Significado do uso da prótese peniana de silicone no seguimento da braquiterapia pélvica / Significado do uso da prótese peniana de silicone no seguimento da braquiterapia pélvica / Meaning of the use of silicone penile prosthesis in the follow-up of pelvic brachytherapy

Objetivo: descrever o significado do uso da prótese peniana de silicone para dilatação vaginal no seguimento da braquiterapia em mulheres com câncer ginecológico. Método: pesquisa narrativa, realizada no Centro de Pesquisas Oncológicas, Brasil, com 34 mulheres, após braquiterapia pélvica, em seguimento no serviço de fisioterapia. Coleta de dados por entrevistas semiestruturadas, incluindo dados sociodemográficos, clínicos e o significado do uso da prótese peniana na dilatação vaginal, submetidas à análise de conteúdo e discutidas à luz do estudo From 'sex toy' to intrusive imposition. Resultados: o significado perpassa o exercício de dilatação vaginal; as dificuldades relacionadas às condições vaginais, doença, tratamento, dor, sexo, constrangimentos, preconceitos, falhas na educação em saúde; as motivações relacionam-se à busca por qualidade de vida, apoio dos companheiros e profissionais. Conclusão: a abordagem de possíveis barreiras emocionais, psicológicas, sociais e físicas deve ser planejada e executada para prevenção da estenose vaginal e melhor acolhimento.

Objective: to describe the meaning of the use of silicone penile prosthesis for vaginal dilation in the follow-up of brachytherapy in women with gynecological cancer. Method: narrative research conducted at the Centro de Pesquisas Oncológicas, Brazil, with 34 women after pelvic brachytherapy, under follow-up at the physical therapy service. Data collection through semi-structured interviews, including sociodemographic and clinical data and the significance of the use of penile prosthesis in vaginal dilation, submitted to content analysis and discussed in the light of the study From 'sex toy' to intrusive imposition. Results: the meaning permeates the vaginal dilation exercise; difficulties related to vaginal conditions, disease, treatment, pain, sex, constraints, prejudices, failures in health education; motivations are related to the search for quality of life, support of partners and professionals. Conclusion: the approach of possible emotional, psychological, social and physical barriers should be planned and executed for prevention of vaginal stenosis and better reception.

Objetivo: describir el significado del uso de una prótesis peneana de silicona para la dilatación vaginal posterior a la braquiterapia en mujeres con cáncer ginecológico. Método: investigación narrativa, realizada en el Centro de Pesquisas Oncológicas, Brasil, con 34 mujeres, después de braquiterapia pélvica, en seguimiento en el servicio de fisioterapia. Recopilación de datos a través de entrevistas semiestructuradas, incluyendo datos sociodemográficos y clínicos y el significado del uso de prótesis peneana en la dilatación vaginal, sometidos a análisis de contenido y discutidos a la luz del estudio From 'sex toy' to intrusive imposition. Resultados: el significado impregna el ejercicio de dilatación vaginal; dificultades relacionadas con condiciones vaginales, enfermedad, tratamiento, dolor, sexo, vergüenza, prejuicios, fallas en la educación para la salud; las motivaciones están relacionadas con la búsqueda de calidad de vida, apoyo de la pareja y profesionales. Conclusión: se debe planificar y ejecutar el abordaje de las posibles barreras emocionales, psicológicas, sociales y físicas para prevenir la estenosis vaginal y una mejor recepción.

Esophageal intramural pseudodiverticulosis in a patient with food bolus impaction / Pseudodiverticulosis intramural esofágica en un paciente con impactación de bolo alimentario

Esophageal intramural pseudodiverticulosis is an uncommon esophageal benign disease. The typical finding during endoscopy is the presence of numerous pinhead-sized outpouchings along the esophageal wall. We reported a case of food bolus impaction secondary to esophageal intramural pseudodiverticulosis. A 67-year-old man presented with sudden-onset dysphagia. Multiple tiny orifices were revealed during upper endoscopy. In addition, there were an impacted food bolus and an esophageal web. The patient was treated with balloon dilatation and proton pump inhibitors. As a result the symptoms disappeared completely. Esophageal intramural pseudodiverticulosis is a rare cause of food bolus impaction and its treatment is directed towards the underlying associated conditions as well as the resolution of complications.

