Download PDF
Endoscopy 1999; 31(7): 517-521
DOI: 10.1055/s-1999-56
Original Article
Georg Thieme Verlag Stuttgart ·New York

Esophageal Achalasia: Intrasphincteric Injection of Botulinum Toxin A Versus Balloon Dilation

S. M. Muehldorfer, T. H. Schneider, J. Hochberger, P. Martus 1 , E. G. Hahn, C. Ell 2
  • 1 Department of Medicine I and Medical Informatics, Biometry and Epidemiology, University of Erlangen-Nuremberg, Germany 2 HSK Wiesbaden, Germany
Further Information

Publication History

Publication Date:
31 December 1999 (online)

Also available at
    Permissions and Reprints

Background and Study Aims: In patients with esophageal achalasia, pneumatic dilation is the treatment of choice, but it bears the risk of perforation in about 4 % of cases. A new nonsurgical method, intrasphincteric injection of botulinum toxin A, has shown promising initial results, and we thus undertook this study to compare the long-term outcome of these two methods.

Patients and Methods: In a prospective randomized study, 24 patients with definitive esophageal achalasia were divided into two equal groups and underwent either balloon dilation or injection of botulinum toxin (20 U injected into each of the four quadrants in the lower esophageal sphincter). The outcome was assessed on the basis of a symptom score documented before treatment and at regular intervals for two and a half years thereafter. Complications associated with the two techniques were also documented.

Results: No relevant complication occurred in either of the treatment groups. lnitially, dilation was successful in 10 of 12 patients (83 %), and botulinum toxin injection in 9 of 12 patients (75 %). The symptom scores showed no significant differences between the two groups before and one month after treatment. Over the two and a half year follow-up, however, all nine successfully treated patients in the botulinum toxin group experienced recurrence of symptoms, but only four of the ten patients (40 %) in the dilation group.

Conclusions: The two treatment methods initially had equal success rates, but in the long term the effect of the botulinum toxin injection was statistically significantly shorter than that of balloon dilation. As fewer risks are associated with the injection treatment, studies should be undertaken either to identify patient subgroups in whom botulinum toxin can be effective long-term or to test substances with longer-lasting effects.

