Giant bile duct dilatation in newborn:A case report

BACKGROUND Giant congenital biliary dilation(CBD)is a rare condition observed in clinical practice.Infants born with this condition often experience a poor overall health status,and the disease progresses rapidly,leading to severe biliary obstruction,infections,pressure exerted by the enlarged CBD on abdominal organs,disturbances in the internal environment,and multiple organ dysfunction.The treatment of giant CBD using laparoscopy is challenging due to the high degree of variation in the shape of the bile duct and other organs,making it difficult to separate the bile duct wall from adjacent tissues or to control bleeding.CASE SUMMARY Herein,we present the details of an 11-d-old male newborn who was diagnosed with giant CBD.The patient was admitted to the neonatal surgery department of our hospital due to a history of common bile duct cyst that was detected more than 3 mo ago,and also because the patient had been experiencing yellowish skin for the past 9 d.The abnormal echo in the fetal abdomen was first noticed by the patient’s mother during a routine ultrasound examination at a local hospital,when the patient was at 24 wk+6 d of pregnancy.This finding raised concerns about the possibility of congenital biliary dilatation(22 mm×21 mm).Subsequent ultrasound examinations at different hospitals consistently confirmed the presence of a congenital biliary dilatation.No specific treatment was administered for biliary dilatation during this period.A computed tomography scan conducted during the hospitalization revealed a large cystic mass in the right upper quadrant and pelvis,measuring approximately 9.2 cm×7.4 cm×11.3 cm.Based on the CONCLUSION The analysis reveals that prenatal imaging techniques,such as ultrasound and magnetic resonance imaging,play a crucial role in the early diagnosis,fetal prognosis,and treatment plan for giant CBD.Laparoscopic surgery for giant CBD presents certain challenges,including difficulties in separating the cyst wall,anastomosis,and hemostasis,as well as severe biliary system infection and ulceration.Consequently,there is a high likelihood of converting to laparotomy.The choice between surgical methods like hepaticojejunostomy(HJ)or hepaticoduodenostomy has not been standardized yet.However,we have achieved favorable outcomes using HJ.Preoperative management of inflammation,biliary drainage,liver function protection,and supportive treatment are particularly vital in improving children’s prognosis.After discharge,it is essential to conduct timely reexamination and close follow-up to identify potential complications.

MEAN APPROXIMATION BY DILATATIONS IN BERGMAN SPACES ON THE UPPER HALF-PLANE

We study sufficient conditions on radial and non-radial weight functions on the upper half-plane that guarantee norm approximation of functions in weighted Bergman,weighted Dirichlet,and weighted Besov spaces on the upper half-plane by dilatations and eventually by analytic polynomials.

Distal Ureteric Dilatations Functioning as Urinary Reservoir in a Case of Ectopic Vesicae;A Case Report

Background: Bladder exstrophy is a rare congenital malformation of the genitourinary system, with an estimated incidence of approximately 1 per 50,000 live births. Clinically, patients do not have capacity to accumulate urine and urine continously leak. We present patient with partial storing capacity from the dialated distal ureters. A case of dialated distal ureters from an 8-year-old female patient with ectopic vesicae is described. The dialated ureters act as reservoir of urine where the patient is partially continent in the night time. These dialated ureters are the compensation for the literally absent bladder. During reconstruction, we observed that they can be used as an additional bladder volume reducing risk of reconstruction failure from tension.

Is endoscopic papillary balloon dilatation really a risk factor for post-ERCP pancreatitis?

Endoscopic papillary balloon dilatation(EPBD) is useful for decreasing early complications of endoscopic retrograde cholangio-pancreatography(ERCP), including bleeding, biliary infection, and perforation, but it is generally avoided in Western countries because of a relatively high reported incidence of post-ERCP pancreatitis(PEP). However, as the efficacy of endoscopic papillary largeballoon dilatation(EPLBD) becomes widely recognized, EPBD is attracting attention. Here we investigate whether EPBD is truly a risk factor for PEP, and seek safer and more effective EPBD procedures by reviewing past studies. We reviewed thirteen randomised control trials comparing EPBD and endoscopic sphincterotomy(EST) and ten studies comparing direct EPLBD and EST. Three randomized controlled trials of EPBD showed significantly higher incidence of PEP than EST, but no study of EPLBD did. Careful analysis of these studies suggested that longer and higher-pressure inflation of balloons might decrease PEP incidence. The paradoxical result that EPBD with small-calibre balloons increases PEP incidence while EPLBD does not may be due to insufficient papillary dilatation in the former. Insufficient dilatation could cause the high incidence of PEP through the use of mechanical lithotripsy and stress on the papilla at the time of stone removal. Sufficient dilation of the papilla may be useful in preventing PEP.

