Suction versus slow-pull for endoscopic ultrasound-guided fine-needle aspiration of pancreatic tumors: a prospective randomized trial.

BACKGROUND: Suction (S) is commonly used to improve cell acquisition during endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). Slow-pull (SP) sampling is another technique that might procure good quality specimens with less bloodiness. We aimed to determine if SP improves the diagnostic yield of EUS-FNA of pancreatic masses. METHODS: Patients with pancreatic solid masses were randomized to four needle passes with both techniques in an alternate fashion. Sensitivity, specificity, positive, and negative predictive values were calculated. Cellularity and bloodiness of cytological samples were assessed and compared according to the technique. RESULTS: Sensitivity, specificity, and accuracy of suction vs. SP were 95.2% vs. 92.3%; 100% vs. 100; 95.7% vs. 93%, respectively. As to the association of methods, they were 95.6, 100 and 96%, respectively. Positive predictive values for S and SP were 100%. There was no difference in diagnostic yield between S and SP (p = 0.344). Cellularity of samples obtained with SP and Suction were equivalent in both smear evaluation (p = 0.119) and cell-block (0.980). Bloodiness of SP and suction techniques were similar as well. CONCLUSIONS: S and SP techniques provide equivalent sensitivity, specificity, and accuracy. Association of methods seems to improve diagnostic yield. Suction does not increase the bloodiness of samples compared to slow-pull.

Partial resection of bilateral ulnar remnants for treatment of carpus valgus in a 3-week-old Hanoverian foal.

A 3-week old Hanoverian foal was presented with bilateral moderate to severe carpal valgus. The deviations were 10 and 14 degrees, respectively for the left and right carpi and orthogonal radiographs of both front limbs highlighted bilateral persistent ulnar remnants. A partial resection of the ulnar remnants and periosteal transection on the disto-lateral aspect of the radius were performed bilaterally under general anesthesia. The valgus deviations began to improve within the first month and the limbs were almost straight (2 degrees for the left and right carpi) 5 1/2 months after surgery. This is the first report of successful surgical correction of bilateral carpal valgus secondary to persistent ulnar remnants in a large breed foal. The combination of partial ulnar remnant resection and radial disto-lateral periosteal transection, detailed in this report, should be considered for treatment of foals with this condition.

Résection ulnaire bilatérale partielle comme traitement d'un valgus des carpes chez un poulain Hanovrien de 3 semaines d'âge. Un poulain Hanovrien de 3 semaines d'âge a été présenté avec un valgus bilatéral des carpes. Les déviations étaient de 10 et 14 degrés, pour les carpes gauche et droit respectivement. Des projections radiographiques orthogonales des deux membres antérieurs ont mis en évidence un ulna persistant bilatéralement. Une résection partielle des ulnas persistants et une section périostée de l'aspect disto-latéral de chaque radius a été effectuée sous anesthésie générale. Une amélioration des déviations a d'abord été observé durant le premier mois et les deux membres antérieurs étaient quasi droits (2 degrés pour chacun des carpes) 5 1/2 mois après la chirurgie. Ceci est le premier rapport de cas à décrire la correction chirurgicale d'un valgus bilatéral des carpes secondaire à la présence d'ulnas persistants, chez un poulain de grande taille. La combinaison de la résection ulnaire partielle et de la section périostée disto-latérale du radius présentée ici devraient être considérée comme traitement des poulains présentant cette condition.(Traduit par Dre Julia Dubuc).

Frequency of Undetected Glove Perforation and Associated Risk Factors in Equine Surgery.

OBJECTIVE: To estimate the frequency of undetected perforations in surgical gloves during equine surgery and to identify risk factors associated with occurrence. STUDY DESIGN: Observational cohort study. SAMPLE POPULATION: Surgical gloves-292 pairs. METHODS: Water leak tests were performed on gloves after equine surgery to detect perforations. Fifty pairs of unused gloves were also tested. Potential risk factors were recorded. Logistic regression was used to explore associations between putative risk factors and perforation. RESULTS: No perforations were detected in the unused gloves. Of 292 pairs of used gloves tested, 80 (27%) had at least one glove perforation per pair. The frequency of perforations was not different between surgery diplomates and residents (P=.69). The length and type of surgery were significantly associated with the likelihood of undetected glove perforation with surgeries longer than 60 minutes approximately 2.5 times more likely to result in glove perforation (P=.005). Surgery classified as soft tissue, orthopedic or exploratory celiotomy was 3 times more likely to result in glove perforation than minimally invasive surgery. The perforations occurred significantly more frequently in the nondominant hand (19%) than the dominant hand (11%) (P=.009). CONCLUSION: There is a high occurrence of undetected glove perforation in equine surgery. Precautions can be suggested based on this study although further investigation is required to assess whether glove perforations are associated with surgical site infections.

