Peroral endoscopic myotomy: is it better to perform it in naive patients or as second-line therapy? Results of an open-label-controlled study in 105 patients.

BACKGROUND: Whether Peroral Endoscopic Myotomy (POEM) can be proposed as a second-line treatment in patients with achalasia remains to be confirmed in real-life series. OBJECTIVE: This study aimed to compare the efficacy, feasibility and safety of POEM between treatment-naïve patients and patients who had prior endoscopic or surgical therapies for achalasia. METHODS: All consecutive patients who underwent a POEM procedure for achalasia in our centre from June 2015 to September 2018 were included in this retrospective study. They were classified into treatment-naïve patients (POEM1) and patients who had at least one previous endoscopic and/or surgical treatment for achalasia (POEM2). RESULTS: A total of 105 patients were included, 52 in the POEM1 group and 53 in the POEM2 group. Clinical success (defined as an Eckardt score ≤ 3) at 6 months was observed in 93% of POEM1 patients and 84% of POEM2 patients (p = 0.18). Technical success rate was not significantly different between the two groups (100% vs 96%, respectively; p = 0.50). No significant difference was noted in terms of adverse event rate (19% vs 19%, respectively; p = 1.00). Post-procedure pain occurred in 12% of treatment-naive and 9% of non-naïve patients (p = 0.76). The median length of hospital stay was 3 days in both groups (p = 0.17). Symptomatic gastroesophageal reflux occurred in 25% of POEM1 patients and 16% of POEM2 patients (p = 0.24). CONCLUSION: Efficacy, feasibility and safety of POEM are not different between treatment-naïve and non-naïve patients. POEM is a valuable second-line approach in patients with persistent symptoms of achalasia after surgical or endoscopic treatments.

Altered epithelial barrier functions in the colon of patients with spina bifida.

Our objectives were to better characterize the colorectal function of patients with Spina Bifida (SB). Patients with SB and healthy volunteers (HVs) completed prospectively a standardized questionnaire, clinical evaluation, rectal barostat, colonoscopy with biopsies and faecal collection. The data from 36 adults with SB (age: 38.8 [34.1-47.2]) were compared with those of 16 HVs (age: 39.0 [31.0-46.5]). Compared to HVs, rectal compliance was lower in patients with SB (p = 0.01), whereas rectal tone was higher (p = 0.0015). Ex vivo paracellular permeability was increased in patients with SB (p = 0.0008) and inversely correlated with rectal compliance (r = - 0.563, p = 0.002). The expression of key tight junction proteins and inflammatory markers was comparable between SB and HVs, except for an increase in Claudin-1 immunoreactivity (p = 0.04) in SB compared to HVs. TGFß1 and GDNF mRNAs were expressed at higher levels in patients with SB (p = 0.02 and p = 0.008). The levels of acetate, propionate and butyrate in faecal samples were reduced (p = 0.04, p = 0.01, and p = 0.02, respectively). Our findings provide evidence that anorectal and epithelial functions are altered in patients with SB. The alterations in these key functions might represent new therapeutic targets, in particular using microbiota-derived approaches.Clinical Trials: NCT02440984 and NCT03054415.

Impact of Gastric Electrical Stimulation on Economic Burden of Refractory Vomiting: A French Nationwide Multicentre Study.

BACKGROUND & AIMS: Medico-economic data of patients suffering from chronic nausea and vomiting are lacking. In these patients, gastric electrical stimulation (GES) is an effective, but costly treatment. The aim of this study was to assess the efficacy, safety and medico-economic impact of Enterra therapy in patients with chronic medically refractory nausea and vomiting. METHODS: Data were collected prospectively from patients with medically refractory nausea and/or vomiting, implanted with an Enterra device and followed for two years. Gastrointestinal quality of life index (GIQLI) score, vomiting frequency, nutritional status and safety were evaluated. Direct and indirect expenditure data were prospectively collected in diaries. RESULTS: Complete clinical data were available for142 patients (60 diabetic, 82 non-diabetic) and medico-economic data were available for 96 patients (36 diabetic, 60 non-diabetic), 24 months after implantation. GIQLI score increased by 12.1 ± 25.0 points (p < .001), with a more significant improvement in non-diabetic than in diabetic patients (+15.8 ± 25.0 points, p < .001 versus 7.3 ± 24.5 points, p = .027, respectively). The proportion of patients vomiting less than once per month increased by 25.5% (p < .001). Hospitalisations, time off work and transport were the main sources of costs. Enterra therapy decreased mean overall healthcare costs from 8873 US$ to 5525 US$ /patient/year (p = .001), representing a saving of 3348 US$ per patient and per year. Savings were greater for diabetic patients (4096 US$ /patient/year) than for non-diabetic patients (2900 US$ /patient/year). CONCLUSIONS: Enterra therapy is an effective, safe and cost-effective option for patients with refractory nausea and vomiting. CLINICALTRIALS: gov Identifier: NCT00903799.

