-
Jornal Brasileiro de Pneumologia :... Apr 2021
Topics: Bronchial Diseases; Dilatation; Humans; Lung Diseases; Thoracic Surgical Procedures
PubMed: 33950093
DOI: 10.36416/1806-3756/e20210012 -
Acta Gastro-enterologica Belgica 2018Diagnostic criteria for esophageal motor disorders have recently been updated with the advent of high-resolution manometry that gives a precise mapping of peristaltic... (Review)
Review
Diagnostic criteria for esophageal motor disorders have recently been updated with the advent of high-resolution manometry that gives a precise mapping of peristaltic abnormalities and an indirect view of bolus transit problems. Achalasia, the best-defined motor disorder, is now divided in subsets of manometric phenotypes that predict outcome of treatment and guide our therapeutic approach. Pharmacological therapy using smooth muscle relaxants for spastic esophageal disorders remains poorly effective and used only as a bridge to more effective therapies : endoscopic balloon dilation and surgical myotomy are both effective therapies in achalasia, myotomy being considered as the preferred approach in children because it is aimed to be definitive, while dilations usually have to be repeated. Recently, peroral endoscopic myotomy was introduced as an alternative to surgical myotomy for achalasia, and was rapidly adopted in tertiary referral centers. Showing excellent short-term results, this technique might be also proposed for other esophageal spastic disorders. Gastroesophageal reflux disease and eosinophilic esophagitis, two prevalent diseases in children that may be associated with hypotensive and hypertensive peristaltic abnormalities, have to be searched because specific effective therapies exist for these diseases that may cure the motility disorders.
Topics: Child; Dilatation; Esophageal Motility Disorders; Esophagoscopy; Gastrointestinal Agents; Humans; Manometry; Phenotype
PubMed: 30024702
DOI: No ID Found -
Acta Bio-medica : Atenei Parmensis Dec 2018Esophageal strictures in pediatric age are a quite common condition due to different etiologies. Esophageal strictures can be divided in congenital, acquired and... (Review)
Review
BACKGROUND
Esophageal strictures in pediatric age are a quite common condition due to different etiologies. Esophageal strictures can be divided in congenital, acquired and functional. Clinical manifestations are similar and when symptoms arise, endoscopic dilation is the treatment of choice. Our aim was to consider the efficacy of this technique in pediatric population, through a wide review of the literature.
METHOD
A search on PubMed/Medline was performed using "esophageal strictures", "endoscopic dilations" and "children" as key words. Medline, Scopus, PubMed publisher and Google Scholar were searched as well. As inclusion criteria, we selected clinical studies describing dilations applied to all type of esophageal strictures in children. Papers referred to single etiology strictures dilations or to adult population only were excluded, as well as literature-review articles.
RESULTS
We found 17 studies from 1989 to 2018. Overall, 738 patients in pediatric age underwent dilation for esophageal strictures with fixed diameter push-type dilators (bougie dilators) and/or radial expanding balloon dilators. Severe complications were observed in 33/738 patients (4,5%) and perforation was the most frequent (29/33). Conversion to surgery occurred only in 16 patients (2,2%).
CONCLUSIONS
Endoscopic dilation is the first-choice treatment of esophageal strictures, it can be considered a safe procedure in pediatric age. Both, fixed diameter push-type dilators and radial expanding balloon dilators, showed positive outcomes in term of clinical results and cases converted to surgery. However, it's essential to perform these procedure in specialized Centers by an experienced team, in order to reduce complications.
Topics: Child; Dilatation; Equipment Design; Esophageal Perforation; Esophageal Stenosis; Esophagoscopy; Humans; Treatment Outcome
PubMed: 30561414
DOI: 10.23750/abm.v89i8-S.7862 -
La Pediatria Medica E Chirurgica :... Dec 2019The management of congenital primary obstructive megaureter (POM) is usually conservative, especially during the first year of life. Endoscopic high-pressure balloon...
