Dyskinesia of the superior oesophageal sphincter: assessment and treatment.

Pharyngo-oesophageal dyskinesias present a common symptomatology associated with those difficulties in swallowing for which the radio-manometric assessment is well known. Radiology, nevertheless, with an overall analysis of deglutition and its iatrogenic complications, as well as manometry of the superior oesophageal sphincter (OSS) with its diversity of results, according to the material, techniques, age, sex and stress involved, has convinced us of the necessity for a supplementary dynamic examination. Electromyography (EMG), simultaneously by the inferior constrictor (IC) and cricopharyngeal (CP) muscles, analyses with precision the electric activity of these two muscles, as well as the pharyngosphincteral synchronism. It is an easy examination, reproducible and without complications. In less than one year, nineteen patients suffering exclusively from a pharyngo-oesophageal dyskinesia benefited by this complete assessment. The secondary aetiologies are clearly predominant. Gastro-oesophageal reflux represents a quarter of those detected by an anamnesis alone. EMG detects 68% of functional anomaly of the OSS; manometry finds 47% and radiology 32%. Extramucosal myotomy of the OSS concerns incomplete or uncoordinated relaxation, preferentially by left cervical approach. The preliminary results, both clinical and manometric, are very satisfactory.

[Incomplete dissolution of calculi. Calcification, cholecystectomy, after treatment of biliary lithiasis with chenodeoxycholic acid]. / Dissolutions incomplètes des calculs. Calcifications, cholécystectomies, après traitement de la lithiase vésiculaire par l'acide chénodésoxycholique.

Among 54 patients with radiolucent asymptomatic gallstones treated by chenodeoxycholic acid (CDCA), 32 failures were observed. In 15 cases the size of gallstones did not change. In 11 cases the size of gallstones decreased but dissolution was not complete. In 6 cases the treatment had to be interrupted early because of the side-effects. In 10 patients (8.7 p. 100 of the treated patients) calcifications of gallstones occurred. In 9 patients (16.7 p. 100), a cholecystectomy had to be performed because of complications. The incidence of biliary complications necessitating cholecystectomy was significantly higher (p less than 0.001) in patients in whom CDCA failed to induce changes in gallstone size than in patients in whom CDCA was successful. Overall, a decrease of gallstones size was observed in 61 p. 100 of the 54 treated patients. However complete dissolution occurred in only two thirds of these patients. Patients in whom gallstone size decreased seldom presented with a biliary complication. Our data suggest that, when no obvious diminution of gallstones size is evident within six months of treatment, it is not advisable to continue the administration of CDCA. In case of failure, the responsibility of CDCA in the appearance of calcifications or even of complications necessitating cholecystectomy has to be discussed.

[Recurrence and prevention of recurrence after dissolution of gallbladder lithiasis by chenodeoxycholic acid in 22 patients]. / Récidives et prévention des récidives après dissolution de la lithiase vésiculaire par l'acide chénodésoxycholique chez 22 patients.

Dissolution of gallstones was observed 33 times in 22 patients. For 11 of them a recurrent lithiasis was dissolved by means of a second or third medical treatment. 21 patients have been followed for 3 to 6 years (median over 4 years). Without longstanding treatment the recurrence rate was 50 p. 100 in 3 years and 87.5 p. 100 in 6 years. Most of the patients should have relapsed in less than 9 years. Recurrences were always successfully treated with the same treatment but relapsed if the treatment was stopped (21 recurrences in 14 patients). A-1 month every 4 months-long standing treatment did not prevent recurrences in 8 patients whereas treatment every other month prevented recurrences in 5. It is therefore suggested to give long treatment after dissolution of gallstones to avoid recurrences. Its duration should be undefinite. Alternatives might include: 1) repeated dissolving treatments in case of recurrences, if relapses occur lately; 2) or longstanding treatment in case of early recurrences.