Achalasia, Pneumatic Dilation, Risks, and Repairs

Pneumatic dilation as a treatment for achalasia is more likely to cause esophageal perforations in the elderly, but these tears can be successfully treated medically, rather than surgically, according to the February issue of Clinical Gastroenterology and Hepatology.

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.

The most serious adverse event of pneumatic dilation is esophageal perforations, which occur during 0.5%–7% of dilations. These are usually repaired surgically, but more conservative medical approaches are available (that would allow patients to avoid surgery). However, there are few data on outcomes of medical treatment of esophageal perforation.

Tim Vanuytsel et al. investigated risk factors for esophageal perforation after pneumatic dilation and long-term outcomes of nonoperative treatment, analyzing data from 830 pneumatic dilations performed on 372 patients with achalasia (confirmed by manometry).

After the dilation, 52 of the patients (14%) had prolonged chest pain, epigastric pain, or fever after the dilation; 16 were found to have a perforation, based on esophagogram analysis.

The patients with the perforations were treated non-surgically: most received total parenteral nutrition for an average of 11 days (nothing by mouth), and all received antibiotic therapy (intravenous and oral) for an average of 21 days. Patients also received acid-suppressive drugs and were carefully monitored. Esophagograms were performed at least once each week, to evaluate healing of the tear, and chest x-rays were taken twice each week.

The conservative medical treatment was somewhat effective—the course of recovery was uncomplicated in 9 patients, who had smaller esophageal tears (<0.5 cm on esophagogram). However, 6 patients developed a pleural effusions and 4 of these required percutaneous drains. One patient died from complications of cardiovascular disease (see figure).

Short- and Long-Term Outcomes After Non-Surgical Therapy for Transmural Esophageal Perforations

The authors concluded that nonsurgical management of esophageal tears is feasible, and can provide good short- and long-term outcomes, but is not devoid of complications.

What factors put patients at greatest risk for esophageal tear during dilation? Patients older than 60 had significantly higher rate of perforation rate than the rest of the patients, but no other demographic (sex), clinical (duration of symptoms and symptom pattern), manometric (LES pressure, presence of vigorous achalasia), or procedure-related (number of previous dilations, balloon diameter, and mercury bag guidance) risk factors were identified. Vanuytsel et al. propose that less-aggressive dilation protocols should be considered for elderly patients.

The authors emphasize that suspicion is a key factor in early diagnosis of perforation after pneumatic dilations—a gastrografin esophagogram should be performed for those with heavy or prolonged pain or fever. However, they say that normal post-dilation pain can last up to 30 minutes, subsides quickly, and is primarily located in the substernal region.

More Information on Achalasia:

Read the article online.
Vanuytsel T, Lerut T, Coosemans W, et al. Conservative management of esophageal perforations during pneumatic dilation for idiopathic esophageal achalasia. Clin Gastroenterol and Hepatol 2012;10:142–149.

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