Balloon Dilation For Achalasia Research Articles

Swallow-Induced Syncope in a Patient with Achalasia

A 48-year-old man was referred for the evaluation of dysphagia and syncope. He suffered from both dysphagia and transient loss of consciousness when eating solid food, especially bread. An upper gastrointestinal barium examination and esophageal manometry suggested achalasia. Ambulatory ECG revealed marked sinus bradycardia when experiencing a syncopal episode following the ingestion of a solid meal. A permanent pacemaker was implanted and the patient's syncopal attacks were relieved following this procedure. However, the dysphagia and cardiac arrhythmia completely disappeared only following a successful pneumatic balloon dilatation for achalasia. This observation suggests that swallowing-induced sinus bradycardia and syncope might occur in the course of achalasia and these rhythm abnormalities could be relieved by successful treatment of the achalasia.

Lower oesophageal sphincter pressure and timed barium oesophagogram: two objective parameters in the non-invasive assessment of primary achalasia

The non-invasive assessment of primary achalasia is not precise. To compare investigations before and 1 month after balloon dilation in achalasia. Fifty-two patients with primary achalasia were enrolled. Subjective and objective variables of oesophageal functions were analysed before and 1 month after balloon dilation. The mean predilation symptom score, lower oesophageal sphincter pressure, height and volume of barium at 5 min were 7.7 +/- 2.6, 62.0 +/- 25.1 mmHg, 9.2 +/- 6.1 cm and 53.2 +/- 49.8 mL respectively; the mean postdilation values were 3.0 +/- 3.0, 34.1 +/- 12.5 mmHg, 7.9 +/- 5.1 cm and 28.0 +/- 30.1 mL respectively. The before dilation volume of barium at 5 min correlates significantly with lower oesophageal sphincter pressure (P < 0.01). The mean symptom scores, lower oesophageal sphincter pressure and volume of barium at 5 min dropped significantly after intervention (P < 0.01), but the reduction in barium height at 5 min was not significant. The percentage changes in volume at 5 min significantly predicted the percentage changes in lower oesophageal sphincter pressure (P < 0.01). The volume of barium retention at 5 min can predict the lower oesophageal sphincter pressure before and after balloon dilation in primary achalasia. This could be used as a non-invasive objective tool for initial and post-dilation assessment.

Esophageal dilation / dilators

Esophageal dilation is the treatment of choice for most patients with esophageal dysphagia (functional and mechanical). Multiple forms of esophageal dilators are available. Mechanical dilators (guidewire/nonguidewire assisted) are the major forms of dilators used. Balloon dilator use has increased but they offer only a marginal advantage over traditional mechanical dilators at a greatly increased cost (2 degrees to single use). Comparative trials are biased in favor of balloon dilators, but balloon dilators are not indicated for empiric dilation for dysphagia. Empiric dilation for solid food dysphagia is still controversial. Dilation is rarely associated with complications and is rarely contraindicated unless previous dilation attempts have been unsuccessful. Special circumstances such as caustic strictures, radiation stricture, and dysphagia associated with eosinophilic esophagitis should engender cautious dilation. Attention to detail about placement of guidewires and stricture type are still critical for safety. Predilation barium studies are not needed in all patients but should be employed if the endoscope is not able to pass the stricture and stricture length and angulation are unknown. Intralesional steroids and proton pump inhibitor therapy are important adjuvant treatments for resistant strictures and reflux associated strictures. Balloon dilation for achalasia is still a viable alternative, but it is likely to decrease in usage with the advent of more widespread laparoscopic myotomy.

Short-term and long-term results of endoscopic balloon dilation for achalasia: 12 years' experience.

