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Background: Achalasia Cardia is a rare esophageal motility disorder. Among various treatment options, Pneumatic Dilatation (PD) is the most widely used and cost effective modality till date. This is the first observational study aiming to evaluate the short term response and complications of PD for Achalasia Cardia in Nepal. Methods: This prospective observational study was conducted between 28th Jan 2020 to 27th Jan 2021. It included 39 patients with Achalasia Cardia diagnosed by clinical presentation, esophagoscopy, barium esophagogram and high resolution manometry. Two patients of Type III achalasia were excluded from study. Thirty seven patients underwent pneumatic dilatation with 30 mm Rigiflex balloon (Boston Scientific, USA) for a duration of 1 minute. Response was assessed by Eckardts score at 3 and 6 months. Result: Among 39 cases (mean age= 39.03±15.017 years, 59% men), commonest was Type II Achalasia (71.8%) followed by Type I (23.1%) and Type III (5.1%). Dysphagia was present in all patients (100%), followed by weight loss (84.6%), regurgitation (79.5%) and chest pain (35.9%). Mean basal Eckardts score and Lower Esophageal Sphincter pressure of the study population was 7.81±1.24 and 24.40±6.83 respectively. Response to pneumatic dilatation was 89.2%. Eckardts score changed significantly from7.81±1.24 to 1.03±1.82 at 6 months (p

Background Gastric sleeve stenosis (GSS) is reported in .7% to 4% of cases after sleeve gastrectomy. Two endoscopic balloon dilation techniques are available with no clear consensus on the therapeutic approach. Objectives To compare the treatment efficacy and safety between hydrostatic and pneumatic balloon dilations for GSS. Setting Academic referral centers, United States and a meta-analysis. Methods Consecutive patients who presented with GSS and underwent endoscopic hydrostatic and/or pneumatic balloon dilations at 3 tertiary care hospitals were included. Clinical success was defined as an improvement of symptoms that allowed the patient to avoid further interventions. A systematic literature search was performed to identify relevant studies for meta-analysis. Results Of 46 patients, 13 had pneumatic dilation only, 26 had hydrostatic dilation only, and 7 had pneumatic dilation after failed hydrostatic dilation. Clinical success was not significantly different among the 3 groups with the success rates of 30.8%, 57.6%, and 57.1% (P = .25) after single dilation and 61.5%, 63.6%, and 71.4% (P = .90) after serial dilations in the pneumatic group, hydrostatic group, and pneumatic after failed hydrostatic group, respectively. Patients who failed hydrostatic balloon dilation (n = 7) had a success rate of 71.4% with subsequent pneumatic dilation. Two serious adverse events were observed in the pneumatic group, whereas none were observed in the hydrostatic group. A meta-analysis of 16 studies involving 360 patients demonstrated higher clinical success with single pneumatic balloon dilation compared with hydrostatic balloon dilation (62.2% versus 36.4%; P = .007) with higher adverse events (3 versus 0 events). Conclusions Hydrostatic balloon dilation should be considered as an initial modality for GSS given its acceptable success rate and high safety profile. In those who fail hydrostatic balloon dilation, a subsequent step-up approach to pneumatic balloon dilation or revisional surgery should be attempted.

The isolated stricture after the sleeve gastrectomy is one of the possible surgical complications. Previous algorithms have been proposed to address the workup and treatment of sleeve gastrectomy stricture. However, current literature lacks standardization and systematic reviews on this topic. This study aimed to review all currently available publications and to create evidence-based recommendations. We searched Medline (PubMed), EMBASE, and Central Cochrane from inception to June 10, 2019. Inclusion criteria were studies reporting treatment of sleeve gastrectomy stricture with no associated leaks. The primary outcome was the reported clinical resolution rate. The final analysis included 32 articles. The pooled reported clinical resolution rate for the primary treatment was 68% (11/16), 82% (296/361), and 75% (34/45) for noninvasive medical therapy, endoscopic, and surgical treatments, respectively (not significant). Among the endoscopic modalities, the pneumatic dilation has the highest clinical success rate. Most rescue surgeries described in the literature were successful. Conclusively, the initial treatment should entail noninvasive medical management followed by the endoscopic approach, if needed. Pneumatic balloon dilation should be the preferred approach, if technically feasible. Revisional surgery should be reserved for endoscopic failure.

