Long-term follow-up after pneumatic dilation for achalasia cardia: factors associated with treatment failure and recurrence

Safety of Pneumatic Dilation in Older Adults with Achalasia: An International Multicenter Cross-Sectional Study

BACKGROUND

Pneumatic dilation (PD) is an effective first line treatment option for many patients with achalasia. PD use may be limited in adults with achalasia who are older than 65 because of concern for adverse events (AE), and less efficacious therapies are often utilized. We explored the periprocedural safety profile of PD in older adults.

METHODS

An international real world cross-sectional study of patients undergoing PD between 2006-2020 in two tertiary centers. Thirty-day AEs were compared between older adults (65 and older) with achalasia and younger patients.

RESULTS

A total of 252 patients underwent 319 PDs. In 319 PDs, 18 (5.7%) complications occurred: 6 (1.9%) perforations and 12 (3.8%) emergency department referrals with benign (non-perforation) chest pain, of which 9 (2.8%) were hospitalized. No bleeding or death occurred within 30 days. Perforation rates were similar in both age groups and across achalasia subtypes. Advanced age was protective of benign chest pain complications in univariate analysis, and the limited number of AEs precluded multivariable analysis.

CONCLUSIONS

The safety of PD in older adults is at least comparable to that of younger patients and should be offered as an option for definitive therapy for older patients with achalasia. Our results may affect informed consent discussions.

True peristaltic recovery is uncommon following treatment, particularly endoscopic dilation for achalasia cardia, though pseudo-recovery often occurs

BACKGROUND

Relieving esophagogastric junction (EGJ) obstruction has been the focus of treatment for achalasia cardia. The recovery of peristalsis has been an elusive goal. Studies analyzing post-intervention peristaltic recovery have several limitations such as the use of conventional manometry or lack of standard definitions of peristalsis. Accordingly, we undertook this study to analyze frequency and pattern of peristaltic recovery following treatment for achalasia cardia on high-resolution manometry (HRM) and standard Chicago definition of peristalsis.

METHODS

Pre and post-intervention HRM records of 71 treatment-naive patients diagnosed as achalasia cardia were retrospectively analyzed. Records with pre and post-intervention HRM on different systems (e.g. solid state and water perfusion) and those with inadequate information were excluded. All HRMs were interpreted as per Chicago classification version 3.0. After pneumatic dilation (PD) or laparoscopic Heller's myotomy (LHM), pseudorecovery of peristalsis was defined as any contraction at least 3 cm in length along 20 mmHg isobaric contour with a distal latency of less than 4.5 seconds. True recovery and premature contractions were defined by standard Chicago classification v3.0 criteria.

RESULTS

Change in diagnosis was observed in 38 of 71 (53.5%) patients after intervention. While pseudo-peristaltic recovery occurred in 11 of 71 (15.5%) patients, only three (4.2%) had a true recovery. Another nine (12.7%) patients showed new premature contractions.

CONCLUSION

True peristaltic recovery is uncommon in achalasia cardia following intervention, particularly PD. Pseudo-peristaltic recovery is more common. Further research is warranted on this issue.

Update on the Diagnosis and Treatment of Achalasia

Achalasia is a rare disease of the esophagus with impaired relaxation of the lower esophageal sphincter and aperistalsis. The etiology is unknown but speculations include a viral or autoimmune etiology. All specialists dealing with swallowing and esophageal diseases should recognize the classic symptoms of dysphagia for solids/liquids, regurgitation, and choking, especially at night. High-resolution manometry is critical for the diagnosis with endoscopy and barium esophagram having a supportive role. The disease cannot be cured but most can return to near normal swallowing and a regular diet with appropriate therapy. Treatment includes smooth muscle relaxants, botulinum toxin injections to the lower sphincter, pneumatic dilation, Heller myotomy, and peroral endoscopic myotomy. One treatment does not fit all and a tailored approach through a multidiscipline team will give the best long-term outcomes.

Achalasia, from diagnosis to treatment

INTRODUCTION

Achalasia is an uncommon esophageal motility disorder and is characterized by alterations of the motility of the esophageal body in conjunction with altered lower esophageal sphincter (LES) relaxation. The clinical presentation of patients with achalasia may be complex; however, the most frequent symptom is dysphagia. The management of patients with achalasia is often challenging, due to the heterogeneous clinical presentation.

AREAS COVERED

The diagnosis and management of achalasia has significantly improved in the last years due to the growing availability of high-resolution manometry (HRM) and the implementation in the therapeutic armamentarium of new therapeutic endoscopic procedures. Traditional therapeutic strategies include botulinum toxin injected to the LES and pneumatic balloon dilation. On the other hand, surgical treatments contemplate laparoscopic Heller myotomy and, less frequently, esophagectomy. Furthermore, in the last few years, per oral endoscopic myotomy (POEM) has been proposed as the main endoscopic therapeutic alternative to the laparoscopic Heller myotomy.

EXPERT OPINION

Diagnosis and treatment of achalasia still represent a challenging area. However, we believe that an accurate up-front evaluation is, nowadays, necessary in addressing patients with achalasia for a more accurate diagnosis as well as for the best treatment options.

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

BACKGROUND

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.

METHODS

Consecutive patients of achalasia cardia (n = 72) attending gastroenterology department were subjected to graded dilatation with 30, 35, and 40 mm pneumatic balloon and followed up (median 48 weeks; range: 4-96 weeks) with Eckardt score. Efficacy was assessed by proportion of patients achieving and maintaining clinical remission (Eckardt score ≤ 3) without requiring surgery during follow-up.

RESULT

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 12 mm 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%.

CONCLUSION

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.

Achalasia Cardia: Balloon, Tunnel, or Knife?

Achalasia cardia is a rare esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter during swallowing and aperistalsis of the esophageal smooth muscles. The treatment approaches to achalasia include nonsurgical treatment with medications (nitrates, calcium channel blockers), endoscopic treatment (balloon pneumatic dilation [PD], botulinum toxin injection [BTI], peroral endoscopic myotomy [POEM]), and surgery (laparoscopic Heller's myotomy [LHM]). The subtype of achalasia (the Chicago Classification) governs the ideal treatment. For the commonly encountered achalasia subtype I and II, PD, LHM, and POEM all have similar efficacy. However, for type III achalasia, POEM seems to be the best line of treatment. Among high-risk elderly patients or those with comorbidities, BTI is preferred. The choice of treatment should be minimally invasive therapy with good short-term and sustained long-term effects with negligible adverse events. POEM seems to be evolving as a first-line therapy among the available therapies. Here, we review the treatment options among achalasia cardia patients with special attention to post-POEM gastroesophageal reflux disease and its management.

