Interventional radiology-assisted transgastric endoscopic drainage of peripancreatic fluid collections.

Summary: Peripancreatic fluid collections (PFCs) occur as a consequence of pancreatitis. Most PFCs resolve spontaneously, although 1%-2% persist and may require intervention. Conventional transluminal endoscopic drainage methods require the PFC to be bulging into the gastric wall; however, it is not uncommon for this to be absent. Imaging guidance for transluminal endoscopic PFC drainage allows the endoscopist to localize nonbulging pseudocysts that cannot be localized using endoscopy alone, to identify and avoid vascular structures between the cyst and the gastric lumen, and to reveal solid or necrotic components within the pseudocyst cavity. Although endoscopic ultrasound (EUS) has been used to meet this need, timely access to therapeutic EUS remains a limiting factor at many centres. We report our technique and experience performing transgastric endoscopic drainage of PFCs under computed tomography (CT) interventional radiology guidance.

S093: pneumatic balloon dilation for palliation of recurrent symptoms of achalasia after esophagomyotomy.

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSION: Serial PBD is safe and effective in treatment of recurrent symptoms of achalasia after esophagomyotomy.

Neuromuscular manifestations of work-related myalgia in women specific to extensor carpi radialis brevis.

This study assessed neuromuscular function in the extensor carpi radialis brevis (ECRB) of female workers diagnosed with work-related myalgia (WRM, n = 14, age 45.2 ± 1.9 years) and the ECRB of healthy controls (CON, n = 10, age 34.6 ± 2.5 years). Groups were compared on voluntary and electrically evoked functional responses at rest (Pre), immediately following a 5 min repetitive task (Post-0) performed at 60% maximal voluntary contraction (MVC), and after 5 min of recovery (Post-5). Despite near complete motor unit activation (MUA) (CON 98% ± 1% vs. WRM 99% ± 1%), at Pre, WRM produced 26% less (P < 0.05) MVC force than CON. Following an MVC, twitch force was increased (P < 0.05) by 94% ± 13% and 54% ± 11% in CON and WRM, respectively (CON vs. WRM; P < 0.05). The peak force and the maximal rates of force development and decline of electrically evoked contractions (10-100 Hz) were generally depressed (P < 0.05) at Post-0 and Post-5 relative to Pre. The response pattern to increasing frequencies of stimulation was not different (P > 0.05) between groups and MUA was not impaired (CON 97% ± 1% vs. WRM 97% ± 1%; P > 0.05). In conclusion, the peripheral weakness observed in the ECRB in WRM at rest does not result in abnormal fatigue or recovery responses after performing a task controlled for relative demand (60% MVC).

Cellular properties of extensor carpi radialis brevis and trapezius muscles in healthy males and females.

In this study, we sought to determine whether differences in cellular properties associated with energy homeostasis could explain the higher incidence of work-related myalgia in trapezius (TRAP) compared with extensor carpi radialis brevis (ECRB). Tissue samples were obtained from the ECRB (n = 19) and TRAP (n = 17) of healthy males and females (age 27.9 ± 2.2 and 28.1 ± 1.5 years, respectively; mean ± SE) and analyzed for properties involved in both ATP supply and utilization. The concentration of ATP and the maximal activities of creatine phosphokinase, phosphorylase, and phosphofructokinase were higher (P < 0.05) in ECRB than TRAP. Succinic dehydrogenase, citrate synthase, and cytochrome c oxidase were not different between muscles. The ECRB also displayed a higher concentration of Na(+)-K(+)-ATPase and greater sarcoplasmic reticulum Ca(2+) release and uptake. No differences existed between muscles for either monocarboxylate transporters or glucose transporters. It is concluded that the potentials for high-energy phosphate transfer, glycogenolysis, glycolysis, and excitation-contraction coupling are higher in ECRB than TRAP. Histochemical measurements indicated that the muscle differences are, in part, related to differing amounts of type II tissue. Depending on the task demands, the TRAP may experience a greater metabolic and excitation-contraction coupling strain than the ECRB given the differences observed.

Excitation-contraction coupling properties in women with work-related myalgia: a preliminary study.

