Introdução: a maioria dos pacientes com neoplasia maligna da via biliar são diagnosticados em fase avançada. A drenagem biliar ecoguiada é uma alternativa às técnicas de drenagem percutânea trans-hepática e cirúrgicas na ocasião de falha do acesso convencional por colangiografia retrógrada endoscópica (CPRE). Objetivo: avaliar a eficácia e segurança da drenagem biliar ecoguiada em pacientes com obstrução biliar maligna e falha da CPRE. Analisar as complicações e qualidade de vida. Métodos: no período de abril de 2010 a setembro de 2011, 32 pacientes portadores de neoplasia maligna avançada da via biliar foram tratados no Serviço de Endoscopia Gastrointestinal do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Todos os pacientes apresentavam quadro clínico de icterícia obstrutiva e falha na drenagem da via biliar pela CPRE. O tratamento preconizado foi a drenagem da via biliar pela técnica ecoguiada, sob controle radiológico. Dos 32 pacientes, três foram excluídos devido à falha do procedimento ecoguiado. Vinte e nove (90,62%) pacientes foram submetidos a drenagem biliar ecoguiada, avaliações clínica, laboratorial e de qualidade de vida. Na avaliação clínica foram observados a evolução dos sinais e sintomas, e complicações relacionadas ao procedimento. Na avaliação laboratorial, foram analisados os níveis de bilirrubina total, gama-glutamil-transferase, fosfatase alcalina e número de leucócitos. A qualidade de vida foi avaliada pelo questionário SF-36. Resultados: dos 32 pacientes,3 (9,4%) foram excluídos devido a falha técnica. O sucesso técnico foi de 90.6% (29/32) e o clínico de 100% (29/29). Em relação aos dados gerais endossonográficos, verificou-se metástase à distância em 6 (18,75%) e invasão do eixo mesentero-portal em 26 (81,25%) pacientes. O diâmetro da via biliar extra-hepática apresentou mediana de 23,45 mm (20 - 30 mm) e da intra-hepática foi de 17,54 mm (10 - 24 mm). A invasão duodenal ocorreu em 10 (31,25%) pacientes e prótese metálica foi posicionada em 7 (21,85%) casos. A coledocoduodenostomia ecoguiada foi o procedimento mais frequente (58,62%). Complicações ocorreram em 6 (18,75%) casos. Verificou-se uma queda significativa dos níveis de bilirubina (p <0,001) e os pacientes obtiveram melhora significativa da qualidade de vida após o procedimento (p<0,05). A sobrevida média foi de 90 dias. Conclusão: a drenagem biliar ecoguiada foi um procedimento eficaz e seguro, com taxa de complicações aceitável, proporcionando melhora significativa na qualidade de vida dos pacientes / Introduction: most of patients with malignant neoplasia of the biliary tract are diagnosed at an advanced stage. Echoguided biliary drainage is an alternative to percutaneous transhepatic and surgical drainage techniques at the time of failure of conventional access by endoscopic retrograde cholangiography (ERCP). Objective: to evaluate the efficacy and safety of echoguided biliary drainage in patients with malignant biliary obstruction and failure of ERCP. To evaluate the complications and quality of life. Methods: from April 2010 to September 2011, 32 patients with advanced malignant biliary tract disease were treated at the Gastrointestinal Endoscopy Service, Clinics Hospital, Faculty of Medicine, University of Sao Paulo. All patients had a clinical picture of obstructive jaundice and failure in the drainage of the biliary tract by ERCP. Treatment was based on echoguided biliary drainage technique under radiological control. Of the 32 patients, three were excluded due to failure of the echoguided procedure. Twenty-nine (90.62%) patients underwent echoguided biliary drainage, clinical, laboratory and quality of life evaluation. In the clinical evaluation were assessed the evolution of signs and symptoms, and procedure-related complications. In laboratory tests, we assessed the levels of total bilirubin, gamma glutamyl transferase, alkaline phosphatase and number of leukocytes. The quality of life was assessed by SF-36 questionary. Results: of 32 patients, three (9.4%) were excluded due to technical failure. Technical success was 90.6% (29/32) and clinical 100% (29/29). In relation to the general endosonographic data, there was distant metastasis in 6 (18.75%) and