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.     

Nonoperative management of esophageal strictures following esophagomyotomy for achalasia

The optimal management of reflux-induced esophageal strictures that occur after esophagomytomy for achalasia is uncertain. This paper presents our experience with the nonsurgical treatment of postesophagomyotomy strictures in achalasia patients using endoscopic dilation and gastric acid suppression. Six patients with achalasia who had undergone prior esophagomyotomy subsequently developed recurrent dysphagia and were found to have an esophageal stricture. Esophagrams typically showed a markedly dilated esophagus with a narrowed, sharply angulated gastroesophageal junction. Esophageal manometry confirmed esophageal aperistalsis and, when measured, the LES pressure was<5 mm Hg. Endoscopy showed esophageal inflammation and a fixed stricture at the gastroesophageal junction. Strictures were dilated under direct visualization using through-the-scope balloon dilators. Patients began gastric acid suppressive treatment at the same time. Five patients who remained symptomatic underwent repeat endoscopy, which demonstrated improvement in esophagitis. Dilation was then repeated with a larger balloon dilator. Over a mean follow-up period of 3.8 years, the average number of repeat dilations per patient was 3.6 (range: 0–12). All patients had symptomatic improvement and weight gain. No patient required surgery. We conclude that esophageal strictures after esophagomyotomy for achalasia can be safely treated using endoscopic dilation and gastric acid suppression, thus avoiding the need for reoperation.     

胃镜下气囊扩张治疗贲门失弛缓症的疗效及随访观察

目的 评价胃镜下用Rigiflex气囊扩张器治疗原发性贲门失弛缓症的近期及远期疗效.方法 经临床症状、食管钡餐、食管测压和胃镜检查确诊的125例贲门失弛缓症患者在胃镜下用直径为3.5 cm的Rigiflex气囊扩张器进行扩张,术后根据临床症状积分、食管体正常蠕动率（EPR）、下食管括约肌静息压（LESBP）、下食管括约肌松弛率（LESRR）、下食管括约肌松弛度（LESRD）、食管钡餐和胃镜进行术后1月、6月、1年、3年和5年的随访.结果 治疗后1月内所有患者临床症状积分、LESBP、食管钡餐和胃镜均显著改善（P＜0.01）,EPR、LESRR和LESRD均无显著改善（P＞0.05）,5年随访中有7例复发,有效率达92.14%.治疗中1例出现食管穿孔.结论 在胃镜下用直径3.5 cm的Rigiflex气囊扩张器治疗原发性贲门失弛缓症是非常有效的方法,疗效较持久.随访中间歇性出现的临床症状可能与失调的食管蠕动和LES的松弛有密切关系.     

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.     

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.     

Predictors of outcome of pneumatic dilation in achalasia.

BACKGROUND & AIMS: Graded pneumatic dilation (PD) is a widely accepted treatment for achalasia. We investigated the potential predictors of outcome in a large group of patients with achalasia and tested the hypothesis that graded PD may not be appropriate for all patients. METHODS: Patients undergoing PD from 1992 to 2002 were evaluated retrospectively. Symptom scores (0-15) for dysphagia (0-5), regurgitation (0-5), and chest pain (0-5), as well as degree of esophageal emptying by timed barium swallow, were assessed for all patients. Failure was defined as the return of symptoms resulting in repeated PD or surgical myotomy. Clinical data assessed for short- and long-term predictors of response. RESULTS: Seventy-five patients with achalasia without previous therapy constituted the studied population. Three-year success rates for PD using 3.0-cm, 3.0-cm followed by 3.5-cm, and 3.0-cm and 3.5-cm followed by 4.0-cm Rigiflex balloons were 37% (95% confidence interval [CI], 26-53), 76% (95% CI, 65-88), and 88% (95% CI, 80-97), respectively. Patient age and sex were important treatment outcome predictors. A Cox proportional hazards model of time to additional therapy on sex and 10-year increase in age showed that 3.0-cm PD was significantly (P = 0.04) more likely to fail in younger men than older men (hazard ratio, 0.63; 95% CI, 0.41-0.98). In 25 of 68 patients (37%) initially treated with a 3.0-cm balloon, PD failed within 3 months. Twenty-two of 25 patients (88%) with early failure were men. CONCLUSIONS: (1) Young men have a greater failure rate with 3.0-cm PD than older men or women in general, and (2) graded PD in this group starting initially with the 3.0-cm balloon is more likely to fail.     

