Long-term results of endoscopic injection of botulinum toxin in elderly achalasic patients with tortuous megaesophagus or epiphrenic diverticulum

Background and Study Aims: Recent studies suggest that endoscopic injection of botulinum toxin (BTX) for achalasia is a safe procedure giving short-te rm relief of symptoms mainly in elderly patients (>50 years). The aim of th e study was to evaluate the clinical efficacy of periodic BTX treatments in high risk achalasia patients. Patients and Methods: A total of 20 consecutive achalasia patients, aged >6 0 years (11 women; 71+/-11 years), with general (ASA class III or IV) and l ocal risk factors (i.e. tortuous megaesophagus or epiphrenic diverticulum) for complications associated with pneumatic dilation, were treated by local injection of 100 U of BTX into the gastric cardia, using the four-quadrant technique. The patients were prospectively followed for a median period of 2 years (range 5-48 months), using a symptom score (1-14 points) and bariu m esophagograms. Results: Symptomatic improvement (decrease of the symptom score greater tha n or equal to 3 points) was found in 16/20 patients (80%), 6 weeks after th e first BTX injection, and the cardia diameter increased from 2.1+/-0.7 to 3.2+/-1.2 mm (P <0.01) (data are means +/ SD). Those patients who initially responded to BTX treatment developed a symptomatic relapse after a median follow-up of 5+/-2 months. They were treated by subsequent BTX re-injection s (2.5+/-1 sessions per patient, range 1-5) resulting in longer lasting sym ptom relief (10+/-3 months, P <0.05 vs, initial BTX injection). At completi on of the study, 14/20 high risk achalasia patients (70%) treated with peri odic BTX injections are still in clinical remission, One further patient di ed without relapse 6 months after a single BTX treatment as a consequence o f progressive heart failure, Four patients who did not respond to BTX injec tion were successfully and uneventfully treated by careful pneumatic dilati on (n=3) or percutaneous endoscopic gastrostomy (n=1). Conclusion: Endoscopic botulinum toxin injection has reasonable long-term e fficacy and safety in elderly achalasia patients who are at increased risk with regard to pneumatic dilation.