Search

The relative importance of cortical and infracortical neural control of deglutition was investigated in nine patients with unilateral cortical or internal capsule stroke, six patients with idiopathic parkinsonism, and seven healthy volunteers. Ten dry then 10 wet swallows were requested, during a right and left electromyographic recording of the mylohyoideus muscles, coupled to a manometric recording of the pharynx, upper esophageal sphincter, esophageal body, and lower esophageal sphincter (LES). Six hemiplegic patients, but no patient with Parkinson's disease, had asynchronous contractions of the mylohyoideus muscle at the onset of swallowing. Four hemiplegic patients and one with Parkinson's disease were unable to trigger dry swallows, but wet swallows were always initiated in all subjects. Four hemiplegic patients and one with Parkinson's disease had nonperistaltic esophageal contractions with either dry or wet swallows. LES relaxation was complete after dry swallows in none of the hemiplegic patients and in two with Parkinsons disease, and after wet swallows in six hemiplegic patients and four with Parkinson's disease. We conclude that a unilateral stroke may abolish the synchronism of mylohyoideus muscle contractions during swallowing, and that both pharyngeal and esophageal stages of deglutition are impaired in either cortical or striatonigral lesions.

Hormis le cas de l’incontinence anale active pour les selles solides, qui peut exceptionnellement etre amelioree par un traitement symptomatique, un traitement symptomatique peut etre propose a un grand nombre de patients sans avoir recours aux examens specialises du perinee. Il est possible d’obtenir une vacuite rectale efficace chez les patients souffrant de difficultes d’exoneration ou d’incontinence anale passive. En cas d’incontinence anale active pour les selles liquides, la plus grande efficacite pour ameliorer les malades repose sur le traitement d’une diarrhee. En cas d’incontinence active pour les gaz, la prise en charge dietetique est sans doute la solution la plus efficace. L’approche clinique est donc suffisante chez un tres grand nombre de patients pour faire disparaitre le symptome sans avoir recours aux examens specialises pour explorer l’anatomie et la physiologie du perinee. Le traitement curatif d’une dyschesie ou d’une incontinence anale necessite l’etude de l’anatomie et de la physiologie du perinee, car les causes de la dyschesie et de l’incontinence anale sont souvent multifactorielles et le choix du traitement doit donc tenir compte de l’intrication frequente des anomalies anatomiques et fonctionnelles. Si l’examen clinique est dans certains cas superieur aux examens complementaires pour etudier ces mecanismes, il n’est pas suffisant pour affirmer l’absence de rupture sphincterienne, de neuropathie, d’enterocele ou de sigmoidocele. L’approche clinique n’est donc pas suffisante pour le traitement curatif d’une dyschesie ou d’une incontinence anale.

Objectif: Evaluer le resultat de l'implantation d'un sphincter anal artificiel pour incontinence fecale severe chez 56 patients operes dans le meme hopital. L'implantation d'un sphincter anal artificiel est propose dans le cadre de l'incontinence anale severe lorsque le traitement local n'est pas adapte ou a echoue. Methodes : Un sphincter anal artificiel a ete implante chez 56 patients de 1993 a 2003. Tous les patients souffraient d'une incontinence fecale totale avec echec du traitement medical. L'evaluation reposait sur un examen physique (continence anale, vidange rectale) et manometrie anorectale. Resultats : Chez les 12 premiers patients, 6 dispositifs ont du etre retires (50 %); la cause de l'echec a ete retrouvee dans tous les cas, ce qui a permis de definir les contre-indications. Parmi les 44 patients suivants, 39 n'ont eu aucune complications dans les suites operatoires, et 8 ont developpe 11 complications : changement du controle de la pompe (3), migration du ballon (2), et difficultes de vidange rectale majeures chez des patients porteurs d'une procidence rectale interne obstructive (3). Le sphincter anal artificiel a du etre retire definitivement dans 9 cas; 3 autres dispositifs ont du etre retires temporairement, et les patients sont en attente de reimplantation. Dans ce dernier groupe de 44 patients, 70% ont un sphincter active : la continence aux selles liquides est normal dans 80.6 %, et la continence aux gaz dans 59.1 %. 11 patients ont des difficultes de vidange fecale. Les etudes manometriques ont montre des pressions moyennes d'H 2 O de 103 et 36cm avec respectivement, sphincter ferme et sphincter ouvert, pour une duree moyenne d'ouverture du sphincter artificiel de 178 secondes. Conclusions : Le resultat fonctionnel a long terme de l'implantation d'un sphincter anal artificiel pour incontinence fecale severe est satisfaisant. La bonne qualite des resultats est directement liee a une selection soigneuse des patients et a une prise en charge chirurgicale et per operatoire appropriee apres courbe d'apprentissage de l'equipe medico-chirurgicale.

