Achalasia: prospective evaluation of relationship between lower esophageal sphincter pressure, esophageal transit, and esophageal diameter and symptoms in response to pneumatic dilation

Results of pneumatic dilation in treating achalasia: predictive factors

Forced pneumatic dilatation (PD) of the cardia is one of the most consecrated therapeutic measures for esophageal achalasia. The procedure only achieved better standardization with the appearance of the Rigiflex balloon. Results and predictive factors of success and failure of PD are reviewed, right after the description of the main technical aspects of the procedure. The success rates, providing control of dysphagia for about 1 year from the procedure using the Rigiflex balloon, are quite satisfactory, with success in more than 75% of patients. It is generally observed that good responses sustained for more than 5 years appear in at least 40% of cases. However, approximately half of the patients submitted to PD require additional dilation and a subgroup of them will undergo surgical treatment to attain adequate control of dysphagia. PD is a method with a low rate of acute complications, with esophageal perforation, the most severe of them, not affecting more than 5% of the cases. The best results could be potentially obtained when predictive factors of success were considered before choosing PD as a therapeutic option, but prospective studies in this field are missing until now.

Achalasia: It Is Not All Black and White

PURPOSE OF REVIEW

This review aims to shed light on subtleties of achalasia diagnosis, including potential pitfalls that may lead to errors. Optimal methods for assessment of disease severity and the relationship between achalasia and other motility disorders will also be reviewed with an emphasis on recent findings from the literature.

RECENT FINDINGS

Adjunctive testing with viscous substances or larger water volumes should be used routinely as it improves the accuracy of achalasia diagnosis. Chronic opiate use can mimic achalasia. The timed barium swallow remains the best test for assessments of disease severity and prognostication, but the functional lumen-imaging probe, a newer tool which measures esophagogastric junction distensibility using impedance planimetry, is emerging as a potentially more powerful tool for these purposes. Functional esophagogastric junction outflow obstruction is possibly part of the achalasia spectrum. By addressing the potential pitfalls described, and through routine and standardized use of the diagnostic tools mentioned herein, the accuracy of diagnosis, severity assessment, and prognostication of achalasia can be improved.

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.

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.

Esophageal stasis on a timed barium esophagogram predicts recurrent symptoms in patients with long-standing achalasia

OBJECTIVES

In achalasia, early recognition of the need for retreatment is of crucial importance to reduce morbidity and long-term complications such as esophageal decompensation. In clinical practice, symptoms and parameters of esophageal function including lower esophageal sphincter (LES) pressure and esophageal emptying are used to decide whether additional treatment is required. However, which of these tests performs best remains unclear.

METHODS

A cohort of 41 patients with long-standing achalasia (median 17 years), underwent esophageal manometry, timed barium esophagogram and symptom evaluation. Patients were followed up for 10 years, and were regarded as a therapeutic failure if Eckardt score was >3 or when retreatment was needed. Predictors of therapeutic failure were evaluated.

RESULTS

Of the 41 included patients, 7 patients had an elevated LES pressure (>10 mm Hg) and 26 had esophageal stasis >5 cm on timed barium esophagogram. During follow-up, 25 patients had recurrence of symptoms and were considered therapeutic failures. Of the 25 patients, 5 had an elevated LES pressure, whereas 22 had esophageal stasis on barium esophagogram. Hence, the sensitivity to predict the need of retreatment is higher for esophageal stasis (88%) compared with LES pressure (20%). A total of 16 patients (39%) were in long-term remission, of which 12 patients (75%) did not have stasis at their initial visit.

CONCLUSIONS

In contrast to LES pressure, esophageal stasis is a good predictor of treatment failure in patients with long-standing achalasia. Based on these findings, we propose to use timed barium esophagogram rather than esophageal manometry as test to decide on retreatment.

Efficacy of treatment for patients with achalasia depends on the distensibility of the esophagogastric junction

BACKGROUND & AIMS

Many patients with persistent dysphagia and regurgitation after therapy have low or no lower esophageal sphincter (LES) pressure. Distensibility of the esophagogastric junction (EGJ) largely determines esophageal emptying. We investigated whether assessment of the distensibility of the EGJ is a better and more integrated parameter than LES pressure for determining efficacy of treatment for patients with achalasia.

METHODS

We measured distensibility of the EGJ using an endoscopic functional luminal imaging probe (EndoFLIP) in 15 healthy volunteers (controls; 8 male; age, 40 ± 4.1 years) and 30 patients with achalasia (16 male; age, 51 ± 3.1 years). Patients were also assessed by esophageal manometry and a timed barium esophagogram. Symptom scores were assessed using the Eckardt score, with a score <4 indicating treatment success. The effect of initial and additional treatment on distensibility and symptoms was evaluated in 7 and 5 patients, respectively.