Narrow portion of the terminal choledochus is a cause of upstream biliary dilatation in patients with anomalous union of the pancreatic and biliary ducts

AIM: To clarify the pathogenesis of biliary dilatation associated with anomalous union of the pancreatic and biliary ducts (AUPBD).METHODS: Direct cholangiopancreatograms of 350 adult patients with or with suspicion of hepatobiliary or pancreatic disorders were reviewed. AUPBD was diagnosed cholangiopancreatographically, when the pancreaticobiliary ductal union was located above the narrow distal segment of the bile duct, which represents the action of the sphincter of Oddi. The narrow portion of the terminal choledochus was defined as symmetrical stricture of the common bile duct just above the pancreaticobiliary ductal union.RESULTS: AUPBD was found in 36 patients. Among cholangiopancreatographic features, the narrow portion of the terminal choledochus was the most pathognomonic for AUPBD (accuracy, 98%); it was present in 29 (81%)patients with AUPBD, but was not found in any patients without AUPBD. Among patients with AUPBD, biliary dilatation (＞10 mm) was more frequent in those with the narrow portion of the terminal choledochus (23/29)than in those without (2/7; P = 0.018) AUPBD. Among the patients with both AUPBD and the narrow portion of the terminal choledochus, there was a strong negative correlation between the minimum diameter of the narrow portion and the maximum diameter of the choledochus (r = -0.78, P＜0.001), suggesting that the degree of biliary narrowing at the narrow portion correlates with that of upstream biliary dilatation.CONCLUSION: The narrow portion of the terminal choledochus, a pathognomonic radiologic feature of AUPBD, may be a cause of biliary dilatation in patients with AUPBD.

Meta-analysis comparison of endoscopic papillary balloon dilatation and endoscopic sphincteropapillotomy

AIM: To assess endoscopic papillary balloon dilatation (EPBD) and endoscopic sphincteropapillotomy (EST) for common bile duct (CBD) stone removal using a meta-analysis. METHODS: Randomized controlled trials published from 1990 to 2012 comparing EPBD with EST for CBD stone removal were evaluated. This meta-analysis was performed to estimate short-term and long-term com-plications of these two treatments. The fixed random effect model or random effect model was established to analysis the data. Results were obtained by analyz-ing the relative risk, odds ratio, and 95%CI for a given comparison using RevMan 5.1. Statistical significance was defined asP < 0.05. Risk of bias was evaluated us-ing a funnel plot. RESULTS: Of the 1975 patients analyzed, 980 of them were treated with EPBD and 995 were treated with EST. Of the patient population, patients in the EPBDgroup were younger (OR=-1.16, 95%CI:-1.49 to 0.84, P<0.01). There were no significant differences in gender proportion, average size of stones, number of gallstones, previous cholecystectomy, the incidence of duodenal diverticulum, CBD diameter or the total follow-up time between EST and EPBD groups. Com-pared with EST, the total stone clearance in the EPBD group decreased (OR=0.64, 95%CI: 0.42 to 0.96,P=0.03), the use of stone extraction baskets significantly increased (OR=1.91, 95%CI: 1.41 to 2.59, P<0.01), and the incidence of pancreatitis significantly increased (OR=2.79, 95%CI: 1.74 to 4.45, P<0.0001). The incidence of bleeding (OR=0.12, 95%CI: 0.04 to 0.34, P<0.01) and cholecystitis (OR=0.41, 95%CI: 0.20 to 0.84, P=0.02) significantly decreased. The stone re-currence rate also was significantly reduced in EPBD (OR=0.48, 95%CI: 0.26 to 0.90, P=0.02). There were no significant differences between the two groups with the incidence of stone removal at first attempt, hours of operation, total short-term complications and infection, perforation, or acute cholangitis. CONCLUSION: Although the incidence of pancreatitis was higher, the overall stone clearance rate and risk of bleeding was lower with EPBD compared to EST.