Solitary rectal ulcer syndrome in 102 patients: Do different phenotypes make sense?

BACKGROUND: Little is known about the pathophysiological mechanisms of solitary rectal ulcer syndrome (SRUS). AIMS: We aim to identify the different phenotypes, taking into account complaints, anatomy and anorectal physiology. METHODS: Complaints, endoscopy results, and physiology data of patients with histologically proven SRUS were collected and analysed. The associated anorectal diseases were faecal incontinence and obstructed defecation. The clinical aspects of SRUS were compared, and factors associated with anorectal diseases were identified. RESULTS: Overall, 102 consecutive patients were included. The predominant lesion was a rectal ulcer (66%), and inflammation of the rectal wall was present in 42% of patients. Abnormal rectal capacities and/or rectal perception was observed in more than half. Nearly half (52%) of the patients met the criteria for obstructed defecation and they tended to more frequently have psychiatric disease (66.7% vs 33.3%; p=0.07). Patients with faecal incontinence (17%) reported more self-perception of anal procidentia (p=0.01) and were more likely to have inflammation of the rectal wall (p=0.02), high-grade internal rectal procidentia (p=0.06) and anal hypotonia (p=0.004); their maximum tolerable volume was lower (p=0.004). CONCLUSION: The characteristics of patients with SRUS suggest different phenotypes. This may be a way to develop a comprehensive treatment strategy.

Jackhammer esophagus: Clinical presentation, manometric diagnosis, and therapeutic results-Results from a multicenter French cohort.

BACKGROUND/AIMS: Jackhammer esophagus (JE) is a hypercontractile esophageal motor disorder defined by at least two swallows with a distal contractile integral (DCI) >8000 mm Hg.s.cm during high-resolution manometry (HRM). The relationship between symptoms and hypercontractility and the response to therapies have been poorly evaluated. The aim of this study was to determine the clinical presentation, manometric diagnosis, and therapeutic results in a large cohort of JE patients. METHODS: Patients with JE diagnosed among the HRM tests performed in nine academic French centers from 01/01/2010 to 08/31/2016 were included. Patient charts were reviewed to collect clinical and therapeutic data. RESULTS: Among the 16 264 HRM tests performed during this period, 227 patients (60.8 ± 13.8 years, 151 male) had JE (1.7%). Dysphagia was the most frequent symptom (74.6%), followed by regurgitation (37.1%) and chest pain (36.6%); 4.7% of the patients were asymptomatic. The diagnostic workup was heterogeneous, and only a minority of patients had esophageal biopsies. None of the individual symptoms were significantly associated with any of the manometric parameters defined, except for dysphagia, which was significantly associated with the mean of all DCIs >8000 mm Hg.s.cm (P = .04). Additionally, the number of symptoms was not associated with any manometric parameter. Medical treatment and endoscopic treatments had poor efficacy and a high relapse rate. CONCLUSION: Jackhammer esophagus is a rare motility disorder. Diagnostic workup is heterogeneous and should be standardized. Symptoms are poorly associated with manometric parameters. The medical treatments and endoscopic therapies currently used are inefficient.

Management of solitary rectal ulcer syndome: Results of a french national survey: Société Nationale Française de Coloproctologie SNFCP, France.

