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Provenzano L, Pulvirenti R, Duci M, Capovilla G, Costantini A, Forattini F, Gamba P, Costantini M, Fascetti-Leon F, Salvador E. Laparoscopic Heller-Dor Is a Persistently Effective Treatment for Achalasia Even in Pediatric Patients: A 25-Year Experience at a Single Tertiary Center. Eur J Pediatr Surg 2023; 33:493-498. [PMID: 36720247 DOI: 10.1055/s-0043-1760822] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Esophageal achalasia (EA) is a rare primary motility disorder in any age group, and particularly rare in the pediatric population, with a reported incidence of 0.18 per 100,000 children a year. EA in pediatric age is currently treated in the same way as in adults, but this approach is based on only a few studies on small case series. The aim of this retrospective study was to assess the long-term outcome of the laparoscopic Heller-Dor (LHD) procedure when performed in pediatric patients with EA at our university hospital. MATERIALS AND METHODS We considered children and adolescents younger than 16 years old diagnosed with EA and treated with LHD between 1996 and 2022. Clinical data were prospectively collected in an ongoing database. Symptoms were recorded and their severity was calculated using the Eckardt score. Barium swallow, esophageal manometry (conventional or high-resolution), and endoscopy were performed before and after the surgical procedure. RESULTS During the study period, 40 children with a median age of 14 years (interquartile range [IQR]: 11-15) underwent LHD. At a median follow-up of 10.5 years (IQR: 4.5-13.9), a good outcome was achieved in 36/40 patients (90%). Two of the four patients whose surgical procedure failed underwent complementary pneumatic dilations successfully, thus increasing the overall success rate to 95%. A previous endoscopic treatment (in five patients) did not affect the final outcome (p = 0.49). An intraoperative mucosal lesion was detected in only one patient (2.5%) and was repaired at the time without further consequences. During the follow-up, 22 patients underwent endoscopy, and 17 had pH monitoring as well: only 2 of these patients showed reflux esophagitis at endoscopy (one of them with abnormal findings on pH monitoring), amounting to a 9.1% rate of instrumentally confirmed postoperative reflux. CONCLUSION LHD is a safe and persistently effective treatment for EA in pediatric age, with a success rate comparable with what is usually obtained in adults, and better than what has been reported to date in the pediatric literature. Adding a fundoplication certainly helps ensure an optimal long-term control of any gastroesophageal reflux induced by the myotomy.
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Affiliation(s)
- Luca Provenzano
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy
| | - Rebecca Pulvirenti
- Division of Pediatric Surgery, Department of Women's and Children's Health, University of Padova, Padova, Veneto, Italy
| | - Miriam Duci
- Division of Pediatric Surgery, Department of Women's and Children's Health, University of Padova, Padova, Veneto, Italy
| | - Giovanni Capovilla
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy
| | - Andrea Costantini
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy
| | - Francesca Forattini
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy
| | - Piergiorgio Gamba
- Division of Pediatric Surgery, Department of Women's and Children's Health, University of Padova, Padova, Veneto, Italy
| | - Mario Costantini
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy
| | - Francesco Fascetti-Leon
- Division of Pediatric Surgery, Department of Women's and Children's Health, University of Padova, Padova, Veneto, Italy
| | - Enato Salvador
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy
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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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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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Pandian TK, Naik ND, Fahy AS, Arghami A, Farley DR, Ishitani MB, Moir CR. Laparoscopic esophagomyotomy for achalasia in children: A review. World J Gastrointest Endosc 2016; 8:56-66. [PMID: 26839646 PMCID: PMC4724031 DOI: 10.4253/wjge.v8.i2.56] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 09/28/2015] [Accepted: 11/17/2015] [Indexed: 02/05/2023] Open
Abstract
Esophageal achalasia in children is rare but ultimately requires endoscopic or surgical treatment. Historically, Heller esophagomyotomy has been recommended as the treatment of choice. The refinement of minimally invasive techniques has shifted the trend of treatment toward laparoscopic Heller myotomy (LHM) in adults and children with achalasia. A review of the available literature on LHM performed in patients < 18 years of age was conducted. The pediatric LHM experience is limited to one multi-institutional and several single-institutional retrospective studies. Available data suggest that LHM is safe and effective. There is a paucity of evidence on the need for and superiority of concurrent antireflux procedures. In addition, a more complete portrayal of complications and long-term (> 5 years) outcomes is needed. Due to the infrequency of achalasia in children, these characteristics are unlikely to be defined without collaboration between multiple pediatric surgery centers. The introduction of peroral endoscopic myotomy and single-incision techniques, continue the trend of innovative approaches that may eventually become the standard of care.
