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Considerable progress has been made in therapeutic endoscopy over recent years and new techniques now offer access to a new space, the submucosal space, thus paving the way for new therapeutic perspectives, in particular, for functional endoscopy. The first of these applications, POEM (Per-oral endoscopic myotomy), has become, since the beginning of the 2010's, an endoscopic alternative to Heller myotomy for the treatment of achalasia. The results of this technique have been fully documented, and the technique has replaced pneumatic dilatation and become the standard treatment for this indication with equivalent effectiveness compared to traditional surgery, but with less morbidity. Indeed, the overall efficacy is around 90%, results are stable over time, and severe morbidity is less than 1%. Later, other motility disorders, such as spastic disorders, have been treated, certainly with less impressive outcomes than for achalasia, but still, of interest. This approach has also been applied to post-fundoplication motility disorders, whose de novo prevalence can be as high as 20%, and for which management is complex; this represents another new non-surgical perspective. The POEM procedure for this indication, in addition to myotomy, allows performance of a partial incision of the wrap with substantial symptomatic relief. In conclusion, the technique seems to have a bright future as it is progressively applied to more and more motility disorders.

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).

Strain Marseille-P2645T was isolated in a colon sample from a Frenchwoman who underwent a colonoscopy. Bacterial cells were Gram negative, non–spore forming, mobile and strictly anaerobic. The genome of strain Marseille-P2645T is 3 950 441 bp long and contains 3374 protein-coding genes. The DNA G+C content is of 51.66 mol%. Strain Marseille-P2645T exhibited a 92.9% sequence similarity with Bacteroides helcogenes strain P36-108T (GenBank accession no. CP002352), the phylogenetically closest species with standing in nomenclature. Strain Marseille-P2645T (= CSUR P2645 = DSM 103034) is therefore a candidate as a type species of a new genus belonging to the Bacteroidaceae family, for which the name of Mediterranea massiliensis gen. nov., sp. nov., is proposed.

Resume Introduction. – La maladie cœliaque est une enteropathie auto-immune survenant sur un terrain genetique de susceptibilite. Sa presentation clinique s'est enrichie ces dernieres annees par des formes extradigestives variees. Exegese. – Nous rapportons l'observation d'une jeune femme, âgee de 20 ans, presentant de facon simultanee une maladie cœliaque et une erythroblastopenie aigue. En plus de la positivite des anticorps antigliadine IgA et IgG, etaient notes des anticorps antinucleaires, des anti-ADN natifs et des anti-SSA/-SSB, sans cependant de signe clinique en faveur d'une maladie lupique ou d'un syndrome sec auto-immun. Le scanner thoracique montrait une hypertrophie thymique en rapport avec une hyperplasie benigne a l'histologie. L'erythroblastopenie disparaissait sous traitement associant regime sans gluten, corticotherapie et thymectomie. Conclusion. – Cette observation, ainsi que les trois autres cas pediatriques precedemment publies, concernent une association non commune entre une maladie cœliaque et une erythroblastopenie. Elles ne permettent cependant pas de conclure a un lien direct entre ces deux pathologies. L'erythroblastopenie pourrait peut-etre representer une nouvelle manifestation dysimmunitaire associee a la maladie cœliaque, mais cela demande a etre confirme par d'autres cas.

Resume Introduction – L'invagination ileale aigue est une pathologie frequente et benigne chez l'enfant. A l'inverse, elle est rare chez l'adulte et le plus souvent associee a une pathologie maligne. Nous rapportons l'observation d'une forme familiale de polypes fibro-inflammatoires benins, revelee par une invagination intestinale aigue. Exegese. – Il s'agit d'un homme, âge de 41 ans, dont la mere avait ete operee a trois reprises pour une invagination intestinale aigue sur polype fibro-inflammatoire, hospitalise pour douleur abdominale evoluant depuis trois mois avec modification du transit, alteration de l'etat general et syndrome subocclusif. La fibroscopie et la coloscopie pratiquees en externe etaient normales. En urgence, le scanner abdominal revelait une invagination aigue de la derniere anse grele sur une probable tumeur responsable d'un syndrome occlusif. L'exerese chirurgicale et l'analyse histologique mettaient en evidence un polype fibro-inflammatoire benin. L'evolution clinique etait excellente. Conclusion. – Le polype fibro-inflammatoire est toujours une lesion benigne. Elle est le plus souvent unique, s'exprimant majoritairement sous forme d'invagination ileale aigue au niveau du grele. La forme familiale presentee ici est exceptionnelle et illustre le caractere hereditaire possible de cette maladie. La pathogenie de ce type de polype reste encore mal connue.