There is no consensus on the treatment for solitary rectal ulcer syndrome (SRUS). This study aimed to obtain information from physicians treating patients with SRUS in a French medical surgical society to facilitate management plans and to develop a support algorithm. Members of the French National Society of Coloproctology (SNFCP) were invited to complete a survey that included twenty items about therapeutic management and healing criteria. Overall, 91 practitioners (median age: 52 [42-59] years) responded to the questionnaire; 64/91 (70.3%) were proctologists, and 27/91 (29.7%) were colorectal surgeons. Only 15 members (16.5%) followed more than 5 patients with SRUS per year. The therapeutic objectives were to improve both patient symptoms (100%) and quality of life (98.9%). Laxative treatment and first-line rehabilitation were agreed upon by 83.5% and 73% of the respondents, respectively. Surgery, mainly rectopexy, was offered after failed medical treatment by 81.1% of the practitioners (79.1%). The first-line strategy preferred by the professionals included laxatives and biofeedback rehabilitation. Surgical treatment, preferably rectopexy, was proposed as a second intervention. No consensus was reached regarding other therapeutic alternatives, and additional studies are required to clarify their indications.

Gastric Electrical Stimulation Reduces Refractory Vomiting in a Randomized Crossover Trial.

BACKGROUND & AIMS: There have been conflicting results from trials of gastric electrical stimulation (GES) for treatment of refractory vomiting, associated or not with gastroparesis. We performed a large, multicenter, randomized, double-blind trial with crossover to study the efficacy of GES in patients with refractory vomiting, with or without gastroparesis. METHODS: For 4 months, we assessed symptoms in 172 patients (66% women; mean age ± standard deviation, 45 ± 12 years; 133 with gastroparesis) with chronic (>12 months) of refractory vomiting (idiopathic, associated with a type 1 or 2 diabetes, or postsurgical). A GES device was implanted and left unactivated until patients were randomly assigned, in a double-blind manner, to groups that received 4 months of stimulation parameters (14 Hz, 5 mA, pulses of 330 µs) or no stimulation (control); 149 patients then crossed over to the other group for 4 months. Patients were examined at the end of each 4-month period (at 5 and 9 months after implantation). Primary endpoints were vomiting score, ranging from 0 (daily vomiting) to 4 (no vomiting), and the quality of life, assessed by the Gastrointestinal Quality of Life Index scoring system. Secondary endpoints were changes in other digestive symptoms, nutritional status, gastric emptying, and control of diabetes. RESULTS: During both phases of the crossover study, vomiting scores were higher in the group with the device on (median score, 2) than the control group (median score, 1; P < .001), in diabetic and nondiabetic patients. Vomiting scores increased significantly when the device was ON in patients with delayed (P < .01) or normal gastric emptying (P = .05). Gastric emptying was not accelerated during the ON period compared with the OFF period. Having the GES turned on was not associated with increased quality of life. CONCLUSIONS: In a randomized crossover study, we found that GES reduced the frequency of refractory vomiting in patients with and without diabetes, although it did not accelerate gastric emptying or increase of quality of life. Clinicaltrials.gov, Number: NCT00903799.

Quality of life in 1870 patients with constipation and/or fecal incontinence: Constipation should not be underestimated.

BACKGROUND: Quality of life is increasingly seen as important, but remains difficult to assess in patients with functional anorectal complaints. OBJECTIVE: We aimed to quantify quality of life and to analyse the symptomatic descriptors associated with a poor outcome in patients with faecal incontinence (FI) and/or constipation. METHODS: The characteristics of the patients, data from self-administered questionnaires and from physical examinations were evaluated prospectively for all cases of functional anorectal disease over a period of thirteen years. Functional anorectal disease included faecal incontinence (FI) and/or constipation. Patients with scores in the lowest quartile of the Gastrointestinal Quality of Life Index (GIQLI) were considered to have suffered severe alterations to their quality of life, and were compared with the other patients. RESULTS: In total, 1870 patients with functional anorectal disease were included (470 with a severely altered quality of life (GIQLI < 70)). Constipation predominated (1212/1870; 65.1%) and severe FI was frequent (761/1870; 40.9%). Severely altered quality of life was significantly associated with constipation (P = 0.0001), urinary urgency and incontinence (P = 0.0001), depression (P = 0.001), diabetes (P = 0.0224), severe FI (P = 0.0001), neurological disease (P = 0.0138) and liquid stools (P = 0.0002) in multivariate analysis. CONCLUSION: Several treatable factors are associated to an impaired quality of life in patients with functional anorectal disorders. Intervention studies are mandatory (stool consistency and frequency).

Defecation disorders in Spina Bifida: Realistic goals and best therapeutic approaches.

