Guy E. E. Boeckxstaens

Long term results of pneumatic dilation in achalasia followed for more than 5 years

OBJECTIVE:We aimed to evaluate the long term therapeutic outcome in achalasia patients treated with pneumatic dilation, specifically focusing on those patients treated more than 15 yr ago.METHODS:All patients treated in our center whose records were available for review were asked to fill out a questionnaire assessing their degree of dysphagia, retrosternal pain, regurgitation, weight loss, and coughing during the night. The number of dilations was collected from the clinical records. The results of the treatment were classified into four different classes (excellent, good, moderate, poor). For those patients who had died, the cause of death was ascertained from the medical records or from the general practitioner.RESULTS:The questionnaires were distributed to 249 patients, 32 of whom had died. Of the 125 patients who completed the questionnaire, 81 (45 male and 36 female) were treated more than 5 yr ago. The mean follow-up was 12 ± 1 yr. The therapeutic success rate was 50%, obtained after a median of four dilations (interquartile range = 3–6). Of this cohort, 25 patients (18 male and seven female, aged 35–84 yr) were treated more than 15 yr ago (mean follow-up = 20.5 ± 0.5 yr). The median number of dilations was four (interquartile range = 3–7), with a therapeutic success rate of 40%. Two patients experienced a perforation, and seven were referred for surgery. Six patients out of 32 (19%) died of esophageal cancer.CONCLUSIONS:The long term success rate of pneumatic dilation is rather low, resulting in permanent successful treatment of achalasia in only 40–50% of patients. Achalasia is a risk factor for esophageal cancer.

Atrophy and Defects Detection of the External Anal Sphincter: Comparison Between Three-Dimensional Anal Endosonography and Endoanal Magnetic Resonance Imaging

PurposeUsing endoanal magnetic resonance imaging, atrophy of the external anal sphincter can be established. This aspect has not been thoroughly investigated using three-dimensional anal endosonography. The purpose of this study was to compare prospectively three-dimensional anal endosonography to magnetic resonance imaging in the detection of atrophy and defects of the external anal sphincter in patients with fecal incontinence. In addition, we compared both techniques for anal sphincter thickness and length measurements.Materials and MethodsPatients with fecal incontinence underwent three-dimensional anal endosonography and magnetic resonance imaging. Images of both endoluminal techniques were evaluated for atrophy and defects of the external anal sphincter. External anal sphincter atrophy scoring with three-dimensional anal endosonography depended on the distinction of the external anal sphincter and its reflectivity. External anal sphincter atrophy scoring with magnetic resonance imaging depended on the amount of muscle and the presence of fat replacement. Atrophy score was defined as none, moderate, and severe. A defect was defined at anal endosonography by a hypoechogenic zone and at magnetic resonance imaging as a discontinuity of the sphincteric ring and/or scar tissue. Differences between three-dimensional anal endosonography and magnetic resonance imaging for the detection of external anal sphincter atrophy and defects were calculated. In addition, we compared external anal sphincter thickness and length measurements in three-dimensional anal endosonography and magnetic resonance imaging.ResultsEighteen patients were included (median age, 58 years; range, 27–80; 15 women). Three-dimensional anal endosonography and magnetic resonance imaging did not significantly differ for the detection of external anal sphincter atrophy (P = 0.25) and defects (P = 0.38). Three-dimensional anal endosonography demonstrated atrophy in 16 patients, magnetic resonance imaging detected atrophy in 13 patients. Three-dimensional anal endosonography agreed with magnetic resonance imaging in 15 of 18 patients for the detection of external anal sphincter atrophy. Using the grading system, 8 of the 18 patients scored the same grade. Three-dimensional anal endosonography detected seven external anal sphincter defects and magnetic resonance imaging detected ten. Three-dimensional anal endosonography and magnetic resonance imaging agreed on the detection of external anal sphincter defects in 13 of 18 patients. Comparison between three-dimensional anal endosonography and magnetic resonance imaging for sphincter thickness and length measurements showed no statistically significant concordance and had no correlation with external anal sphincter atrophy.ConclusionThis is the first study that shows that three-dimensional anal endosonography can be used for detecting external anal sphincter atrophy. Both endoanal techniques are comparable in detecting atrophy and defects of the external anal sphincter, although there is a substantial difference in grading of external anal sphincter atrophy. Correlation between three-dimensional anal endosonography and magnetic resonance imaging for thickness and length measurements is poor. Inconsistency between the two methods needs to be evaluated further.

