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Gastroenterologia Y Hepatologia Oct 2013Pneumatic dilation and surgical myotomy are currently the procedures of choice to treat achalasia. The selection of one or other treatment depends on the experience of...
INTRODUCTION
Pneumatic dilation and surgical myotomy are currently the procedures of choice to treat achalasia. The selection of one or other treatment depends on the experience of each center and patient preferences.
BACKGROUND AND AIMS
To review the experience of pneumatic dilation in patients with achalasia in our center.
MATERIAL AND METHODS
We included all patients with a clinical, endoscopic and manometric diagnosis compatible with achalasia who underwent pneumatic dilation in a 19-year period. All dilations were routinely performed with a Rigiflex(®) balloon, usually at pressures of 250, 250 and 300mm Hg in three inflations of one minute, each separated by one minute. The success of the dilation was assessed on the basis of the patient's symptoms, the number of sessions, the need for surgery, and the presence of complications.
RESULTS
A total of 171 patients were included, 53.2% men and 46.8% women, with a mean age of 51.53±17.78 years (16-87 years), from June 1993 to October 2012. A 35-mm balloon was used in 157 patients, a 30-mm balloon in 9 patients and a 40-mm balloon in 7 patients. A single dilation session was required in 108 patients, two sessions were required in 56 patients, with a mean time between the first and second sessions of 25.23±43.25 months (1-215 months), and 3 sessions were required in 7 patients with a mean time between the second and third sessions of 6.86±5.33 months (1-15 months). Outcome after dilation was successful in 81% of the patients. Of the 140 responders, 121 had complete response (complete disappearance of symptoms without recurrence) and 19 partial response (initial disappearance of symptoms with subsequent reappearance). Surgery (Heller myotomy) was required in 15.8% of the patients. Perforation occurred in 4 of the 171 patients as a complication of the technique; these perforations were satisfactorily resolved, two by conservative treatment and two by surgery. There was no mortality associated with the technique or its complications.
CONCLUSIONS
In our series, pneumatic dilation had a high success rate. In most patients, a single session was required and the complications rate was low. These results show that this technique is safe and effective in these patients, avoiding a large number of surgical interventions.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Dilatation; Esophageal Achalasia; Female; Humans; Male; Middle Aged; Retrospective Studies; Young Adult
PubMed: 23972682
DOI: 10.1016/j.gastrohep.2013.05.009 -
Urology Nov 2019Ultrasound guidance for percutaneous nephrolithotomy (PCNL) has gained acceptance amongst urologists given its numerous advantages over fluoroscopy. While traditionally...
INTRODUCTION
Ultrasound guidance for percutaneous nephrolithotomy (PCNL) has gained acceptance amongst urologists given its numerous advantages over fluoroscopy. While traditionally performed in the prone position, this video demonstrates a step-by-step approach to performing PCNL in the supine position, solely under ultrasound guidance.
MATERIALS AND METHODS
Once in the modified supine (Galdakao-modified Valdivia) position, important anatomic landmarks are identified. It is important to first orient the ultrasound probe such that its cranial side corresponds to the left of the ultrasound screen. After optimizing a target calyx, keeping the needle in the imaging plane of the probe facilitates renal access. Tract dilation under ultrasound guidance is then achieved by keeping the wire and dilators in the same imaging plane.
RESULTS
The 11th and 12th ribs, paraspinous muscle, iliac crest, midaxillary line, and costal margin are the anatomic landmarks that orient the probe to the location of the kidney. Placing the ultrasound probe in the midaxillary line, parallel to the 11th rib allows the operator to identify key renal landmarks: the renal cortex, peri-pelvic fat, collecting system, kidney stone with its associated postacoustic shadow, and the intended target calyx. Controlling the needle is easiest in the longitudinal view, as the needle can be visualized from skin to target. Dilation under ultrasound relies on keeping the wire in view. The tip of the 10-French dilator is based on the location where the wire image disappears as the dilator advances. The balloon dilator tip is visualized on ultrasound reaching the appropriate depth just inside the collecting system, at which time balloon inflation results in complete dilation of the tract.
CONCLUSIONS
This video provides a step-by-step approach demonstrating that PCNL can be performed in the supine position using only ultrasound-guidance. This approach facilitates renal access in this position and obviates the need for radiation exposure.
