DIGESTIVE ENDOSCOPY, Issue 1 2009
László Madácsy
Introduction:, The aim of the present study was to reduce post-endoscopic retrograde cholangiopancreatography (ERCP) complications with a combination of early needle-knife access fistulotomy and prophylactic pancreatic stenting in selected high-risk sphincter of Oddi dysfunction (SOD) patients with difficult cannulation. Methods:, Prophylactic pancreatic stent insertion was attempted in 22 consecutive patients with definite SOD and difficult cannulation. After 10 min of failed selective common bile duct cannulation, but repeated (>5×) pancreatic duct contrast filling, a prophylactic small calibre (3,5 Fr) pancreatic stent was inserted, followed by fistulotomy with a standard needle-knife, then a standard complete biliary sphincterotomy followed. The success and complication rates were compared retrospectively with a cohort of 35 patients, in which we persisted with the application of standard methods of cannulation without pre-cutting methods. Results:, Prophylactic pancreatic stenting followed by needle-knife fistulotomy was successfully carried out in all 22 consecutive patients, and selective biliary cannulation and complete endoscopic sphincterotomy were achieved in all but two cases. In this group, not a single case of post-ERCP pancreatitis was observed, in contrast with a control group of three mild, 10 moderate and two severe post-ERCP pancreatitis cases. The frequency of post-ERCP pancreatitis was significantly different: 0% versus 43%, as were the post-procedure (24 h mean) amylase levels: 206 U/L versus 1959 U/L, respectively. Conclusions:, In selected, high-risk, SOD patients, early, prophylactic pancreas stent insertion followed by needle-knife fistulotomy seems a safe and effective procedure with no or only minimal risk of post-ERCP pancreatitis. However, prospective, randomized studies are awaited to lend to support to our approach. [source]

Sphincter of Oddi dysfunction: role of sphincterotomy

DIGESTIVE ENDOSCOPY, Issue 4 2001
Choichi Sugawa
Sphincter of Oddi dysfunction (SOD) is one of the causes of post-cholecystectomy syndrome and biliary pain and is a challenge from both the diagnostic and therapeutic points of view. Sphincter of Oddi dysfunction is typically diagnosed months to years after cholecystectomy. Continued biliary type pain after cholecystectomy may occur in as many as 10,20% of patients. Ten percent or more of these patients may eventually be shown to have SOD. The syndrome is often associated with a variety of other gastrointestinal disorders thought to be caused by dysmotility. According to the Milwaukee classification, patients with biliary pain can be divided into three types. Type I patients show all the objective signs suggestive of a disturbed bile outflow (i.e. elevated liver function tests, dilated common bile duct and delayed contrast drainage during endoscopic retrograde cholangiopancreatography). Type II patients have biliary type pain along with one or two of the criteria from type I. Type III patients have biliary pain only, with no other abnormalities. The present paper will focus primarily on SOD syn-drome, papillary stenosis and the diagnostic and therapeutic approaches, in particular endoscopic sphincterotomy. [source]

Electrical activation of common bile duct nerves modulates sphincter of Oddi motility in the Australian possum

HPB, Issue 4 2005
Y. Sonoda
Abstract Background: Sphincter of Oddi (SO) motility is regulated by extrinsic and intrinsic nerves. The existence of neural circuits between the SO and the proximal extrahepatic biliary tree has been reported, but they are poorly understood. Using electrical field stimulation (EFS), we determined if a neural circuit exists between the common bile duct (CBD) and the SO in anaesthetized Australian brush-tailed possums. Methods: The gallbladder, cystic duct or CBD were subjected to EFS with a stimulating electrode. Spontaneous SO phasic waves were measured by manometry. Results: EFS at sites on the distal CBD (12,20 mm proximal to the SO), but less commonly at more proximal CBD, evoked a variety of responses consisting of an excitatory and/or inhibitory phase. Bi-phasic responses consisting of an excitation followed by inhibition were the most common. Tri-phasic responses were also observed as well as excitation or inhibition only. These evoked responses were blocked by topical application of local anaesthetic to the distal CBD or transection of the CBD. EFS at sites on the gallbladder body, neck or cystic duct did not consistently evoke an SO response. Pretreatment with atropine or guanethidine reduced the magnitude of the evoked response by about 50% (p<0.05), pretreatment with hexamethonium had no consistent effect and pretreatment with a nitric oxide synthase inhibitor increased the response. Discussion: A neural circuit(s) between the SO and the distal CBD modulates SO motility. Damage to this area of the CBD during bile duct exploration surgery could adversely affect SO motility. [source]

The feasibility and reliability of using circular electrode for sphincter of Oddi electromyography in anaesthetised rabbits

NEUROGASTROENTEROLOGY & MOTILITY, Issue 6 2009
F. Chen
Abstract, Sphincter of Oddi manometry (SOM) is the gold standard for assessing sphincter of Oddi dysfunction (SOD), but is considered a diagnostic sensitivity of 30,80% and associated with significant complications of pancreatitis. Electromyography (EMG) of sphincter of Oddi (SO) using a circular electrode (CE) may be useful in improving diagnostic accuracy and reducing complications. To evaluate the feasibility and reliability of the CE, we record myoelectric activity of SO in rabbits using the CE to compare with the traditional needle electrode (NE). The CE was prepared using a double-channel biogel catheter with two silver rings at the head of the catheter. The CE was then inserted into the lumen of the SO through the duodenal papilla, and myoelectric activity was recorded in the SO in 30 rabbits. An EMG recorded using an NE was performed at the same time, when the SO was in basal state, after injection of cholecystokinin and N-butylscopolamine bromide. Electromyographs recorded by the two methods were then evaluated. Satisfactory SO EMGs were acquired using the CE without any injury. Simultaneous recording revealed a very similar traces and one-to-one correspondence of SO spike bursts (SOSB). Linear regression analysis showed a significant direct correlation between the two methods for SOSB duration and amplitude. The results suggested that CE was comparable with NE in terms of recording efficacy. The CE also has advantages of easy fixation, accurate localisation, broad applicability and ease of achieving satisfactory outcomes without trauma, compared with the NE. [source]