RESULTS

EGJ distensibility was significantly reduced in untreated patients with achalasia compared with controls (0.7 ± 0.9 vs 6.3 ± 0.7 mm(2)/mm Hg; P < .001). In patients with achalasia, EGJ distensibility correlated with esophageal emptying (r = -0.72; P < .01) and symptoms (r = 0.61; P < .01) and was significantly increased with treatment. EGJ distensibility was significantly higher in patients successfully treated (Eckardt score <3) compared with those with an Eckardt score >3 (1.6 ± 0.3 vs 4.4 ± 0.5 mm(2)/mm Hg; P = .001). Even when LES pressure was low, EGJ distensibility could be reduced, which was associated with impaired emptying and recurrent symptoms.

CONCLUSIONS

EGJ distensibility is impaired in patients with achalasia and, in contrast to LES pressure, is associated with esophageal emptying and clinical response. Assessment of EGJ distensibility by EndoFLIP is a better parameter than LES pressure for evaluating efficacy of treatment for achalasia.

Specific esophagogram to assess functional outcomes after Heller's myotomy and Dor's fundoplication for esophageal achalasia

Esophageal emptying assessed at the 'timed barium' esophagogram correlates well with symptomatic outcomes after pneumatic dilation for esophageal achalasia, although 30% of patients with satisfactory outcome exhibit partial improvement in emptying. The aim of the study was to investigate any correlation of esophageal emptying to symptomatic response after laparoscopic Heller's myotomy and Dor's fundoplication. 'Bread and barium' (transit time of a barium opaque bread bolus) and 'timed barium' (height of esophageal barium column 5 minutes after ingestion of 200-250 mL of barium suspension) esophagogram was used to assess esophageal emptying in 73 patients with esophageal achalasia before 1 and 5 years (31 cases) after laparoscopic myotomy and anterior fundoplication. Symptoms assessment was based to a specific score. At 1-year follow-up, excellent and good symptomatic results were obtained in 95% of the cases. Esophageal maximum diameter, esophageal transit time, and esophageal barium column were significantly correlated to each other and to symptom score postoperatively (P < 0.001). Complete and partial (<90% and 50-90% postoperative reduction in barium column, respectively) emptying was seen in 55% and 31% of patients with excellent result. Patients with a pseudodiverticulum postoperatively had a more delayed esophageal emptying than those without. Symptomatic outcome and esophageal emptying did not deteriorate at 5-year follow-up. Esophageal emptying assessed by 'barium and bread' and 'timed barium' esophagogram correlated well with symptomatic outcome after laparoscopic myotomy for esophageal achalasia. Complete symptomatic relief does not necessarily reflect complete esophageal emptying. Outcomes do not deteriorate by time. Because of wide availability, esophagogram can be applied in follow-up of postmyotomy patients in conjunction with symptomatic evaluation.

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 low-compliance 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 process, so that a repeat endoscopy is not needed to assess the mucosal tearing. Previous studies have shown that endoscope-guided PD is an efficient and safe nonsurgical therapy with results that compare well with other treatment modalities. Although the results may be promising, long-term follow-up is required in the near future.

Evaluation of the response to treatment in patients with idiopathic achalasia by the timed barium esophagogram: results from a randomized clinical trial

To choose which treatment would be most effective for the individual patient with newly diagnosed achalasia is difficult for the tending physician. A diagnostic tool that would allow prediction of the symptomatic and functional response after treatment for achalasia is therefore needed. The timed barium esophagogram (TBE) is a method that allows objective assessment of esophageal emptying, but the value of TBE in the clinical management of achalasia remains to be clarified. The aim of this study was first, to assess the ability of TBE to predict symptoms and treatment failure during post-treatment follow-up. Second, to determine whether esophageal emptying as assessed by TBE differs after treatment with pneumatic dilatation or laparoscopic myotomy. Fifty-one patients with newly diagnosed achalasia were prospectively randomized to pneumatic dilatation (n = 26) or laparoscopic myotomy (n = 25). Evaluation with TBE was performed before (n = 46) and after treatment (n = 43). The median interval between treatment and post-treatment TBE was 6 months, and the median follow-up time after the post-treatment TBE was 18 months. Following therapeutic intervention, TBE parameters did not differ significantly between treatment groups. However, significant correlations were found between the height of the barium column at 1 min and the symptom scores at the end of follow up for 'dysphagia for liquids' (P < 0.05, rho = 0.47), 'chest pain' (P < 0.05, rho = 0.42), and the 'Watson dysphagia score' (P < 0.05, rho = 0.46). Patients with less than 50% improvement in this TBE-parameter (height at 1 min) post-treatment had a 40% risk of treatment failure during follow-up. In summary, pneumatic balloon dilatation and laparoscopic myotomy similarly affected esophageal function as assessed by TBE-emptying. Lack of improvement in barium-column height post-treatment was associated with an increased risk of treatment failure which should motivate close surveillance in order to detect symptomatic recurrence at an early stage.

