Endoscopic Botulinum Toxin Injection Research Articles

S1887 Efficacy of Endoscopic Intrapyloric Injection of Botulinum Toxin in the Treatment of Gastroparesis: A Systematic Review and Meta-Analysis

S1887 Efficacy of Endoscopic Intrapyloric Injection of Botulinum Toxin in the Treatment of Gastroparesis: A Systematic Review and Meta-Analysis

Protocol of a randomised controlled phase II clinical trial investigating PREoperative endoscopic injection of BOTulinum toxin into the sphincter of Oddi to reduce bile leakage after hepatic resection: the PREBOT-II trial

IntroductionBile leakage represents a major cause of morbidity following hepatic resection. Although most patients can be managed non-operatively, this complication requires diagnostics and therapeutic interventions. Preoperative endoscopic injection of botulinum...

Endoscopic Botulinum Toxin Injection for Infantile Cricopharyngeal Achalasia: Long Term Effects of a Single Procedure - A Case Report

Background: The cricopharyngeus muscle forms the Upper Esophageal Sphincter and separates the esophagus from the hypopharynx. Its main function is to prevent reflux of gastric contents causing Laryngo-Pharyngeal Reflux. Achalasia secondary to cricopharyngeal muscle dysfunction is more common in adults, the treatment of which would be a cricopharyngeal myotomy. However when this is encountered in the pediatric age group, the challenge lies in accurately diagnosing it and choosing the appropriate management option. We would like to report one such case of cricopharyngeal spasm causing achalasia in an infant presenting with failure to thrive and aspiration pneumonitis and was diagnosed and treated with endoscopic botulinum toxin injection, a minimally invasive procedure and associated with less morbidity, early recovery times and significant improvement of symptoms. Positive response to the minimally invasive method of Inj.Botulinum Toxin with minimal morbidity can always be reassuring of a successful cricopharyngeal myotomy, if required, at a later date. Hence, a trial of Inj.Botulinum Toxin in an otherwise rare condition with a difficult diagnosis can be a safe approach in the pediatric age group and can help prognosticate the role of second stage cricopharyngeal myotomy, if required. Objectives: Minimally invasive procedure on an infant with achalasia secondary to cricopharyngeal spasm presenting with failure to thrive and aspiration pneumonia. Methods: Injecting Botulinum toxin into cricopharyngeal sphincter endoscopically. Results: Positive response seen in the infant evidenced by weight gain and tolerance to solid feeds. Conclusion: Positive response to the minimally invasive method of Inj.Botulinum Toxin with minimal morbidity can always be reassuring of a successful cricopharyngeal myotomy, if required, at a later date. Keywords: Cricopharyngeus, Achalasia, Infant, Endoscopic Botulinum toxin injection

Endoscopic intragastric injection of botulinum toxin in the treatment of patients with morbid obesity: opportunities and prospects

The authors consider modern epidemiological and demographic data on morbid obesity. Literature review is devoted to non-surgical treatment of patients with morbid obesity. The authors analyze the results of experimental and clinical studies on endoscopic intragastric injection of botulinum toxin and bariatric efficacy of this approach. The indications for endoscopic intragastric injection of botulinum toxin and advantages of this technique are clearly formulated. The authors identified the most significant criteria for objective assessment of clinical effectiveness of endoscopic intragastral injection of botulinum toxin, as well as scientific and methodological principles necessary for this technique. Clinical efficacy of intragastric injection of botulinum toxin including overweight loss, anorexigenic and gastroparetic effects indicates inconsistent results and certain unresolved problems. Thus, large-scale multiple-center randomized controlled trials and multivariate analysis are required to determine the role of endoscopic intragastric injection of botulinum toxin in complex treatment of patients with morbid obesity.