The management of congenital primary obstructive megaureter (POM) is usually conservative, especially during the first year of life. Endoscopic high-pressure balloon dilatation (EHPBD) is indicated when symptoms, increasing dilatation and progressive renal damage are recorded, particularly in children younger than one year of age. We identified and described endoscopic prognostic factors predicting the success or failure of endoscopic dilatation. Thirty-eight patients (33 M;5 F) with POM from 2005-2018 were included. Diagnosis was based on US distal ureter dilatation (>7 mm), obstructive MAG-3 diuretic renogram and absence of vesicoureteral reflux (cystography). 24 patients were under 1 year of age. All patients underwent cystoscopy and high-pressure balloon dilatation with 3,5 Fr dilating balloon, after ascending pyelography. Median follow-up was of 6.5 years. We identified characteristics with poor prognosis: stenotic punctiform ureteral ostium and/or ostium located in a bladder diverticulum (9 pts) and stenotic tract longer than 1 cm (5 pts). The patients with a stenotic tract shorter than 1 cm (18 pts) were divided into two groups: <5 mm (5 pts) and between 5 and 10 mm (13 pts) showed a good response to dilatation. Endoscopic evaluation of ureteral ostium with pneumatic dilatation when possible is a useful diagnostic and therapeutic solution for POM treatment, especially under one year of age. EHPBD is effective in short stenotic tracts (<5 mm). It may also be repeated with good results in intermediate stenotic sections (5 mm-1 cm). According to our preliminary results, the procedure is more effective if performed earlier (3-7 months of life). Greater cohort and longer follow-up are needed to verify the stability of these results.
Topics: Child, Preschool; Cystoscopy; Dilatation; Endoscopy; Female; Follow-Up Studies; Humans; Infant; Male; Prognosis; Retrospective Studies; Treatment Outcome; Ureteral Obstruction; Urography
PubMed: 31867939
DOI: 10.4081/pmc.2019.219 -
Saudi Medical Journal Jul 2020To report the results of endoscopic dilatation of esophageal strictures in children, its complications, and their management. The outcomes of esophageal dilatation...
OBJECTIVES
To report the results of endoscopic dilatation of esophageal strictures in children, its complications, and their management. The outcomes of esophageal dilatation differ according to the underlying etiology.
METHODS
The study included 46 patients who underwent esophageal dilatation between 2014-2019. All patients underwent a contrast study of the esophagus before endoscopic dilation to determine the location, number, and length of the narrowing. In addition, the type of dilators (balloon versus semi-rigid dilators), the number of dilatation sessions, the interval between them, and the duration of follow-up were also documented. The median age was 2.47 years, and 26 patients were females. Dysphagia was the main presenting symptom, and the leading cause of stricture was esophageal atresia.
RESULTS
The main treatment modality was endoscopic balloon dilatation (n=29, 63%). The esophageal diameter was significantly increased after dilation (9 [7-11] versus 12 [10-12.8]) mm; p less than 0.001). Topical mitomycin-C was used as adjuvant therapy in 3 patients (6.5%). Esophageal perforation was reported in 2 cases (4.3%). Patients needed a median of 3 dilatation sessions, 25-75th percentiles: 1-5, and the median duration between the first and last dilatation was 2.18 years 25-75th percentiles: 0.5-4.21.
CONCLUSION
Esophageal dilatation is effective for the management of children with esophageal stricture; however, repeated dilatation is frequent, especially in patients with corrosive strictures. Complications are not common, and open surgery is not frequently required.
Topics: Child, Preschool; Deglutition Disorders; Dilatation; Endoscopy, Gastrointestinal; Esophageal Atresia; Esophageal Perforation; Esophageal Stenosis; Female; Humans; Infant; Male; Reoperation; Retrospective Studies; Time Factors
PubMed: 32601640
DOI: 10.15537/smj.2020.7.25166 -
Practical Radiation Oncology Nov 2019Guidelines for the care of women undergoing pelvic radiation therapy (RT) recommend vaginal dilator therapy (VDT) to prevent radiation-induced vaginal stenosis (VS);... (Review)
Review
PURPOSE
Guidelines for the care of women undergoing pelvic radiation therapy (RT) recommend vaginal dilator therapy (VDT) to prevent radiation-induced vaginal stenosis (VS); however, no standard protocol exists. This review seeks to update our current state of knowledge concerning VS and VDT in radiation oncology.
