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.

Olmesartan-associated enteropathy: results of a national survey.

BACKGROUND: Recently, a new enteropathy has been described: olmesartan-associated enteropathy. However, the association has been questioned: a phase 3 trial and a cohort study found no association between gastrointestinal events and olmesartan. AIM: To collect French cases of sartan-associated enteropathy to describe further this entity, confirm or refute causality, and determine if the association exists with other sartans. METHODS: French gastroenterologists were invited to report cases of sartan-associated enteropathy and collect clinical, biological and histological data. Patients with diarrhoea and histological duodenal abnormalities were included. RESULTS: Thirty-six patients with olmesartan-associated enteropathy were reported, including 32 with villous atrophy and four without. There was only one patient with irbesartan-associated enteropathy. None of the patients died. Patients with villous atrophy had diarrhoea, vomiting, renal failure, hypokalaemia, body weight loss and hypoalbuminaemia. Thirty-one patients were hospitalised; four required intensive care. Anti-transglutaminase and anti-enterocyte antibodies were negative; anti-nuclear antibodies were positive (9/11). Endoscopic duodenal biopsies showed villous atrophy (32/32) and polyclonal intra-epithelial CD3+CD8+ lymphocytosis (11/11). Exactly, 14/15 patients responded to steroids and/or immunosuppressants, prescribed because of suspected autoimmune enteropathy. Ten olmesartan interruptions were followed by reintroductions before steroids or immunosuppressants. Interruptions were followed by remissions (9/10), but reintroductions were followed by relapses (9/9). Twenty-nine patients were in remission since olmesartan interruption, including 26 without immunosuppressants. Patients with normal villi had similar clinical characteristics, but mild histological abnormalities (intra-epithelial lymphocytosis and lamina propria lymphocytic infiltration). CONCLUSIONS: Olmesartan causes a severe and immune-mediated enteropathy, with or without villous atrophy. Enteropathy associated with other sartans seems to be very rare.

A prospective and comparative study between stapled hemorrhoidopexy and hemorrhoidal artery ligation with mucopexy.

AIM: The aim of this study was to compare the efficacy between stapled hemorrhoidopexy (Longo technique) and transanal hemorrhoidal artery ligation with mucopexy (THDm) in the treatment of hemorrhoidal disease. PATIENTS AND METHODS: From June 2009 to January 2011, 81 patients having grade II or III hemorrhoidal disease underwent prospective evaluation followed by surgery at two centers (27 Longo and 54 THDm). Symptoms (bleeding, tenesmus, prolapse, fecal incontinence, pain) and the satisfaction score were compared on the first post-operative day and at 1, 6, 12, and 24 months thereafter. The follow-up was 24 months. RESULTS: There was no difference in mean length of stay. One complication (recto-vaginal fistula) was observed after Longo. The prolapse score was significantly lower after THDm than after Longo on the first post-operative day (P < 0.0015). Bleeding score after THDm was significantly lower on the first post-operative day (P = 0.04), but higher thereafter (P = 0.03 and P = 0.04). Tenesmus score after THDm was significantly lower for the first three months (P < 0.06 and 0.001). On the first post-operative day and at one month, the visual analog pain score was significantly lower after THDm than that after Longo (P < 0.0003 et P < 0.01). On the first post-operative day and at one month, the satisfaction score was higher after THDm than after Longo (P < 0.001). CONCLUSION: THDm was safe and effective. Short-term outcomes after THDm were better than after Longo but long-term results seemed to be similar.

Plasma proteasome level is a reliable early marker of malignant transformation of liver cirrhosis.

