Treatment for upper esophageal sphincter dysfunction in a patient with poststroke dysphagia: A case report.
ABSTRACT: RATIONALE:Botulinum toxin injection is a widely used procedure for the treatment of the dysfunction of the upper esophageal sphincter (UES). Although the injection can be guided by ultrasound, electromyography, or computed tomography, such techniques cannot determine the exact extent of narrowed UES and ensure that the narrowed extent is fully covered by the treatment. This report describes a dual guiding technique with ultrasound and the balloon catheter in a patient with poststroke dysphagia to improve these weaknesses. PATIENT CONCERNS:The patient was admitted to a rehabilitation hospital 2 weeks postcerebral infarction. DIAGNOSES:Clinical presentation of the patient included severe hemiplegia and dysphagia. The fiberoptic endoscopic evaluation of swallowing (FEES) revealed penetration/aspiration when swallowing 1 ml water and 1 ml yogurt and pooling in the postcricoid region. INTERVENTIONS:Balloon catheter dilatation procedures and Botulinum toxin injection were performed. We used a dual guiding technique with ultrasound and the balloon catheter to determine the whole segment of UES dysfunction by locating the lowest level of the impaired UES opening and to reduce difficulty in differentiating UES from adjacent tissues during Botulinum toxin injection. OUTCOMES:No persistent progress was observed on the symptoms and volume of the balloon during dilatation. The patient showed quick responses after Botulinum toxin injection. The postinjection balloon catheter dilatation showed an increased maximum volume (preinjection, 5.5 ml vs. postinjection, 14 ml), and the patient was able to eat yogurt, congee, or semi-solid food 100-150 ml 4 weeks after the injection. LESSONS:The dual guiding method holds several advantages, suggesting that it may be considered as a promising choice in dealing with UES dysfunction.
Project description:BACKGROUND: Intrasphincteric injection of botulinum toxin is a new treatment option for achalasia. AIMS: To compare the immediate and long term efficacy of botulinum toxin with that of pneumatic dilatation. METHODS: Symptomatic patients with achalasia were randomised to botulinum toxin (22 patients, median age 57 years) or pneumatic dilatation (20 patients, median age 56 years). Symptom scores were assessed initially, and at one, three, six, nine, and 12 months after treatment. Objective assessment included oesophageal manometry initially and at one month, and barium oesophagram initially and at one, six, and 12 months post-treatment. RESULTS: Pneumatic dilatation resulted in a significantly (p=0.02) higher cumulative remission rate. At 12 months, 14/20 (70%) pneumatic dilatation and 7/22 (32%) botulinum toxin treated patients were in symptomatic remission (p=0.017). Failure rates were similar initially, but failure over time was significantly (p=0.01) higher after botulinum toxin (50%) than pneumatic dilatation (7%). Pneumatic dilatation resulted in significant (p<0.001) reduction in symptom scores, and lower oesophageal sphincter pressure, oesophageal barium column height, and oesophageal diameter. Botulinum toxin produced significant reduction in symptom scores (p<0.001), but no reduction in objective parameters. CONCLUSIONS: At one year pneumatic dilatation is more effective than botulinum toxin. Symptom improvement parallels objective oesophageal measurements after pneumatic dilatation but not after botulinum toxin treatment for achalasia.
Project description:Although the modified balloon dilatation therapy has been demonstrated to improve pharyngeal swallowing function post stroke, the underlying neural mechanisms of improvement are unknown. Our aims are (1) to investigate the effect of modified balloon dilatation on the excitability of corticobulbar projections to the submental muscle in dysphagic patients with brainstem stroke and (2) the relation between changes in excitability and pharyngeal kinematic modifications. Thirty patients with upper esophageal sphincter (UES) dysfunction due to unilateral brainstem stroke were recruited into two groups. The patients in dilatation group received modified balloon dilatation and conventional therapies, and those in control were only treated by conventional therapies (twice per day). The amplitudes of bilateral submental motor evoked potentials (MEPs) induced by transcranial magnetic stimulations over bilateral motor cortex, diameters of UES opening (UOD) and maximal displacement of hyoid (HD) were all assessed at baseline and the endpoint of treatments. Repeated ANOVA analysis revealed significant main effect of group, time and MEP laterality on MEP amplitudes (p = 0.02). There were no differences in the pretreatment measures between groups (all p > 0.05). After treatment, the amplitudes of affected submental MEP evoked by ipsilateral cortical pulse as well as UOD and HD were significantly different in dilatation group compared to control (amplitude: p = 0.02, UOD: p < 0.001, HD: p = 0.03). The differences of pre- and post-treatment amplitudes of the affected MEP evoked by ipsilateral stimulation showed a positive correlation with the improvement of HD (dilatation: R <sup>2</sup> = 0.51, p = 0.03; control: R <sup>2</sup> = 0.39, p = 0.01), rather than UOD in both groups (all p > 0.05). In conclusion, modified balloon dilatation therapy can increase the excitability of affected projection in patients with unilateral brainstem stroke.
