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

Aims: Some patients gained only short-term response (<6 months) after botul inum toxin (BTX) injection for achalasia. This may be due to an incorrect s ite of injection when targeting the lower esophageal sphincter by using end oscopic landmarks only. Patients and methods: 7 elderly patients (4 females, 67+/-20 years) with cl assical 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. Results: 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). How ever, according to the study criteria one patient did not respond to BTX-in jection and underwent subsequent cardiomyotomy. The LES-resting pressure wa s 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 w ho benefitted from BTX-injection. 5 of the 6 patients, who initially benefi ted 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 stu dy entry (p = 0.03). Conclusion: Manometrically-guided endoscopic BTX-injection is a simple, saf e 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 traditi onal method of BTX-application.