THE TREATMENT OF GASTROESOPHAGEAL REFLUX IN PATIENTS AFTER SLEEVE GASTRECTOMY IN THE NEAREST POSTOPERATIVE PERIOD

Purpose of the study is to evaluate the effectiveness of treatment of gastroesophageal reflux disease in patients after sleeve gastrectomy using botulinum toxin injections into the pylorus.Materials and research methods. A prospective controlled study of 42 patients undergoing laparoscopic sleeve gastrectomy with a postoperative period of one to six months. The patients were divided into two groups: the main group (21 patients) underwent complex treatment, including basic conservative therapy, supplemented by endoscopic injection of botulinum toxin into the pylorus; the comparison group (23 patients) received only basic conservative therapy. All patients included in the study were questioned using the GERD-HRQL questionnaire.Research results. In the main group, one month after the botulinum toxin injection, the overall score according to the GERD-HRQL questionnaire reliably reflected the positive dynamics in the course of gastroesophageal reflux disease. Six months after the start of treatment in the main group, the average score was significantly lower than in the comparison group (p  0,05), and the general satisfaction of patients with respect to control over symptoms of gastroesophageal reflux was 85% (satisfactory + neutral). In the comparison group, after 6 months, there was no significant and reliable dynamics, and the general dissatisfaction with the state remained at the level of 65%.Conclusion. Basic conservative therapy in combination with the procedure of endoscopic injection of botulinum toxin into the pylorus effectively helps to reduce the clinical manifestations of gastroesophageal reflux in the immediate postoperative period after sleeve gastrectomy.

Endoscopic Intragastric Injection of Botulinum Toxin A in Obese Patients Accelerates Weight Loss after Bariatric Surgery: Follow-Up of a Randomised Controlled Trial (IntraTox Study).

Background: Intragastric injection of botulinum toxin A (BT-A) has been shown to be effective for weight loss up to six months after administration, according to previous studies. Our objective was to determine, in patients on bariatric surgery waiting lists, the effect of BT-A on weight loss in the pre- and postoperative period and to analyse if there are different responses based on Body Mass Index (BMI). Methods: We performed a follow-up analysis of the IntraTox study, which included 46 patients on bariatric surgery waiting lists in a single-centre, randomised, double-blind, placebo-controlled clinical trial. The treatment group received intragastric BT-A, whereas the control group received physiological saline solution. The one-time procedure was performed at the time of diagnostic endoscopy 7–8 months before surgery. Weight loss was evaluated at admission and after 4 and 12 weeks from the bariatric surgery. Our analysis was stratified by BMI at randomisation. Results: weight loss percentage on the day of surgery, with respect to the initial visit, was −4.5 ± 3.9% for the control group vs. −7.6 ± 4.2%, for the treatment group (p = 0.013). Weight loss percentage tended to remain greater in the treatment group one month after the intervention (−12.7 ± 4.7% vs. −15.2 ± 4.6%, p = 0.07) and become similar three months after (−21.6 ± 4.7% vs. −21.6 ± 4.6%). After stratifying by BMI, only patients with BMI over 50 kg/m2 allocated to the treatment group obtained a greater weight loss at the end of the trial, the day of surgery, and one month after, compared with the placebo group (−4.9 ± 4.9%, −10.8 ± 5.3% and −17.1 ± 3.8% vs. −0.1 ± 2.6%, −4.3 ± 3.2% and −12.8 ± 4.1%, respectively (p < 0.05). Conclusions: intragastric injection of BT-A is effective to achieve significant weight loss, especially in extreme obesity. Its use before bariatric surgery enhances perioperative weight loss.

