javad mikaeli

Pneumatic Balloon Dilation (PBD) as an achalasia treatment is painful procedure because of tearing the lower esophageal sphincter (LES) muscle fibres. Recently, two sedation methods including the moderate sedation and deep sedation are used for increasing the convenience of the patients and gastroenterologist.

To compare the efficacy of moderate and deep sedation in PBD in treatment of Idiopathic Achalasia (IA).

We prospectively assessed 200 IA patients. The first 100 patients (group A) underwent PBD by the moderate sedation using diazepam or midazolam and meperidine injections. The patients in the group B (100 patients) received midazolam, fentanyl and propofol as a deep sedation.  The pulse rate (PR), systolic and diastolic blood pressure (SBP, DBP), respiratory rate (RR), and oxygen saturation were monitored before, during and after PBD and achalasia symptom scores (ASS) were collected before and 1.5 months after treatment.The mean PR during and after procedures in the group B were significantly lower compared to the group A (p 0.001, 0.028). The patients in group B revealed less SBP and DBP after PBD versus group A (p 0.004, 0.002). The mean psi for 30 mm and 35 mm balloon dilators were significantly increased in group B compared to group (p 0.0001, 0.002).

We concluded that the deep sedation of achalasia patients in the PBD process can improved the efficacy of PBD and decreased the complications (transient chest pain) of the procedures. The patients with the deep sedation revealed less tachycardia and blood pressure rising and tolerated more pressure in balloon dilators.

Esophageal motility disorders (EMDs) are common in patients with dysphagia and are effectively diagnosed with high-resolution manometry (HREM). In this study, we aimed to evaluate the prevalence of different types of primary EMDs in patients referred for HREM and to further investigate the factors associated with EMDs.

In this cross-sectional study, all patients referred to the endoscopy section of Shariati Hospital during 2018-2019 (279 patients) were subjected to HREM and were evaluated according to their diagnosis, and the effect of each factor and each symptom on motility disorders was investigated.

84.5% (235) of the participants were diagnosed with at least one esophageal motility disorder; of them, achalasia was the most common form (52.6%). None of the predictive factors showed a statistically significant correlation with EMDs. However, regarding the symptoms, regurgitation and nocturnal cough were significantly more common in patients with EMD (P=0.001 and 0.009, respectively).

This study demonstrates the high prevalence of EMDs in patients undergoing manometry. None of the factors studied, such as age, sex, diabetes, hypothyroidism, smoking, and alcohol and opium consumption, had a statistically significant correlation with EMDs.

Pneumatic balloon dilation (PBD) is a first line treatment for idiopathic achalasia. Here we report the safety and efficacy of graded gradual PBD on short and long-term follow-up.

We evaluated 1370 idiopathic achalasia patients over a period of 24 years (1994-2018), prospectively. 216 patients did not undergo PBD due to comorbid diseases. Ultimately, 1092 achalasia patients were enrolled. All patients underwent graded gradual PBD, with repeat dilation if symptoms relapsed. Response to treatment was evaluated by Vantrappen scoring system.

Of 1092 achalasia patients, 937 patients were treated by PBD and 155 patients were treated by combined therapy (PBD 1 month after Botulinum toxin injection). In short-term follow-up, 728 of 1092 patients underwent one PBD and 77.3% of them had excellent or good response (responders), 163 patients (58.6%) who underwent two PBDs were responders, and 44 (51.2%) patients who underwent three PBDs were responders. Overall, 2193 balloon dilations were performed on 1092 patients (mean 2 PBDs/patient). Of 786 patients with long-term follow-up, 259 patients had excellent or good response with one PBD. The responders with two, three, and four or more dilations were 149, 67, and 67, respectively. The overall response rate was 69%. No any serious complications were noted by using the graded gradual method.

Our results show that graded gradual PBD is a safe and effective method for treatment of achalasia patients, and achieves sufficient short and long-term symptomatic remission with high cumulative success rate.

