Treatment of Achalasia with the Witzel Dilator: A Prospective Randomized Study of Two Methods

Introduction

The treatment of primary achalasia of the esophagus is basically palliative and is aimed at decreasing the lower esophageal sphincter (LES) pressure. Several approaches have been designed with this objective, from pharmacological treatment, such as smooth muscle fibre relaxants, to endoscopic therapies (intrasphincteric botulinum toxin injection [1], endoscopic sclerotheraphy [2], and forceful pneumatic dilation of the cardia), and surgical procedures (cardiomyotomy by laparotomy or laparoscopy). Among the nonpharmacological treatments, pneumatic dilation and surgical cardiomyotomy provide the best long-term results [3] [4] [5] [6]. Pneumatic dilation is the most cost-effective method [7], and also allows rapid recovery of the patient, can be performed as an outpatient procedure in many cases [8], and shows a lower incidence of post-treatment gastroesophageal reflux disease than surgery [3] [4] [9]. For these reasons, pneumatic dilation is considered by many to be the preferred approach [4] [7] [10]. Esophageal perforation, the complication causing the greatest concern, occurs in 2 - 6 % of cases [3] [11] [12] [13].

At present, low-compliance models are most generally employed for pneumatic dilation [14]. The most widely used devices are the Rigiflex (Microvasive Rigiflex Achalasia Dilator, Boston Scientific Corporation, Natick, Massachusetts, USA), which requires radiological control for correct positioning [14] [15], and the Witzel dilator (Wimed GmbH Medizintechnik, Berlin, Germany), which allows correct and easy placement of the balloon in the cardia, and its further dilation and direct vizualization in retroflexion when attached to the distal end of the endoscope. Several studies have shown the Witzel dilator to be safe and effective for the treatment of achalasia [16] [17] [18] [19]. However, the optimal duration of inflation of the balloon for achieving satisfactory results has not yet been clearly established, nor have the correct pressure or number of dilations per session. Several durations, pressures, and numbers of dilations have been used by different groups, who have continued to use them as long as they obtained positive results [20] [21]. However, so far there are no comparative studies of the different techniques of pneumatic dilation using the Witzel dilator.

The object of our study was to make a clinical, radiological, and manometric comparison of the medium-term results obtained using the Witzel dilator in two homogeneous groups of patients with idiopathic achalasia of the cardia, in whom two different endoscopic techniques were employed.

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