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Background Open studies have reported favourable results for sacral nerve stimulation in the treatment of refractory constipation. Here, its efficacy was assessed in a double-blind crossover RCT. Methods Patients with at least two of the following criteria were included: fewer than three bowel movements per week; straining to evacuate on more than 25 per cent of attempts; or sensation of incomplete evacuation on more than 25 per cent of occasions. Response to therapy was defined as at least three bowel movements per week and/or more than 50 per cent improvement in symptoms. Responders to an initial 3-week peripheral nerve evaluation were offered permanent implantation of a pulse generator and were assigned randomly in a crossover design to two 8-week intervals of active or sham stimulation. At the end of the two trial periods, the patients received active stimulation until the final evaluation at 1 year. Results Thirty-six patients (34 women; mean(s.d.) age 45(14) years) underwent peripheral nerve evaluation. Twenty responded and received a permanent stimulator. A positive response was observed in 12 of 20 and 11 of 20 patients after active and sham stimulation periods respectively (P = 0·746). Pain related to the device occurred in five patients and wound infection or haematoma in three, leading to definitive removal of the pulse generator in two patients. At 1 year, 11 of the 20 patients with an implanted device continued to respond. Stimulation had no significant effect on colonic transit time. Conclusion These results do not support the recommendation of permanent implantation of a pulse generator in patients with refractory constipation who initially responded to temporary nerve stimulation. Registration number: NCT01629303 (http://www.clinicaltrials.gov).

Ogilvie's syndrome describes an acute colonic pseudo-obstruction (ACPO) consisting of dilatation of part or all of the colon and rectum without intrinsic or extrinsic mechanical obstruction. It often occurs in debilitated patients. Its pathophysiology is still poorly understood. Since computed tomography (CT) often reveals a sharp transition or "cut-off" between dilated and non-dilated bowel, the possibility of organic colonic obstruction must be excluded. If there are no criteria of gravity, initial treatment should be conservative or pharmacologic using neostigmine; decompression of colonic gas is also a favored treatment in the decision tree, especially when cecal dilatation reaches dimensions that are considered at high risk for perforation. Recurrence is prevented by the use of a multiperforated Faucher rectal tube and oral or colonic administration of polyethylene glycol (PEG) laxative. Alternative therapeutic methods include: epidural anesthesia, needle decompression guided either radiologically or colonoscopically, or percutaneous cecostomy. Surgery should be considered only as a final option if medical treatments fail or if colonic perforation is suspected; surgery may consist of cecostomy or manually-guided transanal pan-colorectal tube decompression at open laparotomy. Surgery is associated with high rates of morbidity and mortality.

Our clinical experience with low dose loxapine (5-15 mg/day) suggests promising efficacy and safety for irritability in autism spectrum disorders (ASD). We studied low dose loxapine prospectively in adolescents and adults with ASD and irritability. Additionally, we measured loxapine and metabolite concentrations, and brain-derived neurotrophic factor (BDNF) as a biomarker of neuromodulation.We performed a 12 week open trial of add-on loxapine in subjects, ages 13-65 years, diagnosed with ASD, and Aberrant Behavior Checklist-Irritability (ABC-I) subscale scores14. Loxapine was dosed flexibly up to 15 mg daily, starting with 5 mg on alternate days. From weeks 1 to 6, other psychoactive medications were tapered if possible; from weeks 6 to 12, all medication doses were held stable. The primary outcome was the Clinical Global Impressions-Improvement subscale (CGI-I), ratings of Much Improved or Very Much Improved. Secondary outcomes were the ABC-I, Repetitive Behavior Scale-Revised, and Schalock Quality of Life scale. Serum BDNF and loxapine and metabolite concentrations were assayed. BDNF rs6265 was genotyped.Sixteen subjects were enrolled; 12 completed all visits. Median age was 18 years (range 13-39). Median final loxapine dose was 7.5 mg/day (2.5-15). All 14 subjects (100%) with data at week 12 were rated as Much Improved on CGI-I at 12 weeks. Mean change on ABC-I at 12 weeks was -31%, p=0.01. Mean body mass index (BMI)-Z decreased between weeks 6 and 12, p=0.03. Side effects were minimal, and prolactin elevation occurred in only one subject. BDNF concentrations measured in 11 subjects increased significantly (p=0.04). Subjects with AG genotype for BDNF rs6265 required a lower dose of loxapine at study end, but had similar behavioral and BDNF concentration changes as the GG genotype.Low dose loxapine shows promise as a repurposed drug for irritability in ASD. Loxapine effects on BDNF warrant further study.

