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Achalasia Balloon Dilation

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Published on Aug 30, 2012

Achalasia is a rare motor disorder of the esophagus, cause by defects in relaxation of the lower esophageal sphincter (LES) and loss of peristalsis. This causes obstruction, progressive dysphagia for solids and liquids, regurgitation of undigested food, chest pain and weight loss.

The LES pressure can be reduced and bolus passage improved with drugs such as nitrates and calcium channel blockers, or injections of botulinum toxin into the esophagogastric junction. However, pneumatic dilation and surgical esophagomyotomy are the first-line therapies for achalasia.

Pneumatic dilatation of the esophagus and the modified Heller myotomy remain the most effective long-term methods of treating achalasia despite recent reports on the use of various drugs, including botulinum toxin, as therapeutic alternatives. Pneumatic dilatation for achalasia has been done for many decades and substantial variations continue to exist in the dilators and techniques used to perform the procedure. There is no general consensus regarding the selection of a dilator, optimal balloon size, inflation pressure, and number or duration of inflations. The major objectives of pneumatic dilatation for this disorder are to relieve symptoms and avoid complications, such as bleeding and perforation. In this question, we will address esophageal perforation associated with the treatment of achalasia by pneumatic dilatation.

The goal of pneumatic dilatation of the lower esophagus for treating achalasia is to reduce the functional obstruction caused by an abnormal lower esophageal sphincter (LES) to improve esophageal emptying and lessen symptoms. The morphologic alterations of this therapy on the anatomic structures of the esophagogastric region are variable. The traumatic consequences of esophageal dilatation may be trivial or serious, and can be classified as: mucosal tears, intramural trauma or transmural injuries; the latter include confined collections of contrast material that appear extramural, and which may relate to a contained perforation or possibly mucosal herniation through a rent in the muscular wall, or complete esophageal rupture with free extravasation of contrast material into the mediastinum.

Several theories on the etiology and pathophysiology of achalasia have been reported but, to date, it is widely accepted that loss of peristalsis and absence of swallow-induced relaxation of the lower esophageal sphincter are the main functional abnormalities. Treatment of achalasia often aims to alleviate the symptoms of achalasia and not to correct the underlying disorder. Medical therapy has poor efficacy, so patients who are good surgical candidates should be offered either laparoscopic myotomy or pneumatic balloon dilatation. Their own preference should be included in the decision-making process, and treatment should meet the local expertise with these procedures. Laparoscopic surgical esophagomyotomy is a safe and effective modality. It can be considered as initial management or as secondary treatment if the patient does not respond to less invasive modalities. Pneumatic dilatation has proven to be a safe, effective, and durable modality of treatment when performed by experienced individuals, and appears to be the most cost-effective alternative. For patients with multiple comorbidities and for elderly patients, who are not good surgical candidates, endoscopic injection of botulinum toxin should be considered a safe and effective procedure. However, its positive effect diminishes over time, and the need for multiple repeated sessions must be taken into consideration. In the management of patients with achalasia, nutritional aspects play an important role. When lifestyle changes are insufficient, it is necessary to proceed to percutaneous gastrostomy under radiological guidance. In the future, intraluminal myotomy or endoscopic mucosectomy will possibly be an option. Further studies are needed to investigate the role of immunosuppressive therapies in those cases in which an autoimmune etiology is suspected.

Pneumatic dilation is an effective and safe treatment for the majority of patients suffering from achalasia of the esophagus. Because of the drawbacks of other forms of treatment, pneumatic dilation is still considered to be the first-line treatment for achalasia. In some selected patient groups (young patients, patients not responsive to pneumatic dilation, patients with severe medical disorders excluding surgical therapy if perforation occurs), esophagomyotomy and intrasphincteric injection of botulinum toxin are valuable alternatives. The choice of the dilator and technique used for dilation should be based on the experience of the dilating physician because the results seem to be similar among the different dilators and techniques.

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