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Background and aims: Closing the internal opening by a clip ovesco has been recently proposed for healing the fistula tract, but, to date, data on benefit are poorly analyzed. The aim was to report a preliminary multicenter experience. Materials and methods: Retrospective study was undertaken in six different French centers: surgical procedure, immediate complications, and follow-up have been collected. Results: Nineteen clips were inserted in 17 patients (M/F, 4/13; median age, 42 years [29-54]) who had an anal fistula: 12 (71 %) high fistulas (including 4 rectovaginal fistulas), 5 (29 %) lower fistulas (with 3 rectovaginal fistulas), and 6 (35 %) Crohn's fistulas. Out of 17 patients, 15 had a seton drainage beforehand. The procedure was easy in 8 (47 %) patients and the median operative time was 27.5 min (20-36.5). Postoperative period was painful for 11 (65 %) patients. A clip migration was noted in 11 patients (65 %) after a median follow-up of 10 days (5.5-49.8). Eleven patients (65 %) who failed had reoperation including 10 new drainages within the first month (0.5-5). After a mean follow-up of 4 months (2-7),, closing the tract was observed in 2 patients (12 %) following the first insertion of the clip and in another one after a second insertion. Conclusion: Treatment of anal fistula by placing a clip on the internal opening is disappointing and deleterious for some patients. A better assessment before dissemination is recommended. [ABSTRACT FROM AUTHOR]

Abstract: Background: Anal incontinence is a frequent complaint that profoundly affects quality of life. Our aim was to determine whether perineal retraining gives additional benefits to standard medical treatment. Methods: Patients with anal incontinence and a Wexner score >4 were randomly assigned to standard conservative treatment (control) or perineal retraining, including biofeedback, in addition to standard treatments (biofeedback). Diaries, self-administered questionnaires and satisfaction scores quantified the benefits. Self-evaluated improvement was the primary outcome measure. A score ≥3 (in an improvement scale from −5 to +5) defined success. Results: Overall, 157 patients were included; 80 in the control group (75% females, mean age 60.1±13.2 years) and 77 in the biofeedback group (79% females, mean age 61.9±10.2 years). After a 4-month follow-up, the success rate was significantly higher in the biofeedback group (57% versus 37%; p <0.021). In the biofeedback group, daily stool frequency, leakage, and faecal urgency significantly decreased, and daily non-urgent perception of stool increased. Conversely, symptomatic scores and quality of life scales did not significantly differ between groups. In a multivariate model, the adjusted odds ratio showed that perineal retraining was significantly associated with a higher chance of self-rated improvement (adjusted Odd Ratio [95%CI]: 2.34 [1.14–4.80]; p =0.021). Conclusions: Perineal retraining offers a moderate but significant benefit for patients suffering from anal incontinence. [Copyright &y& Elsevier]

Background & Aims: Patients with inflammatory bowel disease (IBD) who have been exposed to thiopurines might have an increased risk of skin cancer. We assessed this risk among patients in France. Methods: We performed a prospective observational cohort study of 19,486 patients with IBD, enrolled from May 2004 to June 2005, who were followed up until December 31, 2007. The incidence of nonmelanoma skin cancer (NMSC) in the general population, used for reference, was determined from the French Network of Cancer Registries. Results: Before the age of 50 years, the crude incidence rates of NMSC among patients currently receiving or who previously received thiopurines were 0.66/1000 and 0.38/1000 patient-years, respectively; these values were 2.59/1000 and 1.96/1000 patient-years for the age group of 50 to 65 years and 4.04/1000 and 5.70/1000 patient-years for patients older than 65 years. Among patients who had never received thiopurines, the incidence of NMSC was zero before the age of 50 years, 0.60/1000 for the ages of 50 to 65 years, and 0.84/1000 for those older than 65 years. A multivariate Cox regression model stratified by propensity score quintiles showed that ongoing thiopurine treatment (hazard ratio [HR], 5.9; 95% confidence interval [CI], 2.1–16.4; P = .0006) and past thiopurine exposure (HR, 3.9; 95% CI, 1.3–12.1; P = .02) were risk factors for NMSC. They also identified age per 1-year increase as a risk factor for NMSC (HR, 1.08; 95% CI, 1.05–1.11; P < .0001). Conclusions: Ongoing and past exposure to thiopurines significantly increases the risk of NMSC in patients with IBD, even before the age of 50 years. These patients should be protected against UV radiation and receive lifelong dermatologic screening. [ABSTRACT FROM AUTHOR]

