Botulinum toxin for the treatment of hypercontractile esophagus: Results of a double-blind randomized sham-controlled study.

INTRODUCTION: Botulinum toxin injection is known to be efficient to treat achalasia. We conducted a randomized trial in order to evaluate its efficacy to treat symptomatic hypercontractile esophageal disorders as characterized by esophageal high-resolution manometry. METHODS: Patients with significant dysphagia and/or thoracic pain related to an hypercontractile esophageal motility disorder as defined by the Chicago Classification were randomized to receive an injection of botulinum toxin (100 U in 10 points in the distal part of the esophageal wall) or a sham procedure. Symptoms were assessed at 3 months with the Eckardt score. Patients could receive a first or second botulinum toxin injection 1 month later if symptoms persisted. RESULTS: Twenty-three patients (13 women, mean age 60 years) were included: 13 received botulinum toxin injection, and 10 a sham procedure. The improvement of symptoms at 3 months was significant compared to baseline, but similar in the active treatment and sham procedure arms. However, there was no change in quality of life scores. Seventeen patients received a second injection at 4 months. There was a significant trend toward improvement of symptoms up to the end of follow-up at 12 months, without a significant relationship with the administration of botulinum toxin. DISCUSSION: Botulinum toxin injection is not superior to a sham procedure to improve symptoms related to hypercontractile esophageal disorders, suggesting an important placebo effect in for this type of disease. This observation must be taken into account when evaluating more aggressive therapies such as endoscopic myotomy (clinicaltrials.gov: NCT01955174).

High-resolution Impedance Manometry after Sleeve Gastrectomy: Increased Intragastric Pressure and Reflux are Frequent Events.

INTRODUCTION AND PURPOSE: Sleeve gastrectomy (SG) is gaining ground in the field of bariatric surgery. Data are scarce on its impact on esophagogastric physiology. Our aim was to evaluate the impact of SG on esophagogastric motility with high-resolution impedance manometry (HRIM) and to assess the usefulness of HRIM in patients with upper gastrointestinal (GI) symptoms after SG. METHODS: A retrospective analysis of 53 cases of HRIM performed after SG was conducted. Upper GI symptoms at the time of HRIM were scored. HRIM was analyzed according to the Chicago classification v3.0. A special attention was devoted to the occurrence of increased intragastric pressure (IIGP) after water swallows and reflux episodes as detected with impedance. A measurement of sleeve volume and diameter was performed with CT scan in a subgroup of patients. RESULTS: IIGP occurred very frequently in patients after SG (77 %) and was not associated with any upper GI symptoms, specific esophageal manometric profile, or impedance reflux. Impedance reflux episodes were also frequently observed after SG (52 %): they were significantly associated with gastroesophageal reflux (GER) symptoms and ineffective esophageal motility. The sleeve volume and diameters were also significantly smaller in patients with impedance reflux episodes (p < 0.01). CONCLUSION: SG significantly modified esophagogastric motility. IIGP is frequent, not correlated to symptoms, and should be regarded as a HRIM marker of SG. Impedance reflux episodes were also frequent, associated with GER symptoms and esophageal dysmotility. HRIM may thus have a clinical impact on the management of patients with upper GI symptoms after SG.

Swallowable Obalon® gastric balloons as an aid for weight loss: a pilot feasibility study.

The goal of this study was to evaluate the safety and the impact on weight loss of a new swallowable gastric balloon. In this prospective pilot study, 17 overweight or obese patients were included. Up to three balloons were ingested under fluoroscopic control. All balloons were removed by upper GI endoscopy, 12 weeks after the ingestion of the first balloon. 43 out of 44 attempts (98 %) to swallow a balloon were successful. Nausea and stomach pain were the most frequent side effects. Endoscopic procedures for balloon removal were uneventful. Weight loss was significant at weeks 4, 8, and 12. This pilot study showed no significant side effects induced by up to three balloons, and a significant weight loss.

Regular coffee but not espresso drinking is protective against fibrosis in a cohort mainly composed of morbidly obese European women with NAFLD undergoing bariatric surgery.

