25

The Esophagus after Endoscopic Pneumatic Balloon Dilatation for Achalasia

Farooq Horchang

P. Agha1 H. Lee2

The changes seen on contrast esophagrams after endoscopic pneumatic balloon dilation for the treatment of achalasia are described and illustrated. Sixteen patients had esophagrams within 24 hr after dilation and follow-up esophagrams were obtained 6-24 months later. The radiographic features evaluated in the early postdilation period included detection of esophageal perforation, diameter of the esophagogastnc channel, proximal esophageal dilatation, mucosal integrity, and emptying dynamics of the esophagus. Fourteen patients (88%) had immediate symptomatic improvement of dysphagia. The mean increase in diameter of the esophagogastnc channel was 6.5 mm (range, 4.89 mm) relative to a pretreatment esophagram. Emptying dynamics of the esophagus improved significantly in 12 patients (75%). One patient developed esophageal perforation requiring surgery. On the follow-up esophagrams obtained 6-24 months later, the evaluation was for sustained dilatation of esophagogastnc channel, decrease in esophageal dilatation, and improved emptying dynamics of the esophagus. The effective esophagogastric channel diameter of 8-10 mm correlated well with improved clinical response in 88% of the patients.

Due to the widespread application of endoscopy, there has been renewed interest in the endoscopic treatment of achalasia by the pneumatic balloon dilation method. Recently 1 6 patients with achalasia have been treated with this dilation method using the Witzel pneumatic dilator at our institution [1 ].We discuss the radiographic evaluation of esophageal achalasia after pneumatic balloon dilation treatment and emphasize its value in assessment of this procedure and its complications.

Subjects Between

and

Methods 1985, we evaluated 1 6 patients with achalasia by serial

July 1983 and January

esophagrams

after pneumatic

balloon dilation treatment

at the University

of Michigan

Hospi-

tals. There were nine women and seven men aged 39-80 years (mean, 54). All pneumatic balloon dilations were performed in the endoscopy suite using the Witzel pneumatic dilator (Wimed Med Technik, West Berlin) attached to a forward-viewing gastroscope. The clinical symptoms consisted of dysphagia in all 16 patients, regurgitation in eight, weight loss in four, substernal discomfort and pain in five, and recurrent aspiration in two. Two patients had had

a Heller myotomy
Received

with recurrence

of dysphagia,

and one patient

had had dilation

several

September
1

May 6, 1985: accepted 9, 1985. of Radiology,

after revision

years

earlier

by the hydrostatic

method.

Esophageal

manometry

was performed

in all patients

before pneumatic

balloon dilation.

University of Michigan Hospitals, Box 013, 1405 E. Ann St., Ann Arbor, Ml 48109. Address reprint requests to F. P. Agha.
2

Department

of Internal

Medicine,

Division of

Gastroenterology, University of Michigan Hospitals, Ann Arbor, MI 48109. AJR 146:25-29, January 1986 0361 -803X/86/1461-0025 C)American Roentgen Ray Society

Typical achalasia changes, found in all patients, were aperistalsis to ineffecutal peristalsis in the body of the esophagus and a hypertensive lower esophageal sphincter. The lower esophageal sphincter pressure was 1 2-70 mm Hg (mean, 33 mm Hg). Relaxation of the lower esophageal sphincter was absent or incomplete in 1 3 patients and could not be measured in the other three. Endoscopic examination after adequate lavage of the esophagus excluded neoplastic processes of the esophagogastric region. Predilatation esophagrams were performed in all patients 1-7 days before dilation as baseline studies. The Witzel pneumatic dilator used in this study consists of a 20-cm-long polyvinyl tube with an internal diameter of 10 mm and an external diameter of 11 mm, which is surrounded

26

AGHA

AND

LEE

AJR:146, January 1986

by a 15-cm-long polyurethane balloon (fig. 1). The dilator is fitted over a regular small-caliber forward-viewing fiberoptic gastroscope (OES Gastroscope, model GIF-PlO) with an external diameter of 9 mm and secured by rubber bands at both ends of the dilator. The polyurethane balloon does not expand beyond 40 mm in diameter when inflated to a pressure of 300 mm Hg because of the high coefficient of elasticity of the material. Adequate dilation pressures can be attained in the narrow segment of the esophagus without undue expansion into the adjacent esophagus and stomach. All patients fasted overnight. Before the procedure, surface anaes-

thesia of the oropharynx and light sedation by diazepam intravenously were accomplished. Deep sedation was avoided lest it suppress the
pain sensation, which could warn of a complication. The dilator was introduced with the endoscope. The tip of the endoscope was an-

gulated 180#{176}the stomach for direct view of the cardia, and the in middle of the balloon was positioned across the narrowed segment
of the esophagus under visual control. With the dilator still in view the balloon was dilated to 300 mm Hg for 2 mm. The cuff was deflated if pain occured. The procedure was repeated until it was possible to maintain the 300 mm Hg pressure for 2 mm. After the dilation, the patients were observed for potential signs and symptoms of esoph-

ageal perforation and were hospitalized for 1 day. The contrast esophagrams were obtained within 24 hr after the
dilation treatment. Our technique of radiographic examination of the esophagus for potential perforation has been described previously

