Gut, 1986, 27, 986-989

Techniques

Balloon dilatation in achalasia: a newdilatorJ COX, G K BUCKTON, AND J R BENNETT

From Hull Royal Infirmary, Hull

SUMMARY A newly available balloon dilator for the treatment of achalasia and its advantagesover existing instruments are discussed. Our experience with its use in seven patients is described.

Achalasia is treated by either forceful 'bag' dilata-tion or surgical cardiomyotomy. The only prospec-tive randomised comparison of these treatments'was a small series. Other comparisons have beenretrospective, and although some suggest thatsurgery has a better outcome,2-4 there is evidencethat pneumatic dilatation in experienced hands givesgood results5-7 and its notable advantages - speedand the avoidance of surgery - have led to itsincreasing popularity.

CURRENT DILATORSPneumatic dilators may be cumbersome to use andnone is perfect. The introduction of the dilator maypose special problems. The Hurst-Tucker (Brown-McHardy) has a mercury weighted tip which maynot pass through a tortuous oesophagus. The steeltip of the Rider-Moeller dilator may traumatise theoesophagus. The best reported results7 are with theSippy dilator but this is elaborate to prepare andinsert and requires serial dilatations using a series ofballoon sizes.

Dilators mounted on endoscopes are easy toinsert8 but the operator may still require fluoroscopyto check that the waist of the balloon is correctlysited. With dumb-bell shaped or waisted balloons itis difficult to know whether the cardia is beingdilated by the narrow waist or wider ends. Balloonswhich are not radio-opaque cannot be accuratelysited by fluoroscopy. The use of excessive pressurewhen using a latex balloon may rupture the innerbag, and by direct transmission of full pressurethrough the net to the unrestricted outer bag causeAddress for correspondence: Dr J R Bennett, Hull Royal Infirmary. AnlabyRoad, Hull HU3 2JZ.

Received for publication 13 December 1985

excessive oesophageal dilatation. Lastly, somemodels are difficult to obtain in Britain.We now describe our initial experience with a new

dilator.

THE INSTRUMENTThe Rigiflex Achalasia Dilator (Figs 1 and 2) issimilar in design to the Grunzig angioplasty catheter.The balloon is made of a modified polyethylene(Polytuff 150TM) and is mounted on a flexiblepolyethylene catheter. The balloon is inelastic sothat when inflated it maintains its size and shapedespite high inflation pressures. Increasing thepressure when the balloon is fully inflated makes itharder but not larger, and therefore a net is notnecessary to control its diameter. Should the balloonrupture, the design of Polytuff 150TM ensures that itdoes so through a safe longitudinal tear rather than adamaging transverse 'blow-out'. The burst pressureis about 140 kPa, (20 psi, 1050 mmHg). The 10 cmlong balloon inflates to a maximum diameter of30 mm, 90 Fr. The uninflated diameter of 4*7 mm,14 Fr compares well with the tips of the Mosher(8 mm, 24 Fr), the Hurst-Tucker (12 mm, 36 Fr),and the Rider-Moeller (12.5 mm, 38 Fr) and thediameters of the undilated Hurst-Tucker and Rider-Moeller (18 mm, 54 Fr). The catheter on which theballoon is mounted has a soft, tapered, radio-opaque tip made of PercuflexTM which is said toallow easy placement, but for added safety we havechosen to pass it over a Teflon coated guide wire.Radio-opaque tantalum markers proximal and distalto the balloon help in positioning the uninflatedballoon at fluoroscopy. The balloon can be inflatedwith air or contrast medium - we chose Urografin150 to provide good visibility. The air should be

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3alloon dilatation in achalasia: a new dilator

Fig. 1 The Rigiflex achalasia dilator inflated.

leached entirely from the balloon before use, as theincompressible contrast medium then providesaccurate and reproducible pressure measurements.The balloon is cleaned in Dettox and cold sterilisedin activated gluteraldehyde. If kept cool and dry, theballoon has an unlimited shelf life, unlike the latexballoons. It is manufactured by Rigiflex and distri-buted in England by KeyMed.

Method

PATIENTS

The patient is sedated with intravenous diazepamand an oesophageal washout carried out. The guidewire is inserted through a 3 mm (yellow Kifa)catheter or through the biopsy channel of a fibreopticendoscope and the balloon, connected to a pressuregauge and a syringe of contrast medium is passedover the guide wire with fluoroscopic control. Afterpartial inflation of the balloon by contrast mediumits position is adjusted until the constriction producedby the tonic gastro-oesophageal sphincter is at themidpoint of the balloon (Fig. 2). Further inflationthen produces a cylindrical profile of 30 mm, 90 Fr

diameter which is maintained for 60 seconds (re-quiring pressures ranging from 14 to 104 kPa(2-15 psi, 105-780 mmHg). The contrast is evacuatedby syringe and the balloon removed. The patient iscarefully observed overnight and allowed to drinkonly sterile water until the next morning.

