Primary Motility Research Articles

Bilateral lateral rectus recession versus bilateral lateral rectus recession and one medial rectus resection in correction of exotropia

Purpose The aim of this study was to compare the results of bilateral lateral rectus (BLR) recession to combined BLR recession and one medial rectus (MR) resection in concomitant exotropia (XT) of 40–55 prism diopters (PD). Patients and methods This is a prospective randomized clinical trial that was conducted on 69 XT patients, divided into two groups; group A: BLR recession (n=39 patients) and group B: BLR recession+MR resection (n=30 patients). All study patients were subjected to routine preoperative evaluation, operative procedure in standardized numbers and technique and postoperative follow up to 6 months for alignment in the primary position, ocular motility, and palpebral fissure height (PFH) measurement. Results At the 6-month follow up visit, the success rate (patients with postoperative results ≤8 PD of orthophoria) was 66.7% in group A compared to 73.3% in group B, with no statistically significant difference (P=0.551). The postoperative PFH was significantly different from the preoperative PFH at all follow-up visits in both groups. In group A, the preoperative PFH was 10.59±1.23 mm and increased to 11.40±1.26 mm at 6 months (P<0.001), while in group B, the preoperative PFH was 10.45±1.36 mm and decreased to 10.03±1.33 mm at 6 months postoperatively (P<0.001), with a noted higher mean of postoperative PFH in group A by 7.6% and a lower mean of postoperative PFH in group B by 4%. In group B, the eye with single LR recession showed a 2.15±5.26% increase in PFH while the eye with combined recession and resection showed a 9.39±2.99% decrease in PFH. Lateral gaze deficit was related to XT more than or equal to 50 PD as a significant difference was found on comparing the patients with and without lateral gaze deficit for angle of 50 PD (P=0.028) and for angle of 55 PD (P=0.050). Conclusion The three-muscle procedure was as effective as the two-muscle procedure in correction of comitant XT regarding the postoperative alignment. Adding MR resection led to PFH narrowing. Lateral gaze deficit can occur with large lateral rectus recession for XT of 50 PD and more.

Is Indocyanine Green the New Gold Standard for Checking Completion of Laparoscopic Heller's Cardiomyotomy?

Achalasia cardia is a primary motility disorder of the esophagus marked by the absence of peristalsis and the failure of the lower esophageal sphincter (LES) to relax during swallowing. The preferred surgical approach is laparoscopic Heller's cardiomyotomy with Dor's fundoplication. Given the significant risks of mucosal perforation and the possibility of incomplete myotomy, which can lead to symptom recurrence, it is essential to ensure both the completeness of the myotomy and the preservation of the mucosal integrity. In this study, we present a case series of 15 patients diagnosed with achalasia cardia who underwent laparoscopic Heller's cardiomyotomy with Dor's fundoplication. Intraoperatively, we utilized intraluminal administration of indocyanine green (ICG) dye as an alternative to endoscopy to assess the completeness of the myotomy and to check for any mucosal perforations.

Comprehensive analysis of nutritional parameters in patients with idiopathic achalasia: A prospective study in India.

Achalasia cardia, a primary motility disorder of the esophagus, poses significant malnutrition risks. This study aims at comprehensively assessing the nutritional status in untreated achalasia patients, contrasting it with functional gastrointestinal disorders (FGIDs) cases and impact of per-oral endoscopic myotomy (POEM) on nutrition at one-year. We conducted a prospective study, including consecutive achalasia cases, from December 2021 to April 2022 at a tertiary care centre. Biochemical parameters, anthropometry, subjective global assessment (SGA) and malnutrition universal screening tool were used for nutritional assessment. Cases diagnosed with FGIDs served as controls. As many as118 cases (41.2 ± 13.9years, 61% males) with achalasia and 200 controls (43.4 ± 11.9years, 69% males) were included in the study. Sub-types of achalasia included type I (16.9%), II (76.3%) and III (6.8%). Overall, 38.1% and 6.8% cases were moderately and severely malnourished, respectively. As compared to controls, cases with achalasia had lower pre-albumin (19.4 vs. 25.2; p = 0.001), serum calcium (p = 0.012), vitamin D (p = 0.001), serum iron (p = 0.001), triceps fold thickness (p = 0.002) and hand-grip strength (p = 0.001). On univariate analysis, type-I achalasia, body mass index, % weight loss, lower esophageal sphincter pressures and Eckardt scores were predictors of malnourishment (SGA). On multivariate analysis, type of achalasia, mid arm circumference and low body mass index were significant predictors of malnourishment in cases with achalasia. There was significant improvement in the nutritional status after POEM at one-year follow-up. Achalasia patients demonstrate a notably higher risk of malnutrition compared to individuals with FGIDs. Nutritional status significantly improves after POEM. (NCT05161923).