[2-4]. We examined patients in the semiupright position using Gastrografin (Mallinckrodt) initially. If no esophageal perforation was
identified, the examination was repeated with a low-density sulphate mixture(Sol-O-Pake, E-Z-EM). Films in left posterior right anterior oblique, and lateral projections were obtained. barium oblique, A 15-20

mm delayed film in the upright position to assess emptying

status of

C-

the esophagus 6-24 months

was also obtained. Elective follow-up after dilation treatment were obtained

esophagrams using single-

contrast technique and low-density barium sulphate mixture. The film sequence and projections were similar to the immediate postdilation examination.
The radiographic features evaluated included the diameter of the

esophagogastric channel and proximal esophageal lumen, the intactness of the mucosal contour, and emptying dynamics of the esophagus.

A Results
Fig. 1 .-Witzel pneumatic dilator: tip of gastroscope (A): pneumatic rethane balloon (B, retouched): sphygmomanometer (C). polyu-

Symptomatic the 1 6 patients

improvement immediately

in dysphagia occurred after pneumatic balloon

in 1 4 of dilation

Fig.

2.-Esophagram

with

Gastro-

grafin 2 hr after pneumatic dilation shows free esophageal perforation (arrow)immediately adjacent to hiatal hemia(HH) in this patient with achalasia.

Fig. 3.-A, Predilation esophagram. B, Post-pneumatic balloon dilation esophagram shows significant widening of esophagastric channel and decrease in esophageal dilatation.

AJR:146, January 1986

ESOPHAGUS

AFTER

PNEUMATIC

BALLOON

DILATATION

27

Fig. 4.-A, Esophagram after pneumatic balloon dilation shows irregular mucosal contour in distal esophagus with small ulceration and surrounding submucosal edema (arrow). Note long area of contraction. B and C, Dilatation of esophageal lumen and irregular contractions in body of esophagus.

treatment. One patient with a hiatal hemia and achalasia developed esophageal perforation and required surgical management (fig. 2). The caliber of the esophagogastric channel changed from a mean of 3.5 mm (range, 2.5-7 mm) before dilation to a mean of 1 0 mm (range, 7-i 2 mm) after dilation, increasing in 1 4 of the 1 6 patients (fig. 3). One patient showed minor change, and one patient showed no change in the esophagogastric channel diameter. The mucosal contour of the distal esophagus was smooth in 1 2 patients (75%) and irregular in four (25%). One patient with irregular mucosal contour and a mucosal tear (fig. 4) had guaiac-positive stools for 2 days after pneumatic balloon dilation. A localized uncomplicated intramural hematoma with associated mucosal tear of the esophagus occurred in one patient with advanced sigmoid-shaped achalasic esophagus (fig. 5). There was improvement in the dysphagia after dilation treatment and the clinical course was unremarkable. Emptying of the esophagus was rapid in the upright position (under 1 5 mm) in 14 patients and slow (over 15 mm) in two patients. In two patients, although the esophagogastric channel was widely patent and emptying of the contrast material was rapid, severe irregular nonpropulsive contractions and flow artifacts due to dysmotility were seen in the body of the esophagus with slow emptying [5] (fig. 6). In patients with marked tortuosity of the esophagus (sigmoid esophagus) some barium stagnated in the redundant tortuous segment, but could be evacuated eventually by change in the position of the patient. None of the patients demonstrated radiographic evidence of gastroesophageal reflux. The esophageal dilatation was evaluated by measuring the diameter of the body of the esophagus on pre- and postdila-

tion esophagrams. Reduction in the dilatation of the esophagus was seen in 13 of the 1 6 patients. In three patients with mild dilatation (<5 cm), the esophagus returned to normal caliber (<3 cm) on the esophagram obtained 6 months after dilation. In 1 0 patients with moderate dilatation (5-8 cm), a definite decrease in caliber was seen on esophagram obtained 6-24 months after dilation (<4 cm intemal diameter). Three patients with marked tortuosity and dilatation (>8 cm) did not show any change in the caliber on postdilation esophagrams. All patients on subsequent follow-up at 6-24 months underwent at least one esophageal function test including 24-hr pH monitoring for the detection of gastroesophageal reflux. Only two patients demonstrated nonsymptomatic gastroesophageal reflux. The clinical results of pneumatic balloon dilation were assessed for a period ranging from 4 to 24 months (mean, 12). Eleven patients have remained asymptomatic (excellent response), three had mild symptoms (good response), and two had severe symptoms of dysphagia (poor response). The overall satisfactory clinical response was observed in 14 patients (88%). This correlated well with radiographic improvement in esophagogastric channel diameter in 1 4, decrease in esophageal dilatation in 1 3, and improvement in esophageal emptying dynamics in 12 patients on follow-up esophagrams obtained 6-24 months after dilation treatment.

