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Xiao J, Zhang Y, Fang T, Yuan T, Tian Q, Liu J, Cheng Y, Zhu Y, Cheng L, Cui W. Mineralized manganese dioxide channel as the stent coating for in situ precise tumor navigation. NANO RESEARCH 2021; 14:2145-2153. [DOI: 10.1007/s12274-020-3114-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 09/06/2020] [Accepted: 09/12/2020] [Indexed: 08/30/2023]
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Oude Nijhuis RAB, Zaninotto G, Roman S, Boeckxstaens GE, Fockens P, Langendam MW, Plumb AA, Smout A, Targarona EM, Trukhmanov AS, Weusten B, Bredenoord AJ. European guidelines on achalasia: United European Gastroenterology and European Society of Neurogastroenterology and Motility recommendations. United European Gastroenterol J 2021; 8:13-33. [PMID: 32213062 PMCID: PMC7005998 DOI: 10.1177/2050640620903213] [Citation(s) in RCA: 110] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Achalasia is a primary motor disorder of the oesophagus characterised by absence of peristalsis and insufficient lower oesophageal sphincter relaxation. With new advances and developments in achalasia management, there is an increasing demand for comprehensive evidence-based guidelines to assist clinicians in achalasia patient care. METHODS Guidelines were established by a working group of representatives from United European Gastroenterology, European Society of Neurogastroenterology and Motility, European Society of Gastrointestinal and Abdominal Radiology and the European Association of Endoscopic Surgery in accordance with the Appraisal of Guidelines for Research and Evaluation II instrument. A systematic review of the literature was performed, and the certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation methodology. Recommendations were voted upon using a nominal group technique. RESULTS These guidelines focus on the definition of achalasia, treatment aims, diagnostic tests, medical, endoscopic and surgical therapy, management of treatment failure, follow-up and oesophageal cancer risk. CONCLUSION These multidisciplinary guidelines provide a comprehensive evidence-based framework with recommendations on the diagnosis, treatment and follow-up of adult achalasia patients.
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Affiliation(s)
- R A B Oude Nijhuis
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - G Zaninotto
- Department of Surgery and Cancer, Imperial College, London, UK
| | - S Roman
- Digestive Physiology, Hôpital Edouard Herriot, Lyon, France
| | - G E Boeckxstaens
- Department of Chronic Diseases, Metabolism and Ageing, Translational Research Centre for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
| | - P Fockens
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - M W Langendam
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - A A Plumb
- Centre for Medical Imaging, University College London, London, UK
| | - Ajpm Smout
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - E M Targarona
- Department of General and Digestive Surgery, Hospital De La Santa Creu I Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
| | - A S Trukhmanov
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Blam Weusten
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands.,Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
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El Abiad R, Khashab MA. Role of biodegradable stents in octogenarians with achalasia. Endosc Int Open 2021; 9:E767-E769. [PMID: 34080587 PMCID: PMC8159592 DOI: 10.1055/a-1393-5665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Affiliation(s)
- Rami El Abiad
- Division of Gastroenterology and Hepatology, University of Iowa, Iowa City, Iowa, United States
| | - Mouen A. Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
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Hany M, Ibrahim M, Zidan A, Samir M, Elsherif A, Selema M, Sharaan M, Elhashash M. Role of Primary Use of Mega Stents Alone and Combined with Other Endoscopic Procedures for Early Leak and Stenosis After Bariatric Surgery, Single-Institution Experience. Obes Surg 2021; 31:2050-2061. [PMID: 33409972 DOI: 10.1007/s11695-020-05211-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 12/30/2020] [Accepted: 12/30/2020] [Indexed: 12/13/2022]
Abstract
PURPOSE Surgical therapy for post-bariatric surgery complications is associated with significant morbidity and mortality. Endoscopic options like primarily endoscopically placed fully covered self-expandable metallic stents (SEMS) offer significant benefits for the management of leaks and obstructions or stenosis, and even in case of mega stent failure, further endoscopic techniques could resolve the situation. MATERIALS AND METHODS We conducted a single-centre retrospective study on patients with leakage and stenosis/obstruction after bariatric surgery who were managed primarily by SEMS between January 2015 and January 2019. Clinical success rate was evaluated in terms of the cure of the reason for stenting, the need for other interventions, and the presentation of stent-related complications. RESULTS There were 58 patients included, (50 with leak, 8 with stenosis/obstruction following bariatric surgery). Mean time to stent placement was 6.82 (±1.64) days for the leak group and 35 (±21.13) days for the stenosis group (p = 0.019). Successful outcomes with SEMS alone were achieved in 42 (72.41%) patients, while 16 patients had failed SEMS treatment, of whom 14 were successfully managed by endoscopic procedures while two cases needed surgical intervention. Of the SEMS-related complications encountered, 25.86% were ulcers; 24.13%, vomiting; 22.41%, gastroesophageal reflux disease (GerdQ≥8); 18.96%, stent migration; and 5.17%, stent intolerance. CONCLUSION A mega stent is an effective and safe tool for the early management of post-bariatric surgery leakage and stenosis, and it is associated with acceptable rates of failure that can be managed by further endoscopic techniques in most of the patients.
