Initial experience with peroral endoscopic myotomy for treatment of achalasia in children

Utility of endoscopy in paediatric gastroenterology and hepatology-Review and updates

Paediatric endoscopy has been an integral part of the diagnostic evaluation and management of gastroenterology and hepatology diseases in children. This area of clinical medicine has made meteoric advancements since it was first introduced conserving it's traditional roles of gastroscopy and colonoscopy but broadening significantly it's clinical utility and diagnostic accuracy with new and emerging technology. This article aims to explore and review the current utility and emerging applications of diagnostic and therapeutic endoscopy for the practicing paediatric gastroenterologist and hepatologist.

Advances in Pediatric Endoscopy

Diagnostic and therapeutic endoscopic procedures in children are fundamental to the subspecialty of pediatric gastroenterology. This review highlights significant advancements and trends in pediatric endoscopy, emphasizing the transformative impact of technological innovations in the field. The advent of ultra-thin endoscopes and the development of minimally-invasive techniques have markedly enhanced both diagnostic and therapeutic capabilities, leading to safer and more effective procedures for pediatric patients. Key advancements include transnasal endoscopy, endoscopic ultrasound, and per-oral endoscopic myotomy.

Safety and efficacy of peroral endoscopic myotomy for treating achalasia in pediatric and geriatric patients: A meta-analysis

BACKGROUND

As a less invasive technique, peroral endoscopic myotomy (POEM) has recently been widely accepted for treating achalasia with an excellent safety profile, durability, and efficacy in adults. In pediatric and geriatric patients, the treatment is more difficult.

AIM

To discuss the clinical outcomes of POEM in pediatric and geriatric patients with achalasia.

METHODS

We conducted a comprehensive search of PubMed, Embase and Cochrane Library databases from inception to July 2024. The primary outcomes were technical and clinical success. Secondary outcomes of interest included adverse events and gastroesophageal reflux disease (GERD). The pooled event rates were calculated by comprehensive meta-analysis software.

RESULTS

A total of 32 studies with 547 pediatric patients and 810 geriatric patients were included in this study. The pooled event rates of technical success, clinical success, GERD and adverse events of POEM for treating achalasia in pediatric patients were 97.1% [95% confidence interval (CI): 95.0%-98.3%; I² = 0%; P < 0.000], 93.2% (95%CI: 90.5%-95.2%; I² = 0%; P < 0.000), 22.3% (95%CI: 18.4%-26.7%; I² = 43.874%; P < 0.000) and 20.4% (95%CI: 16.6%-24.8%; I² = 67.217%; P < 0.000), respectively. Furthermore, in geriatric patients, the pooled event rates were 97.7% (95%CI: 95.8%-98.7%; I² = 15.200%; P < 0.000), 93.2% (95%CI: 90.3%-95.2%; I² = 0%; P < 0.000), 23.9% (95%CI: 19.4%-29.1%; I² = 75.697%; P < 0.000) and 10.8% (95%CI: 8.3%-14.0%; I² = 62.938%; P < 0.000], respectively.

CONCLUSION

Our findings demonstrated that POEM was an effective and safe technique for pediatric and geriatric patients with achalasia.

Esophageal dilation with EsoFLIP is faster than CRE balloon dilation combined with EndoFLIP in children

BACKGROUND

Controlled radial expansion (CRE) balloon dilators are traditionally used to dilate esophageal strictures during an esophagogastroduodenoscopy (EGD). EndoFLIP is a diagnostic tool used during an EGD to measure important parameters of the gastrointestinal lumen, capable of assessing treatment before and after dilation. EsoFLIP is a related device that combines a balloon dilator with high-resolution impedance planimetry to provide some of the luminal parameters in real time during dilation. We sought to compare procedure time, fluoroscopy time, and safety profile of esophageal dilation using either CRE balloon dilation combined with EndoFLIP (E + CRE) versus EsoFLIP alone.

METHODS

A single-center retrospective review was performed to identify patients ≤ 21 years of age who underwent an EGD with biopsy and esophageal stricture dilation using E + CRE or EsoFLIP between October 2017 and May 2022.