New Enhancements of the Scrotal One-Incision Technique for Placement of Artificial Urinary Sphincter Allow Proximal Cuff Placement

THE JOURNAL OF SEXUAL MEDICINE, Issue 10 2010
Steven K. Wilson MD
ABSTRACT Introduction., Urinary incontinence impairs sexual functioning and sexual satisfaction. Traditional artificial urinary sphincter (AUS) implantation requires perineal incision for cuff placement and a second inguinal incision for reservoir and pump placement. We believed AUS could be placed easier and quicker through one scrotal incision. Aim., In an effort to effect more proximal placement of the cuff while keeping the advantages of the one scrotal incision technique, we report enhancements to the original surgical technique. Methods., Thirty patients have been operated upon using the enhanced technique. A modification of the SKW retractor system (AMS) facilitates deep bulbar exposure. Twenty patients were first time implantations and 10 were revisions with five of the revisions having had the original AUS placed by traditional two-incision technique. Two of the first time AUS patients received an inflatable penile prosthesis through the same incision. Main Outcome Measures., We evaluated site of cuff placement, sizes of cuffs used, postoperative continence status. Results., All of the virgin AUS required dissection of the bulbocavernosus muscle prior to cuff placement. In scrotally placed revisions, replacement cuffs were situated considerably proximal (4.5,7.5 cm) to the original cuff site. The perineal placed revisions were accomplished through a scrotal incision with replacement of two cuffs in the same site and the three other patients immediately distal. No intraoperative complications were seen. One patient developed scrotal hematoma requiring drainage. Only 15 patients are available for follow-up and all are socially continent (one pad or less). Conclusions., Transscrotal approach is used safely and efficiently for penile implants and AUS implantation. The new enhancements to the one-scrotal incision technique allow more proximal cuff placement as evidenced by the bulbocavernosus muscle dissection and use of larger cuffs. Continence rate is similar to rates achieved with perineal placement of cuff found in the literature. Wilson SK, Aliotta PJ, Salem EA, and Mulcahy JJ. New enhancements of the scrotal one incision technique for placement of artificial urinary sphincter allow proximal cuff placement. J Sex Med 2010;7:3510,3515. [source]

Role of Laryngeal Movement and Effect of Aging on Swallowing Pressure in the Pharynx and Upper Esophageal Sphincter,

THE LARYNGOSCOPE, Issue 3 2000
Masato Yokoyama MD
Abstract Objectives Describe contribution of laryngeal movement to pressure changes at the upper esophageal sphincter (UES) and the effect of aging on the swallowing function. Study Design Manofluorography on 56 nondysphagic adults divided into three age groups: the 21- to 31-year-old group (n = 32), the 61- to 74-year-old group (n = 12) and the 75- to 89-year-old group (n = 12). Analyses of the bolus transit time, the amplitudes and durations of pharyngeal pressures, the timing of a pressure fall at the UES and the laryngeal movements. Methods Intraluminal strain-gauge sensors recorded pressure changes in the oropharynx, hypopharynx and the UES. Motion pictures of the videotapes were fed into a personal computer, and movements of the hyoid bone were measured in both the horizontal and vertical directions as an indication of laryngeal movement. Results In 26- and 70-year-old men with calcification of the thyroid cartilage, it was determined that the larynx and hyoid bone moved in consonance until the end of the rapid hyoid movements in both the superior and anterior directions. In the 21- to 31-year-old group, the magnitude of the pressure fall at the UES was maximal before or almost at the same time as the bolus arrival, in preparation for smooth passage of the bolus from the pharynx to the esophagus. The rapid superior movements of the hyoid bone started significantly early as compared with its anterior movements (P = .0001). The rapid anterior movements of the hyoid bone started simultaneously with the pressure fall at the UES. In the elderly, all segmental transit times were significantly increased. The timing of the pressure fall at the UES was significantly delayed and the UES pressure reached its minimum value after arrival of the bolus at the UES. The minimum pressure at the UES increased to a significantly positive value. The rapid anterior movements of the hyoid were significantly delayed, suggesting that this delay causes the delay in the pressure fall at the UES. Conclusions The rapid superior and anterior movements of the hyoid bone are considered to start at the same time as those of the larynx. In the young group, it is suggested that superior laryngeal movement protects the lower airway prior to the anterior laryngeal movement, causing the pressure fall at the UES to enable the passage of a bolus into the UES. In the elderly, smooth passage of the bolus from the pharynx to the esophagus is hindered and the system that prevents aspiration is rendered inefficient by changes in the swallowing pressures and laryngeal movements with aging. [source]

PROPHYLACTIC PANCREAS STENTING FOLLOWED BY NEEDLE-KNIFE FISTULOTOMY IN PATIENTS WITH SPHINCTER OF ODDI DYSFUNCTION AND DIFFICULT CANNULATION: NEW METHOD TO PREVENT POST-ERCP PANCREATITIS

COMPARING BALLOON DIAMETER ON PERFORMING ENDOSCOPIC PAPILLARY BALLOON DILATATION WITH ISOSORBIDE DINITRATE DRIP INFUSION FOR REMOVAL OF BILE DUCT STONES