BACKGROUND: Proteasomes are the main non-lysosomal proteolytic structures which regulate crucial cellular processes. Circulating proteasome levels can be measured using an ELISA test and can be considered as a tumour marker in several types of malignancy. Given that there is no sensitive marker of hepatocellular carcinoma (HCC) in patients with cirrhosis, we measured plasma proteasome levels in 83 patients with cirrhosis (33 without HCC, 50 with HCC) and 40 controls. METHODS AND RESULTS: Patients with HCC were sub-classified into three groups according to tumour mass. alpha-Fetoprotein (AFP) was also measured. Plasma proteasome levels were significantly higher in patients with HCC compared to controls (4841 (SEM 613) ng/ml vs 2534 (SEM 187) ng/ml; p<0.001) and compared to patients with cirrhosis without HCC (2077 (SEM 112) ng/ml; p<0.001). This difference remained significant when the subgroup of patients with low tumour mass (proteasome level 3970 (SEM 310) ng/ml, p<0.001) was compared to controls and patients with cirrhosis without HCC. Plasma proteasome levels were independent of the cause of cirrhosis and were weakly correlated with AFP levels. With a cut-off of 2900 ng/ml, diagnostic specificity for HCC was 97% with a sensitivity of 72%, better than results obtained with AFP. Diagnostic relevance of plasma proteasome measurement was also effective in low tumour mass patients (sensitivity 76.2% vs 57.1% for AFP). CONCLUSION: The plasma proteasome level is a reliable marker of malignant transformation in patients with cirrhosis, even when there is a low tumour mass.

Clinical trial: Radiofrequency energy delivery in proton pump inhibitor-dependent gastro-oesophageal reflux disease patients.

BACKGROUND: Radiofrequency (RF) energy delivery is an endoscopic procedure developed for the treatment of gastro-oesophageal reflux disease. AIM: To compare RF and a proton pump inhibitor strategy (PPI) in PPI-dependent patients by carrying out a prospective, randomized trial. METHODS: Patients with PPI-dependent typical reflux symptoms were randomly allocated to either RF or PPI regimen alone. The primary endpoint, evaluated at 6-month, was defined as the possibility for the patient to stop or to decrease PPI use to <50% of the effective dose required at baseline. RESULTS: In the RF group, 18/20 patients stopped (n = 3) or decreased (n = 15) PPI use as compared to eight of 16 in the PPI group (P = 0.01). None of the control patients could stop PPI. Health-related quality of life scores were not different between groups. No significant change in oesophageal acid exposure (OAE) was noted between baseline and 6-months after RF. No severe complication was reported. CONCLUSIONS: Radiofrequency energy delivery is a safe and effective therapeutic option, allowing reduction in or discontinuation of PPI therapy in patients with PPI-dependent symptoms, without loss of quality of life. However, in a majority of patients, PPI therapy cannot be completely stopped. The efficacy of RF does not seem to be related to a decrease in OAE.

Ambulatory 24-h oesophageal impedance-pH recordings: reliability of automatic analysis for gastro-oesophageal reflux assessment.

Oesophageal pH-impedance monitoring allows detection of acid and non-acid gastro-oesophageal reflux (GOR) events. Visual analysis of impedance recording requires expertise. Our aim was to evaluate the efficacy of an automated analysis for GOR assessment. Seventy-three patients with suspected GORD underwent 24-h oesophageal pH-impedance monitoring. Recordings analysis was performed visually (V) and automatically using Autoscan function (AS) of Bioview software. A symptom index (SI) > or =50% was considered for a significant association between symptoms and reflux events. AS analysis detected more reflux events, especially non-acid, liquid, pure gas and proximal events. Detection of oesophageal acid exposure and acid reflux events was similar with both analyses. Agreement between V and AS analysis was good (Kendall's coefficient W > 0.750, P < 0.01) for all parameters. During pH-impedance studies, 65 patients reported symptoms. As compared to visual analysis, the sensitivity and specificity of a positive SI determined by AS were respectively 85.7% and 80% for all reflux events, 100% and 98% for acid reflux and 33% and 87.5% for non-acid reflux. Despite good agreement with visual analysis, automatic analysis overestimates the number of non-acid reflux events. Visual analysis remains the gold standard to detect an association between symptoms and non-acid reflux events.

