Pneumatic Dilation For Achalasia Research Articles

Correlation of Balloon Pressure Used for Pneumatic Dilatation in Achalasia with Manometric Findings and Factors Associated With the Need for Repeat Procedure.

Achalasia is a chronic and rare disorder of esophageal motility. It is characterized by spastic or absent esophageal contractions and impairment of relaxation of the lower esophageal sphincter. Treatment modalities include smooth muscle-relaxing medications, botulinum toxin injections to lower the esophageal sphincter, pneumatic dilatation, and surgical interventions. Pneumatic dilatation is deemed to be an effective treatment option and is the most widely used non-surgical intervention. We designed this prospective study to look for any possible correlation between balloon pressure used in pneumatic dilatation, manometric findings, and patient characteristics. And to find any possible association between the need for repeat pneumatic dilatations and factors like gender, age, duration of symptoms, Eckardt score, daily retrosternal pain, manometric findings, and balloon pressures. Thirty-one patients with confirmed achalasia were enrolled in the study. All of these patients underwent pneumatic dilatation. Pearson's correlation coefficient was found to be 0.234 (p-value 0.23) between the required balloon pressure and integrated relaxation pressure (IRP). Six of these patients required repeat pneumatic dilatations. No statistically significant association was noted between the need for repeat intervention and gender, age over 40, age under 20, Eckardt score over 10, daily chest pain, duration of symptoms over two years, and IRP over 30 mmHg. In conclusion, it could be said that pneumatic dilatation does not carry a 100% success rate, and repeat sessions are needed in many of the patients with achalasia. So, long-term follow-up is crucial. Managing expectations and making a realistic plan with proper informational care is important at the beginning of treatment.

Outcome of sequential dilatation in achalasia cardia patients: a prospective cohort study.

Sequential increment of balloon diameter for endoscopic pneumatic dilatation is a protocol that is used for symptomatic relief in achalasia cardia. However, most of the studies evaluating its effectiveness are retrospective in nature. This study intended to look into the efficacy of the above protocol in a prospective fashion. Consecutive patients of achalasia cardia (n = 72) attending gastroenterology department were subjected to graded dilatation with 30, 35, and 40mm pneumatic balloon and followed up (median 48weeks; range: 4-96weeks) with Eckardt score. Efficacy was assessed by proportion of patients achieving and maintaining clinical remission (Eckardt score ≤ 3) without requiring surgery during follow-up. Overall 91% of patients (60 out of 66 with follow-up data) remained symptom free without requirement of surgery. Proportion of type 3 achalasia patients was significantly higher in the group requiring surgery compared to those who did not (p = 0.005). Threshold of 12mm Hg in 4-week post-dilatation integrated relaxation pressure noted to predict future requirement of surgery in type 3 achalasia patients with sensitivity and specificity of 75% and 85%, respectively. Major adverse events requiring in-patient management were 2.9% with perforation noted in 1.9%. A sequential increment of balloon diameter for pneumatic dilatation in achalasia is an effective mode of therapy to achieve and maintain clinical remission in achalasia. The incidents of adverse events are low in this approach. Type 3 achalasia patients are more likely to require surgery despite sequential dilatation.

