Professional Documents
Culture Documents
7, 1998
Copyright © 1998 by Am. Coll. of Gastroenterology ISSN 0002-9270/98/$19.00
Published by Elsevier Science Inc. PII S0002-9270(98)00211-1
Objective: Duration of Inflation in pneumatic balloon ever, has not been established, with intervals between 15 s
dilatation as treatment of achalasia has been variable and 6 min being used (1). The common practice of keeping
ranging from 15 s to 6 min. A 60 s duration appears to the balloon inflated for 60 seconds has been primarily on
be most often used. We compared the efficacy of dilation empirical grounds. We, therefore, compared the efficacy
of achalasia with either 6- or 60-s inflation duration and safety of 6-s dilation, sufficient time to obliterate the
using a Rigiflex dilator of 3.0 cm diameter. Methods: balloon waist, with 60-s duration, as conventionally done.
Eighty-one consecutive patients were prospectively stud- Inasmuch as dilation is potentially hazardous because of the
ied in a randomized fashion, 41 in the 60-s group (A) and risk of perforation and is painful despite the use of medi-
40 patients in the 6-s group (B). Mean age of group A cations for amnesia, a secondary goal was to reduce the
was 43 6 16.2 yr and of group B was 40 6 16.4 yr. complication rate. Many types of balloon dilators have been
Symptoms of dysphagia, chest pain, heartburn, regurgi- used, including the Brown McHardy, Hurst Tucker, Mosher,
tation, and night cough were evaluated at basal (before and Rider Moller instrument. Recently, Rigiflex (Microva-
dilation), 1- and 6-month intervals after dilation in both sive, Watertown, MA) has become more popular because of
groups. Barium swallow was done to assess esophageal ease of use and safety features (2, 3). We therefore used this
emptying 1 wk before dilation and 5 min postdilation in dilator with a 30-mm diameter in all of our patients.
both groups. Results: Significant and sustained improve-
ment was seen for all symptoms in both groups. In MATERIALS AND METHODS
addition, the degree of improvement in symptom scores
between the two groups was similar. Barium esopha- A total of 89 patients were initially screened for this study
gram in both groups at basal and immediately postdila- from 1989 through 1994. Eight patients with extremely
tion showed significant improvement in barium empty- dilated esophagi were excluded from the study because,
ing but there was no significant difference between the presumably, effective emptying of barium pre- and postdi-
two groups, indicative of equal efficacy in both disten- lation would have been markedly impaired and thus would
tion times. Two patients needed repeat dilatation in not be comparable with that of other patients studied. The
group A and one in group B, with one drop out from remaining 81 consecutive patients, were randomly assigned,
group A, who was lost to follow-up, and was excluded 41 (31 men, 10 women) in group A and 40 (19 men, 21
from the analysis. No perforation occurred. Conclusion: women) in group B. The diagnosis of idiopathic achalasia
Short duration of pneumatic balloon dilatation (6-s) is as was based on clinical symptoms (predominantly dysphagia),
effective as longer duration (60-s) in treatment of barium swallow, and manometric criteria. In addition, en-
achalasia. (Am J Gastroenterol 1998;93:1064 –1067. © doscopy was performed in all patients to rule out secondary
1998 by Am. Coll. of Gastroenterology) achalasia.
Esophageal manometry was evaluated by one of two
physicians (A.A.K., S.W.H.S.) using an 8-lumen polyvinyl
catheter, a low compliance pneumohydraulic capillary per-
INTRODUCTION fusion system (Arndorfer medical specialities, Greendale,
Pneumatic dilatation in patients with idiopathic esopha- WI) and a recording physiograph (Hewlett Packard, Chi-
geal achalasia is generally considered to be the procedure of cago, IL). Lower esophageal sphincter (LES) pressure was
choice. Effective interruption of circular muscle fibers of the measured at the maximal end expiratory phase as the mean
lower esophageal sphincter (LES) is the theoretical basis for value obtained from the slow pull-through of four radially
pneumatic dilation. Appropriate duration of dilation, how- placed orifices, oriented at 90° angles 1 cm apart. Four
additional orifices, located 5 cm apart and oriented at 90°
Received Jan. 21, 1997; accepted May 7, 1997. angles, were used for measuring pressures in the esophageal
1064
AJG – July 1998 PNEUMATIC BALLOON DILATION 1065
body by placing the distal orifice 3 cm above the LES. Ten TABLE 1
wet swallows (5 ml of water) were performed to assess Demographic Features
esophageal peristalsis.
Group A Group B
Diagnostic criteria required for achalasia were aperistalsis
Male 32 30
of the esophageal body, incomplete relaxation of the LES
Female 9 10
(residual pressure . 5 mm Hg), and typical barium esopha- Age 43 6 16.2 40 6 16.4
gram. Duration of symptoms (in months) 43 6 32 37 6 21
A diary for symptoms was maintained by all patients, and Height of barium, pre dilatation (cm) 13.0 6 4.3 16.2 6 5.4
was evaluated by a physician who, at 1 and 6 months Height of barium, post dilatation (cm) 7.0 6 2.0 7.2 6 4.1
Width of barium, pre dilatation (cm) 6.3 6 3.3 4.8 1 1.8
follow-up, was unaware of the specific details of the pneu-
Width of barium, post dilatation (cm) 65.1 6 3.9 3.2 6 1.6
matic dilatation. Symptom severity of dysphagia, chest pain, Symptom score, baseline 4.4 6 0.8 4.09 6 0.79
regurgitation, night cough, and heartburn was scored by the Symptom score, 1 month 0.87 6 0.20 0.747 6 0.17
physician on a 0 –3 scale (0 5 none, 1 5 mild, 2 5 Symptom score, 6 months 0.29 6 0.07 0.43 6 0.08
moderate, 3 5 severe). Total score was added as the com- All data except gender (male, female) given as mean 6 SD.
posite score (maximum # 15 for each patient).