invasion of the mesenteric-portal axis in 26 (81.25%) patients. The diameter of extrahepatic biliary tree was 23.45 mm (20 - 30mm) and intrahepatic was 17.54mm(10 - 24mm). The duodenal invasion occurred in 10 (31.25%) and metallic prosthesis was positioned in 7 (21.85) cases. Echoguided choledochoduodenostomy was the most common procedure (58.62%). Complications occurred in 6 (18.75%) cases. There was a significant decrease in bilirubin levels (p <0.001) and patients had significant improvement in quality of life after the procedure (p < 0.05). The median survival was 90 days. Conclusion: echoguided biliary drainage was effective and safe procedure with acceptable complication rates, providing significant improvement in quality of life of patients

Introdução: a maioria dos pacientes com neoplasia maligna da via biliar são diagnosticados em fase avançada. A drenagem biliar ecoguiada é uma alternativa às técnicas de drenagem percutânea trans-hepática e cirúrgicas na ocasião de falha do acesso convencional por colangiografia retrógrada endoscópica (CPRE). Objetivo: avaliar a eficácia e segurança da drenagem biliar ecoguiada em pacientes com obstrução biliar maligna e falha da CPRE. Analisar as complicações e qualidade de vida. Métodos: no período de abril de 2010 a setembro de 2011, 32 pacientes portadores de neoplasia maligna avançada da via biliar foram tratados no Serviço de Endoscopia Gastrointestinal do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Todos os pacientes apresentavam quadro clínico de icterícia obstrutiva e falha na drenagem da via biliar pela CPRE. O tratamento preconizado foi a drenagem da via biliar pela técnica ecoguiada, sob controle radiológico. Dos 32 pacientes, três foram excluídos devido à falha do procedimento ecoguiado. Vinte e nove (90,62%) pacientes foram submetidos a drenagem biliar ecoguiada, avaliações clínica, laboratorial e de qualidade de vida. Na avaliação clínica foram observados a evolução dos sinais e sintomas, e complicações relacionadas ao procedimento. Na avaliação laboratorial, foram analisados os níveis de bilirrubina total, gama-glutamil-transferase, fosfatase alcalina e número de leucócitos. A qualidade de vida foi avaliada pelo questionário SF-36. Resultados: dos 32 pacientes,3 (9,4%) foram excluídos devido a falha técnica. O sucesso técnico foi de 90.6% (29/32) e o clínico de 100% (29/29). Em relação aos dados gerais endossonográficos, verificou-se metástase à distância em 6 (18,75%) e invasão do eixo mesentero-portal em 26 (81,25%) pacientes. O diâmetro da via biliar extra-hepática apresentou mediana de 23,45 mm (20 - 30 mm) e da intra-hepática foi de 17,54 mm (10 - 24 mm). A invasão duodenal ocorreu em 10 (31,25%) pacientes e prótese metálica foi posicionada em 7 (21,85%) casos. A coledocoduodenostomia ecoguiada foi o procedimento mais frequente (58,62%). Complicações ocorreram em 6 (18,75%) casos. Verificou-se uma queda significativa dos níveis de bilirubina (p <0,001) e os pacientes obtiveram melhora significativa da qualidade de vida após o procedimento (p<0,05). A sobrevida média foi de 90 dias. Conclusão: a drenagem biliar ecoguiada foi um procedimento eficaz e seguro, com taxa de complicações aceitável, proporcionando melhora significativa na qualidade de vida dos pacientes / Introduction: most of patients with malignant neoplasia of the biliary tract are diagnosed at an advanced stage. Echoguided biliary drainage is an alternative to percutaneous transhepatic and surgical drainage techniques at the time of failure of conventional access by endoscopic retrograde cholangiography (ERCP). Objective: to evaluate the efficacy and safety of echoguided biliary drainage in patients with malignant biliary obstruction and failure of ERCP. To evaluate the complications and quality of life. Methods: from April 2010 to September 2011, 32 patients with advanced malignant biliary tract disease were treated at the Gastrointestinal Endoscopy Service, Clinics Hospital, Faculty of Medicine, University of Sao Paulo. All patients had a clinical picture of obstructive jaundice and failure in the drainage of the biliary tract by ERCP. Treatment was based on echoguided biliary drainage technique under radiological control. Of