Nasobiliary drainage after endoscopic papillary balloon dilatation may prevent postoperative pancreatitis

AIM:To evaluate the necessity of endoscopic nasobiliary drainage(ENBD)catheter placement after clearance of common bile duct(CBD)stones.METHODS:Patients enrolled in this study were randomly divided into two groups,according to whether or not they received ENBD after the removal of CBD stones.Group 1(ENBD group)was then subdividedinto three groups:G1a patients received an endoscopic papillary balloon dilatation(EPBD),G1b patients received an endoscopic sphincterotomy(EST),and G1c patients received neither.Group 2(non-ENBD group)patients were also subdivided into three groups(G2a,G2b,and G2c),similar to Group 1.The maximum CBD diameter,the time for C-reactive protein(CRP)to normalize,levels of serum amylase,total serum bilirubin(TB)and alanine aminotransferase(ALT),and postoperative hospitalization duration(PHD)were measured.RESULTS:A total of 218 patients(139 males,79females),with an average age of 60.1±10.8 years,were enrolled in this study.One hundred and thirteen patients who received ENBD were included in Group 1,and 105patients who did not receive ENBD were included in Group 2.The baseline clinical characteristics were similar in both groups.There were no significant differences in post-endoscopic retrograde cholangiopancreatography(ERCP)-related complications when Groups 1 and 2 were compared.Seventy-seven patients underwent EPBD,and41 received an ENBD tube(G1a)and 36 did not(G2a).Seventy-three patients underwent EST,and 34 patients received an ENBD tube(G1b)and 39 did not(G2b).The remaining 68 patients underwent neither EPBD nor EST;of these patients,38 received an ENBD tube(G1c)and 30 did not(G2c).For each of the three pairs of subgroups(G1a vs G2a,G1b vs G2b,G1c vs G2c),there were no significant differences detected in the PHD or the time to normalization of CRP,TB and ALT.In the EPBD group,the incidence of post-ERCP pancreatitis,hyperamylasemia and overall patient complications was significantly higher for G2a(post-ERCP pancreatitis:6/36vs 0/41,P=0.0217;hyperamylasemia:11/36 vs 4/41,P=0.0215;overall patient complications:18/36 vs 7/41,P=0.0029).CONCLUSION:After successful CBD stone clearance,ENBD is only beneficial when an EPBD procedure hasbeen performed.

Long-term results of graded pneumatic dilatation under endoscopic guidance in patients with primary esophageal achalasia

AIM:Achalasia is the best known primary motor disorder of the esophagus in which the lower esophageal sphincter (LES)has abnormally high resting pressure and incomplete relaxation with swallowing.Pneumatic dilatation remains the first choice of treatment.The aims of this study were to determine the long term clinical outcome of treating achatasia initially with pneumatic dilatation and usefulness of pneumatic dilatation technique under endoscopic observation without fluoroscopy. METHODS:A total of 65 dilatations were performed in 43 patients with achalasia[23 males and 20 females,the mean age was 43 years(range,19-73)].All patients underwent an initial dilatation by inflating a 30 mm balloon to 15 psi under endoscopic control.The need for subsequent dilatation was based on symptom assessment.A 3.5 cm balloon was used for repeat procedures. RESULTS:The 30 mm balloon achieved a satisfactory result in 24 patients(54%)and the 35 mm ballon in 78% of the remainder(14/18).Esophageal perforation as a short-term complication was observed in one patient(2.3%).The only late complication encountered was gastroesophageal reflux in 2(4%)patients with a good response to dilatation.The mean follow-up period was 2.4 years(6 mo-5 years).Of the patients studied,38(88%)were relieved of their symptoms after only one or two sessions.Five patients were referred for surgery(one for esophageal perforation and four for persistent or recurrent symptoms).Among the patients whose follow up information was available,the percentage of patients in remission was 79%(19/24)at 1 year and 54%(7/13)at 5 years. CONCLUSION:Performing balloon dilatation under endoscopic observation as an outpatient procedure is simple,safe and efficacious for treating patients with achalasia and referral of surgical myotomy should be considered for patients who do not respond to medical therapy or individuals that do not desire pneumatic dilatations.

