Pneumatic Balloon Dilatation Research Articles

Effect of Pneumatic Balloon Dilation to The Changes of Eckardt Score in Patient With Achalasia

Introduction: Achalasia is an esophageal motility disorder, but its pathogenesis remains unclear. The highest incidence is among adults aged 30 – 60 years with the prevalence of 10/100.000 population. Diagnosis of achalasia is based on symptoms and upper endoscopy, barium esophagogram, and esophageal manometry. Pneumatic Balloon Dilation (PBD) is one of the treatment options, whether it is fluoroscopy-guided or direct endoscopy guided. This study aims to analyze the effect of PBD on the changes of Eckardt score among achalasia patients.Methods: An analytical observational study with a retrospective and prospective design was conducted on 18 achalasia patients who performed PBD at Dr. Soetomo General Hospital. Data were then analyzed using t-test. Results: The mean age was 47.8±12.5 years, and the mean achalasia duration was 18.3±5.9 months. There were no differences of achalasia cases between men and women. The mean body weight in the pre and post PBD was 50.9±6.2 vs 53.1±6.5 kg with delta 2.19±1.88 (p <0.0001). The mean BMI in the pre and post PBD was 20.2±2.2 vs 21.1±2.5 kb/m2 with delta 0.89±0.78 (p <0.0001). In addition, the mean Eckardt score in the pre and post PBD was 10.17±1.47 vs 2.5±0.86 (p <0.0001). There were 3 patients with Eckardt score of 4 after PBD and no weight loss after one-month evaluation. Conclusion: There was a significant difference of Eckardt score before and after PBD. The improvement of the Eckardt scores led to the change of weight and body mass index among achalasia patients.

A protocolized approach to endoscopic hydrostatic versus pneumatic balloon dilation therapy for gastric sleeve stenosis: a multicenter study and meta-analysis.

Gastric sleeve stenosis (GSS) is reported in .7% to 4% of cases after sleeve gastrectomy. Two endoscopic balloon dilation techniques are available with no clear consensus on the therapeutic approach. To compare the treatment efficacy and safety between hydrostatic and pneumatic balloon dilations for GSS. Academic referral centers, United States and a meta-analysis. Consecutive patients who presented with GSS and underwent endoscopic hydrostatic and/or pneumatic balloon dilations at 3 tertiary care hospitals were included. Clinical success was defined as an improvement of symptoms that allowed the patient to avoid further interventions. A systematic literature search was performed to identify relevant studies for meta-analysis. Of 46 patients, 13 had pneumatic dilation only, 26 had hydrostatic dilation only, and 7 had pneumatic dilation after failed hydrostatic dilation. Clinical success was not significantly different among the 3 groups with the success rates of 30.8%, 57.6%, and 57.1% (P = .25) after single dilation and 61.5%, 63.6%, and 71.4% (P = .90) after serial dilations in the pneumatic group, hydrostatic group, and pneumatic after failed hydrostatic group, respectively. Patients who failed hydrostatic balloon dilation (n = 7) had a success rate of 71.4% with subsequent pneumatic dilation. Two serious adverse events were observed in the pneumatic group, whereas none were observed in the hydrostatic group. A meta-analysis of 16 studies involving 360 patients demonstrated higher clinical success with single pneumatic balloon dilation compared with hydrostatic balloon dilation (62.2% versus 36.4%; P = .007) with higher adverse events (3 versus 0 events). Hydrostatic balloon dilation should be considered as an initial modality for GSS given its acceptable success rate and high safety profile. In those who fail hydrostatic balloon dilation, a subsequent step-up approach to pneumatic balloon dilation or revisional surgery should be attempted.

Isolated sleeve gastrectomy stricture: a systematic review on reporting, workup, and treatment.

