Danos anatômicos ao esfíncter esofágico inferior após gastrectomia subtotal / Anatomic damage of the lower esophageal sphincter after subtotal gastrectomy

RESUMO - RACIONAL: Disfunção do esfíncter esofágico inferior (EEI), doença do refluxo gastroesofágico e esofagite erosiva em pacientes submetidos à gastrectomia subtotal são ocorrências comumente reconhecidas, mas até agora as causas permanecem obscuras. OBJETIVO: A hipótese deste estudo é que a gastrectomia subtotal provoque alterações na pressão de repouso do EEI e na sua competência, devido ao dano anatômico desta, visto que as fibras oblíquas "Sling", um dos componentes musculares do EEI, são seccionadas durante este procedimento cirúrgico. MÉTODOS: Sete cães adultos sem raça definida (18-30 kg) foram anestesiados e submetidos à transecção do estômago proximal. Em seguida, o remanescente gástrico proximal foi fechado por sutura. No intraoperatório, manometria lenta foi realizada em cada cão, em condições basais (com estômago intacto) e no remanescente gástrico proximal fechado. A média dessas medidas é apresentada, com cada cão servindo como seu próprio controle. RESULTADOS: A pressão média do EEI medida no remanescente gástrico proximal, em comparação com a pressão do EEI no estômago intacto, foi diminuída em cinco cães, aumentada em um cão e sem alterações no outro cão. CONCLUSÃO: A secção transversa superior do estômago e o fechamento do remanescente do estômago por sutura provocam alterações na pressão do EEI. Sugerimos que essas mudanças na pressão do EEI são secundárias à secção das fibras oblíquas "Sling" do esfíncter, um de seus componentes musculares. A sutura e o fechamento do remanescente gástrico proximal, reancora essas fibras com mais, menos ou a mesma tensão, modificando ou não a pressão do EEI.

ABSTRACT - BACKGROUND: Dysfunction of the lower esophageal sphincter (LES), gastroesophageal reflux disease, and erosive esophagitis in patients undergoing subtotal gastrectomy are commonly recognized occurrences, but until now the causes remain unclear. AIM: The hypothesis of this study is that subtotal gastrectomy provokes changes on the LES resting pressure and its competence, due to the anatomical damage of it, given that the oblique "Sling" fibers, one of the muscular components of the LES, are transected during this surgical procedure. METHODS: Seven adult mongrel dogs (18-30 kg) were anesthetized and admitted for transection of the proximal stomach. Later, the proximal gastric remnant was closed by a suture. Intraoperatively, slow pull-through LES manometries were performed on each dog, under basal conditions (with the intact stomach), and in the closed proximal gastric remnant. The mean of these measurements is presented, with each dog serving as its control. RESULTS: The mean LES pressure (LESP) measured in the proximal gastric remnant, compared with the LESP in the intact stomach, was decreased in five dogs, increased in one dog, and remained unchanged in other dogs. CONCLUSION: The upper transverse transection of the stomach and closing the stomach remnant by suture provoke changes in the LESP. We suggested that these changes in the LESP are secondary to transecting the oblique "Sling" fibers of the LES, one of its muscular components. The suture and closing of the proximal gastric remnant reanchor these fibers with more, less, or the same tension, whether or not modifying the LESP.

Estudio mamométrico del esófago en pacientes con dolor torácico no cardíaco / Esophageal manometry in patients with non cardiac chest pain

Background: Non cardiac chest pain can be caused by esophageal problems such as gastroesophageal reflux or smooth muscle motor disorders. Aim: To perform esophageal manometry in patients with non cardiac chest pain. Material and methods: One hundred patients with chest pain in whom coronary problems were discarded, were studied. A computerized esophageal manometry was performed in all and 24 hours esophageal pH measurement was done in 21 patients. Results: Esophageal manometry was normal in eight patients. Nutcracker esophagus was the most common finding, in 36 patients. Twenty eight had a hypotensive sphincter, 16 had unspecific motor disorders, nine had diffuse esophageal spasm, two had a non achalasic esophageal aperistalsis and one had a hypertensive sphincter. Conclusions: Only eight of 100 patients referred to esophageal manometry for non cardiac chest pain, had a normal study.

