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Background and aims Peroral endoscopic myotomy (POEM) is an established therapy for achalasia, but outcome evaluation has often been limited to Eckardt score (ES). The present study was aimed to improve knowledge about outcome evaluation and predictive outcome factors by performing a comprehensive objective evaluation of achalasia patients treated by POEM. Methods This single centre prospective study reports outcome data 12 months after POEM in treatment-naive achalasia patients. A predefined follow-up protocol included ES, high resolution manometry, 24-h pH measurement, upper endoscopy and timed barium esophagogram (TBE). Univariate and multivariate regression analyses were performed to analyze association between post-POEM variables and identify predictive factors for objective outcome. Results Fifty patients were included with a drop-out rate of 3 cm after POEM was associated with treatment failure assessed by ES (p = .04) and TBE (p = .03). Advanced achalasia stage (p = .02) and long symptom duration (p = .04) were identified as independent predictive factors for poor outcome assessed by TBE. Conclusions The present study confirms that POEM is an efficient therapy for achalasia. The comprehensive objective evaluation after POEM demonstrates that long symptom duration and major changes in oesophageal anatomy at diagnosis imply poor treatment outcome, and a post-POEM dilated oesophagus is associated with treatment failure.Key messagesPeroral endoscopic myotomy (POEM) is established as a safe and effective therapy for achalasia.Timed barium esophagogram offers objective variables that are valuable in treatment response evaluation.Advanced achalasia stage and long symptom duration are predictive factors for poor objective treatment response after POEM.

Objectives: Achalasia is a primary motility disorder of the esophagus characterized by aperistalsis and failure of lower esophageal sphincter (LES) relaxation. Treatment of achalasia aims at reducing LES pressure. The common treatment modalities are laparoscopic Heller myotomy and pneumatic dilatation, but during the last decade, a promising treatment, per oral endoscopic myotomy (POEM), has been introduced. The aim of the present study was to perform a systematic review of the literature to assess the outcome of POEM in treatment-naive patients. Materials and methods: A systematic literature search in PubMed, Embase and Cochrane databases was performed using the terms ‘Achalasia AND (POEM OR peroral endoscopic myotomy OR per-oral endoscopic myotomy)’. Inclusion criteria were: original article; English language; n ≥ 20 with ≥90% treatment-naive patients; follow-up ≥3 months; and outcome evaluation of POEM including symptom score and objective tests. Exclusion criteria were: reviews and meta-analyses; pediatric data; duplicates; and articles with overlapping data material. Results: Of the 1641 articles identified, seven were included. The included studies all reported a short-term clinical success of >90%. Clinical success including post-POEM reflux was mainly estimated by symptom scorings. There were few procedure-related complications. Conclusions: The studies of treatment-naive patients indicate a high rate of clinical success. Nevertheless, a more systematic and standardized evaluation is recommended to improve the reports on outcome of POEM. The follow-up rate should be high and the evaluation protocol should include both symptom scoring and objective testing with predefined treatment goals.

Epiphrenic diverticula occur in the lowermost 10 cm of the oesophagus. The main symptoms are dysphagia, regurgitation and pain when swallowing food. The main purpose of the survey was to evaluate the department's results for surgical treatment of this rare and distressing condition.In the period 2002-2012, eleven patients (nine men) underwent surgery for an oesophageal diverticulum consisting of excision (n = 8), myotomy of the lower oesophageal sphincter and Dor fundoplication (n = 2) or all these procedures (n = 1). Two of them were transferred from other hospitals because of complications. Details of pre-operative symptoms and post-operative complications were retrieved retrospectively from patient records. Ten patients who agreed to take part in a retrospective survey responded to a questionnaire a median of 27.5 months (range of 2-105 months) after surgery.There were no fatalities as a result of the treatment. Three patients developed leakage after the diverticulum excision, two of whom required reoperation. The patients experienced considerable symptomatic improvement. According to the retrospective survey, eight of the nine patients with pre-operative dysphagia no longer had it. Four of seven with regurgitation, and all five patients who experienced pain in connection with swallowing, experienced post-operative improvement. The patients reported their condition as completely well (n = 5) or improved (n = 5) after the operation. One patient who had undergone reoperation for leakage and oesophageal mediastinal fistula did not consent to further surgery.Most patients who underwent surgery for epiphrenic oesophageal diverticulum in our department experienced symptomatic improvement after surgery.

