Role of biodegradable stents in octogenarians with achalasia

Achalasia is a primary motility disorder of the esophagus characterized by the loss of inhibitory neurons in the myenteric plexus. Incidence peaks in the third and seventh decades of life [1] [2] It is an incurable disease and definitive treatment is aimed at disrupting the lower esophageal sphincter (LES). Aggressive treatment routes tend to be more durable but are fraught with potentially morbid adverse events (AEs) that may not be tolerated by those with little health reserve. Pneumatic dilation (PD) and laparoscopic Heller myotomy (LHM) have historically been the mainstay therapeutic interventions in patients with acceptable surgical risks. Per-oral endoscopic myotomy (POEM) has emerged as a non-inferior alternative to LHM with comparable risk profile. It is known that higher American Society of Anesthesiologists (ASA) score is associated with more anesthesia-related serious AEs [3]. Due to fear of procedure-related AEs in the face of increased burden of medical comorbidities, achalasia patients 75 years and older are sometimes left untreated [4]. Medication use, akin to nitrates and calcium channel blockers, is virtually ineffective and is marred by intolerable cardiovascular AEs. Botulinum toxin injection is a viable choice, albeit with limited effectiveness and durability [4].

Publication History

Article published online:
27 May 2021

• References

• 1 Mayberry JF. Epidemiology and demographics of achalasia. Gastrointest Endosc Clin N Am 2001; 11: 235-248
• 2 Park W, Vaezi MF. Etiology and pathogenesis of achalasia: the current understanding. Am J Gastroenterol 2005; 100: 1404-1414
• 3 Early DS, Lightdale JR. ASGE Standards of Practice Committee. et al. Guidelines for sedation and anesthesia in GI endoscopy. Gastrointest Endosc 2018; 87: 327-337
• 4 Chen YI, Inoue H, Ujiki M. et al. An international multicenter study evaluating the clinical efficacy and safety of per-oral endoscopic myotomy in octogenarians. Gastrointest Endosc 2018; 87: 956-961
• 5 Mukherjee S, Kaplan DS, Parasher G. et al. Expandable metal stents in achalasia--is there a role?. Am J Gastroenterol 2000; 95: 2185-2188
• 6 Cheng YS. et al. Selection and evaluation of three interventional procedures for achalasia based on long-term follow-up. World J Gastroenterol 2003; 9: 2370-2373
• 7 Cheng YS, Li M-H, Chen W-X. et al. Temporary self-expanding metallic stents for achalasia: a prospective study with a long-term follow-up. World J Gastroenterol 2010; 16: 5111-5117
• 8 Li YD, Chen Y-S, Li M-H. et al. Temporary self-expanding metallic stents and pneumatic dilation for the treatment of achalasia: a prospective study with a long-term follow-up. Dis Esophagus 2010; 23: 361-367
• 9 Zhu Y-Q, Cheng Y-S, Tang G-Y. et al. Comparison of temporary stent insertion with pneumatic dilation of the same diameter in the treatment of achalasia patients: a retrospective study. J Gastroenterol Hepatol 2010; 25: 499-505
• 10 Li YD, Tang G-Y, Cheng Y-S. et al. 13-year follow-up of a prospective comparison of the long-term clinical efficacy of temporary self-expanding metallic stents and pneumatic dilatation for the treatment of achalasia in 120 patients. AJR Am J Roentgenol 2010; 195: 1429-1437
• 11 Hair CS, Devonshire DA. Severe hyperplastic tissue stenosis of a novel biodegradable esophageal stent and subsequent successful management with high-pressure balloon dilation. Endoscopy 2010; 42: E132-E133
• 12 Hernandez-Mondragon OGC, Pineda L, Michel O. Safety and efficacy of biodegradable stents in octagenarian patients with esophageal achalasia. Endosc Int Open 2021; 09: E756-E766
• 13 Hollinger JO, Battistone GC. Biodegradable bone repair materials. Synthetic polymers and ceramics. Clin Orthop Relat Res 1986; 207: 290-305
• 14 Downs DJ, Jadick G, Swaid F. et al. Age and achalasia: how does age affect patient presentation, hospital course, and surgical outcomes?. Am Surg 2017; 83: 952-961
• 15 Schechter RB, Lemme EMO, Novais P. et al. Achalasia in the elderly patient: a comparative study. Arq Gastroenterol 2011; 48: 19-23
• 16 Sanaka MR, Chadalavada P, Alomari M. et al. Peroral endoscopic myotomy is a safe and effective treatment modality for geriatric patients with achalasia. Esophagus 2020; 17: 484-491
• 17 Craft RO, Aguilar BE, Flahive C. et al. Outcomes of minimally invasive myotomy for the treatment of achalasia in the elderly. JSLS 2010; 14: 342-347
• 18 Abe H, Tanaka S, Kawara F. et al. Comparison of the safety and efficacy of peroral endoscopic myotomy between octogenarians and non-octogenarians. Dig Endosc 2021; 33: 110-117
• 19 Lutz W, Sanderson W, Scherbov S. The coming acceleration of global population ageing. Nature 2008; 451: 716-719