Background and aims Transoral incisionless fundoplication (TIF) is an effective endoscopic treatment for refractory GERD with small or absent hiatal hernia (< 2 cm in length and width). The single-session laparoscopic hernia repair followed by transoral incisionless fundoplication (HH + TIF) aims to repair mechanical defects in the lower esophageal sphincter that leads to GERD in patients with hiatal hernias ≥ 2 cm. The procedure effectively treats GERD without causing added postsurgical dysphagia and gas bloating commonly associated with partial laparoscopic fundoplication. We aimed to assess patient satisfaction, symptom resolution, safety, and proton pump inhibitor use following the HH + TIF procedure. Methods Thirty-three patients underwent single-session laparoscopic hernia repair with intraoperative TIF using the Eso-phyX Z device (EndoGastric Solutions, Inc.) between June 2015 and June 2018. The presence of GERD and normal esophageal motility were confirmed with pH testing and manometry prior to the procedure. Data were collected on pre-and post-procedure symptoms, patient satisfaction, PPI use, and complications. Median post-procedure follow-up with symptom surveys was 9 months (11-29 months). Results Patients reported significant decreases in common GERD symptoms including heartburn, regurgitation, cough, and hoarse voice. Eighty-one percent (27/33) of patients were off daily PPIs. Ninety-four percent (31/33) of patients reported 75% or greater satisfaction with the procedure and outcomes. One patient had a superficial mucosal laceration after the procedure, likely due to vomiting, which was treated conservatively. Conclusions The majority of patients reported 75% or greater satisfaction with the procedure and had an improvement in GERD symptoms as well as decreased PPI use. There were no serious adverse events.

Acquired hypoganglionosis (HG) is a rare enteric gastrointestinal neuromuscular disorder previously associated with chronic inflammation that can lead to constipation, ileus, and even death. There is little known about the pathophysiology of acquired hypoganglionosis, and it is unclear if medications are related to the development of the disease. Clozapine is an atypical antipsychotic used to treat refractory schizophrenia that is well known for its side effects including agranulocytosis and gastrointestinal dysmotility. This is an unusual case of acquired hypoganglionosis in a patient with anticholinergic toxicity on clozapine therapy.

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INTRODUCTION: Epidemiologic studies report that about 15% of adults and 30% of people older than 60 years suffer from constipation in the United States. The actual prevalence is likely greater as many people believe their bowel habits are normal and underreport symptoms of constipation. Moreover, most recent surveys assessing current medical management of constipation show that patients are dissatisfied and believe that conventional treatments, like laxatives and colonic stimulants, are suboptimal since they can cause explosive bowel movements which are difficult to control. COMP-4, a combination of ginger, Paullinia cupana, muira puama, and L-citrulline is a novel nutraceutical that has been shown to stimulate the production of nitric oxide and cGMP in smooth muscle cells resulting in smooth muscle relaxation and possibly increases intestinal secretion. In this study, we aim to demonstrate that treatment with COMP-4 is an effective treatment for severe constipation. METHODS: Seventeen patients with constipation were treated COMP-4 (2-4 capsules per day) for 2-4 weeks. Constipation was defined as two or more of the following: the sensation of incomplete evacuation, Bristol stool score 1-2 (hard, lumpy nut or sausage-shaped bowel movements), and straining during the majority of defecations. Patients were surveyed before and after the treatment regarding their approximate number of bowel movements per week, their typical Bristol stool score, the presence of abdominal pain, and the feeling of incomplete evacuation. Statistical analysis was performed using the Wilcoxon rank test with a P < 0.05 considered significant. RESULTS: Following treatment with COMP-4, the average weekly number of stools significantly (P < 0.0001) increased from 2.7+/-0.68 to 7.3+/- 1.11 (Figure 1). Prior to COMP-4, 16/17 patients reported incomplete bowel evacuation during bowel movements. After COMP-4, 10/17 patients reported complete bowel evacuation. The mean Bristol Stool Score significantly (P < 0.0001) increased from 1.5+/- 0.15 to 3.4+/-0.29 with softer and more formed stools (Figure 2). Patients also experienced a significant (P < 0.0001) decrease in abdominal pain (Figure 3). CONCLUSION: The combination of ginger, Paulinia cupana, muira puama, and L-citrulline improves the frequency and consistency of stools and helps relieve symptoms of constipation. The nutraceutical may be a novel agent used to treat severe constipation not responding well to other conventional treatments.