Pediatric to adult transition care in neurogastroenterology and motility: A position paper from the American Neurogastroenterology and Motility Society and European Society of Neurogastroenterology and Motility.

Transition services-programs that support adolescents and young adults (AYAs) as they move from a child-centered to a more autonomous, adult-orientated healthcare system-have been associated with improved short- and long-term healthcare outcomes. Unfortunately, there is a paucity of evidence exploring transition services within the neurogastroenterology and motility (NGM) field. The overall aim of this article, endorsed by the American Neurogastroenterology and Motility Society and European Society of Neurogastroenterology and Motility, is to promote a discussion about the role of transition services for patients with NGM disorders. The AYAs addressed herein are those who have: (a) a ROME positive disorder of gut-brain interaction (DGBI), (b) a primary or secondary motility disorder (including those with motility disorders that have been surgically managed), or (c) an artificial feeding requirement (parenteral or enteral tube feeding) to manage malnutrition secondary to categories (a) or (b). The issues explored in this position paper include the specific physical and psychological healthcare needs of patients with NGM disorders; key healthcare professionals who should form part of a secondary care NGM transition service; the triadic relationship between healthcare professionals, caregivers, and patients; approaches to selecting patients who may benefit most from transition care; methods to assess transition readiness; and strategies with which to facilitate transfer of care between healthcare professionals. Key areas for future research are also addressed, including the construction of NGM-specific transition readiness questionnaires, tools to assess post-transfer healthcare outcomes, and educational programs to train healthcare professionals about transition care in NGM.

The Results of Pneumatic Balloon Dilatation Treatment in Children with Achalasia: A Single-Center Experience.

Achalasia is a primary motility disorder characterized by a relaxation disorder of the lower esophageal sphincter. In pneumatic balloon dilatation, which is one of the treatment methods, the muscle fibers are torn with an endoscopically inflated balloon in the lower esophageal sphincter. This study aimed to evaluate the results of long-term pneumatic balloon dilatation treatment in our clinic for children diagnosed with achalasia. Pediatric patients who underwent pneumatic balloon dilatation with a diagnosis of achalasia in our pediatric gastroenterology clinic between 2016 and 2021 were included in the study. Demographic data of the patients, clinical findings at diagnosis, and follow-up results were evaluated retrospectively. Ten patients who underwent 18 pneumatic balloon dilatation operations were included in the study. The mean follow-up period of the patients was 23.7 ± 14.1 months. It was observed that the procedure was performed once in 3 (30%) patients, twice in 2 (20%) patients, and 3 times in 3 (30%) patients. It is noteworthy that the diameter of the balloon used in the first procedure in patients who needed repeated operations was less than 30 mm. No complications were observed except for chest pain, which was detected in 1 patient. When the patients who needed recurrent dilatation were evaluated, it was noted that the diameter of the balloon in which the first procedure was performed in these patients was smaller. This study is an important contribution to the literature due to the scarcity of the pediatric achalasia data, in which long-term results related to pneumatic balloon dilatation are reported in Turkey.

Autoimmune Dysphagia Related to Rheumatologic Disorders: A Focused Review on Diagnosis and Treatment.

