Introduction Dilatation of the Oesophago-Gastric Junction (OGJ) provides effective symptom relief in 58–95% of patients with achalasia, similar to that achieved by Heller’s myotomy. Dilatation is also used in patients with persistent (>6 months) dysphagia after fundoplication surgery; there is insufficient safety and outcome data of this procedure. Our aim is to compare patient outcome of endoscopic dilatation for both these conditions.
Methods We present 18 month experience of referrals to the dysphagia service 2012–2013. All patients underwent a diagnostic gastroscopy with biopsies, excluding inflammation or neoplasia. Patients with achalasia or clinically relevant outlet obstruction post-fundoplication diagnosed by elevated integrated relaxation pressure (>25 mmHg) on high resolution manometry were selected. Dilatation was performed by 30–35mm Rigiflex II Balloon or Savary-Gillard Bougies (max 18mm) under fluoroscopic guidance. Primary outcome was symptom response at 3–6 months post-procedure by clinic or telephone follow-up. Overall symptom response was documented on an analogue scale from 0% >100% (inadequate <40%, satisfactory 40–60%, good 60–80% and excellent >80%).
Results 46/71 referrals had either achalasia or dysphagia post fundoplication. 30 (41%) had achalasia, 6 had prior Heller’s myotomy and 7 had prior Botulinum toxin. 16 (22%) patients had OGJ obstruction after fundoplication. 29/30 patients with achalasia underwent pneumatic dilatation, one bougie dilatation. Overall symptom response was inadequate in 5 (16% referred for surgery), satisfactory in 3 (11%) and good-excellent in 22 (73%).14/16 patients with post fundoplication dysphagia had pneumatic balloon dilatation, 2 had bougie dilatation. Overall symptom response was inadequate in 7 (44% referred for surgery), satisfactory in 4 (25%) and good-excellent in 5 (31%). Complications from the both groups include chest pain (n = 2), chest infection (n = 1), reflux symptoms (n = 4 in each group) and minor bleeding. All resolved with conservative treatment.
More than half of achalasia and post-fundoplication patients reported “at least satisfactory” outcome 3–6 months after dilatation (84% vs. 56%; p < 0.07 Fisher Exact Test). A good-excellent symptom response was reported more often by achalasia patients (p = 0.010).
Conclusion Endoscopic dilatation is safe and effective treatment for patients with dysphagia related to achalasia and also OGJ obstruction post-fundoplication. A good-excellent response was reported less frequently by the post-fundoplication patients; however more than half had at least “satisfactory” symptom relief and, therefore, a trial of endoscopic dilatation can be considered a viable alternative to re-operation.
Disclosure of Interest None Declared.
Statistics from Altmetric.com
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.