Three manometric patterns are seen in high-resolution manometry (HRM). Response to treatment has been reported to be different in these subtypes. We aimed to investigate the frequency and response to treatment in subtypes of achalasia.

306 patients between 15 to 60 years old, naïve to treatment with idiopathic achalasia (IA) were evaluated prospectively in a cohort study for 8 years. The patients were treated with pneumatic balloon dilation (PBD), and evaluated before and one month after PBD with Achalasia Symptom Score (ASS) and timed barium esophagogram (TBE) and then every 6 months with ASS. The primary study outcome was defined as a reduction in ASS (equal to or less than 4) and a reduction greater than 80% in the volume of barium in TBE at 1 month after PBD compared with baseline values.

According to HRM, 57 were classified as type I (18.62%), 223 as type II (72.9%), and 26 as type III (8.5%). The mean lower esophageal sphincter (LES) residual pressures before treatment were 34.05 ± 31.55, 32.99 ± 17.90, and 37.47 ± 14.07 mmHg in types I, II, and III, respectively (p = 0.18). The mean ASS values before treatment were 12.23, 11.50, and 11.50, for types I, II, and III, respectively (p = 0.29). The ASS dropped to 2.50 in type I, 2.40 in type II, and 2.12 in type III at 1 month after treatment (p = 0.83). Eventually, at the end of follow-up, 24 patients with type I (83%), 82 patients with type II (67%), and five patients with type III (83%) showed sustained good responses (p = 0.528).

Manometric subtypes of achalasia did not have an important role in clinical success in the long term. Achalasia has no definite cure, but with current treatment modalities, palliation of symptoms is possible in over 90% of patients.

Several treatment strategies are available to treat achalasia. Although combined therapy has been used for several years, there are limited data on long-term outcomes. We aimed to determine its long-term efficacy in patients who were resistant or those with rapid relapse.

In this prospective study, we reviewed the records of 1100 patients with achalasia, who were candidates for pneumatic balloon dilatation (PBD) in our center from 1996 to 2018. We enrolled 197 patients resistant to initial treatment or with rapid relapse of symptoms after three sessions of PBD. Clinical evaluation and time barium esophagogram (TBE) were done before treatment, a month afterward, and when clinical symptoms increased in order to confirm relapse, and at the end of follow-up.

A total of 168 patients accepted combined therapy. The mean duration of follow-up was 9.04 years. Achalasia symptom score (ASS) dropped from 10.82 to 3.62 a month after treatment and was 3.09 at the end of the follow-up (p = 0.0001 and 0.001). TBE had a decrease in mean height of barium one month after treatment (9.23 vs. 5.10, p = 0.001), and this reduction persisted until the end of follow-up (3.39, p = 0.001). Vantrappen score at the end of the follow-up showed 56 patients in excellent, 51 in good, 33 in moderate, and 14 in poor condition (89% acceptable response rate).

Our results showed the long-term efficacy of combined treatment in patients with achalasia who otherwise had to undergo a high-risk and costly procedure, which makes it a safe and effective alternative for myotomy.

Achalasia is the most well known esophageal motility disorder. Laparoscopic Heller myotomy (LHM) is the most effective treatment for achalasia. The aim of this study was to review our results on LHM for achalasia. In this cross-sectional study all patients undergoing LHM between 2015 and 2017 were studied. The myotomy was followed by an anterior or posterior partial fundoplication. All patients were followed up for at least six months. We conducted this prospective study on 36 consecutive patients who underwent LHM over 3 years. The mean age of the patients was 36.64 ± 13.47 years. 30 patients (83.3%) underwent Toupet and 6 patients (16.7%) received Dor fundoplication. 11 patients (30.6%) developed reflux after the procedure. According to the Eckardt Symptom Scoring (ESS), the symptoms improved in 74.2% of the patients and remained unchanged in 25.8% of the patients. Analysis of the ESS, indicated a significant change in regurgitation and retrosternal pain, dysphagia, and weight loss after the surgery (p = 0.001, p = 0.002, p = 0.046, and p = 0.001, respectively). LHM with anterior or posterior partial fundoplication is safe and achieves a good outcome in the treatment of achalasia, especially in patients who have not responded to other methods while no serious complication was reported despite several prior endoscopic interventions.