Autoimmune dysphagia is defined as dysphagia caused by autoimmune processes affecting various components of the swallowing processsuch as muscle, neuromuscular junction, nerves, roots, brainstem, or cortex. These autoimmune causes can be classified into gastroenterological, dermatological, rheumatologic, and neurologic. Rheumatological disorders, such as scleroderma, Sjogren's syndrome, systemic lupus erythematosus, rheumatoid arthritis, sarcoidosis, Behcet's disease, anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis, or granulomatosis with polyangiitis, have been associated with dysphagia. Autoimmune dysphagia in the context of rheumatological disorders is particularly significant because it can occur as a sole manifestation or as part of a symptom complex associated with the underlying disorder and often responds to immunosuppressive therapies. However, diagnosing autoimmune dysphagia can be challenging as it requires the exclusion of structural and primary motility disorders through procedures such as endoscopy and manometry. Early diagnosis is important to improve the quality of life and prevent significant mortality and morbidity. Management focuses on treating the underlying disease activity, and a multidisciplinary approach involving various medical specialties may be necessary to achieve success. This article aims to review the autoimmune rheumatological conditions that can lead to dysphagia and discuss the associated pathophysiological mechanisms. We also outline the clinical clues and laboratory testing methods that facilitate early diagnosis, with the goal of improving patient outcomes through timely intervention and appropriate management.

A first-in-class POLRMT specific inhibitor IMT1 suppresses endometrial carcinoma cell growth

Exploring novel molecularly-targeted therapies for endometrial carcinoma is important. The current study explored the potential anti-endometrial carcinoma activity by a first-in-class POLRMT (RNA polymerase mitochondrial) inhibitor IMT1. In patient-derived primary human endometrial carcinoma cells and established lines, treatment with IMT1 potently inhibited cell viability, proliferation, cell-cycle progression and motility, while inducing robust caspase-apoptosis activation. Treatment with the PLORMT inhibitor impaired mitochondrial functions, leading to mtDNA (mitochondrial DNA) transcription inhibition, mitochondrial membrane potential decline, reactive oxygen species formation, oxidative stress and ATP loss in the endometrial carcinoma cells. Similarly, POLRMT depletion, through shRNA-induced silencing or CRISPR/Cas9-caused knockout (KO), inhibited primary endometrial carcinoma cell proliferation and motility, and induced mitochondrial dysfunction and apoptosis. Importantly, IMT1 failed to induce further cytotoxicity in POLRMT-KO endometrial carcinoma cells. Contrarily, ectopic overexpression of POLRMT further augmented proliferation and motility of primary endometrial carcinoma cells. In vivo, oral administration of a single dose of IMT1 substantially inhibited endometrial carcinoma xenograft growth in the nude mice. mtDNA transcription inhibition, oxidative stress, ATP loss and apoptosis were detected in IMT1-treated endometrial carcinoma xenograft tissues. Together, targeting PLORMT by IMT1 inhibited endometrial carcinoma cell growth in vitro and in vivo.

Laparoscopic Heller-Dor Is a Persistently Effective Treatment for Achalasia Even in Pediatric Patients: A 25-Year Experience at a Single Tertiary Center.

