Proliferative activity of intrahepatic colorectal metastases after preoperative hemihepatic portal vein embolization

Although hemihepatic portal vein embolization (PVE) has been used preoperatively to extend indications for hepatectomy in patients with colorectal metastases, the effects of this procedure on tumor growth and outcome remain controversial. To address this issue, we assessed the proliferative activity of intrahepatic metastases after PVE and the long-term outcome of this procedure. Eighteen patients with colorectal metastases underwent preoperative PVE between 1996 and 2000 (PVE group). Twenty-nine patients who underwent major hepatic resection without PVE served as control (non-PVE group). The hepatic parenchymal fraction of the left lobe had significantly increased from 38.1 +/- 3.2% to 45.9 +/- 2.9% 3 weeks after PVE (+20.5%, P <.0001). Tumor volume and percent tumor volume had also significantly increased from 223 +/- 89 mL to 270 +/- 97 mL (+20.8%, P =.016) and from 13.7 + 4.3% to 16.2 + 4.9% (+18.5%, P =.014), respectively. There was no apparent correlation between the increase in parenchymal volume and that in tumor volume. The Ki-67 labeling index of metastatic lesions was 46.6 +/- 7.2% in the PVE group and 35.4 +/- 12.6% in the non-PVE group (P =.013). Long-term survival was similar in the PVE and non-PVE groups, however, disease-free survival was significantly poorer in the PVE group than in the non-PVE group (P =.004). We conclude that PVE increases tumor growth and probably is associated with enhanced recurrence of disease. Although PVE is effective in extending indications for surgery, patient selection for PVE should be cautious.

[A case presenting severe respiratory failure with high antibody titers to Chlamydia pneumoniae]

"HITAZYME C. pneumoniae" is a diagnostic reagent that has been recently developed by adopting an ELISA method for detection of anti-Chlamydia pneumoniae (C. pneumoniae) antibodies. A case presenting bilateral interstitial opacities and severe respiratory failure with high titers of "HITAZYME C. pneumoniae" was described. Sputum, blood, serological, and bronchoalveolar lavage examinations failed to reveal other etiology to explain his severe respiratory illness. Clinicians should be aware that C. pneumoniae may cause severe respiratory failure or ARDS. Further studies are needed to evaluate the role of C. pneumoniae infection in the development of severe pneumonia or ARDS.

A novel alternatively spliced fibroblast growth factor receptor 3 isoform lacking the acid box domain is expressed during chondrogenic differentiation of ATDC5 cells

To determine the role of fibroblast growth factor (FGF).FGF receptor (FGFR) signaling in chondrogenesis, we analyzed the gene expression of alternatively spliced FGFRs during chondrogenic differentiation of ATDC5 cells in vitro. Two isoforms of FGFR3 were expressed in these cells. One was the complete form of FGFR3 (FGFR3) already reported, and the other was a novel one that lacks the acid box domain (FGFR3DeltaAB). The gene of FGFR3DeltaAB was expressed in undifferentiated ATDC5 cells. In contrast, the transcripts of FGFR3 were not detectable in undifferentiated cells but increased during cellular condensation, which is an obligatory step for chondrogenic differentiation. FGFR1 and FGFR2 expression was higher than that of FGFR3 in undifferentiated cells. The gene expression of cell cycle inhibitor p21 was induced during cell condensation and correlated best with the expression of FGFR3 among the FGFR isoforms expressed. The differential expression of FGFR3 isoforms during chondrogenesis suggests that these isoforms may play different roles in the regulation of growth and differentiation in chondrocytes. To define the mitogenic response of FGFR3DeltaAB and FGFR3 to FGFs, their cDNAs were stably transfected into mouse BaF3 pro-B cells. FGFR3 preferentially mediates the mitogenic response to FGF1 and poor response to FGF2. In contrast, FGFR3DeltaAB mediated a higher mitogenic response to FGF2 as well as to FGF1. In addition, FGFR3DeltaAB responds to FGF1 at lower concentrations of heparin than FGFR3 does. These results suggest that the acid box plays an important role in the regulation of FGFR3 to mediate biological activities in response to FGFs.

