Dissertations / Theses on the topic 'Cholelithiasis'

Orientadores: Adriana Maria Alves De Tommaso, Gabriel Hessel
Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas
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Resumo: Pouco se conhece sobre epidemiologia e melhor terapêutica da colelitíase na infância. Sabe-se que o número de casos é crescente e alguns necessitam de cirurgia e apresentam risco de complicações. Este estudo teve por objetivo avaliar os prováveis aspectos envolvidos na colelitíase, de etiologia não-hemolítica, em crianças e adolescentes, na tentativa de esclarecer aspectos relacionados a fatores de risco, quadro clínico, diagnóstico, bem como presença de doenças associadas, complicações, história familiar e as condutas terapêuticas realizadas. Foram avaliados 65 pacientes, de 0 a 18 anos, com colelitíase não-hemolítica, atendidos de janeiro de 1993 a dezembro de 2005 no Hospital de Clínicas da Faculdade de Ciências Médicas da Universidade Estadual de Campinas. O estudo foi descritivo, retrospectivo e prospectivo, utilizando-se dados obtidos por meio de prontuários e entrevistas. Os pais foram convocados para realização de ultra-sonografia abdominal para investigar colelitíase. A investigação laboratorial dos pacientes constou de perfil lipídico (colesterol total e frações e dosagem de triglicérides) e perfil hepático (aminotransferases e gama-glutamiltranspeptidase). Também foi realizado um estudo de caso-controle investigando a influência da colelitíase materna sobre a litíase nos filhos. Quarenta e seis dos 65 doentes eram do sexo feminino (70,77%), com predomínio das meninas nos escolares e adolescentes. Os brancos corresponderam a 69,23% (45/65) e a idade média ao diagnóstico foi de 9,85 anos. Foram sintomáticos 69,23% dos casos (45/65), principalmente acima dos 7 anos, e os principais sintomas e sinais foram: dor abdominal (45), vômitos (27), náuseas (22), empachamento pós-prandial (16), icterícia (12) e intolerância a alimentos gordurosos (9). A mediana de duração do início do quadro clínico até o diagnóstico foi de 6 meses. As condições associadas e fatores de risco estiveram presentes em 43 pacientes (66,15%), principalmente nos menores de 14 anos (freqüente prematuridade nos menores de 6 anos). As alterações do perfil hepático e do perfil lipídico ocorreram, respectivamente, em 21/43 (48,84%) e 14/49 casos (28,57%). Complicações (coledocolitíase e pancreatite) foram raras, com predomínio em adolescentes. A colecistectomia foi realizada em 51 pacientes (78,46%). Foram encontradas 10 mães com diagnóstico de colelitíase e 36 de 57 pacientes (63,16%) apresentavam história familiar de colelitíase. Os resultados permitem concluir que:1. O sexo feminino predominou, progressivamente, a partir do segundo grupo; 2. Queixas freqüentes foram: dor abdominal, vômitos, náuseas e empachamento; 3. O diagnóstico dos sintomáticos foi tardio; 4. Os pacientes acima de 7 anos foram os mais sintomáticos e os menores de 14 anos apresentaram maior positividade para doenças e fatores de risco associados; 5. Os fatores de risco mais relevantes foram: antibioticoterapia parenteral, nutrição parenteral prolongada, cirurgia abdominal, hipertensão portal e prematuridade; 6. Foi freqüente o antecedente pessoal de hepatopatia, além do perfil hepático alterado; 7. Obesidade e dislipidemia grave não foram freqüentes; 8. Coledocolitíase e pancreatite biliar foram raras, predominando nos adolescentes; 9. A conduta predominante foi a colecistectomia laparoscópica; 10. A maioria apresentava história médica sugestiva e(ou) antecedente familiar para colelitíase; 11. Antecedente familiar de dislipidemia, obesidade e urolitíase foi positivo na metade deles; 12. Não se comprovou influência do antecedente materno de colelitíase
Abstract: There is a poor knowledge on the epidemiology and the best therapy of cholelithiasis in childhood. The number of cases is increasing, some requiring surgery which implies in risks and complications. The aim of this study was to evaluate the probable features involved in nonhemolitic cholelithiasis in children and adolescents, as an attempt to elucidate features related to risk factors, clinical picture, diagnosis, as well as the presence of associated diseases, complications, family history and medical treatment. Sixty-five patients from age 0 to 18 years with nonhemolitic cholelithiasis were followed from January 1993 to December 2005 at the Hospital of State University of Campinas. The study was descriptive, retrospective and prospective, and the data were collected from patients' records and interviews. The patients¿ parents were investigated for cholelithiasis by ultrassonography. The laboratorial investigation of patients consisted in the lipidic profile (total cholesterol, fractions and triglyceride dosage) and hepatic profile (aminotransferases and gama-GT). A case-control study was also performed in order to investigate the influence on those children whose mothers had cholelithiasis. Forty-six of 65 patients were female (70.77%), with a predominance of females among scholars and adolescents. Caucasians corresponded to 69.23% (45/85) and the mean age at diagnosis was 9.85 years. The symptomatic patients represented 69.23% (45/65), mainly over 7 years, and the main symptoms and signs were: abdominal pain (45), vomiting (27), nauseas (22), post-prandial discomfort (16), jaundice (12) and fat food intolerance (9). The median time lapse from the beginning of clinical presentation up to diagnosis was 6 months. The associated conditions and risk factors were present in 43 patients (66.15%), mainly below 14 years (frequent prematurity below 6 years). Lipidic and hepatic abnormalities occurred, respectively, in 21/43 (48.84%) and 14/49 cases (28.57%). Complications (choledocolithiasis and pancreatitis) were rare, with predominance in adolescents. Fifty-one patients (78.46%) underwent cholecystectomy. Ten mothers were diagnosed with cholelithiasis and 36 out of 57 patients (63.16%) presented family history of cholelithiasis. Based on these results, the conclusions were: 1.The prevalence in females predominated increasingly in the second group; 2. Frequent complains were: abdominal pain, vomiting, nauseas and post-prandial discomfort; 3. The diagnoses of symptomatics were late; 4. Patients older than 7 years were the most symptomatic and those below 14 years of age had a greater tendency towards associated diseases and risk factors. 5. Relevant risk factors and associated illnesses were: parenteral antibiotics, prolonged parenteral nutrition, abdominal surgery, portal hypertension and prematurity; 6. Hepatical patology and altered hepatic perfil were frequent; 7. Obesity and severe dislipidemia were not frequent; 8.Cholelithiasis and biliary pancreatitis were rare complications, predominating in adolescents; 9. Most patients received laparoscopic cholecystectomy; 10. Most cases had suggestive medical history and(or) family antecedent of cholelithiasis; 11. Family antecedent of dislipidemia, obesity and urolithiasis occurred in half of the patients; 12. The influence of mothers presenting antecedents for cholelithiasis on children and adolescents was not confirmed.
Mestrado
Pediatria
Mestre em Saude da Criança e do Adolescente

У роботі розглядаються особливості перебігу жовчнокам'яної хвороби у хворих, які готуються до відеолапароскопічної холецистектомії. При цитуванні документа, використовуйте посилання http://essuir.sumdu.edu.ua/handle/123456789/6536

Fewer than 25% of Medicare beneficiaries presenting with symptomatic cholelithiasis undergo elective cholecystectomy. To better understand underuse of cholecystectomy, we examined physician follow-up patterns after emergency department (ED) visits for symptomatic gallstones.

Жовчокам’яна хвороба (ЖКХ) є розповсюдженою патологією гепатобіліарної системи. У 10-20% населення працездатного віку розвиваються камені жовчного міхура. Цей показник кожних 10 років збільшується вдвічі. Зросла кількість пацієнтів молодого віку, у віці від 21-30 років хворіє 3,1-4,8% населення (переважно жінки). Патогенез розвитку ЖКХ – це комплексний процес, котрий включає в себе зміну складу жовчі і її потоку (застій жовчі). Існують наукові роботи, що описують дію холецистокініну та естрогенів на роботу жовчовивідних шляхів, але ефект тиреоїдних гормонів вивчений недостатньо. У клінічній практиці можно часто зустріти пацієнтів із ЖКХ, що мають в анамнезі такий діагноз як гіпотиреоз. Тому встановлення взаємозв’язку між зниженою функцією щитовидної залози і патологією жовчовивідних шляхів є актуальною темою сучасності.

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O diagnóstico de litíase biliar tem aumentado em crianças e adolescentes por dois motivos principais: a epidemia da obesidade infantil e a maior facilidade para realização da ultrassonografia. Atualmente, os fatores de risco para litíase biliar em crianças e adolescentes têm mudado e se assemelham aos dos adultos, como: obesidade, o uso de anticoncepcional oral, gravidez na adolescência e história familiar. Na literatura há poucos estudos sobre litíase biliar em pediatria. Em crianças e adolescentes obesos há apenas um estudo sobre litíase biliar realizado na Alemanha por Kaechele et al* que encontraram uma prevalência de 2%. Estes aspectos motivaram a realização de um estudo com hipótese de que a frequência de litíase biliar seria alta entre adolescentes portadores de obesidade. O objetivo do estudo foi descrever a frequência e os fatores associados à litíase biliar em adolescentes com obesidade ou sobrepeso. Realizou-se um estudo descritivo, tipo corte transversal, no ambulatório de obesidade infanto-juvenil do Instituto de Saúde Elpídio de Almeida, em Campina Grande, PB. Foram incluídos os adolescentes de 10 a 19 anos, portadores de obesidade e sobrepeso, atendidos entre maio e dezembro de 2011. A obesidade foi definida como índice de massa corporal >P97 e o sobrepeso >P85, para idade e sexo. O diagnóstico de litíase biliar foi dado por ultrassonografia. A frequência foi elevada (6,1%) e os principais achados no grupo de pacientes com litíase biliar foram a maior frequência no sexo feminino (75%), intolerância à gordura da dieta e média de perda de peso maior do que nos adolescentes sem litíase biliar. Portanto, litíase biliar deve ser investigada sistematicamente em adolescentes obesos na presença ou ausência de sintomas. São necessários novos estudos para definir a prevalência de litíase biliar e estudos prospectivos para melhor compreensão dos fatores de risco desta condição na obesidade infantil.
Salvador

CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior
The aim of the present study was to evaluate prospectively the influence of ursodeoxycholic acid (UDCA) administration in the prevention were cholelithiasis in the first six months after Roux-en-Y gastric bypass surgery. The data was collected through questionnaires which investigate demographic and anthropometric characteristics. Medical records were analysed to evaluate comorbidities as hepatic steatosis, gastroesophageal reflux disease, gastritis, Hypertension, cardiovascular disease, dyslipidemia, osteoarthritis and infertility. Therefore, 137 patients, with whom 69 were from Monsenhor Bruno Clinic (GROUP A) and 68 were from the Obesity Nucleus of Cearà (GROUP B), were sellected. The patients from GROUP A group received UDCA, while the patients from GROUP B, group did not received UDCA. The quantitative categorical results were presented as percentages and counts, and the numerical results were measured as central trend measures. Normality tests were performed for the numerical variables. According on the variables normality, ANOVA or Mann-Whitney tests were performed. For categorical variables, the chi-square test was performed. For paired variables, the McNemar test was applied. The odds ratio were calculated to measure the strength of association between UCDA exposure and the disease. P values up to 0.05 were considered significant. The data were analyzed using Statistical Package for the Social Sciences (SPSS), v23, SPSS, Inc.. There was no statistical significance in the formation or not of the cholelithiasis (p = 0.110) between GROUP A or GROUP B patients according to the naturality.The gender (p = 0.090) and marital status (p = 0.663) did not presented statistical significance either. In the GROUP A group, 68 (57,6%) did not developed cholelithiasis and 1 (5,3%) developed cholelithiasis. In the GROUP B group, 50 (42,4%) did not developed cholelithiasis, while 18 (94,5%) developed this disorder (OR= 24,4, IC95%= 3,1-189,4, p< 0,001). In the GROUP A group, 64 (92,6%) patients did not presented hepatic steatosis and 5 (7,4%) persisted with hepatic steatosis. In the GROUP B group, hepatic steatosis was not evidenced in 68 (100%) patients, however, it was significant to form cholelithiasis (p< 0,024). The others cormobities evalueted presented significative improvement. The results demonstrate that patients from NOC group, who had not received UDCA, had a higher chance of developing cholelithiasis when comparing with the patients from GROUP A group, who had received UDCA (OR= 24,4, IC95%= 3,1-189,4, p< 0,001).
Objetivo: No presente trabalho, objetivou-se avaliar prospectivamente a contribuiÃÃo do uso do Ãcido ursodesoxicÃlico (AUDC), nos primeiros 6 meses de pÃs-operatorio, na fase rÃpida de perda de peso, com o escopo de prevenir colelitÃase nos pacientes que se submetem à Bypass GÃstrico em Y de Roux. MÃtodo: Os dados foram coletados por meio de tÃcnicas de entrevistas e consultas aos prontuÃrio mediante a utilizaÃÃo de formulÃrios para investigaÃÃo de indicadores sÃcios demogrÃfico, antropomÃtricos e, as principais comorbidezes, esteatose hepÃtica, doenÃa do refluxo gastro-esfÃgico, gastrite, hipertensÃo arterial, doenÃa cardiovascular, dislipidemia, osteoartrite e infertilidade. Deste modo, fizeram parte, inscritas no protocolo, 137 pacientes, sendo 69 da ClÃnica Monsenhor Bruno (GRUPO A) e 68 pacientes do NÃcleo do Obeso do Cearà (GRUPO B-GRUPO CONTRÃLE). AnÃlise de Dados EstatÃsticos, foram apresentados os resultados quantitativos categÃricos em forma de percentuais e contagens e os numÃricos em forma de medidas de tendÃncia central. Foram realizados testes de normalidade para as variÃveis numÃricas. Dependendo da normalidade das variÃveis, foram feitos os testes de ANOVA ou Mann-Whitney, conforme adequado. Para categÃricas, foi utilizado o teste do qui-quadrado. Para variÃveis pareadas, do tipo antes e depois, foi utilizado o teste de McNemar. Foram calculadas razÃes de chances (odds ratio) para mensurar associaÃÃo dos determinantes com o desfecho principal. Foram considerados significativas as comparaÃÃes com valor de p atà 0,05.Os dados foram tabulados e analisados pelo software SPSS (Statistical Package for the Social Sciences), v23, SPSS, Inc. para anÃlise e avaliaÃÃo dos dados obtidos na coleta. Resultados: Segundo a amostragem sÃcio-demogrÃficas, comparando-se os pacientes GRUPO A e os do GRUPO B, quando se refere à naturalidade, observa-se que nÃo houve significÃncia estatÃstica na formaÃÃo ou nÃo da colelitÃase (p= 0,110), o mesmo observando-se quanto ao gÃnero, (p= 0,090) e tambÃm ao estado civil (p=0,663). Ressalta-se os resultados dos 69 pacientes do protocolo da GRUPO A que fizeram uso do AUDC, 68 (57,6%) pacientes nÃo desenvolveram colelitÃase, e sÃmente 1 (5,3%) paciente formou colelitÃase, jà os pacientes que compuseram o protocolo do GRUPO B 50 (42,4%) pacientes nÃo formaram colelitÃase, e 18 (94,5%) pacientes formaram colelitÃase (OR= 24,4, IC95%= 3,1-189,4, p< 0,001). Na apreciaÃÃo da esteatose hepÃtica no pÃs-operatÃrio os pacientes que usaram AUDC da GRUPO A registrou-se que 64 (92,6%) destes pacientes, nÃo apresentavam esteatose hepÃtica e 5 (7,4%) dos pacientes permaneciam com esteatose hepÃtica, jà no grupo do GRUPO B que nÃo fizeram uso 68 (100%) pacientes, nÃo evidenciou-se esteatose hepÃtica, mostrou significÃncia estatÃstica na formaÃÃo de colelitÃase (p< 0,024). As demais comorbidezes avaliadas, tiveram melhora com suas doenÃas controladas. ConclusÃo: Os resultados demonstrados deram suporte para concluir que os pacientes do protocolo do GRUPO B, que nÃo usaram o AUDC, evidenciaram uma probabilidade, confirmada pelo dado estatÃstico oddis ration de 24,4 vezes maior de desenvolverm colelitÃase, quando comparado com os pacientes que fizeram uso do AUDC do GRUPO A, com Ãndice de confianÃa de 95%, e p< 0,001, com relevÃncia significante (OR= 24,4, IC95%= 3,1-189,4, p< 0,001).

Незважаючи на розвиток нових методів діагностики та лікування жовчнокам'яної хвороби, хірурги продовжують зустрічатися з хворими, що страждають на це захворювання протягом десятиліть. У деяких з них розвиваються такі ускладнення, як зморщений жовчний міхур, синдром Міріззі, внутрішні жовчні нориці, обтураційна жовчнокам'яна кишкова непрохідність.

Orientador: Elinton Adami Chaim
Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas
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Resumo: Contexto: As lesões iatrogênicas da via biliar são de difícil manejo e requerem equipes com experiência para a reconstrução da via biliar. O objetivo desse estudo foi avaliar tardiamente os 21 anos de experiência em um centro de referência terciário das reconstruções bileodigestivas após a lesão iatrogênica da via biliar pós-colecistectomia e os fatores envolvidos na estenose da anastomose bileodigestiva. Métodos: Análise retrospectiva de 91 pacientes submetidos a hepaticojejunostomia em Y de Roux entre 1993 e 2013. Dados pré-operatórios, sintomas clínicos após a lesão, reoperações, classificação da lesão e evolução ambulatorial foram avaliados. O teste de qui-quadrado e a regressão logística foram usados para determinar os fatores envolvidos na estenose da anastomose bileodigestiva. Resultados: Mulheres eram 84,5% dos pacientes, média de idade de 43 anos. Foi observada associação entre fístula biliar e derivação bileodigestiva no serviço de origem (p=0,009). Colangite e sintomas clínicos no seguimento ambulatorial foram associadas com a classificação de Bismuth (p=0,008 e p<0,001). O aumento em uma unidade na aspartato aminotransferase em 12 meses de pós-operatório, aumentou a chance de apresentar sintomas clínicos no ambulatório em 4,8% (IC 95%=1,003-1,096). A derivação bileodigestiva no serviço de origem aumentou a chance de associação com fístula biliar em 5,9 vezes (IC 95%=1,132-31,142). Conclusão: A reconstrução da via biliar após a lesão iatrogênica no tratamento cirúrgico da colecistectomia deve ser realizado por cirurgiões experientes e, de preferência, em centros de referência terciário
Abstract: Background: Iatrogenic bile duct injuries are difficult to manage and require surgical teams with experience in bile duct repair. The aim of the study was to describe and correlate factors associated with biliary-enteric anastomosis stricture in a tertiary referral center. Methods: A retrospective analysis of 91 patients undergoing Roux-en-Y hepaticojejunostomy from 1993 to 2013 was carried out. Preoperative data, symptoms following injury, reoperations, classification of lesions and outpatient outcome were evaluated. The chi-square test and logistic regression were used to determine factors involved in biliary-enteric anastomosis stricture. Results: Women comprised 84.5% of patients (mean age: 43 years). An association between bile leakage and biliary-enteric anastomosis at the original health care facility (p=0.009) was observed. Cholangitis and symptoms in the outpatient facility were associated with Bismuth classification (p=0.008 and p<0.001). For each additional unit increase in aspartate aminotransferase values in the 12-month postoperative period, the likelihood of outpatient symptoms increased by 4.8% (95% CI=1.003-1.096). A biliary-enteric anastomosis performed at the original health care facility increased 5.9-fold the chance that a bile leakage was associated (95% CI=1.132-31.142). Conclusion: Bile duct reconstruction due to iatrogenic injury is challenging. To achieve success, repair must be performed by experienced surgeons in tertiary referral centers
Mestrado
Fisiopatologia Cirúrgica
Mestre em Ciências

В останні роки спостерігається збільшення кількості випадків ускладненого перебігу жовчнокам’яної хвороби, зокрема біліодигестивних нориць. При цитуванні документа, використовуйте посилання http://essuir.sumdu.edu.ua/handle/123456789/36433