AIMS: Spina Bifida (SB) is a rare congenital condition that frequently impairs the neurological control of both fecal continence and defecation. Several therapeutic strategies have been proposed but impact assessment is lacking. Our objectives were to quantify the symptomatic improvement and to determine the optimal strategy in this rare condition where randomized controlled trials are difficult to conduct. METHODS: Data were extracted from a prospective database. The present analysis focused on patients having undergone at least two gastroenterological assessments. A standardized therapeutic approach was used from the first visit. Improvement was quantified by the variation of quantified symptomatic scores. RESULTS: The data of of 57 adults with SB (gender F/M: 30/27 [52.6/47.4%]; mean age: 33.8 [18.5] years) were extracted. After a mean follow-up of 46 months, 23/57 patients (40.4%) had at least improvement of one point of the Cleveland Clinic Incontinence score (CCIS); 13/57 (22.8%) reported a significant improvement of continence (delta score >50%). Five of the twelve patients (41.6%) with CCIS < 5 at baseline became incontinent over time. The neurological level was not associated with a worse continence outcome. Work on stool consistency and transanal irrigation were the most useful strategies in those with significant improvement of continence. CONCLUSIONS: Using conventional strategies, a benefit on fecal continence occurs in only one out of five patients suffering from Spina Bifida and continent patients at baseline can develop fecal incontinence over time. A strategy targeting improved control of defecation (transanal irrigation) and a standardization of follow-up protocol might be beneficial.

A systematic literature review on solitary rectal ulcer syndrome: is there a therapeutic consensus in 2018?

PURPOSE: To screen all treatments tested for solitary rectal ulcer syndrome (SRUS) without rectal prolapse and to assess their efficacy. METHOD: A systematic review was performed according to the PRISMA guidelines, focusing on the treatment of SRUS without rectal prolapse. The types of treatment and their efficacy were collected and critically assessed. RESULTS: A selection of 20 studies among the 470 publications focusing on SRUS provided suitable data for a total of 516 patients. Only 2 studies were randomised prospective trials that focused on argon plasma treatment. The mean follow-up was 21.8 months and ranged from 0.25 to 90 months. Most of the studies focused on surgery, including rectopexy, stapled transanal rectal resection, excision of the ulcer, the Delorme procedure, proctectomy, low anterior resection, and ostomy. Populations of the studies were heterogeneous and selected outcomes were specific (failure of medical or surgical treatment). Conservative treatment (high-fibre diet, laxatives, change of defecatory habits, and biofeedback treatment) induced a symptomatic improvement in 71/91 patients (63.6%) and healing of mucosal lesion in 17/51 patients (33.3%). Surgeries (all types) improved SRUS in 77% (54-100%) of patients. Argon plasma coagulation is a promising technique but longer follow-up is necessary. CONCLUSIONS: The general quality of the studies focusing on the treatment of SRUS was poor due to the heterogeneity of the population, the sample size of the cohorts, and the heterogeneity of efficacy assessments. The therapeutic approach appears to be multimodal and multidisciplinary and validated in centres of expertise. Further studies evaluating multimodal strategies are needed.

Clinical practice guidelines from the French National Society of Coloproctology in treating chronic constipation.

Chronic constipation is a common symptom that regularly affects the quality of life of adult patients. Its treatment is mainly based on dietary rules, laxative drugs, perineal rehabilitation and surgical treatment. The French National Society of Coloproctology offers clinical practice recommendations on the basis of the data in the current literature, including those on recently developed treatments. Most are noninvasive, and the main concepts include the following: stimulant laxatives are now considered safe drugs and can be more easily prescribed as a second-line treatment; biofeedback therapy remains the gold standard for the treatment of anorectal dyssynergia that is resistant to medical treatment; transanal irrigation is the second-line treatment of choice in patients with neurological diseases, but it may also be proposed for patients without neurological diseases; and although interferential therapy may be a new promising treatment, it needs further evaluation.

Fecal incontinence in patients with spina bifida: The target is the rectum.