Endoscopy in Pregnancy: A Systematic Review

Abstract Background Fetomaternal outcomes are of primary concern for gastrointestinal (GI) endoscopy in pregnancy. We aimed to systematically review the safety and utility of endoscopic procedures in pregnancy. Methods A systematic literature search was performed using PubMed. All original research articles with sample size > 10 involving endoscopy in pregnancy were included for the review along with case report/series describing novel/rare techniques from 1948 to July 2021. Results After screening 12,197 references, 216 citations were found and finally 66 references were included. Esophagogastroduodenoscopy had favorable fetal outcome (>95%) based on two large retrospective studies and a review of case reports. Sclerotherapy and band ligation of varices were safe according to case series. A large nationwide cohort study established safety of endotherapy for nonvariceal bleed. Botulinum toxin and pneumatic dilation in achalasia are only supported by case reports. Percutaneous endoscopic gastrostomy can be useful to support nutrition based on case reports. A retrospective case–control and cohort study with systemic review justified flexible sigmoidoscopy if strongly indicated. Low birth weight was more common when sigmoidoscopy was done in inflammatory bowel disease based on a prospective study. Colonoscopy was considered safe in second trimester based on a case–control study whereas it can be performed otherwise only in presence of strong indication like malignancy. Capsule endoscopy is promising and can be useful in acute small bowel bleeding although risk of capsule retention is unknown. There are no reports of enteroscopy in pregnancy. Twelve retrospective studies and one prospective study showed high success rate of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) (> 90%) in all trimesters and can be performed if strongly indicated. Pregnancy was an independent risk factor for post-ERCP pancreatitis in a large nationwide case–control study. Radiation-free ERCP with wire-guided bile observation, stent-guided or precut sphincterotomy, endoscopic ultrasound (EUS) guidance, and spyscopy have been described. Safety of EUS is limited to case series and can be used in intermediate probability of choledocholithiasis to guide ERCP and endoscopic cystogastrostomy. Conclusion This review concludes that GI endoscopy during pregnancy can be done effectively if strongly indicated with good fetomaternal outcomes. Precautions are advocated during procedures where radiation exposure is expected.

Pneumatic dilation for achalasia: new techniques to improve an old procedure.

Pneumatic dilation for achalasia: new techniques to improve an old procedure.

Laparoscopic Heller myotomy or pneumatic dilatation in achalasia: results of a prospective, randomized study with at least a decade of follow-up.

The most efficient long-term treatment strategy for achalasia has yet to be established. This study compared the long-term results (≥ 10years) after either pneumatic dilatations or laparoscopic myotomy using treatment failure as the primary outcome. Secondary objectives were; the frequency and degree of dysphagia and effects on health-related quality of life (QoL). Out of the 53 patients with achalasia who were initially randomized to either laparoscopic myotomy with a posterior partial fundoplication (LM) or repetitive pneumatic dilatation (PD), 43 remained for scrutiny after a median observation period of 170months (LM; n = 20 and PD; n = 23). At the follow-up of 60months, 10 patients (36%) in the PD group and two patients (8%) in the LM group were classified as treatment failures (p = 0.016). At the latest follow-up time point (≥ 10years), the corresponding numbers were 13 (57%) and 4 (20%), respectively. The Kaplan-Meier analysis of the cumulative incidence of treatment failure revealed a significant advantage of LM over the dilatation strategy (p = 0.036)). QoL assessed by the generic instrument PGWB and the more disease-specific instrument GSRS revealed scores which were similar in the two study groups with no obvious changes over time. Reflux was better controlled in the LM group (p = 0.02 regarding PPI consumption). After more than a decade of follow-up, laparoscopic myotomy reinforces its superiority over repetitive pneumatic dilatation treatment strategy in the management of newly diagnosed achalasia.

Peroral Endoscopic Myotomy versus Pneumatic Dilation in Achalasia: Dissecting the Randomized Controlled Trial

Ponds FA, Fockens P, Lei A, et al. Effect of peroral endoscopic myotomy vs pneumatic dilation on symptom severity and treatment outcomes among treatment-naive patients with achalasia.

Efficacy and safety of pneumatic dilation in achalasia: A systematic review and meta-analysis.

Background and AimsOne of the most used treatments for achalasia is pneumatic dilation of the lower esophageal sphincter to improve esophageal emptying. Multiple treatment protocols have been described with a varying balloon size, number of dilations, inflation pressure, and duration. We aimed to identify the most efficient and safe treatment protocol.MethodsWe performed a systematic review and meta‐analysis of studies on pneumatic dilation in patients with primary achalasia. Clinical remission was defined as an Eckardt score ≤3 or adequate symptom reduction measured with a similar validated questionnaire. We compared the clinical remission rates and occurrence of complications between different treatment protocols.ResultsWe included 10 studies with 643 patients. After 6 months, dilation with a 30‐mm or 35‐mm balloon gave comparable mean success rates (81% and 79%, respectively), whereas a series of dilations up to 40 mm had a higher success rate of 90%. Elective additional dilation in patients with insufficient symptom resolution was somewhat more effective than performing a predefined series of dilations: 86% versus 75% after 12 months. Perforations occurred most often during initial dilations, and significantly more often using a 35‐mm balloon than a 30‐mm balloon (3.2 vs 1.0%); P = 0.027. A subsequent 35‐mm dilation was safer than an initial dilation with 35 mm (0.97% vs 9.3% perforations), P = 0.0017.ConclusionsThe most efficient and safe method of dilating achalasia patients is a graded approach starting with a 30‐mm dilation, followed by an elective 35‐mm dilation and 40 mm when there is insufficient symptom relief.

