Avaliação eletromanométrica do esfíncter superior do esôfago em portadores da forma indeterminada da doença de Chagas

Objetivou-se avaliar as alterações do esfíncter superior esofágico pela eletromanometria em 37 pacientes portadores da forma clínica indeterminada da doença de Chagas. Foram encontrados 18 (48,6%) pacientes portadores de ondas sincrônicas. A média das pressões máximas do esfíncter foi significativamente maior entre os portadores de ondas sincrônicas. Assim, alguns indivíduos portadores da forma indeterminada da doença de Chagas possuem alterações funcionais caracterizadas pelo aumento da pressão do esfíncter superior do esôfago, que podem ser detectadas à eletromanometria.

Evaluation of cytokines (MIG, IFN-gamma, TNF-alpha, IL-4, IL-5, and IL-10) during the different evolutive phases of chagasic esophagopathy

The production of cytokines (MIG, IFN-gamma, TNF-alpha, IL-4, IL-5, and IL-10) was studied in 39 individuals, including 28 with chagasic esophagopathy and 11 nonchagasic patients with gastroesophageal reflux disease. A sandwich enzyme immunoassay employing monoclonal antibody pairs specific for each cytokine was used. IFN-gamma and MIG production was significantly higher in patients with megaesophagus compared to control. Furthermore, in the absence of stimulation TNF-alpha levels were lower in the chagasic group than in the control group. In addition, significantly lower TNF-alpha levels were observed for the advanced form of the disease compared to the nonadvanced form. These results support the hypothesis that, although patients with advanced phase of megaesophagus present low number of CD4+ T lymphocytes, PBMC from this patients are able to respond up specific antigen stimulation.

[Secondary sclerosing cholangitis in a patient with acquired immunodeficiency syndrome treated by common hepatic duct plasty by the laparoscopic route]

We report the case of a patient with obstructive jaundice caused by sclerosing cholangitis secondary to acquired immunodeficiency syndrome. In acquired immunodeficiency syndrome-related cholangiopathy, patients present with right upper quadrant or epigastric pain, fever, diarrhea and characteristic biliary alterations. The patient was submitted to transverse plasty of the common hepatic duct by laparoscopic route.

Evaluation of the response of cortisol, corticotropin and blood platelets kinetics after laparoscopic and open cholecystectomy

PURPOSE

To compare the behavior of serum cortisol and ACTH levels and platelet kinetics after laparoscopic and open cholecystectomy.

METHODS

In this prospective study, 31 patients with symptomatic cholelithiasis submitted to elective cholecystectomy, 17 by the laparoscopic route and 14 by the open route, were compared. Peripheral blood samples were collected on admission of the patient, during anesthetic induction, and 2, 6, 12, 24 and 48 hours after the surgical incision. Platelets were counted in hematoxylin-eosin-stained specimens under a light microscope at 100x magnification. Cortisol and ACTH were measured by chemiluminescence.

RESULTS

Cortisol and ACTH levels showed a significant increase (p < 0.05) within the first hours after surgery compared to preoperative values. At 2 hours, a significantly higher cortisol concentration was observed in the laparoscopic group compared to the open surgery group (p = 0.0365). A return to basal levels during the later postoperative periods (24 and 48 hours) was only observed for ACTH, while serum cortisol continued to be elevated during the same period, being significantly higher in the open surgery group than in the laparoscopic group (p24 = 0.0248 and p48 = 0.032). Different platelet response curves were obtained for the two groups, but their levels were normal at all times studied. No significant difference (p > 0.05) between the post- and preoperative periods was observed for either group.

CONCLUSION

A hormonal response was observed for both procedures studied, but the surgical stress was higher and longer lasting in open surgery compared to the laparoscopic approach. However, no significant variation in platelet kinetics in response to tissue injury was observed between the two procedures.

Real time PCR strategy for the identification of major lineages of Trypanosoma cruzi directly in chronically infected human tissues