Aim Three-dimensional high-resolution anorectal manometry (3DHRAM) is a new technique that can simultaneously provide physiological and topographical data on the terminal part of the digestive tract. Our object was to assess whether 3DHRAM is able to reliably diagnose excessive perineal descent already diagnosed with conventional defaecography, which is considered to be the gold standard. Method All patients referred to our centre for anorectal manometry and conventional defaecography were evaluated with a maximum of 6 months between the two examinations. Anorectal manometry was performed using the 3D High-Resolution Given Imaging® probe. Excessive perineal descent was defined as the downward movement of the anal high-pressure zone during straining. At the end of the straining effort, the high-pressure zone regained its initial position, thereby indicating that the probe had not moved. Results Nineteen female patients of median age 53 (21–70) years were included in the study. All cases with excessive perineal descent diagnosed using defaecography were visualized with 3DHRAM. The degree of perineal descent determined by 3D and conventional defaecography was compared (Spearman correlation 0.726, P = 0.01). In contrast, the averages measured were significantly different; the average was 11.68 ± 3.3 mm for 3DHRAM but 34.21 ± 13.3 mm for conventional defaecography (P = 0.002). Conclusion The results of the study demonstrate that 3DHRAM can diagnose excessive perineal descent with the same degree of reliability as defaecography. Quantitative measures were not correlated, however, possibly because of methodological differences. The study confirms the value of the morphological data provided by 3DHRAM.

La prise en charge initiale de l’incontinence anale peut etre basee sur des regles simples, en particulier sur des conseils hygienodietetiques et la facilitation de l’acces a des toilettes. De nombreux patients peuvent ainsi beneficier d’une combinaison de moyens simples pour ameliorer leurs symptomes.

Pour certains patients la prise en charge initiale (conseils hygienodietetiques et traitement medical) est insuffisante, avec une absence de resultat ou des resultats insuffisants.

Sacral nerve stimulation (SNS) reduces incontinence episodes and improves the quality of life of patients treated for faecal incontinence. However, the exact mechanism of action of this technique remains unclear. The present article reviews the pertinent neuroanatomy and neurophysiology related to SNS and provides explanations for potential mechanisms of action.A systematic review of the literature was performed for studies of the potential mechanisms of action of SNS, using MEDLINE, PubMed, Embase and the Cochrane Library. Articles dealing with the technique, adverse events and economic evaluations of SNS, as well as literature reviews, were excluded, except for reviews dealing with the mechanisms of action of SNS. The following inclusion criteria were used to select articles: (i) articles in English, (ii) randomized, double-blinded, sham-controlled studies, and (iii) cohort studies. Case-control studies or retrospective studies were cited only when randomized or cohort studies could not be found.We propose three hypotheses to explain the mechanism of action of SNS: (i) a somato-visceral reflex, (ii) a modulation of the perception of afferent information, and (iii) an increase in external anal sphincter activity.The mechanism of action of SNS in patients with faecal incontinence almost certainly depends on the modulation of spinal and/or supraspinal afferent inputs. Further research on humans and animals will be required to gain a better understanding of the mechanisms of action of SNS.

International audience; The aim of the present study was to determine the effects of selectively stimulating the afferent fibres running in the dorsal sacral roots (S1, S2, S3) and the somatic (radial and sciatic) nerves on colonic and internal anal sphincter (IAS) electromyographic (EMG) activity in anaesthetized cats to try to understand how sacral nerve stimulation can improve fecal continence in human. Electrically stimulating the afferent fibres present in the sacral dorsal roots and somatic nerves inhibited the colonic spike potential frequency (n = 97) and increased the slow variations in the sphincteric membrane potential (n = 76). These effects were found to have disappeared after administering an alpha-noradrenergic receptor blocker (n = 64) or sectioning the sympathetic efferent fibres innervating these organs (n = 69) suggesting the involvement of the sympathetic system in the effects observed. Moreover, no significant differences were observed between the effects of sacral dorsal root vs somatic nerve stimulation on colonic and sphincteric EMG activity. In conclusion, the data obtained here show that neurostimulation applied to the sacral spinal roots may improve fecal continence by inhibiting colonic activity and enhancing IAS activity via a somatosympathetic reflex.

