. Advancement flap repair has a reasonably high primary recurrence rate and healing is not significantly improved by local application of gentamicin-collagen: impaired intraoperative blood perfusion of the flap is an unlikely reason for non-healing. A decrease in continence occurs also after this kind of surgery, probably due to an impaired internal anal sphincter function.

Introdução: A laceração obstétrica do esfíncter anal (LOEA) está associado com incontinência anal. A episiotomia foi proposta como uma forma de proteção do esfíncter anal no parto, especialmente a episiotomia mediolateral; entretanto, diversos estudos mostraram que o uso de rotina da episiotomia não reduz o risco de LOEA. Objetivo: Este estudo tem por objetivo analisar se a redução na taxa de episiotomia em hospital escola no Brasil foi associada a um aumento na incidência de lacerações obstétricas do esfíncter anal, além de fatores associados a elas. Métodos: Estudo observacional, transversal e retrospectivo, realizado no Hospital de Clínicas de Porto Alegre, Rio Grande do Sul, Brasil. Foram incluídos todos os partos vaginais de gestações únicas, apresentação cefálica, a partir de 34 semanas de idade gestacional, realizados em 2011-2012 (uso liberal da episiotomia) e 2015-2016 (uso restrito da episiotomia), e comparados em relação a taxa de episiotomia mediolateral e de LOEA. Resultados: foram analisados 4268 partos (2043 no período de 2011-2012, 2225 de 2015-2016), foram analisados 2043 partos. A taxa de episiotomia reduziu de 59.4% para 44.2% (p≤0.0001). No período 2011-2012, ocorreram 10 lacerações obstétricas do esfíncter anal em 2043 partos (0.48%), enquanto que no período 2015-2016, ocorreram 31 lacerações em 2225 partos (1.39%). Houve interação quando comparado os dois períodos em relação a realização de episiotomia e a ocorrência de LOEA (p≤0.0001). A episiotomia foi fortemente associada a não ocorrência de LOEA em 2011-2012 (59.5%), enquanto que não ter episiotomia foi associado ao grupo com (67.7%) e sem LOEA (55.7%) em 2015-2016. Fatores associados a LOEA foram indução do parto e distócia de ombro. Conclusão: Houve um aumento na taxa de lacerações do esfíncter anal com a diminuição da taxa de episiotomia. A episiotomia de rotina foi prote / Introduction: Obstetric anal sphincter tear (OAST) is associated with anal incontinence. Episiotomy was proposed as a form of protection of the anal sphincter at delivery, especially mediolateral episiotomy; however, several studies have shown that routine use of episiotomy does not reduce the risk of OAST. Objective: This study aims to analyse whether the reduction in the rate of episiotomy in a school hospital in Brazil was associated with an increase in the incidence of obstetric lacerations of the anal sphincter, in addition to associated factors. Methods: Observational, cross-sectional and retrospective study, conducted at Hospital de Clínicas, Porto Alegre, Rio Grande do Sul, Brazil. We included all vaginal deliveries of single pregnancies, cephalic presentation, from 34 weeks of gestational age, performed in 2011-2012 (liberal episiotomy) and 2015- 2016 (restricted episiotomy), and compared in relation to the rate of mediolateral episiotomy and OAST. Results: 4268 births were analysed (2043 in 2011-2012 and 2225 in 2015-2016). The episiotomy rate decreased from 59.4% to 44.2% (p≤0.0001). In 2011-2012, there were 10 obstetric anal sphincter lacerations in 2043 births (0.48%), while in the period 2015-2016 there were 31 lacerations in 2225 births (1.39%). There was interaction when comparing the two periods in relation to the episiotomy and the occurrence of OAST (p≤0.0001). Episiotomy was strongly related to 2011-2012 group with no OAST (59.5%), while not having an episiotomy was related to both OAST (67.7%) and no OAST (55.7%) group in 2015-2016. Factors associated with OAST were labor induction and shoulder dystocia. Conclusion: There was an increase in the rate of lacerations of the anal sphincter with a decrease in the rate of episiotomy. Routine episiotomy was protective.

