Pneumatic Balloon Research Articles

Sa2002 Sleeve Gastrectomy Stenosis: Clinical Outcomes of a Pneumatic Balloon Treatment Algorithm

Sa2002 Sleeve Gastrectomy Stenosis: Clinical Outcomes of a Pneumatic Balloon Treatment Algorithm

Current status of achalasia management: a review on diagnosis and treatment.

Achalasia is a rare esophageal motility disorder that is characterized by loss of peristalsis and failure of relaxation of the lower esophageal sphincter (LES), particularly during swallowing. This review focuses on the diagnosis of esophageal motility disorders as defined by the Chicago Classification ver 3.0, and presents management options with regard to per-oral endoscopic myotomy (POEM) as the treatment of choice. A concise review of literature was performed for articles related to the management of achalasia, and this was contrasted with our institution's current practice. Achalasia is still incompletely understood, and management is focused on establishing a proper diagnosis, and relieving the obstructive symptoms. Achalasia should be considered when dysphagia is present, and not otherwise caused by an obstruction or inflammation, and when criteria is met as per the Chicago Classification ver 3.0. Lowering LES tone and disruption of LES can be accomplished by various methods, most notably pneumatic balloon dilatation and surgical myotomy. POEM has been gaining momentum as a first line therapy for achalasia symptoms, and can be considered an important tool for motility disorders of the esophagus.

POEM and the management of achalasia

Achalasia is a rare oesophageal motility disorder predominantly causing dysphagia and regurgitation of food and fluids. Diagnosis is made typically after a combination of tests including endoscopy, barium swallow and...

Pneumatic Balloon Dilatation for Achalasia Cardia; Early & late results, a single center study.

Objective:Achalasia Cardia is treated by Pneumatic balloon dilatation, Heller’s Myotomy and recently, by Peroral Esophagaeal Myotomy. This study reports the efficacy of pneumatic balloon dilatation as a non-surgical motility in achieving relief of dysphagia, clinical improvement and recurrence. Long-term complications were reported.Methods:Eight hundred ninety two adult achalasia patients of both genders were treated from January 1988 till December 2011, with pneumatic balloon (Rigiflex Microvasive®) dilatation, under fluoroscopy Barium swallow was obtained prior to and five minutes after dilatation to evaluate for efficacy of dilatation as well as for complications. Patients not responding to 30 mm balloon had repeat dilatation with 35 mm balloon after 8 weeks. All patients were enrolled in regular follow up at one, six months and yearly intervals up to a period of five years. Recurrence was defined as an increase in symptom score at 8 weeks greater than 50% of their baseline value. These patients were treated with 35 mm balloon or referred for surgical intervention.Results:Of 892 patients, follow up was obtained in 50% for 5 years, 9.2% for 4-years), 9.3% for 3-years, 10% for 2-years and 21.5% for 1-year of patients. One patient died after repeat dilatation. Eighty-eight patients were excluded from this analysis (20 died due to non-procedure related causes and another 68 were lost during follow up). Statistically significant improvement was noted in reduction in height and width of barium column and symptom score coupled with weight gain during follow up. Forty-eight patients were subjected to repeat dilatation with 35 mm balloon, two of these developed post-procedure perforations with one mortality. Three non-responsive patients required surgical laparoscopic myotomy. No carcinoma of esophagus was reported during follow up. One patient post dilatation, developed esophageal bezoar. A single pneumatic dilatation achieved a remission rate of 93% at four years, 90% at three years, 95% at two years and 92% at one year post dilatation.Conclusion:Achalasia of esophagus can be effectively and safely treated with balloon dilatation to achieve adequate short and long-term symptomatic relief with a low complication rate.

