Introduction

Low anterior resection syndrome (LARS) occurs after transabdominal rectal surgical removal, most related to colorectal tumors.
It has a significant impact on quality of life, so that some patients prefer a permanent stoma. Main symptoms are diarrhea, fecal incontinence, increased defecation frequency, disturbing fecal urgency and perception of incomplete evacuation.
Treatment is still challenging, and many protocols were developed so far.
Enterosorbents are oral intestinal adsorbents, based on organic mineral with adsorption capacity towards some toxic and harmful substances in the gut, e.g., endotoxins and enterotoxins, physically binding them to its surface, reducing stool frequency and improving its consistency. Until the present day, little is known about their effect on LARS patients.

Aims & Methods

Fifteen consecutive adult patients were referred to treatment with the enterosorbent methylsilicic acid due to poor response to optimal clinical protocol to LARS.
Patients were asked to take one measuring spoon (5g) of 70% methylsilicic acid hydrogel added to 50 mL of water two times a day for a 30-day period.
Mean BSS, global improvement percentage, defecatory frequency, Constipation Scoring System (CSS) and Cleveland Clinic Incontinence Score (CCIS) were applied by the author to the patients during the first appointment and during the 30-day follow-up appointment.
All patients accepted to participate by signing the informed consent form, in compliance to the respective Ethical Committee authorization.

Results

Nine patients were female and average age was 32 years (+- 7 years). All patients informed no difficulty in complying with the enterosorbent protocol.
Initial mean defecatory frequency was 10 (+-3). Mean CSS was 9 (+-5) and CCIS was 15 (+-5). Mean BSS was 5 (+- 2).
By the time of the 30-day follow-up appointment, mean defecatory frequency was 5 (+-2). Mean CSS was 5 (+-3), CCIS was 5 (+-3), and mean BSS was 4 (+-1), p < 0,01. Global improvement percentage was 52,3% (+- 10,2) with no side effects.

Conclusion

The enterosorbent methylsilicic acid hydrogel is a safe and valid tool in treating low anterior resection syndrome patients and may be suitable as a new therapeutic option.

References

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Introduction

Barrett Esophagus (BE) is a long-term complication of inadequately controlled gastroesophageal reflux (GERD) resulting in the metaplastic transformation of the esophageal epithelium. Current therapy involves proton pump inhibitors (PPIs), aiming at reducing gastric, and consequently esophageal acid exposure time (AET), thereby eliminating the main pathogenic drive to dysplasia/adenocarcinoma progression. However, current guidelines recommend a standard dose PPI therapy for BE chemoprevention, without taking into consideration the need for 24-hour pH-impedance monitoring (24h MII-pH), which is the only investigation able to objectively estimate the esophageal acid exposure time (AET) and evaluate the real effectiveness of PPI therapy.

Aims & Methods

This study included prospectively enrolled BE patients referred to our tertiary care center. We identified consecutive patients with histological diagnosis of non-dysplastic BE treated with a standard dose of PPI administered once or twice daily (either pantoprazole or esomeprazole 40mg OD or 20mg BID), according to guidelines. After at least 8 weeks of PPI therapy, all participants underwent a high-resolution manometry (HRM) and 24h MII-pH monitoring on therapy. A cohort of refractory GERD patients matched for age, sex and PPI regimen (dose and type) were used as controls. GERD symptoms were recorded in the whole population by using the standardized GERD-Q questionnaire. Results are expressed as mean±SD.

Results

A total of 33 BE (23M, 50±17 years) and 33 GERD patients (21M, 48±14 years) were enrolled. Typical GERD symptoms were significantly less severe in BE patients compared to controls (2.1±2.1 vs 3.1±2.3; p<0.05). Half of the population of BE patients did not achieve adequate esophageal acid suppression (AET<4%) under standard dose regimen. Despite matching PPI regimen, the risk of having a pathological 24h MII-pH was doubled in BE compared to refractory GERD patients (50% vs 25%; p<0.05). The mean AET was significantly higher in BE compared to GERD patients (6.6±10.2%vs 1.9±3%; p<0.05), particularly in the supine position (7.3±15.5% vs 2.3±5.6%; p<0.05), despite similar levels of gastric acid suppression (44.1± 25.7% vs 49.2±27%; p=NS). Although the average number of reflux events was comparable between BE and controls (49±29 vs 40±22), BE exhibited a notably prolonged reflux clearance time (mean duration of the longest reflux episode: 27.8±25.7 vs 12.7±27.3 min; p<0.05). Furthermore, Type IIIA esophagogastric junction (EGJ) morphology was more prevalent BE group compared to controls (45% vs 21%; p<0.05) as was the prevalence of ineffective esophageal motility (IEM) according to the Chicago Classification version 4.0 (42% vs 12%; p<0.05).

Conclusion

Despite the reduced severity of typical GERD symptoms, analogous therapeutic regimens and comparable gastric acid suppression, BE patients showed a significantly increased esophageal AET, especially in the supine position, compared to refractory GERD patients. Furthermore, at HRM, BE patients showed a higher prevalence of Type IIIA EGJ morphology and IEM that could justify these results. Our data show that half of the whole BE population failed to achieve an adequate esophageal acid suppression despite therapy, emphasizing the relevance of performing an HRM and a 24h MII-pH in all non-dysplastic BE patients, in order to tailor the therapeutic strategy and improve BE long-term outcomes.