Intramural injection with botulinum toxin significantly elongates the pig esophagus ☆ Heidi Fhær Larsen 1 , Thorbjørn Søren Rønn Jensen ⁎ ,1 , Lars Rasmussen, Mark Ellebæk, Niels Qvist Surgical Department A, Odense University Hospital, Denmark Received 19 February 2013; accepted 6 March 2013 Key words: Botulinum toxin type A; Long gap esophageal atresia; Synaptophysin; Pigs; Acetylcholine Abstract Background/Purpose: Surgical treatment of long-gap esophageal atresia (LGEA) is challenging. Methods which facilitate stretching of the esophageal pouches may allow primary anastomosis. Botulinum toxin type A (BTX-A) blocks acetylcholine release in neuromuscular junctions, thereby causing muscle relaxation. We hypothesized that intramural injections with BTX-A into the esophageal wall of piglets would significantly elongate the tissue upon stretch. Methods: Twenty-four piglets were randomized to receive BTX-A of placebo (saline). After one hour, the esophagus was removed en bloc and tested in a stretch-tension device. Results: The mean esophageal elongation was 84% (range 83–101) in the BTX-A-group and 65% (50–78) in the control group. The mean difference between the two groups was 18%, which was significant (p b 0.001). Conclusion: Intramural injections with botulinum toxin type A elongate the esophagus significantly. Clinically, this could be a potential method to achieve primary anastomosis in LGEA. Additional clinical studies are necessary to evaluate the method before it can be generally recommended. © 2013 Elsevier Inc. All rights reserved. In approximately 15% of children born with oesophageal atresia a long-gap (LGEA) is present, where primary anastomosis may be very difficult or even impossible. Surgical treatment of LGEA includes primary gastric transposition [1], different elongation techniques [2,3] or secondary anastomosis after awaiting the spontaneous growth of the upper and lower pouch [4]. Another option may be colon interposition [1,5,6]. However, all procedures are associated with severe side effects. Gastric transposition may lead to significant swallowing dysfunction in one-third of patients [7], and colonic interposition may result in long- term functional problems including dysphagia and is associated with a high frequency of early postoperative complications [7]. The disadvantage of growth by traction is long-term hospital stay with continuous suction on the upper pouch and the placement of a gastrostomy tube for enteral feeding [8]. Patients may also suffer from associated gastroesophageal reflux [4], irrespective of which method has been used. Therefore new treatment modalities facilitat- ing primary anastomosis are highly warranted. Intramural injection of botulinum toxin type A (BTX-A) could be a potential treatment. BTX-A is derived from the gram-positive bacterium Clostridium botulinum. It is well known that BTX-A blocks the acetylcholine release in ☆ Conflicts of interest: The authors of this article reported no conflicts of interest. ⁎ Corresponding author. Tel.: + 45 22334149. E-mail address: tjens07@gmail.com (T.S.R. Jensen). 1 The two first authors contributed equally to the article. www.elsevier.com/locate/jpedsurg 0022-3468/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpedsurg.2013.03.062 Journal of Pediatric Surgery (2013) 48, 2032–2035