Major Complications of Pneumatic Dilation and Heller Myotomy for Achalasia: Single-Center Experience and Systematic Review of the Literature

Abstract

Background & Aims Pneumatic dilation (PD) and laparoscopic Heller myotomy (LHM) can be definitive therapies for achalasia; recent data suggest comparable efficacy. However, risk must also be considered. We reviewed the major complication rate of PD and LHM in a high volume center and reviewed the corresponding literature. Methods We reviewed 12 years of our institution’s achalasia treatment experience. During this interval a consistent technique of PD was used utilizing Rigiflex dilators. Medical records were reviewed for post-procedure complications. We administered a telephone survey and examined medical records to assess efficacy of treatment. We also performed a systematic review of the literature for comparable clinical data and examined 80 reports encompassing 12,494 LHM and PD procedures. Results At our center, 463 achalasia patients underwent 567 PD or LHM procedures. 78% of the PDs used a 30 mm Rigiflex dilator. 157/184 (85%) patients underwent 1 or 2 PD without any subsequent treatment. There were seven clinically significant perforations; one from PD and 6 from LHM. There were no resultant deaths from these perforations; two deaths occurred within 30 days of LHM from unrelated causes. Complications and deaths post-PD were significantly fewer than those post-LHM (p=.02). Conclusions Esophageal perforation from PD at our high-volume center was less common than often reported and lower than that associated with LHM. We conclude that, in the hands of experienced operators using conservative technique, PD has fewer major complications and deaths than LHM.

Advances in the management of oesophageal motility disorders in the era of high-resolution manometry: a focus on achalasia syndromes

“…Considering that the cost of pneumatic dilation is substantially less than LHM and that the risk of oesophageal perforation between techniques is comparable (about 1% when performed by gastroenterologists with extensive experi ence with the procedures) 58 , these findings argue for pneumatic dilation as the preferred initial treatment for type II achalasia.…”

High Resolution Manometry - A Mandatory Examination in the Pre and Postoperative Assessment of Patients with Achalasia

“…In contrast, other authors reported no differences in complications rate or the degree of surgical difficulty, but similar outcomes after myotomy in patients with prior failed PD or Botulinum toxin injection (66,67). In fact, surgical complication rates are thought to be more dependent on surgeon experience and the incidence of previous esophageal surgery than on prior botulinum toxin injection or prior pneumatic dilatation (68).…”

“…In addition, several authors have also reported similar patient outcomes after myotomy even after prior failed pneumatic dilation or Botulinum toxin injections Surgery after botulinum toxin injections has been suggested to be more difficult because of a marked fibrotic reaction that can develop at the gastroesophageal junction that obliterates surgical planes (62)(63)(64)(65). Nevertheless, some authors have reported similar outcomes in this situation to those of a primary procedure (66)(67)(68).…”

“…Several studies have reported higher intraoperative esophageal perforation rates during esophagomyotomy after prior endoscopic intervention (65)(66)(67).…”

“…Most experts recommend avoidance of PD after failed myotomy due to increased perforation rate. Repeated myotomy may be superior to endoscopic treatment if performed by experienced surgeons but esophagectomy should also be considered in appropriately selected patients after myotomy failure (66,67).…”