DIGESTIVE ENDOSCOPY, Issue 4 2004
Hiroshi Nakagawa
Background:, Endoscopic papillary balloon dilatation (EPBD) is one of the methods to remove bile duct stones. EPBD might preserve the function of the sphincter of Oddi despite the potential risk of acute pancreatitis. There are only a few reports of EPBD reducing the risk of acute pancreatitis and, at same time, preserving the function of the sphincter of Oddi. Methods:, We performed EPBD for bile duct stone removal in 60 patients using two balloons with different diameters. Patients were randomized to EPBD with a 6 mm balloon (n = 30) or an 8 mm balloon (n = 30). In both groups, isosorbide dinitrate (ISDN) was infused in a rate of 5 mg/h while low pressure EPBD were being performed. The pressure of the sphincter of Oddi was observed before and after the EPBD procedures. Also, serum amylase level after EPBD was observed for both groups. Results:, Serum amylase level of the 6 mm group was signi,cantly higher than that of the 8 mm group (P < 0.05). Acute pancreatitis occurred in two patients ( 6.7%) in the 6 mm group whereas no case was observed for the 8 mm group. The rates of duct clearance were 93% in the 6 mm group and 100% in the 8 mm group. Stone removals were dif,cult in seven cases with 6 mm balloon dilatations due to the narrow ori,ces of the papilla. In the 6 mm group, there was no signi,cant difference between the basal sphincter of Oddi pressure (BSOP) and the phasic sphincter of Oddi pressure (PSOP) before and after EPBD. However in the 8 mm group, the BSOP observed after the EPBD procedure was signi,cantly higher than BSOP before the treatments. Within this group, BSOP values after EPBD were preserved by approximately 80% of the BSOP values before the treatments. In contrast, there was no signi,cant difference in PSOP before and after the treatments. Regarding the stone numbers, no signi,cant difference was observed in BSOP before and after the treatments for the 6 mm group with less than two stones. Also, as for stone size, no signi,cant difference was observed in BSOP before and after the treatments for the 6 mm group with stones of less than 6 mm in diameter. Conclusion:, We are now conducting EPBD with ISDN infusion using a 6 mm balloon for a patient who has less than two stones with size not exceeding 6 mm in diameter. An 8 mm balloon is used for a patient with more than two stones or a stone greater than 6 mm in size. [source]

Gastrointestinal motility and the brain-gut axis

DIGESTIVE ENDOSCOPY, Issue 2 2003
TADASHI ISHIGUCHI
The role of the brain-gut axis in gastrointestinal motility is discussed according to the specific organs of the gastrointestinal tract. Not only clinical studies but basic animal research are reviewed. Although the mechanism of functional gut disorders remains to be clarified, recent data suggest that there is evidence that the brain-gut axis has significant effects on gastrointestinal motility. The major role of endoscopy in the diagnosis of functional gastrointestinal disorders is to exclude organic gastrointestinal disorders. In the esophagus, the lower esophageal sphincter and a gamma-aminobutyric acid B mechanism are considered to play important roles in gastroesophageal reflux disease. In the stomach, corticotropin-releasing factor, neuropeptide Y and other substances might be involved in the pathogenesis of non-ulcer dyspepsia. In the small intestine, corticotropin-releasing factor, gamma-aminobutyric acid B and other substances are considered to modulate intestinal transit via central mechanisms. In the colon, it is known that psychiatric factors are related to the onset and clinical course of irritable bowel syndrome. Serotonin, corticotropin-releasing factor, gamma-aminobutyric acid, orphanin FQ and neuropeptide Y have been reported as putative neurotransmitters. More efforts in basic science studies and animal and human studies of physiology of the gastointestinal tract are still required. These efforts will elucidate further mechanisms to clarify the etiology of motility disorders and encourage the investigation of new therapies in this field. [source]

Combined treatment of achalasia , botulinum toxin injection followed by pneumatic dilatation: long-term results

DISEASES OF THE ESOPHAGUS, Issue 2 2010
R. Kroupa
SUMMARY Injection of botulinum toxin (BT) and pneumatic dilatation are available methods in nonsurgical treatment of achalasia. Authors anticipate beneficial effect of prior BT injection on the success of pneumatic dilatation and duration of its effect. There are no long-term data available to assess efficacy of combined treatment. From 1998 to 2007, 51 consecutive patients (20 men and 31 women, age 24,83) with achalasia were included and prospectively followed up. Each patient received injection of 200 IU of BT into the lower esophageal sphincter (LES) during endoscopy and 8 days later pneumatic dilatation (PD) under X-ray control was performed. The follow-up was established every 3 months first year and then annually. The efficacy was evaluated by a questionnaire concerning patient's symptoms and manometry. Results were compared with 40 historical controls (16 men and 24 women, age 26,80) treated by PD alone using the same method and follow-up. Fifty-one patients underwent combined treatment. Four patients failed in follow-up and were not included for analysis. The mean duration of follow-up was 48 months with range 12,96 months. Thirty-four of forty-seven (72%) patients were satisfied with results with none or very rare and mild troubles at the time of the last visit. Forty-one patients were followed up more than 2 years. Effect of therapy lasted in 75% (31/41) of them. In 17 patients, more than 5 years after treatment, effect lasted in 12 (70%). Mean tonus of LES before therapy was 29 mm Hg (10,80), 3 months after therapy decreased to 14 mmHg (5,26). The cumulative 5 years remission rate (±95% CI) in combined treated patients 69% ± 8% was higher than in controls 50% ± 9%; however it, was not statistically significant (P= 0.07). In control group 1, case of perforation (2.5%) occurred. Eight patients (17%) with relapse of dysphagia were referred to laparoscopic Heller myotomy with no surgical complication. The main adverse effect was heartburn that appeared in 17 patients (36%). Initial injection of BT followed by PD seems to be effective for long-term results with fewer complications. But the combined therapy is not significantly superior to PD alone. [source]

Esophageal manometry in 28 systemic sclerosis Brazilian patients: findings and correlations

