Does botulinum toxin injection make esophagomyotomy a more difficult operation?

Background: Some patients with achalasia treated by botulinum toxin injecti on still require an esophagomyotomy. In this study, we analyzed the impact of botulinum toxin injection on die technical aspects and outcome of esopha gomyotomy. Methods: We studied 57 patients, with a mean age of 46 years (range, 12-97) who were treated between January 1995 and March 1998 by esophagomyotomy pe rformed via minimally invasive techniques by one team. Operative reports, v ideotapes, and clinical outcome were analyzed to define the technical diffi culties, perforations, and outcome. Results: Fifteen of the 57 patients had received one or more injections of botulinum toxin (botox group) preoperatively. Difficulties in dissection of the submucosal plane were encountered in eight of the 15 cases (53.3%), an d a mucosal laceration (perforation) occurred in two cases (13.3%). Forty-t wo of the 57 patients had not received any injections (non-botox group). In three patients (7%), difficulties in identifying or following the submucos al plane were encountered, although 29 patients had one or more previous di lations, and perforation occurred in one case (2.4%). All mucosal injuries were repaired laparoscopically, and the patients recovered without obvious sequelae. Dysphagia improved significantly after the operation in both grou ps (botox group, from preoperative score of 3.8 to a postoperative score of 0.7; non-botox, from a score of 3.4 preoperatively to 0.5 postoperatively) . Regurgitation also improved in both groups (botox, 2.7 preoperatively, 0. 92 postoperatively; non-botox group, 2.0 preoperatively, 0.56 postoperative ly). Conclusions: Injection of botulinum toxin significantly increases the techn ical difficulties and thus the potential risk of esophagomyotomy. The immed iate results were equally good for both groups in our series, but the long- term sequelae of repented injections are unknown. Laparoscopic Heller myoto my is a safe and affective procedure even after unsuccessful treatment with botulinum toxin.