Relationship between external anal sphincter atrophy at endoanal magnetic resonance imaging and clinical, functional, and anatomic characteristics in patients with fecal incontinence

PurposeExternal anal sphincter atrophy at endoanal magnetic resonance imaging has been associated with poor outcome of anal sphincter repair. We studied the relationship between external anal sphincter atrophy on endoanal magnetic resonance imaging and clinical, functional, and anatomic characteristics in patients with fecal incontinence.MethodsIn 200 patients (mean Vaizey score, 18 (±2.9 standard deviation)) magnetic resonance images were evaluated for external anal sphincter atrophy (none, mild, or severe) by radiologists blinded to anorectal functional test results and details from medical history. Subgroups of patients with and without atrophy were compared for medical history, anal manometry, pudendal nerve latency testing, anal sensitivity testing, external anal sphincter thickness, and external anal sphincter defects. Whenever significant differences were detected, we tested for differences between patients with mild and severe atrophy.ResultsExternal anal sphincter atrophy was demonstrated in 123 patients (62 percent): graded as mild in 79 (40 percent), and severe in 44 patients (22 percent). Patients with atrophy were more often female (P < 0.001) and older (P = 0.003). They had a lower maximal squeeze (P = 0.01) and squeeze increment pressure (P < 0.001). Patients with severe atrophy had a lower maximal squeeze (P = 0.003) and squeeze increment pressure (P < 0.001) than patients with mild atrophy. These effects were not attenuated by potential confounding variables. Patients with atrophy could not be identified a priori by other characteristics.ConclusionsExternal anal sphincter atrophy at endoanal magnetic resonance imaging was depicted in 62 percent of patients, varying from mild to severe. Because increasing levels of atrophy were associated with impaired squeeze function, further studies are needed to evaluate whether grading atrophy is clinically valuable in selecting patients for anal sphincter repair.

Is glutamate involved in transient lower esophageal sphincter relaxations

Glutamate is an important excitatory amino acid and plays a major role in brain stem neurotransmission. Although the effect of glutamate on esophageal motility is well studied, its role in the triggering of transient lower esophageal sphincter relaxations (TLESRs) remains to be determined. Esophageal manometry was performed in 10 healthy volunteers using a perfused sleeve assembly. The effect of intragastric instillation of the nonspecific N-methyl-d-aspartate receptor antagonist dextromethorphan (30 mg) and the glutamate-release inhibitor riluzole (100 mg) was evaluated on esophageal motility and on the rate of TLESRs during isovolumetric gastric distension (500 ml). Dextromethorphan and riluzole had no effect on the amplitude or peristaltic velocity of esophageal pressure waves, basal LES pressure, or LES relaxation after water swallowing. Gastric distension increased the rate of TLESRs from 2.0 (1.0–3.5)/45 min to 5.0 (4.0–7.0)/45 min during placebo (P < 0.05). In contrast, the rate of TLESRs during gastric distension was significantly reduced with riluzole [4.0 (2.5–6.0)/45 min], but not with dextromethorphan. In conclusion, riluzole had no effect on swallow-induced LES relaxation, esophageal peristalsis, or gastric tone, but it reduced the number of TLESRs evoked by gastric distension. These findings suggest that glutamate may be involved in the neurocircuitry underlying TLESRs. However, as the effect was only marginal, additional studies are required to confirm our observations.

Oral S(+)-ketamine does not change visceral perception in health

Application of N-methyl-d-aspartate (NMDA)-receptor antagonists may hold promise for the treatment of visceral pain. In this study we evaluated the effect of oral S(+)-ketamine (sKET), a noncompetitive NMDA-receptor antagonist, on visceral sensitivity in healthy volunteers. Eight healthy volunteers (five male, three female) underwent a gastric barostat study following oral administration of placebo, 25 mg sKET, and 50 mg sKET. Studies were performed in a double-blind randomized crossover fashion. Sensations evoked by stepwise isobaric distension (2 mm Hg/2 min) were scored on a 100-mm visual analogue scale. In addition, fasting and postprandial fundic volume were measured at a fixed pressure level (MDP + 2 mm Hg). During gastric distension, sKET did not alter sensation scores for bloating, nausea, satiation, and pain compared to placebo. sKET had also no effects on the thresholds for pain/discomfort, fundic wall compliance, fundic tone, or meal-induced fundic relaxation. sKET does not reduce visceral perception or gastric motility in healthy volunteers. The role of sKET in conditions characterized by visceral hypersensitivity needs to be studied further.