Introdução: A laceração obstétrica do esfíncter anal (LOEA) está associado com incontinência anal. A episiotomia foi proposta como uma forma de proteção do esfíncter anal no parto, especialmente a episiotomia mediolateral; entretanto, diversos estudos mostraram que o uso de rotina da episiotomia não reduz o risco de LOEA. Objetivo: Este estudo tem por objetivo analisar se a redução na taxa de episiotomia em hospital escola no Brasil foi associada a um aumento na incidência de lacerações obstétricas do esfíncter anal, além de fatores associados a elas. Métodos: Estudo observacional, transversal e retrospectivo, realizado no Hospital de Clínicas de Porto Alegre, Rio Grande do Sul, Brasil. Foram incluídos todos os partos vaginais de gestações únicas, apresentação cefálica, a partir de 34 semanas de idade gestacional, realizados em 2011-2012 (uso liberal da episiotomia) e 2015-2016 (uso restrito da episiotomia), e comparados em relação a taxa de episiotomia mediolateral e de LOEA. Resultados: foram analisados 4268 partos (2043 no período de 2011-2012, 2225 de 2015-2016), foram analisados 2043 partos. A taxa de episiotomia reduziu de 59.4% para 44.2% (p≤0.0001). No período 2011-2012, ocorreram 10 lacerações obstétricas do esfíncter anal em 2043 partos (0.48%), enquanto que no período 2015-2016, ocorreram 31 lacerações em 2225 partos (1.39%). Houve interação quando comparado os dois períodos em relação a realização de episiotomia e a ocorrência de LOEA (p≤0.0001). A episiotomia foi fortemente associada a não ocorrência de LOEA em 2011-2012 (59.5%), enquanto que não ter episiotomia foi associado ao grupo com (67.7%) e sem LOEA (55.7%) em 2015-2016. Fatores associados a LOEA foram indução do parto e distócia de ombro. Conclusão: Houve um aumento na taxa de lacerações do esfíncter anal com a diminuição da taxa de episiotomia. A episiotomia de rotina foi prote / Introduction: Obstetric anal sphincter tear (OAST) is associated with anal incontinence. Episiotomy was proposed as a form of protection of the anal sphincter at delivery, especially mediolateral episiotomy; however, several studies have shown that routine use of episiotomy does not reduce the risk of OAST. Objective: This study aims to analyse whether the reduction in the rate of episiotomy in a school hospital in Brazil was associated with an increase in the incidence of obstetric lacerations of the anal sphincter, in addition to associated factors. Methods: Observational, cross-sectional and retrospective study, conducted at Hospital de Clínicas, Porto Alegre, Rio Grande do Sul, Brazil. We included all vaginal deliveries of single pregnancies, cephalic presentation, from 34 weeks of gestational age, performed in 2011-2012 (liberal episiotomy) and 2015- 2016 (restricted episiotomy), and compared in relation to the rate of mediolateral episiotomy and OAST. Results: 4268 births were analysed (2043 in 2011-2012 and 2225 in 2015-2016). The episiotomy rate decreased from 59.4% to 44.2% (p≤0.0001). In 2011-2012, there were 10 obstetric anal sphincter lacerations in 2043 births (0.48%), while in the period 2015-2016 there were 31 lacerations in 2225 births (1.39%). There was interaction when comparing the two periods in relation to the episiotomy and the occurrence of OAST (p≤0.0001). Episiotomy was strongly related to 2011-2012 group with no OAST (59.5%), while not having an episiotomy was related to both OAST (67.7%) and no OAST (55.7%) group in 2015-2016. Factors associated with OAST were labor induction and shoulder dystocia. Conclusion: There was an increase in the rate of lacerations of the anal sphincter with a decrease in the rate of episiotomy. Routine episiotomy was protective.

Objective Our aim was to compare two regimens of antibiotic prophylaxis at the time of repair of obstetric anal sphincter injury. Benefit of long regimen of antibiotic prophylaxis in comparison with short regimen of antibiotic administration haven't been till now proven. Material and Methods Women who gave vaginal birth in department of gynaecology and obstetrics of the First Faculty of Medicine of Charles University and Hospital Bulovka from 1.1.2008 to 30.6.2013 and who sustained third - or fourth - degree perineal tears have been enrolled in our trial. All women who fulfilled trial criteria received at the time of repair antibiotic prophylaxis which was cefuroxim (second - generation cephalosporin). This antibiotic has good sensitivity to vaginal gram-positive flora and to rectal gram-negative microorganisms too. Suture technique and following postpartum care have been standardized. All enrolled women were checked 2 weeks and 3 months after delivery. We evaluated subjective and objective parameters of healing of the obstetric perineal injury and 3 months postpartum we looked for symptomps regarding anal incontinence. The Manchester questionnaire was used for evaluation of anal incontince occurance. Results Incidence of third - and fourth - degree perineal tears was 1,4 % during period of our...