Esophagectomy often presents anastomotic leaks (AL), due to tenuous perfusion of gastric conduit fundus (GCF). Hybrid (endovascular/surgical) ischemic gastric preconditioning (IGP), might improve GCF perfusion. Sixteen pigs undergoing IGP were randomized: (1) Max-IGP (n = 6): embolization of left gastric artery (LGA), right gastric artery (RGA), left gastroepiploic artery (LGEA), and laparoscopic division (LapD) of short gastric arteries (SGA); (2) Min-IGP (n = 5): LGA-embolization, SGA-LapD; (3) Sham (n = 5): angiography, laparoscopy. At day 21 gastric tubulation occurred and GCF perfusion was assessed as: (A) Serosal-tissue-oxygenation (StO2) by hyperspectral-imaging; (B) Serosal time-to-peak (TTP) by fluorescence-imaging; (C) Mucosal functional-capillary-density-area (FCD-A) index by confocal-laser-endomicroscopy. Local capillary lactates (LCL) were sampled. Neovascularization was assessed (histology/immunohistochemistry). Sham presented lower StO2 and FCD-A index (41 ± 10.6%; 0.03 ± 0.03 respectively) than min-IGP (66.2 ± 10.2%, p-value = 0.004; 0.22 ± 0.02, p-value < 0.0001 respectively) and max-IGP (63.8 ± 9.4%, p-value = 0.006; 0.2 ± 0.02, p-value < 0.0001 respectively). Sham had higher LCL (9.6 ± 4.8 mL/mol) than min-IGP (4 ± 3.1, p-value = 0.04) and max-IGP (3.4 ± 1.5, p-value = 0.02). For StO2, FCD-A, LCL, max- and min-IGP did not differ. Sham had higher TTP (24.4 ± 4.9 s) than max-IGP (10 ± 1.5 s, p-value = 0.0008) and min-IGP (14 ± 1.7 s, non-significant). Max- and min-IGP did not differ. Neovascularization was confirmed in both IGP groups. Hybrid IGP improves GCF perfusion, potentially reducing post-esophagectomy AL.

This work presents several major developments related to a fluorescence confocal microendoscope technology that can provide instantaneous cellular level images from selected depths of tissue inside the human body. The confocal microendoscope systems discussed employ fiber-optic based imaging catheters coupled to custom built slit-scan confocal microscopes. One major new development involves the design, development, and testing of a new flexible confocal microgastroscope (CMG) system for imaging the esophagus. This new system has the potential to aid in the early detection of esophageal cancer. It consists of a new optical scan unit mounted on an endoscopy cart and a new flexible catheter that can be inserted through the instrument channel of a commercial gastroscope. The CMG system has higher spatial resolution and larger field of view than the previous generation clinical confocal microendoscopes in our lab. In addition, the new CMG system can be operated over a greater wavelength range than its predecessor. Central to the CMG system is the design, construction, and testing of a new distal miniature objective that enables high-quality microendoscopy. The miniature objective, built with all glass spherical surfaces, achieves diffraction-limited performance over a 486 to 1000 nm spectral range. The wide achromatic range of this lens allows the CMG system to be used with a variety of contrast agents including agents in the NIR region. In addition, the new miniature objective can be mounted on existing confocal microendoscopes in our lab such as the ovarian clinical confocal microlaparoscope and our laboratory based experimental system. Finally, a new confocal microlaparoscope with an articulating catheter capable of imaging inside the distal portion of fallopian tubes is presented. This instrument is intended to allow the detection of early stage ovarian cancer originating inside the fallopian tube. The new microlaparoscope is compatible with 5 mm trocars and includes a thin 2.2 mm diameter articulating distal tip consisting of a bare fiber bundle and an automated dye delivery system. The distal tip of this new endoscope can be articulated through simple wrist movements and locked in place at a given angle if desired. The thin distal tip and the ability to control the angle of the tip provide the size and flexibility needed to image inside the curved and delicate structures of the fallopian tube. Preliminary imaging results from the new CMG system, the achromatized miniature objective, and the new articulating confocal microlaparoscope are presented to demonstrate the performance and the potential of each system towards the overall goal of in vivo imaging and disease diagnosis.

Thesis (MSc)--Stellenbosch University, 2004. / ENGLISH ABSTRACT: The work presented in this thesis deals with the association between cancers of the upper gastro-intestinal tract and the tumor suppressor gene, TP53, and can be divided into three parts: (i) the analysis of the mutational spectrum of TP53 with respect to laryngeal cancer, (ii) the analysis of the mutational spectrum of TP53 with respect to esophageal cancer and (iii) the analysis of TP53 transcriptional levels in esophageal cancer. Laryngeal cancer (LC) is the 6th most common cancer in the world and the 2nd most common respiratory cancer, with approximately 500 000 new cases per annum detected worldwide. Over the last few years, LC has become increasingly prevalent within the Coloured Community of the Western Cape. The mechanisms of tumorigenesis in LC remain unknown, although smoking and alcohol consumption are considered to be major risk factors. Mutations within the gene TP53 have been strongly implicated as playing a role in cancer development, as they are frequently found in several cancer types. We therefore screened exons 5 - 8 of TP53 for mutations in DNA from tumor biopsies (n=44) and blood samples (n=42) from Coloured LC patients, using polymerase chain reaction - single strand conformation polymorphism (PCR-SSCP) analysis and direct sequencing. Blood samples from a healthy, matched control group (n=40) were included in the study as controls. Significant correlations were found between the occurrence of LC and age and smoking, whereas daily meat consumption was a possible protective factor. In tumor-derived samples, mutations were found in 3 of the exons under investigation, representing 25% of the samples. The mutations were unique to the tumor biopsies, indicating a somatic origin for mutations. The data confirms that the region between codons 175 and 273 of TP53 is a mutational hotspot for cancers in general. This study reports 6 novel