Screening for dysplasia with Lugol chromoendoscopy in longstanding idiopathic achalasia

BACKGROUND: Achalasia patients with longstanding disease are considered to be at risk for developing esophageal cancer. Endoscopic screening is not standardized and detection of dysplastic lesions is difficult, for which Lugol chromoendoscopy could be helpful. Aim was to evaluate the efficacy of screening for esophageal dysplasia and carcinoma in patients with longstanding achalasia using Lugol chromoendoscopy. METHODS: In this cohort study achalasia patients underwent three‐annual screening by Lugol chromoendoscopy between January 2000 and March 2016. Patients with low‐grade dysplasia (LGD) underwent yearly screening, patients with high‐grade dysplasia (HGD) or carcinoma were treated. RESULTS: In total, 230 achalasia patients (144 male, median age 52 years (IQR 43–63) at first endoscopy) were included. Three patients (1.3%, 2 male, age 68 years (range 50–87)) developed esophageal squamous cell carcinoma (ESCC), without LGD at the preceding screening. Incidence rate for ESCC was 63 (95% CI 13–183) per 100 000 persons‐years. LGD was observed in 4 patients (1.7%, 2 male, age 64 years (range 57–73)), without progression to HGD/ESCC during a follow‐up of 9 (IQR 7–14) years. ESCC/LGD was diagnosed 30 (IQR 14–36) years after onset of symptoms and 22 (IQR 4–13) years after diagnosis. Lugol chromoendoscopy tripled the detection rate of suspected lesions (111 lesions white light versus 329 lesions Lugol), but only 8% was histopathological confirmed ESCC or LGD. CONCLUSiON: Achalasia patients with longstanding disease (>20 years) have an increased risk to develop esophageal dysplasia and carcinoma. Endoscopic screening using white light and Lugol chromoendoscopy does not accurately identify precursor lesions for ESCC and therefore cannot be systematically recommended.

Elektrostimulation und Biofeedback-Beckenbodenmuskeltraining bei Patienten mit Stuhlinkontinenz