[A case of bronchioloalveolar carcinoma with multiple cystic shadows on chest CT]

A 68-year-old woman was admitted to our hospital in 1998 with shortness of breath on exertion. On the first admission, chest radiography revealed multiple nodular shadows and areas of ground-glass appearance mainly in the basal lung fields, and chest CT scans showed multiple thin-walled cystic lesions in both lung fields. Bronchioloalveolar carcinoma was diagnosed by transbronchial lung biopsy. The CA 19-9 level in the serum was abnormally high. The disease progressed, and the patient died 7 months after diagnosis. We report this case because CT scans showed multiple cystic lesions, which is very rare. The mechanism of cystic formation in this case of lung cancer may have involved disruption of the alveolar structure and enlargement of disrupted spaces or of the check valve mechanism.

Early, wide excision of heterotopic ossification in the medial elbow

To prevent the occurrence of secondary contracture during maturation of heterotopic ossification of the elbow, early, wide excision of heterotopic ossification was performed on 9 consecutive patients with a stiff elbow caused by the mass. The average duration between initial injury and operation was 7.7 months. The thick, elastic mass on the posterior oblique ligament of the medial collateral ligament, which included mature and immature heterotopic ossification, was resected widely with the posterior oblique ligament, the posteromedial joint capsule, and the surrounding scar tissue. After an average follow-up of 52.0 months, the total arc of motion improved from a preoperative mean of 37.3 degrees to a postoperative mean of 112.8 degrees. No patient complained of instability or pain on movement. Despite recurrence of spotty heterotopic ossification at the medial elbow in 5 cases, at final follow-up, a sufficient range of motion was obtained in all patients.

Radiographic analysis of lumbar spine for low-back pain in the general population

We sought to demonstrate a correlation between low-back pain (LBP) and the plain radiographic findings of the lumbar spine in the general population based on an analysis of 838 persons, 387 of whom presented with complaints of low-back pain. The incidence of intervertebral narrowing and irregular ossification of the vertebral end-plate image increased consistently with age and was higher in the presence of LBP in any age or gender group. Multiregression analysis was performed with the imaging factors as multivariates. As a result, multiregression equations with irregular ossification of the vertebral end-plate image, intervertebral narrowing, spondylolisthesis and abnormal lumbar lordotic angle combined as variates showed the highest significance as predictors of a relationship with LBP. The discrimination analysis was performed using the linear discriminant function, resulting in a true discrimination rate of 65%. Plain radiography of the lumbar spine is thus significant as it provides information which can be evaluated as meaningful findings in the investigation of LBP. In addition, while the significance can be increased by considering multiple factors, it is important to understand the limits of the accuracy of this prediction.

Anatomical major resection versus nonanatomical limited resection for liver metastases from colorectal carcinoma

BACKGROUND

Although systematic anatomical hepatic resection has been reported to improve patient survival in hepatocellular carcinoma, principles of hepatectomy procedure have not been clearly demonstrated in secondary hepatic malignancy. The purpose of the present study was to determine whether selection of surgical procedures for liver resection is associated with the pattern of tumor recurrence or patient survival.

METHODS

During the period of 1980 through 1999, 174 cases underwent liver resection for hepatic metastasis from colorectal cancer. Of these, 96 underwent systematic anatomical major hepatic resection (anatomical group) and 78 cases underwent nonanatomical limited resection (nonanatomical group). Subset analysis of 115 patients with unilobar single or double tumors was also conducted.

RESULTS

The overall 5-year survival rate of 174 patients was 43.2%. Univariate analysis did not show a significant difference in patient survival according to surgical procedure (anatomical group versus nonanatomical group). Operative morbidity and mortality rates were slightly higher in anatomical group. From the subset analysis in unilobar single or double tumors, anatomical major hepatectomy was unnecessary in 80.4% of the cases if the tumors were resectable by nonanatomical limited resection. Ninety percent of the ipsilateral recurrence, which could have been avoided if the first operation was anatomical hemihepatectomy, could undergo second hepatectomy with 5-year survival rate of 58.3%.

CONCLUSIONS

There was not a significant difference in patient survival according to surgical procedure. To minimize surgical stress and operative risk, nonanatomical limited liver resection should be a basic surgical procedure for colorectal metastases.