Discussion

The treatment of achalasia is directed at achieving a reduction in lower esophageal sphincter tone without disrupting the sphincter enough to result in gastroesophageal reflux. Two

28

AGHA

AND

LEE

AJR:146, January 1986

Fig. 5.-Esophagram

shows

localized

intramural

hematoma

with

mucosal

disruption (arrow) in advanced sigmoid-shaped achalasic esophagus. phagia improved after dilation and clinical course was unremarkable.

Dys-

Fig. 6.-A, Esophagram 1 year after dilation shows widely patent esophagogastric channel and moderate dilatation of esophagus. Note transient flow
artifact (arrows) resembling intraluminal diverticulum, dysmotility. B, Another view from same examination gone, but there are tertiary contractions distally.

indicating
shows that

esophageal
artifact is

modes of therapy, endoscopic mechanical dilation and esophagomyotomy, have gained widespread acceptance. Good to excellent results have been reported from both procedures by various authors [6-14]. Pneumatic dilation is a simple, nonoperative procedure, generally accomplished in one or two dilation sessions. If
necessary, further dilation can be performed or the patient

may be referred for esophagomyotomy. Although literature regarding esophageal dilation for achalasia indicates that it is an effective form of treatment, differences in techniques and criteria of follow-up make meaningful comparison difficult. Critical analysis of published literature concerning dilation by Wong and Johnson [1 1 ] showed a spectrum of 40%-95% of patients having no further dysphagia after the first dilation. Olsen et al. [1 5] reported that of patients whofailed to improve after the first dilation, 38% and 1 9% improved after second and third dilations, respectively. In their series, the efficacy of pneumatic dilation was not related to the size and tortuosity of the esophagus. Vantrappen and Hellemans [7] noted that young patients did not respond to pneumatic dilation as well as older patients and that patients with a long history of dysphagia before the dilation (mean duration, 8.2 years) did better than patients with a shorter history (mean duration, 2.5 years). Although significant decrease in lower esophageal sphincter pressure occurs immediately after dilation, it tends to increase slightly over a period of time. Neither relaxation of the lower esophageal sphincter with deglutition nor coordinated esophageal peristalsis returns after pneumatic balloon

dilation

[7].

Vantrappen and Hellemans [7] reported no evidence of reflux after pneumatic dilation evaluated by modified reflux test. Csendes and Strauszer [1 0] and Bennett and Hendrix [8] reported 7% and 17% incidence of reflux, respectively, but found no evidence of peptic strictures. Vantrappen and Hellemans [7], in a review of 1045 cases collected from 16 published papers on achalasia treated with pneumatic dilations, found a 1 0% incidence of reflux esophagitis, 3.4% incidence of peptic strictures, and 1 .6%-9.4% incidence of esophageal perforation. Ellis et al. [1 2] and Okike et al. [13], who published the largest surgical series with long-term follow-up, reported a 3% incidence of complications related to gastroesophageal reflux. Since disabling postoperative reflux esophagitis and even Barrett esophagus [1 6, 1 7] have been recognized after esophagomyotomy for achalasia, some investigators advocate combining an antireflux operation with esophagomyotomy to counteract this complication [1 8, 19]. The main emphasis of radiographic examination after dilation therapy had been to detect potential esophageal perforation [20, 21]. Ott et al. [22] recently compared radiographic appearance and clinical response and concluded that the appearance immediately after dilation was a poor predictor of patient response to treatment. Our results differ from theirs and show a radiographic appearance that correlated well with clinical response in 14 (88%) of 16 patients. The diameter of the esophagogastric channel in the 14 patients with improved symptomatology was over 10 mm in seven patients and 8-

AJR:146, January 1986

ESOPHAGUS

AFTER

PNEUMATIC

BALLOON

DILATATION

29

10 mm in the other seven patients. Two patients with significant residual dysphagia had esophagogastric channel diameters of 4 and 6 mm, respectively. Therefore, it seems that the minimal effective diameter of the esophagogastric channel for improvement in symptomatology was 8-10 mm in our patients.

with pneumatic dilatation. Digestion 1974;1 1 : 124-1 28 1 1 . Wong RKH, Johnson LF. Achalasia. In: Castell DO, Johnson LF, eds. Esophageal function in health and disease. New York: Elsevier Biomedical 1983:99-1 23 12. Ellis FH Jr, Gibbs SP, Crozier RE. Esophagomyotomy for achalasia of the eosphagus. Ann Surg 1980192:157-161

13. Okike

N, Payne WS, Neufeld

DR. Esophagomyotomy

DM, Bernatz
versus

PE, Pairolero
forceful

PC,

Sanderson ACKNOWLEDGMENT We thank Barbara Smith for secretarial assistance.

achalasia of the esophagus:

results in 899 patients.

dilation for Ann Thorac

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