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Vascular and Interventional Radiology |
1 From the Departments of Interventional Radiology (T.S., M.C., A.A.) and Surgery (J.D., W.O.), Guy’s and St Thomas’ Hospital, Lambeth Palace Rd, SE1 7EH London, England. Received June 14, 2001; revision requested July 9; final revision received January 22, 2002; accepted February 1. Address correspondence to T.S. (e-mail: tarun_sabharwal@yahoo.co.uk).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMATERIALS AND METHODS RESULTSDISCUSSIONREFERENCES |
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MATERIALS AND METHODS: Seventy-six patients (mean age, 51 years) underwent balloon dilation with radiologic guidance. A total of 110 procedures were performed from April 1994 to April 2000. Diagnosis of achalasia was established with clinical, radiologic, and manometric data. Dysphagia was a presenting symptom in most patients (90%), regurgitation was present in 39%, retrosternal pain in 22%, and weight loss in 12%. The dilations were performed in a progressive manner starting with a 15-mm-diameter balloon and progressing to 20-, 30-, and 40-mm balloons, as required. Follow-up data were collected retrospectively from patient notes and telephone interviews with the patients and/or their local doctors (mean follow-up, 26 months).
RESULTS: There were no cases of esophageal perforation; 89% (98 of 110) of dilations were considered to be successful, with the patients having restoration of normal or near-normal swallowing (excellent or good initial responses). Fifty-two patients required a single dilation; 22 patients, between two and four dilations; and two patients, five dilations.
CONCLUSION: Balloon dilation with fluoroscopic guidance is a safe and successful treatment for achalasia of the cardia.
© RSNA, 2002
Index terms: Achalasia, 715.745 • Deglutition disorders • Esophagus, interventional procedures, 71.12168, 71.1232 • Esophagus, stenosis or obstruction, 71.744, 71.745
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTSDISCUSSIONREFERENCES |
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Minimally invasive surgery with laparoscopic or thoracoscopic myotomy, without increasing complications, has shortened hospitalization and decreased morbidity, compared with traditional myotomy (4). However, no long-term results are yet available.
Medical treatment with anticholinergic agents or calcium antagonists is disappointing, and bougienage produces only transient relief with a reported 6% incidence of perforation of the esophagus (5). Injection of a botulinum toxin is an attractive alternative because of its safety and low cost per treatment, but the response is short lasting, and there is a need for repeat injections, which leads to increased overall cost compared with pneumatic dilation (6).
Pneumatic dilation remains the first choice in the treatment of esophageal achalasia in many institutions (6–9). Many types of balloon dilators were used in the past, but the balloon used in this study is currently the most popular (9).
The purpose of our study was to report our experience with balloon dilation for achalasia of the cardia.
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MATERIALS AND METHODS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTSDISCUSSIONREFERENCES |
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Sixty-two patients had undergone no previous surgery; 13 patients underwent previous dilations elsewhere. Fourteen patients had undergone previous esophageal surgery: 10 patients underwent Heller cardiomyotomy; three patients underwent antireflux surgery, where the initial diagnosis of achalasia was missed; and one patient underwent surgery for esophageal rupture from an unknown cause. Three patients had received botulinum toxin injections.
The diagnosis of achalasia was established with clinical, radiologic, and manometric data. Ninety percent of patients presented with dysphagia. Thirty-nine percent of patients had regurgitation of food, 22% had retrosternal pain, and 12% had weight loss.
Procedure
Patients gave informed consent for the procedure. Barium esophagography was performed in all patients prior to treatment. In more than 90% of cases, findings showed features consistent with achalasia, including distal narrowing of the esophagus (bird’s beak narrowing) and a variable degree of dilation of the esophagus in all patients. All patients underwent esophagoscopy to rule out malignancy, which can mimic achalasia at esophagography and manometry.
