Efficacy and safety of pneumatic dilation in achalasia: A systematic review and meta‐analysis

Abstract

Background and AimsOne of the most used treatments for achalasia is pneumatic dilation of the lower esophageal sphincter to improve esophageal emptying. Multiple treatment protocols have been described with a varying balloon size, number of dilations, inflation pressure, and duration. We aimed to identify the most efficient and safe treatment protocol.MethodsWe performed a systematic review and meta‐analysis of studies on pneumatic dilation in patients with primary achalasia. Clinical remission was defined as an Eckardt score ≤3 or adequate symptom reduction measured with a similar validated questionnaire. We compared the clinical remission rates and occurrence of complications between different treatment protocols.ResultsWe included 10 studies with 643 patients. After 6 months, dilation with a 30‐mm or 35‐mm balloon gave comparable mean success rates (81% and 79%, respectively), whereas a series of dilations up to 40 mm had a higher success rate of 90%. Elective additional dilation in patients with insufficient symptom resolution was somewhat more effective than performing a predefined series of dilations: 86% versus 75% after 12 months. Perforations occurred most often during initial dilations, and significantly more often using a 35‐mm balloon than a 30‐mm balloon (3.2 vs 1.0%); P = 0.027. A subsequent 35‐mm dilation was safer than an initial dilation with 35 mm (0.97% vs 9.3% perforations), P = 0.0017.ConclusionsThe most efficient and safe method of dilating achalasia patients is a graded approach starting with a 30‐mm dilation, followed by an elective 35‐mm dilation and 40 mm when there is insufficient symptom relief.

Mortality rate after pneumatic dilatation for achalasia

“…In this study, the mortality rate 30 days after PD was surprisingly high with a staggering 1.9% 1. This is contradictory to previous recent literature, in which the mortality rate after pneumatic dilatation was generally 0% 2–4. In the current study, subjects were excluded if they had a prior diagnosis of achalasia in the preceding 5 years since the introduction of ICD-10 coding in 2001.…”

“…It appears that the HES database lacks the cause of death, and it seems unlikely that perforations are entirely responsible for the high mortality. That would only be possible when the mortality rate of perforation would be close to 100%, while it is nowadays closer to 0% 2 4. With this discordance between expected mortality rate from procedure-related complications and actual mortality rate one wonders whether the reported mortality rate is actually procedure-related or not and whether the patients that died in the 30 days after pneumatic dilation would have died anyway regardless of whether they underwent a dilation.…”

2019 Seoul Consensus on Esophageal Achalasia Guidelines

“…Depending on the general condition of the patient, graded PBD (with 30-mm, 35-mm, or 40-mm balloons) is considered one of the primary options for achalasia. 73 According to a retrospective analysis of 209 patients, management of achalasia with initial dilation can provide good or excellent longterm results and high patient satisfaction rates. 74 A prospective randomized European study of PBD and LHM reported that the therapeutic success rate was not significantly different between the 1-and 2-year follow-ups (P = 0.46).…”

Treatment experience with a novel 30-mm hydrostatic balloon in esophageal dysmotility: a multicenter retrospective analysis

“…In comparison, a meta-analysis of pneumatic dilation in the setting of achalasia using a 30-mm balloon found an 81% remission rate at 6 months and 77% at 12 months. 8 Looking at individual conditions, achalasia numerically had a greater percentage of clinical success; however, this was not significant when compared with the EGJOO group (P Z .18). This is possibly because of the small sample size, rendering the statistical test underpowered to detect a significant difference.…”