Diss. Stockholm : Karol. inst.

Orientador: Zacarias Alves de Souza Filho / Tese (doutorado) - Universidade Federal do Paraná, Setor de Ciencias da Saúde, Programa de Pós-Graduaçao em Clínica Cirúrgica. Defesa: Curitiba, 2001 / Inclui bibliografia e anexos

No description available.

Problem Investigated: A multitude of benign disorders affect the anorectal complex often resulting in significant morbidity. For many of these conditions the pathophysiology and clinical management continue to be debated. This is particularly so for anal fissures, anal incontinence and pelvic floor dysfunction. Procedures Followed: A series of clinical trials was performed. Anal Fissure: Two current management regimes for chronic anal fissure, Glyceryl Trinitrate and Botulinum Toxin, were prospectively assessed for manometric and clinical outcome. A new treatment regime, inducible nitric oxide, was prospectively assessed in an animal model and a new manometric observation in anal fissure patients, the Fast Wave, was validated. Anal Incontinence: The magnitude of the problem and the relative role of several previously identified risk factors was assessed from a manometric data-base. The impact of a standard treatment for Crohn???s disease, the seton, on anal continence was assessed via a retrospective cohort study. The long-term outcome of dynamic graciloplasty and re-do anal sphincter repair, two previously accepted treatments for anal incontinence, were also assessed retrospectively. A new intervention for treating anal incontinence, the magnetic ???Chair???, was prospectively trialed in incontinent patients. Pelvic Floor Dysfunction: A new treatment option for rectocoele, the laparoscopic repair, was compared with an accepted treatment option, the transanal repair via a matched cohort study. A further group of patients with multiple symptoms of pelvic floor dysfunction undergoing the same laparoscopic technique were then prospectively assessed for functional outcome across the pelvic floor compartments. General Results: Anal Fissure; The manometric effects of both glyceryl trinitrate and botulinum toxin, demonstrated in this thesis would imply that their mode of impact on the anal sphincter is other than that of anal pressure reduction. Fissure healing is dependent upon the pre-treatment anal resting pressure and fissure grade, not anal pressures following treatment. Inducible nitric oxide does not increase nitrate levels in the rat internal anal sphincter. A new manometric wave form in the hypertonic internal anal sphincter, the Fast Wave, has been validated. Faecal Incontinence; Faecal incontinence is multi-factorial. However, obstetric birth injuries are the most significant factor predisposing to faecal incontinence following age. Furthermore current government policies are failing to address the problem. The dynamic graciloplasty provides symptomatic long-term relief in only 16 percent of patients and results in significant co-morbidity in most patients. Re-do anal sphincter repair provides relief in 60 percent of patients without further side effects. The use of a seton in Crohn???s perianal disease prevents deterioration of patient continence. Extracorporeal magnetic stimulation, the Chair, may provide significant relief for patients with faecal incontinence. Pelvic Floor Dysfunction: The laparoscopic posterior compartment repair provides relief of bowel symptoms in 31 percent of patients. This does not compare favourably with the transanal long-term symptomatic improvement of 67 percent. The results of the laparoscopic pelvic floor repair in patients with multiple symptoms of pelvic floor dysfunction is disappointing, particularly for bowel and bladder symptom improvement. Major Conclusions: This thesis questions the accepted pathophysiology of anal fissure, highlights the long-term implications of obstetric childbirth injuries on faecal continence and raises concerns about current management strategies for faecal incontinence and pelvic floor dysfunction.

Universiẗat, Diss.--Jena, 2007.