RESULTS

Twenty-nine EGDs with esophageal stricture dilation were performed in 23 patients (19 E + CRE and 10 EsoFLIP). The two groups did not differ in age, gender, race, chief complaint, type of esophageal stricture, or history of prior gastrointestinal procedures (all p > 0.05). The most common medical history in the E + CRE and EsoFLIP groups were eosinophilic esophagitis and epidermolysis bullosa, respectively. Median procedures times were shorter in the EsoFLIP cohort compared to E + CRE balloon dilation (40.5 min [IQR 23-57 min] for the EsoFLIP group; 64 min [IQR 51-77 min] for the E + CRE group; p < 0.01). Median fluoroscopy times were also shorter for patients who underwent EsoFLIP (0.16 min [IQR 0-0.30 min] for EsoFLIP dilation; 0.30 min [IQR 0.23-0.55] for the E + CRE group; p = 0.003). There were no complications or unplanned hospitalizations in either group.

CONCLUSION

EsoFLIP dilation of esophageal strictures was faster and required less fluoroscopy than CRE balloon dilation combined with EndoFLIP in children, while being equally as safe. Prospective studies are needed to further compare the two modalities.

Advances in Pediatric Diagnostic Endoscopy: A State-of-the-Art Review

Pediatric endoscopy has revolutionized the way we diagnose and treat gastrointestinal disorders in children. Technological advances in computer processing and imaging continue to affect endoscopic equipment and advance diagnostic tools for pediatric endoscopy. Although commonly used by adult gastroenterologists, modalities, such as endomicroscopy, image-enhanced endoscopy, and impedance planimetry, are not routinely used in pediatric gastroenterology. This state-of-the-art review describes advances in diagnostic modalities, including image-enhanced endoscopy, confocal laser endomicroscopy, optical coherence tomography, endo functional luminal imaging probes, wireless motility/pH capsule, wireless colon capsule endoscopy, endoscopic ultrasound, and discusses the basic principles of each technology, including adult indications and pediatric applications, safety cost, and training data.

Endoluminal Functional Lumen Imaging Probe Is Safe in Children Under Five Years Old

BACKGROUND

Endoluminal functional lumen imaging probe (EndoFLIP) is a minimally invasive, novel device that uses high-resolution impedance planimetry to measure important parameters of the gastrointestinal lumen that aid in the diagnosis of esophageal disorders. EndoFLiP is approved by the US Food and Drug Administration (FDA) for children 5 years and older. We sought to compare its safety and luminal characteristics between children under 5 years of age with children 5 years and older.

METHODS

A single-center retrospective review was performed to identify all patients < 21 years of age who underwent esophagogastroduodenoscopy (EGD) with EndoFLIP between October 2017 and November 2020. Results: Sixty-seven EGDs with EndoFLIP were performed in 56 patients, including 14 that were done in children < 5 years and 53 in children ≥5years. The median age in the < 5-year group was 1.7years (interquartile range [IQR], 0.9-4.4) and the youngest patient was 1 month old. The median age in ≥5-year group was 14.3 years (IQR, 8.2-16.2). Median procedure times were similar (32 minutes [IQR, 25-48] for the < 5-year group; 28 minutes [IQR, 20-33] for ≥5-year group; P  = 0.08). There were no adverse events or unplanned hospitalizations in either group. At 30 mL inflation, the pressure of the lower esophageal sphincter (LES) was statistically different between the 2 groups (P = 0.02).

CONCLUSION

EndoFLIP appears to be safe for use in our small cohort of children < 5 years of age and may be an important tool in the management of esophageal disorders in this age group. There was no difference in procedure time between our 2 age groups and there were no procedure-related complications.

Functional Luminal Imaging Probe in the Management of Pediatric Esophageal Disorders

BACKGROUND

Functional luminal imaging probe (FLIP) measures pressure-geometry relationships of digestive luminal space. When used in esophageal disorders, it provides several luminal parameters that help better understand the pathophysiology. Data about the potential utility of FLIP in pediatrics are scarce and there is no standardized use in children. We aim to describe the use of FLIP in our center, its safety, feasibility, and clinical impact in esophageal disorders in children.

METHODS

Consecutive FLIP recordings performed at the Centre Hospitalier Universitaire-Sainte-Justine, Montréal, Canada between February 2018 and January 2021 were extracted. A chart review was conducted for demographics and medical history. Symptomatology after the procedure was evaluated with validated dysphagia scores.

