Long-Term Results of Endoscopic Injection of Botulinum Toxin in Elderly Achalasic Patients with Tortuous Megaesophagus or Epiphrenic Diverticulum

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Abstract
Achalasia is characterized by aperistalsis of the tubular esophagus and a failure of the lower esophageal sphincter (LES) to relax, because of selective loss of inhibitory neurons of the myenteric plexus [ 1 ]. Since the first use of bougienage in 1672, the treatment of achalasia has been aimed at reducing the contractile LES forces. Today this is done preferentially by pneumatic dilation or cardiomyotomy [ 2 ] [ 3 ] [ 4 ] [ 5 ] [ 6 ] [ 7 ] [ 8 ] [ 9 ] [ 10 ] [ 11 ]. While the results of cardiomyotomy are particularly favorable in younger patients, at present enforced pneumatic dilation is considered to be the standard treatment for older achalasia patients [ 1 ] [ 7 ] [ 8 ] [ 10 ] [ 11 ]. The procedure, however, carries a significant risk of esophageal perforation, which may become a problem in elderly patients with concomitant illness [ 2 ] [ 3 ] [ 4 ] [ 5 ] [ 6 ] [ 7 ] [ 8 ] [ 9 ] [ 10 ] [ 11 ]. Additionally, the risk of perforation during pneumatic dilation may be increased in the presence of a tortuous megaesophagus and/or an epiphrenic diverticulum. Therefore, elderly achalasia patients with concomitant illness and epiphrenic diverticula or a tortuous megaesophagus seem to be the best candidates for alternative forms of treatment. In this respect, the endoscopically guided injection of botulinum toxin (BTX), a potent inhibitor of acetylcholine release from presynaptic cholinergic nerve endings, into the gastric cardia of achalasia patients has shown promising results [ 12 ] [ 13 ] [ 14 ] [ 15 ] [ 16 ] [ 17 ] [ 18 ] [ 19 ]. In addition, BTX injection is reported to be safe and is associated with only minor side effects and complications [ 12 ] [ 13 ] [ 14 ] [ 15 ] [ 16 ] [ 17 ] [ 18 ] [ 19 ]. In the trial reported here, we prospectively evaluated the efficacy and safety of botulinum toxin treatment in achalasia patients aged more than 60 years and with concomitant risk factors which rendered pneumatic dilation very risky.

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