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Nita AF, Chanpong A, Nikaki K, Rybak A, Thapar N, Borrelli O. Recent advances in the treatment of gastrointestinal motility disorders in children. Expert Rev Gastroenterol Hepatol 2023; 17:1285-1300. [PMID: 38096022 DOI: 10.1080/17474124.2023.2295495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 12/12/2023] [Indexed: 01/12/2024]
Abstract
INTRODUCTION Pediatric gastrointestinal motility disorders represent some of the most challenging clinical conditions with largely undefined pathogenetic pathways and therefore limited therapeutic options. Herein, we provide an overview of the recent advances in treatment options for these disorders and their clinical impact. AREAS COVERED PubMed and Medline databases were searched for relevant articles related to the treatment of achalasia, esophageal atresia, gastroparesis, PIPO and constipation published between 2017 and 2022. In this article, we review and summarize recent advances in management of gastrointestinal motility disorders in children with a particular focus on emerging therapies as well as novel diagnostic modalities that help guide their application or develop new, more targeted treatments. EXPERT OPINION Gastrointestinal motility disorders represent one of the most challenging conundrums in pediatric age and despite significant advances in investigative tools, the palette of treatment options remain limited. Overall, while pharmacological options have failed to bring a curative solution, recent advances in minimal invasive therapeutic and diagnostic techniques have emerged as potential keys to symptom and quality of life improvement, such as ENDOFLIP, POEM, cine-MRI, fecal microbiota transplantation.
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Affiliation(s)
- Andreia Florina Nita
- Department of Pediatric Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Atchariya Chanpong
- Department of Pediatric Gastroenterology, Great Ormond Street Hospital, London, UK
- Division of Gastroenterology and Hepatology, Department of Paediatrics, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
- Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, Australia
- Stem Cells and Regenerative Medicine, UCL Institute of Child Health, London, UK
| | - Kornilia Nikaki
- Department of Pediatric Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Anna Rybak
- Department of Pediatric Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Nikhil Thapar
- Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, Australia
- Stem Cells and Regenerative Medicine, UCL Institute of Child Health, London, UK
- School of Medicine, University of Queensland, Brisbane, Australia
- Woolworths Centre for Child Nutrition Research, Queensland University of Technology, Brisbane, Australia
| | - Osvaldo Borrelli
- Department of Pediatric Gastroenterology, Great Ormond Street Hospital, London, UK
- Stem Cells and Regenerative Medicine, UCL Institute of Child Health, London, UK
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Evaluation of the Surgical Management of Achalasia in Children and Young Adults. J Surg Res 2022; 273:9-14. [PMID: 35007858 DOI: 10.1016/j.jss.2021.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 12/10/2021] [Accepted: 12/13/2021] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Achalasia is a rare esophageal motility disorder in children and is most often treated with the Heller myotomy. This study examines the current trends in surgical management of achalasia and evaluates the safety of the Heller myotomy in children compared to the young adult population. METHODS This is a retrospective cohort study of children and young adults aged ≤25 y undergoing a Heller myotomy for achalasia. Data were collected using the adult and pediatric National Surgical Quality Improvement Program databases from 2012 to 2018. Patient characteristics, comorbidities, and 30-d outcomes were evaluated. Operative details of interest included surgical specialty and the use of esophagogastroduodenoscopy and esophageal manometry. Outcomes included operative time, length of stay, reoperation, and other postoperative complications. RESULTS A total of 178 pediatric and 202 young adult patients were included in the study. The majority of surgeries were performed laparoscopically (85.4% pediatric and 95.0% adult). Esophageal manometry was only used in pediatric cases, and esophagogastroduodenoscopy was used in 35 (19.7%) pediatric and 41 (20.3%) adult cases. Thirty-day complications occurred in 7 (3.9%) children and 3 (1.5%) adults. The median operative time for children was 174.5 min and the median length of stay (LOS) was 2 d. The median operative time for adults was 126 min and the median LOS was 1 d (P < 0.01 for both). There was a longer LOS for cases performed by pediatric surgeons (P = 0.03). CONCLUSIONS Heller myotomy continues to be a very safe operation for achalasia with minimal short-term morbidity.
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Miller J, Khlevner J, Rodriguez L. Upper Gastrointestinal Functional and Motility Disorders in Children. Pediatr Clin North Am 2021; 68:1237-1253. [PMID: 34736587 DOI: 10.1016/j.pcl.2021.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Children with disorders affecting the sensory and motor functions of the esophagus will present primarily with swallowing dysfunction, dysphagia, and chest pain, and those with disorders affecting the normal function of the stomach will present with symptoms like abdominal pain, nausea, and vomiting. Recent advances in the mechanisms of disease and technology have increased our understanding of gastrointestinal physiology and that knowledge has been applied to develop new diagnostic studies and therapeutic interventions. We present an overview of the clinical presentation, diagnosis, and treatment of common primary and secondary functional and motility disorders affecting the upper gastrointestinal tract in children.
