Guidelines on the use of oesophageal dilatation in clinical practice

S A Riley; S E A Attwood

doi:10.1136/gut.53.suppl_1.i1

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Guidelines on the use of oesophageal dilatation in clinical practice

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Guidelines on the use of oesophageal dilatation in clinical practice
Sander J O Veldhuyzen van Zanten
Published on: 18 April 2016
Treatment of Achalasia: The role of Laparoscopic cardiomyotomy needs to be emphasized
Sauid Ishaq
Published on: 18 April 2016

Published on: 18 April 2016
Guidelines on the use of oesophageal dilatation in clinical practice
- Sander J O Veldhuyzen van Zanten, Gastroenterologist
Dear Editor
Drs Riley and Attwood are to be commended for their recent publication.[1] We have difficulty with one recommendation related to dilatation. Under 6.1, it is stated that during oesophageal dilatation that the endoscopist should be supported by at least two endoscopy assistants. We agree that this certainly is desirable when complicated strictures are dialatated or if one is dealing with an achalasi...
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Dear Editor
Drs Riley and Attwood are to be commended for their recent publication.[1] We have difficulty with one recommendation related to dilatation. Under 6.1, it is stated that during oesophageal dilatation that the endoscopist should be supported by at least two endoscopy assistants. We agree that this certainly is desirable when complicated strictures are dialatated or if one is dealing with an achalasia patient.
However, for dialatation of Schatzki’s rings or simple peptic strictures, one endoscopy assistant generally is sufficient. At our institution, over the years numerous dialatations have been done with only one assistant and without any adverse consequences.
As written, your guidelines seem to indicate that the standard of care would be to have two endoscopy assistants present and I think this is both unrealistic and unwarranted.
Reference
(1) SA Riley and SEA Attwood. Guidelines on the use of oesophageal dilatation in clinical practice. Gut 2004; 53: 1i-6i.
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Conflict of Interest:
None declared.
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Published on: 18 April 2016
Treatment of Achalasia: The role of Laparoscopic cardiomyotomy needs to be emphasized
- Sauid Ishaq
- Other Contributors:
  Michael T Hallissey, Mark Deakin
Dear Editor
We read with great interest recent guidelines on the use of oesophageal dilatation in clinical practice by Riley and Attwood. In the section on treatment of achalasia the authors recommended pneumatic dilatation as the first line treatment and a graded approach was suggested starting with smallest balloon 3.0 cm and moving to larger balloon size of 3.5 and 4.0 cm if there is an inadequate response wit...
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Dear Editor
We read with great interest recent guidelines on the use of oesophageal dilatation in clinical practice by Riley and Attwood. In the section on treatment of achalasia the authors recommended pneumatic dilatation as the first line treatment and a graded approach was suggested starting with smallest balloon 3.0 cm and moving to larger balloon size of 3.5 and 4.0 cm if there is an inadequate response with the smaller balloon. [1]
We feel that this recommendation cannot be applied to all patients with achalasia as certain subgroups might benefit from early surgical cardiomyotomy.
We would like to point out that response rate to 3.0 cm balloon reported in the literature is 50-75%. Of those failing to respond to smaller size balloon, only up to 33% will respond to 3.5 cm balloon. Of those not responding to 3.0 and 3.5 cm balloon, only 4.6% will respond to 4.0 cm balloon. It seems obvious that we achieve very little by increasing the size of the balloon, but on the contrary, balloon size increases the complication rate. Oesophageal perforation rate goes up from 2% with 3.5cm balloon to 15% with 4cm balloon. [2-12]
It also had been reported by Echardt et al. that complications of pneumatic dilatation other than oesophageal perforation are underreported. Of 67 patients with achalasia who underwent pneumatic dilalation 12 patients (18%) developed morphological complications including perforation in one, intramural haematoma in 2 and diverticuli at gastric cardia in 9. 10 patients (15%) complained of prolonged post dilatation chest pain although pain symptoms were presumably be due to lack of use of sedation in some patients in this trial. [13]