DISEASES OF THE ESOPHAGUS, Issue 8 2009
D. C. Calderaro
SUMMARY Systemic sclerosis (SSc) is a multisystem disease of unknown etiology. Esophageal involvement affects 50,90% of patients and is characterized by abnormal motility and hypotonic lower esophageal sphincter. Data on the association of esophageal abnormalities and age, gender, SSc subset or duration, autoantibody profile, esophageal symptoms, and medication are lacking or conflicting. The aim of this study was the evaluation of these associations in Brazilian sclerodermic patients from the Rheumatology Division, Clinics Hospital, Federal University, Minas Gerais. They underwent medical records review, clinical interview, and esophageal manometry. The normal cutoff level for lower esophageal sphincter pressure was 14 mmHg. Abnormal peristalsis occurred when less than 80% of peristaltic waves were propagated. P -values less than 0.05 were considered significant. Twenty-eight patients were included: 71% were women. The population presented medium age and disease duration of 46 years and 12 years, respectively. Cutaneous diffuse SSc occurred in 39% and its limited form in 61%. Dysphagia, pyrosis, and regurgitation occurred, respectively, in 71%, 43%, and 61% of patients. Lower esophageal sphincter pressure and number of peristaltic waves-propagated medias were, respectively, 17.2 mmHg and 2.3. SSc-related manometric abnormalities were present in 86% of patients. Manometry revealed distal esophageal body hypomotility, hypotonic lower esophageal sphincter, or both, respectively, in 82%, 39%, and 36% of patients. One patient presented the manometric pattern of esophageal achalasia. Male patients more frequently presented hypotonic inferior esophageal sphincter. Manometric findings have had no relationship with the other variables. Nifedipine use did not influence manometric findings. [source]

An increased proportion of inflammatory cells express tumor necrosis factor alpha in idiopathic achalasia of the esophagus

DISEASES OF THE ESOPHAGUS, Issue 5 2009
A. Kilic
SUMMARY Achalasia is a motility disorder characterized by the absence of coordinated peristalsis and incomplete relaxation of the lower esophageal sphincter. The etiology remains unclear although dense inflammatory infiltrates within the myenteric plexus have been described. The nature of these infiltrating cells is unknown. The aim of this study was to evaluate the expression of proinflammatory cytokines , namely, tumor necrosis factor alpha and interleukin-2 , in the distal esophageal muscle in patients with achalasia. Lower esophageal sphincter muscle from eight patients undergoing myotomy or esophagectomy for achalasia of the esophagus were obtained at the time of surgery. Control specimens consisted of similar muscle taken from eight patients undergoing operation for cancer or Barrett's esophagus. The expression of tumor necrosis factor alpha and interleukin-2 were assessed by immunohistochemistry. The total number of inflammatory cells within the myenteric plexus were counted in five high power fields. The percentage of infiltrating cells expressing tumor necrosis factor alpha or interleukin-2 was calculated. Clinical data including demographics, preoperative lower esophageal sphincter pressure, duration of symptoms, and dysphagia score (1 = no dysphagia to 5 = dysphagia to saliva) were obtained through electronic medical records. Statistical comparisons between the groups were made using the unpaired t -test, Fisher's exact test, or Mann,Whitney U test, with a two-tailed P -value less than 0.05 being considered significant. The total number of inflammatory cells was found to be similar between the groups. A significantly higher proportion of inflammatory cells expressed tumor necrosis factor alpha in achalasia as compared with controls (22 vs. 11%; P= 0.02). A similar percentage of infiltrating cells expressed interleukin-2 (40 vs. 41%; P= 0.87). Age, gender, preoperative lower esophageal sphincter pressure, or dysphagia score were not correlated to expression of these cytokines. There was, however, a significant inverse correlation between duration of symptoms and the proportion of inflammatory cells expressing tumor necrosis factor alpha in achalasia (P= 0.007). In conclusion, a higher proportion of infiltrating inflammatory cells expressed tumor necrosis factor alpha in achalasia. Furthermore, this proportion appears to be highest early in the disease process. Further studies are required to more clearly delineate the role of tumor necrosis factor alpha in the pathogenesis of this idiopathic disease. [source]

Body musculature of Beauchampiella eudactylota (Gosse, 1886) (Rotifera: Euchlanidae) with additional new data on its trophi and overall morphology

ACTA ZOOLOGICA, Issue 3 2009
O. Riemann
Abstract This study presents the results of confocal laser scanning microscopy and fluorescence-labelled phalloidin used to visualize the system of body musculature in Beauchampiella eudactylota. Moreover, the poorly known trophi of B. eudactylota are described based on scanning electron microscopy. In total, four paired longitudinal muscles (musculi longitudinales I,IV) and three circular muscles (musculi circulares I,III) were identified. Among these are the musculus longitudinalis ventralis, the musculus longitudinalis dorsalis and the musculus circumpedalis as documented in previous studies for other rotifer species. Compared to other species, B. eudactylota is characterized by the low number of lateral longitudinal muscles and the absence of some longitudinal muscles (musculi longitudinales capitum) and circular muscles (corona sphincter, musculus pars coronalis). Moreover, scanning electron microscopic data on the trophi of B. eudactylota reveal a number of striking similarities to the trophi in some species of Epiphanidae. This suggests that either (1) these similarities represent plesiomorphic characters present both in Epiphanidae and B. eudactylota or (2) they are synapomorphic features of B. eudactylota and some species of Epiphanidae, which would question the monophyly of Euchlanidae. [source]

Randomized controlled trial of intrasphincteric botulinum toxin A injection versus balloon dilatation in treatment of achalasia cardia

DISEASES OF THE ESOPHAGUS, Issue 3-4 2001
U. C. Ghoshal
As the few randomized controlled trials available in the literature comparing botulinum toxin (BT) injection with established endoscopic treatment of achalasia cardia, i.e. pneumatic dilatation, showed conflicting results, we conducted a prospective randomized trial. Seventeen consecutive patients with achalasia cardia diagnosed during a period between December 1997 and February 2000 were randomized into two treatment groups [pneumatic dilatation by Rigiflex dilator (n=10), BT injection by sclerotherapy needle into four quadrants of lower esophageal sphincter (LES) (n=7) 80 units in five cases, 60 units in two cases] after dysphagia grading, endoscopy, barium esophagogram, and manometry, all of which were repeated 1 week after treatment. Patients were followed up clinically for 35.2 ± 14 weeks. Chi-squares, Wilcoxon rank-sum test, Kaplan,Meier method and log-rank tests were used for statistical analysis. After 1 week, 6/7 (86%) BT-treated vs. 8/10 (80%) dilatation-treated patients improved (P=NS). There was no difference in LES pressure and maximum esophageal diameter in the barium esophagogram in the two groups before therapy. Both therapies resulted in significant reduction in LES pressure. The cumulative dysphagia-free state using the Kaplan,Meier method decreased progressively in BT-treated compared with dilatation-treated patients (P=0.027). Two patients with tortuous megaesophagus, one of whom had failed dilatation complicated by perforation previously, improved after BT. One other patient in whom pneumatic dilatation had previously failed improved in a similar manner. BT is as good as pneumatic dilatation in achieving an initial improvement in dysphagia of achalasia cardia. It is also effective in patients with tortuous megaesophagus and previous failed pneumatic dilatation. However, dysphagia often recurs during 1-year follow up. [source]

