Massively dilated esophagus in achalasia: response to pneumatic balloon dilation

OBJECTIVE: Pneumatic balloon dilation is considered by many to be the treatment of choice for achalasia of the esophagus. Patients with untreated, long standing achalasia may develop massively dilated esophagi, sometimes difficult to dilate with a pneumatic balloon and, rarely, may require esophagectomy. We present our experience with nine such patients out of 110 who underwent pneumatic dilation. METHODS: Of 110 patients treated for achalasia by pneumatic balloon dilation, from January 1989 until December 1996, nine patients had massively dilated esophagi with transverse diameter >7 cm. Results of these patients are presented with pre- and postdilation symptom scores and barium esophagograms. This study was conducted at the Department of Gastroenterology, Shaikh Zayed Postgraduate Medical Institute, Lahore, Pakistan. A Microvasive Rigiflex 35 mm (Boston Scientific, Watertown, MA) pneumatic balloon was used for dilation. RESULTS: Although it is often tedious to perform pneumatic dilation in massively dilated esophagus, it was possible to dilate adequately, in all nine cases without complications, with good symptomatic improvement at 12-month follow-up. CONCLUSIONS: We recommend pneumatic balloon dilation in achalasia with massively dilated esophagus as a first line treatment, the failure of which requires surgical intervention.     

Assessment of esophageal emptying post-pneumatic dilation: use of the timed barium esophagram

OBJECTIVES: The reported success rate of pneumatic dilation in patients with achalasia varies from 50% to 93%. This wide variability may be due to using symptom relief post-dilation as the only assessment of success. There are no studies comparing subjective symptom improvements to objective improvement in esophageal emptying after pneumatic dilation. METHODS: Patients with achalasia undergoing pneumatic dilation from 1995 to 1997 were evaluated. Pre- and post-dilation symptoms were recorded using a standardized scoring system. Barium column height was measured 1 min and 5 min after upright ingestion to assess esophageal emptying. Based on percentage of total symptom and barium height improvement post-dilation, patients were grouped according to one of nine outcomes; the association between subjective and objective parameters of improvement was tested. RESULTS: A total of 37 patients underwent 53 pneumatic dilations. There was a significant association (p < 0.001) between improvement in patient symptoms and barium height. In 38 of 53 (72%) pneumatic dilations, the degree of symptom and barium height improvement was similar. Near complete symptom resolution was reported after 26 dilations. In eight of 26 (31%) patients however, there was < 50% improvement in barium height (group A). Compared with the 16 patients with 91-100% improvement in both symptoms and barium height (group B), forward stepwise regression identified age as the only difference between the two groups, with group A patients being significantly (p = 0.04) older. CONCLUSIONS: Objective assessment of esophageal emptying pre- and post-dilation identifies an important subset of patients with poor esophageal emptying who report near complete symptom resolution. This group may benefit from any early repeat pneumatic dilation.     

The effect of pneumatic balloon dilatation on gastric emptying in patients with achalasia

Achalasia is a disease that characterized by relaxation hazard of lower esophageal sphincter. In patients with achalasia, it's known that gastric emptying time is delayed. In this study we aimed to evaluate the difference between the gastric emptying time before and after pneumatic balloon dilatation. Nine achalasia patients (7 female, mean age 51.5 +/- 13.1, range 36-71 year) that were diagnosed as clinically, radiologically and manometrically were enrolled into the study. In all patients, before and after pneumatic dilatation, gastric emptying time was measured with radionuclide method after eating a solid meal. In severely effected patients labeled egg was passed to stomach by a nasogastric tube. One hour after observing initial gastric activity, irradiation was detected dynamically. Radionuclide emptying time before (T1/2) dilatation was a mean of 301.9 +/- 64.7, and after dilatation 221.7 +/- 370.8 minute (p=0.018). As a result, elongation in gastric emptying time in patients with achalasia significantly decreases after effective pneumatic balloon dilatation.     