Graded pneumatic dilation in subtype I and II achalasia: long-term experience in a single center

Background

The efficacy of pneumatic dilation (PD) in the management of achalasia has yielded variable results. The availability of high-resolution manometry led to the identification of 3 clinically relevant subtypes of achalasia, revealing the poor efficacy of PD in subtype III. Furthermore, PD showed a lower response rate in patients with subtype III compared to laparoscopic Heller myotomy and peroral endoscopic myotomy. This study aimed to investigate the short- and long-term efficacy, safety profile and side effects of PD with a "graded approach" in subtypes I and II achalasia.

Methods

We enrolled 141 patients (male 67, mean age=66±16.26 years) with achalasia (n=27 subtype I, n=74 subtype II and n=40 subtype III) between January 2010 and July 2020 at St. Orsola University Hospital, Bologna, Italy. We analyzed the data of patients with subtypes I and II, who underwent a graded-protocol PD. Short- and long-term clinical efficacy, complications and gastroesophageal reflux disease (GERD) were recorded.

Results

One month after graded protocol PD, 100% subtype I and 96.2% subtype II achalasia patients showed clinical remission. The PD procedure was completed without major complications in all patients. In the long-term follow up (median time: 56 months), 95.5% subtype I and 90% subtype II achalasia patients had an Eckardt score ≤3. GERD occurred in 27.7% of all patients.

Conclusion

A graded-protocol PD applied in the appropriate achalasia subtypes was shown to be a safe and highly effective approach, in both the short- and long-term.

Insights into the endoscopic management of esophageal achalasia

Achalasia is a primary esophageal motility disorder characterized by the loss of inhibitory neurons in the myenteric plexus, resulting in impaired relaxation of the esophagogastric junction. Achalasia is an incurable disease, and the treatment modalities are aimed at disruption of the esophagogastric junction and vary widely from pharmacological to endoscopic to surgical. Traditional endoscopic therapy includes pneumatic dilation, botulinum toxin injection, and peroral endoscopic myotomy. This review aims to provide an overview of the endoscopic management of achalasia, while focusing on the utilization of peroral endoscopic myotomy and other novel approaches.

Retrospective study on symptoms and treatment modalities used and short-term follow up of achalasia cardia in Indian setting

Background

Achalasia cardia is a rare esophageal motor disorder that is frequently diagnosed late.

Aim

The aim of this study was to study the symptoms, treatment given, and response to treatment in patients with achalasia cardia in an Indian setting.

Materials and methods

This retrospective study included all patients diagnosed with achalasia cardia on high‐resolution esophageal manometry, using Chicago Classification v 3.0. On follow up, patients were contacted by telephone, and details of the treatment given and response were recorded in a predesigned pro forma. We excluded overseas patients, postoperative cases of achalasia, and those in whom the manometry catheter could not be passed across the gastroesophageal junction.

Results

A total of 452 patients (260 males, median age 44.5 years) were included in the study cohort. The major symptoms included dysphagia for solids and liquids (428, 94.7%), regurgitation (360, 79.6%), naso‐oral regurgitation (182, 40.3%), weight loss (322, 71.3%), and chest pain (158, 35%). Type 2 achalasia (229, 50.6%) was the most common subtype, followed by type 3 (154, 34.1%). Chest pain was more common in type 3, and weight loss and naso‐oral regurgitation were more common in type 2 achalasia. A majority of patients underwent Heller's myotomy and pneumatic dilatation. Of 280 patients for whom treatment details were available, 98% reported good response to endoscopic/surgical management.

Conclusion

The predominant symptoms of achalasia cardia vary per the manometric subtype. Heller's myotomy and pneumatic dilatation are the most commonly used treatment options. Response to treatment is good. The choice of treatment modality was likely influenced by financial reasons and availability of local expertise.

Factors Associated With Achalasia Treatment Outcomes: Systematic Review and Meta-Analysis

BACKGROUND & AIMS

Identification of factors associated with achalasia treatment outcome might help physicians select therapies based on patient characteristics. We performed a systematic review and meta-analysis to identify factors associated with treatment response.

METHODS

We searched MEDLINE, EMBASE, and the Cochrane Library through February 21, 2019, for randomized controlled trials and cohort, case-control, and cross-sectional studies that reported patient-specific outcomes of treatment (botulinum toxin injection, pneumatic dilation, peroral endoscopic myotomy, or laparoscopic Heller myotomy). We assessed the methodologic quality of the included studies using the quality in prognosis studies tool. We planned qualitative and quantitative analyses.

RESULTS

We analyzed data from 75 studies (8 randomized controlled trials, 27 prospective cohort studies, and 40 retrospective studies) on a total of 34 different factors associated with outcomes (3 demographic, 17 clinical, and 14 diagnostic factors). Qualitative assessment showed age, manometric subtype, and presence of a sigmoid-shaped esophagus as factors associated with outcomes of treatment for achalasia with a strong level of evidence. The cumulative evidence for the association with chest pain, symptom severity, and lower esophageal sphincter pressure was inconclusive. A meta-analysis confirmed that older age (mean difference, 7.9 y; 95% CI, 1.5-14.3 y) and manometric subtype 3 (odds ratio, 7.1; 95% CI, 4.1-12.4) were associated with clinical response.

CONCLUSIONS

In a systematic review and meta-analysis, we found age and manometric subtype to be associated with outcomes of treatment for achalasia. This information should be used to guide treatment decisions.

2019 Seoul Consensus on Esophageal Achalasia Guidelines

Esophageal achalasia is a primary motility disorder characterized by insufficient lower esophageal sphincter relaxation and loss of esophageal peristalsis. Achalasia is a chronic disease that causes progressive irreversible loss of esophageal motor function. The recent development of high-resolution manometry has facilitated the diagnosis of achalasia, and determining the achalasia subtypes based on high-resolution manometry can be important when deciding on treatment methods. Peroral endoscopic myotomy is less invasive than surgery with comparable efficacy. The present guidelines (the "2019 Seoul Consensus on Esophageal Achalasia Guidelines") were developed based on evidence-based medicine; the Asian Neurogastroenterology and Motility Association and Korean Society of Neurogastroenterology and Motility served as the operating and development committees, respectively. The development of the guidelines began in June 2018, and a draft consensus based on the Delphi process was achieved in April 2019. The guidelines consist of 18 recommendations: 2 pertaining to the definition and epidemiology of achalasia, 6 pertaining to diagnoses, and 10 pertaining to treatments. The endoscopic treatment section is based on the latest evidence from meta-analyses. Clinicians (including gastroenterologists, upper gastrointestinal tract surgeons, general physicians, nurses, and other hospital workers) and patients could use these guidelines to make an informed decision on the management of achalasia.