Topics: Dilatation; Humans; Nephrolithotomy, Percutaneous; Patient Positioning; Supine Position; Ultrasonography, Interventional
PubMed: 31376473
DOI: 10.1016/j.urology.2019.07.022 -
The Laryngoscope Nov 2021To better assess rates of postoperative complications and mortality following esophageal dilation, and to identify factors associated with adverse outcomes. (Observational Study)
Observational Study
OBJECTIVES/HYPOTHESIS
To better assess rates of postoperative complications and mortality following esophageal dilation, and to identify factors associated with adverse outcomes.
STUDY DESIGN
Observational, retrospective cohort study.
METHODS
We queried a national database of insurance claims for Current Procedural Terminology (CPT) codes representing esophageal dilation performed between 2011 and 2017. Patients aged 18 to 100 who were continuously enrolled with their insurance provider were included. Demographic information, additional CPT codes, concomitant diagnoses, and anticoagulant medication data were collected for all patients included. Postoperative mortality was assessed and International Classification of Diseases (ICD)9/10 codes for complications, including esophageal perforation, hemorrhage, mediastinitis, and sepsis were flagged.
RESULTS
We identified 202,965 encounters for esophageal dilation. Of these procedures, 193 were performed on a patient who underwent percutaneous endoscopic gastrostomy (PEG) during the study period and was analyzed separately. Another 244 dilations were excluded due to repeat entries. Of the remaining 202,528 procedures remaining, 42,310 were repeat dilations in the same patient. Data analysis was confined to each patient's initial dilation. 160,218 initial dilations remained. Of these, 62,107 were performed on male patients and 98,111 were performed on female patients. The average age was 57.7 years. There were 12 mortalities within 30 days postoperatively, representing 0.0075% of all dilations. Esophageal perforation and esophageal hemorrhage were the most common reported complications, with 139 and 110 occurrences, respectively. The overall per-dilation complication rate was 0.215%.
CONCLUSIONS
Evidence from a national insurance claim database suggests that esophageal dilation is a safe procedure with a low rate of serious complications and a 30-day all-cause mortality rate of less than 1 per 10,000 dilations.
LEVEL OF EVIDENCE
4 Laryngoscope, 131:2436-2440, 2021.
Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Case-Control Studies; Current Procedural Terminology; Databases, Factual; Deglutition Disorders; Dilatation; Esophageal Diseases; Esophageal Perforation; Esophagus; Female; Gastrostomy; Hemorrhage; Humans; International Classification of Diseases; Male; Mediastinitis; Middle Aged; Postoperative Complications; Retrospective Studies; Sepsis
PubMed: 33305828
DOI: 10.1002/lary.29322 -
Otology & Neurotology : Official... Aug 2018Compare Eustachian tube balloon dilation versus continued medical therapy (control) for treating persistent Eustachian tube dysfunction (ETD). (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVE
Compare Eustachian tube balloon dilation versus continued medical therapy (control) for treating persistent Eustachian tube dysfunction (ETD).
STUDY DESIGN
Prospective, multicenter, randomized controlled trial.
SETTING
Tertiary care academic center and private practice.
PATIENTS
Diagnosed with medically refractory persistent ETD.
INTERVENTIONS
1:1 Randomization to balloon dilation or control. After 6 weeks, control participants had the option to undergo balloon dilation if symptoms persisted.
MAIN OUTCOME MEASURES
Primary efficacy endpoint was the comparison between treatment arms in the mean change from baseline in the 7-item Eustachian Tube Dysfunction Questionnaire (ETDQ-7) score. Primary safety endpoint was complication rate.
RESULTS
Sixty participants were randomized (31 balloon dilation, 29 control). Mean (SD) change in overall ETDQ-7 score at 6 weeks was -2.9 (1.4) for balloon dilation compared with -0.6 (1.0) for control: balloon dilation was superior to control (p < 0.0001). No complications were reported in either study arm. Among participants with abnormal baseline assessments, improvements in tympanogram type (p < 0.006) and tympanic membrane position (p < 0.001) were significantly better for balloon dilation than control. Technical success was 100% (91 successful dilations/91 attempts) and most procedures (72%) were completed in the office under local anesthesia. Improvements in the ETDQ-7 scores were maintained through 12 months after balloon dilation.
