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de Moura et al. PBD and POEM in dilated megaesophagus

PNEUMATIC BALLOON DILTATION treatment of achalasia.

PBD uses a pneumatic balloon for low compliance, Initial dilatation is performed using a 30-mm balloon
which is a balloon with minimal deformity and uniform and an objective evaluation of the symptoms after
distension throughout its extension. This design 4-6 weeks. For patients who continue to remain
promotes the rupture of the muscular fibers of the LES, symptomatic, dilatation with next-sized balloon should
diminishing its hypertonia. Consequently, this facilitates be made. This serial pneumatic dilation approach has
passage of the alimentary bolus from the esophagus to been shown to have excellent success rates. Although
the gastric chamber [16] . varying between studies, with relief of symptoms in up
to 93% of patients in 6 months to 44% in 6 years [17,18] .
The first balloon built was by Hurst in 1898. Different Additionally, the risk of perforation may be lower with
manufactured models of balloons were developed the serial pneumatic dilation approach.
by Witzel in 1970, the first balloon was used with the
gastroscope. Physical characteristics of the balloons, Some risk factors for failure PBD are: younger age, male
such as the high complacency, defined as high non- sex, wider esophagus, poor emptying on post-treatment
[12]
uniform balloon deformity, could increase the risk timed barium esophagogram and Eckardt et al. scale <
of perforation in the healthy area of the esophagus 3 before treatment.
because the balloon reached its greatest distension
diameter in the area of the minimal resistance. Balloon dilatation of the cardia is not indicated for
advanced megaesophagus, since the reduction of
With the advent of pneumatic balloons with low symptoms is less compared to the non-advanced
complacency, balloons with minimal deformity and form and its durability is less than 6 months. Although,
a paper published from Pakistan
showed that 9
[19]
uniform distension throughout its length, the risk of patients with dilated megaesophagus (Grade > II) with
complications, particularly perforation, was minimized. transverse diameter > 7 cm, were treated using a 35 mm
Currently, the low-compliant balloon is used, which has balloon without complications and with symptomatic
different sizes (30, 35 and 40 mm) and are much larger improvement at 12-month follow-up.
than the standard through-the-scope balloons. As a
result, the pressure generated by PBD is significantly PERORAL ENDOSCOPIC CARDIOMYOTOMY
more effective in fracturing the muscularis propria of
the LES. POEM introduced by Ortega et al. [20] in 1980 and later
standardized by Inoue et al. [21] in 2010, is a new type of
The dilatation can be done under direct endoscopic view, endoscopic treatment, which has been widespread in
in which the balloon is placed at the height of the LES the past seven years.
and the insufflation was performed under endoscopic
vision until the maximum balloon measurement or until This procedure performed with the upper digestive
the patient begins to feel pain. It can also be done endoscopy is an esophageal and gastric myotomy with
under radiological vision, in which the balloon is placed submucosal layer dissection under general anesthesia.
at the height of the LES. Under continuous radioscopy,
the balloon is inflated to its maximum extent, visualizing A cushion is formed in the submucosal layer of the
the formation of a radiological waist in the balloon. esophagus, followed by a 2-cm incision in the mucosa
Some groups interrupt the inflation after radiological to access the submucosal layer through the anterior
waist loss, while other groups inflate the balloon to its or posterior wall. The creation of a submucosal tunnel
maximum size. is carried out to the esophagogastric junction, entering
about 2-4 cm into the stomach.
The treatment of achalasia over the years has been
carried out mainly through PBD due to its greater Next, the myotomy of the gastric part is performed,
availability. However, PBD, although an effective followed by myotomy of the esophageal muscular layer.
method, has variable durability in different studies. Some groups perform the total myotomy of the circular
It is also associated with a theoretical higher risk of and longitudinal layers of the esophagus, while others
gastroesophageal reflux disease occurrence between perform only the myotomy of the circular layer. It is
15-35% of patients due to the total rupture of the important to vary the extent of the esophageal myotomy
circular and longitudinal muscular layers of the LES [16] . from 6 to 10 cm towards the middle esophagus to the
However, this modality presents a low risk for major gastroesophageal junction (GEJ). Finally, the incision
complications and deaths compared to surgery. It is of the mucosal layer is closed with the placement of
currently the most effective non-surgical option for the endoclips or by endoscopic suture.
150 Mini-invasive Surgery ¦ Volume 1 ¦ December 28, 2017