The aims of this study were to assess the prevalence of manometric colonic abnormalities and to evaluate the motor effect of intraluminal bisacodyl in a cohort of refractory constipated patients. Twenty-four hour colonic motility recordings were performed in 40 patients referred for a severe intractable chronic constipation. At the end of each recording session the motor effects of the endoluminal instillation of 10 mg bisacodyl were assessed. These patients were compared with 20 healthy subjects. The number of high-amplitude propagating contractions (HAPC) was significantly decreased in patients with slow transit constipation (12 +/- 11.6 vs 1 +/- 8.6, P < 0.001). Based on manometric patterns four groups of patients were isolated. Ten patients had no spontaneous HAPC, no food-induced colonic motor response and significantly lower colonic activity in transverse colon (374 +/- 1220 vs 3249 +/- 3458, P < 0.05). Five patients had significantly increased sigmoid segmental motility (20298 +/- 6364 vs 88780 +/- 3643, P < 0.001) and eight patients had significantly lower number of HAPC without other manometric abnormalities while 17 patients had normal colonic motility recordings. Endoluminal bisacodyl was able to induce HAPCs in all groups of patients. Patients with severe slow transit refractory constipation represented a heterogeneous group and endoluminal bisacodyl was able to promote a propagated motor activity in a majority of patients even in those suspected of having an inert colon.

PURPOSE: Preliminary studies have shown improvement in fecal incontinence in several patients who received temporary or permanent stimulation. The purpose of this study was to report our experience in sacral nerve stimulation in the treatment of fecal incontinence and to target patients who would benefit most from stimulation. METHODS: Patients with fecal incontinence were studied clinically and manometrically before, during, and after temporary nerve stimulation. If temporary nerve stimulation was clinically successful, the patient was implanted and followed up for six months. RESULTS: Nine patients (6 female) with a mean age of 50.7 ± 12.3 years underwent temporary nerve stimulation. Temporary nerve stimulation was successful in eight patients, six of whom were implanted. Of the patients who could be evaluated, three of five had improved at the six-month follow-up visit, particularly in relation to the number of urgency episodes and delay in postponing defecation. All implanted patients had urinary symptoms. Urinary urgency was also improved by stimulation. During temporary nerve stimulation, the maximal squeeze pressure amplitude increased. After implantation, only the duration of maximal squeeze pressure seemed to improve. CONCLUSION: Sacral nerve stimulation can be used in the management of fecal incontinence, particularly in cases of urge fecal incontinence associated with urinary urgency. This study seems to confirm the effect of sacral nerve stimulation on striated sphincter function.

We report four cases of difficult defaecation and/or faecal incontinence revealing a neurologic disease. These anorectal symptoms were associated with urinary disorders, but urinary symptoms always appeared several years after anorectal complaints. Clinical neurologic examination immediately led us to suspect a neurologic aetiology in two patients with the following signs: perineal hypoesthesia, absence of voluntary anal contraction and anal reflexes in one subject (final diagnosis: L1 neurinoma), and in the other a weakness in both thighs with absent tendon reflexes in the four limbs (final diagnosis: amiodarone neuropathy). In the two other patients with multiple cerebral infarction or multiple system atrophy, the neurologic aetiology was suspected on the absence of anal voluntary contraction contrasting with a normal perineal anatomy, but the final diagnosis was made only two years later when orthostatic arterial hypotension occurred.

This work aimed to see whether (1) biofeedback is useful and (2) whether it needs to be combined with psychotherapy in sexually abused patients with anismus. Fifteen women aged 41.2±4.1 years who had experienced sexual abuse in childhood (9 cases) or adulthood (6 cases) and complained of symptoms of irritable bowel disease were studied. Anismus was recorded during anorectal manometry in all cases. Patients were free to choose biofeedback and/or group psychotherapy and/or individual psychotherapy. When necessary, psychoactive drugs were prescribed after a psychiatric evaluation. Initially all the patients chose biofeedback and none accepted psychotherapy. Eight patients accepted psychotherapy after several weeks of biofeedback. Thirteen patients completed the study: 5 treated by biofeedback alone, 5 with biofeedback and group therapy, and 3 with biofeedback and individual psychotherapy. Eight women recovered completely from their symptoms, only two of whom had had biofeedback without psychotherapy. Conclusion: Biofeedback alone was not always sufficient to cure abused patients, but was chosen initially by all the patients. It could initially be a middle path between somatic treatment and psychotherapy, at a time when patients are not yet ready to undertake the latter.

Percutaneous endoscopic gastrostomy (PEG) is reported to be a safe method for enteral feeding, although its ability to prevent gastro-oesophageal reflux (GOR) during enteral feeding remains controversial. In 12 elderly patients fed enterally to avoid the risk of tracheal aspiration, we have compared two 24-h oesophageal pH profiles, one recorded when enteral feeding was delivered at first via a nasogastric tube (NGT), and the other via a PEG. The second recording was always performed at least 8 days after gastrostomy placement. Enteral nutrition consisted of 500 ml of a polymeric diet delivered 3 times a day at 08:00, 13:00 and 18:00. After gastrostomy placement, enteral feeding was associated with a pathological acid reflux in 8 out of 12 patients. In all of these 8 patients, GOR was mostly related to a high number of reflux episodes. In 4 out of 8 patients, GOR occurred only during the 3 h following the administration of the nutritive diet. In 4 of the patients, GOR did not occur any more after removal of the NGT, whilst gastrostomy placement was followed by GOR in 5 patients. GOR during enteral feeding via PEG is common in elderly subjects. We have shown that a chronological relationship existed in some patients between the endoscopic procedure and the onset of a pathological GOR.