Results

Forceful dilatation of the cardia using this balloonhas been accomplished in seven patients withachalasia. These were three men and four womenaged 28-59 years. Achalasia was diagnosed onhistory, cine-barium studies, intraluminal pH studies,manometry, and endoscopy. One patient had hadtwo oesophageal dilatations under general anaesthe-tic, 10 and eight years previously and had subse-quently passed a Hurst mercury dilator twice weekly.Another had a Hurst-Tucker dilatation four yearspreviously and a Rider-Moeller dilatation two yearspreviously, and a third had received an incompletedilatation with the Hurst-Tucker instrument 10years earlier. The other four patients had notreceived any treatment previously. The oesophagus

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Cox, Buckton, and Bennett

Fig. 2 Radiograph ofballoon dilator in use (a) (lefthand print) initial inflation showing 'waist' (b) (righthand print) fullyinflated to 30mm (90 Fr) diameter.

was markedly dilated in five patients, slightly dilatedin two patients and was tortuous in two patients. Allthe dilatations with the new balloon were uneventful,and there was no significant bleeding and noperforation. The patients left hospital the followingday -having eaten a good breakfast.At review four weeks later all patients reported

improvement in their symptoms without dysphagiaor heartburn and repeat erect radiology showedsatisfactory flow of barium through the cardia. Thefollow up has been short: 6-12 months, (mean 9-6months). Six of the seven patients remain well. Thepatient who had a Hurst-Tucker and a Rider-Moeller dilatation previously, developed a recur-

rence of his symptoms eight months later andmanometry revealed the lower oesophageal sphinc-ter pressure was still raised at 4*9 kPa (50 cmwater). He has now been referred for surgery.

Discussion

Pneumatic dilatation in good hands is a safe, simple,and effective treatment of achalasia. This balloonincreases the margin of safety and ease of dilatationby dispensing with some of the difficulties associatedwith traditional dilators. It is easy to set up and theguide wire, the flexible tip, and the small diameterof the undilated balloon make it easy to introduce.

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Balloon dilatation in achalasia: a new dilator 989

The contrast medium enables the operator to ensurethat the gastro-oesophageal sphincter is at themidpoint of the balloon and it is impossible to dilatethe sphincter beyond the maximum diameter of theballoon. Should the balloon rupture it does sothrough a safe longitudinal tear. The dilatation isaccomplished at a single sitting under diazepamsedation and general anaesthesia is unnecessary.Should the clinician wish to carry out the dilatationwith a series of dilators of increasing size, as inLouvain, similar balloons are available from 20 mmto 40 mm in diameter. The balloon is durable, doesnot perish, is easily sterilised and is readilyavailable. *

*The Rigiflex Achalasia Dilator. Price (3(0 mm balloon) £52210) includingVAT, from KeyMed, KeyMed House, Stock Road, Southend-on-Sea, EssexSS2 50H.

References1 Csendes A, Velasco N, Braghetto I, Henriquez A. Aprospective randomised study comparing forceful

dilatation and esophagomyotomy in patients withachalasia of the oesophagus. Gastroenterology 1981;80: 789-95.

2 Yon J, Christensen J. An uncontrolled comparison oftreatment for achalasia. Ann Surg 1975; 182: 672-6.

3 Okike N, Payne WS, Neufeld DM et al. Esophagotomyversus forceful dilatation for achalasia of the esopha-gus: results in 899 patients. Ann Thorac Surg 1979; 28:119-25.

4 Arvanitakis C. Achalasia of the esophagus. A reap-praisal of esophagomyotomy vs forceful pneumaticdilatation. Dig Dis 1975; 20: 841-6.

5 Bennett JR, Hendrix T R. Treatment of achalasia withpneumatic dilatation. In: Bayless TM, ed. Managementof esophageal disease modern treatment. Vol. 7, no. 6.New York: Harper and Row, 1970.

6 Fellows IW, Ogilvie AL, Atkinson M. Pneumaticdilatation in achalasia. Gut 1983; 24: 1020-3.

7 Vantrappen G, Hellemans J. Treatment of achalasiaand related motor disorders. Gastroenterology 1980;79: 144-54.

8 Witzel L. Treatment of achalasia with a pneumaticdilator attached to a gastroscope. Endoscopy 1981; 13:176-7.

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