La pseudodiverticulosis intramural esofágica es una enfermedad benigna del esófago poco común. El hallazgo típico durante la endoscopia es la presencia de numerosos sáculos del tamaño de una cabeza de alfiler a lo largo de la pared esofágica. Reportamos un caso de impactación de bolo alimentario secundario a pseudodiverticulosis esofágica intramural. Un hombre de 67 años presentó disfagia de aparición repentina. Se encontraron múltiples orificios pequeños en la endoscopia superior. Además, hubo un bolo alimentario impactado y una red esofágica. El paciente fue tratado con dilatación con balón e inhibidores de la bomba de protones. Como resultado, los síntomas desaparecieron por completo. La pseudodiverticulosis intramural esofágica es una causa rara de impactación del bolo alimentario y su tratamiento se dirige a las condiciones asociadas subyacentes, así como a la resolución de complicaciones.

Tratamento das estenoses esofágicas benignas simples com dilatadores de Savary-Gilliard: ainda é necessária a regra de três? / Treating simple benign esophageal strictures with savary-gilliard dilators: is the rule of three still necessary?

ABSTRACT BACKGROUND: Bougies dilation is considered an effective technique for the treatment of simple benign esophageal strictures. The "rule of three" has been advocated to prevent reported adverse events such as bleeding and perforation. However, adherence to this rule has increased the cost and duration of treatment. OBJECTIVE: To demonstrate the safety and long-term benefits of progressive bougie dilations until reaching 15 mm (45Fr) in one single session endoscopy with non-adherence to the rule of three. METHODS: A retrospective analysis of a prospectively collected data of patients with simple benign esophageal strictures treated with multiple progressive bougie dilators until reaching 15 mm (45Fr) in one single session. RESULTS: The median age was 58 years (range 28-89), and 83.3% of patients were female. The main presenting symptom was dysphagia for solids in 11/12 cases (91.6%). The cause of their simple benign esophageal stricture was distributed as follows: 7/12 esophageal webs, 2/12 peptic stenosis, 2/12 Schatzki rings and one caustic injury. 75% required only one session for clinical success. No serious adverse events were described. No recurrence of symptoms was noted in a median follow-up of 20 months. CONCLUSION: The rule of three in patients with simple benign esophageal strictures secondary to esophageal webs, Schatzki rings and peptic strictures treated with Savary-Gilliard dilators is not necessary, showing good clinical results. Prospective studies with more patients are necessary.

RESUMO CONTEXTO: A dilatação por velas é considerada uma técnica eficaz para o tratamento de estenoses esofágicas benignas simples. A "regra de três" tem sido defendida para prevenir eventos adversos relatados, como sangramento e perfuração. No entanto, a adesão a esta regra aumentou o custo e a duração do tratamento. OBJETIVO: Demonstrar a segurança e os benefícios de longo prazo das dilatações progressivas por velas até chegar a 15 mm (45Fr) em uma única sessão de endoscopia com não adesão à regra de três. MÉTODOS: Uma análise retrospectiva de dados coletados prospectivamente de pacientes com estenoses esofágicas benignas simples tratadas com múltiplos dilatadores de velas progressivas até atingir 15 mm (45Fr) em uma única sessão. RESULTADOS: A mediana de idade foi de 58 anos (variação de 28-89) e 83,3% dos pacientes eram do sexo feminino. O principal sintoma de apresentação foi a disfagia para sólidos em 11/12 casos (91,6%). A causa da estenose esofágica benigna simples foi distribuída como segue: 7/12 membranas esofágicas, 2/12 estenose péptica, 2/12 anéis de Schatzki e um ferimento cáustico. 75% necessitaram apenas de uma sessão para o sucesso clínico. Não foram descritos eventos adversos graves. Nenhum retorno dos sintomas foi anotado em uma continuação mediana de 20 meses. CONCLUSÃO: A regra de três em pacientes com as estenoses esofágicas benignas simples secundárias às membranas esofágicas, os anéis de Schatzki e as estenoses péptica tratadas com os dilatadores de Savary-Gilliard não é necessária, mostrando bons resultados clínicos. Estudos prospectivos com mais pacientes são necessários.