Background: Exposure-based therapy for anxiety disorders is believed to operate on the basis of fear extinction. Studies have shown acute administration of D-cycloserine (DCS) enhances fear extinction in animals and facilitates exposure therapy in humans, but the neural mechanisms are not completely understood. To date, no study has examined neural effects of acute DCS in anxiety-disordered populations.Methods: Two hours prior to functional magnetic resonance imaging scanning, 23 spider-phobic and 23 non-phobic participants were randomized to receive DCS 100 mg or placebo. During scanning, participants viewed spider, butterfly, and Gaussian-blurred baseline images in a block-design paradigm. Diagnostic and treatment groups were compared regarding differential activations to spider versus butterfly stimuli.Results: In the phobic group, DCS enhanced prefrontal (PFC), dorsal anterior cingulate (ACC), and insula activations. For controls, DCS enhanced ventral ACC and caudate activations. There was a positive correlation between lateral PFC and amygdala activation for the placebo-phobic group. Reported distress during symptom provocation was correlated with amygdala activation in the placebo-phobic group and orbitofrontal cortex activation in the DCS-phobic group.Conclusions: Results suggest that during initial phobic symptom provocation DCS enhances activation in regions involved in cognitive control and interoceptive integration, including the PFC, ACC, and insular cortices for phobic participants.

Sacral nerve stimulation (SNS) has a place in the treatment algorithm for faecal incontinence (FI). However, after implantation, 15-30% of patients with FI fail to respond for unknown reasons. We investigated the effect of SNS on continence and quality of life (QOL) and tried to identify specific predictive factors of the success of permanent SNS in the treatment of FI.Two hundred consecutive patients (six men; median age = 60; range 16-81) underwent permanent implantation for FI. The severity of FI was evaluated by the Cleveland Clinic Score. Quality of life was evaluated by the French version of the American Society of Colon and Rectal Surgeons (ASCRS) quality of life questionnaire (FIQL). All patients underwent a preoperative evaluation. After permanent implantation, severity and QOL scores were reevaluated after six and 12 months and then once a year.The severity scores were significantly reduced during SNS (P = 0.001). QOL improved in all domains. At the 6-month follow-up, the clinical outcome of the permanent implant was not affected by age, gender, duration of symptoms, QOL, main causes of FI, anorectal manometry or endoanal ultrasound results. Only loose stool consistency (P = 0.01), persistent FI even though diarrhoea was controlled by medical treatment (P = 0.004), and low stimulation intensity (P = 0.02) were associated with improved short-term outcomes. Multivariate analysis confirmed that loose stool consistency and low stimulation intensity were related to a favourable outcome.Stool consistency and low stimulation intensity have been identified as predictive factors for the short-term outcome of SNS.

Divalproex (DVP) delayed release and DVP extended release (DVP ER) are approved by the Food and Drug Administration for bipolar disorder, epilepsy, and migraine prophylaxis. Divalproex ER is given once daily, improving compliance and reducing adverse events. Overnight switch to DVP ER is advised in the package insert but could produce more adverse events in this susceptible population. In this pilot study, we compared tolerability of overnight versus gradual switching to DVP ER in 16 adults with intellectual and developmental disabilities receiving DVP, in 9 for epilepsy and in all 16 for comorbid bipolar disorder. The study design was open with parallel groups. Sixteen subjects with intellectual and developmental disabilities were randomized to overnight or gradual conversion for 4 to 6 days. A blinded rater completed the Multidimensional Observation Scale for Elderly Subjects on days +1, +4, and +8 after the switch began. We found no major differences between the 2 groups at each time point. Neither group of subjects, except for 1 subject in the overnight group, manifested sedation, seizures, worsening of tremor, or gastrointestinal adverse events. One subject in the overnight group manifested acute diarrhea and vomiting, followed by a very brief tonic leg seizure 6 days later. Larger studies are warranted.

UNLABELLED The mechanisms of action of sacral nerve stimulation (SNS) to treat faecal incontinence remain poorly understood. THE AIMS OF OUR STUDY WERE (i) to measure the effect of SNS on rectal function and (ii) to evaluate rectal function as a predictive factor of clinical response to SNS. Rectal function was studied before and 3 months after permanent SNS in 18 patients (17 women, mean age 58.5 years) with faecal incontinence, using an electronic barostat. Rectal sensitivity and volume variations were recorded during isobaric distensions. Three months after SNS, 14 patients had a significant improvement of faecal incontience symptoms and four had not. Baseline 'maximal tolerated volume' was significantly lower in the positive response group (210 +/- 56 vs 286 +/- 30 mL, P = 0.02). Baseline rectal compliance was lower in patients with a positive response than those without, although this difference did not reach significance (6.2 +/- 3.2 vs 9.2 +/- 2.9 mL mmHg(-1),P = 0.10). Rectal compliance was not significantly modified by SNS. Our results suggest that an increased rectal capacity as measured by the maximal tolerated volume may be a predictive factor of poor response to SNS in faecal incontinence. SNS does not significantly modify rectal function.