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Affiliation(s)
- Mohamed Hany
- Surgical Endoscopy and Gastrointestinal Motility Unit, Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, Alexandria, 21561, Egypt.
| | - Mohamed Ibrahim
- Surgical Endoscopy and Gastrointestinal Motility Unit, Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, Alexandria, 21561, Egypt
| | - Ahmed Zidan
- Surgical Endoscopy and Gastrointestinal Motility Unit, Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, Alexandria, 21561, Egypt
| | - Mohamed Samir
- Surgical Endoscopy and Gastrointestinal Motility Unit, Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, Alexandria, 21561, Egypt
| | - Amr Elsherif
- Surgical Endoscopy and Gastrointestinal Motility Unit, Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, Alexandria, 21561, Egypt
| | - Mohamed Selema
- Surgical Endoscopy and Gastrointestinal Motility Unit, Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, Alexandria, 21561, Egypt
| | - Mohamed Sharaan
- Department of Surgery, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Mohamed Elhashash
- Surgical Endoscopy and Gastrointestinal Motility Unit, Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, Alexandria, 21561, Egypt
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Yang K, Cao J, Yuan TW, Zhu YQ, Zhou B, Cheng YS. Silicone-covered biodegradable magnesium stent for treating benign esophageal stricture in a rabbit model. World J Gastroenterol 2019; 25:3207-3217. [PMID: 31333312 PMCID: PMC6626718 DOI: 10.3748/wjg.v25.i25.3207] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 05/14/2019] [Accepted: 06/07/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Stent insertion can effective alleviate the symptoms of benign esophageal strictures (BES). Magnesium alloy stents are a good candidate because of biological safety, but show a poor corrosion resistance and a quick loss of mechanical support in vivo. AIM To test the therapeutic and adverse effects of a silicone-covered magnesium alloy biodegradable esophageal stent. METHODS Fifteen rabbits underwent silicone-covered biodegradable magnesium stent insertion into the benign esophageal stricture under fluoroscopic guidance (stent group). The wall reconstruction and tissue reaction of stenotic esophagus in the stent group were compared with those of six esophageal stricture models (control group). Esophagography was performed at 1, 2, and 3 weeks. Four, six, and five rabbits in the stent group and two rabbits in the control groups were euthanized, respectively, at each time point for histological examination. RESULTS All stent insertions were well tolerated. The esophageal diameters at immediately, 1, 2 and 3 wk were 9.8 ± 0.3 mm, 9.7 ± 0.7 mm, 9.4 ± 0.8 mm, and 9.2 ± 0.5 mm, respectively (vs 4.9 ± 0.3 mm before stent insertion; P < 0.05). Magnesium stents migrated in eight rabbits [one at 1 wk (1/15), three at 2 wk (3/11), and four at 3 wk (4/5)]. Esophageal wall remodeling (thinner epithelial and smooth muscle layers) was found significantly thinner in the stent group than in the control group (P < 0.05). Esophageal injury and collagen deposition following stent insertion were similar and did not differ compared to rabbits with esophageal stricture and normal rabbits (P > 0.05). CONCLUSION Esophageal silicone-covered biodegradable magnesium stent insertion is feasible for BES without causing severe injury or tissue reaction. Our study suggests that insertion of silicone-covered magnesium esophageal stent is a promising approach for treating BES.