Achalasia is a neurodegenerative motility disorder caused by enteric neuron damage in the lower esophageal sphincter. Peroral endoscopic myotomy (POEM) is a standard treatment method for achalasia. Previous treatment modalities may affect the outcome of POEM as they cause submucosal fibrosis. We report a new technique called “hybrid POEM” for the treatment of patients with achalasia who had been previously treated with pneumatic balloon dilatation. We performed two techniques of POEM simultaneously, the standard POEM for the upper part of the submucosal tunnel and open POEM for the stenotic part of the esophagogastric junction. We dissected the mucosa and submucosa, and performed myotomy simultaneously. We overcame submucosal fibrosis of the esophagogastric junction, which was caused by the previous hybrid POEM treatment. The risks of mucosal incision and technical challenge of submucosal tunneling for the fibrotic area may be reduced by hybrid POEM.

To monitor health and diagnose disease in the early stage, future healthcare standards will likely include the continuous monitoring of various vital data. One approach to collect such information is a wearable and flexible device, which detects information from the skin surface. An important dataset is heart pulse information. Herein a method to monitor the detailed pulse signal from a wrist stably and reliably is proposed. Specifically, a soft pneumatic balloon operated by a soft pump applies the appropriate pressure over a tactile sensor onto the radial artery of the wrist to detect detailed heart pulse waves. The soft pump, pneumatic balloon, and flexible tactile pressure sensor are characterized as a fundamental study. Additionally, a proof-of-concept of this integrated device platform is demonstrated by monitoring the heart pulse from a wrist with and without the soft pump functions.

Simple microfluidic systems for handling large particles such as three-dimensional (3D) cultured cells, microcapsules, and animalcules have contributed to the advancement of biology. However, obtaining a highly integrated microfluidic device for handling large particles is difficult because there are no suitable microvalves for deep microchannels. Therefore, this study proposes a microvalve with a trapezoid-shaped cross-section to close a deep microchannel. The proposed microvalve can close a 350 μm deep microchannel, which is suitable for handling hundreds of micrometer-scale particles. A double-inclined lithography process was used to fabricate the trapezoid-shaped cross-section. The microvalve was fabricated by bonding three polydimethylsiloxane layers: a trapezoid-shaped liquid channel layer, a membrane, and a pneumatic channel layer. The pneumatic balloon, consisting of the membrane and the pneumatic channel, was located beneath a trapezoid-shaped cross-section microchannel. The valve was operated by the application of pneumatic pressure to the pneumatic channel. We experimentally confirmed that the expansion of the pneumatic balloon could close the 350 μm deep microchannel.

Achalasia is not uncommonly diagnosed in elderly patients and its incidence and prevalence are growing in this population. However, a scarcity of studies has assessed the typical pathophysiological and clinical features of the disease as well as the effectiveness and safety of the various therapeutic options in elderly populations. Botulinum toxin injection has been used for achalasia treatment since 1994 and is traditionally considered the preferred treatment for fragile elder patients. However, recently more evidence has become available regarding the safety and effectiveness of pneumatic balloon dilation (BD), laparoscopic Heller myotomy (LHM) and per-oral endoscopic myotomy (POEM) in elderly patients with achalasia. In the current review we present the current literature on this topic with a focus on the clinical presentation of achalasia in the elderly and manometric features thereof, as well as summarize the effectiveness and safety of the various therapeutic options. Furthermore, we propose a practical management algorithm as a means to guide the treatment of future cases. We recommend that a conservative/BTI approach should be adopted in the fragile unfit patient. In the elderly fit patient, the treatment decision should be based on the achalasia type, patient preference and the available expertise, similar to the approach adopted for the non-elderly population.

