Prospective study of esophageal botulinum toxin injection in high-risk achalasia patients.

OBJECTIVES

Intrasphincteric injection of botulinum toxin has been reported as a safer treatment alternative to balloon dilation or myotomy in achalasia. We studied botulinum toxin injection in achalasia patients who are at high surgical risk because of age or concomitant medical problems.

METHODS

Consecutive patients who were elderly (age > 60 yr) or who had significant medical problems or both were enrolled after confirming achalasia by history, manometry, and esophageal scintigraphy. Patients underwent esophagogastroduodenoscopy, and 20 units of botulinum toxin were injected into each of four quadrants of the lower esophageal sphincter. Patients were interviewed at 1, 3, 5, and 6 months, and esophageal scintigraphy was repeated at 1 month.

RESULTS

Sixteen patients with increased surgical risks were studied: many had serious coronary heart disease, diabetes, or obstructive lung disease. At 1 month, 12 of 16 patients had a clinical response but 5 developed recurrent symptoms within 6 months. One developed reflux, and two were found to have esophageal wall inflammation, loss of tissue planes, and mediastinal adhesions at subsequent myotomy.

CONCLUSIONS

Intrasphincteric botulinum toxin injection may be appropriate in those achalasia patients who are elderly or have concomitant medical problems but concern persists regarding the length of the response and untoward side effects.