A colelitíase é uma doença frequente na população geral. Um dos seus fatores de risco é a diabetes melitus tipo 2, relacionada à anormalidades metabólicas associadas a sobrepeso, obesidade, resistência à insulina, hipertrigliceridemia e hábitos dietéticos. Fatores de risco semelhantes são encontrados na doença hepática gordurosa não alcoólica (DHGNA). A DHGNA engloba um espectro de condições patológicas que pode evoluir da esteatose, para esteato-hepatite (EHNA), fibrose, cirrose e neoplasia hepática. A distinção entre esteatose e EHNA é de grande relevância na prática clínica, em virtude de a primeira ser uma condição benigna e reversível, enquanto que a segunda apresenta potencial evolutivo para cirrose e carcinoma hepatocelular. Somente a biópsia hepática pode classificar e estadiar a DHGNA. A DHGNA e a colelitíase têm similaridade quanto à patogênese e aos fatores de risco, o que nos motivou a realizar este estudo. Os objetivos do trabalho foram: a) Definir a frequência da esteatose hepática e da EHNA em pacientes com colelitíase submetidos à colecistectomia laparoscópica. b) Avaliar as alterações histopatológicas da DHGNA nos pacientes com colelitíase. c) Avaliar a acurácia dos exames de imagem-ultrassonografia abdominal (US) e tomografia computadorizada (TC) no diagnóstico da DHGNA. d) Relacionar aspectos clínicos, laboratoriais e de imagem com diagnósticos histopatológicos de esteatose e EHNA em portadores de colelitíase. e) Analisar variáveis preditivas da DHGNA na indicação da biópsia hepática para os pacientes com colelitíase a serem submetidos à colecistectomia laparoscópica. Método: Foi realizado estudo prospectivo sequencial de pacientes portadores de colelitíase com indicação cirúrgica que assinaram o termo de consentimento livre e esclarecido. Foram analisados 161 pacientes submetidos à colecistectomia laparoscópica e à biópsia hepática. Os pacientes foram avaliados quanto ao sexo, à idade, história clínica e aos antecedentes pessoais, com ênfase nas comorbidades relacionadas à síndrome metabólica. Foram realizadas as seguintes medidas antropométricas: peso (kg), altura (m) e circunferência abdominal (cm), sendo calculado o Índice de Massa Corpórea (IMC). Além da avaliação bioquímica, foram avaliados parâmetros metabólicos através da dosagem da glicemia e insulinemia de jejum, índice de HOMA IR e perfil lipídico. Os pacientes foram submetidos a dois USs em momentos distintos, nos quais foram avaliados a vesícula biliar, as vias biliares e os possíveis diagnósticos qualitativo e quantitativo da esteatose hepática. Na tomografia abdominal, foram medidos os coeficientes de atenuação hepática e esplênica. O diagnóstico de esteatose foi determinado através de dois índices: TC1 (e-h) calculado pela diferença entre o valor da atenuação esplênica e hepática e o TC2 (h/e) medido pela fração da atenuação hepática sobre a esplênica. Antes da colecistectomia laparoscópica com exploração de vias biliares, foi realizada biópsia hepática com agulha de tru-cut no mesmo tempo cirúrgico. Os parâmetros histopatológicos utilizados para avaliar as biópsias hepáticas foram: esteatose macrovesicular, esteatose microvesicular, infiltrado inflamatório acinar e portal, balonização hepatocelular, corpúsculos hialino de Mallory, alterações ductulares e fibrose perissinusoidal, perivenular, portal, sobrecarga de ferro e pseudoinclusão nuclear de glicogênio. Para o diagnóstico de EHNA, foi utilizado o escore de atividade da doença hepática gordurosa não alcoólica (NAS). Os 161 pacientes foram distribuídos em três grupos formados a partir do resultado da histopatologia hepática: Grupo A - colelitíase sem esteatose (n = 98), Grupo B - colelitíase com esteatose (n = 51) e Grupo C - colelitíase com esteatohepatite (n = 12). Resultados: Entre os 161 pacientes submetidos à colecistectomia com biópsia hepática, 63 (39,1%) eram portadores de DHGNA, dentre eles, 12/161 (7,4%) com EHNA. Cento e trinta e sete (85%) pacientes eram do sexo feminino; 125 (78%) eram brancos. A idade média global foi de 45 anos. A hipertensão arterial sistêmica esteve presente em 40 (25%), diabetes mellitus tipo 2 em 17 (11%) e a síndrome metabólica em 39 (24%). Os aspectos clínicos, laboratoriais e comorbidades que apresentaram diferença estatística significantes entre o grupo A e os grupos B e C foram: idade, IMC, circunferência abdominal, glicemia em jejum, ALT. A síndrome metabólica, a resistência insulínica, diabetes mellitus tipo 2, AST e o colesterol total registraram diferença estatisticamente significante apenas entre os grupos A e C. Não existiram aspectos clínicos, laboratoriais ou de comorbidades que diferenciaram os portadores de esteatose e EHNA. Os exames de US I e II nas duas ocasiões revelaram sensibilidade de 57% e 59%, especificidade de 91% e 90%, respectivamente, e em ambos USs a acurácia foi de 78%. No exame de TC, o índice e o nível de corte de maior sensibilidade (50%), especificidade, (90,72%) e acurácia (74,53%) foi o índice TC 2 (h/e), com nível de corte menor que 1,0 para o diagnóstico da DHGNA. Os parâmetros histopatológicos que apresentaram diferença estatística significante entre os grupos A e C e entre os grupos B e C foram: corpúsculos hialino de Mallory, infiltrado inflamatório portal e fibrose perivenular, perissinusoidal e portal. Houve maior grau de intensidade do infiltrado inflamatório portal nos pacientes do grupo C. Houve diferença estatística significante entre os grupos B e C com relação à esteatose microvesicular e a pseudoinclusão nuclear de glicogênio. Pela regressão logística, foi avaliada a probabilidade de os pacientes portadores de colelitíase apresentarem DHGNA. Os fatores preditivos foram: aumento da glicemia, HOMA-IR, colesterol total, circunferência abdominal e esteatose ao US. Na presença de três ou quatro destes fatores de risco a probabilidade de DHGNA foi de 91%. Conclusão: A prevalência de EHNA em pacientes com colelitíase foi de 7,4% neste grupo de pacientes Assim, é de fundamental importância o reconhecimento dos fatores de risco para a DHGNA em pacientes com colelitíase que serão submetidos à intervenção cirúrgica. Assim sendo, a biópsia hepática durante o procedimento cirúrgico deve ser preconizada na vigência de fatores preditivos, pois é o único método para diferenciar esteatose de EHNA
Cholelithiasis is a very common disease in the population at large, and one of the risk factors is type II diabetes mellitus, which is related to metabolic disorders associated with overweight, obesity, insulin resistance, hypertriglyceridemia and dietary abnormalities. Similar risk factors are found in non-alcoholic fatty liver disease (NAFLD). NAFLD covers a spectrum of pathological conditions that can range from steatosis to steatohepatitis (NASH), fibrosis, cirrhosis and even liver cancer. The distinction between steatosis and NASH is of great importance in clinical practice because the former is a benign, reversible condition whereas the latter can progress to cirrhosis and hepatocellular carcinoma. Only a liver biopsy, however, can be used to classify and stage NAFLD. NAFLD and cholelithiasis have similar pathogenesis and risk factors, a fact which led us to undertake this study, the aims of which were: a) to define the frequency of hepatic steatosis and NASH in patients with cholelithiasis undergoing laparoscopic cholecystectomy; b) to assess the accuracy of abdominal ultrasound imaging (US) and computed tomography (CT) in the diagnosis of NAFLD; c) to assess histological alterations caused by NAFLD in patients with cholelithiasis; d) to relate clinical, laboratory and imaging findings to histopathological diagnoses of steatosis and NASH in cholelithiasis; and e) to analyze predictors of NAFLD used when referring patients with cholelithiasis already scheduled for laparoscopic cholecystectomy for liver biopsy as well. Methods: We performed a prospective sequential study of patients with cholelithiasis who had been referred for surgery and had signed a voluntary informed-consent form. A total of 161 patients were analyzed after they had undergone a laparoscopic cholecystectomy and liver biopsy. Besides sex and age, clinical and medical history were recorded, with emphasis being placed on comorbidities related to metabolic syndrome. The anthropometric measurements weight (kg), height (m) and abdominal circumference (cm) were recorded during the physical examination and the body mass index was calculated. Biochemical and metabolic assessment parameters, including fasting blood sugar and fasting insulin, which were used to calculate the HOMA-IR index, and fasting lipid profile, were evaluated. Patients had two ultrasounds at different times to assess the gallbladder and bile ducts as well as the quantitative and qualitative diagnosis of hepatic steatosis. In the abdominal tomography, the attenuation coefficients of the liver and spleen were measured for diagnosis of steatosis based on two indices: CT1 (S-L), given by the difference between spleen and liver attenuations, and CT2 (L/S), given by the attenuation of the liver divided by the attenuation of the spleen. Before laparoscopic cholecystectomy with bile duct exploration, a liver biopsy with a tru-cut was performed. The following histological parameters were used to evaluate the liver biopsies: macrovesicular steatosis, microvesicular steatosis, acinar and portal inflammatory infiltrate, hepatocellular ballooning, Mallory bodies, ductal changes, perisinusoidal, perivenular and portal fibrosis, iron overload and glycogenated nuclei. The NAFLD activity score was used to diagnose NAFLD in the steatosis or NASH phases. A comparative analysis of the 161 patients was carried out after they had been divided into three groups according to the results of the liver histopathology: group A cholelithiasis without steatosis (n=98), group B - cholelithiasis with steatosis (n=51) and group C - cholelithiasis with NASH (n=12). Results: Of the 161 patients subjected to cholecystectomy with a liver biopsy, 63 (39.1%) had NAFLD, of whom 12 (7.4%) also had NASH. A total of 137 (85%) of the patients were female, and 125 (78%) were Caucasian. Average age was 45 years. Arterial hypertension was observed in 40 (25%) patients, 17 (11%) had diabetes mellitus and 39 (24%) had metabolic syndrome. The clinical and laboratory findings with a statistically significant difference between group A and/or groups B and C were age, BMI, abdominal circumference, fasting blood sugar, total cholesterol, ALT and AST. Metabolic syndrome, insulin resistance and diabetes mellitus only exhibited a statistically significant difference between groups A and C. There were no clinical or laboratory findings or image abnormalities that differentiated steatosis from NASH. The first and second ultrasounds, which were carried out at different times, had sensitivities of 57% and 59% and specificities of 91% and 90%, respectively; both had accuracies of 78%. In the computed tomography, the index with the greatest sensitivity (50%), specificity (90.72%) and accuracy (74.53%) was CT2 (L/S), with a cutoff level of 1.0 for diagnosis of NAFLD. The histopathological parameters with statistically significant differences between the group without steatosis and group C and between groups B and C were Mallory bodies, portal inflammation and perivenular, perisinusoidal and portal fibrosis. Portal inflammation was more intense in patients in group C. There was a statistically significant difference in the intensity of macrovesicular steatosis between groups B and C; this was mild in 42 (82.4%) of the patients in the former group and in only 2 (3.9%) in the latter. There was a statistically significant difference in microvesicular steatosis and glycogenated nuclei between groups B and C. Logistic regression revealed that the associated risk factors for determining the probability of patients with cholelithiasis having NAFLD are increased values of blood glucose, HOMA-IR, total cholesterol abdominal circumference and steatosis on ultrasound. In the presence of three or four risk factors the probability of NAFLD was 91%. Conclusion: The prevalence of NASH in cholelithiasis patients was 7.4%, indicating that NAFLD is a serious problem in this group of patients. It is therefore very important to determine the risk factors for NAFLD in cholelithiasis patients who will be submitted to surgery in order to decide whether a liver biopsy should be performed, as this is the only diagnostic method for differentiating between steatosis and NASH

Biliary lithiasis is a metabolic disease that many risk factors participate of the etiopathogeny, and potentialize an eventual genetic condition. Prevalence in the western countries is about 10-15% of adults, being an important public health trouble. There is no knowledge about its pathogenesis yet, that can be associated to an unusual metabolism of cholesterol and lipoproteins. This study had aims to verify the relationship between serum and biliary levels of protein, cholesterol and calcium in patients with gallstones and gallbladder polip; identify if there is difference between laboratorial serum and biliary concentration of this elements in these two groups; study laboratorial serum and biliary profile in gallstones patients through of protein, cholesterol and calcium levels. This transversal study had two groups: a 41 gallstones patients and a 15 gallbladder polip patients as control group. Everyone was submitted to a videolaparoscopic cholecystectomy, when they had been taken blood and bile samples to be analyzed. In the blood was measured cholesterol total, LDL, HDL fractions, triglycerides, calcium total and protein total. In the bile was measured cholesterol total, calcium total and proteins. Statistical analysis was composed by use of F - test to normal distribution, Levene test to abnormal distribution. Student s t - test to medias comparison, analysis of variance of factor and Pearson correlation test p<0,05 was considered significant. It was found a stronger correlation between three elements measured in gallstone group. In polip group was found a strong correlation between calcium and protein biliary. There is no correlation between serum and biliary elements in gallstone group: calcium, cholesterol, LDL, HDL. Polip group had correlation between biliary protein and LDL serum, calcium biliary and HDL serum.With exception of protein and calcium biliary, more elevated in polip patients, every elements had statistics medias equals. Conclusions: there was no correlation between lipids elements bilia ries and serum in both studied groups; the medias of biliary and serum contents were statistically the same, with exception of protein and calcium biliary, had more elevated levels in polip group. The profile of serum and biliary elements was similar in both groups except for the biliary protein and of the triglycerids that presents some difference.
Litiáse biliar é uma doença metabólica, de cuja etiopatogenia participam vários fatores de risco, que potencializam uma eventual condição genética. A prevalência nos países ocidentais atinge 10 a 15% da população adulta, produtiva, configurando um importante problema de saúde pública. Não se tem ainda um total esclarecimento sobre sua patogênese, que pode estar associada a anormalidades no metabolismo do colesterol e das lipoproteínas. Este trabalho teve como objetivos verificar se há relação entre níveis séricos e biliares da proteína, do colesterol e do cálcio em portadores de colelitíase e de pólipo da vesícula; identificar se há diferença entre os valores laboratoriais séricos e biliares desses elementos obtidos nos dois grupos; estudar o perfil laboratorial sérico e biliar de pacientes portadores de colelitíase, a partir dos elementos supracitados. Esse estudo transversal envolveu 41 pacientes com colelitíase e 15 com pólipos da vesícula biliar como grupo de controle. Todos se submeteram a colecistectomia videolaparoscópica e tiveram amostras de sangue e bile colhidas para análise. Foram dosados no sangue: colesterol total, LDL, HDL, triglicérides, cálcio total e proteínas totais. Na bile dosaram-se: colesterol total, cálcio total e proteínas. A análise estatística consistiu na aplicação do teste F para distribuição normal e de Levene para distribuição não normal, teste t de Student para comparação das médias, análise de variância de um fator e teste de correlação de Pearson. Considerou-se um nível de significância p<0,05. Foram encontradas correlações fortíssimas entre os três elementos biliares pesquisados no grupo de cálculo. No grupo de pólipo houve correlação forte entre proteína e cálcio biliares. Constatou-se a inexistência de correlação, no grupo de cálculo, entre os elementos biliares e os séricos: cálcio, colesterol, LDL e HDL. No grupo de pólipo, houve correlação forte entre proteína biliar e LDL sérico, cálcio biliar e HDL sérico. Com exceção da proteína e do cálcio biliares, mais elevados nos pacientes com pólipo, todos os elementos biliares e séricos dosados tiveram médias estatisticamente iguais. Chegou-se às seguintes conclusões: não houve correlação entre os elementos lipídicos biliares e séricos nos dois grupos estudados; a média dos constituintes biliares e séricos foi estatisticamente igual, com exceção da proteína e do cálcio biliares, que tiveram níveis mais elevados no grupo de pólipo. O perfil dos elementos séricos e biliares foi semelhante nos dois grupos, exceto a proteína biliar e os triglicérides, que apresentaram diferença.