Esophageal achalasia (EA) is a rare primary motility disorder in any age group, and particularly rare in the pediatric population, with a reported incidence of 0.18 per 100,000 children a year. EA in pediatric age is currently treated in the same way as in adults, but this approach is based on only a few studies on small case series. The aim of this retrospective study was to assess the long-term outcome of the laparoscopic Heller-Dor (LHD) procedure when performed in pediatric patients with EA at our university hospital. We considered children and adolescents younger than 16 years old diagnosed with EA and treated with LHD between 1996 and 2022. Clinical data were prospectively collected in an ongoing database. Symptoms were recorded and their severity was calculated using the Eckardt score. Barium swallow, esophageal manometry (conventional or high-resolution), and endoscopy were performed before and after the surgical procedure. During the study period, 40 children with a median age of 14 years (interquartile range [IQR]: 11-15) underwent LHD. At a median follow-up of 10.5 years (IQR: 4.5-13.9), a good outcome was achieved in 36/40 patients (90%). Two of the four patients whose surgical procedure failed underwent complementary pneumatic dilations successfully, thus increasing the overall success rate to 95%. A previous endoscopic treatment (in five patients) did not affect the final outcome (p = 0.49). An intraoperative mucosal lesion was detected in only one patient (2.5%) and was repaired at the time without further consequences. During the follow-up, 22 patients underwent endoscopy, and 17 had pH monitoring as well: only 2 of these patients showed reflux esophagitis at endoscopy (one of them with abnormal findings on pH monitoring), amounting to a 9.1% rate of instrumentally confirmed postoperative reflux. LHD is a safe and persistently effective treatment for EA in pediatric age, with a success rate comparable with what is usually obtained in adults, and better than what has been reported to date in the pediatric literature. Adding a fundoplication certainly helps ensure an optimal long-term control of any gastroesophageal reflux induced by the myotomy.

Opioid-Induced Esophageal Dysmotility (OIED) - A Case Report.

Recent studies have shown that chronic opioid use is associated with an increased risk of symptomatic esophageal motility disorders. Opioid-induced esophageal dysfunction (OIED) is most often identified in patients taking high doses of opioids. This condition is associated with poorer treatment outcomes than primary motility disorders and management of these cases is further complicated by the presence of chronic pain, opioid addiction, and physical and psychological comorbidity.We present the case of a 68-year-old Caucasian woman with OIED, induced by the chronic intake of low-dose Fentanyl and Tramadol prescribed to treat severe back pain. The clinical course highlights the sometimes difficult diagnosis and management of this recently recognized condition.

Prevalence of neurodegenerative/demyelinating disorders in patients with achalasia.

IntroductionEsophageal achalasia is a primary motility disorder. Although the exact pathogenesis is unknown, autoimmune, and neurodegenerative processes seem to be involved similarly to neurodegenerative and/or demyelinating disorders (NDDs). We hypothesized that the prevalence of NDD may be higher among patients with achalasia and vice versa as the background pathogenetic mechanisms are similar.MethodsThis was a prospective, comparative questionnaire-based study. Patients with achalasia and patients with NDD were enrolled. Selected patients with achalasia were thoroughly examined by a neurologist and selected patients with NDD were examined by a gastroenterologist to confirm or rule out NDD or achalasia. We assessed the prevalence of both achalasia and NDD and compared them with their prevalence in general population.ResultsA total of 150 patients with achalasia and 112 patients with NDD were enrolled. We observed an increased prevalence of NDD among patients with achalasia (6.0% (9/150); 95% CI (confidence interval): 3.1–11.2%) as compared to the estimated 2.0% prevalence in general population (p = 0.003). Although 32 out of 112 patients (28.6%) with NDD reported dysphagia, we did not observe significantly increased prevalence of achalasia in these patients (1.8% (2/112) vs 0.8% in general population, p = 0.226).ConclusionThe prevalence of NDD was significantly higher among patients with achalasia (6.0%) compared to general population (2.0%), suggesting an association of these disorders. Large-volume studies are necessary to confirm this finding.

Islet primary cilia motility controls insulin secretion.

Primary cilia are specialized cell-surface organelles that mediate sensory perception and, in contrast to motile cilia and flagella, are thought to lack motility function. Here, we show that primary cilia in human and mouse pancreatic islets exhibit movement that is required for glucose-dependent insulin secretion. Islet primary cilia contain motor proteins conserved from those found in classic motile cilia, and their three-dimensional motion is dynein-driven and dependent on adenosine 5′-triphosphate and glucose metabolism. Inhibition of cilia motion blocks beta cell calcium influx and insulin secretion. Human beta cells have enriched ciliary gene expression, and motile cilia genes are altered in type 2 diabetes. Our findings redefine primary cilia as dynamic structures having both sensory and motile function and establish that pancreatic islet cilia movement plays a regulatory role in insulin secretion.