Endoscopic pneumatic balloon dilation in primary achalasia: predictive factors, complications, and long-term follow-up

Pneumatic dilation (PD) has been widely used in the treatment of idiopathic achalasia with a 70-90% response. The aim of this study was to evaluate the effectiveness of PD and its predictive factors by means of clinical assessment. In addition, we evaluated its safety and the need for subsequent surgical intervention. Fifty-six patients were treated with a Witzel dilator. The response was evaluated at medium (1-5 years) and long term (>5 years). Diverse possible predictive factors to response were analyzed. After the first PD, 85.7% of the 56 patients improved and passed from clinical stage II-III to clinical stage 0-I (P < 0.005). After the second dilation, 84.6% of the patients (13) passed to clinical stage 0-I (P < 0.05). Only patients who were not young (>40 years) avoided a second dilation and/or surgery (P < 0.001). During the first 5 years of follow-up, 80% of patients maintained their response; this percentage decreased to 58% after 10 years. PD therapy of achalasia is a safe technique, with few adverse effects (4% perforations and 10% gastroesophageal reflux). It offers a medium-term response of 80% and long-term response of around 60%. Age was the only predictive response factor.

The role of barium esophagogram measurements in assessing achalasia patients after endoscope-guided pneumatic dilation

Only a few studies have been performed comparing subjective symptom improvements with objective improvement in esophageal emptying after pneumatic dilation (PD), and discrepancy existed. We evaluated whether esophagogram measurements adds to the traditional subjective symptoms scores in assessing achalasia patients after PD. We enrolled 32 new patients with achalasia who received endoscope-guided PD treatment between January 1998 and June 2004. Postdilation investigations were performed by using esophageal emptying on esophagogram prospectively in a blinded manner, along with symptom scores before and after PD at the initial investigation, 6 weeks later, and every 1 year thereafter. Our results showed that seven patients who noted complete relief showed less than 50% improvement in barium column height and esophageal diameter. There was no linear correlation between the degree of patient symptom improvement and esophageal emptying measured by esophagogram (r = 0.181, P = 0.322). A trend of association existed in the relationship between clinical remissions and initial post-PD esophageal emptying improvement (P = 0.067). In summary, the association between the post-PD symptom score improvement and degrees of esophageal emptying may be hampered by the small sample size in the current study. An additional objective parameter like esophagogram to the subjective symptom scores may be more optimal in assessing clinical remissions.

Idiopathic (primary) achalasia

Idiopathic achalasia is a primary esophageal motor disorder characterized by esophageal aperistalsis and abnormal lower esophageal sphincter (LES) relaxation in response to deglutition. It is a rare disease with an annual incidence of approximately 1/100,000 and a prevalence rate of 1/10,000. The disease can occur at any age, with a similar rate in men and women, but is usually diagnosed between 25 and 60 years. It is characterized predominantly by dysphagia to solids and liquids, bland regurgitation, and chest pain. Weight loss (usually between 5 to 10 kg) is present in most but not in all patients. Heartburn occurs in 27%-42% of achalasia patients. Etiology is unknown. Some familial cases have been reported, but the rarity of familial occurrence does not support the hypothesis that genetic inheritance is a significant etiologic factor. Association of achalasia with viral infections and auto-antibodies against myenteric plexus has been reported, but the causal relationship remains unclear. The diagnosis is based on history of the disease, radiography (barium esophagogram), and esophageal motility testing (esophageal manometry). Endoscopic examination is important to rule out malignancy as the cause of achalasia. Treatment is strictly palliative. Current medical and surgical therapeutic options (pneumatic dilation, surgical myotomy, and pharmacologic agents) aimed at reducing the LES pressure and facilitating esophageal emptying by gravity and hydrostatic pressure of retained food and liquids. Although it cannot be permanently cured, excellent palliation is available in over 90% of patients.