Two evolutionary lineages, called Trypanosoma cruzi I and II, have been identified in T. cruzi, the etiologic agent of human Chagas disease. Here, we describe a molecular strategy for direct genetic typing of these major groups of T. cruzi directly in human tissues. The protocol is based on heminested PCR amplification of the D7 region of the 24Salpha ribosomal DNA (rDNA), followed by identification of the products using denaturation curves in real time PCR. The repetitive nature of the gene, and the heminested PCR format insured the high sensitivity necessary to detect the presence of the very scarce T. cruzi DNA present in the chronically infected human tissues. There is 80% DNA sequence homology between the two 24Salpha rDNA alleles that define the T. cruzi I and II groups, sufficient to produce different thermal denaturation curves with melting temperature (TM) values of 81.7+/-0.43 and 78.2+/-0.33 degrees C (mean+/-SEM). Using this technical approach, we analysed tissue samples (esophagi, hearts and colon) from 25 different patients with the gastrointestinal or cardiac forms of Chagas disease; in all of them we found only the presence of T cruzi II. Previous epidemiological and immunological findings had already led to the idea that chronic human infections occurring in Brazil and Argentina might be primarily due to T. cruzi II strains, but all the evidence available had been indirect. Our findings provide definitive proof of this hypothesis and will also allow the establishment of which group of T. cruzi is responsible for Chagas disease in other countries.

Assessment of pulmonary function in patients before and after laparoscopic and open esophagogastric surgery

BACKGROUND

Laparoscopy is a technique used in various surgical procedures. Few studies in the literature compare stress between laparoscopic and open surgery used for esophagogastric surgical procedures. Pulmonary function is known to be significantly affected in open surgeries, increasing postoperative morbidity and mortality. The current study aimed to assess pulmonary function in patients before and after open and laparoscopic esophagogastric surgery.

METHODS

For this study, 75 patients were divided into two groups: 50 patients undergoing laparoscopy and 25 patients undergoing open surgery. The following parameters were determined by spirometry before and after surgery: forced expiratory volume in the first second (FEV(1)), forced vital capacity (FVC), and forced expiratory flow in the midexpiratory phase (FEF(25-75%)).

RESULTS

A decrease in FEV(1,) FVC, and FEF((25-75%)) was observed in the two groups on postoperative days 2, 3, and 4, as compared with the preoperative period. Likewise, FEV(1) and FVC showed a significant reduction on postoperative days 2, 3, and 4 in the patients who underwent to open surgery, but only on the day 2 in those who underwent to laparoscopic surgery. A significant decrease in FEF((25-75%)) was observed only on postoperative day 2 in the group that underwent open surgery. Significant differences in FEV(1) between the groups were observed on postoperative days 2, 3, and 4. No significant difference in FVC was noted between the groups, and a difference in FEF((25-75%)) was observed only on postoperative day 4.

CONCLUSIONS

Postoperative pulmonary dysfunction was more important for the patients undergoing open surgery than for those undergoing laparoscopic surgery.

Estudo eletromanométrico do esôfago em portadores da doença de Chagas em sua forma indeterminada

OBJETIVOS: Avaliar as alterações manométricas dos esfíncteres superior (ESE) e inferior do esôfago, bem como a motilidade de seu corpo, em pacientes com a forma indeterminada da Doença de Chagas. MÉTODO: Foram considerados 37 pacientes portadores da Doença de Chagas, assintomáticos, que apresentavam eletrocardiograma, enema opaco e radiografia contrastada do esôfago sem alterações características da doença (forma indeterminada). Estes foram submetidos à eletromanometria do esôfago em que foram analisados dados sobre a pressão dos esfíncteres e ondas peristálticas do corpo do esôfago. RESULTADOS: Detectouse uma diminuição da média da amplitude de contração do corpo do esôfago (p=0,03) nos portadores de ondas sincrônicas quando comparados com os portadores de ondas assincrônicas. A comparação da média das pressões máximas do ESE nos pacientes portadores de ondas sincrônicas foi significativamente maior (p= 0,02) que a média encontrada nos portadores de ondas assincrônicas. CONCLUSÃO: Encontrou-se um elevado número (48,65%) de portadores de ondas sincrônicas em pacientes com a forma indeterminada da Doença de Chagas; notou-se uma redução da média da amplitude da contração do corpo do esôfago em portadores de ondas sincrônicas e observou-se que a média das pressões máximas do ESE é maior nos pacientes com ondas sincrônicas (207,14 mmHg) quando comparada com os portadores de ondas assincrônicas (142,44 mmHg). Dessa forma propomos uma discussão sobre a classificação atual da Doença de Chagas.