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Affiliation(s)
- Jonathan Miller
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, 3959 Braodway CHN7, New York, NY 10032, USA
| | - Julie Khlevner
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, 3959 Braodway CHN7, New York, NY 10032, USA
| | - Leonel Rodriguez
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Yale New Haven Children's Hospital, Yale University School of Medicine, 333 Cedar Street, LMP 4093, New Haven, CT 06510, USA.
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Tashiro J, Petrosyan M, Kane TD. Current management of pediatric achalasia. Transl Gastroenterol Hepatol 2021; 6:33. [PMID: 34423154 DOI: 10.21037/tgh-20-215] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 07/06/2020] [Indexed: 12/12/2022] Open
Abstract
Achalasia is a rare condition affecting esophageal motility in children. In a manner similar to the disease found in the adult population, children experience symptoms of dysphagia, regurgitation, and chest pain due to a failure of relaxation of the lower esophageal sphincter. Standard diagnostic approaches include upper endoscopy and esophageal manometry. New developments in diagnosis include high-resolution esophageal manometry and the endoscopic functional lumen imaging probe. Therapies available include endoscopic balloon dilations and botulinum toxin injections into the lower esophageal sphincter, as well as surgical interventions. The Heller myotomy was first described in 1913; since then, there have been many modifications to the procedure to improve outcomes and lower morbidity. Currently, the most commonly performed surgical procedure is the laparoscopic Heller myotomy, in which the sphincter muscle is divided using longitudinal incisions with or without a partial fundoplication procedure. In recent years, per oral endoscopic myotomy (POEM) is gaining support as a viable natural orifice therapy for achalasia. Complications of POEM occur at a relatively low rate, and outcomes following the procedure have been promising. The treatment of end-stage achalasia however, may include partial or total esophagectomy with reconstruction if possible. Future research is focused primarily on increasing the efficacy, and lowering complications, of existing therapeutic modalities.
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Affiliation(s)
- Jun Tashiro
- Division of Pediatric General & Thoracic Surgery, Children's National Hospital, Washington, DC, USA
| | - Mikael Petrosyan
- Division of Pediatric General & Thoracic Surgery, Children's National Hospital, Washington, DC, USA
| | - Timothy D Kane
- Division of Pediatric General & Thoracic Surgery, Children's National Hospital, Washington, DC, USA
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Bruenderman EH, Bhutiani N, Martin RCG, Fox MP, van Berkel VH, Block SB, Kehdy FJ. Intraoperative Esophagogastroduodenoscopy During Heller Myotomy: Evaluating Guidelines. World J Surg 2020; 45:808-814. [PMID: 33230586 DOI: 10.1007/s00268-020-05870-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND National guidelines suggest routine intraoperative esophagogastroduodenoscopy (EGD) during laparoscopic Heller myotomy (LHM) to assess for mucosal perforation and myotomy adequacy, but the utility of this is unknown. This study aimed to evaluate the effect of intraoperative EGD on outcomes after LHM. METHODS Patients who underwent LHM in a single center were retrospectively identified. Outcomes were compared between patients who did and did not undergo intraoperative EGD. RESULTS Sixty-one patients were reviewed: 46 (75%) underwent intraoperative EGD and 15 (25%) did not. Mucosal perforations occurred in 2 (4%) of the EGD group and 3 (20%) of the non-EGD group (p = 0.06). All perforations, regardless of EGD use, were recognized laparoscopically. There were no postoperative leaks. Failed myotomy occurred in 5 (11%) who underwent EGD and 1 (7%) who did not (p = 0.64). CONCLUSIONS Because EGD does not appear to improve outcomes after LHM, we emphasize its selective, rather than routine, use.
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Affiliation(s)
- Elizabeth H Bruenderman
- Department of Surgery, University of Louisville, 550 S. Jackson St, 2nd floor, Louisville, KY, 40202, United States of America
| | - Neal Bhutiani
- Department of Surgery, University of Louisville, 550 S. Jackson St, 2nd floor, Louisville, KY, 40202, United States of America
| | - Robert C G Martin
- Department of Surgery, Division of Surgical Oncology, University of Louisville, Louisville, KY, United States of America
| | - Matthew P Fox
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY, United States of America
| | - Victor H van Berkel
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY, United States of America
| | - Stacy B Block
- Department of Surgery, University of Louisville, 550 S. Jackson St, 2nd floor, Louisville, KY, 40202, United States of America
| | - Farid J Kehdy
- Department of Surgery, University of Louisville, 550 S. Jackson St, 2nd floor, Louisville, KY, 40202, United States of America.
