Rapid drink challenge test during esophageal high resolution manometry in patients with esophago-gastric junction outflow obstruction.

BACKGROUND: Esophago-gastric junction (EGJ) outflow obstruction is of unclear significance. Rapid drink challenge (RDC) test is easy to perform during esophageal high resolution manometry. We aimed to assess the yield of RDC test in patients with EGJ outflow obstruction. METHODS: Manometry studies of patients with EGJ outflow obstruction according to the Chicago Classification v3.0 were retrospectively reviewed. Pan-esophageal pressurization (PEP), esophageal shortening, and pressure gradient across the EGJ were analyzed during RDC test (200-mL free drinking in sitting position) and compared according to the causes of EGJ outflow obstruction determined by charts review. KEY RESULTS: Seventy-five patients (29 males, mean age 62 years) were included. Causes of EGJ outflow obstruction were previous esophago-gastric surgery (40%), incomplete form of achalasia (7%), mediastinal neoplasia (7%), other associated conditions (21%), and undetermined (25%). Rapid drink challenge test was successfully performed in 70 patients and associated with PEP and shortening in 41% and 13%, respectively. The causes of EGJ outflow obstruction were similarly distributed in patients with and without PEP during RDC test. Esophageal shortening tended to be more likely in patients with definitive findings of obstruction (achalasia, previous surgery, neoplasia) than in the others. Dysphagia was more severe in patients with PEP and/or shortening during RDC test compared to those without. CONCLUSIONS & INFERENCES: Pan-esophageal pressurization and esophageal shortening were associated with symptoms severity but did not predict the cause of this disorder. Further prospective studies are necessary to determine if RDC test could help to select patients who might benefit from treatment.

Impact of Intragastric Balloon Before Laparoscopic Gastric Bypass on Patients with Super Obesity: a Randomized Multicenter Study.

BACKGROUND: Super obese patients are recommended to lose weight before bariatric surgery. The effect of intragastric balloon (IGB)-induced weight loss before laparoscopic gastric bypass (LGBP) has not been reported. The aim of this prospective randomized multicenter study was to compare the impact of preoperative 6-month IGB with standard medical care (SMC) in LGBP patients. METHODS: Patients with BMI >45 kg/m2 selected for LGBP were included and randomized to receive either SMC or IGB. After 6 months (M6), the IGB was removed and LGBP was performed in both groups. Postoperative follow-up period was 6 months (M12). The primary endpoint was the proportion of patients requiring ICU stay >24 h; secondary criteria were weight changes, operative time, hospitalization stay, and perioperative complications. RESULTS: Only 115 patients were included (BMI 54.3 ± 8.7 kg/m2), of which 55 underwent IGB insertion. The proportion of patients who stayed in ICU >24 h was similar in both groups (P = 0.87). At M6, weight loss was significantly greater in the IGB group than in the SMC group (P < 0.0001). Three severe complications occurred during IGB removal. Mean operative time for LGBP was similar in both groups (P = 0.49). Five patients had 1 or more surgical complications, all in the IGB group (P = 0.02). Both groups had similar hospitalization stay (P = 0.59) and weight loss at M12 (P = 0.31). CONCLUSION: IGB insertion before LGBP induced weight loss but did not improve the perioperative outcomes or affect postoperative weight loss.

Randomized clinical trial of sacral nerve stimulation for refractory constipation.

BACKGROUND: Open studies have reported favourable results for sacral nerve stimulation in the treatment of refractory constipation. Here, its efficacy was assessed in a double-blind crossover RCT. METHODS: Patients with at least two of the following criteria were included: fewer than three bowel movements per week; straining to evacuate on more than 25 per cent of attempts; or sensation of incomplete evacuation on more than 25 per cent of occasions. Response to therapy was defined as at least three bowel movements per week and/or more than 50 per cent improvement in symptoms. Responders to an initial 3-week peripheral nerve evaluation were offered permanent implantation of a pulse generator and were assigned randomly in a crossover design to two 8-week intervals of active or sham stimulation. At the end of the two trial periods, the patients received active stimulation until the final evaluation at 1 year. RESULTS: Thirty-six patients (34 women; mean(s.d.) age 45(14) years) underwent peripheral nerve evaluation. Twenty responded and received a permanent stimulator. A positive response was observed in 12 of 20 and 11 of 20 patients after active and sham stimulation periods respectively (P = 0·746). Pain related to the device occurred in five patients and wound infection or haematoma in three, leading to definitive removal of the pulse generator in two patients. At 1 year, 11 of the 20 patients with an implanted device continued to respond. Stimulation had no significant effect on colonic transit time. CONCLUSION: These results do not support the recommendation of permanent implantation of a pulse generator in patients with refractory constipation who initially responded to temporary nerve stimulation. Registration number: NCT01629303 (http://www.clinicaltrials.gov).

