title: Long-term results of endoscopic injection of botulinum toxin in elderly achalasic patients with tortuous megaesophagus or epiphrenic diverticulum.
abstract: OBJECTIVE
  Recent studies suggest that endoscopic injection of botulinum toxin (BTX) for achalasia is a safe procedure giving short-term relief of symptoms mainly in elderly patients (> 50 years). The aim of the study was to evaluate the clinical efficacy of periodic BTX treatments in high risk achalasia patients.
  
  
  METHODS
  A total of 20 consecutive achalasia patients, aged > 60 years (11 women; 71+/-11 years), with general (ASA class III or IV) and local risk factors (i.e. tortuous megaesophagus or epiphrenic diverticulum) for complications associated with pneumatic dilation, were treated by local injection of 100 U of BTX into the gastric cardia, using the four-quadrant technique. The patients were prospectively followed for a median period of 2 years (range 5-48 months), using a symptom score (1-14 points) and barium esophagograms.
  
  
  RESULTS
  Symptomatic improvement (decrease of the symptom score > or = 3 points) was found in 16/20 patients (80%), 6 weeks after the first BTX injection, and the cardia diameter increased from 2.1+/-0.7 to 3.2+/-1.2 mm (P < 0.01) (data are means +/- SD). Those patients who initially responded to BTX treatment developed a symptomatic relapse after a median follow-up of 5+/-2 months. They were treated by subsequent BTX re-injections (2.5+/-1 sessions per patient, range 1-5) resulting in longer lasting symptom relief (10+/-3 months, P < 0.05 vs. initial BTX injection). At completion of the study, 14/20 high risk achalasia patients (70 %) treated with periodic BTX injections are still in clinical remission. One further patient died without relapse 6 months after a single BTX treatment as a consequence of progressive heart failure. Four patients who did not respond to BTX injection were successfully and uneventfully treated by careful pneumatic dilation (n = 3) or percutaneous endoscopic gastrostomy (n = 1).
  
  
  CONCLUSIONS
  Endoscopic botulinum toxin injection has reasonable long-term efficacy and safety in elderly achalasia patients who are at increased risk with regard to pneumatic dilation.
authors.affiliation: Medizinische Klinik II, Klinikum der J. W. Goethe Universität, Frankfurt am Main, Germany. t.wehrmann@em.uni-frankfurt.de
authors.forename: T
authors.initials: T
authors.lastname: Wehrmann
authors.forename: H
authors.initials: H
authors.lastname: Kokabpick
authors.forename: V
authors.initials: V
authors.lastname: Jacobi
authors.forename: H
authors.initials: H
authors.lastname: Seifert
authors.forename: B
authors.initials: B
authors.lastname: Lembcke
authors.forename: W F
authors.initials: WF
authors.lastname: Caspary
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D018726:Anti-Dyskinesia Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D001905:Botulinum Toxins / Q000008:administration & dosage / Q000627:therapeutic use*; D002299:Cardia; D004936:Diverticulum, Esophageal / Q000150:complications* / Q000000981:diagnostic imaging / Q000188:drug therapy; D016145:Endoscopy, Digestive System; D004931:Esophageal Achalasia / Q000150:complications / Q000000981:diagnostic imaging / Q000188:drug therapy*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007267:Injections / Q000379:methods; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D011859:Radiography; D012449:Safety; D016896:Treatment Outcome
chemical_list: D018726:Anti-Dyskinesia Agents; D001905:Botulinum Toxins