Epiphrenic diverticula: minimal invasive approach and repair in five patients

DISEASES OF THE ESOPHAGUS, Issue 1 2001
D. L. Van Der Peet
Epiphrenic esophageal diverticula are rare and often asymptomatic. If surgery is mandatory, a thoracotomy is used to resect the diverticulum. The results of a minimal invasive approach and repair in five patients are presented. These patients, who all presented with an epiphrenic diverticulum, were evaluated using barium swallow study, esophagoscopy, and manometry. The diverticula were approached by thoracoscopy in all patients and a description of the surgical technique is given. The diverticula were resected using a right-sided approach in four patients. One patient with a diverticulum in the distal esophagus required conversion to laparoscopy. A myotomy was performed in two patients because of high pressures in the lower esophageal sphincter. The postoperative course was uncomplicated in four patients. One patient with Ehlers,Danlos disease had a complicated course owing to leakage, resulting in two re-operations by means of thoracotomy. There was no mortality. The minimal invasive approach of epiphrenic diverticula is feasible. The long-term results are awaited. [source]

Manometric study in Kearns,Sayre syndrome

DISEASES OF THE ESOPHAGUS, Issue 1 2001
K. H. Katsanos
Although swallowing difficulties have been described in patients with Kearns,Sayre syndrome (KSS), the spectrum of manometric characteristics of dysphagia is not yet well known. Moreover, it is conceivable that a combination of various degrees of swallowing difficulties with different patterns in manometric studies exist, each playing a major role in the prognosis, natural history, and quality of life of KSS patients. An 18-year-old girl diagnosed at the age of 5 years with KSS (muscle biopsy) was admitted to our department with an upper respiratory tract infection and dysphagia. Clinical examination revealed growth retardation, external ophthalmoplegia, pigmentary retinopathy, impaired hearing, and ataxia. An electrocardiogram revealed cardiac conduction defects (long Q-T), and brain magnetic resonance imaging showed abnormalities in the cerebellar hemispheres. A manometric and motility study for dysphagia was conducted and the pharynx and upper esophageal sphincter (UES) resting pressures were similar to control group values, but the swallowing peak contraction pressure of the pharynx and the closing pressure of the UES were very low and could not promote effective peristaltic waves. Relaxation and coordination of the UES were not affected although pharyngeal and upper esophagus peristaltic waves proved to be very low and, consequently, were practically ineffective. The patient was started on treatment comprising a diet rich in potassium, magnesium, and calcium, and oral administration of vitamin D and co-enzyme Q10 100 mg daily; she was discharged 6 days later with apparent clinical improvement. [source]

Long-term follow-up of achalasic patients treated with botulinum toxin

DISEASES OF THE ESOPHAGUS, Issue 2 2000
D'Onofrio
Botulinum toxin A (BoTx), a potent inhibitor of acetylcholine release from nerve endings both within the myenteric plexus and at the nerve,muscle junction, has been shown to decrease the lower esophageal sphincter (LES) pressure in patients with achalasia. Because of this property, the esophageal injection of BoTx has been suggested as an alternative treatment in achalasia. The objective of this study was to determine the long-term efficacy and safety of intrasphincteric injection of BoTx in a group of achalasic patients. Nineteen patients (mean age 56.1 ± 19.2 years) were enrolled in the study. All of them were injected endoscopically with 100 U of BoTx by sclerotherapy needle at different sites of the LES. Symptom score (dysphagia, regurgitation and chest pain, each on a 0,3 scale), esophageal manometer and esophageal radionuclide emptying were assessed before the treatment and at 4 weeks, 3 months and 1 year after BoTx injection. In case of failure or relapse (symptom score >2), the treatment was repeated. All but five patients (74%) were in clinical remission at 1 month. Mean symptom score after 1 month of BoTx decreased from 7.1 ± 0.9 to 2.2 ± 2.5 (p < 0.05). LES pressure decreased from 38.4 ± 13.7 to 27.4 ± 13.5 mmHg (p < 0.05) and 10-min radionuclide retention decreased from 70.9 ± 20.7% to 33.8 ± 27.0% (p < 0.05). Side-effects (transient chest pain) were mild and infrequent. At 12 months, the clinical score was 0.9 ± 0.5 (p < 0.05 vs. basal); mean LES pressure was 22.0 ± 7.1 (p < 0.05 vs. basal) and 10-min radionuclide retention was 15.8 ± 6.0% (p < 0.05 vs. basal). The efficacy of the first injection of BoTx lasted for a mean period of 9 months (range 2,14 months). At the time of writing (follow-up period mean 17.6 months, range 2,31), 14 patients (10 with one injection) were still in remission (74%). Our results showed that one or two intrasphincteric injections of BoTx resulted in clinical and objective improvement in about 74% of achalasic patients and are not associated with serious adverse effects; the efficacy of BoTx treatment was long lasting; this procedure could be considered an attractive treatment, especially in elderly patients who are poor candidates for more invasive procedures. [source]

Esophageal motility changes after endoscopic intravariceal sclerotherapy with absolute alcohol

