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Serviço de Endosc= opia Gastrointestinal do HC-FMUSP

Reunião de artigos
•= 3;
•= 3;
•        = ;            &n= bsp;    
•        = ;            &n= bsp;         22/03/2006
•
•Apresentação: Tomazo Antonio Prince Franzini&= #13;
•Coordenação: Dr. Dalton M. Chaves =
• Prof. = Paulo Sakai
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Endoscopy 2006; 38: 241-248
Original Article
•Endoscopic Retrograde Cholangiopancreatography <= /span>
•after a Liquid Fatty Meal: Effect on Deep Common Bile= 3;
•Duct Cannulation Time
•
•M.  Barrie, S.  D.  Klein, C.  A.  Brown, M.  D.  Edge,
•J.  A.  Affronti,Q.  Cai
•
•Division of Digestive Diseases, Emory University School of Medicine,
•Atlanta, Georgia, USA
•
•
------=_NextPart_01C7649D.ED4147F0 Content-Location: file:///C:/95524D79/EndoscopicRetrogradeCholangiopancreatography_arquivos/slide0001.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" INTRODUÇÃO
Introdução
 CPRE é uma ferramenta importante no diagnóstico e tratamento das doen&ccedi= l;as biliopancreáticas.
 O passo importante do procedimento é a canulação do ducto biliar comum (DBC) e/ou do ducto pancreático.
 Falha em obter uma colangiografia = com cateteres e técnicas standard na CPRE varia de 10% a 50%.
 Tempo prolongado para a canulação do DBC pode aumentar significantemen= te a morbidade para o paciente, a ansiedade para o endoscopista, a exposição à radiação para ambos e a ineficiência do procedimento.
 
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Introdução
 Métodos para facilit= ar a canulação são descritos como técnicos <= span style=3D'position:absolute;top:33.5%;left:6.92%;width:86.51%;height:5.25%'= >ou farmacológicos.
 Técnicos: diferentes tipos = de cateteres, precut papilotomia, colocação de stent temporário em ducto pancreático.
 Farmacológicos: nitrato tópico, sincalide IV (agonista da colecistoquinina), colecistoquinina e secretina.
 Os métodos técnicos consomem tempo e são invasivos, e os farmacológicos são pouco eficientes e caros.
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Introdução
 O jejum solicitado antes da CPRE p= ode tornar o procedimento mais difícil, não have= ndo estímulo para a secreção biliar e o relaxamento do esfíncter de Oddi.
 A gordura é o mais potente estimulante natural da secreção biliar e relaxam= ento do esfíncter de Oddi.
 Baseado nessas informaç&oti= lde;es postulou-se que a ingesta de uma refeição ri= ca em gordura traria um efeito benéfico na canulação do DBC.
 Este é um estudo duplo-cego randomizado sobre o efeito de uma refeiçã= ;o líquida rica em gordura na canulação profunda do DBC durante a CPRE.
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Pacientes e Método
 Pacientes encaminhados para CPRE e= m um período de 9 meses foram avaliados para integrar o estudo sob os seguintes critérios de exclusão:
Idade menor que 21 e maior= que 80 anos        = ;            &n= bsp;             Gestação        = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;   Stent preexistente em DCB ou ducto pancreático        = ;            Esfincterotomia cirúrgica ou endoscópica anterior        = ;          Cirurgia Billroth II        = ;            &n= bsp;            = ;            &n= bsp;            = ;            Falta de entendimento do paciente        = ;            &n= bsp;            = ;  CPRE anterior em menos de 1 semana        = ;            &n= bsp;            = ;     Necessidade de manometria biliar
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Pacientes e Método
 Todos os pacientes inclusos no tra= balham assinaram termo de consentimento e foram randomizados = em grupo de estudo(GE) e grupo controle(GC).
 Somente os membros do centro de pe= squisa não eram cegos ao estudo.
 Para determinar quanta gordura e q= uando oferecer outro estudo foi desenvolvido com voluntários e exames de USG após ingesta de gordura.
 Concluiu-se que 40g de óleo= de milho eram adequadas para induzir contração da vesícula biliar, com efeito máximo em 1 hora.
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Pacientes e Método
 
O volume da refeição foi de 90 ml, sendo fornecida ao GE a refeição líquida rica em gordura 1 hora antes do procedimento e ao GC o mesmo volume de líquido sem gordura.
 2 endoscopistas participaram do es= tudo, alternando-se na responsabilidade dos exames a cada 2 semanas podendo manter suas técnicas usuais de canulaçã= o, mas não usar técnica de precut ou stent pancreático temporário.
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Pacientes e Método
Residen= tes : 5 minutos para canulação do DBC, após <= span style=3D'position:absolute;top:30.75%;left:6.92%;width:87.26%;height:5.25%= '>endoscopista senior assumia o procedimento.