BACKGROUND & AIMS: The aim of this study was to determine the influence of coffee and other caffeinated drinks on liver fibrosis of severely obese European patients. METHODS: A specific questionnaire exploring various types of coffee (regular filtrated coffee and espresso), caffeinated drinks, and chocolate was filled in by 195 severely obese patients. All patients had liver biopsies that were analyzed according to the NASH Clinical Research Network Scoring System. Univariate and multivariate analyses of significant fibrosis were performed. RESULTS: Caffeine came mainly from coffee-containing beverages (77.5%). Regular coffee and espresso were consumed in 30.8% and 50.2% of the patients, respectively. Regular coffee, espresso, and total caffeine consumption was similar between patients with and without NASH. While consumption of espresso, caffeinated soft drinks, and chocolate was similar among patients, with respect to the level of fibrosis, regular coffee consumption was lower in patients with significant fibrosis (F ≥2). According to logistic regression analysis, consumption of regular coffee was an independent protective factor for fibrosis (OR: 0.752 [0.578-0.980], p=0.035) in a model including level of AST (OR: 1.04 [1.004-1.076], p=0.029), presence of NASH (OR: 2.41 [1.007-5.782], p=0.048), presence of the metabolic syndrome (NS), and level of HOMA-IR (NS). Espresso, but not regular coffee consumption was higher in patients with lower HDL cholesterol level, higher triglyceride level, and the metabolic syndrome. CONCLUSIONS: Consumption of regular coffee but not espresso is an independent protective factor for liver fibrosis in severely obese European patients.

Impaired postoperative EGJ relaxation as a determinant of post laparoscopic fundoplication dysphagia: a study with high-resolution manometry before and after surgery.

BACKGROUND: Laparoscopic fundoplication (FP) reduces gastroesophageal reflux (GER) efficiently. Dysphagia is its main complication, but no clear data have been published in literature to evaluate risk factors associated with it. The goal of this retrospective study was to identify factors associated with dysphagia occurring after FP for GER disease, with high-resolution manometry (HRM) performed before and after surgery. METHODS: Twenty patients (11 women; mean age, 49 (range, 19-68 years) underwent HRM before and 2-3 months after laparoscopic Nissen-Rossetti FP. Analysis was performed with esophageal pressure topography according to the Chicago Classification. RESULTS: Before FP, ten patients had a manometric hiatal hernia (none after FP). Esophagogastric junction (EGJ) pressures increased after surgery (p < 0.01). Bolus pressurization was present in 2% of all swallows before FP and in 22% after (p = 0.01). Postoperative bolus pressurization percentage was significantly correlated with EGJ relaxation as measured with integrated relaxation pressure (IRP) (r = 0.79, p < 0.01). Eight patients reported dysphagia after FP. The only pre- or post-operative parameter significantly associated with dysphagia was postoperative IRP (5.1 mmHg without vs. 10.3 with dysphagia, p < 0.02). CONCLUSIONS: FP establishes an efficient antireflux mechanism by correcting hiatal hernia and increasing EGJ pressures. EGJ relaxation as measured by IRP is significantly altered after surgery, leading to more frequent motility disorders, and bolus pressurization. Postoperative dysphagia was associated with higher values of IRP.

Osteopathy improves the severity of irritable bowel syndrome: a pilot randomized sham-controlled study.

BACKGROUND: Effective therapies for irritable bowel syndrome (IBS) are disappointing. Therefore, IBS patients have a growing interest for alternative medicines including osteopathy. AIM: We aimed to evaluate the effect of osteopathy on the severity of IBS in a randomized sham-controlled trial. METHODS: We prospectively assigned 30 patients with IBS (23F, 7M, mean age 45.8±16.4 years) fulfilling the Rome III criteria in a 2/1 ratio to receive either osteopathy or sham osteopathy. Two separate sessions were performed at a 7-day interval (days 0 and 7) with a further 3 weeks of follow-up (day 28). The primary outcome included at least a 25% improvement in the IBS severity score at day 7. The secondary outcomes included the impact of IBS on quality of life, psychological factors, and bowel habits. RESULTS: The severity of IBS decreased in both groups at days 7 and 28. At day 7, this decrease was significantly more marked in patients receiving osteopathy compared with those receiving the sham procedure (-32.2±29.1 vs. -9.0±16.0, mean difference normalized to the baseline P=0.01). This difference did not persist at day 28 (P=0.4). Both anxiety and depression scores decreased without difference between groups. Stool frequency and consistency were not significantly modified. CONCLUSION: Osteopathy improves the severity of IBS symptoms and its impact on quality of life. Osteopathy should therefore be considered for future research as an effective complementary alternative medicine in the management of IBS symptoms.