Gas gangrene of the abdominal wall is a rare clinical occurrence with high rates of morbidity and mortality. The primary source of the infection is often unknown. To analyze the primary underlying intestinal etiologies and diagnostic approaches of gas gangrene of the abdominal wall, and to highlight specific treatment problems, particularly that of constructing a colostomy exteriorized through a massively infected abdominal wall.Seven cases of abdominal wall gas gangrene due to a gastrointestinal etiology were identified. (Cases arising from proctologic sources or related to recent abdominal surgery were excluded.) During the same period, 39 other patients presenting with abdominal wall gangrene from non-intestinal sources were treated.The etiologies were: perforated sigmoid diverticulitis (n=2), perforated appendicitis (n=1), acute pancreatitis with associated cecal perforation (n=1), and perforated colorectal cancer (n=3). Four of the seven patients died despite treatment (mortality of 57%).The clinical presentations of these seven cases demonstrate that a GI source must be suspected whenever a patient presents with abdominal wall gas gangrene, even when there are no specific GI symptoms. Imaging, particularly with CT scan, is essential both to visualize the extent of tissue necrosis and to reveal underlying primary GI pathology. This optimizes the surgical approach both by allowing for complete debridement and drainage of infected tissue, and by focussing the intervention on correction of the underlying primary GI source of infection.

To study, by means of defecography, clinical risk factors of enterocele and association with others pelvic floor disorders.Five hundred and forty-four consecutive female patients were investigated by colpocystodefecography with contrast medium in the small bowel. One hundred and thirty-six women with enterocele were compared to 408 women without enterocele.There were no significant differences in age, obstetrical history (parity, foetal macrosomia, instrumental extractions or perineal tear to delivery) between the two groups. More women with enteroceles had histories of hysterectomies (60% versus 24%) or cystopexies (29% versus 13%). Others pelvic floor disorders were associated in 91% of enterocele: rectocele (25%), cystocele (42%), uterine prolapse (28%), rectal intussusception (52%), rectal prolapse (4%) and abnormal perineal descent (30%). Stress urinary incontinence was significantly more frequent in women without enterocele.The study has demonstrated that previous hysterectomy and cystopexy increased the risk of enterocele formation and that enterocele and others pelvic floor disorders are often concomitant. Enterocele may have a pessary effect on urinary disorders. Results of colpocystodefecography reinforce the notion of pelvic floor local disease.

Traditionally, penetrating abdominal wounds justify routine laparotomy. However, this policy can be adapted to mechanism of injury (stab or firearm) and accuracy of imaging procedures if they eliminate visceral injury thus allowing close follow up.Retrospective study of 79 patients (May 1995-May 2002) with a penetrating abdominal wound: (47 (59%) stab wounds and 32 (41 %) firearm wounds). Correlation between imaging and surgical findings, treatment, post-operative course were studied.Sixty-eight patients were operated on from the outset, and 11 underwent close follow-up. Of the 11 patients who had follow-up, (9 after stab wound and 2 after firearm wound), two had to be operated (1 in each group). Correlation between imaging and surgical findings was good in 34 (72%) patients after stab wound and in 21 (80%) after firearm wound; the mean number of visceral injuries was 1 and 3 respectively. Six patients (8%) died (mortality: 2% and 16% respectively), 12 (15%) had postoperative complications.Penetrating abdominal stab wounds can be treated by close follow-up if imaging excludes visceral injury. Firearm wounds still justify routine laparotomy due to both multiplicity of visceral injuries and bad prognosis.

The benefit of enteral nutrition is an established fact for severely burned or multiple injured patients with a reduction of septic morbidity. Enteral nutrition is now possible in upper gastrointestinal tract surgery with the development of nasojejunal triple lumen tube and we report a new application with an operative placement. The aim of the study was to evaluate the nasojejunal triple lumen tube in digestive surgery.From November 1999 to August 2001, a nasojejunal triple lumen tube was placed during surgery for high surgical risk patients (n = 17) or under radioscopic control for the treatment of post operative complications (n = 6).The surgical placement was possible in all cases. The radioscopic placement failed in two cases, one of which being solved with endoscopic procedure. There was no morbidity during the tube placement. Four patients were excluded because of early post operative death (n = 3) or premature removal of the tube by the patient (n = 1). The enteral nutrition was early in 18 patients and its mean duration was 18.2 days (range 3-75). Technical problems occurred in 9 patients and the replacement of the tube was necessary in 8 cases.The nasojejunal triple lumen tube is a feasible, safe and relatively well-tolerated procedure in upper gastrointestinal tract surgery.

