Pneumatic Balloon Dilatation for Achalasia Cardia; Early & late results, a single center study.

S Waqar H Shah,Anwaar Ahmed Khan,Arshad K Butt,K Malik,Altaf Alam

doi:10.12669/pjms.335.13685

Abstract

Objective:Achalasia Cardia is treated by Pneumatic balloon dilatation, Heller’s Myotomy and recently, by Peroral Esophagaeal Myotomy. This study reports the efficacy of pneumatic balloon dilatation as a non-surgical motility in achieving relief of dysphagia, clinical improvement and recurrence. Long-term complications were reported.Methods:Eight hundred ninety two adult achalasia patients of both genders were treated from January 1988 till December 2011, with pneumatic balloon (Rigiflex Microvasive®) dilatation, under fluoroscopy Barium swallow was obtained prior to and five minutes after dilatation to evaluate for efficacy of dilatation as well as for complications. Patients not responding to 30 mm balloon had repeat dilatation with 35 mm balloon after 8 weeks. All patients were enrolled in regular follow up at one, six months and yearly intervals up to a period of five years. Recurrence was defined as an increase in symptom score at 8 weeks greater than 50% of their baseline value. These patients were treated with 35 mm balloon or referred for surgical intervention.Results:Of 892 patients, follow up was obtained in 50% for 5 years, 9.2% for 4-years), 9.3% for 3-years, 10% for 2-years and 21.5% for 1-year of patients. One patient died after repeat dilatation. Eighty-eight patients were excluded from this analysis (20 died due to non-procedure related causes and another 68 were lost during follow up). Statistically significant improvement was noted in reduction in height and width of barium column and symptom score coupled with weight gain during follow up. Forty-eight patients were subjected to repeat dilatation with 35 mm balloon, two of these developed post-procedure perforations with one mortality. Three non-responsive patients required surgical laparoscopic myotomy. No carcinoma of esophagus was reported during follow up. One patient post dilatation, developed esophageal bezoar. A single pneumatic dilatation achieved a remission rate of 93% at four years, 90% at three years, 95% at two years and 92% at one year post dilatation.Conclusion:Achalasia of esophagus can be effectively and safely treated with balloon dilatation to achieve adequate short and long-term symptomatic relief with a low complication rate.

Highlights

Idiopathic achalasia of esophagus is a motility disorder of uncertain etiology which presents as dysphagia, night regurgitation, vomiting, weight loss and chest pain.Pathophysiologically, degeneration of myenteric plexus leads to high amplitude non-peristaltic contractions due to unopposed action of excitatory neurotransmitters
This study reports post dilatation follow up of 892 patients for up to five years
Symptomatic relief was achieved with dilatation using 30 mm balloon in 844 patients documented by serial improvement in mean composite symptom scores at 1month (2.2 ± 0.46), 6 month (1.6 ± 0.7) and 12 month (1.6 ± 0.3) follow up,compared with baseline (11.3 ± 1.9)

Summary

Introduction

Idiopathic achalasia of esophagus is a motility disorder of uncertain etiology which presents as dysphagia, night regurgitation, vomiting, weight loss and chest pain. Degeneration of myenteric plexus leads to high amplitude non-peristaltic contractions (vigorous achalasia) due to unopposed action of excitatory neurotransmitters. Pak J Med Sci September - October 2017 Vol 33 No 5 www.pjms.com.pk 1053 loss of cholinergic neurons over time, results in dilatation and low amplitude simultaneous contractions in the esophageal body (classic achalasia). Treatment options which include pneumatic dilation, surgical myotomy and Per-oral endoscopic myotomy (POEM) disrupt the integrity of lower esophageal sphincter (LES) to achieve symptom resolution, promote esophageal emptying and preventing progression to mega esophagus.[1,2] Pneumatic dilatation can be offered to all age groups, as an outpatient procedure, under conscious sedation and early return to work. There may be mild if any occurrence of gastroesophageal reflux disease (GERD)

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