Extensive preoperative workup in diffuse esophageal leiomyomatosis associated with Alport syndrome influences surgical treatment: A case report.

INTRODUCTION: Diffuse esophageal leiomyomatosis is a rare disease. Misdiagnosis is frequent and previous surgeries can complicate surgical management. The only treatment described for severe symptomatic cases is esophagectomy. PRESENTATION OF CASE: We describe a case of diffuse esophageal leiomyomatosis associated with Alport syndrome in a 21 year-old female where endoscopic ultrasonography (EUS) with concomitant fluoroscopy and 3D-gastric computed tomography (3D-GCT) modified surgical management. DISCUSSION: The diagnosis of diffuse esophageal leiomyomatosis is difficult but can be greatly facilitated by extensive endoscopic and radiologic workup. Esophagectomy should only be entertained after complete anatomic mapping of the lesions, especially after previous surgeries. CONCLUSION: EUS and 3D-GCT should strongly be considered as part of routine preoperative workup in these patients.

Botulinum toxin injection for hypercontractile or spastic esophageal motility disorders: may high-resolution manometry help to select cases?

Endoscopic injections of botulinum toxin in the cardia or distal esophagus have been advocated to treat achalasia and spastic esophageal motility disorders. We conducted a retrospective study to evaluate whether manometric diagnosis using the Chicago classification in high-resolution manometry (HRM) would be predictive of the clinical response. Charts of patients with spastic and hypertensive motility disorders diagnosed with HRM and treated with botulinum toxin were retrospectively reviewed at two centers. HRM recordings were systematically reanalyzed, and a patient's phone survey was conducted. Forty-five patients treated between 2008 and 2013 were included. Most patients had achalasia type 3 (22 cases). Other diagnoses were jackhammer esophagus (8 cases), distal esophageal spasm (7 cases), esophagogastric junction outflow obstruction (5 cases), nutcracker esophagus (1 case), and 2 unclassified cases. Botulinum toxin injections were performed into the cardia only in 9 cases, into the wall of the distal esophagus in 19 cases, and in both locations (cardia and distal esophagus) in 17 cases. No complication occurred in 31 cases. Chest pain was noticed for less than 7 days in 13 cases. One death related to mediastinitis occurred 3 weeks after botulinum toxin injection. Efficacy was assessed in 42 patients: 71% were significantly improved 2 months after botulinum toxin, and 57% remained satisfied for more than 6 months. No clear difference was observed in terms of response according to manometric diagnosis; however, type 3 achalasia previously dilated and with normal integrated relaxation pressure (4s-integrated relaxation pressure < 15 mmHg) had the worst outcome: none of these patients responded to the endoscopic injection of botulinum toxin. Endoscopic injections of botulinum toxin may be effective in some patients with spastic or hypercontractile esophageal motility disorders. The manometric Chicago classification diagnosis does not seem to predict the results. Prospective randomized trials are required to identify patients most likely to benefit from esophageal botulinum toxin treatment.

Achalasia-like disorder after laparoscopic adjustable gastric banding: a reversible side effect?