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Affiliation(s)
- Kai Yang
- Department of Radiological Intervention, Shanghai Sixth People's Hospital East Campus Affiliated to Shanghai University of Medicine & Health Sciences, Shanghai 201306, China
- Department of Radiological Intervention, Shanghai Sixth People's Hospital East Campus Affiliated to Shanghai Jiao Tong University, Shanghai 201306, China
| | - Jun Cao
- Department of Tumor Intervention, Dahua Hospital, Shanghai 200237, China
| | - Tian-Wen Yuan
- Department of Tumor Intervention, Dahua Hospital, Shanghai 200237, China
| | - Yue-Qi Zhu
- Department of Radiological Intervention, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, Shanghai 200233, China
| | - Bi Zhou
- Department of Radiological Intervention, Shanghai Sixth People's Hospital East Campus Affiliated to Shanghai University of Medicine & Health Sciences, Shanghai 201306, China
- Department of Radiological Intervention, Shanghai Sixth People's Hospital East Campus Affiliated to Shanghai Jiao Tong University, Shanghai 201306, China
| | - Ying-Sheng Cheng
- Department of Radiological Intervention, Shanghai Sixth People's Hospital East Campus Affiliated to Shanghai University of Medicine & Health Sciences, Shanghai 201306, China
- Department of Radiological Intervention, Shanghai Sixth People's Hospital East Campus Affiliated to Shanghai Jiao Tong University, Shanghai 201306, China
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History of the Use of Esophageal Stent in Management of Dysphagia and Its Improvement Over the Years. Dysphagia 2017; 32:39-49. [PMID: 28101666 DOI: 10.1007/s00455-017-9781-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Accepted: 01/01/2017] [Indexed: 01/07/2023]
Abstract
The art and science of using stents to treat dysphagia and seal fistula, leaks and perforations has been evolving. Lessons learnt from the deficiencies of previous models led to several improvements making stent deployment easier, and with some designs, it was also possible to remove the stents if needed. With these improvements, besides malignant dysphagia, newer indications for using stents emerged. Unfortunately, despite several decades of evolution, as yet, there is no perfect stent that "fits all." This article is an overview of how this evolution process happened and where we are currently with using stents to manage patients with dysphagia and with other esophageal disorders.
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Yuan T, Yu J, Cao J, Gao F, Zhu Y, Cheng Y, Cui W. Fabrication of a Delaying Biodegradable Magnesium Alloy-Based Esophageal Stent via Coating Elastic Polymer. MATERIALS (BASEL, SWITZERLAND) 2016; 9:384. [PMID: 28773505 PMCID: PMC5503030 DOI: 10.3390/ma9050384] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 04/18/2016] [Accepted: 05/11/2016] [Indexed: 11/16/2022]
Abstract
Esophageal stent implantation can relieve esophageal stenosis and obstructions in benign esophageal strictures, and magnesium alloy stents are a good candidate because of biodegradation and biological safety. However, biodegradable esophageal stents show a poor corrosion resistance and a quick loss of mechanical support in vivo. In this study, we chose the elastic and biodegradable mixed polymer of Poly(ε-caprolactone) (PCL) and poly(trimethylene carbonate) (PTMC) as the coated membrane on magnesium alloy stents for fabricating a fully biodegradable esophageal stent, which showed an ability to delay the degradation time and maintain mechanical performance in the long term. After 48 repeated compressions, the mechanical testing demonstrated that the PCL-PTMC-coated magnesium stents possess good flexibility and elasticity, and could provide enough support against lesion compression when used in vivo. According to the in vitro degradation evaluation, the PCL-PTMC membrane coated on magnesium was a good material combination for biodegradable stents. During the in vivo evaluation, the proliferation of the smooth muscle cells showed no signs of cell toxicity. Histological examination revealed the inflammation scores at four weeks in the magnesium-(PCL-PTMC) stent group were similar to those in the control group (p > 0.05). The α-smooth muscle actin layer in the media was thinner in the magnesium-(PCL-PTMC) stent group than in the control group (p < 0.05). Both the epithelial and smooth muscle cell layers were significantly thinner in the magnesium-(PCL-PTMC) stent group than in the control group. The stent insertion was feasible and provided reliable support for at least four weeks, without causing severe injury or collagen deposition. Thus, this stent provides a new stent for the treatment of benign esophageal stricture and a novel research path in the development of temporary stents in other cases of benign stricture.
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Affiliation(s)
- Tianwen Yuan
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, 600 Yi Shan Road, Shanghai 200233, China.
| | - Jia Yu
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, Orthopedic Institute, Soochow University, 708 Renmin Road, Suzhou 215006, China.
| | - Jun Cao
- Department of Interventional Oncology, Dahua Hospital, Xuhui District, Shanghai 200237, China.
| | - Fei Gao
- Zhejiang Zylox Medical Device Co., Ltd., No. 1500, Wenyi West Road, Hangzhou 311121, China.
| | - Yueqi Zhu
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, 600 Yi Shan Road, Shanghai 200233, China.
| | - Yingsheng Cheng
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, 600 Yi Shan Road, Shanghai 200233, China.
| | - Wenguo Cui
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, Orthopedic Institute, Soochow University, 708 Renmin Road, Suzhou 215006, China.
