title: Treatment of achalasia: botulinum toxin injection vs. pneumatic balloon dilation. A prospective study with long-term follow-Up.
abstract: OBJECTIVE
  In patients with achalasia, intrasphincteric injection of botulinum toxin (BTX) has been suggested as an alternative regimen to balloon dilation and has been shown to be superior to placebo injection. The aim of the present study was to test the effectiveness, the long-term outcome and the cumulative costs of BTX injection in consecutive patients with symptomatic achalasia in comparison with pneumatic balloon dilation.
  
  
  METHODS
  37 patients, who presented with symptomatic achalasia between January 1994 and December 1996 were treated with either BTX injection (n = 23) or pneumatic dilation (n = 14). Patients with short-term or long-term symptomatic failures of the initial procedure were treated again, either with the same or with the alternative method, depending on the initial response and on the patient's wish. Symptoms were assessed using a global symptom score (0 - 10) which was evaluated before treatment and 1 week, 1 month and then every 6 months after the treatment. In addition, body weight and recurrence of symptoms were noted and manometry was carried out before and after treatment. The patients were regularly contacted for the long-term follow-up.
  
  
  RESULTS
  There were significant improvements in the global symptom scores of all patients treated, in both the BTX injection group (before 8.2 +/- 1.3, after 3.0 +/- 1.6) and the dilation group (before 8.3 +/- 1.1, after 2.3 +/- 1.9). There was also a significant decrease of lower esophageal sphincter pressure after treatment in the BTX group and the dilation group. There were no significant differences with regard to overall treatment failure and long-term outcome between patients who had or had not received previous treatment. No major complications were encountered in either group. An actuarial analysis over 48 months comparing patients receiving BTX injection or balloon dilation demonstrated that after 12 months neither therapy was significantly superior. After 24 months a single pneumatic dilation was superior to a single BTX injection, and after 48 months all patients treated by BTX injection had experienced a symptomatic relapse. In contrast, 35 % of all patients treated by dilation and 45 % of patients treated successfully by dilation were still symptom-free in an intention-to-treat analysis after 48 months. When the overall costs of treatment and further treatment after recurrence were compared, dilation and BTX injection showed a similar cost-effectiveness (costs per symptom-free day) after 48 months.
  
  
  CONCLUSIONS
  BTX injection, which can be performed in an outpatient setting, is as safe and cost-effective as balloon dilation in symptomatic achalasia. Taking into account the lower long-term efficacy of BTX injection therapy, however, it is an alternative only in a minority of older or high-risk patients.
authors.affiliation: Department of Internal Medicine II, Technical University of Munich, Klinikum rechts der Isar, Ismaninger Strasse 22, 81675 Munich, Germany. hans.allescher@lrz.tum.de
authors.forename: H D
authors.initials: HD
authors.lastname: Allescher
authors.forename: M
authors.initials: M
authors.lastname: Storr
authors.forename: M
authors.initials: M
authors.lastname: Seige
authors.forename: R
authors.initials: R
authors.lastname: Gonzales-Donoso
authors.forename: R
authors.initials: R
authors.lastname: Ott
authors.forename: P
authors.initials: P
authors.lastname: Born
authors.forename: E
authors.initials: E
authors.lastname: Frimberger
authors.forename: N
authors.initials: N
authors.lastname: Weigert
authors.forename: A
authors.initials: A
authors.lastname: Stier
authors.forename: M
authors.initials: M
authors.lastname: Kurjak
authors.forename: T
authors.initials: T
authors.lastname: Rösch
authors.forename: M
authors.initials: M
authors.lastname: Classen
mesh_terms: D000206:Actuarial Analysis; D000328:Adult; D000368:Aged; D018726:Anti-Dyskinesia Agents / Q000191:economics / Q000627:therapeutic use*; D001905:Botulinum Toxins / Q000191:economics / Q000627:therapeutic use*; D002404:Catheterization / Q000191:economics / Q000379:methods*; D003362:Cost-Benefit Analysis; D004931:Esophageal Achalasia / Q000628:therapy*; D005260:Female; D006801:Humans; D007267:Injections; D008297:Male; D008365:Manometry; D008875:Middle Aged; D011446:Prospective Studies; D012720:Severity of Illness Index; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D018726:Anti-Dyskinesia Agents; D001905:Botulinum Toxins