Pneumatic Dilation for Achalasia without Fluoroscopic Guidance: Safety and Efficacy

Objectives: To describe the technique of pneumatic dilation for achalasia without fluoroscopic guidance and to assess its safety and efficacy. Methods: Twenty-seven consecutive patients who underwent pneumatic dilation with the Rigiflex achalasia balloon under direct endoscopic visnalization were reviewed. The balloon was passed into the stomach over a guidewire, withdrawn across the gastroesophageal junction, and dilated with the endoscope positioned proximally. Patients wore graded pre- and posttreatment on the frequency of dysphagia, daytime regurgitation, nighttime symptoms, chest pain, and heartburn. Response was assessed by the Improvement in dysphagia frequency. Results: Twenty-seven patients (16 females, 11 males; mean age 54.0 yr) underwent 30 pneumatic dilations. The 30-mm balloon was used in most cases (67%). The mean postdilation follow-up was 21.1 months (1.5–57.4 months). The range of inflation pressures was 8–18 psi (median 15 psi), and the duration of inflation was 30–120 s (median 90 s). Eighteen of 27 patients (67%) had excellent or good results, six (22%) had fair results, and three (11%) had poor results. The outcome of pneumatic dilation was successful in 78% of patients after a single dilation and in 89% of patients overall. There were no perforations related to balloon inflation. Conclusions: The Rigiflex balloon can be successfully positioned across the gastroesophageal junction and dilated under direct endoscopic observation. Pneumatic dilation for achalasia can therefore be performed simply, safely, and effectively without the use of fluoroscopy.     

Timed barium oesophagram: better predictor of long term success after pneumatic dilation in achalasia than symptom assessment

BACKGROUND: Symptom relief post pneumatic dilation is traditionally used to assess treatment success in achalasia patients. Recently, we showed that symptom relief and objective oesophageal emptying are concordant in about 70% of patients, while up to 30% of achalasia patients report near complete symptom relief despite poor oesophageal emptying of barium. AIMS: We now report the results of long term clinical follow up in these two groups of achalasia patients, assessing differences in symptomatic remission rates. METHODS: Achalasia patients undergoing pneumatic dilation since 1995 were evaluated both symptomatically and objectively at regular intervals. Pre and post dilation symptoms were recorded. Barium column height was measured five minutes after ingesting a fixed volume of barium per patient to assess oesophageal emptying. Patients who initially reported near complete symptom relief were divided into two groups based on objective findings on barium study: (1) complete oesophageal emptying (concordant group), and (2) poor oesophageal emptying (discordant group). Patients were followed prospectively for symptom recurrence. RESULTS: Thirty four patients with complete symptom relief post pneumatic dilation were identified. In 22/34 (65%) patients, the degree of symptom and barium height improvements was similar (concordant group). In 10/34 (30%) patients, there was < 50% improvement in barium height (discordant group). Significantly (p<0.001) more discordant (9/10; 90%) than concordant (2/22; 9%) patients failed therapy at the one year follow up. Seventeen of 22 (77%) concordant patients were still in remission while all discordant patients had failed therapy by six years of follow up. Length of time in symptom remission (mean (SEM)) post pneumatic dilation was significantly (p=0.001) less for the discordant group (18.0 (3.6) months) compared with the concordant group (59.0 (4.8) months). CONCLUSIONS: (1) Poor oesophageal emptying is present in nearly 30% of achalasia patients reporting complete symptom relief post pneumatic dilation. (2) The majority (90%) of these patients will fail within one year of treatment. (3) Timed barium oesophagram is an important tool in the objective evaluation of achalasia patients post pneumatic dilation.     

Factors determining successful outcome following pneumatic balloon dilation in achalasia cardia.