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Familiari P, Greco S, Volkanovska A, Gigante G, Cali A, Boškoski I, Costamagna G. Achalasia: current treatment options. Expert Rev Gastroenterol Hepatol 2016; 9:1101-14. [PMID: 26186641 DOI: 10.1586/17474124.2015.1052407] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Achalasia is a rare esophageal motility disorder, characterized by impaired swallow-induced, lower esophageal sphincter (LES) relaxation and defective esophageal peristalsis. Unfortunately, there are no etiological therapies for achalasia. Patients present with dysphagia, chest pain and regurgitation of undigested food, often leading to weight loss. The currently available treatments have the common aim of relieving symptoms by decreasing the pressure of the LES. This can be achieved with some medications, by inhibiting the cholinergic innervation (botulinum toxin), by stretching (endoscopic dilation) or cutting (surgery) the LES. Recently, other therapeutic options, including per-oral endoscopic myotomy have been developed and are gaining international consensus. The authors report on the benefits and weaknesses of the different therapies and provide an updated approach to the management of achalasia.
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Affiliation(s)
- Pietro Familiari
- Digestive Endoscopy Unit - Gemelli University Hospital Università Cattolica del Sacro Cuore, Rome, Italy
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Yuan T, Zheng R, Yu J, Edmonds L, Wu W, Cao J, Gao F, Zhu Y, Cheng Y, Cui W. Fabrication and evaluation of polymer-based esophageal stents for benign esophagus stricture insertion. RSC Adv 2016; 6:16891-16898. [DOI: 10.1039/c5ra23763g] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2025] Open
Abstract
In benign esophageal strictures, polymeric lines and membranes were chosen to knit an esophageal stent for relieving esophageal lesions caused by esophageal stenosis and obstruction.
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Affiliation(s)
- Tianwen Yuan
- Orthopedic Institute
- College of Medicine
- Soochow University
- Suzhou
- P. R. China
| | - Reila Zheng
- Orthopedic Institute
- College of Medicine
- Soochow University
- Suzhou
- P. R. China
| | - Jia Yu
- Orthopedic Institute
- College of Medicine
- Soochow University
- Suzhou
- P. R. China
| | - Laura Edmonds
- Orthopedic Institute
- College of Medicine
- Soochow University
- Suzhou
- P. R. China
| | - Wei Wu
- Department of General Surgery
- Yangzhou First Hospital Affiliated to Southeast University
- Yangzhou
- P. R. China
| | - Jun Cao
- Department of Interventional Oncology
- Dahua Hospital
- Shanghai 200237
- China
| | - Fei Gao
- Zhejiang Zylox Medical Device Co., Ltd
- Hangzhou
- P. R. China
| | - Yueqi Zhu
- Department of Radiology
- Shanghai Jiao Tong University Affiliated Sixth People's Hospital
- Shanghai
- P. R. China
| | - Yingsheng Cheng
- Department of Radiology
- Shanghai Jiao Tong University Affiliated Sixth People's Hospital
- Shanghai
- P. R. China
| | - Wenguo Cui
- Orthopedic Institute
- College of Medicine
- Soochow University
- Suzhou
- P. R. China
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Zhao H, Wan XJ, Yang CQ. Comparison of endoscopic balloon dilation with metal stent placement in the treatment of achalasia. J Dig Dis 2015; 16:311-8. [PMID: 25765898 DOI: 10.1111/1751-2980.12241] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To compare the outcomes of endoscopic balloon dilation and metal stent placement in patients with achalasia. METHODS The patients with newly diagnosed achalasia between July 2001 and December 2011 were retrospectively studied. A total of 88 patients underwent either balloon dilation (n = 41) or metal stent placement (n = 47), their global symptom score and esophageal kinetics index were determined before, one week after and one month after the treatment. All the patients were followed up in the Outpatient Clinics or with a telephone interview every 6 months. RESULTS There were significant improvements in the global symptom scores and esophageal kinetics indices in all patients. No major complications were encountered in either group. There were no significant differences with regard to overall treatment failure or long-term outcome. CONCLUSION Balloon dilation and removable stents can effectively relieve clinical manifestations in patients with achalasia.
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Affiliation(s)
- Hang Zhao
- Department of Gastroenterology, First People's Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Xin Jian Wan
- Department of Gastroenterology, First People's Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Chang Qing Yang
- Department of Gastroenterology, Tongji Hospital, Tongji University, Shanghai, China
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Tu ZY, Shi S, He QM, Gao NN. Comparative study of efficacy of dilatation, dilatation with botulinum toxin injection and stenting in treatment of achalasia. Shijie Huaren Xiaohua Zazhi 2014; 22:1121-1126. [DOI: 10.11569/wcjd.v22.i8.1121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the improvement of esophageal dynamics in patients with achalasia after treatment by dilatation, dilatation with botulinum toxin injection and stenting.
