Orientador: Claudio Saddy Rodrigues Coy / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-12T21:58:54Z (GMT). No. of bitstreams: 1 Benetti_ThaisHelena_M.pdf: 1496239 bytes, checksum: ee10ab6259350492bbd669cdbb4a05b8 (MD5) Previous issue date: 2009 / Resumo: A constipação intestinal é um sintoma comum na população, sendo mais frequente em mulheres, podendo ser secundária a erro alimentar, distúrbios orgânicos ou funcionais. Dentre estes, destaca-se a discinesia do assoalho pélvico, caracterizada basicamente por ausência de relaxamento ou contração paradoxal da musculatura pélvica e do canal anal no momento da evacuação. O objetivo deste estudo foi analisar através de dados manométricos a variação da pressão anal de repouso durante o esforço de evacuação com a manobra de Valsalva e com apnéia pós-expiração forçada em portadores de constipação secundária à discinesia do assoalho pélvico. Foram estudados 21 pacientes, com idade média de 47,5 (23-72) anos, sendo 19 (90,4%) do sexo feminino. O diagnóstico foi realizado através de manometria anorretal com cateter de oito canais dispostos no eixo axial, realizando-se as medidas na porção proximal (1) e distal (2) do canal anal. Para o diagnóstico de discinesia do assoalho pélvico considerou-se a elevação dos valores pressóricos em relação ao repouso com esforço de evacuação. Para a avaliação clínica da constipação empregou-se o escore de Agachan. As variáveis estudadas foram: pressão anal média do canal anal por vinte segundos em repouso (R), ao esforço de evacuação com manobra de Valsalva (V) e ao esforço de evacuação em apnéia após expiração forçada (A), assim como a área sob a curva do traçado manométrico nos momentos V e A. A análise dos valores médios da variação da pressão anal de repouso evidenciou diferença entre os canais proximais e distais (p= 0,007), independente do momento, e tendência à diferença nos momentos V e A (p= 0,06). A média dos valores da área sob a curva do traçado manométrico demonstrou diferença entre os momentos V e A (p= 0,0008), tanto na porção proximal como na porção distal do canal anal. Pode-se concluir que o esforço de evacuação associado à apnéia pós-expiração quando comparada ao esforço de evacuação associado à manobra de Valsalva, proporciona menor contração do canal anal pela análise do parâmetro área sob a curva / Abstract: Intestinal constipation - a common symptom in the general population -, is more frequent in women. It may be secondary to improper diet or organic or functional disturbances, such as dyskinesia of the pelvic floor. This is basically characterized by the absence of relaxation or paradoxical contraction of the pelvic floor and the anal sphincter during evacuation. The aim of this study was to analyze, by manometric data, the anal pressure variation at rest, during evacuation effort by using the Valsalva maneuver and forced postexpiratory apnea in subjects with secondary constipation due to dyskinesia of the pelvic floor. Twenty-one patients (19 females - 90.4%) with mean age of 47.5 years old (23-72) were studied. The diagnosis was performed using anorectal manometry, with a catheter containing eight channels disposed at the axial axis, measuring the proximal (1) and distal (2) portions of the anal orifice. In order to diagnose dyskinesia of the pelvic floor, it was considered the elevation of the pressure values in relation to the resting with the evacuation effort. The Agachan score was used for clinical evaluation of the constipation. The variables studied were: mean anal pressure of the anal orifice for twenty seconds at rest (R) to the effort of evacuation using Valsalva (V) maneuver and to the evacuation effort during apnea after forced expiration (A), as well as the area under the curve of the manometric tracing at the moments V and A. The analysis of the mean values of the anal pressure variation at rest evidenced difference between proximal and distal channels (p= 0.007), independent of the moment and tendency to difference at the moments V and A (p= 0.06). The mean of values of the area under the manometric tracing curve showed difference between the moments V and A (p= 0.0008), either at the proximal portion or at the distal portion of the anal orifice. The conclusion is that the evacuation effort associated with postexpiratory apnea, when compared with the evacuation effort associated with the Valsalva maneuver, provides lower elevation of the anal pressure at rest by the parameter area under curve / Mestrado / Pesquisa Experimental / Mestre em Cirurgia

