Pelvic floor dyssynergia: Efficacy of biofeedback training

Paradoxical contraction of the pelvic floor during attempts to defaecate is described as pelvic floor dyssynergia [anismus]. It is a behavioural disorder [no associated morphological or neurological abnormalities]; consequently, biofeedback training has been recommended as a behavioural therapy for such a disorder. The aim of the present study was to evaluate long-term satisfaction of patients diagnosed with pelvic floor dyssynergia after biofeedback. Sixty patients [35 females and 25 males] with a mean age of 30 +/- 12 years and a 4 year duration of constipation were included. Forty-five patients had normal colonic transit and 15 patients had slow colonic transit. History, physical examination and barium enema were done to exclude constipation secondary to organic causes. Colonic and pelvic floor functions [colon-transit time, anorectal manometry, EMG and defaecography] were performed before and after biofeedback treatments. Patients were treated on a weekly basis with an average of [6 +/- 2] sessions. At the end of sessions, 55 out of 60 patients [91.6%] reported a subjectively overall improvement. Symptoms of dyschezia were reported less frequently after biofeedback. Age and gender were not predictive factors of outcome. No symptoms at initial assessment were predictive for patient's satisfaction but the only factor of predictive value was the diagnosis of anismus and the motivated patient who wanted to continue the sessions. Biofeedback remains a morbidity free, low-cost and effective outpatient therapy for well-motivated patients complaining of functional constipation and diagnosed as pelvic floor dyssynergia

Surgical management of gastric gastrointestinal stromal tumor: a single center experience

Gastrointestinal stromal tumors [GISTs] are the most common mesenchymal tumors of the gastrointestinal tract. Surgery remains the mainstay of curative treatment. Our objective is to evaluate the outcome of surgical treatment of primary gastric GIST. Between January 1997 and April 2008, thirty seven consecutive patients underwent resection for GISTs [35 patients with primary gastric GISTs and two patients with intestinal GISTs who were excluded from the study]. These patients underwent upper endoscopy +/- biopsy, barium meal and abdominal CT scan. Patients' demographics and clinical presentations were analyzed. Perioperative parameters measured included operative times, estimated blood loss, intraoperative finding, surgical techniques, morbidity length of hospitalization. Recurrence and survival were also analyzed. Of the 35 patients with gastric GISTs included in the study, 63% were female. The median age was 59 +/- 14 years [range, 23 to 75 years]. The primary presenting symptoms were bleeding and dyspepsia; 43% of these tumors were located mainly in the body of the stomach. Tumor size was <10 cm in 80% of the patients. The average tumor size was 6.3 +/- 3.2 cm [range from 3 to 13 cm]. regarding the surgical management, 20 patients [57%] underwent gastric wedge resection, eight patients [23%] underwent partial gastrectomy and the remaining seven patients [20%] underwent total gastrectomy. Radical resections were found in 32 patients [91.5%] while palliative resections were found in three patients [8.5%]. The resected lymph nodes were negative in 32 patients [91.5%]. Recurrence was noted in three patients, with a median time to recurrence of 14.3 months [range, 7 to 28 months]. The three-and five-years survival in patients who underwent wedge resection was 92% and 81%, respectively, where it was 95% and 87%, respectively, in patients who underwent gastrectomy [either partial or total]. There were no major intraoperative complications or mortalities. Complete surgical resection either through wedge resection or gastrectomy with negative margins remains the gold standard treatment of patients with primary respectable gastric GISTs

Acid and bile reflux in erosive, non-erosive reflux disease and barrett's esophagus