AIMS: The prevalence rate of severe fecal incontinence (FI) in adults with spina bifida (SB) is high. The physiological basis of FI in SB has not been clearly established, which contributes to inadequate care. The aim was to better characterize a large cohort of adults with special consideration of anorectal physiology. METHODS: A multidisciplinary team from a French referral centre for SB prospectively collected data on patients who had an anorectal manometry. Factors associated with severe FI (Cleveland clinical incontinence score ≥ 9) were assessed in a multivariate analysis model. RESULTS: A total of 132 adults with SB (sex ratio M/F: 55 [41.7%]/77 [58.3%]; mean age of 38.2 [11.6] years old) were assessed. Among these patients, 83/132 (62.9%) suffered from severe FI. Rectal perception was not evaluable among 17 patients who had a latex allergy. Overall, 29/115 (25.2%) had maximal tolerable volume (MTV) > 330 mL or no sensation. The absence of anal canal sensitivity, MVT > 330 mL and the amplitude of the recto-anal inhibitory reflex (RAIR) >75% after a rectal isovolumic inflation of 50 mL were significantly associated with severe FI in the multivariate analysis model. Neither neurological level nor other neurological features were associated with severe FI. CONCLUSIONS: This study showed that FI in patients with SB is mainly associated with rectal abnormalities. This should be taken into consideration to improve incontinence management of patients with SB.

Bowel Dysfunction Related to Spina Bifida: Keep It Simple.

BACKGROUND: Although care of urological disorders in spina bifida is well established, there is yet no agreement on a standardized approach to bowel dysfunction in this population. OBJECTIVE: The purpose of this study was to assess bowel dysfunction using validated instruments and the risk factors in adults with spina bifida. DESIGN: A multidisciplinary team prospectively collected patient data, focusing on anorectal and urological symptoms. SETTINGS: The study was conducted with data from a French referral center for spina bifida. PATIENTS: A total of 228 adults with spina bifida (sex ratio men:women, 92 (40%):136 (60%)) with a median age of 34.7 years (range, 26.8-44.7 y) were assessed. MAIN OUTCOMES MEASURES: Factors associated with severe fecal incontinence (Cleveland Clinic Incontinence Score ≥9) and severe bowel dysfunction (Neurogenic Bowel Dysfunction score ≥14) were assessed in a multivariate analysis model. RESULTS: The prevalence rates of severe fecal incontinence and severe bowel dysfunction were 60% (130/217) and 42% (71/168). Bowel dysfunction was the second most common major concern of patients after lower urinary tract dysfunction. Male sex, obesity, urinary incontinence, and a Knowles-Eccersley-Scott symptom constipation score ≥10 were independently associated with severe fecal incontinence. Patients with soft stools had significantly less severe bowel dysfunction. Neither neurologic level nor other neurologic features of spina bifida were associated with severe fecal incontinence or severe bowel dysfunction. LIMITATIONS: The recruitment of patients with spina bifida through a national referral center might have resulted in selection bias, and some data were missing especially regarding BMI and Neurogenic Bowel Dysfunction score (21% and 26% of missing data). CONCLUSIONS: The prevalence rates of severe fecal incontinence and severe bowel dysfunction in adults with spina bifida were high and were adequately perceived by the patients. The present study emphasized the association of bowel dysfunction and fecal incontinence with obesity, urologic disorders, and stool consistency rather than neurologic features. See Video Abstract at http://links.lww.com/DCR/A394.

Factors Associated with Fecal Incontinence in Women of Childbearing Age with Crohn's Disease.

BACKGROUND: Fecal incontinence is common in women with Crohn's disease, but little is known about the impact of childbirth, perianal Crohn's disease, and past surgical history on fecal incontinence. METHODS: Self-administered questionnaires were mailed to consecutive women referred to a tertiary gastroenterology centre with a focus on fecal incontinence and childbirth. These data were cross-referenced with a prospective database of the same patients' own Crohn's disease histories. Fecal incontinence was defined as a Cleveland Clinic Incontinence Score ≥5. Factors associated with fecal incontinence were analyzed. RESULTS: A total of 173 patients were assessed, including 113 parous women. The prevalence of fecal incontinence was 37.5% (95% CI, 30.7-45.0). The disease duration, a history of anal surgery for fistula, the number of childbirths per woman and Crohn's activity were all independently associated with fecal incontinence in a multivariate analysis model. Specifically, among the group of parous women, fecal incontinence was associated with prior abdominal surgery, prior anal surgery, and Crohn's activity. The mode of delivery was not statistically associated with fecal incontinence. CONCLUSIONS: Fecal incontinence is a significant complaint in at least one-third of women of childbearing age with Crohn's disease. Patients'disease and treatment histories seem to have a comparable effect to their childbirth history concerning the presence of fecal incontinence. Both physicians and surgeons who are involved in the management of Crohn's disease need to keep this in mind.