mutations within this same region. Esophageal cancer (EC) has a very high incidence in South Africa, relative to the rest of the world, and is particularly common amongst the Black Transkei population. The goal of this study was to determine whether there are differences in the TP53 mutational pattern observed in the Coloured Western Cape community as compared to that observed in the Black Transkei community. This required the analysis of the molecular structure of TP53, specifically exons 5 - 8, in a group of Coloured EC patients (n=44) treated at Tygerberg Hospital, Cape Town, South Africa. DNA obtained from tumor biopsies and blood (from patients) as well as from apparently healthy surrounding tissue was screened via PCR-SSCP and direct sequencing analysis. Only 4 nucleotide changes were observed from a total of 124 sequences obtained, of which two were novel to esophageal squamous cell carcinoma. These 4 nucleotide alterations were found only within the tumor biopsy sample set, representing 9% of the tumors investigated. This study revealed that the mutational spectrum of TP53 within the Coloured population of the Western Cape greatly differs from that of the Black community of the Transkei. This suggests that a different set of etiological factors are involved in the tumorigenic process for each of these distinct geographical communities, which is the subject of an epidemiological study undertaken by the MRC. The final part of this thesis deals with the quantification and comparison of TP53 transcription levels in esophageal cancer tumor tissue to the TP53 levels in healthy esophageal tissue obtained from patients from a unique geographical and ethnic background. The cohort used in this study consisted of Coloured patients (n=2) treated at Tygerberg Hospital. The LightCycler system was implemented in order to try to accurately quantify TP53 mRNA levels. Unfortunately, the desired results were unattainable due to unforeseen difficulties encountered during the study. These difficulties included the insufficient preservation of samples for RNA based studies. Several recommendations were made concerning future similar studies, including an improved planning strategy as well as the employment of an RNA stabilizing agent. Additionally, a few important contributions were made through this study, including the design and optimization of TP53 primers specifically intended for future RNA studies. These primers would enable the identification of the presence of TP53 RNA species as well as the absence of DNA contamination in a single PCR amplification step. Other contributions include the development of a well-optimized RNA extraction method for the extraction of RNA from tough tissues (such as the human esophageal tissue used in this study). This method makes the extraction of large quantities of RNA from small amounts of tough tissue types possible. In conclusion, this study has made a significant contribution to the field of cancer research, by shedding light on the TP53 mutational spectrum with regards to laryngeal as well as esophageal cancer in a population unique to the Western Cape. The first part of this thesis has been published in Cancer Genetics and Cytogenetics (Barnard, D., K. Lehmann, E.G. Haal, P.O. van Heiden, and l.C. Victor. 2003. The spectrum of mutations in TP53 in laryngeal cancer patients from a high-incidence population shows similarities to many of the known mutational hotspots. Cancer Genetics and Cytogenetics 145:126-132), of which a copy can be found in Appendix I. This work has also been presented (by D. Barnard) at an international conference entitled "Cancer of the Esophagus and Gastric Cardia: From Gene to Cure", held in Amsterdam, the Netherlands during the period 13 - 15 December 2002. / AFRIKAANSE OPSOMMING: Die werk wat in hierdie tesis voorgelê word handel oor die assosiasie tussen kankers van die boonste gastrointestinale weg en die tumor suppressor geen, TP53, en kan in 3 dele gedeel word, (i) die analise van die mutasiespektrum van TP53 in laringiale kanker (LK), (ii) die analise van die mutasiespektrum van TP53 in slukderm kanker (SK) en (iii) die analise van die transkripsievlakke van TP53 in SK. Laringeal kanker (LK) is die 6de algemeenste kanker in die wêreld en die 2de algemeenste respiratoriese kanker, met "n benaderde 500 000 nuwe gevalle jaarliks wêreldwyd. Oor die afgelope paar jare het LK "n toenemende probleem geraak, veral in die Kleurling gemeenskap van die Wes Kaap. Die meganismes van die tumorvorming in LK is onbekend, alhoewel rook-en alkoholgebruik vername risiko faktore is. Die voorkoms van mutasies in TP53 is verskeie kere aangetoon in verskillende kanker tipes en daar word vermoed dat dit "n rol speel in tumorvorming. In hierdie studie is dus na mutasies in eksons 5 - 8 van TP53 gesoek in tumor biopsie weefsel (n=44) en bloed isolate (n=42) van Kleurling LK pasiënte d.m.v. polimerase ketting reaksie - enkelstring konformasie polimorfisme (PKR-ESKP) analisering en direkte volgorde bepaling. Bloed monsters van "n vergelykbare groep (n=40) is ook in die studie ingesluit as "n kontrole. Betekenisvolle positiewe korrelasies is gevind tussen die voorkoms van LK en ouderdom sowel as rook. Daarmee saam is daaglikse vleisinname as potensiële beskermende faktor gevind. In tumor biopsies is mutasies in 3 van die ondersoekte eksons gevind, wat 25% van die biopsie monsters verteenwoordig. Hierdie mutasies is uniek aan die tumor biopsie weefsels en dui op "n somatiese oorsprong van mutasies. Hierdie bevindinge bevestig dat die gedeelte tussen kodons 173 - 273 van TP53 "n hipermuteerbare gebied geassosieer met kankers is. Hierdie studie bevestig 6 nuwe mutasies. Daar is 'n hoë insidensie van slukderm kanker (SK) in Suid Afrika relatief tot die res van die wêreld. Hierdie soort kanker word veral gevind by die Swart populasie van die Transkei. Die doel van hierdie studie was om verskille tussen die TP53 mutasie patroon van die Kleurling gemeenskap van die Wes Kaap en die Swart gemeenskap van die Transkei te vergelyk. Hiervoor is die molekulêre struktuur van TP53, veral eksons 5 - 8, in 'n groep Kleurling SK pasiënte (n=42) wat behandel is by Tygerberg Hospitaal, Kaapstad, Suid Afrika, geanaliseer. Analisering is gedoen deur DNS van tumor, bloed en ook oënskynlike gesonde aangrensende