Achalasia is a rare neurodegenerative disorder causing dysphagia and is characterized by abnormal esophageal motor function as well as the loss of lower esophageal sphincter (LES) relaxation. The assessment and management of achalasia has significantly progressed in recent years due to the advances in high-resolution manometry (HRM) technology along with the improvements and innovations of therapeutic endoscopy procedures. The recent evolution of HRM technology with the inclusion of an adjunctive test, fluoroscopy, and EndoFLIP has enabled more precise diagnoses of achalasia to be made and the subgrouping into therapeutically meaningful subtypes. Current management possibilities include endoscopic treatments such as Botulinum toxin injected to the LES and pneumatic balloon dilation. Surgical treatment includes laparoscopic Heller myotomy and esophagectomy. Furthermore, in recent years, per oral endoscopic myotomy (POEM) has established itself as a principal endoscopic therapeutic alternative to the traditional laparoscopic Heller myotomy. The latest randomized trials report that POEM, pneumatic balloon dilatation, and laparoscopic Heller’s myotomy have comparable effectiveness and complications rates. The aim of the current review is to provide a practical clinical approach to dysphagia and to shed light on the most recent improvements in diagnostics and treatment of achalasia over the last two years.

Microactuators are the most distinctive and challenging microdevices among micro electromechanical systems (MEMS) relative to microsensors or electronic circuits. Soft and flexible microactuators have been achieved by introducing polymers as structural materials in addition to conventional materials. Expanding the application of MEMS to the biomedical field requires particular features, such as softness and small devices. It is important to address small and fragile biological objects while satisfying the demand for minimally invasive medicine. Both MEMS and biomedical applications require three-dimensional microstructures for higher-order functions. In general, microactuators are limited to simple motions such as bending. Our group has developed an openable artificial small intestinal tract system. An array of pneumatic balloon actuators (PBAs) transforms a flat structure into a tube structure representing the small intestine. Coordination of the bending motions of the PBAs enables the formation of a three-dimensional tube structure. Each PBA is 400 μm × 1800 μm × 100 μm. The diameter of the tube structure is 1 mm. Additional higher-order functions of the artificial small intestine, such as peristaltic motion, are currently of interest for us. This paper describes the morphological transformation of a soft microstructure and further potential possibilities of coordinated motions of soft microactuators.

Pneumatic balloon and bougie dilation are widely used methods for pediatric esophageal dilation. There are no studies directly comparing the safety of these techniques in pediatric patients. This study compared adverse events (AEs) of balloon and bougie dilation in children at a single institution.AEs were identified by means of a prospective clinical registry of all procedure related AEs from 2012 to 2015 at a single institution. Identified AEs underwent retrospective review of procedural and clinical details. The category of each AE was recorded and severity was assigned using a 5-point scoring system. AEs were compared between balloon and bougie dilation for different severities.There were 105 patients who underwent 246 dilation sessions. Balloon dilation was performed more commonly (n = 190, 77%) as compared to Maloney dilators (n = 56, 23%). Patients with balloon dilation were younger (3.0 vs 14.5 years, P = 0.0001) and more likely to have strictures from caustic ingestion (42% vs 2%, P 0.0001) or surgical anastomoses (34% vs 5% P 0.0001). Bougie dilation was used more commonly in patients with eosinophilic esophagitis (77% vs 7%, P 0.0001)). In multivariate analysis, each year of increasing age was associated with a 12% increase in any AEs (P = 0.015), but no difference in clinically significant AEs (grade 2 or higher) was identified between dilation methods.Bougie and balloon dilation did not have significant differences in AE rates, but the patient populations differed between the 2 methods. The dilation method should depend on stricture characteristics and endoscopist expertise with each method.

This paper shows the integration of a valve into the pressure supply channel for a pneumatic balloon actuator (PBA). We employed a microvalve using a thermally responsive fluid as the valve that integrates with the PBA. Aqueous Pluronic® F127 solutions are thermally responsive fluids that change their viscosity as a function of temperature. The viscosity of a Pluronic® F127 solution can be controlled by a heater integrated into the supply channel to close and open the channel. In this paper we also show the measured pressure resistance of the microvalve and the demonstration of a PBA integrated with a microvalve. The integration of a valve into the pneumatic actuator allows designing compact pneumatic actuator systems.

Pneumatic balloon dilatation (BD) and laparoscopic Heller's myotomy (LHM) are usually preferred treatment options for relieving dysphagia symptoms in achalasia. The aim of the present study was to describe a new technical method for a safe and effective LHM. Endoscopic BD tube (Rigiflex 30-mm pneumatic balloon) is simultaneously insufflated and desufflated in the esophagus during LHM to assess myotomy in 50 consecutive patients. Dysphagia symptoms were determined using Eckardt's score. Three esophageal mucosal perforations occurred during surgery, which was primary repaired. The preoperative Eckardt score improved significantly from 4.54 ± 1.85 to 0.54 ± 0.73 ( P < 0.001) at the first postoperative annual follow-up. The use of endoscopic BD tube during LHM is an easy and valuable method that allows to assess whether the dissection of muscular fibers in the myotomy area is appropriate or not.

