Bus-guided injection of botulinum toxin for achalasia

Purpose: Preliminary data has suggested that EUS-guided injection of Botox for treatment of achalasia may have an improved long term success rate compared to blind endoscopic injection. Here, we update our results from a previous report with a larger number of patients (pts) and longer follow-up Methods: The study population consists of 7 pts with manometrically confirmed achalasia. All patients underwent questioning in regard to symptoms of regurgitation, chest pain, and dysphagia before treatment and every 3 months after. They were scored based upon the following scale: 0,none; 1, occasionally; 2, daily; 3, with every meal. The maximum possible symptom score was nine; failure of treatment was considered a score of 3 or more. EUS was performed using the Pentax FG32UA linear array echoendoscope. A 4 cm long, 23 gauge needle was passed through the echoendoscope and advanced into the muscularis propria at the level of the LES under real-time EUS guidance. Four injections of 1 cc Botox (20u/cc) were made into the LES in different quadrants. An enlarging hypoechoic zone around the needle was seen as the Botox was injected. Results: Six of seven patients were tolerating a regular diet within 48 hours. Average follow-up was 6.5 months (range 1-13) with six of seven patients reporting no dysphagia, chest pain, or regurgitation (symptoms scores of 0 of 9). Two of the seven patients had had prior balloon dilatation. The seventh patient had undergone two prior Botox injections with blind endoscopic injection that failed; he also did not respond to EUS-guided injection.. Conclusion: EUS-guided Botox injection may have a better long term success (87% versus 66%) than endoscopic blind injection. In patients who have received two prior endoscopie injections of Botox, antibodies may form thus making EUS-guidance of no further benefit. Botox injection is recommended in those who have failed balloon dilatation.