This retrospective study reports 12 years' experience with pneumatic dilation treatment in patients with achalasia and attempts to define factors capable of predicting failure of endoscopic dilation. Consecutive patients with achalasia who received endoscopic balloon dilation were studied retrospectively. Repeat dilation was carried out if dysphagia persisted or recurred. A structured symptom score questionnaire (the Eckardt score) was conducted by phone with patients who had received dilation and had been followed up for more than 2 years. Failure was defined as the presence of significant dysphagic symptoms after more than two repeat dilations. Data for the first 2 years (short-term) and for the subsequent follow-up (long-term) were analyzed. From 1989 to 2001, 66 patients underwent endoscopic balloon dilation for achalasia; three perforations (4.5 %) occurred, with no mortalities. Dysphagic symptoms significantly improved 12 weeks after the procedure ( P < 0.05). Fourteen patients (20 %) required a second dilation procedure within a median of 7 months (range 1 - 52 months), and 13 of them underwent repeat dilations within the first 2 years. Five patients (7.5 %) required further surgical or endoscopic therapy. Fifty-eight patients received pneumatic dilation for more than 2 years; 32 (55 %) responded to the questionnaire. The mean dysphagia score was 1.7 (SD 1.2), with only five patients (16 %) having significant dysphagic symptoms during a median follow-up period of 55 months (range 26 - 130 months). The cumulative success rates for pneumatic dilation after 5 and 19 years were 74 % and 62 %, respectively. Cox regression analysis identified small balloon size (30 mm) as the only significant factor capable of predicting failure of endoscopic dilation ( P = 0.009; relative risk 5.3; 95 % confidence interval, 1.7 to 40.9). Endoscopic balloon dilation is an effective treatment for achalasia, with minimal morbidity (60 % experience long-term benefit).

Balloon dilation for achalasia of the cardia: experience in 76 patients.

To report our experience with balloon dilation for achalasia of the cardia. Seventy-six patients (mean age, 51 years) underwent balloon dilation with radiologic guidance. A total of 110 procedures were performed from April 1994 to April 2000. Diagnosis of achalasia was established with clinical, radiologic, and manometric data. Dysphagia was a presenting symptom in most patients (90%), regurgitation was present in 39%, retrosternal pain in 22%, and weight loss in 12%. The dilations were performed in a progressive manner starting with a 15-mm-diameter balloon and progressing to 20-, 30-, and 40-mm balloons, as required. Follow-up data were collected retrospectively from patient notes and telephone interviews with the patients and/or their local doctors (mean follow-up, 26 months). There were no cases of esophageal perforation; 89% (98 of 110) of dilations were considered to be successful, with the patients having restoration of normal or near-normal swallowing (excellent or good initial responses). Fifty-two patients required a single dilation; 22 patients, between two and four dilations; and two patients, five dilations. Balloon dilation with fluoroscopic guidance is a safe and successful treatment for achalasia of the cardia.

Treatment of achalasia: the short-term response to botulinum toxin injection seems to be independent of any kind of pretreatment

BackgroundIt has been suggested that intrasphincteric injection of botulinum toxin (BTX) may represent an alternative therapy to balloon dilatation in achalasia. The aim of the present study was to test the effectiveness of botulinum toxin injections in achalasia patients, as assessed using lower oesophageal sphincter pressure (LOSP) and symptom scores, and to compare the response in patients with different types of pretreatment (no previous treatment, balloon dilatation, myotomy, BTX injection).MethodsForty patients who presented with symptomatic achalasia were treated with BTX injection (48 injections in 40 patients). Some of the patients had received prior treatment (seven with myotomy, seven with dilatation and eight with BTX). The symptoms were assessed using a global symptom score (0–10), which was evaluated before treatment, 1 week afterwards, and 1 month afterwards. Manometry was also carried out before and after treatment. Three different selections of patients were studied: all patients; untreated patients; and patients with prior BTX, dilatation, or myotomy.ResultsAfter BTX injection, there was a significant reduction in LOSP (before, 38.2 ± 11.3 mmHg; 1 week after, 20.5 ± 6.9 mmHg; 1 month after, 17.8 ± 6.8 mmHg; P < 0.001). The global symptom score and symptom subscores (dysphagia, regurgitation, chest pain) were significantly decreased after 1 week and 1 month. When the beneficial effects following BTX injection were compared (untreated vs. pretreated), neither changes in LOSP nor beneficial effects on the symptom scores significantly differed. After 6 months, 67.7% of all treated patients were still in symptomatic remission (subgroups: previously untreated patients, 61.5%, n = 26; prior dilatation, 71.4%, n = 7; prior myotomy, 71.4%, n = 7; prior BTX, 73.9%, n = 8).ConclusionsBTX injection offers an alternative treatment for achalasia which is safe and can be performed in an outpatient setting. The initial response to BTX, in terms of symptom scores and LOSP, appears to be independent of any prior treatment. A number of patients do not adequately respond to balloon dilatation or myotomy, which are the first-line treatment modalities in achalasia patients. BTX injection can be performed in these patients, and symptomatic benefit can be expected in the same percentages as with BTX injection in untreated patients.