The isolated stricture after the sleeve gastrectomy is one of the possible surgical complications. Previous algorithms have been proposed to address the workup and treatment of sleeve gastrectomy stricture. However, current literature lacks standardization and systematic reviews on this topic. This study aimed to review all currently available publications and to create evidence-based recommendations. We searched Medline (PubMed), EMBASE, and Central Cochrane from inception to June 10, 2019. Inclusion criteria were studies reporting treatment of sleeve gastrectomy stricture with no associated leaks. The primary outcome was the reported clinical resolution rate. The final analysis included 32 articles. The pooled reported clinical resolution rate for the primary treatment was 68% (11/16), 82% (296/361), and 75% (34/45) for noninvasive medical therapy, endoscopic, and surgical treatments, respectively (not significant). Among the endoscopic modalities, the pneumatic dilation has the highest clinical success rate. Most rescue surgeries described in the literature were successful. Conclusively, the initial treatment should entail noninvasive medical management followed by the endoscopic approach, if needed. Pneumatic balloon dilation should be the preferred approach, if technically feasible. Revisional surgery should be reserved for endoscopic failure.

THE TREATMENT OF CHRONIC ANAL FISSURES WITH FISSURE EXCISION AND BOTULINUM TOXIN TYPE A INJECTION (ISRCTN97413456)

AIM: to assess the efficacy of botulinum toxin type A for chronic anal fissure.PATIENTS AND METHODS: the study included 80 patients randomized by random number generation in 2 groups. Forty patients underwent fissure excision in combination with injections of botulinum toxin type A into the internal sphincter (main group) and 40 – in combination with pneumatic balloon dilatation of the anal sphincter (control group).RESULTS: there were no statistically significant differences in the intensity of postoperative pain after defecation and during the day between the groups, p=0.45 and p=0.39, respectively. The groups were comparable in the complications such as perianal skin hematomas (p=0.84), external hemorrhoid thrombosis (p=0.1), urinary retention (p=0.46), long-term non-healing wounds (p=0.76). Transitory weakening of the anal sphincter was significantly more often in the control group. On day 30, the transitory anal incontinence in the main group was detected in 6 (21%), in the control group – in 18 (75%) patients, p=0.0002. On day 60, the weakness of the anal sphincter remained in the main group in 3 (10.7%), in the control group – in 10 (41%) patients, p=0.02.CONCLUSION: botulinum toxin type A and pneumatic balloon dilatation have equal effectiveness in the treatment of chronic anal fissure. The use of botulinum toxin type A can reduce the incidence of transitory weakening of the anal sphincter function in patients with chronic anal fissure.

Pneumatic balloon dilatation versus laparoscopic Heller myotomy for achalasia: a failed attempt at meta-analysis.

The advent of peroral endoscopic myotomy (POEM) shed some light on the role of the current standards in the treatment of idiopathic achalasia, namely endoscopic pneumatic dilatation (PD) and laparoscopic Heller myotomy (LHM). We analyzed the quality of the current evidence comparing LHM and PD. A systematic literature search was performed in Pubmed/Medline, Web of Science, Google Scholar and Cochrane for meta-analyses/systematic reviews comparing PD and LHM or open surgery, limited to English language full-text articles. After a detailed review of these meta-analyses, all studies included were analyzed further in depth with respect to treatment protocol, assessment of success, complications and sequelae such as gastroesophageal reflux (GER), as well as follow-up details. Six randomized controlled trials (RCT), 5 with LHM and 1 with open surgery, were found, published in 10 papers. In contrast to a rather homogeneous LHM technique, PD regimens as well as the clinical dysphagia scores were different in every RCT; most RCTs also showed methodological limitations. There were nine meta-analyses which included a variable number of these RCTs or other cohort studies. Meta-analyses between 2009 and 2013 favored surgery, while the 4 most recent ones reached divergent conclusions. The main difference might have been whether repeated dilatation was regarded as part of the PD protocol or as failure. The variability in PD techniques and in definition of clinical success utilized in the achalasia RCTs on PD versus LHM render the conclusions of meta-analyses unreliable. Further randomized studies should be based on uniform criteria; in the meantime, publication of even more meta-analyses should be avoided.

Precostal top-down extended totally extraperitoneal ventral hernia plasty (eTEP): simplification of a complex technical approach.