ASGE guideline on the management of achalasia

Achalasia is a primary esophageal motor disorder of unknown etiology characterized by degeneration of the myenteric plexus, which results in impaired relaxation of the esophagogastric junction (EGJ), along with the loss of organized peristalsis in the esophageal body. The criterion standard for diagnosing achalasia is high-resolution esophageal manometry showing incomplete relaxation of the EGJ coupled with the absence of organized peristalsis. Three achalasia subtypes have been defined based on high-resolution manometry findings in the esophageal body. Treatment of patients with achalasia has evolved in recent years with the introduction of peroral endoscopic myotomy. Other treatment options include botulinum toxin injection, pneumatic dilation, and Heller myotomy. This American Society for Gastrointestinal Endoscopy Standards of Practice Guideline provides evidence-based recommendations for the treatment of achalasia, based on an updated assessment of the individual and comparative effectiveness, adverse effects, and cost of the 4 aforementioned achalasia therapies.

Frequency and factors associated with malnutrition among patients with achalasia and effect of pneumatic dilation

Background

Although achalasia patients are undernourished, studies are scant. We studied: (i) the frequency of malnutrition among these patients and (ii) the effect of pneumatic dilatation (PD) on malnutrition.

Methods

A total of 70 adult achalasia patients and 70 healthy controls were evaluated through dietary recall, anthropometry, and biochemical parameters, and patients were reevaluated 6 months after PD.

Results

Patients had lower intake of calories (median, interquartile range [IQR]: 1835.0 [1682.5–1915.0] vs 2071.5 [1950–2276.2] kcal/day, P < 0.001), protein (40.9 [36.3–42.2] vs 52.9 [45.7–62] g/day, P < 0.001), calcium (310 [192.5–392.4] vs 477.5 [350–560] mg/day, P < 0.001), and iron (6.7 [4.7–8.8] vs 10.1 [7.5–11.50] mg/day, P < 0.001) than controls. Patients had lower body mass index (BMI: 19.6 [16.6–22] vs 22.8 [19.5,29.1], P < 0.001), midarm circumference (MAMC; 20 [17.5–23] vs 24.1 [21.4–28.5], P < 0.001), biceps (BSFT; 3.1 [1.9–3.9] vs 5.5 [3.8–9.2] mm, P < 0.001), triceps’ skin fold thickness (TSFT; 5 [2.4–7] vs 7.8 [5.1–9.4] mm, P < 0.001), serum protein (7.2 ± 0.8 vs 7.6 ± 0.8 g/dL, P = 0.005), and albumin (4.0 [3.5–4.4] vs 4.1 [3.9–4.2] g/dL, P = 0.009). PD increased calories (1803 [950–2400] vs 2050 [1470–2950] kcal/day), protein intake (41.0 [22–70] vs 45.0 [37.5–80.0] gm/day), BMI (19.6 [12.8–30.0] vs 22.2[15.9–30.0] P = 0.001 for all), and MAMC (21 [14.1–32.0] vs 24.2 [15–32.0] cm, P = 0.03). Reduced intake was a determinant of malnutrition.

Conclusions

Malnutrition is common in achalasia patients, and PD improved it.

Gastroesophageal reflux disease after peroral endoscopic myotomy: Short-term, medium-term, and long-term results

INTRODUCTION AND AIMS

Achalasia is characterized by incomplete relaxation of the lower esophageal sphincter and esophageal aperistalsis. The efficacy of peroral endoscopic myotomy (POEM) is similar to that of the Heller myotomy, with an apparently greater prevalence of gastroesophageal reflux disease. Our aim was to determine the presence of GERD in a post-POEM cohort of Mexican patients with achalasia and follow-up of at least 12 months.

MATERIALS AND METHODS

A retrospective cohort study was conducted on post-POEM patients with a minimum of 12 months of follow-up, within the time frame of 2012 to 2017. Pregnant patients were excluded. Serial endoscopy, pH study, and GERDQ application were performed. Univariate and bivariate data analyses were carried out and statistical significance was set at a P<0.05.

RESULTS

Sixty-eight patients had post-POEM follow-up for 12 months. Of those patients, follow-up continued to 24 months for 58, 36 months for 47, 48 months for 39, and 60 months for 25. Mean patient age was 47.8±14.3 years, 57.3% of the patients were women, 77.9% were treatment-naïve, and 54.4% had type II achalasia. The pH study, endoscopy, and questionnaire were positive in 73, 28, and 18% at 3 months; 48, 35, and 13% at 6 months, and 55, 30, and 15% at 12 months, respectively. Once the proton pump inhibitor was begun, the percentages decreased to 5, 2, and 6% at 24 months; 6, 2, and 8% at 36 months; 4,1, and 6% at 48 months; and 3, 1, and 4% at 60 months, respectively. There was no relation between the efficacy of POEM and the presence or intensity of GERD. There were no secondary complications due to gastroesophageal reflux.

CONCLUSIONS

The post-POEM prevalence of GERD was 50% in the short term (12 months), with no evidence of complications at the medium term or long term (60 months). Gastroesophageal reflux was adequately controlled through proton pump inhibitors administration in over 95% of the cases.

Management of achalasia cardia: Expert consensus statements

Achalasia cardia (AC) is a frequently encountered motility disorder of the esophagus resulting from an irreversible degeneration of neurons. Treatment modalities are palliative in nature, and there is no curative treatment available for AC as of now. Significant advancements have been made in the management of AC over last decade. The introduction of high resolution manometry and per-oral endoscopic myotomy (POEM) has strengthened the diagnostic and therapeutic armamentarium of AC. High resolution manometry allows for the characterization of the type of achalasia, which in turn has important therapeutic implications. The endoscopic management of AC has been reinforced with the introduction of POEM that has been found to be highly effective and safe in palliating the symptoms in short-term to mid-term follow-up studies. POEM is less invasive than Heller's myotomy and provides the endoscopist with the opportunity of adjusting the length and orientation of esophageal myotomy according to the type of AC. The management of achalasia needs to be tailored for each patient, and the role of pneumatic balloon dilatation, POEM, or Heller's myotomy needs to be revisited. In this review, we discuss the important aspects of diagnosis as well as management of AC. The statements presented in the manuscript reflect the cumulative efforts of an expert consensus group.

