[Dysphagia with no apparent cause]. / Dysphaqie sans cause evidente.

Dysphagia can be caused by a number of disorders, benign or malignant, that involve either the oropharynx or the esophagus. The cause of dysphagia can be determinated with an accuracy on the basis of a careful history alone in most cases. In patients without endoscopic abnormality, eosinophilic esophagitis must be suspected. Esophageal manometry is especially useful for the diagnosis of achalasia. There are no specific treatment for motility disorders other than achalasia and its variants.

Is esophageal dysmotility after laparoscopic adjustable gastric banding reversible?

Laparoscopic adjustable gastric banding (LAGB) has become an increasingly popular option to treat morbid obesity. Esophageal dysmotility secondary to LAGB has been described, but is usually reversible after removal of the band. Long-term esophageal dysmotility persisting after removal of the band is an unusual and not yet described complication. We report the case of a 58-year-old obese patient who developed severe dysphagia and vomiting associated with atypical esophageal dysmotility 22 months after gastric band placement. Radiological exploration revealed no acute band slippage but only a pseudoachalasia. Device deflation and then band removal were required in an attempt to treat her symptoms. Esophageal dysmotility persisted for several months after band removal and was still present after a Roux-en-Y gastric bypass performed as revisional operation. Possible mechanisms generating this complication and clinical implications are discussed.

Gastro-esophageal reflux and esophageal motility disorders in morbidly obese patients before and after bariatric surgery.

BACKGROUND: Obesity is a predisposing factor to gastro-esophageal reflux disease (GERD), but esophageal function remains poorly studied in morbidly obese patients and could be modified by bariatric surgery. METHODS: Every morbidly obese patient (BMI > or =40 kg/m2 or > or =35 in association with co-morbidity) was prospectively included with an evaluation of GERD symptoms, endoscopy, 24-hour pH monitoring and esophageal manometry before and after adjustable gastric banding (AGB) or Roux-en-Y gastric bypass (RYGBP). RESULTS: Before surgery, 100 patients were included (84 F, age 38.4 +/- 10.9 years, BMI 45.1 +/- 6.02 kg/m2), of whom 73% reported GERD symptoms. Endoscopy evidenced hiatus hernia in 39.4% and esophagitis in 6.4%. The DeMeester score was pathological in 53.3%; 69% of patients had lower esophageal sphincter (LES) pressure <15 mmHg and 7 had esophageal dyskinesia. BMI was significantly related to the DeMeester score (P = 0.018) but not to LES tone or esophageal dyskinesia. Postoperative data were available in 27 patients (AGB n = 12/60, RYGBP n = 15/36). The DeMeester score (normal < 14.72) was significantly decreased after RYGBP (24.8 +/- 13.7 before vs. 5.8 +/- 4.9 after; P < 0.001) but tended to increase after AGB (11.5 +/- 5.1 before vs. 51.7 +/- 70.7 after; P = 0.09), with severe dyskinesia in 2 cases. CONCLUSION: GERD and LES incompetence are highly prevalent in morbidly obese patients. Preliminary postoperative data show different effects of RYGBP and AGB on esophageal function, with worsening of pH-metric data with occasional severe dyskinesia after AGB.

[Haemorrhoidal disease in pregnancy]. / Pathologie hémorroïdaire de la parturiente.

External hemorrhoids thrombosis affects 8% of women during last trimester pregnancy and 20% of women immediately after delivery. Their treatment is medical with local treatment (with corticoid and anesthetic), defecation regulation and paracetamol. NSAID can be used after delivery in absence of breath-feeding. Local excision is not possible in most of the cases because of inflammation. Surgery has to be an exception because medical treatment is sufficient in almost all cases. Anal fissure is the most frequent differential diagnosis, encountered in 15% after all deliveries. Symptoms associate anal pain during and after defecation with blood on toilet paper. The only identified risk factor for hemorrhoids thrombosis (and anal fissure) is dyschesia. We have to think about it.