Pneumatic Dilation for Achalasia Generally Safe in Older Adults
Key findings
- This retrospective study, conducted at Massachusetts General Hospital and Tel Aviv Medical Center in Israel, evaluated periprocedural adverse events after pneumatic dilation (PD) for achalasia in older adults (≥65 years of age) versus younger adults
- The cohort included 252 patients who underwent 319 PDs; 114 patients (45%) were ages 65 or older, including 86 adults older than 70, and 53 adults older than 75
- The rate of periprocedural adverse events (AEs) was significantly higher among younger adults than older patients (10.9% vs. 2.6% of patients; P=0.017; 8.4% vs. 2.2% of procedures; P<0.05); there was no 30-day mortality or bleeding in either group
- Perforation rates were similar in the two groups, but benign chest pain was significantly more common in younger adults (8% vs. 0.9% of older adults; P<0.01)
- PD for achalasia appears to be a safe management option for selected older adults, although optimally it would be centralized to specializing centers
Achalasia is a neurodegenerative disease that impairs the relaxation of the lower esophageal sphincter, resulting in esophageal food retention that predisposes patients to aspiration-related complications. Peroral endoscopic myotomy is gaining favor as an efficacious and safe treatment, but its availability remains limited, and laparoscopic myotomy is often contraindicated because of comorbidities.
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The mainstay of achalasia treatment is still pneumatic dilation (PD), performed under sedation during esophagogastroduodenoscopy using a balloon inflated with air at the lower esophageal sphincter. It's completed in a series of short procedures, and the patient is usually discharged the same day. The endoscopist increases the balloon diameter in each successive procedure to mitigate the risk of adverse events (AEs).
The few studies that included age-related safety data have had contradictory results. Now, Braden Kuo, MD, director of the Center for Neurointestinal Health in the Division of Gastroenterology at Massachusetts General Hospital, and colleagues have confirmed the overall safety of PD in older adults. Their report appears in the Journal of Clinical Medicine.
Methods
The retrospective study included all consecutive PDs in adult patients with achalasia who underwent PDs at Mass General or Tel Aviv Medical Center in Israel between November 2006 and October 2020. The cohort included 252 patients (55 from Mass General, 197 from Tel Aviv) who underwent 319 PDs. Age, sex, achalasia type according to Chicago Classification 3.0, and number of PDs were similar at the two centers.
114 patients (45%) were ages 65 or older, including 86 adults older than 70 and 53 adults older than 75.
Adverse Events by Age Group
18 PDs were followed by AEs:
- Six esophageal perforations—four in the younger group, two in the older group (P=0.699)
- 12 benign chest pain events starting within the first 24 hours—11 in the younger group, one in the older group (P=0.012)
- Total—15 in the younger group (10.9% of patients), three in the older group (2.6% of patients) (P=0.017)
One of the perforations in the older group resulted in death from sepsis three months after the perforation was sealed. In the other case, the patient was treated conservatively.
Nine of the patients with chest pain were hospitalized, eight in the younger group and one in the older group (P=0.045). All were discharged within 48 hours.
There was no 30-day mortality or bleeding.
Risk of AEs by Age
Results of univariate logistic regression showed that for each five-year increase in age:
- Total AEs—OR, 0.85; 95% CI, 0.74–0.97
- Chest pain—OR, 0.78; 95% CI, 0.66–0.92
- Perforation—OR, 1.01; 95% CI, 0.8–1.28 (no association)
Multivariate analyses could not be performed because of the low number of AEs.
Recommendations for the Clinic
Previous studies have shown the efficacy of PD in older adults is as good as in younger adults, if not better. Coupled with the safety results from the current study, that suggests many patients can receive definitive achalasia treatment to improve esophageal emptying and reduce aspiration complications, which may be important to older adults. PD will optimally be centralized to specializing centers.
In older patients burdened by multiple comorbidities, the importance of thoughtful patient selection cannot be overstated. In many such cases, the injection of botulinum toxin into the lower esophageal sphincter remains a prudent choice.
However, when an older adult is a good candidate, PD could continue being the treatment of preference in locales where peroral endoscopic myotomy is unavailable. Younger adults should be counseled about the risk of chest pain (8% of younger patients in this study), while all adults can be assured the rate of perforation is comparably low (2.9% of younger patients and 1.8% of older patients in this study).
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