BACKGROUND: 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. METHODS: 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. RESULTS: 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). CONCLUSION: 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.

Introduction: Achalasia is an esophageal motility disorder, but its pathogenesis remains unclear. The highest incidence is among adults aged 30 – 60 years with the prevalence of 10/100.000 population. Diagnosis of achalasia is based on symptoms and upper endoscopy, barium esophagogram, and esophageal manometry. Pneumatic Balloon Dilation (PBD) is one of the treatment options, whether it is fluoroscopy-guided or direct endoscopy guided. This study aims to analyze the effect of PBD on the changes of Eckardt score among achalasia patients.Methods: An analytical observational study with a retrospective and prospective design was conducted on 18 achalasia patients who performed PBD at Dr. Soetomo General Hospital. Data were then analyzed using t-test. Results: The mean age was 47.8±12.5 years, and the mean achalasia duration was 18.3±5.9 months. There were no differences of achalasia cases between men and women. The mean body weight in the pre and post PBD was 50.9±6.2 vs 53.1±6.5 kg with delta 2.19±1.88 (p

Achalasia is a chronic disease affecting the myenteric plexus of the esophagus and lower esophageal sphincter. Treatment is aimed at palliating symptoms to improve quality of life. Treatment options for symptom relapse after esophagomyotomy include botox injection, repeat myotomy, per-oral endoscopic myotomy, or pneumatic balloon dilation (PBD). Data demonstrating the safety and efficacy of PBD for recurrence are scarce. With a lack of published data, guidelines have suggested avoiding PBD for recurrent achalasia because of concern for a high risk of perforation. A retrospective review of patients who underwent PBD for recurrent symptoms of achalasia after esophagomyotomy between 2007 and 2017 was conducted. PBD was performed at 30 mm and held for 60 s under fluoroscopic guidance. Patients with residual symptoms had subsequent dilations at increasing 5 mm increments to a maximum of 40 mm. Patient demographics, Eckardt scores, presence of hiatal hernia, time from myotomy to recurrence, and diagnostic modalities were reported. The primary outcome was need for further endoscopic or surgical intervention. Complications are reported as secondary outcomes. One-hundred eight esophagomyotomies were done during the study period. Fourteen patients underwent PBD for recurrent symptoms. The median time to symptom recurrence after esophagomyotomy was 28 months. The median Eckardt score was 6. Ten of 14 patients had an intervention between the initial surgery and PBD (9 standard dilations and 1 botox injection). A total of 23 PBD were done. Seven patients required dilation at 35 mm and two patients required dilation at 40 mm. Eleven patients required no further intervention at a median follow-up of 27.7 months. There were three treatment failures: one required repeat esophagomyotomy and two had no further treatments. There were no periprocedural complications. Serial PBD is safe and effective in treatment of recurrent symptoms of achalasia after esophagomyotomy.

Background Achalasia is a chronic disease that can be managed with effective endoscopic modalities. Aim To evaluate the effectiveness of single setting of pneumatic balloon dilatation for achalasia and assess the long-term success and outcomes. Materials and methods This is a retrospective study of all achalasia patients who underwent pneumatic balloon dilatation at our institute. Patients who could be contacted were inquired regarding their symptoms and dysphagia-free interval after dilatation. Results A total of 72 patients were enrolled. Out of this, 14 patients lost to follow-up. Mean age of 58 patients was 45.02 ± 16.51 years. Male:female ratio was 13:16. Mean predilatation Eckardt score was 7.16 ± 0.834. Type I achalasia was present in 10 (17.2%), type II in 44 (75.9%), type III in 4 (6.9%). Predilatation basal integrated relaxation pressure (IRP) was 28.14 ± 14.76 mm Hg. Postdilatation Eckardt score was 2.40 ± 1.67. Postdilatation dysphagia-free interval was 17.28 ± 6.70 months. A total of 9 patients (15.51%) failed to respond to first dilatation and 49 (84.48%) patients benefited from single setting of pneumatic dilatation. Esophageal perforation occurred in 2/58 (3.44%). We did not find any significant difference in gender distribution, age of presentation, duration of symptom, pre- and postdilatation Eckardt score, type of achalasia, and basal IRP on manometry between type of achalasia. Postdilatation dysphagia-free interval in type II achalasia (18.09 ± 5.976 months) was more than types I and III achalasia cardia (p = 0.066), which showed trend toward significance. Conclusion Pneumatic balloon dilatation of achalasia cardia is a highly effective endoscopic procedure with minimal complications and mortality. Even the single setting of dilatation can have long-lasting dysphagia-free interval. How to cite this article Gupta SJ, Gaikwad NR, Samarth AR, Gattewar SR. Pneumatic Balloon Dilatation for Achalasia Cardia: Outcome, Complications, Success, and Long-term Follow-up. Euroasian J Hepato-Gastroenterol 2017;7(2):138-141.