Caracteristicas clínicas, endoscópicas, manomÚtricas y magnitud de reflujo gastroesofágico ácido patológico en pacientes con esófago en cascanueces: análisis prospectivo de 80 pacientes / Nutcracker esophagus: analysis of 80 patients

Background: The nutcracker esophagus, a primary motor disorder, is frequently associated with noncardic chest pain. Aim: To study the clinical, endoscopic, manometric, and pathological features and 24 h acid reflux in patients with nutcracker esophagus. Patients and methods: Eighty patients (63 females, aged 26 to 70 years) with nutcracker esophagus, defined as the presence of contraction waves of more than 180 mmHg in the esophageal manometry, were studied. All were subjected to an upper gastrointestinal endoscopy, 24 h esophageal pH monitoring and a new manometric study. Results: Eighty percent of patients had symptoms suggestive of gastroesophageal reflux, 31 percent had retrosternal pain and 25 percent had dysphagia. Upper endoscopy was normal in 41 percent and showed erosive esophagitis or Barrett esophagus in 27 percent. Fifty percent of patients had an abnormal acid reflux. There were no significant differences in manometric parameters between patients with and without acid reflux. Conclusions: Symptoms of gastroesophageal reflux not necessarily mean that a pathological reflux is present. Primary motor disorders of the esophagus may cause similar symptoms.

The Gonyautoxin 2/3 epimers reduces anal tone when injected in the anal sphincter of healthy adults

The primary clinical symptom of Paralytic Shellfish Poisoning is acute paralytic illness produced by paralyzing toxins. Paralytic shellfish poison is formed by a mixture of phycotoxins and their toxicity is due to its reversible binding to a receptor site on the voltage-gated sodium channel on excitable cells, thus blocking neuronal transmission. We studied the effect of the gonyautoxin 2/3 epimers by local infiltration in the anal internal sphincter of healthy voluntary adults in order to reduce anal tone. The toxin was injected after prior clinical evaluation, anoscopy and anorectal manometry. Post injection clinical examination, electromyography and anorectal manometry were performed. Resting and voluntary contraction pressures were measured and the anorectal inhibitory and anocortical reflexes were tested by manometry. Blood and urine samples were obtained from each participant, and hemogram, basic metabolic panel, and urinalysis were done both before and one week after the injection. This study shows, for the first time, that gonyautoxin 2/3 reduces the anal tone by relaxing the anal sphincters in 100 % of the participants. Manometric recordings showed a significant decrease in anal maximal voluntary contraction pressure after the toxin injection, dropping to 55.2 ± 6.2 % and 47.0 ± 6.8 % (Mean Value ± Std.Dev.) of the baseline values at 2 minutes and at 24 hours respectively after the injection. Post-injection electromyography showed that activity of the muscle was abolished. We conclude that local administration of gonyautoxin 2/3 to the anal sphincter produces immediate relaxation and a statistically significant decrease in the anal tone (p <0.001)..

Análisis manométrico en afecciones anorrectales benignas / Manometry in benign anorectal diseases

La manometría anorrectal es un método valioso en el diagnóstico y evaluación de pacientes con alteraciones diversas de la función anorrectal. Se presenta nuestra experiencia en los últimos tres años analizando los resultados de 400 manometrías. Se establecen los diagnósticos etiológicos más frecuentes, las características de los diferentes grupos evaluados, y se analizan los patrones manométricos en cada uno de ellos

Efecto de la vagotomía asociada a cirugía antirreflujo sobre la secreción gástrica de ácido en pacientes con reflujo gastroesofágico patológico / Effect fo the super selective vagotomy associated to antireflux surgery on acid gastric secretion in patients with pathologic gastroesophageal reflux

