For how long should dilation be continued ?
H. W. Boyce (Tampa)
Consideration for repeated pneumatic dilations for achalasia must include information on the following: 1) Is the diagnosis of achalasia confirmed ? 2) Who performed the previous dilation(s) and by which technique ? 3) Which balloon or brusque dilation instrument was used ? 4) What was the maximum diameter of the dilator used ? 5) Are the patient's symptoms due to esophageal retention or obstruction ? 6) Has a contraindication for pneumatic dilation developed since the last dilation? 7) Has the patient developed significant sequelae of esophageal obstruction, such as weight loss or pulmonary complications? 8) In a child or adolescent, has growth been delayed due to malnutrition ?
When satisfactory answers to the above questions are known, a decision on whether to repeat dilation or perform esophagomyotomy can properly be made.
Recurrent dysphagia can be difficult to interpret in some patients and may be due to symptoms not related to significant esophageal retention. Therefore, before proceeding with repeat dilation, I require documentation of esophageal retention by barium radiography and confirmation by endoscopy that there is no foreign body such as food or bezoar causing the obstruction, that no acid-reflux stricture has developed and that esophageal carcinoma is not the cause of dysphagia.
The simplest and least expensive method to objectively assess the response to pneumatic dilation of achalasia is by using the barium retention test described by Dr. N. Cohen in 1975 . I utilize this test to establish the degree of retention several days before and the day after pneumatic dilation.
The patient is simply given 240 ml of barium to drink as rapidly as possible in
the upright position. A film or fluoroscopic observation is made immediately after drinking the barium and again at 5 minutes. Following dilation, if there is no more than 1 cm of barium residual in the esophagus at 5 minutes, there is good correlation with good long-term symptomatic relief and significant reduction in lower esophageal sphincter pressure by esophageal manometry. If the patient has had complete emptying of barium by this test on the day following dilation and returns weeks or months later with dysphagia, it is repeated to objectively establish a relation between the symptom of dysphagia and esophageal retention. Radiosotope imaging studies also may be used to objectively assess esophageal retention but are more expensive and time consuming.
My practice has been to progressively increase the size of pneumatic dilator used when a prior dilator size has failed to give adequate or significantly prolonged dysphagia relief. Selection of the size of pneumatic dilator to be used is subjective, based on experiences and operator bias. My procedure has been to use a 30 mm diameter dilator in adolescents, adults of small stature, the elderly and those patients at higher risk because of concomitant disease. Failure of this 30 mm diameter dilator to provide adequate relief, i.e., return of dysphagia in less than one year, has been an indication to proceed with repeat dilation using the 35 mm diameter dilator.
In the typical adult patient with achalasia, the 35 mm diameter balloon is the first size used. If it fails to provide adequate symptomatic relief of dysphagia, a repeat dilation with a 40 mm diameter balloon is recommended within two to three months. In my experience, when there is inadequate relief of dysphagia or when there is proven significant esophageal retention persisting either after two dilations with pneumatic balloons of optimum size for the patient or with a 40 mm diameter balloon, esophagomyotomy is indicated.
To my knowledge, there is no reliable method for determining the need for repeat dilation based on lower esophageal sphincter pressure alone. Therefore, the use of manometry has little role in assisting with the decision as to whether to repeat dilation or refer the patient for esophagomyotomy.
Some patients respond dramatically to pneumatic dilation with symptomatic relief that lasts for years. In such cases, it is proper to repeat dilation as needed after such long intervals unless the patient becomes discouraged or requests the surgical alternative. When symptomatic relief is prolonged, no pulmonary or nutritional sequelae exist and the patient readily accepts repeated pneumatic dilation after long intervals, it is appropriate to continue pneumatic dilation therapy.
The decision to recommend surgery in these patients is not an easy one and must be based on consideration of many factors. In healthy adults with typical achalasia who have failed two pneumatic dilations, the recommendation for surgery is relatively easy if a highly competent surgeon, trained and experienced in esophagomyotomy is available to perform the procedure. If there is no such surgical expertise available nearby and the patient cannot afford to travel elsewhere for surgery, it is not wise to ask a readily available but inexperienced surgeon to perform the myotomy. The net result can be a disaster !