Manometric assessment of peristaltic activity and measurement of lower esophageal sphincter pressures, as well as pH studies, were performed in all patients. In 60 (78%) patients, manometry was performed in our esophageal laboratory. In 22% of patients, manometry was performed in the referring hospital. Findings from manometry showed lack of peristalsis in all cases, confirming the diagnosis of achalasia.
The balloon dilations were performed in the radiology suite with midazolam (Hypnovel; Roche Products, High Wycombe, England) and fentanyl (Sublimaze; Janssen-Cilag, High Wycombe, England) administered intravenously for sedation and analgesia. The procedure was performed by one of three interventional radiologists (T.S., M.C. or A.A.), who were also responsible for obtaining the consent for the procedure. After initial esophagography with water-soluble nonionic contrast medium (iopromide [Ultravist]; Schering, Berlin, Germany) to identify the site and the length of the narrow segment (Figure, part a), the patient was placed on the fluoroscopic table in the left lateral position, the oropharynx was sprayed with lidocaine (Xylocaine; Astra Pharmaceuticals, Kings Langley, England), and a mouthguard was inserted. A 6.5-F biliary manipulation catheter (Cook, Bloomington, Ind) was advanced with a guide wire (Bentson; Cook, Bjaeverskov, Denmark) to the level of the gastroesophageal junction. Contrast medium was injected to outline the narrow segment and enable safe manipulation of the catheter and the guide wire into the stomach. If the catheter could be easily advanced into the duodenum, it was done to allow easier catheter exchange. If the esophagus was grossly dilated with food or liquid residue, a large-bore nasogastric tube was inserted and the contents aspirated.
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In patients undergoing balloon dilation for the first time, a 15-mm balloon was used initially. If there was no blood on the balloon or severe pain (pain intolerable despite safe adequate sedation and analgesia) during dilation, we progressed to 20-, 30-, and 35-mm balloons. If blood was seen on the balloon after dilation or severe pain was experienced by the patient, the procedure was terminated. Balloons larger than 35 mm were not used for patients undergoing their first dilation, even if no blood was seen on the balloon. In patients undergoing their second or subsequent dilation, however, we progressed to a 40-mm balloon if no blood was present on the 35-mm balloon.
We never use general anesthesia for a first dilation, as we consider the patient’s ability to indicate severe pain an important safeguard against the risk of perforation. However, in four (5.2%) of 76 patients undergoing a second or subsequent dilation, we performed the procedure with general anesthesia, because they had not tolerated well the previous dilation performed with sedation and local anesthesia.
Immediately after dilation, the water-soluble contrast medium was injected through the catheter to exclude perforation. After 4–6 hours, when the patient had recovered, barium esophagography was performed to look for a mucosal tear or perforation (Figure, part d). We believe that barium is more sensitive than water-soluble contrast medium for the detection of small perforations. Most patients were discharged the same evening; those with residual discomfort were observed overnight in the hospital before being discharged the following morning. The decision whether to proceed to a repeat dilation was based on the recurrence of the presenting symptoms. A second procedure was performed if symptoms recurred. Recurrence in less than 3 months after the second or subsequent dilation was considered an indication for surgical myotomy.
Evaluation
All patients were followed up in the outpatient clinic, either at our own institution or at the referring hospital. The follow-up ranged from 1 to 51 months (mean, 29 months).
The response to balloon dilation was considered excellent if there was no dysphagia to solids and liquids, good if there was mild dysphagia, or poor if there was little or no improvement. Balloon dilation was considered successful if patients had good or excellent response and if they did not consider that any attempt at further therapy was justified given their satisfaction with their swallowing. For patients who underwent balloon dilation prior to 1999 (53 of 76 patients), this information was obtained retrospectively from the case notes and telephone interviews with the patients or their local doctors. For the other 23 patients, records were kept prospectively. The data recorded included the balloon sizes used; the numbers of patients whose images showed a waist and obliteration of the waist; the total number of dilations per patient; and complications such as perforations, chest pain, and reflux.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTSDISCUSSIONREFERENCES |
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Follow-up data were available for all patients with a 1-year follow-up after balloon dilation. Seven patients were lost to follow-up beyond that time.