Literature data concerning the effect of laparoscopic adjustable gastric banding (LAGB) on esophageal motility are conflicting. Achalasia-like disorder involving the absence of esophageal peristalsis and impaired esophago-gastric junction (EGJ) is probably under-estimated and can result in failure and band removal. The aim of our study was to focus on cases of achalasia-like disorder and study its evolution after band deflating or removal. LAGB patients with food intolerance and whose esophageal manometry confirmed dysmotility were selected from our database. Achalasia-like disorder was defined as the absence of esophageal peristalsis (< 20% contraction waves) with impairment of EGJ relaxation. Manometric control was performed after removal or band deflating; functional results were assessed. Eleven patients among 20 (55%) with esophageal motility disorders (EMD) fitted the manometric criteria of achalasia-like disorder with a mean EGJ resting pressure of 32.1 cmH(2)O and a EGJ relaxation pressure of 24.2. Nine patients out of 11 underwent band removal which resulted in the resolution of their symptoms. The other two underwent band deflation. Manometric control after band removal showed both a decrease in resting and relaxation EGJ pressures (mean of 9.5 and 6.5 cmH(2)O) and a recovery of wave contractions in 87.5% of cases. Four patients underwent revision surgery due to weight regain with a successful outcome. Achalasia-like disorder is a manometric diagnosis and accounts for a significant part of symptomatic EMD after LAGB. It often results in band removal, allowing some reversibility of the disorders.

Persistent dysphagia after removal of an adjustable gastric band for morbid obesity: a rare complication.

Esophageal and gastric pouch dilatations are not uncommon after laparoscopic adjustable gastric banding for morbid obesity. Most of the cases are treated by gastric band deflation or removal. We report here the case of a 44-year-old woman with vomiting and severe dysphagia persisting despite gastric band removal, in relation with a scar stenosis and a gastric pouch trapped in the thorax, treated by laparoscopic surgery. This case underlines the usefulness of high-resolution manometry in the diagnostic work-up of these often difficult cases.

[Unexplained dysphagia in a young adult: management modalities]. / Dysphagie chez un homme jeune: modalités de la prise en charge.

Oropharyngeal dysphagia is very rare in young adults. Thoracic dysphagia work-up must include upper GI endoscopy and esophageal biopsies, to exclude eosinophilic esophagitis, which requires specific treatment with corticosteroids and endoscopic dilations. Esophageal manometry and barium swallow must be performed if upper GI endoscopy and biopsies are negative. High-resolution esophageal manometry, by disclosing a true functional imaging of swallow, appears as a real breakthrough for the diagnosis of dysphagia occurring after antireflux and bariatric surgery.

Elytrocele with and without a history of hysterectomy (303 defecography studies).

OBJECTIVE: To search for clinical risk factors and symptoms of elytrocele in female patients without hysterectomy. PATIENTS AND METHODS: Of 1060 women who underwent defecography, radiographic evidence of elytrocele was observed in 303. History-taking was standardized, and included obstetric, surgical and medical history as well as clinical symptoms and their duration. Group A comprised 192 women with hysterectomy while group B included 111 women with no history of hysterectomy; these two groups were compared. Group B was also compared with patients who had neither elytrocele nor hysterectomy (group C; n=516). RESULTS: Women in group B (no hysterectomy) were younger than those in group A (with hysterectomy) (57.9 years versus 62.8 years; p<0.05). Patients in group B had fewer obstetric (87.4% versus 97.9%; p=0.01) and abdominal (64.9 versus 82.3%; p=0.01) surgical events than those in group A, but more urinary tract surgery (18.9% versus 10.9%) and higher infant birth weights than patients in control group C. Six women (2%) had no surgical or obstetric history: mean age 42.7 years (20.6-74 years). Group B used protection against urinary soiling less often (17.3% versus 29.07%; p=0.017), but had more fecal soiling (23.4% versus 13.6%; p=0.033). Defecography showed that women in group B had more external rectal prolapse (17.7% versus 4.9%; p=0.003) and cystocele (48.6% versus 34.9%; p=0.019) than those in group A. CONCLUSIONS: This study was unable to identify risk factors of elytrocele in patients without hysterectomy except for a history of urinary tract surgery and higher infant birth weights. In some women, the elytrocele may be the result of significant rectal prolapse as part of a major pelvic floor disorder, predominantly in the posterior pelvis. Constitutional or congenital causes could also be involved as several young women free of any surgical or obstetric history nevertheless presented with an elytrocele.

Clinical, sonographic and manometric characteristics and impact on quality of life of fecal incontinence in 92 men referred for endoanal ultrasonography.