Comparison of an alcohol-based hand rub and water-based chlorhexidine gluconate scrub technique for hand antisepsis prior to elective surgery in horses.

This prospective clinical study evaluates the effectiveness of an alcohol-based hand rub (Avagard™) for pre-surgical hand antisepsis in an equine hospital and compares it with traditional scrubbing technique using 4% chlorhexidine gluconate sponges and water. Prior to elective surgery, 3 board-certified surgeons were randomly assigned to hand antisepsis with either technique. Culture samples of each hand were taken at 4 times: before and after neutral soap hand wash, after scrub or rubbing technique, and after surgery. There was no significant difference in mean bacterial colony forming units between scrub and rub techniques over the 3 time periods (P = 0.6), controlling for initial counts. One horse from the scrub group had a skin incision infection following stifle arthroscopy; this was resolved with medical treatment. The alcohol-based hand rub is equivalent in efficacy for pre-surgical hand antisepsis to traditional water-based scrubs in an equine hospital setting.

Comparaison de l'alcool à friction et d'une technique de brossage au gluconate de chlorhexidine à base d'eau pour l'antisepsie des mains avant les chirurgies non urgentes chez les chevaux. Cette étude clinique prospective évalue l'efficacité d'un alcool à friction (AvagardMD) pour l'antisepsie des mains préalable à une chirurgie dans un hôpital équin et elle la compare à la technique de brossage traditionnelle au moyen d'éponges de gluconate de chlorhexidine 4 % et d'eau. Avant une chirurgie non urgente, trois chirurgiens agréés ont été assignés au hasard à l'antisepsie des mains avec l'une ou l'autre technique. Des échantillons de chaque main ont été prélevés quatre fois pour culture : avant et après le lavage des mains avec un savon neutre, après la technique de brossage et de friction et après la chirurgie. Il n'y avait aucune différence significative dans les moyennes des dénombrements bactériens d'unités formatrices de colonies entre les techniques de brossage et de friction pendant les trois périodes de temps (P = 0,6), en tenant compte des témoins pour les dénombrements initiaux. Un cheval du groupe de brossage a développé une infection au site de l'incision après une arthroscopie du grasset qui a été résolue par traitement médical. La friction des mains à l'alcool est équivalente, en matière d'efficacité pour l'antisepsie des mains avant la chirurgie, au brossage traditionnel à l'eau dans un milieu hospitalier équin.(Traduit par Isabelle Vallières).

Comparison Costs of ERCP and MRCP in Patients with Suspected Biliary Obstruction Based on a Randomized Trial.

BACKGROUND: The optimal management of patients with suspected biliary obstruction remains unclear, and includes the possible performance of magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP). OBJECTIVES: To complete a cost analysis based on a medical effectiveness randomized trial comparing an ERCP-first approach with an MRCP-first approach in patients with suspected bile duct obstruction. METHODS: The management strategies were based on a medical effectiveness trial of 257 patients over a 12-month follow-up period. Direct and indirect costs were included, adopting a societal perspective. The cost values are expressed in 2012 Canadian dollars. RESULTS: Total per-patient direct costs were Can$3547 for ERCP-first patients and Can$4013 for MRCP-first patients. Corresponding indirect costs were Can$732 and Can$694, respectively. Causes for differences in direct costs included a more frequent second procedure and a greater mean number of hospital days over the year in patients of the MRCP-first group. In contrast, it is the ERCP-first patients whose indirect costs were greater, principally due to more time away from activities of daily living. Choosing an ERCP-first strategy rather than an MRCP-first strategy saved on average Can$428 per patient over the 12-month follow-up duration; however, there existed a large amount of overlap when varying total cost estimates across a sensitivity analysis range based on observed resources utilization. CONCLUSIONS: This cost analysis suggests only a small difference in total costs, favoring the ERCP-first group, and is principally attributable to procedures and hospitalizations with little impact from indirect cost measurements.

Mutations in HBV DNA polymerase associated with nucleos(t)ide resistance are rare in treatment-naive patients.