METHODS: One hundred and thirty patients with achalasia were selected and divided into three groups: A (n = 30), B (n = 38) and C (n = 62). Group A was treated by water balloon dilatation. Group B was treated by water balloon dilation and botulinum toxin injection. Group C was treated by stenting. The resting pressure of the lower esophageal sphincter (LES), relaxation rate, the percentage of concordant and discordant contraction of esophageal body and the contraction amplitude at 10 cm above the LES were tested and compared before and 1 wk, 6 mo and 12 mo after the treatment (or stent removal).
RESULTS: The differences in all parameters tested among the three groups were not statistically significant before the treatment and 1 wk after the treatment (or stent removal) (P > 0.05 for all). Six months after the treatment (or stent removal), in the group B, the improvement of the resting pressure of the LES was -28.82 mmHg ± 9.18 mmHg, the relaxing ratio was 34.53% ± 10.17%, and the contraction amplitude of esophageal body was -27.47 mmHg ± 8.04 mmHg; the corresponding values in group C were -31.11 mmHg ± 7.46 mmHg, 36.12% ± 10.45%, and -32.01 mmHg ± 9.58 mmHg. The above parameters in groups B and C were significantly higher than those in group A (P < 0.05 for all). Twelve months after the treatment (or stent removal), in group C, the improvement of the resting pressure of the LES (-18.71 mmHg ± 2.64 mmHg), relaxation rate (18.63% ± 7.84%) and the percentage of concordant and discordant contraction of esophageal body (20.54% ± 9.45%, -28.69 mmHg ± 7.56 mmHg) were significantly higher than those in groups A and B (P < 0.05 for all).
CONCLUSION: Water balloon dilation, dilation with botulinum toxin injection and stenting all can improve esophageal dynamics in a short term in patients with achalasia, with stenting having a better long-term effect.
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Zhu Y, Edmonds L, Zhao X, Chen X, Hu C, Cheng Y, Cui W. In vitro and in vivo evaluation of Rapamycin-eluting nanofibers coated on cardia stents. RSC Adv 2014; 4:34405-34411. [DOI: 10.1039/c4ra04771k] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2025] Open
Abstract
Diagram of the process used to fabricate non-biodegradable metal stents with an outer layer of Rapa-loaded fibrous membrane using the electrospinning process. With the release of Rapa, the stents are expected to inhibit fibroblast proliferation and tissue hyperplasia, therefore treating a benign cardia stricture.
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Affiliation(s)
- Yueqi Zhu
- Orthopedic Institute
- Soochow University
- Suzhou, P.R. China
- Department of Radiology
- The Sixth Affiliated People's Hospital
| | - Laura Edmonds
- Orthopedic Institute
- Soochow University
- Suzhou, P.R. China
| | - Xin Zhao
- Center for Biomedical Engineering
- Department of Medicine
- Brigham and Women's Hospital
- Harvard Medical School
- Cambridge, USA
| | - Xinliang Chen
- Orthopedic Institute
- Soochow University
- Suzhou, P.R. China
| | - Changmin Hu
- Orthopedic Institute
- Soochow University
- Suzhou, P.R. China
| | - Yingsheng Cheng
- Department of Radiology
- The Sixth Affiliated People's Hospital
- Medical School of Shanghai Jiao Tong University
- Shanghai, P.R. China
| | - Wenguo Cui
- Orthopedic Institute
- Soochow University
- Suzhou, P.R. China
- Department of Orthopedics
- The First Affiliated Hospital of Soochow University
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Zhu Y, Hu C, Li B, Yang H, Cheng Y, Cui W. A highly flexible paclitaxel-loaded poly(ε-caprolactone) electrospun fibrous-membrane-covered stent for benign cardia stricture. Acta Biomater 2013; 9:8328-8336. [PMID: 23770223 DOI: 10.1016/j.actbio.2013.06.004] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2013] [Revised: 05/16/2013] [Accepted: 06/03/2013] [Indexed: 02/04/2023]
Abstract
In benign esophageal strictures, inflammation reaction and tissue hyperplasia after stent placement greatly limit the stent retention time and affect subsequent scar formation, which is one of the main influences on long-term recurrence rate. A newly developed biodegradable electrospun drug-fiber-coated stent (DFCS) was fabricated to inhibit inflammation and scar formation. The electrospun paclitaxel/poly(ε-caprolactone) (PCL) fibers integrally covered the bare stent using the rotating collection method. The paclitaxel entrapment did not significantly affect the physical properties of electrospun PCL fibrous membranes. The mechanical results demonstrated that electrospun fibers containing paclitaxel covering the stent maintained the original mechanical characteristics of the stent, and no membrane tearing or ablation was observed after hundreds of repeated compressions. Paclitaxel release profiles were controlled mainly via diffusion of drug through the drug content, and stable release of paclitaxel continued up to 32 days at pH 4.0. Higher inhibition of smooth muscle cell proliferation rates was observed on fibrous membranes with higher paclitaxel content. DFCS showed a significant decrease in tissue inflammation and collagen fiber proliferation, and was easily removed from the esophageal part, which had almost no damage to the tissues in the dog model. Therefore, DFCSs may have great potential to markedly attenuate stent-induced inflammation and scar formation in esophageal stenosis therapy.