Normal values and day-to-day variability of 24-h ambulatory oesophageal impedance-pH monitoring in a Belgian-French cohort of healthy subjects.

BACKGROUND: Impedance-pH monitoring is the most sensitive method for detection and characterization of gastro-oesophageal reflux episodes. Normal values from European subjects are lacking. AIM: To build a database of gastro-oesophageal reflux patterns from French and Belgian healthy subjects. METHODS: Seventy-two healthy subjects (35 men, mean age 35 years, 18-72) underwent 24-h ambulatory impedance-pH studies. Gastro-oesophageal reflux episodes were detected using impedance and characterized by pH as acid, weakly acidic, or weakly alkaline. Analysis was performed visually and effects of age, gender and intra-individual reproducibility were evaluated. RESULTS: The total number of gastro-oesophageal reflux episodes was 44 (25,58,75) of which 59% were acid, 28% were weakly acidic and 10% weakly alkaline. Half of gastro-oesophageal reflux episodes were mixed (liquid/gas) and 22% reached 15 cm above the lower oesophageal sphincter. The bolus clearance time was 11 s while acid was chemically cleared in 34 s. Male gender was associated with increased number and proximal extent of total and acid gastro-oesophageal reflux. Repeated studies in 27 subjects showed good reproducibility for number, acidity and air-liquid composition of reflux (Kendall's W-values = 0.72-0.85). CONCLUSIONS: This study demonstrates good reproducibility of 24-h ambulatory impedance-pH studies and provides values of reflux patterns in healthy subjects for comparisons with European gastro-oesophageal reflux disease patients.

[Highly elevated alphafetoprotein and hepatic cirrhosis. It is not always hepatocarcinoma]. / Alpha-foetoprotéine très élevée et cirrhose hépatique. Ce n'est pas toujours un hépatocarcinome.

BACKGROUND: Alphafetoprotein assay contributes considerably to the diagnosis of hepatocarcinoma in patients with hepatic cirrhosis. We report the case of a cirrhotic patient whose elevated alphafetoprotein level was not associated with liver disease. CASE REPORT: Alphafetoprotein level was followed in a 64-year-old man with hepatic cirrhosis. A rise from 415 to 7690 ng/ml between June and November 1997 led to the discovery of adenocarcinoma of the cardia with liver metastasis. This extrahepatic adenocarcinoma was probably the cause of inappropriate secretion of alphafetoprotein. DISCUSSION: Primary liver tumors are obviously not the only source of elevated alphafetoprotein levels. High levels can also be observed in certain, notably digestive tract and embryonary, cancers. Gastric hepatoid adenocarcinoma is a recently described histological entity first described in 1970. Typically, there is an inappropriate secretion of alphafetoprotein due to a secondary liver tumor.

[Deglutition disorders in the elderly. Evaluation methods]. / Les troubles de la déglutition du sujet âgé. Procédés d'évaluation.

FROM DISCOVERY TO CLINICAL DIAGNOSIS: Dysphagia is easy to diagnose in its acute stage and when complicating a known neurological disease. However diagnosis may be greatly delayed when expressed by respiratory or nutritional symptoms, or when the patient presents cognitive disorders, as is frequent in the elderly. In such instances, simple tests such as the water test are clearly indicated. However, although they are reliable for diagnosing dysphagia, they are not precise in diagnosis of inhalation. Clinical examination is essential for diagnosing the etiology of the disorder. In the absence of clinical orientation, a nasofibroscopy is mandatory and digestive endoscopy debatable. SPECIALIZED EXAMINATIONS: The first-line supplementary examination is a videoradiography. It consists in the patient swallowing a liquid or solid barium sulfate bolus. This detects any anatomical or functional abnormalities. It is the examination of choice for the diagnosis of inhalation and its mechanism. Videoendoscopy is complementary to videoradiography. It can be conducted in first intention in patients who cannot be transported to the radiology unit. It provides precise information on glottal closing and pharyngeal contraction. IMPACT ON MANAGEMENT: In a restricted number of patients, the precise knowledge of the mechanism of dysphagia can help to orientate specific treatment. In others, such examinations will orient re-education, postural adaptation and the modification of food texture. In many patients, precise diagnosis of the mechanism at the origin of dysphagia has no impact on the management of dysphagia.

