Efficacy of botulinum toxin injection before pneumatic dilatation in patients with idiopathic achalasia

Abstract

Graded pneumatic dilatation (PD) is an appropriate long-term therapy and botulinum toxin injection (BT) is a relatively short-term therapy in idiopathic achalasia. Their combination has not been previously scrutinized. This study aimed to evaluate the role of BT in enhancing the efficacy of PD with 30 mm balloons. Patients who underwent PD with 30 mm balloons after botulinum toxin injections and a group of age- and sex-matched controls who were treated only with PD were enrolled in the study. Symptom scores were taken before, 1 month after and then every 3 months after PD. There were no significant differences between the two groups in gender, duration or severity of symptoms. One of the 12 patients in the case group relapsed 30 months after PD but the others were in remission for an average of 25.6 months. In the control group, all the patients relapsed after a mean of 12.6 months and needed a 35-mm PD. The cumulative remission rate was significantly higher in the case group compared with the control group (P < 0.01). The mean symptom score decreased by 76% in the case group (P < 0.001) and 53% in the controls (P < 0.01) at the end of the first month. Neither age, sex, nor duration or severity of symptoms were predictive of patients' responses to treatment. It seems that BT may be a meaningful enhancing factor in long-term efficacy of PD. PD with a 30 mm balloon after a BT session may resolve the need for the future higher grade PD.

Achalasia: A review of Western and Iranian experiences

“…One month after dilation, the mean symptom score decreased by 76% in the combined therapy group and by 53% in the control group. Age, sex, duration and severity of symptoms were not correlated with response to treatment [93] . We also conducted a prospective trial.…”

Review article: the management of achalasia – a comparison of different treatment modalities1

“…The treatment with botulinum toxin injection may have a beneficial effect on subsequent pneumatic dilatations and initial data report that response to subsequent dilatations may be enhanced by prior injection with botulinum toxin. 26 The consequence of prior injections of botulinum toxin in patients that subsequently require surgical therapy remains controversial. 27,28 Additionally, botulinum toxin has been used in patients in whom the surgical myotomy or pneumatic dilatation is unsuccessful.…”

Clinical Study on Combined Therapy of Botulinum Toxin Injection and Small Balloon Dilation in Patients with Esophageal Achalasia

“…However, BT injection can only induce a temporary symptomatic remission in some patients with achalasia. Mikaeli et al [4] reported that treatment with BT was effective only in the short-term and repeated injections were needed to maintain remission. Our study suggested that the response rate to 100 U BT injection decreased from 89.65% at 30 days after the treatment to 55.17% at 1 year after the treatment and, additionally, 13.79% (4/29) patients still had response to BT injection at 2 years after treatment.…”

“…The effect of a single injection of BT wanes over time, without precise explanations. It is possible that the atrophy of postsynaptic nerve ending and muscle, secondary to block of acetylcholine release at presynaptic sites, is reversible [4]. …”

“…The severity of each of these symptoms was scored on a scale of 0–3 as described elsewhere (0 = none; 1 = weekly; 2 = daily, 3 = in each meal) for solid dysphagia, liquid dysphagia and active regurgitation, and (0 = none; 1 = monthly; 2 = weekly, 3 = daily) for passive regurgitation and chest pain [4,5]. The highest obtainable score was 15.…”