Orientador: Claudio Saddy Rodrigues Coy / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-15T06:38:30Z (GMT). No. of bitstreams: 1 Yamamoto_LucyJunka_M.pdf: 1210901 bytes, checksum: f8b8277ea067650320a38afa55786f8a (MD5) Previous issue date: 2010 / Resumo: Constipação é um sintoma com conceito amplo. Pode ser primária, em que a causa definida não é encontrada, ou ainda, ser secundária, quando causas específicas são reconhecidas. A constipação primária é um termo coletivo que envolve diferentes desordens funcionais. Dentre estas, a discinesia do assoalho pélvico é caracterizada pela inabilidade de esvaziar o reto durante o esforço de evacuação na ausência de obstrução mecânica. Para melhor diagnóstico, investigação mais específica, principalmente às relacionadas à fisiologia anorretal são necessárias, como a manometria anorretal. O objetivo deste estudo foi a caracterização manométrica de portadores de constipação com e sem elevação dos valores de pressão ao esforço de evacuação. Trinta pacientes com queixa de constipação, com escore de Agachan mínimo 10, foram submetidos à manometria norretal com cateter de oito canais dispostos no eixo axial. Do total, 28 eram do sexo feminino (90%) com média de idade de 51,5 anos (dp = 12,4). Os pacientes foram divididos em dois grupos, sendo incluídos no G1 os que apresentaram manutenção da elevação da pressão anal ao esforço de evacuação e no G2 os que evidenciaram diminuição destes valores. Para o diagnóstico de discinesia do assoalho pélvico considerou-se a elevação da pressão durante o esforço de evacuação. As variáveis estudadas foram pressão anal em repouso, de contração voluntária e ao esforço de evacuação. A análise dos dados deste estudo, possibilitou identificar com intervalo de confiança de 95% que a diferença de pressão maior que 16,5 mmHg entre as pressões médias de repouso e de evacuação, e a diferença percentual maior que 79,2% na pressão média, e diferença de pressão maior que 16,2 mmHg na pressão máxima, entre o repouso e esforço de evacuação, e a diferença percentual maior que 57,4% na pressão máxima podem identificar portadores de constipação secundária à discinesia do assoalho pélvico / Abstract: Constipation is a symptom with many causes. It can be classified as primary when its cause is unknown or secondary when a specific cause can be pointed out. Primary constipation is a collective term that adds together different disorders. From those, the pelvic floor dyssynergia is characterized by the inability to empty the rectum after straining in the absence of mechanic obstruction. To provide a better diagnosis, specific exams, including anorectal physiology tests are necessary. Anorectal manometry can be taken as an example of those exams. The aim of this study was to describe manometric parameters found in patients with constipation with or without increase in anal pressures during straining. Thirty patients with constipation and Agachan score of at least 10 were evaluated using anorectal manometry (a probe with eight axially oriented channels was employed). They were 28 females (90%), with a mean age of 51,5 (+ 12,4) years. Patients were divided accorded with manometric findings into: Group 1 (G1) which included those that showed sustained increase in anal pressures during straining and Group 2 (G2) which included the patients who presented a decrease in those values. Diagnosis of pelvic floor dyssynergia was made when a increase in anal pressures during straining was found. Resting pressure, maximum squeeze pressure and maximal evacuation effort pressure were evaluated. Data analysis shows with confidence interval of 95% that a difference larger than 16,5 mmHg between median resting and evacuation effort pressure or a percentual difference higher than 79,2% in median pressures and the difference larger than 16,2 mmHg in maximal pressures between rest and straining and the percentual difference higher than 57,4% can identify patients with pelvic floor dyssynergia constipation / Mestrado / Cirurgia / Mestre em Cirurgia

Background: Non-obstructive Dysphagia (NOD) is one of the most common symptoms evaluated using esophageal manometry. Although manometry is considered the gold standard, many NOD patients have normal evaluations. Esophageal function testing with combined multichannel intraluminal impedance and esophageal manometry (MII-EM) is performed using ten 5-mL swallows of a liquid and a viscous material and provides supplemental information about bolus transit. The aim of this study was to evaluate esophageal function using combined MII-EM in patients with NOD who had normal evaluations with liquid manometry. Methods: Multichannel intraluminal impedance and esophageal manometry was performed in consecutive patients presenting for evaluation of NOD. Patients were excluded if any abnormality was detected during liquid manometry. Viscous manometry and liquid and viscous impedance data were analyzed to detect manometric or bolus transit abnormalities. Patients referred for GERD evaluation without any swallowing complaints were used as patient controls and were subject to the same exclusion criteria as the NOD group. All swallow evaluations were performed with 10 liquid and 10 viscous swallows. Key Results: Data from 240 patients were evaluated, 129 with NOD and 111 patient controls. In the NOD group, 9% (12/129) had abnormal liquid impedance and 29% (37/129) had abnormal viscous impedance. In the control group, 4% (4/111) had abnormal liquid impedance and 16% (18/111) had abnormal viscous impedance. Chi-square analysis showed a significant difference between the two study groups for viscous impedance (P = 0.02) but not for liquid impedance (P = 0.12). Conclusions and Inferences: Our data support our belief that a normal liquid manometry with an abnormal viscous impedance analysis in a patient with NOD indicates abnormal esophageal motility. Therefore, viscous impedance should be performed on all patients during the evaluation of NOD.