weefsel van dieselfde pasiënte te onderwerp aan PKR-ESKP analise en direkte volgorde bepaling. Slegs 4 nukleotied veranderings is gevind in 124 volgorde bepalings, waarvan 2 nuwe veranderings is in SK. Hierdie 4 nukleotied veranderinge verteenwoordig 9% van al die tumors wat ondersoek is in die studie. Hierdie studie bewys dat die mutasiespektrum van TP53 in die Kleurling gemeenskap van die Wes Kaap grootliks verskil van die Swart gemeenskap van die Transkei. Dit impliseer dat verskillende etiologiese faktore moontlik 'n rol mag speel op die tumorvormingsproses in die 2 afsonderlike geografiese gemeenskappe. Hierdie is die onderwerp van 'n epidemiologiese studie wat deur die MNR onderneem word. Die laaste deel van hierdie tesis handel oor die kwantifisering en vergelyking van TP53 transkripsievlakke in SK tumor weefsel teenoor TP53 vlakke in gesonde slukderm weefsel van pasiënte in 'n unieke geografiese en etniese agtergrond. Die studie populasie in hierdie projek het bestaan uit Kleurling pasiënte (n=2) wat by Tygerberg hospitaal behandel is. Die "LightCycler" sisteem is gebruik vir die akkurate kwantifisering van TP53 boodskapper RNS vlakke. Ongelukkig is die verlangde resultate nie gekry nie as gevolg van onvoorsiene probleme wat ondervind is tydens die studie. Hierdie probleme sluit in die onvoldoende preserv RNS studies. Hierdie inleiers maak dit nou moontlik om die teenwoordigheid van TP53 RNS spesies sowel as die afwesigheid van DNS kontaminasie in een PKR amplifikasie stap te kan identifiseer. 'n Ander belangrike bydrae is die ontwikkeling van 'n goed geoptimaliseerde RNS ekstraksie metode vir moeilike starre weelfsel tipes (soos menslike slukderm weefsel in hierdie studie) en maak die ekstraksie van groot hoeveelhede RNS uit klein hoeveelhede van moeilik hanteerbare weefsel tipes moontlik. Om saam te vat, hierdie studie het betekenisvolle bydraes gemaak tot die veld van kankernavorsing deur die ontrafeling van die TP53 mutasiespektrum in beide laringeale sowel as slukderm kanker, in 'n populasie uniek aan die Wes Kaap. Die eerste deel van hierdie tesis is gepubliseer in Cancer Geneties and Cytogenetics (Barnard, D., K. Lehmann, E. G. Hoal, P. D. van Heiden, and T. C. Victor. 2003. The spectrum of mutations in TP53 in laryngeal cancer patients from a high-incidence population shows similarites to many of the known mutational hotspots. Cancer Genetics and Cytogenetics 145: 126-132) en 'n afskrif van die artikel is ingesluit in Appendix I. Hierdie werk is ook voorgedra (deur D. Barnard) by 'n internasionale kongres getiteld "Cancer of the Esophagus and Gastric Cardia: From Gene to Cure", wat in Amsterdam, Nederland gehou is gedurende 13 - 15 Desember 2002

A thesis submitted to the Faculty of Medicine, University of the Witwatersrand, for the degree of Doctor of Philosophy in Medicine. / Despite having been initially described more than fifty years ago, sclerotherapy of oesophageal varices has only relatively recently became regarded as one of the primary modalities both to control bleeding oesophageal varices and to prevent recurrent bleeding. Sclerotherapy, however, ts associated with numerous complications and its exact mechanism of action, particularly that pertaining to its effect on haemostasis, has to date been poorly documented. One of the problems of comparing the various trials has been the diversity of both the technique and the type and concentration of the sclerosants used. (Abbreviation abstract) / Andrew Chakane 2018

Os pacientes infectados pelo vírus da imunodeficiência humana (HIV) freqüentemente apresentam alterações digestivas, sendo o esôfago um alvo comum de lesões estruturais. A etiologia infecciosa é a mais freqüente neste grupo de pacientes. Múltiplos agentes já foram implicados como causadores de lesões esofágicas. As infecções virais são uma das principais causas de tais lesões, sendo os vírus mais implicados o citomegalovirus (CMV) e o vírus herpes simples (HSV). Muitas lesões ulceradas permanecem sem diagnóstico etiológico, mesmo após exaustiva investigação, sendo denominadas úlceras idiopáticas ou aftosas. Os métodos de diagnóstico usuais são demorados e pouco sensíveis. Assim, nosso estudo tem como principal objetivo estudar o papel do método da reação em cadeia da polimerase (PCR) no diagnóstico destas lesões. Durante o período de outubro de 1996 a outubro de 1997, foram estudados 79 pacientes HIV-positivos, que foram submetidos ao exame de endoscopia digestiva alta por indicação clínica. Estes foram submetidos a 89 exames endoscópicos, sendo colhidas 96 biópsias, as quais foram armazenadas em nitrogênio líquido (50) ou em freezer a –70oC (46). O DNA foi extraído usando método baseado na lise hipotônica, digestão com proteinase K, extração com fenol-clorofórmio e precipitação em etanol. Uma quantidade fixa foi usada para amplificação em ciclador térmico, utilizando primers específicos para CMV, Herpesvirus, HPV, HIV, Haemophilus ducreyi, Treponema pallidum e as micobactérias M. tuberculosis, M. avium e M. intracellulare. O produto final foi submetido a uma eletroforese em gel de agarose e corado com brometo de etídeo. A endoscopia não revelou alterações esofágicas em 26 exames (29,2%). As alterações observadas foram monilíase esofágica em 33 exames (37,1%), úlceras em 22 (24,7%); esofagite em 10 (11,2%) e áreas lugol-negativas em 9 (10,1%). A PCR resultou positiva para o CMV em 19 amostras (19,8%), para o Herpes em 4 (4,2%), para o HPV em 17 (17,7%), para o HIV em 37 (38,5%) e para o H. ducreyi em 3 (3,1%). Nenhuma amostra foi positiva para o T. pallidum e para micobactérias. No estudo de 29 amostras de 22 úlceras esofágicas a PCR detectou o CMV em 9 amostras (31%), o Herpes em 3 (10,3%), o HPV em 6 (20,7%), o HIV em 19 (65,5%) e o H. ducreyi em 2 (6,9%) e em 8 (36,4%) não foi detectado nenhum agente. O CMV foi detectado com freqüência nas úlceras esofágicas, sendo difícil diferenciar se havia infecção ativa ou latente. O HIV teve uma incidência elevada nas biópsias de úlceras, o que pode sugerir um possível papel etiológico deste agente em tais lesões. O HPV foi o terceiro agente mais freqüente, mas não foi possível caracterizá-lo como causador de lesões esofágica ulceradas. A PCR apresentou potencial para tornar-se um método útil na investigação das lesões esofágicas em pacientes