the 32 patients, three were excluded due to failure of the echoguided procedure. Twenty-nine (90.62%) patients underwent echoguided biliary drainage, clinical, laboratory and quality of life evaluation. In the clinical evaluation were assessed the evolution of signs and symptoms, and procedure-related complications. In laboratory tests, we assessed the levels of total bilirubin, gamma glutamyl transferase, alkaline phosphatase and number of leukocytes. The quality of life was assessed by SF-36 questionary. Results: of 32 patients, three (9.4%) were excluded due to technical failure. Technical success was 90.6% (29/32) and clinical 100% (29/29). In relation to the general endosonographic data, there was distant metastasis in 6 (18.75%) and invasion of the mesenteric-portal axis in 26 (81.25%) patients. The diameter of extrahepatic biliary tree was 23.45 mm (20 - 30mm) and intrahepatic was 17.54mm(10 - 24mm). The duodenal invasion occurred in 10 (31.25%) and metallic prosthesis was positioned in 7 (21.85) cases. Echoguided choledochoduodenostomy was the most common procedure (58.62%). Complications occurred in 6 (18.75%) cases. There was a significant decrease in bilirubin levels (p <0.001) and patients had significant improvement in quality of life after the procedure (p < 0.05). The median survival was 90 days. Conclusion: echoguided biliary drainage was effective and safe procedure with acceptable complication rates, providing significant improvement in quality of life of patients

Introdução: os tumores biliopancreáticos geralmente são diagnosticados num estágio avançado sem condições de ressecção cirúrgica. A drenagem biliar por colangiopancreatografia retrógrada endoscópica (CPRE) é o padrão ouro no tratamento paliativo desses pacientes. Entretanto, em alguns casos a CPRE pode falhar. A drenagem biliar guiada por ultrassom endoscópico (DB-USE) surgiu como uma alternativa nesses casos de falha da CPRE. Os dois métodos principais para a DB-USE são a coledocoduodenostomia (CDS) e a hepaticogastrostomia (HGS). Porém, não existe um consenso sobre a melhor das duas técnicas. Portanto, realizamos uma revisão sistemática e metanálise para avaliar esses dois principais métodos de DB-USE. Métodos: uma revisão sistemática foi conduzida utilizando-se as bases de dados eletrônicas Medline, EMBASE, Cochrane, Scopus e LILACS. Foram selecionados estudos comparando a CDS com a HGS em pacientes com obstrução biliar maligna com falha na CPRE. Os riscos de vieses foram avaliados pela escala de Jadad para os ensaios clínicos randomizados e pela Newcastle Ottawa Scale para os estudos de coorte. Os dados dos estudos foram extraídos segundo os seguintes desfechos: sucesso técnico, sucesso clínico, eventos adversos, sobrevida e tempo do procedimento. A análise estatística foi realizada utilizando-se os softwares RevMan 5 e Comprehensive Meta-Analysis. Resultados: Foram selecionados 10 estudos, sendo dois ensaios clínicos randomizados, dois estudos prospectivos e seis estudos retrospectivos. Um total de 434 pacientes foram incluídos na metanálise: 208 submetidos a drenagem biliar via HGS e os 226 restantes submetidos a CDS. O sucesso técnico para a CDS-USE e HGS-USE foi de 94,1% e 93,7%, respectivamente, não apresentando significância estatística (OR = 0,96, IC 95% = 0,39, 2.33). O sucesso clínico foi de 88,5% na CDS-USE e 84,5% na HGS-USE. Não foi observada diferença nos dois grupos (OR = 0,76, IC 95% = 0,42, 1.35). Em relação aos eventos adversos, também não foi identificada diferença estatística (OR = 0,97, IC 95% = 0,60, 1.56). A diferença entre as médias do tempo de procedimento foi de -2,69 (-4,44, -0,95). Portanto, a CDS-USE foi dois minutos mais rápido. Em relação à sobrevida após o procedimento, a diferença entre as médias foi de 39,5 (-9,75, 88,93). Porém, essa análise foi limitada devido a alta heterogeneidade (I2=97%). Conclusão: A CDS-USE e a HGS-USE apresentam equivalentes eficácia e segurança. Ambas as técnicas estão associadas a uma alta taxa de sucesso técnico e clínico. A escolha da técnica deve ser baseada na experiência do endoscopista e também pela anatomia do paciente. Novos ensaios clínicos randomizados são necessários para comparar os dois procedimentos / Background and Aims: Biliopancreatic tumors are usually diagnosed at an advanced stage without conditions of surgical resection. Biliary drainage by endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard in the palliative treatment of these patients. However, in some cases ERCP may fail. Endoscopic ultrasound guided biliary drainage (EUS-BD) has emerged as an alternative in these cases of ERCP failure. The two main methods for EUS-BD are choledochoduodenostomy (CDS-EUS) and hepaticogastrostomy (HGS-EUS). However, there is no consensus if one approach is better than the other. Therefore, we conducted a systematic review and meta-analysis to evaluate these two main EUS-BD methods. Methods: a systematic review was conducted using databases Medline, EMBASE, Cochrane, Scopus and LILACS. We selected studies comparing CDS and HGS in patients with malignant biliary obstruction with ERCP failure. Risks of bias were assessed by the Jadad scale for randomized clinical trials and by the Newcastle Ottawa Scale for cohort studies. The data from the studies were extracted according to the following outcomes: technical success, clinical success, adverse events, survival and procedure time. Statistical analysis was performed using the software RevMan 5 and Comprehensive Meta-Analysis. Results: among the ten studies included in meta-analysis two were randomized clinical trials, RCT, two prospective and six retrospective. A total of 434 patients were included in the meta-analysis: 208 underwent biliary drainage via HGS-USE and the remaining 226 submitted to CDS-USE. The technical success for CDS-USE and HGS-USE was 94.1% and 93.7%, respectively, without statistical significance (OR = 0.96, IC 95% = 0.39, 2.33). Clinical success was 88.5% in CDS-USE and 84.5% in HGS-USE. No difference was observed in the two groups (OR = 0.76, IC 95% = 0.42, 1.35). In relation to adverse events, no statistical difference was identified (OR = 0.97, 95% CI = 0.60, 1.56). Pooled difference in means was -2.69 (-4.44, -0.95). Therefore CDS was about two minutes faster. Regarding the survival after the procedure, pooled difference in means was 39.5 (-9.75, 88.93). Therefore, this analysis was limited by considerable heterogeneity (I2=97%). Conclusion: EUS-CDS and EUS-HGS have equal efficacy and safety and are both associated with very high technical and clinical success. The choice of approach may be selected based on endoscopist\'s expertise and patient anatomy. Further prospective clinical trials are required to further compare the two procedures

La survenue de lésions hépatiques représente une cause majeure de retrait des médicaments au cours de leur développement et après leur mise sur le marché. La manifestation la plus fréquente des effets secondaires liés aux médicaments est lacholestase qui résulte d’un blocage de la sécrétion biliaire. Ils peuvent être prévisibles, généralement dépendants de la dose, ou dans certains cas n’être observés que chez un nombre restreint de patients traités, par exemple avec la chlorpromazine (CPZ), un neuroleptique. Il s’agit alors d’une hépatotoxicité idiosyncratique. Notre travail a eu pour but d’induire une cholestase avec ce médicament et d’étudier les mécanismes impliqués, en présence ou non d’un stress inflammatoire en utilisant comme modèle expérimental les cellules hépatiques différenciées HepaRG dérivées d’un cholangio-hépatocarcinome humain. Nous avons tout d’abord validé ce modèle en montrant que les principaux transporteurs d’influx et d’efflux canaliculaires et basolatéraux sont bien localizes dans les domaines membranaires appropriés, et que les canalicules biliaires sont fonctionnels et fermés comme dans les hépatocytes humains cultivés en sandwich, le modèle de référence. Le traitement par CPZ à une concentration élevée (50μM) entraine après 15min la génération d’un stress oxydant associé à une altération du potentiel membranaire mitochondrial et de la distribution péricanaliculaire des microfilaments de F-actine et à une inhibition de l’efflux canaliculaire de l’acide taurocholique. Après 24h, on observe notamment une inhibition de l’expression des deux principaux transporteurs canaliculaires, BSEP et MDR3, du transporter d’influx NTCP