The use of the internet in data assimilation in rare diseases

The incidence and prevalence of achalasia is 0.6/100,000 people per year and 1/10,000, respectively. It is difficult then for one center to accumulate a large cohort of patients. One study (Gut 33:1011,1992) described the presenting symptoms in only 38 patients. To approach this problem differently, we used the internet to access a larger patient population. Using search engines at Google and Yahoo, Inc., we identified achalasia support groups. We examined the most populated support group (YSG) and assembled the exchanged messages into 4 categories: support, symptoms, treatment, and diagnosis. Next, a survey modeled after a previous study (ibid) was composed and posted on a university-sponsored Web site for March 2003, advertised to YSG members, and then removed from the server. The results were entered into a database and analyzed. There were 6 support groups identified; 1 was foreign. The most populated site was the Yahoo, Inc., group with 298 active members. We analyzed the 3,222 messages posted from October 6, 2002 through October 5, 2003. The message composition was as follows: 67% support, 16% symptoms, 12% treatment, and 5% diagnosis. Of 298 Yahoo site members, we had 88 respondents to the survey from 9 countries. The data from 83 were analyzed (5 were not completed). Respondents were 66 women (55%), 29 men (24%), and 5 non-gender-identified respondents. They ranged in age from 6 to 72 years at time of diagnosis. In the 83 respondents, dysphagia symptoms were reported by 98%, regurgitation by 68%, chest pain by 81%, weight loss by 69%, and epigastric pain by 67%, similar to those reported in the study cited in Gut. The modalities used to evaluate these achalasia patients were as follows: 83% had monometry, 87% had radiography, and 89% had endoscopy. The mean time from symptom onset to diagnosis was 5 years. The treatments attempted on this population were balloon dilatation in 57%, botulinum toxin injection (Botox) in 8%, myotomy in 12%, by lifestyle/diet modification in 12%, and other treatments in 11%. We believe that the Internet can provide physician-researchers with useful information about common and uncommon diseases on a global basis. The Internet allows patients to voice concerns that they may not freely express to their doctor and provides a modality to collect data from a larger number of patients than may be available at any single institution.

Review article: the management of achalasia - a comparison of different treatment modalities

BACKGROUND

Achalasia is an uncommon primary oesophageal motor disorder with an unknown aetiology. Therapeutic options for achalasia are aimed at decreasing the lower oesophageal sphincter pressure, improving the oesophageal empting, and most importantly, relieving the symptoms of achalasia. Modalities for treatment include pharmacologic, endoscopic, pneumatic dilatation and surgical. The decision of which modality to use involves the consideration of multiple clinical and economic factors.

AIM

To review the management strategies currently available for achalasia.

METHODS

A Medline search identified the original articles and reviews the published in the English language literature between 1966 and 2006.

RESULTS

The results reveal that pharmacotherapy, injection of botulinum toxin, pneumatic dilatation and minimally invasive surgical oesophagomyotomy are variably effective at controlling the symptoms of achalasia but that each modality has specific strengths and weaknesses which make them each suitable in certain populations. Overall, pharmacologic therapy results in the shortest lived, least durable response followed by botulinum toxin injection, pneumatic dilatation and surgery, respectively.

CONCLUSION

The optimal treatment for achalasia remains an area of controversy given our lack of complete understanding about the pathophysiology of the disease as well as the high numbers of clinical relapse after treatment. Further research focusing on optimal dosing of botulinum toxin injection and optimal timing of repeated graduated pneumatic dilatations could add to our knowledge regarding long-term therapy.

Therapeutic effects of a laparoscopic Heller myotomy and Dor fundoplication on the chest pain associated with achalasia

PURPOSE

The therapeutic effects of a laparoscopic Heller myotomy and Dor fundoplication (LHD) on the chest pain associated with achalasia were investigated.

METHODS

Sixty-six patients who were diagnosed to have achalasia underwent LHD. The degree of dilatation was assessed based on the maximum horizontal diameter of the esophagus (Grades I-III). The type of dilatation was assessed based on the shape of the distal esophagus, namely, spindle type (Sp), flask type (Fk), and sigmoid type (Sig). The degree of improvement was classified into three grades as follows: A (complete disappearance), B (partial response), and C (unchanged).

RESULTS

Chest pain improved (A or B) in 22 patients (92%). The statistical results revealed that the improvement of postoperative A or B was significantly better in patients with Sp than in those with Fk or Sig (P = 0.0213). In addition, the results revealed that the improvement of postoperative A or B was significantly better in patients with grade I and grade II than in those with grade III (P = 0.004).