Este trabalho teve como meta principal ampliar o estudo anteriormente relatado por Mercuri em 2000, agora com a caracterização química e termoanalítica de cálculos biliares e as biles vesiculares humanas, especificamente, de pacientes do sexo masculino. Para ambos os tipos de caracterização foram utilizadas várias técnicas, como: (a) Análise Elementar (AE), para determinação de teores de C, H e N. (b) Espectroscopia no infravermelho com transformada de Fourier (FTIR), com o objetivo de verificar as bandas de absorção no IV e assim identificar algumas substâncias que fazem parte desses materiais. (c) Difratometria de Raios X (DRX), para identificar formações cristalinas de espécies presentes nas amostras de cálculos biliares. (d) Espectrometria de Absorção Atômica (AAS), para a determinação do teor de alguns metais como por exemplo: Cd, Pb e Cu. (e) Ressonância Magnética Nuclear (RMN), para ratificar a presença de colesterol e afastar a hipótese de ter-se ergosterol na amostra e (f) TG/DTG e DSC aplicadas para o estudo do comportamento térmico das amostras de cálculos biliares e biles. Este trabalho permitiu concluir que: alguns tipos de cálculos biliares do universo de pacientes do sexo masculino que foram estudados puderam ser inseridos na classificação proposta anteriormente, no entanto, cinco dessas amostras não se encaixaram em nenhum desses grupos, sugerindo, com isso, a adição de novos grupos. Verificou-se, também, que a porcentagem de cálculos biliares formados por colesterol é menor para essa classe de pacientes. Em duas amostras de cálculos biliares encontrou-se CaCO3 cristalizado como aragonita, outra indicou a presença de fosfato de cálcio e em duas dessas amostras foram encontrados um alto teor de chumbo. No caso das biles, seis amostras indicaram a presença de NaCl (halita) e uma delas indicou, também, a presença de colesterol.
This work had as goal main to enlarge the study previously related for Mercuri in 2000, now with the chemical and thermoanalytical characterization of gallstones and the human vesicular bile, specifically, of patient of the masculine sex. For both the kinds of characterization were used several techniques, as: (a) Elementary analysis (AE), for contents determination of C, H and N. (b) Fourier Transform Infrared Spectroscopy (FTIR), with objective of verifying the absorption bands in the IV and thus identify some substances that do part of these materials. (c) X-rays diffraction (DRX), to identify present crystalline species formations in the gallstones sample. (d) Atomic Absorption Spectrometry (AAS), for some metals content determination such as: Cd, Pb and Cu. (e) Nuclear Magnetic resonance (RMN), to ratify the cholesterol presence and to remove the hypothesis of have ergosterol in the sample and (f) TG/DTG and DSC applied to the gallstones and bile samples thermal behavior study. This work allowed to conclude that: some universe gallstones kinds of patient of the masculine sex that were studied could be inserted in the proposed classification previously, however, five of these samples did not case in none of these groups, suggesting, with that, the addition of new groups. It verified, also, that the gallstones percentage formatted for cholesterol is smaller for this class of patient. In two gallstones samples were found CaCO3 crystallized as aragonite, other indicated the calcium phosphate presence and in two of these samples were found a Pb high content. In the biles case, six samples indicated presence of NaCl (halita) and their one indicated, also, the cholesterol presence.

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Introduction: Cholelithiasis is very prevalent surgical disease, with approximately 60,000 admissions per year in the Unified Health System in Brazil (Sistema Único de Saúde - SUS). Is often asymptomatic or oligosymptomatic and major complications arise from the migration of calculi to biliary low tract. Despite these complications are severe and life threatening, many patients refuse surgical treatment. Objectives: To understand the reasons why individuals with cholelithiasis refuse cholecystectomy before complications inherent to the presence of gallstones in the bile duct and pancreatitis occur. Methods: To investigate the justifications for refusing to submit to surgery we performed individual interviews according to a predetermined script. In these interviews, we evaluate the degree of knowledge of individuals about the disease and its complications and the reasons for the refusal of surgical treatment. We interviewed 20 individuals with cholelithiasis who refused or postponed surgical treatment without a plausible reason. In these interviews, we apply the thematic analysis (MINAYO, 2006). Results: The majority of participants has good knowledge of their disease and its possible complications, were well oriented and had the right surgical indications by their physicians. The refusal for surgery is based primarily on negative experiences of themselves or family members with surgery, including anesthesia; unexplained fears of surgery and, some, cannot specify the reason for the denial or prefer to get the risk and wait for complications to then have to solve them compulsorily. Conclusions: The reasons for the refusal to surgical resolution of cholelithiasis are diverse, but are closely related to personal negative surgical experiences or related persons or complex problems of psychological nature that must be adequately addressed by the surgeon and other qualified professionals. Our study has the proposal of an informed consent that brings all the information about the surgery, its preoperative and postoperative risks, as well as figures with friendly format intended to inform and to help the patients in their decisions
Introdução: A colelitíase é uma doença de resolução cirúrgica muito prevalente, com aproximadamente 60.000 internações por ano no SUS. Muitas vezes é assintomática ou oligossintomática e as principais complicações advêm da migração dos cálculos para as vias biliares baixas. Apesar das complicações serem graves e com risco de morte, muitos pacientes se recusam ao tratamento cirúrgico. Objetivos: Entender as razões pelas quais os indivíduos com colelitíase recusam a colecistectomia antes que ocorram complicações inerentes à presença de cálculos na vesícula, nas vias biliares e a possível pancreatite. Métodos: Para conhecer as justificativas da recusa à cirurgia realizamos entrevistas individuais segundo um roteiro de perguntas pré-determinadas. Nestas entrevistas procuramos avaliar o grau de conhecimento dos indivíduos sobre a doença e suas complicações e as razões para a recusa do tratamento cirúrgico. Entrevistamos 20 indivíduos portadores de colelitíase que se recusavam ou adiavam sem uma justificativa plausível o tratamento cirúrgico. A estas entrevistas aplicamos a análise temática (Minayo, 2006). Resultados: A grande maioria dos entrevistados tem bom conhecimento de sua doença, das possíveis complicações, foram bem orientados e tiveram a indicação cirúrgica pelos seus médicos assistentes. A recusa para a cirurgia foi baseada (principalmente) em experiências negativas próprias ou de familiares com o ato cirúrgico, incluindo aí a anestesia; medos inexplicáveis do ato cirúrgico e alguns não conseguiram especificar a razão para a recusa, preferiram correr o risco e esperar pelas complicações para então ter que resolvê-las. Conclusões: As razões para a recusa à resolução cirúrgica da colelitíase são diversas, mas estão intimamente ligadas às experiências cirúrgicas negativas pessoais ou de pessoas relacionadas ou a complexos problemas de natureza psicológicas que devem ser adequadamente abordados pelo cirurgião e por outros profissionais habilitados. Nosso estudo faz a proposta de um termo de consentimento livre e esclarecido que traz todas as informações sobre a cirurgia, seus riscos pré e pós-operatório assim como figuras com formato amigável que pretendem informar e ajudar o paciente na sua decisão.

INTRODUÇÃO: Cerca de 20% da população é portadora de colelitíase, sendo esta afecção a principal causa abdominal de internação hospitalar em países desenvolvidos. Considerando-se que somente nos Estados Unidos são realizadas cerca 700.000 colecistectomias a cada ano, pode-se estimar a importância do problema para a saúde pública. A diminuição do número de incisões tem o potencial de reduzir o trauma cirúrgico e oferecer melhor resultado estético. OBJETIVOS: Descrever técnica de colecistectomia laparoscópica com duas incisões (CL2i) utilizando apenas material convencional, sem aumentar complicações, nem tempo operatório, oferecendo a mesma segurança da colecistectomia videolaparoscópica convencional. MÉTODO: Série prospectiva de casos consecutivos, comparada a outra série histórica de casos operados pela técnica laparoscópica convencional (CLC). A CL2i foi realizada com 3 portais em 2 incisões, sendo dois na incisão umbilical e outro no epigástrio. Foram operados 72 pacientes (36 em cada grupo) pelo mesmo cirurgião. RESULTADOS: Não houve diferença estatística entre os grupos quanto sexo, média de idade, índice de massa corpórea (IMC) e tempo de internação. Os procedimentos foram classificados pelo cirurgião de acordo com o grau de dificuldade e não houve diferença entre as séries (p < 0,05). Ocorreram complicações menores em 5,6% (n = 2) procedimentos em cada grupo. Não houve diferença entre as médias de tempo operatório (p= 0,989), que foram de 49 (IC95% 42 a 56) min na CLC e 40 (IC95% 35 a 44) min na CL2i. Não houve necessidade de portais adicionais em nenhum caso, nem de conversão para cirurgia aberta. CONCLUSÕES: A técnica de colecistectomia laparoscópica com duas incisões (CL2i) é factível, segura e com bom resultado estético, permitindo operar utilizando apenas instrumental laparoscópico convencional, sem aumentar tempo operatório ou risco de complicações
INTRODUCTION: About 20% of the population has cholelithiasis and this is the main abdominal cause of hospitalization in developed countries. Considering that only in the United States about 700,000 cholecystectomies are done each year, it is possible to estimate the importance of the problem for public health. Decreasing the number of incisions can reduce surgical trauma and offer better aesthetic results. OBJECTIVE: To describe a two-incision laparoscopic cholecystectomy technique (TILC) using only conventional material, without increasing complications, nor operative time, offering the same safety as conventional laparoscopic cholecystectomy. METHOD: A consecutive and prospective case series, compared to another historical series operated by conventional laparoscopy cholecystectomy (LC). The TILC was performed with 3 trocars in 2 incisions, two trocars in umbilical incision and one in epigastrium. A total of 72 patients were operated on by the same surgeon (36 in each group). RESULTS: There were no significant differences between groups for gender, mean age, body mass index (BMI) or length of hospital stay. The procedures were classified by the surgeon according to surgical difficulty and there was no difference between the series (p < 0.05). There were minor complications in 5.6% (n = 2) procedures in each group. There were no differences between means of operative time (p = 0.989), which were 49 (95% CI 42 to 56) min in LC and 40 (CI 95% 35 to 44) min in TILC. There was no need for additional portals in any case, nor for conversion to open surgery. CONCLUSIONS: Two-incision laparoscopic cholecystectomy (TILC) is feasible, safe and with good aesthetic result, using the same instruments of LC, without increasing operative time or complications

