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Montalva L, Farha E, Hervieux E, Ali L, Rousseau V, Schmitt F, Guinot A, Sassi N, Grosos C, Arnaud AP, Scalabre A, Dubois R, Bonnard A. Complications after Heller myotomy in children: a national multicenter study on the impact of prior endoscopic dilatation and identification of risk factors. Surg Endosc 2024; 38:3602-3608. [PMID: 38769183 DOI: 10.1007/s00464-024-10884-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 04/28/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Although esophageal achalasia has been historically treated by Heller myotomy, endoscopic esophageal dilatations are nowadays often the first-line treatment in children. The aim was to assess whether performing an endoscopic dilatation before a Heller myotomy is associated with higher risks of esophageal perforation in children. METHODS A retrospective multicentric study was performed, including children that underwent a Heller myotomy (2000-2022, 10 centers). Two groups were compared based on the history of previous dilatation before myotomy. Outcomes esophageal perforation (intra-operative or secondary) and post-operative complications requiring surgery (Clavien-Dindo III). Statistics Comparisons using contingency tables or Kruskal-Wallis when appropriate. Statistical significance: p-value < 0.05. RESULTS A Heller myotomy was performed in 77 children (median age: 11.8 years), with prior endoscopic dilatation in 53% (n = 41). A laparoscopic approach was used in 90%, with associated fundoplication in 95%. Esophageal perforation occurred in 19% of children (n = 15), including 12 patients with intra-operative mucosal tear and 3 with post-operative complications related to an unnoticed esophageal perforation. Previous endoscopic dilatation did not increase the risk of esophageal perforation (22% vs 17%, OR: 1.4, 95%CI: 0.43-4.69). Post-operative complications occurred in 8% (n = 6), with similar rates regardless of prior endoscopic dilatation. Intra-operative mucosal tear was the only risk factor for post-operative complications, increasing the risk of complications from 5 to 25% (OR: 6.89, 95%CI: 1.38-31.87). CONCLUSIONS Prior endoscopic dilatations did not increase the risk of esophageal perforation or postoperative complications of Heller myotomy in this cohort of children with achalasia. Mucosal tear was identified as a risk factor for post-operative complications.
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Affiliation(s)
- Louise Montalva
- Department of Pediatric Surgery and Urology, AP-HP, Robert-Debré Children University Hospital, 48 Boulevard Sérurier, 75019, Paris, France.
- Paris-Cité University, Paris, France.
| | - Elie Farha
- Department of Pediatric Surgery and Urology, AP-HP, Robert-Debré Children University Hospital, 48 Boulevard Sérurier, 75019, Paris, France
| | - Erik Hervieux
- Department of Pediatric Surgery, Armand Trousseau University Hospital, Paris, France
| | - Liza Ali
- Department of Pediatric Surgery and Urology, AP-HP, Robert-Debré Children University Hospital, 48 Boulevard Sérurier, 75019, Paris, France
- Paris-Cité University, Paris, France
| | - Véronique Rousseau
- Department of Pediatric Surgery, AP-HP, Necker-Enfants Malades, Paris, France
| | - Françoise Schmitt
- Department of Pediatric Surgery, Angers University Hospital, Angers, France
| | - Audrey Guinot
- Department of Pediatric Surgery, Hôtel-Dieu University Hospital, Nantes, France
| | - Nizar Sassi
- Department of Pediatric Surgery, Strasbourg University Hospital, Strasbourg, France
| | - Céline Grosos
- Department of Pediatric Surgery, Limoges University Hospital, Limoges, France
| | - Alexis P Arnaud
- Department of Pediatric Surgery, Rennes University Hospital, University of Rennes, Rennes, France
| | - Aurélien Scalabre
- Department of Pediatric Surgery, University Hospital, Saint-Etienne, France
| | - Remi Dubois
- Department of Pediatric Surgery, Hospices Civils de Lyon, Hôpital Femme Mère Enfant University Hospital, Bron, France
| | - Arnaud Bonnard
- Department of Pediatric Surgery and Urology, AP-HP, Robert-Debré Children University Hospital, 48 Boulevard Sérurier, 75019, Paris, France
- Paris-Cité University, Paris, France