BACKGROUND & AIMS: Prior studies have detected hepatitis B virus (HBV) DNA polymerase mutations in treatment-naive patients. However, most of these studies used either direct polymerase chain reaction sequencing, which detects these mutations with low levels of sensitivity, or patient cohorts that were not well-characterized. We investigated the prevalence of HBV mutations in DNA polymerase by using a line probe assay. METHODS: In a prospective, cross-sectional study, we enrolled 198 treatment-naive patients with chronic hepatitis B (52.5% male; mean age, 41 years) from February 2009 to May 2011 from 3 gastroenterology and liver clinics in Northern California. Exclusion criteria included infection with hepatitis C or D viruses or human immunodeficiency virus. All patients completed a questionnaire (to determine demographics, history of liver disease, prior treatments, family medical history, drug and alcohol use, and environmental risk factors for hepatitis) that was administered by a research coordinator; mutations in HBV DNA polymerase were detected by using the INNO-LiPA HBV DR v.3 assay. RESULTS: Most patients were Vietnamese (48.5%) or Chinese (36.4%) and were infected with HBV genotypes B (67.5%) or C (24.2%). Mutations in HBV DNA polymerase were found in 2 patients (1%), rtI233V (n = 1) and rtM250M/L (n = 1). CONCLUSIONS: In a multicenter prospective study of treatment-naive patients with chronic hepatitis B, we detected mutations in HBV DNA polymerase in only 1%. Because of the low prevalence of these mutations and the uncertain clinical significance of such quasispecies, routine HBV DNA polymerase mutation analysis cannot be recommended before initiation of antiviral therapy for treatment-naive patients with chronic hepatitis B. The analysis requires further molecular and clinical studies.

High proportion of hepatitis C virus in community Asian American patients with non-liver-related complaints.

GOALS AND BACKGROUND: Besides United States population born between 1945 and 1965, screening for hepatitis C virus (HCV) is not recommended for the general US population. However, HCV may be more prevalent in certain subgroups and screening may be warranted. The goal of this study was to examine the proportion of HCV in a large sample of community Asian American patients presenting for non-liver-related complaints. STUDY: We conducted a cross-sectional study of 1246 patients tested for hepatitis C virus antibodies (anti-HCV) referred to 2 gastroenterology clinics for non-liver-related gastrointestinal reasons between January 2001 and February 2011. We determined HCV status and patient history via electronic medical record review. RESULTS: Of the 1246 study patients tested for anti-HCV, the majority were Asian (81.4%) and 29 Asian patients (2.9%) had positive anti-HCV. HCV proportion in the remaining 232 non-Asians (non-Hispanic whites and Hispanics) was 1.7%. Asians with positive anti-HCV were more likely to have had blood transfusions (31.0% vs. 6.6%, P<0.0001) or acupuncture (10.3% vs. 1.5%, P<0.0001). Of the 976 Asian patients with hepatitis B surface antigen testing, 38 (3.9%) also had detectable hepatitis B surface antigen. CONCLUSIONS: Among patients seen at community gastroenterology clinics for non-liver-related reasons, HCV proportion was 1.7% for non-Asians and 2.9% for Asians. Screening for HCV should be offered to high-risk patients presenting to gastroenterology clinics with unrelated gastrointestinal complaints.

Less-established risk factors are common in Asian Americans with hepatitis C virus: a case-controlled study.

BACKGROUND AND AIMS: The Centers for Disease Control and Prevention recommend screening for hepatitis C virus (HCV) in patients with injection drug use, blood transfusion before 1992, stigmata of liver disease, or born between 1945 and 1965. The purpose of this study was to examine risk factors for HCV acquisition in Asian Americans. METHODS: This was a case-controlled study, with 471 consecutive patients testing positive for anti-HCV between January 2001 and December 2008. Controls included 471 patients with negative HCV matched at a one-to-one ratio for sex, age (±5 years), and ethnicity. RESULTS: For Asian patients, the most common risk factors were blood transfusion and acupuncture or exposure to dirty needles (27 and 20 %, respectively). On multiple logistic regression, potential predictors for a positive anti-HCV test in Asians were acupuncture or exposure to dirty needles (OR = 12.9, P < 0.0001), body tattoo (OR = 12.0, P = 0.001), and history of blood transfusion (OR = 5.7, P < 0.0001). DISCUSSION: Acupuncture and exposure to dirty needles are independent risk factors of HCV infection. Asians coming from endemic areas should be screened for HCV even when commonly-known risk factors for Western patients are not present.