Correlação manométrico-radiológica e sua importância no tratamento cirúrgico do megaesôfago chagásico

Foram analisados os achados radiológicos e manométricos de 43 pacientes portadores de megaesôfago chagásico com sorologia positiva para doença de Chagas. Encontrou-se uma redução significante dos valores da pressão máxima do corpo do esôfago com relação ao estádio da esofagopatia: grau I/II - 42,9mmHg; grau III - 23,6mmHg; grau IV - 15,6mmHg. Observou-se que cinco (35,7%) pacientes classificados como grau III, do ponto de vista radiológico, apresentaram valores da pressão máxima do corpo do esôfago inferiores a 20mmHg, sendo considerados portadores de megaesôfago avançado, devendo ser tratados por esofagectomia subtotal com esofagogastroplastia ao invés de cardiomiotomia com válvula anti-refluxo. Constatou-se que o estudo manométrico é útil em pacientes portadores de megaesôfago grau III para a escolha do melhor procedimento cirúrgico.

Análise comparativa de três tipos de válvulas anti-refluxo associada à cirurgia de heller: estudo experimental em cães

OBJETIVO: Comparar experimentalmente, em cães, três técnicas de esofagogastrofundoplicatura - anterior, posterior e lateral - após cardiomiotomia ampla. MÉTODO: Os animais foram separados aleatoriamente em quatro grupos: Grupo A: Válvula anti-refluxo anterior (n=5); Grupo P: válvula anti-refluxo posterior (n=5); Grupo L: Válvula anti-refluxo lateral (n=5); Grupo C: Grupo controle, no qual não foi realizado nenhum tipo de fundoplicatura após a cardiomiotomia (n=10). A avaliação pré-operatória foi realizada através de endoscopia, biópsia da mucosa gastroesofágica, pHmetria e manometria esofágica. Após cinco semanas, realizou-se reavaliação, baseada em dados endoscópicos, pHmétricos, manométricos e histopatológicos. Os animais foram mortos e os segmentos esofagogástricos retirados para exame histopatológico RESULTADOS: Ao exame histopatológico detectou-se esofagite em todos os casos do grupo controle e em nove casos dos grupos com válvulas, e nestes, quando presente, a esofagite foi de menor extensão e de grau menos avançado do que no grupo controle. Através da manometria pré e pós-operatória, observou-se que: 1) o grupo controle apresentou uma redução na pressão na ZAP de 39,2mmHg para 23,4mmHg; 2) os grupos A, P, e L apresentaram uma variação da ZAP de 39,7, 39,9 e 39,7mmHg para 40,9, 44,8 e 41,3mmHg, respectivamente. CONCLUSÕES: 1) A cardiomiotomia ampla provoca refluxo gastroesofágico e conseqüente esofagite; 2) As três válvulas anti-refluxo estudadas restauram o segmento de alta pressão e diminuem a incidência de refluxo e de esofagite.

Excluded-loop hepatojejunal anastomosis with use of laparoscopy in late management of iatrogenic ligature of the bile duct

Although the procedures adopted for bile duct surgery are routine, serious complications occasionally occur. This article reports the authors' experience in managing an iatrogenic ligature of the bile duct. The patient in this case had undergone open cholecystectomy and had significant jaundice in the early postoperative period. During the investigation, a complete ligature of the common hepatic duct was discovered. An anastomosis of the common hepatic duct with an excluded jejunum loop was performed with use of laparoscopy. Periodic follow-up continuing until 30 months after surgery showed the patient was asymptomatic, and ultrasonography, percutaneous transhepatic cholangiography, and cholangioresonance findings were normal. We consider the procedure feasible and technically advantageous when done with the assistance of laparoscopy.

Estudo da microflora do megaesôfago chagásico

Pacientes portadores de megaesôfago chagásico foram submetidos à endoscopia digestiva alta e coleta do material com pinças e sondas especiais, em condições estéreis. Foram realizadas quatro coletas, sendo uma do líquido de estase e três fragmentos da mucosa esofagiana respectivamente a um, três e cinco centímetros da transição esôfago-gástrica (linha Z). O material foi enviado em meio de cultura aos laboratórios de microbiologia e de anatomia patológica para a identificação dos germes presentes. Posteriormente, os resultados foram correlacionados ao grau de evolução do megaesôfago segundo a classificação de Ferreira-Santos. Observou-se que é alta a incidência de germes patogênicos no megasôfago, independentemente do grau de dilatação, transformando a cirurgia para o tratamento desta afecção em potencialmente contaminada. Não houve diferença significativa quanto à positividade das culturas em relação ao grau de dilatação esofágica.