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Nicolas A, Aumar M, Tran LC, Tiret A, Duclaux-Loras R, Bridoux-Henno L, Campeotto F, Fabre A, Breton A, Languepin J, Kyheng M, Viala J, Coopman S, Gottrand F. Comparison of Endoscopic Dilatation and Heller's Myotomy for Treating Esophageal Achalasia in Children: A Multicenter Study. J Pediatr 2022; 251:134-139.e2. [PMID: 35853483 DOI: 10.1016/j.jpeds.2022.07.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 07/08/2022] [Accepted: 07/13/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare the efficacy of, and complications from, the 2 main treatments for achalasia: endoscopic dilatation and surgical cardiomyotomy (Heller's myotomy). STUDY DESIGN We retrospectively collected data on children treated for achalasia over an 11-year period from 8 tertiary pediatric centers. A line of treatment was defined as performing either Heller's myotomy or 1-3 sessions of endoscopy dilatation over 3 months. Treatment success was a priori defined as clinical improvement and no need for new treatment. RESULTS Ninety-seven children (median age, 12 years; 57% boys) were included. The median time to diagnosis was 10.5 months, and the median follow-up period was 27 months. Thirty-seven children were treated by Heller's myotomy and 60 by endoscopy dilatation as the first-line treatment. After adjustment for potentially confounding factors, Heller's myotomy was significantly more successful than endoscopy dilatation (hazard ratio, 3.93 [1.74; 8.88]; P = .001), with a median survival without failure of 49 and 7 months, respectively, and with no significant difference in the occurrence of complications (35.2% for Heller's myotomy, 29.7% for endoscopy dilatation, P = .56). Hydrostatic dilatation was as successful as pneumatic dilatation (hazard ratio, 1.35 [0.56; 3.23]; P = .50). CONCLUSIONS Heller's myotomy is more successful than endoscopy dilatation, with no significant difference in the occurrence of serious complications. This raises the potential role of peroral endoscopic myotomy as an alternative treatment to Heller's myotomy.
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Affiliation(s)
- Audrey Nicolas
- Department of Pediatrics, CHU Limoges, Limoges, France; Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Jeanne de Flandre Children's Hospital, CHU Lille and University Lille, Lille, France
| | - Madeleine Aumar
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Jeanne de Flandre Children's Hospital, CHU Lille and University Lille, Lille, France; University Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, Lille, France
| | - Léa Chantal Tran
- University Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, Lille, France
| | - Alice Tiret
- Department of Pediatric Gastroenterology and Nutrition, Hôpital Universitaire Robert-Debré, Assistance Publique-Hôpitaux de Paris, University Paris, Paris, France
| | - Rémi Duclaux-Loras
- Department of Pediatric Gastroenterology Hepatology and Nutrition, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Bron, France
| | - Laure Bridoux-Henno
- Department of Child and Adolescent Medicine, CHU Rennes Hôpital Sud, Rennes Cedex 2, France
| | - Florence Campeotto
- Pediatric Gastroenterology Department, APHP Necker-Enfants Malades Hospital, Paris, France
| | - Alexandre Fabre
- Pediatric Multidisciplinary Pediatric APHM, Timone Enfant, Marseille, France; Aix-Marseille University, INSERM, GMGF, Marseille, France
| | - Anne Breton
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Purpan University Hospital, Toulouse, France
| | | | - Maéva Kyheng
- ULR 2694 - METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, University Lille, CHU Lille, Lille, France; Department of Biostatistics, University Lille, CHU Lille, Lille, France
| | - Jérôme Viala
- Department of Pediatric Gastroenterology and Nutrition, Hôpital Universitaire Robert-Debré, Assistance Publique-Hôpitaux de Paris, University Paris, Paris, France
| | - Stéphanie Coopman
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Jeanne de Flandre Children's Hospital, CHU Lille and University Lille, Lille, France
| | - Frédéric Gottrand
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Jeanne de Flandre Children's Hospital, CHU Lille and University Lille, Lille, France; University Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, Lille, France.
