Pneumatic Balloon Dilation Has Limited Effectiveness in Patients After Foregut Surgery

Alla Zemlyak, MD, Sofiane El-djouzi, MD, Paul D Colavita, MD, Dimitrios Stefanidis, MD, Brant T Heniford, MD. Carolinas Medical Center

Introduction
Pneumatic balloon dilation has been used successfully for the treatment of esophageal pathology. Our objective was to analyze the outcomes of pneumatic balloon dilation after foregut procedures.
Methods and Procedures
Prospectively collected data between 2007-2010 on pneumatic balloon dilations after foregut surgery were reviewed at a single institution. Patients after esophagectomy, fundoplication, vertical banded gastroplasty, or gastric bypass were included in the analysis. Patient demographics, presenting symptoms, surgical procedure, number of endoscopies, number of dilations and other endoscopic treatments were recorded.
Results
Twenty seven patients underwent pneumatic balloon dilation following surgery. Eight patients had esophagectomy, 4 patients had gastric bypass, 2 had prior vertical banded gastroplasty, and 13 patients had a fundoplication (12 Nissen, 1 Toupet). Of the anti-reflux procedures, 7 were referred from an outside hospital. Average patient age was 59 (24-91) with 63% women. The major presenting symptoms were dysphagia and vomiting. Five patients had their first dilation within the first post-operative year and 8 patients were 3 or more years out from surgery. The total number of dilations per patient ranged from 1 to 9. The timing of dilation after the surgery did not affect the outcomes. Mean follow up was 18.5 (1-46) months. In the esophagectomy group the number of anastomotic balloon dilations per patient ranged between 1 and 9; the patient with 9 dilations eventually underwent esophageal stent placement. Only one patient reported relief of symptoms at follow up. Out of 4 gastric bypass patients, only one had complete relief of nausea and vomiting after dilation while one did not improve even after seven balloon dilations. Two vertical band gastroplasty patients had 3 and 5 gastric dilations each with no relief; one eventually had a stent placed. Two Nissen patients reported significant relief of dysphagia after single balloon dilation of the GE junction while the rest did not improve after a single or multiple dilations (1-9). In summary, only 4 of 27 postsurgical patients (14.8%) had symptomatic relief of dysphagia or vomiting after pneumatic balloon dilation. Three of the successfully treated patients improved after their first dilation and one improved after the second one while the rest underwent a total of 60 dilations without symptom relief. There were no procedure related complications.
Conclusion
Pneumatic balloon dilation after foregut surgery has limited effectiveness for the treatment of postoperative dysphagia and vomiting. Our data suggests that in the absence of symptom relief after the initial dilation, repeat dilations are unlikely to be effective, are costly, likely delay effective operative intervention, and should be avoided.

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