KEY RESULTS

Nineteen patients were included (11 girls, median age 16 years, range 3.2-19.6) with achalasia (n = 5), post-Heller's myotomy dysphagia (n = 3), esophagogastric junction outflow obstruction (n = 3), congenital esophageal stenosis (n = 2); post-esophageal atresia repair stricture (n = 3), and post-fundoplication dysphagia (n = 3). There was no significant correlation between integrated relaxation pressure measured with high resolution manometry and distensibility index (DI). The use of FLIP made it possible to differentiate between dysphagia related to an esophageal obstruction (DI < 2.8 mm2/mmHg) and dysphagia without major motility disorder (DI > 2.8 mm2/mmHg) that guided the indication for dilation. FLIP led to a change in management in 47% of the patients. Forty-seven percent of the patients were symptom free at the time of the evaluation.

CONCLUSIONS INFERENCES

FLIP provides key esophageal luminal values and therefore can play an important role in pediatric esophageal disorders management.

POEM Is a Durable Treatment in Children and Adolescents With Achalasia Cardia

BACKGROUND AND AIM

Per-oral endoscopic myotomy (POEM) is emerging as an effective treatment for pediatric achalasia. There are limited data on the long-term efficacy of POEM in children and adolescents with achalasia. In this study, we aim to evaluate the outcomes of POEM at ≥4 years follow-up.

METHOD

The data of consecutive children who underwent POEM (September 2013-July 2021) and completed at least 4 years follow-up were analyzed retrospectively. The primary outcome was clinical success (Eckardt ≤ 3) at ≥4 years follow-up. The secondary outcomes included the prevalence of gastroesophageal reflux disease (GERD) and predictors of recurrent symptoms (Eckardt ≥2) after POEM.

RESULTS

A total of 69 children underwent POEM for achalasia during the study period. Of these, 41 (59.4%) children completed ≥4 years [mean 68.5 months (range 48-94)] follow-up, and 38 were included in the final analysis. The subtypes of achalasia included type I (28.9%), type II (60.5%), and type III (2.6%). There was a history of prior treatment in 11 children (28.9%). Clinical success was recorded in 36 (94.7%) patients who successfully underwent POEM. Recurrent symptoms (Eckardt ≥ 2) were noticed in 12 (31.6%) children at ≥4 years. On multivariate analysis, there were no identifiable factors which predicted recurrent symptoms after POEM. Symptomatic GERD and erosive esophagitis were detected in 13.8% (4/29) and 57.1% (8/14) of the children, respectively.

CONCLUSION

POEM is a durable treatment modality for achalasia in the pediatric population irrespective of the sub-type of achalasia and history of prior treatment.

Current management of pediatric achalasia

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.

Clinical outcomes of peroral endoscopic myotomy for achalasia in children: a systematic review and meta-analysis

Peroral endoscopic myotomy (POEM) is a novel minimally invasive intervention, which has shown to be effective and safe for treating achalasia in adults. Presently, POEM was also reported to be effective for achalasia in children. So we conducted this study to explore the clinical outcomes of POEM for pediatric achalasia. A systematic literature search in PubMed, Embase, and Cochrane databases was performed, which covered the period from January 2009 to June 2020. Selecting studies and collecting data was independently by two reviewers according to predefined criteria. The statistical analysis was carried out using Comprehensive Meta-Analysis software version 2 and Review Manager 5.3. A total of 11 studies with 389 children were identified in the final analysis. Pooled technical success of POEM treatment achalasia was achieved in 385 children (97.4%; 95% confidence interval [CI], 94.7%-98.7%), and the pooled clinical success was achieved in 348 children (92.4%; 95% CI, 89.0%-94.8%). After POEM, the Eckardt score was significantly decreased by 6.76 points (95% CI, 6.18-7.34, P < 0.00001), and the lower esophageal sphincter pressure was significantly reduced by 19.38 mmHg (95% CI, 17.54-21.22, P < 0.00001). The pooled major adverse events rate related to POEM was 12.8% (95% CI, 4.5%-31.5%) and the gastroesophageal reflux rate was 17.8% (95% CI, 14.2%-22.0%). Our current study demonstrated that the POEM was an effective and safe technique for treating achalasia in children. Further randomized comparative studies of POEM and other therapeutic methods are warranted to determine the most effective treatment modality for achalasia in children.

