Dominiek De Wulf

Pathophysiology, diagnosis and management of postoperative dumping syndrome

Dumping syndrome is a frequent complication of esophageal, gastric or bariatric surgery. Rapid gastric emptying, with the delivery to the small intestine of a significant proportion of solid food as large particles that are difficult to digest, is a key event in the pathogenesis of this syndrome. This occurrence causes a shift of fluid from the intravascular component to the intestinal lumen, which results in cardiovascular symptoms, release of several gastrointestinal and pancreatic hormones and late postprandial hypoglycemia. Early dumping symptoms comprise both gastrointestinal and vasomotor symptoms. Late dumping symptoms are the result of reactive hypoglycemia. Besides the assessment of clinical alertness and endoscopic or radiological imaging, a modified oral glucose tolerance test might help to establish a diagnosis. The first step in treating dumping syndrome is the introduction of dietary measures. Acarbose can be added to these measures for patients with hypoglycemia, whereas several studies advocate guar gum or pectin to slow gastric emptying. Somatostatin analogs are the most effective medical therapy for dumping syndrome, and a slow-release preparation is the treatment of choice. In patients with treatment-refractory dumping syndrome, surgical reintervention or continuous enteral feeding can be considered, but the outcomes of such approaches are variable.

Botulinum toxin reduces Dysphagia in patients with nonachalasia primary esophageal motility disorders.

BACKGROUND & AIMS Endoscopic injection of botulinum toxin (BTX) has shown benefits for patients with diffuse esophageal spasm (DES) and nutcracker esophagus (NE) in small uncontrolled trials. We investigated the effect of BTX on symptoms of patients with DES or NE and assessed manometry findings in a prospective, double-blind, randomized, controlled study. METHODS We assessed 22 patients with dysphagia-predominant, manometry-confirmed DES or NE (6 men; age, 63 ± 2 y) at a tertiary care medical center. Patients were given injections of BTX (8 × 12.5 U) or saline (8 × 0.5 mL) in 4 quadrants, at 2 and 7 cm above the esophagogastric junction. After 1 month, patients crossed over between groups and received endoscopic injections of BTX or saline. When the study began and 4 weeks after each injection, the patients were assessed by esophageal manometry and completed a symptom questionnaire (to determine solid and liquid dysphagia, chest pain, and regurgitation and heartburn; all scored 0-4). Responders were defined based on modified Vantrappen criteria for achalasia. RESULTS After BTX injections, patients had significant decreases in total symptom scores (sum of solid and liquid dysphagia and chest pain; from 7.6 ± 0.7 to 4.8 ± 0.8; P = .01); this decrease was not observed in patients who received saline injections. Moreover, BTX injection stabilized unintentional weight loss (weight gain of 0.3 ± 0.3 after BTX injection vs further weight loss of 1.6 ± 0.5 kg after saline injection; P = .01). Fifty percent of patients had a response 1 month after BTX injection, compared with 10% after saline injection (P = .04); 30% still had a response 1 year after BTX injection. BTX injection also caused a significant decrease in the mean esophagogastric junction pressure, compared with baseline (15.8 ± 1.7 vs 24.0 ± 2.8 mm Hg; P = .02). CONCLUSIONS In a prospective controlled study of patients with DES and NE, injections of BTX reduced symptoms and stabilized unintentional weight loss. TRIAL REGISTRY http://www.targid.eu, ML2669, ML6294.

771 Influence of Baclofen On the Postprandial Acid Pocket At the Gastro-Esophageal Junction

in the number of postprandial reflux episodes at 5cm distal to the LES compared to placebo. The reductions at 5cm were significant at the 10% significance level (p=0.0961 and p= 0.0905 for capromorelin and ghrelin respectively). The high doses of capromorelin (20 mg) and ghrelin (5 pmol/kg/min) demonstrated significant reductions (39% and 47%, respectively) in the number of reflux events measured at 15 cm above the LES compared to placebo. These reductions were statistically significant at the 5% significance level (p= 0.042 and p=0.012, respectively). Increases in distal esophageal amplitude were observed on average for all active treatments during both saline and viscous swallows compared to placebo. For the high doses of capromorelin and ghrelin, the increases were statistically significant at the 1% level for saline swallows (p=0.006 and p=0.009, respectively). There were no serious adverse events. CONCLUSION:. The highest tested doses of capromorelin and human recombinant ghrelin had effects on reflux parameters and on esophageal physiology, at doses that appear to be well tolerated. Further studies are warranted to evaluate the role of capromorelin in the therapeutic armamenterium for GERD.