A new algorithm (Fastpac™) has been designed to speed up full threshold tests with the Humphrey Field Analyser. We studied the utility of this algorithm by comparing central 24-2 threshold programs obtained with standard and Fastpac™ algorithms in 43 hypertensive or glaucomatous eyes. The Fastpac™ reduced testing time by 35% to 45%. In glaucomatous eyes, the time spared was inversely correlated with the degree of visual field impairment. Global indices were used to compare visual fields. Mean absolute differences in indices did not exceed 0.98 dB. Correlations between indices in glaucoma patients with standard and Fastpac™ strategy were respectively 0.99 and 0.98 for mean deviation and pattern standard deviation. The intra-test variability (short-term fluctuation) was slightly higher with Fastpac™ with a lower correlation between algorithms (r=0.62). The use of Fastpac™ achieves a mean time reduction of 40% and does not significantly modify global indices obtained with the Humphrey perimeter in hypertensive and glaucomatous eyes.

Conventional methods of disinfecting sewage are all highly sensitive to variations in the effluent quality upstream of the disinfection stage. Microfiltration was tested as a tertiary treatment downstream of biofiltration, simulating very poor biofilter efficiency, to test the limits of the microfiltration process. Despite the poor quality of the secondary effluent (COD between 100 and 400 mgO2/l, BOD5 between 30 and 150 mgO2/l and suspended solid concentrations between 15 and 90 mg/l), the microfiltration process (filtration level : 0.2 µm) eliminated all faecal germs and tenia and ascaris eggs. The total elimination of free amoeba cysts still needs to be confirmed. With the COD and BOD5 reduced by an average of 60 and 70% respectively, the effluent quality is equivalent to level e after microfiltration (COD: 90 mgO2/l and BOD5 = 30 mgO2/l on samples averaged over 24 hours). Turbidity, measured instead of suspended solids at outlet from the microfilter, was 99 % eliminated. The colour remained between 50 and 150 mg Pt.Co/l. Under the operating conditions applied, the minimum filtration cycle was 72 hours for a minimum permeate flow of 80 1/h/m2 of membrane. When microfiltration process was used to treat a secondary effluent of good quality (COD between 14 and 40 mg/l; turbidity between 1.4 and 5.1 NTU) the germ elimination remained the same; the COD removal (31 % average elimination) allowed us to get an effluent with an average COD concentration of 24 mgO2/l. The filtration cycle was much longer (300 hours).

We describe the procedure with which cortical potential responses are evoked by a stimulation of the anal canal to assess the integrity of its sensory pathways. These potentials were recorded in 66 patients. In 44 patients, a cortical evoked response was obtained with a succession of positive and negative peaks, W shaped (35 cases) or V shaped (nine cases). In seven cases, cortical responses were interpreted differently by two independent observers. In these seven patients, such differences could be explained by an insufficient amplification of the recorded electrical waves recorded on paper (

Conventional methods of disinfecting sewage water are all highly sensitive to variations in the effluent quality upstream of the disinfection stage. Microfiltration was tested as a tertiary treatment downstream of biofiltration, simulating very poor biofilter efficiency, to test the limits of the microfiltration process. Despite the poor quality of the secondary effluent (COD between 100 and 400 mgO2/l, BOD5 between 30 and 150 mgO2/l and suspended solid concentrations between 15 and 90 mg/l), the microfiltration process (filtration level : 0.2 µm) eliminated all faecal germs and tenia and ascaris eggs. The total elimination of free amoeba cysts still needs to be confirmed. With the COD and BOD5 reduced by an average of 60 and 70% respectively, the effluent quality is equivalent to level e after microfiltration (COD: 90 mgO2/l and BOD5=30 mgO2/l on samples averaged over 24 hours). Turbidity, measured instead of suspended solids at outlet from the microfilter, was 99% eliminated. The colour remained between 50 and 150 mg Pt.Co/l. Under the operating conditions applied, the minimum filtration cycle was 72 hours for a minimum permeate flow of 80 l/h/m2 of membrane.

This study was designed to determine the effect of ornithine α-ketoisocaproate (O-KIC), a compound reducing muscle protein breakdown in physiological conditions, on liver factors involved in drug metabolism in rats with acute retrograde pyelonephritis. 91 rats were assigned to 7 groups differing in the level of food intake, induced infection, and the treatment by O-KIC (168 mg/kg bw/day). Rats were killed on the third day. O-KIC increased nitrogen balance and weight gain in controls, but not in malnourished infected or non-infected rats. Liver glutathione was significantly reduced by O-KIC in malnourished infected and non-infected rats. Though O-KIC induced a rise in liver microsomal proteins in control and infected animals, it decreased cytochrome P-450 in controls, and aminopyrine demethylase in both control and infected groups.