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Yu YR, Rosenfeld EH, Chiou EH, Chumpitazi BP, Fallon SC, Brandt ML. High-resolution manometric guidance during laparoscopic Heller myotomy: Impact on quality of life and symptom severity for children with achalasia. J Pediatr Surg 2019; 54:1063-1068. [PMID: 30808541 DOI: 10.1016/j.jpedsurg.2019.01.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 01/27/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND High-resolution esophageal manometry (HREM) during laparoscopic Heller myotomy (LHM) with fundoplication for achalasia allows tailoring of myotomy length and wrap tightness. The purpose of this study is to quantify long-term postoperative symptom severity and quality of life using validated questionnaires. METHODS Children ≤18 years with achalasia who previously underwent LHM with intraoperative HREM from 2010 to 2017 were prospectively surveyed. Eckardt Symptom Score (ESS), Achalasia Severity Questionnaire (ASQ), Pediatric Quality of Life Inventory (PedsQL), and Pediatric GERD Symptom and Quality of Life (PGSQ) questionnaires were administered. Scores for historical controls were obtained from prior survey instrument validation studies as comparison. RESULTS Of 30 eligible patients, 12 (40%) completed the surveys. Mean age at time of surgery was 13 ± 3 years. Assessment was performed at least 10 months after surgery with mean time elapsed of 3.6 ± 2 years. Average premyotomy lower esophageal sphincter (LES) pressure, postmyotomy LES pressure, and postfundoplication LES pressure were 30 ± 10 mmHg, 14 ± 6 mmHg, and 18 ± 9, respectively. ESS (2.3/12), ASQ (39/100 ± 16), PGSQ (symptom: 0.6/4 ± 0.4, school: 0.4/4 ± 0.4), and overall PedsQL (82/100 ± 15) were similar to those of healthy historical controls. CONCLUSION Children with achalasia undergoing LHM with intraoperative HREM had sustained long-term symptom improvement and quality of life scores comparable to healthy patients. STUDY AND LEVEL OF EVIDENCE Retrospective, II.
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Affiliation(s)
- Yangyang R Yu
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.
| | - Eric H Rosenfeld
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Eric H Chiou
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Bruno P Chumpitazi
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Sara C Fallon
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Mary L Brandt
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
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Triantafyllou T, Theodoropoulos C, Georgiou G, Kalles V, Chrysikos D, Filis K, Zografos G, Theodorou D. Long-term outcome of myotomy and fundoplication based on intraoperative real-time high-resolution manometry in achalasia patients. Ann Gastroenterol 2018; 32:46-51. [PMID: 30598591 PMCID: PMC6302195 DOI: 10.20524/aog.2018.0326] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 10/16/2018] [Indexed: 12/29/2022] Open
Abstract
Background Current treatment options for achalasia of the esophagus predominantly consist of endoscopic myotomy or laparoscopic myotomy combined with a partial fundoplication. The intraoperative use of conventional manometry has previously been proposed with various results. The aim of the present study was to introduce the use of high-resolution manometry (HRM) during surgical treatment for achalasia and to assess the long-term outcome of this technique. Methods We enrolled achalasia patients within the time period November 2013 to July 2016 who underwent HRM and evaluation of Eckardt scores (ES) before and after tailored laparoscopic myotomy and fundoplication with intraoperative recording using HRM. Results Twenty patients were classified as having achalasia type I (20%), type II (55%), or type III (25%). During surgery, 9 myotomies were extended and 13 fundoplications were modified according to HRM findings. Mean resting (16.1 vs. 41.9 mmHg) and residual (9 vs. 28.7 mmHg) pressures of the lower esophageal sphincter and ES (0.7 vs. 6.9) were significantly eliminated postoperatively over a mean follow-up time of 17.7 months. Conclusions The use of intraoperative HRM gives us the advantage of simultaneous real-time estimation of intraluminal pressures of the esophagus and the ability to identify the exact points that produce pressure during laparoscopy. Consequently, it may be the key to the tailoring of the Heller-Dor technique and improving the outcomes for achalasia patients.