Restoring the sense of touch in robotic surgery is an emerging need several researchers tried to address. In this paper, we focused on the slave side proposing a pneumatic sensor to estimate contact forces occurring during the interaction between surgical instruments and anatomical areas. It consists of a tiny pneumatic balloon, which, after being inflated, appears near the tip of the instrument during the measurement phase only. This paper presents a mathematical method relating the intensity of the contact force to the variation of pressure inside the balloon. The latter was modeled as a spherical elastic membrane, whose behavior during contact was characterized taking into account both the deformation of the membrane and the compression of the contained gas. Geometrical considerations combined with an energetic approach allowed us to compute the force of interest. The effectiveness of our sensing device has been confirmed by experimental results, based on comparison with a high-performance commercial force sensor.

This paper reports our recent achievement of high bending-force generation by a soft microactuator. In vivo medical instruments such as endoscopes require improved functions to reduce restrictions caused by the operation from the outside of a body. In general, microactuators can provide precise motions but not good high forces. We attempted to overcome this drawback and successfully demonstrated Newton-level high force generation by a cantilever-type soft microactuator using pneumatic balloon actuator. A high-force bending motion is expected to lift tissues/organs up during an endoscopic operation. The innovative reinforcement design of a soft microactuator using a combination of ribs and conversion film is described and followed by device characterization. The Newton-level force generation by a cantilever-type soft microactuator of dimensions 16 mm × 40 mm × 850 µm is described.

For comfortable and convenient human life, human-interactive and communicative robot has attractive attention from industrial to home-use applications. One of human-friendly robotic structures is pneumatic balloon type soft robots using mainly silicone rubber operated by compressed air. In this study, we develop a tactile pressure sensor array integrated with pneumatic soft robotic hand to monitor tactile pressure like a human skin. The important advance of this study is to integrate flexible sensors embedded in soft robotic hand without sacrificing softness and flexibility.

Achalasia is an esophageal motility disorder that results in clinically significant dysphagia. The esophageal manometry findings are characterized by aperistalsis in the body of the esophagus and incomplete relaxation in the lower esophageal sphincter during swallowing. The etiology of achalasia is unknown, and the current therapeutic interventions target the underlying pathophysiology of the disease. Endoscopic therapies, such as pneumatic balloon dilation and botulinum toxin injection, typically only produce temporary improvement of dysphagia symptoms. The cornerstone of surgical therapy for achalasia is esophagomyotomy. The video-assisted thoracoscopic approach for esophagomyotomy was described by Pellegrini in 1992. Thoracoscopic myotomy is an effective alternative to laparoscopic myotomy for the surgical management of achalasia. The thoracoscopic myotomy has demonstrated comparable results to laparoscopic myotomy for clinical relief of dysphagia and minimal postoperative complications.

