Timed barium oesophagram: better predictor of long term success after pneumatic dilation in achalasia than symptom assessment

Abstract

Background: Symptom relief post pneumatic dilation is traditionally used to assess treatment success in achalasia patients. Recently, we showed that symptom relief and objective oesophageal emptying are concordant in about 70% of patients, while up to 30% of achalasia patients report near complete symptom relief despite poor oesophageal emptying of barium.

Aims: We now report the results of long term clinical follow up in these two groups of achalasia patients, assessing differences in symptomatic remission rates.

Methods: Achalasia patients undergoing pneumatic dilation since 1995 were evaluated both symptomatically and objectively at regular intervals. Pre and post dilation symptoms were recorded. Barium column height was measured five minutes after ingesting a fixed volume of barium per patient to assess oesophageal emptying. Patients who initially reported near complete symptom relief were divided into two groups based on objective findings on barium study: (1) complete oesophageal emptying (concordant group), and (2) poor oesophageal emptying (discordant group). Patients were followed prospectively for symptom recurrence.

Results: Thirty four patients with complete symptom relief post pneumatic dilation were identified. In 22/34 (65%) patients, the degree of symptom and barium height improvements was similar (concordant group). In 10/34 (30%) patients, there was < 50% improvement in barium height (discordant group). Significantly (p<0.001) more discordant (9/10; 90%) than concordant (2/22; 9%) patients failed therapy at the one year follow up. Seventeen of 22 (77%) concordant patients were still in remission while all discordant patients had failed therapy by six years of follow up. Length of time in symptom remission (mean (SEM)) post pneumatic dilation was significantly (p=0.001) less for the discordant group (18.0 (3.6) months) compared with the concordant group (59.0 (4.8) months).

Conclusions: (1) Poor oesophageal emptying is present in nearly 30% of achalasia patients reporting complete symptom relief post pneumatic dilation. (2) The majority (90%) of these patients will fail within one year of treatment. (3) Timed barium oesophagram is an important tool in the objective evaluation of achalasia patients post pneumatic dilation.

Figure 1

Kaplan-Meier graph of the remission rate (%) in the concordant and discordant groups of achalasia patients. Over a six year follow up period, significantly (p<0.001) more patients in the concordant group (17/22; 77%) were in symptom remission than in the discordant group (0/10; 0%).

Figure 2

Oesophageal barium emptying in the discordant and concordant groups of achalasia patients at one month post pneumatic dilation (PD) compared with long term follow up values. Despite reporting near complete symptom relief post PD, the discordant group of patients had poor oesophageal emptying at one month post therapy, which continued long term until the report of symptom failure (n=10). In the concordant group, symptom relief post PD accompanied by complete barium emptying at one month post PD persisted long term in patients available for follow up oesophagram (n=10).

Figure 3

A 42 year old female with an initial symptom score of 11 and significant oesophageal barium retention (A) underwent pneumatic dilation with the 3.0 cm Rigiflex balloon. She had complete symptom relief one month after treatment and her barium oesophagram showed complete oesophageal emptying by one minute (B), illustrating the concordance between symptoms and the degree of improvement in barium height. Four years after the initial pneumatic dilation the patient continues to be symptom free and timed barium oesophagram confirmed the subjective report with complete emptying by one minute (C).

Figure 4

A 74 year old female with a pre therapy symptom score of 9 and significant oesophageal barium retention (A) underwent treatment with the 3.0 cm Rigiflex balloon with near complete (95%) improvement in her symptoms. However, oesophageal barium emptying (B) showed minimal improvement compared with pre therapy levels. The patient had symptom recurrence after seven months of follow up requiring therapy. Repeat dilation with a 3.5 cm balloon relieved all her symptoms and oesophageal barium emptying was complete by five minutes (C), emphasising the superiority of timed barium oesophagram in assessing success post pneumatic dilation.