Six patients with complete transection of the spinal cord and six healthy volunteers were examined by using anorectal manometry together with electromyographic (EMG) recording of the external anal sphincter composed of striated muscle. Anal pressure and EMG activity of the external anal sphincter were continuously recorded at rest and during gradual rectal distention (10, 20, 30, 40, and 50 ml) by means of an air-filled balloon eliciting a rectoanal inhibitory reflex (RAIR) at the upper part, and an inflation reflex (IR) at the lower part of the anal canal. All patients and controls had a RAIR for each rectal distention volume. A relationship between the duration of the RAIR and the rectal distention volume was present in controls only. In controls the IR was present for each rectal distention volume, whereas it was present in only one patient for a 40-ml volume. During the resting period, all controls showed continuous tonic EMG activity of the external anal sphincter, but after 30 minutes all the patients showed a decrease and ultimately in five cases a disappearance of the tonic EMG activity of the external anal sphincter. In spinal patients, the presence or absence of EMG activity of the external anal sphincter did not modify the anal canal pressure. These results indicate that: 1) the tonic EMG activity of the external anal sphincter seems to be under the control of supraspinal structures, because in spinal patients it disappears in the absence of sensitive inputs toward the spinal cord; 2) the absence of EMG activity at rest indicates that the external anal sphincter is not implicated in the RAIR disturbances observed in spinal patients; 3) the IR is not a spinal reflex but is under voluntary control, because it is not present in spinal humans; 4) in spinal humans the tonic EMG activity of the external anal sphincter does not play a role in the maintenance of the anal pressure at rest.

Fecal incontinence (FI) is a debilitating condition that can be socially and personally incapacitating. A broad range of treatment options, often stepwise, are available, depending on severity. This prospective study reports a large single-centered series of patients who have benefited of temperature-controlled radio frequency (Secca) energy delivered to the anal canal. This investigation was a single-center, nonrandomized, prospective, clinical study of a single patient group with each serving as the control. All patients had experienced FI for at least 3 months and had attempted, but were not satisfied, with the results of medical and/or surgical therapies. The study aims to evaluate changes in FI symptom scores and quality of life between the baseline and follow-up intervals. Between March 2005 and March 2006, 15 Secca procedures were performed. All 15 patients were alive and in contact with the investigational site at time of 12 months. There were no long term complications. The mean Wexner score improved from 14.07 (±4.5) at baseline to 12.33 (±4.6) at 1 year (p = 0.02). The mean fecal incontinence quality of life of life score was only improved in the depression subscore. There were no changes in endoanal ultrasound and anorectal manometry. This prospective trial confirmed the safety of the Secca procedure. Although we demonstrated a significant improvement in the Wexner Score, these clinical results have to be mitigated because most patients remained in the moderate incontinences category as defined by the scoring system and did not improved their quality of life excepted in the depression subscore.

To compare the efficacy of latanoprost, bimatoprost and travoprost for lowering IOP in patients with glaucoma.In order to carry out this meta-analysis, randomized trials (2001-2004) were identified on Medline and EMBASE using the following key words: glaucoma, ocular hypertension (OHT), randomization, trial, latanoprost, bimatoprost and travoprost. The studies had to compare at least two prostaglandin analogues as mono-therapy. Cross-over experimental designs were excluded. The main outcome measure was IOP at final visit. Statistical analyses included random effects, pooled estimates of treatment effects, tests for publication bias, and random-effects models to obtain adjusted treatment effects on final IOP after lowering for baseline IOP, and duration of follow-up. Random effects Poisson regression models were used to estimate the adjusted effects of treatments on response rates (IOP18 mmHg).Nine studies were used in the analysis. Patient mean age varied from 56.7 to 68.8 years and baseline IOP ranged from 22.3 to 26.5 mmHg. Three hundred and seventy-eight patients were treated with bimatoprost, 385 with travoprost and 555 with latanoprost. Patients treated with travoprost and bimatoprost had lower IOP levels at the end of follow-up (-0.98 mmHg [95% CI: -2.08; 0.13; p = 0.08] and -1.04 mmHg [95% CI: -2.11;0.04; p = 0.06], respectively) than those treated with latanoprost. The combined effect of newer prostaglandin analogues (bimatoprost/travoprost) was an adjusted decrease of 1.00 mmHg [95% CI: -1.91;-0.10], p = 0.03], or a 17% higher adjusted response rate (Incidence Rate Ratio 1.17, 95% CI, 1.00-1.35, p = 0.04), compared to latanoprost.Travoprost and bimatoprost may have greater efficacy in lowering IOP for patients with OHT or glaucoma.

La prevalence des incontinences anales et urinaires represente un probleme de sante publique en raison de leur retentissement parfois majeur en termes de qualite de vie et du cout financier induit par leur prise en charge. Un a deux tiers des femmes consultant pour incontinence urinaire se disent genees dans la vie quotidienne. Les troubles de la continence sont souvent un motif d’institutionnalisation des personnes âgees. En France, pour la seule prise en charge de l’incontinence urinaire en 1995, le cout des protections etait compris entre 244 et 300 millions d’euros par an dans la population generale, le cout de la prise en charge en institution des personnes âgees incontinentes etait de 1,5 milliards d’euros par an, et le surcout lie a la prise en charge de l’incontinence dans les hopitaux de court sejour etait de 50 millions d’euros par an.