Bilirubin is the main component of most common bile duct stones. Normally, almost all bilirubin in bile is conjugated to glucuronic acid or some other sugar moiety. These conjugates are unstable and liable to deconjugation. Unconjugated bilirubin is insoluble and may precipitate as the calcium salt found in brown pigment stones. The pattern of bilirubin conjugates in common duct bile of patients with choledocholithiasis has been unknown.In a clinical series of 55 patients with choledocholithiasis common-duct bile was aspirated, and the bilirubin conjugates analyzed with high-performance liquid chromatography. One stone from each patient was analyzed for cholesterol and bilirubin content to determine stone type.Sixteen patients had cholesterol stones, 38 patients had brown pigment stones, and 1 patient had a black stone. Patients with pigment stones had a lower percentage of bilirubin diglucuronide (median, 60.3%; interquartile range, 49.7%-67.3%) than patients with cholesterol stones (64.0%; 60.2%-73.3%) (Mann-Whitney, P=0.015). No significant difference was found for the other bilirubin conjugates, total bilirubin, or biliary pH when pigment and cholesterol stone patients were compared. The time of bile sampling in relation to papillotomy and treatment of cholestasis was not associated with the low percentage of bilirubin diglucuronide. The observation of reduced values for bilirubin diglucuronide could not be ascribed to duodenal diverticula or Billroth-II gastric resection.The percentage of the main bilirubinate conjugate, bilirubin diglucuronide, is decreased in the common duct bile of patients with pigmented compared with cholesterol stones.

Common duct gallstones are mainly of the brown pigment type, which are usually attributed to bacterial factors. Bacterial beta-glucuronidase most probably plays a role in the pathogenesis in many but not all patients. The role of other bacterial factors is more undecided. The aims of this study were to investigate a possible association between lipopolysaccharides (LPS) and choledocholithiasis, and to examine the interrelationship to beta-glucuronidase. Common duct bile obtained at endoscopic retrograde cholangiography in 86 patients was assayed for LPS by a limulus amebocyte lysate test, and beta-glucuronidase activity at pH 7.0 was measured. We found that both elevated concentration of LPS and the presence of juxtapapillary duodenal diverticula were associated with common duct stones (p0.01, both). Patients who had their common duct stones removed recently had a lower LPS concentration and a lower activity of beta-glucuronidase than those who had a stone in situ (p0.01, both), but still higher LPS concentration than those without choledocholithiasis at all (p0.01). In multiple logistic regression analysis, elevated LPS was the significant predictor of common duct stones (p0.01), and not confounding with neither beta-glucuronidase nor juxtapapillary diverticula. We conclude that gram-negative bacteria convey bacterial factors associated with choledocholithiasis, by mechanisms independent of, and additional to beta-glucuronidase.

Alterations of the small intestinal absorptive surface are a probable cause of D-xylose malabsorption in chronic alcoholism. Delayed gastric emptying, however, may influence the (13)C-D-xylose breath test, which is used to study intestinal function in alcoholics. The aim of this study was to measure gastric emptying in alcoholics to elucidate whether retention of the test meal could explain the malabsorptive pattern of the (13)C-D-xylose breath test observed in alcoholics.Fifteen alcoholics performed the (13)C-octanoic acid and the (13)C-D-xylose breath tests on consecutive days in a random order. The (13)CO(2) expired was measured every 30 or 15 min for 4 h in the (13)C-D-xylose and the (13)C-octanoic acid breath tests, respectively, using a mass spectrometer equipped with a gas chromatograph. Test meals consisted of 100 mg of (13)C-D-xylose and 5 g of unmarked D-xylose dissolved in 250 ml water and 91 mg (13)C-octanoic acid embedded in a one-egg omelette served with white bread with margarine, respectively.The alcoholic patients had a lower (13)C-D-xylose breath index compared with healthy controls (p0.0001). None of the (13)C-octanoic acid breath test variables, T(50%), T(max), T(lag), or GEC revealed any significant differences between the groups.The pathological (13)C-D-xylose breath test in this group of alcoholics is unlikely to be caused by delayed gastric emptying. Malabsorption is the probable cause of the pathological (13)C-D-xylose breath test results in alcoholics.