Per oral endoscopic myotomy (POEM) in pediatric patients with esophageal achalasia: First Latin-American experience

BACKGROUND

Achalasia is the most common primary motor disorder of the esophagus, but its incidence in pediatric patients is low. Laparoscopic Heller myotomy (LHM) is the current surgical standard of care treatment. Per-oral endoscopic myotomy (POEM) has emerged as a safe and effective therapeutic alternative in adult patients. We herein report the outcomes of a cohort of pediatric patients with achalasia treated by POEM at a Chilean medical center.

METHODS

This is a retrospective analysis of prospectively collected data on children who underwent POEM for esophageal achalasia. Clinical follow-up was evaluated by recording the Eckardt score, a high-resolution esophageal manometry (HREM) three months after the procedure, and an annual upper gastrointestinal endoscopy.

RESULTS

Five patients with esophageal achalasia confirmed by HREM and with a mean age of 11 (5 to 15) years underwent POEM between 2017 and 2019. One patient had a previous LHM. No morbidity or mortality was observed. All patients resolved their dysphagia and no patient required further interventions. Mean Eckardt score reduced from 10 points preoperatively to 1 point postoperatively. Two patients currently have mild esophagitis (confirmed by endoscopy).

CONCLUSION

Our results support the previously reported safety and effectiveness of POEM. Longer follow-up and larger cohorts will be important to confirm its role in the treatment of children with esophageal achalasia.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

Level IV.

Treating children with achalasia using per-oral endoscopic myotomy (POEM): Twenty-one cases in review

BACKGROUND

Per-oral endoscopic myotomy (POEM), a modern treatment for achalasia, has only recently emerged as an option for pediatric patients. Here we describe and characterize the success of POEM in children with achalasia.

METHODS

A single-institution prospective cohort study was performed of patients <18 years old who underwent POEM from 2014 to 2019. Main outcomes were success at one year (Eckardt ≤3), procedure duration, complications, reintervention.

RESULTS

The median age of patients (n = 21) was 13 years (range 2-17). Median procedure duration was 92 min (range 52-259) with case duration plateau of 87.4 min and learning rate of 15.5 cases. Intraoperative complications included capnoperitoneum requiring needle decompression and mucosotomy requiring additional clips. One patient experienced chest pain with small capnoperitoneum seen on chest radiography, and three patients had extraluminal carbon dioxide found incidentally on routine radiography. All were managed with observation. Pre- versus 1-month postprocedure Eckardt scores were significantly improved (7 ± 2 versus 1 ± 2, p < 0.0001, and median ± SD) with 100% symptomatic relief at one year. To achieve this, 13 patients required further dilation(s), one required laparoscopic Heller myotomy, and two required repeat POEM.

CONCLUSIONS

POEM is a viable and safe treatment for pediatric patients with achalasia. We demonstrate improvement in symptoms and procedure proficiency with minimal intra- and postoperative complications.

TYPE OF STUDY

Prospective cohort study.

LEVEL OF EVIDENCE

Level II.

Multicenter Evaluation of Clinical Efficacy and Safety of Per-oral Endoscopic Myotomy in Children

OBJECTIVES

Per-oral endoscopic myotomy (POEM) is a recommended treatment modality for achalasia, but there is little published data for its use in children. The objective of the present study was to evaluate whether POEM is clinically effective and safe for children.

METHODS

International multicenter retrospective study conducted in 14 tertiary centers that included consecutive children who underwent POEM between January 2012 and August 2018. Outcomes, such as clinical response were assessed whenever available. Adverse events and factors associated with clinical failure were also investigated.

RESULTS

A total of 117 patients (mean ± SD age: 14.2 ± 3.7 years) underwent POEM for achalasia (type I, n = 36; type II n=66; type III, n=8). Among these, 30 (26%) were pretreated (botulinum injection and/or pneumatic dilatation). Mean ± SD baseline Eckardt score was 7.5 ± 2.0. Clinical success was achieved in 90.6% of cases (95%CI [83.8%;95.2%]) in the intention-to-treat analysis. The mean ± SD Eckardt score post-POEM was 0.9 ± 1.2 (P < 0.001). The mean duration of follow-up time 545 days (range: 100-1612). A total of 7 adverse events occurred (4 mucosotomies, 2 subcutaneous emphysema, 1 esopleural fistula). Gastroesophageal reflux symptoms were seen in 17 patients (15%); missing data for 10 patients (9%). There was a trend towards more frequent clinical failure in achalasia associated with genetic disorders (40% vs 8%, P = 0.069).