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Background Outstanding, among the factors associated to cholelithiasis after bariatric surgery, are those related to metabolism and synthesis of lipoproteins, such as apolipoprotein E (ApoE) and protein from cholesterol ester transfer protein (CETP). Methods - 220 patients have been part of the study, 114 (G1) with cholelithiasis postoperatively and 106 (G2) without cholelithiasis in over 8 months period, including the analysis of apoE-Hha I and CETP-TaqIB polymorphisms per PCR / RFLP and biochemical profile [total cholesterol (TC), lipoprotein cholesterol fraction of low (LDL), high (HDLc) and very low density (VLDLc), triglycerides (TG) and glucose levels. It was accepted level of significance for P <0.05. Results - Preoperatively, it was observed that in G1 54% of the patients with the APOE*4 allele had serum altered levels of LDL. Postoperatively, there was a decrease (P <0.001) of LDL with TG in G2 (85.3 ± 32.1 mg / dL, P <0.0001) and glucose (G1 = 83.2 ± 10.7 mg / dL; G2 = 84.7 ± 11.5 mg / dL, P <0.0001 for both), TC and LDL and HDL cholesterol increased only in G2 (P <0.0001). The B1 allele was related to decreased (P <0.01) of TC, LDLc and TG postoperatively in both groups, in addition to lowering glucose levels and increase HDL cholesterol only in G2 (P <0.0001). The genotype APOE*_/4 in G2 was associated with decreased levels of TC, LDL, TG and glucose levels and increased levels of HDL cholesterol (P<0.01) postoperatively. Conclusions - This study does not confirm the association of apoE-Hha-I and CETP-TaqIB with gallstones in the late postoperative period after bariatric surgery. However, B1 allele seems to enhance the action of bariatric surgery in the control of dyslipidemia effectively reducing levels of TC, LDL and TG, with additional benefit to those without gallstones by decreasing blood glucose levels and also increase HDL cholesterol. The relationship of APOE*4 with increased LDLc preoperatively only in G1 suggests its association with cholelithiasis in the late postoperative bariatric surgery, which should be evaluated in prospective studies.
Introdução- Destacam-se entre os fatores associados à colelitíase após cirurgia bariátrica, aqueles relacionados a metabolismo e síntese de lipoproteínas plasmáticas, como apolipoproteína E (apo E) e proteína de transferência do éster de colesterol (CETP). Objetivos-Avaliar a associação das variantes genéticas apoE-Hha I e CETP-TaqIB na colelitíase e sua influência no perfil bioquímico,além de perfil antropométrico e co-morbidades em pacientes com obesidade mórbida após cirurgia bariátrica. Métodos- Foram estudados 220 pacientes: 114 (G1) com colelitíase no pós-operatório e 106 (G2) sem colelitíase, em período >8 meses, incluindo a análise dos polimorfismos apoE-HhaI e CETP-TaqIB por PCR/RFLP e perfil bioquímico [colesterol total (CT), fração de colesterol de lipoproteína de baixa (LDLc), alta (HDLc) e muito baixa densidade (VLDLc), triglicérides (TG) e glicemia], além do índice de massa corporal (IMC), cintura abdominal (CA), hipertensão e diabete melito. Admitiu-se nível de significância para P<0,05. Resultados- Houve semelhança entre os grupos para os genótipos de apoE-HhaI e CETP-TaqIB. O genótipo APOE*3/3 prevaleceu em ambos os grupos (G1: 65% e G2:73%; P=0,204), enquanto genótipos APOE*_/4 destacaram-se em G1 (23% versus 16%; P=0,269). Para CETP o alelo B1 prevaleceu em G1 (0,59) e G2 (0,62; P=0,558). O perfil bioquímico, com valores recomendados já no pré-operatório em ambos os grupos, exceto para TG (141,4±75,4; 159,3±90,9mg/dL, respectivamente, P=0,123) e glicemia (113,0±53,2; 105,8±34,3mg/dL, respectivamente; P=0,262), mostrou decréscimo (P<0,001) no pós-operatório para todas as variáveis, incluindo TG (respectivamente, 89,0±34,6mg/dL; 85,3±32,1mg/dL; P<0,0001 para ambos) e glicemia (respectivamente, 83,2±10,7mg/dL; 84,7±11,5mg/dL; P<0,0001 para ambos). Níveis de HDLc mostraram acréscimo no pós-operatório apenas em G2 (52,5±14,7 versus 43,0±11,9; P<0,0001). Em G1, 54% dos pacientes portadores do alelo APOE*4 tinham níveis séricos alterados de LDLc no pré-operatório. O genótipo APOE*3/3, em G1, associou-se com decréscimo nos níveis de CT, LDLc, TG e glicemia e aumento nos níveis de HDLc (P<0,01). O mesmo ocorreu para genótipos APOE*_/4, em G2. O alelo B1 relacionou-se com decréscimo (P<0,01) de CT, LDLc e TG no pós-operatório em ambos os grupos, além de redução de glicemia e aumento de HDLc apenas em G2 (P<0,0001).Ambos os grupos mostraram redução nos valores de IMC e CA, além de hipertensão e diabete melito. Conclusões: Variantes de apoE-HhaI e CETP-TaqIB não diferenciam os grupos com e sem colelitíase no pós-operatório tardio de cirurgia bariátrica. Presença de APOE*4 relacionada com aumento de LDLc no pré-operatório, sugere sua influência no desenvolvimento de colelitíase no pós- operatório tardio, a ser confirmado em estudos prospectivos. CETP-Taq IB, representado pelo alelo B1 parece potencializar a ação da cirurgia bariátrica no controle do perfil bioquímico, particularmente em G2 com aumento de HDLc e decréscimo da glicemia. Além disso, independente da presença de colelitiase, a cirurgia bariátrica controla também doenças crônicas como diabete melito e hipertensão arterial.

Хвороби, пов’язані з біомінералізацією (ХПБ) можна визначити як захворювання, при яких відбувається формування біомінеральних депозитів, що мають суттєвий вплив на їх перебіг і прогноз. До цих нозологій відносяться холе-, нефро-, сіало-, панкрео-, простатолітіаз, атерокальциноз судин та серцевих клапанів, кальцифікація при онкологічних хворобах щитоподібної залози, матки та інших локалізацій. Більшість хвороб, пов’язаних з біомінералізацією, мають своїм наслідком утворення патологічних біомінералів кальцій-фосфатної природи. Причини, які ведуть до зростання поширеності ХПБ, надзвичайно різноманітні та різнопланові: екологічні, соціально-економічні, кліматичні, порушення обміну речовин.
Болезни, связанные с биоминерализацией (БСБ) можно определить как заболевания, при которых происходит формирование биоминеральных депозитов, которые имеют существенное влияние на его течение и прогноз. К этим нозологиям можно отнести холе, нефро-, сиало-, панкрео-, простатолитиаз, атерокальциноз сосудов и сердечных клапанов, кальцификация при онкологических болезнях щитовидной железы, матки и других локализаций. Большинство болезней, связанных с биоминерализацией, имеют своим следствием образования патологических биоминералов кальций-фосфатного природы. Причины, ведущие к росту распространенности БСБ, чрезвычайно разнообразны и разноплановы: экологические, социально-экономические, климатические, нарушения обмена веществ.
Diseases associated with biomineralization (DAB) are diseases with biomineral deposits formation, which have a significant impact on the disease course and prognosis. These nosologies include hole-, nephro-, sialo-, pancreo-, prostatolithiasis, vessels and heart valve atherocalcinosis, calcification in the case of cancer diseases of the thyroid gland, uterus and of other locations. Most of diseases associated with biomineralization result in formation of pathological biominerals of calcium phosphate nature. Reasons, which lead to increased prevalence of DAB, extremely vary: environmental, social, economic, climatic, metabolic diseases.

Pacientes com retocolite ulcerativa inespecífica,quando submetidos à colectomia, apresentam aumento na freqüência de cálculos vesiculares de colesterol. A hipomotilidade da vesícula biliar tem sido apontada como um importante fator na formação dos cálculos vesiculares de colesterol, ao lado da supersaturação biliar de colesterol e da nucleação dos cristais de colesterol (fatores nucleantes e antinucleantes). A estase vesicular aumenta o tempo de reabsorção de água pela mucosa da vesícula biliar com conseqüente superconcentração dos solutos, além de gerar o tempo necessário para a nucleação do colesterol, retenção e fusão dos cristais e,finalmente,formação dos cálculos. Embora a composição biliar já tenha sido estudada em pacientes colectornizados, não há informações sobre o comportamento da motilidade da vesícula biliar em pacientes com retocolite ulcerativa inespecífica com e sem colectomia. No presente trabalho,o esvaziamento vesicular foi estudado através do método ultra-sonográfico e após ingestão de dieta líqüida gordurosa em indivíduos controles (n=40), pacientes com retocolite ulcerativa inespecífica sem (n=30) e com colectomia (n =20). Como o esvaziamento gástrico pode interferir no vesicular, o tempo de esvaziamento gástrico, medido por método ultra-sonográfico, foi calculado nos três grupos. O esvaziamento vesicular foi significantemente diminuído nos pacientes com retocolite ulcerativa inespecífica com colectomia e após estímulo alimentar: esta alteração não foi conseqüência de esvaziamento gástrico retardado pois o tempo de esvaziamento gástrico foi semelhante nos três grupos. Ademais, a redução da motilidade vesicular nos pacientes colectomizados relacionou-se com a colectomia propriamente dita, uma vez que indivíduos controles e pacientes com retocolite ulcerativa inespecífica sem colectomia apresentaram esvaziamentos vesiculares semelhantes. Além disso,os resultados desta investigação reforçam a relevância do papel da motilidade vesicular na colelitíase e sua participação, juntamente com a diminuição do \"pool\" de ácidos biliares,na patogênese da calculo se vesicular de colesterol em pacientes com retocolite ulcerativa inespecífica submetidos à colectomia.
Patients with ulcerative colitis, who have their colon removed, are at increased risk of developing cholesterol gallstones. Gallbladder hypomotility has been quoted as being an important factor for cholesterol gallstone formation, together with biliary supersaturation of cholesterol and nucleation of cholesterol crystals (nucleating and antinucleating factors). Gallbladder stasis increases the time for water reabsorption by the gallbladder mucosa with ensuing solute superconcentration; moreover, gallbladder stasis renders enough time for cholesterol nucleation. crystal retention and fusion, and finally, stone formation. Although bile composition, in these patients, has already been studied, there is no information concerning the nature of gallbladder motility in patients with ulcerative colitis with or without colectomy. ln the present work, gallbladder emptying was studied by means of ultrasound examination, and after ingestion of a standard liquid fatty meal in controls (n=40), ulcerative colitis patients without colectomy (n=30) and with colectomy (n=20). Also, in order to rule out the influence of gastric emptying on gallbladder motility, the gastric emptying time was calculated, in the three groups, using the ultrasound method. Gallbladder emptying was significantly impaired in patients with ulcerative colitis with colectomy after a fatty-meal stimulus. and this abnormality was not a consequence of delayed gastric ernptying. since gastric emptying time was similar in the three groups. Furthermore. impaired gallbladder motility in ulcerative colitis patients with colectomy was related to the colectorny itself, since controls and ulcerative colitis

