Pneumatic Balloon Dilatation

Description

Pneumatic balloon dilatation is a non-surgical procedure used to treat achalasia, where the lower esophageal sphincter fails to relax and esophageal peristalsis is disrupted. During the procedure, endoscopy is utilised to pass a balloon through the sphincter, which is then inflated and results in the destruction of the associated muscle fibres. This allows food to be able to pass into the stomach. It is the first line non-surgical treatment for achalasia patients, and is commonly used in patients who are either waiting for, or not fit for a laparoscopic heller myotomy surgical procedure.

The procedure is performed under sedation, and recovery times are quick. The patient can be discharged after the 5-6 hour waiting period where the patient is monitored to check for any complications. Patients can begin by eating a soft diet followed by incorporation of solid foods as they see fit.

The main complication of the procedure is perforation of the oesophagus. For this reason, patients are closely monitored after the procedure has been completed to check for any signs and symptoms of perforation, as well as having their vital signs evaluated.

What is it?

Pneumatic balloon dilatation is a non-surgical treatment used in the treatment of achalasia patients. It involves the insertion of a cylinder-shaped balloon into the distal end of the oesophagus, which disrupts and forcefully breaks the muscles fibres of the lower esophageal sphincter.

Pneumatic balloon dilatation is conducted in conjunction with endoscopy, which allows access and visualisation of the lower portion of the oesophagus for the surgeon (1).

Why is it done?

Pneumatic balloon dilatation is the first-line non-surgical therapy used in the treatment of achalasia, which is a functional disorder where the lower esophageal sphincter fails to relax and there is a lack of coordinated peristalsis (contractions) of the oesophagus. This causes food and liquid build up in the oesophagus and prevents food from passing into the stomach for digestion. The cause of achalasia is not fully known but its signs and symptoms are well recognised. It is one of the main causes of dysphagia (difficulty swallowing) and typically results in:

1. Chest pain - This is often due to reflux and regurgitation of the food.
2. Weight loss - Not all the food you eat may get digested as it is prevented from passing into the stomach.
3. Dysphagia - You may feel as if food is getting stuck on its way down to the stomach (2).

There is no definitive cure for achalasia, and hence treatments are focused on alleviating the symptoms and providing the best possible care. The gold standard treatment for achalasia is a surgical procedure known as a laparoscopic heller myotomy. This involves the dissection of the longitudinal muscle fibres that form the lower esophageal sphincter, thus allowing food to pass through into the stomach. This procedure is often performed with a Nissen Fundoplication to prevent reflux. It follows that laparoscopic heller myotomy provides the most long-term solution for achalasia. The other treatments include:

1. Pneumatic Balloon Dilatation
2. Botox Injection
3. Medical Treatments using calcium channel blockers and nitrates

These other treatments and non-surgical procedures do not provide as long a relief from the symptoms of achalasia than a laparoscopic heller myotomy does, and may require repeat procedures at intervals of between 1 - 5 years as there may be a recurrence of symptoms. However, there may be certain cases where a non surgical approach such as a pneumatic balloon dilatation is performed instead of the gold standard surgical approach. These include:

1. If the patient is scheduled for a laparoscopic heller myotomy and symptomatic relief is needed in the meantime.
2. If the patient is not a candidate for surgical procedures due to the presence of other co-morbidities and diseases.
3. If the patient does not want an invasive surgical procedure, and would rather a non-surgical approach (3).

Pneumatic balloon dilatation can also be used as the next step in the management of achalasia following unsuccessful treatment with either a botox injection or a surgical myotomy. The treatment can also be used in combination with botox injections, both of which are non-surgical interventions. This combination therapy has been shown to result in a higher success rate in some studies of around 57% compared with 36% for pneumatic balloon dilatation alone (4).

Anaesthesia

You will need to be awake during the procedure and hence anaesthetic is not routinely given. However, many patients may find the procedure uncomfortable, and hence there is the option to be given a sedative. This will not put you to sleep, but will help you relax and make the procedure more tolerable.

Will I need to do any preparation?

You will be required to fast for at least 12 hours before the procedure is scheduled to take place. If the achalasia is severe, you may be prescribed a liquid diet for the 24-48 hours preceding the procedure.