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   

Achalasia

Opinion statement  The optimal treatment of achalasia includes several options and presents a challenge for most gastroenterologists. There are numerous patient variables that must be assessed including age, degree of symptoms, duration of disease, desires of each patient, and related comorbidities. Treatment includes both medical and surgical options, with medical therapy further subclassified into pharmacologic and pneumatic dilation. Pneumatic dilations with a polyethylene dilator (sizes of 3.0, 3.5, and 4.0 cm) and laparoscopic myotomy represent the most common forms of therapy. A graduated increase in dilator size, based on symptomatic response, minimizes complications and is successful in more than 90% of patients. Further dilations or adjustment of pharmacologic therapy should be based on symptoms, weight gain, and a timed barium meal. Referral for myotomy should be considered for patients who do not respond to medical therapy or individuals that do not desire pneumatic dilations. Most patients responding to botulinum toxin (Botox; Allergan, Irvine, CA) injections will require repeat treatment at 3- to 6-month intervals. Due to cost constraints, Botox therapy should be reserved for patients who are at an increased risk from possible complications of a dilation or surgery, or those with less than 2 years of life expectancy. The most cost-effective course of therapy per patient cured over a 5-year period is pneumatic dilation, then Botox, and finally laparoscopic myotomy.     

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.     

Endoscope-guided pneumatic dilation for treatment of esophageal achalasia

Pneumatic dilation(PD) is considered to be the first line nonsurgical therapy for achalasia.The principle of the procedure is to weaken the lower esophageal sphincter by tearing its muscle fibers by generating radial force.The endoscope-guided procedure is done without fluoroscopic control.Clinicians usually use a lowcompliance balloon such as Rigiflex dilator to perform endoscope-guided PD for the treatment of esophageal achalasia.It has the advantage of determining mucosal injury during the dilation proce...     

Pneumatic balloon dilation in achalasia: a prospective comparison of balloon distention time

Objective: Duration of Inflation in pneumatic balloon dilatation as treatment of achalasia has been variable ranging from 15 s to 6 min. A 60 s duration appears to be most often used. We compared the efficacy of dilation of achalasia with either 6- or 60-s inflation duration using a Rigiflex dilator of 3.0 cm diameter.
Methods: Eighty-one consecutive patients were prospectively studied in a randomized fashion, 41 in the 60-s group (A) and 40 patients in the 6-s group (B). Mean age of group A was 43 ± 16.2 yr and of group B was 40 ± 16.4 yr. Symptoms of dysphagia, chest pain, heartburn, regurgitation, and night cough were evaluated at basal (before dilation), 1- and 6-month intervals after dilation in both groups. Barium swallow was done to assess esophageal emptying 1 wk before dilation and 5 min postdilation in both groups.
Results: Significant and sustained improvement was seen for all symptoms in both groups. In addition, the degree of improvement in symptom scores between the two groups was similar. Barium esophagram in both groups at basal and immediately postdilation showed significant improvement in barium emptying but there was no significant difference between the two groups, indicative of equal efficacy in both distention times. Two patients needed repeat dilatation in group A and one in group B, with one drop out from group A, who was lost to follow-up, and was excluded from the analysis. No perforation occurred.
Conclusion: Short duration of pneumatic balloon dilatation (6-s) is as effective as longer duration (60-s) in treatment of achalasia.     

