Primary Motility  Disorders of the  Esophagus
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OESO©2015
 
Volume: Primary Motility Disorders of the Esophagus
Chapter: Achalasia (hypomotility) is the best known entity
 

The technique of pneumatic dilatation

J. Escourrou, M. Delvaux, L. Buscail (Toulouse)

Achalasia is treated by either forceful balloon dilation or surgical cardiomyotomy. Several retrospective studies suggested that surgery had a better outcome [1]; there is nevertheless evidence that endoscopic balloon dilation in experienced hands gives good results [6], and the advantage to not require surgery have led to its increasing popularity.

The motility disorder in achalasia causes both a loss of normal peristaltic contractions of the esophagus and the failure of the lower esophageal sphincter

(LES) to relax [6]. The aim of pneumatic dilation is to rupture the circular muscle fibers of the LES while leaving the mucosa intact. This is obtained by forcefully dilating the lower esophagus by a balloon that allows the diffuse transmission of the pressure through the entire sphincter area.

Description of the procedure

The pneumatic dilation of the LES consists in inserting a guide wire under visual control into the stomach and to pass the balloon over the guide wire with fluoroscopic control (figure 1). This procedure allows correct and safe positioning of the balloon in the cardial area in spite of the presence of a tortuous and dilated esophagus or of diverticula {figure 2). The middle part of the balloon must be positioned at the level of the LES. The balloon is connected to a pressure gauge and is progressively inflated until an intraballoon pressure of 200 to 250 mmHg is reached. This pressure is maintained for 2 to 4 minutes. The decrease of the intraballoon pressure indicates that the LES muscle fibers are progressively disrupted, and thereby the effectiveness of the procedure.

0138F1.JPG

Figure 1. The dilator of Rider and Moeller allows a correct positioning of the apparatus at the cardia level because of the balloon design. The inflation pressure is recorded by a manometer and progressively increased up to 200 - 250 mmHg.

0138F2.JPG

Figure 2. Correct positioning of the dilation balloon figured on a chest X-ray.

Clinical results

Forceful pneumatic dilation is effective to relieve dysphagia in 70 to 80 p. cent of patients, (figure 3) The results of several large series of the literature are reported table 1. The patients were followed up to 4 years in some studies [4, 6, 7] and their results demonstrate that the clinical improvement obtained by forceful dilation could be maintained for several years. In some patients, the recurrence of the dysphagia may lead to repeated dilation sessions. Failures of pneumatic dilations are more

Table 1. Late results of forceful dilatation.

Number

Duration

Clinical

cases

follow-up*

results**

Sanderson [5]

313

2.5

65.2

Bennett-Hendrix [2]

48

2.5

70

Vantrappen-Hellemans [6]

403

7.8

77

Kurlander [4]

62

1 to 20

92

* years (mean or range)

** expressed as the percentage of the patients improved by the dilatation.

0138F3.JPG

Figure 3. Assessment of the clinical results of the forceful dilation by a barium meal. Before the procedure (left part), the esophageal barium clearance is delayed. After dilatation (right part), the passage of barium through the cardia is rapid and abundant.

frequently observed in young patients (age < 35 y.) and in patients with recent history of achalasia (less than 5 years) [7].

Forceful dilation has also been used with success in patients who previously undergone cardiomyotomy. In these cases, the dilation will be very carefully progressive according to the increased risk of perforation.

Complications

Perforation is the most frequent immediate complication of pneumatic dilation. It is scarcely encountered in the series of the literature, the rate varying from 1 to 5 p. cent [7]. The outcome of perforation after pneumatic dilation is dramatically altered if it is not early recognized and if the patient was not fasted [6, 7].

Progressive dilation must be performed in all cases in order to lower the perforation risk and moreover, will be more effective than single stretching of the cardia as reported in several studies [7]. The late complication is essentially the appearance of a gastroesophageal reflux that can be observed in 0.7 p. cent of patients [3]. The rate of post-operative reflux should be lower in patients who undergone endoscopic dilation (0.7 %) than in surgical patients (3 %) [3].

Conclusion

Pneumatic dilation of the LES is an effective treatment in patients with achalasia. The endoscopic management of these patients allows to obtain results similar to those expected from surgery [7]. Moreover, as patients who have failed to benefit from endoscopic dilation seem to respond to esophagomyotomy as well as if they had not had previous treatment, it would seem reasonable to perform a forceful dilation as the initial therapy in patients with achalasia and to reserve esophagomyotomy for those who failed to benefit from dilatation.

References

1. Arvanitakis C (1975) Achalasia of the esophagus. A reappraisal of esophagomyotomy versus forceful pneumatic dilatation. Dig Dis 20: 841-846.

2. Bennett JR, Hendrix TR (1970) Treatment of achalasia with pneumatic dilatation. Mod Treat 7 : 1217-1228.

3. Csendes A, Velasco N, Braghetto L, Henriquez A (1981) A prospective randomized study comparing forceful dilatation and esophagomyotomy in patients with achalasia of the esophagus. Gastroenterology 80: 789-795.

4. Kurlander DJ, Raskin HF, Kirsner JB, Palmer WL (1963) Therapeutic value of the pneumatic dilator in achalasia of the esophagus : long term results in 62 living patients. Gastroenterology 45: 604-613.

5. Sanderson DR, Ellis FH, Olsen AM (1970) Achalasia of the esophagus: results of therapy by dilatation, 1950-1967. Chest 58: 116-121.

6. Vantrappen G, Hellemans J (1980) Treatment of achalasia and related motor disorders. Gastroenterology 79: 144-154.

7. Vantrappen G, Janssens J (1983) To dilate or to operate? That is the question. Gut 24: 1013-1019.


Publication date: May 1991 OESO©2015