Sphincter Relaxation Research Articles

Achalasia

Achalasia is characterized by peristaltic failure and incomplete relaxation of the lower esophageal sphincter. The incidence and prevalence of achalasia increase with age, although achalasia can affect all age groups. The pathophysiology of achalasia involves the loss of inhibitory ganglion cells in the myenteric plexus of the esophagus. Its main symptoms include dysphagia, chest pain, regurgitation, and weight loss. The method of diagnosing achalasia has evolved from conventional manometry in the 1970s to high-resolution manometry in the 2010s. High-resolution manometry based on spatiotemporal plots can diagnose achalasia more precisely than conventional manometry. Moreover, novel parameters such as integrated relaxation pressure (IRP) (according to the Chicago classification) have increased diagnostic accuracy. However, cases of achalasia presenting with normal IRP have been reported. Therefore, the novel Chicago classification version 4.0 has adopted additional tests. These tests include the stress test for esophageal motor disorders, timed barium esophagography, and test using a functional lumen imaging probe that measures the distensibility of the esophagogastric junction. Achalasia was previously treated using surgical myotomy, balloon dilation, and botulinum toxin injection. However, peroral endoscopic myotomy (POEM) has recently become the mainstay treatment. POEM has a higher clinical success rate and a lower complication rate than surgical myotomy. Esophageal cancer and pulmonary conditions such as aspiration pneumonia are possible complications of achalasia. In this review, the current knowledge regarding achalasia together with novel diagnostic and therapeutic strategies are discussed.

A case of significant weight loss and severe malnutrition caused by achalasia

Achalasia is caused by chronic degeneration of ganglionic cells in the myenteric plexus that leads to failure of relaxation of the lower esophageal sphincter (LES). This leads to aperistalsis of the digital esophagus and eventually led to dilation of the lower esophagus. We present the case of a 37-year-old man who initially presented with dysphagia for solid food and then slowly developed dysphagia for liquid over the past 6 months. He had significant weight loss, and his esophagogastroduodenoscopy (EGD) showed esophagitis and gastritis. The imaging of computed tomography (CT) with oral contrast showed dilation of the distal esophagus and mild circumferential thickening at the gastroesophageal junction. After the failure of response to BoTox-infiltration in the LES, the patient was taken for Heller’s myotomy. He showed immediate improvement in dysphagia after surgical intervention. This case study includes findings from CT scan, X-ray, and EGD with biopsies in this patient. This paper also summarizes the therapeutic options of BoTox-injection and surgical myotomy

A COMPARATIVE STUDY OF CAUDAL BLOCK USINGLIGNOCAINE ALONE AND WITH KETAMINE FOR ADULTANORECTAL SURGERIES

Background -we want to compare the effects of lignocaine alone & lignocaine with ketamine in the caudal block for anorectal surgeries Methods- A prospective, randomized, comparative study was conducted at the Department of Anaesthesiology, ACSR Govt Medical college on 50 ASA I, and II patients aged between 18 to 60years posted for elective anorectal surgeries, during the period of November 2020 to February 2022,by dividing the patients into two groups Results-In this study the mean time to the first analgesia was 7.9 min. in the control group and 5.6 in the study group (p < 0.05). The mean time to start was 13 min. in the control and 11 min. in the study group (p < 0.05). The sensory block level reached in the control group was T12 and in the study group was T 10. The motor blockade was significantly less in the study group than in the control group (p < 0.05). Anal sphincter relaxation was better in the study group than in the control group. The discomfort caused by the awkward positioning was less in the ketamine group than in the control. In the study group, patients had acceptable sedation which contributed to a sense of well-being superior patient satisfaction and better working conditions for surgery. Both groups were compared in the incidence of intraoperative and postoperative complications. In the study group the total duration of analgesia was significantly prolonged (210 min. vs. 247 min. p value <0.05 ) There was no hypotension in the study group whereas in the control group there was a mean fall of 4 mm Hg. in the systolic BP. The addition of Ketamine in the subanaesthetic dose of 0.5 mg / Kg to the Caudal epidural block provides comparatively better anaesthesia than Lignocaine alone. Conclusion- We concluded that Caudal Epidural Block ( CEB) using Lignocaine 30 ml with Adrenaline ( 1 in 200 000 dilutions) is a safe, reliable and simple technique that can be practised for this kind of surgery. Ketamine as an adjuvant in sub anaesthetic doses significantly improves the quality,duration, and patient comfort in the caudal block.