Endoscopic papillary balloon intermittent dilatation and endoscopic sphincterotomy for bile duct stones

AIM: To compare the effectiveness and safety of endoscopic papillary balloon intermittent dilatation (EPBID) and endoscopic sphincterotomy (EST) in the treatment of common bile duct stones. METHODS: From March 2011 to May 2012, endoscopic retrograde cholangiopancreatography was performed in 560 patients, 262 with common bile duct stones. A total of 206 patients with common bile duct stones were enrolled in the study and randomized to receive either EPBID with a 10-12 mm dilated balloon or EST (103 patients in each group). For both groups a conventional reticular basket or balloon was used to remove the stones. After the procedure, routine endoscopic nasobiliary drainage was performed. RESULTS: First-time stone removal was successfully performed in 94 patients in the EPBID group (91.3%) and 75 patients in the EST group (72.8%). There was no statistically significant difference in terms of operation time between the two groups. The overall incidence of early complications in the EPBID and EST groups was 2.9% and 13.6%, respectively, with no deaths reported during the course of the study and follow-up. Multiple regression analysis showed that the success rate of stone removal was associated with stone removal method [odds ratio (OR): 5.35; 95%CI: 2.24-12.77; P=0.00], the transverse diameter of the stone (OR: 2.63; 95%CI: 1.19-5.80; P=0.02) and the presence or absence of diverticulum (OR: 2.35; 95%CI: 1.03-5.37; P=0.04). Postoperative pancreatitis was associated with the EST method of stone removal (OR: 5.00; 95%CI: 1.23-20.28; P=0.02) and whether or not pancreatography was performed (OR: 0.10; 95%CI: 0.03-0.35; P=0.00). CONCLUSION: The EPBID group had a higher success rate of stone removal with a lower incidence of pancreatitis compared with the EST group.

Endoscopic papillary large balloon dilatation with sphincterotomy is safe and effective for biliary stone removal independent of timing and size of sphincterotomy

AIM To describe the efficacy and safety of endoscopic papillary large balloon dilatation(EPLBD) in the management of bile duct stones in a Western population. METHODS Data was collected from the endoscopic retrograde cholangiopancreatography(ERCP) and Radiology electronic database along with a review of case notes over a period of six years from 1 st August 2009 to 31 st July 2015 and incorporated into Microsoft excel. Statistical analyses were performed using Med Calc for Windows,version 12.5(Med Calc Software,Ostend,Belgium). Simple statistical applications were applied in order to determine whether significant differences exist in comparison groups. We initially used simple proportions to describe the study populations. Furthermore,we used chi-square test to compare proportions and categorical variables. Non-parametric Mann-Whitney U-test was applied in order to compare continuous variables. All comparisons were deemed to be statistically significant if P values were less than 0.05.RESULTS EPLBD was performed in 229 patients(46 females) with mean age of 68 ± 14.3 years. 115/229(50%) patients had failed duct clearance at previous ERCP referred from elsewhere with standard techniques. Duct clearance at the Index* ERCP(1 st ERCP at our centre) was 72.5%. Final duct clearance rate was 98%. EPLBD after fresh sphincterotomy was performed in 81(35.4%). Median balloon size was 13.5 mm(10-18). In addition to EPLBD,per-oral cholangioscopy(POC) and electrohydraulic lithotripsy(EHL) was performed in 35(15%) patients at index* ERCP. 63(27.5%) required repeat ERCP for stone clearance. 28(44.5%) required POC and EHL and 11(17.4%) had repeat EPLBD for complete duct clearance. Larger stone size(12.4 mm vs 17.4 mm,P < 0.000001),multiple stones(2,range(1-13) vs 3,range(1-12),P < 0.006) and dilated common bile duct(CBD)(12.4 mm vs 18.3 mm,P < 0.001) were significant predictors of failed duct clearance at index ERCP. 47 patients(20%) had ampullary or peri-ampullary diverticula. Procedure related adverse events included 2 cases of bleeding and pancreatitis(0.87%) each.CONCLUSION EPLBD is a safe and effective technique for CBDS removal. There is no difference in outcomes whether it is performed at the time of sphincterotomy or at a later procedure or whether there is a full or limited sphincterotomy.