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Affiliation(s)
- Tania Triantafyllou
- Department of Surgery, 1 Propaedeutic Surgical Clinic, Hippocration General Hospital of Athens, University of Athens (Tania Triantafyllou, Charalampos Theodoropoulos, Georgia Georgiou, Vasileios Kalles, Konstantinos Filis, Georgios Zografos, Dimitrios Theodorou)
| | - Charalampos Theodoropoulos
- Department of Surgery, 1 Propaedeutic Surgical Clinic, Hippocration General Hospital of Athens, University of Athens (Tania Triantafyllou, Charalampos Theodoropoulos, Georgia Georgiou, Vasileios Kalles, Konstantinos Filis, Georgios Zografos, Dimitrios Theodorou)
| | - Georgia Georgiou
- Department of Surgery, 1 Propaedeutic Surgical Clinic, Hippocration General Hospital of Athens, University of Athens (Tania Triantafyllou, Charalampos Theodoropoulos, Georgia Georgiou, Vasileios Kalles, Konstantinos Filis, Georgios Zografos, Dimitrios Theodorou)
| | - Vasileios Kalles
- Department of Surgery, 1 Propaedeutic Surgical Clinic, Hippocration General Hospital of Athens, University of Athens (Tania Triantafyllou, Charalampos Theodoropoulos, Georgia Georgiou, Vasileios Kalles, Konstantinos Filis, Georgios Zografos, Dimitrios Theodorou)
| | - Demosthenis Chrysikos
- General and Oncologic Hospital of Kifissia "Agii Anargiri" (Demosthenis Chrysikos), Athens, Greece
| | - Konstantinos Filis
- Department of Surgery, 1 Propaedeutic Surgical Clinic, Hippocration General Hospital of Athens, University of Athens (Tania Triantafyllou, Charalampos Theodoropoulos, Georgia Georgiou, Vasileios Kalles, Konstantinos Filis, Georgios Zografos, Dimitrios Theodorou)
| | - Georgios Zografos
- Department of Surgery, 1 Propaedeutic Surgical Clinic, Hippocration General Hospital of Athens, University of Athens (Tania Triantafyllou, Charalampos Theodoropoulos, Georgia Georgiou, Vasileios Kalles, Konstantinos Filis, Georgios Zografos, Dimitrios Theodorou)
| | - Dimitrios Theodorou
- Department of Surgery, 1 Propaedeutic Surgical Clinic, Hippocration General Hospital of Athens, University of Athens (Tania Triantafyllou, Charalampos Theodoropoulos, Georgia Georgiou, Vasileios Kalles, Konstantinos Filis, Georgios Zografos, Dimitrios Theodorou)
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Clinical factors and high-resolution manometry predicting response to surgery for achalasia in children. J Surg Res 2018; 229:345-350. [PMID: 29937012 DOI: 10.1016/j.jss.2018.04.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 04/05/2018] [Accepted: 04/13/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND Esophageal achalasia is an uncommon condition in children. Although many interventions exist for the management of this disorder, esophageal (Heller) myotomy offers one of the most durable treatments. Our institution sought to review patients undergoing Heller myotomy concentrating on preoperative clinical factors that might predict postoperative outcomes. MATERIALS AND METHODS All patients from January 1, 2007, to December 31, 2016, who underwent surgical treatment for achalasia at our tertiary pediatric hospital were identified and included in the study cohort. Electronic medical records for these patients were reviewed for clinical presentation variables, nonsurgical preoperative treatment, surgical approach, clinical response to surgery, need for postoperative treatment for ongoing symptoms, and high-resolution manometry (HRM) data. RESULTS Twenty-six patients were included in the study, and all underwent myotomy with partial fundoplication (median age: 14.4 y [interquartile range 11.6-15.5]). At a median follow-up of 9.75 mo (interquartile range 3.5-21 mo), 16 (61.5%) patients reported good resolution of their dysphagia symptoms with surgery alone. Two patients (7.7%) had perforation of the gastrointestinal tract requiring surgical intervention. Eight patients (30.8%) required additional treatment for achalasia, with 5 (19.2%) of these undergoing additional surgery or endoscopic treatment. Patients who had preoperative dilation did not have good resolution of their dysphagia (n = 2; P = 0.037). Two of four patients undergoing postoperative dilation had preoperative dilation. None of these patients underwent preoperative manometry. There was a statistically significant difference in the ages of patients who required postoperative intervention and those who did not (14.1 versus 15.2 y old, respectively; P = 0.043). In patients who reported improvement of gastroesophageal reflux disease/reflux type symptoms after Heller myotomy, lower esophageal residual pressure (29.1 versus 18.7 mmHg; P = 0.018) on preoperative HRM was significantly higher than in those who did not report improvement after surgery. Higher upper esophageal mean pressure (66.6 versus 47.8 mmHg; P = 0.05) also predicted good gastroesophageal reflux disease/reflux symptom response in a similar manner. CONCLUSIONS Current analysis suggests that preoperative dilation should be used cautiously and older patients may have a better response to surgery without need for postoperative treatment. In addition, preoperative HRM can aid in counseling patients in the risk of ongoing symptoms after surgery and may aid in determining if a fundoplication should be completed at the index procedure. Further research is needed to delineate these factors. LEVEL OF EVIDENCE Level III.