BACKGROUNDAchalasia, as an incurable disease is defined by the lack of normal esophageal peristalsis and loss of lower esophageal sphincter relaxation due to impaired myenteric neural plexus. The exact cause of myenteric neural cells degeneration in achalasia is still unknown. One hypothesis is that certain neurotropic viruses and autoimmune factors cause the inflammatory response in myenteric network, which consequently destroy neural cells. This study was designed to find the evidence of viral causes of achalasia.
METHODSIn this case-control study, 52 patients with achalasia and 50 controls referred to Shariati Hospital, were evaluated for the genome of neurotropic viruses, HPV, and adenovirus by polymerase chain reaction (PCR) and reverse transcription (RT) PCR techniques.
RESULTSGenome assessment of neurotropic DNA viruses turned out negative in the patients, however, the genome of HSV-1 (Herpes simplex virus) was found in tissues of six controls. No neurotropic RNA viruses were observed in the tissue samples and whole blood of both the patients and controls. Among non-neurotropic viruses, adenovirus genome was positive in tissues of two out of 52 patients and three out of 50 controls. In addition, one out of 52 patients and two out of 50 controls were positive for HPV infection in tissues.
CONCLUSIONWe could not detect any significant relationship between achalasia and HPV, adenovirus, and neurotropic viruses in the cases. Nevertheless, it does not exclude the hypothesis of either an alternate viral species or resolved viral infection as the etiology of achalasia.

Although Heller myotomy is one of the most effective treatments for achalasia, it may be associated with early or late symptom relapse in some patients. Therefore, additional treatment is required to achieve better control of symptoms. To evaluate the safety and efficacy of pneumatic balloon dilation (PBD) in patients with symptom relapse after Heller myotomy. Thirty six post-myotomy patients were evaluated from 1993 to 2013. Six patients were excluded from the analysis because of comorbid diseases or epiphrenic diverticula. Thirty patients were treated with PBD. Primary outcome was defined as a decrease in symptom score to 4 or less and a reduction greater than 80% from the baseline in the volume of barium in timed barium esophagogram in 6 weeks. Achalasia symptom score (ASS) was assessed at 1.5, 3, 6, and 12 months after treatment and then every six months in all patients and PBD was repeated in case of symptom relapse (ASS>4). The mean age of the patients was 45.5±13.9 years (range: 21-73). Primary outcome was observed in 25 patients (83%). The mean ASS of the patients dropped from 7.8 before treatment to 1.3±2.0 at 1.5 months after treatment (p=0.0001). The mean volume and height of barium decreased from 43.1±33.4 and 7.1±4.7 to 6.0±17.1 and 1.1±2.2, respectively (p =0.003, p =0.003). The mean duration of follow-up was 11.8±6.3 years. At the end of the study, 21 patients (70%) reported sustained good response. No major complications such as perforation or gross bleeding were seen. PBD is an effective and safe treatment option for achalasia in patients with symptom relapse after Heller myotomy.