ZusammenfassungFragestellung und Hintergrund:Das Beckenbodentraining ist eine attraktive Behandlung für Patienten mit Stuhlinkontinenz, die berichteten Ergebnisse unterscheiden sich jedoch. Diese Studie wurde durchgeführt, um das Ergebnis einer Beckenbodenrehabilitation in einer großen Serie konsekutiver Patienten mit fäkaler Inkontinenz unterschiedlicher Ätiologie zu beurteilen.Patienten und Methodik:Die Studie umfasste insgesamt 281 Patienten (252 Frauen). Es wurden Daten zur Krankengeschichte, zur analen Manometrie, zur rektalen Kapazitätsmessung sowie zur endoanalen Sonographie gesammelt. Auf der Basis von Integrität und Art des analen Sphinkterkomplexes sowie möglicher zugrundeliegender Ursachen der Stuhlinkontinenz wurden Patientenuntergruppen gebildet. Anschließend wurden die Patienten zum Beckenbodentraining überwiesen, das aus neun Sitzungen für Elektrostimulation und Beckenbodenmuskeltraining mit Biofeedback bestand. Das Ergebnis der Beckenbodenrehabilitation wurde mit dem Vaizey-Score, analer Manometrie und den Befunden rektaler Kapazitätsmessungen dokumentiert.Ergebnisse:Im Vergleich zum Ausgangswert verbesserte sich der Vaizey-Score bei 143 von 239 Patienten (60%), bei 56 Patienten (23%) blieb er unverändert, und bei 40 Patienten (17%) verschlechterte er sich. Der mittlere Vaizey-Score reduzierte sich um 3,2 Punkte (p < 0,001). Eine ≥ 50%ige Reduktion des Vaizey-Scores wurde bei 32 Patienten beobachtet (13%). Der mittlere Kneifdruck (+5,1 mmHg; p = 0,04) sowie das maximal tolerierte Volumen (+11 ml; p = 0,01) verbesserten sich gegenüber dem Ausgangswert. Ruhedruck (p = 0,22), Perzeptionsschwelle (p = 0,52) und Dranggefühl (p = 0,06) blieben unverändert. Die Untergruppenanalysen zeigten keine wesentlichen Unterschiede in den Auswirkungen des Beckenbodentrainings zwischen den Untergruppen.Schlussfolgerung:Das Beckenbodentraining führt insgesamt zu einer moderaten Verbesserung der Schwere der fäkalen Inkontinenz, des Kneifdrucks und des maximal tolerierten Volumens. Nur bei wenigen Patienten wurde eine wesentliche Verbesserung gegenüber dem Ausgangswert des Vaizey-Scores beobachtet. Weitere Studien sind erforderlich, um Patienten zu identifizieren, die höchstwahrscheinlich von einem Beckenbodentraining profitieren werden.AbstractPurpose:Pelvic floor rehabilitation is an appealing treatment for patients with fecal incontinence but reported results vary. This study was designed to assess the outcome of pelvic floor rehabilitation in a large series of consecutive patients with fecal incontinence caused by different etiologies.Methods:A total of 281 patients (252 females) were included. Data about medical history, anal manometry, rectal capacity measurement, and endoanal sonography were collected. Subgroups of patients were defined by anal sphincter complex integrity, and nature and possible underlying causes of fecal incontinence. Subsequently patients were referred for pelvic floor rehabilitation, comprising nine sessions of electric stimulation and pelvic floor muscle training with biofeedback. Pelvic floor rehabilitation outcome was documented with Vaizey score, anal manometry, and rectal capacity measurement findings.Results:Vaizey score improved from baseline in 143 of 239 patients (60 percent), remained unchanged in 56 patients (23 percent), and deteriorated in 40 patients (17 percent). Mean Vaizey score reduced with 3.2 points (p < 0.001). A Vaizey score reduction of ≥ 50 percent was observed in 32 patients (13 percent). Mean squeeze pressure (+5.1 mmHg; p = 0.04) and maximal tolerated volume (+11 ml; p = 0.01) improved from baseline. Resting pressure (p = 0.22), sensory threshold (p = 0.52), and urge sensation (p = 0.06) remained unchanged. Subgroup analyses did not show substantial differences in effects of pelvic floor rehabilitation between subgroups.Conclusions:Pelvic floor rehabilitation leads overall to a modest improvement in severity of fecal incontinence, squeeze pressure, and maximal tolerated volume. Only in a few patients, a substantial improvement of the baseline Vaizey score was observed. Further studies are needed to identify patients who most likely will benefit from pelvic floor rehabilitation.