METHODS AND MATERIALS
A comprehensive literature review (1972-2017) was conducted using search terms "vaginal stenosis," "radiation," and "vaginal dilator." Information was organized by key concepts including VS definition, time course, pathophysiology, risk factors, and interventions.
RESULTS
VS is a well-described consequence of pelvic RT, with early manifestations and late changes evolving over several years. Strong risk factors for VS include RT dose and volume of vagina irradiated. Resultant vaginal changes can interfere with sexual function and correlational studies support the use of preventive VDT. The complexity of factors that drive noncompliance with VDT is well recognized. There are no prospective data to guide optimal duration of VDT, and the consistency with which radiation oncologists monitor VS and manage its consequences is unknown.
CONCLUSIONS
This review provides information concerning VS definition, pathophysiology, and risk factors and identifies domains of VDT practice that are understudied. Prospective efforts to monitor and measure outcomes of patients who are prescribed VDT are needed to guide practice.
Topics: Constriction, Pathologic; Dilatation; Female; Humans; Radiation Oncology; Vagina
PubMed: 31302301
DOI: 10.1016/j.prro.2019.07.001 -
Gastroenterology Jun 2023For patients with achalasia experiencing persistent or recurrent symptoms after laparoscopic Heller myotomy (LHM), pneumatic dilation (PD) is the most frequently used... (Randomized Controlled Trial)
Randomized Controlled Trial
The Efficacy of Peroral Endoscopic Myotomy vs Pneumatic Dilation as Treatment for Patients With Achalasia Suffering From Persistent or Recurrent Symptoms After Laparoscopic Heller Myotomy: A Randomized Clinical Trial.
BACKGROUND & AIMS
For patients with achalasia experiencing persistent or recurrent symptoms after laparoscopic Heller myotomy (LHM), pneumatic dilation (PD) is the most frequently used treatment. Per-oral endoscopic myotomy (POEM) is increasingly being investigated as rescue therapy. This study aimed to determine the efficacy of POEM vs PD for patients with persistent or recurrent symptoms after LHM.
METHODS
This randomized multicenter controlled trial included patients after LHM with an Eckardt score >3 and substantial stasis (≥2 cm) on timed barium esophagogram and randomized to POEM or PD. The primary outcome was treatment success, defined as an Eckardt score of ≤3 and without unscheduled re-treatment. Secondary outcomes included the presence of reflux esophagitis, high-resolution manometry, and timed barium esophagogram findings. Follow-up duration was 1 year after initial treatment.
RESULTS
Ninety patients were included. POEM had a higher success rate (28 of 45 patients [62.2%]) than PD (12 of 45 patients [26.7%]; absolute difference, 35.6%; 95% CI, 16.4%-54.7%; P = .001; odds ratio, 0.22; 95% CI, 0.09-0.54; relative risk for success, 2.33; 95% CI, 1.37-3.99). Reflux esophagitis was not significantly different between POEM (12 of 35 [34.3%]) and PD (6 of 40 [15%]). Basal lower esophageal sphincter pressure and integrated relaxation pressure (IRP-4) were significantly lower in the POEM group (P = .034; P = .002). Barium column height after 2 and 5 minutes was significantly less in patients treated with POEM (P = .005; P = .015).
CONCLUSIONS
Among patients with achalasia experiencing persistent or recurrent symptoms after LHM, POEM resulted in a significantly higher success rate than PD, with a numerically higher incidence of grade A-B reflux esophagitis.
NETHERLANDS TRIAL REGISTRY
NL4361 (NTR4501), https://trialsearch.who.int/Trial2.aspx?TrialID = NTR4501.