The objective of the research was to assess the effectiveness of balloon pneumatic dilation and laparoscopic Heller myotomy in treatment of patients with achalasia cardia. Materials and methods. Twenty-one patients with achalasia cardia were examined and treated using pneumatic balloon dilation and laparoscopic Heller myotomy in the Department of Surgery from January 2016 to April 2018. There were 8 (38.1%) men and 13 (61.9%) women at the age of 28 to 75 years (the average age was (51.47 ± 3.63) years) and disease duration of 1 month to 8 years (the average disease duration was (3.05 ± 0.49) years). Results and discussion. With the help of radiological methods of examination, all the patients were divided into 4 groups according to the esophageal diameter: Group I included 5 (23.8%) patients with the esophagus up to 4-5 cm in diameter; Group II comprised 6 (28.6%) patients with the esophagus up to 4-6 cm in diameter; Group III included 5 (23.8%) patients with the esophagus up to 6-8 cm in diameter; Group IV consisted of 5 (23.8%) patients with the esophagus of more than 8 cm in diameter and an S-shaped configuration. A significant decrease in the diameter of the esophagus according to fluoroscopy (p

This paper presents a novel tongue movement training device using intraoral sensory stimuli from pneumatic balloon actuators placed on an artificial palate.

Achalasia is an oesophageal motility disorder of unknown cause, primarily characterized by absence of peristalsis of the esophageal body and impaired relaxation of lower oesophageal sphincter resulting invariably in dysphagia for solids/liquids or both and regurgitation of undigested foods. The diagnosis is usually made by classical symptoms, barium swallow X-ray of oesophagus or by endoscopy. Goal of treatment is to relieve symptoms, improve esophageal emptying and reduce the risk of associate complications. The two most successful treatment options are pneumatic dilation of lower oesophageal sphincter and surgical myotomy. This quasi-experimental study was carried out from January 2010 to December 2011 involving 31 patients of Achalasia Cardia admitted in the Department of Gastroenterology of BSMMU, Dhaka who underwent pneumatic balloon dilatation. Immediately after pneumatic dilatation all the patients got relief of dysphagia and were discharged from hospital next day. At follow-up 4 weeks after pneumatic dilatation, majority (96.2%) of the patients remained improved symptomatically. Significant weight gain was also found at 4 weeks after pneumatic dilatation. Pneumatic dilatation came out to be a simple, safe and effective method for treating patients with achalasia cardia.Bangladesh Med J. 2015 May; 44 (2): 76-81

Background: Deep infiltrating endometriosis (DIE) of the large bowel is infiltration of the large-bowel wall by endometrial-like implants and is associated with fibrosis and muscular hyperplasia. Deep endometriosis affects ∼20% of patients with endometriosis. Objective: The aim of this research was to assess the importance of anastomotic stricture (AS) after large-bowel resection for DIE of the colon. Materials and Methods: This was a retrospective analysis of prospectively collected data. A consecutive series of 113 colonic resections for DIE were performed to address pain and/or infertility. There were low and very-low resections (n = 82) with mechanical end-to-end anastomosis associated with or without partial colpectomy, segmental sigmoid resections with side-to-end anastomosis (n = 27), and ileocecal resections with latero–lateral anastomosis (n = 4). Pneumatic balloon dilatation was performed in cases of AS (n = 22 in 13 patients). Patients were asked preoperatively and at 4, 8, 12, and 24 ...

BACKGROUND 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. Aim : To evaluate the safety and efficacy of pneumatic balloon dilation (PBD) in patients with symptom relapse after Heller myotomy. METHODS 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). RESULTS 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. CONCLUSION PBD is an effective and safe treatment option for achalasia in patients with symptom relapse after Heller myotomy.

BACKGROUND/AIMS Currently, forceful endoscopic pneumatic balloon dilatation (PBD), laparoscopic Heller myotomy (LHM) with or without an anti-reflux procedure, and peroral endoscopic myotomy are the preferred treatment options for achalasia. The aim of the present study was to retrospectively compare postoperative outcomes after LHM plus Dor fundoplication (DF) between patients who underwent prior endoscopic balloon dilatation and those who did not. MATERIALS AND METHODS Sixty-five patients who underwent HM+DF between January 2008 and December 2016 were retrospectively analyzed. Of these, 45 had a history of endoscopic PBD. Pre- and postoperative achalasia symptoms, including weight loss, dysphagia, heartburn, and regurgitation, were evaluated using the Eckardt score. RESULTS Fifty (76.9%) patients underwent laparoscopic surgery and 15 (23.1%) underwent open surgery. When patients were compared according to the presence of preoperative endoscopic PBD, no significant difference were observed in terms of age, sex, preoperative lower esophageal sphincter pressure, operation time, hospitalization period, and follow-up period (p>0.05). The mean Eckardt score at the first postoperative year was significantly lower than the preoperative Eckardt score (4.51±1.8 vs. 0.52±0.7; p