BACKGROUND: Pneumatic balloon dilation is a popular method of treating patients with achalasia cardia. It may be useful to know the factors that predict response to this treatment. AIM: To determine predictors of outcome following pneumatic balloon dilation in patients with achalasia cardia. METHODS: Records of 62 patients who had undergone pneumatic dilation using Rigiflex balloon dilators (Boston Scientific, Boston, MA, USA) were reviewed. Follow-up data were available for 52 patients. Data from patients with and without improvement in symptoms were compared. RESULTS: Of the 52 patients (age mean 44 [range 11-68] years; 27 male; median symptom duration 20 [4-90] months], 42 (81%) patients had response in symptoms after balloon dilatation. On univariate analysis, the responders more often had age> 40 years (26/42 [62%] versus 1/10 [10%], p=0.003), and less often had lower esophageal sphincter pressure> 50 mmHg (8/10 [80%] versus 10/42 [24%], p=0.0007) and mid-esophageal body hypocontraction (7/10 [70%] versus 12/24 [29%] p=0.01) than the non-responders. On multivariate analysis only age 相似文献   

Sixteen years follow up of achalasia: A prospective study of graded dilatation using Rigiflex balloon

Pneumatic balloon dilatation is the treatment of choice for esophageal achalasia. Rigiflex (Microvasive, Watertown, MA) polyethylene balloon dilators have been used with varying success and complications. The aim of this study was to evaluate the efficacy of graded balloon dilatation, to achieve symptomatic improvement in patients with achalasia. From January 1987 until the end of December 2003, 300 patients were evaluated and treated for achalasia, with 30 mm balloons. Patients who did not achieve satisfactory symptomatic responses during follow up underwent repeat dilatation with 35-mm balloons. They were studied at the onset then at 1 and 6 month intervals and then yearly for postdilatation symptom evaluation for dysphagia, regurgitation, night cough and heartburn. Baseline and 5-min postdilatation barium swallow studies were obtained to compare barium height and width for efficacy of dilatation and to evaluate for complications. No patients developed cancer of the esophagus in 16 years follow up. Barium height, width, composite symptom score and weight improved significantly during follow up. Two patients, who needed repeat dilatation with 35-mm balloons, developed esophageal perforation; one was successfully managed with intensive medical care management, whereas the other patient died despite surgical intervention. The authors conclude that pneumatic balloon (Rigiflex) dilatation for achalasia of the esophagus is a successful first option, when applied in an incremental balloon size to achieve desired results in symptomatic relief.     

Efficacy of rigiflex balloon dilatation in 12 children with achalasia: a 6-month prospective study showing weight gain and symptomatic improvement

Achalasia cardia is a disease of adolescents and is rare in children. In total, 12 children with primary achalasia, with a mean age of 10.8 +/- 2 years, were prospectively evaluated for the efficacy of a 30-mm-diameter Rigiflex balloon for relief of symptoms and weight gain after 1 and 6 months of follow up. The 12 children were evaluated and treated for achalasia, with pneumatic balloon dilatation, from January 1998 to December 2000. They were studied for basal, 1-, and 6-month post-dilatation composite symptoms for dysphagia, regurgitation, night cough and heartburn. Basal and 5-min post-dilatation barium swallow were obtained to compare barium height and width for efficacy of dilatation and to evaluate for complications. There were no complications. Barium height, width, composite symptom score and weight improved significantly up to the 6-month follow up. Rigiflex balloon dilatation of 30-mm diameter is safe and effective in children with achalasia.     

Vector volume analysis of the lower esophageal sphincter in achalasia and the effect of balloon dilation.

