Minimally invasive surgery for achalasia in patients >40 years: more favorable than anticipated

The efficacy of Heller myotomy in patients >40 years—a significant predictor suggesting a favorable response to pneumatic dilation—has been questioned. The aim of our study was to evaluate the results obtained in patients aged <40 and >40 years undergoing minimally invasive surgery (MIS) for achalasia.

In January 2008, we established the MIS technique for achalasia in our clinic. In the following period from January 2008 to March 2011, 74 patients underwent primary laparoscopic myotomy for achalasia. The procedure was accomplished with an anterior 180° semifundoplication according to Dor in all patients. The Eckardt score and the Gastrointestinal Quality of Life Index (GQLI) served as outcome measures.

The median age of patients was 45.5 years (range, 18–85 years) with a median duration of preoperative achalasia symptoms of 57 months (range, 2–468 months). There were no conversions to open surgery and—except for one patient with a sterile pleural effusion—no postoperative complications. At a median follow-up of 12 months, the preoperative Eckardt score of 7.0 (range, 3–12) was found to be significantly decreased to a median of 2 (range, 0–6; P < 0.001). With regard to patients <40 and >40 years, the postoperative Eckardt score obtained in the older patient population was not significantly lower (P = 0.074). There was no statistically significant difference between the two groups with respect to the postoperative GQLI (P = 0.860). Neither gender nor preoperative Botox injection or pneumatic dilation inserted a significant influence on the postoperative clinical outcome (P > 0.05).

Laparoscopic Heller myotomy for achalasia is associated with a high success rate as the primary therapeutic option and after failure of endoscopic therapy. It can be performed safely and with favorable outcomes also in patients >40 years. However, the long-term durability of the procedure remains to be established.