Among the therapeutic options for achalasia are pneumatic dilatation (PD)، an appropriate long-term therapy، and botulinum toxin injection (BT) that is a relatively short-term therapy. This study aimed to compare therapeutic effect of repetitive pneumatic dilation with a combined method (botulinum toxin injection and pneumatic dilation) in a group of achalasia patients who are low responder to two initial pneumatic dilations. Thirty- four patients with documented primary achalasia that had low response to two times PD (<50% decrease in symptom score and barium height at 5 minute in timed esophagogram after 3month of late PD) were randomized to receive pneumatic dilation (n=18) or botulinum toxin injection and pneumatic dilation by four weeks interval (n=16)، PD and BT+PD groups respectively. Symptom scores were evaluated before and at 1، 6 and 12 months after treatment. Clinical remission was defined as a decrease in symptom score ≥ 50% of baseline. There were no significant differences between the two groups in gender، age and achalasia type. Remission rate of patients in BT-PD group in comparison with PD group were 87. 5% vs. 67. 1% (P = 0. 7)، 87. 5% vs. 61. 1% (P = 0. 59) and 87. 5% vs. 55. 5% (P = 0. 53) at 1، 6 and 12 months respectively. There were no major complications in either group. The mean symptom score decreased by 62. 71% in the BT-PD group (P < 0. 002) and 50. 77% in the PD group (P < 0. 01) at the end of the first year. Despite a better response rate in BT+PD group، a difference was not statistically significant. A difference may be meaningful if a large numbers of patients are included in the study.

Multiple esophageal diverticula is a rare entity that may be seen in the course of esophageal motor disorders. Herein, I reported a 45 year-old man presented with intermittent chest pain and dysphagia since 20 years ago that exaggerated during the last six months. Barium swallow and upper GI endoscopy revealed multiple diverticula along the esophagus and his esophageal manometry showed high amplitude contractions (‹180 mmHg) in distal part of the esophagus that confirmed the diagnosis of nutcracker esophagus.

Cancer of the gallbladder is an uncommon but a fatal disease. Cholelithiasis has been identified as a major risk factor for this cancer. The objective of this study was to evaluate the association between the presence of cholelithiasis and gallbladder cancer. 1,136 patients who underwent cholecystectomy between 1993 and 2003 in Shariati Hospital, affiliated to Tehran University of Medical Sciences were retrospectively studied and the proportion of patients who has had cholelithiasis was determined. Finally, we identified those patients with cholelithiasis who were also diagnosed as gallbladder cancer. 1,055 (92.8%) patients underwent cholecystectomy for cholelithiasis; 1.4% of these patients had also pathology-proven cancer. On the other hand, during this period, 20 patients with gallbladder cancer were diagnosed; the initial diagnosis in 70.5% of these patients were cholelithiasis. In only 5% of cancer patients, the diagnosis of neoplasia was made initially. Although a very small portion of those with gallbladder stone will develop cancer, most of patients with gallbladder cancer present with signs and symptoms of gallbladder stone which may imply a close correlation between these two conditions. Therefore, prophylactic cholecystectomy may be beneficial for patients with chronic gallbladder stone.

Endoscopic therapies can decrease the morbidity of patients with high risk peptic ulcer. The aim of this study was to evaluate the beneficial effects of oral omeprazole therapy in patients with bleeding peptic ulcer who received combined endoscopic treatment (epinephrine injection and Argon Plasma Coagulation). Eighty six patients with bleeding from gastric, duodenal or stomal ulcers and endoscopic stigmata of recent bleeding were enrolled in our study. All patients received injection of epinephrine (1:10,000) and also their ulcers were treated with Argon Plasma Coagulator. The patients then randomly assigned to receive oral omeprazole (40 mg every 12 hours) or placebo. Five (11.6%) of 43 patients in the placebo group had rebleeding; but no rebleeding was detected among 43 patients in omeprazole group (p= 0.05). One patient in the Placebo group underwent surgery for control of his rebleeding; but none of the patients in omeprazole group needed surgery. One patient in the placebo group and none of the patients in the omeprazole group died. The average hospital stay was 5 days in the omeprazole group and 5.8 days in the placebo group. Addition of oral omeprazole to combined endoscopic therapy significantly reduces recurrent bleeding rates.