Ureteral access sheaths: a comprehensive comparison of physical and mechanical properties

ABSTRACT Introduction: Ureteral access sheaths (UAS) facilitate flexible ureteroscopy in the treat- ment of urolithiasis. The physical properties of UAS vary by manufacturer and model. We compared three new UAS: Glideway (GW, Terumo, 11/13Fr, 12/14Fr), Pathway (PW, Terumo 12/14F) and Navigator HD (NHD, Boston Scientific, 11/13Fr, 12/14Fr) in the domains of safety characteristics, positioning characteristics, lubricity and radio- opacity. Materials and Methods: In vitro testing of the three UAS included safety testing-tip perforation force, sheath edge deformation and dilator extraction forces. Positioning characteristics tested included tip bending, stiffness (resistance to coaxial buckling forces), kinking (resistance to perpendicular forces), and insertion forces. Lubricity was assessed by measured frictional forces of the outer sheath. Finally, radio-opacity was tested utilizing fluoroscopic imaging of the three 12F sheaths and inner dilators. Results: The PW (0.245 lb) and GW (0.286 lb) required less force for tip perforation compared to the NHD (0.628 lb). The NHD sheath edge deformation was mild compared to more severe deformation for the PW and GW. The PW (1.008 lb) required greater force than the GW (0.136 lb) and NHD (0.043 lb) for inner dilator removal. The GW (3.69 lbs) and NHD (4.17 lb) had similar inner dilator tip stiffness when bent, while the PW had the weakest inner dilator tip, 1.91 lbs. The PW (0.271 lb) was most susceptible to buckling and kinking (1.626 lb). The most lubricious UAS was the NHD (0.055 lbs for 12F). The NHD (0.277 lbs) required the least insertional force through a biological model and possessed the greatest radio-opacity. Conclusions: Comparison of different commercially available UAS in various sizes reveals that there are mechanical differences in sheaths that may play a role clinically. The Terumo sheaths' (GW and PW) were outperformed by the Boston Scientific NHD in simulating safety, ease of use and radio-opacity.

Complicaciones durante la esofagoscopía con o sin dilatación con globo y con anestesia general en pacientes pediátricos: estudio prospectivo y observacional / Complications during esophageal endoscopy with or without baloon dilation under general anesthesia in pediatric patients: a prospective and observational study

Antecedentes. Durante una esofagoscopía en niños, pueden ocurrir complicaciones durante la dilatación. Identificamos alteraciones cardiorrespiratorias durante la esofagoscopía con o sin dilatación con globo y las complicaciones posoperatorias, en niños con anestesia. Métodos. Estudio prospectivo, observacional de procedimientos endoscópicos en niños de 0-16 años. Se dividieron en dos grupos: con endoscopía-dilatación (Grupo ED) y dilatación con globo por estenosis esofágica, y con endoscopía sin dilatación (Grupo E): endoscopía diagnóstica, esofagoscopía de control o escleroterapia. Registramos parámetros hemodinámicos y ventilatorios y las complicaciones durante la endoscopía, la dilatación y el seguimiento de dos horas en la sala de recuperación. Resultados. Incluimos 102 procedimientos en 60 pacientes. La presión inspiratoria máxima (PIM) aumentó significativamente en ambos grupos (p < 0,001) y aumentó significativamente durante el procedimiento en el grupo ED (p < 0,001). La diferencia en la PIM antes y después de la endoscopía se correlacionó negativamente en ambos grupos. Al subdividir los grupos según el punto de corte de 2 años para comparar la diferencia en la PIM antes y después de la endoscopía, la PIM aumentó de manera estadísticamente significativa en ambos grupos en los menores de 2 años. En el grupo ED, la frecuencia cardíaca aumentó estadísticamente significativa (p < 0,001). Conclusión. Durante la endoscopía, la PIM aumentó en niños con o sin dilatación con globo, especialmente en el grupo ED, y fue mayor en los niños más pequeños. Es necesario observar y tratar atentamente las complicaciones cardiorrespiratorias graves durante la dilatación con globo y con anestesia general.

Background. Complications can occur during esophagoscopy as a result of applied procedure in children, especially during dilation techic. Our aim was to identify cardio-respiratory alterations during esophagoscopy with or without baloon dilation under anesthesia in children, and to investigate the postoperative complications. Methods. Prospective, observational study of endoscopic procedures in patients 0-16 years. The patients were divided into two groups: the endoscopy-dilation group (Group ED: endoscopy and balloon dilation due to esophageal stricture) and endoscopy without dilation (Group E: endoscopy for diagnostic reasons, control esophagoscopy or sclerotherapy). Hemodynamic and ventilatory parameters alterations and complications during endoscopy, dilation and two-hours follow-up time in the postoperative recovery room were recorded. Results. 102 procedures in 60 patients were included. Peak inspiratory pressure (PIP) values significantly increased after endoscopy in both groups (p<0.001). There was a significant increase in mean PIP values in the dilation group during the procedure (p<0,001). The difference in PIP values before and after the endoscopy was negatively correlated with age in both groups. When the groups were subdivided taking two years of age as a cut-off point in comparing PIP difference before-after endoscopy, PIP increase was statistically significant in both groups under two-years old. In the dilation group, statistically significant increase of HR was detected during the procedure (p<0,001). Conclusion. During endoscopy PIP increased in patients with or without baloon dilation especially in the dilation group. PIP increase was higher in younger children. Severe respiratory and cardiovascular complications during balloon dilation under general anesthesia should be carefully observed and managed.