Perforation following pneumatic dilation of achalasia cardia in a university hospital in northern India: A two-decade experience

Pneumatic dilation (PD) is a cost-effective first-line treatment for achalasia. The most feared complication of PD is esophageal perforation (EP). As data on EP after PD for achalasia are not widely reported, we present the frequency, risk factors, and treatment-outcome of EP. Records of patients undergoing PD for achalasia (January 1995 to September 2015) were retrospectively reviewed. Of 433 patients (age 38 years, 13-88, 57% male), and 521 dilations, 12 were complicated by EP (2.7% of patients and 2.3% of PD). EP occurred in 7 (3.4%), 4 (1.7%), and 1 (4.1%) with use of balloon diameters 30, 35, and 40 mm, respectively. In most (11/12, 92%), EP occurred during the first PD. No risk factor for EP was identified (p = 0.65 for the first dilation vs. > 1 dilation, and 0.75 for balloon size of 30 mm vs. > 30 mm). Seven patients with contrast leak on esophagogram and/or computed tomography scan underwent surgery. One other with contrast leak was successfully treated with a fully covered self-expandable metal stent (FC-SEMS); the remaining four with small leak/pneumomediastinum were managed conservatively. The median duration of hospital stay following perforation was 13 days (7-26) and 8 days (6-10) in surgery and conservative groups, respectively. No mortality was observed in either group. The frequency of EP with PD was 2.3%. Though most EP (92%) occurred during the first dilation, neither the balloon size nor repeated dilations were identified as risk factors. Both surgical and conservative approaches had a favorable outcome in appropriate settings.

Management of recurrent symptoms after per-oral endoscopic myotomy in achalasia

BACKGROUND AND AIMS

Per-oral endoscopic myotomy (POEM) has been rapidly gaining ground as a treatment for achalasia. Although POEM is a safe and effective treatment, a subset of patients has persistent or recurrent symptoms after POEM. This study aimed to examine the efficacy of different retreatments after failed POEM.

METHODS

POEM was performed on 441 patients with achalasia at 3 tertiary-care hospitals between 2010 and 2015. A review of prospectively collected data was conducted. All patients with achalasia with significant persistent or recurrent symptoms within 3 years after POEM, defined as an Eckardt symptom score >3, were included.

RESULTS

Forty-three of 441 patients (9.8%) had persistent or recurrent symptoms after POEM, of which 34 (8%) received 1 or more retreatments. Retreatment with laparoscopic Heller myotomy and retreatment with POEM showed a modest efficacy of 45% and 63%, respectively, whereas pneumatic dilatation showed a poor efficacy of only 0% to 20%, depending on the size of the balloon. Male patients were more likely to have retreatment failure than female patients (P = .038).

CONCLUSIONS

In patients with achalasia with persistent or recurrent symptoms after failed POEM, retreatment with laparoscopic Heller myotomy or retreatment with POEM has a higher efficacy than retreatment with pneumatic dilatations. Failure of retreatment occurred more often in male patients.

Laparoscopic Heller's Myotomy for Achalasia Cardia: One-Time Treatment in Developing Countries?

Laparoscopic Heller's myotomy (LHM) and endoscopic balloon dilation are two main treatment modalities for achalasia cardia. The best treatment modality in Indian setting, however, is still unknown. Here, we present the early results of LHM in achalasia. Hospital data from January 2009 to October 2013 was analyzed. Preoperative assessment included Eckardt's scoring, esophagogastroduodenoscopy, barium swallow examination, and esophageal manometry. Thirty-five patients (19 males and 16 females, median age 31 years, range 12-65) underwent LHM with partial fundoplication (with intraoperative endoscopy). All patients had dysphagia (median duration 48 months, range 1-240), and eight (22.8 %) had chest pain. Four (11 %) patients had recurrent achalasia. Most of the patients (80 %) came from rural areas, and 68.5 % were ≤40 years of age. Fundoplication was added in all except four patients (megaesophagus in one, left lobe hepatomegaly in one, and postsurgical recurrent achalasia in two). The median operative time was 180 min (range 120-300). Intraoperative complications included esophageal mucosal injury (n = 2) and pleural breach (n = 3) with one conversion. The median postoperative stay was 7 days (range 4-27) with a morbidity of 5.7 % (leak in one and subphrenic collection in one patient) and a mortality of 1 % (due to myocardial infarction). After a median follow-up of 9.5 months (range 1-47 months), four (11.4 %) patients had recurrent dysphagia and three (8.5 %) had gastroesophageal reflux. Most of the patients (six of eight) had relief in chest pain. To conclude, predominance of rural, young, and male patients in this study suggests that LHM might be the first-line treatment for achalasia in developing countries like India where predominant population is still rural that prefers one-time treatment, though it needs to be compared with a newly described procedure per oral endoscopic myotomy (POEM).

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.

Achalasia: current treatment options

Achalasia is a rare esophageal motility disorder, characterized by impaired swallow-induced, lower esophageal sphincter (LES) relaxation and defective esophageal peristalsis. Unfortunately, there are no etiological therapies for achalasia. Patients present with dysphagia, chest pain and regurgitation of undigested food, often leading to weight loss. The currently available treatments have the common aim of relieving symptoms by decreasing the pressure of the LES. This can be achieved with some medications, by inhibiting the cholinergic innervation (botulinum toxin), by stretching (endoscopic dilation) or cutting (surgery) the LES. Recently, other therapeutic options, including per-oral endoscopic myotomy have been developed and are gaining international consensus. The authors report on the benefits and weaknesses of the different therapies and provide an updated approach to the management of achalasia.

POEM, the Prototypical "New NOTES" Procedure and First Successful NOTES Procedure

Peroral endoscopic myotomy (POEM) was first performed in 2008 as a novel treatment of achalasia. It is now performed globally, demonstrating the evolution of the first successful natural orifice transluminal endoscopic surgery (NOTES) procedure. There is extensive data demonstrating the safety and efficacy of POEM, and now long-term data has emerged demonstrating that the efficacy is durable. POEM is also being used to successfully treat diffuse esophageal spasm (DES) and jackhammer esophagus. With jackhammer esophagus and DES, inclusion of the lower esophageal sphincter in the myotomy minimizes the risk of symptom development from iatrogenic ineffective esophageal motility.

Peroral Endoscopic Myotomy for Treating Achalasia and Esophageal Motility Disorders

Peroral endoscopic myotomy (POEM) is the application of esophageal myotomy to the concept of natural orifice transluminal surgery (NOTES) by utilizing a submucosal tunneling method. Since the first case of POEM was performed for treating achalasia in Japan in 2008, this procedure is being more widely used by many skillful endosopists all over the world. Currently, POEM is a spotlighted, emerging treatment option for achalasia, and the indications for POEM are expanding to include long-standing, sigmoid shaped esophagus in achalasia, even previously failed endoscopic treatment or surgical myotomy, and other spastic esophageal motility disorders. Accumulating data about POEM demonstrate excellent short-term outcomes with minimal risk of major adverse events, and some existing long-term data show the efficacy of POEM to be long lasting. In this review article, we review the technical details and clinical outcomes of POEM, and discuss some considerations of POEM in special situations.