Endogenous 5-HT tonically inhibits spontaneous firing activity of dorsal hippocampus CA1 pyramidal neurons through stimulation of 5-HT(1A) receptors in quiet awake rats: in vivo electrophysiological evidence

The present study was performed to examine an overall effect of endogenous serotonin (5-HT) on the spontaneous firing activity of the dorsal hippocampus CA1 pyramidal neurons in quiet awake rats. A selective 5-HT(1A) antagonist N-[2-[4-(2-methoxyphenyl)-1-piperazinyl]ethyl]-N-(2-pyridinyl)cyclohe xanecarboxamide (WAY-100635: 0.03-0.2 mg/kg, s.c.) significantly increased the firing activity. A depletion of 5-HT with parachlorophenylalanine (PCPA: 500 mg/kg/day x 3 days) completely abolished this increasing effect of WAY-100635. The baseline spike frequency of the PCPA-treated rats (3.90 +/- 0.39 Hz) was significantly higher than that of the vehicle-treated rats (2.09 +/- 0.19 Hz). A 5-HT(2A) antagonist ritanserin (1 mg/kg, i.p.) and a 5-HT(3/4) antagonist 2-methoxy-4-amino-5-chloro benzoic acid 2-(diethylamino) ethyl ester (SDZ-205557: 3 mg/kg, s.c.) did not modify the firing activity and the increasing effect of WAY-100635. These results suggest that, in quiet awake rats, endogenous 5-HT would tonically inhibit the spontaneous firing activity of the CA1 pyramidal neurons mainly through stimulating 5-HT(1A) receptors.

Partitioned real-space density functional calculations of bielectrode systems under bias voltage and electric field

We have developed a new partitioned real-space density functional (PRDF) method and applied it to bielectrode systems under bias voltage and electric field. The electronic states, electrostatic potentials, local electric fields, and chemical potentials of biased jelliums and two Si5 clusters are fully self-consistently determined. We overcame an essential difficulty in obtaining the electronic states of biased systems from the conventional density functional method by dividing the entire system into subsystems of each electrode. The PRDF method can be applied to multielectrode systems and enables the investigation of ionic systems with computational efficiency.

Performance of a partially packed charcoal pellet bioreactor for acetic acid fermentation

The performance of a partially packed charcoal pellet bioreactor was compared to that of a fully packed bioreactor for aerobic acetic acid production. In the fully packed charcoal pellet bioreactor, it was considered that the shortening of an actual retention time of the culture broth limited the bioreactor performance under high dilution rate and high aeration conditions. By reducing the filling ratio of charcoal pellets to 44%, which increased the actual retention time of the culture broth, the maximum productivity increased from 3.9 g/l/h in the fully packed bed bioreactor to 5.7 g/l/h in the partially packed bioreactor without affecting the operational stability.

The presence and role of the dopamine DA-2 receptor in the human decidua

OBJECTIVES

Our objectives were to identify the presence of the dopamine DA-2 receptor in human decidua and to study its function in human parturition.

METHODS

Human term decidual tissues were obtained during vaginal delivery and then homogenized. The P3 fraction was prepared for a radiolabeled receptor assay with [3H] spiperone as the ligand. Human decidual tissues obtained at cesarean section before the onset of labor were incubated in Krebs-Ringer buffer at 37 degrees C for 30 minutes in the presence of dopamine with or without (-)-sulpiride. The level of prostaglandin (PG) F in the medium was measured with a RIA kit. Differences were assessed with the Wilcoxon non-parametric test.

RESULTS

Scatchard analysis showed a single class of binding sites having an equilibrium dissociation constant (Kd) of 2.25 +/- 0.59 nM (mean +/- SD) and a maximum binding capacity (Bmax) value of 166.5 +/- 77.7 fmol/mg protein (n = 3). Dopamine significantly increased the production of PGF. This stimulatory effect of dopamine was suppressed by (-)-sulpiride (p < 0.05; n = 7).

CONCLUSION

The DA-2 receptor was demonstrated in the human decidua. Dopamine can stimulate PGF production via this receptor.

Three cases of malignant pheochromocytoma treated with cyclophosphamide, vincristine, and dacarbazine combination chemotherapy and alpha-methyl-p-tyrosine to control hypercatecholaminemia

We describe 3 cases of malignant pheochromocytoma with multiple metastases which were treated with cyclophosphamide, vincristine and dacarbazine (CVD) combination chemotherapy and alpha-methyl-p-tyrosine. Case 1 was operated on first but hypercatecholaminemia could not be completely controlled. Cases 2 and 3 received chemotherapy, CVD combination chemotherapy and/ or alpha-methyltyrosine and good control of hypercatecholaminemia was attained. In all cases it was possible to control hypercatecholaminemia during most of the time they were administered a-methyltyrosine despite the presence of tumors. None of the patients suffered hypertension crises. In our patients treatment with CVD plus a-methyl-p-tyrosine proved to be safe and ameliorated the clinical course.