Management of Acid- and Alkali-Induced Esophageal Strictures in 79 Adults by Endoscopic Dilation: 8-Years’ Experience in New Delhi

Experience with endoscopic dilation of acid- and alkali-induced strictures of the esophagus using Savary-Gilliard (SG) and balloon dilators is limited, especially in adults. The aim of this study was to determine the safety and efficacy of endoscopic dilation in the management of corrosive esophageal strictures and to compare results with regard to acid- vs. alkali-induced strictures. The records of 230 patients who were treated by endoscopic dilation between 1997 and 2005 at our center were reviewed. This study included all the patients who had corrosive-induced esophageal strictures. SG dilators were used in most of our patients [67/79 (85%)], while only a few patients [12/79 (15%)] were treated with balloon dilators. Dilation was found to be successful after an initial course of dilation (not requiring further dilations) in 28/37 (75.67%) cases in the SG dilator group and in 9/12 (75%) in the balloon group. Strictures caused by acids required a greater mean number of dilations for initial relief of dysphagia compared with that for alkalis. Some of these patients responded to a second course of dilation, leading to final combined SG dilator and balloon dilator success rates of 24/28 (86%) in the acid group and 17/21 (81%) in the alkali group. A total of 359 sessions of dilations were performed with a complication rate of 2/359 (0.56%). Endoscopic dilation using Savary-Gilliard and balloon dilators is safe and effective in managing corrosive esophageal strictures, but it is operator-dependent and the final outcome depends largely on the technical expertise and appropriate selection of patients.     

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.     

Esophageal dilation / dilators

Opinion statement Esophageal dilation is the treatment of choice for most patients with esophageal dysphagia (functional and mechanical). Multiple forms of esophageal dilators are available. Mechanical dilators (guidewire/nonguidewire assisted) are the major forms of dilators used. Balloon dilator use has increased but they offer only a marginal advantage over traditional mechanical dilators at a greatly increased cost (2° to single use). Comparative trials are biased in favor of balloon dilators, but balloon dilators are not indicated for empiric dilation for dysphagia. Empiric dilation for solid food dysphagia is still controversial. Dilation is rarely associated with complications and is rarely contraindicated unless previous dilation attempts have been unsuccessful. Special circumstances such as caustic strictures, radiation stricture, and dysphagia associated with eosinophilic esophagitis should engender cautious dilation. Attention to detail about placement of guidewires and stricture type are still critical for safety. Predilation barium studies are not needed in all patients but should be employed if the endoscope is not able to pass the stricture and stricture length and angulation are unknown. Intralesional steroids and proton pump inhibitor therapy are important adjuvant treatments for resistant strictures and reflux associated strictures. Balloon dilation for achalasia is still a viable alternative, but it is likely to decrease in usage with the advent of more widespread laparoscopic myotomy.     

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.     

机械扩张治疗贲门失弛缓症

采用纤维型金属贲门扩张器治疗贲门失弛缓症27例,男10例,女17例,年龄16～54岁。病史5个月～12年。贲门狭窄段横径0.1～0.4cm,平均0.2mm。扩张横径2.8～3.2cm,平均3.0cm。扩张后饮食改善26例(96.3％),无效1例(3.7％),与本院手术治疗组比较,无显著性差异(P>0.01)。本文阐述了纤维型金属贲门扩张器的结构特征,扩张方法,扩张前准备,扩张中与扩张后可能出现的问题及预防处理措施等,认为贲门失弛缓症如无食管溃疡等合并症,以先行扩张治疗为宜。     

Pneumatic Dilatation in Achalasia Under Endoscopic Guidance: Correlation Pre- and Postdilatation by Radionuclide Scintiscan

Pneumatic dilation of the lower esophageal sphincter was accomplished by endoscopic visualization and positioning of a modified polyurethane dilator (90 F diameter) without fluoroscopy in 17 consecutive patients with advanced symptomatic achalasia. All patients were monitored for completeness of dilation by pre- and postdilation radionuclide scintiscan. Despite advanced megaesophagus, prior dilatations, or complicating disease, all patients showed prompt relief of symptoms.     