DISEASES OF THE ESOPHAGUS, Issue 2 2000
Ghoshal
Endoscopic sclerotherapy (EST) leads to structural and motility changes in the esophagus; the former are thought to be commoner after EST with absolute alcohol (AA), which is a commonly used sclerosant in India as it is cheap and effective. There are no previous studies on changes in esophageal motility after EST with AA. Accordingly, we studied patients with portal hypertension before (n = 24) and after (n = 22) variceal obliteration by EST with AA using a water perfusion esophageal manometry system. Contraction amplitude in the distal esophagus was reduced in the post-EST group compared with the pre-EST group (63.4 ± 24.9 vs. 18.2 ± 14.3 mmHg, p < 0.01). Duration of esophageal contraction in both the proximal and distal esophagus became prolonged in the post-EST compared with the pre-EST group (3.3 ± 0.8 vs. 5.4 ± 2.6 and 4.3 ± 1.1 vs. 6.6 ± 2.3 s, p < 0.001 for both). Lower esophageal sphincter (LES) pressure was reduced in the post-EST compared with the pre-EST group, although the difference was not significant statistically. Abnormal contraction waveforms were more frequent in the post-EST group. One patient in the post-EST group had persistent dysphagia in the absence of endoscopically documented stricture at the time of manometric study. This study shows frequent occurrence of esophageal dysmotility after EST with AA; however, esophageal dysmotility after EST was infrequently associated with motor dysphagia. [source]

The Use of Contrast Echocardiography in the Diagnosis of an Unusual Cause of Congestive Heart Failure: Achalasia

ECHOCARDIOGRAPHY, Issue 2 2004
George Stoupakis M.D.
Extrinsic compression of the left atrium is a potentially life-threatening but unusual cause of congestive heart failure. Achalasia is a motility disorder characterized by impaired relaxation of the lower esophageal sphincter and dilation of the distal two-thirds of the esophagus. We report only the third known case in the world literature of massive left atrial compression by a dilated esophagus in a patient with achalasia. The use of contrast echocardiography with perflutren protein-type A microspheres allowed for differentiation between a compressive vascular structure and the esophagus. This resulted in prompt treatment leading to hemodynamic stability after nasogastric decompression and Botulinum toxin injection at the gastroesophageal junction. (ECHOCARDIOGRAPHY, Volume 21, February 2004) [source]

Effect of paddock vs. stall housing on 24 hour gastric pH within the proximal and ventral equine stomach

EQUINE VETERINARY JOURNAL, Issue 4 2008
L. HUSTED
Summary Reasons for performing study: Stall housing has been suggested as a risk factor for ulcer development in the equine stomach; however, the exact pathogenesis for this has not been established. Objectives: To investigate the effect of 3 environmental situations (grass paddock, stall alone or stall with adjacent companion) on pH in the proximal and the ventral stomach. Methods: Six horses with permanently implanted gastric cannulae were used in a randomised, cross-over, block design. Each horse rotated through each of three 24 h environmental situations. Horses remained on their normal diet (grass hay ad libitum and grain b.i.d.) throughout the study. Intragastric pH was measured continuously for 72 h just inside the lower oesophageal sphincter (proximal stomach) and via a pH probe in the gastric cannula (ventral stomach). Results: Neither proximal nor ventral 24 h gastric pH changed significantly between the 3 environmental situations. Mean hourly proximal gastric pH decreased significantly in the interval from 01.00,09.00 h compared to the interval from 13.00,20.00 h, regardless of environmental situation. Median hourly proximal pH only differed in the interval from 06.00,07.00 h compared to the interval 14.00,19.00 h. Neither mean nor median hourly ventral gastric pH varied significantly with the time of day. Conclusions: The change in housing status used in the current study did not affect acid exposure within either region of the equine stomach. The pH in the ventral stomach was uniformly stable throughout the study, while the proximal pH demonstrated a 24 h circadian pattern. Potential relevance: Since stall housing was not associated with prolonged acid exposure to the proximal stomach, this aspect alone does not explain the increased risk of squamous ulcer development. The circadian rhythm associated with proximal intragastric pH warrants further investigation. [source]

Electrical activation of common bile duct nerves modulates sphincter of Oddi motility in the Australian possum

Autologous bone-marrow-derived mesenchymal stem cell transplantation into injured rat urethral sphincter

INTERNATIONAL JOURNAL OF UROLOGY, Issue 4 2010
Yoshiaki Kinebuchi
Objectives: To evaluate the functional and histological recovery by autologous bone-marrow-derived mesenchymal stem cell (BMSC) transplantation into injured rat urethral sphincters. Methods: BMSC were harvested from female Sprague,Dawley retired breeder rats for later transplantation. The cells were cultured, and transfected with the green fluorescence protein gene. The urethral sphincters were injured by combined urethrolysis and cardiotoxin injection. One week after injury, the cultured BMSC were injected autologously into the periurethral tissues. Controls included sham-operated rats and injured rats injected with cell-free medium (CFM). Abdominal leak point pressures (LPP) were measured before and after surgery during the following 13 weeks. The urethras were then retrieved for histological evaluation. The presence of green-fluorescence-protein-labeled cells and the regeneration of skeletal muscles, smooth muscles, and peripheral nerves were evaluated by immunohistochemical staining. Results: LPP was significantly reduced in the injured rats. It increased gradually after transplantation, but there was no significant difference between the BMSC and CFM groups. In the BMSC group, transplanted cells survived and differentiated into striated muscle cells and peripheral nerve cells. The proportions of skeletal muscle cells and peripheral nerves in the urethra were significantly greater in the BMSC group compared to the CFM group. Conclusions: Despite a clear trend towards recovery of LPP in BMSC-transplanted urethras, no significant effect was detected. Further study is required for clinical applications for the treatment of stress urinary incontinence. [source]

Editorial Comment to Autologous bone-marrow-derived mesenchymal stem cell transplantation into injured rat urethral sphincter

INTERNATIONAL JOURNAL OF UROLOGY, Issue 4 2010
Hitoshi Masuda md phd
No abstract is available for this article. [source]

Current use of the artificial urinary sphincter and its long-term durability: A nationwide survey in Japan