CONCLUSION

LHD is an effective therapeutic technique for the treatment of chest pain associated with achalasia. These results suggest that both the morphological type and esophageal dilatation are useful predictors for the improvement of chest pain after surgical therapy.

Metastatic bone cancer as a recurrence of early gastric cancer - characteristics and possible mechanisms

The surgical outcome of most early gastric cancer (EGC) is usually satisfactory. Some cases show bone metastasis even though the depth of cancer invasion is confined to the mucosa. The most frequent site for recurrence of EGC is the liver. Cases of EGC with bone metastasis are reviewed to clarify the clinicopathological characteristics of EGC giving rise to bone metastasis. Possible mechanisms and risk factors underlying this rare condition are proposed. Forty-six cases of bone metastasis from EGC are reviewed from published reports and meeting proceedings in Japan. This investigation suggests that risk factors for bone metastasis from EGC include depressed-type signet-ring cell carcinoma, poorly differentiated carcinoma, and/or the likely involvement of lymph node metastasis, even though the cancer is confined to the gastric mucosa. The risk factors do not include recurrence of EGC in the liver. We speculate that the mechanism of bone metastasis from EGC is via lymphatic channels and systemic circulation. Post-operative follow-up of cases should consider the development of bone metastasis from EGC. We propose the use of elevated alkaline phosphatase levels for the detection of bone metastasis and recommend bone scintigraphy in positive cases.

Long-term results of pneumatic dilation for achalasia: A 15 years’ experience

AIM: Although most patients with achalasia respond to pneumatic dilation, one-third experienced recurrence, and prolonged follow-up studies on parameters associated with various outcomes are scanty. In this retrospective study, we reported a 15-years’ experience with pneumatic dilation treatment in patients with primary achalasia, and determined whether previously described predictors of outcome remain significant after endoscopic dilation.

METHODS: Between September 1989 and September 2004, 39 consecutive patients with primary symptomatic achalasia (diagnosed by clinical presentation, esophagoscopy, barium esophagogram, and manometry) who received balloon dilation were followed up at regular intervals in person or by phone interview. Remission was assessed by a structured interview and a previous symptoms score. The median dysphagia-free duration was calculated by Kaplan-Meier analysis.

RESULTS: Symptoms were dysphagia (n = 39, 100%), regurgitation (n = 23, 58.7%), chest pain (n = 4, 10.2%), and weight loss (n = 26, 66.6%). A total of 74 dilations were performed in 39 patients; 13 patients (28%) underwent a single dilation, 17 patients (48.7%) required a second procedure within a median of 26.7 mo (range 5-97 mo), and 9 patients (23.3%) underwent a third procedure within a median of 47.8 mo (range 37-120 mo). Post-dilation lower esophageal sphincter (LES) pressure, assessed in 35 patients, has decreased from a baseline of 35.8 ± 10.4-10.0 ± 7.1 mmHg after the procedure. The median follow-up period was 9.3 years (range 0.5-15 years). The dysphagia-free duration by Kaplan-Meier analysis was 78%, 61% and 58.3% after 5, 10 and 15 years respectively.

CONCLUSION: Balloon dilation is a safe and effective treatment for primary achalasia. Post-dilation LES pressure estimation may be useful in assessing response.

Rigiflex pneumatic dilation of achalasia without fluoroscopy: a novel office procedure

BACKGROUND

Pneumatic balloon dilation is the most effective nonsurgical treatment to relieve functional obstruction of the gastroesophageal junction in achalasia. Since its inception, the conventional technique has been performed under direct fluoroscopic control with or without a guidewire. To overcome the impediments of the conventional technique and radiation exposure, we have devised a novel technique of achalasia dilation without fluoroscopy. The aim of the study was to evaluate the efficacy, the safety, and the outcome of the new method.

METHODS

Fifty-six patients (34 men, 22 women) (mean age 32 years) with achalasia cardia were subjected, over a span of 2 years, to dilation with a Gruntzig-type (Rigiflex balloon) pneumatic dilator with the new technique. Clinical response and complications were assessed.

OBSERVATIONS

Excellent improvement in dysphagia, pain, and regurgitation was observed in 92.9%, 89.3%, and 89.3% patients at 24 hours, 6 weeks, and 6 months after dilation, respectively. The mean time to maneuver the Rigiflex balloon to the antrum was 30 seconds. The procedure was successfully done in all patients, and there were no procedural failures. The mean time of the procedure was 8 minutes. There were no complications or mortality during the study.

CONCLUSIONS

Achalasia dilation with this new technique has excellent results and is devoid of the side effects of radiation. It can be done as an office procedure, without the need of a fluoroscopy setup.