Background: The aim was to investigate a possible association between D-glucaric acid (DGA), biliary bilirubin glucuronidation and brown pigment stones in the common bile duct. Methods: A high performance liquid chromatography method with a strong cation resin (HPX-87H) was developed for measuring biliary DGA. Bile was obtained during ERCP by deep cannulation of the common bile duct in 100 patients with suspected biliary disease. Results: The concentration of DGA in common bile duct bile was 60 (1.1-633) μmol l -1 (median, range). The values were lower than previously reported. There were no differences in DGA concentrations in patients with common bile duct stones compared to patients without common bile duct stones, irrespective of stone type, cholesterol or brown pigment stones. Bilirubin conjugates in common duct bile did not vary with DGA concentrations. Conclusion: DGA is probably insignificant in the pathogenesis of common bile duct stones.

The relationship between the preceding phase of the migrating motor complex (MMC) and postprandial motility in the small intestine was studied.In eight healthy subjects small-bowel manometry was performed, and a 55-ml caloric liquid bolus (280 kJ) containing paracetamol and 14C-D-xylose was instilled into the duodenum during phase I and late phase II of the intestinal MMC, respectively, in randomized order. Blood samples were drawn at regular intervals and analysed for insulin, gastrin, glucose, paracetamol, and 14C-D-xylose.After bolus administration during late phase II a phase-III-like activity succeeded by quiescence occurred in the duodenum in seven of eight subjects, whereas administration during phase I initiated irregular contractions in seven of eight subjects (P0.05). The caloric bolus induced a significant increase in serum insulin and gastrin. Areas under the curves for serum insulin, gastrin, glucose, paracetamol, and 14C-D-xylose were not modulated by the preceding phase of the MMC.The present study shows that a nutrient bolus instilled into the intestinal lumen induces MMC-like activity when administered during late phase II. These findings provide further evidence of interference between MMC and postprandial motility.

Background: Common bile duct stones represent a clinical problem often involving severe infection, cholangitis and cholestasis. Stasis and infection are thought to play a part in the pathogenesis of choledocholithiasis. Investigations on the etiology of common bile duct stones are, however, scarce because of the difficult access to common bile duct stones and bile. In a clinical series of common bile duct stones, we studied the gross appearance of stones extracted endoscopically from the common bile duct and measured the cholesterol and bilirubinate content in order to elucidate factors of importance to etiology. Methods: In 135 patients treated endoscopically for bile duct stones, the stones or parts of the stones were collected. Appearances of the cut surface of the stones were studied and described. Cholesterol and bilirubinate content were analyzed enzymatically and with infrared spectroscopy. The growth in bile of gas-producing bacteria previously shown to be correlated with enterobacteriacea was investigated. Results: Seventy-five percent of the stones were pigment stones, the majority with concentric pigmented layering. There was good agreement between cholesterol measurements. With a cutoff at 50% for the infrared measurements and 25% for the enzymatic assay only 3 stones were discordant between cholesterol measurements and visual inspection. Twenty-one of 23 patients with a previous Billroth-II gastric resection had pigment stones (p < 0.05). Gas-producing bacteria were significantly more prevalent in the bile from patients with layered pigment stones. Conclusion: Pigment stones with concentric layering highly suggestive of a cyclic process of crystallization were recovered from the common bile duct in 70% of the patients in our series.

The phase of the migrating motor complex (MMC) in the proximal small intestine at meal intake modulates gastric emptying, which is accelerated after intake during phase II. In the present study the relationship between phase of the MMC at meal intake and the postprandial endocrine response was studied.Eight healthy subjects ingested a caloric liquid meal of 2020 kJ during phase I and late phase II of the intestinal MMC, respectively, in a randomized order. Blood samples were drawn at regular intervals after meal intake and analysed for insulin, gastrin, neurotensin, cholecystokinin, motilin, and somatostatin by radioimmunoassays.The area under the curve (AUC) until 15 min for serum insulin (P0.05) and plasma neurotensin (P0.02) and AUC until 120 min for serum gastrin (P0.05) were higher after intake during late phase II than after phase I. Plasma cholecystokinin increased earlier (P0.05) after intake during late phase II than after phase I. Plasma motilin and somatostatin were not influenced by preceding phase of the MMC.This study shows that the phase of intestinal MMC at meal intake modulates the postprandial endocrine response, which may be explained by the prior entry of nutrients to the small intestine after intake during phase II.