Se estudió la secreción gástrica basal (BAO) y la secreción gástrica máxima estimulada (PAO) en 3 grupos de pacientes con reflujo GE crónico sometidos a cirugía. a) 18 casos con calibración cardial y gastropexia posterior, asociado a vagotomía suprasectiva; b) 22 casos sometidos a switch duodenal y vagotomía supraselectiva y, c) 23 casos con vagotomía y gastrectomía parcial, 11 de ellos analizados 8 a 10 años después de la cirugía. La secreción ácida basal (BAO) se redujo en cerca de 60 por ciento en los pacientes sometidos a vagotomía supraselectiva y en 96 por ciento después de vagotomía-gastrectomía. La secrección máxima (PAO) se redujo en 50 por ciento en los casos con vagotomía supraselectiva y en 89 por ciento después de vagotomía-gastrectomía. Estos resultados explican en parte la alta recurrencia del reflujo ácido en pacientes con esófago de Barrett sometidos a cirugía antirreflujo con vagotomía supraselectiva. Por el contrario, después de vagotomía-gastrectomía, esta recurrencia es muy baja

Eficacia y aceptabilidad en mujeres venezolanas de un anticonceptivo oral monofásico que contiene 20 microgramos de etinilestradiol y 150 microgramos de desogestrel / Efficacy and acceptability in Venezuelan females of a oral monophasic contraceptive containing ethynilestradiol 20 micrograms and desogestrel 150 micrograms

Evaluar la eficacia anticonceptiva, control de ciclo, aceptabilidad por parte de la usuaria, cambios en el peso corporal y tensión arterial con el uso de un anticonceptivo oral monofásico que contiene 20 microgramos de etilestradiol y 150 microgramos de desogestrel. Estudio abierto no comparativo multicéntrico donde participaron 122 mujeres proporcionando datos relativos a 600 ciclos. Ocho centros privados localizados en Caracas, Barquisimeto y Mérida. De las 122 mujeres evaluadas durante 600 ciclos, no se presentó embarazo, el control del ciclo tuvo una duración en todos los casos entre 3 a 5 y no huvo cambios estadísticamente significativos con respecto al peso corporal y tensión arterial. Los resultados derivados de este estudio sugieren que la reducción en la dósis de etinilestradiol a 20 microgramos permite todavía una máxima eficacia, buena aceptabilidad y un adecuado control de ciclo

Distocia de hombros / Dystocia of shoulders

Se presentan 25 casos de distocia de hombros con una incidencia de 0,12 por ciento. El 92 por ciento tenía 2 o más gestantes y el 20 por ciento presentó embarazos postérmino. Los factores determinantes para la distocia fueron: el peso fetal, la paridad y el embarazo prolongado. La maniobra más utilizada fue la de Mc Roberts sola o combinada en 22 (88 por ciento) de los casos, con 27,3 por ciento de fracasos y 3 complicaciones fetales: 2 fracturas de clavícula y 1 elongación del plexo braquial. El promedio del peso fetal al nacer fue de 4244 g. El 20 por ciento presentó un Apgar a los 5 minutos menor de 7. la mortalidad materna fue de 16 por ciento y la fetal 24 por ciento

Manometría anorrectal en fisura anal / Anorectal manometry in anal fissure

Se efectuó manometría anorrectal pre y postoperatorio en 15 pacientes portadores de fisura anal, los cuales fueron sometidos a esfinterotomía lateral. Los resultados fueron comparados con un grupo control. La presión de reposo fue significativamente mayor en los pacientes que en el grupo control. (111ñ27 cm H2O vs 70ñ14 cm H2O), luego de la cirugía la presión disminuyó a valores no diferentes de lo normal (80ñ15 cm H2O). El estudio confirma la existencia de una presión de reposo aumentada en portadores de fisura anal, la cual es causada por hiperactividad del esfínter interno anal y la esfinterotomía interna lateral reduce efectivamente la presión anal y permite la cicatrización de la fisura