Botulinum Toxin Injection Versus Laparoscopic Myotomy for the Treatment of Esophageal Achalasia: Economic Analysis of a Randomized Trial

Overview

Journal Surg Endosc

Publisher Springer

Specialties Gastroenterology
General Surgery
Radiology

Date 2004 Mar 18

PMID 15026896

Citations 18

Authors

G Zaninotto

V Vergadoro

V Annese

M Costantini

M Costantino

D Molena

C Rizzetto

M Epifani

A Ruol

L Nicoletti

E Ancona

Affiliations

Soon will be listed here.

Abstract

Background: The treatment of esophageal achalasia is still controversial: current therapies are palliative and aim to relieve dysphagia by disrupting or relaxing the lower esophageal sphincter muscle fibers with botulinum toxin. The aim of this study was to compare the clinical and economic results of two such treatments: laparoscopic myotomy and botulinum toxin injection.

Methods: A total of 37 patients with esophageal achalasia were randomly assigned to receive laparoscopic myotomy (20) or two Botox injections 1 month apart (17). All patients were treated at the same hospital and were part of a larger multicenter study. Symptom score, lower esophageal sphincter pressure, and esophageal diameter at barium swallow were compared. The economic analysis was performed considering only the direct costs (cost per treatment and cost effectiveness, i.e., cost per patient healed).

Results: Mortality and morbidity were nil in both groups. The actuarial probability of being asymptomatic at 2 years was 90% for surgery and 34% for Botox (p < 0.05). The initial cost was lower for Botox (1,245 Euros) than for surgery (3,555 Euros), but when cost effectiveness at 2 years was considered, this difference nearly disappeared: Botox 3,364 Euros, surgery 3,950 Euros.

Conclusion: Botox is still the least costly treatment, but the minimal difference in the longer term does not justify its use, given that surgery is a risk-free, definitive treatment.

Citing Articles

Botulinum Toxin A Use in the Gastrointestinal Tract: A Reappraisal After Three Decades.

Mohajir W, Khurana S, Singh K, Chong R, Bhutani M Gastroenterol Hepatol (N Y). 2023; 19(4):198-212.

PMID: 37705841 PMC: 10496347.

ACG Clinical Guidelines: Diagnosis and Management of Achalasia.

Vaezi M, Pandolfino J, Yadlapati R, Greer K, Kavitt R Am J Gastroenterol. 2020; 115(9):1393-1411.

PMID: 32773454 PMC: 9896940. DOI: 10.14309/ajg.0000000000000731.

Achalasia: treatment, current status and future advances.

Swanstrom L Korean J Intern Med. 2019; 34(6):1173-1180.

PMID: 30866609 PMC: 6823561. DOI: 10.3904/kjim.2018.439.

Laparoscopic esophagomyotomy for achalasia in children: A review.

Pandian T, Naik N, Fahy A, Arghami A, Farley D, Ishitani M World J Gastrointest Endosc. 2016; 8(2):56-66.

PMID: 26839646 PMC: 4724031. DOI: 10.4253/wjge.v8.i2.56.

Hospitalization for esophageal achalasia in the United States.

Molena D, Mungo B, Stem M, Lidor A World J Gastrointest Endosc. 2015; 7(13):1096-102.

PMID: 26421106 PMC: 4580951. DOI: 10.4253/wjge.v7.i13.1096.

References

Zaninotto G, Costantini M, Portale G, Battaglia G, Molena D, Carta A . Etiology, diagnosis, and treatment of failures after laparoscopic Heller myotomy for achalasia. Ann Surg. 2002; 235(2):186-92. PMC: 1422413. DOI: 10.1097/00000658-200202000-00005. View

Bloomston M, Boyce W, Mamel J, Albrink M, Murr M, Durkin A . Videoscopic Heller myotomy for achalasia--results beyond short-term follow-up. J Surg Res. 2000; 92(2):150-6. DOI: 10.1006/jsre.2000.5886. View