Patient Reported Outcomes After Pneumatic Dilation for Achalasia

Introduction: Patient reported outcomes (PRO) and quality of life (QOL) in achalasia patients are an emerging determinants of achalasia treatment success. We examined PRO after pneumatic dilation (PD) in treatment naive patients to assess correlation with the Eckardt score, an objective measurement of disease severity. We also explored PPI use and GERD symptoms before and after PD as a measure of QOL. Methods: An IRB approved retrospective cross-sectional study was conducted at a tertiary care university clinic. 51 treatment naive patients seen between 2002-2014 with manometric diagnosis of idiopathic achalasia were included. Patients with confounding esophageal or autoimmune pathology were excluded. Patients responded to a telephone questionnaire based on the Achalasia Severity Questionnaire regarding pre- and post-PD metrics including QOL, perception of disease severity, GERD symptoms, PPI use, and willingness to undergo repeat PD. Descriptive statistics, Wilcoxon sign rank test for matched pairs, and Spearman correlation were used for statistical analysis. Results: Eckardt score, QOL, and perception of disease severity improved after PD (p<0.001). Associations between improvements in Eckardt score and QOL (r2= -0.429, p<0.01); Eckardt score and perception of disease severity (r2=0.389, p<0.01); and perception of disease severity and QOL (r2=0.561, p<0.01) were found. There was a weak correlation between improved QOL and decreased PPI use (r2= -0.141, p<0.05). There was no significant association between PD failure and worsening of QOL, perception of disease severity, or Eckardt score (p=0.41). 22/51 patients reported pre-PD reflux symptoms compared to 14/51 post-PD. 31/51 reported pre-PD PPI use compared to 19/51 post-PD. Reported reflux symptoms decreased after PD (X2, p=0.017). Conclusion: PD improves Eckardt scores, QOL, and perception of disease severity in treatment naive achalasia patients. Improvements in QOL and perception of disease severity are associated with improved Eckardt scores, and are therefore reasonable metrics for gauging PD success. PD failure did not result in worsening of QOL, perception of disease severity, or Eckardt scores. Though post-procedural GERD is commonly reported, we found that reported reflux symptoms and PPI use decreased after PD. We conclude that patient reported outcomes are important factors in a holistic treatment approach to achalasia.

VS02.05: LAPAROSCOPIC TREATMENT OF IATROGENIC ESOPHAGEAL PERFORATION AFTER PNEUMATIC DILATION FOR ESOPHAGEAL ACHALASIA

Abstract Description We present in this video a case of laparoscopic surgical repair of an esophageal perforation during pneumatic dilation for achalasia. When diagnososed with achalasia and offered adequate treatment, the patient chose pneumatic dilation. We followed the protocol used in the European trial but, after the second dilation with a 3.5 cm balloon, a perforation of the esophageal wall occurred. Gastrografin swallow and a CT confirmed the perforation. For the worsening conditions of the patient, we preferred the surgical treatment, as opposed to the conservative one. At laparoscopy, the lesion was well visible on the left lateral wall of the esophagus, 2 cm above the cardia. The mucosa was sutured with interrupted stitches, and the muscular layer reconstructed with continuous suture. A Heller myotomy was then performed on the anterior esophageal wall, and a Dor fundoplication completed the operation. The patient was discharged in 7th POD and at a 1-year follow-up she is free of dysphagia. The laparoscopic surgical repair of esophageal perforation during pneumatic dilation is feasible: proper treatment of the basic disease with myotomy is necessary, however, to achieve good final results. Disclosure All authors have declared no conflicts of interest.