Instrumental esophageal perforation: A case series

Esophageal perforation is a rare but dreadful surgical emergency. The main etiology is iatrogenic trauma, mostly related to endoscopic instrumentation. The treatment is controversial; however, surgery remains the mainstay. In this article, 3 cases of instrumental perforation of esophagus are described. In all cases, diagnosis was based on clinical, radiographic, and endoscopic findings. The first case was a 4-year-old girl with a corrosive stricture of esophagus who received 8 sessions of dilatation over 1 year; the last session resulted in perforation. Unfortunately, she was not referred to thoracic surgery at once but kept in gastroenterology department for several days, and hence, empyema developed. Conservative treatment was employed first followed by elective gastric pull-up via laparotomy and left neck incision 3 months later. She regained normal swallowing of fluid and semisolid food but developed a chronic neck sinus that required few drainage operations. The second case was of a 54-year-old man with dysphagia and a normal esophagus who developed perforation during rigid esophagoscopy. The perforation was immediately detected and an urgent primary repair was performed via left thoracotomy. The third case was of a 24-year-old man with persistent achalasia cardia despite 2 trans-abdominal esophagomyotomies. Perforation occurred during second session of pneumatic balloon dilatation but was directly referred to a thoracic surgeon who performed an urgent esophagectomy. All patients survived. We conclude that a good outcome of this potentially fatal condition is possible with early diagnosis and intervention provided by an expert surgical team.

A Case of Pseudoachalasia Hiding a Malignant Pleural Mesothelioma

Malignant pleural mesothelioma (MPM) is a rare cancer with a poor prognosis. We describe a case of MPM with an uncommon onset, characterized by pseudoachalasia as demonstrated with high-resolution manometry (HRM). A 56-year-old man was referred to our hospital reporting worsening dysphagia. On the hypothesis of an esophageal motor disorder, the patient was referred for an HRM examination, which revealed features consistent with a diagnosis of type II achalasia. At the time of the first pneumatic dilation the endoscopist stopped the procedure in order to prevent perforation when he noticed only partial expansion of the pneumatic balloon. A CT scan and subsequent CT-guided excisional biopsy revealed an epithelioid pleural mesothelioma infiltrating the muscle wall. Given his good clinical condition, the patient was eligible for chemotherapy with cisplatin 75 mg/m2 and pemetrexed 500 mg/m2, resulting in a good response with partial remission of the disease and resolution of the dysphagia symptoms. Pseudoachalasia as the first or only manifestation of mesothelioma is a rare occurrence that may expose patients to the risk of diagnostic delay. Close attention should be paid whenever a patient with symptoms and signs consistent with achalasia shows unusual features.

Retrograde intrarenal surgery (RIRS), regular and small sized percutaneous nephrolithotomy (PCNL) in daily practice: European Association of Urology Section of Urolithiasis (EULIS) Survey.

A wide selection of both anterograde and retrograde mini-invasive procedures exist for stones' treatment. The 2016 European Association of Urology (EAU) guidelines still don't univocally define a best option. Our purpose is to give an overview on some European Stone Centers' customs and to compare real life clinical practice with statements of opinion leaders and Guidelines. In 2015 we performed a survey in 3 step about the spread of retrograde intrarenal surgery (RIRS) and percutaneous nephrolithotomy (PCNL) techniques among EAU Section of Urolithiasis (EULIS) members. The 1st and 2nd steps dealt with the definition of EULIS urologist and department by collecting personal opinions about the endoscopic techniques. The third step was about clinical results. This paper presents data from the first two steps. Ninety-one people answered. Out of them, 80% are European and 42% work in Centres fully dedicated to stone treatment. In particular, 50% of responders perform more than 80 RIRS/year, 25% more than 80 PCNL/year, 48% more than 100 extracorporeal shock wave lithotripsy (SWL)/year. RIRS is mainly used to treat stones < 2 cm both as primary treatment and after SWL failure. 73% don't perform routine pre-stenting and 66% ordinarily use a ureteral sheath. Hospital stay for RIRS is 24h for 70% of responders. Regular PCNL is performed by 87% of the responders, MiniPCNL by 58%, Ultra-MiniPCNL by 23% and MicroPCNL by 28%. Pneumatic balloon dilation is the favourite dilation technique (49%). 37% of responders perform PCNL always in the supine position, 21% always in the prone one. Almost all the responders agree about using Mini, Ultra-Mini and MicroPCNL for 1-2 cm stones. Approximately 50% also use MiniPCNL for stones > 2 cm. our survey confirms the great heterogeneity existing in stones' treatment techniques in daily practice.

Mucosal perforation during laparoscopic surgery for achalasia: impact of preoperative pneumatic balloon dilation.