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Abstract
Achalasia is a rare neurogenic motility disorder of the esophagus, occurring in approximately 0.11 cases per 100,000 children. The combination of problems (aperistalsis, hypertensive lower esophageal sphincter (LES), and lack of receptive LES relaxation) results in patients having symptoms of progressive dysphagia, weight loss, and regurgitation. Treatment modalities have evolved over the past few decades from balloon dilation and botulinum toxin injection to laparoscopic Heller myotomy and endoscopic myotomy. Most data on achalasia management is extrapolated to children from adult experience. This article describes understanding of the pathogenesis and discusses newer therapeutic techniques as well as controversies in management.
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Affiliation(s)
- Saleem Islam
- Division of Pediatric Surgery, University of Florida College of Medicine, 1600 SW Archer Rd, PO Box 100119, Gainesville, Florida 32610.
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Pacilli M, Davenport M. Results of Laparoscopic Heller's Myotomy for Achalasia in Children: A Systematic Review of the Literature. J Laparoendosc Adv Surg Tech A 2016; 27:82-90. [PMID: 27901639 DOI: 10.1089/lap.2016.0169] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Achalasia is a rare disorder in children who are commonly treated by laparoscopic Heller's myotomy (LHM). However, there are no large studies evaluating the results of LHM in the pediatric population, and the need of a concomitant fundoplication remains unclear. The aim of the study is to appraise the results of LHM based on a systematic literature review. MATERIALS AND METHODS MEDLINE search of the English literature was performed for "achalasia," "children," "laparoscopy," "Heller," "myotomy," and "cardiomyotomy." Frequency of postoperative symptoms was grouped to calculate the percentage of patients with symptoms improvement. Incidence of postoperative gastro-esophageal reflux (GER) and dysphagia between patients with and without fundoplication at the time of LHM was compared by Fisher's Exact Test. P < .05 was regarded as significant. RESULTS Twenty-one studies were analyzed (331 children, 1-19 years). All studies were retrospective case-series reviews. Intraoperative complications occurred in 33 patients (10%), with esophageal perforations in 31 (9%), and conversion to open procedure in 9 (2.7%). Fundoplication was performed in 271 (82%): Dor (n = 205, 76%), Toupet (n = 49, 18%), Thal (n = 13, 4.5%), and Nissen (n = 4, 1.5%). Incidence of postoperative GER and dysphagia was similar between children with and without fundoplication (P = 1). Forty-nine (15%) required re-intervention: pneumatic dilatations (n = 30, 9%), redo-surgery (n = 23, 7%), botox injection (n = 1, 0.3%), and medical therapy (n = 5, 1.5%). DISCUSSION LHM for achalasia is effective in 85% of children. Revision surgery is required in 7%. There is no difference in incidence of GER and dysphagia between patients with and without fundoplication. Routine use of an additional fundoplication might not be justified.
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Affiliation(s)
- Maurizio Pacilli
- Department of Paediatric Surgery, King's College Hospital , London, United Kingdom
| | - Mark Davenport
- Department of Paediatric Surgery, King's College Hospital , London, United Kingdom
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Real-time Continuous Esophageal High-resolution Manometry (HRM) During Laparoscopic Heller Myotomy and Dor Fundoplication for the Treatment of Achalasia. A Promising Novelty in Regards of Perfecting Surgical Technique: Could It Guide Surgical Technique Toward Excellent Results? Surg Laparosc Endosc Percutan Tech 2016; 26:e163-e166. [PMID: 27846179 DOI: 10.1097/sle.0000000000000336] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
High-resolution manometry (HRM) is the gold-standard diagnostic tool for achalasia of the esophagus. Laparoscopic Heller-Dor technique is the preferred surgical approach with success rate estimated 90%. The use of intraoperative HRM provides real-time estimation of intraluminal esophageal pressures and identifies the exact points of esophageal luminal pressure during laparoscopy. Ten patients with achalasia underwent surgery. All patients preoperatively completed 1 manometric study and Quality of Life questionnaires (EORTC QLQ-C30 version 3.0) with Eckardt scores. We collected intraoperative manometry data and repeated manometric studies, EORTC QLQ-C30, and Eckardt scores postoperatively. Median Eckardt score was decreased from 7.5 to 0.5, mean resting pressure decreased from 51.4 to 11.9 mm Hg, whereas mean residual pressure diminished from 45.9 to 9.5 mm Hg postoperatively. The simultaneous use of HRM during the Heller-Dor technique may lead to an individualized management of the disease.