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Mohan C, Riedel BD, Nield LS. A 14-year-old female with difficulty swallowing. Pediatr Ann 2015; 44:22-5. [PMID: 25621624 DOI: 10.3928/00904481-20151226-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Tannuri ACA, Tannuri U, Velhote MCP, Romão RLP. Laparoscopic extended cardiomyotomy in children: an effective procedure for the treatment of esophageal achalasia. J Pediatr Surg 2010; 45:1463-6. [PMID: 20638525 DOI: 10.1016/j.jpedsurg.2009.08.023] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2009] [Revised: 08/20/2009] [Accepted: 08/21/2009] [Indexed: 01/06/2023]
Abstract
PURPOSE Achalasia of the esophagus is characterized by aperistalsis and incomplete relaxation of the lower esophageal sphincter in response to swallowing. The objective of the present study is to present the experience of a modified Heller myotomy via a laparoscopic approach for the treatment of children who had this condition. METHODS A retrospective review of medical records of all patients who underwent this procedure from 2000 to 2009 was performed. The procedure consisted of an extended esophagomyotomy beginning on the lower part of the lower esophageal sphincter and continuing 5 to 6 cm above on the lower third of the esophagus, and then extended 3 to 4 cm below to the stomach, associated with an anterior 180-degree hemi-fundoplication according to Dor's technique. RESULTS Fifteen patients were included in the study. There were 8 female and 7 male patients. Mean operating time was 190 minutes with no intraoperative complications and 1 conversion to open surgery because of difficulty in dissecting an inflamed distal esophagus. In a mean follow-up period of 32.3 months, 2 patients had recurrence of mild dysphagia that disappeared spontaneously, and 1 required a single botulinum toxin injection with complete resolution of symptoms. CONCLUSION We conclude that the laparoscopic extended Heller myotomy with Dor fundoplication is a safe and effective method for the treatment for achalasia in the pediatric population even in advanced cases.
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Affiliation(s)
- Ana Cristina Aoun Tannuri
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit and Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
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Jung C, Michaud L, Mougenot JF, Lamblin MD, Philippe-Chomette P, Cargill G, Bonnevalle M, Boige N, Bellaïche M, Viala J, Hugot JP, Gottrand F, Cezard JP. Treatments for pediatric achalasia: Heller myotomy or pneumatic dilatation? ACTA ACUST UNITED AC 2010; 34:202-8. [PMID: 20303225 DOI: 10.1016/j.gcb.2009.10.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2009] [Revised: 10/21/2009] [Accepted: 10/29/2009] [Indexed: 01/22/2023]
Abstract
AIM The treatment of achalasia consists of reducing distal esophageal obstruction by either Heller myotomy surgery or endoscopic pneumatic dilatation. The aim of the present study was to evaluate the short- and middle-term results of these procedures in children. METHODOLOGY For technical reasons, children under six years old (n=8) were treated by surgery only, whereas patients over six years old (n=14) were treated by either Heller myotomy or pneumatic dilatation. RESULTS Of the children aged under six years, 75% were symptom-free at six months and 83% at 24 months of follow-up. Of the patients aged over six years, complete remission was achieved by Heller myotomy in 44.5% vs. 55.5% by pneumatic dilatation after six months, and in 40% vs. 65%, respectively, after 24 months. Both pneumatic dilatation and Heller myotomy showed significant rates of failure. CONCLUSION These results suggest that pneumatic dilatation may be considered a primary treatment in children over six years old. Also, where necessary, Heller myotomy and pneumatic dilatation may be used as complementary treatments.