UVOD. Bilijarna kalkuloza je najčešće oboljenje hepatobilijarnog sistema, a holecistektomija predstavlja jedan od najčešće izvođenih operativnih zahvata. Laparoskopska holecistektomija je danas zlatni standard lečenja holelitijaze. Laparoskopska holecistektomija je pokazala poboljšanje u klinički značajnim ishodima kao što su skraćenje operativnog vremena, kraća hospitalizacija, smanjenje jačine i trajanja postoperativnog bola i brži povratak dnevnim i radnim aktivnostima. Postoperativna bol i vreme potpunog oporavka ostaju dva glavna problema posle nekomplikovane laparoskopske holecistektomije koje bi trebalo poboljšati. Bol koji je povezan sa laparoskopskom holecistektomijom je kompleksan i multifaktorijalan. On nastaje oštećenjem tkiva, disekcijom i uklanjanjem žučne kesice iz svoje lože, stimulacijom periportalnih nerava, iritacijom dijafragme, mehaničkim i hemijskim interakcijama gasa i pneumoperitoneuma, incizijama portova. Istraživanja su označila parijetalni i visceralni bol kao dva glavna mehanizma nastanka bola kod laparoskopske holecistektomije. Bol se ne može meriti nego proceniti jer je subjektivni osećaj. Pokazalo se potrebnim da se na čvršćim naučnim osnovama da odgovor na pitanje da li je moguće blokirati parijetalni i visceralni bol posle laparoskopske holecistektomije u akutnoj fazi. CILJEVI. Cilj studije je da uporedi standardnu analgeziju (ne-opioidnu) (grupa O) sa davanjem parijetalne blokade (grupa P), ili davanjem visceralne blokade (grupa V), ili sa obe date blokade (grupa P+V). Primarni ishodi studije su bolesnikov procenjeni bol pre operacije i posle operacije na 1, 2, 4, 6, 12, 24, 48 sati i 7. dana. Sekundarni ishodi studije su bolesnikova procenjena mučnina na 1,2,4,6,12 sati i bolesnikova procenjena mobilnost 1. 2. i 7. dan. HIPOTEZA. Blokada postoperativnog visceralnog bola i blokada postoperativnog parijetalnog bola posle laparoskopske holecistektomije putem intraperitonealne lokalne infiltracije anestetikom i putem lokalne infiltracije anestetikom pristupnih laparoskopskih portova može značajno smanjiti rani postoperativni bol. MATERIJAL I METODE. Ova prospektivna, randomizirana jednostruko slepa studija je započela septembra 2014. godine i trajala je do januara 2016. godine. Istraživanje je sprovedeno na Klinici za abdominalnu, endokrinu i transplantacionu hirurgiju i Urgentnom centru Kliničkog centra Vojvodine u Novom Sadu kod bolesnika operisanih metodom laparoskopske holecistektomije. Rad je podeljen u nekoliko celina. 1. Procena veličine uzorka; 2. Procena podobnosti za studiju; 3. Anketiranje i uključivanje u studiju; 4. Razvrstavanje u grupe i operativni rad; 5. Period postoperativnog praćenja; 6. Statistička obrada i pisanje rada.1. Procena veličine uzorka. Studija je realizovana podelom bolesnika u 4 grupe. Neophodni broj bolesnika je izračunat uzimajući podatke iz pilot istraživanja slične studije iz 2012. godine. Veličina uzorka je računata za primarni ishod studije  (bolesnikov procenjen bol sa NAS) na pretpostavci da treba biti 20% smanjenja bola u prvom postoperativnom satu, uz verovatnoću Tip 1 greške α=0.05 i Tipa 2 greške β=0.10 da postigne adekvatnu statističku snagu oko 80% i da otkrije 20% razlike u srednjoj vrednosti procenjenog bola jedan sat nakon laparoskopske  holecistektomije. Procenjeni broj ispitanika po grupama prema zadatim kriterijumima je bio (P+V=65; P=68; V=68; O=65). Studija je započela uključivanjem prvog bolesnika u studiju a završena ispunjenim periodom praćenja sve dok poslednji bolesnik nije doneo upitnike o bolu, mučnini i kretanju. 2. Procena podobnosti za studiju. U periodu studije ukupan broj holecistektomiranih bolesnika je bio 1024 (440 klasično i 584 laparoskopski). Samo pogodni bolesnici su anketirani (584) i pročitali su informacioni list o istraživanju. Uključivanje ili procena podobnosti bolesnika za studiju sprovedena je na osnovu uključnih i isključnih kriterijuma. U studiju nije uključeno ukupno 226 bolesnika. Od tog broja 82 bolesnika je odbilo učestvovati u studiji a 144 bolesnika nije ispunilo uključne postavljene kriterijume. Svojim potpisom potvrdilo je učešće u studiji 358 bolesnika. 3. Anketiranje i uključivanje u studiju. Nakon prijema bolesnika u bolnicu ispitivači su uzimali anamnezu i bolesnicima je ponuđen informacioni list i informisani pristanak. Nakon čitanja informacije, potpisivanja informisanog pristanka i zadovoljavanja  uključnih i isključnih kriterijuma 358 bolesnika je uključeno u studiju. Obavljena je preoperativna priprema i ispitivači su popunili deo podataka u individualnom listu. 4. Razvrstavanje u grupe i operativni rad. Neposredno preoperativno od strane nezavisne osobe neuključene u studiju napravljena je randomizacija izabranih (n=358) u studijske grupe tablicama slučajnog izbora, tako da bolesnici nisu znali kojoj grupi pripadaju, dok su operater i osoblje to znali na početku operacije (jednostruko slepa studija). Nakon randomizacije i operacije bolesnici pripadaju jednoj od sledeće 4 grupe: Kontrolna grupa O=89, u kojoj su bolesnici sa urađenom laparoskopskom  holecistektomijom bez visceralne blokade anestetikom i bez parijetalne blokade anestetikom. Eksperimentalna grupa P=88, u kojoj su bolesnici sa urađenom laparoskopskom holecistektomijom bez visceralne blokade anestetikom i sa parijetalnom blokadom anestetikom. Eksperimentalna grupa V=92, u kojoj su bolesnici sa urađenom laparoskopskom holecistektomijom sa visceralnom blokadom anestetikom i bez parijetalne blokade anestetikom. Eksperimentalna grupa P+V=89, u kojoj će biti bolesnici sa urađenom laparoskopskom holecistektomijom sa visceralnom blokadom anestetikom i sa parijetalnom blokadom anestetikom. Primenjivan je uobičajni, standardni protokol anestezije za laparoskopske operacije kod svih ispitanika. Svim bolesnicima plasirana je orogastrična sonda koja se nakon operacije odstranjivala. Kod  bolesnika kod kojih je primenjivan lokalni anestetik neposredno pre početka operacije pravio se rastvor lokalnog anestetika (Marcaine® 0,25%). Bolesnici su otpušteni sa bolničkog lečenja prvog postoperativnog dana, pod uslovom da nisu imali komplikacija. 5. Postoperativno praćenje i ispunjavanje upitnika. Po dolasku na odeljenje  bolesnicima je odmah uključivana ista analgezija. Tokom ispunjavanja informisanog pristanka, bolesnici su dobili upitnik na kojoj će sami procenjivati nivo bola, mučnine i kretanja tokom ležanja u bolnici i vremena praćenja od 7 dana kući. Bolesnici su dolazili na unapred zakazane postoperativne kontrole 7 do 10 dana posle operacije i donosili ispunjene upitnike. Otpušteno je i za praćenje ostalo n=302 laparoskopski operisanih bolesnika a isključeno iz studije n=20 bolesnika. 6. Statistička obrada i pisanje rada. Ukupno je analizirano 274 listića operisanih bolesnika: u Grupi P+V =67; u Grupi P =70; u Grupi V =70 i u Grupi O =67. Od osnovnih deskriptivnih statističkih parametara za kvalitativnu i kvantitativnu procenu dobijenih rezultata su korišćeni apsolutni brojevi, relativni brojevi, mediana, mod, aritmetička sredina i standardna devijacija (SD). Obrada podataka se vršila  osnovnim i naprednim statističkim metodama i programima. Rezultati su prikazani tabelarno i grafički. REZULTATI. Demografski podaci. Ukupno je bilo 188 žena i 86 muškaraca, u odnosu 2,2 : 1. Prosečna starost cele grupe je bila 52,1 ± 15,72 godine. Ukupno je bilo 179 zaposlenih i 95 nezaposlenih. Ukupno je bilo 45 ispitanika sa osnovnim obrazovanjem, 153 ispitanika sa srednjim obrazovanjem i 76 ispitanika sa visokim obrazovanjem. Ukupno je bilo 186 nepušača i 88 pušača. Prosečna vrednost BMI cele grupe je bila 27,24 ± 4,21 kg/m2. Prosečna vrednost ASA u celoj grupi je bila 2,03 (mediana=2, mod=2). Ne postoji statistički značajna razlika između posmatranih grupa u odnosu na posmatrane parametre. Laboratorijski podaci. Postoji statistički značajna razlika u vrednosti leukocita između posmatranih grupa (p=0,039), u vrednosti uree između posmatranih grupa (p=0,040). Ne postoji statistički značajna razlika u vrednosti eritrocita, trombocita, hemoglobina, ŠUK-a, kreatinina i bilirubina posmatranih grupa. Operativni i postoperativni podaci. Ne postoji statistički značajna razlika u količini upotrebljenog Fentanila između posmatranih grupa. Postoji statistički značajna razlika u dužini trajanja operacije između posmatranih grupa (p=0,003), u trajanju postavljenog abdominalnog drena između posmatranih grupa (p=0,024), u trajanju hospitalizacije između posmatranih grupa (p=0,027), u broju dana do povratka uobičajenim aktivnostima između posmatranih grupa (p=0,000), u broju uzetih tableta između posmatranih grupa (p=0,000). Prosečna ocena zadovoljstva bolesnika posle operacije u celoj grupi je bila 8,80 (mediana=9; mod=10). Najbolju ocenu zadovoljstva bolesnika posle operacije je imala grupa P+V. Procena bola, mučnine i kretanja. Postoji statistički značajna razlika između posmatranih grupa u proceni jačine bola pre operacije (p=0,003). Postoji statistički značajna razlika između posmatranih grupa u proceni jačine bola 1h posle operacije (najbolju procenu bola je imala grupa P+V); u proceni jačine bola 2h posle operacije (najbolju procenu bola je imala grupa P+V); u proceni jačine bola 4h posle operacije (najbolju procenu bola je imala grupa P); u proceni jačine bola 6h posle operacije (najbolju procenu bola je imala grupa P+V); u proceni jačine bola 12h posle operacije (najbolju procenu bola je imala grupa P+V); u proceni jačine bola 24h posle operacije (najbolju procenu bola je imala grupa P+V); u proceni jačine bola 48h posle operacije (najbolju procenu bola je imala grupa P) i u proceni jačine bola 7 dana posle operacije (najbolju procenu bola je imala grupa P). Procenjena bol se pojačava otprilike 2,5 sata posle operacije sa vrhom 3 sata posle operacije, a smanjuje se na istu vrednost kao 2. sata posle operacije, otprilike 5. sata posle operacije. U vremenskim intervalima 1, 2. i 7. postoperativni dan postoji značajno poboljšanje u postoperativnoj mobilnosti bolesnika. U vremenskim intervalima 1, 2, 4, 6 i 12 sati postoji značajno poboljšanje u procenjenoj vrednosti mučnine bolesnika. Korelacije. Statistički značajna pozitivna korelacija ocene bola posle 1. sata, posle 2. sata, posle 6. sata, posle 12. sata je utvrđena sa brojem uzetih tableta (p=0,000), kao i procene mučnine (p=0,000). Statistički značajna pozitivna korelacija procene bola posle 4. sata je utvrđena sa brojem uzetih tableta (p=0,006), kao i aktivnosti (p=0,014). Statistički značajna korelacija procene bola posle 24. sata je utvrđena sa brojem uzetih tableta (p=0,000; pozitivna) i trajanjem operacije (p=0,028; negativna). Statistički značajna pozitivna korelacija procene bola posle 48. sata i posle 7 dana je utvrđena sa brojem uzetih tableta (p=0,000). ZAKLJUČCI: Primena lokalnog anestetika datog na bilo koji način značajno smanjuje bol posle laparoskopske holecistektomije. Primena lokalnog anestetika datog i  portalno i visceralno (P+V) značajno smanjuje bol u odnosu na samo portalnu (P) ili visceralnu (V) primenu u vremenskim intervalima 2, 6, 12 sat posle laparoskopske holecistektomije. Portalna (P) primena sa ili bez visceralne (V) primene lokalnog anestetika značajno smanjuje bol u vremenskim intervalima 1, 4, 24, 48 sati i 7 dana posle laparoskopske holecistektomije. Najbolje kretanje je bilo u grupi P+V posle laparoskopske holecistektomije. Najbolje smanjenje procenjene mučnine je bilo u grupi P posle laparoskopske holecistektomije. Najraniji povratak uobičajenim aktivnostima zabeležen je u grupi P+V. Najbolja ocena zadovoljstva bolesnika hirurškim lečenjem bila je u grupi P+V. Postoperativna bol ima najznačajniju pozitivnu korelaciju sa procenjenom mučninom i brojem tableta uzetih od momenta otpusta do prve kontrole bolesnika.
INTRODUCTION: Biliary calculosis is the most frequent disease of the hepatobiliary system, and cholecystectomy is one of the most frequently performed surgical procedures. Today laparoscopic cholecystectomy represents the golden standard in treating cholelithiasis. Laparoscopic cholecystectomy showed improvement in the clinically significant outcomes, such as: reducing the duration of the surgery, shorter hospital stay, reducing the intensity and duration of postoperative pain and faster return to normal daily and working activities. Postoperative pain and the time of full recovery remain the two major problems after a non-complicated laparoscopic cholecystectomy and they should be improved. The pain related to laparoscopic cholecystectomy is complex and multi-factorial in origin. The pain occurs due to damaged tissues, dissection and removal of gallbladder from its cavity, stimulation of periportal nerves, irritation of the diaphragm, mechanical and chemical interaction of gases and pneumoperitoneum and port incisions. Researches have denoted parietal and visceral pains as two major mechanisms in occurrence of pain in laparoscopic cholecystectomy. Pain cannot be measured, but estimated, as it is a subjective feeling. It was considered necessary to find the answer, based on solid scientific evidence, if it was possible to block parietal and visceral pain after laparoscopic cholecystectomy in its acute phase. OBJECTIVES: The aim of this study is to compare standard, non-opioid, analgesia (group O) with applying parietal blockade (group P), or visceral blockade (group V), or compare with both applied blockades (group P+V). The primary outcomes of the study are the patient´s estimated pain before surgery and 1, 2, 4, 6, 12, 24, 48 hours and 7th day after the surgery. The secondary outcomes of this study are the patient´s estimated nausea level during 1, 2, 4, 6, 12 hours, along with the patient´s estimated mobility 1st, 2nd and 7th day, postoperatively. HYPOTHESIS. Blockade of postoperative visceral pain and blockade of postoperative parietal pain following laparoscopic cholecystectomy, applying intraperitoneal local infiltration with anesthetic and also by local infiltration with anesthetic through accessible laparoscopic ports, can significantly reduce early postoperative pain. MATERIAL AND METHODS: This prospectively randomized single-blinded study started in September 2014 and lasted up to January 2016. The research was carried out at the Clinic for Abdominal, Endocrine and Transplantation Surgery and Emergency Center, Clinical Center of Vojvodina in Novi Sad and it involved patients who underwent laparoscopic cholecystectomy. This study has been divided into several units. 1. Assessment of sample size; 2. Assessment of eligibility for the study; 3. Survey and inclusion in the study; 4. Group formation and operational work; 5. Period of postoperative follow-up; 6. Statistical processing and writing the paper.1. Assessment of sample size. The study was realized by dividing the patients into 4 groups. The number of patients necessary was determined based on the data taken as pilot study from a similar study from 2012. Sample size was calculated for the primary outcome of the study (patient´s estimated pain with NAS) based on the assumption that a pain reduction of 20% should occur during the first postoperative hour, with the probability of Type 1 error α=0.05 and Type 2 error β=0.10 to reach the adequate statistical power of about 80%, and to reveal 20% difference in the average value of the estimated pain one hour after the laparoscopic cholecystectomy. The assessed number of respondents in groups according to the set criteria was (P+V =65;P =68;V =68; O =65). The study started when the first patient was included and it ended with the complete follow-up period when the last patient handed in the survey about pain, nausea and mobility. 2. Assessment of eligibility for the study. During the study the number of patients undergoing surgery applying the method of cholecystectomy was 1024 (440 classical and 584 laparoscopic). Only the suitable patients were surveyed (584) and given to read the information leaflet about the study. Inclusion and assessment of patients´ eligibility was performed on the basis of inclusion and exclusion criteria. A total of 226 patients was not included in the study. Out of that number 82 patients refused to participate in the study and 144 did not fulfill the inclusive criteria set. By signing 358 patients confirmed their participation in the study. 3. Survey and inclusion in the study. After admitting the patients to hospital the surveyors took their anamnesis and the patients were offered an information leaflet and informed consent. Following the reading of the information leaflet, signing the informed consent and satisfying the criteria for inclusion and exclusion, 358 patients were included in the study. Preoperative preparations were performed and the surveyors filled in some of the data on the individual list. 4. Group formation and operational work. Prior to the surgery an independent person not included in the study carried out the randomisation of the patients chosen (n=358) into study groups by random selection tables. The patients did not know which group they belonged to, while it became known to the surgeon and the operation stuff at the beginning of the surgery (singleblinded study). After randomization and surgery the patients belonged to one of the following groups: Control group O=89 of patients with performed laparoscopic cholecystectomy without visceral blockade by anesthetic and without parietal blockade by anesthetic. Experimental group P=88 of patients with performed laparoscopic cholecystectomy without visceral blockade by anesthetic but with parietal blockade by anesthetic. Experimental group V=92 of patients with performed laparoscopic cholecystectomy with visceral blockade by anesthetic but without parietal blockade by anesthetic. Experimental group P+V=89 of patients with performed laparoscopic cholecystectomy with visceral blockade by anesthetic and with parietal blockade by anesthetic. The standard protocol of anesthesia for laparoscopic cholecystectomy was applied to all patients. An orogastric tube used during the surgery, was removed after it. In patients with applied local anesthetic immediately before surgery a solution of local anesthetic was made (Marcaine® 0,25%). The patients were discharged from hospital the first postoperative day, provided that no complications occurred. 5. Postoperative follow-up and completing the questionnaire. When admitted to the ward the patients were given the same kind of analgesia. While completing the informed consent the patients were given a questionnaire for estimating their pain level, nausea and mobility during their stay in hospital and during the 7-day follow-up period at home. The patients were required to come for 7 and 10-day postoperative check-ups by appointment and then they handed in the questionnaires. n=302 patients with performed laparoscopic cholecystectomy were released and designated for follow-up, and n=20 patients were excluded from the study. 6. Statistical processing and writing the paper. In total 274 operated patients´ slips were analysed, by groups as follows: in Group P+V =67; in Group P =70; in Group V =70 and in Group O =67. From the basic descriptive statistical parametres for qualitative and quantitative assessment of results obtained, absolute numbers, relative numbers, the median, mode, arithmetic mean and standard deviation (SD) were used. Data processing was carried out using basic and advanced statistical methods and programmes. The results are presented in tabular and graphical manner. RESULTS. Demographic data. In total there were 188 women and 86 men, in proportion 2,2 : 1. The average age of the whole group was 52,1 ± 15,72 years. In total there were 179 employed and 95 unemployed persons. In total there were 45 surveyed patients with primary education, 153 surveyed patients with secondary education and 76 surveyed patients with higher education. In total there were 186 nonsmokers and 88 smokers. The mean BMI value of the whole group was 27,24 ± 4,21 kg/m2. The mean value of ASA of the whole group was 2,03 (the median=2, mode=2). There is no significant difference among the groups observed considering the observed parametres. Laboratory data. There is a statistically significant difference in the value of leukocytes among the observed groups (p=0,039), and in the value of urea among the observed groups (p=0,040). There is no statistically significant difference in the value of the erythrocyte, platelets, hemoglobin, blood glucose, creatinine and bilirubin of the  observed groups. Operative and postoperative data. There is no statistically significant difference in the amount of Fentanyl® applied among the observed groups. There is statistically significant difference in the length of the surgery among the observed groups (p=0,003), in the duration of the positioning of abdominal drainage among the observed groups (p=0,024), in the duration of hospital stay among the observed groups (p=0,027), in the number of days until getting back to regular activities among the observed groups  (p=0,000), in the number of taken pills among the observed groups (p=0,000). The patients´ average satisfaction grade after surgery in the whole group was 8,80 (the median=9; mode=10). Group P+V had the best patient‘s satisfaction grade after the surgery. Assessment of pain, nausea and mobility. There is statistically significant difference in the estimation of pain intensity before surgery among the observed groups (p=0,003). There is statistically significant difference in the estimation of pain intensity 1 hour after surgery among the observed groups (P+V having the best estimated pain); in the estimation of pain intensity 2 hours after  surgery (P+V having the best estimated pain); in the estimation of pain intensity 4 hours after surgery (P having the best estimated pain); in the estimation of pain intensity 6 hours after surgery (P+V having the best estimated pain); in the estimation of pain intensity 12 hours after surgery (P+V having the best estimated pain); in the estimation of pain intensity 24 hours after surgery (P+V having the best estimated pain); in the estimation of pain intensity 48 hours after surgery (P having the best estimated pain) also in the estimation of pain intensity 7 days after surgery (P having the best estimated pain). The estimated pain intensifies at about 2,5 hours after surgery and peaks 3 hours after surgery, and decreases to the same level as it was during 2nd hour after surgery approximately during 5th hour after surgery. There is considerable improvement in mobility of patients in the time interval 1st, 2nd and 7th postoperative days. There is considerable improvement in estimated nausea level of patients in the time interval 1, 2, 4, 6 and 12 hours. Correlations. Statistically significant positive correlation in estimated pain after 1st hour, after 2nd hour, after 6th hour and after 12th hour was determined by the number of tablets taken (p=0,000), just like the estimated nausea level (p=0,000). Statistically significant positive correlation in estimated pain after 4th hour was determined by the number of tablets taken (p=0,006), just like the activities (p=0,014). Statistically significant positive correlation in estimated pain after 24th hour was determined by the number of tablets taken (p=0,000; positive), and by the duration of the surgery (p=0,028; negative). Statistically significant positive correlation in estimated pain after 48th hour and after 7 days was determined by the number of tablets taken (p=0,000). CONCLUSIONS: The application of local anesthetic, regardless of how it was applied, considerably reduces pain after laparoscopic cholecystectomy. The application of local anesthetic by port or viscerally (P+V) considerably reduces pain compared to only by port (P) or only visceral (V) application in the time intervals of 2, 6, and 12 hours after laparoscopic cholecystectomy. The application of local anesthetic by port (P), with or without visceral (V), considerably reduces pain in the time intervals of 1, 4, 24, and 48 hours and 7 days after laparoscopic cholecystectomy. The best mobility was shown by group P+V after laparoscopic cholecystectomy. Estimated nausea was most reduced in group P after laparoscopic cholecystectomy. Group P+V presented the earliest return to regular activities. The best patients´ satisfaction grade with surgical treatment was shown by group P+V. Postoperative pain is most considerably positively correlated with the estimated nausea and pills taken, from the moment of patient´s release from hospital to the first check-up. 