Estenosis esofágica congénita: diagnóstico y tratamiento. Serie de casos / Congenital esophageal stenosis: diagnosis and treatment. Cases review

La estenosis esofágica congénita es una patología infrecuente y no existe un tratamiento estandarizado. Se evaluó el diagnóstico, tratamiento y evolución de 11 pacientes con estenosis esofágica congénita tratados en nuestro centro. El síntoma más frecuente fue la disfagia. La edad al momento del diagnóstico varió entre 1 día y 14 años (media= 4,7 años). El esofagograma confirmó el diagnóstico. Cinco pacientes presentaron malformaciones asociadas. Cuatro pacientes fueron tratados quirúrgicamente y siete, con dilataciones. La histopatología identificó tres de tipo fibromuscular y una con restos traqueobronquiales. Todos evolucionaron favorablemente con un seguimiento promedio de 4,5 años. Las dilataciones fueron efectivas en la mayoría de los pacientes que se trataron por este método.

Congenital esophageal stenosis is a very rare condition and there is no standard treatment. We report the diagnosis, treatment and outcome of 11 patients with this condition managed at our institution. The most common symptom was dysphagia. The age at diagnosis was between 1 day and 14 years (mean age: 4.7 years). The esophagogram confirmed the diagnosis. Five patients presented associated anomalies. Four patients received surgical treatment and 7 only balloon dilatations. Pathologic examinations showed 3 fibromuscular stenosis and one with tracheobronchial remnants. All patients had a good outcome with a mean follow up of 4.5 years. Balloon dilatations were the definitive treatment in most of the patients.

Dilatación con balón de gran diámetro en el manejo de coledocolitiasis de difícil extracción: experiencia clínica / Large balloon dilation for removal of choledocholithiasis difficult to extract: clinical experience

Objetivo: Describir la experiencia clínica con la técnica de dilatación de la esfinterotomía papilar con balones de gran diámetro en pacientes con coledocolitiasis de difícil extracción. Materiales y métodos: Estudio retrospectivo, diseño descriptivo. Serie de Casos. Se analizaron las historias clínicas de 18 pacientes que fueron sometidos a colangiopancreatografía retrograda endoscópica (CPRE) más dilatación papilar con balón de gran diámetro (DPBGD) por presentar coledocolitiasis de gran tamaño (≥15 mm), desproporción de diámetro entre cálculo y colédoco distal y/o papila yuxtadiverticular. Se emplearon balones dilatadores CRETM entre 12 y 20mm de diámetro. Se consignaron datos como éxito del procedimiento, uso de litotricia; así como complicaciones durante el procedimiento. Resultados: La edad promedio fue 66,1 años. Hubo predominio del género femenino (66,7%). El tamaño promedio de los cálculos en vía biliar fue de 16,7 mm. Las indicaciones de DPBGD fueron: coledocolitiasis gigante (12 pacientes, 66,7%), discordancia entre el diámetro del cálculo y el colédoco distal (6 pacientes, 33,3%). El diámetro de los balones de dilatación más frecuentemente empleados fueron: 15 mm (8 pacientes, 44,4%), 18 mm (5 pacientes, 27,8%), 12 mm (3 pacientes, 16,7%) y 20 mm (2 pacientes, 11,1%). Se consiguió la extracción completa de los cálculos en 15 pacientes (83,3%). Se precisó litotricia en 4 pacientes (22,2%). Hubo 3 pacientes en los que la extracción con balón fue frustra, realizándose manejo quirúrgico. Se reportó 1 caso de pancreatitis aguda leve (5,5%). Conclusiones: Los resultados demuestran que la dilatación con balón es una alternativa segura y eficaz en el manejo de los cálculos en vía biliar de difícil extracción