Retromuscular mesh augmentation is generally considered to be the ideal technique for repairing ventral hernias and can be performed laparoscopically by 'enhanced view totally extraperitoneal plasty' (eTEP)-a technically complex procedure that requires a high level of surgical expertise. We aimed to develop a simplified technical modification. Thirty-one patients with ventral hernias were operated with a modified precostal, top-down eTEP approach, and prospectively recorded in our hernia registry. We describe this novel standardized precostal access and the bilateral development of both retromuscular compartments with a cylindrical dilating balloon port. Demographic-, hernia-specific-, and perioperative data were analyzed retrospectively. Twenty-two primary and 9 incisional hernias with an average defect size of 34.5cm2 were repaired. An average implant of 420cm2 always completely covered diastasis recti and/or scars from previous midline laparotomies. Average procedure time was 128min. One conversion was required due to peritoneal injury. Postoperatively there was one local infection and one patient suffered an interparietal herniation. There were no recurrences during the average 8-month follow-up period. With technical modification of precostal access and pneumatic balloon dilation of both retro-rectus compartments, the complex procedure can be simplified through time saving and straightforward unidirectional 'top-down' dissection. The better overview facilitates the crossover for connecting both retro-rectus spaces. In addition, the cranial access allows the anterior- and posterior layers to be closed up to the xiphoid.

P201 LAPAROSCOPIC TRANSHIATAL OMENTAL REPAIR OF IATROGENIC ESOPHAGEAL PERFORATION IN ACHALASIA

Abstract Aim Laparoscopic transhiatal omental patch repair(OPR) of esophageal perforation after pneumatic balloon dilatation(PBD) for achalasia. Background&Methods In August 2018 a 72yrs woman with a history of dysphagia for solids and liquids, nocturnal regurgitation and chest pain had a diagnosis of achalasia. After inhalation during a barium swallow the patient developed fever, respiratory insufficiency and worsening of vital signs leading to ICU and intubation. She developed a right-pleural empyema, massive pneumothorax and right-upper lobe abscess, requiring thoracotomy and right-superior lobectomy. She had been scheduled for a Per Oral Endoscopic Myotomy in November. After the submucosal tunnel, the procedure had been suspended due to presence of fibrosis. In December the patient underwent a first PBD up to 30mm with symptoms resolution and 2kg weight regain. In February, few hours after a second PBD up to 35mm, she complained mild pain at the left hemithorax and fever. 24hrs later a CTscan with water-soluble-contrast revealed a 3cm long esophageal perforation 5cm above the diaphragm and left paraesophageal mediastinal abscess without pleural involvement. Endoscopic treatment was excluded for significant dilatation of the esophagus and the fragile esophageal wall. Because of the frailty status of the patient, the delayed diagnosis, the high risk of a direct suture of the esophageal wall through a left thoracotomy, the even higher risk of an emergency esophagectomy, we performed a laparoscopic approach. Limited dissection of the esophagogastric-junction and of the left diaphragmatic crura allowed access to the abscess cavity, no attempt to direct suture was done, a drain was placed, a pedicled omental flap was realized filling the cavity and repairing the esophageal defect. A jejunostomy was placed. Results The post-op period was uneventful; a CTscan with per-os contrast on POD3 and POD9 didn’t show any collection. The patient started an oral semisolid-diet on POD11. An EGDS on POD19 confirmed the presence of the OPR in the esophageal lumen and after 2-months showed a completely re-epithelialized esophagus. Conclusions Laparoscopic trans hiatal OPR of esophageal perforation in achalasia proved to be a minimally invasive and effective procedure in this patient due to its immunogenic and angiogenetic properties.

Endoscopic Repair of Large Gastric Perforation Following Pneumatic Dilation of Sleeve Gastrectomy Stenosis.

Sleeve gastrectomy has become the most commonly performed bariatric surgery in the USA (English et al.in Surg Obes Relat Dis. 14(3):259-63, 2018). Despite the rising popularity of this procedure, gastric stenosis is a known complication with an incidence of up to 4% (Rebibo et al. in Obes Surg. 26(5):995-1001, 2016). Endoscopic pneumatic balloon dilation is increasingly utilized to treat this condition and to ameliorate symptoms of nausea, vomiting, reflux, and/or dysphagia (Dhorepatil et al. in BMC Surg. 18(1):52, 2018). Pneumatic balloon dilation does carry a risk of gastric perforation of up to 3% in the limited literature to date (Donatelli et al. in Surg Obes Relat Dis. 13(6):943-50, 2017), historically requiring immediate surgical consultation for repair (Donatelli et al. Surg Obes Relat Dis. 13(6):943-50, 2017). In this case series, two cases of gastric perforation during pneumatic dilation for gastric sleeve stenosis were repaired successfully endoscopically with use of an endoscopic suturing system, resulting in correction of gastric defect and elimination of symptoms.