[Social phobia with somatic symptoms including nausea and urgency of micturition]

The common symptoms of the social anxiety response include blushing, trembling, feelings of muscular tension of the face, and fear of eye contact. However, the ICD-10 mentions other less familiar symptoms such as nausea, urgency of micturition or defecation, gastrointestinal discomfort, and diarrhea as symptoms of social phobia. Since some of these somatic symptoms are classified as panic-like symptoms in the DSM-IV, it is sometimes difficult to distinguish between social phobia and agoraphobia when these somatic symptoms appear in situations usually associated with agoraphobia. We investigated whether social phobic patients with familiar symptoms (classical group; N = 24) and those with unfamiliar symptoms such as nausea, urgency of micturition or defecation (N/U group; N = 13) could be distinguished on the basis of several selected demographic and psychological tests. Fear of negative evaluation (FNE), social avoidance and distress (SAD), brief social phobia scale (BSPS), and Rosenberg's self esteem score (Se) were compared among these two groups and 82 controls. We also investigated whether they have "fears of making other people feel uncomfortable" which is believed to be a characteristic symptom for what is known in Japanese as "taijin-kyofu-sho." Both groups had higher scores on FNE, SAD, fear and avoidance scores of BSPS, and lower scores on Se as compared with controls. However, neither group differed in demographic variables or results of psychological tests, except for higher scores on the performance score of BSPS and increased rate of "fears of making other people feel uncomfortable" in the classical group. It is suggested that social phobia patients had common social phobic symptomatology and psychopathology irrespective of their somatic symptoms.

Clinical experience of long-term transdermal treatment with nitric oxide donor for women with preeclampsia

Isosorbide dinitrate (ISDN), a nitric oxide donor, was applied transdermally for 4-16 days to 4 preeclamptic women with oligohydramnios, intrauterine fetal growth retardation (IUGR), and elevated resistance of blood flow in the uterine arteries. Pulsed Doppler ultrasonography revealed immediate and drastic improvement of pulsatility index (PI) of uterine arteries following treatment with ISDN. The average PI in uterine arteries of the 4 patients was reduced to approximately 67% of that of the untreated state. In 2 patients the amniotic fluid gradually increased over a few days which suggested improvement of fetoplacental circulation during administration of ISDN. This study suggests that long-term transdermal ISDN is an effective therapy, at least in a portion of preeclamptic women, to avoid maternal hypertension, fetal distress, oligohydramnios, and IUGR, and consequentially to prolong the gestational period.

Randomized comparison of intra-arterial versus intravenous infusion of ACNU for newly diagnosed patients with glioblastoma

This prospective randomized trial was performed to compare the effectiveness of intra-arterial ACNU with intravenous ACNU in newly diagnosed patients with supratentorial glioblastoma. The primary end points were overall survival and progression-free survival. Within 3 weeks after surgery, patients were randomly assigned to receive either intravenous or intra-arterial ACNU (80 mg/m2) once every 6 weeks concomitant with radiotherapy. Intraarterial ACNU was administered for the first 3 courses followed by intravenous administration. Eighty-four patients were enrolled onto this study and among them 82 patients who passed eligibility criteria were analyzed. Patients characteristics were not different significantly between 2 treatment arms. Median survival and progression-free survival time was 59 and 24 weeks, respectively for intra-arterial arm and 56 and 45 weeks, respectively for intravenous arm. There was no significant difference respectively between two treatment arms. Among the prognostic variables including age, Karnofsky performance status, extent of surgery and treatment arm, Cox's proportional hazards model showed that age was the only significant factor for both survival and progression-free survival (P = 0.003 and 0.016, respectively). With regard to toxicity, there was no significant difference between two treatment arms. Leukoencephalopathy was not observed in intra-arterial arm. In conclusion, intra-arterial ACNU when administered by the method in this study does not increase the survival and progression-free survival of newly diagnosed patients with glioblastoma over that afforded by intravenous ACNU.

