Per-oral endoscopic myotomy appears safe, effective for achalasia in octogenarians

Last Updated: 2017-03-06

By Will Boggs MD

NEW YORK (Reuters Health) - Per-oral endoscopic myotomy (POEM) appears safe and effective for treating octogenarians with achalasia, according to an international multicenter retrospective study.

“Many would be reluctant to perform such an extensive procedure in this patient population; however, we are showing that it can be safely performed in relatively healthy octogenarians,” Dr. Yen-I Chen from Johns Hopkins Medical Institutions in Baltimore, Maryland, told Reuters Health by email.

POEM, a less invasive alternative to laparoscopic Heller myotomy (LMH) for treating achalasia, has demonstrated effectiveness and low serious adverse event rates, but no studies have focused on octogenarians.

Dr. Chen and colleagues from eight medical centers in the U.S., Europe and Asia used their medical records to assess the clinical effectiveness of POEM in octogenarians.

The 76 patients included in the study had severe symptoms, with a mean Eckardt score of 7.0 and a mean integrated relaxation pressure (IRP) of 24.2 mm Hg, and the median duration of symptoms before POEM was 24.0 months.

The POEM procedure averaged 103.7 minutes, the researchers report in Gastrointestinal Endoscopy, online February 21. The median hospital duration was three days, and the median follow-up was 256 days.

Technical success was achieved in 71 patients (93.4%), and clinical success as defined by an Eckardt score of 3 or less was attained in 90.8% of the patients.

In the 21 patients studied post-POEM, mean IRP declined from 24.4 mm Hg to 11.6 mm Hg (p<0.001).

There were 14 adverse events in 11 patients, with only one event graded as severe; 16.1% of patients reported post-POEM reflux symptoms.

“Despite their advanced age, octogenarians can benefit from POEM,” Dr. Chen concluded. “For physicians who perform POEM, it is important to keep in mind that there may be some additional challenges associated with changes of the esophagus with age, prolonged disease duration, and previous therapy.”

“As with any procedure, alternatives should be discussed, such as dilation, botox injection, and Heller myotomy,” Dr. Chen explained. “The main advantage of POEM is that it can achieve sustained response without needing multiple endoscopic sessions while maintaining a minimal invasive endoscopic approach. As such POEM in octogenarians can be considered as a first modality or following failure without other approaches.”

The researchers note, “Further studies are needed to assess the long-term outcome POEM in octogenarians as well as its efficacy and safety when directly compared with LMH or pneumatic dilation (PD).”

Dr. Philip O. Katz, chief of gastroenterology and nutrition from Einstein Medical Center and Sidney Kimmel Medical College in Philadelphia, Pennsylvania, told Reuters Health by email, “POEM should be considered (with PD, LHM, etc.) as primary treatment for achalasia in this population provided the surgeon/endoscopist is prepared to manage adverse events. It’s likely safer than LHM but that remains to be proven.”

“Achalasia can be treated ‘successfully’ regardless of age,” said Dr. Katz, who was not involved in the study. “The elderly should be considered for definitive treatment (something other than botox) of achalasia unless risks outweigh benefits.”

Dr. Katz added, “The care of achalasia must in every way be individualized.”

SOURCE: http://bit.ly/2mMcuix

Gastrointest Endosc 2017.