Esophagectomy for achalasia: patient selection and clinical experience

Background. In 1989, we predicted an increasing number of esophagectomies for megaesophagus and for recurrent symptoms after prior esophagomyotomy or balloon dilatation for achalasia. Patient selection in this group is challenging, as the potential operative morbidity of an esophagectomy must be weighed against the expected clinical outcome after a redo esophagomyotomy or alternative procedures designed to salvage the native esophagus. Methods. The hospital records of 93 patients undergoing esophagectomy for achalasia during the past 20 years were reviewed retrospectively and the results of operation assessed using our prospectively established Esophageal Resection Database and follow-up information obtained through personal contact with the patients. Results. Patient age averaged 51 years. Indications for esophagectomy included tortuous megaesophagus (64%), failure of prior myotomy (63%), and associated reflux stricture (7%). Ninety-four percent of the patients underwent a transhiatal esophagectomy. Stomach was used as the esophageal substitute in 91% cases. Intraoperative blood loss averaged 672 mL. Postoperative length of stay averaged 12.5 days. Major complications included anastomotic leak (10%), recurrent laryngeal nerve injury (5%), delayed mediastinal bleeding requiring thoracotomy (2%), and chylothorax (2%). There were 2 hospital deaths (2%) from respiratory insufficiency and sepsis. Follow-up has averaged 38 months. In all, 95% of patients eat well; nearly 50% have required an anastomotic dilatation; troublesome regurgitation has been rare; and 4% have refractory postvagotomy dumping. Conclusions. Esophagectomy, preferably through a transhiatal approach, is generally safe and effective therapy in selected patients with achalasia. Unique technical considerations include difficulty encircling the dilated cervical esophagus, deviation of the esophagus into the right chest, large aortic esophageal arteries, and adherence of the exposed esophageal submucosa to the adjacent aorta after prior myotomy.

Massively dilated esophagus in achalasia: response to pneumatic balloon dilation

OBJECTIVE: Pneumatic balloon dilation is considered by many to be the treatment of choice for achalasia of the esophagus. Patients with untreated, long standing achalasia may develop massively dilated esophagi, sometimes difficult to dilate with a pneumatic balloon and, rarely, may require esophagectomy. We present our experience with nine such patients out of 110 who underwent pneumatic dilation. METHODS: Of 110 patients treated for achalasia by pneumatic balloon dilation, from January 1989 until December 1996, nine patients had massively dilated esophagi with transverse diameter >7 cm. Results of these patients are presented with pre- and postdilation symptom scores and barium esophagograms. This study was conducted at the Department of Gastroenterology, Shaikh Zayed Postgraduate Medical Institute, Lahore, Pakistan. A Microvasive Rigiflex 35 mm (Boston Scientific, Watertown, MA) pneumatic balloon was used for dilation. RESULTS: Although it is often tedious to perform pneumatic dilation in massively dilated esophagus, it was possible to dilate adequately, in all nine cases without complications, with good symptomatic improvement at 12-month follow-up. CONCLUSIONS: We recommend pneumatic balloon dilation in achalasia with massively dilated esophagus as a first line treatment, the failure of which requires surgical intervention.

A comparison of barium swallow and erect esophageal transit scintigraphy following balloon dilatation for achalasia