Assessment of the effect of balloon dilation of the lower esophageal sphincter in achalasia currently relies on symptom scores, radiologic studies, or manometry. We have used vector volume analysis which constructs a three-dimensional (3D) pressure profile to examine the effects of balloon dilation on the sphincter. Studies were performed in 26 normal subjects and in 11 patients with achalasia in whom vector volume was determined before and/or after balloon dilation. Vector volume analysis was performed using a multilumen manometry catheter with eight side-reading ports. The catheter was withdrawn through the sphincter using a continuous pull-through technique. A 3D pressure profile was constructed. Vector volume of the lower esophageal sphincter shows a marked radial and linear asymmetry in normal subjects. 3D pressure profiles showed a symmetrical increase in lower esophageal sphincter pressure in untreated achalasia. Mean vector volumes pre and postdilation fell from 254 to 88 cm3 respectively. This was associated with a fall in the mean radial symmetry index from 0.83 to 0.76. Improvement in dysphagia occurred in those patients in whom pressure fell to 15 mmHg or below in at least three adjacent segments. This technique may be a useful tool in the assessment of patients with achalasia and postdilation results may help to predict the long-term outcome of treatment.     

Impact of preoperative balloon dilatation on outcomes of laparoscopic surgery in young patients with esophageal achalasia

Background

Balloon dilatation is reportedly less effective for young patients with esophageal achalasia than for older patients. However, there is no consensus on the impact of prior balloon dilatation on outcomes of surgical treatment. This study investigated the significance of preoperative balloon dilatation on surgical outcomes in young patients with esophageal achalasia.

Methods

Of patients aged less than 40 years who had undergone a laparoscopic Heller–Dor operation for esophageal achalasia, 201 with a postoperative follow-up period of at least 1 year were included. They were divided into two groups with and without a history of balloon dilatation, and compared preoperative pathological conditions and surgical outcomes.

Results

This study included 100 men and 101 women with a median age of 31 years, of whom 158 patients without a history of pneumatic dilatation (79%, non-PD group) and 43 with a history of pneumatic dilatation (21%, PD group) The preoperative symptom scores for dysphagia and regurgitation were significantly higher in the non-PD group. Although no differences were observed in surgical outcomes or postoperative course, the esophageal clearance rates calculated on preoperative and postoperative timed barium esophagograms were lower in terms of both height and width of the barium column in the PD group than in the non-PD group. Subjectively, both groups expressed equally high satisfaction.

Conclusions

In patients aged less than 40 years with esophageal achalasia, although preoperative balloon dilatation did not affect subjective levels of satisfaction with surgery, postoperative improvement in esophageal clearance in the lower esophagus was inhibited.

     

Prospective randomized comparison of Brown-McHardy and microvasive balloon dilators in treatment of achalasia

We report the results of a randomized prospective study comparing a standard bougie rubber balloon dilator [Brown-McHardy (BMH)] and a newer polyethylene dilator passed over a guide wire [Microvasive Rigiflex (MVR)]. Twenty achalasia patients (15M, 5F, mean age 45.4 yr) considered candidates for either dilator were randomized. Symptom assessment, body weight, and upright radionuclide solid esophageal emptying study were measured before and 6 months after pneumatic dilatation. All dilatations were performed by one of three experienced gastroenterologists under fluoroscopic guidance. Overall success occurred with 10/10 BMH and 7/10 MVR. One patient not improved with MVR had myotomy; the other two were successfully treated by BMH. No complications occurred with either dilator.     

Endoscopic dilation of benign colorectal anastomotic stricture after low anterior resection: A prospective comparison study of two balloon types

BACKGROUND: Benign strictures arise in 5.8% to 20% of colorectal anastomoses. For such strictures, endoscopic dilation has proven to be a valid and safe treatment. A variety of endoscopic techniques have been proposed, but controlled prospective trials are lacking. This study compared dilation of this colorectal anastomotic stricture with an over-the-wire balloon designed for treatment of achalasia and with a through-the-scope balloon. METHODS: Thirty patients with symptoms caused by benign colorectal anastomotic stricture were randomly allocated to two treatment groups: 15 underwent dilation with a through-the-scope balloon and 15 had dilation with an over-the-wire balloon. Success was defined as an anastomotic lumen wide enough to allow passage of a standard 13-mm-diameter colonoscope, with resolution of symptoms. The success of dilation, the number of sessions required, the complications, and the duration of the dilation were recorded. Patients were followed for 24 months. RESULTS: Dilation was successful in all patients, with no procedure-related complication. The mean number of sessions required was 2.6 (0.98) in the through-the-scope group and 1.6 (0.77) in the over-the-wire group ( p = 0.009). The duration of response in days was greater in the over-the-wire group vs. the through-the-scope group, 560.8 (248.5) days vs. 294.2 (149.3) days, respectively, p = 0.016. CONCLUSIONS: Through-the-scope and over-the-wire dilation techniques are both effective and safe for treatment of benign colorectal anastomotic strictures. Using a greater diameter over-the-wire pneumatic balloon reduces the number of dilation sessions required and provides a longer-lasting response to dilation.     

