This ASG video tip is sponsored by Braintree, maker of the newly approved Soufflave and Soutab. Hi, this is Bernice Pereira with the ASG tip for endoscopic pneumatic dilation for akalasia. These are my relevant disclosures. So today we're talking about the indications for pneumatic dilation for akalasia as well as the technique for pneumatic dilation and post-treatment considerations as well as patient selection. As a background, akalasia is a failure of the low esophageal sphincter to relax and it's also accompanied with some loss of distal esophageal peristalsis. There are three different types of akalasia and different types of therapy that tailor to each type of akalasia. As you'll see here, there is a treatment algorithm. Obviously for type 3, POEMS is preferred because you get a little bit of a longer myotomy so it helps treat the underlying esophageal spasms that go along with type 3 akalasia. With type 1 to 2 akalasia, you can do actually pneumatic dilations, lapel myotomies or POEMS. With akalasia, the goal is to really kind of tear or stretch those low esophageal muscle fibers. You get about usually an 85% response in patients with akalasia depending on the type they have and it typically lasts anywhere from one to two years. About a third of the patients though will relapse and have recurrent symptoms anywhere from four to six years post-therapy. The best predictors of akalasia, those patients who are female, older than the age of 40 years of age, type 2 akalasia and a narrow esophageal diameter seem to predict those who better respond to pneumatic dilation. In terms of patient prep, we typically have patients be on a clear liquid diet up to 24 hours prior to the procedure. The reason is, is with these patients they typically may have food or even liquid in the distal esophagus which poses an aspiration risk. This is typically done with anesthesia either MAC or general. Fluoroscopy is required for this dilation and it is recommended you either have thoracic surgical backup in case of perforation or at least the ability to place esophageal stents. For equipment you'll need a fluoroscopy table or fluoroscopy machine. I recommend CO2 insufflation if possible just because there's less discomfort in the case of perforation versus air insufflation. You will need a guide wire of some sort, either a 0.035 inch short guide wire or a savory guide wire and of course radio opaque markers. You're going to want to do your regular ophthalmic examination. You want to delineate the GE junction on fluoroscopy. So typically what we would do is bring the gastroscope up to the GE junction and use a radio opaque marker which could be something as simple as a paperclip and that will help delineate externally on fluoroscopy where your GE junction lies. I typically tape this on the patient's body. You're then going to want to advance your 0.035 inch or savory guide wire into the antrum and you're going to remove the scope leaving the guide wire in place. You are then going to advance your achalasia balloon. We typically lube the end the plastic tip as well as the whole balloon itself and when you look at the balloon there's going to be different radio opaque markers on the balloon itself. The center of the balloon is demarcated by two radio opaque markers and you want to try and get those to be adjacent to where the GE junction is. So you're going to line those two markers up with where your paperclip or radio opaque marker is. You're then going to inflate and you're going to hold pressure for about 60 seconds. After 60 seconds you could deflate the balloon and you're going to want to make sure the balloon is completely deflated before removing it from the patient. Sometimes you can use a syringe to suction out any remaining air within it. Afterwards you then want to go in with the gastroscope again and you want to evaluate for any severe mucosal injuries or perforations. Things to consider is there is a 2% perforation risk. There's also patients who will have issues with increased acid reflux because again you're decreasing that lower soft gel sphincter pressure and you've got to come up with a plan in terms of what to happen if the patient doesn't respond. So typically what I'll do is I will have start with the first balloon. I'll have the patient call our office a week or two afterwards to see whether their symptoms persist or not. If their symptoms persist we then bring them back in within at least two or three weeks after the last procedure to repeat the dilation with a bigger balloon and you can do that all the way up to the 40 millimeter balloon. If their symptoms resolve then we usually stop pneumatic dilation. In terms of perforation, you're going to want to need consultation with a thoracic surgeon because usually these patients have to go to the OR pretty quickly. If thoracic backup is not available the other thing you can do is place an esophageal stent. A lot of patients with achalasia tend to have wider or dilated esophagus so sometimes this can lead to stent migration. So if possible you can even suture the esophageal stent in place. So in conclusion the pneumatic dilations can work pretty well with type 1 or type 2 achalasia only. Type 3 you really should be setting patients for POEMS. You need fluoroscopy and thoracic backup all the ability to place an esophageal stent in case there is evidence of a perforation. And the other important thing is if they have no success after three balloon treatments you can actually repeat it again to see if this will benefit. Also repeated treatments don't affect your risks or success rates of undergoing a POEM or myotomy. So if they last for at least 6 to 12 months you can repeat this again if it occurs. There's no issue with referring them for a POEM or a myotomy. you

sponsored ASG video tip

endoscopic pneumatic dilation

akalasia treatment options

patient selection

esophageal stents