The role of dilatation methods and lateral subcutaneous sphincterotomy in the internal anal sphincter spasm treatment (systematic literature review and meta-analysis)

The main link in the pathogenesis of anal fissure is a spasm of the internal sphincter of the rectum, in connection with which many methods of muscle relaxation have been developed. A special place is occupied by dilatation methods, which are quite diverse. To assess their effectiveness and safety, the authors carried out a systematic review and meta-analysis of 9 selected randomized clinical trials comparing the results of treatment of chronic anal fissure using dilatation methods of internal anal sphincter relaxation and the traditionally used method of lateral subcutaneous sphincterotomy. The results of treatment of 716 patients were analyzed with an assessment of such indicators as the frequency of fissures epithelialization, postoperative complications, and the development of anal sphincter insufficiency and relapses of the disease. There were no statistically significant differences in the frequency of fissure healing in the groups with the use of dilatation methods of internal sphincter relaxation and lateral subcutaneous sphincterotomy (OR=1; CI=0.34;2.96; p=1). When assessing the risk of the disease recurrence in both groups, there were also no statistically significant differences (OR=0.93; CI=0.56;1.56; p=0.79). Postoperative complications were also comparable in both groups (OR=0.81; CI=0.4;1.63; p=0.55). There were no statistically significant differences in the incidence of anal incontinence (OR=1; CI=0.34;2.96; p=1). It should be noted that the use of uncontrolled dilatation is associated with a high risk of developing anal incontinence, while the introduction of controlled dilatation reduces the risk of this complication to a minimum. The use of controlled dilatation methods for relaxation of the internal sphincter is a safe alternative to lateral subcutaneous sphincterotomy, including in the treatment of anal fissures in combination with hemorrhoids.

POEM and GERD: Prevalence, Mechanisms, Potential Strategies for Prevention, and Management

Achalasia is a neurodegenerative condition characterized by the absence of normal esophageal peristalsis and failure of lower esophageal sphincter (LES) relaxation. Treatment has traditionally been sphincter based, with pneumatic dilation (PD) and laparoscopic Heller myotomy with partial fundoplication (LHM) constituting the accepted durable therapeutic options. However, peroral endoscopic myotomy (POEM) has emerged as safe and effective treatment for achalasia. Studies have demonstrated noninferiority of POEM compared with PD and LHM, with likely superiority in patients with type 3 achalasia.

Clinical presentation, videourodynamic characteristics, and treatment outcome in men with interstitial cystitis-like lower urinary tract symptoms.

In men, lower urinary tract symptoms (LUTS) similar to interstitial cystitis/bladder pain syndrome (IC/BPS) are difficult to diagnose, and treatment outcomes are poor. This study investigated clinical characteristics and videourodynamic study (VUDS) parameters, pathophysiology, and treatment outcomes in men with IC-like LUTS. Men with frequency, urgency, dysuria, and bladder pain initially diagnosed as IC/BPS by ESSIC criteria were assessed to rule out other lower urinary tract diseases (LUTD) by voiding diary, digitorectal examination, urinalysis, VUDS, and cystoscopic hydrodistention. Subsequent treatments for LUTD and specific treatment for IC/BPS were based on VUDS and cystoscopic findings. Clinical VUDS characteristics and treatment outcomes were compared with those of women with IC/BPS. Seventy consecutive men (median age 54.5years) were enrolled. The median maximum bladder capacity under cystoscopic hydrodistention was 650mL (IQR 495-763) and glomerulation grade was 2 (1.0-2.0). The patients had moderate anxiety and depression severity; 49% had improved treatment outcomes. On VUDS, 42 (60%) patients had variable LUTD, including detrusor overactivity (n = 14), bladder neck dysfunction (n = 15), dysfunctional voiding (n = 3), and poor relaxation of the external sphincter (n = 24); also, 22 (31.4%) had a previous bladder outlet procedure. The self-reported treatment outcome was significantly better for patients with vs. without LUTD (p = 0.014). Men with IC-like LUTS diagnosed as IC/BPS may have bladder outlet dysfunction as well as bladder dysfunction, causing a hypersensitive and painful bladder. The IC-like symptoms in the patients with LUTD might, in part, originated from bladder outlet dysfunction rather than the bladder alone.