CONCLUSIONS
Balloon dilation is a safe and effective treatment for persistent ETD. Based on improved ETDQ-7 scores, balloon dilation is superior to continued medical management for persistent ETD. Symptom improvement is durable through a minimum of 12 months. Procedures are well tolerated in the office setting under local anesthesia.
Topics: Adult; Aged; Dilatation; Ear Diseases; Eustachian Tube; Female; Follow-Up Studies; Hearing Tests; Humans; Male; Middle Aged; Patient Satisfaction; Prospective Studies; Treatment Outcome
PubMed: 29912819
DOI: 10.1097/MAO.0000000000001853 -
BMJ Case Reports Mar 2015A 72-year-old man presented to the high dependency unit following an elective incisional hernia repair. He was extubated in the immediate postoperative period. Following...
A 72-year-old man presented to the high dependency unit following an elective incisional hernia repair. He was extubated in the immediate postoperative period. Following established type 2 respiratory failure (secondary to hospital-acquired pneumonia), he required tracheal intubation and was ventilated in the intensive care unit (ICU). He failed extubation and subsequently had a percutaneous single-stage dilational tracheostomy fitted as indicated. During the tracheostomy, while inflating the dilation balloon (used to dilate the trachea), the balloon burst in the trachea, at a pressure of 3 atmospheres. Following this, the entire dilating unit and tracheostomy tube were removed; no debris was left inside the trachea as confirmed by bronchoscope (used throughout the procedure). He made good recovery and was discharged to a surgical ward. This case report summarises the indications for tracheostomy, and reports the rare event of balloon rupture and how to manage it within the ICU setting.
Topics: Aged; Critical Care; Dilatation; Equipment Failure; Herniorrhaphy; Humans; Intubation, Intratracheal; Male; Respiration, Artificial; Respiratory Insufficiency; Trachea; Tracheostomy; Treatment Outcome
PubMed: 25814025
DOI: 10.1136/bcr-2014-207122 -
Journal of Clinical Gastroenterology Jul 2014Dilation of a cricopharyngeal (CP) bar can be a safe and effective means of nonsurgical treatment as elderly patient population has high morbidity and is at a higher...
GOALS
Dilation of a cricopharyngeal (CP) bar can be a safe and effective means of nonsurgical treatment as elderly patient population has high morbidity and is at a higher risk of surgical complications.
BACKGROUND
CP bar is a relatively uncommon radiologic finding, which is an infrequent cause of oropharyngeal dysphagia in the elderly population.
METHODS
Patients were included in study from January 2007 to January 2012, if their dysphagia was solely attributed to CP bar on predilation radiologic imaging by either modified barium swallow or barium esophagogram. A functional outcome swallowing score (FOSS) was calculated at 1, 4, and 6 months from initial and last dilation performed.
RESULTS
A total of 31 patients with a mean age of 71.65 (54 to 88) years and mean body mass index 27.81 (15 to 41) were included in the study. Over the time period of 5 years, a total of 53 dilations were performed. The median predilation FOSS was 3. The median postdilation FOSS was 1 at the end of 6 months from last dilation performed. There were no immediate or remote complications.
CONCLUSIONS
On follow-up from first dilation, 65% patients had statistically significant improvement in FOSS lasting for at least 6 months. Savary dilation seems to be a safe and effective treatment for symptomatic CP bar patients.
Topics: Aged; Aged, 80 and over; Barium; Deglutition Disorders; Dilatation; Esophageal Stenosis; Follow-Up Studies; Humans; Male; Middle Aged; Pharyngeal Muscles; Retrospective Studies; Time Factors; Treatment Outcome
PubMed: 24231933
DOI: 10.1097/MCG.0000000000000026 -
The Journal of the American Osteopathic... Sep 2016The 3-piece inflatable penile prosthesis was introduced in 1973 as a treatment for men with erectile dysfunction. Consisting of 2 corporal cylinders, 1 pump, and a...
BACKGROUND
The 3-piece inflatable penile prosthesis was introduced in 1973 as a treatment for men with erectile dysfunction. Consisting of 2 corporal cylinders, 1 pump, and a fluid-filled reservoir, the prosthesis is placed by blunt dissection into the retropubic space. The dissection for the reservoir is performed blindly into a space juxtaposed with nerves, vessels, and the bladder.