Pneumatic balloon dilatation in achalasia: a prospective comparison of safety and efficacy with different balloon diameters

BACKGROUND

Pneumatic dilatation is considered to be the first line therapy for achalasia, but long-term outcome studies are scarce and limited by their retrospective design. There is also no consensus on the optimal method for performing pneumatic dilation as regard to balloon diameter, amount and the rate inflation pressure.

AIM

To address these questions in a large long-term prospective study.

METHODS

Over a period of 10 years 262 achalasia patients referred to our centre were enrolled. All patients underwent a pre-treatment clinical evaluation and were followed every 6 months. The first 62 patients (group A) underwent dilatation with initial use of a 35 mm balloon with inflation pressure of 10 psi in 10 seconds (s). In group B (200 patients) we initially used a 30 mm balloon with inflation pressure of 10 psi in 30 s. Dilatation was repeated with incrementally larger balloons (35 and 40 mm) in case of relapse. We used rigiflex balloon and maintained pressure for 60 s after inflation in both groups.

RESULTS

Three perforations occurred in group A whereas no perforation took place in Group B. The cumulative proportional remission rate with single dilatation in groups A and B decreased from 83 and 75% in 6 months to 60 and 57% after 30 months of therapy respectively, the differences did not reach statistical significance. In patients who had undergone further dilatations the probability of remaining in remission at 1 year after the first and the second dilatation was 38 and 88% in group A, 20 and 89% in group B respectively. The probability of remaining in remission for 2 years increased from 20% after the first dilatation to 70% after the second dilatation.

CONCLUSION

Graded pneumatic balloon dilatation with 30 mm diameter and slower rate of balloon inflation is an effective and safe initial method of therapy for achalasia. The duration of remission can be extended by repeated dilatation with larger size balloon.

Achalasia: a review of therapeutic options and outcomes

Advances in achalasia has led to the development of new therapeutic options. This review will focus on methodology and outcomes of two established techniques; pneumatic dilation and surgical myotomy; and one new technique, LES injection of botulinum A toxin.

Achalasia: a disease of varied and subtle symptoms that do not correlate with radiographic findings

OBJECTIVE

Dysphagia is the hallmark of achalasia, and when frequent or marked, it is believed to be a good predictor of the clinical and radiographic severity of disease. We aimed to evaluate the presence and severity of dysphagia and other symptoms in achalasia and to correlate these symptoms with findings on barium studies.

METHODS

The symptoms and radiographs of 38 patients with confirmed achalasia were reviewed, 20 prospectively, 18 retrospectively. The number of typical and atypical symptoms both initially and at the time of the barium esophagogram was tallied. The severity of typical symptoms at the time of the barium esophagogram was scored on a point system. A scoring system was also devised to rate the severity of the radiographic findings. Symptoms and radiographic findings were compared.

RESULTS

Dysphagia was the initial symptom in only 39% of patients, whereas heartburn, regurgitation, and slow eating occurred initially in 24%, 24%, and 16% of patients, respectively. At the time of the barium esophagogram, all symptoms were reported by a greater percentage of patients than at presentation. The median time period between initial symptoms and symptoms reported at the time of the barium esophagogram was 48 months (range 2-360 months). At the time of the barium esophagogram, the most frequently reported symptoms were slow eating and regurgitation (79% each), followed by dysphagia (76%), and stereotyped movements (including arching of the neck and shoulders, raising of the arms, standing and sitting straight, and walking) with meals (60%). The mean number (+/-SD) of initial achalasia-related symptoms per patient was 1.34 (+/-0.67) and increased to 5.50 (+/-2.05) at the time of the barium esophagogram. The mean typical symptoms score at the time of the barium esophagogram was 3.4 (+/-1.5). Most patients (97%) reported a greater number of achalasia symptoms at the time of the barium esophagogram than initially, despite a mean total radiological score of only 2.58 (out of a maximum of 10 points). There was no statistically significant relationship between the total number of symptoms at the time of the barium esophagogram and the total radiographic score (r = -0.05, and p = 0.77) and between the typical symptom score at the time of the barium esophagogram and the total radiographic score (r = -0.11, and p = 0.51) by Spearman coefficient.

CONCLUSIONS

Achalasia is a disease with many atypical and subtle symptoms, both initially and over time. Dysphagia is initially present in only 39% of patients and is not the most frequently reported symptom over time. Neither the severity nor the total number of achalasia-related symptoms correlates with the severity of radiographic findings.