infectados pelo HIV. / Patients infected by Human Immunodeficiency Virus (HIV) usually present digestive abnormalities and the esophagus is a common target of structural lesions. Infections are the most frequent cause of esophageal lesions in these patients. Several agents were already implied in this process. Viral infections are one of the main causes of such lesions and cytomegalovirus (CMV) and herpes simplex virus (HSV) were the most involved agents. Many ulcerated lesions persist without etiologic diagnosis even after exhaustive investigation, being denominated idiopathic or aphthous ulcers. The usual diagnostic methods are difficult and have low sensitivity. Thus, the main objective of our study was to evaluate the role of the polimerase chain reaction (PCR) method in the diagnosis of these lesions. During the period of October of 1996 to October of 1997, 79 HIV-positive patients were studied. They were submitted to upper digestive endoscopies, which were indicated on clinical basis. These patients were submitted to 89 upper digestive endoscopies, being obtained 96 biopsies, which were stored in liquid nitrogen or in a 70oC freezer. DNA was extracted using a method based on hypotonic lyses, proteinase K digestion, extraction with phenol-chloroform and precipitation in ethanol. A fixed amount was used for amplification in thermal cycler, using specific primers for CMV, herpesvirus, human papillomavirus (HPV), HIV, Haemophilus ducreyi, Treponema pallidum, Mycobacterium tuberculosis, Mycobacterium avium and Mycobacterium intracellulare. The final products were submitted to an electrophoresis in agarose gel and stained with ethidium bromide. The endoscopies did not reveal esophageal alterations in 26 exams(29,2%). The abnormalities observed were esophageal candidiasis in 33 exams (37,1%), ulcers in 22 (24,7%); esophagitis in 10 (11,2%) and lugol-negative areas in 9 (10,1%). The PCR was positive to CMV in 19 samples (19,8%), for Herpes in 4 (4,2%), for HPV in 17 (17,7%), for HIV in 37 (38,5%) and for the H. ducreyi in 3 (3,1%). No sample was positive for T. pallidum or micobacterium. In the study of the esophageal ulcers by PCR, CMV was detected in 9 samples (31%), Herpes in 3 (10,3%), HPV in 6 (20,7%), HIV in 19 (65,5%), H. ducreyi in 2 (6,9%) and any agent was detected in 8 samples (36,4%). CMV was frequently detected in esophageal ulcers, being difficult to differentiate between active and latent infections. The HIV had an elevated incidence in ulcer biopsies, which may suggest a possible etiologic role of this virus in such lesions. HPV was the third more frequent agent, but it was not possible to attribute the esophageal lesions to that virus. In conclusion, this study suggests that the PCR can be an useful method in the investigation of esophageal lesions in HIV infected patients.

Introdução: A diminuição do tônus basal e da extensão do esfíncter inferior do esôfago são considerados como principais mecanismos responsável pela ocorrência de refluxo gastroesofágico. Um adequado clareamento esofágico depende da presença de peristaltismo primário e secundário efetivos. Ainda há dúvidas se o achado de alterações do peristaltismo esofágico em pacientes com doença do refluxo gastroesofágico é uma anormalidade primária ou surge como consequência da agressão causada pelo refluxo. Objetivo: avaliar as alterações motoras esofágicas do esfíncter inferior do esôfago e do corpo esofágico em diferentes formas da doença do refluxo gastroesofágico. Métodos: foram selecionados 268 prontuários de pacientes encaminhados para avaliação motora do esôfago através de manometria como parte da investigação diagnóstica da doença do refluxo gastroesofágico e foram distribuídos em quatro grupos: SE: 33 pacientes sem esofagite ao estudo endoscópico; EE: 92 pacientes que apresentavam esofagite erosiva (classificação de Los Angeles); BC: 101 pacientes que apresentavam esôfago de Barrett curto (< 3 cm) e BL: 42 pacientes que apresentavam esôfago de Barrett longo (> 3 cm). Resultados: O grupo SE apresentou um tamanho médio do esfíncter inferior do esôfago maior quando comparado aos grupos EE, BC e BL, estes foram semelhantes quando comparados entre si. Considerando esfíncter curto quando seu tamanho total encontrava-se menor do que 2 cm, os grupos EE, BC e BL foram semelhantes quando comparados entre si. Quanto à média de pressão do esfíncter, observamos que o grupo SE apresentou valor médio maior em relação aos grupos EE, BC e BL, estes foram semelhantes quando comparados entre si. Observou-se que os grupos EE e BL foram semelhantes e apresentaram maior percentual de hipotonia acentuada do esfíncter inferior do esôfago quando comparados ao grupo BC. Os grupos EE, BC e BL apresentaram amplitude de contração no segmento distal, significativamente inferiores quando comparados ao grupo SE; os grupos BC e BL foram semelhantes quando comparados entre si. Os grupos EE, BC e BL foram semelhantes em relação ao percentual de hipocontratilidade acentuada do segmento distal do corpo esofágico. Em relação à motilidade esofágica, observou-se que não houve diferença entre os grupos EE, BC e BL, o grupo SE não apresentou esta alteração. Conclusões: Os doentes com sintomas típicos de refluxo gastroesofágico, mas sem esofagite ao estudo endoscópico, não apresentaram comprometimento da função motora esofágica. Aqueles com esofagite de refluxo e esôfago de Barrett curto tiveram comprometimento da função motora esofágica, intermediárias entre os pacientes sem esofagite e com esôfago de Barrett longo. As alterações mais intensas na motilidade esofágica e esfíncter inferior do esôfago foram mais observadas no grupo com esôfago de Barrett longo. Estes fatos indicam que as alterações motoras do esôfago surgem como conseqüência do comprometimento da mucosa esofágica por RGE. / Introduction: A more extensive damage to the system of refluxate contention and to the esophageal clearance are thought to be associated to the increased occurrence of esophageal inflammation. Objective: This study aimed to assess the esophageal motor alterations of the lower esophageal sphincter and esophageal body, in the various forms of gastro-esophageal reflux disease. Methods: two hundred and sixty eigth patients were selected and split into four groups: NE: 33 patients who had presented