Manometrically-guided endoscopic injection of botulinum toxin for esophageal achalasia: a pilot trial

Some patients gained only short-term response (< 6 months) after botulinum toxin (BTX) injection for achalasia. This may be due to an incorrect site of injection when targeting the lower esophageal sphincter by using endoscopic landmarks only.

7 elderly patients (4 females, 67 +/- 20 years) with classical achalasia received manometrically-guided botulinum toxin injection by means of a double-channel endoscope. Thereafter, they were clinically re-evaluated at 6 weeks and later on at bi-monthly intervals.

The mean symptom score decreased 6 weeks after the manometrically-guided BTX-treatment from 12 +/- 2 (before BTX) to 6 +/- 2 points (p = 0.02). However, according to the study criteria one patient did not respond to BTX-injection and underwent subsequent cardiomyotomy. The LES-resting pressure was found not to be altered in this patient (6 weeks after BTX-injection) but manometry revealed a marked decrease of the LES-tone in 3 other patients who benefitted from BTX-injection. 5 of the 6 patients, who initially benefited from BTX-injection, relapsed 10 months (range, 6-13 months) after their initial BTX-treatment. They all were treated with repeated BTX-injections. At completion of the study (1.5-year follow-up) the mean symptom score of the 6 patients was still significantly lower (6 +/- 2 points) than before study entry (p = 0.03).

Manometrically-guided endoscopic BTX-injection is a simple, safe and highly effective (during 1.5-year follow-up) technique for treatment of esophageal achalasia. With the manometrically-guided injection technique one may obtain a longer lasting symptomatic response than with the traditional method of BTX-application.