Balloon Dilation For Achalasia Research Articles

378. LAPAROSCOPIC PRIMARY CLOSURE OF ESOPHAGEAL RUPTURE CAUSED BY BALLOON DILATATION FOR ACHALASIA AND HELLER'S MYOTOMY WITH DOR FUNDOPLICATION

Abstract Background Achalasia is a Primary motor disorder of the esophagus cased by Insufficient lower esophageal sphincter relaxation and loss of esophageal peristalsis. Major clinical presentations are Dysphagia, regurgitation, and occasional chest pain with or without weight loss. One of most commonly performed conservative treatment is pneumatic dilatation and its most serious complication is esophageal perforation. In this presentation we will introduce a case of esophageal perforation caused by pneumatic dilatation for esophageal achalasia treated with laparoscopic primary closure of perforation and simultaneous Heller’s myotomy with Dor Fundoplication. Methods Esophageal perforation occurred during endoscopic pneumatic dilatation occurred in 61-year-old female patient with achalasia. Initially endoscopic clipping was performed but the patient showed leukocytosis, tachycardia and decreased oxygen saturation with dyspnea. Chest CT showed intraabdominal and mediastinal free air and defect in distal esophagus. Then the patient was referred for surgery. During laparoscopic exploration, 3cm mucosal and 6cm muscle tearing at distal esophagus 2cm proximal to the esophagogastric junction at 3 o’clock direction. After removal of endoscopic clips, primary closure of esophageal rupture in 2-layed method and simultaneous Heller’s Myotomy with Dor fundoplication at 12 o’clock direction was performed. Results The patient showed rapid recovery from septic condition. Nasogastric tube was removed 4 days after surgery. Upper GI series checked with gastrografin 5 days after surgery showed no leakage and no delayed passage in distal esophagus. Chest tube and abdominal drain were removed and the patient was discharged 10 days after surgery. There was no dysphagia and reflux during follow-up afterwards. Conclusion Primary closure for esophageal rupture occurred during balloon dilatation for achalasia and simultaneous Heller’s myotomy with Dor fundoplication by approaching the esophagus from a different direction were successfully performed reducing not only the risk of fulminant sepsis but also the burden of the surgery for achalasia that would be needed to be performed later.

Esophageal two-phase supine/standing scintigraphy and balloon dilatation in achalasia: 20 years of experience

Background/Aim. The most frequent therapeutic method for achalasia is balloon dilatation (BD). Esophageal scintigraphy is potentially the most convenient method for the evaluation of achalasia by quantifying esophageal transit. The aim of this study was to present the results of esophageal scintigraphy (ES) in achalasia treated by BD for a long period of time, from 1997 to 2016, and to set parameters suitable for predicting treatment outcomes. Methods. Two-phase ES in anterior projection was performed. The first phase involved swallowing 10 mL of water with 18.5 MBq 99mTc in a supine position. The second phase was performed in a standing position after swallowing 100 mL of water. The retention index (RI) of esophageal radioactivity was calculated after the imaging using registered esophageal and gastric counts. ES was performed in 52 patients (34 males and 18 females, aged 22?75 years, the median age 44 years) before and after BD. In 31 patients, only two scintigraphies were performed. In the remaining 21 patients, follow-up and repeated scintigraphies were continued including the patients with therapeutic failure and repeated BD. BD was repeated in 8 patients, and those were followed up and evaluated over time. Modified BD was performed with Rigiflex balloon dilators. Results. A typical scintigraphic finding in the supine position was passive esophageal filling without the evidence of motility, and in most patients, 43 of them (83%), radionuclide elimination in the stomach was absent. Evaluating values before and long after the first BD, it was shown that certain values of RI indicated remission or relapse of the disease. The RI difference higher than 50% after BD was a reliable indicator of a longer remission. The age and gender of patients had no impact on the outcome of dilatation, but younger patients were with a higher risk of early failure (6 patients during the first year after BD). ES showed that the first BD was initially successful in 50 patients and after the follow-up in 41 (79%) patients. Conclusion. A two-phase supine/standing ES is most suitable for diagnosing and the follow-up of achalasia. RI represents an important parameter for the evaluation and prediction of therapeutic response. The RI difference of more than 50% after BD is a reliable predictor of a longer remission. Age and gender have no impact on dilatation outcome, but patients younger than 40 years have a higher risk of early therapeutic failure.