This paper presents a soft micro-finger composed of a soft micro-actuator and a flexible micro-sensor. Proposed micro-finger is, for the first time, integrated with a pneumatic balloon actuator (PBA) and a strain sensor using liquid metal. Both actuator and sensor can be formed by simple structures with cavities or channels sandwiched by two thin films. The strain sensor is fabricated by filling the space with liquid metal. Proposed design can provide simple batch-fabrication of integrated actuators and sensors for soft micro-fingers. We could succeed in detecting the motion of PBA (560μm×130μm×900μm) by the liquid metal based strain sensor (50μm×50μm×2mm). The gage factor of demonstrated strain sensor is estimated at 0.8. We can say the combination of proposed actuator and sensor is excellent in terms of both fabrication and performance.

Background and study aims: Esophagrams are often obtained routinely after pneumatic balloon dilation for achalasia, even in asymptomatic patients, as there is a risk of postprocedure esophagogastric perforation, which is a potentially life-threatening complication. The aim of this study was to determine whether the combination of a clinical suspicion of perforation and endoscopic re-examination after pneumatic dilation for achalasia can detect esophagogastric perforation, and thereby preclude the need for routine esophagrams in all patients. Patients and methods: All patients who underwent pneumatic dilation between January 2002 and June 2012 at our single tertiary referral center were identified retrospectively. Procedures were categorized into two groups: Group 1 underwent routine esophagograms after pneumatic dilation, and Group 2 underwent esophagograms only if there was a clinical suspicion of perforation. The detection rate of esophageal perforation after pneumatic dilation was compared between the two groups. Results: A total of 119 achalasia dilation procedures were performed in 70 patients. Group 1 included 49/119 procedures (41.2 %), all of which were followed by routine esophagograms. Group 2 included 70/119 procedures (58.8 %), 12 of which were followed by esophagograms based on a clinical suspicion of perforation. No esophageal perforations were found in Group 1, whereas three were found in Group 2. No perforations occurred in the 58 procedures that were not followed by esophagograms. The overall rate of perforation was 3/119 (2.5 %). Conclusions: Esophagrams obtained routinely after pneumatic dilation for achalasia did not reveal unsuspected esophagogastric perforations. No esophageal perforations were missed after procedures that were not followed by esophagograms. Obtaining an esophagram only in cases of clinical suspicion of perforation and endoscopic evaluation may be an alternative to routine esophagograms in patients undergoing pneumatic dilation for achalasia.

Post intubation tracheal stenosis is a clinical problem caused by regional ischemic necrosis of the airway. Its treatment options include tracheal resection with end to end anastomosis, laser resection and stenting. Laser resection followed by balloon dilatation of the soft stenosis is an innovative procedure. It is relatively simple and inexpensive procedure to perform. This case report highlights the importance of this innovative surgical procedure to alleviate the suffering of this elderly diabetic male with chronic renal failure and with a poor cardiac status ‘a high risk surgical patient’. Laser ablation of the stenotic segment followed by balloon dilation was performed under direct visualization. Quality of life following this procedure is also good in relation to post-operative morbidity.

Background and Aims Pneumatic balloon dilatation (PD) is a mainstay in achalasia treatment. The aim of this study was to identify predictive factors for successful treatment. Methods We retrospectively reviewed 76 patients with a diagnosis of achalasia who underwent PD from June 2010 to May 2013. Clinical symptoms were assessed using Eckardt score and manometry data were analyzed using resting and relaxation pressure (4sIRP) of lower esophageal sphincter (LES) and the distal contractile integral (DCI), which was calculated for 10 s from the start of deglutition between the upper margin of the LES and lower margin of upper esophageal contraction. Patients with achalasia were classified into three groups based on the Chicago classification. Results Among 76 patients, 52 patients received PD, and the treatment was unsuccessful in 9 patients (6 in class I and 3 in class III). When comparing prognostic factors between successful and unsuccessful treatment groups, the mean value for 4sIRP in the unsuccessful treatment group was significantly lower than that in the successful treatment group (P

Many pneumatic actuators have been developed to be lightweight with high output for decreasing the impact force. However, for pneumatic actuators it is difficult to maintain exact control because these actuators have constraints. In this study, we developed model predictive control (MPC) that can accommodate these constraints when applied to the pneumatic actuator we developed. As described here, we compared and evaluated the control performance using MPC and proportional–integral–derivative (PID) control with an anti-windup control system. © 2016 Institute of Electrical Engineers of Japan. Published by John Wiley & Sons, Inc.