Background: Non-obstructive Dysphagia (NOD) is one of the most common symptoms evaluated using esophageal manometry. Although manometry is considered the gold standard, many NOD patients have normal evaluations. Esophageal function testing with combined multichannel intraluminal impedance and esophageal manometry (MII-EM) is performed using ten 5-mL swallows of a liquid and a viscous material and provides supplemental information about bolus transit. The aim of this study was to evaluate esophageal function using combined MII-EM in patients with NOD who had normal evaluations with liquid manometry. Methods: Multichannel intraluminal impedance and esophageal manometry was performed in consecutive patients presenting for evaluation of NOD. Patients were excluded if any abnormality was detected during liquid manometry. Viscous manometry and liquid and viscous impedance data were analyzed to detect manometric or bolus transit abnormalities. Patients referred for GERD evaluation without any swallowing complaints were used as patient controls and were subject to the same exclusion criteria as the NOD group. All swallow evaluations were performed with 10 liquid and 10 viscous swallows. Key Results: Data from 240 patients were evaluated, 129 with NOD and 111 patient controls. In the NOD group, 9% (12/129) had abnormal liquid impedance and 29% (37/129) had abnormal viscous impedance. In the control group, 4% (4/111) had abnormal liquid impedance and 16% (18/111) had abnormal viscous impedance. Chi-square analysis showed a significant difference between the two study groups for viscous impedance (P = 0.02) but not for liquid impedance (P = 0.12). Conclusions and Inferences: Our data support our belief that a normal liquid manometry with an abnormal viscous impedance analysis in a patient with NOD indicates abnormal esophageal motility. Therefore, viscous impedance should be performed on all patients during the evaluation of NOD.

Faecal incontinence (FI) is a prevalent complaint in Western populations and causes significant disability. Impaired motor function of the anal canal is a common pathophysiological feature and assessment of sphincteric function with manometry is a routine part of symptom assessment. High-resolution anorectal manometry (HRAM) may provide a more detailed understanding of anorectal function, however its clinical utility has not been established. Aims The principal aims of this thesis were to: (1) Explore existing practices of anorectal manometry (2) Examine current evidence supporting the use of HRAM (3) Develop and validate a protocol for the performance of HRAM (4) Define normal values for traditional measures of sphincteric function using HRAM (5) Develop and validate novel measures of sphincteric function, and explore whether they improve diagnostic accuracy in patients with FI (6) Examine anorectal function over a prolonged period with HRAM to evaluate the phenomenon of anal sampling (referred to in this thesis as transient anal sphincter relaxations [TASRs]) Methods The following methods were used: (1) A worldwide survey of current practices of anorectal manometry (2) A systemic review of the literature (3) Prospective studies (both standard and prolonged) of anal function in healthy volunteers and patients with FI Results The practice of anorectal manometry is markedly variable internationally with no two centres surveyed employing the same methods. Within the 62 centres surveyed, there were 16 combinations of ways in which squeeze data were reported. A review of the literature demonstrated a growing evidence base for the use of HRAM however there is a paucity of data that confirm added benefits of HRAM over conventional manometry. A standardized protocol for HRAM was developed to allow the reporting of traditional measures of anorectal function. Novel measures derived from HRAM were developed which demonstrate increased sensitivity for the detection of impaired sphincteric control in patients with FI (sensitivity of traditional measure [conventional squeeze increment] 36% vs. 59% for the novel HRAM measure [5-second squeeze profile]). Transient anal sphincter relaxations (TASRs) were characterized using HRAM. In health, TASRs are often perceived by the individual as the urge to pass wind (39% of events) and their frequency increases following meal consumption. Conversely in FI, TASRs are a rare occurrence and are generally not perceived (only one patient (1/10 [10%]) with FI reported GI sensations associated with TASR events). Conclusions Anorectal manometry is in need of standardization. Novel measures derived from HRAM may improve diagnostic utility and further exploration of TASR characteristics might give insight into the pathophysiology of FI.

