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

Aims: Some patients gained only short-term response (<6 months) after botulinum toxin (BTX) injection for achalasia. This may be due to an incorrect site of injection when targeting the lower esophageal sphincter by using endoscopic landmarks only. Patients and methods: 7 elderly patients (4 females, 67+/-20 years) with classical 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). However, according to the study criteria one patient did not respond to BTX-injection and underwent subsequent cardiomyotomy. The LES-resting pressure was 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 who benefitted from BTX-injection. 5 of the 6 patients, who initially benefited 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 study entry (p = 0.03). Conclusion: Manometrically-guided endoscopic BTX-injection is a simple, safe 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 traditional method of BTX-application.