PREDICTORS OF FAILURE OF PNEUMATIC DILATION IN ACHALASIA

Aims:

Although endoscopic peroral endoscopic myotomy (POEM) is an innovative and promising technique, its place remains to be defined and the first line treatment is still based on pneumatic dilation (PD) in several countries. The purpose of this study is to assess the results of endoscopic dilation and to determine the predictive factors for failure of this treatment.

Methods:

Patients with achalasia undergoing DP between 2000 and 2017 in our department were included and evaluated retrospectively. The dilatations were performed with balloons of 30 to 35 mm. The efficacy of the treatment was judged on the clinical improvement of the symptoms (Eckart score). Failure was defined by a number of dilations > 2 or surgical treatment.

Results:

Sixty-eight patients were included. The average age was 47 years old with female to male ratio of 1.3. Manometry confirmed the diagnosis by showing esophageal aperistalsis present in all patients. The average pressure of the lower esophageal sphincter (LES) was 32 mmHg (5 – 60 mmHg). A total of 93 PDs were performed with an average of 1.3 dilations per patient. Clinical recurrence requiring a second dilatation session was found in 22% of patients. Failure of endoscopic treatment was noted in 6% of cases. In a univariate analytical study, age under 30 years (p = 0.002), number of dilations (p < 0.0001), initial pressure of LES < 35 mmHg (p < 0.0001) and vigorous achalasia (p = 0.002) were significantly associated with dilatation failure. In multivariate analysis, only young age (p = 0.004), low pressure of LES (p = 0.003) and vigorous achalasia (p < 0.001) were independent predictors of PD failure. In our study sex was not significantly associated with treatment failure.

Conclusions:

Pneumatic dilation is an effective, simple and well tolerated technique. However, in case of clinical and manometric predictive factors of PD failure, another endoscopic treatment such as POEM should be proposed as first line.