Effects of lysophosphatidic acid on sling and clasp fibers of the human lower esophageal sphincter

Background This study aims to explore the role of lysophosphatidic acid receptors in the regulation mechanisms of contraction and relaxation of human lower esophageal sphincter. Methods Between July 2015 and March 2016, muscle strips were collected from a total of 30 patients (19 males, 11 females; mean age: 62±9.9 years; range, 52 to 68 years) who underwent an esophagectomy for mid-third esophageal carcinomas. The specimens were maintained in oxygenated Krebs solution. Muscle tension measurement technique in vitro was used to examine the effects of non-selective lysophosphatidic acid receptors agonists and antagonists, as well as selective lysophosphatidic acid receptors agonists on the clasp and sling fibers of human lower esophageal sphincter. Results The non-selective dopamine receptor agonist lysophosphatidic acid induced the contraction of the clasp and sling fibers of the human lower esophageal sphincter. The response induced by nonselective lysophosphatidic acid receptor agonist was inhibited completely by non-selective lysophosphatidic acid receptor antagonist. The selective lysophosphatidic acid 1 and 2 receptor agonist and the selective lysophosphatidic acid 3 receptor agonist induced a concentration-dependent contractile response of the clasp and sling fibers of the human lower esophageal sphincter. There was no significant difference in contraction rates between the clasp and sling fibers (p>0.05). Conclusion This study indicates that lysophosphatidic acid regulates the lower esophageal sphincter is through its receptor; the lysophosphatidic acid receptors may be involved in the contractile response of the human lower esophageal sphincter.

Comparison of Various Analgesic Protocols for Control of Postoperative Pain Following Anorectal Surgery

Background: Anorectal pathology is commonly perceived it and handled in common surgical practitioners’ fistula and abscess, hemorrhoids, fissures, condyloma, and other pathological conditions. Because of the strong sensory innervations of the canal of anal, patients endure severe discomfort during anorectal surgery. It is generally most severe in the first twenty-four hours especially after excisional hemorrhoidectomy. the aim of this study is a comparison between different analgesic protocols used to relieve pain postoperative anorectal surgery.
 Methods: PubMed, Embase, Medline, Science Gate, Scientific Report, Elsevier, Google Scholar, and Cochrane Evidence Based Medicine Reviews were used to conduct a review search. Review of newly released books and papers with regard to the topic, as well as manual searches (Comparison of various analgesic protocols for control of postoperative pain following anorectal surgery), was started at (May,2021). we searched the published studies from 2011 to the present date by the full text:(various analgesic protocols post anorectal surgery).
 Results: Anorectal surgery is marked by excruciating discomfort after the procedure. Using the new technique during anorectal surgery as hemorrhoidectomy to avoid more excision of anal mucosa and the skin, putting the suture nearest to the dentate line and away from the internal anal sphincter, and good hemostasis to avoid the inserting of the anal pack are the most essential methods to lessen pain postoperatively regardless of the type of anorectal surgery performed or the instrument to use during it. We found more protocols using multimodality pain management for the relief of pain, topical drugs that produce direct relaxation of the internal anal sphincter, topical intervention as a pudendal nerve block, a method of surgery as surgical sphincterotomy, and technical tips to reduce pain as ligasure.
 Conclusion: Multimodal pain treatment has been demonstrated to minimize pain intensity and opioid doses in various kinds of surgery. According to the highest degree of proof, using current technological procedures and tools as a ligasure with some topical agent as GTN glyceryl trinitrate ointment provided amazing excellent alleviation of postoperative pain following anorectal surgery.