We investigated the potential role of selected excitation-contraction coupling processes in females with work-related myalgia (WRM) by comparing WRM with healthy controls (CON) using tissue from extensor carpi radialis brevis (ECRB) and trapezius (TRAP) muscles. For the ECRB, age (mean ± SE) was 29.6 ± 3.5 years for CON (n = 9) and 39.2 ± 2.8 years for WRM (n = 13), while for the TRAP, the values were 26.0 ± 2.1 years for CON (n = 7) and 44.6 ± 2.9 years for WRM (n = 11). For the sarcoplasmic reticulum (SR) of the ECRB, WRM displayed concentrations (nmol·(mg protein)(-1)·min(-1)) that were lower (P < 0.05) for Total (202 ± 4.4 vs 178 ± 7.1), Basal (34 ± 1.6 vs 30.1 ± 1.3), and maximal Ca(2+)-ATPase activity (Vmax, 168 ± 4.9 vs 149 ± 6.3), and Ca(2+)-uptake (5.06 ± 0.31 vs 4.13 ± 0.29), but not SERCA1a and SERCA2a isoforms, by comparison with CON. When age was incorporated as a co-variant, Total, Basal, and Ca(2+)-uptake remained different from CON (P < 0.05), but not Vmax (P = 0.13). For TRAP, none of the ATPase properties differed between groups (P > 0.05) either before or following adjustment for age. No differences (P > 0.05) were observed between the groups for Ca(2+)-release in the SR for either TRAP or ECRB. Similarly, no deficiencies, regardless of muscle, were noted for either the Na(+)-K(+)-ATPase content or the α and ß subunit isoform distribution in WRM. This preliminary study provides a basis for further research, with expanded numbers, investigating the hypothesis that abnormalities in SR Ca(2+)-regulation are involved in the cellular etiology of WRM.

Preliminary observations on high energy phosphates and metabolic pathway and transporter potentials in extensor carpi radialis brevis and trapezius muscles of women with work-related myalgia.

This study compared both the extensor carpi radialis brevis (ECRB) and the trapezius (TRAP) muscles of women with work-related myalgia (WRM) with healthy controls (CON) to determine whether abnormalities existed in cellular energy status and the potentials of the various metabolic pathways and segments involved in energy production and substrate transport. For both the ECRB (CON, n = 6-9; WRM, n = 13) and the TRAP (CON, n = 6-7; WRM, n = 10), no differences (P > 0.05) were found for the concentrations (in millimoles per kilogram of dry mass) of ATP, PCr, lactate, and glycogen. Similarly, with one exception, the maximal activities (in moles per milligram of protein per hour) of mitochondrial enzymes representative of the citric acid cycle (CAC), the electron transport chain (ETC), and ß-oxidation, as well as the cytosolic enzymes involved in high energy phosphate transfer, glycogenolysis, glycolysis, lactate oxidation, and glucose phosphorylation were not different (P > 0.05). The glucose transporters GLUT1 and GLUT4, and the monocarboxylate transporters MCT1 and MCT4, were also normal in WRM. It is concluded that, in general, abnormalities in the resting energy and substrate state, the potential of the different metabolic pathways and segments, as well as the glucose and monocarboxylate transporters do not appear to be involved in the cellular pathophysiology of WRM.

A pilot study to determine whether differences exist in histochemical properties between the trapezius and extensor carpi radialis brevis muscles in women with work-related myalgia.

To investigate fibre-type abnormalities in women with work-related myalgia (WRM), tissue samples were extracted from their trapezius (TRAP) and the extensor carpi radialis brevis (ECRB) muscles and compared with healthy controls (CON). For the ECRB samples (CON, n = 6; WRM, n = 11), no differences (P > 0.05) were found between groups for any of the properties examined, namely fibre-type (I, IIA, IIX, IIAX) distribution, cross-sectional fibre area, capillary counts (CC), capillary to fibre area ratio, and succinic dehydrogenase activity. For the TRAP samples (CON, n = 6; WRM, n = 8), the only difference (P < 0.05) observed between groups was for CC (CON > WRM), which was not statistically significant (P > 0.05) when age was used a covariant. A comparison of the properties of these 2 muscles in the CON group indicated a higher (P < 0.05) and lower (P < 0.05) percentage of type I and type IIA fibres, respectively, in the TRAP as well as higher (P < 0.05) CC, which was not specific to fibre type. These preliminary results suggest that the properties employed to characterize fibre types do not differentiate CON from WRM for either the TRAP or ECRB. As a consequence, the role of inherent fibre-type differences between these muscles in the pathogenesis of WRM remains uncertain.

