Botulinum for achalasia

Case: 58 years old male with known history of achalasia is admitted to ICU with aspiration pneumonia. Patient previously had refused surgical interventions for achalasia. Gastrointestinal (GI) service recommends botulinum toxin injection. Botulinum toxin therapy provides permanent cure for achalasia?

A) True

B) False

Answer: B

Achalasia can be cured or contained with various pharmacological and surgical interventions. The more definitive therapy are pneumatic dilation, surgical myotomy, or Peroral Endoscopic Myotomy (POEM). Botulinum toxin injection is a short-term procedure that provides relief for a few months. It has a high relapse rate. It can be repeated but makes other definite therapies difficult in the future.

Botulinum toxin is injected into the Lower Esophageal Sphincter (LES). It paralyzes the excitatory (acetylcholine-releasing) neurons and decreases the basal LES pressure. It makes esophageal emptying easy when esophageal pressures exceed the partially paralyzed LES.

#GI

References:

1. Khashab MA, Vela MF, Thosani N, et al. ASGE guideline on the management of achalasia. Gastrointest Endosc 2020; 91:213.

2. Campos GM, Vittinghoff E, Rabl C, et al. Endoscopic and surgical treatments for achalasia: a systematic review and meta-analysis. Ann Surg 2009; 249:45.

3. Smith CD, Stival A, Howell DL, Swafford V. Endoscopic therapy for achalasia before Heller myotomy results in worse outcomes than heller myotomy alone. Ann Surg 2006; 243:579.