Peroral endoscopic myotomy: an evolving treatment for achalasia

Peroral endoscopic myotomy (POEM) was first performed in Japan in 2008 for uncomplicated achalasia. With excellent results, it was adopted by highly skilled endoscopists around the world and the indications for POEM were expanded to include advanced sigmoid achalasia, failed surgical myotomy, patients with previous endoscopic treatments and even other spastic oesophageal motility disorders. With increased uptake and performance of POEM, variations in technique and improved management of adverse events have been developed. Now, 6 years since the first case and with >3,000 procedures performed worldwide, long-term data has shown the efficacy of POEM to be long-lasting. A growing body of literature also exists pertaining to the learning curve, application of novel technologies, extended indications and physiologic changes with POEM. Ultimately, this once experimental procedure is evolving towards becoming the preferred treatment for achalasia and other spastic oesophageal motility disorders.

Management of primary achalasia: The role of endoscopy

Achalasia is an oesophageal motor disorder which leads to the functional obstruction of the lower oesophageal sphincter (LES) and is currently incurable. The main objective of all existing therapies is to achieve a reduction in the obstruction of the distal oesophagus in order to improve oesophageal transit, relieve the symptomatology, and prevent long-term complications. The most common treatments used are pneumatic dilation (PD) and laparoscopic Heller myotomy, which involves partial fundoplication with comparable short-term success rates. The most economic non-surgical therapy is PD, with botulinum toxin injections reserved for patients with a higher surgical risk for whom the former treatment option is unsuitable. A new technology is peroral endoscopic myotomy, postulated as a possible non-invasive alternative to surgical myotomy. Other endoluminal treatments subject to research more recently include injecting ethanolamine into the LES and using a temporary self-expanding metallic stent. At present, there is not enough evidence permitting a routine recommendation of any of these three novel methods. Patients must undergo follow-up after treatment to guarantee that their symptoms are under control and to prevent complications. Most experts are in favour of some form of endoscopic follow-up, however no established guidelines exist in this respect. The prognosis for patients with achalasia is good, although a recurrence after treatment using any method requires new treatment.

High-resolution manometry is comparable to timed barium esophagogram for assessing response to pneumatic dilation in patients with achalasia

BACKGROUND

Reduction in height of barium column in timed barium esophagogram (TBE) and lower esophageal sphincter (LES) pressure on manometry has been used to assess efficacy of pneumatic dilation (PD) in patients with achalasia; data comparing these two methods to assess efficacy of PD are scanty.

METHODS

Sixty-two patients with achalasia undergoing PD were evaluated clinically (Eckardt's score), high-resolution manometry (HRM), and TBE (films at 1 and 5 min) before and 4 weeks after PD using 30 and 35 mm Rigiflex balloon (Microvasive, Milliford, MA, USA) in female and male patients, respectively. Response was defined clinically as Eckardt's score <3, by manometry as LES pressure <22.5 mmHg, and by TBE as adequate esophageal emptying (reduction in height of barium column by more than 50 % of pretreatment value in 5-min radiograph).

RESULTS

Forty-three out of sixty-two (69 %) patients [age 34 ± 12 years, 36 (58 %) male] responded, and 19 (31 %) did not respond to the first session of PD as assessed by post-PD Eckardt's score. Thirty-eight out of 43 (88 %) responders had adequate esophageal emptying of barium in TBE, while 31/43 (72 %) had LES pressure below 22.5 mmHg on HRM (p = ns). Eight out of 19 (42 %) nonresponders showed failure in esophageal emptying (defined by lack of reduction in height of barium column by 50 %) in TBE, and 11/19 (58 %) had LES pressure >22.5 mmHg (p = ns). Kaplan-Meier analysis showed that response on TBE and HRM at 1 month predicted clinical response well during 6 months follow up.

CONCLUSION

TBE and esophageal HRM were comparable in assessing efficacy of PD in treatment of achalasia.

Treatment of esophageal motility disorders based on the chicago classification

OPINION STATEMENT

The Chicago Classification divides esophageal motor disorders based on the recorded value of the integrated relaxation pressure (IRP). The first group includes those with an elevated mean IRP that is associated with peristaltic abnormalities such as achalasia and esophagogastric junction outflow obstruction. The second group includes those with a normal mean IRP that is associated with esophageal hypermotility disorders such as distal esophageal spasm, hypercontractile esophagus (jackhammer esophagus), and hypertensive peristalsis (nutcracker esophagus). The third group includes those with a normal mean IRP that is associated with esophageal hypomotility peristaltic abnormalities such as absent peristalsis, weak peristalsis with small or large breaks, and frequent failed peristalsis. The therapeutic options vary greatly between the different groups of esophageal motor disorders. In achalasia patients, potential treatment strategies comprise medical therapy (calcium channel blockers, nitrates, and phosphodiesterase 5 inhibitors), endoscopic procedures (botulinum toxin A injection, pneumatic dilation, or peroral endoscopic myotomy) or surgery (Heller myotomy). Patients with a normal IRP and esophageal hypermotility disorder are candidates for medical therapy (nitrates, calcium channel blockers, phosphodiesterase 5 inhibitors, cimetropium/ipratropium bromide, proton pump inhibitors, benzodiazepines, tricyclic antidepressants, trazodone, selective serotonin reuptake inhibitors, and serotonin-norepinephrine reuptake inhibitors), endoscopic procedures (botulinum toxin A injection and peroral endoscopic myotomy), or surgery (Heller myotomy). Lastly, in patients with a normal IRP and esophageal hypomotility disorder, treatment is primarily focused on controlling the presence of gastroesophageal reflux with proton pump inhibitors and lifestyle modifications (soft and liquid diet and eating in the upright position) to address patient's dysphagia.

Association between gastroesophageal reflux disease after pneumatic balloon dilatation and clinical course in patients with achalasia

Background/Aims

The occurrence of gastroesophageal reflux disease (GERD) is known to be associated with lower post-treatment lower esophageal sphincter pressure in patients with achalasia. This study aimed to elucidate whether GERD after pneumatic balloon dilatation (PD) has a prognostic role and to investigate how the clinical course of GERD is.

Methods

A total of 79 consecutive patients who were first diagnosed with primary achalasia and underwent PD as an initial treatment were included in this retrospective study. Single PD was performed using a 3.0 cm balloon. The patients were divided into two groups: 1) who developed GERD after PD (GERD group) and 2) who did not develop GERD after PD (non-GERD group). GERD was defined as pathological acid exposure, reflux esophagitis or typical reflux symptoms.