The purpose of this study was to evaluate the incidence and severity of retinopathy of prematurity (ROP) in infants of birth weight less than 1.500 g and/or under 32 weeks'gestation.Ninety-four preterm infants were examined following the Royal College of Ophthalmologists guidelines and retinopathy was graded using the International Classification of ROP. Screening limits were 1 500 g birth weight or 32 weeks'gestational age. Fundus examinations for ROP were performed at 5 weeks'chronological age from birth. Pupil dilation was obtained with instillation of 1% tropicamide three times at 15-minute intervals.The 94 infants examined for ROP had a median gestational age of 292.3 weeks and a median birth weight of 1 110340 g. ROP was diagnosed in 21 of 94 subjects (22.3%) by fundus examination. ROP stage 3 developed in one preterm infant, ROP stage 2 developed in five preterm infants, and ROP stage 1 developed in 15 preterm infants. No premature babies developed stage 4 or stage 5 ROP. The disease regressed spontaneously in all cases and none of the infants required cryo/laser therapy. In the most premature infants, 23-26 weeks'gestation, 57% developed ROP and one developed severe ROP (stage 3). No disease more posterior to peripheral zone 2 was observed. The incidence of ROP was higher in infants exposed to greater than 21% oxygen (24.2%) than in infants who did not receive oxygen (17.8%). Oxygen, blood transfusion, and cardiopathy appear to be associated with an increased incidence of retinopathy of prematurity.ROP continues to be a common problem associated with prematurity in France. This study found a similar incidence of prethreshold ROP when compared to recent studies. The data showed that blood transfusion and cardiopathy may play a role in the development of ROP in premature infants.

Congenital cataracts are an important cause of visual impairment in children. Approximately one-third of congenital cataracts are hereditary. The disease, when inherited as an isolated abnormality, is phenotypically and genetically heterogeneous. Autosomal dominant forms with high penetrance appear to be the most common. To date, thirteen genes have been implicated in cataractogenesis. The identification of the genetic mutations causing congenital cataracts will provide a better understanding of cataractogenesis in childhood and provide further insights into normal lens development.

Fibre-supplements in enteral feeding could increase the risk of gastro-oesophageal reflux (GOR). The aim of this study was to assess in humans the physiological effects of the supplementation of the enteral diet with different types of dietary fibre on gastro-oesophageal reflux episodes, gastric acidity and gastric emptying.pH profiles were compared in 12 healthy volunteers between three different formula (500 kcal, 250 mL x h-1) delivered in a random order and containing either no fibre, either soy polysaccharide fibre only or mixed fibre from pea and inuline. Enteral diets were instilled through a nasogastric tube. Oesophageal and gastric pH recordings were combined with the ultrasound measurement of gastric antral area during the infusion.More GOR were observed with a fibre-free diet (median 4, range 1-10) than with a mixed (median 1.5, range 0-5) (P=0.04) or soy polysaccharide fibre (median 1.5, range 0-5) (P=0.04) diet. The median duration of GOR was longer with the mixed fibre (median 3.6, range 1.8-7.2) than with the fibre-free diet (mean 1.8 min, range 1-3.6) (P0.05). The number of GOR episodes lasting more than 5 min, the duration of the longest GOR and the percent of time under pH 4 were not significantly different with the three diets. The intragastric pH profile and the ultrasound antral area were not different with all three diets.Addition of fibre to the enteral formula had limited effects on the onset of GOR episodes. It decreased the number of GOR but increased their duration. These effect were more pronounced with the formula containing soluble fibre. At variance, the addition of fibre had no significant effect on gastric emptying and gastric acid secretion.

PURPOSE: This study was designed to analyze critically the short-term and long-term outcome of sphincteroplasty and to identify high-risk factors. METHODS: Eighty-six patients with fecal incontinence associated with an ultrasound defect of the external anal sphincter were treated by anal sphincteroplasty. Clinical and physiologic assessment was made before surgery, and clinical evaluation was made three months and an average of 40 months after surgery. RESULTS: The evaluation of 86 patients three months after surgery showed that 42 patients were totally continent (49 percent), 28 were incontinent for gas (33 percent), and 16 still had fecal incontinence (19 percent). Seventy-four patients (86 percent) were contacted 40 months after surgery. Twenty-one patients (28 percent) were totally continent, 17 were incontinent to gas (23 percent), and 36 were incontinent to feces (49 percent). Forty-six percent of patients felt they were clearly improved after surgery. Poor results were associated with an internal anal sphincter defect. CONCLUSIONS: Our study suggests that in the long term, one-third of patients are totally continent after sphincteroplasty. One-half of patients are satisfied, but only if their incontinence to feces has totally disappeared. Results of sphincteroplasty deteriorate with time. One factor in poor prognosis is the presence of an associated defect of the internal anal sphincter.