Imperiale T, OCONNOR J, Vaezi M, Richter J . A cost-minimization analysis of alternative treatment strategies for achalasia. Am J Gastroenterol. 2000; 95(10):2737-45. DOI: 10.1111/j.1572-0241.2000.03181.x. View

Vaezi M, Richter J, Wilcox C, Schroeder P, Birgisson S, Slaughter R . Botulinum toxin versus pneumatic dilatation in the treatment of achalasia: a randomised trial. Gut. 1999; 44(2):231-9. PMC: 1727388. DOI: 10.1136/gut.44.2.231. View

Spiess A, Kahrilas P . Treating achalasia: from whalebone to laparoscope. JAMA. 1998; 280(7):638-42. DOI: 10.1001/jama.280.7.638. View

Passaretti S, Zaninotto G, Di Martino N, Leo P, Costantini M, Baldi F . Standards for oesophageal manometry. A position statement from the Gruppo Italiano di Studio Motilità Apparato Digerente (GISMAD). Dig Liver Dis. 2000; 32(1):46-55. DOI: 10.1016/s1590-8658(00)80044-4. View

Patti M, Pellegrini C, Horgan S, Arcerito M, Omelanczuk P, Tamburini A . Minimally invasive surgery for achalasia: an 8-year experience with 168 patients. Ann Surg. 1999; 230(4):587-93; discussion 593-4. PMC: 1420907. DOI: 10.1097/00000658-199910000-00014. View

Zaninotto G, Annese V, Costantini M, Del Genio A, Costantino M, Epifani M . Randomized controlled trial of botulinum toxin versus laparoscopic heller myotomy for esophageal achalasia. Ann Surg. 2004; 239(3):364-70. PMC: 1356234. DOI: 10.1097/01.sla.0000114217.52941.c5. View

Zaninotto G, Costantini M, Molena D, Buin F, Carta A, Nicoletti L . Treatment of esophageal achalasia with laparoscopic Heller myotomy and Dor partial anterior fundoplication: prospective evaluation of 100 consecutive patients. J Gastrointest Surg. 2000; 4(3):282-9. DOI: 10.1016/s1091-255x(00)80077-3. View

10.

Muehldorfer S, Schneider T, Hochberger J, Martus P, Hahn E, Ell C . Esophageal achalasia: intrasphincteric injection of botulinum toxin A versus balloon dilation. Endoscopy. 1999; 31(7):517-21. DOI: 10.1055/s-1999-56. View

11.

Parkman H, Reynolds J, Ouyang A, Rosato E, Eisenberg J, Cohen S . Pneumatic dilatation or esophagomyotomy treatment for idiopathic achalasia: clinical outcomes and cost analysis. Dig Dis Sci. 1993; 38(1):75-85. DOI: 10.1007/BF01296777. View

12.

Csendes A, Braghetto I, Henriquez A, Cortes C . Late results of a prospective randomised study comparing forceful dilatation and oesophagomyotomy in patients with achalasia. Gut. 1989; 30(3):299-304. PMC: 1378449. DOI: 10.1136/gut.30.3.299. View

13.

Hunter J, Trus T, Branum G, Waring J . Laparoscopic Heller myotomy and fundoplication for achalasia. Ann Surg. 1997; 225(6):655-64; discussion 664-5. PMC: 1190864. DOI: 10.1097/00000658-199706000-00003. View

14.

VANTRAPPEN G, Janssens J . To dilate or to operate? That is the question. Gut. 1983; 24(11):1013-9. PMC: 1420125. DOI: 10.1136/gut.24.11.1013. View

15.

Rosati R, Fumagalli U, Bona S, Bonavina L, Pagani M, Peracchia A . Evaluating results of laparoscopic surgery for esophageal achalasia. Surg Endosc. 1998; 12(3):270-3. DOI: 10.1007/s004649900649. View

16.

Annese V, Bassotti G, Coccia G, Dinelli M, DOnofrio V, Gatto G . A multicentre randomised study of intrasphincteric botulinum toxin in patients with oesophageal achalasia. GISMAD Achalasia Study Group. Gut. 2000; 46(5):597-600. PMC: 1727941. DOI: 10.1136/gut.46.5.597. View