Problem Investigated: A multitude of benign disorders affect the anorectal complex often resulting in significant morbidity. For many of these conditions the pathophysiology and clinical management continue to be debated. This is particularly so for anal fissures, anal incontinence and pelvic floor dysfunction. Procedures Followed: A series of clinical trials was performed. Anal Fissure: Two current management regimes for chronic anal fissure, Glyceryl Trinitrate and Botulinum Toxin, were prospectively assessed for manometric and clinical outcome. A new treatment regime, inducible nitric oxide, was prospectively assessed in an animal model and a new manometric observation in anal fissure patients, the Fast Wave, was validated. Anal Incontinence: The magnitude of the problem and the relative role of several previously identified risk factors was assessed from a manometric data-base. The impact of a standard treatment for Crohn???s disease, the seton, on anal continence was assessed via a retrospective cohort study. The long-term outcome of dynamic graciloplasty and re-do anal sphincter repair, two previously accepted treatments for anal incontinence, were also assessed retrospectively. A new intervention for treating anal incontinence, the magnetic ???Chair???, was prospectively trialed in incontinent patients. Pelvic Floor Dysfunction: A new treatment option for rectocoele, the laparoscopic repair, was compared with an accepted treatment option, the transanal repair via a matched cohort study. A further group of patients with multiple symptoms of pelvic floor dysfunction undergoing the same laparoscopic technique were then prospectively assessed for functional outcome across the pelvic floor compartments. General Results: Anal Fissure; The manometric effects of both glyceryl trinitrate and botulinum toxin, demonstrated in this thesis would imply that their mode of impact on the anal sphincter is other than that of anal pressure reduction. Fissure healing is dependent upon the pre-treatment anal resting pressure and fissure grade, not anal pressures following treatment. Inducible nitric oxide does not increase nitrate levels in the rat internal anal sphincter. A new manometric wave form in the hypertonic internal anal sphincter, the Fast Wave, has been validated. Faecal Incontinence; Faecal incontinence is multi-factorial. However, obstetric birth injuries are the most significant factor predisposing to faecal incontinence following age. Furthermore current government policies are failing to address the problem. The dynamic graciloplasty provides symptomatic long-term relief in only 16 percent of patients and results in significant co-morbidity in most patients. Re-do anal sphincter repair provides relief in 60 percent of patients without further side effects. The use of a seton in Crohn???s perianal disease prevents deterioration of patient continence. Extracorporeal magnetic stimulation, the Chair, may provide significant relief for patients with faecal incontinence. Pelvic Floor Dysfunction: The laparoscopic posterior compartment repair provides relief of bowel symptoms in 31 percent of patients. This does not compare favourably with the transanal long-term symptomatic improvement of 67 percent. The results of the laparoscopic pelvic floor repair in patients with multiple symptoms of pelvic floor dysfunction is disappointing, particularly for bowel and bladder symptom improvement. Major Conclusions: This thesis questions the accepted pathophysiology of anal fissure, highlights the long-term implications of obstetric childbirth injuries on faecal continence and raises concerns about current management strategies for faecal incontinence and pelvic floor dysfunction.

Thesis (doctoral)--Amsterdam, 1979.

Proefschrift Universiteit Maastricht. / Met lit. opg. - Met samenvatting in het Nederlands.