CONCLUSIONS

POEM in pediatric patients appears to be effective and safe, although there was a trend towards more frequent clinical failure achalasia associated with genetic disorders. Further studies are needed to assess the long-term outcomes, especially the consequences of GERD.

Gastrointestinal Dysmotility and the Implications for Respiratory Disease

Purpose of the review

Gastroesophageal reflux disease (GERD) is frequently implicated as a cause for respiratory disease. However, there is growing evidence that upper gastrointestinal dysmotility may play a significantly larger role in genesis of respiratory symptoms and development of underlying pulmonary pathology. This paper will discuss the differential diagnosis for esophageal and gastric dysmotility in aerodigestive patients and will review the key diagnostic and therapeutic interventions for this dysmotility.

Recent findings

Previous studies have shown an association between GERD and pulmonary pathology in children with aerodigestive disorders. Recent publications have demonstrated the presence of esophageal and gastric dysfunction, using fluoroscopic and nuclear medicine studies, in aerodigestive patients who commonly present to pulmonary and otolaryngology clinics. High-resolution impedance manometry (HRIM) has revolutionized our understanding of esophageal dysmotility and its role in pathogenesis of aspiration and esophageal dysfunction and subsequent respiratory compromise.

Summary

Esophageal and gastric dysmotility have a profound effect on development of respiratory symptoms and pulmonary sequalae in aerodigestive patients. However, our understanding of the pathophysiology is in its infancy. Prospective studies in are needed to address key clinical questions such as: What degree of dysmotility initiates respiratory compromise? What diagnostic tests and therapeutic options best predict aerodigestive outcomes?

Clinical Management of Pediatric Achalasia: A Survey of Current Practice

OBJECTIVES

Pediatric achalasia is a rare neurodegenerative disorder of the esophagus that requires treatment. Different diagnostic and treatment modalities are available, but there are no data that show how children can best be diagnosed and treated. We aimed to identify current practices regarding the diagnostic and therapeutic approach toward children with achalasia.

METHODS

Information on the current practice regarding the management of pediatric achalasia was collected by an online-based survey sent to members of the European and North American Societies for Pediatric Gastroenterology Hepatology and Nutrition involved in pediatric achalasia care.

RESULTS

The survey was completed by 38 centers from 24 countries. Within these centers, 108 children were diagnosed with achalasia in the last year (median 2, range 0-15). Achalasia was primarily managed by a pediatric gastroenterologist (76%) and involved a multidisciplinary team in 84% of centers, also including a surgeon (87%), radiologist (61%), dietician (37%), speech pathologist (8%), and psychologist (5%). Medical history taking and physical examination were considered most important to establish the diagnosis (50%), followed by (a combination of) manometry (45%) or contrast swallow (21%). Treatment of first choice was Heller myotomy (58%), followed by pneumatic dilation (46%) and peroral endoscopic myotomy (29%).

CONCLUSION

This study shows a great heterogeneity in the management of pediatric achalasia amongst different centers worldwide. These findings stress the need for well-designed intervention trials in children with achalasia. Given the rarity of this disease, we recommend that achalasia care should be managed in centers with access to appropriate diagnostic and treatment modalities.

Peroral endoscopic myotomy (POEM) for the treatment of pediatric achalasia: a systematic review and meta-analysis

BACKGROUND

Achalasia is a rare primary esophageal dysmotility disorder in children. Peroral endoscopic myotomy (POEM) is a novel endoscopic technique which has shown promising results for treating achalasia in adults. However, limited data on efficacy and safety in pediatric patients are available. We performed a systematic review and meta-analysis to evaluate the efficacy and safety of POEM in pediatric achalasia.

