Pneumatic Dilation: Keep It in the Tool Box

Treatment of achalasia is primarily directed at relieving the functional esophagogastric outflow obstruction responsible for the patients’ symptoms.1 The disease is incurable, so treatment is in a word—palliative.2 A myotomy is performed at the esophagogastric junction (EGJ), in which, essentially a defect is created to treat a defect. Success is optimized when we achieve long term improvement of dysphagia and avoid the development of gastroesophageal reflux disease (GERD). Three options are available to meet this goal. Today endoscopic myotomy (POEM) has been the procedure of greatest enthusiasm, with the literature supporting strong “long-term” success in relief of primary symptoms, such that in many centers it has supplanted laparoscopic Heller myotomy as the go-to treatment regardless of age, gender, or subtype of achalasia. The issue of development of GERD post-POEM has been acknowledged. However, the need for long term medical therapy and the potential for development of severe GERD is minimized by enthusiasm for a procedure which is relatively easy to master by clinicians with advanced endoscopic skills and favored by patients because they believe they are not having an “operation.” On the other hand, endoscopic pneumatic dilation (PD) has been largely forgotten as a first line treatment. PD has 70% to 85% success in relief of dysphagia in appropriately selected patients, with little morbidity when carefully performed and arguably less long-term development of GERD. In this issue of Foregut, a gastroenterologist and surgeon discuss the pros and cons of PD.3,4 Dr. Shemmeri et al5 address the importance of outcomes beyond the Eckardt score in evaluating treatment and 2 gastroenterologists with extensive experience, Drs Clarke and Boeckxstaens,6 present their technique of PD in a “How I do it piece.” Dr. Clarke presents his preference for EsoFLIP and Dr Boeckxstaens describes a long-used technique, which while clearly successful, is not commonly performed in the US. I have performed more than 700 PDs since 1986, using a technique initially taught to me when I was a fellow, by Don Castell and Joel Richter, that I have modified with input from my current partner and co-author on this manuscript Felice Schnoll-Sussman. Success has been excellent with only 20% of my patients opting for additional treatment with Heller or POEM after 1 or 2 dilations, and only 1 perforation, requiring operative intervention. Together the number of patients opting for PD have decreased in the past 5 years principally due to enthusiasm for POEM. All procedures are performed in the endoscopy suite with fluoroscopy. Our technique is as follows: All patients are placed on a liquid diet for 72 hours and then NPO after midnight on the evening prior to the procedure. This aggressive preparation is necessary to increase the likelihood of ensuring the esophagus is without retained solid residue, which if present increases the procedure time. Though almost all our dilations are now performed with endotracheal intubation (general anesthesia), a “clean” esophagus minimizes the potential likelihood of aspiration and shortens procedure time. The esophagus is cleared of all remaining solid and liquid residue. The PD can be performed supine or with the patient in the left lateral position. After performing a full diagnostic endoscopy ruling out any additional pathology or contraindication to dilation, we perform a pre-dilation endoFLIP study if it has not been done prior. Subsequently a guide wire is passed into the antrum under direct visualization. The stomach is maximally deflated, and the endoscope withdrawn. The relationship of the endoscope to the diaphragm is noted on fluoroscopy and the squamocolumnar junction (SCJ) located as the distance from the incisors. An unfolded paper clip is taped to the patient’s chest, marking the location of the SCJ. A permanent ink mark is placed on the dilator indicating this distance to the SCJ plus 1 cm. These 2 interventions result in an easier (and we believe) more accurate placement of the balloon across the LES region. The Rigiflex balloon dilator is passed over the wire and positioned at the mark on the dilator. Under fluoroscopy, the dilator position in confirmed at the level of the visualized paper clip, then gently inflated looking for a centrally located “waist.” The dilator’s radio-opaque markers are then fluoroscopically positioned across the gastroesophageal junction. Extreme care is taken to perform the dilation with minimal to no movement of the dilator and the central waist. The balloon is subsequently inflated until the waist is obliterated (usually 10 PSI) and the pressure maintained at this level for 15 seconds. The balloon is then deflated and removed. A repeat endoscopy is performed to evaluate for signs of perforation following which 50 cc of contrast injected through the biopsy channel to document no evidence of leak. The contrast is suctioned, and the procedure terminated. With this approach a post op Gastrografin/barium swallow is not needed. The patient is observed for 1 to 2 hours to be certain that no delayed perforation has resulted. The patient is subsequently discharged on a liquid diet and advanced as tolerated the following day with 1143799 GUTXXX10.1177/26345161221143799ForegutKatz and Schnoll-Sussman article-commentary2022