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Background: Laparoscopic Heller-Dor (LHD) surgery is the current treatment of choice for patients with esophageal achalasia, but elderly patients are generally referred for less invasive treatments (pneumatic-dilations or botulinum-toxin injections). The aim was to assess the effect of age on the surgical outcome of patients receiving laparoscopic Heller-Dor as primary treatment.
Methods: We evaluated the patients who underwent surgery from 1992 to January 2012 . Patients who had already been treated for esophageal achalasia and patients with sigmoid-shaped mega-esophagus (stage 4) were excluded. Symptoms were scored using a detailed questionnaire for dysphagia, regurgitation, and chest pain; barium swallow, endoscopy, and esophageal-manometry were performed, before and 6 months after the treatment. Patients were classified in three age brackets: group A (≤45 years), group B (45-70) and group C (≥70). Treatment was defined as a failure if the postoperative symptom-score was >10th percentile of the preoperative score (i.e.>8)
Results: We consecutively performed the LHD as primary treatment in 514 achalasia patients, 272 (53%) in group A, 208 (40.4%) in group B and 34 (6.6%) in group C. The mortality was nil; the conversion and morbidity rates were both 1.2% with no-difference in the 3 groups.
Group C patients had higher preoperative symptom scores (p=0.02), while the symptom duration was similar in all groups. At a median follow-up of 40 months (IQR 15-80), the median of symptom scores was significantly lower after surgery (18 [IQR 14-20] vs 0 [IQR 0-3]; p<0.0001). The median of resting LES pressure decreased from 27mmHg (IQR 19-36) to 11mmHg (IQR 8-14) (p<0.001) and the residual LES pressure from 10mmHg (IQR 5-17) to 3mmHg (QR: 1-5) (p<0.001). No statistically significant differences emerged between the 3 groups in any of these aspects.
Mucosal tears occurred in 16 patients (3%): 5 (1.8%) in group A; 8 (3.9%) in group B; and 3 (8.9%) in group C (p=0.06). The postoperative hospital stay was slightly longer for group C (p=0.06). The treatment failure rate was quite similar: 31 failures in group A (11.4%), 19 in group B (9.1%) and 2 in group C (5.9%) (p=0.55)(table). The failures were seen more in manometric-pattern III (22.2%, p=0.002). All the patients whose surgical treatment failed were treated with pneumatic dilations. The overall success rate of this combined treatment was therefore 98.4% (507/515). Postoperative 24-hour pH-monitoring was abnormal in 16 patients (6.6%): 7 patients were in group A, 6 in group B and 3 in group C (p: n.s.)
Discussion: LHD is often performed in old patients as a "last resource", after other treatments have failed. Given our high success and low complication rate, this study supports the use of LHD as the first treatment of achalasia in elderly patients with an acceptable surgical risk.
Table. Postoperative findings in the three groups. Data are shown as median and IQR (in brackets).

	Group A (≤45 yrs) n = 272	Group B (45-70 yrs) n = 208	Group C (≥70 yrs) n = 34	p value
Postoperative symptom score	0 (0-3)	0 (0-3)	0 (0-3)	0.89
Postoperative chest pain score	0 (0-0)	0 (0-0)	0 (0-0)	0.11
LES resting pressure (mmHg)	10 (8-13)	12 (8-17)	10 (7-14)	0.07
LES residual pressure (mmHg)	3 (1-5)	3 (2-6)	2 (1-4)	0.21
Esophageal diameter (mm)	20 (18-27)	22 (20-25)	22 (20-25)	0.95
Mucosa tear	5 (1.8%)	8 (3.9%)	3 (8.9%)	0.06
Postoperative hospital stay (days)	3 (3-4)	3 (3-4)	3 (3-6)	0.06
Failures	31 (11.4%)	19 (9.1%)	2 (5.9%)	0.55