UNLABELLED: Anal incontinence (AI) is a frequent symptom with considerable impact on quality of life. The aim of this study was to describe the clinical, sonographic and manometric characteristics of a male population with AI. MATERIALS AND METHODS: Endoanal ultrasonography (EAU) was performed in 92 men referred for exploration of AI. Anal incontinence severity was evaluated by the Jorge and Wexner score (JW). The gastrointestinal quality-of-life index (GIQLI) was determined in 57% of patients. Anorectal manometry was performed in 62.6% of patients. RESULTS: The average JW score was 11+/-1. Anal incontinence had considerable impact on quality of life: average GIQLI=81+/-4. Seventeen patients presented an anal sphincter defect on EAU, 16 of whom had a history of coloproctological surgery. Prior surgery was significantly more common among patients who had a defect on ultrasonography; manometry showed significantly lower resting anal pressure. CONCLUSION: Our study confirms the severity of AI in a male population and its impact on quality of life. It also highlights the high prevalence of anal sphincter defects in patients with a history of anal surgery.

Results of laparoscopic Heller myotomy without anti-reflux procedure in achalasia. Monocentric prospective study of 106 cases.

BACKGROUND: Heller myotomy (HM) combined with an anti-reflux procedure has been shown to be effective for the treatment of achalasia, as postoperative gastro-esophageal reflux (GER) is observed in about 10% of the cases. Laparoscopy has brought an undeniable benefit in providing excellent visualisation of the gastro-esophageal junction (GEJ) without lateral and posterior dissection. Respecting the anatomical fixation of the GEJ seems to permit the performing of HM without an anti-reflux procedure, the need for which is therefore debatable. The purpose of this study was to analyse the results of this controversial procedure. METHODS: A monocentric prospective study was carried out on 106 patients who underwent HM without an anti-reflux procedure. The postoperative assessment consisted of a manometry and a 24-hour pH study two months after surgery, and a yearly clinical examination for a minimum of five years. The data capture was done using a statistical analysis. RESULTS: There was no mortality, one conversion to an open procedure, and four mucosal perforations. Postoperative morbidity was 2%. The average follow-up period was 55 months (range, 2 to 166), with 10 patients lost to follow-up. Good functional results were observed in 91.4% of patients at one year, and 78.6% at five years. Two months after surgery, a 9.4% prevalence of GER was detected in the pH study, and the lower esophageal sphincter pressure had significantly decreased. After a long term follow-up we observed an 11.3% global rate of GER. No repeat surgery was necessary to control postoperative GER. CONCLUSIONS: Laparoscopic HM without anti-reflux procedure gives good functional results provided the anatomical fixation of the GOJ is respected.

Characterization of reflux events after fundoplication using combined impedance-pH recording.

BACKGROUND: Laparoscopic fundoplication effectively controls symptoms of gastro-oesophageal reflux disease (GORD) and decreases acid reflux, but its impact on non-acid reflux is not known. The aim of the study was to characterize reflux events after fundoplication using oesophageal combined multichannel intraluminal impedance (MII)-pH monitoring, to demonstrate its efficacy on acid as well as non-acid reflux events. METHODS: Thirty-six patients in whom ambulatory MII-pH recording was performed after laparoscopic fundoplication were reviewed retrospectively. There were 23 symptomatic and 13 asymptomatic patients, whose results were compared with those of 72 healthy volunteers. RESULTS: Oesophageal acid exposure was low in all but one operated patient, and there was no difference between those with and without symptoms. The median number of reflux events over 24 h was lower after fundoplication (11 in operated patients compared with 44 in healthy volunteers; P < 0.001). Almost all reflux events were non-acid after surgery whereas acid reflux episodes were predominant in healthy volunteers. Proximal reflux events were less common in operated patients. Non-acid reflux events were significantly associated with symptoms after surgery in some patients. CONCLUSION: Fundoplication restores a competent barrier for all types of reflux. Reflux events are mostly non-acid after surgery, and such events may be positively correlated with symptoms.

Unresectable hepatocellular carcinoma: survival and prognostic factors after lipiodol chemoembolisation in 89 patients.