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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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Pneumatic balloon dilation in pediatric achalasia: efficacy and factors predicting outcome at a single tertiary pediatric gastroenterology center. Gastrointest Endosc 2012; 76:927-32. [PMID: 22921148 DOI: 10.1016/j.gie.2012.06.035] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2012] [Accepted: 06/23/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND The use of pneumatic dilation (PD) is well established in adults with achalasia; however, it is less commonly used in children. OBJECTIVE To evaluate the efficacy of PD in pediatric achalasia and to define predictive factors for its treatment failure. DESIGN Single-center, prospective cohort study. SETTING Academic tertiary referral center. PATIENTS Twenty-four patients with achalasia were enrolled from January 2004 to November 2009 and were followed for a median of 6 years. INTERVENTION PD was performed with the patients under general anesthesia. MAIN OUTCOME MEASUREMENTS Efficacy and safety of PD. Follow-up was performed by using the Eckardt score, barium swallow contrast studies, and esophageal manometry at baseline; 1, 3, and 6 months after dilation; and every year thereafter. A Cox regression model was used to identify independent predictors of failure after the first PD. RESULTS The PD success rate was 67%. In 8 patients, the first PD failed, but the parents of one patient refused a second PD and requested surgery. Of the 7 patients who underwent repeated treatment, the second PD failed in 3 (43%). Overall, only 3 of the 24 patients underwent surgery (overall success rate after a maximum of 3 PDs was 87%). Multivariate analysis showed that only older age was independently associated with a higher probability of the procedure success (hazard ratio [HR] 0.66; 95% CI, 0.45-0.97). LIMITATIONS Small sample size, single-center study. CONCLUSIONS PD is a safe and effective technique in the management of pediatric achalasia. Young age is an independent negative predictive factor for successful clinical outcome.
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Barth BA, Banerjee S, Bhat YM, Desilets DJ, Gottlieb KT, Maple JT, Pfau PR, Pleskow DK, Siddiqui UD, Tokar JL, Wang A, Song LMWK, Rodriguez SA. Equipment for pediatric endoscopy. Gastrointest Endosc 2012; 76:8-17. [PMID: 22579260 DOI: 10.1016/j.gie.2012.02.023] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Accepted: 02/17/2012] [Indexed: 02/07/2023]
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Pastor AC, Mills J, Marcon MA, Himidan S, Kim PCW. A single center 26-year experience with treatment of esophageal achalasia: is there an optimal method? J Pediatr Surg 2009; 44:1349-54. [PMID: 19573660 DOI: 10.1016/j.jpedsurg.2008.10.117] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2008] [Revised: 10/09/2008] [Accepted: 10/30/2008] [Indexed: 12/27/2022]
Abstract
PURPOSE Treatment modalities for achalasia are evolving and remain controversial. Herein, we report the relative efficacy and outcomes after dilatation or myotomy in children with achalasia. METHODS A retrospective analysis of all children treated for achalasia at a tertiary center from 1981 to 2007 was performed (n = 40). Demographics, presenting symptoms, perioperative parameters, and outcomes were analyzed using t tests and chi(2) statistics. RESULTS Thirty patients were initially treated by esophageal dilatation (ED), whereas 10 were treated by laparoscopic or open Heller myotomy (HM). Both groups were similar with respect to age (10.6 vs 12.4 years; P = .19). There were 18 males and 12 females in the ED group, compared to 5 males and 5 females in the HM group (P = .72). Mean duration of symptoms before diagnosis, including dysphagia, vomiting, food sticking, chest pain, and weight loss, was 15.9 months for ED and 10.7 months for HM (P = .41). Mean time from diagnosis to initial intervention was 76 days in ED vs 86 days in HM (P = .78). Subsequent interventions by myotomy or both dilatation and myotomy were required in 9 (30%) of 30 patients in the ED group and 2 (20%) of 10 patients in the HM group (P = .70). A clear transition from open to laparoscopic approach occurred between 1995 and 2001. Mean operating times were comparable (186.3 vs 156.0 minutes; P = .48). Of 14 laparoscopic myotomies, 11 (79%) had fundoplication, and 2 (18%) of the 11 were converted to open procedure. Intraoperative mucosal perforation rates were similar between open and laparoscopic groups (17% vs 18%). At follow-up, 32% of ED patients vs 43% HM had complete symptom relief (mean follow-up duration, 75.2 months; SD, 196.5). CONCLUSION Both dilatation and myotomy are effective immediate treatment of achalasia. A clear transition to and preference for laparoscopic approach has occurred in the treatment of achalasia in children.
