Botulinum toxin versus pneumatic dilatation in the treatment of achalasia: a randomised trial

Vaezi, Michael F.; Richter, Joel E.; Wilcox, C. Mel; Schroeder, Patrick L.; Birgisson, Sigurbjörn; Slaughter, Robert L.; Koehler, Robert E.; Baker, Mark E.

doi:10.1136/gut.44.2.231

Cited by 269 publications

(145 citation statements)

References 13 publications

(18 reference statements)

Supporting

Mentioning

132

Contrasting

Unclassified

Order By: Relevance

“…A randomized controlled trial published in 2017 comparing POEM with pneumatic dilation found the POEM procedure to be more efficacious in terms of therapeutic success, but also more likely to result in post-procedure reflux oesophagitis 61 . The preceding discussion makes no mention of medical treatments for achalasia, specifically botulinum toxin [62][63][64][65] , calcium-channel blockers 66 , nitrates 66 and phosphodiesterase type 5 inhibitors 67 primarily because, although these agents provide some symptomatic benefit, they are not durable therapies and they do not halt the disease progression toward oesophageal decompensation characterized by dilatation and food retention. For example, in the case of botulinum toxin injected into the LES, about two-thirds of patients with achalasia report an improvement in dysphagia, but most relapse within a year and repeat treatments have diminished effectiveness, making it a poor firstline therapy [62][63][64][65] .…”

Section: Poemmentioning

confidence: 99%

Advances in the management of oesophageal motility disorders in the era of high-resolution manometry: a focus on achalasia syndromes

Kahrilas

Bredenoord

Fox

et al. 2017

Nat Rev Gastroenterol Hepatol

View full text Add to dashboard Cite

High-resolution manometry (HRM), along with the analysis algorithms characterized in the Chicago Classification (CC) first proposed in 2008, have led to a major restructuring of the classification of oesophageal motility disorders. The inherently quantitative output of HRM devices fuelled enthusiastic expectation among motility experts that these advances would add a level of precision to the diagnosis of oesophageal motility disorders that was not previously possible. Nowhere was this advance more evident than in our concept of achalasia, now differentiated into subtypes as a direct result of HRM. Coincident with the assimilation of HRM into clinical practice was the development of a major therapeutic intervention for the management of oesophageal motility disorders, per-oral endoscopic myotomy (POEM). Not only does the POEM procedure provide a therapeutic option for myotomy with reduced morbidity relative to laparoscopic or open myotomy, but it also enables a calibrated intervention that is customized to patient-specific physiology. Together, these develop ments fostered an increasing emphasis on targeting therapy to specific aspects of oesophageal dysfunction, as measured by physiological testing, rather than discrete diagnoses. Again, nowhere is this evolution more evident than in our strategies for managing achalasia. This Consensus Statement examines the effect of HRM on our current understanding of oesophageal motility disorders with a focus on how this technology has affected the diagnosis, epidemiology and management of achalasia and achalasia-like syndromes. on behalf of the International Working Group for Disorders of Gastrointestinal Motility and FunctionAbstract | High-resolution manometry (HRM) and new analysis algorithms, summarized in the Chicago Classification, have led to a restructured classification of oesophageal motility disorders. This advance has led to increased detection of clinically relevant disorders, in particular achalasia. It has become apparent that the cardinal feature of achalasia -impaired lower oesophageal sphincter (LES) relaxation -can occur in several disease phenotypes: without peristalsis (type I), with pan-oesophageal pressurization (type II), with premature (spastic) distal oesophageal contractions (type III), or with preserved peristalsis (outlet obstruction). Furthermore, no manometric pattern is perfectly sensitive or specific for achalasia caused by a myenteric plexopathy, and there is no biomarker for this pathology. Consequently, physiological testing reveals other syndromes not meeting achalasia criteria that also benefit from therapies formerly reserved for achalasia. These findings have become particularly relevant with the development of a minimally invasive technique for performing a long oesophageal myotomy, the per-oral endoscopic myotomy (POEM). Optimal management is to render treatment in a phenotype-specific manner; that is, POEM calibrated to patient-specific physiology for spastic achalasia and the spastic disorders, and more conservative strategies...

show abstract

Section: Poemmentioning

confidence: 99%

Advances in the management of oesophageal motility disorders in the era of high-resolution manometry: a focus on achalasia syndromes

Kahrilas

Bredenoord

Fox

et al. 2017

Nat Rev Gastroenterol Hepatol

View full text Add to dashboard Cite

show abstract

“…achieve a stable effect on symptoms, and in the experience of other authors, the long-term results appear to be less satisfactory than those obtained by pneumatic dilatation. 7 Although the exact role of botulinum toxin is still to be de®ned, there is widespread agreement that this approach is useful for patients who cannot undergo dilatation and who are not surgical candidates. 8 The use of botulinum toxin has been found to be remarkably safe; however, the possibility that it could induce oesophagogastric re¯ux has not yet been formally evaluated.…”

Section: Introductionmentioning

confidence: 99%

Comparison of two different formulations of botulinum toxin A for the treatment of oesophageal achalasia