Predictors of outcome in patients with achalasia treated by pneumatic dilation.

This prospective study investigates whether the effect of pneumatic dilation in patients with achalasia can be predicted on the basis of patient characteristics, type of treatment, or results of postdilation investigations. Over a period of 10 years, 54 consecutive patients with newly diagnosed achalasia were treated with pneumatic dilation and underwent pretreatment and posttreatment manometric, radiographic, and scintigraphic investigations. They were followed up every 2 years until the fall of 1991. Among the factors evaluated in the initial examination, only young age adversely affected outcome (P < 0.05). With the exception of the diameter of the dilating balloon, the treatment characteristics had a low predictive value. Postdilation lower esophageal sphincter pressure was the single most valuable factor for predicting the long-term clinical response (P < 0.0005). However, patients with high sphincter pressures and poor treatment results benefited from repeated dilations by having progressively longer remissions. It is concluded that young patients are poor candidates for pneumatic dilation, that treatment should be aimed at near complete inflation of the dilating bag, and that postdilation sphincter pressure may guide further treatment.     

肌切开术和气囊扩张治疗食管贲门失弛缓症的前瞻性研究

目的　比较手术和气囊扩张治疗食管贲门失弛缓症的疗效。方法　对 ４８ 例患者（手术１８ 例,气囊扩张 ３０ 例）进行了一年以上的随访观察,通过对临床症状, Ｘ 线钡餐食管造影,胃镜检查和食管２４ 小时连续ｐ Ｈ 监测等进行比较分析。结果　手术和气囊扩张治疗食管贲门失弛缓症在以上几个方面差异均无显著性。结论　手术和气囊扩张均是治疗食管贲门失弛缓症安全有效的方法。而气囊扩张由于其方法简单,不必住院,费用较低等更适合我国国情。     

内镜下短期放置食管支架与气囊扩张治疗贲门失弛缓症的疗效与安全性比较

目的 比较内镜下短期放置特制可回收防反流支架与气囊扩张治疗贲门失弛缓症的近远期疗效及安全性,探讨贲门失弛缓症有效、安全的治疗方法.方法 129例贲门失弛缓症患者按治疗方式分为两组：气囊扩张组63例;特制可回收食管支架组66例.观察比较两组患者治疗前、治疗后1个月、6个月和1年的有效率、吞咽困难症状评分、食管宽度变化、并发症、住院时间及费用.结果 （1）两组患者治疗后随访期间吞咽困难症状较前均明显改善（P〈0.05）,气囊扩张组治疗1个月、6个月、1年后症状缓解有效率分别为100.0%,96.7%,91.5%,食管支架组治疗后同期有效率为100.0%,98.0%,97.1%.（2）治疗后1个月、6个月两组吞咽困难评分改善程度差异均无统计学意义（P〉0.05）,治疗后1年食管支架组吞咽困难评分改善程度优于气囊扩张组（P〈0.05）.（3）治疗后两组患者食管最狭窄处均较前明显增宽、食管最宽处均较前明显缩小（P〈0.05）,且食管宽度变化相似,差异均无统计学意义（P〉0.05）.（4）气囊扩张组1例发生食管穿孔,4例发生消化道出血.食管支架组无穿孔、出血等严重并发症发生,1例发生肉芽组织增生,2例发生支架移位,1例患者发生支架脱落.（5）两组患者住院时间比较无统计学差异（P〉0.05）,食管支架组住院费用高于气囊扩张组（P〈0.05）.结论 与内镜下气囊扩张比较,特制可回收食管支架治疗贲门失弛缓症的近期疗效与其相似,但远期疗效更优,且安全性高,是治疗贲门失弛缓的较理想选择.     