Effects of consecutive days of exercise and recovery on muscle mechanical function.

PURPOSE: To investigate the effects of three consecutive days of prolonged exercise on muscle mechanical function, 12 volunteers (.VO(2peak) = 44.8 +/- 2.0 mL.kg(-1).min(-1), mean +/- SE) cycled at approximately 60% .VO(2peak) until fatigue. METHODS: Quadriceps muscle function was assessed before and after exercise on day 1 (E1) and day 3 (E3) and during three consecutive days of recovery (R1, R2, R3), using both voluntary and electrically induced contractions at various stimulation frequencies. RESULTS: Exercise on E1 and E3 resulted in a 40% (120 +/- 12 vs 72 +/- 10 N) and 35% (117 +/- 14 vs 78 +/- 8 N) deficit (P < 0.05) in force at 10 Hz, respectively, which remained depressed (P < 0.05) by 32-34% during R1-R3. At 100 Hz, force, although not altered by exercise at E1 or E3, was decreased (P < 0.05) by 12-16% during recovery. The maximal rate of relaxation (-dF/dtmax) at 10 Hz was reduced (P < 0.05) by 38% on E1, by 32% on E3, and remained depressed by 38% through R3. At 100 Hz, -dF/dtmax was only depressed (P < 0.05) during recovery. Maximal rate of force development (+dF/dtmax) at 10 Hz was reduced (P < 0.05) by exercise, but not in recovery. Maximal voluntary contraction force was depressed (P < 0.05) with exercise at both E1 and E3 and remained depressed (P < 0.05) throughout recovery. The reduction (P < 0.05) in motor unit activation assessed with the interpolated twitch technique, observed during recovery, suggests that part of the incomplete recovery (weakness) is central in origin. CONCLUSIONS: These results demonstrate that three consecutive days of prolonged exercise result in a weakness that persists for at least 3 d, compromising force during both voluntary and induced contractions.

Metabolic, enzymatic, and transporter responses in human muscle during three consecutive days of exercise and recovery.

This study investigated the responses in substrate- and energy-based properties to repetitive days of prolonged submaximal exercise and recovery. Twelve untrained volunteers (Vo(2)(peak) = 44.8 +/- 2.0 ml.kg(-1).min(-1), mean +/- SE) cycled ( approximately 60 Vo(2)(peak)) on three consecutive days followed by 3 days of recovery. Tissue samples were extracted from the vastus lateralis both pre- and postexercise on day 1 (E1), day 3 (E3), and during recovery (R1, R2, R3) and were analyzed for changes in metabolism, substrate, and enzymatic and transporter responses. For the metabolic properties (mmol/kg(-1) dry wt), exercise on E1 resulted in reductions (P < 0.05) in phosphocreatine (PCr; 80 +/- 1.9 vs. 41.2 +/- 3.0) and increases (P < 0.05) in inosine monophosphate (IMP; 0.13 +/- 0.01 vs. 0.61 +/- 0.2) and lactate (3.1 +/- 0.4 vs. 19.2 +/- 4.3). At E3, both IMP and lactate were lower (P < 0.05) during exercise. For the transporters, the experimental protocol resulted in a decrease (P < 0.05) in glucose transporter-1 (GLUT1; 29% by R1), an increase in GLUT4 (29% by E3), and increases (P < 0.05) for both monocarboxylate transporters (MCT) (for MCT1, 23% by R2 and for MCT4, 18% by R1). Of the mitochondrial and cytosolic enzyme activities examined, cytochrome c oxidase (COX), and hexokinase were both reduced (P < 0.05) by exercise at E1 and in the case of hexokinase and phosphorylase by exercise on E3. With the exception at COX, which was lower (P < 0.05) at R1, no differences in enzyme activities existed at rest between E, E3, and recovery days. Results suggest that the glucose and lactate transporters are among the earliest adaptive responses of substrate and metabolic properties studied to the sudden onset of regular low-intensity exercise.