GERD may occur with acid, bile or in a mixed form. Endoscopic injury and mucosal metaplasia are a known sequlae to pathological GERD to study the contribution of acid and duodenogas-troesophageal reflux [DGER] to endoscopic severity in patients with GERD and Barrett's esophagus. Ninety-one patients [60 males, 31 females; mean age 36.12 +/- 12.65 years] complaining of reflux symptoms underwent upper gastrointestinal endoscopy and graded to non-erosive reflux disease [NERD], erosive reflux disease [ERD] and Barrett's esophagus [BE]. Esophageal manometry and simultaneous ambulatory 24-h esophageal pH and bilirubin monitoring [Bilitec 2000] were done to all patients. Seventy one patients [78.0%] had ERD [Savory-Miller [grade I-III], 11 patients [12.1%] had NERD and 9 patients [9.9%] had BE by endoscopy. Combined 24-h esophageal bilirubin and pH monitoring revealed that: 39 patients [42.9%] had mixed acid and bile reflux, 16[17.6%] had pathological acid reflux only, 18 [19.8%] had bile reflux only and 18 patients [19.8%] had no evidence of abnormal reflux. The percentage of the total time that bilirubin absorbance was 0.14, in 71 patients with ERD was [8.18 +/- 11.28%], and in 9 patients with BE was [15.48 +/- 30.48%] which was significantly greater than that in 11 patients with NERD [4.48 +/- 8.99%], p<0.05 and p=0.01 respectively. All BE patients had abnormal esophageal bile reflux [3 bile alone and 6 mixed bile and acid]; 44 of 71 patients [61.97%] with ERD had abnormal esophageal bile reflux [13 bile alone and 31 mixed bile and acid]; meanwhile 15 of them [21.2%] had abnormal acid exposure alone. Despite having NERD, 4 patients [36.4%] had abnormal esophageal bile reflux, two of them mixed with acid. Mixed reflux [acid and bile] is the chief pattern of reflux in GERD patients. Bile reflux either alone or in a mix with acid reflux contributes to severity of erosive, non-erosive reflux disease as well as in Barrett's esophagus

Dysphagia after total laryngectomy: motility report.

Detailed motility studies of the pharynx and esophagus with its two sphincters were performed in 31 patients having cancer larynx to find the correlation between postoperative motility changes and occurrence of dysphagia. After the operations, there was only one patient complained of dysphagia although all patients showed a well-defined decrease in the intraluminal pressures in the pharynx and upper esophageal sphincter. The upper and middle thirds of the esophageal body showed normal contractions in eight patients and weaker contractions in 23 of the cases postoperatively. All cases showed weaker contractions in the lower esophageal body. All the postoperative recordings resulted in an incomplete relaxation of the upper esophageal segment [UES] and incoordination. Although total laryngectomy completely interrupted the continuity of the proximal digestive tube and may caused derangement in the esophageal motility, dysphagia was not a striking postoperative symptom in those patients

Evaluation of laryngopharyngeal manifestations of gastroesophageal reflux disease

Thirty-one patients with recurrent severe reflux symptoms were studied for esophageal motility, endoscopy, radiology as well as 24-hour pH esophageal monitoring. All patients were subjected to full history taking and fiberoptic laryngopharyngoscopy. 23 patients had persistent laryngopharyngeal symptoms mainly dysphonia. Erythema was a constant sign in all complaining patients and there were 8 cases with contact granuloma and 6 cases had cordal nodules. The occurrence of laryngopharyngeal manifestations [LPHM] in GERD patients was not related neither to the severity of endoscopic esophagitis nor to the lower esophageal sphincter pressure [LESP] and esophageal body peristaltic abnormalities. On the other hand, the LPHM were more related to hiatal hernia [88.9%] and abnormally relaxed upper esophageal sphincter. The 24-hour pH esophageal monitoring was a valuable tool in detecting pathologic acid reflux in 76.9% of the patients and its results were proportionate to the severity of LPHM

Post-gastrojejunostomy entero-gastric reflux: is it always Symptomatic?

Evaluation of the problem of enterogastric reflux in duodenal ulcer patients managed by anterior and posterior truncal vagotomy and simple loop gastrojejunostorny. Between September 1976 and May 1996, 709 duodenal ulcer patients were managed by different surgical techniques. Anterior and posterior truncal vagotomy with simple loop gastrojejunostomy were done for 372 patients [52.5%]. Of the last group, 75 random patients were studied for enterogastric reflux. The mean postoperative period was 6.5 years, the mean age was 43 years, 64 were men and 11 were women. Careful clinical examination, barium meal study and esophagogastroscopy with histological examination of multiple gastric biopsies were done for all patients. Dual channel simultaneous esophageal and gastric 24h pH monitoring was done for 28 patients. Patients were classified into 2 groups, group 1 included 44 patients [58.7%] free of symptoms and group 2 included 30 patients [40%] who complained of one or more symptom of gastritis, however, the classic symptoms of alkaline refiux gastritis were found only in 8 patients [10.7%]. One patient [1.3%] was excluded due to proved ulcer recurrence. Endoscopic evidence of gastritis was found in 50% in group I versus 73.3% in group 2 [P<0.05]. Histopathologic evidence of gastritis was found in 77.3% in group 1 versus 46.7% in group 2 [P=0.007]. PH monitoring revealed alkaline gastric reflux in 50% in group I versus 75% in group 2 [P>0.05] alkaline esophageal reflux in 33.3% in group 1 versus 50% in group 2 [P<0.05] and mixed esophageal reflux [i.e alkaline and acidic] in 16.7% in group 1 versus 18.8% in group 2 [P> 0.05]. Enterogastric refiux is not an infrequent problem after trurcal vagotomy and loop gas trogejunostory. Pathologic alkaline gastric reflux should be proved by endoscopy, histopathology and pH metry before deciding remedial surgery

