Excellent outcomes of laparoscopic esophagomyotomy for achalasia in patients older than 60 years of age

Abstract

BackgroundThe effectiveness of an esophagomyotomy for dysphagia in elderly patients with achalasia has been questioned. This study was designed to provide an answer.MethodsA total of 162 consecutive patients with achalasia who had a laparoscopic myotomy and Dor fundoplication and who were available for follow-up interview were divided by age: <60 years (range, 14–59; 118 patients), and ≥60 years (range, 60–93; 44 patients). Primary outcome measures were severity of dysphagia, regurgitation, heartburn, and chest pain before and after the operation as assessed on a four-point Likert scale, and the need for postoperative dilatation or revisional surgery.ResultsFollow-up averaged 64 months. Older patients had less dysphagia (mean score 3.6 vs. 3.9; P < 0.01) and less chest pain (1.0 vs. 1.8; P < 0.01). Regurgitation (3.0 vs. 3.2; P = not significant (NS)) and heartburn (1.6 vs. 2.0, P = NS) were similar. Older patients were no different in degree of esophageal dilation, manometric findings, number of previous pneumatic dilatations, or previous botulinum toxin therapy. None of the older patients had previously had an esophagomyotomy, whereas 14% of younger patients had (P < 0.01).After laparoscopic myotomy, older patients had better relief of dysphagia (mean score 1.0 vs 1.6; P < 0.01), less heartburn (0.8 vs. 1.1; P = 0.03), and less chest pain (0.2 vs. 0.8, P < 0.01). Complication rates were similar. Older patients did not require more postoperative dilatations (22 patients vs. 10 patients; P = 0.7) or revisional surgery for recurrent or persistent symptoms (3 vs. 1 patients; P = 0.6). Satisfaction scores did not differ, and more than 90% of patients in both groups said in retrospect they would have undergone the procedure if they had known beforehand how it would turn out.ConclusionsThis retrospective review with long follow-up supports laparoscopic esophagomyotomy as first-line therapy in older patients with achalasia. They appeared to benefit even more than younger patients.

Pneumatic dilation versus laparoscopic Heller myotomy for the treatment of achalasia: variables related to a good response

“…In the study performed by Roll et al in 162 patients with achalasia who underwent laparoscopic Heller esophageal myotomy with partial fundoplication, patients over 60 years had better results, suggesting that laparoscopic esophageal myotomy can be used as first-line therapy in elderly patients with achalasia. 32 In the study by Schuchert et al, a low LESP was associated with poor response to Heller myotomy, what is different to our findings that a LESP below 32 mmHg is related to a good response to myotomy. However, 59.5% (119 patients) of patients had undergone other forms of treatment (PD or botulinum toxin) prior to surgery, what could have influenced the final results.…”

Minimally invasive surgery for achalasia in patients >40 years: more favorable than anticipated

“…Our results are supported by two recently published studies on minimally invasive myotomy in the elderly, which have shown that this group appears to benefit at least as much from this approach as younger patients [23,24].…”

Management of achalasia in the UK, do we need new guidelines?

“…This number falls to 55% in patients over the age of 60. This is likely due to both patient and surgeon choice, as well as a reflection on the presence of comorbidities in this population age group, although a study in 2010 suggests LHM can achieve good results in patients over the age of 60 [13].…”