et une surexpression du transporteur basolatéral MRP4. Ces effets suggèrent une réponse compensatrice des cellules face à l’accumulation intracellulaire des acides biliaires. L’inflammation est considérée comme un facteur de susceptibilité dans l’hépatotoxicité idiosyncratique. Nous avons recherché si dans un context inflammatoire induit par l’IL-6 et l’IL-1β, les effets cytotoxiques et cholestatiques de CPZ sont aggravés. Après un prétraitement de 24h par les deux cytokines proinflammatoires, les cellules HepaRG, ont été co-exposées à 20μM CPZ pendant 1 à 5 jours. Bien que les cytokines aient induit un stress inflammatoire et inhibé le métabolisme de la CPZ et les transcrits de CYP3A4 et CYP1A2, deux principaux CYPs impliqués dans le métabolisme de ce médicament, la modulation des effets cytotoxiques et cholestatiques de la CPZ observés est restée limitée, y compris après 5 jours. Une cytotoxicité accrue de 20% et une amplification de l’inhibition des transcrits et de l’activité de NTCP ainsi que la dérégulation de l’expression d’autres gènes liés à la cholestase, ont été constatées suite au co-traitement à CPZ et aux cytokines. Au total, nos résultats montrent qu’il est possible d’induire une cholestase in vitro à partir des cellules HepaRG et que la cholestase induite par CPZ a pour origine l’induction d’un stress oxydant. Ils montrent en outre que l’étude de certains facteurs de susceptibilité peut être envisagée. / Drug-induced liver injury is the major cause of drug withdrawal during development and marketing process. The most common manifestation of adverse drug reactions is cholestasis, which results from alteration of bile flow. Adverse drug reactions are usually classified either as dose-dependent and reproducible (intrinsic) or unpredictable (idiosyncratic) occurring only in certain susceptible patients as observed with chlorpromazine (CPZ), a neuroleptic drug. Our work aimed to induce cholestasis with this drug and to study the mechanisms involved in the presence or absence of an inflammatory stress using differentiated HepaRG liver cells derived from a human cholangio-hepatocarcinoma as an experimental model. We firstly validated this cell model by demonstrating that the major canalicular and basolateral influx and efflux transporters are localized to the appropriate membrane domains, and that the bile canaliculi are functional and closed as in sandwichcultured human hepatocytes, the reference model. Treatment with CPZ at a high concentration (50μM) induces, as early as 15min, generation of oxidative stress which is associated with altered mitochondrial membrane potential, disruption of the pericanalicular F-actin cytoskeleton distribution and inhibition of canalicular efflux of taurocholic acid. After 24-hour treatment with CPZ, mRNA expression of the two main canalicular bile transporters, BSEP and MDR3, and of the main influx transporter, NTCP, was decreased. By contrast, expression of MRP4 mRNA, a basolateral transporter, was increased. These latter events likely represent hepatoprotective responses which aim to reduce intrahepatic accumulation of toxic BA. Inflammation is considered as a factor of susceptibility to idiosyncratic hepatotoxicity. We investigated whether in an inflammatory stress induced by IL-6 and IL-1β, cytotoxic and cholestatic effects of CPZ are exacerbated. After a 24 hour pre-treatment by either pro-inflammatory cytokines, HepaRG cells were co-exposed to 20μM CPZ for 1 to 5 days. Although cytokines have induced inflammatory stress and inhibited the metabolism of CPZ and transcripts of CYP3A4 and CYP1A2, two main CYPs involved in the metabolism of this drug, the modulation of cytotoxic and cholestatic effects of CPZ was limited, even after 5 daily treatments. Increased cytotoxicity by 20 %, amplification of NTCP mRNA and activity inhibition and deregulation of the expression of other genes associated with cholestasis, were observed in CPZ- and cytokine-co-treated cells. Altogether, our results show that it is possible to induce in vitro cholestasis using HepaRG cells and that CPZ-induced cholestasis depends on the generation of oxidative stress. They also show that the certain susceptibility factors may be investigated.