Per oral endoscopic myotomy for achalasia: A Taiwanese single‐center experience

AbstractEndoscopic treatment of achalasia includes endoscopic botulinum toxin injection, endoscopic pneumatic dilations (PD) but surgery owns longer durability. Per oral endoscopic myotomy (POEM) carries high expectations with good short and mid‐term report and only minor morbidity in Western and Eastern countries outside Taiwan. The purpose of this study is to report a 2‐year clinical outcome and safety of POEM among a prospective registered achalasia cohort in southern Taiwan. We, retrospectively, analyzed 22 prospective registered patients who received POEM for achalasia, adhered and completed 2‐year regular follow‐up studies between July 2015 and December 2020 from Kaohsiung Chang Gung Memorial Hospital, Taiwan. Then, 22 of achalasia patients (8 males: 14 females) were enrolled into this study (male/female: 8/14, mean age: 45.0 years). All 22 patients had received high‐resolution manometry to diagnose and classify the phenotype. Fifteen patients were diagnosed as type I achalasia and seven as type II by Chicago classification. Clinical remission rates were 100% at 3 months, 6 months, 1 year, and 95.5% at 2 years. Four patients who recurred after previous PD were successfully treated with POEM with clinical remission. Three patients had fever after POEM. Two patients (9.1%) had gastroesophageal reflux disease (GERD) after POEM procedure. POEM is an effective and safe treatment of choice for achalasia with 95.5% of 2‐year clinical remission in this Taiwanese study. Post‐POEM GERD is low in the current study but the concern for potential GERD needs long‐term follow‐up reports to further clarify especially with larger scale quality studies.

Endoscopic Botulinum Toxin Injection for Refractory Enuresis Based on Urodynamic Assessment.

PurposeThis study aimed to determine the urodynamic characteristics of refractory enuresis and explored whether those characteristics can be managed through differential endoscopic injections with botulinum toxin.MethodsIn total, 27 patients with nonmonosymptomatic enuresis who showed no response after conservative treatment for more than 12 months were included. The patients then underwent a videourodynamic study and received a differential endoscopic injection of botulinum toxin on the same day. Reduced capacity, detrusor overactivity, and bladder neck widening were the 3 major abnormal findings assessed during the filling phase, while sphincter hyperactivity was the only abnormality assessed during the emptying phase. An intravesical or intrasphincteric injection of botulinum toxin was attempted according to the videourodynamic study findings. Follow-up was conducted at 1, 3, 6, and 12 months after treatment.ResultsThe median age was 10 years (range, 7–31 years). Although 19 and 8 patients had a preoperative diagnosis of overactive bladder or dysfunctional voiding, respectively, the urodynamic diagnosis was different in more than half of the patients. Those showing detrusor overactivity benefited from intravesical botulinum toxin injection, whereas those with only sphincter hyperactivity benefited from both intravesical and intrasphincteric injections. Treatment resistance to botulinum toxin seemed to be attributable to bladder neck widening. Time had no apparent effect on efficacy, which persisted 6 months after the injection. More than 80% of the patients maintained the benefits of the injection after 1 year.ConclusionsVideourodynamic studies were useful for identifying the reasons underlying refractory nonmonosymptomatic enuresis and helpful for determining the appropriate site of botulinum toxin injection.

Comparison of endoscopic injection of botulinum toxin and steroids immediately after endoscopic submucosal dissection to prevent esophageal stricture: a prospective cohort study.

Background: Widespread endoscopic submucosal dissection (ESD) in early esophageal cancer patients is closely associated with esophageal stricture, which dramatically reduces patients' quality of life and increases huge medical burdens. Endoscopic injection of steroid was proved as a protective method for post-ESD strictures. Other materials such as botulinum toxin type A (BTX-A) may be potential candidates. We conducted this prospective cohort study to compare the efficacy and feasibility of endoscopic injection of BTX-A and triamcinolone acetonide (TA) for the prevention of esophageal stricture.Methods: Seventy-eight patients with esophageal mucosal defects of more than two thirds of the circumference were successively enrolled and divided into 3 groups: BTX-A group (group A, n=26), TA group (group B, n=16) and control group (group C, n=36). Patients in group A were immediately injected with BTX-A after ESD, in group B were immediately injected with TA and in group C received ESD only. Endoscopy was performed when patients reported dysphagia symptoms and at 6 and 12 weeks post-ESD in patients without symptoms. Patients who experienced post-ESD esophageal strictures in all groups received bougie dilation. All patients were followed up for one year.Results: The proportion of patients developing stricture in BTX-A group was 30.00% (intention to treat analysis, 9/30) and 26.92% (per protocol analysis, 7/26), in TA group was 40.90% (intention to treat analysis, 9/22) and 43.75% (per protocol analysis, 7/16), and in control group was 84.21% (intention to treat analysis, 32/38) and 83.33% (per protocol analysis, 30/36) (p<0.001). When further comparing between each of the two groups, the incidence of esophageal stricture was lower in BTX-A group than that in control group (p<0.001), and lower in TA group than that in control group (p=0.004). Furthermore, in entire circumference mucosal defect subgroup, the esophageal stricture was significantly lower in BTX-A group than that in TA group (33.3% vs 100%, p=0.0454).Conclusions: Endoscopic injection of BTX-A and TA were effective in preventing post-ESD esophageal strictures and BTX-A injection was particularly effective in entire circumference mucosal defect patients. Multi-centered, randomized prospective study with larger sample size should be conducted. (Clinical trial registration number: ChiCTR2100042970, registered 1 February 2021, retrospectively registered, http://www.chictr.org.cn/listbycreater.aspx)

