Implantation of microballoons in the management of fecal incontinence.

PURPOSE: The implantation of expandable microballoons has proved successful for the treatment of stress urinary incontinence. This led us to test its effectiveness in the treatment of severe fecal incontinence. METHODS: Six patients (four male), of average age of 43 (range, 29-60) years, with severe fecal incontinence, underwent implantation of expandable microballoons in the submucosa of the anal canal. The implantation was performed under intravenous sedation as an outpatient procedure. Anal manometry, endosonography, and incontinence assessment with a scoring system were performed before and after the implantation. RESULTS: With a mean follow-up of 8.6 (range, 7-12) months, the incontinence scores improved in all patients from an average of 16.16 (standard deviation: +/- 1.6) before the implantation to an average of 5 (standard deviation: +/- 1.26) after the procedure. The anal pressure at rest was not improved in any patient (mean: 50.16 before treatment to a mean of 53 after treatment). No significant adverse events were associated with the procedure, and no serious postimplantation complications were noted. DISCUSSION: Anal implantation of expandable microballoons seems to be a simple, safe, and effective method that restores the fecal continence without hindering normal defecation.

Endoscopic implantation of Plexiglas (PMMA) microspheres for the treatment of GERD.

BACKGROUND: A gelatinous implant containing polymethylmethacrylate (PMMA) beads is successfully used to augment the diminished thickness of the chorium in patients with skin defects and wrinkles. The aim of the present study was to determine whether submucosal injection of PMMA microspheres into the lower esophageal folds decreases the severity of symptoms and acid reflux in patients with GERD. METHODS: Endoscopic submucosal implantation of PMMA was carried out in 10 patients with GERD who were either refractory to or dependent on proton pump inhibitors. Symptom severity score, 24-hour pH monitoring, upper GI endoscopy, and EUS were performed to evaluate the efficacy of implantation. RESULTS: A significant decrease in the symptom severity score and mean total time with esophageal pH less than 4 was noted after the implantation of PMMA (p < 0.05). Seven of 10 patients were taking no medication after PMMA implantation. There were no serious procedure-related complications. CONCLUSIONS: Endoscopic implantation of PMMA into the submucosa of the lower esophageal folds may be a new method for treating GERD. Further studies are required to determine the long-term efficacy of the procedure.

Pelvic floor study in patients with obstructive defecation: influence of biofeedback.

The aim of this study was to evaluate the pathophysiologic abnormalities in patients with obstructive defecation or dyssynergia and to assess the role of biofeedback treatment. Three groups were studied. Group A had 24 patients with obstructive defecation; B, 25 patients with constipation; and C, 22 healthy volunteers. Rectosigmoid segmental transit time of group A was 28.5 hours (SD +/- 13.4); B, 17.2 hours (SD +/- 11.5); and C, 8.5 hours (SD +/- 6.3) (p < 0.05). There was no statistical difference in resting and squeezing anal pressure among the three groups. Anorectal angle at rest revealed no difference among the three groups. At strain, a statistically significant difference between groups A and C (p < 0.05) and a marginal difference between groups A and B was noted. Rectocele of the anterior rectal wall was present at strain in 17/24 patients of group A and 7/22 patients of group C (p < 0.05). Electromyography during strain revealed abnormal contractions of puborectalis muscle and external anal sphincter, in 13 and 14 patients of group A, respectively, which differed from that observed in groups B and C (p < 0.001). Biofeedback treatment was applied with good results in 7 of 11 patients of group A. At six months, constipation relapsed in only one of treated patients. Patients suffering from obstructive defecation seem to have slower rectosigmoid transit time than the others. Defecography shows smaller anorectal angle at strain and rectocele of the anterior rectal wall more often. Abnormal pelvic floor contraction at strain is often noted in anal electromyography. Some of these patients seem to respond favorably to biofeedback treatment.

The use of ERCP in the study of patients with hepatic echinococcosis before and after surgical intervention.

BACKGROUND: Biliary tree involvement is the most common complication of hydatid liver disease, which is difficult to detect and manage. METHODS: During the last 7 years, we examined by ERCP 26 cases with echinococcal liver involvement. Indications in the preoperative group included cholangitis in 6 cases, right-sided hypochondralgia involving 4, preoperative assessment in 4, and icterus in 1 case. In the postoperative group, the indications for ERCP were cholangitis in 5 cases, external biliary fistulas in 5, and biliary colic in 1 case. RESULTS: ERCP findings in the preoperative group included external bile duct compression in 11 cases (73.3%), biliary fistula affecting 3 (20%), and echinococcal remnants within the common bile duct in 1 case (6.6%). With regard to the postoperative group, biliary fistula formation was detected in 6 cases (54.5%), echinococcal remnants within the common bile duct in 4 (36.3%), and external bile duct compression involving 1 case (9%). Endoscopic sphincterotomy was successfully performed in 13 patients in both groups. No serious complications were encountered. CONCLUSION: ERCP is a safe and helpful preoperative or postoperative tool that aids in the diagnosis and often the treatment of echinococcal liver disease with involvement of the bile ducts.

Intraluminal duodenal diverticulum.

A 76-year-old man with an iron deficiency anemia during the previous 4 years and recent melena was presented. Gastroscopy showed a sessile polypoid lesion in the area of the papilla of Vater and histology was normal. Barium swallow follow-through and CT scan revealed a round intraluminal filling defect. ERCP demonstrated extrinsic compression of both ducts. Emergency laparotomy was performed because of upper GI bleeding and because attempts at endoscopic haemostasis of the oozing polypoid mass were unsuccessful. A soft compressible polypoid mass was found, which on palpation excreted a viscous milky liquid through a tiny opening. Histology showed normal duodenal mucosa bilaterally, a diagnostic finding of intraluminal duodenal diverticulum. The atypical age of presentation as well as gastroscopic and roentgenographic findings of this rare entity are illustrated.

ABO blood group, secretor status and detection of Helicobacter pylori among patients with gastric or duodenal ulcers.

Patients (454) referred for gastroscopy to the General Hospital of Athens were examined to determine (1) if non-secretors were over-represented among patients with ulcers and (2) if there was an association with ABO blood group or secretor status and carriage of Helicobacter pylori. Compared with the local population, among patients with either gastric ulcer (51) or duodenal ulcer (96) there was a significant increase in the proportion of those who were blood group O (P less than 0.025); however, there were no significant differences in the proportions of non-secretors. H. pylori was identified in 62% of the 454 patients: 59.5% of those without evidence of ulcers; 62.5% of those with gastric ulcer; 88% of those with duodenal ulcer (P less than 0.0005). These bacteria were cultured more often and in higher numbers from patients with duodenal ulcer (P less than 0.025). There was no association between ABO blood group and prevalence of H. pylori. The prevalence of H. pylori among non-secretors with gastric ulcer (12.5%) was significantly lower than that for non-secretors with duodenal ulcer (100%) (P less than 0.0005). This was not observed for secretors.