Elongation of the inferior rectus tendon with fascia lata graft for large vertical squint angles in patients with Graves’ orbitopathy

PurposeTo investigate the use of fascia lata (FL) grafts for inferior rectus muscle (IRM) tendon elongation in patients with large vertical squint angles with Graves’ orbitopathy (GO).MethodsIn this retrospective study, we included a consecutive series of 20 eyes of 13 patients with GO who underwent IRM tendon elongation with FL. Orthoptic and ophthalmologic examinations including measurement of the head posture, the extent of deviation in primary position (PP), elevation, motility, and binocular diplopia at the tangent of Harms were conducted preoperatively and after a mean postoperative time of 10.8 (5.0–35.0) months in all patients.ResultsThe mean total repositioning distance was 9.3 ± 3.6 (3.5–16.0) mm. Postoperatively, we found a significant increase in elevation (5.4 ± 2.4 vs. 2.7 ± 2.4 mm preoperatively, p = 0.011). A significant reduction in vertical squint angle (2.8 ± 3.7 vs. 20.2 ± 18.8 Δ preoperatively, p = 0.004), chin elevation (2.3 ± 3.7 vs. 12.9 ± 6.3° preoperatively, p < 0.001), extorsion in PP (0.1 ± 3.8 vs. 8.4 ± 7.8° preoperatively, p = 0.002), and in elevation (1.8 ± 4.8 vs. 11.1 ± 10.9° preoperatively, p = 0.004) occurred postoperatively. A mean dose–effect relation of 2.6 ± 2.9 Δ/mm was calculated. Postoperatively, the lower eyelid retraction was significantly increased (1.5 ± 1.4 vs. 0.4 ± 0.5 mm preoperatively, p = 0.005).ConclusionIRM tendon elongation with FL is a feasible and effective procedure without relevant risk for surgery-related complications.

Laparoscopic Heller Myotomy and Toupet Fundoplication.

Esophageal achalasia is a primary motility disorder of unknown origin. The goal of treatment is to eliminate the resistance caused by a non-relaxing lower esophageal sphincter, therefore allowing passage of foodand liquid from the esophagus into the stomach. A myotomy with a partial fundoplication (anterior Doror posteriorToupet) is considered the standard of care for patients with achalasia. In the following review, we describe the indications and technique for a posterior partial fundoplication (Toupet).

Laparoscopic Heller myotomy and robotic Heller myotomy: when is it indicated?

Achalasia is a primary motility disorder of unknown origin. Palliative treatment is often adopted to resolve its symptoms by eliminating the resistance due to a non-relaxing and hypertensive lower esophageal sphincter. There are three available effective treatment modalities: pneumatic dilation, laparoscopic Heller myotomy with fundoplication, and peroral endoscopic myotomy. In choosing the proper treatment, it is important to remember that the esophagus lacks peristalsis in patients with achalasia. So once the lower esophageal sphincter is eliminated, reflux may occur with the potential of causing reflux symptoms, esophagitis, peptic strictures, Barrett’s esophagus, and cancer. For this reason, we believe that laparoscopic myotomy offers the best chance in most patients of improving esophageal emptying while protecting them from abnormal reflux.

Esophagogastric Junction Outflow Obstruction and Hiatal Hernia: Is Hernia Repair Alone Sufficient?