Endoscopic intragastric injection of botulinum toxin A in obese patients on bariatric surgery waiting lists: A randomised double-blind study (IntraTox study)

Several studies have evaluated the effect of intragastric injection of botulinum toxin A to treat obesity, achieving mixed results. Our objective is to determine the effect of intragastric botulinum toxin A on weight loss, satiety, biomarkers, and quality of life of obese patients prior bariatric surgery. Design: single-centre, randomised, double-blind, placebo-controlled clinical trial in 52 obese patients on bariatric surgery waiting lists. Two-arm parallel: the treatment group was administered intragastric botulinum toxin A by endoscopy, whereas the control group was administered physiological saline solution. Weight loss was evaluated at weeks 2, 4, 8, 16, and 24, as well as changes in body composition, satiety (Visual analogue scale (VAS) and GCSI questionnaire), quality of life (GIQLI questionnaire), and biomarkers of satiety and appetite. Weight loss at weeks 2, 4, 8, 16, and 24 after the endoscopy, with respect to the basal visit, was 0.6±2kg, 0.4±2.7kg, 0.4±3.1kg, 0.2±4.5kg, and 0.6±4.3kg for the control group vs 1.9±2.1kg, 2±2.6kg, 2.8±4.1kg, 3.5±5.3kg, and 4.5±7kg for the treatment group, respectively, being differences between groups significant at all times (p=0.016, 0.031, 0.014, 0.021, and 0.023, respectively). Treatment group patients obtained a significantly higher score for GIQLI questionnaire compared with baseline (104.4±13.9 points vs 97.7±15.6 points; p=0.024), showing a significant improvement in the section of subjective physical capacity. No significant differences were found regarding perception of satiety, or biomarkers of satiety and appetite. Intragastric injection of botulinum toxin A is an effective and safe procedure to achieve a moderate weight loss and improve quality of life. Registered under clinicaltrialsregister.eu Identifier EudraCT number 2015-004391-29 https://www.clinicaltrialsregister.eu/ctr-search/trial/2015-004391-29/ES.

Protocol of a randomised controlled phase II clinical trial investigating PREoperative endoscopic injection of BOTulinum toxin into the sphincter of Oddi to reduce postoperative pancreatic fistula after distal pancreatectomy: the PREBOTPilot trial

IntroductionPostoperative pancreatic fistula (POPF) is still the most frequently occurring and clinically relevant complication after distal pancreatectomy (DP). Preoperative endoscopic injection of botulinum toxin (BTX) into the sphincter of Oddi...

Peroral endoscopic myotomy for management of gastrointestinal motility disorder.

Achalasia is a type of esophageal motility disorder, consisting of relaxation dysfunction of the lower esophagus and disturbed esophageal peristalsis. Related clinical symptoms include dysphagia, regurgitation, chest pain, and weight loss. Traditional treatment options include endoscopic botulinum toxin injection, endoscopic pneumatic dilation, and laparoscopic Heller's myotomy. These therapies mainly relieve symptoms by reducing the pressure on the lower esophageal sphincter and reducing blood flow resistance at the esophagogastric junction. Based on endoscopic submucosal dissection and natural orifice transluminal endoscopic surgery, peroral endoscopic myotomy (POEM) is a purely endoscopic method of myotomy with minimal invasiveness and a low rate of adverse events when performed by experienced operators. Since then, numerous studies have shown the significant clinical efficacy and safety of POEM. The purpose of this article is to introduce different modified POEMs, special indications for different POEMs, and their advantages as well as disadvantages.