Relationship between Trypanosoma cruzi and human chagasic megaesophagus: blood and tissue parasitism

The persistence of Trypanosoma cruzi in tissue and blood of 52 patients in the digestive form of chronic Chagas disease was studied. These patients had chagasic megaesophagus and underwent corrective surgery. Parasitologic (xenodiagnosis, hemoculture, or both), histopathologic (hematoxylin and eosin, and peroxidase-anti-peroxidase staining), and molecular (polymerase chain reaction [PCR] followed by slot-blot hybridization) tests were used in the analysis. The presence of T. cruzi, its genomic fragments, or its antigens could be detected in 98% (51 of 52) of the patients. The parasite was randomly identified in 76.9% of esophageal tissues and in 90.4% by PCR and in 73.1% by parasitologic methods from the blood. Fifty percent (26 of 52) of tissue samples had inflammation, 80.8% of which was associated with the parasite. Trypanosoma cruzi was also identified unassociated with inflammatory alterations. Higher tissue parasitism and intense inflammatory processes were observed in esophageal tissue from patients with Grade IV megaesophagus. These data demonstrate that in the digestive form of Chagas' disease, particularly in cases of megaesophagus, T. cruzi is frequently found, both in blood and tissues and may contribute to the pathogenic mechanisms involved.

Fast events in protein folding: structural volume changes accompanying the early events in the N-->I transition of apomyoglobin induced by ultrafast pH jump

Ultrafast, laser-induced pH jump with time-resolved photoacoustic detection has been used to investigate the early protonation steps leading to the formation of the compact acid intermediate (I) of apomyoglobin (ApoMb). When ApoMb is in its native state (N) at pH 7.0, rapid acidification induced by a laser pulse leads to two parallel protonation processes. One reaction can be attributed to the binding of protons to the imidazole rings of His24 and His119. Reaction with imidazole leads to an unusually large contraction of -82 +/- 3 ml/mol, an enthalpy change of 8 +/- 1 kcal/mol, and an apparent bimolecular rate constant of (0.77 +/- 0.03) x 10(10) M(-1) s(-1). Our experiments evidence a rate-limiting step for this process at high ApoMb concentrations, characterized by a value of (0. 60 +/- 0.07) x 10(6) s(-1). The second protonation reaction at pH 7. 0 can be attributed to neutralization of carboxylate groups and is accompanied by an apparent expansion of 3.4 +/- 0.2 ml/mol, occurring with an apparent bimolecular rate constant of (1.25 +/- 0.02) x 10(11) M(-1) s(-1), and a reaction enthalpy of about 2 kcal/mol. The activation energy for the processes associated with the protonation of His24 and His119 is 16.2 +/- 0.9 kcal/mol, whereas that for the neutralization of carboxylates is 9.2 +/- 0.9 kcal/mol. At pH 4.5 ApoMb is in a partially unfolded state (I) and rapid acidification experiments evidence only the process assigned to carboxylate protonation. The unusually large contraction and the high energetic barrier observed at pH 7.0 for the protonation of the His residues suggests that the formation of the compact acid intermediate involves a rate-limiting step after protonation.

Antimicrobiano parenteral exclusivo ou associado com a via oral na prevenção de infecção após cirurgia colorretal

Estudo prospectivo da incidência de complicações infecciosas, após operações para câncer colorretal. Sessenta e nove pacientes foram divididos em dois grupos, tendo o primeiro grupo recebido neomicina e metronidazol, por via oral, associados a gentamicina e metronizadol por via parenteral e o segundo grupo somente gentamicina e metronidazol por via parenteral. Foi estabelecido como objetivo principal a avaliação da influência do antimicrobiano administrado no preparo intestinal sobre a incidência de complicações infecciosas pós-operatórias. Os pacientes que receberam antimicrobianos por via oral no preparo intestinal apresentaram menor porcentagem de complicações infecciosas (14,29%) em relação aos pacientes que receberam apenas antimicrobiano por via parenteral (38,24%), sendo esta diferença estatisticamente significante, em nível de 5%. Esses dados apóiam a sugestão de associar antimicrobianos por via oral aos antimicrobianos por via parenteral na tentativa de reduzir as complicações infecciosas na cirurgia colorretal.

Leiomyosarcoma of the esophagus in a patient with chagasic megaesophagus: case report and literature review

Leiomyosarcoma constitutes approximately 0.5% of the malignant neoplasias of the esophagus and its association with megaesophagus has not been described. We report on a case of a woman with dysphagia that was slowly progressive from the age of 19 due to chagasic megaesophagus. The woman was subjected to cardiomyotomy at the age of 49. She presented a rapid worsening of the dysphagia due to leiomyosarcoma at the age of 61, and was subjected to subtotal esophagectomy with cervical esophagogastroplasty. She developed pulmonary and hepatic metastases 14 months after surgery and died six months later.