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Affiliation(s)
- Aimee C Pastor
- Division of General Surgery, Hospital for Sick Children, Toronto, Ontario, Canada
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Lin JY, Lee ZF, Yen YC, Chang YT. Pneumatic dilation in treatment of late-onset primary gastric outlet obstruction in childhood. J Pediatr Surg 2007; 42:e1-4. [PMID: 17270531 DOI: 10.1016/j.jpedsurg.2006.10.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Late-onset primary gastric outlet obstruction in childhood is a rare condition. Only 8 cases of such were reported. Diagnosis should be considered while ruling out mechanical and structural lesions. Up to now, Heineke-Mikulicz pyloroplasty has been the standard treatment. However, we succeeded in treating this condition by using pneumatic dilation. There is no sign of recurrence for 1 year. We propose the etiology, diagnosis, and the relationship between late-onset primary gastric outlet obstruction and esophageal achalasia in childhood.
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Affiliation(s)
- Jao-Yo Lin
- Division of Pediatric Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan
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Viola S, Goutet JM, Audry G, Girardet JP. Le mégaœsophage de l'enfant : profil clinique et évolution à long terme. Arch Pediatr 2005; 12:391-6. [PMID: 15808427 DOI: 10.1016/j.arcped.2004.10.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2004] [Accepted: 10/25/2004] [Indexed: 12/18/2022]
Abstract
UNLABELLED Achalasia of the cardia is rare in children. We report our experience in the management of 20 children with achalasia. PATIENTS Twenty children (seven girls including two sisters) with achalasia were studied, seven of them had a morbid association. Age at diagnosis ranged from eight months to 18 years (med: 6.4 yrs). Duration of symptoms prior to diagnosis ranged from one to 62 months (med: 8 months). Regurgitations, weight loss and recurrent pneumonias were the most common presenting symptoms. Diagnosis was established using esophageal manometry, which showed aperistalsis throughout the esophageal body with impaired relaxation of lower esophageal sphincter in all children, and chest x-ray and barium esophagram, which were abnormal in 11 and 18 children respectively. OUTCOME Nifedipine used in nine children was ineffective. Two balloon dilatations were performed in one child with a poor result. Surgery with Heller's myotomy combined with an antireflux procedure was performed in 19 children. One child died six months later due to an hypoglycemic coma. During the follow-up (6 months-21 years) symptoms reappeared in five children. Seventy-two percent of the children had no symptoms one year after the surgery and 45%, five years after. Esophageal manometry performed after surgery in seven children showed a normal lower esophageal sphincter pressure but with impaired relaxation, and an aperistalsis throughout the esophageal body. These results justify prolonged follow-up of children with achalasia of the esophagus.
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Affiliation(s)
- S Viola
- Service de gastroentérologie et nutrition pédiatriques, hôpital Armand-Trousseau, assistance publique-hôpital de Paris, 26 avenue du Dr-Arnold-Netter, 75571 Paris cedex 12, France
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Khan AA, Shah SWH, Alam A, Butt AK, Shafqat F. Efficacy of Rigiflex balloon dilatation in 12 children with achalasia: a 6-month prospective study showing weight gain and symptomatic improvement. Dis Esophagus 2003; 15:167-70. [PMID: 12220427 DOI: 10.1046/j.1442-2050.2002.00246.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Achalasia cardia is a disease of adolescents and is rare in children. In total, 12 children with primary achalasia, with a mean age of 10.8 +/- 2 years, were prospectively evaluated for the efficacy of a 30-mm-diameter Rigiflex balloon for relief of symptoms and weight gain after 1 and 6 months of follow up. The 12 children were evaluated and treated for achalasia, with pneumatic balloon dilatation, from January 1998 to December 2000. They were studied for basal, 1-, and 6-month post-dilatation composite symptoms for dysphagia, regurgitation, night cough and heartburn. Basal and 5-min post-dilatation barium swallow were obtained to compare barium height and width for efficacy of dilatation and to evaluate for complications. There were no complications. Barium height, width, composite symptom score and weight improved significantly up to the 6-month follow up. Rigiflex balloon dilatation of 30-mm diameter is safe and effective in children with achalasia.
