Treatment of patients with achalasia with botulinum toxin: a multicenter prospective cohort study

Abstract

Botulinum toxin (BT) injection is an alternative treatment of achalasia. The aim of the study was to examine outcomes of patients treated with BT in the Czech Republic. Since 1997, 49 patients with achalasia have been treated with BT. We prospectively evaluated the effect of BT injection on 41 patients during a median follow-up of 24 months (range 9-62). Esophageal manometry was performed before and at 3-5 months after the injection. In 16 patients, BT was injected from the antegrade angle only (subgroup A), in 15 patients, BT was injected from both retrograde and antegrade angles (subgroup B) and, in 10 patients, BT injection was combined with subsequent balloon dilatation (subgroup C). Immediate clinical response was achieved in 93% of patients. Clinical remission was sustained beyond 3 months in 83% of patients (responders). Fourteen responders (41%) did not experience a relapse during the median of 22 months. Twenty responders (59%) experienced symptomatic relapse approximately 8 months after the injection. Ten relapsers underwent BT reinjection, five (50%) of them were asymptomatic for another 14 months. The remaining five (50%) patients reported a second relapse approximately 6 months after the reinjection. Median duration of the symptom-free period was 11.5 months after the first BT injection, and 10.5 months after the second (P = 0.21). We did not find any significant predictor of a favorable outcome; responders tended to be older and to have a lower basal lower-esophageal-sphincter pressure. Patients in subgroup C were more likely to be in remission at 1 and 2 years as compared with patients in subgroup A. BT injection is an effective treatment of achalasia in the short term. However, almost 70% of patients experience a relapse within 2 years. BT injection should therefore be reserved for patients at risk for more invasive procedures or for patients who prefer this treatment.

SAGES guidelines for the surgical treatment of esophageal achalasia

“…A single injection of botulinum toxin has been shown to be effective in approximately 85% of patients with achalasia, but its effect diminishes over time (50% at 6 months and 30% at 1 year) [9,13,14], and universal symptomatic relapse occurs at 2 years [15].This treatment effect can be maximized by repeat injections [16], but its long-term effectiveness remains limited. The best results of botulinum toxin have been achieved in older patients [17] who tend to have higher lower esophageal pressures than younger patients [18], patients with vigorous achalasia, and patients whose LES pressures do not exceed C50% of the upper limit of normal [14,19].…”

The Treatment of Diabetic Gastroparesis With Botulinum Toxin Injection of the Pylorus

“…Botulinum toxin injection of the LES was enthusiastically greeted as a therapeutic option given initial reports describing significant success in relieving symptoms (16,17). Over the last several years, however, an accumulating body of evidence has demonstrated that botulinum toxin injection provides long-term benefits (Ͼ12 months) in only a minority of patients (20) and is often ineffective in younger patients (21,22). Balloon dilation of the LES is generally more efficacious at providing long-term relief of symptoms (23) and is more cost-effective (24).…”

Per-oral endoscopic myotomy for achalasia: An American perspective

“…Until recently, the three traditional options for this were botulinum (Botox) injection (BTI) into the LES, pneumatic dilation (PD) of the LES and surgical myotomy (often with subsequent fundoplication to minimize reflux). BTI has been well validated as therapy for achalasia with good short-term benefit, but has poor long-term efficacy at diminishing dysphagia [7,8] . However, it is a safe and effective treatment option for the infirm and elderly [9] .…”