By Will Boggs, MD
NEW YORK (Reuters Health) May 30 - Pneumatic dilatation is an effective initial therapy for idiopathic achalasia, but relapse is common, researchers from Australia report.
"Substantial recurrence rate (not just from pneumatic dilatation but also from myotomy) in a chronic relapsing condition means that patients and their doctors need to be alerted to this likelihood and that patients must come back for regular review and/or present with recurrent symptoms," Dr. Ian J. Cook from St. George Hospital in Sydney and the University of New South Wales told Reuters Health in an email.
Previous research has shown that 60% to 95% of patients can expect short-term (12-24 months) success after pneumatic dilatation, and 75% to 90% can expect short-term success after surgical myotomy.
Long-term outcome data are sparse, but relapse rates seem to range from 25% to 30% through five years after either treatment.
Dr. Cook and colleagues investigated the cumulative relapse rate and long-term outcome after pneumatic dilatation as first-line therapy for achalasia in a retrospective study of 301 patients.
They reported their findings May 10 online in Alimentary Pharmacology & Therapeutics.
In the first 12 months, 29 of 278 assessable patients received alternative treatments, including 22 who underwent elective myotomy or Botox, seven who received one additional pneumatic dilatation, and 15 who received two additional pneumatic dilatations.
Over the average follow-up of 9.3 years, 55% of patients received one dilatation, 33% required two, 11% required three, 3% required four, and 0.7% required 5 dilatations (a mean of 1.7 dilatations per patient, including the initial one).
Based on interval therapy and symptom scores, the researchers estimate the relapse rates to be 18% by two years, 41% by five years, and 60% by 10 years.
Eighty-two percent of patients were in remission a year after the initial dilatation. At the end of follow-up, regardless of nature, timing or frequency of any interval therapy, 71% of the 111 patients who responded to a survey were in remission.
More than 90% of the survey respondents reported that they could eat most or all of the types of food they wanted to, though about a third said they sometimes needed to drink water to facilitate swallowing food boluses. Four in 10 said they were bothered by how long it took to eat a meal, but only a quarter felt that their lifestyle was limited by achalasia.
Predictors of clinical response included the presence of blood on the balloon during the index pneumatic dilatation (greater success when blood was present) and age under 40 years (lower success). None of the variables examined predicted long-term success in patients who had clinical success at 12 months.
There were only 10 procedure-related perforations in a total of 499 pneumatic dilatations performed (2%). Chest pain was reported immediately after 9% of dilatations, but it was a poor predictor of perforation.
"Compliance with the stepwise (30-35-40mm) balloon dilatation until an endpoint is achieved is essential," Dr. Cook said. "Patients and their doctors should be persistent with the initial dilatation sequence until either they have a good response, fail to respond to the largest balloon, or sustain a perforation. I say this because some patients disappear after a 30- or 35-mm balloon thinking that it's failed when they haven't had an adequate 'dose.'"
When should follow-up occur? Dr. Cook said, "Assuming no apparent symptom recurrence - six months, 12 months in the first instance. Thereafter, every two yrs. Although the precise interval is unknown, the high recurrence rate and the fact that 30% of those who relapse don't re-present justify the above strategy."
Aliment Pharmacol Ther 2013.
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