Management of common bile duct stones in cirrhotic patients with coagulopathy: a comparison of supra-papillary puncture and standard cannulation technique.

BACKGROUND AND STUDY AIMS: Bleeding is not uncommon following endoscopic sphincterotomy. Supra-papillary puncture (SPP) might be safer than standard cannulation (SC) techniques in patients with coagulopathy. The aim of the study was to compare the safety and effectiveness of SPP and SC. PATIENT AND METHODS: This was a prospective case control intervention study. Decompensated cirrhotic patients with coagulopathy and choledocolithiasis underwent SC and SPP methods for biliary access. RESULTS: One hundred five patients (56 [53.3%] men, mean [SD] age 56 [15.8]) underwent ERCP. SC and SPP were performed in 63 and 42 patients, respectively. Biliary access was achieved in 56/63 (89%) and 40/42 (95%) of patients undergoing SC and SPP, respectively (P = 0.13; 95% CI [-0.16; 0.03]). Complications occurred in 10/63 (15.8%) patients undergoing SC and 5/42 (11.9%) SPP (P = 0.28; 95% CI [-0.17, 0.16]). Five (7.9%) and two (3.2%) episodes of post-sphincterotomy bleeding was seen in the SC and SPP groups, respectively (P = 0.36; 95% CI [-0.16, 0.05]). In contrast, three (4.8%) episodes of pancreatitis were seen in the SC and none in the SPP group (P = 0.05; 95% CI [0.001; 0.004]). A cost-effectiveness analysis demonstrated that SPP is an acceptable alternative at an ICER of US$ 5,974.92 per additional successful procedure. CONCLUSION: SPP is a safe and effective technique for the management of common bile duct stones in decompensated cirrhotic patients. Conditional to the willingness-to-pay and to the local ERCP-related costs, SPP is also a cost-effective alternative to the SC methods. SPP is associated with a lower rate of complications but larger studies to validate these findings are necessary.

Comprehensive gene expression profiling in lungs of mice infected with Mycobacterium tuberculosis following DNAhsp65 immunotherapy.

BACKGROUND: The continued increase in tuberculosis (TB) rates and the appearance of extremely resistant Mycobacterium tuberculosis strains (XDR-TB) worldwide are some of the great problems of public health. In this context, DNA immunotherapy has been proposed as an effective alternative that could circumvent the limitations of conventional drugs. Nonetheless, the molecular events underlying these therapeutic effects are poorly understood. METHODS: We characterized the transcriptional signature of lungs from mice infected with M. tuberculosis and treated with heat shock protein 65 as a genetic vaccine (DNAhsp65) combining microarray and real-time polymerase chain reaction analysis. The gene expression data were correlated with the histopathological analysis of lungs. RESULTS: The differential modulation of a high number of genes allowed us to distinguish DNAhsp65-treated from nontreated animals (saline and vector-injected mice). Functional analysis of this group of genes suggests that DNAhsp65 therapy could not only boost the T helper (Th)1 immune response, but also could inhibit Th2 cytokines and regulate the intensity of inflammation through fine tuning of gene expression of various genes, including those of interleukin-17, lymphotoxin A, tumour necrosis factor-alpha, interleukin-6, transforming growth factor-beta, inducible nitric oxide synthase and Foxp3. In addition, a large number of genes and expressed sequence tags previously unrelated to DNA-therapy were identified. All these findings were well correlated with the histopathological lesions presented in the lungs. CONCLUSIONS: The effects of DNA therapy are reflected in gene expression modulation; therefore, the genes identified as differentially expressed could be considered as transcriptional biomarkers of DNAhsp65 immunotherapy against TB. The data have important implications for achieving a better understanding of gene-based therapies.

Prospective evaluation of EUS versus CT scan for staging of ampullary cancer.

