Surgical or laparoscopic diverticulectomy combined with long esophagomyotomy is considered the treatment of choice for symptomatic patients with ED [2, 3, 5, 6]. However, for elderly patients with comorbid conditions, such as our patient, surgical or even laparoscopic intervention is associated with significant morbidity and mortality. As a consequence we preferred to start treatment with BTX injection in the lower esophageal sphincter. Despite BTX injection has been widely used in the treatment of achalasia [7], the reported role of the use of BTX in other dyskinetic diseases of the esophagus, such as diffuse esophageal spasm, isolated LES hypertension, dysphagia due to esophageal diverticula and other specific esophageal disorders, is very limited [8, 9].
There are only 3 reports on the use of BTX injection to resolve dysphagia due to midesophageal or epiphrenic diverticula. DeVault injected 80 IU (1 ml of 20 IU) through a 5 mm sclerotherapy needle into each of the four quadrants of the proximal aspect of the narrowed area distal to the diverticulum [10]. All 3 patients with midesophageal diverticula had remarkable improvement in their swallowing and remained in remission at 6-month follow-up examination. Unfortunately, there is no information on the long-term course of these patients. Pitchford and Price described a 75-year-old man with symptomatic epiphrenic diverticulum in whom they injected 100 IU of BTX into the LES, providing complete symptomatic relief [11]. Ten months later, however, the patient presented again with recurrent symptoms and underwent epiphrenic diverticulectomy. In a recent published paper we have described two elderly patients with dysphagia caused by large epiphrenic diverticula who were treated with BTX injected endoscopically at multiple sites in the region of the lower esophageal sphincter and esophageal wall near to the diverticulum, because they were unable to withstand surgical or laparoscopic intervention due to severe associated comorbid diseases [12]. Symptoms improved immediately and the beneficial effect of BTX remained for 5-6 months. During the long-term follow-up the patient developed symptomatic relapses, treated by subsequent BTX re-injections resulting in longer-lasting symptom relief.
In the patient described herein the initial use of BTX injection (100 IU) in the lower esophageal sphincter was not associated with symptom's relief. Our dilemma was to proceed to gastrostomy, enteral feeding, or to try an endoscopic treatment which combined the balloon dilation of compressed by the diverticulum esophageal lumen with simultaneous BTX (100 IU) injection in the proximal aspects of narrowest area of esophageal lumen. The relief of symptoms justified our therapeutic choice.