Made available in DSpace on 2014-06-11T19:30:23Z (GMT). No. of bitstreams: 0 Previous issue date: 2010-02-23Bitstream added on 2014-06-13T19:39:57Z : No. of bitstreams: 1 takegawa_bk_dr_botfm.pdf: 2505732 bytes, checksum: caff44b11cfdc05e43c5608674bbc096 (MD5) / O abaixamento endoanal do cólon (AEC) introduzido em 1998 por De la Torre & Ortega tem tornado obsoleta as cirurgias realizadas em dois ou mais tempos, na correção da moléstia de Hirschsprung (MD). Esta técnica é preconizada principalmente em recém-nascido e lactente. O objetivo deste trabalho é descrever nossa casuística demonstrando os aspectos clínicos, cirúrgicos, complicações, seguimento e medida manométrica do canal anorretal no pré e pósoperatório. Foi um estudo retrospectivo de 6 anos (2001 a 2007) onde foram estudadas 36 crianças com MD operados pela AEC. Os dados clínicos, cirúrgicos e seguimento ambulatorial foram coletados dos prontuários médicos. Foram 36 crianças (26 meninos e 10 meninas). A mediana da idade por ocasião do diagnóstico foi de 36 dias (1 a 2507 dias). Enema opaco revelou zona de transição em 32 pacientes. A manometria demonstrou ausência de reflexo retoesfincteriano em 35 pacientes. A biópsia retal por sucção em 16 pacientes, coradas com acetilcolinesterase confirmou a doença em 12 e em 4 mostrou padrão equívoco. No pré-operatório a média de pressão de repouso foi de 72,8 ± 26,3 mmHg sem diferença estatística com grupo controle (74,5 ± 25,2 mmHg). Na manometria pós-operatória a média foi de 69,7 ± 24,6 mmHg, sem diferença estatística, quando comparada com o pré-operatório. A mediana de idade na cirurgia foi de 154 dias (3 a 2.855 dias). O tempo médio de cirurgia foi de 200,1 minutos (55 a 310 minutos). A média de comprimento ressecado foi de 28,4 cm (11 a 48 cm). Houve 2 pacientes com necessidade de conversão para laparotomia. O tempo médio de internação foi de 6,6 ± 2,1 dias (2 a 48 dias). Evacuação entre as primeiras 48 horas ocorreu em 35 pacientes. Introdução da dieta nas primeiras 48 horas de pós-operatório foi em 35 pacientes. Realizou-se a dilatação anal em 14 pacientes por estenose anal... / The endoanal colon pull-through (ECP) procedure introduced by De la Torre & Ortega in 1998 has caused surgeries performed at two or more times to become obsolete for Hirschsprung’s Disease (HD) correction. This technique is mainly recommended for newborns and infants. The present study aimed at describing our patients, showing clinical and surgical aspects, complications, follow-up and the manometric measurement of the anorectal canal in the pre- and postoperative periods. It was a 6-year retrospective study (2001 a 2007) in which 36 children (26 boys and 10 girls) with HD operated by ECP were evaluated. The clinical, surgical and outpatient follow-up data were collected from the children’s medical charts. Their age median on the occasion of diagnosis was of 36 days (1 to 2,507 days). Opaque enema showed a transition zone in 32 patients, and manometry revealed the absence of rectosphincteric reflex in 35 patients. Suction rectal biopsy in 16 patients, as stained by acethylcolinesterase, confirmed the disease in 12 and showed an equivocal standard in 4 patients. In the preoperative period, the at rest pressure mean was of 72.8 ± 26.3 mmHg without a statistical difference in relation to the control group (74.5 ± 25.2 mmHg). In postoperative manometry, the mean was of 69.7 ± 24.6 mmHg, without statistical difference as compared to that of the preoperative period. The age median at the time of surgery was of 154 days (3 to 2.855 days). The mean surgery duration was of 200.1 minutes (55 to 310 minutes). The mean resected length was of 28.4 cm (11 to 48 cm). Two patients needed to be converted to laparotomy. The mean hospitalization period was of 6.6 ± 2.1 days (2 to 48 days). Bowel voiding in the first 48 hours occurred in 35 patients. Diet introduction in the first postoperative hours occurred in patients. Anal dilation was performed by anal stenosis in 14 patients... (Complete abstract click electronic access below)

