Balloon Dilatation

Dilatation for achalasia dates back to the seventeenth century when Thomas Willis described the successful use of periodic dilatation with whalebone of various sizes in a patient who in retrospect is thought to have had achalasia. Unfortunately serial dilatation for achalasia usually results in only a temporary and partial symptomatic response. A better response can be obtained with the use of large diameter balloon dilatators (>30 mm) placed across the EG junction and distended rapidly to obliterate the waist produced by the contracted LES.

A variety of balloon dilatators have been used for this purpose. Overtime, a consensus has been reached that a low compliance balloon that could be blown up with sufficient pressure to a predetermined maximum diameter, and could not be further distended once that diameter was reached, had the best effect-complication profile. Traditionally, at least in the United States, a 35 mm balloon was used in adults and a 30 mm balloon was used for the occasional child with achalasia. Earlier reinforced latex balloons were replaced by polyethylene balloons, largely due to concerns about disinfection of reusable balloon dilatators.

In the United States, commercially available polyethylene balloons with central channels for placement over a guide wire are available with outer diameters of 30,35 and 40 mm when fully distended; outside the United States, dilatators with diameters up to 50 mm are available. To minimize the risk of perforation, reported to range between 1 and 5% in recent series, there has been a tendency among endoscopists to start with the 30 mm balloon, reserving the 35 mm balloon for patients in whom the initial treatment fails. Some endoscopists will go on to dilatate with a 40 mm balloon if the 35 mm balloon does not achieve an adequate result. However others feel that the increased risk associated with these larger balloons favors moving toward other options, especially surgery.

The usual approach is to perform the dilatation as part of an upper endoscopy. The guide wire is positioned in the distal stomach. The scope is withdrawn and the dilatator is passed under fluoroscopic control until it straddles the EG junction. The balloon is then inflated by a rapid, step-wise sequence of increments until the waist is obliterated as observed under fluoroscopy. The balloon is then deflated, to a sigh of relief from the patient who generally experiences at least moderate pain during the period of full inflation. There is considerable variation in technique described in the medical literature concerning the duration of time for which balloon distension is maintained, ranging from 15 seconds to 2 minutes, and there are no objective studies to favor one recommendation over another.

Traditionally, the pressure required to achieve full distension is noted and is determined again at the end of the procedure; a drop in the pressure required that distends the EG junction a 3 pounds per square inch suggests good response. However, the real effect of treatment is based on the patient's symptomatic response, generally augmented by other postprocedural objective studies. It is common to see some streaks of blood on the deflated balloon after it is removed, suggesting that a mucosal tear has occurred. The clinical response presumably reflects traumatic injury to the sphincter muscle. The literature suggests that a good long term response can be obtained in 60 to 90% of patients, with clinically significant postdilatation reflux disease being uncommon. A major advantage over surgery is that the patients can generally return to their regular daily regimen the next day.

Constipation Prescription

Constipation Prescription

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