OBJECTIVES Peroral endoscopic myotomy (POEM) is a novel treatment modality for achalasia cardia. The procedure is technically challenging and time consuming. Recently, a new triangle tip knife (TTJ) has been introduced, which is equipped with water jet facility. In the present study, we analyzed the feasibility, safety, and efficacy of POEM in children with new triangle tip knife. METHODS We retrospectively evaluated the data of children (18 years or younger) who underwent POEM using TTJ knife at our institution. All POEM procedures were performed under general anesthesia in an endoscopy suite. Technical feasibility, safety, efficacy, and procedure duration were assessed. RESULTS Ten children (4 boys, 6 girls) with mean age of 14.2 ± 2.74 (9-18) years, underwent POEM with TTJ knife. The subtypes of achalasia cardia were type I (4), type II (5), and type III (1). Two children had prior treatment with pneumatic balloon dilatation. POEM was performed via anterior route in majority of children (70%). Mean operating time was 47.6 ± 19.74 (30-98) minutes with no significant difference between anterior and posterior approaches to POEM (48.57 ± 24.01 vs 45.3 ± 3.51; P

There is a large variability in clinical practice and in the literature, and no controlled trial with adequate sample size for performing pneumatic balloon dilation (BD) for achalasia. We aimed to evaluate the efficacy and safety of pneumatic BD for achalasia over a 12-year period. We undertook a retrospective review of the medical records of 45 patients who underwent BD for achalasia at a single institution between 2000 and 2013. The primary objectives were the efficacy and safety of BD, patients were followed up every 6 months and the secondary goal was the evaluation of the epidemiological characteristics of achalasia. A total of 45 patients were analysed, of whom 25 (55.6 %) were female. The mean age (SD) of the sample was 54 years. Out of 66 dilations, we were successful in 62 dilations (93.94 %); three were unsuccessful due to perforation of the oesophagus, and one dilation was declared unsuccessful. Of the total patients, three (6.6 %) needed more than two BDs. Endoscopically controlled BD based on the free choice of the diameter of a balloon and duration of dilation is an effective and safe therapeutic modality of achalasia.

Peroral endoscopic myotomy (POEM) is a natural orifice, translumenal endoscopic surgical procedure that achieves endoscopic myotomy by conducting a submucosal tunnel as an operating space. It is conventionally performed in achalasia. Recently, several centers worldwide have reported the feasibility of this procedure not only in early achalasia but also in other particular patient cohorts. Possible indications for POEM include previously failed Heller myotomy, pneumatic balloon dilatation or POEM, sigmoid achalasia, pediatric patients, spastic esophagus disorders, Zenker’s diverticulum and gastroparesis. However, its application in large numbers of special patient groups awaits knowledge of the long-term outcome and greater experience with POEM.

Achalasia is a rare oesophageal motility disorder predominantly causing dysphagia and regurgitation of food and fluids. Diagnosis is made typically after a combination of tests including endoscopy, barium swallow and oesophageal manometry. The advent of high-resolution manometry has led to the Chicago Classification which divided achalasia into three types. This improved the understanding of presentation, prognosis and might also help tailor therapy. Botulinum toxin has been shown to have good, but short-term efficacy. The predominant treatments include pneumatic balloon dilatation and laparoscopic Heller's myotomy, both of which have similar and durable outcomes, although the success of both reduces with time. Per-oral endoscopic myotomy (POEM) has been shown to be as effective, safe and durable as earlier treatments for achalasia; however, randomised controlled trials are lacking. Indications for POEM are expanding to other hypercontractile motility disorders of the oesophagus.

This paper describes biomedical applications of micromachines and introduces a couple of examples from our own studies. Pneumatic balloon actuator has been designed as small, soft, safe micromachines. Pneumatic balloon actuator is micro machined by polymer structures and driven by pneumatic pressure. These features are attractive for biomedical applications. This paper demonstrates examples from medical to bio applications by using the pneumatic balloon actuator. The micro actuator has been designed according to requirements for individual applications.