Tempo = de canulação do DBC: início da tentativa de canulação (desde= o residente) até o sucesso da canulação profunda do DBC.
Caso canulação inadvertida do ducto pancreático mantinha-s= e a contagem até a canulação do DBC.
Tempo = de fluoroscopia na canulação do DBC =3D        = ;            &n= bsp;        Tempo da fluoroscopia ao com= pletar a canulação do DBC – Tempo da fluoroscopia no início da canulação do DBC.=
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Pacientes e Método
Considerado falha= de canulação:
- Papila maior não localizada= ou não visualizada em posição adequada.
- Agitação do paciente impedindo procedimento.
- Tempo de canulação m= aior que 1 hora.
Acompanhamento dos pacientes:
Por 3 d= ias após CPRE e avaliados para sintomas como dor abdominal, náusea, vômito e sangramento.
Fotos da papila maior foram realizadas antes da canulação em <= /span>todos os pacientes.
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Pacientes e Método
An&aac= ute;lise estatística: estudo desenhado não para examinar a diferença na taxa de canulação do DBC, m= as sim para avaliar o tempo médi= o para a canulação nos 2 grupos.
Student= t test e Wilcoxon rank-sum test usados para comparar o tempo médio de canulação e fluoroscopia entre os grupos.
Teste = exato de Fisher usado para verificar a canulação em = diferentes categorias nos grupos.
Valor do P<=3D 0.05 foi considerado estatisticamente significante.
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Resultados
Pacientes verific= ados para aptidão: 161
Excluidos: 76 = ;
Recusou participa= r: 1
Portanto 84 pacie= ntes foram randomizados nos 2 grupos.
Procedimento n&at= ilde;o se completou em 6 pacientes.
Analisados os resultados de 78 pacientes.
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Resultados-Figura 1
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Resultados
Idade, sexo, indicações de CPRE e procedimentos realizados em cada grupo foram similares.        = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;         
        = ;            &n= bsp;            = ;            &n= bsp;             GE        = ;            &n= bsp;             GC
Idade         = ;      55 +/- 13         = ;            &n= bsp;       55 +/- 15
Sexo F/M 16/22 20/20
Ind. CPRE relacionada a neo        = ;    12 19
Ind. CPRE não-relacionada a neo 26 31
CPRE diagnóstica 15= 14
Escovado VB 12 10
DBC stent 14 15
Varredura balão   8 9
Esfincterotomia   9 11
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Resultados
O asp= ecto da refeição gordurosa era parecido, mas não igual ao = da refeição controle. Portanto foram usados cop= os com tampa e opacos para que os endoscop= istas não soubessem qual refeição o paciente havia ingerido. (foto 1)
No GE evidenciou-se bile no lúmen duodenal próximo à papila= maior em 82% dos pacientes. Nesses pacientes um óstio = papilar aberto era visto mais facilmente. (foto 2)
No GC b= ile no lúmen duodenal: 28% e na maioria dos casos o óstio não estava óbvio.
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Resultados-Foto 1
•= =
=
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Resultados
A média e mediana do tempo de canulação do DBC foram menores no grupo da refeição gordurosa do que no controle.
M&eacu= te;dia: 8.0 vs. 14.7 minutos (P=3D 0.005)        = ;            &n= bsp;            = ;   Mediana: 8.0 vs. 11.5 minuto= s (P=3D 0.008)
A média e mediana do tempo de fluoroscopia foram:
M&eacu= te;dia: 3.3 vs. 6.1 minutos (P=3D 0.040)        = ;            &n= bsp;            = ;  Mediana: 2.5 vs. 3.9 minutos= (P=3D 0.013)
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Resultados
=
Canulaç&at= ilde;o profunda do DBC foi conseguida em:        = ;         
88% (3= 3/38) GE        = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;    85% (34/40) GC
Por&ea= cute;m dos 11 pacientes em que não se conseguiu a canulação,= 6 (3/5 GE) e (3/6 GC) foram por problemas não relacionad= os à canulação com= o: hipotensão, agitação, perda do acesso venoso.
Porta= nto a verdadeira taxa de canulação profunda do DBC deve ser de 94% (33/35) GE e 92% (34/37) GC.
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Resultados
Canul= ação do DBC foi realizada pelos residentes em 13 pacientes do GE e 7 do GC. Comparando estes pacientes não houve = = diferença estatística no tempo da canulação.
Nos ou= tros pacientes (20 GE e 27 GC) a canulação foi realizada <= /span>pelo endoscopista senior e houve diferença estatística significante na média e mediana do tempo de canulação. (P=3D 0.002).&= #13;
No GC = 9/34 (26%) das canulações demoraram 20 min ou mais.    No GE 2/33 (6%) das canulações demoraram 20 min= ou mais.