Controversy remains whether preoperative pneumatic balloon dilation (PBD) influences the surgical outcome of laparoscopic esophagocardiomyotomy in patients with esophageal achalasia. The aim of this study was to evaluate whether preoperative PBD represents a risk factor for surgical complications and affects the symptomatic and/or functional outcomes of laparoscopic Heller myotomy with Dor fundoplication (LHD). A retrospective chart review was conducted on a prospectively compiled surgical database of 103 consecutive patients with esophageal achalasia who underwent LHD from November 1994 to September 2014. The following data were compared between the patients with preoperative PBD (PBD group; n=26) and without PBD (non-PBD group; n=77): (1) patients' demographics: age, gender, body mass index, duration of symptoms, maximum transverse diameter of esophagus; (2) operative findings: operating time, blood loss, intraoperative complications; (3) postoperative course: complications, clinical symptoms, postoperative treatment; and (4) esophageal functional tests: preoperative and postoperative manometric data and postoperative profile of 24-h esophageal pH monitoring. (1) No significant differences were observed in the patients' demographics. (2) Operative findings were similar between the two groups; however, the incidence of mucosal perforation was significantly higher in the PBD group (n=8; 30.7%) compared to the non-PBD group (n=6; 7.7%) (p=0.005). (3) Postoperative complications were not encountered in either group. The differences were not significant for postoperative clinical symptoms, the incidence of gastroesophageal reflux disease, or necessity of postoperative treatments. (4) Lower esophageal sphincter pressure was effectively reduced in both groups, and no differences were observed in manometric data or 24-h pH monitoring profiles between the two groups. Multivariate logistic regression analysis showed that preoperative PBD and the maximum transverse diameter of esophagus were significantly associated with intraoperative mucosal perforation. Although postoperative outcomes were not affected, additional caution is recommended in identifying intraoperative mucosal perforation in patients with preoperative PBD when performing LHD.

Integration of optical waveguide on pneumatic balloon actuator for flexible scanner in endoscopic imaging diagnosis applications

This paper reports a flexible scanner consisting of a scanning actuator and optical waveguides for medical imaging applications such as endoscopic fluorescence imaging diagnosis. The 0.3-mm-thick and 5-mm-wide functional scanner was designed to be smaller enough than the 10 mm-diameter of channel of endoscope. The proposed device can be used to introduce an excitation light into the abdominal cavity or digestive tract. A pneumatic balloon actuator (PBA) consisting of polydimethylsiloxane (PDMS) is used as the scanning actuator for the scanner in consideration of its small, soft, and safe features. The SU-8 optical waveguides with high refractive index (nSU-8 = 1.575) are integrated onto the PBA structure made of PDMS with a lower refractive index (nPDMS = 1.405). Excitation light at a wavelength of 405 nm is transmitted through an optical fiber to the SU-8 waveguides. The outgoing light from the waveguide can be scanned by the bending motion of the PBA. The waveguide functions as a detector as well. Our developed device has successfully scanned, excited, and detected light from fluorescence beads at a wavelength of 540 nm distributed in a pseudo-tissue.

Esophagogastric Junction Outflow Obstruction Transformed to Type II Achalasia.

