title: Does botulinum toxin injection make esophagomyotomy a more difficult operation?
abstract: BACKGROUND
  Some patients with achalasia treated by botulinum toxin injection still require an esophagomyotomy. In this study, we analyzed the impact of botulinum toxin injection on the technical aspects and outcome of esophagomyotomy.
  
  
  METHODS
  We studied 57 patients, with a mean age of 46 years (range, 12-97) who were treated between January 1995 and March 1998 by esophagomyotomy performed via minimally invasive techniques by one team. Operative reports, videotapes, and clinical outcome were analyzed to define the technical difficulties, perforations, and outcome.
  
  
  RESULTS
  Fifteen of the 57 patients had received one or more injections of botulinum toxin (botox group) preoperatively. Difficulties in dissection of the submucosal plane were encountered in eight of the 15 cases (53.3%), and a mucosal laceration (perforation) occurred in two cases (13.3%). Forty-two of the 57 patients had not received any injections (non-botox group). In three patients (7%), difficulties in identifying or following the submucosal plane were encountered, although 29 patients had one or more previous dilations, and perforation occurred in one case (2.4%). All mucosal injuries were repaired laparoscopically, and the patients recovered without obvious sequelae. Dysphagia improved significantly after the operation in both groups (botox group, from preoperative score of 3. 8 to a postoperative score of 0.7; non-botox, from a score of 3.4 preoperatively to 0.5 postoperatively). Regurgitation also improved in both groups (botox, 2.7 preoperatively, 0.92 postoperatively; non-botox group, 2.0 preoperatively, 0.56 postoperatively).
  
  
  CONCLUSIONS
  Injection of botulinum toxin significantly increases the technical difficulties and thus the potential risk of esophagomyotomy. The immediate results were equally good for both groups in our series, but the long-term sequelae of repeated injections are unknown. Laparoscopic Heller myotomy is a safe and effective procedure even after unsuccessful treatment with botulinum toxin.
authors.affiliation: Department of Surgery, University of Washington, 1959 NE Pacific Street, Box 356410, Seattle, WA 98195, USA.
authors.forename: S
authors.initials: S
authors.lastname: Horgan
authors.forename: K
authors.initials: K
authors.lastname: Hudda
authors.forename: T
authors.initials: T
authors.lastname: Eubanks
authors.forename: J
authors.initials: J
authors.lastname: McAllister
authors.forename: C A
authors.initials: CA
authors.lastname: Pellegrini
mesh_terms: D018726:Anti-Dyskinesia Agents / Q000008:administration & dosage* / Q000627:therapeutic use; D001905:Botulinum Toxins / Q000008:administration & dosage* / Q000627:therapeutic use; D016022:Case-Control Studies; D004931:Esophageal Achalasia / Q000188:drug therapy / Q000601:surgery*; D004943:Esophagogastric Junction; D004947:Esophagus / Q000601:surgery*; D006801:Humans; D007267:Injections; D007431:Intraoperative Complications / Q000209:etiology; D010535:Laparoscopy; D011446:Prospective Studies; D016896:Treatment Outcome
chemical_list: D018726:Anti-Dyskinesia Agents; D001905:Botulinum Toxins