No GC = fio guia foi usado em 5 pacientes e em 3 desses 5 mais de um cateter foi usado. No GE somente 1 cateter foi usado.
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Resultados
Seguimento dos pacientes por 3 dias após CPRE:
 Nenhum caso de dor abdominal impor= tante, nausea, vômitos ou sangra= mento da esfincterotomia ocorreu.
 Um paciente do GE e 3 do GC aprese= ntaram dor abdominal leve que durou menos q= ue 24 horas.
 Não foram realizados exames= de sangue de rotina após os proced= imentos, portanto não sendo possível o diagnóstico de <= /span>pancreatite pós CPRE nestes pacientes.
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Discussão<= /div>
O jej= um noturno ou de 8 horas tradicionalmente solicitado antes de uma CPRE pode tornar o procedimento mais difícil do= que ele deveria ser.
Como consequencia do jejum o esfíncter de Oddi do paciente torna-se mais justamente fechado e a secreção b= iliar no duodeno é menor. <= /span>
No entendimento dos autores esse é o primeiro relato do uso da = ingesta de uma refeição líquida gorduros= a para facilitar a canulaç&at= ilde;o durante a CPRE.
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Discussão<= /div>
Em al= guns pacientes o orifício do DBC ou do ducto pancreático <= /span>não é facilmente identificado.
A canulação às cegas da papila maior às 11 hs po= de ter sucesso em mãos experientes, = mas quando prolongada causa edema, trauma= e sangramento aumentando a morbidade.
A inge= sta da refeição gordurosa tornou muito mais fácil a <= /span>identificação do orifício do DBC e pancreático, evitando a canula&= ccedil;ão às cegas.
N&atild= e;o houve complicações como aspiração neste estudo, pois o volume de 90 ml oferecido 1 = hora antes já havia passado pelo est&oci= rc;mago no momento do procedimento.
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Discussão<= /div>
Pacien= tes com gastroparesia podem ter resíduos alimentares gástricos e a pequena quantidade da refeiç&atil= de;o gordurosa líquida n&atild= e;o traria outros riscos.
Em 1999= a Sociedade Americana de Anestesiologia revisou seus guidelines e liberou o consumo de refeição líquida clara 2 hs ante= s de procedimentos eletivos necessitando de anestesia geral, local ou sedação. Neste estudo a refeição foi admini= strada menos que 2 hs porém em um volume pequeno.
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Discussão<= /div>
Agentes anti-secretores como a somatostatina previnem a pancreatite pós-CPRE. Isso levanta a hipótese q= ue realizar uma CPRE em um pâncreas secretando (estimulado pela gordura), poderia elevar a ocorrência de pancreatite. =
Por&ea= cute;m outros anti-secretores como o octreotide não tem efeito na prevenção da pancreatite e também o m= enor número de tentativas de canulação e o relaxamento do esfíncter de Oddi estão associados à prevenção da pancreatite.
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Discussão<= /div>
O uso da refeição líquida gordurosa diminuiu 2.8 minutos em média o tempo de fluoroscopia em cada CPRE, reduzindo = significantemente o tempo de exposição  à radiação p= elo paciente e pela equipe de CPRE.
Tamb&= eacute;m o uso da refeição gordurosa pode diminuir o custo da = CPRE pois fio-guia não foi necessário no GE e s= omente 1 cateter foi usado por pacien= te.
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Discussão<= /div>
O mec= anismo que facilita a canulação do DBC após a ingesta da refeição gordurosa deve estar relacionado &agra= ve; secreção de colecis= toquinina. (figura 2)
Dentre= as diferentes gorduras, o triglicerídeo de cadeia longa é o mais potente estimulante da secreção de colecistoquinina. A refeiç&ati= lde;o líquida gordurosa usada neste estudo contém 100% desse triglicerídeo.
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Discussão-Figura 2
=
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Discussão<= /div>
A possibilidade de que os resultados deste estudo tenham ocorrido por acaso é muito pequena, se não for = zero.
Prime= iro pois a gordura é um estimulante da secreção biliar e = do relaxamento do esfíncter de Oddi.
Segund= o este estudo randomizado duplo-cego basicamente evita qualquer bias que possam vir dos autores. <= /div>
A inge= sta da refeição gordurosa não teve efeito na taxa de = canulação do DBC neste estudo, porém ele é relativamente pequeno= para esta finalidade.
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Discussão<= /div>
A pancreatite é uma grande e temida complicação da CPRE= que com o menor tempo de canulaç&atild= e;o conseguido pela ingesta da refei&c= cedil;ão gordurosa pode ser reduzida. Porém outros estudos serão necessários para confirmação.
Caso os procedimentos fossem realizados somente pelos 2 = endoscopistas senior o tempo médio de canulação poderia ser melhor = do que os relatados neste estudo.