Conforming an Extracorporeal Lithotripter System for Video Urodynamic Studies

Objectives: This study aimed to evaluate the efficiency using existing fluoroscopic unit and lithotripter table of an extracorporeal lithotripter system for video urodynamic studies (VUDS) to determine anatomical abnormalities in patients with neurogenic lower urinary tract dysfunction (NLUTD).
 Methods: The extracorporeal lithotripsy system was adapted to obtain optimum fluoroscopic view according to body shape and observed organs of patients. We reviewed the VUDS data of 25 patients with NLUTD.
 Results: “Christmas tree bladder” (CTB) was found in 5 (20%) patients. Vesicoureteral reflux (VUR) and external detrusor sphincter dyssynergia (DESD) were detected in 3 (12%) and 4 (16%) patients, respectively. Four (16%) patients with normal coordination between detrusor contraction and external sphincter relaxation were proven by VUDS. CTB, VUR, or DESD was not observed in 10 (40%) patients with flaccid bladder. Hematuria, urinary tract infection, or autonomic dysreflexia did not occur in any of the patients.
 Conclusions: VUDS can discern anatomical abnormalities of the urinary tract, and patients in undeveloped areas of the world who have NLUTD can have easier access to VUDS because of the decreasing capital cost of VUDS.

Laparoscopic Heller Myotomy and Dor Fundoplication.

Achalasia is an esophageal motility disorder characterized by disordered esophageal peristalsis with failed relaxation of the lower esophageal sphincter resulting in a functional obstruction.Treatment can include medical, endoscopic, or surgical interventions. Although none of these are curative, they each offer methods to create esophageal outflow. This article discusses our preferred surgical technique used for laparoscopic Heller myotomy with Dor fundoplication. This technique has been developed over the author's career. The technique discussed provides a safe and effective strategy to manage achalasia.

Update on the Diagnosis and Treatment of Achalasia.

Achalasia is a rare disease of the esophagus with impaired relaxation of the lower esophageal sphincter and aperistalsis. The etiology is unknown but speculations include a viral or autoimmune etiology. All specialists dealing with swallowing and esophageal diseases should recognize the classic symptoms of dysphagia for solids/liquids, regurgitation, and choking, especially at night. High-resolution manometry is critical for the diagnosis with endoscopy and barium esophagram having a supportive role. The disease cannot be cured but most can return to near normal swallowing and a regular diet with appropriate therapy. Treatment includes smooth muscle relaxants, botulinum toxin injections to the lower sphincter, pneumatic dilation, Heller myotomy, and peroral endoscopic myotomy. One treatment does not fit all and a tailored approach through a multidiscipline team will give the best long-term outcomes.

Laparoscopic Heller Myotomy with Dor Fundoplication: An Operation that has Withstood the Test of Time.

Achalasia is a primary esophageal motility disorder characterized by aperistalsis and defective relaxation of the lower esophageal sphincter in response to swallowing. Patients' symptoms include dysphagia, regurgitation, weight loss, chest pain and aspiration. The disease is idiopathic, and the goal of treatment is to eliminate the resistance determined by the abnormal lower esophageal sphincter, therefore allowing passage of the ingested food from the esophagus into the stomach. Three effective treatment modalities are available today-pneumatic dilatation, peroral endoscopic myotomy, and laparoscopic Heller myotomy with a partial fundoplication. We described the technique to perform a laparoscopic Heller myotomy and a Dor fundoplication. Five steps to perform a laparoscopic Heller myotomy and a Dor fundoplication were described. The surgical approach is favored in many centers as it is very effective in relieving symptoms, while avoiding pathologic gastroesophageal reflux in most patients.

Achalasia.

