Yield of Routine Esophagrams for Detection of Esophago-Gastric Perforations after Pneumatic Balloon Dilation for Achalasia

Abstract

Purpose: Routine esophagrams are often obtained after pneumatic balloon dilation for achalasia even in asymptomatic patients due to the high risk of perforation associated with achalasia dilation. However, there is no data regarding the clinical utility of these routinely performed esophagrams for detection of esophago-gastric perforations after achalasia dilation. The aim of this study was to determine the yield of routine esophagrams in detecting esophago-gastric perforations after achalasia balloon dilation. Methods: The endoscopy database at the University of Florida was retrospectively reviewed to identify all patients who underwent pneumatic achalasia balloon dilation from 1/2002 to 6/2012. Data assessed included patient demographics, size of balloon used, immediate post-procedure symptoms, tears seen on upper endoscopy (EGD) after dilation, and other endoscopy related complications. Results: 121 pneumatic balloon dilations for achalasia were performed in 76 patients (53% male) during this period. Mean age of patients was 58 years (range: 18-87 years). 84 procedures (69%) were performed with a 30 mm balloon, 34 (28%) with a 35 mm balloon, 2 (2%) with a 40 mm balloon and 1 procedure (1%) with a 30 mm balloon followed by a 35 mm balloon during the same EGD. Of these 121 dilations, 59 (49%) did not have post-dilation esophagrams while 62 (51%) were followed by an esophagram after pneumatic dilation. 54 of these 62 were performed routinely without clinical concern for perforation while 8 were done due to clinical suspicion of perforation. Contrast extravasation (contained leak) was seen in 2 out of these 8 cases while no perforation was identified in the group that underwent routine esophagrams (0/54). Overall rate of perforation was 2/121 (1.7%). Esophageal tears were seen on endoscopy immediately after dilation in both these cases and managed conservatively with hospital admission, antibiotics, kept NPO and discharged within 2 days. There was no clinical evidence of perforation during follow-up in any of the 59 patients who did not have an esophagram after pneumatic dilation. Conclusion: This study shows that routine esophagrams obtained after pneumatic dilation for achalasia did not reveal unsuspected esophago-gastric perforations. We suggest that esophagrams should only be performed in patients where there is clinical suspicion of perforation based on endoscopy after achalasia dilation or in patients with symptoms and/or signs suggesting perforation.