Achalasia is the most frequent primary motor disorder of the esophagus. It is still a rare disease that may occur in both sexes at any age with a prevalence of less than 1/10,000 and with a new cases’ incidence of 0.6–1/100,000 citizens/year [
Aim of the study is to evaluate the efficacy of the endoscopic (pneumatic dilation) versus surgical (Heller myotomy) treatment in patients affected by esophageal achalasia through the analysis of parameters deriving from the barium X-ray examination, performed before and after surgical or endoscopic treatment.
The study was approved by the Institutional Ethical Committee and conducted according with the ethical principles of the Declaration of Helsinki. Written informed consent was obtained in all patients.
From January 2009 to December 2014 all the patients referring to our radiology departments for radiological evaluation of achalasia, based on previous esophageal manometry, and planned for surgical or endoscopic treatment were investigated about their clinical history and eligible patients were considered for enrolment in this study. Patients with concomitant systemic neurological and/or rheumatologic disease (e.g., Parkinson disease, scleroderma) were excluded.
Each patient underwent barium X-rays evaluation before and after endoscopic or surgical treatment.
The examination was performed with Siemens AXIOM Luminos DRF equipment. Pronto Bario HD (Bracco, Milan, Italy) has been used as contrast medium; each patient received 98,45 g of powder for oral suspension diluted in 90 mL of water and administered as a single bolus prior to the execution of swellings at 0, 1, 2, and 5 minutes (Figure
X-rays show the height of barium column 0, 1, 2, and 5 minutes after barium oral administration.
To obtain the logistic model we calculated, for each variable, the mean change was observed after the intervention of the total sample. For each patient were introduced five dichotomous variables (one for each initial variable), assuming value 1 if the reduction found in a particular patient results to be greater than or equal to the average reduction and 0 otherwise. Finally, for each variable, we evaluated the possible relationship with the treatment and we calculated odds ratio.
Fifty-two patients were initially considered for the study, 12 patients were excluded due to the presence of concomitant systemic neurological disease, 17 did not give their consent, and 4 patients were lost to the evaluation after treatment. Nineteen patients were finally enrolled: 10 males and 9 females, age range was 27–76 y.o. for men and 41–75 for women. Eleven patients underwent surgical Heller myotomy treatment and Dor fundoplication and 8 had endoscopic pneumatic dilation treatment performed, due to the high operative risk and refusal of surgical treatment.
The mean variation of esophageal diameter before and after treatment is −2.1 mm for surgery and 1.74 mm for pneumatic dilation (OR 0.167, CI 95% 0.02–1.419, and
Table shows the variation of esophageal diameter and the height of barium column before and after surgical or endoscopic treatment at 0, 1, 2, and 5 minutes after barium administration.
Surgery | Endoscopy | |||||
---|---|---|---|---|---|---|
Myotomy | Pneumatic dilation | |||||
11 patients | 8 patients | |||||
Before | After | Δ | Before | After | Δ | |
Esophagus diameter (cm) | 5.20 | 3.10 | –2.10 | 4.80 | 6.54 | +1.74 |
Column baryta height | ||||||
0′ | 23.95 | 11.9 | –12.05 | 26.50 | 14.66 | –11.89 |
1′ | 21.30 | 7.31 | –14.00 | 25.85 | 12.61 | –13.24 |
2′ | 19.64 | 4.84 | –14.79 | 24.42 | 11.56 | –12.86 |
5′ | 16.69 | 3.75 | –12.94 | 23.06 | 8.61 | –14.45 |
Table shows OR, CI 95%, and
Odd ratio | Confidence interval (95%) |
|
||
---|---|---|---|---|
|
||||
Esophagus | 0.167 | 0.02 | 1.419 | 0.1011 |
Column baryta height | ||||
0′ | 0.625 | 0.093 | 4.222 | 0.6297 |
1′ | 0.625 | 0.093 | 4.222 | 0.6297 |
2′ | 0.429 | 0.062 | 2.972 | 0.3911 |
5′ | 0.9 | 0.133 | 6.080 | 0.9139 |
The standard in diagnosing and classifying achalasia is represented by the esophageal manometry documenting the impaired relaxation of the LES and the absence or the alteration of peristaltic waves in the distal esophagus [
Upper endoscopy is usually performed to rule out cancer or a peptic stricture and, particularly in patients older than 50 years with dysphagia and weight loss, attention should be paid on the possible presence of a tumor underlying achalasia (pseudoachalasia) [
The barium X-ray examination allows to confirm the diagnosis and to assess the degree of esophageal dilation, the axis of the esophagus, and the presence of an associated epiphrenic diverticulum [
In the early stages, the only sign may be the endoluminal stagnation of cm, with a progressive increase in the height of the barium column until its pressure causes the forced opening and subsequent rapid emptying of the LES.
The cause for an initial reduction of inhibitory neurons in achalasia is unknown; then etiological therapies still do not exist, but only symptomatic treatments [
Another type of treatment consists of endoscopic therapy that includes the botulinum toxin injection (BTI) and the pneumatic dilation (PD) [
BTI is based on a botulinum toxin endoscopic injection in the cardia leading to an inhibition of release of acetylcholine from the myenteric plexus resulting in reduction of smooth muscle contraction of the cardiac region. The effects of a single treatment can persist for six months or more (up to 2-3 years).
The PD consists in the endoscopic introduction, through the mouth, of special dilators, on a metal guide introduced until after the cardia, with the patient maintained under sedation. The dilators consist in cylindrical balloon length of about 12 cm and with variable diameter (2.5 to 4 cm), progressively positioned in the cardiac region. Once placed, it is swollen for 1 minute at 15 PSI pressure. Usually one or two dilations are sufficient to obtain a good result. In 3% of cases, however, there is a cumulative risk of incurring postoperative complications such as tearing and/or perforation of the esophagus. With this method 60–70% of good results may be obtained [
In our study, the barium X-ray examination of the esophagus (Figure
The authors declare that there is no conflict of interests regarding the publication of this paper.