Katzka D A, Castell D O
Department of Medicine, Graduate Hospital, Philadelphia, Pennsylvania, USA.
Am J Gastroenterol. 1999 Mar;94(3):637-42. doi: 10.1111/j.1572-0241.1999.00927.x.
Intrasphincteric injection of botulinum toxin is useful in achalasia but is limited by its short term efficacy. The aim of this study was to evaluate the use of botulinum toxin in selected patients in whom its short duration of action may be useful in guiding therapy before considering more invasive procedures that might not be indicated.
Over a 3 yr period, botulinum toxin was injected into the lower esophageal sphincter in patients with: 1) symptoms consistent with achalasia but insufficient manometric criteria to make the diagnosis; 2) complex clinical situations in which there were factors in addition to achalasia that may be contributing to the patient's symptoms and that required different treatment; 3) atypical manifestations of achalasia; 4) advanced achalasia in which it was unclear that sphincter-directed therapy (vs esophagectomy) would be of benefit; and 5) after Heller myotomy. Clinical response was assessed mostly by symptom improvement, but in some patients follow-up barium swallow or radioscintigraphy was available.
Eleven patients were identified. Ten had complete symptomatic response to the injection. Two patients have undergone subsequent successful pneumatic dilation, one a successful laparoscopic myotomy, and another currently scheduled for surgical myotomy. The only patient without response had advanced achalasia requiring esophagectomy.
Intrasphincteric injection of botulinum toxin into the lower esophageal sphincter is a useful and safe means of guiding therapy in those patients with a variant of achalasia, atypical achalasia, or complex achalasia in which it is unclear that more invasive procedures such as pneumatic dilation or surgical myotomy are the correct therapy.
食管括约肌内注射肉毒杆菌毒素对贲门失弛缓症有效，但受其短期疗效限制。本研究旨在评估在特定患者中使用肉毒杆菌毒素的情况，其作用持续时间短可能有助于在考虑可能不适用的更具侵入性的手术之前指导治疗。
在3年期间，对以下患者的食管下括约肌注射肉毒杆菌毒素：1）有与贲门失弛缓症相符的症状但测压标准不足以确诊；2）复杂临床情况，除贲门失弛缓症外还有其他因素可能导致患者症状且需要不同治疗；3）贲门失弛缓症的非典型表现；4）晚期贲门失弛缓症，尚不清楚针对括约肌的治疗（与食管切除术相比）是否有益；5）海勒肌切开术后。临床反应主要通过症状改善来评估，但部分患者有随访钡餐吞咽或放射性核素显像检查结果。
共确定11例患者。10例注射后症状完全缓解。2例患者随后成功接受了气囊扩张术，1例成功进行了腹腔镜肌切开术，另1例目前计划进行手术肌切开术。唯一无反应的患者为晚期贲门失弛缓症，需要进行食管切除术。
对食管下括约肌进行括约肌内注射肉毒杆菌毒素，对于那些患有贲门失弛缓症变异型、非典型贲门失弛缓症或复杂贲门失弛缓症且尚不清楚气囊扩张术或手术肌切开术等更具侵入性的手术是否为正确治疗方法的患者而言，是一种有用且安全的治疗指导手段。