We evaluated the relationship between radionuclide esophageal transit studies and barium swallow appearances in a group of patients following forceful balloon dilatation for the treatment of achalasia of the cardia. Paired erect radionuclide esophageal transit studies and erect barium swallows of a group of patients who had undergone pneumatic balloon dilatation for the treatment of achalasia were analyzed. Indices derived from the radionuclide transit study were the percentage of maximum activity remaining in the esophagus 30 s after swallowing a dilute volume of tracer (A30 s) and the percentage of retained activity remaining at 100 s after washout with a bolus of water (A100 s). Indices derived from the barium swallow were a subjective grading of the degree of esophageal dilatation on a 4-point scale and a similar grading of the maximum distensibility of the gastroesophageal channel. Twenty five pairs of radionuclide and barium studies in 18 patients were analyzed. There was statistically significant correlation between the amount of retained activity on the radionuclide studies and degree of esophageal dilatation on the barium studies (r = 0.69 for A30 s, r = 0.56 for A100 s, P = < 0.01). There was no correlation between the amount of retained activity on the radionuclide studies and the degree of distension of the gastroesophageal channel on barium studies. The relationship between the radionuclide esophageal transit curve and barium appearances of the esophagus following pneumatic balloon dilatation for the treatment of achalasia is complex. The transit study provides unreliable information about the distensibility of the gastroesophageal channel and should not be relied upon in isolation for assessment of the efficacy of treatment.

Pneumatic balloon dilation in achalasia: a prospective comparison of balloon distention time

Objective: Duration of Inflation in pneumatic balloon dilatation as treatment of achalasia has been variable ranging from 15 s to 6 min. A 60 s duration appears to be most often used. We compared the efficacy of dilation of achalasia with either 6- or 60-s inflation duration using a Rigiflex dilator of 3.0 cm diameter. Methods: Eighty-one consecutive patients were prospectively studied in a randomized fashion, 41 in the 60-s group (A) and 40 patients in the 6-s group (B). Mean age of group A was 43 ± 16.2 yr and of group B was 40 ± 16.4 yr. Symptoms of dysphagia, chest pain, heartburn, regurgitation, and night cough were evaluated at basal (before dilation), 1- and 6-month intervals after dilation in both groups. Barium swallow was done to assess esophageal emptying 1 wk before dilation and 5 min postdilation in both groups. Results: Significant and sustained improvement was seen for all symptoms in both groups. In addition, the degree of improvement in symptom scores between the two groups was similar. Barium esophagram in both groups at basal and immediately postdilation showed significant improvement in barium emptying but there was no significant difference between the two groups, indicative of equal efficacy in both distention times. Two patients needed repeat dilatation in group A and one in group B, with one drop out from group A, who was lost to follow-up, and was excluded from the analysis. No perforation occurred. Conclusion: Short duration of pneumatic balloon dilatation (6-s) is as effective as longer duration (60-s) in treatment of achalasia.

Invited comment on Chawda et al: Acomparison of barium swallow and erect esophageal transit scintigraphy following balloon dilation for achalasia

Invited comment on Chawda et al: Acomparison of barium swallow and erect esophageal transit scintigraphy following balloon dilation for achalasia

Para-endoscopic balloon dilatation in achalasia—a new technique using the Microvasive Rigiflex balloon dilator

SummaryThe ideal definitive therapy for achalasia of the cardia has yet to be established. Balloon dilatation is a simple, quick, safe and effective method for treating achalasia, and is being increasingly used as the first option in treatment of achalasia. Various types of balloons and techniques of dilatation have been described. In most reports, dilatation is performed by passing the dilator over a guidewire and inflating the balloon under fluoroscopic control. A new technique of balloon dilatation with the Microvasive Rigiflex balloon dilator, performed under direct vision without fluoroscopic control, is described. Our experience with this technique is reported and the literature reviewed.

Balloon dilatation in achalasia: a new dilator.

A newly available balloon dilator for the treatment of achalasia and its advantages over existing instruments are discussed. Our experience with its use in seven patients is described.

Therapeutic endoscopy of the upper gastrointestinal tract.

Therapeutic endoscopy of the upper gastrointestinal tract has advanced rapidly with the introduction of the fibrescope. Day care techniques with intravenous analgesia have replaced in-patient surgery under general anaesthesia. Oesophageal conditions are particularly amenable to endoscopic therapy. Using a wire guide, peptic strictures may be easily dilated, and palliative intubation of malignant strictures has benefitted many elderly patients. Balloon dilatation for achalasia has become the intitial treatment, cardiomyotomy being reserved for those few patients who require several dilatations. Injection sclerotherapy of oesophageal varices has been shown to prolong survival and reduce bleeding, and has replaced portacaval shunting as the primary treatment. In the stomach, new endoscopic techniques for stopping gastroduodenal bleeding by electrocoagulation are being developed. Large foreign bodies can be retreived, and balloon dilatation for pyloric stenosis has been attempted.