title: An international multicenter study evaluating the clinical efficacy and safety of per-oral endoscopic myotomy in octogenarians.
abstract: OBJECTIVE
  Per-oral endoscopic myotomy (POEM) for achalasia is particularly appealing in the elderly because it is minimally invasive. However, data in patients aged ≥80 years are scarce. The aim of this study was to assess the clinical outcome of POEM in octogenarians.
  
  
  METHODS
  This was a multicenter retrospective study at 8 centers. Consecutive octogenarians with achalasia who underwent POEM between 2010 and 2016 were included. Rates of technical success (completion of myotomy), clinical response (Eckardt score ≤3), and adverse events (severity graded as per American Society for Gastrointestinal Endoscopy lexicon) were assessed.
  
  
  RESULTS
  A total of 76 patients (47.4% female, mean age 84 years) underwent POEM for treatment of achalasia: type I, 17.1%; type II, 35.5%; type III, 17.1%; and unspecified, 30.3%. Overall, 41.1% were treatment naïve, whereas others had previous botulinum toxin injection and/or pneumatic dilation. The mean (± standard deviation [SD]) age-adjusted Charlson comorbidity index score was 6.2 ± 2.4, with the majority of patients having American Society of Anesthesiologists Physical Status Classification System (ASA) scores of II/III. Technical success was 93.4%, with a median follow-up of 256 days. Fourteen adverse events occurred in 11 patients (14.5%). There were 3 inadvertent mucosotomies, 6 cases of symptomatic capnoperitoneum and/or capnomediastinum, 2 esophageal leaks, 1 cardiac arrhythmia, and 2 other). The severities of these adverse events were mild (78.6%), moderate (14.3%), and severe (7.1%). Clinical success was achieved in 90.8% of patients, with a mean (± SD) Eckardt score reduction from 7.0 ± 2.3 to 0.8 ± 0.1 (P < .001), a median follow-up of 256 days, and interquartile range of 66 to 547.
  
  
  CONCLUSIONS
  Although the rate of technical success may be somewhat lower and the rate of adverse events slightly higher than previously reported, our data suggest that POEM in octogenarians is safe and effective, supporting its role as a primary modality for achalasia in this patient population.
authors.affiliation: Department of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
authors.forename: Yen-I
authors.initials: YI
authors.lastname: Chen
authors.affiliation: Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Koto-Ku, Tokyo, Japan.
authors.forename: Haruhiro
authors.initials: H
authors.lastname: Inoue
authors.affiliation: Department of Surgery, Section of Minimally Invasive Surgery, NorthShore University Health System, Evanston, Illinois, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Ujiki
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, USA.
authors.forename: Peter V
authors.initials: PV
authors.lastname: Draganov
authors.affiliation: Division of Gastrointestinal and Minimally Invasive Surgery, The Oregon Clinic, Portland, Oregon, USA.
authors.forename: Paul
authors.initials: P
authors.lastname: Colavita
authors.affiliation: Digestive Physiology, Hospices Civils de Lyon and Lyon University, Lyon, France.
authors.forename: Francois
authors.initials: F
authors.lastname: Mion
authors.affiliation: Baystate Medical Center, University of Massachusetts School of Medicine, Springfield, Massachusetts, USA.
authors.forename: John
authors.initials: J
authors.lastname: Romanelli
authors.affiliation: Institute of Digestive Disease, The Chinese University of Hong Kong, Shatin, Hong Kong.
authors.forename: Philip
authors.initials: P
authors.lastname: Chiu
authors.affiliation: Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Koto-Ku, Tokyo, Japan.
authors.forename: Valerio
authors.initials: V
authors.lastname: Balassone
authors.affiliation: Department of Surgery, Section of Minimally Invasive Surgery, NorthShore University Health System, Evanston, Illinois, USA.
authors.forename: Lava
authors.initials: L
authors.lastname: Patel
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, USA.
authors.forename: Ali
authors.initials: A
authors.lastname: Abbas
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, USA.
authors.forename: Dennis
authors.initials: D
authors.lastname: Yang
authors.affiliation: Division of Gastrointestinal and Minimally Invasive Surgery, The Oregon Clinic, Portland, Oregon, USA.
authors.forename: Christy
authors.initials: C
authors.lastname: Dunst
authors.affiliation: Digestive Physiology, Hospices Civils de Lyon and Lyon University, Lyon, France.
authors.forename: Mathieu
authors.initials: M
authors.lastname: Pioche
authors.affiliation: Digestive Physiology, Hospices Civils de Lyon and Lyon University, Lyon, France.
authors.forename: Sabine
authors.initials: S
authors.lastname: Roman
authors.affiliation: Digestive Physiology, Hospices Civils de Lyon and Lyon University, Lyon, France.
authors.forename: Jérôme
authors.initials: J
authors.lastname: Rivory
authors.affiliation: Digestive Physiology, Hospices Civils de Lyon and Lyon University, Lyon, France.
authors.forename: Thierry
authors.initials: T
authors.lastname: Ponchon
authors.affiliation: Baystate Medical Center, University of Massachusetts School of Medicine, Springfield, Massachusetts, USA.
authors.forename: David
authors.initials: D
authors.lastname: Desilets
authors.affiliation: Digestive Endoscopy Unit, Humanitas Research Hospital, Rozzano, Milan, Italy.
authors.forename: Roberta
authors.initials: R
authors.lastname: Maselli
authors.affiliation: Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Koto-Ku, Tokyo, Japan.
authors.forename: Manabu
authors.initials: M
authors.lastname: Onimaru
authors.affiliation: Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Koto-Ku, Tokyo, Japan.
authors.forename: Jun
authors.initials: J
authors.lastname: Nakamura
authors.affiliation: Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Koto-Ku, Tokyo, Japan.
authors.forename: Yoshitaka
authors.initials: Y
authors.lastname: Hata
authors.affiliation: Department of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
authors.forename: Gulara
authors.initials: G
authors.lastname: Hajiyeva
authors.affiliation: Department of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
authors.forename: Amr
authors.initials: A
authors.lastname: Ismail
authors.affiliation: Department of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
authors.forename: Saowanee
authors.initials: S
authors.lastname: Ngamruengphong
authors.affiliation: Department of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
authors.forename: Majidah
authors.initials: M
authors.lastname: Bukhari
authors.affiliation: Department of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
authors.forename: Yamile Haito
authors.initials: YH
authors.lastname: Chavez
authors.affiliation: Department of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
authors.forename: Vivek
authors.initials: V
authors.lastname: Kumbhari
authors.affiliation: Digestive Endoscopy Unit, Humanitas Research Hospital, Rozzano, Milan, Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Repici
authors.affiliation: Department of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
authors.forename: Mouen A
authors.initials: MA
authors.lastname: Khashab
mesh_terms: D000369:Aged, 80 and over; D016099:Endoscopy, Gastrointestinal / Q000009:adverse effects; D004931:Esophageal Achalasia / Q000601:surgery*; D049630:Esophageal Sphincter, Lower / Q000601:surgery*; D005260:Female; D006801:Humans; D038622:Internationality; D008297:Male; D000074433:Myotomy / Q000009:adverse effects / Q000379:methods*; D011183:Postoperative Complications / Q000209:etiology; D012189:Retrospective Studies; D016896:Treatment Outcome