PURPOSE: Pudendal neuralgia caused by nerve compression may be improved by surgical decompression of the pudendal nerve. This study was undertaken to determine if clinical symptoms, electrophysiological investigations, and the efficacy of preoperative pudendal nerve blocks could be used to predict the efficacy of surgery. METHODS: Twelve consecutive patients complaining of anal pain, genital pain, or both, exacerbated in the sitting position and unsuccessfully treated by analgesic drugs before referral were studied. In these 12 patients decompression of the pudendal nerve was performed after unsuccessful CT-guided injection of corticosteroids in the pudendal nerve at the ischial spine or after pain relapse following successful injections. Nineteen nerves were decompressed by surgery, and the compressed area was located between the sacrospinal and sacrotuberal ligaments for 18 nerves. RESULTS: Three months after surgery, four patients were totally relieved, and three were only partially improved. After 21 months of follow-up, three patients were cured, one was slightly improved, and eight remained in pain. In the three patients cured by surgery, pain completely disappeared for at least two weeks after a nerve block repeated twice before surgery, whereas pain relief was observed in only one of the nine other patients (P=0.018). None of the three patients cured by surgery were being treated for depression, whereas six of the nine remaining patients were receiving antidepressants or were followed by a psychiatrist (P=0.09). Results of surgery did not depend on other preoperative clinical or electrophysiological data. CONCLUSIONS: This preliminary study suggests that complete disappearance of pain for at least two weeks after a nerve block repeated twice before surgery may be the best criterion to predict success. Based on this criterion, surgery would have been performed in four patients in this study, of whom three would have been cured.

To evaluate colonic motility in patients with myelomeningocele, the transit time of radiopaque markers was studied in 22 patients with myelomeningocele and 22 age and sex matched controls. Mean colonic transit time was significantly longer in patients than in controls (103.2 +/- 49 h versus 23.3 +/- 13 h; P < 10(-7). Thirteen of 22 patients with myelomeningocele were severely constipated. Six patients had constipation secondary to delayed colonic transit, particularly in the left colon, and seven had increased rectosigmoid transit. The clinical questionnaire and particularly the frequency of bowel movements did not predict colonic transit. Among 13 patients with increased colonic transit, eight had more than five bowel movements per week and, thus, six of them did not use laxatives or enemas, despite the presence of faecal incontinence. There was no relationship between colonic transit time and the level of the spinal lesion or patient mobility in patients with myelomeningocele. Rectoanal dyssynergia was found in 14 of the 22 patients, but equally often in patients with delayed rectosigmoid transit (4/7) as in the other patients (10/15) (P = ns). Uninhibited detrusor contractions were observed more often in patients with increased colonic transit time than in others (8/12 versus 1/8, P = 0.05). In the absence of a correlation between colonic transit time, clinical symptoms, anorectal motility, level of spinal lesion, patient mobility, evaluation of colonic transit of radiopaque markers should be assessed routinely in all patients with myelomeningocele to plan the most appropriate treatment, mainly in case of unhibited detrusor contractions.

The results of repair to the internal and sphincter alone has been evaluated in five patients with persistent anal incontinence following surgery which affected the internal anal sphincter. All had passive incontinence for solid or liquid stool. Symptoms, anorectal manometry, and anal endosonography were evaluated before and after surgery. After surgery three patients felt improved but had still persistent symptoms, and no patients achieved full continence. Three patients showed an increased maximal and resting pressure, but only one of them was within the normal range. Post operatively, all the anal ultrasound scans showed a persistent internal sphincter defect, and two showed an unsuspected external anal sphincter defect. Although some patients felt symptomatically improved, the overall clinical, manometric and radiological findings after internal and sphincter repair were disappointing.

The aim of this study was to assess the reliability of cortical evoked potentials after electrical stimulation of the anal canal. Cortical evoked potentials were recorded on 243 patients presenting with perineal pain (28 patients), impotence (55 patients), anal incontinence (52 patients), urinary continence (30 patients), constipation (49 patients), and on 29 neurological patients, by stimulating the external anal sphincter and penis (or clitoris). The inter- and intra-observer reproducibility was studied by coding recordings interpreted by three different observers on two separate occasions. The influence of recording characteristics and clinical data were assessed. To study operator dependence, five operators investigated the patients. Only one of them was well trained in this technique. The interpretation of the coded curves by the observers was poorly reproducible in about 15% of cases, depending on time between the two readings and the quality of recordings. The interpretation of cerebral responses after anal stimulation were observer-dependent and influenced by the knowledge of clinical data. This was also observed with cortical evoked potentials after electrical stimulation of the penis or clitoris, but to a lesser extent. The cerebral evoked potentials method was also operator-dependent, mainly after anal stimulation. When a study of cortical evoked potentials by perineal stimulation is needed in clinical practice, it seems logical to prefer cortical evoked potentials by penile or clitoral stimulation as they seem easier to obtain than those evoked by anal stimulation if the investigators are not well trained for the performance of electrophysiological studies as the former are much less operator- and observer-dependent.

To evaluate the links between gastrointestinal disorders and sexual abuse, we asked 344 patients consulting in a specialized tertiary care university hospital or a gastroenterologist in private practice, if they had been sexually abused. Forty per cent of patients suffering from lower functional digestive disorder gave a history of having been victims of sexual abuse in contrast to only 10% of patients with organic diseases (P

The aim of this work was to analyze clinical symptoms in light of anorectal manometry results. We compared the frequency of clinical symptoms in relation with the presence or absence of functional anomalies. Using this methodology, the following relationships may be suggested: the need to wear a pad, with a decreased resting pressure at the upper part of the anal canal; the inability to delay rectal evacuation, with decreased anal voluntary contraction; interference of incontinence with social activities, with decreased duration of anal voluntary contraction; urinary symptoms, with an increased threshold volume of rectal distention needed to elicit the rectoanal inhibitory reflex; and complete rectal prolapse, with reduced length of the anal canal.