Study of clinical, diagnostic and therapeutic aspects of mesenteric and mesocolic cystic lymphangiomas.15 cases were retrospectively analysed: 5 adults (mean age 36.8 years, range 26 to 46) and 10 children (mean age 23 months, range 0 to 5 years). Diagnosis was prenatal in 1 case. Symptoms were: abdominal pain (80%), fever (20%), abdominal mass (46%), occlusive syndrome (33%), chylous ascitis 1 case. Tumours were mesenteric (86%) or mesocolic (13%).Complete resection was performed in 11 cases (including 10 bowel resections), incomplete resections in 3 and doxycycline sclerotherapy once. Mean follow-up is 5 years. One recurrence occurred 6 years after complete resection and 1 tumour increased after incomplete resection. Patient treated by sclerotherapy was non symptomatic with a 3.5 years follow-up after last injection.Mesenteric and mesocolic cystic lymphangiomas are congenital benign tumours. Complete resection should be performed whenever possible. Intracystic sclerotherapy with doxycyclin is possible for unresectable lymphangiomas.

The goal of this study was to evaluate the clinical and functional consequences of anal sphincter echographic lesions in patients with fecal incontinence.From January 1997 to April 2001, 100 patients with fecal incontinence (90 women, 10 men) were prospectively explored by transanal ultrasound and vectormanometry. Internal and external sphincter defects, as well as their extension, were analyzed with regard to their clinical and functional expressions (resting and squeeze anal sphincter pressures, anal sphincter asymmetry index).Among the 100 patients, 42 had no echographic lesions, 58 had a defect: 26 had an isolated defect (internal sphincter (n = 3), external sphincter (n = 23) and 32 had combined internal and external sphincter defects. Squeeze anal pressures were significantly lower in the group of patients with combined defects, compared to the group with isolated defect or without defect. Anal asymmetry index was higher in the group of patients with combined defects, compared to the other groups. There was a positive correlation between the radial extension of the defect and the importance of clinical complaints.Echographic anal sphincter lesions are frequent in fecal incontinence and are clinically and functionally significant.

Hepatic portal venous gas is a radiological symptom associated with a poor prognosis (75% to 90% mortality). The aim of this retrospective study was to report 7 cases observed over a 2-year period.From June 1997 to November 1999, hepatic portal venous gas was diagnosed in 6 patients by CT scan and in one patient by echosonography. It was not detected in any case by plain abdominal X-rays. Three patients had small bowel obstruction with necrosis, three had extensive superior mesenteric infarction and one had preperforative necrosis of the colon.One patient with extensive intestinal infarction and a metastatic head and neck cancer was not operated. Two patients were operated, but the extensive mesenteric infarction was not amenable to surgical management. Three of the 7 patients died, while the other four patients survived after resection of the necrotic small intestine (n = 3) and left colectomy extended to the transverse colon (n = 1).Hepatic portal venous gas was associated with intestinal necrosis in the seven cases of this series. The severity of portal venous gas is only correlated with the severity of the disease causing portal venous gas.

The aim of this prospective descriptive study was to evaluate the accuracy of abdomino-pelvic ultrasonography in suspected acute appendicitis in adults.From March to July 1998, 100 consecutive patients, 63 women, 37 men (mean age: 25 years), after examination by a visceral surgeon for suspected acute appendicitis, had an abdominal ultrasonography (US) examination with high frequency transducer (7.5 to 9 MHz). The US examination concerned appendice, periappendicular tissues and neighbouring organs. The US data were correlated with the histopathologic findings in operated on patients, and with the clinical and biological follow up in non operated patients.Fourty-seven patients had acute appendicitis; 53 were operated on and 47 non operated. Analysis of US data revealed sensitivity 91.5%, specificity 94.3%, positive predictive value 93.5%, negative predictive value 94.3%, accuracy 93%; 75% of the other diagnosis were found by US.Systematic abdominal ultrasonography in suspected acute appendicitis is recommended in adults.

