POEM for Achalasia: Safe and Highly Effective in Geriatric Patients

Per oral endoscopic myotomy (POEM) is as safe and effective for patients 65 years or older as it is for younger patients, according to a new Cleveland Clinic study published online in Esophagus (2020 May 11 [Epub ahead of print]). The retrospective review of patients undergoing the minimally invasive procedure to treat achalasia demonstrated 95% treatment success with few complications in both older and younger patient groups.

“How to treat achalasia in the elderly has been a matter of controversy,” says the study’s senior author, Siva Raja, MD, PhD, a thoracic surgeon and Surgical Director of Cleveland Clinic’s Center for Esophageal Diseases. “We found POEM to be a good option regardless of patient age.”

Evidence is scant for treating achalasia in the elderly

While laparoscopic Heller myotomy is considered by many to be the gold standard for treating achalasia, it is sometimes deemed too risky for older patients. Practitioners are inclined to treat the elderly with pneumatic dilation or botulinum toxin, which can be less effective in the long run. Medications are even less effective and often have side effects.

POEM, first reported as a treatment for achalasia in 2010, has increasingly become an initial option due to its high rate of effectiveness and minimally invasive nature. But its safety and efficacy in the geriatric population has not been well studied, particularly in the U.S.

Study design and results

Patient population. Records of all patients who underwent POEM for achalasia at Cleveland Clinic between April 2014 and May 2019 were reviewed; 93 patients were “young” (< 65 years), and 55 were “old” (≥ 65 years). Most baseline characteristics, including median Eckardt symptom score, were similar between the two groups, with the following exceptions:

• Timed barium esophagram (TBE) height at 1 minute (9.6 cm in young patients vs. 12.5 cm in old patients; P = 0.033)
• TBE width at 5 minutes (3.0 cm in young patients vs. 2.0 cm in old patients; P = 0.026)
• History of Heller myotomy (28.0% of young patients vs. 7.3% of old patients; P = 0.003)
• History of botulinum toxin injection (12.9% of young patients vs. 38.2% old patients; P = 0.001)

Results. Rates of treatment success (defined as improvement in Eckardt score to ≤ 3) were 94.9% in the young group vs. 94.7% in the old group (P = 1.00).

Complications were few, with none recorded in 94.6% of the young group and 98.2% of the old group (P = 0.412). No significant differences between the groups were found in types of complications or in readmission rates within 30 days.

At two-month follow-up, both groups were significantly improved in terms of Eckardt scores and high-resolution manometry measures. Older patients achieved greater improvement in TBE height at 1 and 5 minutes. The two groups had similar rates of symptomatic gastroesophageal reflux disease as well as abnormal esophageal pH study findings.

A good choice for elderly patients

“POEM had similar and high success rates among both young and old age groups,” notes study co-author Sudish Murthy, MD, PhD, Section Head of Thoracic Surgery at Cleveland Clinic. “In both groups it was highly effective in achieving symptom relief with few complications.”

He adds that POEM achieved better esophageal drainage on TBE in the elderly and conjectures that structural differences in the esophageal wall may account for this. Older patients tended to have thinner esophageal circular muscle, making myotomy especially effective, while younger patients tended to have thicker muscle and more scar tissue.

Lead author Madhu Sanaka, MD, of Cleveland Clinic’s Department of Gastroenterology, points out that while the study was limited by its retrospective design and short median follow-up of slightly more than two months, it appears to be the first to analyze clinical outcomes of POEM among different age groups in the U.S. Because all patients were treated at a tertiary care center performing a high volume of POEM procedures, results might not be applicable to smaller hospitals.

“Nevertheless,” Dr. Raja concludes, “given the disadvantages of other treatment options for elderly patients with achalasia, we recommend POEM as a safe and effective choice. With additional favorable evidence — that is, from long-term outcomes and comparison with Heller myotomy — POEM may emerge as the preferred approach for this population.”