Long-term results of graded pneumatic dilatation under endoscopic guidance in patients with primary esophageal achalasia

Abstract

Aim: Achalasia is the best known primary motor disorder of the esophagus in which the lower esophageal sphincter (LES) has abnormally high resting pressure and incomplete relaxation with swallowing. Pneumatic dilatation remains the first choice of treatment. The aims of this study were to determine the long term clinical outcome of treating achalasia initially with pneumatic dilatation and usefulness of pneumatic dilatation technique under endoscopic observation without fluoroscopy.

Methods: A total of 65 dilatations were performed in 43 patients with achalasia [23 males and 20 females, the mean age was 43 years (range, 19-73)]. All patients underwent an initial dilatation by inflating a 30 mm balloon to 15 psi under endoscopic control. The need for subsequent dilatation was based on symptom assessment. A 3.5 cm balloon was used for repeat procedures.

Results: The 30 mm balloon achieved a satisfactory result in 24 patients (54%) and the 35 mm ballon in 78% of the remainder (14/18). Esophageal perforation as a short-term complication was observed in one patient (2.3%). The only late complication encountered was gastroesophageal reflux in 2 (4%) patients with a good response to dilatation. The mean follow-up period was 2.4 years (6 mo - 5 years). Of the patients studied, 38 (88%) were relieved of their symptoms after only one or two sessions. Five patients were referred for surgery (one for esophageal perforation and four for persistent or recurrent symptoms). Among the patients whose follow up information was available, the percentage of patients in remission was 79% (19/24) at 1 year and 54% (7/13) at 5 years.

Conclusion: Performing balloon dilatation under endoscopic observation as an outpatient procedure is simple, safe and efficacious for treating patients with achalasia and referral of surgical myotomy should be considered for patients who do not respond to medical therapy or individuals that do not desire pneumatic dilatations.

Figure 1

Manometric samples from a normal individual (A) and a patient with achalasia (B). Figure A illustrates the normal peristaltic activity forwarding at cranio-caudal direction whereas figure B shows typical manometric findings of achalasia. Note the aperistalsis, weak and simultaneous contractions (mirror sign), and incomplete LES relaxation after swallow. Basal LES pressure is high (40 mmHg).

Figure 2

Technique for pneumatic dilatation under endoscopic control without fluoroscopy. The balloon was positioned so that its midsection was at the high pressure level (A). The balloon was inflated and the endoscopist observes with endoscope proximally to balloon (B). With successful dilatation the ischemic ring of dilated segment was diminished or disappeared (C).

Figure 3

Lower esophageal sphincter pressures (LESP) (A) and symptom scores (B) of patients with therapeutic response initially and at one month after pneumatic dilatation.

Figure 4

Percentage of patients with excellent and good response to dilatation at 6 mo, 1, 3 and 5 years.

Figure 5

Kaplan-Meier plot for the two treatment groups of patients who were dilated once² or twice¹. The cumulative one, three and five year remission rates were higher in patients dilated twice but this difference was not statistically significant (Log-rank χ² = 2.10, P = 0.1471).