Expandable metal stents in achalasia--is there a role?

OBJECTIVE: Achalasia is treated with pneumatic dilation or myotomy, and botulinum toxin injections are occasionally used. We review our community's experience with expandable metal stents in six patients who failed medical treatment or were poor surgical candidates. METHODS: Eight stents were placed in six patients between July 1995 and November 1997. Four patients had achalasia and two pseudoachalasia. Four patients underwent successive botulinum toxin injections. One patient only agreed to periodic Maloney dilatations or a stent. Pneumatic dilation was performed in one patient and considered high risk in the rest. All were poor surgical candidates. Three different stents were used: Gianturco Rosch Z stent, Wallstent I, and Wallstent II. RESULTS: One-month mortality and morbidity were 33% and 50%, respectively. Two patients were asymptomatic on a liquid diet for > or =6 months but required repeat endoscopy for recurrent dysphagia because of food bolus impaction and proximal stent migration in each. CONCLUSIONS: Expandable metal stents in achalasia or pseudoachalasia do not provide sustained symptom relief, and their use is associated with unacceptably high morbidity and mortality. We do not recommend the use of these devices in patients who have failed medical therapy or who are poor surgical candidates.

Serum neutralizing antibody response to the vacuolating cytotoxin of Helicobacter pylori.

Approximately 50% of Helicobacter pylori isolates produce a cytotoxin in vitro that induces vacuolation of eukaryotic cells. To determine the in vivo relevance of this phenomenon, we sought to detect cytotoxin-neutralizing antibodies in sera from H. pylori-infected persons. As a group, sera from 29 H. pylori-infected patients neutralized the activity of the purified cytotoxin to a significantly greater extent than sera from 24 uninfected persons (P = 0.007). The cytotoxin neutralizing activity in sera from H. pylori-infected persons was mediated predominantly by the purified IgG fraction. Sera from H. pylori-infected persons neutralized the cytotoxins produced by multiple H. pylori strains, but failed to neutralize trimethylamine-induced cell vacuolation. Neutralization of cytotoxin activity by human or immune rabbit sera was associated with immunoblot IgG recognition of an 87-kD H. pylori protein. Similarly, neutralization of the toxin by sera was associated with IgG recognition of the purified cytotoxin in an enzyme-linked immunosorbent assay (P less than 0.0001). The presence of cytotoxin-neutralizing antibodies in sera from H. pylori-infected persons indicates that the cytotoxin is synthesized in vivo.