BACKGROUND: Malignancies of the biliary and pancreatic systems are associated with a poor prognosis. However, ampullary cancer carries a better prognosis and is often diagnosed when curative treatment is still possible. Accurate staging is important for the determination of the most appropriate treatment option. OBJECTIVES: (1) To determine the test performance characteristics of EUS and CT in loco-regional staging of ampullary neoplasms, and (2) to determine the impact of CT scan results on the test performance characteristics of EUS. DESIGN AND SETTING: Prospective single-arm intervention study performed in 2 academic hospitals. RESULTS AND MAIN OUTCOME MEASUREMENTS: Thirty-seven patients were screened and 33 staged with EUS and CT. A total of 27 patients (13 men; mean age, 69.5 years; mean serum bilirubin level, 12.6 mg/dL) with locally advanced disease completed the protocol with EUS and CT and underwent surgical resection. Tumor classifications were as follows: 2 patients (7.4%), T1 tumors; 13 patients (48.1%), T2 tumors; and 12 patients (44.4%), T3 tumors, as per surgical pathology. Seventeen tumors (62.9%) were classified as N0 and 10 (37.1%) as N1. The difference in proportion of correct tumor (74.1% vs 51.8%; P = .15, 95% CI, -0.06-0.50) and lymph node (81.4% vs 55.5%; P = .07, 95% CI, -0.01-0.53) staging by EUS and CT, respectively, was not statistically significantly different. However, the strength of tumor (kappa 0.51 vs 0.11) and nodal (kappa 0.59 vs 0.05) agreement with pathology was statistically significantly higher for EUS than for CT (P < .05). EUS was more sensitive and specific than CT for tumor and nodal staging, and the association of CT to EUS data did not improve the final test accuracy. LIMITATION: Low number of T1 tumors. CONCLUSIONS: EUS is an accurate diagnostic test and exhibits a high level of agreement with surgical pathology. CT findings do not improve the test performance characteristics of EUS. Therefore, the evaluation for metastatic disease should not be compromised by CT protocols that aim to perform tumor and nodal staging. Further studies to determine the role of specialized CT protocols in patients with ampullary malignancies are needed.

Achalasia: a review of therapeutic options and outcomes.

Advances in achalasia has led to the development of new therapeutic options. This review will focus on methodology and outcomes of two established techniques; pneumatic dilation and surgical myotomy; and one new technique, LES injection of botulinum A toxin.

Cost-effectiveness of palliation of unresectable esophageal cancer.

INTRODUCTION: Different modalities of palliation for obstructive symptoms in patients with unresectable esophageal cancer (EC) exist. However, these therapeutic alternatives have significant differences in costs and effectiveness. METHODS: A Markov model was designed to compare the cost-effectiveness (CE) of self-expandable stent (SES), brachytherapy and laser in the palliation of unresectable EC. Patients were assigned to one of the strategies, and the improvement in swallowing function was compared given the treatment efficacy, probability of survival, and risks of complications associated to each strategy. Probabilities and parameters for distribution were based on a 9-month time frame. RESULTS: Under the base-case scenario, laser has the lowest CE ratio, followed by brachytherapy at an incremental cost-effectiveness ratio (ICER) of $4,400.00, and SES is a dominated strategy. In the probabilistic analysis, laser is the strategy with the highest probability of cost-effectiveness for willingness to pay (WTP) values lower than $3,201 and brachytherapy for all WTP yielding a positive net health benefit (NHB) (threshold $4,440). The highest probability of cost-effectiveness for brachytherapy is 96%, and consequently, selection of suboptimal strategies can lead to opportunity losses for the US health system, ranging from US$ 4.32 to US$ 38.09 million dollars over the next 5-20 years. CONCLUSION: Conditional to the WTP and current US Medicare costs, palliation of unresectable esophageal cancers with brachytherapy provides the largest amount of NHB and is the strategy with the highest probability of CE. However, some level of uncertainly remains, and wrong decisions will be made until further knowledge is acquired.

Outcome of cirrhotic patients undergoing cholecystectomy: applying Bayesian analysis in gastroenterology.

BACKGROUND AND AIM: Cholelithiasis is a common finding in patients with cirrhosis. Previous studies showed that open cholecystectomy (OC) carries a high risk of postoperative complications and deaths in cirrhotic patients. Laparoscopic cholecystectomy (LC) has significantly decreased hospital stay and postoperative morbidity in non-cirrhotic patients. The aim of this study was to evaluate the outcomes of cirrhotic patients after LC and OC in a tertiary center. METHODS: The outcomes of 33 cirrhotic patients matched by age and sex to 66 non-cirrhotic controls who underwent cholecystectomy were assessed using Bayesian analysis. Both non-informative and informative priors were used to calculate posterior distributions for parameters under investigation. RESULTS: Twenty-four (72%) cirrhotic patients had LC and 9 (27%) OC. A similar percentage of patients in the control group underwent LC (78%) and OC (21%). Emergent cholecystectomy was not different between cirrhotic and controls (95% credible interval [CrI]-0.35, 0.02). Mean blood loss, duration of surgery and conversion rate was not different between cirrhotic and controls, but cirrhotic patients had a longer length of hospital stay than controls (CrI 0.88, 4.71). Cirrhotic patients undergoing LC had lower volume of blood loss (CrI -363.85 mL, -49.28 mL), shorter duration of surgery (CrI -79.82 min, -19.74 min), lower amount of intravenous fluid during surgery (CrI -1532.9 mL, -495.4 mL) and shorter hospital stay (CrI -11.14 days, -1.20 days) than cirrhotic patients undergoing OC. Child-Pugh class B class and admission diagnosis of biliary pancreatitis were associated with a longer hospital stay. CONCLUSION: Laparoscopic cholecystectomy is a safe and effective alternative to OC in Child-Pugh class A and B cirrhotic patients undergoing elective or emergent cholecystectomy. Although outcomes of cirrhotic patients undergoing LC and OC in a tertiary center are not different, LC is associated with less intraoperative bleeding, shorter duration of surgery and fewer days of in-hospital care.