The results of balloon dilation are summarized in Table 2. Eighty-eight percent (98 of 110) of balloon dilations performed with increasing balloon diameters resulted in excellent (n = 60) or good (n = 38) initial responses.
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Immediate Outcome
After treatment, 74 (97%) of 76 patients were able to swallow satisfactorily. There were no cases of esophageal perforation. Ninety-six percent (73 of 76) of patients were treated without recourse to surgery. After dilation, four patients (5.2%) initially complained of severe chest pain, which was resolved with an analgesic within 24 hours. Findings from barium esophagography (either the initial study 4–6 hours after dilation or the additional study after severe chest pain 4–12 hours after dilation) in these patients did not show any evidence of perforation.
Long-term Relief of Dysphagia
The mean time from dilation to last follow-up assessment was 26 months. Thirty-two (78%) of 41 patients who were followed up for longer than 2 years remained essentially symptom free after one (n = 22) or two (n = 10) dilations (Table 1).
Patients who underwent prior dilation at another institution did not have as successful an outcome as patients who underwent an initial dilation at our hospital (10 of 22, 46% vs 42 of 54, 77%, respectively). In patients treated elsewhere, nine (41%) of 22 had previously undergone esophageal surgery, and three had received botulinum toxin injections (Table 1).
Fourteen patients had undergone previous esophageal surgery; of these, seven (50%) needed more than one dilation and two (14%) also required repeat surgical myotomy to relieve symptoms after a poor initial response to balloon dilation. Thus, only seven patients who previously underwent esophageal surgery experienced relief of dysphagia after a single dilation.
Three patients with repeat poor responses to balloon dilations underwent cardiomyotomy. In one of these patients, surgery failed to relieve dysphagia; he subsequently discharged himself and was lost to follow-up. The second patient underwent a difficult operation and required esophagectomy, with a prolonged stay in the intensive care unit with finally an excellent result. The third patient initially responded well to surgery but subsequently required further balloon dilation for relief of recurrent dysphagia. Three (4%) of 76 patients had symptomatic gastroesophageal reflux, which resolved in all cases within 2 weeks.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTSDISCUSSIONREFERENCES |
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All studies in which no perforations were reported (7,9,14) included fewer than 30 patients. The maximum balloon diameter in two-thirds (67%) of dilations performed in our study was 30 mm (the balloon sizes used in our study were similar to those used in these studies). Most of the patients had good or excellent results and did not require further dilations with a larger balloon diameter. Progressive balloon dilations yield excellent results, with balloons larger than 30 mm needing to be used in relatively few patients (6). The Laplace law, which states that the tension applied on the wall for a given pressure increases rapidly with the square of the balloon radius, suggests that use of larger balloons is likely to be associated with a substantially higher risk of perforation. In a retrospective study, in which risk factors for esophageal perforation in 218 patients who underwent 270 pneumatic dilations were evaluated, Borotto et al (15) reported that perforation always occurred during the first dilation.
Our policy of not progressing to a balloon of larger size when blood is detected on the balloon being used for the procedure is based on the assumption that tissue damage has occurred in such cases and that this is a useful marker of success. By terminating the procedure when blood staining on the balloon is observed, we believe that we decrease the likelihood of unnecessary further injury to tissues and reduce the risk of perforation.
Treatment in our hospital was successful in 46% (10 of 22) of patients in whom surgery or dilation performed at other institutions had failed to relieve symptoms. We believe that accurate positioning of the balloon across the lower esophageal sphincter and maintenance of the position throughout inflation with fluoroscopic guidance are essential to success. We also believe that obliteration of a balloon waist is an adequate indication of the disruption of muscle fibers, and the presence of blood on the balloon is an indication of a successful myotomy.