Laparoscopic cholecystectomy: a recent experience

A long the period from October 1992 to July 1993, 162 consecutive patients with gall stones were considered for laparoscopic cholecystectomy in the Gastroenterology Center of Mansoura. 106 females and 56 males, their ages ranged from 23 to 65 years. All the patients underwent ultrasonic abdominal examination, complete laboratory, chest and cardiac assessment. E.R.C.P., papillotomy and stone extraction when needed was done in cases with history [or] of jaundice before the procedure. Cardiac and hypertensive patients were excluded from the study. Laparoscopic cholecystectomy was successful in 135 out of the 262 cases [83.3%]. 27 cases failed to be completed by laparoscopy [16.7%], 5 cases were due to uncontrollable bleeding, 3 from injured cystic artery and 2 from cirrhotic liver. The other failures were due to marked dense adhesions with acutely inflammed gall bladder in 9 cases, injury of common bile duct in 2 cases, injury of gall bladder with escape of multiple small stones intra-abdominally in 2 cases, 5 cases gall bladder masses, failure to grasp or manipulate thick walled gall bladders that were packed with multiple small stones in 2 cases, presence of cholecysto-duodenal fistula in one case and injury of the right common iliac vessels by the trochar in one case. There were no deathes, but post-operative major complications occured in 4 cases that needed laparotomy, 2 cases of internal haemorrhage and 2 cases of biliary peritonitis. There were 6 minor complications, 3 surgical emphysema, and 3 small collections in gall bladder bed, that all passed conservatively. The shortest time of the procedure was 20 minutes and the longest was 3 hours. The median post-operative stay was 2 days and all the patients could start oral diet in the morning of the second day. In Conclusion, from this recent experience and results. We could suggest what are the possible difficulties and complications that could be met with laparoscopic cholecystectomy and we suggest that it should tried in most of patients who require elective or urgent cholecystectomy specially if radiological and endoscopic support are available

Parietal cell vagotomy [P.C.V.] 15 years experience

Along 15 years, 106 patients had elective parietal cell vagotomy for duodenal ulceration. Ninty nine patients have complete follow up from 12 months to 15 years. Of those, 42 patients had surgery over 10 years ago and 35 patients survived for more than 10 years. There was no hospital mortality. Gastric stasis recorded early in 3 cases [3%] and 2 of them required reoperation in 2 patients splenectomy was required as a result of operative trauma. Mild dumping occured in 2 cases [2%] and mild diarrhea in other 2 cases, 40 cases suffered from early mild and transient [40.4%] dysphagia. From 2-10 years after surgery, thirty patients [30%] have had recurrent ulceration. In seven [7%] of these cases the recurrence was asymptomatic. The overall clinical results by using modified Vi-sick's were excellent and very good in 66.4% of cases and unsatisfaction in 33.6%

Correlation of CT and operative staging in cancer head of the pancreas

In a current series of 150 patients with obstructive jaundice studied by abdominal CT, there were only 30 cases with operatively proved pancreatic carcinoma. A correct CT diagnosis was made in 24 cases [80%] while 6 patients [20%] were incorrectly diagnosed. The primary CT finding of pancreatic carcinoma was a tumour mass with associated bile and or pancreatic duct dilatation. The mass was located in the head in 28 cases [93%] and involved most of the gland in 2 cases [7%]. On CT, the mass was demonstrated as a central hypodense zone in 18 cases representing the hypovascular scirrhous tumour surrounded by normal parenchyma or inflammatory tissue caused by obstructive pancreatitis. In 6 cases, the mass was heterogenous in density. The common bile duct was dilated in all of our cases. A dilated pancreatic duct was seen in 12 cases, Tumour obstruction of the main pancreatic duct causing rupture of lateral side branch ducts resulted in the formation of post obstructive pseudo-cysts in 2 cases. Knowledge of this finding is important to avoid the mis-diagnosis of a tumour as pancreatitis with pseudocysts. The secondary findings of local tumour extension or metastatic diasease help to differentiate malignant masses from benign ones and aid in tumour staging and resectability. One or more of the ancillary findings were seen in 22 out of 24 correctly diagnosed cases. CT diagnosed resectable tumours in 2 cases. During operation however one case only was resectable