METHODS

We searched MEDLINE, Embase, PubMed, and Web of Science databases through July 2018. Studies were eligible for inclusion if they conducted POEM in pediatric patients. Main outcomes were Eckardt score and lower esophageal sphincter (LES) pressure before and after POEM. Secondary outcomes were clinical success rate and adverse events associated with POEM. Two reviewers independently reviewed the studies, collected data, and assessed quality of evidence using Methodological Index for Non-Randomized Studies (MINORS). Pooled estimates were calculated using random effects meta-analyses. Heterogeneity was quantified using the inconsistency statistic, and funnel plot was used to assess publication bias.

RESULTS

A total of 12 studies with 146 pediatric patients (53.68% female) underwent POEM for the treatment of achalasia (mean duration of disease of 19.48 months). There was a significant reduction in Eckardt score by 6.88 points (Mean Difference (MD) 6.88, 95% confidence interval (CI), 6.28-7.48, P < .001) and LES pressure by 20.73 mmHg (MD 20.73, 95% CI, 15.76-25.70, P < .001) following POEM. At least 93% of the patients experienced improvement or resolution of achalasia symptoms both short and long terms after POEM, with small proportion of patients experiencing minor adverse effects which could be managed conservatively.

CONCLUSIONS

POEM is efficacious and safe for treating achalasia in pediatric populations. Large comparative or randomized trials are warranted to confirm the efficacy and safety of POEM compared to other surgical procedures for achalasia.

Outcome of peroral endoscopic myotomy in children with achalasia

BACKGROUND AND AIMS

Achalasia cardia is rare in children and optimum endoscopic management options are not well known. Peroral endoscopic myotomy (POEM) is a novel treatment modality for achalasia with excellent results in adult patients. The long-term outcomes of POEM are not well known in children. In this study, we aim to evaluate the outcome of POEM in children with idiopathic achalasia.

METHODS

We analyzed the data of children (≤ 18 years) diagnosed with achalasia from September 2013 to January 2018. Technical success, clinical success, and adverse events were assessed. Post-POEM, gastroesophageal reflux (GER) was assessed with 24-h pH-impedance study and esophagogastroduodenoscopy.

RESULTS

A total of 44 children (boys-23, girls-21) with mean age of 14.5 ± 3.41 years (4-18) were diagnosed with achalasia during the study period. Of these, 43 children underwent POEM. The subtypes of achalasia according to Chicago classification were type I-11, type II-29, type III-2, and unclassified-2. Eighteen children (40.9%) had history of prior treatment. POEM was successfully performed in 43 children (technical success-97.72%). Intra-operative adverse events occurred in 11 (25.6%) children including retroperitoneal CO2 (7), capnoperitoneum (3), and mucosal injury (1). Clinical success at 1, 2, 3, and 4 years' follow-up was 92.8%, 94.4%, 92.3%, and 83.3%, respectively. Erosive esophagitis was detected in 55% (11/20) children. On 24-h pH study, GER was detected in 53.8% (7/13) children.

CONCLUSION

POEM is a safe, effective, and durable treatment for achalasia in children. However, GER is a potential concern and should be evaluated in prospective studies before adopting POEM for the management of achalasia in children.

Clinical factors and high-resolution manometry predicting response to surgery for achalasia in children

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.

Clinical management of pediatric achalasia

Achalasia is a rare esophageal motility disorder. Much of the literature is based on the adult population. In adults, guidance of therapeutic approach by manometric findings has led to improvement in patient outcome. Promising results have been achieved with novel therapies such as PerOral Endoscopic Myotomy (POEM). Areas covered: In this review, we provide an overview of the novel diagnostic and therapeutic tools for achalasia management and in what way they will relate to the future management of pediatric achalasia. We performed a PubMed and EMBASE search of English literature on achalasia using the keywords 'children', 'achalasia', 'pneumatic dilation', 'myotomy' and 'POEM'. Cohort studies < 10 cases and studies describing patients ≥ 20 years were excluded. Data regarding patient characteristics, treatment outcome and adverse events were extracted and presented descriptively, or pooled when possible. Expert commentary: Available data report that pneumatic dilation and laparoscopic Heller's myotomy are effective in children, with certain studies suggesting lower success rates in pneumatic dilation. POEM is increasingly used in the pediatric setting with promising short-term results. Gastro-esophageal reflux disease (GERD) may occur post-achalasia intervention due to disruption of the LES and therefore requires diligent follow-up, especially in children treated with POEM.