Treatment of Achalasia by Injection of Sclerosant Substances: A Long-Term Report

Abstract

Endoscopic sclerotherapy (EST) with ethanolamine oleate (EO) was proposed as a treatment for achalasia, based on the well-known necrotizing effect against the esophageal muscle layers. The aim of this study is to evaluate long-term efficacy of EST. Four consecutive series of patients with achalasia were treated according to different schedules over a period of 20years, by using EO or polidocanol (PD). The primary outcome was dysphagia relief. Secondary outcomes were lower esophageal sphincter pressure, esophagogram, gastroesophageal reflux and endoscopic ultrasonography (EUS). Patients not responding to EST were treated with 30mm dilation. A total of 103 patients completed the treatment. On medium-term evaluation, 75 patients who completed the treatment reached a clinical response labeled as "good," 23 were assessed as "fair," and 5 were assessed as failures. EUS has become a very informative tool to guide the treatment. The overall follow-up lasted for 87.9±66.7months. Twelve patients experienced a late failure. The cumulative expectancy of being free of recurrence was 90% at 50months with EO, but it was only 65% with PD. Those patients who responded to rescue measures remained in good or fair clinical condition during the remaining follow-up. Young age, PD, and the so-called fusiform pattern on esophagogram proved to be significant predictors of poor prognosis. EST with EO is a promising alternative to classic therapies for achalasia. In contrast, PD-treated patients showed an important trend to fibrosis and clinical recurrence. Dilation seems particularly effective after EST, when this technique has failed.