Achalasia is a rare disorder of the oesophageal smooth muscle characterized by impaired relaxation of the lower oesophageal sphincter (LES) and absent or spastic contractions in the oesophageal body. The key pathophysiological mechanism is loss of inhibitory nerve function that probably results from an autoimmune attack targeting oesophageal myenteric nerves through cell-mediated and, possibly, antibody-mediated mechanisms. Achalasia incidence and prevalence increase with age, but the disorder can affect all ages and both sexes. Cardinal symptoms consist of dysphagia, regurgitation, chest pain and weight loss. Several years can pass between symptom onset and an achalasia diagnosis. Evaluation starts with endoscopy to rule out structural causes, followed by high-resolution manometry and/or barium radiography. Functional lumen imaging probe can provide complementary evidence. Achalasia subtypes have management and prognostic implications. Although symptom questionnaires are not useful for diagnosis, the Eckardt score is a simple symptom scoring scale that helps to quantify symptom response to therapy. Oral pharmacotherapy is not particularly effective. Botulinum toxin injection into the LES can temporize symptoms and function as a bridge to definitive therapy. Pneumatic dilation, per-oral endoscopic myotomy and laparoscopic Heller myotomy can provide durable symptom benefit. End-stage achalasia with a dilated, non-functioning oesophagus may require oesophagectomy or enteral feeding into the stomach. Long-term complications can, rarely, include oesophageal cancer, but surveillance recommendations have not been established.

Childhood esophageal achalasia: Case report from Afghanistan with literature review.

Introduction and importanceEsophageal achalasia is a motility disorder of the esophagus with unknown etiology characterized by the failure of lower esophageal sphincter relaxation. Diagnosis is made by barium esophagography, endoscopy, and esophageal manometery. Heller Esophagomyotomy along with Dor's fundoplication is the treatment of choice. Persisting undiagnosed cases may lead to malnutrition.Case presentationWe present a case of an 8-year-old child suffering from dysphagia and regurgitation. The child was misdiagnosed and maltreated for the suspicion of respiratory tract and gastrointestinal problems in the local clinics. During this time, he remained unresponsive to the mentioned treatments, and the local physician advised him to have an upper gastrointestinal (GI) endoscopy, which revealed esophageal achalasia (EA).On admission to our pediatric surgery ward, the patient had coexistent parotitis, which was treated conservatively. Following recovery, the patient was prepared for surgery and underwent esophageal myotomy along with Dor's fundoplication.Clinical discussionEsophageal achalasia is rare in children, but poses major health challenges to children if left untreated. Symptomatic treatment may mask the actual picture of the problem and last for years. Following surgery and discharge from the hospital in a three-month follow-up interval of time, our patient exhibited full recovery, with gaining 4 kg weight.ConclusionsRespiratory and gastrointestinal conditions with similar signs and symptoms should always be considered in differential diagnosis of esophageal achalasia, especially where there is no direct access to a pediatric specialized complex. On-time evaluation and treatment will further prevent children from malnutrition in long-lasting undiagnosed patients.

Anorektal Fizyolojik Çalışmalar ve Klinik Kullanımdaki Yerleri

Anorectal Physiological Studies and Their Place in Clinical Use ABSTRACT Defecation is a complex process that is difficult to directly examine and analyze. In anorectal diseases, defecation function may be impared, resulting in associated symptoms such as incontinence and/ or constipation. Therefore, the need for physiologically relevant and easy- to- use diagnostic tests is important to identify the underlying mechanisms. For this purpose, we wanted tos hare with you the results we have compiled from the studies carried out on this subject in recent years. Keywords: Anal sphincter relaxation, anorectal physiology, defecation, anorectal tests

LncRNA expression in idiopathic achalasia: New insight and preliminary exploration into pathogenesis.

Idiopathic achalasia is a primary esophageal motility disorder characterized by the absence of esophageal peristalsis and impaired relaxation of the lower esophageal sphincter (LES). However, the pathogenesis of idiopathic achalasia remains unclear. To further understand the pathogenesis, we conducted lncRNA and mRNA microarray analyses. LES specimens from 5 patients and 4 controls were used for microarray. Potential target genes with significantly changed lncRNA and mRNA were predicted using cis/trans-regulatory algorithms, followed by the Gene Ontology and KEGG pathway enrichment analysis to understand the biophysical effect. Finally, 7,133 significantly dysregulated mRNAs (3,136 increased and 3,997 decreased), along with 6,892 significantly dysregulated lncRNAs (4,900 increased and 1,992 decreased). Biophysical function analysis revealed that the cell adhesion molecule (CAM) pathway was a common pathway. The predicted lncRNA targets of NRXN1 (Down FC: 9.07), NTNG2 (UP FC: 2.75), CADM1 (Down FC: 2.26), NLGN1 (Down FC: 4.60), NEGR1 (Down FC: 2.335), CD22 (Down FC: 5.62), HLA-DQB1 (Down FC: 5.06), and HLA-DOA (Down FC: 2.31) were inputted in this pathway, which was mainly located in the synapse part of the neural system and immune system. Our study demonstrates the lncRNAs and corresponding mRNAs that may play important roles in idiopathic achalasia.