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Affiliation(s)
- Yueqi Zhu
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, 188 Shizi St, Suzhou, Jiangsu 215006, People's Republic of China
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Müller M, Eckardt AJ, Wehrmann T. Endoscopic approach to achalasia. World J Gastrointest Endosc 2013; 5:379-390. [PMID: 23951393 PMCID: PMC3742703 DOI: 10.4253/wjge.v5.i8.379] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Accepted: 05/10/2013] [Indexed: 02/05/2023] Open
Abstract
Achalasia is a primary esophageal motor disorder. The etiology is still unknown and therefore all treatment options are strictly palliative with the intention to weaken the lower esophageal sphincter (LES). Current established endoscopic therapeutic options include pneumatic dilation (PD) or botulinum toxin injection. Both treatment approaches have an excellent symptomatic short term effect, and lead to a reduction of LES pressure. However, the long term success of botulinum toxin (BT) injection is poor with symptom recurrence in more than 50% of the patients after 12 mo and in nearly 100% of the patients after 24 mo, which commonly requires repeat injections. In contrast, after a single PD 40%-60% of the patients remain asymptomatic for ≥ 10 years. Repeated on demand PD might become necessary and long term remission can be achieved with this approach in up to 90% of these patients. The main positive predictors for a symptomatic response to PD are an age > 40 years, a LES-pressure reduction to < 15 mmHg and/or an improved radiological esophageal clearance post-PD. However PD has a significant risk for esophageal perforation, which occurs in about 2%-3% of cases. In randomized, controlled studies BT injection was inferior to PD and surgical cardiomyotomy, whereas the efficacy of PD, in patients > 40 years, was nearly equivalent to surgery. A new promising technique might be peroral endoscopic myotomy, although long term results are needed and practicability as well as safety issues must be considered. Treatment with a temporary self expanding stent has been reported with favorable outcomes, but the data are all from one study group and must be confirmed by others before definite recommendations can be made. In addition to its use as a therapeutic tool, endoscopy also plays an important role in the diagnosis and surveillance of patients with achalasia.
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Cai XB, Dai YM, Wan XJ, Zeng Y, Liu F, Wang D, Zhou H. Comparison between botulinum injection and removable covered self-expanding metal stents for the treatment of achalasia. Dig Dis Sci 2013; 58:1960-6. [PMID: 23397470 DOI: 10.1007/s10620-013-2564-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Accepted: 01/03/2013] [Indexed: 12/09/2022]
Abstract
BACKGROUND Intrasphincteric injection of botulinum toxin (BTX) and removable self-expanding metal stents (SEMS) have both been used for the treatment of achalasia. AIM To compare the effectiveness and long-term outcome of SEMS placement and BTX injection in patients with achalasia. METHODS A total of 110 patients with newly diagnosed achalasia were enrolled in the study between July 2003 and December 2009. The patients received either BTX injection (n = 51) or SEMS placement (n = 59). Clinical symptoms, objective parameters, and long-term clinical outcomes were evaluated after 7 and 30 days and then every 6 months until withdrawal from the study. The mean duration of follow-up was 28 months (range 10-36 months). RESULTS Improvements in global symptom and dysphagia scores and in basal lower esophageal sphincter pressure were significantly more marked in the SEMS group than in the BTX group (all P < 0.05). After 12 months, the remission rate in the SEMS group (81.28 %) was statistically significantly higher than that in the BTX group (64.58; P < 0.05). At 36 months, the remission rates in the two groups were 49.1 and. 4.2 %, respectively (P < 0.01). The symptom-free interval was 831 ± 46 days in the SEMS group and 522 ± 42 days in the BTX group (P < 0.01). No side effects were reported with BTX treatment. In the SEMS group there were 13 episodes of chest pain, nine cases of regurgitation, and four stent migrations. No serious complications occurred. CONCLUSION Removable SEMS was associated with better long-term outcomes than BTX injection in patients with achalasia.