Aim: Real-world evidence on the management of hemorrhoidal disease (HD) is limited. This international study collected clinical practice data on the effectiveness of conservative treatments for acute HD on symptoms and quality of life (QoL), providing perspectives of treatment modalities from different continents. Patients & methods: The 4-week observational prospective CHORALIS study involved adult outpatients consulting for spontaneous complaints of hemorrhoids (graded using Goligher classification) and prescribed conservative treatments according to usual clinical practice. Assessments were: anal pain/discomfort (visual analog scale [VAS]), other signs/symptoms (patient questionnaire), Patient Global Impression of Change (PGI-C) questionnaire and disease-specific QoL (HEMO-FISS-QoL questionnaire). Results: Of 3592 participants, 3505 were analyzed (58.4% male; age 40.5 ± 13.7 years; history of HD in 48.4%; 72.1% Goligher grade I and II). Pain and discomfort were the most common symptoms. Most treatments were venoactive drugs (VADs; 90.9%), particularly micronized purified flavonoid fraction (MPFF; 73.7%) and diosmin (14.6%). All VAD-based therapies improved signs/symptoms (number/intensity/frequency of pain, discomfort, bleeding, swelling, itching and soiling) and QoL. MPFF was associated with a significantly greater proportion of patients with no symptoms (48.8 vs diosmin 34.4%, p < 0.001), pain disappearance (69.7 vs diosmin 52.8%, p < 0.001), treatment impact at 1 week rated on PGI-C as 'very much better' (30.5 vs diosmin 17.9%, p < 0.001) and shorter times to improvement (mean ± SD 3.9 ± 1.5 days vs diosmin 4.2 ± 1.7 days). Conclusion: In this prospective real-world study of patients with acute HD, conservative therapies consisting mainly of VADs, including MPFF, improved the clinical signs and symptoms of disease, as well as QoL. This study evidence supports clinical advantages associated with VADs, mostly MPFF, for effectively managing acute HD.

Background and Aim: The CHORUS study (Chronic venous and HemORrhoidal diseases evalUation and Scientific research) was conducted to provide data on patients presenting with hemorrhoidal disease (HD) in clinical practice and to explore the frequency with which it coexists with chronic venous disease (CVD) and shared risk factors., Methods: This international, noninterventional study enrolled adult patients attending a consultation for hemorrhoidal complaints. The questionnaire completed by physicians established the subjects' demographic and lifestyle characteristics and collected information on HD grade and symptoms and signs of CVD., Results: A total of 5617 patients were analyzed. Symptoms commonly reported were bleeding (71.8%), pain (67.4%), swelling (55.0%), itching (44.1%), and prolapse (36.2%). Multivariate analysis revealed the variables with the strongest association with HD severity were older age, higher CVD CEAP (Clinical manifestations, Etiologic factors, Anatomic distribution of disease, and underlying Pathophysiology) class, constipation, and male gender (all P < 0.0001). Elevated BMI was a risk factor for HD recurrence. Among women, number of births had a significant association with both HD grade and recurrence. The presence of CVD, reported in approximately half the patients (51.2%), was strongly associated with advanced grade of HD (P < 0.0001). Treatments most commonly prescribed were venoactive drugs (94.3%), dietary fiber (71.4%), topical treatment (70.3%), analgesics (26.3%), and surgery (23.5%)., Conclusions: CHORUS provides a snap shot of current profiles, risk factors, and treatments of patients with HD across the globe. The coexistence of HD and CVD in more than half the study population highlights the importance of examining for CVD among patients with a hemorrhoid diagnosis, particularly when shared risk factors are present., (© 2019 The Authors. Journal of Gastroenterology and Hepatology published by Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Objectives: Surgical treatment of diverticula of the esophagus is associated with substantial mortality and morbidity. Few data have been published concerning results of minimally invasive surgery. The aim of the study was to retrospectively assess the results of minimally invasive surgery (either thoracoscopy or laparoscopy) in a first series of patients with diverticula of the thoracic esophagus., Methods: Eleven consecutive patients with symptomatic thoracic diverticula of the esophagus were operated on between December 1992 and March 1999. Five were operated on by right thoracoscopy, 4 by laparoscopy and 2 by thoracoscopy and laparoscopy. The procedure performed varied according to the location and the macroscopic aspect of the diverticulum, as well as of the associated disorders (gastroesophageal reflux, hiatal hernia and/or motor disorders)., Results: Postoperative mortality was nil. Three patients developed an esophageal fistula; one with an esophago-bronchial fistula required another operation. Postoperative pain was treated with morphine (median duration 4 days) or IV paracetamol (5 days). Long term results were excellent in 1 patient, good in 6, fair in 2 and poor in 2. These 2 latter patients were operated on another time. One of them was operated on 3 years later for aperistalsis of the esophagus and the other one was operated 4.5 years later for paraesophageal hernia; late results of these operations were fair., Conclusion: These results suggest that minimally invasive surgery does not confer significant benefit compared with open surgery in the treatment of diverticula thoracic esophagus.

