Long-Term Results of Endoscopic Injection of Botulinum Toxin in Elderly Achalasic Patients with Tortuous Megaesophagus or Epiphrenic Diverticulum

Introduction

Achalasia is characterized by aperistalsis of the tubular esophagus and a failure of the lower esophageal sphincter (LES) to relax, because of selective loss of inhibitory neurons of the myenteric plexus [1]. Since the first use of bougienage in 1672, the treatment of achalasia has been aimed at reducing the contractile LES forces. Today this is done preferentially by pneumatic dilation or cardiomyotomy [2] [3] [4] [5] [6] [7] [8] [9] [10] [11]. While the results of cardiomyotomy are particularly favorable in younger patients, at present enforced pneumatic dilation is considered to be the standard treatment for older achalasia patients [1] [7] [8] [10] [11]. The procedure, however, carries a significant risk of esophageal perforation, which may become a problem in elderly patients with concomitant illness [2] [3] [4] [5] [6] [7] [8] [9] [10] [11]. Additionally, the risk of perforation during pneumatic dilation may be increased in the presence of a tortuous megaesophagus and/or an epiphrenic diverticulum. Therefore, elderly achalasia patients with concomitant illness and epiphrenic diverticula or a tortuous megaesophagus seem to be the best candidates for alternative forms of treatment.

In this respect, the endoscopically guided injection of botulinum toxin (BTX), a potent inhibitor of acetylcholine release from presynaptic cholinergic nerve endings, into the gastric cardia of achalasia patients has shown promising results [12] [13] [14] [15] [16] [17] [18] [19]. In addition, BTX injection is reported to be safe and is associated with only minor side effects and complications [12] [13] [14] [15] [16] [17] [18] [19].

In the trial reported here, we prospectively evaluated the efficacy and safety of botulinum toxin treatment in achalasia patients aged more than 60 years and with concomitant risk factors which rendered pneumatic dilation very risky.

References

• 1 Reynolds J C, Parkman H P. Achalasia.  Gastroenterol Clin North Am. 1989;  18 223-55
• 2 Vantrappen G, Hellemans J. Treatment of achalasia and related motor disorders.  Gastroenterology. 1980;  79 144-54
• 3 Csendes A, Braghetto I, Henriquez A. Late results of a prospective randomized study comparing forceful dilatation and esophagomyotomy in patients with achalasia.  Gut. 1989;  30 299-304
• 4 Gelfand M, Kozarek R A. An experience with polyethylene balloons for pneumatic dilation in achalasia.  Am J Gastroenterol. 1989;  84 924-7
• 5 Stark G A, Castell D O, Richter J E, Wu W C. Prospective randomized comparison of Brown-McHardy and Microvasive balloon dilators in treament of achalasia.  Am J Gastroenterol. 1990;  85 1322-6
• 6 Bourgeosis N, Coffernils M, Buset M, et al. Management of dysphagia in suspected esophageal motor disorders.  Dig Dis Sci. 1991;  36 268-73
• 7 Eckardt V F, Aignherr C, Bernhard G. Predictors of outcome in patients with achalasia treated by pneumatic dilation.  Gastroenterology. 1992;  103 1732-8
• 8 Parkman H P, Reynolds J C, Ouyang A, et al. Pneumatic dilatation or esophagomyotomy as treatment for idiopathic achalasia: clinical outcomes and cost analysis.  Dig Dis Sci. 1993;  38 75-85
• 9 Kadakia S C, Wong R HK. Graded pneumatic dilation using Rigiflex achalasia dilators in patients with primary esophageal achalasia.  Am J Gastroenterol. 1993;  88 34-8
• 10 Abid S, Champion G, Richter J E. Treatment of achalasia: the best of both worlds.  Am J Gastroenterol. 1994;  89 979-85
• 11 Wehrmann T, Jacobi V, Jung M, et al. Pneumatic dilation in achalasia with a low-compliance balloon: results of a 5-year prospective evaluation.  Gastrointest Endosc. 1995;  1 31-6
• 12 Pasricha P J, Ravich W J, Hendrix T R, et al. Treatment of achalasia with intrasphincteric injection of botulinum toxin.  Ann Intern Med. 1994;  121 590-1
• 13 Pasricha P J, Ravich W J, Hendrix T R, et al. Intrasphincteric botulinum toxin for the treatment of achalasia.  N Engl J Med. 1995;  332 774-8
• 14 Rollan A, Gonzalez R, Carvajal S, Chianale J. Endoscopic intrasphincteric injection of botulinum toxin for the treatment of achalasia.  J Clin Gastroenterol. 1995;  20 189-91
• 15 Pasricha P J, Rai R, Ravich W J, et al. Botulinum toxin for achalasia: long-term outcome and predictors of response.  Gastroenterology. 1996;  110 1410-5
• 16 Annese V, Basciani M, Perri F, et al. Controlled trial of botulinum toxin injection versus placebo and pneumatic dilatation in achalasia.  Gastroenterology. 1996;  111 1418-24
• 17 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 1724-30
• 18 Culilliere C, Ducrotte P, Zerbib F, et al. Achalasia: outcome of patients treated with intrasphincteric injection of botulinum toxin.  Gut. 1997;  41 87-92
• 19 Gordon J M, Eaker E Y. Prospective study of esophageal botulinum toxin injection in high-risk achalasia patients.  Am J Gastroenterol. 1997;  10 1812-7
• 20 Moreto M, Ojembarrena E, Rodriguez M L. Endoscopic injection of ethanolamine as an effective treatment for achalasia: a first report.  Endoscopy. 1996;  28 539-45