Topics: Humans; Esophageal Achalasia; Heller Myotomy; Esophageal Sphincter, Lower; Dilatation; Barium; Treatment Outcome; Esophagitis, Peptic; Natural Orifice Endoscopic Surgery
PubMed: 36907524
DOI: 10.1053/j.gastro.2023.02.048 -
The Cochrane Database of Systematic... Sep 2014Vaginal dilation therapy is advocated after pelvic radiotherapy to prevent stenosis (abnormal narrowing of the vagina), but can be uncomfortable and psychologically... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Vaginal dilation therapy is advocated after pelvic radiotherapy to prevent stenosis (abnormal narrowing of the vagina), but can be uncomfortable and psychologically distressing.
OBJECTIVES
To assess the benefits and harms of different types of vaginal dilation methods offered to women treated by pelvic radiotherapy for cancer.
SEARCH METHODS
Searches included the Cochrane Central Register of Controlled Trials (CENTRAL 2013, Issue 5), MEDLINE (1950 to June week 2, 2013), EMBASE (1980 to 2013 week 24) and CINAHL (1982 to 2013).
SELECTION CRITERIA
Comparative data of any type, which evaluated dilation or penetration of the vagina after pelvic radiotherapy treatment for cancer.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed whether potentially relevant studies met the inclusion criteria. We found no trials and therefore analysed no data.
MAIN RESULTS
We identified no studies for inclusion in the original review or for this update. However, we felt that some studies that were excluded warranted discussion. These included one randomised trial (RCT), which showed no improvement in sexual scores associated with encouraging women to practise dilation therapy; a recent small RCT that did not show any advantage to dilation over vibration therapy during radiotherapy; two non-randomised comparative studies; and five correlation studies. One of these showed that objective measurements of vaginal elasticity and length were not linked to dilation during radiotherapy, but the study lacked power. One study showed that women who dilated tolerated a larger dilator, but the risk of objectivity and bias with historical controls was high. Another study showed that the vaginal measurements increased in length by a mean of 3 cm after dilation was introduced 6 to 10 weeks after radiotherapy, but there was no control group; another case series showed the opposite. Three recent studies showed less stenosis associated with prophylactic dilation after radiotherapy. One small case series suggested that dilation years after radiotherapy might restore the vagina to a functional length.
AUTHORS' CONCLUSIONS
There is no reliable evidence to show that routine, regular vaginal dilation during radiotherapy treatment prevents stenosis or improves quality of life. Several observational studies have examined the effect of dilation therapy after radiotherapy. They suggest that frequent dilation practice is associated with lower rates of self reported stenosis. This could be because dilation is effective or because women with a healthy vagina are more likely to comply with dilation therapy instructions compared to women with strictures. We would normally suggest that a RCT is needed to distinguish between a casual and causative link, but pilot studies highlight many reasons why RCT methodology is challenging in this area.
Topics: Anti-Inflammatory Agents; Benzydamine; Brachytherapy; Constriction, Pathologic; Dilatation; Estrogens; Female; Humans; Hyperbaric Oxygenation; Pelvis; Radiation Injuries; Radiotherapy; Rupture; Sexual Dysfunction, Physiological; Time Factors; Vagina
PubMed: 25198150
DOI: 10.1002/14651858.CD007291.pub3 -
Inflammatory Bowel Diseases May 2018Colectomy with ileoanal pouch is the standard of care for most patients with ulcerative colitis (UC) who require surgery. However, 5%-38% of patients with ileoanal pouch...
BACKGROUND AND AIMS
Colectomy with ileoanal pouch is the standard of care for most patients with ulcerative colitis (UC) who require surgery. However, 5%-38% of patients with ileoanal pouch develop pouch strictures that can severely impact the functional results. We retrospectively evaluated the efficacy and safety of endoscopic balloon dilation of ileoanal pouch strictures in patients with inflammatory bowel disease (IBD).
METHODS
All consecutive patients with IBD that underwent endoscopic balloon dilatation of a pouch stricture at our institution between January 1, 2011, and April 31, 2016, were included. Clinical, endoscopic, and surgical variables were collected retrospectively. Stricture-related pouch failure was defined by the need for surgical management of pouch stricture including pouch excision, diversion ileostomy, or stricturoplasty. Secondary outcomes included technical success, clinical success, and safety.
