ORIGINAL ARTICLES
Minimally invasive myotomy for achalasia in the elderly
Arman Kilic Æ Matthew J. Schuchert Æ Arjun Pennathur Æ Rodney J. Landreneau Æ
Miguel Alvelo-Rivera Æ Neil A. Christie Æ Sebastien Gilbert Æ Ghulam Abbas Æ
James D. Luketich
Received: 4 April 2007 / Accepted: 9 October 2007 / Published online: 20 November 2007
Ó Springer Science+Business Media, LLC 2007
Abstract
Background Elderly patients with achalasia are more
frequently being referred for minimally invasive Heller
myotomy (MIM). The associated morbidity and mortality
of MIM in the elderly are not well defined. The objective of
this study was to review our experience with MIM in the
elderly.
Methods We identified a total of 57 patients (32 men, 25
women) 70 years or older (mean age 78 years, range 70 to
96 years) who underwent MIM [55 laparoscopically (LAP),
2 videothoracoscopically (VATS)] for achalasia at our
institution. Clinical outcomes were analyzed including
postoperative surgical interventions (redo myotomy,
esophagectomy), and dysphagia scores (range: 1, no dys-
phagia to 5, dysphagia to saliva).
Results Thirty-seven (59.6%) patients had prior endo-
scopic therapy. There was no perioperative mortality and
median hospital stay was 3 days. There were three (5.3%)
conversions to open due to adhesions and concern
regarding the viability of the myotomy following repair of
a small perforation. A total of 11 (19.3%) patients had
complications, including three (5.3%) intraoperative
esophageal perforations, three pleural effusions, one
(1.8%) pneumonia, one intraoperative gastric perforation,
one C. difficile infection, one ileus, and one postoperative
intubation. Mean follow-up was 23.5 months. Mean
dysphagia score improved from 3.38 preoperatively to 1.36
following MIM (p \ 0.0001), with 55 (96.5%) patients
experiencing an improvement. Reoperation for recurrent
dysphagia was required in four (7.0%) of the patients.
Conclusions MIM can be performed safely in elderly
patients with achalasia in centers with significant experi-
ence in laparoscopic foregut surgery. MIM affords similar
symptomatic improvement in the elderly as compared to
younger patients. MIM should be seriously considered as a
therapeutic strategy in elderly achalasia patients.
Keywords Achalasia Á Myotomy Á Minimally invasive Á
Heller myotomy Á Esophagomyotomy Á Megaesophagus
Achalasia is the most common primary esophageal motility
disorder [1]. Patients are typically diagnosed following
barium esophagogram illustrating a ‘‘bird’s beak’’ appear-
ance at the distal esophagus and manometric evaluation
demonstrating incomplete relaxation of the lower esopha-
geal sphincter (LES) with an absence of coordinated
peristalsis. Due to the unknown cause of achalasia, the goal
of all current treatment remains symptom relief.
Surgical therapy for achalasia was first described in
1913 by Ernest Heller, a German surgeon [2]. His double
myotomy technique was modified by Zaaijer a decade
later, and Zaaijer’s single anterior myotomy remains the
favored procedure in modern practice [3]. Concern
regarding postoperative reflux in the setting of myotomy
led Dor [4] and Toupet [5] to introduce anterior and pos-
terior fundoplications, respectively, in the early 1960s. The
controversy about whether or not to include a fundoplica-
tion continues to this day, although a recent randomized
trial found that the addition of an anterior wrap lowers rates
Presented as a poster at the 2007 SAGES Annual Meeting.
A. Kilic Á M. J. Schuchert Á A. Pennathur Á
R. J. Landreneau Á M. Alvelo-Rivera Á N. A. Christie Á
S. Gilbert Á G. Abbas Á J. D. Luketich (&)
Heart, Lung, and Esophageal Surgery Institute, University of
Pittsburgh Medical Center, 200 Lothrop St., Suite C-800,
Pittsburgh, PA, Pennsylvania 15261
e-mail: luketichjd@upmc.edu
123
Surg Endosc (2008) 22:862–865
DOI 10.1007/s00464-007-9657-2