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Affiliation(s)
- Xiao Bo Cai
- Department of Gastroenterology, First People's Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200080, China
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Zeng Y, Dai YM, Wan XJ. Clinical remission following endoscopic placement of retrievable, fully covered metal stents in patients with esophageal achalasia. Dis Esophagus 2013; 27:103-8. [PMID: 23796127 DOI: 10.1111/dote.12083] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Metal stents may represent an alternative therapy in the treatment of achalasia. We therefore evaluated the effectiveness of retrievable, fully covered metal stents in patients with achalasia. Fifty-nine patients with achalasia were treated with retrievable, fully covered metal stents. Symptoms using a global symptom score (0-10), lower esophageal sphincter (LES) resting pressure, LES relaxation, and simultaneous contraction of the esophagus were analyzed before and 1 week and 1 month after intervention. Complications and treatment outcomes were followed up at 6, 12, 18, and 24 months postoperatively. Stent placement was successful, and clinical symptoms resolved (P < 0.01) in all patients. Regurgitation, dysphagia and chest pain improved significantly (all P < 0.01). Therapy improved LES resting pressure (51.4 ± 9.7 mmHg pretherapy vs. 20.9 ± 8.1 mmHg post-therapy), LES relaxation (58.1 ± 17.1% pretherapy vs. 84.5 ± 18.9% post-therapy), and simultaneous contraction of the esophagus (36.1 ± 8.6% pretherapy vs. 69.4 ± 23.1% post-therapy) 1 month after stent placement (all P < 0.01). The cumulative clinical remission rates 6, 12, 18, 24, 30, and 36 months after stent removal were 90.9%, 81.8%, 76.4%, 69.1%, 65.5%, and 49.1%, respectively. All patients tolerated stent placement. Twelve patients (25.5%) complained of substernal pain and five (10.6%) had substernal burning. Stents migrated in four patients (8.5%). Insertion of retrievable, fully covered metal stents is an effective and safe treatment in patients with achalasia.
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Affiliation(s)
- Y Zeng
- Department of Gastroenterology, Shanghai First People's Hospital, School of Medicine, Shanghai Jiaog Tong University, Shanghai, China
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Zhu YQ, Cui WG, Cheng YS, Chang J, Chen NW, Yan L. Evaluation of biodegradable paclitaxel-eluting nanofibre-covered metal stents for the treatment of benign cardia stricture in an experimental model. Br J Surg 2013; 100:784-793. [PMID: 23553755 DOI: 10.1002/bjs.9106] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2013] [Indexed: 12/27/2022]
Abstract
BACKGROUND Benign strictures at the cardia are troublesome for patients and often require repeated endoscopic treatments. Paclitaxel can reduce fibrosis. This study evaluated a biodegradable paclitaxel-eluting nanofibre-covered metal stent for the treatment of benign cardia stricture in vitro and in vivo. METHODS Drug release was investigated in vitro at pH 7·4 and 4·0. Eighty dogs were divided randomly into four groups (each n = 20): controls (no stent), bare stent (retained for 1 week), and two drug-eluting stent (DES) groups with retention for either 1 week (DES-1w) or 4 weeks (DES-4w). Lower oesophageal sphincter pressure (LOSP) and 5-min barium height (5-mBH) were assessed before, immediately after stent deployment, at 1 week, and 1, 3 and 6 months later. Five dogs in each group were killed for histological examination at each follow-up point. RESULTS Stent migration rates were similar (0 bare stent versus 2 DES; P = 0·548). The percentage and amount of paclitaxel released in vitro was higher at pH 4·0 than at pH 7·4. After 6 months, LOSP and 5-mBH were both improved in the DES-1w (P = 0·004 and P = 0·049) and DES-4w (both P < 0·001) groups compared with the bare-stent group, with better relief when the stent was retained for 4 weeks (P = 0·004 and P = 0·007). The DES was associated with a reduced peak inflammatory reaction and less scar formation compared with bare stents, especially when inserted for 4 weeks. CONCLUSION The DES was more effective for the treatment of benign cardia stricture than bare stents in a canine model. Retention of the DES for 4 weeks led to a better clinical and pathological outcome than 1 week.
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Affiliation(s)
- Y-Q Zhu
- Department of Radiology, Sixth Affiliated People's Hospital, Medical School of Shanghai Jiao Tong University, Shanghai, China
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Abstract
Achalasia is a rare primary esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter, absent or decreased esophageal peristaltic waves and synchronous contractions. As the exact pathogenesis of the disease remains unclear, treatment options focus on the alleviation of the functional obstruction caused by lower esophageal sphincter and prevention of gastroesophageal reflux disease at the same time. Treatment modalities include pharmacological therapy, interventional therapy, surgical treatment and spinal rotation massage. This article reviews the latest progress in treatment of achalasia, with particular emphasis on the evolution of main treatments which include endoscopic pneumatic dilation, Heller myotomy and per-oral endoscopic myotomy (POEM).
