Dilation for Esophageal Achalasia

Fig. 4.1

Thirty millimeter Rigiflex balloon with radiopaque markers defining the upper, middle, and lower borders

Although PD was initially performed in the hospital setting with an overnight stay, for the last 20 years, this procedure has been performed in outpatient ambulatory surgical centers [6]. Prior to performing PD in the practice of the senior author, all patients with suspected achalasia have their diagnosis confirmed by high-resolution manometry. The diagnosis of achalasia is based on the Chicago Classification (achalasia types I, II, and III) [7]. In addition, timed barium esophagram (TBE) is performed [8]. In this technique, after drinking 8 oz. of low-density barium in the standing position, two-on-one spot films are obtained at 1 and 5 min to assess liquid emptying [9]. Next, the esophagus is rinsed with water followed by ingestion of a 13 mm barium tablet. The passage of the tablet is evaluated 5 min after ingestion. TBE allows for assessment of the degree of esophageal dilation, megaesophagus, and the rate of esophageal emptying of liquid barium and barium tablet over 5 min. In patients with markedly dilated esophagus or slow esophageal emptying, we recommend 3 days of clear liquids prior to PD. In all other patients, we recommend nothing per mouth status after midnight on the day of procedure.

Before PD is initiated, upper endoscopy under conscious sedation with propofol is performed. Initially, the patient is placed in the left lateral position with elevation of his/her head at least 30°. In our practice, intubation to protect the airway is required in less than 1% of patients. The esophagus (esophageal mucosa and LES) is carefully assessed with removal of any fluid and soft retained food with standard suction. In patients with large amounts of retained food, we perform water lavage with a large bore nasogastric tube.

All achalasia patients usually have mild to moderate dilation of the esophageal body with tortuosity of the distal third of the esophagus and some retention of clear secretions (saliva) and small amounts of soft food. Although the esophageal mucosa usually appears normal, some patients will show reddened, friable, thickened, cracked, desquamating mucosa with megaesophagus and chronic stasis. Endoscopic evidence of candidiasis with the classic white plaques may also be seen.

It is imperative to perform a careful inspection of the LES during upper endoscopy [6]. Patients with achalasia usually have a puckered appearance to the LES, which remains closed with air insufflation (Fig. 4.2). The gastroesophageal junction (Z-line) may not be easily seen due to its location 1–2 cm below the spastic area, which represents the proximal border of the LES. Upon applying gentle pressure, the endoscope should easily pass into the stomach, and about 25% will be associated with a popping release [6]. However, pseudoachalasia should be suspected if excessive pressure is required. We recommend a detailed evaluation of the gastric cardia in the retroflex view to ensure that there is no lesion suspicious for malignancy. In all instances of suspected cancer, multiple cold forceps biopsies should be performed within the distal esophagus and gastric cardia and consideration given to performing endoscopic ultrasound or chest CT scan.

../images/473262_1_En_4_Chapter/473262_1_En_4_Fig2_HTML.jpg — Fig. 4.2

Puckered appearance of the LES in patient with classic achalasia

After upper endoscopy is concluded, a Savary wire is placed into the stomach followed by blind passage of the Rigiflex balloon into the stomach. At that point, we change the patient’s position from left lateral to supine and then initiate fluoroscopy for proper location and insufflation. It is our standard practice to start with the 30 mm balloon in the majority of our patients. In some patients, particularly younger healthy men, we may start with the 35 mm balloon because the LES is more difficult to disrupt in this population. Patients after Heller myotomy have scarring at the LES; therefore we always use a 35 mm balloon initially in this group of patients [6].