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Petrosyan M, Khalafallah AM, Guzzetta PC, Sandler AD, Darbari A, Kane TD. Surgical management of esophageal achalasia: Evolution of an institutional approach to minimally invasive repair. J Pediatr Surg 2016; 51:1619-22. [PMID: 27292598 DOI: 10.1016/j.jpedsurg.2016.05.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 05/01/2016] [Accepted: 05/20/2016] [Indexed: 02/09/2023]
Abstract
BACKGROUND Surgical management of esophageal achalasia (EA) in children has transitioned over the past 2 decades to predominantly involve laparoscopic Heller myotomy (LHM) or minimally invasive surgery (MIS). More recently, peroral endoscopic myotomy (POEM) has been utilized to treat achalasia in children. Since the overall experience with surgical management of EA is contingent upon disease incidence and surgeon experience, the aim of this study is to report a single institutional contemporary experience for outcomes of surgical treatment of EA by LHM and POEM, with regards to other comparable series in children. METHODS An IRB approved retrospective review of all patients with EA who underwent treatment by a surgical approach at a tertiary US children's hospital from 2006 to 2015. Data including demographics, operative approach, Eckardt scores pre- and postoperatively, complications, outcomes, and follow-up were analyzed. RESULTS A total of 33 patients underwent 35 operative procedures to treat achalasia. Of these operations; 25 patients underwent laparoscopic Heller myotomy (LHM) with Dor fundoplication; 4 patients underwent LHM alone; 2 patients underwent LHM with Thal fundoplication; 2 patients underwent primary POEM; 2 patients who had had LHM with Dor fundoplication underwent redo LHM with takedown of Dor fundoplication. Intraoperative complications included 2 mucosal perforations (6%), 1 aspiration, 1 pneumothorax (1 POEM patient). Follow ranged from 8months to 7years (8-84months). There were no deaths and no conversions to open operations. Five patients required intervention after surgical treatment of achalasia for recurrent dysphagia including 3 who underwent between 1 and 3 pneumatic dilations; and 2 who had redo LHM with takedown of Dor fundoplication with all patients achieving complete resolution of symptoms. CONCLUSIONS Esophageal achalasia in children occurs at a much lower incidence than in adults as documented by published series describing the surgical treatment in children. We believe the MIS surgical approach remains the standard of care for this condition in children and describe the surgical outcomes and complications for LHM, as well as, the introduction of the POEM technique in our center for treating achalasia. Our institutional experience described herein represents the largest in the "MIS era" with excellent results. We will refer to alterations in our practice that have included the use of flexible endoscopy in 100% of LHM cases and use of the endoscopic functional lumen imaging probe (EndoFLIP) in both LHM and POEM cases which we believe enables adequate Heller myotomy.
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Affiliation(s)
- Mikael Petrosyan
- Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC, 20010-2970
| | - Adham M Khalafallah
- Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC, 20010-2970
| | - Phillip C Guzzetta
- Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC, 20010-2970
| | - Anthony D Sandler
- Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC, 20010-2970
| | - Anil Darbari
- Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC, 20010-2970
| | - Timothy D Kane
- Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC, 20010-2970.
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Miyano G, Miyake H, Koyama M, Morita K, Kaneshiro M, Nouso H, Yamoto M, Fukumoto K, Urushihara N. Laparoscopic Heller Myotomy for Non-Dilated Esophageal Achalasia in Children with Intraoperative Stepped Dilation Under Image Guidance: Attempting Complete Myotomy. J Laparoendosc Adv Surg Tech A 2016; 26:409-12. [PMID: 26845662 DOI: 10.1089/lap.2015.0217] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
This study presents a modified surgical approach to laparoscopic myotomy for achalasia using stepped dilation with a Rigiflex balloon and contrast medium under image guidance. A 10-year-old boy with persistent dysphagia and vomiting had ingested only liquids for 3 months, losing >10 kg in body weight. Barium swallow and esophageal manometry diagnosed esophageal achalasia with mild esophageal dilatation. After failed pneumatic dilatation, laparoscopic Heller myotomy with Dor fundoplication was performed. Prior to surgery, a Rigiflex balloon dilator was placed within the esophagus near the diaphragmatic hiatus. A four-port technique was used, and mobilization of the esophagus was limited to the anterior aspect. A 5-cm Heller myotomy was performed, extending another 2 cm onto the anterior gastric wall. During myotomy, the Rigiflex balloon was serially dilated from 30 to 50 mL, and filled with contrast medium under fluoroscopic image guidance in order to maintain appropriate tension on the esophagus to facilitate myotomy, and to confirm adequate myotomy with sufficient release of lower esophageal sphincter by resecting residual circular muscle fibers. Residual circular muscle fibers can be simultaneously visualized under both fluoroscopic image guidance and direct observation through the laparoscope, and they were cut precisely until the residual notch fully disappeared. Dor fundoplication was completed. The operative time was 180 minutes, and oral intake was started after esophagography on postoperative day 1. As of the 12-month follow-up, the patient has not shown any symptoms, and his postoperative course appeared satisfactory.