L’objectiu d’aquesta tesi és determinar la prevalença i caracteritzar la relació entre la litiasi vesicular i la colecistectomia per laparoscòpia i el reflux gastroesofàgic (RGE) àcid. Objectius secundaris que permeten assolir el principal són traduir i validar un qüestionari de símptomes de reflux gastroesofàgic i determinar la seva sensibilitat, especificitat i precisió diagnòstica per al diagnòstic clínic de reflux, avaluar mitjançant mètodes clínics (el qüestionari de símptomes de Carlsson-Dent validat) i mètodes funcionals (pH-metria de 24h i manometria esofàgica) la prevalença de reflux gastroesofàgic en pacients amb colelitiasi i en pacients colecistectomitzats per via laparoscòpica i comparar aquesta prevalença amb la d’un grup control (pacients amb hèrnia o hemorroides) pre i postintervenció; i finalment, mesurar la capacitat de buidament vesicular dels pacients amb colelitiasi mitjançant ecografies seriades. A partir d’una població de 120 pacients derivats a l’Hospital de Mataró per sospita de reflux gastroesofàgic es determina la sensibilitat, especificitat i precisió diagnòstica del qüestionari de símptomes de Carlsson-Dent traduït al català. S’administra el qüestionari i posteriorment es realitza una pH-metria de 24h i/o una fibrogastroscòpia com a gold standard per confirmar o descartar el diagnòstic de reflux objectivant que el qüestionari clínic té una sensibilitat del 82,2% i una especificitat del 60,6% amb el punt de tall de 4,5 punts a partir del qual es fa el diagnòstic de reflux gastroesofàgic, considerant-se una bona eina diagnòstica amb una àrea sota la corba de 0,81. Amb el qüestionari de símptomes validat es calcula la prevalença de reflux gastroesofàgic a un grup de 135 pacients amb colelitiasi i a un grup control (71 pacients amb hèrnia o hemorroides) objectivant que els pacients amb colelitiasi obtenen de mitjana una puntuació molt més alta en el qüestionari de símptomes que el grup control (7,3 vs 2,8; p<0,05) i, per tant, la prevalença de reflux en els pacients amb litiasi vesicular és major que en els pacients controls (71,9% vs 28,2%; p<0,001). Al realitzar les proves funcionals digestives a una part del pacients amb colelitiasi s’objectiva que, de mitjana, els 63 pacients estudiats presenten un pH<4 més del 7,9% del temps de registre (considerant-se patològic a partir del 4%) i que la prevalença de reflux segons la pH-metria és del 54%. La manometria esofàgica mostra una pressió mitjana de l’EEI i una longitud dins dels paràmetres de la normalitat. A 128 pacients amb colelitiasi se’ls hi realitza un estudi de buidament vesicular objectivant que el 60% presenten un buidament >50% en resposta a una ingesta de prova i, per tant, són contractors. La resta, un 40%, són no contractors. Partint de la base que els pacients no contractors presenten alteracions del buidament vesicular que poden augmentar l’alliberació de colecistocinina i, per tant, induir RGE, s’administra el qüestionari de símptomes objectivant que tant els pacients contractors com els no contractors obtenen una puntuació elevada (7,3 vs 7,2, p=0,947). Tampoc existeixen diferències en cap dels paràmetres avaluats a la pH-metria de 24h ni a la manometria. Al repetir l’estudi en els postoperatori, s’observa que els pacients colecistectomitzats obtenen en el qüestionari de símptomes una puntuació superior que els pacients intervinguts d’hèrnia o hemorroides (5,3 vs 1,2, p<0,001) i que la prevalença de reflux és del 47,8% en el grup d’estudi i del 11,8% en el grup control (p<0,001). Al realitzar la pH-metria de 24h en un subgrup de pacients colecistectomitzats s’objectiva que, de mitjana, els pacients presenten un pH<4 el 8,1% del temps de registre i que la prevalença de reflux segons la pH-metria és del 51,6%. La manometria, igual que preoperatòriament, no mostra alteracions significatives. En conclusió, els pacients amb colelitiasi tenen una prevalença de (RGE) elevada i molt superior a la del grup control i malgrat disminuir després de la intervenció, aquesta persisteix alta, tant des del punt de vista clínic com funcional. Els nostres resultats suggereixen que existeix una intensa associació entre la litiasi vesicular, els símptomes postcolecistectomia i el RGE.
The objective of this thesis is to determine the prevalence of gastroesophageal reflux disease (GERD) in patients with cholelithiasis and laparoscopic cholecystectomy and characterize the relationship between them. And Secondary objectives that help achieve the first are to translate and validate a reflux symptom questionnaire (Carlsson-Dent Questionnaire) and determine its sensitivity, specificity and diagnostic accuracy in the clinical diagnosis of reflux; to determine the prevalence of gastroesophageal reflux by clinical methods (the questionnaire) and functional methods (ambulatory pH monitoring and esophageal manometry) in patients with cholelithiasis and laparoscopic cholecystectomy and compare this prevalence pre- and postintervention with that of a control group (patients with hernia or hemorrhoids); and finally, to measure gallbladder emptying with serial ultrasounds in patients with cholelithiasis. The sensitivity, specificity and diagnostic accuracy of the Carlsson-Dent Questionnaire translated into Catalan was determined on a population of 120 patients referred to Mataró Hospital for suspected GERD. First, the Catalan translation of the questionnaire was given to the patient and then an esophageal pH monitoring and/or a fibrogastroscopy was performed to confirm or rule out the diagnosis of reflux. The questionnaire was found to have a clinical sensitivity of 82.2% and a specificity of 60.6%, using a cutoff point of 4.5 for the diagnosis of GERD and thus can be considered a good diagnostic tool with an area under the curve of 0.81. Using the validated symptom questionnaire, the prevalence of GERD was estimated in a group of 135 patients with cholelithiasis and in a control group of 71 patients with hernia or hemorrhoids. Patients with cholelithiasis scored much higher than the control group (7.3 vs 2.8; p<0.05) showing that the prevalence of reflux those patients was greater than in the controls (71.9% vs 28.2%; p<0.001). Functional methods were tested on a subgroup of 63 patients with cholelithiasis and it was found that the average of the group presented a pH<4 more than 7.9% of the recording time (>4% is considered pathological), giving a prevalence of reflux by pH-metry of 54%. Esophageal manometry indicated that the average pressure and the length of the lower oesophageal sphincter (LOS) were within the parameters of normality. A study of gallbladder emptying was made on 128 patients with cholelithiasis and found that 60% emptied more than 50% in response to ingestion of a test meal and were therefore considered to be contractors. The remaining 40% were considered non-contractors. Assuming that patients with cholelithiasis have abnormal gallbladder emptying that increases the release of cholecystokinin which in turn increases the number of transient relaxations of the LOS with the presence of GERD, the translated questionnaire was administered and found that both, contractors and non-contractors, scored high (7.3 vs 7.2, p = 0.947). There were no differences between the parameters in the pH-metry or manometry either. When repeating the study in patients after surgery, cholecystectomy patients scored higher in the translated questionnaire than the control group (5.3 vs 1.2, p<0.001) and the prevalence of reflux was 47.8% in the study group and 11.8% in the control group (p<0.001). When pH-metry was performed on a subgroup of cholecystectomy patients, they had, on average, a pH<4 for 8.1% of the registration time and the prevalence of reflux by pH-metry was 51.6%. Manometry, as in the preoperative group, showed normal LOS pressure and length. In conclusion, patients with cholelithiasis had a high prevalence of reflux, much higher than the control group, which remained high from both clinical and functional perspectives despite decreasing after intervention. Our results suggest a strong association between cholelithiasis, post-cholecystectomy symptoms and GERD.

