Post written by David L. Diehl, MD, FASGE, AGAF, FACP, from the Department of Gastroenterology and Hepatology, Geisinger Commonwealth School of Medicine, Geisinger Medical Center, Danville, Pennsylvania, USA.

Although pneumatic dilation (PD) of the lower esophageal sphincter has had a long—and successful—history of use in the management of achalasia and related disorders, the advent of peroral endoscopic myotomy (POEM) has moved PD to a largely secondary role.

Most advanced centers that have expertise with achalasia have adopted a “POEM-first” policy. As a result, the number of PD procedures seems to be falling. Along with this, local expertise in performing the PD procedure is becoming rare.

Yet, PD still can be useful, and I contend that it still has a role in the management of disorders of failed lower esophageal sphincter relaxation. For example, for many patients, typically those elderly, PD can be a reasonable alternative to POEM. In addition, it may be used to treat recurrence of symptoms in patients who already underwent POEM or patients who have symptomatic dysphagia after a fundoplication procedure.

In this Top Tips article, my aim is to draw attention to current indications for PD, make the reader aware of important procedural details, and discuss what to look for immediately after dilation. I discuss what to do in the case of perforation, which fortunately is uncommon but needs to be promptly recognized and addressed. I include a focused 6-minute video accompanying the article.

I am certain this Top Tips article will be useful to any endoscopist who wants to feel more comfortable performing the PD procedure in their clinical practice.

Fluoroscopic “tattooing” of the lower esophageal sphincter aids in proper dilation balloon placement and is more accurate than the use of skin markers.

Read the full article online.

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