Our aim was to compare the results of the analysis of postprandial duodenojejunal motor patterns provided by a conventional computer-aided analysis with those provided by the new nonlinear mathematical method borrowed from 'chaos theory for determining how nonlinear analysis can improve fed motor pattern analysis and detect organization of postprandial contractions. Ten patients who had been explored for an idiopathic gastroparesis, and 20 healthy volunteers underwent duodenojejunal manometric recording for 3 h after a 750 kcal meal. Computer-aided analysis on each half-hour of the postprandial recording period calculated the number of waves (NW) and the area under the curve (AUC). Pressure signals were concurrently described by phase portraits obtained by plotting each pressure value at time t with the pressure value at time t + 1 s. The shape and amplitude of phase portraits were visually analysed and the relative area covered (RAC) by the phase portraits was calculated. With conventional analysis, NW and AUC were maximal during the first post-meal hour then decreased with time both in healthy volunteers and gastroparetic patients. With this analysis, the only difference between patients and controls was a lower NW (P < 0.02) in patients, observed only in the duodenum. Phase portraits analysis demonstrated lower RAC, a different distribution of RAC and more regular phase portraits in patients than in controls. Phase portraits outlined the heterogeneity of the patient group contrasting with the homogeneity of the control group when no subgroup was demonstrated by conventional analysis. We therefore conclude that the study of post prandial duodenojejunal motor behaviour could be improved by nonlinear dynamic analysis.

In order to evaluate the influence of esophageal dysfunction on lung function abnormalities in progressive systemic sclerosis (PSS), we compared pulmonary function tests in 24 patients with PSS according to esophageal motility. We observed three groups of subjects with normal esophageal motility (8 cases), impaired peristalsis but normal lower esophageal sphincter (LES; 7 cases), and impaired peristalsis and LES function (9 cases). Dynamic lung compliance was significantly lower in patients with impaired peristalsis and LES function than in the two other groups, suggesting that a gastroesophageal reflux (GER) could enhance pulmonary fibrosis in PSS.

Twenty-three patients (ages 44-82) with angina-like chest pain with a negative stress test and a normal coronary angiogram were studied for myocardial lactate metabolism during atrial pacing and for esophageal motor function with manometric measurements and acid infusion test. Eight patients had an abnormal myocardial lactate metabolism during maximal atrial pacing. Esophageal motor anomalies were observed in six of these eight patients and nine of the 15 subjects with normal myocardial lactate metabolism. The frequency and type of these anomalies were not different between the two groups of patients. Perfusion of acid into the esophagus reproduced the spontaneous pain syndrome in three patients, independent of any simultaneous motor dysfunction. These results suggest that esophageal motor anomalies must be interpreted with caution in patients with angina-like chest pain before affirming the exclusively esophageal origin of the pain.

La necessite de recourir ð des essais therapeutiques controles en double insu pour apprecier l’efficacite des traitements portant sur les affections du tractus digestif superieur est actuellement unanimement admise. Lors de ces essais, l’endoscopie occupe une place importante, d’une part pour definir les criteres d’inclusion, d’autre part pour evaluer l’efficacite du traitement, par exemple la cicatrisation d’un ulcere. Cependant en depit de progres methodologiques importants dans la conduite de ces essais, l’analyse de la litterature revele de nombreuses divergences dans les resultats de telles etudes. Le but de cet Editorial est de montrer ð l’aide de quelques exemples dans quelle mesure les parametres endoscopiques retenus dans ces essais sont susceptibles d’influencer les resultats et d’expliquer les discordances.

Protein malnutrition decreases the activity of drug-metabolizing liver microsomal enzymes. In the first part of our study, we evaluated those enzymes during malnutrition and refeeding. Then we compared the effects of different nutritional patterns on these parameters. During malnutrition (M), rats were fed a 5% casein diet. During refeeding, they were randomized in 3 groups: oral refeeding (20% casein diet: A), continuous total parenteral nutrition (TPN: B) and oral energy refeeding (glucose + lipids) + continuous amino-acid infusion (C). Rats were sacrificed before and at various times during malnutrition and refeeding (2 to 28 days). There was no difference in caloric intake between the 3 groups. Nitrogen balance was not different in A and B. It was lower in C, though nitrogen intake was not different. Body and liver weights were not different between the 3 groups. Microsomal proteins and cytochrome P-450 were improved in A and B but not in C compared to M. Our results suggest that TPN (but not continuous amino-acids infusion + oral energy intake) is as effective as oral nutrition on rehabilitation of microsomal enzymes in malnourished rats.

Lung function was studied in 10 patients with Crohn's disease during and after an attack of the disease. Pulmonary volumes and lung transfer factor were not impaired but functional residual capacity was greater during the attack than during remission; it was also greater than in normal subjects. FRC values and disease activity decreased concomitantly during remission as well as finger clubbing. The etiology of this impairment was unknown.