with typical complaints of gastroesophageal reflux, albeit with no esophagitis on endoscopy; EE: 92 patients who had erosive esophagitis (Los Angeles classification); SBE: 101 patients who had short Barretts esophagus (< 3 cm); and LBE: 42 patients who had long Barretts esophagus (> 3 cm). All the patients underwent esophageal manometry with an 8-channel computerized system and a low compliance pneumo-hydraulic perfusion pump. Results: The manometric evaluation of the esophagus detected that the mean lower esophageal sphincter length in group NE was longer in comparison with the other groups (EE, SBE and LBE), which were all similar among themselves. Taking lower esophageal sphincter to be shortened with a total length equal or shorter than 2 cm, the groups EE, SBE and LBE were similar when compared one to another. This abnormality was not detected in group NE. Lower esophageal sphincter pressure, as assessed by the mean respiratory pressure, showed the group NE the highest mean value, while no difference was found between groups EE, SBE and LBE. Percentages of patients showing marked lower esophageal sphincter hypotonia (<6 mmHg) showed the groups EE and LBE had higher percentages of hypotonia as compared with group SBE. Comparison between groups EE and LBE in this respect yielded no difference. As to the mean amplitude of contraction of the distal segment swallowing complex showed that the groups EE, SBE and LBE had significantly lower amplitudes when compared with group NE; groups SBE and LBE were similar. The percentage of marked hypocontractility of the distal segment of the esophageal body (< 30 mmHg) was similar among groups EE, SBE and LBE. In relation to the esophageal motility, no difference could be detected among groups EE, SBE and LBE. Conclusions: patients who had presented with typical complaints of gastroesophageal reflux disease, albeit with no esophagitis on endoscopy didnt have alterations of esophageal motor function. The groups who had erosive esophagitis and short Barretts esophagus had intermediary alterations of esophageal function; the group long Barretts esophagus showed lower mean value and higher percentage of marked hypotonia of LES and the highest percentage of marked hypocontractility and alteration in esophageal periltalsis. These findings sugest also that esophageal abnormalities are secondary to esophageal mucosa damage.

Submitted by Fabíola Silva (fabiola.silva@famerp.br) on 2016-09-27T15:41:08Z No. of bitstreams: 1 marcelomaiacaixetademelo_tese.pdf: 11249406 bytes, checksum: 55e0affbf2716e2a9db836ff23bb3bc8 (MD5) / Made available in DSpace on 2016-09-27T15:41:08Z (GMT). No. of bitstreams: 1 marcelomaiacaixetademelo_tese.pdf: 11249406 bytes, checksum: 55e0affbf2716e2a9db836ff23bb3bc8 (MD5) Previous issue date: 2014-06-27 / Introduction: Chagasic megaesophagus (ME) is associated with a higher occurrence of esophagus cancer, while adenomas and adenocarcinomas are rare in the Chagasic Megacolon (MC). Concentration alterations in some proteins may be associated either with esophagic and colorectal carcinogenesis or with chagasic megacolon and megaesophagus. Objective: Study the association between digestive Chagas disease and carcinogenesis, considering the influence of c-Myc, GBP-2, APC, IFN- and T.cruzi proteins. Material and Method: Blocks of paraffin wax containing fragments of mucous membrane early diagnosed as 1 – normal esophagus (n=16); 2 – chagasic megaesophagus (n=10); 3 – normal colon (n=10) and 4 – chagasic megacolon (n=10) were selected. These tissues were analysed by means of immunohistochemical technique using c-Myc, GBP-2, APC, IFN- and T.cruzi antibodies. Results: The result of the GBP-2 protein expression showed higher positivity in ME (100%) when compared to MC (40%) (p = 0.011). Comparing ME with normal esophagus there was significant difference (p = 0.001), having 100% of positivity for GBP-2 in megaesophagus and 31.3% in normal esophagus. In the analysis of the IFN- expression in MC and normal colon a higher positivity was observed in MC (90%) in relation to normal colon (30%) being the difference significant (p = 0.02). As for the expression of IFN- protein, a higher positivity was observed in MC (90%) in relation to ME (40%). Conclusions: A higher frequency of expression of GBP-2 protein in chagasic megaesophagus and IFN- in chagasic megacolon explains, respectively, the increase of espinocellular carcinoma incidence in patients with chagasic megaesophagus and the protector effect of the chagasic megacolon against the colorectal adenocarcinoma. / Introdução: Megaesôfago chagásico (ME) está associado a maior ocorrência do câncer de esôfago enquanto no megacólon chagásico (MC) adenomas e adenocarcinomas são raros. Alteração nas concentrações de algumas proteínas pode estar associada tanto à carcinogênese esofágica e colorretal como ao megacólon e megaesôfago chagásicos. Objetivo: estudar a associação entre forma digestiva da doença de Chagas e carcinogênese, considerando-se a influência das proteínas c-Myc, GBP-2, APC, IFN- e T. cruzi. Material e Método: Foram selecionados blocos de parafina contendo fragmentos de mucosa anteriormente diagnosticados como; (1) esôfago normal (n=16); (2) megaesôfago chagásico (n=10); (3) cólon normal (n=10) e (4) megacólon chagásico (n=10). Esses tecidos foram analisados por meio de técnica imunoistoquímica utilizando os anticorpos c-Myc, GBP-2, APC, IFN- e T. cruzi. Resultados: O resultado da expressão da proteína GBP-2 mostrou maior positividade no ME (100%) quando comparado com MC (40%) (P = 0,011). Comparando ME com esôfago normal houve diferença significativa (P = 0,001), tendo 100% de positividade para GBP-2 no megaesôfago e 31,3% no esôfago normal. Na análise da expressão do IFN- no MC e cólon normal verificou-se maior positividade no MC (90%) em relação ao cólon normal (30%), sendo a diferença significativa (P = 0,02). A expressão da proteína IFN- apresentou maior positividade no MC (90%) em relação ao ME (40%). Conclusões: A maior frequência de expressão das proteínas GBP-2 no megaesôfago chagásico e IFN- no megacólon chagásico explicam, respectivamente, o aumento da incidência de carcinoma espinocelular em portadores de megaesôfago chagásico e o efeito protetor do megacólon chagásico contra o adenocarcinoma colorretal.

