Clinical Trial of Endoscopic Botulinum Toxin Injection for the Treatment of Primary Achalasia

Ham, Jeong Sik; Jang, Jae Young; Choi, Woo Bong; Lim, Hee Hyeok; Hong, Su Jin; Moon, Jong Ho; Cho, Young Duk; Kim, Jin Oh; Cho, Joo Young; Kim, Yoen Soo; Lee, Joon Seong; Lee, Moon Sung; Whang, Sung Kyu; Shim, Chan Sup

Abstract

Primary achalasia is a disorder of swallowing in which the lower esophageal sphincter fails to relax. Traditional treatment methods are balloon dilatation and myotomy, but these methods have critical complications and even fatal including esophageal perforation, gastroesophageal reflux, and continuing dysphagia. Botulinum toxin, which has been used for dystonias of skeletal muscles, is presented as a new alternative treatment method for achalasia, aimed to lowering of LES pressure by Pasricha et al. They also reported that endoscopic botulinum toxin injection into LES was effective, safe, and simple method without any significant complication. We report 7 cases of primary achalasia treated with endoscopic botulinum toxin injection, who showed clinical improvement without any complication. We compared results of pre-treatment with those of post-treatment using botulinum toxin in the aspects of clinical, radiological, manometrical recording in these cases. Symptomatic improvement was shown in 4 cases(57.1%), symptom score was decreased from 7.43+/-0.53 to 4.43+/-2.51(p=0.03), The luminal diameter at esophagogastric junction increased from a mean of 3.21+/-0,99 mm to 5.14+/-0.90 mm (p=0.015), and luminal diameter at esophageal body decreased from a mean of 40.29+/-19.37 mm to 32.71+/-15.45 mm (p=0.015). In follow up manometric recording, peristaltic waves at the body were recovered in 2 cases(28.6%), gastroesophageal pressure gradient(AP) was non-significantly decreased from 6.30+/-4.0 mmHg to 3.12+/-4.47 mmHg (p=0.45). One patient complained of transient chest pain within one hour after the botulinum toxin injection, but she did not need any medication. We concluded that botulinum injection was a simple, safe, and effective therapeutic method for primary achalasia, even though further evaluatian should be performed in the much more cases and the results of long term follow-up, and cost-effectiveness of this method.