Long-term results of endoscopic balloon dilatation of lower gastrointestinal tract strictures in Crohn's disease:A prospective study

AIM:To examine the long-term results of endoscopic treatment in a prospective study conducted over a period of 10 years,1997 to January 2007.METHODS:A total of 25 patients(20 female and five male:aged 18-75 years),with at least one symptom of stricture not passable with the standard colonoscope and with a confirmed scarred Crohn's stricture of the lower gastrointestinal tract,were included in the study.The main symptom was abdominal pain.The endoscopic balloon dilatation was performed with an 18 mm balloon under endoscopic and radiological control.RESULTS:Eleven strictures were located in the colon,13 at the anastomosis after ileocecal resection,three at the Bauhin valve and four in the ileum.Four patients had two strictures and one patient had three strictures.Of the 31 strictures,in 30 was balloon dilatation successful in a single endoscopic session,so that eventually the strictures could be passed easily with the standard colonoscope.In one patient with a long stricture of the ileum involving the Bauhin valve and an additional stricture of the ileum which were 15 cm apart,sufficient dilatation was not possible.This patient therefore required surgery.Improvement of abdominal symptoms was achieved in all cases which had technically successful balloon dilatation,althoughin one case perforation occurred after dilatation of a recurrent stricture.Available follow-up was in the range of 54-118 mo(mean of 81 mo).The relapse rate over this period was 46%,but 64% of relapsing strictures could be successfully dilated again.Only in four patients was surgery required during this follow-up period.CONCLUSION:We conclude from these initial results that endoscopic balloon dilatation,especially for short strictures in Crohn's disease,can be performed with reliable success.Perforation is a rare complication.It is our opinion that in the long-term,the relapse rate is probably higher than after surgery,but usually a second endoscopic treatment can be performed successfully,leading to a considerable success rate of the endoscopic procedure.

Is endoscopic papillary large balloon dilatation without endoscopic sphincterotomy effective?

AIM: To evaluate the safety and efficacy of endoscopic papillary large balloon dilatation(EPLBD) without endoscopic sphincterotomy in a prospective study.METHODS: From July 2011 to August 2013, we performed EPLBD on 41 patients with nae papillae prospectively. For sphincteroplasty of EPLBD,endoscopic sphincterotomy(EST) was not performed,and balloon diameter selection was based on the distal common bile duct diameter. The balloon was inflated to the desired pressure. If the balloon waist did not disappear, and the desired pressure was satisfied, we judged the dilatation as complete. We used a retrieval balloon catheter or mechanical lithotripter(ML) to remove stones and assessed the rates of complete stone removal, number of sessions, use of ML and adverse events. Furthermore, we compared the presence or absence of balloon waist disappearance with clinical characteristics and endoscopic outcome.RESULTS: The mean diameters of the distal and maximum common bile duct were 13.5 ± 2.4 mm and16.4 ± 3.1 mm, respectively. The mean maximum transverse-diameter of the stones was 13.4 ± 3.4mm, and the mean number of stones was 3.0 ± 2.4.Complete stone removal was achieved in 97.5%(40/41)of cases, and ML was used in 12.2%(5/41) of cases.The mean number of sessions required was 1.2 ± 0.62.Pancreatitis developed in two patients and perforation in one. The rate of balloon waist disappearance was73.1%(30/41). No significant differences were noted in procedure time, rate of complete stone removal(100% vs 100%), number of sessions(1.1 vs 1.3, P= 0.22), application of ML(13% vs 9%, P = 0.71),or occurrence of pancreatitis(3.3% vs 9.1%, P =0.45) between cases with and without balloon waist disappearance.CONCLUSION: EST before sphincteroplasty may be unnecessary in EPLBD. Further investigations are needed to verify the relationship between the presence or absence of balloon waist disappearance.

Double-balloon enteroscopy-assisted dilatation avoids surgery for small bowel strictures: A systematic review

AIM To evaluate the therapeutic role of double-balloon enteroscopy(DBE) in small bowel strictures and to propose a standard approach to small bowel strictures.METHODS Systematic review of studies involving DBE in patients with small bowel strictures. Only studies limited to small bowel strictures were included and those with ileo-colonic strictures were excluded. RESULTS In total 13 studies were included,in which 310 patients were dilated. The average follow-up time was 31.8 mo per patient. The complication rate was 4.8% per patient and 2.6% per dilatation. Surgery was avoided in 80% of patients. After the first dilatation,46% were treated with re-dilatation and only 17% required surgery.CONCLUSION DBE-assisted dilatation avoids surgery in 80% of patients with small bowel strictures and is safe and effective. We propose a standardized approach to small bowel strictures.