Esophagogastric junction outflow obstruction (EGJOO) is attributed to primary/idiopathic causes or secondary/mechanical causes, including hiatal hernias (HH). While patients with HH and EGJOO (HH+EGJOO) may undergo HH repair without myotomy, it is unclear if an underlying motility disorder is missed by therapy which addresses only the secondary EGJOO cause. The goal of this study was to determine if HH repair alone is sufficient management for HH+EGJOO patients. A retrospective review of patients who underwent HH repair between January 1, 2016 and January 31, 2020 was performed. Patients who underwent high-resolution esophageal manometry(HREM) within one year before HH repair were included. Patients with and without EGJOO on pre-operative HREM were compared. Sixty-three patients were identified. Pre-operative HREM findings included: 43 (68.3%) normal, 13 (20.6%) EGJOO, 4 (6.3%) minor disorder or peristalsis, 2 (3.2%) achalasia, and 1 (1.6%) major disorder of peristalsis. No differences between patients with EGJOO or normal findings on pre-operative manometry were found in pre-operative demographics/risk factors, pre-operative symptoms, and pre-operative HREM, except higher integrated relaxation pressure in EGJOO patients. No differences were noted in length of stay, 30-day complications, long-term persistent symptoms, or recurrence with mean follow-up of 26-months. Of the 3 (23.1%) EGJOO patients with persistent symptoms, 2 underwent HREM demonstrating persistent EGJOO and none required endoscopic/surgical myotomy. Most HH+EGJOO patients experienced symptom resolution following HH repair alone and none required additional intervention to address a missed primary motility disorder. Further study is required to determine optimal management of patients with persistent EGJOO following HH repair.

Bradycardia secondary to achalasia cardia: A case report

Achalasia cardia (AC) is a primary motility disorder of the esophagus characterized by the absence of oesophageal peristalsis and incomplete relaxation of the lower oesophageal sphincter. AC is known to be associated with symptomatic bradycardia, dizziness and rarely swallow syncope.

Impaired Proximal Esophageal Contractility Predicts Pharyngeal Reflux in Patients With Laryngopharyngeal Reflux Symptoms.

OBJECTIVES:The pathophysiology of laryngopharyngeal reflux (LPR) remains incompletely understood. Proximal esophageal motor dysfunction may impair bolus clearance, increasing the risk of pharyngeal refluxate exposure. We aimed to evaluate the association of proximal esophageal contractility with objective reflux metrics.METHODS:We evaluated adults with LPR symptoms undergoing high-resolution manometry (HRM) and combined hypopharyngeal-esophageal multichannel intraluminal impedance-pH testing at a tertiary center between March 2018 and August 2019. Routine parameters per Chicago classification were obtained on HRM. Proximal esophageal contractility was evaluated using proximal contractile integral (PCI), which quantifies contractile pressure >20 mm Hg for the region spanning the distal margin of the upper esophageal sphincter and transition zone. Univariate (Kendall correlation and Student t test) and multivariable (general linear regression and logistic regression) analyses were performed.RESULTS:We enrolled 138 patients (66.7% women, mean age 57.1 years) in this study. Lower PCI was associated with an elevated risk of increased pharyngeal reflux (adjusted odds ratio 0.83 per 100 mm Hg-s-cm change in PCI, 95% confidence interval: 0.69–0.98), with a trend toward increased bolus exposure time and total reflux events, after multivariable adjustment. The relationship between PCI and pharyngeal reflux was strongest among participants without a primary motility disorder on HRM (adjusted odds ratio 0.63, 95% confidence interval: 0.42–0.85, P interaction = 0.04). Among continuously expressed reflux parameters, lower PCI was significantly associated with more distal acid reflux events (β = −0.0094, P = 0.03) and total reflux events (β = −0.0172, P = 0.05), after adjusting for confounders.DISCUSSION:Reduced proximal esophageal contractility as assessed by decreased PCI on HRM independently predicted increased pharyngeal reflux in patients with LPR symptoms, particularly among those without a coexisting motility disorder.

Combined Rectus Muscle Transposition With Posterior Fixation Sutures (Augmented Knapp Procedure) for the Surgical Treatment of Double Elevator Palsy.