Atrophie- und Defekterkennung beim externen analen Sphinkter

ZusammenfassungFragestellung und Hintergrund:Durch Anwendung der endoanalen Magnetresonanz Imaging-Technik (MRI) kann eine Atrophie des externen analen Sphinkters festgestellt werden. Diese Situation wurde durch Anwendung der dreidimensionalen analen Endosonographie (3D-AE) noch nicht genau untersucht. Zweck dieser Studie war es, die 3D-AE mit der MRI prospektiv zu vergleichen, und zwar bei der Erkennung einer Atrophie wie auch von Defekten des externen analen Sphinkters bei Patienten mit fäkaler Inkontinenz. Außerdem verglichen wir beide Techniken hinsichtlich der Dicke und Länge des analen Sphinkters.Patienten und Methodik:Patienten mit fäkaler Inkontinenz bekamen eine 3D-AE sowie eine MRI. Die Bilder beider endoluminaler Techniken wurden hinsichtlich einer Atrophie und Defekten des externen analen Sphinkters evaluiert. Das Scoring einer Atrophie des externen analen Sphinkters mittels 3D-AE war von der Differenzierung des externen analen Sphinkters und seinen Reflektionseigenschaften abhängig. Das Scoring einer Atrophie des externen analen Sphinkters mittels MRI war abhängig von der Muskelmasse und dem Vorliegen von Fetteinlagerungen. Der Atrophie-Score wurde als nicht vorhanden, mäßig, und schwer definiert. Ein Defekt wurde bei der analen Endosonographie durch eine hypoechogene Zone und bei der MRI als Diskontinuität des Sphinkterrings und/oder Narbengewebe definiert. Unterschiede zwischen 3D-AE und MRI bei der Erkennung einer externen analen Sphinkteratrophie und Defekten wurden erarbeitet. Zusätzlich verglichen wir die externe anale Sphinkterdicke und -länge bei 3D-AE und MRI.Ergebnisse:Es wurden 18 Patienten in die Studie eingeschlossen (mittleres Alter 58 Jahre; Bereich 27–80; 15 Frauen). Die 3D-AE und die MRI unterschied sich nicht signifikant bei der Erkennung einer externen analen Sphinkteratrophie (p = 0,25) und von Defekten (p = 0,38). Die 3D-AE zeigte bei 16 Patienten und die MRI bei 13 Patienten eine Atrophie. Die 3D-AE stimmte mit der MRI bei 15 von 18 Patienten bei der Erkennung einer externen analen Sphinkteratrophie überein. Unter Anwendung des Gradingsystems erreichten 8 der 18 Patienten den gleichen Grad. Die 3D-AE erkannte sieben externe anale Sphinkterdefekte und die MRI erkannte zehn. Die 3D-AE und die MRI stimmten bei der Erkennung externer analer Sphinkterdefekte bei 13 von 18 Patienten überein. Der Vergleich zwischen 3D-AE und MRI bei der Messung von Sphinkterdicke und -länge zeigte keine statistisch signifikante Übereinstimmung und hatte keine Korrelation zu einer externen analen Sphinkteratrophie.Schlussfolgerung:Dies ist die erste Studie, die zeigt, dass die 3D-AE zur Erkennung einer externen analen Sphinkteratrophie eingesetzt werden kann. Die beiden endoanalen Techniken sind bei der Erkennung einer Atrophie sowie Defekten des externen analen Sphinkters vergleichbar, es gibt jedoch einen wichtigen Unterschied beim Grading einer externen analen Sphinkteratrophie. Die Korrelation zwischen 3D-AE und MRI bei der Dicke- und Längenmessung ist schlecht. Die Unterschiede zwischen den beiden Methoden müssen noch näher untersucht werden.AbstractPurpose:Using endoanal magnetic resonance imaging, atrophy of the external anal sphincter can be established. This aspect has not been thoroughly investigated using three-dimensional anal endosonography. The purpose of this study was to compare prospectively three-dimensional anal endosonography to magnetic resonance imaging in the detection of atrophy and defects of the external anal sphincter in patients with fecal incontinence. In addition, we compared both techniques for anal sphincter thickness and length measurements.Materials and Methods:Patients with fecal incontinence underwent three-dimensional anal endosonography and magnetic resonance imaging. Images of both endoluminal techniques were evaluated for atrophy and defects of the external anal sphincter. External anal sphincter atrophy scoring with three-dimensional anal endosonography depended on the distinction of the external anal sphincter and its reflectivity. External anal sphincter atrophy scoring with magnetic resonance imaging depended on the amount of muscle and the presence of fat replacement. Atrophy score was defined as none, moderate, and severe. A defect was defined at anal endosonography by a hypoechogenic zone and at magnetic resonance imaging as a discontinuity of the sphincteric ring and/or scar tissue. Differences between three-dimensional anal endosonography and magnetic resonance imaging for the detection of external anal sphincter atrophy and defects were calculated. In addition, we compared external anal sphincter thickness and length measurements in threedimensional anal endosonography and magnetic resonance imaging.Results:Eighteen patients were included (median age, 58 years; range, 27–80; 15 women). Three-dimensional anal endosonography and magnetic resonance imaging did not significantly differ for the detection of external anal sphincter atrophy (p = 0.25) and defects (p = 0.38). Three-dimensional anal endosonography demonstrated atrophy in 16 patients, magnetic resonance imaging detected atrophy in 13 patients. Three-dimensional anal endosonography agreed with magnetic resonance imaging in 15 of 18 patients for the detection of external anal sphincter atrophy. Using the grading system, 8 of the 18 patients scored the same grade. Three-dimensional anal endosonography detected seven external anal sphincter defects and magnetic resonance imaging detected ten. Three-dimensional anal endosonography and magnetic resonance imaging agreed on the detection of external anal sphincter defects in 13 of 18 patients. Comparison between three-dimensional anal endosonography and magnetic resonance imaging for sphincter thickness and length measurements showed no statistically significant concordance and had no correlation with external anal sphincter atrophy.Conclusion:This is the first study that shows that three-dimensional anal endosonography can be used for detecting external anal sphincter atrophy. Both endoanal techniques are comparable in detecting atrophy and defects of the external anal sphincter, although there is a substantial difference in grading of external anal sphincter atrophy. Correlation between three-dimensional anal endosonography and magnetic resonance imaging for thickness and length measurements is poor. Inconsistency between the two methods needs to be evaluated further.