Orientador: Juvenal Ricardo Navarro Goes / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-07-22T13:57:55Z (GMT). No. of bitstreams: 1 Coy_ClaudioSaddyRodrigues_D.pdf: 4008380 bytes, checksum: 382316fa7133820137dfca2c5117f3c1 (MD5) Previous issue date: 1997 / Resumo: As cirurgias de preservação esfincteriana no tratamento do câncer de reto têm significado importante progresso na manutenção da qualidade de vida dos pacientes após a ressecção retal completa, sem comprometer significantemente o seu prognóstico. O presente estudo tem como objetivos comparar as técnicas cirúrgicas de anastomose coloanal manual com e sem reservatório avaliando-se os resultados funcionais e análise dos parâmetros fisiológicos na medição do mecanismo de continência fecal envolvido. As hipóteses levantada para este estudo são: 1) a anastomose coloanal com reservatório apresentaria melhores resultados funcionais do que a anastomose coloanal sem reservatório, 2) a medição de parâmetros fisiológicos estaria correlacionada ao índice funcional e poderia predizer os resultados funcionais. Foram estudados 42 pacientes operados pelo Grupo de Coloproctologia da Disciplina de Moléstias do Aparelho Digestivo da Faculdade de Ciências Médicas da Universidade Estadual de Campinas, no penodo de 1979 a 1995. Vinte e seis pacientes eram do sexo feminino e a idade variou entre 28 e 80 anos (média de 55,6 :t 13,9 anos). As indicações de cirurgia foram: adenocarcinoma do reto (40 pacientes), adenoma viloso retal (um) e hemangioma retal (um). As cirurgias realizadas foram: anastomose coloanal manual primária, com derivação fecal (cinco pacientes - 11,9%); anastomose coloanal retardada (12 pacientes - 28,5%) e anastomose coloanal manual com reservatório (25 pacientes - 59,6%). Foram incluídos no estudo os pacientes que tiveram suas estorpias fechadas (ou ressecção do coto cólico e anastomose coloanal) há pelo menos seis meses, sem radioterapia pós-operatória e que estavam livres de doença abdominal e pélvica por ocasião da avaliação. Foram considerados como pertencentes ao grupo 1 os pacientes submetidos a anastomose coloanal sem reservatório e grupo 2 os que tiveram seu trânsito reconstruido com anastomose coloanal com reservatório. Os dados cJínicos foram: freqüência média de evacuações diurnas e' noturnas e ocorrência de evacuações fragmentadas. Os pacientes responderam a questionário específico sobre função esfincteriana (índice funcional) para posterior quantificação dessa função. Os parâmetros fisiológicos estudados foram: pressão anal média de repouso, pressão anal máxima de contração voluntária, pesquisa do reflexo inibitório anoneorretal, valor médio de pressão anal de repouso na zona de mais alta pressão, índice de assimetria da zona de mais alta pressão em repouso, localização da zona de mais alta pressão em repouso em relação ao comprimento do canal anal, volume correspondente a primeira sensação anoneorretal, ao desejo de evacuar e à capacidade máxima neor-retal, além da medida de complacência neorretal. Utilizou-se o teste não paramétrico, não pareado, bi-caudal (Mann-Whitney), sendo considerados significantes valores de p< 0,05, para a comparação das médias de freqüência de evacuações diurnas e noturnas, dos valores médios do índice funcional e parâmetros fisiológicos entre os dois grupos. Para a análise da ocorrência de evacuações fragmentadas e reflexo anoneorretal, utilizou-se a tabela de contingência, sendo o valor de significância estabelecido pelo teste exato de Fischer. Para calcular a existência de correlação entre o índice funcionál e os parâmetros fisiológicos, foi utilizado o cálculo do coeficiente de correlação, sendo considerado estatisticamente significante valores de p< 0,05. Pacientes do grupo 1 apresentaram freqüência média de evacuações diurnas maior do que os pacientes do grupo 2 (3,6 :t 1,9 e 2,7 :t 1,9 ; p<0,05). A freqüência média de evacuações noturnas foi similar entre os grupos 1 e 2 (0,9 :t 1,3 e 0,6 :t 1,9, respectivamente, ns). Evacuações fragmentadas ocorreram mais freqüentem ente entre os pacientes do grupo 1 ( 64,0% e 20,0%, p< 0,05). A análise do índice funcional mostrou melhores resultados entre os pacientes do grupo 2 (48,9 :t8,5 e 42,2 :t8,8; p< 0,05) e a ocorrência do reflexo inibitório anoneorretal foi mais freqüente nos pacientes do gJiUpO 1 (23,5% e 12,0% ; p< 0,05). A análise dos parâmetros fisiológicos mostrou ser a pressão anal média de repouso na zona de mais alta pressão do grupo 1 maior do que nos pacientes do grupo 2 ( 38,3 :t13,7 mmHg e 28,0 ::tIO,1 mmHg; p< 0,05). A quantidade de ar no interior do balão locado no neorreto necessária para desencadear o desejo de evacuação foi significantemente maior no grupb 2 (139,8 :t78,3 ml e 68,8 :t47,5 ml ; p<0,05). Os valores de complacência do neorreto foram maiores nos pacientes do grupo 2 (10,9 :t6,8 mI/mmHg e 5,7 :t3,6 ml/mmHg ; p<0,05). Os demais parâmetros fisiológicos (pressão anal média de repouso, pressão anal máxima de contração voluntária, índice de assimetria e localização da zona de mais alta pressão em repouso, volume de insuflação do balão intra-neoITetal cOITespondente a primeira sensação anoneoITetal e capacidade máxima neoITetal) não apresentaram significância estatística entre os dois grupos. A cOITelação entre os parâmetros fisiológicos e o índice funcional, mostrou significância estatística para a pressão anal média de repouso, pressão anal máxima de contração voluntária, pressão anal média na zona de mais alta