There is also evidence showing that younger patient and patients with vigorous achalasia (achalasia patients with high amplitude contractions in oesophageal body) are less responsive to balloon dilatation. In younger patients (age 18 – 40 years) 2 years remission figures are markedly lower at 32%, compared with 67% response in older patients. [6, 14-15]
A Patient who is diagnosed to have achalasia up to the age of 40 years has a 35% chance of eventually undergoing a myotomy in spite of repeated pneumatic dilatations. This risk is even higher in the youngest patients. [16]
It has been suggested by many that preoperative pneumatic dilatation makes myotomy difficult and increases the risk of intraoperative mucosal perforation. [17, 14]
On the other hand mean response rate following Laparoscopic and open myotomy (Heller’s myotomy) is 90% and 83% respectively (response rate higher in Laparoscopic group). Symptomatic relapse in these trials were reported approximately 2.4% of the patients in the first postoperative year then 1% of the patients annually in the subsequent years. It is important to recognise however that in the reported series Laparoscopic myotomy has 0-1% mortality. [18-26]
As yet there have been no prospective randomized trials comparing balloon dilatation to laparoscopic cardiomyotomy but one prospective randomised controlled trial compared pneumatic dilatation to Heller myotomy via open thoracotomy, reporting more than 90% symptoms resolution in surgical group compared with only 50% in the pneumatic dilatation group (P<_0.01 at="at" _5="_5" years="years" range="range" _24-156="_24-156" months.="months." in="in" this="this" trial="trial" the="the" oesophageal="oesophageal" perforation="perforation" rate="rate" following="following" pneumatic="pneumatic" dilatation="dilatation" group="group" was="was" _5.4="_5.4" and="and" up="up" to="to" _11="_11" required="required" repeat="repeat" dilatation.="dilatation." spite="spite" of="of" criticism="criticism" for="for" methods="methods" it="it" still="still" remains="remains" best="best" control="control" data="data" comparing="comparing" two="two" most="most" effective="effective" therapies="therapies" achalasia.="achalasia." _2="_2" p="p"/> It is also relevant to mention here that there is 7 to 33-fold risk of Squamous cell carcinoma (SCC) in patients with longstanding achalasia. Interestingly, risk of developing SCC in patients with achalasia treated by pneumatic dilatation is 4.5 times higher than those treated by surgical myotomy. [27-28]
Thus, in view of the reported low response and high complication rate with pneumatic dilatation, our opinion is that it is more appropriate to have a selective approach to different groups of patients with achalasia. Taking into account of relative risk: benefit ratio: Graded pneumatic dilatation for all will cause more harm than good.
We would hope that following comment would be taken into account during next revision of guidelines.
We believe that with the recent encouraging results with laparoscopic myotomy, it is time that the conventional hierarchical approach to achalasia therapy should change. Although pneumatic dilatation should still be considered in appropriate patients, but for patients who fail to respond to the smaller balloon (3.0 cm) and particularly young patients and patients with vigorous achalasia, who are less likely to respond to pneumatic dilatation, Laparoscopic cardiomyotomy should be considered as first line treatment. It not only is more effective and safe, but also has lower relapse rate when compared with pneumatic dialatation. An additional advantage of laparoscopic surgery is that an anti-reflux procedure can be added to prevent acid reflux. In view of least additional response and highest complication rate, the use of 4.0 cm balloon should be discouraged.
References
1. Riley S A and Attwood S E A: Guidelines on the use of oesophageal dilatation in clinical practice: :Gut 2004; 53 (Suppl 1): i1-i6).
2. Csendes A, Braghetto I, Henriquez A, Cortes C. Late results of a prospective randomised study comparing forceful dilatation and oesophagomyotomy in patients with achalasia. Gut. 1989;30:299-304.
3. Gelfand MD, Lozarek RA: An experience with a polyethylene balloon for pneumatic dilation for achalasia. Am J Gastroenterol 84:924-927, 1989.