121 9. Summárý Purpose: This study was designed to evaluate the role of interventional radiology in liver transplantation programme. The aim is to present our experience, technical outcomes and long-term clinical results with chemoembolization of hepatocellular carcinoma in patients before liver transplantation and with percutaneous treatment of vascular and biliary complication after orthotopic liver transplantation. Methods: Twenty five patients (17 men, 8 women, mean age 57.76 years) with HCC were scheduled for TACE prior to liver transplantation from 2008 to 2012. Twenty three procedures were performed, 7 c-TACE in 2008 and 16 DEB TACE in next years. Thirty patients (13 men, 17 women, mean age 46.4 years) with biliary strictures after liver transplantation without endoscopic access possibility were treated with balloon dilatation and biliary duct drainage from 1996 and 2010. Twenty patients (13 men, 7 women, mean age 45.25 years) were treated with PTA/stent due to hepatic artery stenosis after liver transplantation between 1996 and 2011. Stents were placed to the hepatic/celiac artery in 16 PTAs, balloon dilatation alone was performed in 7 stenosis due to tortuosity of the vessel. Results: Liver transplantation was performed to 20 patients after TACE. Only one patient (4.5 %) was excluded from waiting...

Ambientes marinhos adjacentes a centros urbanos, como a Baía de Santos, estão sujeitos à introdução de contaminantes que apresentam caráter tóxico, como os hidrocarbonetos policíclicos aromáticos (PAHs). A biodisponibilidade dos PAHs pode ser avaliada através de biomarcadores de exposição, como metabólitos biliares e atividade da 7-etoxiresorufina-desetilase (EROD). Este trabalho investigou a biodisponibilidade dos PAHs na Baía de Santos através dos metabólitos biliares, usando a atividade EROD como análise auxiliar. Coletas mensais foram realizadas em três regiões da Baía de Santos entre junho e dezembro de 2005. As espécies escolhidas foram: Stellifer rastrifer, Micropogonia furnieri, Nebris microps e Sphoeroides testudineus. Os metabólitos foram analisados através de cromatógrafo a líquido com detector de fluorescência (HPLC/F). A concentração de metabólitos biliares e de atividade EROD variou, respectivamente de 65,5 a 589 g.g-1 de bile e 6,88 a 262 pmol.min-1.mg-1 de proteína. Os níveis de metabólitos de fenantreno e benzo(a)pireno foram menores na espécie N. microps e maiores na S. testudineus, não havendo diferenças significativas entre as espécies para os metabólitos de naftaleno. Não houve diferenças significativas dos metabólitos estudados entre os locais e períodos de coleta. A biodisponibilidade de PAHs na Baía de Santos foi evidenciada pelos metabólitos e confirmada pela atividade EROD. / Marine environments near urban areas, such as Santos Bay, are subjected to toxic contaminants input, as polycyclic aromatic hydrocarbons (PAHs). The PAHs bioavailability can be evaluated through biomarkers, such as biliary metabolites and 7-ethoxyresorufin-O-deethylase activity (EROD). The goal of the present study was to evaluate the PAH bioavailability in Santos Bay through the biliary metabolites, and the EROD activity as an auxiliary analysis. The samples were collected in three different regions of Santos Bay. The chosen species were: Stellifer rastrifer, Micropogonia furnieri, Nebris microps e Sphoeroides testudineus. The metabolites were analyzed through a high performance liquid chromatograph with fluorescence detector (HPLC/F). The metabolites and the EROD activity concentration varied, respectively, from 65,5 to 589 g.g-1 of bile and 6,88 a 262 pmol.min-1.mg-1 of protein. The phenanthrene and benzo(a)pirene metabolites levels were lower to N. microps and higher to S. testudineus. The naphthalene metabolites did not present significant differences among the species. There were no significant differences in the metabolites for the sampling areas and the period of collection. The PAHs bioavailability was evidenced by the metabolites and confirmed through the EROD activity.