Pneumatic balloon dilatation for achalasia—how and why I do it

: Pneumatic balloon dilatation for the treatment of achalasia has been used for over a century and continues to have a role. Although relatively simple to perform, there are multiple steps that should be followed to deliver the treatment safely and effectively, and these are detailed. The results of pneumatic dilatation have been compared to those of laparoscopic cardiomyotomy and to per-oral endoscopic myotomy (POEM) and suggest that, provided multiple balloon dilatations are performed, acceptable results can be attained. In patients treated with a previous myotomy, or with anatomical challenges in accessing the hiatus, pneumatic dilatation is a useful option in the treatment of achalasia.

Layer-to-layer closure using a side channel tube and twin gasper forceps for large iatrogenic perforation during balloon dilatation for achalasia

Layer-to-layer closure using a side channel tube and twin gasper forceps for large iatrogenic perforation during balloon dilatation for achalasia

Pneumatic Balloon Dilatation for Achalasia Cardia: Outcome, Complications, Success, and Long-term Follow-up.

Background:Achalasia is a chronic disease that can be managed with effective endoscopic modalities.Aim:To evaluate the effectiveness of single setting of pneumatic balloon dilatation for achalasia and assess the long-term success and outcomes.Materials and methods:This is a retrospective study of all achalasia patients who underwent pneumatic balloon dilatation at our institute. Patients who could be contacted were inquired regarding their symptoms and dysphagia-free interval after dilatation.Results:A total of 72 patients were enrolled. Out of this, 14 patients lost to follow-up. Mean age of 58 patients was 45.02 ± 16.51 years. Male:female ratio was 13:16. Mean predilatation Eckardt score was 7.16 ± 0.834. Type I achalasia was present in 10 (17.2%), type II in 44 (75.9%), type III in 4 (6.9%). Predilatation basal integrated relaxation pressure (IRP) was 28.14 ± 14.76 mm Hg. Postdilatation Eckardt score was 2.40 ± 1.67. Postdilatation dysphagia-free interval was 17.28 ± 6.70 months. A total of 9 patients (15.51%) failed to respond to first dilatation and 49 (84.48%) patients benefited from single setting of pneumatic dilatation. Esophageal perforation occurred in 2/58 (3.44%). We did not find any significant difference in gender distribution, age of presentation, duration of symptom, pre- and postdilatation Eckardt score, type of achalasia, and basal IRP on manometry between type of achalasia. Postdilatation dysphagia-free interval in type II achalasia (18.09 ± 5.976 months) was more than types I and III achalasia cardia (p = 0.066), which showed trend toward significance.Conclusion:Pneumatic balloon dilatation of achalasia cardia is a highly effective endoscopic procedure with minimal complications and mortality. Even the single setting of dilatation can have long-lasting dysphagia-free interval.How to cite this article: Gupta SJ, Gaikwad NR, Samarth AR, Gattewar SR. Pneumatic Balloon Dilatation for Achalasia Cardia: Outcome, Complications, Success, and Long-term Follow-up. Euroasian J Hepato-Gastroenterol 2017;7(2):138-141.