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Affiliation(s)
- C Jung
- Service de gastroentérologie et nutrition pédiatrique, hôpital Robert-Debré, AP-HP, 48, boulevard Sérurier, 75019 Paris, France
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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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Askegard-Giesmann JR, Grams JM, Hanna AM, Iqbal CW, Teh S, Moir CR. Minimally invasive Heller's myotomy in children: safe and effective. J Pediatr Surg 2009; 44:909-11. [PMID: 19433168 DOI: 10.1016/j.jpedsurg.2009.01.022] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2009] [Accepted: 01/15/2009] [Indexed: 11/30/2022]
Abstract
PURPOSE The aim of the study was to review a single institution experience of minimally invasive Heller's myotomy in pediatric patients with achalasia. METHODS An institutional review board-approved retrospective review from 1999 to 2005 identified patients 18 years old and younger who underwent a minimally invasive Heller's myotomy for achalasia. RESULTS Twenty-six patients were identified with a mean age of 15 (range, 4-18 years). There were 11 female and 15 male patients. There were 3 intraoperative complications (2 esophageal mucosal injuries and 1 aspiration). There was no mortality. All 26 surgeries were completed laparoscopically. Two patients had Dor fundoplication, whereas 23 patients had Toupet fundoplication. Average length of hospital stay was 2.7 days (range, 1-4 days) excluding the 3 patients with intraoperative complications and 3.5 days for all patients (range, 1-17 days). Postoperative follow-up ranged from 0 to 75 months (mean, 20 months). Postoperatively, one patient developed reflux symptoms (incidence 4%). Seven patients (27%) had recurrence of symptoms at a mean of 13 months (range, 1-66 months) after their operation. CONCLUSIONS Laparoscopic Heller's myotomy with fundoplication is a safe and effective treatment of symptomatic achalasia in the pediatric population. Complications were low in this group of patients and comparable to other published reports in the literature.
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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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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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Cataliotti F, Livoti G, Di Pace MR. Esophageal achalasia and hypertrophic pyloric stenosis associated with a phytobezoar in an adolescent. J Pediatr Surg 2002; 37:1363-4. [PMID: 12194136 DOI: 10.1053/jpsu.2002.35017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Esophageal achalasia is an uncommon condition in children. The authors report on a 14-year-old girl who showed a very unusual association of cardiospasm and hypertrophic pyloric stenosis with a gastric phytobezoar.
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Affiliation(s)
- F Cataliotti
- Department of Pediatric Surgery, University of Palermo, Italy
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Rothenberg SS, Partrick DA, Bealer JF, Chang JH. Evaluation of minimally invasive approaches to achalasia in children. J Pediatr Surg 2001; 36:808-10. [PMID: 11329595 DOI: 10.1053/jpsu.2001.22967] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Achalasia is an uncommon disease in children, but when present can result in severe disabling symptoms often requiring surgical intervention. This report describes the authors' experience with thoracoscopic (TH) and later laparoscopic Heller (LH) myotomy for definitive treatment of this disease. METHODS Nine patients with achalasia were referred for surgical therapy. Ages ranged from 5 to 17 years and weight from 23 to 78 kg. All had undergone at least one dilatation with recurrence of symptoms. The first 4 were treated by TH and the last five by LH. The 5 LH procedures also included a partial fundoplication. RESULTS All procedures were completed successfully using minimally invasive techniques. Operating times averaged 95 minutes for TH and 62 minutes for LH. One patient undergoing TH had a small esophageal perforation repaired primarily. The other 3 TH patients were started on clear liquids within 1 day and discharged on day 2. One patient had recurrent symptoms at 6 months and underwent a LH for an incomplete TH. All 5 LH patients were discharged on postoperative day 1. One had an esophageal perforation 4 days after operation requiring laparoscopic repair. Seven of 9 patients are asymptomatic. Studies of pH levels in 2 asymptomatic TH patients show mild gastroesophageal reflux (GER). CONCLUSIONS Minimally invasive Heller myotomy is a safe and effective procedure in children. TH results in a slightly longer operating time and hospital stay and, without a partial fundoplication, also may be associated with a higher incidence of silent GER. From these results, we prefer LH with a Dor fundoplication for treatment of achalasia in children.