Os estuários são o receptáculo final de muitos contaminantes antrópicos, como os hidrocarbonetos policíclicos aromáticos (HPAs), que podem ser tóxicos aos organismos. A biodisponibilidade dos HPAs pode ser avaliada através de biomarcadores de exposição, como os metabólitos biliares. Este trabalho teve como objetivo avaliar a biodisponibilidade do HPAs em peixes da espécie Mugil curema do Estuário de Santos e de Cananéia, através da análise de metabólitos de HPAs em bile de peixes. As coletas no Estuário de Cananéia foram realizadas nos meses de junho e novembro de 2008 e as coletas no Estuário de Santos foram realizadas entre os meses de março e maio de 2009. Os metabólitos foram analisados através de cromatografia líquida com detector de fluorescência (HPLC/F). A concentração de metabólitos biliares totais para o Estuário de Cananéia variou entre 0,91 a 89,97 ?g g-1 de bile, e para o Estuário de Santos variou de 4,68 a 528,43 ?g g-1 de bile. Houve diferença significativa entre os locais estudados. Observou-se também que não houve diferença significativa entre as amostras de machos e de fêmeas. A biodisponibilidade de HPAs foi considerada como baixa para o Estuário de Cananéia e alta para o Estuário de Santos. Valores de referência foram propostos para analise ambiental de metabólitos biliares de HPAs, sendo estipulada uma concentração de 2,22 ?g g-1 de bile para locais não contaminados. / Estuaries are the final receptacle to many anthropic contaminants, such as polycyclic aromatic hydrocarbons (PAHs), who can be toxic to organisms. The PAH bioavailability can be evaluated through biomarkers, such as biliary metabolites. This work had as objective evaluate the PAHs bioavailability in fishes of Mugil curema from Santos and Cananéia Estuaries, through the analysis of PAHs metabolites in fish bile. The Cananéia Estuary sampling was made in June and November from 2008 and the Santos Estuary sampling was made between the months of March and May from 2009. The metabolites were analyzed through a high performance liquid chromatograph with fluorescence detector (HPLC/F). The biliary metabolites concentrations from the Cananéia Estuary varied between 0,91 a 89,97 ?g g-1 of bile, and from Santos Estuary varied between 4,68 a 528,43 ?g g-1 of bile. There were significant differences between the sampling sites. There were no significant differences between the male and female samples. The PAHs bioavailability was considered low to Cananéia Estuary and high to Santos Estuary. Reference values were proposed to PAHs biliary metabolites environmental analysis, been stipulated a concentration of 2,22 ?g g-1 of bile to uncontaminated sites.

Background The gallstone prevalence in the western world is 10-20%. Most gallstones are silent, but symptoms and complications appear in 20-40%. The incidence of symptom development in patients with silent gallstones is 2-4% per year. The indication for surgical (including endoscopic) treatment of gallstones is symptoms of certain magnitude, and no contraindications. During the past three decades an intense technical development in imaging (ultrasound, computerised tomography and magnetic resonance imaging), endoscopic therapy, and surgery has taken place. The aim of this thesis is to scrutinize changes in management of complicated gallstone disease on a population-based level, using national register data. Have the new methods improved the treatment of acute pancreatitis, common bile duct stones and acute gallbladder disease? Methods Data is collected from National Patient Register (NPR) run by The Swedish National Board of Health and Welfare. NPR collects discharge data from every admission from every Swedish hospital. Mortality is calculated as standardised mortality ratio (SMR) using age-, gender-, and calendar year specific survival estimates. We have studied both general trends in admissions and treatment alternatives and outcomes in defined patient cohorts. Length of hospital stay, readmission, and mortality has been used as proxy indicators of the effectiveness of treatment strategies used. Results During the study period mortality in acute pancreatitis (SMR within 90 days of admission) improved and hospital stay for all patients with acute pancreatitis decreased. Cholecystectomy rate at or shortly after index stay for mild acute biliary pancreatitis increased from 14.5 % to 22.7 %. Of all patients with acute pancreatitis 68.4 % of the patients had no aetiological diagnosis in the register. The incidence of bile duct interventions increased 27.8% from 1988 through 2006. The favoured treatment of bile duct stones changed from open choledocholithectomy to endoscopic sphincterotomy with stone extraction during the same period. However, in 2006, still 19.6% of bile duct interventions for stones were performed as choledochotomy and in the great majority of these cases as open surgery. This indicates a continuing need of education in open bile duct surgery. Mean hospital stay for treatment of common bile duct stones decreased significantly (4.5 days) during the period studied. The mortality (SMR) diminished although without statistical significance during the time period, and there was no significant difference in SMR between choledochotomy and endoscopic sphincterotomy. For acute gallbladder disease a moderate increase of admissions occurred from 1988 through 2006. The relation between acute cholecystectomies versus all cholecystectomies did not change during this period. Of all patients admitted with acute gallbladder disease 32.3 % were cholecystectomised during their first hospital stay, whereas 20.3 % underwent elective cholecystectomy and 6.1 % emergency cholecystectomy within two years of first admission. 41.4 % of patients were not operated on for gallbladder disease within two years of first admission with this diagnosis. Mortality from first admission and 90 days onwards was elevated three-fold during the entire period without time trend, without statistical difference between age groups, and between patients who had cholecystectomy at first admission or later. Conclusion During the audit period treatment of acute pancreatitis improved. However, etiological classification and timing of cholecystectomy in mild acute biliary pancreatitis fell below accepted guidelines. Interventions on the common bile duct for gallstone disease increased significantly. Common bile duct clearance has been separated from cholecystectomy, and cholecystectomy often not done. Only one third of all patients with acute gallbladder disease underwent cholecystectomy at first admission. There is room for improvement in treatment of complicatedgallstone disease, and, gallstone surgeons still need good knowledge in open biliary surgery.