The importance of process issues as predictors of time to endoscopy in patients with acute upper-GI bleeding using the RUGBE data.

BACKGROUND: Early endoscopy has been shown to improve outcomes and optimize cost-effectiveness in nonvariceal upper-GI bleeding (NVUGIB). However, there is little information regarding clinical and process determinants that affect the time from onset of bleeding to performance of the endoscopy. OBJECTIVE: The aim of this study was to identify factors that predict time to endoscopy in patients with new onset NVUGIB. DESIGN: Linear regression models were constructed with time between triage (outpatients) or onset of bleeding (inpatients) and the performance of endoscopy. SETTING: The RUGBE is a nationwide, multicenter database collected for the purpose of obtaining descriptive data on patients with NVUGIB. PATIENTS: The study population consisted of 1500 patients (89.6%) who underwent gastroscopy within 48 hours. RESULTS: Median time to endoscopy was 12 hours (95% CI 11.0, 13.0). Endoscopy after working hours (regression coefficient [beta] -3.52; 95% CI -5.47, -1.58), availability of an endoscopy nurse on-call for the procedure (beta -2.48; 95% CI -3.83, -1.14), and admission to a hospital unit were associated with a shorter interval to endoscopy. In contrast, the presence of chest pain (beta 3.65; 95% CI 1.64, 5.67) or dyspnea (beta 2.79; 95% CI 1.10, 4.48), absence of gross blood on rectal examination (beta 2.20; 95% CI 0.69, 3.71), and inpatient status at onset of bleeding (beta 14.6; 95% CI 8.70, 20.4) were independent predictors of a delayed endoscopy. Subgroup analysis showed that actual time intervals as well as independent predictors of time until endoscopy differed between inpatients and outpatients. LIMITATIONS: Retrospective analysis. CONCLUSIONS: The timing of endoscopy in patients with NVUGIB is dependent on both clinical and process parameters, which differ between inpatient and outpatient settings. They bear implications with regards to shaping practice and deciding on resource allocation in order to facilitate an early endoscopy, which is currently recommended for improved patient outcomes.

Treatment of achalasia with botulinum A toxin.

Achalasia is an idiopathic neuromuscular disorder of the esophagus which is associated with absence of esophageal peristalsis and incomplete relaxation of a normal or raised lower esophageal sphincter (LES). Dysphagia is the most commonly associated symptom. Conventional therapeutic approaches are directed to reducing LES pressure and include orally-administered smooth muscle relaxants, forceful sphincter dilation with balloon dilators, and open or laparoscopic-assisted myotomy of the LES. Pharmacologic therapies have a low success rate. Forceful dilation has a perforation complication rate of 2% to 5%, and myotomies may precipitate significant gastroesophageal reflux, a complication minimized when a partial fundal wrap is employed simultaneously. In recent years, botulinum toxin, utilized widely as a striated muscle relaxant in managing blepharospasm, anal sphincter spasm, and muscle spasm complicating CVAs, and in smoothening facial wrinkles, has been extended to the management of achalasia on the basis that it impairs smooth muscle responsiveness to acetylcholine. Eighty units of Botox (botulinum toxin) are injected directly into the endoscopically (endoscopic ultrasound techniques may facilitate localization) located LES region (20 units into each of 4 quadrants). Symptom relief lasting 6 months on average is experienced in more than 65% of treated patients, and the complication rate is negligible. This therapeutic option is reserved for patients too ill to undergo any surgical procedure and is most effective when the lower esophageal region is hypertonic.