Tu1231 One Year Follow-Up After Poem and Balloon Dilatation for Achalasia - the Results Seem Similar. A Romanian Prospective Survey

Tu1231 One Year Follow-Up After Poem and Balloon Dilatation for Achalasia - the Results Seem Similar. A Romanian Prospective Survey

Utility of clinical suspicion and endoscopic re-examination for detection of esophagogastric perforation after pneumatic dilation for achalasia

Esophagrams are often obtained routinely after pneumatic balloon dilation for achalasia, even in asymptomatic patients, as there is a risk of postprocedure esophagogastric perforation, which is a potentially life-threatening complication. The aim of this study was to determine whether the combination of a clinical suspicion of perforation and endoscopic re-examination after pneumatic dilation for achalasia can detect esophagogastric perforation, and thereby preclude the need for routine esophagrams in all patients. All patients who underwent pneumatic dilation between January 2002 and June 2012 at our single tertiary referral center were identified retrospectively. Procedures were categorized into two groups: Group 1 underwent routine esophagograms after pneumatic dilation, and Group 2 underwent esophagograms only if there was a clinical suspicion of perforation. The detection rate of esophageal perforation after pneumatic dilation was compared between the two groups. A total of 119 achalasia dilation procedures were performed in 70 patients. Group 1 included 49/119 procedures (41.2 %), all of which were followed by routine esophagograms. Group 2 included 70/119 procedures (58.8 %), 12 of which were followed by esophagograms based on a clinical suspicion of perforation. No esophageal perforations were found in Group 1, whereas three were found in Group 2. No perforations occurred in the 58 procedures that were not followed by esophagograms. The overall rate of perforation was 3/119 (2.5 %). Esophagrams obtained routinely after pneumatic dilation for achalasia did not reveal unsuspected esophagogastric perforations. No esophageal perforations were missed after procedures that were not followed by esophagograms. Obtaining an esophagram only in cases of clinical suspicion of perforation and endoscopic evaluation may be an alternative to routine esophagograms in patients undergoing pneumatic dilation for achalasia.

The efficacy of balloon dilation in achalasia is the result of stretching of the lower esophageal sphincter, not muscular disruption.

SummaryPneumatic dilation (PD) of the lower esophageal sphincter (LES) in achalasia is a major palliative treatment. It is generally believed, although never substantiated, that therapeutic efficacy of ballooning in achalasia is the result of the disruption and tearing of the muscular layers of the LES. To clarify this issue, we investigated the frequency of muscular disruption at the LES, 24 hours after PD, by employing the endoscopic ultrasound (EUS), in a group of 43 consented patients with achalasia. Between July 2009 and March2012, 51 consecutive adult patients with tentative diagnosis of achalasia, some with recurrence of symptoms after an earlier treatment with balloon dilation, were evaluated and underwent PD, using Rigiflex balloon without major adverse effect. Out of the 51 evaluated, 43 eligible and consenting patients who underwent EUS, 24 hours after PD, using Olympus GF‐UE 160 echoendoscope and an Aloka Prosound probe at 7.5 MHZ, are the subjects of this study. The EUS in 43 eligible patients revealed an intact LES in 36 (83.7%), small area of muscular disruption in 5 (11.6%) and small hematoma in 2 patients (4.6%). Our data convincingly demonstrate that the clinical effectiveness of balloon dilation in achalasia is not the result of muscular disruption, but of circumferential stretching of the LES. Our findings on the mechanism of action of PD in achalasia could result in modifying the current method of dilation for a safer procedure, by slowing the rate of inflation and allowing the sphincter to slowly stretch itself to the distending balloon.

Efficacy and safety of pneumatic balloon dilation in achalasia: a 12-year experience

There is a large variability in clinical practice and in the literature, and no controlled trial with adequate sample size for performing pneumatic balloon dilation (BD) for achalasia. We aimed to evaluate the efficacy and safety of pneumatic BD for achalasia over a 12-year period. We undertook a retrospective review of the medical records of 45 patients who underwent BD for achalasia at a single institution between 2000 and 2013. The primary objectives were the efficacy and safety of BD, patients were followed up every 6 months and the secondary goal was the evaluation of the epidemiological characteristics of achalasia. A total of 45 patients were analysed, of whom 25 (55.6 %) were female. The mean age (SD) of the sample was 54 years. Out of 66 dilations, we were successful in 62 dilations (93.94 %); three were unsuccessful due to perforation of the oesophagus, and one dilation was declared unsuccessful. Of the total patients, three (6.6 %) needed more than two BDs. Endoscopically controlled BD based on the free choice of the diameter of a balloon and duration of dilation is an effective and safe therapeutic modality of achalasia.