Mycotic aneurysm of the distal thoracic aorta after botulinum toxin injection for esophageal dysmotility

Endoscopic injection of botulinum toxin is a common method to treat esophageal dysmotility and achalasia. Patients undergoing this procedure who subsequently present with abdominal or back pain and constitutional symptoms should be evaluated for possible complications of the procedure, including occult esophageal perforation, mediastinitis, and mycotic aneurysm of the thoracic aorta. The case described herein illustrates the importance of serial imaging in a patient with persistent symptoms after botulinum toxin injection to identify and to treat occult aortic inoculation leading to mycotic aneurysm before sepsis and aortic rupture ensue with their attendant morbidity and mortality risks.

Endoscopic management of gastrointestinal motility disorders – part 1: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

ESGE recommends the use of a graded pneumatic dilation protocol in achalasia, starting with a 30-mm dilation and followed by a 35-mm dilation at a planned interval of 2 - 4 weeks, with a subsequent 40-mm dilation when there is insufficient relief, over both a single balloon dilation procedure or the use of a larger balloon from the outset.Strong recommendation, high quality of evidence, level of agreement 100 %.ESGE recommends being cautious in treating spastic motility disorders other than achalasia with peroral endoscopic myotomy (POEM).Strong recommendation, very low quality of evidence, level of agreement 87.5 %.ESGE recommends against the routine use of botulinum toxin injections to treat patients with non-achalasia hypercontractile esophageal motility disorders (Jackhammer esophagus, distal esophageal spasm). However, if, in individual patients, endoscopic injection of botulinum toxin is chosen, ESGE recommends performing injections into four quadrants of the lower esophageal sphincter and in the lower third of the esophagus.Strong recommendation, low quality of evidence, level of agreement 78.6 %.ESGE recommends that endoscopic pylorus-directed therapy should be considered only in patients with symptoms suggestive of gastroparesis in combination with objective proof of delayed gastric emptying using a validated test, and only when medical therapy has failed.Strong recommendation, very low quality of evidence, level of agreement 100 %.ESGE recommends against the use of botulinum toxin injection in the treatment of unselected patients with gastroparesis. Strong recommendation, high quality of evidence, level of agreement 92.9 %.ESGE recommends consideration of gastric peroral endoscopic myotomy (G-POEM) in carefully selected patients only, because it is an emerging procedure with limited data on effectiveness, safety, and durability. G-POEM should be performed in expert centers only, preferably in the context of a clinical trial.Strong recommendation, low quality of evidence, level of agreement 100 %.

3099 Endoscopic Botulinum Toxin Injection for Tacrolimus-Induced Achalasia in a Renal Transplant Recipient

INTRODUCTION: Multiple medications have been associated with secondary achalasia. Here we present a patient who developed dysphagia 4 days after his renal transplant and was found to have achalasia thought to be due to his tacrolimus; he was successfully treated with botulinum injection. To our knowledge, this is the first case of tacrolimus-induced achalasia ever reported in a renal transplant patient; it is also the first case in a transplant patient to be treated endoscopically with botulinum injection. CASE DESCRIPTION/METHODS: A 58 year old man with a history of end stage renal disease secondary to focal segmental glomerulosclerosis presented with progressive renal failure and underwent deceased kidney transplant without complications. At clinic, follow-up on post-operative day #4, the patient reported difficulty in swallowing since post-operative day two. A modified barium swallow study (Figure 1) demonstrated severe esophageal dysmotility and lower esophageal sphincter dysfunction concerning for achalasia. Upper endoscopy (Figure 2) one week later revealed a dilated esophagus with mild edema but without focal lesions or ulcerations. Esophageal manometry (Figure 3) evidenced outflow obstruction of the esophagogastric junction and weak peristalsis in the esophageal body, confirming the diagnosis of achalasia. Surgical therapy and changing his calcineuron inhibitor for achalasia were considered too high risk in this patient so shortly after transplant. The patient ultimately underwent therapy with endoscopic botulinum toxin injection (100 units) of the lower esophageal sphincter. He had excellent results with immediate and complete resolution of dysphagia. DISCUSSION: The proposed mechanism for CNI induced changes in esophageal motility involves inhibition of nitric oxide synthase by CNIs. Nitric oxide (NO) is responsible for esophageal peristalsis as well as relaxation of the lower esophageal sphincter (LES). Although it is unclear why switching between different CNIs would lead to symptom resolution, individual variation in the reaction to the different chemical structures of tacrolimus and cyclosporine has been proposed. Botulinum toxin can be considered as a therapeutic option in those patients who are not candidates for a change in their immunosupression. To our knowledge, this is the first case of botulinum induced achalasia reported after a kidney transplant and also the first successfully treated with botulinum toxin injection.