OBJECTIVE
To propose a novel approach for inflatable penile prosthesis reservoir placement involving gentle dilation of the retropubic space using a Foley catheter balloon.
METHODS
Patient medical records from 1 surgeon were reviewed. Patients did not have a history of pelvic surgery or prostatectomy. Each implant was approached using a penoscrotal incision, and the retropubic space was dilated with a 30-mL Foley catheter balloon filled to 100-mL capacity before reservoir placement. The postoperative visits were examined for complications, including reservoir infection and herniation. A literature search of penile prosthesis reservoir placement technique and complications (eg, herniation, infection) of reservoir placement was also performed.
RESULTS
Fifteen patient records were examined. The reservoir herniation rate was 0% and the infection rate was 7%. The average reservoir herniation rate is reported to be 1% to 3%, and the average infection rate is reported to be 1% to 5%.
CONCLUSION
The use of a Foley catheter balloon is a safe, atraumatic, cost-effective, and easily performed method of dilating the retropubic space for subsequent inflatable penile prosthesis reservoir placement.
Topics: Adult; Aged; Dilatation; Erectile Dysfunction; Humans; Male; Middle Aged; Penile Implantation; Penile Prosthesis; Retrospective Studies; Treatment Outcome; Urinary Catheterization; Urinary Catheters
PubMed: 27571296
DOI: 10.7556/jaoa.2016.118 -
Pediatric Transplantation Nov 2019To evaluate whether a serial biliary dilation protocol improves outcomes and decreases total biliary drainage time for biliary strictures following pediatric liver...
To evaluate whether a serial biliary dilation protocol improves outcomes and decreases total biliary drainage time for biliary strictures following pediatric liver transplantation. From 2006 to 2016, 213 orthotopic deceased and living related liver transplants were performed in 199 patients with a median patient age of 3.1 years at a single pediatric hospital. Patients with biliary strictures were managed by IR or surgically by the transplant team. Patients managed by IR were divided into two groups. The first group was managed with a standardized three-session protocol consisting of dilation every two weeks for three dilations. The second group was managed clinically with varying number and interval of dilations as determined by a multidisciplinary team. The location of biliary stricture, duration of drainage, number of balloon dilations, balloon diameter, time interval between dilations, and success of percutaneous treatment were recorded. Thirty-four patients developed biliary strictures. Thirty-one patients were managed with percutaneous intervention. Three strictures could not be crossed and were converted to operative management. Ten patients were managed in the three-session protocol, and 18 patients were managed in the clinically treated group. There was no significant difference in clinical success rates between groups, 80% and 61%, respectively. The three-session protocol group trended toward a lower total biliary drain indwell time (median 49 days) compared with the clinically treated group (median 89 days), P = .089. Our study suggests that a three-session dilation protocol following transplant-related biliary stricture may decrease total biliary drainage time for some patients.
Topics: Adolescent; Biliary Tract; Biliary Tract Surgical Procedures; Catheterization; Child; Child, Preschool; Cholestasis; Constriction, Pathologic; Dilatation; Drainage; Female; Humans; Infant; Liver Transplantation; Male; Postoperative Complications; Retrospective Studies
PubMed: 31313460
DOI: 10.1111/petr.13551 -
European Journal of Gastroenterology &... Jul 2014Eosinophilic esophagitis (EoE) is a chronic, immune/antigen-mediated disease seen in an increasing number of young adults. Solid food dysphagia is the most common...
BACKGROUND
Eosinophilic esophagitis (EoE) is a chronic, immune/antigen-mediated disease seen in an increasing number of young adults. Solid food dysphagia is the most common presenting symptom, and food impactions are not uncommon because of stricturing and decreased compliance of the esophagus. Although esophageal dilation is effective in managing patients with EoE, it needs to be performed cautiously, given a perceived higher rate of perforation.
AIM
The aim of this study was to evaluate the safety of a strict wire-guided dilation protocol used in patients with EoE.