Randomized controlled trial comparing botulinum toxin injection to pneumatic dilatation for the treatment of achalasia

BACKGROUND

Therapeutic options for achalasia include pharmacological therapy, surgical myotomy, pneumatic dilatation and intrasphincteric botulinum toxin injection.

AIM

To compare botulinum toxin injection with pneumatic dilatation in a randomized trial.

PATIENTS/METHODS

Forty adults with newly diagnosed achalasia were randomized to receive botulinum toxin (n=20) or pneumatic dilatation (n=20). Symptom scores were evaluated at 1, 6 and 12 months. Clinical relapse was defined as a symptom score greater than 50% of baseline. Relapsers received a second botulinum toxin injection or pneumatic dilatation.

RESULTS

The cumulative 12-month remission rate was significantly higher after a single pneumatic dilatation (53%) compared to a single botulinum toxin injection (15%)(P < 0.01). The 12-month estimated adjusted hazard for relapse and need for retreatment for the botulinum toxin group was 2.69 times that of the pneumatic dilatation group (95% confidence interval; 1.18-6.14). When a second treatment was administered to the relapsers in each group, the cumulative remission rate 1 year after initial treatment was significantly higher in the pneumatic dilatation group (100%) compared to the botulinum toxin group (60%) (P < 0.01). There were no major complications in either group.

CONCLUSIONS

Pneumatic dilatation is more efficacious than botulinum toxin in providing sustained symptomatic relief in patients with achalasia. The efficacy of a single pneumatic dilatation is similar to that of two botulinum toxin injections.

A cost-minimization analysis of alternative treatment strategies for achalasia

OBJECTIVE

The aim of this study is to compare the costs per cure of alternative strategies for the treatment of achalasia.

METHODS

A cost-minimization model compared three strategies for otherwise healthy adults of any age with achalasia: 1) laparoscopic Heller myotomy with fundoplication (LHM); 2) pneumatic dilation (PD), with LHM reserved for treatment failures; 3) botulinum toxin (Botox) injection of the lower esophageal sphincter, with PD reserved for treatment failures. Probabilities of short- and long-term efficacy, treatment failure, symptomatic recurrence rates, and complications were derived from the published literature. Only direct costs were considered during the 5-yr time horizon.

RESULTS

Respective reference case costs per cure of PD, Botox, and LHM strategies were $3,111, $3,723, and $10,792. Despite short- and long-term efficacy of 96% and 94%, respectively, the LHM strategy was most costly. Initial PD remained less costly than initial Botox, provided that rates of PD efficacy and perforation were > or = 70% and < 9.5%, respectively, and cost of a Botox session was > or = $450. The results were not sensitive to the probabilities of short- and long-term response to Botox, recurrence after PD, LHM efficacy, and post-LHM gastroesophageal reflux disease, nor to the costs of LHM and PD.

CONCLUSIONS

For otherwise healthy patients with achalasia, initial PD is the least costly strategy provided that the PD perforation rate remains < 10%. Initial Botox is less costly only when nonendoscopic-related costs decrease by 25%. Initial LHM is the most costly strategy under all clinically plausible scenarios. Subsequent analyses should include a longer time horizon and an assessment of patient ference for each strategy.

Treatment of achalasia: recent advances in surgery

Achalasia is an uncommon motility disorder of the esophagus with an uncertain etiology. Considerable debate exists regarding the most effective treatment for long-term relief of symptoms. For decades, pneumatic dilatation has been the primary treatment option, and surgery was reserved for patients who required repeated dilations or for those who were not willing to undergo the risk of perforation associated with dilatation. Recently botulinum toxin injection of the lower esophageal sphincter has been shown to provide substantial short-term relief from dysphagia; however, its effect only lasts for a short period of time. Recently, minimally invasive surgical techniques have been developed to perform a Heller myotomy effectively with an antireflux procedure. This has become a primary treatment option for many patients. We present a review of the outcome of different therapeutic options of achalasia with a special focus on laparoscopic procedures.

Long-term outcome of achalasia treatment: the need for closer follow-up

Treatment of achalasia includes pneumatic dilation (PD) and surgical myotomy (SM). Success rates range from 32% to 98% and are mostly based on symptomatic response. Our aims were to determine the long-term outcome of patients treated for achalasia and the adequacy of long-term follow-up. Patients treated with PD or SM between 1986 and 1990 were contacted by telephone after a minimum of 4 years after treatment, and asked about symptoms and need for retreatment since their discharge from our institution. Symptomatic response was classified as excellent/good or fair/poor using the Vantrappen score. Treatment was deemed a failure if patients were symptomatic on callback, needed retreatment, technical problems occurred during PD, or perforation occurred. Forty-seven PD patients and 15 SM patients were studied. There were no significant differences in clinical parameters between groups. Median time to callback was 82 and 73 months, respectively. Failure rates were high, respectively 74% and 67%. Importantly, 38% of PD and 33% of SM patients failed to seek help despite symptom recurrence. Achalasia treatment failures are higher than anticipated. This may be because of the lack of routine follow-up as well as patients' failure to seek help when symptoms recur. Achalasia patients need closer follow-up and may benefit from early intervention based on objective tests rather than symptoms alone.

