Easy clip to treat anal fistula tracts: a word of caution.

BACKGROUND AND AIMS: Closing the internal opening by a clip ovesco has been recently proposed for healing the fistula tract, but, to date, data on benefit are poorly analyzed. The aim was to report a preliminary multicenter experience. MATERIALS AND METHODS: Retrospective study was undertaken in six different French centers: surgical procedure, immediate complications, and follow-up have been collected. RESULTS: Nineteen clips were inserted in 17 patients (M/F, 4/13; median age, 42 years [29-54]) who had an anal fistula: 12 (71%) high fistulas (including 4 rectovaginal fistulas), 5 (29%) lower fistulas (with 3 rectovaginal fistulas), and 6 (35%) Crohn's fistulas. Out of 17 patients, 15 had a seton drainage beforehand. The procedure was easy in 8 (47%) patients and the median operative time was 27.5 min (20-36.5). Postoperative period was painful for 11 (65%) patients. A clip migration was noted in 11 patients (65%) after a median follow-up of 10 days (5.5-49.8). Eleven patients (65%) who failed had reoperation including 10 new drainages within the first month (0.5-5). After a mean follow-up of 4 months (2-7),, closing the tract was observed in 2 patients (12%) following the first insertion of the clip and in another one after a second insertion. CONCLUSION: Treatment of anal fistula by placing a clip on the internal opening is disappointing and deleterious for some patients. A better assessment before dissemination is recommended.

[Achalasia mimicking psychiatric eating disorders]. / Achalasie mimant des troubles du comportement alimentaire.

Anorexia nervosa and psychogen vomiting are psychiatric eating disorders characterized by unexplained weight loss and induced vomiting. These diagnoses require absence of somatic disease. Achalasia is a primary disorder of the esophagus that can be responsible for the same symptoms. This may occult the real diagnosis, especially as dysphagia is not constant and variable in time. We report four cases of achalasia mistakenly diagnosed and treated as anorexia nervosa or psychogen vomiting. Achalasia was unrecognized because specific symptoms, such as dysphagia, were overlooked or misinterpreted by the patients' physicians and psychiatrists, or by the patients themselves. In patients with such eating disorders considered to be psychiatric, physicians should inquire about signs suggestive of achalasia. The diagnosis of achalasia is suspected by imaging and endoscopy, and confirmed or ruled out by manometry.

[18F]-FDG uptake in soft tissue dermatome prior to herpes zoster eruption: an unusual pitfall.

Authors report on a case of [18F]-fluorodeoxyglucose ([18F]-FDG) uptake in the soft tissue of a patient referred for [18F]-FDG coincidence detection emission tomography (CDET) in a search for recurrence of colorectal cancer. A herpes zoster eruption occurred in the same site within two days, but was spontaneously resolved. To the best of our knowledge this is the first description of a false positive [18F]-FDG result in relation to a viral infection of soft tissue. It shows that interpretation of subcutaneous foci has to be cautious in patients with or without a past history of herpes zoster even in pain-free areas and prior to skin eruption.

[Minimally invasive surgery for diverticula of the thoracic esophagus. Results in 11 patients]. / Traitement par vidéo-chirurgie des diverticules de l'oeophage thoracique.

OBJECTIVES: Surgical treatment of diverticula of the esophagus is associated with substantial mortality and morbidity. Few data have been published concerning results of minimally invasive surgery. The aim of the study was to retrospectively assess the results of minimally invasive surgery (either thoracoscopy or laparoscopy) in a first series of patients with diverticula of the thoracic esophagus. METHODS: Eleven consecutive patients with symptomatic thoracic diverticula of the esophagus were operated on between December 1992 and March 1999. Five were operated on by right thoracoscopy, 4 by laparoscopy and 2 by thoracoscopy and laparoscopy. The procedure performed varied according to the location and the macroscopic aspect of the diverticulum, as well as of the associated disorders (gastroesophageal reflux, hiatal hernia and/or motor disorders). RESULTS: Postoperative mortality was nil. Three patients developed an esophageal fistula; one with an esophago-bronchial fistula required another operation. Postoperative pain was treated with morphine (median duration 4 days) or IV paracetamol (5 days). Long term results were excellent in 1 patient, good in 6, fair in 2 and poor in 2. These 2 latter patients were operated on another time. One of them was operated on 3 years later for aperistalsis of the esophagus and the other one was operated 4.5 years later for paraesophageal hernia; late results of these operations were fair. CONCLUSION: These results suggest that minimally invasive surgery does not confer significant benefit compared with open surgery in the treatment of diverticula thoracic esophagus.