Prevalence and characteristics of acid gastro-oesophageal reflux disease in Jackhammer oesophagus.

BACKGROUND: An association between acid gastro-oesophageal reflux disease (GERD) and Jackhammer oesophagus has been suggested. AIM: To assess the prevalence and characteristics of acid-GERD in Jackhammer oesophagus and the efficacy of proton pump inhibitors. METHODS: Data and outcomes of patients with Jackhammer oesophagus were assessed. Two groups were compared: (i) GERD, defined by endoscopic oesophagitis or by an increase in acid exposure time or by an acid-hypersensitive oesophagus and (ii) non-GERD defined by normal oesophageal acid exposure without acid-hypersensitive oesophagus. RESULTS: Among the 1994 high-resolution manometries performed, 44 Jackhammer oesophagus (2.2%) were included (sex ratio M/F: 19/25; median age: 66 [61-75] years). Nineteen patients (43.2%) had GERD, 16 (36.4%) had no GERD and 9 patients (20.4%) were undetermined. Dysphagia was the predominant symptom (37/43 (86%)). After a median follow-up of 25.3 months [9.6-31.4], dysphagia was improved in 22/36 (61.1%) patients. Dysphagia improvement as well as other symptoms improvement was not associated with GERD status or proton-pump inhibitors use. CONCLUSION: The prevalence of GERD is high among patients with Jackhammer oesophagus. The rates of symptom improvement in Jackhammer oesophagus were high regardless of the use of proton-pump inhibitors treatment or of the presence of GERD.

High-Resolution Manometry Improves the Diagnosis of Esophageal Motility Disorders in Patients With Dysphagia: A Randomized Multicenter Study.

OBJECTIVES: High-resolution manometry (HRM) might be superior to conventional manometry (CM) to diagnose esophageal motility disorders. We aimed to compare the diagnosis performed with HRM and CM and confirmed at 6 months in a multicenter randomized trial. METHODS: Patients with unexplained dysphagia were randomized to undergo either CM or HRM. Motility disorders were diagnosed using the Castell and Spechler classification for CM and the Chicago classification for HRM. Diagnosis confirmation was based on clinical outcome and response to treatment after 6-month follow-up. The initial diagnosis and percentage of confirmed diagnoses were compared between the two arms (CM and HRM). RESULTS: In total, 247 patients were randomized and 245 analyzed: 122 in the CM arm and 123 in the HRM arm. A manometric diagnosis was more frequently initially achieved with HRM than with CM (97% vs. 84%; P<0.01). Achalasia was more frequent in the HRM arm (26% vs. 12% in the CM arm; P<0.01) while normal examinations were more frequent in the CM arm (52% vs. 28% in the HRM arm; P<0.05). After follow-up, the initial diagnosis was confirmed in 89% of patients in the HRM arm vs. 81% in the CM arm (P=0.07). Finally, overall procedure tolerance was better with CM than with HRM (P<0.01). CONCLUSIONS: This randomized trial demonstrated an improved diagnostic yield for achalasia with HRM compared with CM. Diagnoses tended to be more frequently confirmed in patients who underwent HRM, suggesting that esophageal motility disorders could be identified earlier with HRM than with CM (ClinicalTrial.gov, NCT01284894).

[Factors and clinical forms of gastroesophageal reflux disease in adults]. / Facteurs en cause et formes cliniques du reflux gastro-oesophagien chez l'adulte. Une prévalence élevée qui augmente avec l'âge.

Factors and clinical forms of gastroesophageal reflux disease in adults. Gastro-oesophageal reflux (GERD) is a common complaint. Factors involved in GERD are the antireflux barrier dysfunction, the oesophageal sensitivity disorders, impaired oesophageal clearance, the acid component of the refluxate, and impaired gastric emptying. Risk factors for GERD are hiatal hernia and obesity. Although heartburn or regurgitations are specific to characterize GERD, patients usually report a number of associated symptoms such as cough, eructation, globus, hiccups, chest pain, and sleep disturbances. Complications of GERD are oesophagitis, gastrointestinal haemorrhage, peptic stricture or Barrett's oesophagus.