pressão e localização da zona de mais alta pressão em repouso, entre os pacientes do grupo 2. A anastomose coloanal sem reservatório pode estar relacionada a maior freqüência de evacuações diurnas e ocoITência de evacuações fragmentadas, enquanto que a confecção de reservatório esteve relacionada a melhores resultados funcionais / Abstract: Sphincter-saving procedures for the treatment of carcinoma of the rectum have represented important progress in the maintenance of patient' s life quality following complete proctectomy without significantly compromising its prognosis. The purpose of this study is to compare manual coloanal anastomosis with and without colonic pouch and evaluate functional results as well as analysis ofthe physiologic parameters. The hypothesis for this study are: 1) colonic pouch anal anastomosis would present better functional results than straight coloanal anastomosis, 2) physiologic parameter measurements would be important to the prediction of functional results. Forty-two patients were undergone to surgery by the Coloproctology Unit, Discipline of the Diseases of th~ Digestive System, School of Medical Sciences, State University of Campinas from 1979 to 1995. Twenty-six patients were female with ages ranging from 28 to 80 (mean age, 55.6:i:13.9) years. Indications for surgery were the following: adenocarcinoma of the rectum (40 patients), rectal villous adenoma (1 patient) and rectal hemangioma (1 patient). Surgeries performed were: primary manual coloanal anastomosis with fecal diversion (5 patients - 11.9%), delayed coloanal anastomosis (12 patients - 28.5%), and manual colonic pouch anastomosis (25 patients - 59.6%). Patient;s with stoma closure or following colic stump ressection within a six-month period with no post-surgical radiotherapy and absence of pelvic or abdominal disease at the time of the evaluation were included in the study. Patients considered as Group 1 ~ere submitted to straight coloanal anastomosis, and Group 2 patients with colonic pouch-anal anastomosis. Clinical data analysed were: mean frequency of daily and noctumal evacuations, and occurrence of fragmented evacuations. Patients responded to a questionary on sphincterian function (functional index) for posterior quantification of this function. Physiological parameters studied were: m-ean resting pressure, maximum squeeze pressure, search of anoneorectal inhibitory reflex, mean resting pressure in the highest resting pressure zone, asimmetry index in the highest resting pressure zone, leveI of the highest pressure zone in relation to the length of the anal canal, corresponding volume to the first anoneorectal sensation, the need to evacuate and maximum neorectal capacity besides neorectal compliance measurement. For statistical analysis, non-parametric unpaired, bi-caudal test (Mann-Whitney) was used, considering significant values of p<0.05 to compare day and night evacuation frequency measurements with the mean values of the functional index and physiological parameters among both groups. For the analysis of occurrence of non-fragmented evacuations and anoneorectal reflex, contingence table and the significance value determined by the Fischer test. To calculate correlation between functional index and physiological parameters, correlation coefficient was used and values ofp<0.05 were considered statistically significant. Group 1 patients presented a mean frequency of daily evacuations higher than Group 2 (3.6j:1.9 and 2.7 j:1.9; p<0.05). The number ofnocturnal evacuations was similar between groups (0.9j:1.3 and 0.6j:1.9 respectively, ns). Fragmented evacuations occurred more frequently among Group 1 patients (64% and 20%, p<0.05) and the occurrence ofthe inhibitory anoneorectal reflex was more frequent in Group 1 patients (23.5% and 12.0%; p<0.05). The analysis ofthe functional index showed better results among Group 2 patients (48.9j:8.5 and 42.2j:8.8; p<0.05) and the occurrence of the anoneorectal inhibitory reflex was more frequent in Group 1 patients (23.5% and 12.0%; p<0.05). Analysis of physiological parameters showed mean anal resting pressure in the highest pressure zone higher ~n Group 1 compared to Group 2 patients (38.3j:13.7 mmHg and 28.0j:10.1 mmHg; p<0.05). Mean air volume necessary to trigger the need to evacuate was significantly higher in Group 2 (139.8j:78.3ml and 68.8j:47.5ml; p<0.05). Neorectal compliance values were higher in Group 2 patients (10.9j:6.8ml/mmHg and 5.7j:3.6ml/mmHg; p<0.05). Other physiological parameters (mean resting anal pressure, maximum anal squeeze pressure, asimetry index and the leveI of the highest resting zone pressure, intraneorectal balloon inflation volume correspondent to the first anoneorectal sensation and maximum neorectal capacity did not present statistical difference among the two groups. Correlation between the physiological parameters and functional index showed statistical significance in the mean resting anal pressure, maximum anal squeeze pressure, mean anal pressure in the highest pressure zone and the leveI of the highest resting pressure zone among Group 2 patients. Straight coloanal anastomosis may be related to higher evacuation frequency and the occurrence of fragmented evacuations, while colonic p01!lch was related to better functional results in this study / Doutorado / Doutor em Cirurgia

Source: Masters Abstracts International, Volume: 47-01, page: 0318. Adviser: Janice Cormier. Includes bibliographical references