To evaluate the surgical results of full horizontal tendon rectus muscle transposition to the superior rectus muscle insertion, augmented by posterior fixation sutures, in patients with double elevator palsy. In this retrospective comparative study, 17 patients treated by the augmented Knapp procedure (study group) were compared with 28 patients treated by the standard Knapp procedure (control group). Pre-operative and postoperative vertical deviation in primary position, ocular motility, binocular function, and rate of reoperation were evaluated. The mean preoperative near and distance deviations (hypotropia) decreased by 93% and 97% in the study group and 68% and 69% in the control group, respectively. The improvement in near and distance deviation was statistically more significant in the study group than the control group (P = .001 for each parameter). The mean preoperative elevation deficiency in abduction and adduction improved by 64% and 66% in the study group and 37% and 39% in the control group, respectively. The improvement in elevation deficiency in abduction and adduction was statistically significantly greater in the study group than the control group (P = .001 and .04, respectively). Reoperation was required in 15 patients (54%) in the control group and 2 (12%) in the study group during the follow-up period of 26 ± 4 months. The postoperative improvement in near and distance deviation and elevation deficiency in abduction and adduction was significantly better in the augmented Knapp procedure than the standard Knapp procedure. This procedure demonstrated a stronger effect in the treatment of double elevator palsy. [J Pediatr Ophthalmol Strabismus. 2022;59(1):17-23.].

Mast cell infiltration and activation in the gallbladder wall: Implications for the pathogenesis of functional gallbladder disorder in adult patients

BackgroundFunctional gallbladder disorder (FGD) is characterized by recurrent biliary colic with a decreased gallbladder ejection fraction on cholescintigraphy but absence of visible gallbladder abnormalities on ultrasonography. FGD is generally regarded as a primary gallbladder motility disturbance, however, the underlying pathophysiology remains largely unknown. In this study, we investigated the potential role of mast cells in the pathogenesis of FGD by examining mast cell density and activation in the gallbladder wall. DesignTwenty adult patients with FGD undergoing cholecystectomy were included in the study. Seven patients with no gallbladder disease were served as controls who were subject to incidental cholecystectomy during abdominal surgery such as partial hepatectomy. The density of mast cells in the gallbladder wall was assessed by immunohistochemistry and by toluidine blue special stain. Mast cell activation was evaluated by calculating the percentage of degranulated mast cells on toluidine blue stain. ResultsCompared to the controls, patients with FGD showed a significant increase in mast cell infiltration in the gallbladder walls. Peak mast cell accumulation was predominantly located in the inner muscular layer of the gallbladder wall. Mast cell activation was also markedly increased in the FGD group as evidenced by significantly enhanced mast cell degranulation. ConclusionsMast cell infiltration and activation were significantly increased in the muscular wall of gallbladders from FGD patients, suggesting potential involvement of mast cells in the compromised gallbladder motility in adult patients with FGD.

Optional Management of Achalasia in 2021: Dilatation or Myotomy

AbstractAchalasia cardia is a primary motility disorder of the esophagus, defined by lack of normal esophageal peristalsis along with inadequate relaxation of lower esophageal sphincter . The mainstay of management in achalasia includes pneumatic dilatation, Heller’s myotomy and peroral endoscopic myotomy (POEM). Pneumatic dilatation and Heller’s myotomy have gained maturity over several decades. The current best practice with regard to pneumatic dilatation is graded and on-demand dilatation in appropriately selected cases with type I and II achalasia. Laparoscopic Heller’s myotomy plus partial fundoplication is minimally invasive with reduced postoperative reflux and has virtually replaced open Heller’s myotomy with or without fundoplication. The subtyping of achalasia using high-resolution manometry bears prognostic significance and may help in choosing appropriate therapeutic modality in these patients. Since all the three modalities are effective for type I and II achalasia, the choice among these depends on the availability, expertise, and patient’s preferences. On the other hand, POEM is more effective than pneumatic dilatation and Heller’s myotomy and, therefore, preferred in type III achalasia. Although POEM is effective across the spectrum of esophageal motility disorders, the incidence of gastroesophageal reflux is high and needs to be considered while choosing among various options in these patients. In cases with failed POEM, redo POEM appears to be effective in alleviating symptoms.