Some investigators (6) do not believe that there is a need for a routine use of fluoroscopy for balloon dilations. However, guidelines of the American Society for Gastrointestinal Endoscopy state that fluoroscopy is mandatory for the placement of a balloon dilator (16). We believe that fluoroscopic guidance facilitates negotiation of tight strictures and enables less traumatic crossing of the cardia; thus, it helps minimize the risk of perforation due to inappropriate advancement of instruments outside the esophageal lumen. Furthermore, it is not uncommon during inflation for the balloon to slide into the stomach or even into the esophagus. Fluoroscopy enables immediate detection and correction of misplacement; this could be missed with endoscopy, leading to full inflation of a large balloon in the esophagus and consequent perforation. However, it is important for the patient to initially undergo endoscopy and manometry to confirm the diagnosis and exclude malignancy.
Symptomatic gastroesophageal reflux occurs frequently after cardiomyotomy (17). Antireflux surgical procedures are frequently performed at the same time as cardiomyotomy, especially when an abdominal route is used for the operation (18). In our study, symptomatic gastroesophageal reflux was seen in only 4% of patients following dilation and resolved spontaneously in all cases. It appears that balloon dilation is less likely to lead to permanent loss of competence of the lower esophageal sphincter than is a surgical incision. This is probably a result of the retained integrity of the phrenicoesophageal ligament.
Some patients experience chest pain following balloon dilation (11,19–22). In the study by Eckardt et al (21), chest pain occurred in 15% of patients between 1 and 10 hours after pneumatic dilation. We encountered four cases of severe postdilation chest pain. Patients who had chest pain after the procedure responded as well or better than did patients who had no pain after dilation.
Recurrent dysphagia occurs in 3%–20% of patients and can be treated with repeated balloon dilation (23). Some authors recommend surgery for patients in whom dysphagia recurs after three pneumatic dilations, as multiple dilations may lead to fibrosis and diminish the likelihood of successful surgery (24,25). However, Eckardt et al (26) found that surgery was equally effective in patients who underwent several dilations as in those who chose to undergo surgery as the initial treatment. Because surgery offers no clear benefits over balloon dilation, we believe that balloon dilation should be repeated except in those patients in whom it is ineffective or leads to very short-lasting relief of dysphagia.
Fellows et al (2) reported that symptomatic relief is more difficult to achieve with pneumatic dilation in patients younger than 45 years, and this view is shared by Vantrappen et al (27). Eckardt et al (26) advocate surgery for achalasia as the first-line treatment for patients younger than 18 years. Our results support this approach: The five patients who required more than two dilations in our series were all younger than 48 years, and the two who required five dilations were 17 and 25 years old.
It would be desirable to perform a randomized trial of balloon dilation and minimally invasive surgical myotomy for the treatment of achalasia. However, because the results of balloon dilation are comparable to that of surgery, it is unlikely that informed consent can be obtained for random patient allocation to these two methods of treatment in light of a high degree of patient satisfaction with dilation (2).
In conclusion, balloon dilation with fluoroscopic guidance is a safe and successful treatment for esophageal achalasia, even after previous esophageal surgery. The dilations should be performed with increasing balloon diameters starting with small balloons, progressing to larger sizes only as required to minimize the rate of esophageal perforation.
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FOOTNOTES |
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REFERENCES |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTSDISCUSSIONREFERENCES |
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This article has been cited by other articles:
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  T. Sabharwal, N. Fotiadis, and A. Adam Modern trends in interventional radiology Br. Med. Bull., April 30, 2007; (2007) ldm006v1. [Abstract] [Full Text] [PDF]
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 M. C. Uthappa, R. Uberoi, J. Phillip-Hughes, P. Boardman, T. Sabharwal, M. Cowling, J. Dussek, W. Owen, and A. Adam Balloon Dilation for Achalasia of the Cardia: A Day Case Procedure [letter] * Dr Sabharwal and colleagues respond: Radiology, August 1, 2003; 228(2): 594 - 594. [Full Text] [PDF]
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