Pneumatic dilation in the management of achalasia

Over the course of 20th and 21st centuries, the diagnosis and treatment of achalasia have evolved significantly. While a variety of techniques are employed, the decision of which intervention to use for any given patient remains highly individualized. While surgical and endoscopic myotomy are important cornerstones in the management of achalasia, pneumatic dilation (PD) remains an effective way to address failed lower esophageal sphincter (LES) relaxation and it deserves to be discussed as an option especially for those patients hesitant regarding myotomy. Factors favoring successful PD include older age (greater than 45 years), female gender, narrow esophagus, and type 2 pattern of achalasia. It generally is not routinely considered in pediatric patients. Its role is not only in the primary management of achalasia but also as rescue therapy when other interventions have failed. Traditionally, a concern for the use of PD has centered on the risk of perforation and of subsequent emergent surgery and myotomy. In a subset of centers with sufficient expertise and volume, it is a relatively well tolerated and effective procedure. Should perforation occur, it can often be managed conservatively without surgical intervention. At our institution, systematic use of graded guide-wire directed dilation and fluoroscopy enhances the safety profile of the procedure, as well as obtaining a post-procedure esophagram. In the coming years we look forward to rigorous comparisons of the two principal endoscopic approaches [PD vs. per-oral endoscopic myotomy (POEM)] to determine efficacy and durability. While it is known that routine, non-pneumatic balloon and bougie dilation is insufficient to manage achalasia, counseling on the use of novel variations of dilation such as dilation guided by planimetry in the form of EsoFLIP technology is limited by the relative lack of comparative data. In short, while POEM has been an exciting newer technique increasingly employed over the past decade and Heller myotomy remains a mainstay of surgical management, PD continues to have an important role in the present-day management of achalasia.