Pneumatic dilation and botulinum toxin: when and why?

Pneumatic dilation and botulinum toxin:when and why? The endoscopic treatment options of achalasia include botulinum toxin (BT) injection and pneumatic dilation (PD) of the lower esophageal sphincter (LES). BT can reduce the LES pressure by blocking the release of acetylcoline from presynaptic cholinergic nerve terminals in the myenteric plexus. Although the procedure is safe and good initial response is reported, there is a wide variability in the duration of the response and the effect tends to decrease over time. BT is usually recommended for elderly patients or patients with comorbid illnesses, who are poor candidates for more invasive procedures. PD aims at tearing the muscle fibers of the LES and is considered the most effective nonsurgical treatment for achalasia. Technical details of the procedure vary in different institutions and in many clinical settings the choice between PD or minimally invasive surgical myotomy depends upon local expertise in the procedures. Further endoscopic treatment options such as submucosal esophageal myotomy or self-expanding metallic stents are being studied.

New technique for endoscopic removal of intragastric balloon placed for treatment of morbid obesity.

BACKGROUND: Placement and removal of the intragastric balloon for obesity are performed endoscopically often under general anesthesia. We propose a safer and faster technique for endoscopic removal of the intragastric balloon using standard sedation. METHODS: In 87 obese patients, we performed 3 removal techniques: 1) standard gastroscope and foreign body forceps, 2) standard gastroscope and retrieval snare, 3) double-channel gastroscope and foreign body forceps plus symmetrical "shark model" polypectomy snare. Balloon retrieval time, number of times the grasping devices lost the balloon, amount of antispasmodic drug, symptoms cumulative score and VAS score for discomfort were evaluated. RESULTS: The technique by double-channel gastroscope and foreign body forceps plus symmetrical polypectomy shark retrieval snare showed a significantly lower balloon retrieval time, number of lost balloons, total number of ampoules used, symptoms cumulative score and VAS score compared to the other two techniques (Dunn's P<0.05). Number of lost balloons was positively associated with number of antispasmodic ampoules used, balloon retrieval time and VAS score. CONCLUSIONS: Technique by double-channel gastroscope and foreign body forceps plus symmetrical polypectomy shark retrieval snare, allows balloon removal safely, quickly and easily, avoiding loss of the balloon, with good patient endurance.