2116 Salvage Therapy for Recurrent Gastrojejunal Anastomotic Stricture Using a Lumen-Apposing Metal Stent

INTRODUCTION: Gastrojejunal (GJ) anastomotic stricture following Roux-en-Y gastric bypass is a well-known complication of the surgery with reported ranges varying from 2.9-23%.1 Unfortunately, prior endoscopic interventions for these strictures have had limited durability of treatment response. CASE DESCRIPTION/METHODS: A 71-year-old male with previous Roux-en-Y gastric bypass presented to our hospital with 2 weeks of nausea, vomiting, weight loss, and severe hypoglycemia. Initial imaging with CT abdomen showed a fluid-filled and distended gastric pouch with likely stenosis of the GJ anastomosis. An upper GI series was performed which confirmed significant stenosis at the GJ anastomosis (Figure 1a). An EGD was performed at which time the stricture was successfully dilated using a through-the-scope (TTS) 6-7-8 mm and then an 8-9-10 mm balloon dilator (Figure 2). Unfortunately, the patient did not clinically respond to dilation and was unable to advance diet beyond liquids, requiring initiation of total parenteral nutrition. Subsequently, the patient underwent a repeat EGD with placement of a 20 mm × 10 mm lumen apposing metal stent (LAMS) (Axios, Boston Scientific) under fluoroscopic guidance. The stent was successfully dilated with a TTS 12-13.5-15 mm balloon dilator to a maximal size of 13.5 mm with obliteration of the waist. The LAMS was then sutured into place with the endoscopic suturing device (OverStitch, Apollo Endosurgery, Inc) using 2.0 polypropylene suture and placing 2 interrupted sutures with cinches on both ends (Figure 3). An upper GI series was repeated 24 hours after LAMS, which showed excellent functioning of the stent without leak or obstruction (Figure 1b). Over the next five days, the patient’s symptoms abated, diet was gradually advanced to low residue diet, TPN was discontinued, and the patient was discharged home. DISCUSSION: Management of these strictures has primarily been pneumatic balloon dilation or fully covered self-expanding stents; however, dilation is unlikely to achieve durable response and other stents are associated with complications of stent migration and recurrence of symptoms after removal. Previous case reports have documented successful treatment of GJ anastomotic strictures using LAMS with excellent response given its novel shape and anchoring phalanges. 1 We further show the successful endoscopic suturing of the LAMS, which will allow for prolonged time for stent placement with enhanced risk-mitigation for stent migration.

A437 Endoscopic hydrostatic balloon dilation versus pneumatic dilation for post-sleeve gastrectomy symptomatic gastric stenosis: A multicenter experience

Gastric stenosis (GS) is a potential adverse event after sleeve gastrectomy (SG). Different endoscopic interventions are available with no clear guidelines. Our aim was to compare the treatment efficacy and safety between hydrostatic and pneumatic balloon dilation for post-SG symptomatic GS.

A rare ca(u)se of dysphagia

Achalasia is a rare lower esophageal motility disorder, in which there is destruction of myenteric plexi leading to the loss of esophageal peristalsis and inadequate relaxation of the lower esophageal sphincter in response to swallowing. Although the etiology of achalasia cardia is unclear, it is likely to be caused by autoimmune etiology. It is characterized by dysphagia of solids and liquids, regurgitation, weight loss, chest pain, heartburn, and nocturnal cough. Achalasia can be diagnosed on the clinical history and confirmed by barium swallow, and esophageal manometry which is the gold standard technique for diagnosis. Even though achalasia cannot be cured permanently, pneumatic balloon dilatation and myotomy remain the definitive treatment of choice in spite of availabilities of pharmacological therapies. We report a case of 25-year-old male admitted with chronic dysphagia and weight loss, diagnosed to be having achalasia cardia and treated accordingly.

Sa1986 MULTICENTER SERIES OF PNEUMATIC BALLOON DILATION FOR THE MANAGEMENT OF POST-SLEEVE GASTRECTOMY GASTRIC STENOSIS

Symptomatic stenosis after sleeve gastrectomy (SG) occurs in up to 4% of patients due to scarring, staple line rotation and staple line imbrications. Management with traditional hydrostatic through-the-scope dilation balloons often fails due to limited expansion force and small balloon diameter. Pneumatic balloon dilation with 30-35mm has gained attraction for this indication. Our aim was to describe a multicenter experience of the effectiveness and safety of pneumatic balloon dilation for management of symptomatic SG stenosis.

