Botulinum neurotoxin-A does not spread to distant muscles after intragastric injection: A double-blind single-fiber electromyography study

Intragastric Botulinum Toxin Injection and Botulism: An Alarm for Clinicians

Clostridium botulinum produces the most potent bacterial toxin, botulinum toxin A (BTXA), which has various therapeutic and cosmetic indications. Intragastric BTXA injection is a new obesity treatment method that was argued to be safe due to the inactivation of BTXA through the liver or metabolization within the gastric wall. However, a 36-year-old woman was admitted to the intensive care unit (ICU) due to developing botulism as a result of an intragastric injection of BTXA. The diplopia, headaches, ptosis, decreased muscle force, and respiratory distress two days after injection were her first chief complaints, and also, she experienced significant dysphagia, hoarse voice, thick tongue, constipation, hyposmia, and hypogeusia after two weeks. This case report highlights the necessity for physicians to have sufficient information about this method and consider possible life-threatening adverse effects including botulism.

[Endoscopic intragastric injection of botulinum toxin in the treatment of patients with morbid obesity: opportunities and prospects]

The authors consider modern epidemiological and demographic data on morbid obesity. Literature review is devoted to non-surgical treatment of patients with morbid obesity. The authors analyze the results of experimental and clinical studies on endoscopic intragastric injection of botulinum toxin and bariatric efficacy of this approach. The indications for endoscopic intragastric injection of botulinum toxin and advantages of this technique are clearly formulated. The authors identified the most significant criteria for objective assessment of clinical effectiveness of endoscopic intragastral injection of botulinum toxin, as well as scientific and methodological principles necessary for this technique. Clinical efficacy of intragastric injection of botulinum toxin including overweight loss, anorexigenic and gastroparetic effects indicates inconsistent results and certain unresolved problems. Thus, large-scale multiple-center randomized controlled trials and multivariate analysis are required to determine the role of endoscopic intragastric injection of botulinum toxin in complex treatment of patients with morbid obesity.

Contribution of Single-Fiber Evaluation on Monitoring Outcomes Following Injection of Botulinum Toxin-A: A Narrative Review of the Literature

Botulinum toxin-A (BoNT-A) blocks acetylcholine release at the neuromuscular junction (NMJ) and is widely used for neuromuscular disorders (involuntary spasms, dystonic disorders and spasticity). However, its therapeutic effects are usually measured by clinical scales of questionable validity. Single-fiber electromyography (SFEMG) is a sensitive, validated diagnostic technique for NMJ impairment such as myasthenia. The jitter parameter (µs) represents the variability of interpotential intervals of two muscle fibers from the same motor unit. This narrative review reports SFEMG use in BoNT-A treatment. Twenty-four articles were selected from 175 eligible articles searched in Medline/Pubmed and Cochrane Library from their creation until May 2020. The results showed that jitter is sensitive to early NMJ modifications following BoNT-A injection, with an increase in the early days’ post-injection and a peak between Day 15 and 30, when symptoms diminish or disappear. The reappearance of symptoms accompanies a tendency for a decrease in jitter, but always precedes its normalization, either delayed or nonexistent. Increased jitter is observed in distant muscles from the injection site. No dose effect relationship was demonstrated. SFEMG could help physicians in their therapeutic evaluation according to the pathology considered. More data are needed to consider jitter as a predictor of BoNT-A clinical efficacy.

Jitter Evaluation in Distant and Adjacent Muscles after Botulinum Neurotoxin Type A Injection in 78 Cases

To study the jitter parameters in the distant (DM) and the adjacent muscle (AM) after botulinum neurotoxin type A (BoNT/A) injection in 78 patients, jitter was measured by voluntary activation in DM (n = 43), and in AM (n = 35). Patients were receiving BoNT/A injections as a treatment for movement disorders. Mean age 65.1 years (DM) and 61.9 years (AM). The mean jitter was abnormal in 13.9% (maximum 41.4 µs) of DM, and 40% (maximum 43.7 µs) of AM. Impulse blocking was sparse. We found no correlation of the mean jitter to age, BoNT/A most recent injection (days/units), number of muscles injected, total BoNT/A units summated, number of total BoNT/A sessions, beta-blockers/calcium channel blockers use, and cases with local spread symptoms such as eyelid drop/difficulty swallowing. Maximum mean jitter (41.4/43.7 µs) for DM/AM occurred 61 and 131 days since the most recent BoNT/A, respectively. The far abnormal mean jitter (32.6/36.9 µs) occurred 229 and 313 days since the most recent BoNT/A. We suggested that jitter measurement can be done after BoNT/A in a given muscle other than the injected one, after 8 (DM) and 11 (AM) months, with reference >33 µs and >37 µs, respectively.

The Positive Effects of a Calorie-Restricting High-Protein Diet Combined with Intragastric Botulinum Toxin Type A Application Among Morbidly Obese Patients: A Prospective, Observational Analysis of Eighty-Seven Grade 2 Obese Patients

PURPOSE

Many studies evaluating the effect of intragastric botulinum toxin type A injection (IG-BTxA) for the treatment of obesity have been published. However, none of these studies combined this procedure with a calorie-restricting high-protein diet. Herein, we aimed to evaluate the effects of IG-BTxA application combined with a calorie-restricting high-protein diet.

MATERIALS AND METHODS

This prospective cohort study is conducted with eighty-seven grade 2 obese patients treated between January 2019 and August 2019. Group 1: IG-BTxA + refused to consult the dietitian; group 2: IG-BTxA + get calorie-restricting high-protein diet; group 3: only get a calorie-restricting high-protein diet. Loss of weight, treatment adaptation (visual analog scale score), the status and changes of comorbid conditions, and changes in eating behaviors (Self-Regulation of Eating Behaviour Questionnaire score) were assessed.

RESULTS

Loss of weight, treatment adaptation, and positive behavioral change in eating preferences were significantly higher in group 2 (p = 0.01; p = 0.001; p < 0.01, respectively). Additionally, the decrease in medication requirement for diabetes and hypertension was higher in group 2 (p < 0.05).

CONCLUSION

IG-BTxA application before calorie-restricting high-protein diet facilitates adaptation to the new diet style and helps to lose weight faster in grade 2 obese patients. Also, more positive results were achieved in terms of controlling comorbid diseases.

Spanish consensus document on bariatric endoscopy. Part 2: specific endoscopic treatments

During the last years we have been witnessing a significant increase in the number and type of bariatric endoscopic techniques: we have different types of balloons, suture systems, injection of substances and malabsorptive prosthesis, etc. Also, some endoscopic revisional procedures for patients with weight regain after bariatric surgery have been incorporated. This makes it necessary to protocolize, position and regularize all these techniques, through a consensus that allows their clinical application with the maximum medical rigor and scientific evidence available.