Results

Twenty one patients (26.6%) developed GERD after PD during follow-up. There were no significant differences between the two groups in demographic or clinical factors including pre- and post-treatment manometric results. All patients in GERD group were well responsive to maintenance proton pump inhibitor therapy including on demand therapy or did not require maintenance. During a median follow-up of 17.8 months (interquartile range, 7.1–42.7 months), achalasia recurred in 15 patients (19.0%). However, the incidence of recurrence did not differ according to the occurrence of GERD after PD.

Conclusions

GERD often occurs after even a single PD for achalasia. However, GERD after PD is well responsive to PPI therapy. Our data suggest that GERD after PD during follow-up does not appear to have a prognostic role.

Respiratory dysfunction is common in patients with achalasia and improves after pneumatic dilation

BACKGROUND

Dysphagia, regurgitation, and chest pain are common achalasia, with a variable report of pulmonary symptoms possibly due to micro-aspiration. Pneumatic dilation (PD) may improve pulmonary function. Data on pulmonary dysfunction among achalasia patients are scanty, and the effect of PD is unknown.

AIM

To evaluate pulmonary dysfunction in patients with achalasia based on clinical and radiologic evaluation and spirometry and to study the effect of PD at 1-month follow-up.

METHODS

Patients with achalasia (diagnosed using high-resolution manometry and the Chicago classification) were evaluated prospectively by spirometry before (n = 38) and 1 month after PD (n = 31). All patients received a chest X-ray, and patients with respiratory abnormality before PD received high-resolution computed tomography of the thorax.

RESULTS

Of the 38 patients, 17 and 21 had type I and II achalasia, respectively. The respiratory symptoms, such as pharyngeal symptoms [27/38 (71 %) vs. 8/31 (26 %); P = 0.0001], cough [23/38 (60.5 %) vs. 5/31 (16 %), P = 0.0001], and dyspnea [8/38 (21 %) vs. 0/31 (0 %), P = 0.006], improved after treatment with PD. Spirometry showed abnormalities in 17/38 (45 %) patients before and in 8/15 (53 %) after PD. Median FEV(1), FVC, PEFR, and percentage of predicted MEF(25-75), improved from 78 % (36-85), 74 % (48-100), 62 % (18-72), and 48 % (15-66) before to 83 % (58-94), 86 % (55-99), 69 % (38-81), and 59 % (33-78) after PD, respectively (P < 0.05 for all).

CONCLUSION

Respiratory symptoms and spirometry abnormalities are common in patients with achalasia and improved after successful PD.

For patients with primary achalasia the clinical success of pneumatic balloon dilatation can be predicted from the residual fraction of radionuclide during esophageal transit scintigraphy

BACKGROUND

Esophageal transit scintigraphy (ETS) and esophagography have long been used to evaluate patients with achalasia. The objectives of our study were to evaluate the efficacy of endoscopic pneumatic dilatation (EPD) as treatment for Koreans with achalasia and to determine which findings from ETS and esophagography predict successful treatment of achalasia.

METHODS

Patients with achalasia who were treated by EPD between April 2002 and January 2012 were recruited. We defined the success of EPD as 6 months or more of clinical remission without symptoms or a decrease in the Eckardt scores by at least two points and a total Eckardt score not exceeding 3. We reviewed the percentage of maximum scintigraphic activity retained in the esophagus at 30 s (R 30) and the post-PD rate of reduction of R 30 ((Pre R 30 - Post R 30)/Pre R 30 × 100) by ETS. Possible predictive factors determined by ETS and esophagography were analyzed.

RESULTS

Our study included 53 eligible patients. The median symptom score (Eckardt score) was 5 (4-8). R 30 and T 1/2 were, respectively, 61.8 % and 38.5 min before EPD and 20 % and 4.19 min after EPD. Successful EPD was achieved for 40 of 53 (75.47 %) patients. Age (≥40, p = 0.027) and post-PD rate of reduction of R 30 (>20 %, p = 0.003) were best prognostic indicators of clinical success. There were no perforations related to EPD.

CONCLUSION

Older age and a post-PD rate of reduction of R 30 were strongly associated with better outcomes. Examination with ETS before and after EPD can be used to objectively assess a patient's short-term response to EPD.

Achalasia

Achalasia is a rare motility disorder of the oesophagus characterised by loss of enteric neurons leading to absence of peristalsis and impaired relaxation of the lower oesophageal sphincter. Although its cause remains largely unknown, ganglionitis resulting from an aberrant immune response triggered by a viral infection has been proposed to underlie the loss of oesophageal neurons, particularly in genetically susceptible individuals. The subsequent stasis of ingested food not only leads to symptoms of dysphagia, regurgitation, chest pain, and weight loss, but also results in an increased risk of oesophageal carcinoma. At present, pneumatic dilatation and Heller myotomy combined with an anti-reflux procedure are the treatments of choice and have comparable success rates. Per-oral endoscopic myotomy has recently been introduced as a new minimally invasive treatment for achalasia, but there have not yet been any randomised clinical trials comparing this option with pneumatic dilatation and Heller myotomy.

Ethanolamine oleate as a novel therapy is effective in resistant idiopathic achalasia

Idiopathic achalasia (IA) is a primary motor disorder of the esophagus. Recently, ethanolamine oleate (EO) has been introduced as a novel therapy in IA. We investigate the long-term efficacy of EO injection in the selected IA patients. Two hundred twenty patients with IA were evaluated prospectively. Thirty-one patients who were resistant to or poor candidate of pneumatic balloon dilation and/or cardiomyotomy were enrolled in this study. EO was injected into the lower esophageal sphincter three times at 2-week intervals. Patients were evaluated with the achalasia symptom score (ASS), timed barium esophagogram, and manometry before and after the injections. A good response was defined as a greater than 50% reduction from baseline in the ASS, height and/or volume of barium in TBE, and absence of severe dysphagia or regurgitation at 1.5 months after the last injection. Relapse was defined as two or more points increase in dysphagia score after an initial good response. The mean age of patients was 49.32 ± 19.3 years. Twenty-nine patients had a good response and two had a poor response. The mean ASS decreased from 12.48 (±2.06) to 4.50 (±2.96) (P = 0.0001), and the mean volume of barium decreased from 115.35 (±93.40) to 45.50 (±60.86) mL at 1.5 months after the last injection (P = 0.0001).The mean lower esophageal sphincter pressure was 30.47 ± 13.95 before the treatment and decreased to 14.30 ± 11.89 at 1.5 months after the treatment. (P = 0.0001). The mean duration of follow up was 30.16 ± 11.3 (18-68) months. Twelve patients in whom symptoms relapsed were treated effectively with reinjection. In some patients, minor complications (chest pain and erosion in the distal esophagus) occurred. This study indicates that EO has a long-term effect and can be considered for use in the selected IA patients.