INTERNATIONAL JOURNAL OF UROLOGY, Issue 1 2009
Yoichi Arai
Objectives: Although the artificial urinary sphincter (AUS) is one of the most effective surgical treatments for severe urinary incontinence, little is known about its use in Japan. A nationwide survey was done to determine contemporary trends in AUS use and its long-term durability. Methods: Data on AUS units sold in Japan were provided directly by Takai Hospital Supply Co., Ltd., Tokyo, Japan, and a survey form was sent to all 44 institutes where AUS implantation had been carried out. The survey included various demographic and preoperative variables, surgical variables, and postoperative outcomes. Results: Between 1994 and 2007, a total of 100 AUS devices had been provided in Japan. Of the 44 institutes, 24 responded to the survey, and a total of 64 patients were enrolled in the study. Post-urological surgery incontinence accounted for 81.3% of the indications. During the mean follow-up of 50 months, mechanical failure occurred in four (6.2%), and the device was removed in 13 (20.3%) due to infection (14.0%), erosion (4.7%), or urination difficulty (1.5%). Of the 58 patients evaluated, 91.4% reported social continence. Five- and 10-year failure-free rates were 74.8% and 70.1%, respectively. On multivariate analysis, operative time was an independent predictor of treatment failure (P = 0.0334). Conclusions: Considering recent trends in prostate surgery, the AUS may be significantly underused in Japan. Although excellent long-term durability has been achieved, a learning effect appears to be evident. The Japanese urological community needs to provide appropriate patients with this treatment option. [source]

Urodynamic findings in children with cerebral palsy

INTERNATIONAL JOURNAL OF UROLOGY, Issue 8 2005
M IHSAN KARAMAN
Abstract Aim: More than one-third of children with cerebral palsy are expected to present with dysfunctional voiding symptoms. The voiding dysfunction symptoms of the cerebral palsy patients in the present study were documented. Methods: Of the study group, 16 were girls and 20 were boys (mean age: 8.2 years). Children with cerebral palsy were evaluated with urodynamics consisting of flow rate, filling and voiding cystometry, and electromyography findings of the external urethral sphincter to determine lower urinary tract functions. Treatment protocols were based on the urodynamic findings. Anticholinergic agents to reduce uninhibited contractions and to increase bladder capacity were used as a treatment. Clean intermittent catheterization and behavioral modification were used for incomplete emptying. Results: Of the children, 24 (66.6%) were found to have dysfunctional voiding symptoms. Daytime urinary incontinence (47.2%) and difficulty urinating (44.4%) were the most common symptoms. Urodynamic findings showed that neurogenic detrusor overactivity (involuntary contractions during bladder filling) with a low bladder capacity was present in 17 (47.2%) children, whereas detrusor,sphincter dyssynergia was present in four patients (11%). The mean bladder capacity of patients with a neurogenic bladder was 52.2% of the expected capacity. Conclusions: The present study concluded that voiding dysfunction was seen in more than half of the children with cerebral palsy, which is a similar result to other published studies. We propose that a rational plan of management of these patients depends on the evaluation of the lower urinary tract dysfunction with urodynamic studies. These children benefit from earlier referral for assessment and treatment. [source]

Body positions and esophageal sphincter pressures in obese patients during anesthesia

ACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 4 2010
A. DE LEON
Background: The lower esophageal sphincter (LES) and the upper esophageal sphincter (UES) play a central role in preventing regurgitation and aspiration. The aim of the present study was to evaluate the UES, LES and barrier pressures (BP) in obese patients before and during anesthesia in different body positions. Methods: Using high-resolution solid-state manometry, we studied 17 patients (27,63 years) with a BMI,35 kg/m2 who were undergoing a laparoscopic bariatric surgery before and after anesthesia induction. Before anesthesia, the subjects were placed in the supine position, in the reverse Trendelenburg position (+20°) and in the Trendelenburg position (,20°). Thereafter, anesthesia was induced with remifentanil and propofol and maintained with remifentanil and sevoflurane, and the recordings in the different positions were repeated. Results: Before anesthesia, there were no differences in UES pressure in the different positions but compared with the other positions, it increased during the reverse Trendelenburg during anesthesia. LES pressure decreased in all body positions during anesthesia. The LES pressure increased during the Trendelenburg position before but not during anesthesia. The BP remained positive in all body positions both before and during anesthesia. Conclusion: LES pressure increased during the Trendelenburg position before anesthesia. This effect was abolished during anesthesia. LES and BPs decreased during anesthesia but remained positive in all patients regardless of the body position. [source]

Comparison of the contractile properties, oxidative capacities and fibre type profiles of the voluntary sphincters of continence in the rat

JOURNAL OF ANATOMY, Issue 3 2010
Maria Buffini
Abstract The external urethral sphincter (EUS) and external anal sphincter (EAS) are the principal voluntary striated muscles that sustain continence of urine and faeces. In light of their common embryological origin, shared tonic sphincteric action and synchronized electrical activity in vivo, it was expected that they would exhibit similar physiological and structural properties. However, the findings of this study using paired observations of both sphincters isolated from the rat show clearly that this is not the case. The anal sphincter is much more fatigable than the urethral sphincter. On completion of a fatigue protocol, the amplitude of the last twitch of the EAS had declined to 42 ± 3% of the first twitch, whereas the last twitch of the EUS was almost identical to that of the first (95 ± 3%). Immunocytochemical detection of myosin heavy-chain isoforms showed that this difference was not due to the presence of more slow-twitch oxidative type 1 fibres in the EUS compared with the EAS (areal densities 4 ± 1% and 5 ± 1%, respectively; P = 0.35). In addition, the fatigue difference was not explained by a greater contribution to force production by fast oxidative type 2A fibres in the urethral sphincter. In fact, the anal sphincter contained a higher areal density of type 2A fibres (56 ± 5% vs. 37 ± 4% in the EUS, P = 0.017). The higher oxidative capacity of the EUS, measured histochemically, explained its fatigue resistance. These results were surprising because the fatigue-resistant urethral muscle exhibited faster single-twitch contraction times compared with the anal sphincter (56 ± 0.87 ms vs. 72.5 ± 1.16 ms, P < 0.001). Neither sphincter expressed the type 2X myosin isoform but the fast-twitch isoform type 2B was found exclusively in the EUS (areal density 16 ± 2%). The type 2B fibres of the EUS were small (diameter 19.5 ± 0.4 ,m) in comparison to typical type 2B fibres of other muscles. As a whole the EUS is a more oxidative than glycolytic muscle. In conclusion, analysis of the twitch mechanics and fatigue of two sphincters showed that the EUS contained more fatigue-resistant muscle fibres compared with the EAS. [source]