RESULTS
Eighty-eight endoscopic balloon dilatations were identified in 20 patients. Sixty percent of patients were female, with a median age at ileoanal pouch of 28.6 years (interquartile range [IQR], 25.5-37.2). Ileoanal pouch was performed for UC in 95% of cases; 95% of patients underwent J pouch; and 65% had a stapled anastomosis, whereas 35% had a handsewn anastomosis. Strictures were diagnosed at a median of 4.6 years (0.2-10.6) after surgery, and half of patients were symptomatic. The most frequent location of stricture was the anal-pouch anastomosis (87%). Half of patients were found to have associated pouchitis, 4 (20%) had at least 1 fistula, and 5 (25%) had ulcerations of the pouch. At the end of follow-up, 6 patients (30%) underwent a change in diagnosis from UC to Crohn's disease (CD) of the pouch, and in 1 patient (5%) a diagnosis of ischemic stricture was made. A median of 3.5 dilatations per patient (IQR, 2.0-7.0) were performed. Technical efficacy was observed in 87 procedures (98%). Twenty-two procedures were preceded by obstructive symptoms, and a clinical improvement after endoscopic balloon dilatation was observed in 95% of cases. After a median follow-up of 3.0 years (2.1-3.5), only 1 patient had stricture-related pouch failure. After the first dilatation, 4 patients were hospitalized for obstructive symptoms. Conservative management with another endoscopic balloon dilation was clinically effective in all cases. No major complications related to dilation were observed.
CONCLUSION
Endoscopic balloon dilatation of ileoanal pouch strictures is largely effective and safe and can be recommended as the first line strategy to treat ileoanal pouch strictures in patients with IBD.
Topics: Adult; Anastomosis, Surgical; Catheterization; Colectomy; Colonic Pouches; Constriction, Pathologic; Dilatation; Endoscopy, Gastrointestinal; Female; Humans; Inflammatory Bowel Diseases; Kaplan-Meier Estimate; Male; Middle Aged; Retrospective Studies; Treatment Outcome
PubMed: 29697797
DOI: 10.1093/ibd/izy006 -
The Cochrane Database of Systematic... Apr 2015Hysteroscopy is an operation in which the gynaecologist examines the uterine cavity using a small telescopic instrument (hysteroscope) inserted via the vagina and the... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Hysteroscopy is an operation in which the gynaecologist examines the uterine cavity using a small telescopic instrument (hysteroscope) inserted via the vagina and the cervix. Almost 50% of hysteroscopic complications are related to difficulty with cervical entry. Potential complications include cervical tears, creation of a false passage, perforation, bleeding, or simply difficulty in entering the internal os (between the cervix and the uterus) with the hysteroscope. These complications may possibly be reduced with adequate preparation of the cervix (cervical ripening) prior to hysteroscopy. Cervical ripening agents include oral or vaginal prostaglandin, which can be synthetic (e.g misoprostol) or natural (e.g. dinoprostone) and vaginal osmotic dilators, which can be naturally occurring (e.g. laminaria) or synthetic.
OBJECTIVES
To determine whether preoperative cervical preparation facilitates cervical dilatation and reduces the complications of operative hysteroscopy in women undergoing the procedure for any condition.
SEARCH METHODS
In August 2014 we searched sources including the Menstrual Disorders and Subfertility Group (MDSG) Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL, ClinicalTrials.gov and reference lists of relevant articles. We searched for published and unpublished studies in any language.
SELECTION CRITERIA
Two review authors independently selected randomised controlled trials (RCTs) of cervical ripening agents used before operative hysteroscopy in pre- and postmenopausal women. Cervical ripening agents could be compared to each other, placebo or no treatment.
DATA COLLECTION AND ANALYSIS
Data extraction and quality assessment were conducted independently by two review authors. The primary review outcomes were effectiveness of cervical dilatation (defined as the proportion of women requiring mechanical cervical dilatation) and intraoperative complications. Secondary outcomes were mean time required to dilate the cervix, preoperative pain, cervical width, abandonment of the procedure, side effects of dilating agents and duration of surgery. We calculated odds ratios (ORs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, with 95% confidence intervals ( CIs). Data were statistically pooled where appropriate. Heterogeneity was assessed using the I(2) statistic. The overall quality of the evidence was assessed using GRADE methods.