Ascending aortic dilatation rate after transcatheter aortic valve replacement in patients with bicuspid and tricuspid aortic stenosis: A multidetector computed tomography follow-up study

BACKGROUND: Current data is lacking about the progression of ascending aortic dilatation after transcatheter aortic valve replacement(TAVR) in aortic stenosis(AS) patients with bicuspid aortic valve(BAV) and tricuspid aortic valve(TAV). This study aims to assess the ascending aortic dilatation rate(mm/year) after TAVR in patients with BAV versus TAV using a multidetector computed tomography(MDCT) fol ow-up and to determine the predictors of ascending aortic dilatation rate.METHODS: Severe AS patients undergoing TAVR from March 2013 to March 2018 at our center with MDCT follow-ups were included. BAV and TAV were identified using baseline MDCT. Baseline and follow-up MDCT images were analyzed,and the diameters of ascending aorta were measured. Study end point is ascending aortic dilatation rate(mm/year). Furthermore,factors predicting ascending aortic dilatation rate were also investigated.RESULTS: Two hundred and eight patients were included,comprised of 86 BAV and 122 TAV patients. Five,4,3,2,and 1-year MDCT follow-ups were achieved in 7,9,30,46,and 116 patients. The ascending aortic diameter was significantly increased after TAVR in both BAV group(43.7±4.4 mm vs. 44.0±4.5 mm;P<0.001) and TAV group(39.1±4.8 mm vs. 39.7±5.1 mm;P<0.001). However,no difference of ascending aortic dilatation rate was found between BAV and TAV group(0.2±0.8 mm/year vs. 0.3±0.8 mm/year,P=0.592). Multivariate linear regression revealed paravalvular leakage(PVL) grade was independently associated with ascending aortic dilatation rate in the whole population and BAV group,but not TAV group. No aortic events occurred during follow-ups.CONCLUSION: Ascending aortic size continues to grow after TAVR in BAV patients,but the dilatation rate is mild and comparable to that of TAV patients. PVL grade is associated with ascending aortic dilatation rate in BAV patients post-TAVR.

Endoscopic balloon catheter dilatation via retrograde or static technique is safe and effective for cricopharyngeal dysfunction

To evaluate the safety and efficacy of upper esophageal sphincter (UES) dilatation for cricopharyngeal (CP) dysfunction. To determine if: (1) indication for dilatation; or (2) technique of dilatation correlated with symptom improvement. METHODSAll balloon dilatations performed at our institution from over a 3-year period were retrospectively analyzed for demographics, indication and dilatation site. All dilatations involving the UES underwent further review to determine efficacy, complications, and factors that predict success. Dilatation technique was separated into static (stationary balloon distention) and retrograde (brusque pull-back of a fully distended balloon across the UES). RESULTSFour hundred and eighty-eight dilatations were reviewed. Thirty-one patients were identified who underwent UES dilatation. Median age was 63 years (range 27-81) and 55% of patients were male. Indications included dysphagia (28 patients), globus sensation with evidence of UES dysfunction (2 patients) and obstruction to echocardiography probe with cricopharyngeal (CP) bar (1 patient). There was evidence of concurrent oropharyngeal dysfunction in 16 patients (52%) and a small Zenker’s diverticula (≤ 2 cm) in 7 patients (23%). Dilator size ranged from 15 mm to 20 mm. Of the 31 patients, 11 had dilatation of other esophageal segments concurrently with UES dilatation and 20 had UES dilatation alone. Follow-up was available for 24 patients for a median of 2.5 mo (interquartile range 1-10 mo), of whom 19 reported symptomatic improvement (79%). For patients undergoing UES dilatation alone, follow-up was available for 15 patients, 12 of whom reported improvement (80%). Nineteen patients underwent retrograde dilatation (84% response) while 5 patients had static dilatation (60% response); however, there was no significant difference in symptom improvement between the techniques (P = 0.5). Successful symptom resolution was also not significantly affected by dilator size, oropharyngeal dysfunction, Zenker’s diverticulum, age or gender (P > 0.05). The only complication noted was uvular edema and a shallow ulcer after static dilatation in one patient, which resolved spontaneously and did not require hospital admission. CONCLUSIONUES dilatation with a through-the-scope balloon by either static or retrograde technique is safe and effective for the treatment of dysphagia due to CP dysfunction. To our knowledge, this is the first study evaluating retrograde balloon dilatation of the UES.