麻醉胃镜下贲门失弛缓症气囊扩张治疗的临床研究

目的 研究麻醉胃镜下贲门失弛缓症气囊扩张治疗的效果及患者对治疗的反应。方法 贲门失弛缓症患者15例,在确诊后应用咪唑安定和丙泊酚行麻醉胃镜下气囊扩张治疗。观察患者扩张治疗中的反应,记录操作时间、清醒时间及检查前中后心率、血压及血氧饱和度变化,记录扩张治疗前、治疗后3 d临床症状积分及测压指标。结果 麻醉时所有患者均入睡,无术中知晓,一般于术后1-5 min内唤醒。患者扩张治疗直至术后苏醒需17-27 min,平均23.2 min。检查中及检查后无心率、血压及血氧饱和度的改变。扩张治疗后22患者的临床症状与治疗前相比明显改善(P<0.01)。结论 在扩张治疗中引入麻醉胃镜技术,减轻了患者痛苦、增加了治疗的依从性。麻醉中保持呼吸道通畅,严密监测心率、血压及血氧饱和度是治疗安全、可行的保证。     

Treatment of Achalasia: The Best of Both Worlds

Objective: To conduct a retrospective analysis of one center's experience with treating achalasia over 4 yr with skilled gastroenterologists using primarily the Rigiflex halloon dilator and with a senior surgeon performing Heller myotomies. Methods: Newly diagnosed cases of achalasia were identified hy a computer search of hospital records. Charts were reviewed for the presence/ severity of dysphagia, regurgitation, heartburn, and chest pain. Weight loss was also recorded. Esophageal manometries and barium swallows were reviewed. Choice of treatment was made freely by patients. With an a priori definition of success, follow-up was conducted by telephone interviews. Results: A total of 45 achalasia patients (mean age, 46 yr; 32 females, 13 males) were identified with a symptoms-frequency as follows: dysphagia, 100%; regurgitation, 78%; heartburn, 50%; and chest pain, 42%. Mean weight loss was 17.5 pounds. Primary treatment was pneumatic dilation in 36 patients and surgery in nine patients. In a total of 45 pneumatic dilations, three (6.6%) were complicated by perforation. Five (14%) patients required repeat dilation. Mean duration of follow-up for pneumatic dilation and surgery was 27 months and 20.8 months, respectively. The overall excellent-good success rates were: pneumatic dilation 88% and surgery 89%. In comparing the efficacy of pneumatic dilation versus surgery, all symptoms were improved significantly ( p < 0.01) in both groups, except heartburn, which increased postmyotomy. Conclusions: If both procedures are available by skilled operators, pneumatic dilation and surgery are equally effective in the treatment of achalasia.     

Achalasia: diagnosis and management.

Achalasia is a primary esophageal motor disorder of unknown cause that produces complaints of dysphagia, regurgitation, and chest pain. The current treatments for achalasia involve the reduction of lower esophageal sphincter (LES) pressure, resulting in improved esophageal emptying. Calcium channel blockers and nitrates, once used as an initial treatment strategy for early achalasia, are now used only in patients who are not candidates for pneumatic dilation or surgery, and in patients who do not respond to botulinum toxin injections. Because of the more rigid balloons, the current pneumatic dilators are more effective than the older, more compliant balloons. The graded approach to pneumatic dilation, using the Rigiflex (Boston Scientific Corp, Boston, MA) balloons (3.0, 3.5, and 4.0 cm) is now the most commonly used nonsurgical means of treating patients with achalasia, resulting in symptom improvement in up to 90% of patients. Surgical myotomy, once plagued by high morbidity and long hospital stay, can now be performed laparoscopically, with similar efficacy to the open surgical approach (94% versus 84%, respectively), reduced morbidity, and reduced hospitalization time. Because of the advances in both balloon dilation and laparoscopic myotomy, most patients with achalasia can now choose between these two equally efficacious treatment options. Botulinum toxin injection of the LES should be reserved for patients who can not undergo balloon dilation and are not surgical candidates.     