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Discussão<= /div>
A refeição gordurosa é uma substância natural, ba= rata e facilmente disponível= e baseada neste estudo segura para adminis= tração antes da CPRE.
Apesar = de não haver como prever o grau de dificuldade do procedimento, é recomendado que pacientes enquadrados = nos critérios de seleção usados neste estudo= devam receber uma refeição líquida gordurosa antes da CPRE para diminuir o tempo de canulação do DBC e da exposição à radiação.
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Clique par= a sair.", SCREEN_MODE=3D"Frames", gIsEndShow=3D0, NUM_VIS_SLDS=3D32, SCRIPT= _HREF=3D"script.js", FULLSCR_HREF=3D"fullscreen.htm"; var gCurSld =3D gPrevSld =3D 1, g_offset =3D 0, gNtsOpen =3D gHasNts =3D gO= tlTxtExp =3D 0, gHasNarration =3D 0, gOtlOpen =3D true window.gPPTHTML=3DSupportsPPTHTML() var gMainDoc=3Dnew Array(new hrefList("slide0033.htm",1,-1,1),new hrefList(= "slide0032.htm",1,-1,1),new hrefList("slide0001.htm",1,-1,1),new hrefList("= slide0002.htm",1,-1,1),new hrefList("slide0003.htm",1,-1,1),new hrefList("s= lide0004.htm",1,-1,1),new hrefList("slide0005.htm",1,-1,1),new hrefList("sl= ide0006.htm",1,-1,1),new hrefList("slide0007.htm",1,-1,1),new hrefList("sli= de0008.htm",1,-1,1),new hrefList("slide0009.htm",1,-1,1),new hrefList("slid= e0010.htm",1,-1,1),new hrefList("slide0011.htm",1,-1,1),new hrefList("slide= 0012.htm",1,-1,1),new hrefList("slide0013.htm",1,-1,1),new hrefList("slide0= 030.htm",1,-1,1),new hrefList("slide0014.htm",1,-1,1),new hrefList("slide00= 15.htm",1,-1,1),new hrefList("slide0016.htm",1,-1,1),new hrefList("slide001= 7.htm",1,-1,1),new hrefList("slide0019.htm",1,-1,1),new hrefList("slide0020= .htm",1,-1,1),new hrefList("slide0021.htm",1,-1,1),new hrefList("slide0022.= htm",1,-1,1),new hrefList("slide0023.htm",1,-1,1),new hrefList("slide0024.h= tm",1,-1,1),new hrefList("slide0025.htm",1,-1,1),new hrefList("slide0031.ht= m",1,-1,1),new hrefList("slide0026.htm",1,-1,1),new hrefList("slide0027.htm= ",1,-1,1),new hrefList("slide0028.htm",1,-1,1),new hrefList("slide0029.htm"= ,1,-1,1)); /********************************************* Frameset functions These functions control slide navigation and state of the frameset. **********************************************/ function FullScrInit() { g_allowAdvOnClick =3D GetCurSld().mAdvOnClk document.body.style.backgroundColor=3D"black" document.oncontextmenu=3Dparent._CM; document.onkeydown =3D _KDH; document.ondragstart=3DCancel document.onselectstart=3DCancel self.focus() } function Redirect( frmId ) {=09 var str=3Ddocument.location.hash,idx=3Dstr.indexOf('#'), sId=3DGetSldId() if(idx>=3D0) str=3Dstr.substr(1); if( window.name !=3D frmId && ( sId !=3D str) ) { obj =3D GetObj("Main-File") window.location.href=3Dobj.href+"#"+sId return 1 } return 0 } var MHTMLPrefix =3D CalculateMHTMLPrefix();=20 function CalculateMHTMLPrefix() { if ( document.location.protocol =3D=3D 'mhtml:') {=20 href=3Dnew String(document.location.href)=20 Start=3Dhref.indexOf('!')+1=20 End=3Dhref.lastIndexOf('/')+1=20 if (End < Start)=20 return href.substring(0, Start)=20 else=20 return href.substring(0, End)=20 } return ''; } function GetTags(base,tag) { if(g_supportsPPTHTML) return base.all.tags(tag); else return base.getElementsByTagName(tag); } function UpdNtsPane(){ if(frames["PPTNts"]) PPTNts.location.replace( MHTMLP= refix+GetHrefObj( gCurSld ).mNtsHref ) } function UpdNavPane( sldIndex ){ if(gNavLoaded) PPTNav.UpdNav() } function UpdOtNavPane(){ if(gOtlNavLoaded) PPTOtlNav.UpdOtlNav() } function UpdOtlPane(){ if(gOtlLoaded) PPTOtl.UpdOtl() } function SetHasNts( fVal ) { if( gHasNts !