Long-term outcome following pneumatic dilatation as initial therapy for idiopathic achalasia: an 18-year single-centre experience

BACKGROUND

Relapse after treatment for idiopathic achalasia is common and long-term outcome data are limited.

AIM

To determine the cumulative relapse rate and long-term outcome after pneumatic dilatation (PD) for achalasia in a tertiary referral centre.

METHODS

A retrospective study of 301 patients with achalasia treated with PD as first-line therapy. Short-term outcome was measured at 12 months. Long-term outcome was assessed in those who were in remission at 12 months by cumulative relapse rate and cross-sectional analysis of long-term remission rate regardless of any interval therapy, using a validated achalasia-specific questionnaire.

RESULTS

Eighty-two percent of patients were in remission 12 months following initial PD. Relapse rates thereafter were 18% by 2 years; 41% by 5 years and 60% by 10 years. Whilst 43% patients underwent additional treatments [PD (29%), myotomy (11%) or botulinum toxin (3%)] beyond 12 months, 32% of those who had not received interval therapy had relapsed at cross-sectional analysis. After a mean follow-up of 9.3 years, regardless of nature, timing or frequency of any interval therapy, 71% (79/111) patients were in remission. The perforation rate from PD was 2%. Chest pain had a poor predictive value (24%) for perforation.

CONCLUSIONS

Long-term relapse is common following pneumatic dilatation. While on-demand pneumatic dilatation for relapse yields a good response, one-third of relapsers neither seek medical attention nor receive interval therapy. Close follow-up with timely repeat dilatation is necessary for a good long-term outcome. Given the poor predictive value of chest pain for perforation, routine gastrografin swallow is recommended postdilatation.

Recent trends in the management of achalasia

Radical treatment for achalasia is currently unavailable. At present, most palliative procedures are designed improve the passage of food through the gastroesophageal junction and thereby alleviate symptoms. Drug therapy is of limited, transient effectiveness. Pneumatic dilation (PD) is considered superior to endoscopic botulinum toxin injection (EBTI). The mainstay of surgical treatment for achalasia is laparoscopic Heller myotomy (LHM) with fundoplication, currently considered superior to PD. Per oral endoscopic myotomy (POEM), a "state-of-the-art" procedure for minimally invasive surgery, holds great promise for the future management of achalasia. Definitive conclusions regarding the benefits and risks of currently available treatments for achalasia must await the accumulation of evidence from well-designed clinical trials.

Laparoscopic Heller's cardiomyotomy achieved lesser recurrent dysphagia with better quality of life when compared with endoscopic balloon dilatation for treatment of achalasia

Achalasia is a rare primary motility disorder of esophagus; treatments include endoscopic balloon dilatation (EBD) and laparoscopic Heller's cardiomyotomy (LC). This study compared EBD versus LC for treatment of achalasia with focus on quality of life (QoL) and prevalence of post-treatment gastroesophageal reflux disease. This was a retrospective cohort study of all patients diagnosed with achalasia older than 16 treated with either EBD or LC from January 1998 to April 2008. Patients' demographic data, comorbidities, postintervention GERD symptoms, QoL, recurrence of dysphagia, reintervention rate, hospital stay, and time to resumption of diet were collected. Sixty-eight patients were recruited into the study (EBD n= 50; LC n= 18). A significant improvement in QoL was found in patients undergoing LC (0.917 vs. 0.807, P= 0.006). A higher proportion of patients treated with EBD developed post-treatment gastroesophageal reflux symptoms (60.5% vs. 43.8%) when compared with LC, although statistically insignificant (P= 0.34). Patients treated with balloon dilatation had a greater percentage of recurrence of dysphagia (55.1% vs. 26.7%; P= 0.235) and need of reintervention (42.1% vs. 9.1%; P= 0.045). However, these patients had a shorter median hospital stay (1d [range 0-4]) and earlier resumption of diet (0d [range 0-3]). Although EBD is associated with a quicker perioperative recovery, LC accomplished a better QoL, lower incidence of recurrence of dysphagia, and need of reintervention after treatment for achalasia.

Management of achalasia

Achalasia is a rare motility disorder of the esophagus characterized by the absence of peristalsis and defective relaxation of the lower esophageal sphincter. Patients present at all ages with dysphagia and regurgitation as main symptoms. The diagnosis is suggested by barium swallow and endoscopy and confirmed by manometry. Because there is no curative treatment for achalasia, treatment is confined to disruption of the lower esophageal sphincter to improve bolus passage. The most successful therapies are pneumodilation and laparoscopic Heller myotomy, with comparable short-term clinical rates of success. The prognosis of achalasia patients is good, but re-treatment is often necessary.

Major complications of pneumatic dilation and Heller myotomy for achalasia: single-center experience and systematic review of the literature

OBJECTIVES

Pneumatic dilation (PD) and laparoscopic Heller myotomy (LHM) can be definitive therapies for achalasia; recent data suggest comparable efficacy. However, risk must also be considered. We reviewed the major complication rate of PD and LHM in a high-volume center and reviewed the corresponding literature.

METHODS

We reviewed 12 years of our institution's achalasia treatment experience. During this interval, a consistent technique of PD was used utilizing Rigiflex dilators. Medical records were reviewed for post-procedure complications. We administered a telephone survey and examined medical records to assess efficacy of treatment. We also performed a systematic review of the literature for comparable clinical data and examined 80 reports encompassing 12,494 LHM and PD procedures.

RESULTS

At our center, 463 achalasia patients underwent 567 PD or LHM procedures. In all, 78% of the PDs used a 30-mm Rigiflex dilator. In all, 157/184 (85%) patients underwent 1 or 2 PD without any subsequent treatment. There were seven clinically significant perforations; one from PD and six from LHM. There were no resultant deaths from these perforations; two deaths occurred within 30 days of LHM from unrelated causes. Complications and deaths post-PD were significantly fewer than those post-LHM (P=0.02).

CONCLUSIONS

Esophageal perforation from PD at our high-volume center was less common than often reported and lower than that associated with LHM. We conclude that, in the hands of experienced operators using conservative technique, PD has fewer major complications and deaths than LHM.

High-resolution Manometry: Esophageal Disorders Not Addressed by the "Chicago Classification"

The development of the high-resolution esophageal manometry (HRM) and the Chicago classification have improved the diagnosis and management of esophageal motility disorders. However, some conditions have yet to be addressed by this classification. This review describes findings in HRM which are not included in the current Chicago classification based on the experience in our center. This includes the analysis of the upper esophageal sphincter, proximal esophagus, longitudinal muscle contraction, disorders related to gastroesophageal reflux disease and respiratory symptoms. The utility of provocative tests and the use of HRM in the evaluation of rumination syndrome and post-surgical patients will also be discussed. We believe that characterization of the manometric findings in these areas will eventually lead to incorporation of new criteria into the existing classification.