Tu1366 Immediate Combined Endoscopic and Radiographic Evaluation of the Esophagus After Balloon Dilation for Achalasia Is Sufficient to Detect Leaks in Asymptomatic Patients

The current (2013) ACG achalasia guidelines recommend that after pneumatic dilation, first, a water-soluble esophagogram, then, if negative, a barium esophagogram be performed. However evidence for this algorithm is lacking. The aim of this study is to determine if a simpler post-procedure algorithm is sufficient.

Randomized Study Comparing Peroral Endoscopic Myotomy, Botulinum Toxin Injection and Balloon Dilation for Achalasia: One-year Follow-up: ACG International Award

Randomized Study Comparing Peroral Endoscopic Myotomy, Botulinum Toxin Injection and Balloon Dilation for Achalasia: One-year Follow-up: ACG International Award

497 Primary Results of a Randomized Study Comparing PerOral Endoscopic Myotomy,Botulinum Toxin Injection and Balloon Dilation for Achalasia

Endoscopic treatments for achalasia include peroral endoscopic myotomy (POEM),botulinum toxin injection (BTI) and balloon dilation (BD),yet no randomized studies have compared POEM with the other two treatments.This study was aimed to compare the short term efficacy and safety of the three treatments in a randomized manner.

Endoscopic closure of transmural esophageal perforation after balloon dilation for achalasia

Endoscopic closure of transmural esophageal perforation after balloon dilation for achalasia

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

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.

Complete Endoscopic Closure (Clipping) of a Large Esophageal Perforation After Pneumatic Dilation in a Patient with Achalasia

The risk of esophageal perforation following endoscopic balloon dilation for achalasia is in the range of 1%-5%, with a mortality rate of 1%-20%. Perforations need to be recognized early, and, if reasonable, an immediate endoscopic repair should be pursued quickly. Herein, we report a case of successful endoscopic closure by clipping of a large iatrogenic perforation in a patient with achalasia. An 80-year-old woman with achalasia was admitted to our institution to undergo pneumatic dilation. A 40-mm balloon dilator with inflation pressure of 20 psi was used for 2 minutes as usual. During the procedure, the patient had a transient bradycardia. Endoscopic control showed a 2-cm rupture of the distal esophagus. Prompt endoscopic repair of the perforation by endoclips (n=6) was then attempted, followed by conservative management by total parenteral nutrition and intravenous antibiotics. Endoscopic clipping completely closed the esophageal perforation. The patient was given oral nutrition 10 days later without any complications. Six months after discharge from the hospital, the patient was healthy and free of dysphagia. Endoscopy showed complete healing of the esophageal mucosa without luminal stenosis. This report highlights that prompt endoscopic clipping is a useful means to close a large esophageal perforation caused by pneumatic dilation.

S1524: Utility of Routine Esophagrams for Detection of Esophageal Perforations After Pneumatic Balloon Dilation for Achalasia

Pneumatic balloon dilation for achalasia is associated with a high risk of perforation and routine esophagrams are often obtained after dilation even in asymptomatic patients. There is no data regarding the clinical utility of routinely performed esophagrams for detection of esophageal perforation after achalasia dilation.

Endoscopic Balloon Dilation Under Exclusive Endoscopic Control for Achalasia or Hypertensive Lower Esophageal Sphincter Is a Safe and Efficient Alternative to Dilation Under Fluoroscopy

Introduction/Aim: Endoscopic balloon dilation for achalasia or hypertensive lower esophageal sphincter (HLES) is often performed under fluoroscopic control, however not always required. Our aim was evaluation of feasibility, safety and efficiency of a balloon dilation procedure using exclusive control by a gastroscope placed in a parallel direction, 2 or 3 cm above the proximal end of the dilation balloon. Patients and Methods: 25 balloon dilations sessions were performed without fluoroscopy, between 12.2003 and 4.2008, in 23 patients (M: 7 - F: 16 - mean age: 59.5 - range: 18-86), for symptomatic achalasia (n=19) or HLES (n=4).