Biliary excretion is an important elimination route for many drugs and metabolites. For such compounds, it is important to know the extent of excretion and drug exposure in the bile, e.g., for the risk assessment of drug interactions, liver toxicity and the effects of genetic variants. In this thesis, duodenal aspiration of bile was performed in healthy volunteers and complemented with experiments in an in vivo model in pigs to increase the understanding of the intestinal and hepatobiliary disposition of two direct thrombin inhibitors. The compounds investigated, ximelagatran and AZD0837, are both prodrugs that require bioactivation to exert their pharmacological effect. Upon co-administration with erythromycin and ketoconazole, respectively, altered plasma exposure to ximelagatran and AZD0837 and their respective metabolites has been observed. The main objective of this thesis was to characterize the biliary excretion of the compounds, and investigate whether this elimination route explains the observed drug-drug interactions. High plasma-to-bile AUC ratios were observed, in particular for ximelagatran, its active metabolite melagatran, and AR-H067637, the active metabolite of AZD0837. These high ratios indicate the involvement of active transporters in the biliary excretion of the compounds, which is important since transporters constitute possible sites for drug interactions. The effects of erythromycin and ketoconazole on the plasma exposure of the prodrugs and metabolites were confirmed in both the pig and the clinical studies. The changes seen in plasma for ximelagatran and its metabolites were partly explained by reduced biliary clearance. Inhibited CYP3A4 metabolism likely caused the elevated plasma levels of AZD0837, whereas reduced biliary clearance was seen for AR-H067637 suggesting an effect on its excretion into bile. In summary, the studies led to mechanistic insights in the hepatobiliary disposition of ximelagatran and AZD0837, and demonstrate the value of combined clinical and animal studies for the investigation of the biliary drug excretion.

The general aim of this thesis was to improve the understanding of the in vivo pharmacokinetics and, in particular, the metabolism of finasteride, a 5α-reductase inhibitor used in the treatment of enlarged prostate glands and male pattern baldness. CYP3A4 has been identified as the major enzyme involved in the sequential metabolism of finasteride to ω-OH finasteride (M1) and ω-COOH finasteride (M3). The consequences of induced and inhibited metabolism on the pharmacokinetics of finasteride and its metabolites were investigated in humans and pigs. Both studies included bile collection. The collected human and pig samples were used for the metabolite identification. As expected, induced metabolism led to reduced plasma exposure of finasteride and inhibited metabolism had the opposite effect. The interactions were investigated in detail and included examination of the biliary pharmacokinetics of finasteride and its metabolites. In pigs, the study included monitoring of the hepatic extraction over time, deconvolution and the development of a semi-physiological model for comparison of the effects on the gut wall and liver metabolism. For M3, the concentration ratios of bile to plasma and the renal clearance indicated that carrier-mediated processes are involved in the biliary and urinary excretion. This was not, however, the case for finasteride. The metabolite, M1, could not be quantified either in humans or pigs. Instead, two other OH metabolites, M1 isomers, were identified in humans. These metabolites were found to undergo glucuronide conjugation. In humans, one glucuronide was identified intact and in pigs, both glucuronides were identified intact in bile and in urine. In addition, a glucuronide of M3 was identified in human bile. In conclusion, advances have been made in the understanding of the pharmacokinetics of finasteride, in particular in relation to the metabolism. Hopefully, the findings of this comprehensive investigation can be applied to other drugs and novel chemical entities.