=3D fVal ) { gHasNts=3DfVal UpdNavPane() } } function ToggleOtlText() { gOtlTxtExp=3D!gOtlTxtExp UpdOtlPane() } function ClearMedia() { // Clear any sounds playing before launching another browser window. Other= wise, // in fullscreen mode, you'll continue to hear the sound in the frames mod= e. if (PPTSld.pptSound) PPTSld.pptSound.loop =3D 0; } function FullScreen() {=20 if ( PPTSld.g_animUseRuntime ) PPTSld.document.body.pause(); ClearMedia(); var href =3D ( document.location.protocol =3D=3D 'mhtml:') ? FULLSCR_HREF = : FULLSCR_HREF+"#"+GetHrefObj(gCurSld).mSldHref; if(PPTNav.event.ctrlKey) { var w =3D (window.screen.availWidth * 1.0) / 2.0 var h =3D w * (PPTSld.g_origH * 1.0) / PPTSld.g_origW win =3D window.open( MHTMLPrefix+href,null,"toolbar=3D0,resizable=3D1,top= =3D0,left=3D0," + "width=3D"+ w + ",height=3D" + h ); if( win.document.body && PPTSld.g_animUseRuntime ) win.document.body.PPTSldFrameset=3Dwindow; } else { win =3D window.open( MHTMLPrefix+href,null,"fullscreen=3Dyes" ); if( win.document.body && PPTSld.g_animUseRuntime ) win.document.body.PPTSldFrameset=3Dwindow; } } function ToggleVNarration() { rObj=3DPPTSld.document.all("NSPlay") if( rObj && !PPTSld.g_animUseRuntime ) { if( (rObj.playState =3D=3D 1)||(rObj.playState =3D=3D 0) ) rObj.Play() else if( rObj.playState =3D=3D 2 ) rObj.Pause() else return; } else if( PPTSld.g_animUseRuntime ) { narObj =3D PPTSld.document.all("narrationID") if( narObj ) narObj.togglePause() } } function GetCurSldNum() { =20 obj=3DGetHrefObj(gCurSld) if( obj.mOrigVis =3D=3D 1 ) return obj.mSldIdx else =20 return gCurSld } function GetNumSlds() { =20 if( GetHrefObj(gCurSld).mOrigVis =3D=3D 1 ) return GetSldList().mNumVisSlds; else return GetSldList().mList.length } function GetSldNum( href ) { for(ii=3D0; ii 1 ) PopSldList(); else if( !IsFramesMode() ) { if( gLoopCont ) GoToFirst() else EndShow() } } function GoToPrevSld() { ii=3DgCurSld-1 if( ii > 0 ) { obj=3DGetHrefObj(ii) while ( obj && ( obj.mVis =3D=3D 0 ) && ( ii>0 ) ) obj=3DGetHrefObj(--ii) if( ii =3D=3D 0 ) ii=3D1 GoToSldNum(ii) } } function GoToFirst(){ GoToSld( GetHrefObj(1).mSldHref ) } function GoToLast() { ii=3DGetSldList().mList.length if( ii !=3D gCurSld ) GoToSld( GetHrefObj(ii).mSldHref ) } function GoToSldNum( num ) { if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue obj =3D GetHrefObj( num ) obj.mVis=3D1 gPrevSld=3DgCurSld gCurSld =3D num; PPTSld.location.replace(MHTMLPrefix+obj.mSldHref) if( IsFramesMode() ) { UpdNavPane(); UpdOtlPane(); UpdNtsPane() } } function GoToSld( href ) { if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue GetHrefObj( GetSldNum(href) ).mVis=3D1 PPTSld.location.replace(MHTMLPrefix+href) } function SldUpdated( id ) { if( id =3D=3D GetHrefObj(gCurSld).mSldHref ) return gPrevSld=3DgCurSld gCurSld=3DGetSldNum(id) if( IsFramesMode() ) { UpdNavPane(); UpdOtlPane(); UpdNtsPane() } } function PrevSldViewed(){ GoToSld( GetHrefObj(gPrevSld).mSldHref ) } function HasPrevSld() { return ( gIsEndShow || ( gCurSld !=3D 1 && GetHrefO= bj( gCurSld-1 ).mVis =3D=3D 1 )||( GetCurSldNum() > 1 ) ) } function HasNextSld() { return (GetCurSldNum() !=3D GetNumSlds()) } function CloseWindow() { if( HideMenu() ) return; =09 var event =3D PPTSld.event; if( !IsFramesMode() && event && (event.keyCode=3D=3D27 || event.keyCode=3D= =3D32 || event.type=3D=3D"click" ) ) window.close( self ); CatchNumKeys( self, event ); } function Unload() { gIsEndShow=3D0; } function SetupEndShow() { gIsEndShow=3D1; PPTSld.document.body.scroll=3D"no"; PPTSld.document.onkeypress=3DCloseWindow; PPTSld.document.onclick=3DCloseWindow; PPTSld.document.oncontextmenu=3D_CM; } function EndShow() { if( IsFramesMode() ) return if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue doc=3DPPTSld.document var dir =3D doc.body.dir if( dir !=3D "rtl" ) dir =3D "ltr"; doc.open() doc.writeln('