Decreased CD4(+) circulating T lymphocytes in patients with gastrointestinal chagas disease

The gastrointestinal form of Chagas disease is characterized by lumenal enlargement and wall thickening of the esophagus and/or colon. Very little is known about the involvement of the immune system in the development of the gastrointestinal form of the disease. In this paper we describe our initial observations on the phenotypic analysis of peripheral blood mononuclear cells from patients with the gastrointestinal form of Chagas disease. A significant decrease in the absolute number of CD3(+) T cells as well as in CD19(+) B lymphocytes was observed. However, the most striking observation was an inversion of the CD4/CD8 ratio, contrasting with results from cardiac chagasic patients in whom the ratio is normal. A decrease of the percentage of CD4(+)CD28(+) cells and an increase in the expression of HLA-DR both on CD4(+) and on CD8(+) cells suggest that although these T cells express activation markers their function may be altered by the lack of CD28 expression.

Evidence for survival and metabolic activity of encapsulated xenogeneic hepatocytes transplanted without immunosuppression in Gunn rats

BACKGROUND

Hepatocyte transplantation could be an alternative to whole organ transplantation to correct enzymatic disorders. To this end, it would be of major importance to use xenogeneic cells without immunosuppression. The aim of this study was to investigate the survival and metabolic activity of encapsulated xenogeneic hepatocytes in the absence of immunosuppression. For this purpose, we used Gunn rats genetically incapable of bilirubin conjugation.

METHODS

Xenogeneic (from guinea pigs) and allogeneic (from Lewis rats) hepatocytes (2x10(7)) were isolated, macroencapsulated in hydrogel hollow fibers made with an acrylonitrile-sodium methallyl-sulfonate copolymer, and transplanted into the peritoneum of Gunn rats without any immunosuppression. Plasma bilirubin levels were evaluated weekly. Bilirubin conjugates in bile and cell morphology were studied after 5 and 12 weeks, respectively.

RESULTS

In Gunn rats transplanted with xenogeneic hepatocytes, a significant decrease in the serum bilirubin level was observed between 3 and 9 weeks after transplantation when compared with controls transplanted with empty hollow fibers: it fell to 62% of the initial level at weeks 5-7 (P < 0.01). A comparable result was observed in Gunn rats transplanted with encapsulated allogeneic cells. Bilirubin conjugates were observed in bile samples of rats transplanted with encapsulated hepatocytes. After explantation, hollow fibers appeared intact with minimal fibrosis. Cell viability and hepatocyte morphology were preserved.

CONCLUSIONS

These results indicate that macroencapsulated xenogeneic hepatocytes can survive and remain functional for more than 2 months when transplanted in vivo in the absence of any immunosuppression.

Transplantation of allogeneic hepatocytes without immunosuppression: long-term survival

BACKGROUND

Hepatocyte transplantation could be an alternative to whole liver transplantation. Allogeneic hepatocytes are rejected if transplanted without immunosuppression. The aim of this study was to transplant allogeneic hepatocytes in the peritoneum and to protect them from rejection by encapsulation in a new semipermeable membrane.

METHODS

Rat hepatocytes were encapsulated in hydrogel-based hollow fibers, obtained from AN69 copolymer, before being transplanted into the peritoneum of rats. Outcome of allogeneic hepatocytes encapsulated in hollow fibers was compared with that of syngeneic hepatocytes encapsulated in hollow fibers, with that of free allogeneic hepatocytes, and with allogeneic hepatocytes encapsulated in hollow fibers left open. Cell viability was assessed by erythrosin exclusion, structure by electron microscopy, and function by albumin release.

RESULTS

Up to 90 days, viability of allogeneic hepatocytes in hollow fibers was greater than 80%. The structure remained normal at electron microscopy. Albumin release was 16.5 +/- 0.3 micrograms/24 hr/10(6) hepatocytes (day 15), 14.2 +/- 2.0 micrograms/24 hr/10(6) hepatocytes (day 30), 8.8 +/- 0.1 micrograms/24 hr/10(6) hepatocytes (day 60), and 11.4 +/- 0.3 micrograms/24 hr/10(6) hepatocytes (day 90). Free hepatocytes and hepatocytes in hollow fibers left open did not survive at day 15.

CONCLUSIONS

Viability and function of encapsulated allogeneic hepatocytes were maintained up to 90 days after transplantation, without immunosuppression.