title: Botulinum toxin injection for hypercontractile or spastic esophageal motility disorders: may high-resolution manometry help to select cases?
abstract: Endoscopic injections of botulinum toxin in the cardia or distal esophagus have been advocated to treat achalasia and spastic esophageal motility disorders. We conducted a retrospective study to evaluate whether manometric diagnosis using the Chicago classification in high-resolution manometry (HRM) would be predictive of the clinical response. Charts of patients with spastic and hypertensive motility disorders diagnosed with HRM and treated with botulinum toxin were retrospectively reviewed at two centers. HRM recordings were systematically reanalyzed, and a patient's phone survey was conducted. Forty-five patients treated between 2008 and 2013 were included. Most patients had achalasia type 3 (22 cases). Other diagnoses were jackhammer esophagus (8 cases), distal esophageal spasm (7 cases), esophagogastric junction outflow obstruction (5 cases), nutcracker esophagus (1 case), and 2 unclassified cases. Botulinum toxin injections were performed into the cardia only in 9 cases, into the wall of the distal esophagus in 19 cases, and in both locations (cardia and distal esophagus) in 17 cases. No complication occurred in 31 cases. Chest pain was noticed for less than 7 days in 13 cases. One death related to mediastinitis occurred 3 weeks after botulinum toxin injection. Efficacy was assessed in 42 patients: 71% were significantly improved 2 months after botulinum toxin, and 57% remained satisfied for more than 6 months. No clear difference was observed in terms of response according to manometric diagnosis; however, type 3 achalasia previously dilated and with normal integrated relaxation pressure (4s-integrated relaxation pressure < 15 mmHg) had the worst outcome: none of these patients responded to the endoscopic injection of botulinum toxin. Endoscopic injections of botulinum toxin may be effective in some patients with spastic or hypercontractile esophageal motility disorders. The manometric Chicago classification diagnosis does not seem to predict the results. Prospective randomized trials are required to identify patients most likely to benefit from esophageal botulinum toxin treatment.
authors.affiliation: Department of Digestive Diseases, Hospices Civils de Lyon, E. Herriot Hospital, Lyon, France.
authors.forename: S
authors.initials: S
authors.lastname: Marjoux
authors.affiliation: Department of Digestive Diseases, CHU Rennes, Rennes, France.
authors.forename: C
authors.initials: C
authors.lastname: Brochard
authors.affiliation: Department of Digestive Diseases, Hospices Civils de Lyon, E. Herriot Hospital, Lyon, France.|Department of Physiology, Lyon 1 University, Lyon, France.|Inserm U1032, LabTAU, Lyon, France.
authors.forename: S
authors.initials: S
authors.lastname: Roman
authors.affiliation: Department of Digestive Diseases, Hospices Civils de Lyon, E. Herriot Hospital, Lyon, France.
authors.forename: R
authors.initials: R
authors.lastname: Gincul
authors.affiliation: Department of Digestive Diseases, CHU Rennes, Rennes, France.
authors.forename: M
authors.initials: M
authors.lastname: Pagenault
authors.affiliation: Department of Digestive Diseases, Hospices Civils de Lyon, E. Herriot Hospital, Lyon, France.|Department of Physiology, Lyon 1 University, Lyon, France.|Inserm U1032, LabTAU, Lyon, France.
authors.forename: T
authors.initials: T
authors.lastname: Ponchon
authors.affiliation: Department of Digestive Diseases, CHU Rennes, Rennes, France.
authors.forename: A
authors.initials: A
authors.lastname: Ropert
authors.affiliation: Department of Digestive Diseases, Hospices Civils de Lyon, E. Herriot Hospital, Lyon, France.|Department of Physiology, Lyon 1 University, Lyon, France.|Inserm U1032, LabTAU, Lyon, France.
authors.forename: F
authors.initials: F
authors.lastname: Mion
mesh_terms: D065087:Acetylcholine Release Inhibitors / Q000008:administration & dosage*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001905:Botulinum Toxins / Q000008:administration & dosage*; D015154:Esophageal Motility Disorders / Q000145:classification / Q000188:drug therapy* / Q000503:physiopathology; D004945:Esophagoscopy / Q000379:methods; D004947:Esophagus / Q000503:physiopathology; D005260:Female; D006801:Humans; D007267:Injections / Q000379:methods; D008297:Male; D008365:Manometry / Q000379:methods; D008875:Middle Aged; D009128:Muscle Spasticity; D018579:Patient Selection; D011237:Predictive Value of Tests; D011312:Pressure; D012189:Retrospective Studies; D016896:Treatment Outcome
chemical_list: D065087:Acetylcholine Release Inhibitors; D001905:Botulinum Toxins
keywords: achalasia; distal esophageal spasm; endoscopic treatment; jackhammer esophagus