Impact of Surgical Intervention on Nonobstructive Dysphagia: A Retrospective Study Based on High-Resolution Impedance Manometry in a Taiwanese Population at a Single Institution.

Esophageal motility disorders account for a large proportion of nonobstructive dysphagia cases, which constitute a heterogeneous group of diagnoses that commonly result in peristaltic derangement and impaired relaxation of the lower esophageal sphincter. We performed a single-institution retrospective study enrolling consecutive patients with chief complaints of dysphagia who underwent HRIM from December 2014 to December 2019, and analyzed demographic, clinical, and manometric data using descriptive statistics. In total, 277 identified patients were included in the final analysis. Ineffective esophageal motility (n = 152, 24.5%) was the most common diagnosis by HRIM, followed by absent contractility, EGJ outflow obstruction, type II achalasia, and type I achalasia. Furthermore, surgery including exploratory, laparoscopic, and robotic myotomy, as well as POEM, is considered the most effective treatment for patients with non-spastic achalasia and EGJOO, due to its effective symptom palliation and prevention of disease progression; surgery also contributes to an obvious improvement of dysphagia compared with slightly less efficacy for other related symptoms. Our study aimed to elaborate the clinical characteristics of patients with nonobstructive dysphagia based on HRIM in a Taiwanese population, and to analyze the therapeutic outcomes of such patients who ultimately underwent surgical interventions.

Impaired nitrergic relaxation in pyloric sphincter of the 6-OHDA Parkinson's disease rat.

Patients with Parkinson's disease (PD) often suffer from delayed gastric emptying, but the underlying mechanism remains unclear. We have shown previously that a PD rat model comprising bilateral substantia nigra destruction by 6-hydroxydopamine (6-OHDA rats) exhibits gastroparesis with alteration of neural nitric oxide synthase (nNOS) and acetylcholine in gastric corpus. However, changes in pyloric motility in the 6-OHDA rats have not been characterized. Solid gastric emptying test, immunofluorescence, Western blot, and in vitro pyloric motility recordings were used to assess pyloric motor function in the 6-OHDA rats. The 6-OHDA-treated rats displayed delayed solid gastric emptying and a lower basal pyloric motility index. In the 6-OHDA rats, high K+-induced transient contractions were weaker in pyloric sphincters. Electric field stimulation (EFS)-induced pyloric sphincter relaxation was lower in the 6-OHDA rats. NG-nitro-l-arginine methyl ester (l-NAME), a nonselective inhibitor of NOS, markedly inhibited the EFS-induced relaxation in both control and 6-OHDA rats. Pretreatment of tetrodotoxin abolished the effect of EFS on the pyloric motility. In addition, nNOS-positive neurons were extensively distributed in the pyloric myenteric plexus, whereas the number of nNOS-immunoreactive neurons and the protein expression of nNOS were significantly decreased in the pyloric muscularis of 6-OHDA rats. However, sodium nitroprusside-induced pyloric relaxations were similar between the control and 6-OHDA rats. These results indicate that the pyloric sphincters of 6-OHDA rats exhibit both weakened contraction and relaxation. The latter may be due to reduced nNOS in the pyloric myenteric plexus. The dysfunction of the pyloric sphincter might be involved in the delayed gastric emptying.NEW & NOTEWORTHY Reduced nitrergic neurons in pyloric myenteric plexus potently contributed to the attenuated relaxation in 6-hydroxydopamine (6-OHDA) rats, subsequently affecting gastric emptying. SNP could well improve the relaxation of pylori in 6-OHDA rats. The present study provides new insight into the diagnosis and treatment of delayed gastric emptying in patients with PD.