A patient who had a cecostomy because of a complicated appendicitis at the age of 17 functioned with an excluded colon for 47 years. He was then hospitalized for diverticulitis and left pericolic abscess. After treatment of the abscess by left segmental colectomy and reanastomosis, the cecostomy was closed. Two years later, he presented a normal bowel habit and improvement of his diverticulosis. Rectal manometric study showed that the rectal was normal both before and two years after surgery. Occurrence of diverticular disease in a normally innervated and vascularized, but almost empty, colon presenting with normal mechanical properties is consistent with Burkitt's hypothesis concerning long-term effects of a low residue diet on the gastrointestinal tract.

The elastic properties of the rectal wall have been studied in 16 normal adults (group I) and in 24 patients with ulcerative colitis, during a nonactive (13 cases, group II) or an active period (11 cases, group III). The rectal intraluminal pressures after accommodation to the distension were significantly higher in group III than in groups I and II. These pressures were not related to distending volumes in groups I and II but were correlated with the distending volumes in group III. The rectal elasticity coefficient was significantly greater in group III than in the other two groups. There was an inverse correlation between the rectal elasticity coefficient and the rectal area. These results suggest a loss of the rectal distensibility in active colitis.

Resume Nous avons etudie le pH œsophagien nocturne de six sujets sains. Une electrode pH etait placee 5 cm audessus du cardia et un enregistrement EEG et polygraphique assurait la surveillance du sommeil. L'etude se deroulait deux nuits consecutives, mais l'enregistrement complet n'etait realise que pendant la seconde. Les reflux gastro-œsophagiens (RGO) ont ete definis par des chutes de pH d'au moins 2 unites, superieures a 30 sec. Ils ont ete mesures entre le debut du sommeil et l'eveil definitif. Dix RGO ont ete observes chez quatre des six sujets. Ils sont tous survenus pendant une veille ou une reaction d'eveil, jamais en sommeil lent (SL) ou sommeil paradoxal (SP). Ceci est en accord avec les resultats deja publies concernant des sujets normaux, mais ne correspond pas a ce qui a pu etre decrit chez des nourrissons rechappes de mort subite ou des enfants asthmatiques : des RGO surviennent pendant le SL ou le SP. Une perturbation œsophagienne pendant le sommeil pourrait etre a l'origine de ces troubles, ou bien en etre la consequence.

The supraspinal control of colonic motility and anorectal motility is poorly documented. We had the opportunity to study colonic function, esophageal function, and urinary bladder function in three patients who presented with vascular lesions limited to the anterior (case 1) or the posterior area (cases 2 and 3) of the pons. Esophageal manometry, urodynamic examination, whole and segmental transit time measurements (using radiopaque markers) and anorectal motility were systematically performed. The results were the following: (1) in the first case esophageal motility was not altered, whereas abnormal micturition, right colonic inertia, and absence of rectoanal inhibitor reflex were observed; (2) in cases 2 and 3, there was a poor esophageal coordination, the micturition and rectoanal inhibitor reflex were normal, and the transit time of the left colon was increased. Our observations are consistent with the previously described localization of neurological areas controlling swallowing and micturition; they also favor the pons as the possible level of supraspinal control of colonic and anorectal motility.

The surgical cure of gastroesophageal reflux was investigated in 10 asthmatic adults with a mean post-operative follow-up period of 21 months. The patients had severe asthma, and gastroesophageal reflux confirmed by 3-hour post-prandial pH monitoring. Medical treatment for reflux was effective on the clinical signs of the reflux but ineffective on the respiratory signs. The clinical course of the asthma, and 3-hour post-prandial pH monitoring were evaluated before 3, 6, and after 6 months. The reflux was cured by surgery in 8 cases, and improved in two. Immediate post-operative surveillance of the asthma revealed no cure. There were three immediate failures, and two recurrences before 6 months post-operative. Improvement was stable beyond 6 months in 5 patients (suppression or 80% reduction of corticosteroids in 3 cases, considerable reduction in the use of bronchodilators in 2 cases). Our results suggest that the surgical treatment of gastroesophageal reflux may be useful, at least for suppressing an aggravating factor in the respiratory illness.

The effect of somatostatin on the rectal muscle has been studied in 15 healthy volunteers who received on 2 separate days and in a random order a continuous 1-hour infusion somatostatin (250 micrograms initially as an intravenous bolus and then 250 micrograms/h via infusion) or placebo (saline 0.15 M). Our results show that somatostatin significantly reduces the rectal basal tone after 30 and 50 min of infusion without modifying the rectal distensibility. Although they were obtained through a pharmacological increase of plasma somatostatin levels, these data suggest that somatostatin could play a part in the reservoir function of the rectum.

Fecal incontinence and/or constipation are frequent complaints in multiple sclerosis associated with urinary bladder dysfunction, incontinence, and/or retention. Total and segmental colonic transit were studied by determination of radiopaque markers, and anorectal function by anorectal manometry, in 16 multiple sclerosis patients clinically defined (with urinary bladder dysfunction shown by urodynamic examination). Fifteen multiple sclerosis patients had constipation and 14 had increased colonic transit time; ten multiple sclerosis patients had fecal incontinence and five had spontaneous rectal contractions. It is suggested that increased colonic transit and anorectal dysfunction were secondary to neurologic disorders just as urinary bladder dysfunction is due to neurologic disorders in multiple sclerosis.