Celiac disease is an autoimmune enteropathy that appears on a predisposed genetic background. Its clinical presentation has been extended those last years by varied extradigestive manifestations.This is a case report of a twenty-year-old woman who presented simultaneously a celiac disease and pure red cell aplasia. The IgA and IgG antigliadin antibodies as well as antinuclear, anti-DNA, anti-SSA and anti-SSB antibodies were detected, without any clinical symptom supporting the diagnosis of systemic lupus erythematosus or Sjögren syndrome. Thoracic CT-scan reveals a thymus enlargement and biopsy concludes to thymus hyperplasia at histological examination. Pure red cell aplasia regressed after gluten-free diet, corticoid therapy and thymectomy.This observation, added to the three others paediatric cases previously published in the literature concern an uncommon association between pure red cell aplasia and celiac disease. However, they are not enough to conclude to a direct link between these two disorders. Pure red cell aplasia could represent un new dysimmune manifestation occurring in celiac disease, but this will need to be confirmed with others cases.

Acute ileum intussusception is a frequent and mostly benign condition in childhood. Conversely, it is a rare condition during adulthood and generally associated with an underlying malignancy. We report a familial form of benign inflammatory fibroid polyps, revealed by an acute ileum intussusception.A 41-year-old man, whose mother had undergone three surgical procedures for acute ileum intussusception associated with inflammatory fibroid polyp, was admitted for a abdominal pain that started three month ago. The patient displayed alteration of the intestinal transit, weight loss and sub-occlusive syndrome. Upper and lower endoscopies, performed before admission, were normal. In the emergency room, the abdominal computed tomography-scan revealed an acute intussusception of the last loop of the small intestine, probably caused by a tumor and leading to an occlusive syndrome. Surgical resection and histological analysis concluded to an inflammatory fibroid polyp. Clinical outcome was excellent.Inflammatory fibroid polyp is always a benign tumor. It is usually isolated, expressing itself mainly in the form of an acute intussusception when located in the small bowel. The familial form presented here is exceptional and illustrates the possibility of an inherited transmission of this disease. However the pathogenesis of this type of polyp is still unclear.

Objectifs Realiser un etat des lieux en France sur la neuromodulation des racines sacrees (NMS) dans le cadre des troubles du bas appareil urinaire (TBAU) et grossesse. Methodes Il s’agit d’une etude transversale realisee a partir d’un questionnaire en ligne envoye aux investigateurs du Registre National InterStim enCaptureTM. Un questionnaire devait etre rempli par patiente enceinte apres implantation. Une reponse negative etait demandee si aucune patiente n’avait ete enceinte. Les questions portaient sur : – l’indication et l’efficacite avant la grossesse ; – la desactivation et son impact sur les symptomes ; – les modalites d’accouchement ;– l’enfant ; – la reactivation du boitier et son efficacite. L’objectif principal etait de recenser le nombre de grossesses sous NMS pour TBAU. Les objectifs secondaires etaient d’evaluer l’impact de la NMS sur la grossesse et inversement. Resultats Quarante-huit medecins ont ete contactes, vingt-trois medecins ont repondu. Huit grossesses ont ete recensees sur 6 centres. Les patientes avaient ete implantees entre 2003 et 2011. Deux patientes n’etaient pas satisfaites par l’efficacite de la NMS avant la grossesse. Trois patientes avaient eu une grossesse avant l’implantation dont 2 par cesarienne. Trois patientes ont eteint le boitier avant d’etre enceinte, toutes l’ont desactive pendant la grossesse, avec recidive des symptomes. Quatre patientes ont eu une cesarienne (2 pour atonie uterine), 3 ont accouche par voie basse et une est en cours, aucun probleme neonatal n’a ete signale. Sept patientes ont reactive leur boitier, 50 % ont eu une degradation de l’efficacite de la NMS. Conclusion Nous avons recense 8 grossesses sous NMS pour troubles vesico-sphincteriens, il y a eu 4 cesariennes, aucun probleme neonatal, et l’efficacite de la NMS en post-partum s’est degradee chez 50 % d’entre elles ( Tableau 1 ).