Abstract
Background: Achalasia Cardia is a rare esophageal motility disorder. Among various treatment options, Pneumatic Dilatation (PD) is the most widely used and cost effective modality till date. This is the first observational study aiming to evaluate the short term response and complications of PD for Achalasia Cardia in Nepal.
 Methods: This prospective observational study was conducted between 28th Jan 2020 to 27th Jan 2021. It included 39 patients with Achalasia Cardia diagnosed by clinical presentation, esophagoscopy, barium esophagogram and high resolution manometry. Two patients of Type III achalasia were excluded from study. Thirty seven patients underwent pneumatic dilatation with 30 mm Rigiflex balloon (Boston Scientific, USA) for a duration of 1 minute. Response was assessed by Eckardts score at 3 and 6 months.
 Result: Among 39 cases (mean age= 39.03±15.017 years, 59% men), commonest was Type II Achalasia (71.8%) followed by Type I (23.1%) and Type III (5.1%). Dysphagia was present in all patients (100%), followed by weight loss (84.6%), regurgitation (79.5%) and chest pain (35.9%). Mean basal Eckardts score and Lower Esophageal Sphincter pressure of the study population was 7.81±1.24 and 24.40±6.83 respectively. Response to pneumatic dilatation was 89.2%. Eckardts score changed significantly from7.81±1.24 to 1.03±1.82 at 6 months (p<0.001). None of the patients had major complications. Younger age (23±6.377 years) had poor response to treatment, while predilatation Lower Esophageal Sphincter pressure, gender and type of achalasia did not affect the treatment outcome.
 Conclusion: PD is safe and effective treatment modality for Achalasia. Younger patients have poor response to treatment with Pneumatic Dilatation.
Highlights
Achalasia is a rare neurodegenerative esophageal motility disorder characterized by aperistalsis in the smooth muscle esophagus and failure of lower esophageal sphincter (LES) to relax during swallowing
Findings diagnostic of Achalasia on High Resolution Manometry (HRM) were defined as absent peristalsis with impared relaxation of the LES reflected by an integrated relaxation pressure (IRP) of at least 15 mm Hg.[6]
All dilatations were performed under fluoroscopic guidance with a Rigiflex (Microvasive, Boston Scientific Corporation, Boston, MA, USA) achalasia balloon dilator by experienced gastroenterologists according to the ACG Clinical Guideline, 2014, 2018 ISDE achalasia guidelines and ASGE guidelines 2019.1,10,11 A stiff guidewire was placed into the stomach through the endoscope
Summary
Achalasia is a rare neurodegenerative esophageal motility disorder characterized by aperistalsis in the smooth muscle esophagus and failure of lower esophageal sphincter (LES) to relax during swallowing. These lead to symptoms of dysphagia, regurgitation, chest pain and weight loss.[1] Incidence of Achalasia varies between 0.03-3 per 100000 persons per year. Three achalasia subtypes have been defined based on High Resolution Manometry (HRM). Laparoscopic Heller Myotomy and Peroral Endoscopic Myotomy (POEM) are efficacious for subtypes I and II, whereas POEM does best for achalasia type III.[4] Though POEM is coming up as a good treatment option, it is still not practiced in resource limited country like Nepal. This study will bring forward the outcome of PD, the most practiced treatment modality, in our population
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