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An international multicenter study evaluating the clinical efficacy and safety of per-oral endoscopic myotomy in octogenarians

Published:February 21, 2017DOI:https://doi.org/10.1016/j.gie.2017.02.007

      Background and Aims

      Per-oral endoscopic myotomy (POEM) for achalasia is particularly appealing in the elderly because it is minimally invasive. However, data in patients aged ≥80 years are scarce. The aim of this study was to assess the clinical outcome of POEM in octogenarians.

      Methods

      This was a multicenter retrospective study at 8 centers. Consecutive octogenarians with achalasia who underwent POEM between 2010 and 2016 were included. Rates of technical success (completion of myotomy), clinical response (Eckardt score ≤3), and adverse events (severity graded as per American Society for Gastrointestinal Endoscopy lexicon) were assessed.

      Results

      A total of 76 patients (47.4% female, mean age 84 years) underwent POEM for treatment of achalasia: type I, 17.1%; type II, 35.5%; type III, 17.1%; and unspecified, 30.3%. Overall, 41.1% were treatment naïve, whereas others had previous botulinum toxin injection and/or pneumatic dilation. The mean (± standard deviation [SD]) age-adjusted Charlson comorbidity index score was 6.2 ± 2.4, with the majority of patients having American Society of Anesthesiologists Physical Status Classification System (ASA) scores of II/III. Technical success was 93.4%, with a median follow-up of 256 days. Fourteen adverse events occurred in 11 patients (14.5%). There were 3 inadvertent mucosotomies, 6 cases of symptomatic capnoperitoneum and/or capnomediastinum, 2 esophageal leaks, 1 cardiac arrhythmia, and 2 other). The severities of these adverse events were mild (78.6%), moderate (14.3%), and severe (7.1%). Clinical success was achieved in 90.8% of patients, with a mean (± SD) Eckardt score reduction from 7.0 ± 2.3 to 0.8 ± 0.1 (P < .001), a median follow-up of 256 days, and interquartile range of 66 to 547.

      Conclusion

      Although the rate of technical success may be somewhat lower and the rate of adverse events slightly higher than previously reported, our data suggest that POEM in octogenarians is safe and effective, supporting its role as a primary modality for achalasia in this patient population.

      Abbreviations:

      ASA (American Society of Anesthesiology Physical Status Classification System), ASGE (American Society for Gastrointestinal Endoscopy), BT (botulinum toxin), POEM (per-oral endoscopic myotomy)
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      References