Current therapies for achalasia: comparison and efficacy

Achalasia is a primary esophageal motor disorder of unknown etiology producing 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 initial treatment strategy for early achalasia, are now only used in patients who are not candidates for pneumatic dilation or surgery and those not responding to botulinum toxin injections. By virtue of the more rigid balloons, the current pneumatic dilators are more effective and have better efficacy than the older more compliant balloons. The graded approach to pneumatic dilation using the Rigiflex balloons (3.0, 3.5, and 4.0 cm) are 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 with high morbidity and long hospital stay, can now be performed laparoscopically with similar efficacy to the open surgical approach (94% vs. 84%, respectively), reduced morbidity, and hospitalization time. Given 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 cannot undergo balloon dilation and are not surgical candidates.

High- and low-compliance balloon dilators in patients with achalasia: a randomized prospective comparative trial

BACKGROUND

Pneumatic dilation is the most effective nonsurgical method for treatment of achalasia. The most serious complication of this procedure is esophageal perforation, which occurs in about 5% of cases. We completed a randomized prospective comparative trial with a high-compliance latex balloon (HCB) mounted on an endoscope (40 mm maximum distension diameter, 6 psi inflation pressure) and a low-compliance balloon (LCB) (35 mm, 20 psi) with respect to efficacy and side effects.

METHODS

Twenty-five patients (13 treated with HCB, 12 treated with LCB) were included. The symptom score was assessed both before and after dilation, biannually, for up to 2 years, and complications were graded for severity. All dilations lasted for 3 minutes and were performed under direct endoscopic control. Patients were randomly assigned to the two different balloon types.

RESULTS

One perforation was observed in the LCB group (not significant between HCB and LCB). Superficial mucosal tears appeared in 40% of all dilations. Initial dilation treatment was successful in 20 of 25 (80%) patients (10 of 13 HCB, 10 of 12 LCB). There were no significant differences in the median pretreatment and post-treatment symptom scores. Three patients required repeated dilations during the observation period. They were treated with the competing balloon system and showed no difference compared with the initial posttreatment symptom score.

CONCLUSIONS

No significant difference could be demonstrated between the HCB and LCB system as far as the complication rate and the clinical outcome are concerned. In consequence, both systems appear equally effective, although the endoscope-mounted system (HCB) can be handled more easily.

Quality of life among patients treated for achalasia

The present study is an attempt to capture the quality of life of achalasia patients after a successful treatment. It is also an effort to assess the extent of the subsequent restrictions achalasia may have imposed upon the patients' life-style. All achalasia patients who were successfully treated between 1984 and 1992 were identified. Qualified patients were supplied with a 12-item quality-of-life questionnaire that had been designed to assess the patients' perceptions of their swallowing function and their general health; the restrictions achalasia had imposed on five areas of performance, which encompassed social activities, family relationships, travel experiences, sports and housework activities, were also assessed. Sixty-six patients were offered the questionnaire and 52 (77.6%) returned a completed form. Forty-one of the group had pneumatic dilatation and the remaining 11 had cardiomyotomy. Some form of dysphagia was reported by 36 patients (69%) and a dietary modification was exercised by 29 (56%) of them. Heartburn was reported by 31 (59%) of the patients. Fifteen percent of the patients felt that the disease interfered with their social activities, 8% experienced difficulty in their family relations, 13% believed that the disease restricted travel and athletics, and finally, 9% stated that their symptoms placed restrictions on their ability to do housework. The group that received pneumatic dilation experienced less restriction in the performance areas of sports, travel, and housework. However, this difference was only significant in the area of sports (P = 0.04). It is concluded that: (1) The restoration of the normal swallowing mechanism is not often achieved after treatment for achalasia. The majority of patients who have been treated continue to have a component of difficulty for the rest of their lives. (2) These residual symptoms leave an impact on the patients' life-style. This impact is least important in the performance area of family relationship and most impressive in the area of sports. (3) Finally, those patients who have been treated with cardiomyotomy are more restricted in sport activities than those who received pneumatic dilatation.