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Affiliation(s)
- S S Rothenberg
- Departments of Pediatric Surgery, Hospital for Infants and Children, Presbyterian/St Luke's Medical Center and The Children's Hospital, University of Colorado, Denver, CO, USA
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Nakajima K, Wasa M, Kawahara H, Soh H, Taniguchi E, Ohashi S, Okada A. Surg Laparosc Endosc Percutan Tech 2000; 10:236-238. [DOI: 10.1097/00019509-200008000-00011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Laparoscopic Esophagomyotomy With Dor Anterior Fundoplication in a Child With Achalasia. Surg Laparosc Endosc Percutan Tech 2000. [DOI: 10.1097/00129689-200008000-00011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Esposito C, Mendoza-Sagaon M, Roblot-Maigret B, Amici G, Desruelle P, Montupet P. Complications of laparoscopic treatment of esophageal achalasia in children. J Pediatr Surg 2000; 35:680-3. [PMID: 10813322 DOI: 10.1053/jpsu.2000.5942] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND/PURPOSE The aim of this study was to evaluate the incidence and management of the complications that occurred in some children who underwent laparoscopic Heller's esophagocardiomyotomy in the authors' institutions. METHODS Between March 1993 and October 1998, the files of all the children with achalasia who underwent laparoscopic Heller's esophagocardiomyotomy in a community hospital in Naples, Italy, and a private hospital in Paris, France, were reviewed. A 5-port technique was used associating Heller's esophagocardiomyotomy to an antireflux surgical mechanism (Dor's or Toupet's) in all cases. Intra- and postoperative complications, as well as the postoperative outcome, were evaluated. RESULTS Ten laparoscopic Heller's esophagocardiomyotomies were performed in 5 girls and 5 boys with achalasia. Age ranged between 2 and 13 years. Mean operating time was 120 minutes. Hospital stay ranged between 3 and 41 days. Complications were recorded in 3 patients: in 2 an esophageal mucosal perforation and in 1 a prolonged dysphagia. Two of these complications occurred in the last patients operated on. Follow-up varied from 6 months to 6 years. All children were free of symptoms. CONCLUSIONS The results show that laparoscopic Heller's esophagocardiomyotomy in children is a feasible procedure. Assessment of mucosal integrity immediately after the myotomy must be performed. Complications can happen even if the operation is performed by expert laparoscopic surgeons.
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Affiliation(s)
- C Esposito
- Division of Pediatric Surgery, University of Naples, Italy
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18
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Hurwitz M, Bahar RJ, Ament ME, Tolia V, Molleston J, Reinstein LJ, Walton JM, Erhart N, Wasserman D, Justinich C, Vargas J. Evaluation of the use of botulinum toxin in children with achalasia. J Pediatr Gastroenterol Nutr 2000; 30:509-14. [PMID: 10817280 DOI: 10.1097/00005176-200005000-00009] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Achalasia is rare in children. Recently, injection of botulinum toxin into the lower esophageal sphincter has been studied as an alternative to esophageal pneumatic dilatation or surgical myotomy as treatment for achalasia. In the current study, the effects of botulinum toxin were investigated in the largest known series of children with achalasia. METHODS Treatment for achalasia was assessed in 23 pediatric patients who received botulinum toxin from June 1995 through November 1998. Those who continued to receive botulinum toxin and did not subsequently undergo pneumatic dilatation or surgery were considered repeat responders. Results were compared with those of published studies evaluating the use of botulinum toxin in adults with achalasia. RESULTS Nineteen patients initially responded to botulinum toxin. Mean duration of effect was 4.2 months +/- 4.0 (SD). At the end of the study period, three were repeat responders, three experienced dysphagia but did not receive pneumatic dilatation or surgery, three underwent pneumatic dilatation, eight underwent surgery, three underwent pneumatic dilatation with subsequent surgery, and three awaited surgery. Meta-analysis shows that, in the current study group, the data point expressing time of follow-up evaluation versus percentage of patients needing one injection session without additional procedures (botulinum toxin injection, pneumatic dilatation, or surgery) falls within the curve for those in studies on adult patients receiving botulinum toxin for achalasia. CONCLUSIONS Botulinum toxin effectively initiates the resolution of symptoms associated with achalasia in children. However, one half of patients are expected to need an additional procedure approximately 7 months after one injection session. The authors recommend that botulinum toxin be used only for children with achalasia who are poor candidates for either pneumatic dilatation or surgery.