A 53-year-old woman presented with dysphagia for 2 months. She denied any acid regurgitation or heartburn symptoms. Esophagogastroduodenoscopy revealed no abnormal findings. However, bird-beak appearance of the distal esophagus was noticed on the esophagography. For evaluation of esophageal motility disorders, she underwent esophageal high resolution manometry (HRM). On the HRM, the integrated relaxation pressure was elevated and accompanied by compartmentalized esophageal pressurization, while esophageal body peristalsis, distal contractile integral, and distal latency were normal (Figure A). According to the Chicago classification (CC),1 she was diagnosed with esophagogastric junction outflow obstruction (EGJOO).1 The patient’s dysphagia was tolerable without specific treatment. However, the dysphagia became aggravated 1 year later. She underwent esophagography and HRM again. On the HRM, panesophageal pressurization with failed lower esophageal sphincter relaxation was noticed (Figure B). According to the CC she was diagnosed as type 2 achalasia. After pneumatic balloon dilatation, her symptoms improved (Eckardt score, 1). Figure Esophageal high-resolution manometry (HRM) findings of a patient present with dysphagia intially and 1 year later. (A) Esophagogastric junction outflow obstruction. HRM shows preserved esophageal body peristalsis but elevated integrated relaxation pressure ... The CC defines EGJOO as the presence of some instances of intact or weak peristalsis, elevated median integrated relaxation pressure above 15 mmHg, and discrepancy to the criteria of achalasia.1 The revised CC addresses the potential etiology of EGJOO including early form of achalasia, mechanical obstruction, esophageal wall stiffness, or manifestation of hiatal hernia.2 Due to the loose current definition of EGJOO, heterogeneous groups are included in this category. Indeed, EGJOO is presented with various symptoms. In recent studies, patients with EGJOO presented with dysphagia in 36%, heartburn/regurgitation in 25%, atypical symptoms of gastroesophageal reflux disease in 21%, and chest pain in 11%.2,3 In addition, various clinical courses of EGJOO ranging from spontaneous symptom resolution to requirement of myotomy were observed.2–4 EGJOO is just a manometric diagnosis. Thus, we need to investigate the underlying etiology further to manage the patients with EGJOO appropriately. Herein we present a EGJOO patient who transformed to a type II achalasia with time, which may be the most important etiology within the EGJOO category. Although the significance remains unclear, compartmentalized esophageal pressurization was observed in this case. In the future, it would be interesting to evaluate the role of compartmentalized esophageal pressurization in patients with EGJOO.

Outcome of pneumatic balloon dilatation of lower oesophageal sphincter of oesophagus of patients suffering from achalasia cardia

Achalasia is an oesophageal motility disorder of unknown cause, primarily characterized by absence of peristalsis of the esophageal body and impaired relaxation of lower oesophageal sphincter resulting invariably in dysphagia for solids/liquids or both and regurgitation of undigested foods. The diagnosis is usually made by classical symptoms, barium swallow X-ray of oesophagus or by endoscopy. Goal of treatment is to relieve symptoms, improve esophageal emptying and reduce the risk of associate complications. The two most successful treatment options are pneumatic dilation of lower oesophageal sphincter and surgical myotomy. This quasi-experimental study was carried out from January 2010 to December 2011 involving 31 patients of Achalasia Cardia admitted in the Department of Gastroenterology of BSMMU, Dhaka who underwent pneumatic balloon dilatation. Immediately after pneumatic dilatation all the patients got relief of dysphagia and were discharged from hospital next day. At follow-up 4 weeks after pneumatic dilatation, majority (96.2%) of the patients remained improved symptomatically. Significant weight gain was also found at 4 weeks after pneumatic dilatation. Pneumatic dilatation came out to be a simple, safe and effective method for treating patients with achalasia cardia.Bangladesh Med J. 2015 May; 44 (2): 76-81

High-resolution manometric subtypes as a predictive factor for the treatment of achalasia: A meta-analysis and systematic review.

To assess manometric subtypes as predictive factors for the treatment efficacies of pneumatic balloon dilatation (PBD) and laparoscopic Heller myotomy (LHM) in patients with achalasia. A systematic search of the Pubmed, Embase and Cochrane Library database was conducted to identify relevant publications on high-resolution manometric subtypes and different therapies for achalasia with predefined inclusion and exclusion criteria. Data on the success rates after PBD or LHM for different manometric subtypes were extracted. The pooled odds ratio (OR) and 95% confidence interval (CI) for different manometric subtypes were estimated using STATA 13.0. In all, nine studies met the inclusion criteria. A total of 298 patients having achalasia receiving PBD and 429 undergoing LHM were included in the meta-analysis. The pooled OR between the subtypes of achalasia after PBD or LHM showed that the best and worse treatment outcomes were found in patients with type II and III achalasia, respectively (type I vs type II after PBD: OR 0.16, 95% CI 0.08-0.36, P = 0.000; type I vs type III after PBD: OR 3.64, 95% CI 1.55-8.53, P = 0.003; type II vs type III after PBD: OR 27.18, 95% CI 9.08-81.35, P = 0.000; type I vs type II after LHM: OR 0.26, 95% CI 0.12-0.56, P = 0.001; type I vs type III after LHM: OR 1.89, 95% CI 0.80-4.50, P = 0.148; type II vs type III after LHM: OR 6.86, 95% CI 2.72-17.28, P = 0.000). Type II achalasia shows the best prognosis after PBD and LHM, while type III achalasia has the worst prognosis.