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Major complications of pneumatic dilation and Heller myotomy for achalasia: single-center experience and systematic review of the literature. Am J Gastroenterol 2012; 107:1817-25. [PMID: 23032978 PMCID: PMC3808165 DOI: 10.1038/ajg.2012.332] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Pneumatic dilation (PD) and laparoscopic Heller myotomy (LHM) can be definitive therapies for achalasia; recent data suggest comparable efficacy. However, risk must also be considered. We reviewed the major complication rate of PD and LHM in a high-volume center and reviewed the corresponding literature. METHODS We reviewed 12 years of our institution's achalasia treatment experience. During this interval, a consistent technique of PD was used utilizing Rigiflex dilators. Medical records were reviewed for post-procedure complications. We administered a telephone survey and examined medical records to assess efficacy of treatment. We also performed a systematic review of the literature for comparable clinical data and examined 80 reports encompassing 12,494 LHM and PD procedures. RESULTS At our center, 463 achalasia patients underwent 567 PD or LHM procedures. In all, 78% of the PDs used a 30-mm Rigiflex dilator. In all, 157/184 (85%) patients underwent 1 or 2 PD without any subsequent treatment. There were seven clinically significant perforations; one from PD and six from LHM. There were no resultant deaths from these perforations; two deaths occurred within 30 days of LHM from unrelated causes. Complications and deaths post-PD were significantly fewer than those post-LHM (P=0.02). CONCLUSIONS Esophageal perforation from PD at our high-volume center was less common than often reported and lower than that associated with LHM. We conclude that, in the hands of experienced operators using conservative technique, PD has fewer major complications and deaths than LHM.
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Chuah SK, Hsu PI, Wu KL, Wu DC, Tai WC, Changchien CS. 2011 update on esophageal achalasia. World J Gastroenterol 2012; 18:1573-1578. [PMID: 22529685 PMCID: PMC3325522 DOI: 10.3748/wjg.v18.i14.1573] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Revised: 12/06/2011] [Accepted: 12/13/2011] [Indexed: 02/06/2023] Open
Abstract
There have been some breakthroughs in the diagnosis and treatment of esophageal achalasia in the past few years. First, the introduction of high-resolution manometry with pressure topography plotting as a new diagnostic tool has made it possible to classify achalasia into three subtypes. The most favorable outcome is predicted for patients receiving treatment for type II achalasia (achalasia with compression). Patients with type I(classic achalasia) and type III achalasia (spastic achalasia) experience a less favorable outcome. Second, the first multicenter randomized controlled trial published by the European Achalasia Trial group reported 2-year follow-up results indicating that laparoscopic Heller myotomy was not superior to endoscopic pneumatic dilation (PD). Although the follow-up period was not long enough to reach a convincing conclusion, it merits the continued use of PD as a generally available technique in gastroenterology. Third, the novel endoscopic technique peroral endoscopic myotomy is a promising option for treating achalasia, but it requires increased experience and cautious evaluation. Despite all this good news, the bottom line is a real breakthrough from the basic studies to identify the actual cause of achalasia that may impede treatment success is still anticipated.
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Abstract
Achalasia is a primary esophageal motility disorder characterized by aperistalsis and incomplete or absent relaxation of the lower esophageal sphincter (LES). The cause of the disease remains elusive and there is no intervention that improves the esophageal body function. Currently, treatment options focus on palliation of symptoms by reducing the LES pressure. The most effective and well-tolerated treatments continue to be the laparoscopic Heller myotomy and endoscopic pneumatic dilation; however, newer techniques (eg, peroral endoscopic myotomy and self-expanding metal stents) show promise. Botulinum toxin and pharmacologic therapy are reserved for those who are unable to undergo more effective therapies. Treatment options should be tailored to the patient, using current predictors of outcome such as the patient's age and post-treatment LES pressures. The aim of this article is to highlight current literature and provide an up-to-date approach to the treatment of achalasia.
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Affiliation(s)
- Joseph G Cheatham
- Walter Reed Army Medical Center, Gastroenterology Service, Department of Medicine, Building 2, 7F47, 6900 Georgia Avenue, NW, Washington, DC 20307, USA.
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Abstract
Partially covered self-expandable esophageal stents have been associated with unacceptable complications when used for benign esophageal disorders. With the introduction of removable or potentially removable fully covered stents and biodegradable stents, interest in using expandable stents for benign indications has been revived. Although expandable stents can offer a minimally invasive alternative to surgery, they can be associated with serious complications; hence, this approach should be considered in carefully selected patients, preferably on a protocol basis.
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Affiliation(s)
- Kulwinder S Dua
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA.
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