Outcomes of pneumatic dilation in achalasia: Extended follow-up of more than 25years with a focus on manometric subtypes.

Pneumatic dilation (PD) is the most popular nonsurgical treatment for achalasia. This study investigated predicting factors, including manometric subtypes for symptom recurrence in the long term, in patients with achalasia treated with a single PD. Between 1983 and 2013, a total of 107 patients were treated initially with a single PD and included in this longitudinal cohort study. Outcomes were correlated with demographics, symptoms (Eckardt score), and esophagographic and manometric features. Manometric tracings were retrospectively classified according to the three subtypes of the Chicago classification. Ninety-one (85%) patients were successfully treated after the first PD. The median follow-up was 13.8years (interquartile range 7-20). During follow-up, 54% of the patients experienced a clinical relapse. The overall cumulative success rates at 2, 5, 10, 15, 20, and 25years were 64%, 53%, 49%, 42%, 36%, and 36%, respectively. Age <40years, lower esophageal sphincter pressure >15mmHg, a cardia width <5mm, and an esophageal barium column height >1cm 4 to 12weeks post-dilation significantly correlated with symptom recurrence, whereas achalasia subtypes did not significantly correlate with the treatment results. Pneumatic dilation in achalasia is an effective therapy in the short term, but its effect wanes in the very long term. Young age at presentation, a high lower esophageal sphincter pressure, a narrow cardia, and an esophageal barium column of >1cm after PD are predictive factors for the need of repeated treatment.

Combined Endoscopic and Radiographic Evaluation of the Esophagus Immediately After Pneumatic Dilatation for Achalasia

Combined Endoscopic and Radiographic Evaluation of the Esophagus Immediately After Pneumatic Dilatation for Achalasia

French comment on article: Utility of clinical suspicion and endoscopic re-examination for detection of esophagogastric perforation after pneumatic dilation for achalasia

La perforation de l’œsophage est une complication qui survient après 1 à 3 % des dilatations endoscopiques pour achalasie. La fréquence de cette complication redoutée fait qu’une opacification radiologique systématique de l’œsophage au décours du geste est parfois proposée.

Over-the-Scope Clip Closure of Oesophageal Perforation after Pneumatic Dilatation for Achalasia

Pneumatic dilatation of the oesophagus is the first line method of therapy of achalasia. Pneumatic balloon dilatation induces forceful stretching of the lower oesophageal sphincter (LES), which weakens the LES by tearing its muscle fibers. Complications of Pneumatic balloon dilatation include oesophageal perforation in 1.6 % and heartburn in 45 %. Recently endoscopic approach has been introduced in treating gastrointestinal perforations which is less invasive than surgery and have the advantages of lesser morbidity and mortality, shorter hospital stay, and shorter periods of avoiding oral feeding. The main endoscopic methods used to close GI perforations are endoclips and covered self-expandable stents the margins. We report the case of a 51 year-old female patient presenting with oesophageal tear after pneumatic dilatation for achalasia. Over-the-scope clip (OTSC) was used for the Closure of the oesophageal tear. To the best of our knowledge this is the first case report of successful closure of oesophageal tear secondary to post pneumatic dilation of the oesophagus for the treatment of Achalasia using the OTSC.

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.

971 Does Post-Procedure Esophagogastric Junction (EGJ) Distensibility Predict Treatment Success in Newly Diagnosed Achalasia Patients?