Mo1962 Systematic Treatment of Sleeve Gastrectomy Stenosis With Hydrostatic and Pneumatic Balloon Dilatation Is Safe and Effective

Mo1962 Systematic Treatment of Sleeve Gastrectomy Stenosis With Hydrostatic and Pneumatic Balloon Dilatation Is Safe and Effective

Implementation of soft microfingers for a hMSC aggregate manipulation system.

This paper describes a pneumatic balloon actuator (PBA) composed of polydimethylsiloxane (PDMS) for cellular aggregate manipulation. We evaluated the ability of the microdevice to manipulate a tiny and sensitive cellular aggregate without causing serious damage. We used human mesenchymal stem cells (hMSCs) for the cellular aggregate. We describe the design, fabrication, characterization and operation of the soft microfingers to pinch and release a spherical hMSC aggregate (φ200 μm), and we employed a PBA to serve as an artificial muscle to drive the microfingers. A design of the microfingers in terms of dimensions, generated force and contact conditions was accomplished. The designed dimensions of a single finger were 560 μm×900 μm. In summary, we demonstrate the utility of the surface modification of a fingertip for pinching and releasing a cellular aggregate and describe a manipulation system that was constructed to drive and control the microfingers. The implemented manipulation system, which is composed of microfingers and a positioning mechanism, was tested and verified in a series of operations.

The Problem of Anastomotic Stricture After Rectosigmoid Resection in Deep Infiltrating Endometriosis

Abstract Background: Deep infiltrating endometriosis (DIE) of the large bowel is infiltration of the large-bowel wall by endometrial-like implants and is associated with fibrosis and muscular hyperplasia. Deep endometriosis affects ∼20% of patients with endometriosis. Objective: The aim of this research was to assess the importance of anastomotic stricture (AS) after large-bowel resection for DIE of the colon. Materials and Methods: This was a retrospective analysis of prospectively collected data. A consecutive series of 113 colonic resections for DIE were performed to address pain and/or infertility. There were low and very-low resections (n = 82) with mechanical end-to-end anastomosis associated with or without partial colpectomy, segmental sigmoid resections with side-to-end anastomosis (n = 27), and ileocecal resections with latero–lateral anastomosis (n = 4). Pneumatic balloon dilatation was performed in cases of AS (n = 22 in 13 patients). Patients were asked preoperatively and at 4, 8, 12, and 24 ...

Improvement of Flexible Linear Stepping Actuator Driven by Pneumatic Balloons and Brakes

The development of soft actuator for the rehabilitation device and power assisting devices has been required based on aging society. However, a flexible actuator that can generate both larger force and longer displacement has not been developed. It is also difficult to realize a flexible displacement sensor with long stroke while deforming its form according to the actuator’s shape. In the previous study, the flexible actuator with larger force and longer stroke that can adjust its stroke by giving stepping motion using pneumatic balloons and brakes was proposed and tested. However, the slipping of the pneumatic brake prevents the larger generated force. In this paper, the improved pneumatic brake using a pneumatic balloon and a mechanical chuck is described. The fundamental performance of the actuator using the improved brake is also described.

Achalasia Cardia – Recent Advances in Diagnosis and Endoscopic Management

Achalasia Cardia is a rare neurodegenerative disorder of esophagus resulting in defective peristalsis and impaired relaxation of lower esophageal sphincter. The exact etiopathogenesis of achalasia is not known. Achalasia is associated with significant morbidity and impaired quality of life. The standard of care in patients with achalasia has been pneumatic balloon dilatation and laparoscopic heller's myotomy. Recent advancements in the diagnosis and endoscopic management have greatly improved the outcomes of this disorder. Subtyping of esophageal motility disorders with high resolution manometry has served to predict treatment outcomes and plan appropriate treatment. Per oral endoscopic myotomy (POEM) is an novel minimally invasive treatment option for all types of achalasia cardia. Short and mid term efficacy are excellent. Randomized trials are required to confirm its superiority over the currently established treatment modalities.

