In-office transnasal esophagoscope-guided botulinum toxin injection of the lower esophageal sphincter

Abstract

Thin caliber transnasal esophagoscopes allow for a rapidly expanding array of office-based esophageal procedures, including botulinum toxin injections, in unsedated patients. While botulinum toxin has been used in the esophagus and lower esophageal sphincter for many years, there is no current description of performing this procedure in an unsedated patient using transnasal esophagoscopy. Indications include achalasia, hypertensive lower esophageal sphincter, distal esophageal spasm, nutcracker esophagus and obstructing muscular rings. There is a paucity of data in the literature pertaining to spastic esophageal motility disorders and muscular rings. Randomized controlled trials of achalasia treatments suggest that botulinum toxin injections should be reserved for patients who are poor surgical candidates and/or have failed pneumatic dilation. In-office transnasal esophagoscopy-guided lower esophageal sphincter botulinum toxin injection has not been described in the literature. Indications include esophageal spasm, muscular rings and achalasia, with recent data suggesting that botulinum toxin should not be an initial therapy for most patients with achalasia.