Objective: The aim of this study was to report the initial experience of the combined use of biliary sphincterotomy plus balloon dilatation of the papilla for management of large stones. Materials and methods: Design: Retrospective, descriptive. This study included 18 patients in whom a hydrostatic dilatation of the papilla with large balloons was performed between June 2012 and April 2014. Patients had multiple large stones, tapered distal common bile duct, previous sphincterotomy, or peri/ intradiverticular papilla. CRE™ dilatation balloons with diameters ranging from 12 to 20 mm were used. Data were recorded as successful procedure, use of lithotripsy and complications during the procedure. Results: The average age was 66.1 years. There was a predominance of the female gender (66.7%). The average size of the bile duct stones was 16.7 mm. The main indications were: giant choledocholithiasis (12 patients, 66.7%) and tapered distal common bile duct (6 patients, 33.3%). The dilatation balloons diameter used were: 15 mm (8 patients, 44.4%), 18 mm (5 patients, 27.8%), 12 mm (3 patients, 16.7%) and 20 mm (2 patients, 11.1%). Complete stone clearance was achieved in 15 patients (83.3%). Lithotripsy was performed in 4 patients (22.2%). There were 3 patients in whom the removal with balloon was unsuccessful, performed surgical management. It was reported 1 case of mild acute pancreatitis (5.5%). Conclusions: The results show that endoscopic papillary large balloon dilation after sphincterotomy is a safe and effective technique for treatment of difficult bile duct stones

Use and outcomes of amplatz renal dilator for treatment of urethral strictures

ABSTRACT Introduction Urethral stricture disease is still a major problem in men. Many procedures are available for the treatment of urethral strictures; urethral dilatation is one of the oldest. The blind dilatation of urethral strictures may be a difficult and potentially dangerous procedure. The purpose of this study was to describe safe urethral dilatation using amplatz renal dilator and to report outcomes. Materials and Methods From 2010 to 2014, a total of 26 men with primary urethral strictures were managed by urethral dilatation using amplatz renal dilators. The parameters analyzed included presentation of patients, retrograde urethrography (RGU) findings, pre-and postoperative maximum flow rate (Qmax) on uroflowmetry (UF) and post-void residual urine (PVR). Patients were followed-up at 1.6 and 12 months. The technique described in this paper enables such strictures to be safely dilated after endoscopic placement of a suitable guidewire and stylet over which amplatz renal dilators are introduced. Results The mean age of the patients was 57.6 (35–72) years. The median stricture length was 0.82 (0.6–1.5)cm. Pre-operative uroflowmetry showed Qmax of 7.00 (4–12) mL/sec and ultrasonography showed PVR of 75.00 (45–195)mL. Postoperatively, Qmax improved to 18.00 (15–22)mL/sec (p<0.001) at 1 month, 17.00 (13–21)mL/sec (p<0.001) at 6 months and 15.00 (12–17)mL/sec (p<0.001) at 12 months. The post-operative PVR values were 22.50 (10–60)mL (p<0.001), 30.00 (10–70)mL (p<0.001) and 30.00 (10–70) mL (p<0.001) at 1.6 12 months, respectively. The median procedure time was 15.00 (12–22) minutes. None of the patients had a recurrence during a 12-month period of follow-up. Conclusion Urethral dilatation with amplatz renal dilators avoids the risks associated with blind dilatation techniques. This tecnique is a safe, easy, well-tolerated and cost-effective alternative for treatment of urethral strictures.

A Novel method of ensuring safe and accurate dilatation during percutaneous nephrolithotomy

ABSTRACT Objective: To report our technique that helps locate the guidewire into the ureter enabling safe dilatation during PCNL. Materials and Methods: Cases in which the guidewire failed to pass into the ureter following successful puncture of the desired calyx were subjected to this technique. A second guidewire was passed through the outer sheath of a 9 Fr. metallic dilator cannula, passed over the first guidewire. The cannula and outer sheath were removed, followed by percutaneous passage of a 6/7.5 Fr ureteroscope between the two guidewires, monitoring its progress through both the endoscopic and fluoroscopic monitors. Once the stone was visualized in the calyx a guidewire was passed through the working channel and maneuvered past the stone into the pelvis and ureter under direct endoscopic vision. This was followed by routine tract dilatation. Results: This technique was employed in 85 out of 675 cases of PCNL carried out at our institute between Jan 2010 to June 2014. The mean time required for our technique, calculated from the point of introduction of the ureteroscope untill the successful passage of the guidewire down into the ureter was 95 seconds. There were no intraoperative or postoperative complications as a result of this technique. Guidewire could be successfully passed into the ureter in 82 out of 85 cases. Conclusions: Use of the ureteroscope introduced percutaneously through the puncture site in PCNL, is a safe and effective technique that helps in maneuvering the guidewire down into the ureter, which subsequently enables safe dilatation.

