Pneumatic Dilation Safe, Efficacious Treatment for EGJ Obstruction

Pneumatic dilation is efficacious in treating nonachalasia obstructive disorders of the esophagogastric junction.

Although training in this treatment technique is not widely offered, pneumatic dilation provides safe and efficacious treatment for patients with nonachalasia disorders causing dysphagia, according to study findings published in Gastrointestinal Endoscopy.

Researchers conducted a 2-part study. The primary study involved a prospective, single-center analysis from January 2019 to April 2022 analyzing outcomes following pneumatic dilation for esophagogastric junction outflow obstruction (EGJOO) or postfundoplication esophagogastric junction obstruction (PF-EGJO). The second part of the study included a 2-question survey sent to advanced endoscopy fellowship sites across the United States to assess attitudes about pneumatic dilation training.

During the prospective study, the researchers analyzed the efficacy of pneumatic dilation for EGJOO using Eckardt scores (ES) of 2 or less to indicate successful treatment. Patients completed the Brief Esophageal Dysphagia Questionnaire (BEDQ) before and after pneumatic dilation.

Clinicians screened patients with nonobstructive dysphagia using barium esophagrams, high-resolution manometry (HRM), and functional lumen imaging probe (FLIP) topography. Patients had experienced dysphagia symptoms on average for a length of 17.2 months prior to screening.

Of the 61 included patients, 15 had achalasia, while 32 had EGJOO and 14 had PF-EGJO. Patients with achalasia demonstrated higher barium tablet retention (P =.043) and higher integrated relaxation pressure (IRP) (P =.043) than those with EGJOO and PF-EGJO.

Initial pneumatic dilation involved insertion of a 30 mm sized balloon down the esophagus and expansion of the balloon to dilate the esophagogastric junction (EGJ). Eleven patients (18%) needed pneumatic dilation using a 35 mm balloon, while 4 patients needed repeat pneumatic dilation with a 30 mm balloon during follow-up.

Average follow-up following the pneumatic dilation was around 37.5 weeks. Collectively following pneumatic dilation, these 61 patients demonstrated reduced average ES from 6.30 preintervention to 2.89 postintervention (P <.0001). Of the 61 patients, 33 (54.1%) achieved an ES of 2 or less following treatment. Average ES improved by 49.6%, while average subjective symptoms on the BEDQ improved by 55.3%.

When comparing patient subgroups, 9 of the 15 (60%) patients with achalasia, 19 of the 32 (59.4%) patients with EGJOO, and 5 of the 14 (35.7%) patients with PF-EGJO achieved ES of 2 or less following pneumatic dilation. All subgroups demonstrated significant decreases in postpneumatic dilation ES compared with baseline levels.

Only 1 patient with achalasia experienced perforation during the endoscopic procedure and 2 other patients had post-dilation bleeding that required hemoclip placement. Two other patients underwent overnight observation for nausea and pain immediately following pneumatic dilation, and 5 patients called within 48 hours of the procedure to report chest pain, but none experienced perforations.

Of the 78 advanced endoscopy program directions queried with the survey, 45 (57.7%) responded. Of the 45 respondents, 15 programs (33.3%) offered training in pneumatic dilation to advanced endoscopy fellows, while 30 (66.6%) did not.

Most programs (56.7%) explained that they did not offer training in pneumatic dilation because clinical demand for this intervention was low. Other reasons included the use of esophageal peroral endoscopic myotomy (POEM) instead of pneumatic dilation or the fact that only esophageal specialists performed pneumatic dilation at their institutions.

“PD [pneumatic dilation] is an effective and safe therapy for non-achalasia obstructive disorders of the EGJ, EGJOO and PF-EGJO,” the study authors wrote. “There would be benefit in more widespread training in PD, likely best delivered to advanced endoscopy fellowship trainees.”

Study limitations include risk of selection bias, reliance on patient adherence to postintervention protocols, lack of uniform time points for symptom assessment, and asking only surface-level questions in the clinician survey.

References:

Desai N, Kline M, Duncan D, et al. Expanding the role of pneumatic dilation for non-achalasia patients – A comparative study. Gastrointest Endosc. Published online October 10, 2022. doi:10.1016/j.gie.2022.09.032