Project description:Correct guiding of the catheter is a critical issue in almost all balloon catheter applications, including arterial stenosis expansion, coronary arterial diseases, and gastrointestinal tracking. To achieve safe and precise guiding of the balloon catheter, a novel imaging method with high-resolution, sufficient depth of penetration, and real-time display is required. Here, we present a new balloon catheter guiding method using fast photoacoustic microscopy (PAM) technique for precise balloon catheter tracking and visualization as a feasibility study. We implemented ex vivo and in vivo experiments with three different medium conditions of balloon catheter: no air, air, and water. Acquired cross-sectional, maximum amplitude projection (MAP), and volumetric 3D PAM images demonstrated its capability as a new imaging guiding tool for balloon catheter tracking and visualization.
Project description:BACKGROUND:Delta-shaped anastomosis is a common method of intracorporeal gastroduodenostomy in totally laparoscopic distal gastrectomy. One common postoperative complication of this procedure is anastomotic stenosis, and endoscopic balloon dilatation is a major remedy for such complications. Other treatment strategies are necessary to manage unsuccessful endoscopic balloon dilatation. CASE PRESENTATION:We present a case where systemic steroid treatment was applied in sustained anastomotic stenosis after endoscopic balloon dilatation. We performed delta-shaped anastomosis in laparoscopic distal gastrectomy to treat early-stage gastric cancer in a patient. The patient experienced abdominal pain post-surgery; subsequent investigation revealed edematous anastomotic stenosis. The stenosis sustained even after endoscopic balloon dilatation and local steroid injection. Consequently, we applied systemic steroid treatment. CONCLUSION:Systemic steroid treatment improved the stenosis and no recurrence was observed. These results suggest that systemic steroid application could be useful to treat anastomotic stenosis.
Project description:Primary lingual dystonia is a rare condition, especially when it is only induced by speaking. Trihexyphenidyl failed to improve the symptoms. Several case series have demonstrated the effectiveness of botulinum toxin injection for the management of focal lingual movement disorders. Only 1 case of botulinum toxin injection for primary lingual dystonia induced by speaking has been reported, but this treatment has limited effectiveness. Our patient was treated with botulinum toxin using a superficial approach for injection into the tongue with continuing excellent results. Lingual botulinum toxin injection is a fairly simple, safe and viable treatment option for lingual dystonia induced by speaking.
Project description:BACKGROUND: Botulinum toxin A is a potent inhibitor of the release of acetylcholine from nerve endings. Local injection of botulinum toxin has recently been suggested to be helpful in sphincter of Oddi dyskinesia by decreasing sphincter of Oddi pressure. AIMS: To explore the mechanism of action of botulinum toxin A on sphincter of Oddi (SO) muscle. METHODS: Four piglets underwent duodenoscopy and SO manometry was performed. After obtaining a baseline pressure, the SO was injected with normal saline and the experiment repeated after one week. The SO was then injected endoscopically with botulinum toxin (40 U) with follow up manometry one week later. The sphincter of Oddi was removed from 10 pigs, cut into three rings, and placed in an organ bath. The force of contraction was measured and registered on a polygraph. Rings were stimulated by 70 V (10 Hz, 0.5 ms) electrical field stimulation for 20 seconds, exogenous acetylcholine (100 microM), and KCl (125 mM). Botulinum toxin (0.1 U/ml) or atropine (1 microM) was added to the incubation medium and the stimulation was repeated. RESULTS: Mean basal SO pressure in the pigs remained unchanged after saline injection but decreased to about 50% of baseline value following botulinum toxin injection (p = 0.04). The contractions induced by direct stimulation of SO smooth muscle with KCl were not significantly affected by either atropine or botulinum toxin. In all rings exogenous acetylcholine induced contractions, which were totally blocked by atropine, but not by botulinum toxin. Electrical field stimulation induced contractions that were inhibited by both atropine and botulinum toxin. CONCLUSION: Botulinum toxin inhibits pig sphincter of Oddi smooth muscle contractions by a presynaptic cholinergic mechanism, similar to that described in skeletal muscle.