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Affiliation(s)
- Go Miyano
- Department of Pediatric Surgery, Shizuoka Children's Hospital , Shizuoka, Japan
| | - Hiromu Miyake
- Department of Pediatric Surgery, Shizuoka Children's Hospital , Shizuoka, Japan
| | - Mariko Koyama
- Department of Pediatric Surgery, Shizuoka Children's Hospital , Shizuoka, Japan
| | - Keiichi Morita
- Department of Pediatric Surgery, Shizuoka Children's Hospital , Shizuoka, Japan
| | - Masakatsu Kaneshiro
- Department of Pediatric Surgery, Shizuoka Children's Hospital , Shizuoka, Japan
| | - Hiroshi Nouso
- Department of Pediatric Surgery, Shizuoka Children's Hospital , Shizuoka, Japan
| | - Masaya Yamoto
- Department of Pediatric Surgery, Shizuoka Children's Hospital , Shizuoka, Japan
| | - Koji Fukumoto
- Department of Pediatric Surgery, Shizuoka Children's Hospital , Shizuoka, Japan
| | - Naoto Urushihara
- Department of Pediatric Surgery, Shizuoka Children's Hospital , Shizuoka, Japan
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Peroral endoscopic myotomy periprocedural evaluation: Predicting and measuring outcomes. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2013. [DOI: 10.1016/j.tgie.2013.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Hallal C, Kieling CO, Nunes DL, Ferreira CT, Peterson G, Barros SGS, Arruda CA, Fraga JC, Goldani HAS. Diagnosis, misdiagnosis, and associated diseases of achalasia in children and adolescents: a twelve-year single center experience. Pediatr Surg Int 2012; 28:1211-7. [PMID: 23135808 DOI: 10.1007/s00383-012-3214-3] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/24/2012] [Indexed: 12/11/2022]
Abstract
PURPOSE Although achalasia is a rare disorder in children, its symptom may mimic common childhood diseases. This study aimed to assess the diagnosis and management of achalasia in children and adolescents in a Brazilian single center during a 12-year period. METHODS Patients with achalasia were identified from a database built during the period of January 2000-January 2012 from a Pediatric Gastroenterology reference center. Information regarding demographic data, clinical symptoms, diagnosis, treatment, and long-term follow-up were described. RESULTS Thirteen patients were studied; median age was 7 (1-14) years. Most frequent symptoms were vomiting (84.6 %) and dysphagia (69.2 %). Weight loss occurred in 46.0 % of patients and chronic cough in 46.1 %. Associated disorders were Down's syndrome, Allgrove syndrome, and congenital central hypoventilation syndrome. Achalasia was misdiagnosed with anorexia nervosa. Six patients were previously treated as having gastroesophageal reflux disease and asthma. Five patients had pneumatic balloon dilation as initial therapy whereas five had esophageal myotomy. Finally, 11 patients had surgical therapy with a favorable follow-up. CONCLUSION Achalasia symptoms may mimic common diseases in children, and therefore, may delay the diagnosis. This study emphasizes the importance of the clinical symptoms for the diagnosis of achalasia, mainly in those cases with associated disorders.
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Affiliation(s)
- Cristiane Hallal
- Post-Graduate Program Sciences in Gastroenterology, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.
