Achalasia--which method of treatment to choose for senior patients?
Achalasia is an uncommon illness affecting 1 per 100,000 patients a year. It encompasses a rare, primary motor disorder of the distal esophagus.
Over the period 1998-2006, 115 patients underwent various treatments for achalasia; the subgroup of seniors consisted of 26 patients. Six patients of these (age 69.7 y) underwent a modified Heller cardiomyotomy due to failure of previous endoscopic interventions. Standard esophageal manometry and 24 hour pH metry were performed pre- and postoperatively.
Six senior patients with achalasia underwent a laparoscopic Heller myotomy. Average preoperative tonus of the LES was 55 mmHg, postoperative tonus of the LES decreased to 11 mmHg. We performed Toupet partial fundoplication in all patients; no microperforation of the esophagus was found in the preoperative esophagoscopy. We recorded minimal pathological gastroesophageal reflux in pH metry - the average preoperative DeMeester score was 8, postoperatively 10.5. Prolonged dysphagia was not present in any patient--preoperative GIQLI score was 94, postoperative score was 106. There was no mortality or morbidity in the group of the operated patients.
Our operational results and postoperative follow-up show that laparoscopic Heller myotomy with Toupet partial fundoplication is a safe and effective treatment and can be recommended as the method of first choice for senior patients with no contraindication for laparoscopic operation.
Available from: Andrzej Lewandowski
- "Both methods require subjective as well as objective tools for evaluation of their outcomes. Several authors reported divergence between patients’ subjective symptomatic improvement and objective result of the treatment [5,10]. The most sensitive objective examination for LES disruption is esophageal manometry; however, the examination is not sufficient in long-term follow-up (evaluation of esophageal mucosa). "
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The optimal therapeutic schedule in patients with achalasia is still under discussion. The aim of this study was to review our institution’s experience with myotomy and dilation in patients with achalasia.
Clinical data were available for 59 patients who had ever had myotomy (n=38), dilation (n=21), or both procedures (n=8) between 2000 and 2007. Patients were followed prospectively with objective (a barium esophagogram) and subjective (a simple survey that scored dysphagia and overall patient satisfaction with the procedure) diagnostic tools. In the group of patients after pneumatic dilatations, frequency of interventions was higher (1, 2) than in the myotomy group (0, 2) at 2-year follow-up. Patients after myotomy with recurrence of dysphagia were treated with dilations.
Mean time of dysphagia occurrence was similar in both groups (10 months). The statistically significant differences in treatment outcomes in both groups were in favor of myotomy during 2-year follow-up.
The data indicates that both methods of treatment might be useful in dysphagia control, but better results are obtained after myotomy. Repeat interventions are more frequent after endoscopic dilation. One method of treatment does not exclude the other. A short period of symptom relief after myotomy may suggest the myotomy was incomplete.
Available from: PubMed Central
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ABSTRACT: An increasing number of elderly patients diagnosed with achalasia are being referred for minimally invasive myotomy. Little data are available about the operative outcomes in this population. The objective of this study was to review our experience with this procedure in an elderly population.
A retrospective review was performed of 51 consecutive patients, 65 years of age or older, diagnosed with achalasia who underwent a minimally invasive myotomy at our institution. Prior therapies, perioperative outcomes, and postoperative interventions were also analyzed.
Of the 51 patients, 28 (55%) had undergone prior endoscopic therapy, and 2 patients (7%) had a prior myotomy. Mean duration of symptoms was 10.9 years (range, 0.5 to 50). No perioperative mortality occurred, and the median hospital stay was 3 days. Two patients (3.8%) had complications, including a gastric mucosal injury and one atelectasia. Eleven patients (21%) required additional therapy postoperatively. Symptom improvement was described in all patients.
Laparoscopic Heller myotomy can safely be performed in elderly patients, providing significant symptom relief. No evidence suggests that surgery should not be considered a first-line treatment. Advanced age does not appear to adversely affect outcomes of laparoscopic Heller myotomy.
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