[Deglutition disorders in the elderly. Management]. / Les troubles de la déglutition du sujet âgé. Prise en charge.

GENERAL PRINCIPLES: The management of dysphagia requires multi-disciplinary interventions, implying various procedures, the choice of which depends on the results of the global prior assessment of the patient. General measures for oral hygiene, dental care and the organization of conditions in which meals are taken are essential, particularly for dependent patients. A change in food texture or in viscosity of liquids is a strategy commonly used. However, such changes must depend on objective bases and not unnecessarily penalize patients or expose them to further risks of complications. COMPENSATION AND RE-EDUCATION TECHNIQUES: Various strategies can help to counteract deficient deglutition mechanisms. Among these, adopting a particular position while swallowing is helpful in many dysphagic patients, but may be limited by severe cervical stiffness. The swallow reflex can be enhanced by sensorial stimulation techniques, although they are only effective short-term. Execution of voluntary maneuvers improves efficacy and safety when swallowing, but learning these maneuvers can be difficult or even impossible, even when accepted by the patients and compliance is inconsistent. Re-education techniques are intended to lastingly improve swallowing, but it is difficult to obtain the active participation of many elderly patients. Furthermore, these commonly used techniques lack seriousness and require validation. MISCELLANEOUS PROCEDURES: The efficacy of pharmacological intervention is not clear, other than in certain particular etiological contexts and, as with procedures enhancing the stimulating properties of food and liquids, will obviously be developed in the future. Surgery, or related techniques, provides help in certain specific conditions, notably when an anatomical disorder is responsible for the disorder. Gastrostomy is still controversial, not only with regard to its optimal practical use and its capacity to decrease respiratory infection risks and improve nutritional prognosis, but also with regard to its impact on patients' survival and quality of life.

Esophageal solid bolus transit: studies using concurrent videofluoroscopy and manometry.

OBJECTIVE: Our aim was to assess the efficacy and mechanism of solid bolus transit through the esophagus. METHODS: Eight healthy volunteers were studied with concurrent manometry and videofluoroscopy while swallowing 5 ml liquid barium, a 5-6 mm diameter bread ball, and 4 g chewed bread in both a supine and upright posture. As many as four successive swallows were performed until clearance was achieved. RESULTS: The esophageal clearance of liquid barium was 100% with the first swallow. Clearance of the unchewed bread ball occurred with the first swallow in only 6.7% of trials in the upright posture and 5.9% in the supine posture. After four swallows, clearance was 100% and 52.9% in the upright and supine postures, respectively. Chewed bread was more readily cleared than unchewed bread, with 100% clearance after two swallows in the upright posture and 91% clearance after four swallows in the supine posture. The most common locus of bread stasis was at the aortic arch and carina. The bread boluses were noted to move more effectively when localized in the head as opposed to the tail of the bolus composite. Nonocclusive contractions often occurred at the bolus tail despite the increased peristaltic amplitude seen with the chewed bread. Failed peristalsis, a frequent cause for solid clearance failure, was observed during 30% of all bread swallows. This usually occurred distal to the stopping point of the bolus, suggesting it to be the result rather than the cause of impaired transit. CONCLUSIONS: Although infrequently perceived by these normal subjects and in contradistinction to liquid clearance, bread is rarely cleared from the esophagus with a single swallow. Mastication and an upright posture facilitate the esophageal transport of solids. Bolus composition and impaired bolus transit alter the amplitude and conductance of peristalsis. Manometric data pertaining to liquid clearance through the esophagus do not readily apply to bread.

