What is the role of endoscopic therapy in the treatment of esophageal motility disorders?

Updated: Dec 29, 2017
  • Author: Eric A Gaumnitz, MD; Chief Editor: Praveen K Roy, MD, AGAF  more...
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Answer

Note the following:

  • Esophagogastroduodenoscopy (EGD) with pneumatic dilation is the standard endoscopic therapy for patients with achalasia and can be performed on an outpatient basis. Forceful distension of the LES to 3 cm with disruption of the circular muscle layer is needed for symptomatic relief. This distension and disruption cannot be achieved with the standard bougie (to 56F), which provides temporary benefit at best. Balloon dilators specifically designed to treat patients with achalasia achieve adequate diameter for lasting effectiveness. Achalasia dilators are long, noncompliant, cylindrical balloons that are positioned fluoroscopically or endoscopically across the LES and then inflated to a certain characteristic diameter: 30 mm, 35 mm, or 40 mm.

  • Technique details are variable among different practitioners.

  • Response rates vary from 50-93%. If no response is seen after 2 successive balloon dilations, it is unlikely to work.

  • Chest pain is felt during inflation, even under sedation. The major complication is perforation, which occurs at a rate as high as 8%. Patients should be observed for 3-6 hours before discharge, or, alternatively, a water-soluble contrast esophagram should be performed postdilation.

  • If no perforation is noted, the patient's diet can be advanced slowly over a few days. Acid suppression should be used after vigorous dilation with significant mucosal tears, as they are at risk for subsequent gastroesophageal reflux. If perforation complicates a pneumatic dilation, intervention varies according to severity. Small or intramural perforations can be managed with a conservative approach, including IV antibiotics, nothing by mouth, and observation; large perforations or progression of symptoms requires surgical repair, which carries favorable prognosis if performed early. At the time of surgery, a myotomy can be coupled with a repair operation.

  • After pneumatic dilation, the best outcome predictor is measuring the residual LES pressure. If the pressure is less than 10 mm Hg, the outcome usually is excellent. If the LES pressure is more than 20 mm Hg postdilation, the clinical outcome usually is poor. The dilation can be repeated, although poor initial results and rapid recurrence postdilation indicate a poor response to repeat dilation. The overall success rate with endoscopic dilation is reportedly 30-98% in different series. This therapy has no effect on future Heller myotomy if surgery ultimately is needed.

  • Pneumatic dilation showed positive results in a subset of patients with DES and LES dysfunction. This is based mainly on case reports and case series. Further verification of its role in this setting is needed.


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