The most important part of the PD is accurate location of the balloon by fluoroscopy. We want to see the impingement on the waist caused by the non-relaxing LES on the middle portion of the balloon near the double opaque markers (Fig. 4.3). This usually occurs at the level of the diaphragm or 2–3 cm above with the exception of patients after Heller myotomy who may have the waist below the diaphragm. Once the accurate placement of balloon is confirmed fluoroscopically, the balloon is slowly distended to achieve flattening of the waist (Fig. 4.4). This usually occurs with 7–15 psi of air pressure which is held for 1 min while monitoring the balloon position fluoroscopically [6]. In other centers, the pneumatic balloon is kept distended for 15–120 seconds, and sometimes repeat dilation is performed before balloon removal. It is important for the endoscopist to secure the catheter snugly to the mouth guard as the esophagus will try to push the balloon distally into the stomach. After completing the dilation, the air is removed with a 50 cc syringe and the balloon is removed. The presence of blood on the balloon indicates a mucosal tear but is not predictive of a successful dilation. We do not perform a repeat endoscopy immediately after PD. In our center, PD itself lasts approximately 5 min. The main elements of PD are illustrated in Fig. 4.5. Following the PD, patients are monitored for 30–60 min. We routinely obtain an upright barium esophagram before discharge to assess for esophageal perforation but not the degree of esophageal emptying. The rationale for the use of barium over the gastrografin is that the former allows for better visualization of small leaks without the fear of respiratory problems in cases of aspiration. Following the barium esophagrams, the patient receives liquids and is discharged with our cell phone number, in case other problems arise. Patients may travel distances if required; however, we advise them to stay locally for one night to ensure that they can be transferred to our hospital if they develop any complications. We evaluate all our patients in 4–6 weeks after pneumatic dilation with assessment of symptoms and esophageal emptying by TBE . Repeat high-resolution esophageal manometry is rarely performed. In patients with persistent symptoms, especially in conjunction with poor esophageal emptying on TBE , we recommend repeat PD with the next larger balloon. We repeat PD until either satisfactory symptom relief or failure to respond to the largest 40 mm balloon occurs. All patients without response to PD with the 40 mm balloon are referred for Heller myotomy.

../images/473262_1_En_4_Chapter/473262_1_En_4_Fig3_HTML.jpg — Fig. 4.3

Inflation of a 30 mm Rigiflex balloon revealing a “waist” at the EGJ. The waist is always on the left side of the balloon

../images/473262_1_En_4_Chapter/473262_1_En_4_Fig4_HTML.jpg — Fig. 4.4

Flattening of the “waist” following inflation of a 30 mm Rigiflex balloon

../images/473262_1_En_4_Chapter/473262_1_En_4_Fig5_HTML.jpg — Fig. 4.5

Pneumatic dilatation with the Rigiflex system. (Reprinted with permission © Lancet Publishing Group [2])

Complications After Pneumatic Dilation

Contraindications to PD are poor cardiopulmonary status or other comorbid illnesses that would prevent surgery should an esophageal perforation occur. For these sicker patients, botulinum toxin injections might be the better treatment. Up to 33% of patients have complications during or after PD, although most are minor including chest pain, aspiration pneumonia, fever, painful mucosal tears without perforation, and hematoma [10]. Esophageal perforation is the most serious complication with an overall rate in experienced hands of 1.9% (range 0–16%) of which 50% require surgery. Small perforations and deep, painful tears may be treated conservatively with antibiotics and sometimes esophageal stents. However, surgical repair through a thoracotomy is best for large perforations with extensive soilage of the mediastinum. Most perforations occur during the initial dilation; difficulty keeping the balloon in position is a potential risk factor [2].Although no other predictors for perforation have been identified, the European Achalasia Trial did report four perforations, mostly in older patients, when the first PD was done with a 35 mm compared with a 30 mm balloon [2]. Severe GERD is infrequent after PD, but 15–35% of patients have heartburn , which improves with proton-pump inhibitors [11].

Long-Term Success of Pneumatic Dilation

Repeated series from throughout the world confirm the effectiveness of PD for the treatment of achalasia. In a review of more than 1100 patients (24 studies) with an average follow-up of 37 months [11], Rigiflex pneumatic dilation resulted in good to excellent symptom relief in 74%, 86%, and 90% of patients treated with 30, 35, and 40 mm balloons, respectively. Consistent across these studies after 4–6 years, approximately 30 to 40% have symptom relapses (Fig. 4.6) [12, 13]; however, long-term remission can be achieved in nearly all these patients by repeat dilation by an on-demand strategy based on symptom relapse [14]. This approach is particularly popular in Europe and Australia with centers very experienced in PD and the lack of monetary incentives to pursue surgical myotomy [12, 14, 15]. In the senior author’s experience, a single PD has been successful in several women up to 15 years and one young man for 22 years.