Differential responsiveness to contractile agents of isolated smooth muscle cells from human colons as a function of age and inflammation.

To study the involvement of age and inflammation in motor colonic activity in man, contractile responses to CCK, carbachol, and KCl of isolated colonic smooth muscle cells (SMC) from normal and inflamed human colons were evaluated; the incidence of sex and smoking on contraction was also analyzed. Contractile responses to the three agonists were significantly lower in tissues with a low degree of inflammation than in tissues with high level of inflammation or normal tissues. This reduction in cell responsiveness appears to be nonspecific and nonreceptor mediated. A positive correlation of the contractile responses to the three stimulants with the age of patients was observed. In contrast, no association was found between sex, smoking, and cell contraction. In conclusion, contractions of SMC due to CCK, carbachol, and KCl were significantly modified during life; inflammation of the colon led to a loss of SMC responsiveness.

Function of upper esophageal sphincter during swallowing: the grabbing effect.

This study investigated deglutitive axial force developed within the pharynx, upper esophageal sphincter (UES), and cervical esophagus. Position and deglutitive excursion of the UES were determined using combined manometry and videofluoroscopy in eight healthy volunteers. Deglutitive clearing force was quantified with a force transducer to which nylon balls of 6- or 8-mm diameter were tethered and positioned within the oropharynx, hypopharynx, UES, and cervical esophagus. Axial force recordings were synchronized with videofluoroscopic imaging. Clearing force was dependent on both sphere diameter (P < 0.05) and location, with greater force exhibited in the hypopharynx and UES compared with the oropharynx and esophagus (P < 0.05). Within the UES, the onset of traction force coincided with passage of the pharyngeal clearing wave but persisted well beyond this. On videofluoroscopy, the persistent force was associated with the aboral motion of the ball caught within the UES. Force abated with gradual slippage of the UES around the ball. The force attributable to the combination of UES contraction and laryngeal descent was named the grabbing effect. The grabbing effect functions to transfer luminal contents distal to the laryngeal inlet at the end of the pharyngeal swallow, presumably acting to prevent regurgitation and/or aspiration of swallowed material.

Timing, propagation, coordination, and effect of esophageal shortening during peristalsis.

BACKGROUND & AIMS: Minimal information exists on the characteristics and effect of esophageal shortening during peristalsis in the human esophagus. The aim of this study was to quantify esophageal shortening during peristalsis and determine the relationship between shortening, circular muscle contraction, and generation of propulsive force. METHODS: Ten volunteers had three metal clips endoscopically affixed at the squamocolumnar junction and 4.5 and 9 cm proximal to it, defining proximal and distal segments in the lower esophagus. A strain gauge manometer was positioned within the proximal segment along with a traction force sensing balloon. Axial clip movement was assessed with concurrent manometry and videofluoroscopy during swallowing to examine the determinants of propulsive force. RESULTS: Esophageal shortening was coordinated with circular muscle contraction such that each propagated distally as overlapping segments of contraction at a velocity of about 2.5 cm/s. Propulsive force within the proximal segment occurred after shortening, during the circular muscle contraction, with the magnitude of propulsive force correlated with the degree of distal shortening. CONCLUSIONS: (1) Both circular and longitudinal esophageal muscle contraction occur as propagating segments during peristalsis, with the longitudinal muscle contraction leading the circular muscle. (2) Propulsive force occurs during proximal circular and distal longitudinal muscle contraction.

Effect of carbonated water on gastric emptying and intragastric meal distribution.

Carbonated water has long been advocated to relieve dyspeptic symptoms, suggesting that it may alter gastric motility via gastric distension. This study aimed to determine the effect of carbonated water on gastric emptying of a radiolabeled mixed meal in eight healthy volunteers. Meal emptying and its distribution within the stomach were assessed with carbonated and still water in a crossover study. Emptying of both solid and liquid, including the duration of the lag phase, was identical for both drinks. However, the proximal stomach contained a greater proportion of solids (74 +/- 7% vs 56 +/- 8%, P < 0.05) and liquids (43 +/- 5% vs 27 +/- 4%, P < 0.05) with carbonated water as opposed to still water. Retention of the meal within the proximal stomach ended with the lag phase and was likely related to proximal distension. In conclusion, carbonated water did not alter overall gastric emptying but profoundly modified intragastric distribution of the meal.

