Prospective clinical and manometric study comparing pneumatic dilatation and sublingual nifedipine in the treatment of oesophageal achalasia.

Abstract

The traditional approach to the treatment of patients with achalasia is based on stretching or cutting the muscle fibres at the oesophagogastric junction by pneumatic dilatation'6 or surgical myotomy.7 12 More recently, nitro derivatives and calcium antagonists, particularly nifedipine, have been proved to be effective in reducing lower oesophageal pressure and improving oesophageal emptying in patients with achalasia.' '7 The results obtained both with surgical or mechanical procedures, such as myotomy and dilatation, and with drug treatment are well known."'0 No prospective study, however, has been reported comparing drug treatment with nifedipine and pneumatic dilatation.The aim of our study was to perform such a prospective trial to determine whether there is a significant difference in the results of both treatments. MethodsThirty consecutive patients with clinical, radiological, endoscopic, and manometric evidence of oesophageal achalasia, stage I or II using the classification of Adams et al,2' were randomly assigned to two groups. Patients with sigmoid dilatation of the oesophagus or those who had had treatment for achalasia were excluded. Group A had 16 patients assigned to undergo pneumatic dilatation (seven men, nine women; mean age 49.5 years, range 18-82 years). The mean duration of symptoms was 4-1 years (range 6 months-8 years) and the mean oesophageal diameter 3-8 cm (range 2-6 cm). Group B had 14 patients who were treated with sublingual nifedipine (six men, eight women; mean age 51-3 years, range 17-83 years). The mean duration of symptoms was 3.5 years (range 6 months-7 years) and the mean oesophageal diameter 3.9 cm (range 2.5-6 cm). CLINICAL STUDYThe patients were examined and details of the severity of dysphagia, regurgitation, retrosternal pain, and weight loss were taken before the study and every three months for a mean follow up of 21.4

Meta-Analysis of Randomized and Controlled Treatment Trials for Achalasia

“…Coccia et al [14] compared the clinical and manometric effects of sublingual nifedipine with pneumatic dilation in a randomized controlled trial, where excellent or good clinical results were observed in 75% of dilated patients and in 77% of patients treated with nifedipine. One patient could not tolerate nifedipine because of headache.…”

“…First, patients of any age and both sexes underwent clinical, manometric, radiographic, and endoscopic evaluation to confirm primary achalasia and were randomly assigned to two or more treatment groups. Second, severity of symptoms was evaluated by a modified symptom score [14] consisting of the sum of the scores for dysphagia, regurgitation, and chest pain. Third, esophageal function was reevaluated at 1 year after therapy by esophageal manometry.…”

Surgical Treatment of Achalasia: Current Status and Controversies

“…The long-acting nitrates, such as isosorbide dinitrate (Isordil, Wyeth-Ayerst, Philadelphia, Pa., USA), are effective in decreasing LES pressure by 30-65% when administered sublingually or orally, symptoms improve in 53-87% of patients with achalasia [11]. A study that compared sublingual nifedipine to sublingual isosorbide dinitrate noted that both agents decreased LES pressure but the effect was slightly, but not significantly, better with nitrates (65%) compared with nifedipine (49%) [12].…”

Medical Therapy of Achalasia: A Benefit Reserved for Few

“…Among the various substances used in clinical practice to relax the LES [10], we used nifedipine and isosorbide dinitrate (ISD), the effectiveness of which in decreasing LES pressure and improving symptoms of achalasia has been demonstrated by various manometric and clinical studies [12, 13, 14, 15]. Although ISD is more effective and faster in relaxing LES than nifedipine, we used the latter as the drug of choice because it has the advantage of reducing the amplitude of esophageal pressure waves less, as observed in a previous manometric study [16].…”