Efficacy and strategy of pneumatic dilatation in achalasia

We read with interest the article by Eckardt et al regarding the long term results of pneumatic dilatation in achalasia (Gut 2004;53:629–33). Fifty four patients were followed up for a median of 14 years after a single pneumatic dilatation using the Browne-McHardy dilator. Five and 10 year remission rates were 40% and 36%, respectively, and repeated dilatations only mildly improved the clinical response. Most of the relapses occurred within one year of dilatation. Patients with post-dilatation lower oesophageal sphincter pressures of ,10 mm Hg had a significantly better outcome. The authors suggest that failure to respond to the first dilatation should lead to consideration of alternative therapy. We disagree with this conclusion and we would like to bring to your attention a recent prospective study on the long term effects of pneumatic dilatation in 11 patients with achalasia. A different approach was chosen—that is, treatment consisted of one or more pneumatic dilatations under conscious sedation in order to achieve stable clinical remission, defined as persisting one year after dilatation. To this end, closer follow up was performed in the first year after dilatation (scheduled assessments at three and 12 months). Thereafter, clinical and manometric assessments were performed yearly for six years. The clinical score was according to Eckardt et al. Five patients needed one (30 mm diameter Rigiflex dilator) and six needed two (30 and 35 mm diameter) dilatations. No complications occurred. All patients remained in clinical remission and their lower oesophageal sphincter pressure decreased to ,10 mm Hg and remained unchanged over time. There are similarities in the results of the two studies: (1) the outcome of our 11 patients was comparable with that of the eight patients of Eckardt et al with a lower oesophageal sphincter pressure of ,10 mm Hg who had a remission rate of 75% at six years; and (2) the observation that the six patients in our series who needed a second dilatation all relapsed within one year of the first dilatation agrees with the data by Eckardt et al, showing that most relapses occur in the first 12 months. However, our dilatations were more successful and, importantly, a second dilatation led to a sustained remission in all patients. We do not know the reasons for this difference but we believe it may be at least partly related to our use of the non-compliant Rigiflex dilator, which is currently considered the best choice, although there are no adequately powered comparisons with the Browne-McHardy dilator in the literature. Similarly to our result, a recent paper has shown very good efficacy of a second dilatation with the Rigiflex dilator in patients who had relapsed. Another possible reason is the use of conscious sedation during the procedure which allowed us to complete all dilatations; Eckardt et al, who used topical anaesthesia only, had to prematurely terminate 17% of the procedures. In conclusion, our published experience and our current clinical practice, involving treatment and follow up of 10–15 new achalasia patients each year, suggest that performance of one or two dilatations until stable clinical remission is a valuable strategy, and that pneumatic dilatation under conscious sedation with the Rigiflex dilator is an effective long term treatment in most patients with achalasia.