Pneumatic dilation for achalasia: late results of a prospective follow up investigation

Abstract

Background: and aims: In this prospective study, we determined the long term clinical course of patients with achalasia who were treated by pneumatic dilation using the Browne-McHardy dilator, and determined whether previously described predictors of outcome remain significant after prolonged follow up.

Methods: Between 1981 and 1991, 54 consecutive patients were treated by pneumatic dilation and followed up at regular intervals for a median of 13.8 years. Remission was determined with the use of a structured interview and a previously described symptom score. Duration of remission was evaluated by Kaplan-Meier estimates of time to recurrence. Predictors of outcome were determined using the log rank test.

Results: Complete follow up until 2002 was obtained in 98% of all patients. Seven patients had died and were censored. A single pneumatic dilation resulted in a five year remission rate of 40% and a 10 year remission rate of 36%. Repeated dilations only mildly improved the clinical response. Patients who were older than 40 years had a significantly better outcome than younger patients (log rank test, p = 0.0014). However, the most significant predictive factor for a favourable long term outcome was a post-dilation lower oesophageal sphincter pressure of less than 10 mm Hg (log rank test, p = 0.0001).

Conclusions: Long term results of pneumatic dilation are less favourable than previously thought. Young patients and those not responding to a single pneumatic dilation should be offered alternative therapy. Patients who remain in remission for five years are likely to benefit from the longlasting treatment effect of pneumatic dilation.

Figure 1

Kaplan-Meier curve. Time to become symptomatic after the first dilatation.

Figure 2

Kaplan-Meier curve. Time to become symptomatic after the first, second, and third dilatation for patients receiving three dilatations.

Figure 3

Kaplan-Meier curve. Time to become symptomatic by patient age (up to 40 years and older than 40 years).

Figure 4

Estimated probability of staying in remission (from the Cox proportional hazards model) after the first dilatation for at least two years and at least 10 years by age.

Figure 5

Kaplan-Meier curve. Time to become symptomatic by patient post-dilatation lower oesophageal sphincter pressure (<10 mm Hg, 10–<20 mm Hg, ⩾ 20 mm Hg).

Figure 6

Estimated probability of staying in remission (from the Cox proportional hazards model) after the first dilatation for at least two years and at least 10 years by post-dilatation lower oesophageal sphincter (LOS) pressure.