1728 A Spastic Spiral: Paraneoplastic Pseudoachalasia in an Elderly Male With Multiple Malignancies

INTRODUCTION: Pseudoachalasia is an uncommon condition that is difficult to distinguish from primary achalasia. Pseudoachalasia is usually caused by malignancy involving the gastroesophageal junction (GEJ); however, a paraneoplastic etiology has been reported in rare cases. Our aim is to describe the diagnosis and management of a case of paraneoplastic pseudoachalasia resulting from acetylcholine receptor (AchR) ganglionic (a3) antibodies. CASE DESCRIPTION/METHODS: A 72-year-old male with a history of lung adenocarcinoma, bladder transitional cell carcinoma and prostate adenocarcinoma presented with acute chest pain, regurgitation, and dysphagia. Positron emission tomography scan showed increased distal esophageal uptake prompting a referral for endoscopy. Endoscopy showed a tortuous, spiraling esophageal body, distal esophageal ulcer, and narrowed GEJ (Figure 1). Ulcer biopsies returned benign, and endoscopic ultrasound (EUS) was performed. EUS of the GEJ showed diffuse thickening of the muscularis mucosa with no discrete mass. Motility evaluation was performed. Barium esophagram demonstrated a corkscrew esophagus and persistently narrowed GEJ (Figure 2). Esophageal manometry was attempted, but the catheter was unable to traverse the lower esophageal sphincter. Tracings of the esophageal body revealed spastic contractions with occasional pan-esophageal pressurization suggestive of possible mixed Type II/III achalasia (Figure 3). A paraneoplastic serum autoantibody panel was obtained and returned positive with AChR a3 antibody level of 220 pmol/L (normal &lt; 53). Evaluation for recurrent malignancy was negative. Trial of a cholinesterase inhibitor and calcium channel blocker were attempted without improvement. Intravenous immunoglobulin therapy was declined by the patient. Endoscopic botulinum toxin injection to the esophageal body and LES was performed and resulted in sustained symptom relief. DISCUSSION: Paraneoplastic pseudoachalasia is rare, and requires a high index of suspicion for diagnosis. It may be the initial clinical sign of malignancy, or as in our case, a finding concerning for recurrent malignancy prompting re-evaluation. Prior reports suggest AChR antibodies are associated with adenocarcinomas. In patients with known malignancy who present with achalasia-type symptoms, a paraneoplastic autoantibody panel can assist with diagnosis. Treatment of the malignancy is the primary therapy, while medications and endoscopic interventions remain anecdotal.

Cervical spondylodiscitis following cricopharyngeal botulinium toxin injection

BackgroundIatrogenic cervical spondylodiscitis is rare, but may occur after various medical interventions. MethodsWe report a case of a diabetic 70-years-old female with C5–C6 spondylodiscitis and symptomatic epidural abscess with neck pain and upper limb paresis after endoscopic botulinum toxin injection for the treatment of dysphagia. Treatment included antibiotic therapy with amoxicillin and later on benzylpenicillin for the next ten weeks and corporectomy with spondylodesis. ResultThe patient made an excellent recovery, with complete resolution of paresis and only minor residual hypoesthesia at one year after operation. ConclusionCervical spondylodiscitis should be considered early, in patients with neck pain after endoscopic cricopharyngeal injection, as timely diagnosis and treatment can prevent serious and irreversible neurological deficit.