Changes in pressure waves after endoscopic intervention in patients with achalasia: A focus on peristaltic recovery of the esophageal body

We conducted the present study to investigate the recovery of peristalsis of the esophageal body and evaluate the pressure changes observed on manometry before and after endoscopic intervention. Forty-five patients were diagnosed with achalasia, and 36 received endoscopic or surgical treatment. We collected the data of 24 patients who underwent manometry before and after treatment (pneumatic balloon dilatation, n=7; botulinum toxin injection, n=10; peroral endoscopic myotomy, n=7). The lower esophageal sphincter (LES) resting pressure and nadir LES relaxation pressure decreased regardless of the achalasia subtype or type of endoscopic intervention following treatment (p<0.05). Among patients with a nadir LES relaxation pressure of <4 mmHg, 42.9% (6/14) exhibited partial esophageal peristaltic wave recovery. However, no patients with a nadir LES relaxation pressure of >4 mmHg exhibited peristaltic wave recovery (p=0.024). Of the six patients with peristaltic wave recovery, two had type I achalasia (15.4%), three had type II (33.3%), and one had type III (100.0%). The Eckardt score, symptom duration, and type of intervention were not associated with the recovery of peristaltic waves. Our results suggest that normalization of the nadir LES relaxation pressure can be a predictive factor for the recovery of esophageal peristalsis.

Over-the-Scope Clip Closure of Oesophageal Perforation after Pneumatic Dilatation for Achalasia

Pneumatic dilatation of the oesophagus is the first line method of therapy of achalasia. Pneumatic balloon dilatation induces forceful stretching of the lower oesophageal sphincter (LES), which weakens the LES by tearing its muscle fibers. Complications of Pneumatic balloon dilatation include oesophageal perforation in 1.6 % and heartburn in 45 %. Recently endoscopic approach has been introduced in treating gastrointestinal perforations which is less invasive than surgery and have the advantages of lesser morbidity and mortality, shorter hospital stay, and shorter periods of avoiding oral feeding. The main endoscopic methods used to close GI perforations are endoclips and covered self-expandable stents the margins. We report the case of a 51 year-old female patient presenting with oesophageal tear after pneumatic dilatation for achalasia. Over-the-scope clip (OTSC) was used for the Closure of the oesophageal tear. To the best of our knowledge this is the first case report of successful closure of oesophageal tear secondary to post pneumatic dilation of the oesophagus for the treatment of Achalasia using the OTSC.

Assessment of Pneumatic Balloon Dilation in Patients with Symptomatic Relapse after Failed Heller Myotomy: A Single Center Experience.

BACKGROUND Although Heller myotomy is one of the most effective treatments for achalasia, it may be associated with early or late symptom relapse in some patients. Therefore, additional treatment is required to achieve better control of symptoms. Aim: To evaluate the safety and efficacy of pneumatic balloon dilation (PBD) in patients with symptom relapse after Heller myotomy. METHODS Thirty six post-myotomy patients were evaluated from 1993 to 2013. Six patients were excluded from the analysis because of comorbid diseases or epiphrenic diverticula. Thirty patients were treated with PBD. Primary outcome was defined as a decrease in symptom score to 4 or less and a reduction greater than 80% from the baseline in the volume of barium in timed barium esophagogram in 6 weeks. Achalasia symptom score (ASS) was assessed at 1.5, 3, 6, and 12 months after treatment and then every six months in all patients and PBD was repeated in case of symptom relapse (ASS>4). RESULTS The mean age of the patients was 45.5±13.9 years (range: 21-73). Primary outcome was observed in 25 patients (83%). The mean ASS of the patients dropped from 7.8 before treatment to 1.3±2.0 at 1.5 months after treatment (p=0.0001). The mean volume and height of barium decreased from 43.1±33.4 and 7.1±4.7 to 6.0±17.1 and 1.1±2.2, respectively (p=0.003, p=0.003). The mean duration of follow-up was 11.8±6.3 years. At the end of the study, 21 patients (70%) reported sustained good response. No major complications such as perforation or gross bleeding were seen. CONCLUSION PBD is an effective and safe treatment option for achalasia in patients with symptom relapse after Heller myotomy.