References

  • 1 Wienbeck M, Barnert J. Therapie der Achalasie.  Dtsch Med Wochenschr. 1989;  114 1971-1973
    PubMedSearch in Google Scholar
  • 2 Katz P. Achalasia: two effective treatment options - let the patient decide.  Am J Gastroenterol. 1994;  89 969-970
    PubMedSearch in Google Scholar
  • 3 Richter J E. Surgery or pneumatic dilatation for achalasia: a head-to-head comparison. Now are all the questions answered.  Gastroenterology. 1989;  97 1340-1341
    PubMedSearch in Google Scholar
  • 4 Abid S, Champion G, Richter J E, et al. Treatment of achalasia: the best of both worlds.  Am J Gastroenterol. 1994;  89 979-985
    PubMedSearch in Google Scholar
  • 5 Stark G A, Castell D O, Richter J E, et al. Prospective randomized comparison of Brown-McHardy and microvasive balloon dilators in treatment of achalasia.  Am J Gastroenterol. 1990;  85 1322-1326
    PubMedSearch in Google Scholar
  • 6 Vaezi M F, Richter J E. Current therapies for achalasia: comparison and efficacy.  J Clin Gastroenterol. 1998;  27 21-35
    CrossrefPubMedSearch in Google Scholar
  • 7 Rabinovici R, Katz E, Goldin E, et al. The danger of high compliance balloons for esophageal dilatation in achalasia.  Endoscopy. 1990;  22 63-64
    PubMedSearch in Google Scholar
  • 8 Muehldorfer S M, Kekos G, Hahn E G, et al. Complications of therapeutic gastrointestinal endoscopy.  Endoscopy. 1992;  24 276-283
    PubMedSearch in Google Scholar
  • 9 Jankovic J, Brin M F. Therapeutic uses of botulinum toxin.  N Engl J Med. 1991;  324 1186-1194
    PubMedSearch in Google Scholar
  • 10 Lees A J. Botulinum toxin.  BMJ. 1992;  305 1169-1170
    PubMedSearch in Google Scholar
  • 11 MacKenzie I, Burnstock G, Dolly J O. The effects of purified botulinum neurotoxin type A on cholinergic, adrenergic and non-adrenergic, atropine-resistant autonomic neuromuscular transmission.  Neurosience . 1982;  7 997-1006
    PubMedSearch in Google Scholar
  • 12 Pasricha P J, Rai R, Ravich W J, et al. Botulinum toxin for achalasia: long-term outcome and predictors of response.  Gastroenterology. 1996;  110 1410-1415
    CrossrefPubMedSearch in Google Scholar
  • 13 Annese V, Basciani M, Perri F, et al. Controlled trial of botulinum toxin injection versus placebo and pneumatic dilation in achalasia.  Gastroenterology. 1996;  111 1418-1424
    CrossrefPubMedSearch in Google Scholar
  • 14 Fishman V M, Parkman H P, Schiano T D, et al. Symptomatic improvement in achalasia after botulinum toxin injection of the lower esophageal sphincter.  Am J Gastroenterol. 1996;  91 1724-1730
    PubMedSearch in Google Scholar
  • 15 Eaker E Y, Gordon J M, Vogel S B. Untoward effects of esophageal botulinum toxin injection in the treatment of achalasia.  Dig Dis Sci. 1997;  42 724-727
    CrossrefPubMedSearch in Google Scholar
  • 16 Pasricha P J, Ravich W J, Hendrix T R, et al. Intrasphincteric botulinum toxin for the treatment of achalasia.  N Engl J Med. 1995;  322 774-778
    PubMedSearch in Google Scholar
  • 17 Barnert J, Wienbeck M. Diagnose und Differentialdiagnose der Achalasie.  Dtsch Med Wochenschr. 1989;  114 1968-1970
    PubMedSearch in Google Scholar
  • 18 Kim C H, Cameron A J, Hsu J J, et al. Achalasia: prospective evaluation of relationship between lower esophageal sphincter pressure, esophageal transit, and esophageal diameter and symptoms in response to pneumatic dilation.  Mayo Clin Proc. 1993;  68 1067-1073
    PubMedSearch in Google Scholar
  • 19 Bhutani M S. Gastrointestinal uses of botulinum toxin.  Am J Gastroenterol. 1997;  92 929-933
    PubMedSearch in Google Scholar
  • 20 Dodds W J, Dent J, Hogan W J, et al. Paradoxical lower esophageal sphincter contraction induced by cholecystokinin-octapeptide in patients with achalasia.  Gastroenterology. 1981;  80 327-333
    PubMedSearch in Google Scholar
  • 21 Pasricha P J, Ravich W J, Kalloo A N. Effects of intrasphincteric Botulinum Toxin on the lower esophageal sphincter in piglets.  Gastroenterology. 1993;  105 1045-1049
    PubMedSearch in Google Scholar
  • 22 Vantrappen G, Hellemans J. Treatment of achalasia and related motor disorders.  Gastroenterology. 1980;  79 144-154
    PubMedSearch in Google Scholar
  • 23 Pasricha P J, Ravich W J, Hendrix T R, et al. Treatment of achalasia with intrasphincteric injection of botulinum toxin.  Ann Intern Med. 1994;  121 590-591
    CrossrefPubMedSearch in Google Scholar
  • 24 Csendes A, Braghetto I, Henriquez A, et al. Late results of a prospective randomised study comparing forceful dilatation and oesophagomyotomy in patients with achalasia.  Gut. 1989;  30 299-304
    CrossrefPubMedSearch in Google Scholar
  • 25 Annese V, Basciani M, Borrelli O, et al. Intrasphincteric injection of botulinum toxin is effective in long-term treatment of esophageal achalasia.  Muscle Nerve. 1998;  21 1540-1542
    PubMedSearch in Google Scholar
  • 26 Kadakia S C, Wong R K. Graded pneumatic dilation using Rigiflex achalasia dilators in patients with primary esophageal achalasia.  Am J Gastroenterol. 1993;  88 34-38
    PubMedSearch in Google Scholar
  • 27 Muehldorfer S M, Hahn E G, Ell C. High- and low-compliance balloon dilators in patients with achalasia: a randomized prospective trial.  Gastrointest Endosc. 1996;  44 398-403
    PubMedSearch in Google Scholar
  • 28 Cuilliere C, Ducrotte P, Zerbib F, et al. Achalasia: outcome of patients treated with intrasphincteric injection of botulinum toxin.  Gut. 1997;  41 87-92
    PubMedSearch in Google Scholar
  • 29 Annese V, Bassotti G, Coccia G, et al. Multicentre, dose-finding study of botulinum toxin for the therapy of esophageal achalasia.  Gastroenterology. 1998;  114 A713 (Abstract)
    PubMedSearch in Google Scholar
  • 30 Hoffman B J, Knapple W L, Bhutani M S, et al. Treatment of achalasia by injection of botulinum toxin under endoscopic ultrasound guidance.  Gastrointest Endosc. 1997;  45 77-79
    CrossrefPubMedSearch in Google Scholar
  • 31 Vaezi M F, Richter J E, Wilcox C M, et al. Botulinum toxin versus pneumatic dilatation in the treatment of achalasia: a randomised trial.  Gut. 1999;  44 231-239
    CrossrefPubMedSearch in Google Scholar
  • 32 Gordon J M, Eaker E Y. Prospective study of esophageal botulinum toxin injection in high-risk achalasia patients.  Am J Gastroenterol. 1997;  92 1812-1817
    PubMedSearch in Google Scholar

Steffen M. MuehldorferM.D. 

Department of Medicine I

University of Erlangen-Nuremberg

Krankenhausstrasse 12

91054 Erlangen, Germany

Phone: + 49-9131-8536909

Email: steffen.muehldorfer@med1.med.uni-erlangen.de