Randomized controlled trial of botulinum toxin versus laparoscopic heller myotomy for esophageal achalasia.
OBJECTIVE
To compare laparoscopic cardia myotomy and fundoplication with botulinum toxin (BoTx) injection in patients with esophageal achalasia.


BACKGROUND
Although myotomy is thought to offer better results, recent studies have reported 80% success rates after 2 BoTx injections a month apart. No randomized controlled trials comparing the 2 treatments have been published so far.


METHODS
Newly diagnosed achalasia patients were randomly assigned to BoTx injection or laparoscopic myotomy. Symptoms were scored; lower esophageal sphincter resting and nadir pressures were measured by manometry; barium swallow was used to assess esophageal diameter pre- and post-treatment. Eight to one hundred units of BoTx were injected twice, a month apart, at the esophagogastric junction. Myotomy included anterior partial (Dor) or Nissen fundoplication.


RESULTS
Eighty patients were involved in the study: 40 received BoTx and 40 underwent myotomy. Mortality was nil. One surgical patient bled from the trocar site. Median hospital stay was 6 days for surgery; BoTox patients were treated as day-hospital admissions. All patients completed the follow-up. After 6 months, the results in the 2 groups were comparable, although symptom scores improved more in surgical patients (82% confidence interval [CI] 76-89 vs. 66% CI 57-75, P < 0.05). The drop in lower esophageal sphincter pressure was similar in the 2 groups; the reduction in esophageal diameter was greater after surgery (19% CI 13-26 vs. 5% CI 2-11, P < 0.05). Later on, symptoms recurred in 65% of the BoTx-treated patients and the probability of being symptom-free at 2 years was 87.5% after surgery and 34% after BoTx (P < 0.05).


CONCLUSIONS
Laparoscopic myotomy is as safe as BoTx treatment and is a 1-shot treatment that cures achalasia in most patients. BoTx should be reserved for patients who are unfit for surgery or as a bridge to more effective therapies, such as surgery or endoscopic dilation.
Zaninotto
Giovanni
G
Department of Medical and Surgical Sciences, Clinica Chirurgica 4, University of Padova, Padova, Italy. giovanni.zaninotto@unipd.it
Annese
Vito
V
Costantini
Mario
M
Del Genio
Alberto
A
Costantino
Michela
M
Epifani
Magdalena
M
Gatto
Giovanni
G
D'onofrio
Vittorio
V
Benini
Luigi
L
Contini
Sandro
S
Molena
Daniela
D
Battaglia
Giorgio
G
Tardio
Berardino
B
Andriulli
Angelo
A
Ancona
Ermanno
E
D000293:Adolescent; D000328:Adult; D000368:Aged; D018726:Anti-Dyskinesia Agents / Q000627:therapeutic use*; D001905:Botulinum Toxins / Q000627:therapeutic use*; D003679:Deglutition; D013505:Digestive System Surgical Procedures; D004931:Esophageal Achalasia / Q000601:surgery*; D004943:Esophagogastric Junction / Q000502:physiology; D005260:Female; D006801:Humans; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged
D018726:Anti-Dyskinesia Agents; D001905:Botulinum Toxins