As infecções virais são as maiores responsáveis pelas úlceras esofágicas no portador do HIV, sendo o Citomegalovírus (CMV) o agente mais observado, seguido pelo Herpes Vírus Simples (HSV). A abordagem clínica adequada e a utilização de métodos diagnósticos precisos são de grande relevância para o estabelecimento etiológico. Os objetivos deste trabalho foram: avaliar a prevalência de úlceras esofágicas em portadores do HIV; pesquisar os agentes etiológicos associados; verificar a acurácia dos métodos diagnósticos comparando as impressões obtidas pela endoscopia digestiva alta (EDA), histologia utilizando o método de Hematoxilina-Eosina (H&E) e Imuno-histoquímica (IH) para pesquisa de CMV e HSV; avaliar o impacto da coloração para fungos (Gomori metenamina prata- GMS) e bacilos álcool-ácidos resistentes [BAAR- Ziehl-Neelsen (ZN)] e a relevância numérica da amostragem tecidual na avaliação etiológica. Trata-se de um estudo descritivo, retrospectivo, do tipo transversal, baseado em levantamento de dados demográficos, clínico-laboratoriais, endoscópicos obtidos por revisão de prontuários e análise histológica às cegas de biópsias endoscópicas (H&E, IH, GMS e ZN) de úlceras esofágicas em 41 portadores do HIV, no período de agosto de 2002 a setembro de 2006. A IH foi considerada método padrão. No período avaliado, 399 portadores do HIV submeteram-se à EDA, detectando-se úlcera esofágica em 41 pacientes (23 homens, 25 a 56 anos) com uma prevalência de 10,27%. A mediana da contagem de CD4 foi 49 céls/mm3 e da carga viral 58869,5 cópias/ml. A EDA revelou 29/41úlceras esofágicas suspeitas de infecção pelo CMV; 7/41 pelo HSV; 2/41 relacionada ao refluxo gastroesofágico (DRGE); 1/41 por monilíase; 1/41 por paracoccidioidomicose (PCM) e 1/41 inespecífica. O H&E detectou: 25/41 úlceras com aspectos inflamatórios inespecíficos (61%); 6/41 associadas à monilíase (16%); 4/41 por infecção pelo CMV (10%); 2/41 HSV (5%); 1/41CMV e HSV (2%); 1/41 por PCM (2%); 1/41 devido a Histoplasmose (2%) e 1/41 infiltração neoplásica por Linfoma não Hodgkin (2%). A IH para CMV e HSV confirmou os achados do H&E e detectou mais um caso. A EDA revelou sensibilidade alta (100%) para a detecção da úlcera esofágica, especificidade baixa para a caracterização etiológica viral (15%) quando comparada ao H&E e a IH. O H&E mostrou-se um método adequado para avaliação etiológica com sensibilidade de 87% e especificidade de 100% quando comparada a IH. A pesquisa de BAAR pelo ZN foi negativa nas 34 amostras realizadas. O GMS confirmou a presença de fungos detectados ao H&E e foi fundamental na caracterização morfológica do Histoplasma capsulatum e do Paraccocidioides brasiliensis. O número de amostras não influenciou na avaliação etiológica final. Os nossos achados recomendam o H&E como método adequado na avaliação etiológica de úlceras esofágicas no portador do HIV e indicam a IH para pesquisa viral somente nos casos suspeitos, porém, não típicos ao H&E. / Viral infections are the main cause of esophageal ulcers in HIV carriers, cytomegalovirus (CMV) being the most frequently observed, followed by Herpes Simplex Virus (HSV). An appropriate clinical approach and the use of precise diagnostic methods are very important for etiological evaluation. The aim of this work has been: to evaluate the prevalence of esophageal ulcers in HIV carriers; to research the associated etiological agents; to check the accuracy of the diagnostic methods, comparing the impressions obtained by the upper gastrointestinal endoscopy (UGE), histology using the Hematoxiline-Eosin (H&E) method, and immunohistochemistry (IH) to investigate CMV and HSV; to evaluate the impact of the staining for fungus (Gomori methenamine silver GMS) and for resistant alcohol-acid bacillus (BAAR-Ziehl-Neelsen ZN), and the numerical relevance of tissue samples in the etiological characterization. This is a descriptive, retrospective, transversal study, based on demographic, clinic-laboratorial and endoscopic data, obtained by the review of medical charts and blind histological analysis of endoscopic biopsies (H&E, IH, GMS an ZN) of esophageal ulcers of 41 HIV carriers, from August 2002 to September 2006. The IH has been chosen as the standard method. Along the evaluated period, 399 HIV carriers were submitted to UGE, and esophageal ulcer was detected in 41 patients (25 to 56 years old, 23 males), with a prevalence of 10.27%. The median of the CD4 count was 49 cells/mm3, and the viral load 58869.5 copies/ml. UGE has revealed 29/41 esophageal ulcers under suspicion of infection by CMV; 7/41 by HSV; 2/41 related to gastroesophageal reflux (GER)/ 1/41 by moniliasis; 1/41 by paracoccidioidomycosis (PCM) and 1/41 non-specific. H&E has detected 25/41 ulcers with non-specific inflammatory aspects (61%); 6/41 associated with moniliasis (16%); 4/41 caused by CMV infection (10%); 2/41 by HSV (5%); 1/41 by CMV and HSV (2%); 1/41 by PCM (2%); 1/41 due to Hystoplasmosis (2%) and 1/41, to neoplastic infiltration by non-Hodgkin lymphoma (2%). IH for CMV and HSV has confirmed the H&E findings and has detected another case. UGE has revealed high sensitivity (100%) for the detection of esophageal ulcer and low specificity for the viral etiological characterization (15%), as compared to H&E and IH. H&E has shown to be an adequate method for the etiological evaluation, with 87% of sensitivity and 100% of specificity, as compared to IH. BAAR research by ZN was negative in the 34 samples studied. GMS has confirmed the presence of fungus detected by H&E and has been fundamental in the morphological characterization of Histoplasma capsulatum and Paraccocidioides brasiliensis. Our findings support the use of H&E as a suitable method for the etiological evaluation of esophageal ulcers in HIV carriers and indicate IH for viral search only in suspect cases that are non-typical under H&E.