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Affiliation(s)
- A A Khan
- Department of Gastroenterology, Shaikh Zayed Postgraduate Medical Institute, Sheikh Zayed Hospital, Lahore, Pakistan.
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Abstract
Recent improvements in laparoscopic equipment, technique, and skills have contributed to advancement of the laparoscopic approach to even relatively rare pediatric surgical diseases. Two invasive operations that now may be approached laparoscopically are adrenalectomy and esophagomyotomy. Both techniques, initially described in the early 1990s, are particularly well suited for the laparoscopic approach and have become accepted as the preferred technique among general surgeons. Despite infrequent indications for either of these operations in children, pediatric surgeons experienced in minimally invasive techniques may apply the laparoscopic approach in a safe and effective manner. Furthermore, regarding achalasia in the pediatric population specifically, the offering of a less-invasive surgical approach may contribute toward more primary definitive surgical management being offered initially rather than after prolonged supportive medical care. The goal of this article is to familiarize the reader with the current laparoscopic approach to benign pediatric adrenal conditions and esophageal motility disorders in children.
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Affiliation(s)
- Kelly A Miller
- Department of Surgery, Children's Hospital of Pittsburgh, PA, USA
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Mehra M, Bahar RJ, Ament ME, Waldhausen J, Gershman G, Georgeson K, Fox V, Fishman S, Werlin S, Sato T, Hill I, Tolia V, Atkinson J. Laparoscopic and thoracoscopic esophagomyotomy for children with achalasia. J Pediatr Gastroenterol Nutr 2001; 33:466-71. [PMID: 11698765 DOI: 10.1097/00005176-200110000-00009] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Minimally invasive esophagomyotomy, consisting of a laparoscopic or thoracoscopic approach, has become a preferred surgical treatment for adults with achalasia. This multicenter study reports on the clinical status of children who have undergone minimally invasive esophagomyotomy for achalasia. METHODS Symptomatology for achalasia was assessed in 22 pediatric patients who underwent minimally invasive esophagomyotomy for achalasia between 1995 and 2000. All patients were evaluated for duration of hospitalization, postoperative resumption of feeds, postoperative complications, and symptomatic relief. Participants were assigned pre-and postoperative symptom severity scores ranging from 0 (no symptoms) to 3 (severe). RESULTS The median age of the 10 females and 12 males at time of surgery was 11.3 years +/- 3.4 (standard deviation). Transabdominal laparoscopic esophagomyotomy with fundoplication was performed in 18 patients, and thoracoscopic esophagomyotomy without fundoplication was performed in 4. Two patients required conversion from transabdominal laparoscopic esophagomyotomy to open esophagomyotomy because of intraoperative esophageal perforation. The mean duration of postsurgical follow-up was 17 +/- 16 (standard deviation) months (range, 1-54 months). Mean duration of hospitalization (days +/- standard error or mean) was less for transabdominal laparoscopic esophagomyotomy than for converted open esophagomyotomy (2.7 +/- 0.3 vs. 9.0 +/- 3.0 days; P < 0.05) or for thoracoscopic esophagomyotomy (4.8 +/- 1.7 days; P = not significant). Mean time to resumption of soft feedings (days +/- standard error or mean) occurred sooner after transabdominal laparoscopic esophagomyotomy than after converted open esophagomyotomy (2.0 +/- 0.2 vs. 5.5 +/- 0.5 days; P < 0.001) or after thoracoscopic esophagomyotomy (4.0 +/- 1.3 days; P = not significant). Patients experienced significant pre-to postoperative improvement in mean severity score with regard to dysphagia (2.6 vs. 0.4; P < 0.001) and regurgitation (1.7 vs. 0.2; P < 0.001). CONCLUSIONS Minimally invasive esophagomyotomy can provide excellent symptomatic relief from dysphagia and regurgitation for children with achalasia.