Sa1211 PER-ORAL ENDOSCOPIC MYOTOMY (POEM) IN THE TREATMENT OF ACHALASIA; CLINICAL OUTCOMES OF 430 PATIENTS, SINGLE CENTER STUDY

Per-oral endoscopic myotomy(POEM) is one of the minimally invasive treatment options for achalasia, which has shown to be more effective than classical treatment methods such as pneumatic balloon dilatation and Heller’s myotomy. This abstract presents our work on the outcomes of patients with achalasia and other esophageal motility disorders treated with POEM procedure in the last 4 years.

Mo1240 – Pneumatic Balloon Dilation for Recurrence of Symptoms After Heller Myotomy

Mo1240 – Pneumatic Balloon Dilation for Recurrence of Symptoms After Heller Myotomy

Management of Esophageal Achalasia in Quebec.

BackgroundEsophageal achalasia is a defective relaxation of the lower esophageal sphincter with a loss of esophageal peristalsis causing dysphagia. Treatment can be Heller myotomy, pneumatic balloon dilation, Botox injections, peroral endoscopic myotomy (POEM) or medical. The main objective of the study was to measure the extent of post-treatment dysphagia depending on the type of treatment.MethodsThis was a retrospective study conducted at the Centre Hospitalier de l’Universite de Montreal (CHUM) between 2011 and 2017. All patients with manometric diagnostic of achalasia in our department were included. Data were collected with the electronic health record and a standardized post-treatment telephone survey to evaluate the extent of dysphagia and the use of proton pump inhibitor (PPI).ResultsA total of 169 patients were included. The most frequent treatments were Heller myotomy (60%), Botox injection (18%) and endoscopic balloon dilation (16%). There was a significant difference in the management of patients treated at the CHUM and outside the CHUM for the frequency of pneumatic dilation (28 vs. 7%; P = 0.001) and Heller myotomy (49 vs. 69%; P = 0.02). An Eckardt score ≤ 3 was found in 80% of patients. No significant score difference was found between the CHUM and outside CHUM groups or between the different treatments. The post-treatment use of PPI was of 49% and was not significantly different depending on the site or the type of treatment.ConclusionHeller myotomy stays the most frequent treatment, especially outside our tertiary center. The rate of post-treatment dysphagia is low no matter the treatment choice. The use of PPI stays frequent regardless of the management site or the type of treatment used.

Diagnostics and Minimally Invasive Surgery for Achalasia Cardia

The objective of the research was to assess the effectiveness of balloon pneumatic dilation and laparoscopic Heller myotomy in treatment of patients with achalasia cardia.
 Materials and methods. Twenty-one patients with achalasia cardia were examined and treated using pneumatic balloon dilation and laparoscopic Heller myotomy in the Department of Surgery from January 2016 to April 2018. There were 8 (38.1%) men and 13 (61.9%) women at the age of 28 to 75 years (the average age was (51.47 ± 3.63) years) and disease duration of 1 month to 8 years (the average disease duration was (3.05 ± 0.49) years).
 Results and discussion. With the help of radiological methods of examination, all the patients were divided into 4 groups according to the esophageal diameter: Group I included 5 (23.8%) patients with the esophagus up to 4-5 cm in diameter; Group II comprised 6 (28.6%) patients with the esophagus up to 4-6 cm in diameter; Group III included 5 (23.8%) patients with the esophagus up to 6-8 cm in diameter; Group IV consisted of 5 (23.8%) patients with the esophagus of more than 8 cm in diameter and an S-shaped configuration. A significant decrease in the diameter of the esophagus according to fluoroscopy (p<0.05) alongside with a decrease in the lower esophageal sphincter pressure according to manometry are indicative in assessing the effectiveness of achalasia cardia treatment after minimally invasive surgery. There were no complications when performing pneumatic balloon dilation and laparoscopic Heller myotomy.
 Conclusions. In 7 (33.3%) patients, recurrences of achalasia cardia after balloon pneumatic dilation occurred within 2 - 10 months: in 4.7% of patients in Group I and 9.5% of patients in Group II, Group III, and Group IV. In recurrent achalasia cardia, repeated dilation was ineffective. There was performed laparoscopic Heller myotomy with Dor fundoplication, which was effective in 80.0% of cases.