Esophageal Diverticulum - Indications and Efficacy of Therapeutic Endoscopy.

Objective Esophageal diverticulum is rare, and the concomitance of esophageal motility disorders (EMDs) and the efficacy of novel endoscopic treatment have not been investigated in Japan. Methods An examination including high-resolution manometry (HRM) was performed for patients with both EMDs and epiphrenic diverticulum. EMD-related epiphrenic diverticulum and Zenker's diverticulum were treated using salvage peroral endoscopic myotomy (s-POEM) and endoscopic diverticulotomy, respectively. Results Six cases of epiphrenic diverticulum were diagnosed in this study. Among 125 patients with achalasia and spastic disorders, concomitant epiphrenic diverticulum was observed in 4 (3.2%). Of these, three showed a normal lower esophageal sphincter pressure on HRM, although gastroscopy and esophagography revealed typical findings of an impaired lower esophageal sphincter relaxation. These four patients were successfully treated with s-POEM, and the Eckardt score improved from 6.3 to 0.25 at 32.5 (range: 13-56) months of follow-up, with equivalent treatment efficacy to that observed for achalasia and spastic disorders without epiphrenic diverticulum. In contrast, the two remaining cases of epiphrenic diverticulum had normal esophageal motility. Six cases of Zenker's diverticulum were diagnosed, and endoscopic diverticulotomy was successfully performed in all. The dysphagia score decreased from 2.8 to 0.17 at 14.8 (range: 2-36) months of follow-up. Overall, 12 endoscopic treatments were performed for esophageal diverticulum; no adverse events were observed. Conclusion In epiphrenic diverticulum patients, concomitant EMDs are not rare and should be carefully diagnosed. A normal lower esophageal sphincter pressure on HRM does not always mean a normal lower esophageal sphincter relaxation. S-POEM and endoscopic diverticulotomy are effective minimally invasive treatment options for EMD-related epiphrenic diverticulum and Zenker's diverticulum.

Treatment of chronic anal fissure botulinum toxin type A 40 U in comparison with lateral subcutaneous sphincterotomy (NCT03855046)

AIM: to improve the results of chronic anal fissure treatment.PATIENTS AND METHODS: the prospective randomized study included 176 patients divided in two groups. Eighty-eight patients underwent fissure excision in combination with injection of botulinum toxin type A (incobotulinum toxin) into the internal anal sphincter (main group, BTA), and 88 patients underwent anal fissure excision in combination with lateral subcutaneous sphincterotomy (control group, LIS).RESULTS: on the 30th day after surgery, spasm of internal anal sphincter, according to profilometry, persisted in 14.8% of patients of the main group (BTA) and 22.7% of patients in the control group (LSS) (p = 0.18), and on the 60th day in 20.4% and 14.8% of patients, respectively (p = 0.32). On the 60th day after surgery, the postoperative wound did not epithelialize in 14% of patients in the BTA group and 1% of the LSS group (p = 0.0006). On the 30th day after surgery, complaints of incontinence were noted by 32% of patients in the BTA group and 31% in the LSS group (p = 0.87), on the 60th day — 7% and 11% of patients, respectively (p = 0.29). The intensity of pain after surgery in the compared groups did not differ both after defecation and during the day (p > 0.05). Expansion of the surgery volume increases the chance of developing temporary anal sphincter incontinence (ASI) by 2.44 times on the 30th day of observation (p = 0.01) and by 3 times — on day 60 (p = 0.04). The use of BTA as a method of internal anal sphincter relaxation increases the chance of slowing down the epithelization of the postoperative wound by 13.7 times [p = 0.01], and the expansion of the surgery volume — by 3.47 times [p = 0.03].CONCLUSION: the use 40 U of botulinum toxin type A after anal fissure excision is not inferior to lateral subcutaneous sphincterotomy in elimination of spasm internal anal sphincter with a comparable incidence of temporary anal sphincter incontinence within 2 months after surgery. Neurotoxin serves as an alternative to sphincterotomy, however, in some cases, it requires the addition of a agent containing human recombinant epidermal growth factor to the postoperative management of patients.