Efficacy and safety of a novel technique using endoscopic ultrasound—guided fine-needle injection of botulinum toxin and balloon dilation in achalasia

Abstract

Background and Aims

Achalasia is an esophageal motility disorder characterized by the inability of the lower esophageal sphincter to relax. Endoscopic methods are currently the mainstay treatment of achalasia and include local administration of botulinum toxin (Botox; Allergan Aesthetics, Westport, Ireland), pneumatic dilation, and peroral endoscopic myotomy. Botox injections traditionally have been performed by standard endoscopy, which lacks precision requiring frequent interventions. Our study introduces a novel technique using endoscopic ultrasound—guided fine-needle injection of Botox combined with controlled radial expansion balloon dilation (EUS-BTID) for treating achalasia. We hypothesize that this combined approach will enhance the efficacy and offer a favorable safety profile compared with standard endoscopic Botox injection.

Methods

We conducted a single-center retrospective study to evaluate the efficacy and safety of a novel technique using EUS-BTID to treat achalasia using electronic medical records.

Results

Our study included a total of 43 patients, with a mean age of 76 years (standard deviation 14 years). The most frequent achalasia subtype was type II (46%). Among 16 patients (37.2%) who underwent multiple sessions of EUS-BTID, the number of sessions ranged from 2 to 14, with the 14-session maximum occurring in a single patient. The average interval between repeat procedures across all patients was 273 days. The primary outcome of improved dysphagia scores, measured by the Eckardt score, was observed in 86.7% of patients, with 70.0% achieving scores indicative of complete remission. After EUS-BTID, the median Eckhardt score significantly improved from 6 (interquartile range, 4-7) to 2 (interquartile range, 1-4) (P < .0001). No serious adverse events were reported; only 2 patients (4.6%) experienced mild transient postprocedural symptoms, including chest discomfort and emesis.

Conclusion

The novel EUS-BTID technique appears to be an effective and safe treatment option for achalasia. The combination of endoscopic ultrasound—guided Botox injection and balloon dilation offers significant improvements in symptom relief with a favorable safety profile and durability and can be applied in high-risk patients or probably as a bridge to more definitive therapy. Although our study provides encouraging evidence supporting the use of EUS-BTID, further research is required to validate these findings.