' + ENDSHOW_MESG + '

') doc.close() } function SetSldVisited(){ GetSldList().mList[gCurSld-1].mVisited=3Dtrue } function IsSldVisited(){ return GetSldList().mList[gCurSld-1].mVisited } function hrefList( sldHref, visible, advDelay, advClk ) { this.mSldHref=3D this.mNtsHref =3D sldHref this.mOrigVis=3D this.mVis =3D visible this.mVisited=3D false this.mAdvDelay=3D advDelay this.mAdvOnClk=3D advClk } function SldList(arr,curSld,fEnd) { this.mCurSld =3D curSld; this.mList =3D new Array(); var idx =3D 1; for(ii=3D0;ii 0) { PushSldList(sldList,fEnd); gCurSld =3D 1; } else if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue } function PushSldList(arr,fEnd) { var ii =3D gSldStack.length; gSldStack[ii] =3D new SldList(arr,gCurSld,fEnd); GoToSld( gSldStack[ii].mList[0].mSldHref ); } function PopSldList() { if (gSldStack[gSldStack.length-1].fEndShow) EndShow() else { gCurSld =3D gSldStack[gSldStack.length-1].mCurSld; gSldStack[gSldStack.length-1] =3D null; gSldStack.length--; var sldList =3D gSldStack[gSldStack.length-1]; GoToSld( sldList.mList[gCurSld - 1].mSldHref ); } } var custShowList=3Dnew Array(); /********************************************* Navigation button implementation There are 2 types of buttons: ImgBtn, TxtBtn implemented as function objects. They share a similiar interface so the event handlers can call SetActive, for example, on a button=20 object without needing to know exactly=20 what type of button it is. **********************************************/ //---------------------------------- function ImgBtn( oId,bId,w,action ) //---------------------------------- { var t=3Dthis t.Perform =3D _IBP t.SetActive =3D _IBSetA t.SetInactive=3D _IBSetI t.SetPressed =3D _IBSetP t.SetDisabled=3D _IBSetD t.Enabled =3D _IBSetE t.ChangeIcon =3D null t.UserAction =3D action t.ChgState =3D _IBUI t.mObjId =3D oId t.mBorderId=3D bId t.mWidth =3D w t.mIsOn =3D t.mCurState =3D 0 } function _IBSetA() { if( this.mIsOn ) { obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 ) obj.style.posTop=3D0 } } function _IBSetI() { if( this.mIsOn ) { obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 ) obj.style.posTop=3D0=20 } } function _IBSetP() { if( this.mIsOn ) { obj=3Dthis.ChgState( gShadowClr,gHiliteClr,2 ) obj.style.posLeft+=3D1; obj.style.posTop+=3D1 } } function _IBSetD() { =20 obj=3Dthis.ChgState( gFaceClr,gFaceClr,0 ) obj.style.posTop=3D0=20 } function _IBSetE( state ) { var t=3Dthis GetObj( t.mBorderId ).style.visibility=3D"visible" if( state !=3D t.mIsOn ) { t.mIsOn=3Dstate if( state ) t.SetInactive() else t.SetDisabled() } } function _IBP() { var t=3Dthis if( t.mIsOn ) { if( t.UserAction !=3D null ) t.UserAction() if( t.ChangeIcon ) { obj=3DGetObj(t.mObjId) if( t.ChangeIcon() ) obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-4)*t.mWidth else obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-0)*t.mWidth } t.SetActive() } =20 } function _IBUI( clr1,clr2,nextState ) { var t=3Dthis SetBorder( GetObj( t.mBorderId ),clr1,clr2 ) obj=3DGetObj( t.mObjId ) obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-nextState)*t.mWidth-obj= .style.posTop t.mCurState=3DnextState return obj } //----------------------------------------- function TxtBtn( oId,oeId,action,chkState ) //----------------------------------------- { var t=3Dthis t.Perform =3D _TBP t.SetActive =3D _TBSetA t.SetInactive=3D _TBSetI t.SetPressed =3D _TBSetP t.SetDisabled=3D _TBSetD t.SetEnabled =3D _TBSetE t.GetState =3D chkState t.UserAction =3D action t.ChgState =3D _TBUI t.mObjId =3D oId t.m_elementsId=3D oeId t.mIsOn =3D 1 } function _TBSetA() { var t=3Dthis if( t.mIsOn && !t.GetState() ) t.ChgState( gHiliteClr,gShadowClr,0,0 ) } function _TBSetI() { var t=3Dthis if( t.mIsOn && !t.GetState() ) t.ChgState( gFaceClr,gFaceClr,0,0 ) } function _TBSetP() { if( this.mIsOn ) this.ChgState( gShadowClr,gHiliteClr,1,1 ) } function _TBSetD() { =20 this.ChgState( gFaceClr,gFaceClr,0,0 ) this.mIsOn =3D 0 } function _TBSetE() { var t=3Dthis if( !t.GetState() ) t.ChgState( gFaceClr,gFaceClr,0,0 ) else t.ChgState( gShadowClr,gHiliteClr,1,1 ) t.mIsOn =3D 1 } function _TBP() { var t=3Dthis if( t.mIsOn ) {=20 if( t.UserAction !