Hepatitis B is one of the most important etiologic factors of acute and chronic hepatitis, cirrhosis of the liver and hepatocellular carcinoma. The best preventive method is vaccination. The Aim of the study was to evaluate the immunization rate against hepatitis B in medical health personnel. This study was conducted on 331 health care workers employed in public, semiprivate, and private hospitals that had received the complete dosage of vaccination with an average duration of 0-3 years since the last dose, and had not previously received any booster or HBV - Immunoglobulin. The Shariati (public), Imam Khomeini (public), Baqiyatallah (semi-private) and Day (private) hospitals were the sites of our research. Regarding the age and occupational status, persons were randomly selected and data relating to demographic aspects and serum anti-HBS titer were recorded in all individuals and then were evaluated. Results show that out of the 331 cases, 47 (14.2%) were non-responder (Anti-HBs titer ‹10 IU/L), 160 (54.4%) had low  response (10|£|Anti-HBs titer |£|100 IU/L), and 104 persons (31.4%) were found to have good response (Anti-HBs titer ›100 IU/liter). There was no significant relationship between the antibody titer and other variables including age, gender, smoking, body mass index (BMI) and duration since last dose of vaccine. We suggest the assessment of Anti-HBs titer after complete vaccination in high-risk groups to find non- and low-responders in order to revaccinate them.

Cholangiocarcinoma is a malignant tumor of the biliary tract epithelium. Although it is not a common tumor, it has a high mortality rate so that the five-year survival of the patients is only 5%. Most patients are found to have irresectable tumor on initial presentation. These have led to an emphasis on the role of palliative treatment. 43 patients with Cholangiocarcinoma (from 1996-2003) based on ERCP were included in this study. Demographic aspects, clinical and Para clinical manifestations as well as the risk factors were investigated and survival rates of the patients were compared with or without stenting of the biliary tract. 27 patients (62.8%) were male and 16(37.2%) were female with mean age of 65. Ulcerative colitis accompanied with PSC was diagnosed in just one case. Jaundice, weight loss and pruritus were the main complaints of the patients. Twenty-seven cases received stent in biliary tract through ERCP while no treatment was performed in other patients due to technical failure or patients’ disagreement. Mean survival time for all patients was 125 days. There were no statistically significant difference between survival rate of the patients with stent and without it. In this study cholangiocarcinoma in our patients was less frequently seen to accompany UC and PSC. Curative surgical resection is not possible in the majority of cases, and palliative treatment only decreases the severity of the symptoms but has no significant effect on survival.

Background and objective- Estimation of the colonic transit time (CTT) or the transit time of various bowel segments helps in the pathological diagnosis of constipation and in determining the required treatment. The aim of this study was to recognize the mechanism and type of passage of feces in various segments of the large bowel among patients who attended different GI clinics with constipation.Methods-Among the patients with chronic constipation and no signs of organic or endocrine disease, the time taken for evacuation of the colon (CTT) was estimated by the ingestion of ten radio-opaque markers, each 1-3 mm in length, for 6 consecutive days after which a plain abdominal X- ray was taken on the seventh day. A comparison was then made between the time required for evacuation of the markers from the colon and the patient’s age, sex, frequency of defecation, severity and pressure at the time of defecation.Results-A total of 64 patients (28 male and 36 female) with a mean age of 37.3 years and a range of 13-76 years were included in the study. The frequency of defecation was less than once a week, once a week and twice a week in 7, 41 and 16 patients, respectively. Moreover, 26 patients had no pressure on defecation. Among the 64 persons under study, 37 had abnormal colonic transit time (over 34 hours). The remaining 27 patients who complained of severe constipation were found to have a normal transit time. The duration of abnormal defecation was unrelated to sex, chronicity of the disease or pressure on defecation. Delayed bowel evacuation in the right colon, left colon and rectosigmoid was found in 8, 26 and 15 patients, respectively. Conclusion-The estimation of bowel evacuation time using radio-opaque markers can be very helpful in determining the mechanism, pathophysiology and treatment of constipation. In addition, it is a helpful method in the recognition of false cases in patients who complain of severe constipation but who have a normal bowel transit time. Thus it is possible to use suitable treatment according to the motility disorder of the different areas of the bowel.