ACHALASIA TREATMENT IN PATIENTS OVER 80 YEARS OF AGE. A MULTICENTER SURVEY.
Orlando R. Zotti1, Fernando A. M. Herbella*1, Priscila R. Armijo2, Dmitry Oleynikov2, José L. de Aquino7, Vania A. Merhi7, Vic Velanovich4, Renato Salvador5, Mario Costantini5, Donald Low8, Andrea Wirsching8, Piers R. Boshier8, Richard R. Gurski6, Leonardo Kristem6, Marco G. Patti3
1Department of Surgery, Federal University of Sao Paulo, Sao Paulo - SP, Sao Paulo, Brazil; 2Department of Surgery, University of Nebraska, Omaha, NE; 3Department of Surgery, University of North Carolina, Chapel Hill, NC; 4Department of Surgery, University of South Florida, Tampa, FL; 5Department of Surgery, University of Padua, Padua, Italy; 6Department of Surgery, Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil; 7Department of Surgery, Catholic University of Campinas, Campinas, Brazil; 8Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, WA
Background and aims: Laparoscopic Heller s myotomy (LHM), per oral endoscopic myotomy (POEM) and pneumatic dilatation (PD) are well-established methods to treat achalasia. In regards to age, it is known that PD have low success rates in younger patients and LHM seems to be safe and efficient in patients over 60 years of age. The ideal algorithm of treatment in the older is; however, still elusive. Certainly, age and comorbities may influence clinical decision in the very old patient (>80 years). This multicenter study aims to evaluate outcomes and changes in routine therapeutic options in the very old.
Methods: Twenty high volume centers for the treatment of achalasia were surveyed: 13 did not agree to participate or have not treated patients > 80 years; 7 participate in the study (United States n=3, Brazil n=3, Italy n=1). Therapeutic options and outcomes in patients over 80 years of age with achalasia were reviewed.
Results: Data from 78 (56% males, mean age 84±4 years) patients were reviewed. Three centers tailored treatment based on advanced age (43% of the centers, 14% of the patients). Primary treatment was endoscopic in 38 (49%) patients (15 botulinum toxin injection, 13 PD, and 10 association of both methods); surgical in 37 (47%) patients (36 LHM, 9 cardioplasty+gastrectomy); and clinical in 3 (4%) patients. Secondary treatment was necessary due to recurrent symptoms in 30 (38%) patients; 27 of them with endoscopic treatment as primary treatment (7 Botox, 7 PD, 6 Botox + PD) and 3 with a previous LHM. LHM was performed in 20 (67%) of these patients patients and endoscopic treatment in 10 (33%) (5 POEM, 4 PD, 1 botox). A total of 11 (23%) patients submitted to LHM had postoperative complications. Seven had LHM as primary treatment and had the following complications: 2 delirium, 2 cardiovascular complications, 1 stroke, 1 pneumonia, and 1 right popliteal artery occlusion. Four had LHM as secondary treatment and had the following complications: 2 urinary retention, 1 delirium, and 1 esophageal leak. Mortality was represented by 2 cases of cardiac complications in patients with Chagasic cardiopathy that underwent a cardioplasty + gastrectomy (22% mortality for the method). The mean time of hospitalization was 4±2 days for those who did not presented complications and 7±6 days for those that present complications.
Conclusion: Most specialized centers do not tailor treatment based on advanced age. Endoscopic treatment as primary treatment in this population has a high rate of recurrence, especially after botulinum toxin injection. Cardioplasty+gastrectomy has a high rate of complications and mortality in very old patients. LHM seems to be a safe option with good outcomes in this population.
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