MAIN RESULTS
Nineteen RCTs with a total of 1870 participants were included. They compared misoprostol with no treatment or placebo, dinoprostone or osmotic dilators.Misoprostol was more effective for cervical dilatation than placebo or no intervention, with fewer women requiring mechanical dilatation (OR 0.08, 95% CI 0.04 to 0.16, five RCTs, 441 participants, I(2)=0%, moderate quality evidence). This suggests that in a population in which 80% of women undergoing hysteroscopy require mechanical dilatation without use of preoperative ripening agents, use of misoprostol will reduce the need for mechanical dilatation to between 14% and 39%. Misoprostol was associated with fewer intraoperative complications (OR 0.37, 95% CI 0.18 to 0.77, 12 RCTs, 901 participants, I(2)=0%, moderate quality evidence). This suggests that in a population in which 3% of women undergoing hysteroscopy experience intraoperative complications without use of preoperative ripening agents, use of misoprostol will reduce the risk of complications to 2% or less.When specific complications were considered, the misoprostol group had a lower rate of cervical laceration or tearing (OR 0.25, 95% CI 0.11 to 0.57, nine RCTS, 669 women, I(2)=0%, moderate quality evidence) or false track formation (OR 0.34, 95% CI 0.12 to 0.97, seven RCTs, 560 participants, I(2)=0%, moderate quality evidence). There was no evidence of a difference between the groups in rates of uterine perforation (0.42, 95% CI 0.13 to 1.38, seven RCTs, 455 participants, I(2)=0%, low quality evidence) or uterine bleeding (OR 0.51, 95% CI 0.10 to 2.49, four RCTs, 340 participants, I(2)=0%, low quality evidence). Some treatment side effects (mild abdominal pain, vaginal bleeding, and increased body temperature) were more common in the misoprostol group.Compared with dinoprostone, misoprostol was associated with more effective cervical dilatation, with fewer women requiring mechanical dilatation (OR 0.58; 95% CI 0.34 to 0.98; one RCT, 310 participants, low quality evidence) and with fewer intraoperative complications (OR 0.32; 95% CI 0.12 to 0.83, one RCT, 310 participants, low quality evidence). However treatment side effects were more common in the misoprostol arm.Compared to osmotic dilatation (laminaria), misoprostol was associated with less effective cervical dilatation, with more women in the misoprostol group requiring mechanical dilatation (OR 5.96, 95% CI 2.61 to 13.59, one RCT, 110 participants, low quality evidence). There was no evidence of a difference between misoprostol and osmotic dilators in intraoperative complication rates (OR 5.14, 95% CI 0.24 to 109.01, three RCTs, 354 participants, low quality evidence), with only two events reported altogether.The overall quality of the evidence ranged from low to moderate. The main limitations in the evidence were imprecision and poor reporting of study methods.
AUTHORS' CONCLUSIONS
There is moderate quality evidence that use of misoprostol for preoperative ripening of the cervix before operative hysteroscopy is more effective than placebo or no treatment and is associated with fewer intraoperative complications such as lacerations and false tracks. However misoprostol is associated with more side effects, including preoperative pain and vaginal bleeding. There is low quality evidence to suggest that misoprostol has fewer intraoperative complications and is more effective than dinoprostone.There is also low quality evidence to suggest that laminaria may be more effective than misoprostol, with uncertain effects for complication rates. However the possible benefits of laminaria need to be weighed against the inconvenience of its insertion and retention for one to two days.
Topics: Cervical Ripening; Cervix Uteri; Dilatation; Dinoprostone; Female; Humans; Hysteroscopy; Laminaria; Misoprostol; Oxytocics; Pregnancy; Preoperative Care; Randomized Controlled Trials as Topic
PubMed: 25906113
DOI: 10.1002/14651858.CD005998.pub2