The Use of Rigiflex Pneumatic Balloon Dilator during Laparoscopic Heller's Myotomy in Patients with Achalasia: A Novel Technical Method and Its Surgical Outcomes

Pneumatic balloon dilatation (BD) and laparoscopic Heller's myotomy (LHM) are usually preferred treatment options for relieving dysphagia symptoms in achalasia. The aim of the present study was to describe a new technical method for a safe and effective LHM. Endoscopic BD tube (Rigiflex 30-mm pneumatic balloon) is simultaneously insufflated and desufflated in the esophagus during LHM to assess myotomy in 50 consecutive patients. Dysphagia symptoms were determined using Eckardt's score. Three esophageal mucosal perforations occurred during surgery, which was primary repaired. The preoperative Eckardt score improved significantly from 4.54 ± 1.85 to 0.54 ± 0.73 (P < 0.001) at the first postoperative annual follow-up. The use of endoscopic BD tube during LHM is an easy and valuable method that allows to assess whether the dissection of muscular fibers in the myotomy area is appropriate or not.

Pneumatic balloon dilation versus myotomy for the treatment of achalsia

Pneumatic balloon dilation versus myotomy for the treatment of achalsia

Is pneumatic balloon dilation safe and effective primary modality of treatment for post-sleeve gastrectomy strictures? A retrospective study

BackgroundThe optimal treatment of sleeve strictures has not been agreed upon at the current time. At our institution, we began using pneumatic balloon dilation to help resolve these obstructions in 2010. Herein we report our experience with pneumatic balloon dilation for the treatment of sleeve strictures.MethodsFrom Jan 2010 to Dec 2016 we retrospectively reviewed our prospectively kept database for patients who developed a Laparoscopic Sleeve Gastrectomy (LSG) stricture within 90 days of surgery. If the stricture was found, then we dilated all our patients initially at 30 mm at 10 PSI for 10-20 min (14.5 min average) and increased the balloon size (30-40 mm) and duration (10-30 min) in subsequent sessions if the first session was unsuccessful.ResultsThe review found that 1756 patients underwent either LSG or the first step of a Laparoscopic Duodenal Switch (LDS) (1409 LSG & 356 LDS). Of the 1756 patient 33 patients (24 underwent LSG, and 9 underwent LDS) developed a stricture as a complication of LSG. The average age of the patients was 46.4 (±9.6) years, and the average BMI was 43.7 (±6.4). The most common location for stricture was mid-body of the sleeve (54.5%). The average time from the primary surgery to diagnosis and first pneumatic dilation was 5.6 months (± 6.8) and 5.9 months (± 6.6) respectively. We successfully used pneumatic dilation in 31 (93.9%) of these patients to relieve the stricture.ConclusionWe conclude that pneumatic dilation is an effective procedure in patients with post sleeve gastrectomy stricture.

Management of achalasia cardia: Expert consensus statements.

Achalasia cardia (AC) is a frequently encountered motility disorder of the esophagus resulting from an irreversible degeneration of neurons. Treatment modalities are palliative in nature, and there is no curative treatment available for AC as of now. Significant advancements have been made in the management of AC over last decade. The introduction of high resolution manometry and per-oral endoscopic myotomy (POEM) has strengthened the diagnostic and therapeutic armamentarium of AC. High resolution manometry allows for the characterization of the type of achalasia, which in turn has important therapeutic implications. The endoscopic management of AC has been reinforced with the introduction of POEM that has been found to be highly effective and safe in palliating the symptoms in short-term to mid-term follow-up studies. POEM is less invasive than Heller's myotomy and provides the endoscopist with the opportunity of adjusting the length and orientation of esophageal myotomy according to the type of AC. The management of achalasia needs to be tailored for each patient, and the role of pneumatic balloon dilatation, POEM, or Heller's myotomy needs to be revisited. In this review, we discuss the important aspects of diagnosis as well as management of AC. The statements presented in the manuscript reflect the cumulative efforts of an expert consensus group.