Comparison of endoscopic papillary balloon dilatation and endoscopic sphincterotomy for bile duct stones

Endoscopic treatment for bile duct stones is low-invasive and currently considered as the first choice of the treatment. For the treatment of bile duct stones, papillary treatment is necessary, and the treatments used at the time are broadly classified into two types; endoscopic papillary balloon dilatation where bile duct closing part is dilated with a balloon and endoscopic sphincterotomy(EST) where bile duct closing part is incised. Both procedures have advantages and disadvantages. Golden standard is EST, however, there are patients with difficulty for EST, thus we must select the procedure based on understanding of the characteristics of the procedure, and patient backgrounds.

Predictors of outcomes of endoscopic balloon dilatation in strictures after esophageal atresia repair: A retrospective study

BACKGROUND Endoscopic balloon dilatation (EBD) has become the first line of therapy for benign esophageal strictures (ESs);however,there are few publications about the predictive factors for the outcomes of this treatment.AIM To assess the predictive factors for the outcomes of EBD treatment for strictures after esophageal atresia (EA) repair.METHODS Children with anastomotic ES after thoracoscopic esophageal atresia repair treated by EBD from January 2012 to December 2016 were included.All procedures were performed under tracheal intubation and intravenous anesthesia using a three-grade controlled radial expansion balloon with gastroscopy.Outcomes were recorded and predictors of the outcomes were analyzed.RESULTS A total of 64 patients were included in this analysis.The rates of response,complications,and recurrence were 96.77%,8.06%,and 2.33%,respectively.The number of dilatation sessions and complications were significantly higher in patients with a smaller stricture diameter (P=0.013 and 0.023,respectively) and with more than one stricture (P=0.014 and 0.004,respectively).The length of the stricture was significantly associated with complications of EBD (P=0.001).A longer interval between surgery and the first dilatation was related to more sessions and a poorer response (P=0.017 and 0.024,respectively).CONCLUSION The diameter,length,and number of strictures are the most important predictive factors for the clinical outcomes of endoscopic balloon dilatation in pediatric ES.The interval between surgery and the first EBD is another factor affectingresponse and the number of sessions of dilatation.

Short and long-term outcomes of endoscopic balloon dilatation for Crohn's disease strictures