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Affiliation(s)
- M Mehra
- Department of Pediatrics, Division of Gastroenterology and Nutrition, University of California Los Angeles School of Medicine, Los Angeles, California 90095-1752, USA.
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Abstract
Achalasia is rare in children, more so familial. We report two siblings with familial achalasia who presented in their infancy with vomiting and failure to thrive. Achalasia can be misdiagnosed as upper gastrointestinal obstruction as happened in one of our siblings. Esophageal contrast roentgenography is diagnostic. Both the children were treated successfully by transabdominal esophagomyotomy with fundoplication.
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Affiliation(s)
- P S Rao
- Department of Pediatric Surgery, Kasturba Medical College, Manipal-576119, Karnataka, India
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Abstract
BACKGROUND Injection of botulinum toxin (BTx) into the lower esophageal sphincter (LES) of adult patients with achalasia results in the effective relief of symptoms. The aim of the present study was to examine the effectiveness of BTx in pediatric patients suffering from achalasia. METHODS Seven patients suffering from achalasia with or without prior treatment were treated with intrasphincteric injection of BTx. The median duration of follow up was 15 months. RESULTS All seven patients improved. The median interval before recurrence of symptoms was 4 months (range 1-14 months). There was an inverse relationship between the pretreatment LES pressure and the duration of response (r=-0.6). The mean pretreatment LES pressure in the subgroup with a response greater than 6 months was 38+/-10 mmHg compared with 61+/-12 mmHg in the other four patients (P= 0.05). All seven patients required retreatment. CONCLUSION Botulinum toxin is effective in relieving symptoms in pediatric patients suffering from achalasia, producing a sustained response beyond 6 months in 43% of patients.
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Affiliation(s)
- K S Ip
- Department of Paediatric Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Melbourne, Victoria, Australia
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WALDHAUSEN JOHNH, HORGAN SANTIAGO, PELLEGRINI CARLOS. Laparoscopic Heller Myotomy and Dor Fundoplication for Achalasia in Children. ACTA ACUST UNITED AC 1999. [DOI: 10.1089/pei.1999.3.23] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Tovar JA, Prieto G, Molina M, Arana J. Esophageal function in achalasia: preoperative and postoperative manometric studies. J Pediatr Surg 1998; 33:834-8. [PMID: 9660208 DOI: 10.1016/s0022-3468(98)90653-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND/PURPOSE Aperistalsis observed in children with achalasia may be secondary to sphincteric spasm or reflect a primary esophageal dysfunction. The aim of this study was to assess manometrically sphincteric function and esophageal motility before and after successful myotomy. METHODS Conventional stationary and pull-through manometry were performed preoperatively in 14 patients and postoperatively in 13. Ambulatory 24-hour manometry was carried out in four and eight patients in these two groups, respectively, and the results were compared with those of 23 refluxing youngsters. RESULTS Sphincter hypertony with lack or incompleteness of relaxation was found preoperatively in all patients, and sphincter pressure decreased dramatically after myotomy in all of them. All patients had aperistalsis preoperatively, and only a few had some primary, but weak, contractions postoperatively. Ambulatory manometry results confirmed a reduced number of motor events even during meals and only insignificant improvement of progressiveness, completeness and amplitude of waves after myotomy irrespective of the time elapsed since the procedure, the degree of recovery of esophageal caliber, and the clinical outcome. CONCLUSIONS Motor disorders in achalasia in children are similar to those of adults with the same disease. Motor recovery is observed only in some patients, although it is never complete, and their esophagi will remain ineffective for life. Because myotomy destroys the sphincter, and motility is permanently impaired in this condition, a fundoplication must be interposed to allow long-term mucosal protection.