The use of nasal dilator strips as a placebo for trials evaluating continuous positive airway pressure

OBJECTIVES: The aim of the current study was to compare the objective and subjective effects of continuous positive airway pressure to the use of nasal dilator strips in patients with acromegaly and moderate to severe obstructive sleep apnea. METHODS: We studied 12 patients with acromegaly and moderate to severe obstructive sleep apnea (male/ females = 8/4, age = 52±8 ys, body mass index = 33.5±4.6 Kg/m², apnea-hypopnea index = 38±14 events/h) who had been included in a randomized, crossover study to receive three months of treatment with continuous positive airway pressure and nasal dilator strips. All patients were evaluated at study entry and at the end of each treatment by polysomnography, and Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index and treatment satisfaction questionnaires. ClinicalTrials.gov: NCT01265121 RESULTS: The apnea-hypopnea index values decreased significantly with continuous positive airway pressure treatment but did not change with the use of nasal dilator strips. All of the subjective symptoms improved with both treatments, but these improvements were significantly greater with continuous positive airway pressure than with the nasal dilator strips CONCLUSION: The use of nasal dilator strips had a much smaller effect on the severity of obstructive sleep apnea in patients with acromegaly and moderate to severe obstructive sleep apnea in comparison to the use of continuous positive airway pressure. Moreover, the improvement in several subjective parameters without any significant objective improvement in obstructive sleep apnea resulting from the use of nasal dilator strips is compatible with a placebo effect.

Percutaneous tracheotomy: forceps vs. cone dilatation techniques

Percutanoeous tracheotomy [PT] is a minimal invasive procedure alternative to surgical tracheotomy. PT offers an added advantage of enormous decrease of time interval between decision of doing tracheotomy and actually doing it. Moreover hazards of patient transport can be avoided as it can be safely performed at the bedside. We started doing PT in 2003 and performed 100 cases using forceps dilatation. Later we switched over to cone dilatation where we performed 215 cases. This study aims to compare two techniques of forceps vs. cone dilatation methods for PT. A total of 100 cases of PT were performed starting from December 2003 to August 2005 using the forceps dilatation method [group A]. Further 215 cases were conducted [group B] from September 2003 to July 2008 using the cone dilatation method. Time of performing both procedures was recorded. Also incidence of complications was also recorded in both groups. The incidence of minor bleeding in group A was 9%, whereas in group B was 5.58%. Major bleeding occurred in two patients in group B. Both cases suffered of pneumothorax and emphysema. One patient developed life-threatening tension pneumothorax and required cardio pulmonary resuscitation. This was one case in this series, in which the procedure has contributed to patient's morbidity. Guide wire-related technical difficulties were seen in 2% of the cases in group A, and 3.7% of cases in group B. forceps dilatation PT is superior to the cone dilatation technique in terms of safety. Further studies are needed to confirm our results

Estenoses benignas de esôfago: abordagem endoscópica com velas de Savary-Gilliard / Benign strictures of the esophagus: endoscopic approach with Savary-Gilliard bougies

RACIONAL: As estenoses benignas de esôfago são complicações decorrentes de diversas causas. Possuem tratamentos similares, na maioria dos casos necessitando de dilatação endoscópica, no entanto a resposta terapêutica, tempo ideal de tratamento, assim como intervalo entre as sessões podem ser variáveis. OBJETIVO: Analisar, do ponto de vista endoscópico, as estenoses benignas de esôfago em 14 anos de experiência no Hospital Universitário Clementino Fraga Filho da Universidade Federal do Rio de Janeiro, RJ, avaliando etiologia, a extensão da estenose, o número de dilatações necessário para atingir resposta terapêutica satisfatória, assim como a relação entre a extensão da estenose e a resposta terapêutica. MÉTODO: Foram analisadas 2.568 dilatações endoscópicas com uso de velas de Savary-Gilliard em 236 pacientes, durante um período de 14 anos e 10 meses, até junho de 2007. RESULTADOS: A estenose péptica foi a causa mais freqüentemente encontrada, seguida pela estenose cáustica. As estenoses longas e cáusticas necessitaram de maior número de sessões para ausência de disfagia. Estenoses pépticas e curtas responderam melhor a número menor de sessões de dilatação. CONCLUSÃO: A estenose péptica foi a causa mais comum e respondeu bem à terapia endoscópica, em concordância com a literatura. As estenoses cáusticas foram as mais refratárias, principalmente as longas. Quanto maior foi a extensão da estenose, também maior foi o número de sessões necessárias. Estenoses curtas apresentaram boa evolução na maioria dos casos. O número de dilatações necessárias dependeu diretamente da causa e da extensão da estenose.

