Wehrmann T, Kokabpick H, Jacobi V, Seifert H, Lembcke B, Caspary W F
Medizinische Klinik II, Klinikum der J. W. Goethe Universität, Frankfurt am Main, Germany.
Endoscopy. 1999 Jun;31(5):352-8. doi: 10.1055/s-1999-27.
Recent studies suggest that endoscopic injection of botulinum toxin (BTX) for achalasia is a safe procedure giving short-term relief of symptoms mainly in elderly patients (> 50 years). The aim of the study was to evaluate the clinical efficacy of periodic BTX treatments in high risk achalasia patients.
A total of 20 consecutive achalasia patients, aged > 60 years (11 women; 71+/-11 years), with general (ASA class III or IV) and local risk factors (i.e. tortuous megaesophagus or epiphrenic diverticulum) for complications associated with pneumatic dilation, were treated by local injection of 100 U of BTX into the gastric cardia, using the four-quadrant technique. The patients were prospectively followed for a median period of 2 years (range 5-48 months), using a symptom score (1-14 points) and barium esophagograms.
Symptomatic improvement (decrease of the symptom score > or = 3 points) was found in 16/20 patients (80%), 6 weeks after the first BTX injection, and the cardia diameter increased from 2.1+/-0.7 to 3.2+/-1.2 mm (P < 0.01) (data are means +/- SD). Those patients who initially responded to BTX treatment developed a symptomatic relapse after a median follow-up of 5+/-2 months. They were treated by subsequent BTX re-injections (2.5+/-1 sessions per patient, range 1-5) resulting in longer lasting symptom relief (10+/-3 months, P < 0.05 vs. initial BTX injection). At completion of the study, 14/20 high risk achalasia patients (70 %) treated with periodic BTX injections are still in clinical remission. One further patient died without relapse 6 months after a single BTX treatment as a consequence of progressive heart failure. Four patients who did not respond to BTX injection were successfully and uneventfully treated by careful pneumatic dilation (n = 3) or percutaneous endoscopic gastrostomy (n = 1).
Endoscopic botulinum toxin injection has reasonable long-term efficacy and safety in elderly achalasia patients who are at increased risk with regard to pneumatic dilation.
近期研究表明，内镜下注射肉毒杆菌毒素（BTX）治疗贲门失弛缓症是一种安全的方法，主要能使老年患者（>50岁）的症状得到短期缓解。本研究的目的是评估定期BTX治疗对高危贲门失弛缓症患者的临床疗效。
共有20例连续的贲门失弛缓症患者，年龄>60岁（11例女性；71±11岁），存在与气囊扩张相关并发症的全身（美国麻醉医师协会III或IV级）和局部危险因素（即迂曲的巨食管或膈上憩室），采用四象限技术在胃贲门局部注射100 U BTX进行治疗。采用症状评分（1 - 14分）和食管钡餐造影对患者进行前瞻性随访，中位随访期为2年（范围5 - 48个月）。
首次注射BTX 6周后，16/20例患者（80%）症状改善（症状评分降低≥3分），贲门直径从2.1±0.7增加到3.2±1.2 mm（P < 0.01）（数据为均值±标准差）。那些最初对BTX治疗有反应的患者在中位随访5±2个月后出现症状复发。随后对他们进行BTX再次注射治疗（每位患者2.5±1次，范围1 - 5次），从而使症状缓解持续时间更长（10±3个月，与首次注射BTX相比P < 0.05）。研究结束时，14/20例接受定期BTX注射治疗的高危贲门失弛缓症患者（70%）仍处于临床缓解状态。另有1例患者在单次BTX治疗6个月后因进行性心力衰竭死亡，未出现复发。4例对BTX注射无反应的患者通过谨慎的气囊扩张（n = 3）或经皮内镜下胃造口术（n = 1）成功且顺利地得到治疗。
内镜下注射肉毒杆菌毒素对因气囊扩张风险增加的老年贲门失弛缓症患者具有合理的长期疗效和安全性。
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