Chest pain is one of the most common symptoms responsible for emergency department and primary care office visits in the United States. Chest pain can be noncardiac and may be attributed to multiple causes. Esophageal disorders including reflux, motility and functional conditions, affect a large proportion of patients with NCCP and lead to significant morbidity. The use of HRM has changed the diagnostic approach to esophageal motility disorders. It is the most specific and sensitive test for diagnosing motor disorders and a promising procedure in detecting dysmotility disorders in patients with NCCP. Despite the increased sensitivity of HRM, the main indications for esophageal manometry exclude NCCP. This study assessed the percentage of undiagnosed esophageal motility disorders in patients with NCCP referred for high resolution manometry. Differences in HRM findings in patients with NCCP versus patients meeting AGA recommendations for the clinical use of esophageal manometry were also compared. A retrospective descriptive design was utilized. Two hundred-nineteen patient charts were reviewed. One hundred sixty-eight (77%) patients underwent HRM and met AGA recommendations for esophageal manometry; 51 (23%) patients underwent the procedure after receiving a NCCP diagnosis. Findings showed that 116 (69%) patients in the AGA group had abnormal findings while 52 (31%) did not. In the NCCP group 34 (67%) had abnormal findings compared to 17 (33%) who did not. To compare normal and abnormal HRM findings in patients with NCCP versus those meeting AGA criteria, Chi-Square analysis was performed between the groups. The results were not statistically significant (p = 0.10). iv There were no significant differences in the results of HRM in both groups indicating the findings on HRM are the same despite the indication for the procedure. The findings support the use of HRM as a diagnostic tool in patients with chest pain after cardiac workup and endoscopic evaluation. This indicates a possible need to update the AGA indications for esophageal manometry and increase the awareness among healthcare providers regarding the use of HRM in patients with chest pain. Implication for future research is also discussed.

Pressure within the esophagus arises from two mechanisms: intrabolus pressure, which is a hydrodynamic phenomenon, and esophageal occlusion pressure, which is a contact phenomenon. Current esophageal manometers are sensitive to both hydrodynamic and contact pressures and cannot distinguish between the two measurements in the absence of other information. It has been shown that measurement of intrabolus pressure is a clinically relevant parameter in esophageal manometry. There is no single device available that can obtain this measurement directly. This work presents a novel fibre optic-based flexible catheter for high resolution manometry with sensing pods that can be selectively sensitized to either hydrodynamic pressure alone, or contact and hydrodynamic pressure, offering sensing schemes not possible with existing high resolution manometers. The catheter is designed to be used with a time division multiplexing interrogation technique, yielding a system capable of exceeding the 36-sensor count limit of current solid state manometers. The device consists of rigid sensing pods connected by flexible tubing with in-fiber Bragg gratings acting as sensing elements within each of the pods. Absent in each sensing pod are rigid anchor points, representing a novel departure from comparable designs and resulting in increased sensitivity and decoupling from axial loading. Device functionality is demonstrated through bench top trials. A pressure sensitivity of 1.8 pm/mmHg and axial sensitivity of 11 mmHg/N of applied load is demonstrated. Crosstalk between individual sensors is characterized and a compensation scheme is developed and validated. Temperature response is demonstrated to be linear such that its confounding can be corrected for procedurally. Sensing schemes afforded by this design may yield clinically relevant parameters not achievable by any single existing device. / Graduate

Thesis (Ph. D.)--University of Wisconsin--Madison, 1952. / Typescript. Vita. eContent provider-neutral record in process. Description based on print version record. Includes bibliographical references (leaves 74-78).