Witzel pneumatic dilation for achalasia: safety and long-term efficacy

Forceful dilation of the lower esophageal sphincter is considered primary therapy for achalasia. The Witzel pneumatic balloon dilator, unlike fluoroscopically placed dilators, is placed over a standard gastroscope allowing positioning and dilation under direct vision. We report our experience with the Witzel dilator in 45 patients with achalasia over a 5-year period. All patients had at least one major symptom score of 8 out of 10 for dysphagia and/or regurgitation before dilation. After Witzel dilation, symptomatic response was graded as excellent (score 0 to 2), good (score 3 to 5), fair (score 6 to 8), and poor (no improvement). Symptom response was assessed after 1 week, 1 month, 6 month, 1 year, and present. The mean period of follow-up was 25 months (range, 3 to 85 months). Passage of the balloon across the gastroesophageal junction was technically unsuccessful in three patients. Esophageal perforation occurred in two patients (4%) and transient chest pain greater than 2 days in three patients (7%). There was no bleeding or death. Symptomatic long-term improvement was excellent in 25 patients (63%), good in 6 patients (15%), fair in 4 patients (10%), and poor in 5 patients (12%). A repeat Witzel dilation was performed in five patients but resulted in good/excellent improvement in only one patient. We conclude that pneumatic dilation with the Witzel balloon is a safe, effective procedure for achalasia.     

An experience with polyethylene balloons for pneumatic dilation in achalasia

The Rigiflex achalasia dilator system was used to treat consecutively 24 patients with achalasia. The 30-mm balloon achieved a 70% satisfactory result, and the 35-mm balloon, 93%, including two patients who did not achieve a good response to the smaller balloon. No complications occurred. Dilation pressure, which averaged only 7 +/- 2 (SD) lb/inch2 (psi), was determined by insufflating 1-2 psi more than needed for complete gastroesophageal waist expansion at fluoroscopy. The mean lower esophageal sphincter pressure (LESP) of 39 +/- 11 (SD) mm decreased by 68% with the 35-mm balloon and 60% with the 30-mm. Solid food emptying by radionuclide scintiscan, which pretreatment averaged 62 +/- 36% (mean +/- SD) retention at 20 min, was highly variable both before and in response to dilation. A decrease in scintigraphy of less than 25% retention was present in two of three unsatisfactory treatment responses. A decrease of LESP of greater than 50% and scintigraphy greater than 25% corresponded well with a satisfactory response from the dilation. The excellent results obtained with this system, as well as the distinct advantages of durability, presence of three reliable sizes, and ease of use, make this an attractive alternative to other dilating systems in the treatment of achalasia.     

Esophageal and Lower Response to Balloon Distention in Patients with Achalasia Esophageal Sphincter

Achalasia is characterized by absent orincomplete lower esophageal sphincter (LES) relaxationand aperistalsis in the smooth muscle esophageal body inresponse to swallowing. The esophageal and LES response to distention has not previously been studied.I aimed to characterize the responses to esophagealballoon distention in achalasia patients in comparisonto controls. Sixteen consecutive achalasia patients and 11 healthy volunteers underwent standardesophageal manometry followed by graded midesophagealballoon distention during which LES (as measured by theDent sleeve) and esophageal body pressures were monitored. Subject perception of distention wasalso recorded using a standardized scoring system. TheLES relaxation response to esophageal balloon distentionwas markedly impaired in achalasia patients, irrespective of whether the patient hadradiological evidence of a dilated or nondilatedesophagus. However, phasic contractions proximal to thedistending balloon were preserved. The esophageal bodyresponses below the balloon were inconsistent in bothgroups, and not significantly different from oneanother. Pain-sensation scores were significantly lowerin achalasia patients at the highest distending volumes, but this difference was attributable to thesubgroup of patients with a dilated esophagus.Distention-induced LES relaxation is markedly impairedin achalasia patients in keeping with loss of intrinsic inhibitory innervation. Preservation of theproximal excitation suggests that extrinsic vagalreflexes are intact.