4. Barkin JS, Guelrud M, Reiner DK, Goldberg RI, Phillips RS: Forceful balloon dilation: An outpatient procedure for achalasia. Gastrointest Endosc 36:1123-1126, 1990.
5. Makela J. Kiviniemi H, Laitinen S: Heller's cardiomyotomy compared with pneumatic dilation for the treatment of oesophageal achalasia. Eur J Surg 157:411 414, 1991
6. Kadakia SC, Wong RKH: Graded pneumatic dilation using Rigiflex achalasia dilators in patients with primary esophageal achalasia. Am J Gastroenteol 88:34-38, 1993.
7. Kim CH, Cameron AJ, Hsu JJ, Talley NJ, Trastek VF, Pairolero PC, O'Connor MK, Colwell LJ, Zinsmeister AR: Achalasia: Prospective evaluation of relationship between lower esophageal sphincter pressure, esophageal diameter and symptoms in response to pneumatic dilation. Mayo Clin Proc 68:1067-1073, 1993.
8. Lee JD, Cecil BD. Brown PE, Wright RA: The Cohen test does not predict outcome in achalasia after pneumatic dilation. Gastrointest Endosc 39:157-160, 1993.
9. Abid S, Champion G, Richter JE, McElvein R, Slaughter RL, Koehler RE: Treatment of achalasia: The best of both worlds. Am J Gastroenterol 89:979-985, 1994.
10. Wehrmann T, Jacobi V, Jung M, Lembeke B, Caspary WF: Pneumatic dilation in achalasia with a low-compliance balloon: Results of a 5-year prospective evaluation. Gastrointest Endosc 42:31-36, 1995.
11. Bhatnagar MS, Nanivadekar SA, Sawant P, Rathi PM: Achalasia cardia dilatation using polyethylene balloon (Rigiflex) dilations. Indian J Gastroenterol 15:49-51, 1996.
12. Agha FP, Lee HH: The esophagus after endoscopic pneumatic balloon dilatation for achalasia. AJR 146:25-29, 1986.
13. Eckardt VF, Kanzler G, Westermeier T, Complications and their impact after pneumatic dilation for achalasia: prospective long-term follow-up study. Gastrointest Endosc. 1997 May;45(5):349-53.
14. Eckardt VF, Aignherr C, Bernhard G. Predictors of outcome in patients ith achalasia treated by pneumatic dilation. Gastroenterology. 1992;103: 1732-1738.
15. Sanderson DR, Ellis FH Jr, Schlegel JF, Olsen AM: Syndrome of vigorous achalasia: clinical and physiological observations. Dis Chest 1967: 52: 508-517.
16. Gockel I, Junginger T, Bernhard G, Eckardt VF: Heller’s myotomy for failed pneumatic dilation in Achalasia How effective is it?: Annals of Surgery; Vol 239, Number 3, March 2004
17. Morino M, Rebecchi F, Festa V, Garrone: Preoperative pneumatic dilatation represents a risk factor for laparoscopic Heller myotomy. Surgical Endoscopy 2000 Sep; 14(9):870-1
18. Rosati R, Fumagalli U, Bonavina L, Segalin A, Montorsi M, Bona S, Peracchia A: Laparoscopic approach to esophageal achalasia. Am J Surg 169:424-427, 1995.
19. Ancona E, Anselmino M, Saninotto G, Costantini M, Rossi M, Bonavina L, Boccu C, Buin F, Peracchia A: Esophageal achalasia: Laparoscopic versus conventional open Heller-Dor operation. Am J Surg 170:265-270, 1995.
20. Esposito PS, Sosa JL, Sleeman D, Santelices AA: Laparoscopic management of achalasia. Am Surg 63:221-223, 1997.
21. Morino M, Rebecchi F, Festa V, Garone C: Laparoscopic Heller cardiomyotomy with intraoperative manometry in the management of oesophageal achalasia. Int Surg 80:332-335, 1995.
22. Anselmino M, Perdikis G, Hinder RA, Polishuk PV, Wilson P, Terry JD, Lanspa SJ: Heller myotomy is superior to dilatation for the treatment of early achalasia. Arch Surg 132:233-240, 1997
23. Delgado F, Bolufer JM, Martinez-Abad M, Martin J, Blanes F, Castro C, Moreno-Osset E, Mora F, Benages A: Laparoscopic treatment of esophageal achalasia. Surg Lap Endosc 2:83-90, 1996
24. Slim K, Pezet D, Chipponi J, Boulant J, Mathieu S: Laparoscopic myotomy for primary esophageal achalasia; a prospective evaluation. Hepato -Gastroenterology 44:11-15, 1997.
25. Hunter JG, Trus TL, Branum GD, Waring JP: Laparoscopic Heller myotomy and fundoplication for achalasia. Ann Surg 225:655-665, 1997
26. Raiser F, Perdikis G, Hinder RA, Swanstrom LL, Fillipi CJ, McBride PJ, Kaztada N, Neary PJ: Heller myotomy via minimal access surgery: An evaluation of anti-reflux procedures. Arch Surg 131:593-598, 1996.
27. Ribeiro U Jr, Posner MC, Safatale-Ribeiro AV & Reynolds JC. Risk factor for squamous cell carcinoma of the oesophagus. British journal of surgery 1996;83: 1174-1185.
28. Brossard E, Ollyo JB, Fontolliet CH et al. Achalasia and squamous cell carcinoma of the esophagus: is endposcopic surveillance justified? Gastroenterology 1992; 102 (supplement): A44
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Conflict of Interest:
None declared.
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