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Affiliation(s)
- M Hurwitz
- Department of Pediatrics, University of California Los Angeles School of Medicine, 90095-1752, USA
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Abstract
BACKGROUND Minimally invasive surgery (MIS) has become an important aspect of general surgery. The degree to which pediatric surgeons have incorporated MIS into their practice is not known. STUDY DESIGN An MIS survey was sent to all members of the American Pediatric Surgical Association. Respondents were separated into two groups: nonperformers and performers of MIS. Performers were asked how they were trained in MIS and the total number and types of minimally invasive procedures they have performed. RESULTS Eighty-two percent of surveyed pediatric surgeons perform MIS. Eighty-seven percent received some or all of their training in a postgraduate course. Two percent received their only training during their general surgery residency. Forty-seven percent of performers reported 50 or fewer total procedures. A wide variety of procedures were reported, but laparoscopic cholecystectomy (95%) was the procedure most frequently reported. Thoracoscopic procedures (71%) were also reported at high rates. CONCLUSIONS Most pediatric surgeons in our survey perform MIS. The high rate of laparoscopic cholecystectomies reported suggests that the initial MIS experience of pediatric surgeons in our survey is similar to adult general surgeons. The frequency, however, of thoracic cases reported indicates that MIS techniques are being applied to all areas of pediatric surgery. The total minimally invasive procedure experience of our respondents also suggests that pediatric surgeons are early in their learning curve.
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Affiliation(s)
- A M Firilas
- University of Arkansas School for Medical Sciences and Arkansas Children's Hospital, Little Rock 72202-3591, USA
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Kaliciński P, Dluski E, Drewniak T, Kamiński W. Esophageal manometric studies in children with achalasia before and after operative treatment. Pediatr Surg Int 1997; 12:571-5. [PMID: 9354727 DOI: 10.1007/bf01371901] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
This study manometrically assessed and compared esophageal function in 16 children with achalasia before and after surgical treatment (anterior esophagomyotomy with antireflux partial fundoplication). Manometric examinations were done in 10 children preoperatively and in 12, 3 months to 8 years postoperatively. Both pre- and postoperative examinations were done in 6 patients. The following parameters were measured: lower esophageal sphincter (LES) pressure and length, spontaneous motility of the esophageal body, and motility provoked by swallowing of fluids. Preoperative examinations confirmed disturbances typical for achalasia: increased LES pressure (mean 39.4 mmHg), lack of relaxation upon swallowing, and various types of anomalous esophageal motility (lack of propulsive waves, segmental waves, breaks in propagation of contractions, tonic contractions, etc.). Postoperative examinations showed normalization of LES pressure; however, relaxation did not appear in any patient. Esophageal motility improved after surgery in most patients and was already noticeable 3-6 months postoperatively, but motility never returned to normal. Clinically, all but 1 patient with reflux esophagitis were doing well despite persistent motility disturbances. Our study confirms that achalasia is a complex motor disorder of the entire esophagus. The improvement of esophageal contractility after esophagomyotomy suggests both primary and significant secondary damage to motility of the esophageal body in most patients. It appears that secondary disturbances are reversible to some extent in children after surgical treatment.
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Affiliation(s)
- P Kaliciński
- Department of Pediatric Surgery and Organ Transplantation, Children's Memorial Health Institute, Al. Dzieci Polskich 20, PL-04-736 Warsaw, Poland
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