        • Samo S.
        • Carlson D.A.
        • Gregory D.L.
        • et al.
        Incidence and prevalence of achalasia in central Chicago, 2004-2014, since the widespread use of high-resolution manometry.
        Clin Gastroenterol Hepatol. 2016; 15: 366-373
        • Boeckxstaens G.E.
        • Zaninotto G.
        • Richter J.E.
        Achalasia.
        Lancet. 2014; 383: 83-93
        • Sonnenberg A.
        Hospitalization for achalasia in the United States 1997-2006.
        Dig Dis Sci. 2009; 54: 1680-1685
        • Boeckxstaens G.E.
        • Annese V.
        • des Varannes S.B.
        • et al.
        Pneumatic dilation versus laparoscopic Heller's myotomy for idiopathic achalasia.
        N Engl J Med. 2011; 364: 1807-1816
        • Tsuboi K.
        • Omura N.
        • Yano F.
        • et al.
        Identification of risk factors for mucosal injury during laparoscopic Heller myotomy for achalasia.
        Surg Endosc. 2016; 30: 706-714
        • Vaezi M.F.
        • Pandolfino J.E.
        • Vela M.F.
        American College of Gastroenterology clinical guideline: diagnosis and management of achalasia.
        Am J Gastroenterol. 2013; 108 (quiz 1250): 1238-1249
        • Gennaro N.
        • Portale G.
        • Gallo C.
        • et al.
        Esophageal achalasia in the Veneto region: epidemiology and treatment. Epidemiology and treatment of achalasia.
        J Gastrointest Surg. 2011; 15: 423-428
        • Markar S.R.
        • Zaninotto G.
        Laparoscopic Heller myotomy for achalasia: Does the age of the patient affect the outcome?.
        World J Surg. 2015; 39: 1608-1613
        • Leyden J.E.
        • Moss A.C.
        • MacMathuna P.
        Endoscopic pneumatic dilation versus botulinum toxin injection in the management of primary achalasia.
        Cochrane Database Syst Rev. 2014; (CD005046.pub3:CD005046)
        https://doi.org/10.1002/14651858
        • Chandrasekhara V.
        • Desilets D.
        • Falk G.W.
        • et al.
        • American Society for Gastrointestinal Endoscopy PIVI Committee
        The American Society for Gastrointestinal Endoscopy PIVI (Preservation and Incorporation of Valuable Endoscopic Innovations) on peroral endoscopic myotomy.
        Gastrointest Endosc. 2015; 81 ([abstract]) (e1081): 1087-1100
        • Inoue H.
        • Sato H.
        • Ikeda H.
        • et al.
        Per-oral endoscopic myotomy: a series of 500 patients.
        J Am Coll Surg. 2015; 221: 256-264
        • Talukdar R.
        • Inoue H.
        • Nageshwar Reddy D.
        Efficacy of peroral endoscopic myotomy (POEM) in the treatment of achalasia: a systematic review and meta-analysis.
        Surg Endosc. 2015; 29: 3030-3046
        • Cotton P.B.
        • Eisen G.M.
        • Aabakken L.
        • et al.
        A lexicon for endoscopic adverse events: report of an ASGE workshop.
        Gastrointest Endosc. 2010; 71: 446-454
        • Kumbhari V.
        • Familiari P.
        • Bjerregaard N.C.
        • et al.
        Gastroesophageal reflux after peroral endoscopic myotomy: a multicenter case-control study.
        Endoscopy. 2017; 49: 634-642
        • Pasricha P.J.
        • Hawari R.
        • Ahmed I.
        • et al.
        Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia.
        Endoscopy. 2007; 39: 761-764
        • Akintoye E.
        • Kumar N.
        • Obaitan I.
        • et al.
        Peroral endoscopic myotomy: a meta-analysis.
        Endoscopy. 2016; 48: 1059-1068
        • Finlayson E.V.
        • Birkmeyer J.D.
        Operative mortality with elective surgery in older adults.
        Eff Clin Pract. 2001; 4: 172-177
        • Linn B.S.
        • Linn M.W.
        • Wallen N.
        Evaluation of results of surgical procedures in the elderly.
        Ann Surg. 1982; 195: 90-96
        • Cock C.
        • Besanko L.
        • Kritas S.
        • et al.
        Impaired bolus clearance in asymptomatic older adults during high-resolution impedance manometry.
        Neurogastroenterol Motil. 2016; 28: 1890-1901
        • DeVault K.R.
        Presbyesophagus: a reappraisal.
        Curr Gastroenterol Rep. 2002; 4: 193-199
        • Soergel K.H.
        • Zboralske F.F.
        • Amberg J.R.
        Presbyesophagus: esophageal motility in nonagenarians.
        J Clin Invest. 1964; 43: 1472-1479
        • Zboralske F.F.
        • Amberg J.R.
        • Soergel K.H.
        Presbyesophagus: cineradiographic manifestations.
        Radiology. 1964; 82: 463-467
        • Shiwaku H.
        • Inoue H.
        • Yamashita K.
        • et al.
        Peroral endoscopic myotomy for esophageal achalasia: outcomes of the first over 100 patients with short-term follow-up.
        Surg Endosc. 2016; 30: 4817-4826
        • Smith C.D.
        • Stival A.
        • Howell D.L.
        • et al.
        Endoscopic therapy for achalasia before Heller myotomy results in worse outcomes than Heller myotomy alone.
        Ann Surg. 2006; 243 (discussion 584-76): 579-584
        • Snyder C.W.
        • Burton R.C.
        • Brown L.E.
        • et al.
        Multiple preoperative endoscopic interventions are associated with worse outcomes after laparoscopic Heller myotomy for achalasia.
        J Gastrointest Surg. 2009; 13: 2095-2103
        • Khashab M.A.
        • El Zein M.
        • Kumbhari V.
        • et al.
        Comprehensive analysis of efficacy and safety of peroral endoscopic myotomy performed by a gastroenterologist in the endoscopy unit: a single-center experience.
        Gastrointest Endosc. 2016; 83: 117-125
        • Chavez Y.H.
        • Beard K.W.
        • Inoue H.
        • et al.
        Comprehensive analysis of adverse events associated with peroral endoscopic myotomy (POEM) in 1826 patients: an international multicenter study.
        Gastrointest Endosc. 2016; 83 ([Abstract]): AB173
        • Stavropoulos S.N.
        • Desilets D.J.
        • Fuchs K.H.
        • et al.
        • NOSCAR POEM White Paper Committee
        Per-oral endoscopic myotomy white paper summary.
        Gastrointest Endosc. 2014; 80: 1-15
        • Kilic A.
        • Schuchert M.J.
        • Pennathur A.
        • et al.
        Minimally invasive myotomy for achalasia in the elderly.
        Surg Endosc. 2008; 22: 862-865
        • Metman E.H.
        • Lagasse J.P.
        • d'Alteroche L.
        • et al.
        Risk factors for immediate complications after progressive pneumatic dilation for achalasia.
        Am J Gastroenterol. 1999; 94: 1179-1185
        • Craft R.O.
        • Aguilar B.E.
        • Flahive C.
        • et al.
        Outcomes of minimally invasive myotomy for the treatment of achalasia in the elderly.
        JSLS. 2010; 14: 342-347
        • Docimo Jr., S.
        • Mathew A.
        • Shope A.J.
        • et al.
        Reduced postoperative pain scores and narcotic use favor per-oral endoscopic myotomy over laparoscopic Heller myotomy.
        Surg Endosc. Epub. 2016 Jun 23;
        • Marano L.
        • Pallabazzer G.
        • Solito B.
        • et al.
        Surgery or peroral esophageal myotomy for achalasia: a systematic review and meta-analysis.
        Medicine (Baltimore). 2016; 95: e3001