BACKGROUND: The majority of patients with hepatocellular carcinoma are not eligible for surgical radical treatment (resection or liver transplantation) and lipiodol chemoembolisation is an efficient alternative procedure in this indication. AIMS: To identify prognostic factors in patients treated with lipiodol chemoembolisation. PATIENTS AND METHODS: During 10 years, 89 consecutive patients with unresectable hepatocellular carcinoma underwent lipiodol chemoembolisation as a single treatment. There were 80 males and 9 females, with a median age of 65 years. Treatment consisted of one to six courses of hepatic intra-arterial lipiodol with doxorubicine and gelatin sponge. RESULTS: The median survival was 13 months with a 13.6% survival rate at 4 years. Univariate analysis showed that serum levels of albumin, bilirubin, alkaline phosphatase and alpha-fetoprotein, Child's class, tumour type, tumour size and intensity of lipiodol capture after the first course of lipiodol chemoembolisation were significant prognostic factors of survival. In the multivariate analysis, four parameters remained associated with a significantly better outcome: Child's class A, largest lesion<5 cm, uninodular tumour and intense lipiodol capture. CONCLUSIONS: While lipiodol chemoembolisation is associated with good results only in some patients, in the absence of lipiodol capture, it should be ruled out.

Esophageal capsule endoscopy versus esophagogastroduodenoscopy for evaluating portal hypertension: a prospective comparative study of performance and tolerance.

BACKGROUND AND STUDY AIMS: Esophagogastroduodenoscopy (EGD) is the most effective method for examining the upper gastrointestinal tract, and particularly for evaluating portal hypertension in cirrhotic patients, especially for screening purposes. The aim of this study was to assess the feasibility, safety, accuracy, and tolerance of PillCam ESO capsule endoscopy for this indication. PATIENTS AND METHODS: In this prospective study, unsedated EGD and capsule endoscopy examinations were conducted on the same day in cirrhotic patients at the time of diagnosis. The patients quantified the tolerability (relative to pain, nausea, choking sensations, etc.) of the two procedures using a 100-mm visual analogue scale. The time required for the recording and for diagnosis with the capsule examination were documented, as were the patients' preferences in comparison with EGD. Two independent endoscopists blinded to the EGD diagnoses assessed the diagnostic accuracy of the images obtained. RESULTS: Twenty-one patients were included in the study (mean age 62, mean Model for End-Stage Liver Disease score 10.5, mean Child-Pugh score 7.3). The procedure was safe. One patient was unable to swallow the capsule. The mean recording time was 213 s (range 6 - 1200 s); the procedure accurately assessed the presence or absence of esophageal varices in 16 of 19 patients (84.2 %); and it correctly indicated a need for primary prophylaxis (esophageal varices of grade 2 or more and/or red signs) in 100 % of cases. The tolerability of the capsule endoscopy examination was significantly better, and all of the patients preferred capsule endoscopy to EGD (which was transnasal in 11 patients). CONCLUSIONS: Capsule endoscopy was feasible, safe, accurate, highly acceptable, and preferred by cirrhotic patients undergoing screening for portal hypertension. This new technique requires further and more extensive evaluation, as well as assessment of its cost-effectiveness.

[Enterocele: clinical risk factors and association with others pelvic floor disorders (about 544 defecographies)]. / Entérocèle: facteurs de risque clinique et associations à d'autres troubles de la statique pelvienne (à partir de 544 défécographies).

OBJECTIVE: To study, by means of defecography, clinical risk factors of enterocele and association with others pelvic floor disorders. PATIENTS AND METHODS: Five hundred and forty-four consecutive female patients were investigated by colpocystodefecography with contrast medium in the small bowel. One hundred and thirty-six women with enterocele were compared to 408 women without enterocele. RESULTS: There were no significant differences in age, obstetrical history (parity, foetal macrosomia, instrumental extractions or perineal tear to delivery) between the two groups. More women with enteroceles had histories of hysterectomies (60% versus 24%) or cystopexies (29% versus 13%). Others pelvic floor disorders were associated in 91% of enterocele: rectocele (25%), cystocele (42%), uterine prolapse (28%), rectal intussusception (52%), rectal prolapse (4%) and abnormal perineal descent (30%). Stress urinary incontinence was significantly more frequent in women without enterocele. DISCUSSION AND CONCLUSIONS: The study has demonstrated that previous hysterectomy and cystopexy increased the risk of enterocele formation and that enterocele and others pelvic floor disorders are often concomitant. Enterocele may have a pessary effect on urinary disorders. Results of colpocystodefecography reinforce the notion of pelvic floor local disease.

