Geriatric patients with esophageal motility disorders benefit more from minimally invasive peroral endoscopic myotomy: a multicenter study in Japan

Summary Geriatric patients with existing studies on the safety and efficacy of peroral endoscopic myotomy (POEM) for achalasia involve small sample sizes and single institutions. However, multi-center, large-scale data analyses are lacking. The study aimed to clarify the characteristics of geriatric patients with esophageal motility disorders (EMDs) and determine the procedure-related outcomes and clinical course following POEM. This cohort study included 2,735 patients with EMDs who were treated at seven Japanese facilities between 2010 and 2019. The patients’ characteristics and post-POEM clinical courses were compared between the geriatric (age ≥ 75 years; n = 321) and non-geriatric (age < 75 years; n = 2,414) groups. Compared with the non-geriatric group, the geriatric group had higher American Society of Anesthesiologists physical status scores; more recurrent cases; lower incidence of chest pain; and higher incidence of type III achalasia, distal esophageal spasm, and Jackhammer esophagus. Furthermore, the incidence of sigmoid esophagus was higher, although esophageal dilation was not severe in this group. POEM was safe and effective for geriatric patients with treatment-naïve and recurrent EMDs. Furthermore, compared with the non-geriatric group, the geriatric group had lower post-POEM Eckardt scores, fewer complaints of refractory chest pain, and a lower incidence rate of post-POEM reflux esophagitis. Geriatric patients are characterized by worse clinical conditions, more spastic disorders, and greater disease progression of EMDs, which are also the indications for minimally invasive POEM. POEM is more beneficial in geriatric patients as it has lowering symptom scores and incidence rates of reflux esophagitis.

The Surgical Management of Peptic Ulcer Disease

The treatment of peptic ulcer disease has evolved substantially through the decades since the discovery of acid-reducing agents and helicobacter pylori bacteria. With the success of medical treatment, surgical therapy continues to play a less prominent role in the care of this disease. Operative candidates include the naive patient treated with over-the-counter NSAIDs who are often those with undiagnosed Helicobacter pylori, requiring less complicated initial surgery. With more surgeons graduating with less experience operating on PUD with evolving operative techniques, the question arises as to what constitutes the optimal surgical approach, especially in the elective vs. emergent settings. Recent literature discussing GI bleeding associated with COVID-19 also merits discussion of surgical options in this chapter. Future surgical options may include minimally invasive endoscopic surgeries akin to per-oral endoscopic myotomy of the pylorus; however, this has not yet been described in this disease.