Treatment Of Achalasia By Endoscopic Injection Of Botulinum Toxin

Background and Aims: Achalasia is a esophageal disorder characterized by aperistalsis and failure of lower esophageal Sphincter(LES)to relax. At present ,forceful dilation is considered to be the standard treatment at most centers .However, the procedure carries a low risk of perforation, and single dilations often fail to achieve long-term remission, with most patients requiring more dilation. The present study aimed to test the hypothesis that injection of botolinum toxin under endoscopic ultrasound guidance may effectively reduce the occurrence of spasm at the level of the gastric cardia, offering an effective treatment for achalasia.Subjects and Methods: A total of 182 achalasia patients were treated by endoscopic injection of botulinum toxin. The patients were confirmed with esophageal manometry and secondary causes were excluded with routine upper endoscopy and barium meal. The LES was identified by EUS as a thickened hypoechoic zone. A total of four 1ml injections (80U) of botulinum toxin were made in different quadrants of the LES in each patient. A dysphagia score, which was the sum of the individual scores of dysphagia, regurgitation, and chest pain, was given to each patient, and LESP and LESRP were measured before and after treatment.Results: 95.6% (174/182) patients got clinical remission. TheLESP, LESRP and dysphagia score were decreased significantly after the treatment, LESP: before 46.54±27. 60mmHg, after 20. 77 ± 11. 36, P<0.01; LESRP: before 15. 57 ± 8. 30 mmHg, after 9. 49 ± 7. 31mmHg. dysphagia score: before 6.33± 2.27, after 1.69 ± 1.14, P<0.01.78.8% (104/132), 65.0% (67/103 ), 40.5% (32/79), 26.0% (13/50), 20.0% (5/25) patients were still in clinical remission after 12, 24, 36, 48 and 60 months follow-up respectively.Conclusions: Endoscopic botulinum toxin injection appeared to be a very safe, effective and promising alternative for the currently available therapeutic tools for achalasia. It has satisfactory medium-term efficacy in more than 2/3 of patients, but the long-term result should be improved.