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ZINC THERAPY INDUCTION OF INTESTINAL METALLOTHIONEIN IN WILSON'S DISEASE

previously been treated with Botox injections, and 42 had not (29 had had dilations). Data on operative complications and outcome was collected prospectively. We found that preoperative injection of Botox made the operation significantly more difficult to perform. The difficulties were related to the obliteration of the submucosal plane, perhaps as a result of the trauma or submucosal injection of Botox. The mucosa was difficult to identify, and the edges of the myotomy were more difficult to separate away from each other following the submucosal plane. A significantly larger number of patients who were treated with Botox had a laceration of the mucosa when compared with the patients who had not received Botox. On the other hand, the results at 6 months in terms of relief of dysphagia and other symptoms were comparable between the two groups; thus, the operative difficulty, in our hands, did not compromise the ultimate result. The use of Botox in the treatment of patients with achalasia is widespread, but the data published is consistent in showing that the recurrence rate is high. Indeed, even when the results are as good as those observed in the patients treated with pneumatic dilations, they last only for the short term. We have shown that the surgical myotomy is more difficult in this group of patients. Thus, we believe that the time may have come to question the widespread use of Botox, an expensive and relatively ineffective form of treatment for patients with achalasia, and perhaps to restrict it to a few high volume centers which are capable of conducting studies such as those presented by Prakash et al. Only in this way will the medical profession learn the ultimate truth. It may be, as suggested by Pasricha et al. (4) that older patients or other subsets are more likely to benefit from Botox injections, and that despite the short term results, Botox may have an important role in the management of those patients who, for medical reasons, are poor candidates for surgery.