Safety and Efficacy of Graded Gradual Pneumatic Balloon Dilation in Idiopathic Achalasia Patients: A 24-Year Single-Center Experience

Background: Pneumatic balloon dilation (PBD) is a first line treatment for idiopathic achalasia. Here we report the safety and efficacy of graded gradual PBD on short and long-term follow-up. Methods: We evaluated 1370 idiopathic achalasia patients over a period of 24 years (1994-2018), prospectively. 216 patients did not undergo PBD due to comorbid diseases. Ultimately, 1092 achalasia patients were enrolled. All patients underwent graded gradual PBD, with repeat dilation if symptoms relapsed. Response to treatment was evaluated by Vantrappen scoring system. Results: Of 1092 achalasia patients, 937 patients were treated by PBD and 155 patients were treated by combined therapy (PBD 1 month after Botulinum toxin injection). In short-term follow-up, 728 of 1092 patients underwent one PBD and 77.3% of them had excellent or good response (responders), 163 patients (58.6%) who underwent two PBDs were responders, and 44 (51.2%) patients who underwent three PBDs were responders. Overall, 2193 balloon dilations were performed on 1092 patients (mean 2 PBDs/patient). Of 786 patients with long-term follow-up, 259 patients had excellent or good response with one PBD. The responders with two, three, and four or more dilations were 149, 67, and 67, respectively. The overall response rate was 69%. No any serious complications were noted by using the graded gradual method. Conclusion: Our results show that graded gradual PBD is a safe and effective method for treatment of achalasia patients, and achieves sufficient short and long-term symptomatic remission with high cumulative success rate.

Diagnosis and Management of Achalasia: Updates of the Last Two Years

Achalasia is a rare neurodegenerative disorder causing dysphagia and is characterized by abnormal esophageal motor function as well as the loss of lower esophageal sphincter (LES) relaxation. The assessment and management of achalasia has significantly progressed in recent years due to the advances in high-resolution manometry (HRM) technology along with the improvements and innovations of therapeutic endoscopy procedures. The recent evolution of HRM technology with the inclusion of an adjunctive test, fluoroscopy, and EndoFLIP has enabled more precise diagnoses of achalasia to be made and the subgrouping into therapeutically meaningful subtypes. Current management possibilities include endoscopic treatments such as Botulinum toxin injected to the LES and pneumatic balloon dilation. Surgical treatment includes laparoscopic Heller myotomy and esophagectomy. Furthermore, in recent years, per oral endoscopic myotomy (POEM) has established itself as a principal endoscopic therapeutic alternative to the traditional laparoscopic Heller myotomy. The latest randomized trials report that POEM, pneumatic balloon dilatation, and laparoscopic Heller’s myotomy have comparable effectiveness and complications rates. The aim of the current review is to provide a practical clinical approach to dysphagia and to shed light on the most recent improvements in diagnostics and treatment of achalasia over the last two years.

Effect of Pneumatic Balloon Dilation to The Changes of Eckardt Score in Patient With Achalasia

Introduction: Achalasia is an esophageal motility disorder, but its pathogenesis remains unclear. The highest incidence is among adults aged 30 – 60 years with the prevalence of 10/100.000 population. Diagnosis of achalasia is based on symptoms and upper endoscopy, barium esophagogram, and esophageal manometry. Pneumatic Balloon Dilation (PBD) is one of the treatment options, whether it is fluoroscopy-guided or direct endoscopy guided. This study aims to analyze the effect of PBD on the changes of Eckardt score among achalasia patients.Methods: An analytical observational study with a retrospective and prospective design was conducted on 18 achalasia patients who performed PBD at Dr. Soetomo General Hospital. Data were then analyzed using t-test. Results: The mean age was 47.8±12.5 years, and the mean achalasia duration was 18.3±5.9 months. There were no differences of achalasia cases between men and women. The mean body weight in the pre and post PBD was 50.9±6.2 vs 53.1±6.5 kg with delta 2.19±1.88 (p <0.0001). The mean BMI in the pre and post PBD was 20.2±2.2 vs 21.1±2.5 kb/m2 with delta 0.89±0.78 (p <0.0001). In addition, the mean Eckardt score in the pre and post PBD was 10.17±1.47 vs 2.5±0.86 (p <0.0001). There were 3 patients with Eckardt score of 4 after PBD and no weight loss after one-month evaluation. Conclusion: There was a significant difference of Eckardt score before and after PBD. The improvement of the Eckardt scores led to the change of weight and body mass index among achalasia patients.

Diagnostics and Minimally Invasive Surgery for Achalasia Cardia

The objective of the research was to assess the effectiveness of balloon pneumatic dilation and laparoscopic Heller myotomy in treatment of patients with achalasia cardia. Materials and methods. Twenty-one patients with achalasia cardia were examined and treated using pneumatic balloon dilation and laparoscopic Heller myotomy in the Department of Surgery from January 2016 to April 2018. There were 8 (38.1%) men and 13 (61.9%) women at the age of 28 to 75 years (the average age was (51.47 ± 3.63) years) and disease duration of 1 month to 8 years (the average disease duration was (3.05 ± 0.49) years). Results and discussion. With the help of radiological methods of examination, all the patients were divided into 4 groups according to the esophageal diameter: Group I included 5 (23.8%) patients with the esophagus up to 4-5 cm in diameter; Group II comprised 6 (28.6%) patients with the esophagus up to 4-6 cm in diameter; Group III included 5 (23.8%) patients with the esophagus up to 6-8 cm in diameter; Group IV consisted of 5 (23.8%) patients with the esophagus of more than 8 cm in diameter and an S-shaped configuration. A significant decrease in the diameter of the esophagus according to fluoroscopy (p<0.05) alongside with a decrease in the lower esophageal sphincter pressure according to manometry are indicative in assessing the effectiveness of achalasia cardia treatment after minimally invasive surgery. There were no complications when performing pneumatic balloon dilation and laparoscopic Heller myotomy. Conclusions. In 7 (33.3%) patients, recurrences of achalasia cardia after balloon pneumatic dilation occurred within 2 - 10 months: in 4.7% of patients in Group I and 9.5% of patients in Group II, Group III, and Group IV. In recurrent achalasia cardia, repeated dilation was ineffective. There was performed laparoscopic Heller myotomy with Dor fundoplication, which was effective in 80.0% of cases.