Achalasia Treatment in Patients over 80 Years of Age: A Multicenter Survey

Population

Patients with achalasia older than 80 years who were primarily treated in the participant institutions were included in the study.

Variables studied

Retrospective chart and databases review were performed by each center. Variables recorded were demographic (age and gender), clinical (symptoms, health status, and presence of comorbidities), manometric (Chicago classification), and therapeutic (tailoring for age, primary and secondary treatments, complications, length of stay, follow-up time, and outcomes).

Ethics

This study was approved by the ethics committee of the coordinating center (CAAE 79580017.5.0000.5505) and other centers according to local necessity and rules. Informed consent was waived due to the retrospective nature of the protocol.

Participating centers

Seven centers agreed to participate: three from the United States, three from Brazil, and one from Italy. Other invited centers either did not treat patients >80 years or refused to participate. All participating centers are linked to academic surgical departments. All gastroenterology centers declined participation.

Population

A total of 85 patients were included. There were 46 (54%) men and 39 (46%) women, with a mean age of 83.9 ± 3.8 (range 80–97) years.

Clinical data

Symptoms and comorbidities were not evaluated since most centers had no records of these data.

Manometric data

High-resolution manometry data were available for 25 (32%) patients. Chicago classification type I was diagnosed in 9 (36%) patients, type II in 14 (56%), and type III in 2 (8%). In other patients, achalasia diagnosis was based on conventional manometry and/or barium swallow.

Therapeutic data

Four (57%) centers tailored treatment based on age, representing 12 (14%) patients included in the study.

The mean follow-up time was 19.6 ± 20.3 (range 2–70) months.

Primary endoscopic treatment was performed in 43 (51%) patients: 18 (21%) botulinum toxin (BT) injection, 15 (18%) PD, and 10 (12%) an association of the two methods. Primary surgical treatment was performed in 39 (46%) patients: 30 (35%) LHM and 9 (11%) cardioplasty + gastrectomy (Serra-Doria or Holt–Large procedure). Clinical and behavioral measures only were adopted in 3 (3%) patients (Fig. 1).

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FIG. 1.

Therapeutic flowchart for patients >80 years of age with achalasia.

There was a need for secondary treatment in 34 (40%) patients: 30 (35%) initially treated by endoscopic therapy and 4 (5%) who underwent surgical procedures. LHM was the secondary treatment of choice for 20 (59%) of these patients and 14 (41%) underwent endoscopic treatment—5 POEM, 6 PD, and 3 BT (Fig. 1). Patients who did not undergo a retreatment had satisfactory alimentary satisfaction and weight maintenance.

Eleven out of 50 (22%) patients after LHM had some postoperative complications. Seven patients had LHM as the primary treatment and presented with the following complications: 2 delirium, 1 stroke, 1 pneumonia, 1 right popliteal artery occlusion, and 2 cardiovascular complications. Four had LHM as secondary treatment and presented with the following complications: 1 delirium, 2 urinary retention, and 1 esophageal leak. The mean time of hospitalization was 4.3 ± 1.8 days for those who did not present complications and 6.8 ± 6.3 days for those who presented complications (Fig. 2).

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FIG. 2.

Flowchart demonstrating complications in primary and secondary treatments.

One patient died due to cardiovascular complications after a cardioplasty and gastrectomy.

Endoscopic treatment in the oldest-old

PD is a widely used treatment for achalasia. ² Although results for PD are slightly worse than those of LHM, ⁵ the less invasive nature of the procedure makes it attractive to be applied in the oldest-old patients. Moreover, older age has been repeatedly described as a prognostic factor for better results for PD.^3,6–8 Although there are no previous specific studies on octogenarians, age higher than 40, ⁸ 45, ⁶ or 60 years ⁷ has been linked to better outcomes and lower rate of repeated procedures. The loss of tissue elasticity with aging may render PD more efficient. Some authors pointed out that young men present with worse outcomes. ³ We did not categorize results by gender due to the small number of patients and heterogeneity of the sample, but the gender effect seems to fade off after 70 years of age. ³

BT is also an endoscopic treatment for achalasia with very low rate of complications that were curiously found even less frequent in the old. ⁹ BT outcomes are inferior to other types of therapy, ¹⁰ but similarly to PD it may appear to be an attractive option in the oldest-old although a multicenter study showed a 7% rate of major complications. ⁹ A significant number of patients indeed had this treatment in our population. Previous studies focused on BT in patients older than 80 years to show poor outcomes and significant morbidity. Only 18 out of 33 (54%) patients improved symptoms in a single-center 2-year follow-up series with a minimum weight gain. ¹¹ Interestingly, symptom recurrence is expected after BT and may not be considered a treatment failure, but in our series, symptom recurrence was rarely treated by repeated BT.

POEM is a more recent therapy for achalasia. ² This treatment was used only as rescue therapy in our series, probably due to the recent availability of the method. Efficacy and safety of POEM in the oldest-old are still unknown.

In our study, outcomes were suboptimal for endoscopic therapy in this population due to a significant rate of secondary treatment.

Surgical treatment in the oldest-old

LHM gives excellent results both in terms of complications and in the resolution of symptoms.^2,10 Almost half of the patients in this series were offered this option as the primary therapy, and when rescue procedures are included, this number increased to 70%. The complication rate is higher than most large series,^12,13 but represented mostly by Clavien–Dindo I or II clinical complications. It is worth mentioning that some complications present in our series are not usually found in achalasia series, but common in the perioperative period in the old, such as delirium (that occurred in 38% of the surgical patients) and vascular complications associated with the positioning of legs in stirrups. Surgeons may be aware on how to prevent and recognize these conditions and adopt simple measures such as natural light therapy, early mobilization, family interactions, and the avoidance of narcotics to prevent delirium. Mortality was null. Rescue therapy was necessary in 13% of the cases who had LHM as primary treatment. Endoscopic treatment was used as secondary treatment with high rate of success as shown in general series, ¹² demonstrating that the operation first followed by endoscopy if necessary approach ¹⁴ is safe and successful in this specific population.

Cardioplasty + gastrectomy is a technique used by some South American surgeons as an alternative to esophagectomy in patients with Chagas' disease and massive dilated megaesophagus. ¹⁵ In this series, it accounted for the only case of mortality in the series and it should probably be avoided in this population.

Study limitations and strengths

This is a retrospective multicenter study encompassing worldwide centers with different database settings. Limitations came from this study design. First, data on clinical follow-up and endoscopic complications were not available. Lack of data on pre-existing comorbidites and additional demographics also impacted our study, since we were unable to describe which population received which approach (could have affected the complications), and whether there was a difference on that. Also, all participant centers were affiliated to surgical departments even though they were all able to offer either surgical or endoscopic treatment. In contrast, this series encompasses a significant number of patients.