Annese

Bassotti

Coccia

et al. 1999

Aliment Pharmacol Ther

View full text Add to dashboard Cite

Background: Intrasphincteric injection of botulinum toxin has been reported as a safe and effective alternative treatment in oesophageal achalasia, especially in high‐risk and elderly patients.Aim: To compare two formulations of botulinum toxin in the management of achalasia.Patients and methods: We randomly compared the efficacy and safety of 100 U of Botox (Allergan, Irvine, USA) and 250 U of Dysport (Ipsen, Milan, Italy), injected through a sclerotherapy needle at the level of the lower oesophageal sphincter, in 78 consecutive patients with achalasia. Symptom score, oesophageal manometry and 24 h pH‐metry were recorded (before and 1 month after therapy). Symptom score was also obtained 6 months after treatment.Results: One month after treatment, the effects of the toxin on symptoms and oesophageal tests were similar for both formulations. Lower oesophageal sphincter pressure decreased from 31 ± 12 to 18 ± 5 mmHg after Botox, and from 35 ± 9 to 18 ± 10 after Dysport. At the end of the follow‐up period (6 months), symptom score decreased from 5 ± 1.2 to 1.2 ± 0.8 after Botox and from 5.2 ± 1.5 to 1.5 ± 1 after Dysport. Moreover, the percentages of patients who failed to respond to treatment (10% and 17.5%) and who relapsed during follow‐up (12% and 24%) did not differ significantly. No patient complained of reflux symptoms after treatment, although abnormal acid exposure was documented in two subjects.Conclusions: Both formulations of botulinum toxin have comparable efficacy in the treatment of oesophageal achalasia, for up to 6 months of follow‐up.

show abstract

“…When comparing the initial symptomatic relief after Botox injection with the one after PD or LHM, 5 randomized studies have shown a similar effect, but a fastter loss of response in patients treated with Botox (30)(31)(32)(33).…”

Section: Endoscopic Injection Of Botoxmentioning

confidence: 99%

High Resolution Manometry - A Mandatory Examination in the Pre and Postoperative Assessment of Patients with Achalasia

Dimitriu¹,

Gheorghe²

2018

chr

View full text Add to dashboard Cite

RezumatManometria esofagiană cu rezoluţie înaltă este actual investigaţia gold-standard în diagnosticul acalaziei şi a bolilor esofagiene funcţionale. Această examinare este întotdeauna precedată de endoscopia digestivă superioară, care are scopul de a face diagnosticul diferenţial al acalaziei cu pseudoacalazia (formaţiuni tumorale de fornix gastric/esofag distal). La momentul actual, nu există tratament curativ pentru acalazie. Însă, cele 3 subtipuri de acalazie (conform clasificării Chicago) au răspuns diferit în ceea ce priveşte eficacitatea în tratamentului ales. Astfel, comparativ cu tipurile I şi III, tipul II de acalazie are cel mai bun răspuns la intervenţiile terapeutice invazive (dilatare pneumatică sau cardiomiotomie Heller). În schimb, în tipul III cardiomiotomia Heller este de ales ca prima abordare terapeutică. Miotomia endoscopică perorală (POEM) este o tehnică relativ recentă, care necesită însă studii pe termen lung în ceea ce priveşte siguranţa şi eficacitatea. Articolul prezent îşi propune să prezinte variantele actuale de tratament ale acalaziei, comparându-le pe baza eficacităţii şi siguranţei pe termen scurt şi lung, subliniind de asemenea rolul manometriei cu rezoluţie înaltă în diagnosticul, alegerea metodei terapeutice şi prognosticul acestor pacienţi. Review ArticleAbstract High resolution manometry (HRM) is currently the gold standard for the diagnosis of achalasia and other functional esophageal disorders. All patients accusing dysphagia should be endoscopically evaluated prior to manometric investigations in order to rule out pseudoachalasia. The Chicago HRM classification has led to a subclassification of three manometric types of achalasia that seem to have different results to treatment. None of the actual achalasia treatment options are curative. Type II achalasia patients respond best to all treatment options compared to those with types I and III. Pneumatic dilation (PD) or Heller miotomy (LHM) can be both chosen as initial therapy in type I and II as they have good outcome , while type III achalasia patients respond better to LHM as a first therapeutic option. Peroral endoscopic myotomy (POEM) is a promising new technique but long-term follow-up studies for its safety and efficacy must be performed. This article reviews the current therapeutic options in achalasia and other functional esophageal disorders, based on the differences in safety and efficacy between approaches, highlighting the impact of HRM to predict the outcome but also the role of the techinque in guiding antireflux surgery.

show abstract

Botulinum toxin versus pneumatic dilatation in the treatment of achalasia: a randomised trial

Cited by 269 publications

References 13 publications

Advances in the management of oesophageal motility disorders in the era of high-resolution manometry: a focus on achalasia syndromes

Advances in the management of oesophageal motility disorders in the era of high-resolution manometry: a focus on achalasia syndromes

Comparison of two different formulations of botulinum toxin A for the treatment of oesophageal achalasia

High Resolution Manometry - A Mandatory Examination in the Pre and Postoperative Assessment of Patients with Achalasia

Contact Info

Product

Resources

About