Medium and long-term outcomes after pneumatic dilation or laparoscopic Heller myotomy for achalasia: a meta-analysis

Recent randomized studies comparing outcomes after pneumatic dilation (PD) and laparoscopic Heller myotomy (LHM) for the treatment of achalasia are conflicting and limited to short-term follow-up. Our meta-analysis compared the long-term durability of these approaches, with the hypothesis that LHM offers superior long-term remission compared with PD. We identified 36 studies published between 2001 and 2011 with at least 5 years of follow-up. Those studies describing PD included 3211 patients (mean age, 49.8 y). For PD, the mean 5-year remission rate was 61.9% and the mean 10-year remission rate was 47.9%. Overall, 1526 patients (mean age, 46.3 y) were treated with LHM; 83% received a fundoplication. In contrast, the mean 5- and 10-year remission rates after LHM were 76.1% and 79.6%, respectively. Finally, the perforation rate for LHM was twice that of PD (4.8% vs. 2.4%; P<0.05). We conclude that despite a higher frequency of perforation, LHM affords greater long-term durability.

Pathogenesis of achalasia cardia

Achalasia cardia is one of the common causes of motor dysphagia. Though the disease was first described more than 300 years ago, exact pathogenesis of this condition still remains enigmatic. Pathophysiologically, achalasia cardia is caused by loss of inhibitory ganglion in the myenteric plexus of the esophagus. In the initial stage, degeneration of inhibitory nerves in the esophagus results in unopposed action of excitatory neurotransmitters such as acetylcholine, resulting in high amplitude non-peristaltic contractions (vigorous achalasia); progressive loss of cholinergic neurons over time results in dilation and low amplitude simultaneous contractions in the esophageal body (classic achalasia). Since the initial description, several studies have attempted to explore initiating agents that may cause the disease, such as viral infection, other environmental factors, autoimmunity, and genetic factors. Though Chagas disease, which mimics achalasia, is caused by an infective agent, available evidence suggests that infection may not be an independent cause of primary achalasia. A genetic basis for achalasia is supported by reports showing occurrence of disease in monozygotic twins, siblings and other first-degree relatives and occurrence in association with other genetic diseases such as Down’s syndrome and Parkinson’s disease. Polymorphisms in genes encoding for nitric oxide synthase, receptors for vasoactive intestinal peptide, interleukin 23 and the ALADIN gene have been reported. However, studies on larger numbers of patients and controls from different ethnic groups are needed before definite conclusions can be obtained. Currently, the disease is believed to be multi-factorial, with autoimmune mechanisms triggered by infection in a genetically predisposed individual leading to degeneration of inhibitory ganglia in the wall of the esophagus.

The Kagoshima consensus on esophageal achalasia

Esophageal achalasia is a primary esophageal motility disorder characterized by lack of peristalsis and a lower esophageal sphincter that fails to relax appropriately in response to swallowing. This article summarizes the most salient issues in the diagnosis and management of achalasia as discussed in a symposium that took place in Kagoshima, Japan, in September 2010 under the auspices of the International Society for Diseases of the Esophagus.

Conservative management of esophageal perforations during pneumatic dilation for idiopathic esophageal achalasia

BACKGROUND & AIMS

Esophageal perforation is the most serious adverse event of pneumatic dilation (PD) for achalasia; it is usually managed by surgical repair. We investigated risk factors for esophageal perforation after PD and evaluated safety and long-term outcome of nonsurgical management strategies.

METHODS

We analyzed medical records of patients with achalasia who were treated with PD from 1992-2010 at the University Hospital Gasthuisberg in Leuven, Belgium; all patients with esophageal perforation were contacted to determine long-term outcomes. Achalasia outcomes were assessed by using the Vantrappen criteria.

RESULTS

Of 830 PD procedures performed on 372 patients with manometry-confirmed achalasia (57 ± 1 years, 51% male), 16 were complicated by transmural esophageal perforation (4.3% of patients, 1.9% of dilations). Age >65 years was the only significant risk factor for complications (odds ratio, 3.5; 95% confidence interval, 1.2-10.2). All patients were treated conservatively with broad-spectrum antibiotics and nothing by mouth. In 6 patients (38%) the clinical course was further complicated by a pleural effusion, which required a drain in 4 patients. One patient (6%) died of mediastinal hemorrhage within 12 hours after PD. Patients with complications were discharged after 19 ± 2.3 days, compared with 4 ± 0.2 days for those without complications (P < .0001). Long-term outcomes (mean follow-up, 84 ± 14 months) were determined for 12 patients (75%); 11 had excellent or good outcomes (69%), and 1 had a moderate outcome (6%).

CONCLUSIONS

Age >65 years is a significant risk factor for esophageal perforation after PD. Nonsurgical management of transmural esophageal tears is feasible, with favorable short-term and long-term outcomes, but is not devoid of complications.

Pneumatic dilation for achalasia cardia: reduction in lower esophageal sphincter pressure in assessing response and factors associated with recurrence during long-term follow up

BACKGROUND

Data on utility of post-pneumatic dilation (PD) lower esophageal sphincter (LES) pressure measurement in evaluating short and long-term efficacy of dilation, which tears the non-relaxing LES in achalasia, are scanty.

METHODS

Post-PD LES pressure was measured in 72/98 patients with achalasia. The best cut-off pressure classifying responders and non-responders was determined by receiver operating characteristic (ROC) curve. Factors associated with non-response and recurrence were evaluated.

RESULTS

Of 98 patients (41.1 ± 13.3 years, 58 male), 75 improved, three had perforation requiring surgery, and 20 did not respond to the first PD session. Of 18/20 patients undergoing a second PD, 11 improved and six non-responders needed myotomy. 37/58 (71%) male and 17/40 (42.5%) female patients had a first PD with a 35-mm balloon (P = 0.03). Age and gender of patients did not influence outcome. LES pressure was lower in responders or in those having recurrence than in non-responders (17 mmHg [6.4-75], 11 mmHg [4.6-31]vs 25 mmHg [13-55]). On the ROC curve, 22.5 mmHg was the best cut-off value differentiating responders and non-responders (area under curve [AUC] 0.73). Of the 86 patients responding to PD, 20 had recurrence. Patients who responded to one session of PD or had LES pressure <10 mmHg after the procedure recurred less often, although there was no relationship with age and gender.

CONCLUSION

Post-PD LES pressure measurement is useful to assess treatment response. Patients responding to the first session and those with post-PD LES pressure <10 mmHg tended to recur less. Age and gender did not influence outcome, which might be related to preferential use of a 35-mm balloon, particularly for male patients, during the first session.