pyloric injection of botulinum toxin for the treatment of refractory gastroesophageal reflux disease accompanied with gastroparesis

background: patients with gastroesophageal reflux disease (gerd) unresponsive to proton pump inhibitor (ppi) therapy are often labeled as having refractory gerd. one of the probable etiologies of refractory gerd is delayed gastric emptying. refractory gerd associated with gastroparesis is a complex condition with no definitive treatment to date. we opted, for the first time, to test the hypothesis that whether endoscopic pyloric injection of botulinum toxin alleviates the symptoms of both disease conditions. materials and methods: thirteen patients with refractory gerd plus gastroparesis -as confirmed by gastric emptying scintigraghy- underwent endoscopic pyloric injection of botulin. results: injection significantly improved both gastroparesis- and refluxrelated symptoms in the majority of patients but the duration of symptom relief was relatively short. responders to treatment had significantly higher total reflux symptom scores (before injection) than nonresponders. all but one of the patients in whom gastroparesis symptoms improved also had improvements in reflux symptoms-which supports our hypothesis. conclusion: we believe that response to toxin injection is a reliable predictor of response to subsequent surgery (pyloroplasty or pyloromyotomy) following the recurrence of symptoms.