Project description:Objective: To examine the effectiveness of intradermal botulinum toxin type A injection in improving skin texture and midface lift while reducing pore size and sebum production, as well as investigate the differences in effectiveness between onabotulinumtoxinA and abobotulinumtoxinA using intradermal and intramuscular injection methods. Design: A 16-week, single-blind, split-face, randomized study. Each patient served as their own control, receiving onabotulinumtoxinA and abobotulinumtoxinA randomized to either the left or right side of the face. Patients received intradermal botulinum toxin type A injections at Week 0 and intramuscular botulinum toxin type A injections at Week 2. Participants: Ten women aged 35 to 65 years who exhibited static rhytids in the glabellar and periorbital area. Measurements: The primary endpoint was efficacy of split-face treatment of intradermal and intramuscular onabotulinumtoxinA and abobotulinumtoxinA as assessed by a blinded evaluator using baseline and post-treatment photographs. The secondary endpoints included safety as assessed by adverse events and patient satisfaction measured by questionnaires completed at baseline and post-treatment. Results: Intradermal injection of botulinum toxin type A led to a statistically significant improvement in skin texture (p=0.004) while also resulting in mild midface lift (p=0.024), but did not provide a significant reduction of pore size and sebum production. There was no statistically significant difference between onabotulinumtoxinA and abobotulinumtoxinA when injected intradermally or intramuscularly. Conclusion: Intradermal injection of botulinum toxin type A appears to be a safe and effective therapy that provides an improvement in facial skin texture and midface lift. Registry: clinicaltrials.gov (ID#: NCT02907268).
Project description:PURPOSE:To investigate the efficacy of botulinum toxin injection without electromyographic guidance for the treatment of consecutive esotropia. METHODS:A retrospective study was performed on 49 subjects with consecutive esotropia who received botulinum toxin injection in the medial rectus muscles without the use of electromyographic guidance. Treatment was considered successful if the final ocular alignment was orthotropic or esodeviation was ?10 prism diopters (PD) during distant fixation. RESULTS:The mean age was 15.2 ± 8.3 years. The mean esodeviation before injection was 21.8 ± 9.1 PD at distance and 21.3 ± 8.3 PD at near. The mean number of injections per patient was 1.3 ± 0.7, and 46 patients (93.9%) received two or fewer injections. At 6 months after the final injection, the mean angle of esodeviation was 7.3 ± 6.0 PD at distance and 7.5 ± 6.6 PD at near (all p<0.001), and 69.4% showed successful alignment. By multivariate analysis, an initial postoperative esodeviation of ?18 PD at one month after exotropia surgery was considered to be a predictive factor for successful botulinum toxin injection (P = 0.007). Vertical deviation and/or ptosis occurred in 4 patients (8.2%) at two weeks after injection, which all resolved within three months. There was no recurrence of exotropia up to the final follow-up examination. CONCLUSION:Botulinum toxin injection without electromyographic guidance is safe and effective in the treatment of consecutive esotropia without causing recurrent exotropia. Successful botulinum toxin injection is likely in patients with an initial postoperative esodeviation of 18PD or less at one month after exotropia surgery.
Project description:Objective To investigate the clinical feasibility of the injection test for balloon placement during oesophageal pressure measurement in patients without spontaneous breathing. Methods The injection test was performed in 12 mechanically ventilated patients under deep sedation and paralysis. During withdrawal of the balloon from the stomach and air injection into the gastric lumen of the catheter, the presence of the injection test wave in the balloon pressure tracing indicated that the whole balloon was positioned above the lower oesophageal sphincter (LES). The positive pressure occlusion test was performed at different balloon positions. Results In each patient, the injection test wave appeared at a distinct balloon depth, with a mean?±?standard deviation of 41.9?±?3.3?cm and range from 37?cm to 47?cm. The optimal ratio of changes in the balloon and airway pressure (0.8-1.2) during the positive pressure occlusion test was obtained when the balloon was located 5?cm and 10?cm above the LES in nine (75%) and three (25%) patients, respectively. Conclusions The injection test is feasible for identification of the whole balloon position above the LES during passive ventilation. The middle third of the oesophagus might be the optimal balloon position.
Project description:Unrecognized vaginal intubation during the barium enema procedure with subsequent balloon inflation and contrast instillation is a potentially fatal complication of an otherwise common and routine procedure. We describe a patient who, while undergoing a routine barium enema, had misplacement of the enema catheter into the vagina, subsequent rupture of the superior/lateral vagina upon inflation of the catheter retention balloon, and injection of barium contrast into the retroperitoneum. The patient was admitted for surgical repair of the vaginal laceration and monitoring for chemical peritonitis; and was managed without exploratory laparotomy. We review the existing literature, summarize 18 reported cases from worldwide literature, detail potential complications and propose management and prevention strategies based on the mechanism of injury.