PNEUMATIC BALLOON DILATION FOR RECURRENCE OF SYMPTOMS AFTER HELLER MYOTOMY
Nadav Sahar*, Michael V. Chiorean, Michael Gluck, Shayan S. Irani, Fredrik Klevebro, Donald Low, Andrew S. Ross, Richard A. Kozarek
Virginia Mason Medical Center, Seattle, WA
Background:
Symptomatic relapse is not uncommon in patients who undergo Heller myotomy for achalasia, appearing in 10-20% of cases. However, there is no consensus on the optimal approach to treat these patients.
Aims:
To assess the efficacy and safety of pneumatic dilation as a therapeutic option for symptomatic post-Heller myotomy patients.
Methods:
We reviewed a prospectively maintained database of achalasia patients referred for endoscopic procedures at our tertiary referral center. Patients who were surgically treated with Heller myotomy and fundoplication between 2004 and 2018 were identified, and those with recurrence of symptoms who underwent pneumatic dilation were selected. Symptomatic relapse was assessed based on typical complaints, to include dysphagia, regurgitation, retrosternal chest pain, and weight loss. All patients were evaluated with a high-resolution manometry study and/or a contrast esophagogram before undergoing dilation. Pneumatic dilation was performed with a 30 mm balloon, with subsequent dilations performed in graded fashion with 35-40 mm balloons if deemed necessary, based on patients' report of symptomatic improvement or relapse. Patient demographics, procedural details, and adverse events were recorded.
Results:
Fifteen patients (8M, 7F), with a median age of 67 years (range 27-77) and median BMI of 27 Kg/m2 (range 22-39) were identified. Patients were symptomatic for a median of 2 years (range 0.5-12) and pneumatic dilation was performed after a median of 5 years from time of Heller myotomy (range 1-45). Seven patients were treated with botulinum toxin injections before attempts at dilation. Mean lower esophageal sphincter resting pressure before dilation was 24 mmHg (range 7-41) and mean integrated relaxation pressure was 18 mmHg (range 8-25).
Patients were followed for a median of 21 months (range 2-35). Initial pneumatic dilation with a 30 mm balloon led to symptomatic relief lasting a median of 12 months (range 1-36). Five patients underwent 1 or 2 subsequent repeat dilations with 35 and 40 mm balloons, remaining symptom-free a median 6 months after each procedure. One patient elected to undergo placement of an esophageal metal stent for recurrence of symptoms a month from his initial dilation.
In total, 22 pneumatic balloon dilations were performed. One perforation occurred in the distal esophagus after dilation with a 30 mm balloon and was diagnosed 24 hours after the procedure. The patient was treated with placement of a fully covered esophageal metal stent and a thoracotomy with drainage.
Conclusion:
Pneumatic dilation is a useful and efficacious treatment modality for symptomatic relapse after Heller myotomy. Improvement in symptoms can last up to a year with the option of additional dilations with balloons of larger diameter. Clinicians should be aware of the risk of perforation in this patient population.
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