Comparison of temporary stent insertion with pneumatic dilation of the same diameter in the treatment of achalasia patients: A retrospective study

Background and Aim: To retrospectively analyze and compare the clinical efficacy of temporary stent insertion with pneumatic dilation of the same diameter in the treatment of achalasia based on a long‐term follow up. Methods: A total of 101 treated achalasia patients were divided into a pneumatic dilation group (Group A, n = 38) and a temporary stent insertion group (Group B, n = 63). The diameter of the balloon or stent used was 30 mm. The total symptom scores (TSS) and esophageal manometry were used to assess the symptoms and lower esophageal sphincter (LES) pressure improvement. Barium swallow–esophageal studies were used to assess esophageal emptying objectively. TSS and LES pressure improvement were assessed, recorded, and compared during the regular interval follow up. Results: Forty‐nine pneumatic dilations and 65 stent insertions were successfully performed in all patients under fluoroscopy. Complications included pain, reflux, and bleeding, which occurred in nine (23.6%), eight (21.1%), and three (8%) patients in Group A, and in 27 (42.9%), eight (12.7%), and 10 (15.9%) patients in Group B, respectively. The stent was retained approximately 4–7 days and was retrieved via endoscope. TSS, esophageal manometry, and barium esophagram post‐treatment significantly improved compared to those given pretreatment (P < 0.0001). At the end of follow up, TSS and LES pressure in Group B were 4.00 ± 1.00 and 43.67 ± 12.66 mmHg, compared to 10.20 ± 0.45 (P = 0.0096) and 58.60 ± 8.65 mmHg (P = 0.1687) in Group A. The Kaplan–Meier method revealed better symptom remission in Group B compared to Group A (log–rank test, P = 0.0212). Conclusion: Retrievable stent placement is more effective than the same diameter pneumatic dilation for the treatment of achalasia with a long‐term follow up.     

Risk factors for immediate complications after progressive pneumatic dilation for achalasia

OBJECTIVE: The aim of this retrospective study was to determine the risk factors of early complications after progressive pneumatic dilation for achalasia. METHODS: Five hundred four dilations were performed in 237 consecutive achalasic patients between 1980 and 1994 with the same technique: low-pressure pneumatic dilation every other day with balloons of increasing diameter until success criteria were obtained (depending on manometric examination and esophageal x-ray transit performed 24 h after each dilation). Clinical, radiographical, endoscopical, and manometrical data as technical procedure characteristics for patients with perforations or other early complications were compared with those without complications. RESULTS: We observed 15 complications (6% of patients): 7 perforations (3%), 3 asymptomatic esophageal mucosal tears, 4 esophageal hematomas, and 1 fever. Perforations occurred in 6 of 7 patients during the first dilation. The mean age was 68.5 yr in the group with complications versus 56.4 yr for the remainder (p < 0.05). Two deaths occurred in patients older than 90 yr. Instability of the balloon during dilations was noted in 8 of 15 cases of complications versus 57 of 222 patients (p < 0.05). No other data differed significantly. CONCLUSIONS: This study showed a low prevalence of early complications using this progressive technique. Patients with hiatal hernia, esophageal diverticulum, or vigorous achalasia may safely undergo progressive pneumatic dilation. Only patients older than 90 yr should be referred for progressive pneumatic dilation with caution. Most of perforations arose during the first dilation, but there was no predictive pretherapeutic factor of perforation.