Predictive factors of poor response to the first pneumatic dilation session in achalasia

Aims Primary achalasia is a motility disorder of the esophagus, and its management in our country relies on pneumatic dilation (PD) or Heller myotomy. The aim of our study was to describe the clinical and paraclinical aspects of achalasia and identify factors predisposing to a poor response after the first PD session.

Methods This was a retrospective study spanned 13 years, from 2010 to 2023, including all patients diagnosed with achalasia and treated with PD. Dilation was performed using a 30 mm balloon during the first session. Treatment effectiveness was assessed by the Eckart Score, defining a poor response to the first session as a score>3. Patients with secondary achalasia were not included.

Results We collected data from 25 patients, with a mean age of 47±21.3 years. The female-to-male ratio was 1.08. Dysphagia was present in all cases, and food impaction occurred in 2 patients. The mean diagnostic delay was 23.4±11.3 months. Gastroscopy revealed a notch (N=14, 56%), rosette appearance of the cardia (N=3, 12%), and esophageal stasis (N=5, 20%). It was normal in 12% of cases. Manometry showed achalasia type 1, 2, and 3 in 68%, 20%, and 12% of patients, respectively. The mean lower esophageal sphincter (LES) pressure was 33.9±5.9 mmHg and the mean integrated relaxation pressure (IRP) was 27.2±6 mmHg. Seven patients had undergone Heller myotomy previously, with a mean surgery-to-PD interval of 8.2±4.3 years. After the first PD session, a poor response was observed in 48% of patients (N=12). The mean symptoms recurrence interval was 8.5±5.6 months. One session was sufficient for 13 patients, while 12 patients required a second session. In total, 37 PD sessions were performed with an average of 1.5 dilations per patient.

In univariate analysis, age<50 years, duration of symptoms over 24 months, initial LES pressure<35 mmHg, and a history of Heller myotomy were significantly associated with a poor response to the first PD session (p=0.043, p=0.027, p=0.02, and p=0.002, respectively).

In multivariate analysis, a symptom duration of over 24 months, initial LES pressure<35 mmHg, and a history of Heller myotomy were independent predictive factors of a poor response to the first PD session (p=0.047, p=0.009, p=0.001, respectively). The type of achalasia was not identified as a risk factor for a poor response (p=0.12).

Conclusions Pneumatic dilation is an effective, simple, and safe treatment for achalasia. Its indication should consider the presence or absence of predictive factors for a poor response.

Conflicts of interest

Authors do not have any conflict of interest to disclose.

Publikationsverlauf

Artikel online veröffentlicht:
15. April 2024