Before the procedure, you will have an appointment with the doctor who will go through on the day procedures and talk to you about the different options for treatment, alongside consulting you on whether you would like to be given a sedative during the procedure to make it more comfortable. If you are on any anticoagulation medication such as warfarin or clopidogrel, your doctor will need to know this so they can take appropriate measures and if necessary ask you to stop taking these medications a few days before your procedure.

The Procedure

The whole procedure usually takes between 15 - 30 minutes. There are a number of different balloon dilators currently in use, including:

1. Mosher bag
2. Sippy dilators
3. Brown-McHardy dilator
4. Rider-Moeller dilator
5. Rigiflex balloon

The choice of which exact dilator is used depends upon the preference of the surgeon. Before beginning the procedure, the surgeon will inflate the balloon and inspect for any leaks which may make it unsuitable to use for the pneumatic balloon dilatation procedure (9).

The steps of the procedure are as follows:

1. On arrival at the hospital, you will be given a surgical gown to wear and taken to the endoscopy unit. You will be asked to lie on your left hand side for the procedure.
2. Once the balloon has been thoroughly inspected for any leaks, it is placed to the side and a regular endoscopic examination begins. This is a procedure which involves inserting a thin tube with a camera on the end through the mouth and then down the oesophagus into the stomach. This allows the surgeon to visualise the gastro-intestinal tract and to check for any malignancy (cancer) which may be present at the cardia of the oesophagus (region that borders the oesophagus entry into the stomach). This malignancy is known as pseudoachalasia and can mimic the signs and symptoms of primary achalasia. This is rare and if the doctors find this, they may take a biopsy for review and stop the procedure at this point.
3. A guidewire is placed through a special channel in the endoscope into the stomach. A suction tube may also be placed into your mouth to prevent a build up of saliva and to ensure you can continue breathing well.
4. Once the oesophagus and stomach have been observed for any other pathology that may explain the symptoms, the endoscope is removed. The surgeon takes care to ensure that the position of the guidewire in the stomach is not disrupted.
5. The surgeon begins the pneumatic balloon dilatation procedure by preparing the equipment. This involves lubricating the balloon and the tip of the catheter to ensure that they can be easily passed through the relevant structures.
6. The balloon and catheter are passed over the in place guidewire until the lower esophageal sphincter is reached. Some contrast agent can be injected into the balloon to allow for radiographic visualisation and monitoring to ensure that the balloon is in the correct place. It is imperative to ensure that the lower esophageal sphincter occurs at the middle of the balloon. This ensures that the procedure is safe and minimises the risks of any complications.
7. Once the balloon is in place, it can be slowly inflated. The radiographic visualisation can prompt the surgeon to make small adjustments to the position of the balloon if necessary. At this stage, before the balloon is inflated, you may be administered a dose of sedatives (usually opiates) to help you relax and prevent any muscle spasms during inflation of the balloon.
8. Once the balloon has been fully inflated, the muscles of the lower esophageal sphincter are destroyed. The balloon is then deflated, and re-inflated to ensure that the initial inflation was successful.
9. The balloon is then deflated a second time and then removed alongside the guidewire and the procedure is finished (10).

Post Procedure

Once the procedure has finished, you will be taken to the recovery area where you will be closely monitored for 5-6 hours. This allows detection of any complications such as perforation, and allows time for the major effects of the sedative to wear off. You will then be discharged home if no complications arise.

Due to the effects of the sedative, you will have to be picked up from the hospital by a family member/friend as you will not be able to drive safely. They should also stay with you for 24 hours until the sedative wears off and you can begin your normal day to day activities.

Caring for yourself at home

Before being discharged, you will be asked to keep an eye out for any long-lasting and severe chest pain as this is a sign of esophageal perforation and may require surgical correction. This can occur even after discharge. Due to the effects of the sedative, you will be asked to avoid any driving or heavy lifting for 24 hours to allow the effects of the sedative to wear off.

You can begin to eat a normal diet as you see fit however it is recommended that you start with a soft diet and gradually eat more solid foods, and you will be given a follow up appointment with either your doctor or the surgeon to further discuss your recovery and talk about the next steps.

Where can I find more information

NHS information on Achalasia - https://www.nhs.uk/conditions/achalasia/