=3D null ) t.UserAction() if( !t.GetState ) return if( t.GetState() ) t.SetPressed() else t.SetActive() } =20 } function _TBUI( clr1,clr2,lOffset,tOffset ) { SetBorder( GetObj( this.mObjId ),clr1,clr2 ) Offset( GetObj( this.m_elementsId ),lOffset,tOffset ) } function Offset( obj, top, left ){ obj.style.top=3Dtop; obj.style.left=3Dle= ft } function SetBorder( obj, upperLeft, lowerRight ) { s=3Dobj.style; s.borderStyle =3D "solid" s.borderWidth =3D 1=20 s.borderLeftColor =3D s.borderTopColor =3D upperLeft s.borderBottomColor=3D s.borderRightColor =3D lowerRight } function GetBtnObj(){ return gBtnArr[window.event.srcElement.id] } function BtnOnOver(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetActive() } function BtnOnDown(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetPressed() } function BtnOnOut(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetInactive() } function BtnOnUp() { b=3DGetBtnObj() if( b !=3D null ) b.Perform() else Upd() } function GetNtsState(){ return parent.gNtsOpen } function GetOtlState(){ return parent.gOtlOpen } function GetOtlTxtState(){ return parent.gOtlTxtExp } function NtsBtnSetFlag( fVal ) { s=3Ddocument.all.item( this.m_flagId ).style s.display=3D"none" if( fVal ) s.display=3D"" else s.display=3D"none" } function _BSetA_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etActive() } function _BSetI_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etInactive() } function _BSetP_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etPressed() } function _BSetA_BorderImg() {=20 b =3D gBtnArr[this.mBorderId]=20 if( b !=3D null && this.mIsOn && !b.GetState() ) { obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 ) obj.style.posTop=3D0 } } function _BSetI_BorderImg() {=20 b =3D gBtnArr[this.mBorderId] if( b !=3D null && this.mIsOn && !b.GetState() ) { obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 ) obj.style.posTop=3D0 } } var gHiliteClr=3D"THREEDHIGHLIGHT",gShadowClr=3D"THREEDSHADOW",gFaceClr=3D"= THREEDFACE" var gBtnArr =3D new Array() gBtnArr["nb_otl"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOtlPan= e,GetOtlState ) gBtnArr["nb_otlElem"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOt= lPane,GetOtlState ) gBtnArr["nb_nts"] =3D new ImgBtn( "nb_nts","nb_ntsBorder",10,parent.ToggleN= tsPane ) gBtnArr["nb_nts"].SetActive =3D _BSetA_BorderImg; gBtnArr["nb_nts"].SetInactive =3D _BSetI_BorderImg; gBtnArr["nb_ntsBorder"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.= ToggleNtsPane,GetNtsState ) gBtnArr["nb_ntsElem"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.To= ggleNtsPane,GetNtsState ) gBtnArr["nb_prevBorder"] =3D gBtnArr["nb_prev"]=3D new ImgBtn( "nb_prev","n= b_prevBorder",30,parent.GoToPrevSld ) gBtnArr["nb_nextBorder"] =3D gBtnArr["nb_next"]=3D new ImgBtn( "nb_next","n= b_nextBorder",30,parent.GoToNextSld ) gBtnArr["nb_sldshw"]=3D new ImgBtn( "nb_sldshw","nb_sldshwBorder",18,parent= .FullScreen ) gBtnArr["nb_sldshwBorder"] =3D new TxtBtn( "nb_sldshw","nb_sldshwBorder",pa= rent.FullScreen,null ) gBtnArr["nb_sldshwBorder"].SetActive =3D _BSetA_Border; gBtnArr["nb_sldshwBorder"].SetInactive =3D _BSetI_Border; gBtnArr["nb_sldshwText"] =3D new TxtBtn( "nb_sldshw","nb_sldshwText",parent= .FullScreen,null ) gBtnArr["nb_sldshwText"].SetActive =3D _BSetA_Border; gBtnArr["nb_sldshwText"].SetInactive =3D _BSetI_Border; gBtnArr["nb_voice"] =3D gBtnArr["nb_voiceBorder"] =3D new ImgBtn( "nb_voice= ","nb_voiceBorder",18,parent.ToggleVNarration ) gBtnArr["nb_otlTxtBorder"] =3D gBtnArr["nb_otlTxt"]=3D new ImgBtn( "nb_otlT= xt","nb_otlTxtBorder",23,parent.ToggleOtlText ) gBtnArr["nb_ntsBorder"].m_flagId=3D "nb_nts" gBtnArr["nb_ntsBorder"].SetFlag =3D NtsBtnSetFlag gBtnArr["nb_otlTxt"].ChangeIcon=3D GetOtlTxtState /********************************************* Context menu implementation _CM() is the function that's hooked up to the oncontextmenu event. Once we're asked to show the menu, we first build it by creating DIVs on-the-fly. Then we position it=20 within the screen area so it doesn't get clipped. Creating the DIVs using createElement() means we don't have to write out any extra HTML into the slide HTML files. **********************************************/ var sNext=3D"Avançar",sPrev=3D"Voltar",sEnd=3D"Finalizar apresenta&c= cedil;ão",sFont=3D"Arial",sArrow=3D"Seta",sFreeform=3D"Forma livre",= sRect=3D"Retângulo",sOval=3D"Elipse" function ShowMenu() { BuildMenu(); var doc=3DPPTSld.document.body,x=3DPPTSld.event.clientX+doc.scrollLeft,y= =3DPPTSld.event.clientY+doc.scrollTop m =3D PPTSld.document.all.item("ctxtmenu") m.style.pixelLeft=3Dx if( (x+m.scrollWidth > doc.clientWidth)&&(x-m.scrollWidth > 0) ) m.style.pixelLeft=3Dx-m.scrollWidth m.style.pixelTop=3Dy if( (y+m.scrollHeight > doc.clientHeight)&&(y-m.scrollHeight > 0) ) m.style.pixelTop=3Dy-m.scrollHeight m.style.display=3D"" } function _CM() { if( !parent.IsFullScrMode() ) return; if(!PPTSld.event.ctrlKey) { ShowMenu() return false } else HideMenu() } function BuildMenu() { if( PPTSld.document.all.item("ctxtmenu") ) return var mObj=3DCreateItem( PPTSld.document.body ) mObj.id=3D"ctxtmenu" mObj.style.visibility=3D"hidden" var s=3DmObj.style s.position=3D"absolute" s.cursor=3D"default" s.width=3D"120px" SetCMBorder(mObj,"menu","black") var iObj=3DCreateItem( mObj ) SetCMBorder( iObj, "threedhighlight","threedshadow" ) iObj.style.padding=3D2 CreateMenuItem( iObj,sNext,M_GoNextSld,M_True ) CreateMenuItem( iObj,sPrev,M_GoPrevSld,M_HasPrevSld ) =09 CreateSeparator( iObj ) CreateMenuItem( iObj,sEnd,M_End,M_True ) mObj.style.visibility=3D"visible" } function Cancel() { window.event.cancelBubble=3Dtrue; window.event.returnVa= lue=3Dfalse } function Highlight() { ChangeClr("activecaption","threedhighlight") } function Deselect() { ChangeClr("threedface","menutext") } function Perform() { e=3DPPTSld.event.srcElement if( e.type=3D=3D"menuitem" && e.IsActive() ) e.Action() else PPTSld.event.cancelBubble=3Dtrue } function ChangeClr( bg,clr ) { e=3DPPTSld.event.srcElement if( e.type=3D=3D"menuitem" && e.IsActive() ) { e.style.backgroundColor=3Dbg e.style.color=3Dclr } } function M_HasPrevSld() { return( parent.HasPrevSld() ) } function M_GoNextSld() { if( gIsEndShow ) M_End(); else GoToNextSld() } function M_GoPrevSld() { if( gIsEndShow ) { gIsEndShow=3D0; history.back();= PPTSld.event.cancelBubble=3Dtrue; } else GoToPrevSld() } function M_True() { return true } function M_End() { window.close( self ) } function CreateMenuItem( node,text,action,eval ) { var e=3DCreateItem( node ) e.type=3D"menuitem" e.Action=3Daction e.IsActive=3Deval e.innerHTML=3Dtext if( !e.IsActive() ) e.style.color=3D"threedshadow" e.onclick=3DPerform e.onmouseover=3DHighlight e.onmouseout=3DDeselect s=3De.style; 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charset="us-ascii" INTRODUÇÃO ------=_NextPart_01C7649D.ED4147F0 Content-Location: file:///C:/95524D79/EndoscopicRetrogradeCholangiopancreatography_arquivos/outline.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii"
 An= otações
Apresenta= ção de slides
Estrutura de tópicos
= = =
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