Botulinum toxin versus pneumatic dilatation in the treatment of achalasia:a randomised trial

Background-Intrasphincteric of botulinum toxin is a new option for achalasi a. Aims-To compare the immediate and long term efficacy of botulinum toxin wit h that of pneumatic dilatation. Methods-Symptomatic patients with achalasia were randomised to botulinum to xin (22 patients, median age 57 years) or pneumatic dilatation (20 patients , median age 56 years). Symptom scores were assessed initially, and at one, three, six, nine, and 12 months after treatment. Objective assessment incl uded oesophageal manometry initially and at one month, and barium oesophagr am initially and at one, six, and 12 months posttreatment. Results-Pneumatic dilatation resulted in a significantly (p=0.02) higher cu mulative remission rate. At 12 months, 14/20 (70%) pneumatic dilatation and 7/22 (32%) botulinum toxin treated patients were in symptomatic remission (p=0.017). Failure rates were similar initially, but failure over time was significantly (p=0.01) higher after botulinum toxin (50%) than pneumatic di latation (7%). Pneumatic dilatation resulted in significant (p<0.001) reduc tion in symptom scores, and lower oesophageal sphincter pressure,oesophagea l barium column height, and oesophageal diameter. Botulinum toxin produced significant reduction in symptom scores (p<0.001), but no reduction in obje ctive parameters. Conclusions-At one year pneumatic dilatation is more effective than botulin um toxin. Symptom improvement parallels objective oesophageal measurements after pneumatic dilatation but not after botulinum toxin treatment for acha lasia.