Anorexia nervosa and psychogen vomiting are psychiatric eating disorders characterized by unexplained weight loss and induced vomiting. These diagnoses require absence of somatic disease. Achalasia is a primary disorder of the esophagus that can be responsible for the same symptoms. This may occult the real diagnosis, especially as dysphagia is not constant and variable in time. We report four cases of achalasia mistakenly diagnosed and treated as anorexia nervosa or psychogen vomiting. Achalasia was unrecognized because specific symptoms, such as dysphagia, were overlooked or misinterpreted by the patients' physicians and psychiatrists, or by the patients themselves. In patients with such eating disorders considered to be psychiatric, physicians should inquire about signs suggestive of achalasia. The diagnosis of achalasia is suspected by imaging and endoscopy, and confirmed or ruled out by manometry.

Hemorrhoidal disease (HD) is a trophic disorder of the anal canal characterized by recurrent, self-resolving acute episodes. The author reports the results of a double-blind, placebo-controlled trial of the efficacy of Daflon 500 mg in the treatment of acute and chronic symptoms of hemorrhoids. One hundred and twenty outpatients (54 men, 66 women) suffering from an acute episode of HD during the previous two months were included. They received Daflon 500 mg (group D, n = 60) or placebo (group P, n = 60) two tablets daily for two months. The patients were examined at entry (T0) and at two months (T2). At T0, the two groups did not differ in terms of age, sex, weight, height, history of symptoms of HD; 7 patients were excluded from analysis because of treatment failure (group D, n = 2; group P, n = 3), or lost to follow-up (group P, n = 2). In group D, 40% of patients had an attack during the trial with a mean duration of 2.6 days and a mean severity of 1.1 scored on a scale from 1 to 3. These values were significantly different (P < 0.01) from the corresponding values in the P group: 70%, 4.6 days and 1.6 respectively. Each symptom and sign was scored on a scale of severity. The overall symptom score, scored from 0 to 15, decreased from 6.6 (group D) and 6.1 (group P) (NS) to 1.1 and 4.0 respectively (P < 0.01) at the end of treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

In 119 gastrointestinal patients, serum transaminases (ASAT) and alkalines phosphatases (AP) were prospectively measured on the first and the twenty first days of a continuous enteral nutrition (CEN) regimen. The exclusion criteria were: recent surgical procedure, transfusion or total parenteral nutrition (TPN), or a cancer during the previous five years. Of the 119 patients, 71 patients were included in the study. The patients received: (a) an exclusive elemental CEN (n = 25, all with Crohn's disease) or non elemental CEN (n = 9), providing 40 kCal/kg of ideal body weight (IBW)/day; (b) a non exclusive non elemental CEN providing a minimum of 30 kCal/kg IBW/day. Of the 56 patients having normal hepatic function tests (HFT) on the first day, only 2 developed mild abnormalities (incidence of 3.6%). Of the 15 remaining patients having abnormal HFT on the first day, HFT improved or returned to normal in 8 cases. During CEN: the appearance of abnormal HFT seems rare, pre-existing abnormalities can improve and there is no associated morbidity. These results suggest that there is no hepatic side effects of CEN, in contrast to TPN, and that CEN must be preferred over TPN whenever the choice is possible.