Introduction: Although initial treatment success rates with pneumatic dilation in achalasia are high, recurrences may occur in more than 50% of patients. Identification of patients in need of re-treatment may be difficult as they are accustomed to a certain level of discomfort. LES pressure ≥10mmHg is considered as an indication for additional therapy but several studies reported a significant proportion of patients with persistent symptoms and low or absent LES pressure. We aimed to study whether post-procedure assessment of esophagogastric junction (EGJ) distensibility can predict treatment success in newly diagnosed achalasia patients. Methods: Eighteen newly diagnosed achalasia patients (10 male, mean age 47.9, range 19-75) underwent 2 pneumatic dilations (PD) with 30and 35mm balloons separated by 1 week. Before and after the 30mm dilation, EGJ distensibility was measured using an endoscopic functional luminal imaging probe (EndoFLIP). Using an EndoFLIP probe with an inflatable bag, EGJ distensibility (cross-sectional area of the diaphragmatic hiatus (CSA)/ pressure within bag during distensions; mm2/mmHg) was measured with 20-, 30-, 40and 50ml distensions. After 3 months patients were assessed by esophageal manometry and with validated symptom questionnaires to determine the Eckardt score, with a score ,4 indicating treatment success. Results: Mean post-procedure EGJ distensibility increased at the 20-, 30, 40and 50ml distention volumes (p,0.05) (Table 1). According to the Eckardt score at 3 months after treatment, 14 out of 18 achalasia patients (77.8%) were considered as having treatment success; treatment failures (n=4) underwent an additional PD with the 40mm balloon. Post-procedure EGJ distensibility of successfully treated patients at 40 and 50ml distention volumes were not significantly higher than in treatment failures (40ml: 3.1±0.5 vs. 2.6±1.2, p=0.69; 50ml: 4.7±0.7 vs. 2.8±1.2, p=0.20). At 3 months after treatment, LES pressure of successfully treated patients was lower than in treatment failures (11±1 vs. 36±12, p=0.13) and a good correlation was found between LES pressure and symptom scores (r=0.88, p,0.001). Post-procedure EGJ distensibility at 40 and 50ml distention volumes correlated poorly with symptom scores at 3 months (40ml: r=-0.10, p=0.70; 50ml: r=-0.26, p=0.37) and modestly with LES-pressure (40ml: r=-0.32, p=0.24; 50ml: r=-0.55, p=0.05). Conclusion: Post-procedure Esophagogastric Junction (EGJ) Distensibility of newly diagnosed achalasia patients improves after pneumatic dilation but is not associated with treatment success after 3 months as compared with symptom scores and LES pressure. Mean EGJ distensibility during volume distentions

Pneumatic dilation versus laparoscopic Heller myotomy for the treatment of achalasia: variables related to a good response

Achalasia is a motor disorder characterized by esophageal aperistalsis and failure of lower esophageal sphincter relaxation. The cardinal symptoms are dysphagia, food regurgitation and weight loss. The most effective treatments are pneumatic dilation (PD) of the cardia and Heller esophageal myotomy with partial fundoplication. There is still controversy regarding which treatments should be initially done. The aims of this study were to evaluate clinical response and the variables related to good results in both treatments. Ninety-two patients with achalasia diagnosed by esophageal manometry were randomized to receive either PD or laparoscopic Heller myotomy with partial fundoplication. After the procedure, patients were followed up clinically and submitted to esophageal manometry and pH monitoring. Three months after treatment, 73% of the patients from PD group and 84% of the surgery group had good results (P = 0.19). After 2 years of follow-up, 54% of the PD group and 60% of the surgery group (P = not significant) were symptom free. Variables related to a good response to PD were a 50% drop in lower esophageal sphincter pressure (LESP) or a LESP <10 mmHg after treatment. Patients over 40 years old with LESP ≤32 mmHg before treatment and a drop in LESP >50% after treatment significantly achieved better responses after surgical treatment when compared with PD. The reflux rate was significantly higher in the PD group (27.7%) compared with the surgery group (4.7%), P = 0.003. We concluded that surgical treatment and PD for achalasia are equally effective even after 2 years of follow-up. The choice of treatment for achalasia should be based on the following parameters: treatment availability, rate of good results, complication rates, variables related to good responses and also the patient's wish.

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.

Sp951 Endoscopic Closure of Acute Esophageal Perforation Following Pneumatic Dilation for Achalasia

Sp951 Endoscopic Closure of Acute Esophageal Perforation Following Pneumatic Dilation for Achalasia

Principles of training in GI endoscopy

Principles of training in GI endoscopy

Pneumatic dilation for achalasia - the way forward: authors’ reply

Pneumatic dilation for achalasia - the way forward: authors’ reply