Orientador: Maria Aparecida Coelho de Arruda Henry / Banca: Renê Ganberini Prado / Banca: Alexandre Bakonyi Neto / Banca: Antonio Gonçalves Oliveira Filho / Banca: Flávio de Oliveira Pileggi / Resumo: O abaixamento endoanal do cólon (AEC) introduzido em 1998 por De la Torre & Ortega tem tornado obsoleta as cirurgias realizadas em dois ou mais tempos, na correção da moléstia de Hirschsprung (MD). Esta técnica é preconizada principalmente em recém-nascido e lactente. O objetivo deste trabalho é descrever nossa casuística demonstrando os aspectos clínicos, cirúrgicos, complicações, seguimento e medida manométrica do canal anorretal no pré e pósoperatório. Foi um estudo retrospectivo de 6 anos (2001 a 2007) onde foram estudadas 36 crianças com MD operados pela AEC. Os dados clínicos, cirúrgicos e seguimento ambulatorial foram coletados dos prontuários médicos. Foram 36 crianças (26 meninos e 10 meninas). A mediana da idade por ocasião do diagnóstico foi de 36 dias (1 a 2507 dias). Enema opaco revelou zona de transição em 32 pacientes. A manometria demonstrou ausência de reflexo retoesfincteriano em 35 pacientes. A biópsia retal por sucção em 16 pacientes, coradas com acetilcolinesterase confirmou a doença em 12 e em 4 mostrou padrão equívoco. No pré-operatório a média de pressão de repouso foi de 72,8 ± 26,3 mmHg sem diferença estatística com grupo controle (74,5 ± 25,2 mmHg). Na manometria pós-operatória a média foi de 69,7 ± 24,6 mmHg, sem diferença estatística, quando comparada com o pré-operatório. A mediana de idade na cirurgia foi de 154 dias (3 a 2.855 dias). O tempo médio de cirurgia foi de 200,1 minutos (55 a 310 minutos). A média de comprimento ressecado foi de 28,4 cm (11 a 48 cm). Houve 2 pacientes com necessidade de conversão para laparotomia. O tempo médio de internação foi de 6,6 ± 2,1 dias (2 a 48 dias). Evacuação entre as primeiras 48 horas ocorreu em 35 pacientes. Introdução da dieta nas primeiras 48 horas de pós-operatório foi em 35 pacientes. Realizou-se a dilatação anal em 14 pacientes por estenose anal... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: The endoanal colon pull-through (ECP) procedure introduced by De la Torre & Ortega in 1998 has caused surgeries performed at two or more times to become obsolete for Hirschsprung's Disease (HD) correction. This technique is mainly recommended for newborns and infants. The present study aimed at describing our patients, showing clinical and surgical aspects, complications, follow-up and the manometric measurement of the anorectal canal in the pre- and postoperative periods. It was a 6-year retrospective study (2001 a 2007) in which 36 children (26 boys and 10 girls) with HD operated by ECP were evaluated. The clinical, surgical and outpatient follow-up data were collected from the children's medical charts. Their age median on the occasion of diagnosis was of 36 days (1 to 2,507 days). Opaque enema showed a transition zone in 32 patients, and manometry revealed the absence of rectosphincteric reflex in 35 patients. Suction rectal biopsy in 16 patients, as stained by acethylcolinesterase, confirmed the disease in 12 and showed an equivocal standard in 4 patients. In the preoperative period, the at rest pressure mean was of 72.8 ± 26.3 mmHg without a statistical difference in relation to the control group (74.5 ± 25.2 mmHg). In postoperative manometry, the mean was of 69.7 ± 24.6 mmHg, without statistical difference as compared to that of the preoperative period. The age median at the time of surgery was of 154 days (3 to 2.855 days). The mean surgery duration was of 200.1 minutes (55 to 310 minutes). The mean resected length was of 28.4 cm (11 to 48 cm). Two patients needed to be converted to laparotomy. The mean hospitalization period was of 6.6 ± 2.1 days (2 to 48 days). Bowel voiding in the first 48 hours occurred in 35 patients. Diet introduction in the first postoperative hours occurred in patients. Anal dilation was performed by anal stenosis in 14 patients... (Complete abstract click electronic access below) / Doutor