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Affiliation(s)
- J A Tovar
- Department of Surgery, Hospital Infantil Universitario La Paz, Madrid, Spain
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Affiliation(s)
- M J Nowicki
- Division of Pediatric, Naval Medical Center, Portsmouth, Virginia 23708, USA
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Gershman G, Ament ME, Vargas J. Frequency and medical management of esophageal perforation after pneumatic dilatation in achalasia. J Pediatr Gastroenterol Nutr 1997; 25:548-53. [PMID: 9360212 DOI: 10.1097/00005176-199711000-00012] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- G Gershman
- Department of Pediatrics, UCLA School of Medicine, USA
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20
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Abstract
Although achalasia is not a common illness in the United States and Europe, there continues to be a need for surgical therapy for treatment. Laparoscopic Heller myotomy and partial fundoplication has, for the most part, replaced open surgery (abdominal or thoracic) as the surgical treatment of choice. In order to perform this procedure well, one must select patients carefully, evaluate them fully, and adhere to the technical principles required to achieve consistently good results.
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Affiliation(s)
- J G Hunter
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
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21
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Störungen der Ösophagus- und Magenmotilität bei Kindern. Eur Surg 1997. [DOI: 10.1007/bf02619745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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23
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Khoshoo V, LaGarde DC, Udall JN. Intrasphincteric injection of Botulinum toxin for treating achalasia in children. J Pediatr Gastroenterol Nutr 1997; 24:439-41. [PMID: 9144129 DOI: 10.1097/00005176-199704000-00015] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- V Khoshoo
- Ochsner Hospital and Clinic, New Orleans, LA 70121, USA
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24
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Robertson FM, Jacir NN, Crombleholme TM, Moriarty KP, Verhave M. Thoracoscopic esophagomyotomy for achalasia in a child. J Pediatr Gastroenterol Nutr 1997; 24:215-7. [PMID: 9106110 DOI: 10.1097/00005176-199702000-00017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- F M Robertson
- Division of Pediatric Surgery, Tufts University School of Medicine, Boston, Massachusetts, USA
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25
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Ganatra JV, Bostwick HE, Medow MS, Beneck D, Berezin S. Candida esophagitis in a child with achalasia. J Pediatr Gastroenterol Nutr 1996; 22:330-3. [PMID: 8708892 DOI: 10.1097/00005176-199604000-00020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- J V Ganatra
- Department of Pediatrics, New York Medical College, Valhalla 10595, USA
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26
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Abstract
Twelve children with achalasia were treated by the technique of balloon dilatation in the years 1984-1991. Follow-up from 2 to 8 years (mean 3.5 years) showed complete relief of obstruction in 10 patients, while two required esophagomyotomy. Balloon dilatation is effective in the treatment of achalasia.
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Affiliation(s)
- V N Perisic
- Department of Gastroenterology and Hepatology, University Children's Hospital, Belgrade, Yugoslavia
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27
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Abstract
This report summarizes a worldwide survey of achalasia in childhood. The data were obtained by circulating a questionnaire to pediatric surgeons throughout the world. Information was received regarding 175 patients, and the analysis is presented. Childhood achalasia appears to be more common in boys, and familial cases are rare. Regurgitation of food and dysphagia are the most frequent symptoms in affected children. Although 18% of patients had symptom onset during infancy, only 6% of the patients were identified as having achalasia during infancy. The survey suggests only a fair clinical response to transthoracic esophagocardiomyotomy and a good to excellent clinical response to transabdominal esophagocardiomyotomy. A cooperative effort between several institutions will permit the development of prospective treatment protocols for children with achalasia.
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Affiliation(s)
- N A Myers
- Royal Children's Hospital, Melbourne, Australia
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28
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Abstract
Several treatment options are available in the management of achalasia of the cardia. Of a recent series of 14 children, 12 were treated by a modified Heller's myotomy combined with a floppy Nissen fundoplication. Symptoms were dramatically improved in nine during a mean follow up period of 3.9 years. Recurrent oesophageal pain was the most resistant symptom and continued to be moderately severe in three patients, two of whom obtained temporary relief by oesophageal balloon dilatation. Two patients treated by pneumatic dilatation alone have residual symptoms. These results support a primary surgical approach to the management of achalasia in children.