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Lee CW, Kays DW, Chen MK, Islam S. Outcomes of treatment of childhood achalasia. J Pediatr Surg 2010; 45:1173-7. [PMID: 20620315 PMCID: PMC4011012 DOI: 10.1016/j.jpedsurg.2010.02.086] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2010] [Accepted: 02/22/2010] [Indexed: 12/30/2022]
Abstract
PURPOSE The optimal management of achalasia in children and adolescents remains unclear. The aim of this study was to review a single institution's experience with endoscopic and surgical interventions in children with achalasia. METHODS A retrospective review was conducted of the medical records of children treated for achalasia from 1978 to 2008. Patient demographics and interventions were reviewed. Outcomes after procedural intervention were evaluated. RESULTS Thirty-five patients with achalasia were identified, and data were available for 34 (age, 13 +/- 6 years; male, 62%). Eighteen patients underwent esophageal dilation (ED), and 16 patients underwent Heller myotomy (HM). Follow-up was available for 30 patients (ED, 15; HM, 15). There was symptom recurrence in 15 of 15 ED cases and 8 (53%) of 15 HM cases (P < .01). Additional interventions were performed in 14 (93%) of 15 ED cases and 6 (40%) of 15 HM cases (P < .01). CONCLUSIONS Heller myotomy may provide more durable long-term outcomes, as defined by symptom recurrence and need for subsequent intervention, and may be considered the procedure of choice.
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Affiliation(s)
- Constance W Lee
- Division of Pediatric Surgery, University of Florida College of Medicine, Gainesville, FL
| | - David W Kays
- Division of Pediatric Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Mike K Chen
- Division of Pediatric Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Saleem Islam
- Division of Pediatric Surgery, University of Florida College of Medicine, Gainesville, FL,Address all communication to: Saleem Islam MD, MPH, Associate Professor of Surgery, Division of Pediatric Surgery, University of Florida College of Medicine, 1600 SW Archer Road, PO Box 100119, Gainesville, FL 32610, Phone: 352-273-8800, Fax: 352-273-8772,
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Logan MS, Vossoughi F, Watson CM, Amarnath R, Camps JI. A novel technique for the surgical treatment of achalasia in children: evaluated with postoperative esophageal manometry. J Laparoendosc Adv Surg Tech A 2009; 19:589-93. [PMID: 19575636 DOI: 10.1089/lap.2009.0122] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The current surgical treatment for achalasia in the pediatric population is the laparoscopic Heller myotomy with or without a fundoplication. Although medical management with serial dilations and botulism toxin injections may offer short-term benefits, surgical therapy offers definitive treatment. In this article, we propose a modified surgical technique that avoids pitfalls associated with the standard procedure and evaluated our results with postoperative manometry. METHODS Charts were reviewed for all patients having undergone the proposed surgical procedure. Seven patients underwent postoperative manometry, while 12 answered a short questionnaire. RESULTS While manometry showed a statistically significant reduction of lower esophageal sphincter tone, from a mean preoperative lower esophageal sphincter (LES) of 56.1 mm Hg (SD = 8.88, 95% CI = 50.36-61.93) to mean postoperative LES tone of 11.69 mm Hg (SD = 11.69, 95% CI = 3.287-20.08; P < 0.0001), peristalsis was not consistently affected, although a trend toward improvement was noted. Symptoms related to dysphagia were noted in 42% of patients postoperatively but were mild, while all patients showed improved feeding tolerance and weight gain. Interestingly, patients with a postoperative LES pressure <12 mm Hg were more likely to have no symptoms, although this LES pressure was arbitrarily chosen and the study was not powered to detect this outcome (chi-square = 3.73, df = 1; P < 0.053). CONCLUSIONS The proposed surgical technique for the treatment of achalasia in children was successful at improving feeding and weight gain and attaining normal postoperative LES tone; however, underlying esophageal dysmotility persisted.
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Affiliation(s)
- Melissa S Logan
- Department of Surgery, The University of Virginia, Charlottesville, VA, USA
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Abstract
AIM: To evaluate the efficacy and safety of Heller myotomy (HM) for recurrent achalasia, performed after different methods of first-line treatment.
METHODS: We searched for studies published in PubMed from 1966 to March 2008 on treatment of recurrent achalasia with HM after failure with different methods of first-line treatment. The efficacy of HM was assessed by a pooled estimate of response rate with individual studies weighted proportionally to sample size.
RESULTS: Sixteen studies were eligible and included in the review. The results showed that HM has a better remission rate for recurrent achalasia after failure of HM [weighted mean (SD)] of 86.9% (21.8%) compared with 81.6% (23.8%) for pneumatic dilatation (PD). One study evaluated the efficacy of HM after failure of PD combined with botulinum toxin injection (83%). The most common complications were perforation and gastroesophageal reflux.
CONCLUSION: HM has the best efficacy in patients with recurrent achalasia who were treated with HM as first-line treatment. Future studies should focus on how to increase the success rate and decrease the complications of HM.
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