Enhancement of retrovirus-mediated gene transfer to rat liver in vivo by infusion of hepatocyte growth factor and triiodothyronine

BACKGROUND/AIMS

Gene transfer using recombinant Moloney murine leukemia viruses (rMoMuLV) requires mitosis of the target cell. Previously, we and others have used partial hepatectomy for induction of hepatocellular proliferation for gene transfer to the liver in vivo by exsanguineous perfusion with rMo-MuLV. We hypothesized that induction of hepatocellular proliferation by combined administration of two hepatocellular mitogens, hepatocyte growth factor (HGF) and triiodothyronine (T3), should permit rMo-MuLV-mediated gene transfer into liver without invasive approaches.

METHODS

HGF (1 mg/kg) was perfused continuously into the portal vein of Wistar male rats and T3 (2 mg/kg) was injected subcutaneously. Twenty-four hours after injecting HGF and T3, the state of proliferation of hepatocytes was estimated from the incorporation of 5'-bromo-2'-deoxy-uridine (BrdU). The amphotropic retroviral receptor (Ram-1) expression of liver was evaluated at different time points after injecting HGF and T3 by means of Northern blotting using Ram-1 cDNA probe. In order to evaluate the role of hormone treatment on gene transfer, the liver was perfused exsanguineously with rMoMuLV 24 h after injection with hormones.

RESULTS

Rats treated with a combination of HGF and T3 expressed BrdU and beta-galactosidase in 8.3% and 0.7% of hepatocytes, respectively. On the other hand, there was near absence of gene transfer in untreated rats perfused with rMoMuLV Twenty-four hours after the initial manipulation, abundant expression of Ram-1 mRNA was observed in rat hepatocytes treated with HGF plus T3.

CONCLUSIONS

Stimulation of hepatocellular mitosis and upregulation of Ram-1 expression by HGF and T3 augment retrovirus-mediated gene transfer into hepatocytes.

Linkage of autosomal recessive hereditary spastic paraplegia with mental impairment and thin corpus callosum to chromosome 15A13-15

To date, three loci for autosomal recessive hereditary spastic paraplegia (ARHSP) linked to chromosomes 8p12-q13, 16qter, and 15q13-15 have been characterized. We have clinically characterized 13 Japanese ARHSP families and performed genetic linkage analyses. All 13 families were classified as having the "complicated" form, which manifests with mental impairment and thin corpus callosum. Linkage to the 8p12-q13 and 16qter loci was excluded, although 10 of the 13 families showed marker data consistent with linkage to the 15q13-15 locus. The multipoint LOD score of the 10 families linked to chromosome 15 was above 9.00 in the 3-centimorgan segment flanked by D15S994 and D15S659, with a maximum multipoint LOD score of 9.68 at a position 1.2 centimorgans telomeric from D15S994 to D15S659. We have shown that ARHSP with thin corpus callosum, a subtype of recessive spastic paraplegia, maps to chromosome 15q13-15.

Effects of a benzodioxan derivative MKC-242 on the firing activity of the dorsal hippocampus CA1 pyramidal neurons in awake and urethane- anaesthetized rats: in vivo electrophysiological evidence for a 5-HT 1A agonistic property

The aim of the present in vivo study was to determine whether a benzodioxan derivative MKC-242, (S)-5-[3-[(1,4-benzodioxan-2-ylmethyl)amino]propoxy]-1,3-benzodioxole hydrochloride, possesses an agonistic activity at postsynaptic serotonin (5-HT)1A receptors in the rat hippocampus when administered systemically. We examined the effects of acute administrations of MKC-242 on the firing activities of dorsal hippocampus CA1 pyramidal neurons. In quiet awake rats, s.c. administrations of MKC-242 significantly decreased the spontaneous firing activity in a dose-dependent manner at doses of 0.3-6 mg/kg. In urethane-anaesthetized rats, i.v. injections of MKC-242, at cumulative doses of 0.3-3 mg/kg, also significantly and dose-dependently inhibited the firing activity induced by microiontophoretically applied quisqualate. These decreasing effects were antagonized by the selective 5-HT1A antagonists WAY-100135 (5 mg/kg, s.c.) and WAY-100635 (0.2 mg/kg, s.c. to the awake rats and 0.4 mg/kg, i.v. to the anaesthetized rats), thereby confirming that MKC- 242 decreased the firing activities by stimulating 5-HT1A receptors. The selective depletion of 5-HT produced by the 3-d administration of the 5-HT synthesis inhibitor, parachlorophenylalanine (500 mg/kg.d, i.p.), did not affect the decreasing effect of MKC-242 in the awake animals, indicating that postsynaptic 5-HT1A receptors mediated the decreasing effect. The present results provided the first in vivo electrophysiological evidence that MKC-242, when systemically administered, exerts a 5-HT1A agonistic action at the postsynaptic level.