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Affiliation(s)
- R Emblem
- Department of Paediatric Surgery, Institute of Child Health, London
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29
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Abstract
The Dor-Gavriliu procedure was utilized in six children with achalasia of the cardia from 1983 to 1991. Four boys and two girls (mean age, 10.1 years; range, 3 months to 16 years) presented with symptoms of weight loss (83%), emesis (83%), dysphagia (67%), recurrent respiratory infections (67%), and nocturnal regurgitation (33%). The diagnosis of achalasia was established by barium swallow in all patients; esophageal manometry was used in four patients to confirm the diagnosis. Follow-up ranged from 10 months to 8 years (mean, 3.5 years). Four neurologically normal patients had excellent results with complete resolution of their preoperative symptoms. Two neurologically impaired children, both afflicted with Down's syndrome, had less than excellent results. One moderately impaired child had a good result (required three postoperative bougie dilations over 8 years without demonstration of gastroesophageal reflux); the second, more severely impaired child, had only a fair result (persistent failure to thrive with the development of grade II gastroesophageal reflux). The Dor-Gavriliu procedure uses a transabdominal, anterior esophageal myotomy with incorporation of an effective, nonobstructing, antireflux mechanism that should prevent myotomy reapposition.
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Affiliation(s)
- K B Allen
- Department of Cardiovascular-Thoracic Surgery, Rush-Presbyterian-St Luke's Medical Center, Chicago, IL
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30
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Tuck JS, Bisset RA, Doig CM. Achalasia of the cardia in childhood and the syndrome of achalasia alacrima and ACTH insensitivity. Clin Radiol 1991; 44:260-4. [PMID: 1659963 DOI: 10.1016/s0009-9260(05)80192-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Achalasia of the cardia is an uncommon condition with an incidence of 0.1 cases per year per 100,000 population under 14 years. A review of experience at Booth Hall Children's Hospital over the past 10 years has revealed six cases of achalasia in children. This includes two cases of the rare syndrome of achalasia, alacrima and ACTH insensitivity (also known as Triple A syndrome) and its variants. There are 23 previously reported cases of Triple A syndrome and a further eight cases of its variants reported in the world literature. One-third of these cases (10 out of 31) have associated neurological abnormalities. The clinical and radiological features of achalasia are reviewed. The importance of barium studies in making the diagnosis is emphasized. However, early cases may show only spasm or incoordination, and manometry is required to confirm the diagnosis in these equivocal cases. In this series only three of the six barium studies were diagnostic and the remainder were diagnosed by manometry; all cases were subsequently confirmed by histology. Delay in diagnosis may result in severe lung damage due to repeated aspiration; this occurred in one of the six cases and was the cause of the child's death.
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Affiliation(s)
- J S Tuck
- Department of Radiology, Booth Hall Children's Hospital, Manchester
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Nihoul-Fékété C, Bawab F, Lortat-Jacob S, Arhan P, Pellerin D. Achalasia of the esophagus in childhood: surgical treatment in 35 cases with special reference to familial cases and glucocorticoid deficiency association. J Pediatr Surg 1989; 24:1060-3. [PMID: 2809952 DOI: 10.1016/s0022-3468(89)80215-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Achalasia of the esophagus is a relatively rare problem in children, but it can result in severe lung disease, growth retardation, or respiratory death in young infants. Surgical esophagocardiomyotomy remains the treatment of choice, and this report details a 25-year experience with 35 children with achalasia of the esophagus and their long-term postoperative follow-up. Occurrence of achalasia in the first 6 months of life, the existence of familial cases, and the association of achalasia with genetic diseases (familial dysautonomia, glucocorticoid insufficiency, Rozycki syndrome) suggest that achalasia in childhood may in certain cases represent a congenital problem.
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Affiliation(s)
- C Nihoul-Fékété
- Department of Pediatric Surgery, Hôpital des Enfants Malades, Paris, France
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