by Siu-wang Lau.
Thesis (M.Phil.)--Chinese University of Hong Kong, 2000.
Includes bibliographical references (leaves 121-127).
Abstracts in English and Chinese.
Contents page
Acknowledgement --- p.ii
Abstract --- p.iii
Abbreviations --- p.v
Contents --- p.vi
Introduction --- p.1
Chapter Part I
Chapter 1 --- Principle of Fourier transform infrared spectroscopy (FTIR) --- p.9
Chapter 2 --- Experimental --- p.15
Chapter 2.1 --- Method of calibration curve for FTIR --- p.15
Chapter 2.2 --- Method of standard addition for FTIR 18 、
Chapter 3 --- Results --- p.19
Chapter 3.1 --- Results of the method of calibration curve for FTIR --- p.26
Chapter 3.2 --- Results of the method of standard addition for FTIR --- p.34
Chapter 4 --- Discussion --- p.37
Chapter 5 --- Interferences between the major components when two standard chemicals were considered each time (mixture of two standard compounds) --- p.41
Chapter 5.1 --- Introduction --- p.41
Chapter 5.2 --- Procedures --- p.43
Chapter 5.3 --- Results --- p.47
Chapter 5.4 --- Discussion --- p.80
Chapter 6 --- Interferences between the major components when four standard chemicals were considered each time (mixture of four standard compounds) --- p.83
Chapter 6.1 --- Introduction --- p.83
Chapter 6.2 --- Experimental --- p.83
Chapter 6.3 --- Results --- p.85
Chapter 6.4 --- Conclusion --- p.89
Chapter 7 --- Discussion --- p.90
Chapter Part II
Chapter 1 --- Introduction --- p.92
Chapter 2 --- Principle of flame emission spectroscopy (FES) --- p.92
Chapter 3 --- Introduction of the analysis of total calcium by FES --- p.94
Chapter 4 --- Experimental --- p.104
Chapter 4.1 --- Methods of digestion --- p.104
Chapter 4.2 --- Methods of oxidation --- p.105
Chapter 4.3 --- Calibration of standard --- p.106
Chapter 5 --- Results --- p.107
Chapter 6 --- Discussion --- p.112
Chapter Part III
Chapter 1 --- Estimation of total calcium by FTIR --- p.113
Chapter 2 --- Experimental --- p.113
Chapter 3 --- Results --- p.115
Chapter 4 --- Discussion --- p.119
Chapter Part IV --- Conclusion --- p.120
Chapter Part V --- References --- p.121
Appendices
Appendix 1 Example of the calculation of analyte content by the method of calibration curve --- p.128
Appendix 2 Examples of the calculations of the analytes by the method of standard addition --- p.130
Appendix 3 IR spectrum of a mixture of four standard chemicals --- p.132
Appendix 4 IR spectrum of a sample --- p.133

碩士
嘉南藥理科技大學
醫療資訊管理研究所
94
Objectives: The aim of the study was to evaluate the accuracy of coding in a regional hospital. Furthermore, identifying that errors of coding was associated with the changes of DRGs assignment. Methods: The subjects were a sample of 507 admissions with cholelithiasis and/ or choledocholithisis from January 1st 2003 to December 31st 2005 in a regional hospital inpatient claim data. A retrospective audit was carried out, involving comparison of the original coding in the medical records with blindly recoding by two senior certified coders. The main outcome measures were the levels of disagreement between original and auditing coding. The reasons for DRGs discrepancies after DRGs grouping were also determined. The descriptive statistics, pair t-test, chi square test, pearson’s correlation and logistic regression analysis were performed with SPSS 12.0. Results: (1) Coding errors occurred in 13.53 per cent of all codes, 12.86 per cent of diagnoses and 14.38 percent of procedures. The three common coding errors were other procedure undercoding (29.38%), diagnosis miscoding (20.94%), and diagnosis unnecessary coding (15.0%). (2) The number of coding errors were positively related to LOS, number of diagnosis and procedures codes (p<0.0001). (3) Significant associations were found between operating room (OR) and non OR procedure for coding error and undercoding. (4) Miscoding and incomplete medical record documentation accounted for the change in DRGs assignment 55.56% and 11.11%, respectively. (5) After controlling for patient characteristics, predictors of change in DRGs assignment were miscoding of procedures, resequencing of procedure, incomplete diagnosis documentation, miscoding of diagnosis and undercoding of secondary diagnosis (p<0.05). Conclusions: Coding errors were more prevalent in complex cases with multiple codes. The predictors of DRGs discrepancy suggest that coders need to work cautiously for coding in more complex cases and the need to improve medical record documentation to ensue that DRGs variation is kept to a minimum.

Trabalho de Projeto do Mestrado Integrado em Medicina apresentado à Faculdade de Medicina
Background: Gallstone Disease (GD) is common in the western countries and when symptomatic or complicated, is associated with high morbidity rates. Laparoscopic cholecystectomy is the gold standard treatment for symptomatic GD. The identification of the individuals that would benefit from early LC as well as defining adequate timing for said treatment it’s becoming increasingly important.Methods: 59 subjects admitted in a surgical ward for symptomatic GD were screened using two methods: interview and consultation of patient file. Were described three concepts of patient admission: (1) major complication; (2) minor complication (biliary colic); (3) programmed. Several clinic and demographic data was collected and the patient was asked about his previous knowledge of his GD (including previous symptomatic episodes)Results: The medium age of participants was 66,5 years with the 80-89 years interval and the male sex showing themselves to be most prevalent. 55,9% were admitted for a major complication and the remaining 44,1% were admitted in a programmed way. 35,6% had suffered from multiple episodes of biliary colic. 21% of the patients admitted for a major complication had suffered from a previous episode of GD complication and two of those had multiple episodes. Biliary colic was the reason for the majority of the programmed admissions with only one patient in this group suffering from multiple major complications. Medical treatment was preferred.Discussion/Conclusion: Was found a group of patients with multiple major complication history of GD, and it is believed that this type of patients may worsen their conditions while waiting for LC. This is associated with high patient morbidity as well as higher healthcare costs. Surgical treatment after a first symptomatic episode seems safe and efficient possibility and should be considered, if conditions and resources are presented.
Introdução: A litíase vesicular (LV) é comum no mundo ocidental e quando sintomática ou complicada, associa-se a altas taxas de morbilidade. A colecistectomia laparoscópica é considerado o tratamento padrão para eliminar definitivamente as complicações da litíase sintomática. Torna-se assim cada vez mais importante identificar os doentes que mais beneficiariam de tratamento cirúrgico precoce, bem como definir os tempos mais adequados para este mesmo tratamento.Métodos: Foram avaliados 59 doentes internados em enfermarias de Cirurgia por LV sintomática através de entrevista e consulta dos processos clínicos. Foram definidos três conceitos para descrever o motivo de internamento do doente: (1) complicação major; (2) complicação minor (cólica biliar); (3) programado. Foram colhidos diversos dados demográficos e clínicos e questionado o conhecimento prévio relativamente ao diagnóstico de LV (incluindo episódios sintomáticos prévios). Resultados: A idade média dos inquiridos foi de 66,5 anos, com o escalão etário dos 80-89 anos e o sexo masculino a serem mais prevalentes. 55,9% dos doentes foram internados por complicação major e os restantes 44,1% foram internados de forma programada. 35,6% dos doentes tinham sofrido de cólica biliar pelo menos uma vez. 21% dos doentes internados por complicação major já tinham tido um espisódio prévio de complicação de LV e dois desses chegaram mesmo a ter episódios múltiplos. A maioria dos doentes internados de forma programada tinham tido apenas episódios de cólica biliar, sendo que apenas um destes doentes teve múltiplas complicações major. Deu-se preferência ao tratamento médico nos doentes internados por complicação major.Discussão/Conclusão: Verificou-se a existência de um grupo de doentes com história de múltiplas complicações de LV, admitindo-se que estes e outros doentes na mesma situação possam agravar a sua condição ao aguadar pelo diferimento de colecistectomia laparoscópica. Tal encontra-se associado a aumento da morbilidade bem como ao aumento dos custos para o serviço de saúde. O tratamento cirúrgico definitivo após um primeiro episódio sintomático torna-se assim uma possibilidade segura e eficaz a ser considerada, desde que existam recursos e condições que o permitam.