Laparoscopic Heller's cardiomyotomy in achalasia. Is intraoperative endoscopy useful, and why?

BACKGROUND: Inappropriate length of the myotomy incision along the stomach, the most common technical fault during Heller's cardiomyotomy, is related to the difficulty of identifying the gastro-esophageal junction, in particular during laparoscopic surgery. The goal of this study was to evaluate the contribution of endoscopy to gastro-esophageal junction identification during laparoscopic Heller's cardiomyotomy. METHODS: In a group of 19 patients with intraoperative endoscopy with laparoscopic Heller's cardiomyotomy, surgical and endoscopic criteria for gastro-esophageal junction identification have been assessed. Then postoperative results of this group were compared with those of another group of 16 patients previously operated on without intraoperative endoscopy. RESULTS: Endoscopic and laparoscopic criteria for gastro-esophageal junction identification were discordant in 11 patients (11/19, 58%). The cardia was in all these cases at a more distal site with endoscopic criteria. Complications ascribable to suboptimal technique were more frequent in the group without intraoperative endoscopy (7/16 patients) than in the other group (2/19 patients). CONCLUSIONS: Endoscopy during laparoscopic Heller's cardiomyotomy is of great assistance in identifying the cardia, and thereby could improve surgical outcomes.

Daflon 500 mg in the treatment of hemorrhoidal disease: a demonstrated efficacy in comparison with placebo.

Hemorrhoidal disease (HD) is a trophic disorder of the anal canal characterized by recurrent, self-resolving acute episodes. The author reports the results of a double-blind, placebo-controlled trial of the efficacy of Daflon 500 mg in the treatment of acute and chronic symptoms of hemorrhoids. One hundred and twenty outpatients (54 men, 66 women) suffering from an acute episode of HD during the previous two months were included. They received Daflon 500 mg (group D, n = 60) or placebo (group P, n = 60) two tablets daily for two months. The patients were examined at entry (T0) and at two months (T2). At T0, the two groups did not differ in terms of age, sex, weight, height, history of symptoms of HD; 7 patients were excluded from analysis because of treatment failure (group D, n = 2; group P, n = 3), or lost to follow-up (group P, n = 2). In group D, 40% of patients had an attack during the trial with a mean duration of 2.6 days and a mean severity of 1.1 scored on a scale from 1 to 3. These values were significantly different (P < 0.01) from the corresponding values in the P group: 70%, 4.6 days and 1.6 respectively. Each symptom and sign was scored on a scale of severity. The overall symptom score, scored from 0 to 15, decreased from 6.6 (group D) and 6.1 (group P) (NS) to 1.1 and 4.0 respectively (P < 0.01) at the end of treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

[A prospective study of liver test anomalies during continuous enteral nutrition]. / Etude prospective des anomalies des tests hépatiques au cours de l'alimentation entérale continue.

In 119 gastrointestinal patients, serum transaminases (ASAT) and alkalines phosphatases (AP) were prospectively measured on the first and the twenty first days of a continuous enteral nutrition (CEN) regimen. The exclusion criteria were: recent surgical procedure, transfusion or total parenteral nutrition (TPN), or a cancer during the previous five years. Of the 119 patients, 71 patients were included in the study. The patients received: (a) an exclusive elemental CEN (n = 25, all with Crohn's disease) or non elemental CEN (n = 9), providing 40 kCal/kg of ideal body weight (IBW)/day; (b) a non exclusive non elemental CEN providing a minimum of 30 kCal/kg IBW/day. Of the 56 patients having normal hepatic function tests (HFT) on the first day, only 2 developed mild abnormalities (incidence of 3.6%). Of the 15 remaining patients having abnormal HFT on the first day, HFT improved or returned to normal in 8 cases. During CEN: the appearance of abnormal HFT seems rare, pre-existing abnormalities can improve and there is no associated morbidity. These results suggest that there is no hepatic side effects of CEN, in contrast to TPN, and that CEN must be preferred over TPN whenever the choice is possible.

[Hepato-biliary complications in enteral nutrition]. / Les complications hépato-biliaires de la nutrition entérale.

Hepatobiliary complications of enteral nutrition have been studied little. The incidence of increase in hepatic enzymes during enteral nutrition is minimal, less than 5% and no clinical hepatic disorder has been observed during enteral nutrition. The gall bladder is contractile and echo-less. Unlike total parenteral nutrition, enteral nutrition does not cause any hepatobiliary complications.