Solid pseudopapillary tumors of the pancreas are exceptional. The aims of our study were to reevaluate the mode of presentation of these tumors and to analyze the role of pathological examination in diagnostic assessment and prognostic evaluation.We report the clinical, radiological and pathological findings in a retrospective series of 13 patients in whom a diagnosis of solid pseudopapillary tumor of the pancreas was made between 1983 and 1997. There were 12 females (median age: 22.5 years) and one male, aged 73.The tumor was discovered incidentally (3 cases) or because of nonspecific digestive symptoms (10 cases). Biological data were uninformative. The tumor was pancreatic in 12 cases and duodenal in 1. In all cases, imaging techniques showed an heterogeneous lesion with no or poor vascularization. A cystic component was identified in 4 cases. Surgical resection was performed in all cases. Pathological examination showed an encapsulated tumor in 8 cases, a non-encapsulated but well-limited lesion in 3 cases and an infiltrative tumor in 2 cases. At the time of diagnosis, multiple liver metastases were present in 1 case. Mean duration of follow-up was 24 months (range: 3-168). At last follow-up, all patients, including the patient with synchronous metastatic disease, were alive, without local recurrence.Our study confirms that most cases of solid pseudopapillary tumors of the pancreas present with a suggestive clinical picture, including their occurrence in young women and their good prognosis after surgical resection. However, our results also underline the occurrence of cases presenting with unusual features, including old age, male sex, extra-pancreatic localization and malignant evolution. Histopathological examination is essential for the establishment of the diagnosis but morphological data are of little prognostic value.

We report a case of a 17-year-old patient with an haemothorax related to an intra-abdominal spleen rupture. The nature of this haemothorax is unusual and the problem is how to obtain the etiology in this case. The spleen was in intra-abdominal position on all radiological examinations and was the source of bleeding. Therefore, laparotomy is the only convenient therapy.

In four cases, angiomyolipoma of the liver was discovered incidentally by ultrasound investigation. Based on a review of 26 other previously reported cases and as was borne out in our series, the diagnosis is suggested by the demonstration of fatty material on CT-scan and confirmed by needle aspiration biopsy. Magnetic resonance may be contributive as well.

In this prospective and randomized trial involving 38 patients operated upon for generalized or localized peritonitis, 2 combinations of antibiotics were assessed on the basis of 5 predetermined criteria: number of successes and failures, duration of fever, leucocytosis, antibiotic therapy and stay in hospital. No significant difference was observed between the two therapeutic groups. The spectrum of sensitive organisms and the effectiveness of treatment could be considered satisfactory whatever the combination utilized. The 86.8 percent clinical success rate suggests that the cefotaxime-clindamycin combination should be used more frequently than it is now.

A series of 223 resections for esophageal squamous cell carcinoma performed from 1975 to 1982 (70% were palliative or cleaning resections) is presented. Postoperative mortality and morbidity are not significantly different after palliative resection from those after curative resection. The long-term results are encouraging and clearly superior to those obtained with other medical and surgical palliative therapies. These findings lead the authors to support the use of palliative resection for esophageal carcinoma, except in cases of cervical tumors with a poor prognosis.

A retrospective study of 112 patients with acute obstructive carcinoma of the colon (added to 16 prospective recent cases), whose mean age was 74 years, with metastasis or peritoneal carcinosis in 23% of the cases, shows a high operative mortality (38.4%), an average survival of 804 days and a five years survival actuarial rate of 17.5%. 80% of further deaths were due to cancer. These results and the data of literature encourage the authors to suggest, whenever a curative resection is to be considered, a decompressive proximal colostomy combined to a short investigating laparotomy, followed by a two-stage resection 2 or 3 weeks later.

Among 67 blunt hepatic traumas treated during a 4 years period, 34 required an emergency surgery for reasons of severe bleeding, with 16 deaths of which 11 were directly due to the liver injury. 33 patients, whose hemodynamic stability contrasted with major hepatic lesions (5 deep fractures, 28 central hematomas combined with 5 subcapsular hematomas and 3 multiple parenchymatous fractures), were subjected to nonoperative management. One patient died from sudden hemorrhage and a second one underwent further drainage for a residual pelvic abscess. In the 32 alive patients, a close watch over with ultrasound and CT scan gave prominence to a complete disappearance of the lesions within 4 to 24 weeks. The nonoperative management of such hepatic injuries may be a safe and reasonable alternative to a high risk surgery, as far as the hemodynamic condition or associated visceral lesions do not require an emergency surgery.

Three patients had colonic perforation as a result of percutaneous nephrostomy and lithotripsy. These patients did not respond to conservative measures and required surgery (colostomy, hemicolectomy, drainage). This report reviews the anatomic and technical aspects of percutaneous access to the kidney. Fluoroscopy and ultrasonography do not allow simple and accurate information of the position of the colon, and CT is the method of choice. Some factors seem of high risk : thin and young patient, female, dilated pelvo-calyceal system, associated colonic obstruction.