Literature selections curated by Lewis Flint, MD, FACS, and reviewed by the ACS Brief editorial board.
Study Examines Impact of Treatments for Achalasia
Ciomperlik H, Dhanani NH, Mohr C, et al. Systematic Review of Treatment of Patients with Achalasia: Heller Myotomy, Pneumatic Dilation, and Peroral Endoscopic Myotomy (POEM). J Am Coll Surg. 2022, in press.
The authors of this article emphasized that achalasia affects 0.1% of the population and causes symptoms such as dysphagia, regurgitation, reflux symptoms, and pulmonary complications. Reduced quality of life is a consequence of these symptoms. This systematic review analyzed data from six randomized controlled trials to provide guidance for clinicians who are planning treatment for patients with achalasia. The main outcome of interest was long-term quality of life measured by standard scales. Evaluated treatments included Heller myotomy, pneumatic dilation, and peroral endoscopic myotomy (POEM).
The data analysis showed that quality of life over long-term follow up (3 to 5 years) did not differ significantly for any of the treatment approaches, but the quality of the evidence was low. The findings do suggest, however, that treatment should be tailored to the individual patient based on patient preference and careful risk assessment. Each treatment modality has characteristics that influence outcomes: Heller myotomy requires an open or minimally invasive procedure that usually requires an inpatient stay and is associated with pain, pneumatic dilation carries a risk for perforation, and POEM requires a clinician with specific endoscopic skills.
The authors recommended that factors such as age, comorbid conditions, risk for postoperative complications, availability of skilled caregivers, and patient preferences should be evaluated when treatment for achalasia is being planned.
Is National Guideline-Recommended Treatment for Locally Advanced Rectal Cancer in Older Patients Superior to Other Approaches?
Nassoiy S, Christopher W, Marcus R, et al. Treatment Utilization and Outcomes for Locally Advanced Rectal Cancer in Older Patients. JAMA Surg. Nov 1 2022;157(11):e224456. doi:10.1001/jamasurg.2022.4456
In this study, the authors analyzed data from the National Cancer Database for patients 80 years of age and older who underwent treatment for advanced rectal cancer. The focus was to determine the usage of national guideline recommended treatment (neoadjuvant chemoradiation therapy (NACRT) followed by surgical resection) compared with other approaches (resection followed by adjuvant therapy or resection alone).
The study cohort consisted of 3,868 patients; male patients composed 52.8% of the study group and the mean age was 83.4 years. Recommended treatment was used in 58.8% of patients. Factors associated with use of NACRT + resection were more recent diagnosis, age range of 80 to 85 years, fewer comorbid conditions, larger tumors, and node positive disease. NACRT + resection was associated with significantly improved overall survival.
The authors recommended increased efforts to expand usage of NACRT + resection in this patient group.
Editorial
Guillem JG, Luo WY, Agala CB. Neoadjuvant Chemoradiation Therapy for All Elderly Patients With Locally Advanced Rectal Cancer? JAMA Surg. Nov 1 2022;157(11):e224457. doi:10.1001/jamasurg.2022.4457
The editorial by José G. Guillem, MD, MPH, MBA, and coauthors that accompanied the article urged caution in interpreting the conclusions of the study because of significant defects in the analysis. For example, there was not adequate risk adjustment to assure that patients with similar comorbid conditions and surgical risk were compared; the editorialists noted that techniques such as propensity scoring could have improved risk-based comparisons. They concluded that until high-quality studies are available that take these factors along with rates of postoperative complications into account, the optimal proportion of elderly patients who should receive NACRT + resection will remain unclear.