Correlation between gross anatomical topography, sectional sheet plastination, microscopic anatomy and endoanal sonography of the anal sphincter complex in human males

JOURNAL OF ANATOMY, Issue 2 2009
S. Al-Ali
Abstract This study elucidates the structure of the anal sphincter complex (ASC) and correlates the individual layers, namely the external anal sphincter (EAS), conjoint longitudinal muscle (CLM) and internal anal sphincter (IAS), with their ultrasonographic images. Eighteen male cadavers, with an average age of 72 years (range 62,82 years), were used in this study. Multiple methods were used including gross dissection, coronal and axial sheet plastination, different histological staining techniques and endoanal sonography. The EAS was a continuous layer but with different relations, an upper part (corresponding to the deep and superficial parts in the traditional description) and a lower (subcutaneous) part that was located distal to the IAS, and was the only muscle encircling the anal orifice below the IAS. The CLM was a fibro-fatty-muscular layer occupying the intersphincteric space and was continuous superiorly with the longitudinal muscle layer of the rectum. In its middle and lower parts it consisted of collagen and elastic fibres with fatty tissue filling the spaces between the fibrous septa. The IAS was a markedly thickened extension of the terminal circular smooth muscle layer of the rectum and it terminated proximal to the lower part of the EAS. On endoanal sonography, the EAS appeared as an irregular hyperechoic band; CLM was poorly represented by a thin irregular hyperechoic line and IAS was represented by a hypoechoic band. Data on the measurements of the thickness of the ASC layers are presented and vary between dissection and sonographic imaging. The layers of the ASC were precisely identified in situ, in sections, in isolated dissected specimens and the same structures were correlated with their sonographic appearance. The results of the measurements of ASC components in this study on male cadavers were variable, suggesting that these should be used with caution in diagnostic and management settings. [source]

Esophageal motility in patients with sliding hiatal hernia and reflux esophagitis

JOURNAL OF DIGESTIVE DISEASES, Issue 2 2002
Ping YE
OBJECTIVE: To study the radiographic and esophageal motility changes that are characteristic of patients with both sliding hiatus hernia (HH) and reflux esophagitis. METHODS: Thirty patients were diagnosed with HH by using gastroscopy. These patients were divided into two groups according to the severity of their esophagitis: group HH1 (grades A and B, n= 18); group HH2 (grades C and D, n= 12). Sliding HH was confirmed by barium meal examination. Radiographic techniques were used to test for spasms and strictures, the coarseness of the mucosa, and to study the types of reflux and clearance. Esophageal pH (24-h), lower esophageal sphincter pressure and the frequency and amplitude of esophageal peristalsis during reflux were also studied. RESULTS: Radiography revealed that the mucosa was coarse in all cases. Eighty percent of patients had sucking reflux and 36.7% had passive clearance. The percentages of total, supine and upright acid exposure times were greater in patients with HH than those in the controls (P < 0.01), but the difference between the HH1 and HH2 groups was not significant. Lower esophageal sphincter resting pressure was less in the HH group than that in the control group (P < 0.05). However, there were no differences in the length of the sphincter among groups. During episodes of acid reflux, the frequency and amplitude of peristalsis, and the percentage of normal primary esophageal peristalsis were all lower in HH patients than in the controls, and the duration of peristalsis was increased relative to that of the controls (P < 0.05). CONCLUSIONS: Sucking reflux and passive clearance are very important in HH. Esophageal acid exposure time does not correlate with the severity of esophagitis. Lowered lower esophageal sphincter resting pressure, decreased frequency and amplitude, and increased duration of esophageal peristalsis during the episode of reflux may play an important role in the pathogenesis of sliding HH. [source]

The ontogeny of the alimentary tract of larval pandora, Pagellus erythrinus L.

JOURNAL OF FISH BIOLOGY, Issue 2004
V. Micale
The ontogenesis of the alimentary tract and its associated structures (liver, pancreas, gall bladder) was studied in common pandora Pagellus eythrinus L., a promising species for diversification in Mediterranean aquaculture. Mass production of pandora has been limited so far by high larval and juvenile mortalities, which appear to be related to nutritional deficiencies. The development of the larval digestive system was studied histologically from hatching (0 DAH) until day 50 (50 DAH) in reared specimens, obtained by natural spawning from a broodstock adapted to captivity. At first feeding (3,4 DAH) both the mouth and anus had opened and the digestive tract was differentiated in four portions: buccopharynx, oesophagus, incipient stomach and intestine. The pancreas, liver and gall bladder were also differentiated at this stage. Soon after the commencement of exogenous feeding (5,6 DAH), the anterior intestinal epithelium showed large vacuoles indicating the capacity for absorption of lipids, whereas acidophilic supranuclear inclusions indicating protein absorption were observed in the posterior intestinal epithelium. Both the bile and main pancreatic ducts had opened in the anterior intestine, just after the pyloric sphincter, at this stage. Intestinal coiling was apparent since 4 DAH, while mucosal folding began at 10 DAH. Scattered mucous cells occurred in the oral cavity and the intestine, while they were largely diffused in the oesophagus. Gastric glands and pyloric caeca were firstly observed at 28 DAH and appeared well developed by 41 DAH, indicating the transition from larval to juvenile stage and the acquisition of an adult mode of digestion. [source]