BACKGROUND: Benign esophageal strictures are complications that result from different causes. They are usually similarly approached, most of the cases needing endoscopic dilation. However the response to therapy, optimal timing for treatment and interval between sessions can vary. AIM: The authors evaluate 14 years of experience with benign stricture of the esophagus from the endoscopic point of view in the "Clementino Fraga Filho" University Hospital, Federal University of Rio de Janeiro, RJ, Brazil. They evaluated etiology, length of stricture, number of dilations needed to reach satisfactory therapeutic response, and the relation between length of stricture and therapeutic response. METHODS: We analyzed 2,568 endoscopic dilations using Savary-Gilliard dilators in 236 patients. The follow up period was 14 years and 10 months, until June of 2007. RESULTS: Peptic strictures were the more frequent, followed by caustic strictures. Long strictures and caustic strictures needed more sessions to abolish dysphagia. Peptic strictures and short ones had better response to a smaller number of sessions. CONCLUSION: In this study, peptic strictures were the commonest etiology and responded best to endoscopic therapy, in accordance with published literature. Caustic strictures were the most refractory, mainly the long segments. The longer the extension of stenosis, the greater was the number dilation sessions needed for relief. Short strictures had a good prognosis in the great majority of cases. The number of dilations depended directly on the etiology and the extension of the stricture.

Dilatación de la estenosis benigna de la anastomosis colo-rectal mediante bujías de Savary-Gilliard / Dilation of benign anastomotic colorectal strictures using Savary-Gilliard bougies

Antecedentes: La estenosis cicatricial de una anastomosis colorrectal (CRA) ocurre aproximadamente en un 20 por ciento de los pacientes, la mayoría son asintomáticos y menos del 5 por ciento de los casos requiere algún procedimiento de corrección. Este estudio analiza la técnica y los resultados de la dilatación endoscópica con bujías de una estenosis de una CRA grapada. Pacientes y método: Revisión retrospectiva de todas las dilataciones de una CRA efectuadas en el periodo 1997-2004 por una estrechez cicatricial crítica (<10 mm), con o sin síntomas. La dilatación se efectuó mediante bujías de Savary-Gilliard bajo visión fluoroscópica. Resultados: De un total de 349 CRA con suturas mecánicas realizadas en forma consecutiva en dicho periodo, 15 pacientes (4,3 por ciento) requirieron de una o más sesiones de dilatación. La altura promedio de la estenosis desde el margen anal fue 12,7 cm (extremos 7-17). El diámetro promedio de la estrechez fue 7 mm (extremos 2-10). El intervalo entre la confección de la CRA y el diagnóstico de la complicación fue de 19 meses como promedio (extremos 2-67). Once pacientes (73 por ciento) presentaban síntomas obstructivos, los que progresaron a una obstrucción mecánica en 5. Se efectuó 18 dilataciones en los 15 pacientes, logrando una dilatación hasta 15 mm y mejoría del cuadro clínico en forma definitiva en 12 pacientes. Tres pacientes presentan una re-estenosis que requiere un nuevo procedimiento de dilatación, logrando éxito en 2 de ellos. Un paciente debió operarse por una perforación luego de la segunda sesión, quedando con una ileostomía transitoria. Conclusión: En nuestra experiencia logramos una corrección de la estrechez benigna de la CRA con una sesión de dilatación en el 80 por ciento de los casos, cifra que se eleva al 93 por ciento con dos sesiones. La técnica de dilatación con bujías es una técnica reproducible, de bajo costo, simple y eficiente.

Background: Benign strictures occur in up to 22 percent of patients following anterior resection, most of them presenting no symptoms and less than 5 percent needing some correcting procedure. This study was conducted to assess the efficacy of dilation using Savary-Gilliard bougies. Patients and method: From 1997 to 2004, 349 consecutive patients underwent anterior resection. Fifteen patients (4,3 percent) developed a critical stricture of colorectal anastomosis (<10 mm). Dilation was carried out under fluoroscopic guidance using Savary-Gilliard bougies of increasing diameters up to 15 mm. Results: Mean height of stenosis to anal verge was 12,7 cm (range 7-17). The strictures had a mean diameter of 7 mm (range 2-10). Four patients were diagnosed during routine follow up. In eleven patients, symptoms developed at a mean of 19 months after surgery (range 2-67). Five patients complained of pain and abdominal distension which, in one case, progressed to intestinal obstruction. The total number of dilation sessions was 21 and the average number per patient was 1.4 (range 1-4). Immediate symptomatic relief was achieved in 12 cases in one session and good long-term dilation was achieved in 14 patients (93 percent) after a 22 (range 7-44) mean follow-up period. There was one case of bowel perforation with the guide wire who needed a temporary ileostomy. Conclusion: Endoscopic dilation with Savary bougies is an inexpensive, simple, safe and efficient method of treating benign colorectal anastomotic strictures.

