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Background and Aims: Injection of botulinum toxin (BT) from direct vision into the lower esophageal sphincter (LES) lowers its basal tone and improves symptomatology in most of the patients with achalasia. We hypothesized that the effect could be improved by better degree of LES infiltration by toxin administered from both prograde and retrograde views. The aim of the study was to investigate the feasibility, safety and efficacy of this modified method of intrasphincteric BT injection in patients with achalasia., Patients and Method: Sixteen patients with achalasia were treated with BT injection. Hundred units of BT (Botox) were diluted with 4 ml of normal saline. Aliquots of 0.5 ml were injected into four quadrants of the LES from retrovision and then into each quadrant from direct vision. The patients were followed up for a median of 25.5 months (range 19-31)., Results: No serious adverse events were noted. All patients responded well to the injection within one week and 3 patients (18.7 %) experienced an early relapse. The remaining 13 patients were classified as responders. After a single BT injection, 11 responders reported a relapse and 2 patients remained asymptomatic. The median symptom-free interval was 17 months (8-28). Five patients with a relapse underwent BT reinjection. Three of them remained asymptomatic and two experienced the second relapse. After BT reinjection, the median symptom-free interval was 16 months (10-19). All other patients with a relapse and without BT reinjection were treated with either balloon dilatation or surgery and are currently asymptomatic., Conclusion: Combining injection of BT into the LES from both direct vision and retrovision was feasible, safe and produced a rapid response which was sustained for more than 1 year in the majority of patients. This method of BT administration might be superior to the traditional injection from direct view only, and a randomized and prospective study comparing those techniques of administration should be performed.

Background and Study Aims: 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., Patients and 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)., Conclusion: 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.