[Helicobacter pylori in central serous chorioretinopathy and diffuse retinal epitheliopathy. Results of the first prospective pilot study]. / Rôle de l'Helicobacter pylori dans la choriorétinopathie séreuse centrale et l'épithéliopathie rétinienne diffuse. Résultats de la première étude prospective pilote.

PURPOSE: Helicobacter pylori has been implicated in focal occlusive arterial diseases in young people. Central serous chorioretinopathy (CSC) and diffuse retinal epitheliopathy (DRE) being suspected vascular occlusive diseases of choriocapillaris, the purpose of this study was to determine the prevalence of H. pylori infection in patients with long-lasting (>6 months) CSC and/or DRE. METHODS: Sixteen consecutive patients living in southeastern France were included in this prospective pilot study. H. pylori infection was assessed by the (13)C-urea breath test, serology, as well as histology of gastric biopsy specimens in some cases. RESULTS: Evidence for H. pylori infection was detected in nine out of the 16 patients with active long-lasting CSC/DRE (56.3%). H. pylori-infected patients more frequently presented gastric pain (four of nine H. pylori-positive patients: 44%) than H. pylori-negative patients (one out of seven: 14%). Men were more frequently H. pylori-positive (seven men out of ten: 70%) than women (two women out of a total of six: 33%). DISCUSSION: When the prevalence of H. pylori infection (56.3%) was compared to the prevalence in a historical control population from southeastern France (27.5%), it was found to be significantly higher (P<0.05). CONCLUSION: These results may indicate a possible association between H. pylori infection and CSC/DRE manifestations. This new etiopathogenic hypothesis deserves to be confirmed in a national or international multicenter study because it could lead to a new therapeutic approach in CSC/DRE, i.e., Helicobacter pylori eradication.

Endothelial cell marker expression in dysplastic lesions of the liver: an immunohistochemical study.

BACKGROUNDS/AIMS: Hepatocellular carcinoma usually contains continuous capillary vessels lacking the differentiation markers specific for normal sinusoidal endothelial cells. We therefore aimed to search for alterations in endothelial cell marker expression in precancerous liver lesions. METHODS: Expression of the endothelial cell markers CD31, CD34 and BNH9 was analyzed in 138 dysplastic lesions from 40 cirrhotic patients (20 with and 20 without hepatocellular carcinoma). RESULTS: No expression of the three endothelial cell markers was detected in cirrhotic nodules and in non dysplastic regenerative macronodules. The three markers were detected in 29.8% of dysplastic lesions and 47% of hepatocellular carcinomas. At least one marker was detected in 75% of dysplastic lesions and 100% of hepatocellular carcinomas. The three markers were more frequently expressed in areas of small cell than of large cell change (34 vs 10%). No correlation was found with the grade of dysplasia, the occurrence of arterialization and the association with hepatocellular carcinoma. CONCLUSIONS: Alterations in the hepatic microcirculation comparable to those observed in hepatocellular carcinoma are present in a significant proportion of dysplastic lesions of the liver and may be indirect markers of the process of liver carcinogenesis.

Assessment of Helicobacter pylori gene expression within mouse and human gastric mucosae by real-time reverse transcriptase PCR.

Despite increasing knowledge on the biology of Helicobacter pylori, little is known about the expression pattern of its genome during infection. While mouse models of infection have been widely used for the screening of protective antigens, the reliability of the mouse model for gene expression analysis has not been assessed. In an attempt to address this question, we have developed a quantitative reverse transcriptase PCR (RT-PCR) that allowed the detection of minute amounts of mRNA within the gastric mucosa. The expression of four genes, 16S rRNA, ureA (encoding urease A subunit), katA (catalase), and alpA (an adhesin), was monitored during the course of a 6-month infection of mice and in biopsy samples from of 15 infected humans. We found that the selected genes were all expressed within both mouse and human infected mucosae. Moreover, the relative abundance of transcripts was the same (16S rRNA > ureA > katA > alpA), in the two models. Finally, results obtained with the mouse model suggest a negative effect of bacterial burden on the number of transcripts of each gene expressed per CFU (P < 0.05 for 16S rRNA, alpA, and katA). Overall, this study demonstrates that real-time RT-PCR is a powerful tool for the detection and quantification of H. pylori gene expression within the gastric mucosa and strongly indicates that mice experimentally infected with H. pylori provide a valuable model for the analysis of bacterial gene expression during infection.