Primary sinusoidal lymphoma of the liver revealed by autoimmune hemolytic anemia.

Primary liver lymphomas usually present with the clinical picture of a liver tumor, and are characterized by a predominantly portal invasion by lymphoid cells of the B-cell phenotype. We report a case of primary sinusoidal lymphoma of the liver, in a 36 year-old male patient, revealed by homogeneous hepatosplenomegaly and infiltration of liver sinusoids by morphologically normal lymphocytes, without destruction of the parenchyma. Immunohistochemistry in paraffin-embedded tissue sections was positive for the pan T-cell marker MTI, weakly positive for UCHLI, and negative for CD3, and B-cell markers were negative; these findings were consistent with the diagnosis of T-cell lymphoma. The clinical, histological and immunological presentation of this lymphoma was similar to that of hepatosplenic gamma delta T-cell lymphoma. Autoimmune hemolytic anaemia preceded the lymphoma. Despite chemotherapy, the patient died 24 months after the initial presentation in the leukemic phase. A better understanding of this exceptional but characteristic entity is required for an accurate and early diagnosis.

Esophageal bolus transit imaged by ultrafast computerized tomography.

BACKGROUND & AIMS: Conventional transit imaging techniques detect only the solid or liquid component of a swallowed bolus within the esophagus. This study aimed to dynamically image the composition, distribution, and propulsion of esophageal contents during swallowing. METHODS: Multiple adjacent cross-sectional images of the esophagus were obtained in 7 subjects using ultrafast computerized tomography. Images from two 10-mL swallows were synchronized and analyzed for bolus distribution and propulsion, cross-sectional area, intraluminal volume, and intraluminal content. RESULTS: Both liquid and air were swallowed, with the relative distribution varying among levels. Within the ampulla, air occupied 71% of the luminal cross-sectional area. Air was propelled ahead of the liquid bolus at 17 cm/s compared with 7 cm/s for fluid (P < 0.01) and accumulation within the ampulla. Mean bolus velocity was slower through the ampulla. A variable (8-32 mL) volume of air was ingested during swallowing. CONCLUSIONS: Ultrafast computerized tomography studies during transit of a swallowed bolus through the esophagus showed substantial aerophagia and partial bolus separation with air preceding fluid. The ampulla exhibited greater distention that the tubular esophagus because the bolus accumulated at this level before transfer across the hiatus.

Pharyngeal swallowing elicited by fluid infusion: role of volition and vallecular containment.

Nonalimentary swallows minimize aspiration by clearing accumulated fluid from the pharynx. This study aimed to define 1) the pharyngeal sensory field to elicit swallowing and 2) the effect of infusion rate, volition, taste, and temperature on pharyngeal swallows. Test solutions were directed into the valleculae at 6.5, 11.5, and 32 ml/min through a catheter in eight healthy volunteers. Deglutition was signaled with electromyography and electroglottography. Spatial distribution of infusate before swallowing was studied using videofluoroscopy coupled with a video timer. Volitional control was assessed with rapid or restrained swallows. Pharyngeal swallow latency decreased as the instillation rate increased, was potently modified with volition, and was unchanged by infusate taste or temperature. Water infusion into the valleculae did not trigger pharyngeal swallowing until liquids overflowed and reached the aryepiglottic folds or pyriform sinuses. The variation in swallow latency among flow rates was mainly due to the duration of liquid containment within the valleculae. This suggests that the valleculae act to contain pharyngeal secretions and residue and prevent aspiration by diverting their contents around the larynx before swallowing.