METHODS
A retrospective review was performed to identify patients treated for EoE by a single physician (K.M.) over a 9-year period at UPMC. Medical records were reviewed to obtain information on demographic, clinical, and outcome data. Newly diagnosed and previously known EoE patients (biopsy proven) who underwent serial wire-guided bougie dilation were included in this study. All procedures were performed using monitored anesthesia care. On the basis of the initial endoscopic inspection, a bougie size was chosen that was subjectively considered to approximate the size of the esophageal lumen diameter. Fluoroscopy was used for safe guide wire placement if the endoscope could not traverse the stricture. After each bougie passage, the esophagus was reintubated with the endoscope to assess for mucosal tears. Serial dilation by 1 mm increments was continued until a small to moderate mucosal tear was seen, whereupon the procedure was terminated. For an index endoscopy for suspected EoE, biopsies were also taken to confirm the diagnosis.
RESULTS
Thirty patients were identified, mean age 33 years, 90% men. Solid food dysphagia was present in all. Twenty-seven patients (90%) were diagnosed with EoE during the index dilation; 17% underwent dilation for known, but symptomatic EoE. The median initial bougie size was 11. The median final bougie size was 15 mm; 24 patients (80%) had resultant mucosal tears. One patient complained of postprocedure chest pain requiring opioids. There were no perforations or hospitalizations. After dilation, patients were placed on swallowed fluticasone for 6 weeks (87%), maintenance montelukast (90%), or a prednisone taper (7%). Six patients (20%) underwent repeat dilation for recurrent dysphagia. All except one of these patients were on medical therapy for EoE.
CONCLUSION
Serial wire-guided dilation guided by repeated endoscopic inspection is safe in patients with EoE. Caution should be exercised when choosing the initial dilator size.
Topics: Adult; Deglutition Disorders; Dilatation; Eosinophilic Esophagitis; Esophageal Stenosis; Esophagoscopy; Female; Follow-Up Studies; Humans; Male; Retrospective Studies
PubMed: 24901815
DOI: 10.1097/MEG.0000000000000103 -
Surgical Endoscopy Sep 2018Achalasia is a chronic disease affecting the myenteric plexus of the esophagus and lower esophageal sphincter. Treatment is aimed at palliating symptoms to improve...
BACKGROUND
Achalasia is a chronic disease affecting the myenteric plexus of the esophagus and lower esophageal sphincter. Treatment is aimed at palliating symptoms to improve quality of life. Treatment options for symptom relapse after esophagomyotomy include botox injection, repeat myotomy, per-oral endoscopic myotomy, or pneumatic balloon dilation (PBD). Data demonstrating the safety and efficacy of PBD for recurrence are scarce. With a lack of published data, guidelines have suggested avoiding PBD for recurrent achalasia because of concern for a high risk of perforation.
METHODS
A retrospective review of patients who underwent PBD for recurrent symptoms of achalasia after esophagomyotomy between 2007 and 2017 was conducted. PBD was performed at 30 mm and held for 60 s under fluoroscopic guidance. Patients with residual symptoms had subsequent dilations at increasing 5 mm increments to a maximum of 40 mm. Patient demographics, Eckardt scores, presence of hiatal hernia, time from myotomy to recurrence, and diagnostic modalities were reported. The primary outcome was need for further endoscopic or surgical intervention. Complications are reported as secondary outcomes.
RESULTS
One-hundred eight esophagomyotomies were done during the study period. Fourteen patients underwent PBD for recurrent symptoms. The median time to symptom recurrence after esophagomyotomy was 28 months. The median Eckardt score was 6. Ten of 14 patients had an intervention between the initial surgery and PBD (9 standard dilations and 1 botox injection). A total of 23 PBD were done. Seven patients required dilation at 35 mm and two patients required dilation at 40 mm. Eleven patients required no further intervention at a median follow-up of 27.7 months. There were three treatment failures: one required repeat esophagomyotomy and two had no further treatments. There were no periprocedural complications.
CONCLUSION
Serial PBD is safe and effective in treatment of recurrent symptoms of achalasia after esophagomyotomy.
Topics: Adult; Dilatation; Esophageal Achalasia; Female; Fluoroscopy; Heller Myotomy; Humans; Male; Middle Aged; Recurrence; Retrospective Studies
PubMed: 29905893
DOI: 10.1007/s00464-018-6271-4