Barium swallow was performed by a consultant radiolo-
gist who was blinded to the type of dilation procedure Wilcoxon matched pairs signed rank test was used for
performed. Typical features of achalasia i.e., dilatation of calculation of Z-scores for basal versus 1-month, basal ver-
the esophageal body, absence of definitive peristalsis, and sus 6-month, and 1-month versus 6-month scores both for
smooth narrowing at the distal esophagus was noted in all the entire sample and within group analysis. Wilcoxon
patients. Emptying of the esophagus was tested by having matched pairs signed rank test was also used for analysis of
the patient swallow 100 ml of barium in the standing posi- barium height and width before dilation and 5 min after
tion. The estimated percentage emptying of the esophagus dilation. Kruskal-Wallis one way ANOVA was used for
was evaluated for 5 min. Less than 50% emptying was comparison between two groups to evaluate basal, 1-month,
considered impaired and .50% was considered effective and 6-month composite scores. For all analyses, a p value
emptying. Barium swallow was repeated 5 min after dilation #0.05 was considered significant.
primarily to detect perforations or tears, but also to assess
emptying. Width and length of barium column in pre- and RESULTS
postdilatation barium swallow was also measured to objec-
tively assess the effective emptying of the esophagus. Demographic features are presented in Table 1. Mean
Dilatation of the LES was accomplished by passing the scores for dysphagia, chest pain, regurgitation, night cough,
wire-guided balloon (Microvasive) across the gastroesoph- and heartburn in both groups A and B at basal, 1-month, and
ageal junction under fluoroscopic control and placing the 6-month intervals are shown in Table 2. Mean total scores
balloon center at the level of diaphragm. The balloon was in the 81 patients showed overall improvement from a basal
slowly inflated so that the indentation or “waist” created by score of 4.36, to 1-month score of 0.81 and 6-months score
the LES was identified and positioned in the center of of 0.35 (p , 0.001), confirming the overall efficacy of
balloon. The balloon was then rapidly inflated to 30 mm pneumatic balloon dilation in relieving symptoms of acha-
diameter to a pressure of 10 psi, and inflation was main- lasia (Fig. 1). Comparison of mean dysphagia scores in
tained at this pressure for 60 s in group A and for 6 s in groups A and B showed similar improvement between basal
group B. A pressure limit of 10 psi was selected because an and both 1-month and 6-month scores (Fig. 2).
earlier study (4) had suggested inflation pressure $11 psi Pairwise comparison of mean scores between groups A
was an independent risk factor for possible complications of and B at baseline, 1 month, and 6 months did not reveal a
pneumatic dilatation. In each case complete obliteration of significant difference (p 5 0.21, 0.40, and 0.25 respectively)
the waist was achieved with diameter reaching 30 mm. showing that the samples were comparable at basal level and
Out-patient follow-up was carried out at 1- and 6-month efficacy of dilatation was also comparable in both groups.
intervals after dilation for evaluation of symptom scores as The results of barium swallow also showed improvement
recorded in the diary by the patients. This study was ap- in both groups when compared at basal and 5 min postdi-
proved by the institutional review board of the Shaikh Zayed lation periods (Table 1). Height of barium column decreased
Hospital, Lahore, and informed consent was obtained from from a mean value of 13.0 6 4.3 cm before dilation to 7.0 6
all the patients studied. 2.0 cm postdilation (p , 0.001) in group A, whereas in
group B it decreased from 16.2 6 5.4 cm predilation to
Statistical analysis 7.2 6 4.1 cm postdilation (p , 0.001). Width of barium did
Friedman’s two way ANOVA was used to compare the not show a significant reduction in pre- and postdilation
overall improvement in symptom scores at basal, 1-month, values in group A (p . 0.05) and group B (p . 0.05).
and 6-month intervals for the entire sample of 81 patients Thirty-five patients (85.4%) in group A showed effective
and for within-group evaluation of groups A and B. The emptying after dilatation versus 35 patients (88.4%) in
1066 KHAN et al. AJG – Vol. 93, No. 7, 1998
TABLE 2
Mean Scores for Clinical Parameters Recorded
Group A Group B
Variables
Basal 1 Month 6 Months Basal 1 Month 6 Months
Dysphagia 2.45 0.47 0.21 2.34 0.40 0.24
Pain 0.34 0.03 0.03 0.24 0.02 0.02
Regurgitation 1.03 0.00 0.00 0.85 0.00 0.05
Night cough 0.13 0.00 0.00 0.20 0.00 0.00
Burning 0.50 0.37 0.05 0.46 0.32 0.12
Total score 4.45 0.87 0.29 4.09 0.74 0.43
For all variables scoring was done as follows: 0 5 none; 1 5 mild; 2 5 moderate; and 3 5 severe.
DISCUSSION