AIM:To investigate the short and long-term outcomes of endoscopic balloon dilatation(EBD) for Crohn's disease(CD) strictures.METHODS:Between January 1995 and December 2011,47 EBD procedures were performed in 30 patients(8 females and 22 males) with CD.All patients had strictures through which an endoscope could not pass,and symptoms of these strictures included abdominal pain,abdominal fullness,nausea,and/or vomiting.The 47 strictures included 17 anastomotic and 30 de novo strictures.Endoscopy and dilatation were performed under conscious sedation with intravenous diazepam or flunitrazepam.The dilatations were all performed using through-the-scope balloons with diameters from 8 mm to 20 mm on inflation and lengths of 30-80 mm.Each dilatation session consisted of two to four,3-min multistep inflations of the balloon,repeated at intervals of 1 wk until adequate dilatation(up to 15-20 mm in diameter) was achieved.The follow-up data were collected from medical records and analyzed retrospectively.Primary success was defined as passage of the scope through the stricture after EBD.Longterm outcomes were analyzed focusing on interventionfree survival and surgery-free survival demonstrated by the Kaplan-Meier method.(Intervention-free meant cases in which neither endoscopic balloon re-dilatation nor surgery was needed after the first dilatation during the observation period).The log rank test was used to evaluate the difference in long-term outcomes between anastomotic and de novo stricture cases.RESULTS:Primary success was achieved in 44 of the 47 strictures(93.6%).Balloon dilatations failed in 3 cases(6.4%).In 1 case,EBD was a technical failure because the guide-wire could not be passed through the stricture which showed severe adhesion and was a flexural lesion of the intestine.In 2 cases,unexpected perforations occurred immediately after balloon dilatation.Of the 47 treatments,complications occurred in 5(10.6%).All 5 patients had de novo strictures.One suffered bleeding,two high fever and there were colorectal perforations.One of the patients with a colorectal perforation was treated surgically,the other was managed conservatively.These 2 cases correspond to the two aforementioned EBD failures.Long-term outcomes were evaluated for the 44 successfully-treated strictures after a median follow-up of 26 mo(range,2-172 mo).During the observation period,re-strictures after EBDs occurred in 26 cases(60.5%).Fourteen of these 26 re-stricture cases underwent EBD again,but in two EBD failed and surgery was ultimately performed in both cases.Twelve of the 26 re-stricture cases were initially treated surgically when the re-strictures occurred.Finally,30 of the 47 strictures(63.8%) were successfully managed with EBD,allowing surgery to be avoided.Intervention-free survival evaluated by the Kaplan-Meier method was 75% at 12 mo,58% at 24 mo,and 43% at 36 mo.There was no significant difference between the anastomotic strictures(n = 16) and de novo strictures(n = 28) in the intervention-free survival as evaluated by the log-rank test.Surgery-free survival evaluated by the Kaplan-Meier method was 90% at 12 mo,75% at 24 mo,and 53% at 36 mo.The 16 anastomotic strictures were associated with significantly better surgery-free survivals than the 28 de novo strictures(log-rank test:P < 0.05).CONCLUSION:Anastomotic strictures were associated with better long-term outcomes than de novo strictures,indicating that stricture type might be useful for predicting the long-term outcomes of EBD.

Extraordinary cause of acute gastric dilatation and hepatic portal venous gas: Chronic use of synthetic cannabinoid

Addiction to synthetic cannabinoids(SCs) is a growing social and health problem worldwide. Chronic use of SCs may cause adverse effects in the gastrointestinal system. We describe a very rare case of acute gastric dilatation(AGD) and hepatic portal venous gas(HPVG),with findings of acute abdomen resulting from chronic use of a SC, Bonzai. AGD and HPVG were detected by computerized tomography examination. Patchy mucosal ischemia was seen in endoscopic examination. Despite the findings of an acute abdomen, a non-surgical approach with nasogastric decompression, antibiotic therapy, and close radiologic and endoscopic followup was preferred in the presented case. Clinical and radiologic findings decreased dramatically on the first day, and endoscopic findings gradually disappeared over 7 d. In conclusion, this case shows that chronic use of a SC may cause AGD and accompanying HPVG,which can be managed non-surgically despite the findings of acute abdomen.

Balloon dilatation for treatment of hepatic venous outflow obstruction following pediatric liver transplantation

AIM To assess the efficacy and safety of balloon dilatation for the treatment of hepatic venous outflow obstruction(HVOO) following pediatric liver transplantation.METHODS A total of 246 pediatric patients underwent liver transplantation at our hospital between June 2013 and September 2016. Among these patients, five were ultimately diagnosed with HVOO. Seven procedures(two patients underwent two balloon dilatation procedures) were included in this analysis. The demographic data,types of donor and liver transplant, interventional examination and therapeutic outcomes of these five children were analyzed. The median interval time between pediatric liver transplantation and balloon dilatation procedures was 9.8 mo(range: 1-32).RESULTS Five children with HVOO were successfully treated by balloon angioplasty without stent placement, with seven procedures performed for six stenotic lesions. All children underwent successful percutaneous intervention. Among these five patients, four were treated by single balloon angioplasty, and these patients did not develop recurrent stenosis. In seven episodes of balloon angioplasty across the stenosis, the pressure gradient was 12.0 ± 8.8 mm Hg before balloon dilatation and 1.1 ± 1.5 mm Hg after the procedures, which revealed a statistically significant reduction(P < 0.05). The overall technical success rate among these seven procedures was 100%(7/7), and clinical success was achieved in all five patients(100%). The patients were followed for 4-33 mo(median: 15 mo). No significant procedural complications or procedurerelated deaths occurred.CONCLUSION Balloon dilatation is an effective and safe therapeutic option for HVOO in children undergoing pediatric liver transplantation. Venous angioplasty is also recommended in cases with recurrent HVOO.