Endoscopic botulinum toxin injection for treatment of pharyngeal dysphagia in patients with cricopharyngeal dysfunction

Background: Dysphagia associated with neurologic disorders is a problem worldwide. However, few studies have assessed the efficacy of endoscopic botulinum toxin injections into the cricopharyngeal muscle using a pharyngoscope.Methods: Fourteen patients who received an endoscopic botulinum toxin injection due to cricopharyngeal muscle dysfunction and a neurological disorder from 2006 to 2017 were retrospectively reviewed at a single tertiary medical center. The toxin was injected at a 100 international unit (IU) total dose under direct endoscopic vision. The success of the procedure was evaluated comprehensively using the following: clinical resolution of the previous symptoms, functional oral intake scale (FOIS) for the clinical evaluation of swallowing, and videofluoroscopic swallowing study (VFSS) to check decreased retention of barium at the pyriform sinus and the epiglottic vallecula.Results: The study included 12 males and 2 females (mean age, 58 years old; range, 37–82 years). Three patients (21.4%) were confirmed clinically and eleven were confirmed by VFSS. Eleven patients (78.6%) were managed successfully with the injection. Three patients (21.4%) did not improve despite the injection.Conclusion: An endoscopic botulinum toxin injection may be a good treatment option for patients with dysphagia and cricopharyngeal dysfunction due to a neurological disorder. Large, prospective, long-term follow-up studies are needed in the future.

Office-based endoscopic botulinum toxin injection in laryngeal movement disorders

IntroductionBotulinum toxin injection is widely used for the treatment of laryngeal movement disorders. Electromyography-guided percutaneous injection is the technique most commonly used to perform intralaryngeal botulinum toxin injection. ObjectiveWe describe an endoscopic approach for intralaryngeal botulinum toxin injection under local anaesthesia without using electromyography. TechniqueA flexible video-endoscope with an operating channel is used. After local anaesthesia of the larynx by instillation of lidocaine, a flexible needle is inserted into the operating channel in order to inject the desired dose of botulinum toxin into the vocal and/or vestibular folds. ConclusionEndoscopic botulinum toxin injection under local anaesthesia is a reliable technique for the treatment of laryngeal movement disorders. It can be performed by any laryngologist without the need for electromyography. It is easy to perform for the operator and comfortable for the patient.

Reproducibility of preoperative endoscopic injection of botulinum toxin into the sphincter of Oddi to prevent postoperative pancreatic fistula.

BackgroundA postoperative pancreatic fistula (POPF) is the most common and potentially life-threatening surgical complication in pancreatic surgery. One possible pharmacological treatment could be the endoscopic injection of botulinum toxin (BTX) into the sphincter of Oddi to prevent POPF. Promising data reported a significantly reduced rate of clinically relevant POPF. We analyzed the effect of BTX injection in our patients undergoing distal pancreatectomy (DP).MethodsA retrospective analysis of patients undergoing DP was performed. Patients with preoperative endoscopic injection of BTX into the sphincter of Oddi were included. The end points were postoperative outcomes including POPF. BTX patients were compared with a historical cohort and matched in a 1:1 ratio using a propensity score analysis.ResultsA total of 19 patients were treated with endoscopic injection of BTX before open (n=8) or laparoscopic (n=11) DP. The median age of the patients was 67 years and the mean body mass index was 25.9 kg/m2. In median, the intervention was performed 1 day (range, 0–14 days) before the operation. There were no intervention-related complications. The incidence of POPF was not statistically different between the two groups: a clinically relevant POPF grade (B/C) occurred in 32% (BTX) and 42% (control; p=0.737). Likewise, there were no significant differences in postoperative drain fluid amylase levels, morbidity, and mortality.ConclusionThe present study could not reproduce the published results of a significant lowering of grade B/C POPF. The explanations could be the timing of BTX injection before surgery and the endoscopic technique of BTX injection. However, the conflicting results after BTX injection in two high-volume centers prompt a randomized controlled multicenter trial with trained endoscopists.