Made available in DSpace on 2014-07-29T15:25:19Z (GMT). No. of bitstreams: 1 Tese Orlando M da Mota.pdf: 619245 bytes, checksum: 8c9d25ddb6ce5f94a96176a085b305f1 (MD5) Previous issue date: 2012-05-10 / Context and Objectives: This thesis was divided into two parts. In the first one risk factors for esophageal cancer were analyzed using data from a case and control study. In the second part the survival of the esophageal cancer patients from the first study was analyzed. The aim of this study was to evaluate the risk factors for esophageal cancer in an area where the incidence is low and survival of patients undergoing treatment in a low-volume hospital. Methods: This is a case-control study hospital based. The analysed variables were: sociodemographic data, habits, (tobacco and alcohol). The sample was analyzed using the chi-square test, Mann-Whitney test and Mantel-Haenszel approach for multivariate analysis. The strength of the risk was calculated using odds ratios (OR) with significance defined at 5% and 95% confidence intervals. Results: It was analysed 99 cases of esophageal cancer and 223 controls. The risk of esophageal cancer was higher in patients &#8805; 55 years (OR = 1.95; P= 0.01). Patients from rural areas had almost five times high risk in comparison with urban. (OR 4.9; P < 0.001). Smoking was a risk factor among cases (OR = 3.8; P < 0.001), exposure to smoke from wood stoves (OR = 4.42; P < 0.001) as well as frequent consumption of apples and pears OR 0,27 (CI95% 0,11 -0,70) and fish OR 0,23 (CI 0,07 0,75), were found as protective factors. We analysed the survival of 99 cases of the esophageal cancer. The average survival was 32.7% for the first year, 25,2% for the second year and 11,0% for the third year. Conclusion: In a region in which the incidence of esophageal cancer is low, the most significant risk factors were living rurally, smoking, exposure to a wood stove and dary products consumption. Survival in patients with esophageal cancer for the third year was 11%, the patients undergoing surgical treatment survival in the third were 19,6%. / Esta pesquisa dividiu-se, em duas partes. Na primeira, avaliou-se os fatores de risco para o câncer do esôfago através de um estudo caso-controle. Na seguinte, analisamos estadiamento e sobrevida dos pacientes portadores de câncer do esôfago selecionados para estudo de casos e controles. Pacientes e Métodos Foram recrutados 99 casos de câncer do esôfago e 223 controles hospitalares não portadores de câncer. Analisaram-se os dados sóciodemográficos, hábitos, estilo de vida e a sobrevida dos 99 pacientes tratados no Hospital Araújo Jorge (HAJ). Os casos e controles foram submetidos à análise estatística pelo teste do qui-quadrado, teste de Mann-Whitney e análise multivariada pelo método Mantel Haenszel. O risco foi calculado por meio da OR com nível de significância de 5% e intervalo de confiança de 95%. Resultados Os pacientes com Idade acima de 55 anos apresentaram maior risco OR 1,95 (IC 95% 1,18 - 3,20 p=0,01), pacientes oriundos de zona rural tiveram OR= 4,9 (IC 95% 2,9 - 8,2 p<0,001). O tabagismo foi fator de risco para os casos OR=3,8 (IC 95%1,9 - 7,8 p<0,001), a exposição à fumaça do fogão à lenha OR=4,42 (IC95% 2,34 - 8,03, p<0,001) também foi significante. Consumo de frutas ricas em vitaminas e minerais (maçãs e peras) OR 0,27 (IC95% 0,11 - 0,70); carne de peixes OR 0,23 (IC95% 0,07 - 0,75) foram fatores de proteção estatisticamente significantes. A análise de sobrevida global dos 99 casos de câncer do esôfago do primeiro ao terceiro ano foram: 32,7%, 25,2% e 11%, respectivamente. Conclusão: Em área de baixa incidência para o câncer do esôfago os fatores de risco mais importantes foram o tabagismo, a procedência rural, a exposição ao fogão à lenha e o consumo de laticínios. A sobrevida global dos pacientes com câncer do esôfago em 3 anos, submetidos a tratamento curativo e paliativo foi 11%, já a sobrevida dos submetidos a tratamento cirúrgico curativo 19,6%.