Facteurs en cause et formes cliniques du reflux gastro-oesophagien chez l'adulte. Le reflux gastro-oesophagien est un motif de consultation fréquent. Les facteurs impliqués sont, par ordre d'importance, la défaillance de la barrière anatomique anti-reflux, les troubles de la sensibilité oesophagienne, l'altération de la clairance oesophagienne, la composition du reflux et le ralentissement de la vidange gastrique. La hernie hiatale et l'obésité sont des facteurs de risque. Le reflux gastro-oesophagien peut se manifester par des signes fonctionnels typiques, comme le pyrosis ou les régurgitations mais aussi par des signes cliniques atypiques qui évoquent des affections cardiovasculaires, respiratoires, ou oto-rhino-laryngées. Les complications du reflux sont l'oesophagite peptique, l'hémorragie digestive, la sténose peptique et l'endobrachyoesophage.

Long-term impact of full-thickness rectal prolapse treatment on fecal incontinence.

BACKGROUND: Fecal incontinence is frequently associated with rectal prolapse, but little is known about recovery after treatment of the prolapse. OBJECTIVE: We therefore aimed to investigate the long-term outcome of fecal incontinence in a cohort of patients suffering from full-thickness rectal prolapse. DESIGN: A database of 145 patients diagnosed with full-thickness rectal prolapse was compiled prospectively over a 7-year period (2003-2010). MAIN OUTCOME MEASURES: Patients were referred to a single institution and assessed by standardized questionnaires, anorectal manometry, endosonography, and evacuation proctography. Fecal incontinence was evaluated according to the Cleveland Clinic Score; continence improvement was defined by ≥50% improvement of the Cleveland Clinic Score. RESULTS: Among the population studied (134 women, 11 men; median follow-up, 38.9 months [range, 21.2-67.2]), 103 patients (71%) underwent operation for their prolapse and 42 (29%) did not. According to the Cleveland Clinic Score, 139 patients (96%) suffered from fecal incontinence before treatment and 64 (46%) reported improvement at the end of the follow-up. Pretreatment history of incontinence symptoms for >2 years (hazard ratio [HR], 1.99; 95% CI, 1.14-3.46; P = .015) and ventral rectopexy (HR, 1.86; 95% CI, 1.026-3.326; P = .04) were associated with continence improvement. Patients who underwent an operative procedure other than ventral rectopexy had similar outcome as compared with nonoperated patients. Conversely, chronic pelvic pain precluded fecal incontinence improvement (HR, 0.32; 95% CI, 0.135-0.668; P = .0017). LIMITATIONS: Follow-up, returned questionnaires, and the heterogeneous reasons put forth for declining surgery may introduce some methodologic bias. CONCLUSION: Fecal incontinence in patients suffering from rectal prolapse is improved when ventral rectopexy is performed compared with other operative or medical therapies.

Long-term results of pneumatic dilatation for relapsing symptoms of achalasia after Heller myotomy.

BACKGROUND: The aim of this study was to assess the efficacy and safety of pneumatic dilatation (PD) to treat symptom recurrence after Heller myotomy (HM). METHODS: Consecutive patients receiving PD for relapsing symptoms following prior HM were included in this retrospective single-center study. Eckardt score ≤3 and/or ∆ Eckardt (difference between Eckardt score before and after dilatation) ≥3 defined the success of initial dilatation. Patients who maintained response longer than 2 months after initial dilatation were defined as short-term responders. Relapsers were offered further on-demand dilatation. Remission was defined as an Eckardt score ≤3 at the study endpoint. Kaplan-Meier survival curves were used to determine relapse rates. KEY RESULTS: Eighteen patients (11 women, seven men) were included from January 2004 to January 2013. Ten patients had type I achalasia, and seven had type III, according to the Chicago classification. Thirty-nine PDs were performed (1.5 [1-2.25] per patient). All patients had short-term responses. The remission rate at the endpoint, after a median follow-up of 33 months, was 78%, but 44% were treated with on-demand PD during the follow-up interval. The proportions of patients without relapse and subsequent PD were 72% at 12 months, 65% at 24 and 36 months, and 49% at 48 months. No factors predictive of long-term response, particularly the type of achalasia, could be identified in this series. There were no perforations. CONCLUSIONS & INFERENCES: In treating symptom recurrence following HM, PD was safe and effective over the long term when combined with subsequent PD.