Dilating missile trocar for primary port establishment: a cadaver study.

The missile trocar was developed for controllable entry force, smaller fascial defects and post-operative pain improvement. The trocar was composed of a fascial-dilating long-conical head and a handle. Accompanied with this trocar, the authors designed a rectus sheath-hooking instrument to promote negative intra-abdominal pressure during the trocar puncture. The hooking procedure allowed room air to pass through the central canal of the trocar and fill the space between the intestinal loops and the trocar tip. The abdominal access procedure succeeded in forty-five attempts in fresh cadavers. No second attempt was done. The trocar accessed into the peritoneal cavity at every attempt without intestinal penetration. The missile trocar may be an alternative device for establishment of the primary port. Its efficacy and safety still has to be proved.

Estenosis de hepaticoyeyunoanastomosis luego de lesión quirúrgica de la vía biliar: tratamiento percutáneo / Percutaneous treatment of hepaticojejunoanastomosis stenosis due to biliary injury

Objetivos: Se analizan pacientes con estenosis de hepaticoyeyunoanastomosis secundarias a reparación quirúrgica de lesiones en la vía biliar, tratadas con dilatación percutánea transhepática. Diseño: Análisis retrospectivo. Población: Veintidos pacientes, dieciseis de ellos del sexo femenino, la edad osciló entre los 30 y 68 años con un promedio de 44 años. Todas las lesiones de la vía biliar fueron producidas durante el transcurso de una colecistectomía, en 17 casos laparoscópica y 5 convencional. Resultados: La canulación de la vía biliar se logró en 1 a 3 sesiones en el 100 por ciento de los pacientes. El éxito de la dilatación, objetivado por la visión colangiográfica de permeabilidad y buen diámetro de la anstomosis biliodigestiva, se demostró en 21 casos (95,4 por ciento). El corto seguimiento de 3 a 49 meses (16,1 meses promedio), permitió observar 2 recurrencias de síntomas con reestenosis. No hubo mortalidad en la serie estudiada

Out-patient esophageal dilation: an experience in 130 patients using Savary-Gilliard dilators.

Experience of outpatient esophageal dilation using Savary-Gilliard dilators in 130 patients during a 17 month period is reported. The strictures were radiation induced (48), tumoral stenoses (40), anastomotic (16) and due to other causes (26). Both fluoroscopy and endoscopy were used in 58%, endoscopy alone in 23% and fluoroscopy alone in 19% of patients for placement of the guide wire. One hundred and twenty six stricture dilations (97%) were technically successful. Eighty one (62%) patients could be dilated to 14 mm or more. One hundred and nineteen (94%) patients were dilated in one or two sessions. Among the 109 patients who followed up, dilation was successful in providing adequate dysphagia relief in 97 patients and facilitated the performance of other therapies in 9 patients. Major complications included severe continuous chest pain (1 case), hematemesis (2), fever (4) and transient stridor (2). The patient with persistent pain and 9 patients undergoing other therapies required hospitalization. There were no perforations or death. We conclude that esophageal dilation with Savary-Gilliard dilators is safe and effective even in tumors and post-radiation strictures. It can be performed on an outpatient basis in a majority of patients.

Construçäo da vagina por método incruento / Construction of the vagina by non-surgical method

Após experiência de construçäo cirúrgica da vagina artificial em 150 casos, os AA. pasaram a dar crédito ao método incruento proposto por FranK em 1940. Prepararam moldes de acrílico, cilíndricos e de diámetros variando de 1,5 a 3,0 cm, e trataram dez casos de auséncia congênita da vagina e doze de estados intersexuais identificados com o sexo feminino. Além de morbilidade nula, os resultados foram satisfatórios, pois, 16 pacientes já terminaram o tratamento, com vagina de 12x3 cm., sendo que oito já iniciaram atividade sexual satisfatória para ambos os parceiros