Schnurri interacts with Mad in a Dpp-dependent manner

BACKGROUND

Decapentaplegic (Dpp) is a member of the transforming growth factor-beta superfamily. Dpp governs various developmental processes in Drosophila through the transcriptional regulation of a variety of genes. Signals of Dpp are transmitted from the cell membrane to the nucleus by Medea and Mad, both belonging to the Smad protein family. Mad was shown to bind to the Dpp-responsive element in genes such as vestigial, labial, and Ultrabithorax. The DNA binding affinity of Smad proteins is relatively low, and requires other nuclear factor(s) to form stable DNA binding complexes. schnurri (shn) was identified as a candidate gene acting downstream of Dpp receptors, but its relevance to Mad has remained unknown.

RESULTS

We characterized the biochemical functions of Shn. Shn forms homo-oligomers. Shn is localized in the nucleus, and is likely to have multiple nuclear localizing signals. Finally, we found that Shn interacts with Mad in a Dpp-dependent manner.

CONCLUSIONS

The present results argue that Shn may act as a nuclear component of the Dpp signalling pathway through direct interaction with Mad.

Gene delivery with optimized electroporation parameters shows potential for treatment of gliomas

Electroporation, a standard laboratory method of introducing exogenous molecules into cells, has been gaining importance as a very effective non-viral physical technique of gene delivery. In this study, we have used subcutaneous model of the C6 rat glioma cells and established an optimal condition to obtain very high gene expression in tumor tissues using both reporter and functional genes. Tumors grown on the flanks of Wistar rats are exposed and directly injected with plasmid DNA having the constructs of luciferase, green fluorescent protein and, the fragment of the diphtheria toxin, DT-A. The tumors are then subjected to square wave pulses from an electroporator. Gene expression is found to be several orders of magnitude higher when the tumors are pulsed with the optimized electrical parameters compared to the controls. For luciferase, the enhancement is approximately 135-fold, for the green fluorescent protein, gene expression is seen over a wide area within the sections examined, as contrast to a few punctate dots in the control specimens, and finally, DT-A shows massive death in the tumor tissue. A special circular array of six needles through which pulses are delivered with rotating electric field is found to be highly efficient in transferring genes inside the tumor. Direct injection of plasmid DNA followed by electroporation allows very high in vivo gene transfer and its subsequent expression into tumor tissues. This method may be applicable to any solid tumor.

[Measles pneumonia presenting with multiple nodular opacities on chest radiographs]

A 22-year-old woman presented with fever, cough, and maculopapular erythematous rash on hands and feet. These symptoms developed 14 days after the onset of natural measles in the patient's daughter. Chest radiographs obtained on the first examination showed multiple nodular opacities and infiltrates in the left and right lung fields. Serological examinations disclosed elevated levels of the specific IgM antibody and a remarkably elevated hemagglutination inhibition (HI) titer, indicating a recent measles infection. The patient's symptoms, skin eruptions, and abnormal chest radiograph findings disappeared after several days. However, chest computed tomographic scans taken 8 months after the initial examination revealed small, residual nodular opacities. Other than the fact that the patient had received attenuated measles virus vaccine, these findings were typical of the clinical course for atypical pneumonia. We concluded that in the differential diagnosis of multiple nodular opacities on chest radiographs, adequate attention should be given to pulmonary involvement of measles infection.

[Esophageal dilation therapy for achalasia of the esophagus]

Esophageal dilation therapy for esophageal achalasia has a 300-year history and remains the first-line therapy because of its low cost, progressively decreasing morbidity and mortality, and possibility of surgery for patients who do not improve. Another advantage is the feasibility of repeated trial even after surgery. The aim of this procedure is to produce a controlled tear in the lower esophageal sphincter muscle. Precise esophagographic, endoscopic, and manometric diagnosis is necessary for successful esophageal dilation therapy. In addition, the exclusion of pseudoachalasia using echogram or CT scan is important. The procedure should be carried out accurately to prevent complications. If perforation occurs, appropriate, timely management is required.