As infecções virais são as maiores responsáveis pelas úlceras esofágicas no portador do HIV, sendo o Citomegalovírus (CMV) o agente mais observado, seguido pelo Herpes Vírus Simples (HSV). A abordagem clínica adequada e a utilização de métodos diagnósticos precisos são de grande relevância para o estabelecimento etiológico. Os objetivos deste trabalho foram: avaliar a prevalência de úlceras esofágicas em portadores do HIV; pesquisar os agentes etiológicos associados; verificar a acurácia dos métodos diagnósticos comparando as impressões obtidas pela endoscopia digestiva alta (EDA), histologia utilizando o método de Hematoxilina-Eosina (H&E) e Imuno-histoquímica (IH) para pesquisa de CMV e HSV; avaliar o impacto da coloração para fungos (Gomori metenamina prata- GMS) e bacilos álcool-ácidos resistentes [BAAR- Ziehl-Neelsen (ZN)] e a relevância numérica da amostragem tecidual na avaliação etiológica. Trata-se de um estudo descritivo, retrospectivo, do tipo transversal, baseado em levantamento de dados demográficos, clínico-laboratoriais, endoscópicos obtidos por revisão de prontuários e análise histológica às cegas de biópsias endoscópicas (H&E, IH, GMS e ZN) de úlceras esofágicas em 41 portadores do HIV, no período de agosto de 2002 a setembro de 2006. A IH foi considerada método padrão. No período avaliado, 399 portadores do HIV submeteram-se à EDA, detectando-se úlcera esofágica em 41 pacientes (23 homens, 25 a 56 anos) com uma prevalência de 10,27%. A mediana da contagem de CD4 foi 49 céls/mm3 e da carga viral 58869,5 cópias/ml. A EDA revelou 29/41úlceras esofágicas suspeitas de infecção pelo CMV; 7/41 pelo HSV; 2/41 relacionada ao refluxo gastroesofágico (DRGE); 1/41 por monilíase; 1/41 por paracoccidioidomicose (PCM) e 1/41 inespecífica. O H&E detectou: 25/41 úlceras com aspectos inflamatórios inespecíficos (61%); 6/41 associadas à monilíase (16%); 4/41 por infecção pelo CMV (10%); 2/41 HSV (5%); 1/41CMV e HSV (2%); 1/41 por PCM (2%); 1/41 devido a Histoplasmose (2%) e 1/41 infiltração neoplásica por Linfoma não Hodgkin (2%). A IH para CMV e HSV confirmou os achados do H&E e detectou mais um caso. A EDA revelou sensibilidade alta (100%) para a detecção da úlcera esofágica, especificidade baixa para a caracterização etiológica viral (15%) quando comparada ao H&E e a IH. O H&E mostrou-se um método adequado para avaliação etiológica com sensibilidade de 87% e especificidade de 100% quando comparada a IH. A pesquisa de BAAR pelo ZN foi negativa nas 34 amostras realizadas. O GMS confirmou a presença de fungos detectados ao H&E e foi fundamental na caracterização morfológica do Histoplasma capsulatum e do Paraccocidioides brasiliensis. O número de amostras não influenciou na avaliação etiológica final. Os nossos achados recomendam o H&E como método adequado na avaliação etiológica de úlceras esofágicas no portador do HIV e indicam a IH para pesquisa viral somente nos casos suspeitos, porém, não típicos ao H&E. / Viral infections are the main cause of esophageal ulcers in HIV carriers, cytomegalovirus (CMV) being the most frequently observed, followed by Herpes Simplex Virus (HSV). An appropriate clinical approach and the use of precise diagnostic methods are very important for etiological evaluation. The aim of this work has been: to evaluate the prevalence of esophageal ulcers in HIV carriers; to research the associated etiological agents; to check the accuracy of the diagnostic methods, comparing the impressions obtained by the upper gastrointestinal endoscopy (UGE), histology using the Hematoxiline-Eosin (H&E) method, and immunohistochemistry (IH) to investigate CMV and HSV; to evaluate the impact of the staining for fungus (Gomori methenamine silver GMS) and for resistant alcohol-acid bacillus (BAAR-Ziehl-Neelsen ZN), and the numerical relevance of tissue samples in the etiological characterization. This is a descriptive, retrospective, transversal study, based on demographic, clinic-laboratorial and endoscopic data, obtained by the review of medical charts and blind histological analysis of endoscopic biopsies (H&E, IH, GMS an ZN) of esophageal ulcers of 41 HIV carriers, from August 2002 to September 2006. The IH has been chosen as the standard method. Along the evaluated period, 399 HIV carriers were submitted to UGE, and esophageal ulcer was detected in 41 patients (25 to 56 years old, 23 males), with a prevalence of 10.27%. The median of the CD4 count was 49 cells/mm3, and the viral load 58869.5 copies/ml. UGE has revealed 29/41 esophageal ulcers under suspicion of infection by CMV; 7/41 by HSV; 2/41 related to gastroesophageal reflux (GER)/ 1/41 by moniliasis; 1/41 by paracoccidioidomycosis (PCM) and 1/41 non-specific. H&E has detected 25/41 ulcers with non-specific inflammatory aspects (61%); 6/41 associated with moniliasis (16%); 4/41 caused by CMV infection (10%); 2/41 by HSV (5%); 1/41 by CMV and HSV (2%); 1/41 by PCM (2%); 1/41 due to Hystoplasmosis (2%) and 1/41, to neoplastic infiltration by non-Hodgkin lymphoma (2%). IH for CMV and HSV has confirmed the H&E findings and has detected another case. UGE has revealed high sensitivity (100%) for the detection of esophageal ulcer and low specificity for the viral etiological characterization (15%), as compared to H&E and IH. H&E has shown to be an adequate method for the etiological evaluation, with 87% of sensitivity and 100% of specificity, as compared to IH. BAAR research by ZN was negative in the 34 samples studied. GMS has confirmed the presence of fungus detected by H&E and has been fundamental in the morphological characterization of Histoplasma capsulatum and Paraccocidioides brasiliensis. Our findings support the use of H&E as a suitable method for the etiological evaluation of esophageal ulcers in HIV carriers and indicate IH for viral search only in suspect cases that are non-typical under H&E.