Factors Predicting Outcome of Balloon Dilatation in Achalasia

Factors Predicting Outcome of Balloon Dilatation in Achalasia

Factors Predicting Outcome of Balloon Dilatation in Achalasia

Balloon dilatation of the lower esophageal sphincter (LES) is one of the effective nonsurgical treatment options in the management of achalasia. We aimed to determine the long-term results of graded balloon dilatation and the factors predicting outcome. Patients followed for more than 12 months between January 1995 to March 2005, without history of endoscopic or surgical therapy before the study, were included (n = 111, mean age 46.3 +/- 16.9 years; follow-up period 46.3 [12-150] months). Patients were evaluated by barium swallow contrast studies, upper endoscopy, and esophageal manometry. Pneumatic dilatation was performed with the use of polyethylene balloon system. Patient outcome was evaluated according to manometric studies and Van Trappen staging as determined following face-to-face interviews with the patients. We determined clinical response rates of 98%, 85.7%, and 75% at months 24, 48, and 60. According to receiver-operating characteristics (ROC) analysis, age <or=37.5 years, LES pressure (LESP) >or=30.5 mmHg, LESP after first balloon dilatation >or=17.5 mmHg, and balloon number >2 were found to negatively affect treatment response. Young age and higher esophageal body pressure at admission were determined to be negative predictive factors (P = 0.038, relative risk (RR) 2.6, 95% confidence interval [CI] 1.05-6.4 and P = 0.05, RR 1.069, 95% CI 0.99-1.14, respectively). Balloon dilatation is an effective treatment of achalasia. Young age, higher esophageal body pressure, and high LESP after first balloon dilatation are negative predictive factors. Patients with young age requiring more than two balloon dilatations are likely to be unresponsive to the treatment.

Incidence, Clinical Management and Outcomes of Esophageal Perforations after Endoscopic Dilatation

Esophageal dilatation is performed for the treatment of anatomic and sometimes functional narrowing of the esophageal lumen caused by a variety of benign and malignant conditions. Esophageal perforation is the major complication associated with endoscopic dilatation. The object of this study was to assess the incidence of perforation, management and outcomes after endoscopic esophageal dilatation. All patients who underwent endoscopic esophageal dilatation at our institution from June 2001 to December 2006 were identified. Data were obtained by searching our prospectively collected electronic database (MEDOS AG, Langenselbold, Germany), which includes all endoscopic reports as well as discharge summaries of patients who have undergone endoscopy in our department. 248 patients (148 male, 100 female, mean age 58 years, range 14-87 years) underwent 365 esophageal dilatations: 74 pneumatic balloon dilatations for achalasia, 79 balloon dilatations for other reasons such as tumors, peptic stenosis, or post-radiotherapy stenosis and 212 dilatations with Savary bougies. The overall incidence of perforation based on the number of procedures was 2.2% (8 perforations/365 procedures) and 3.2% (8/248 patients) based on the number of patients. The perforation rate was 1.9% for bougie dilatation, 0% for balloon dilatation and 5-4% for pneumatic balloon dilatation for achalasia. Five patients were treated surgically and 3 patients were managed conservatively. The mean hospital stay was 14 days (7-33 days). One patient in whom the perforation was recognized 16 days after the dilatation died. Endoscopic esophageal dilatation is a safe procedure for the palliation of malignant strictures, for the management of benign strictures as well as for the therapy of achalasia. The perforation rate after these procedures is low. Early recognition of the perforation is associated with a good outcome. Small perforations can be treated conservatively.