Selecting the surgical procedure for simple and complicated esophageal achalasia in children

Long-term outcomes of peroral endoscopic myotomy for achalasia in pediatric patients: a prospective, single-center study

BACKGROUND

Peroral endoscopic myotomy (POEM) has been developed to provide a less-invasive myotomy for achalasia in adults but seldom has been used in pediatric patients.

OBJECTIVE

To evaluate the feasibility, safety, and efficacy of POEM for pediatric patients with achalasia.

DESIGN

Single-center, prospective study.

SETTING

Academic medical center.

PATIENTS

A total of 27 pediatric patients (mean age 13.8 years, range 6-17 years) with achalasia.

INTERVENTIONS POEM MAIN OUTCOME MEASUREMENTS

The primary outcome was symptom relief during follow-up, defined as an Eckardt score of ≤3. Secondary outcomes were procedure-related adverse events, clinical reflux adverse events, and lower esophageal sphincter (LES) pressure on manometry before and after POEM.

RESULTS

A total of 26 cases (96.3%) underwent successful POEM. A submucosal tunnelling attempt failed in 1 case because of serious inflammation and adhesion. No serious adverse events related to POEM were encountered. During a mean follow-up period of 24.6 months (range 15-38 months), treatment success was achieved in all patients (mean score before vs after treatment 8.3 vs 0.7; P < .001). Mean LES pressure also decreased from a mean of 31.6 mm Hg to 12.9 mm Hg after POEM (P < .001). Five patients developed clinical reflux adverse events (19.2%).

LIMITATIONS

Single center and lack of some objective evaluations.

CONCLUSION

This relatively long-term follow-up study adds to the evidence that POEM seems to be a promising new treatment for pediatric patients with achalasia, resulting in long-term symptom relief in all cases and without serious adverse events.

Paediatric laparoscopic Heller's cardiomyotomy: a single centre series

BACKGROUND

The optimal management of oesophageal achalasia remains unclear in the paediatric population due to the rarity of the disease. This study reviews the institutional experience of the laparoscopic Heller's cardiomyotomy (HC) procedure and attempts to define the most appropriate treatment.

METHODS

A retrospective review of children undergoing HC at a single institution was performed. Demographics, pre-operative investigations, and interventions were reviewed. Post-operative outcomes and follow up were evaluated. Data is expressed as median (range).

RESULTS

Twenty-eight children were included (13 male, 15 female) whose median age was 13 (3.2-17.4) years. Nine children underwent a pre-operative oesophageal balloon dilatation (OBD) a median of 1(1-6) times. Others included botulinum toxin injection (n=1) and Nifedipine (n=1). All had a pre-operative upper gastrointestinal contrast series, and twenty-five had upper gastrointestinal endoscopy and manometry. All had laparoscopic HC with no conversions, and ten had a concomitant fundoplication. Post-operative intervention occurred in eight (28%) incorporating OBD (n=7), of whom four required a redo HC. One patient underwent a redo without intervening OBD. Follow-up was for a median of 0.83 (0-5) years with fourteen children discharged from surgical follow-up. Twenty-seven have thus far had a good outcome.

CONCLUSION

This study comprises the largest series of paediatric laparoscopic HC reported to date. It is effective with or without a fundoplication and is the best long term treatment modality available. OBD for persisting symptoms following HC may obviate the need for redo myotomy.

Laparoscopic extended cardiomyotomy in children: an effective procedure for the treatment of esophageal achalasia

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.

A single center 26-year experience with treatment of esophageal achalasia: is there an optimal method?

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.

Esophageal achalasia of unknown etiology in infants

BACKGROUND

Achalasia cardia is an uncommon disease in children particularly in infants. We present 8 cases of achalasia who were encountered over a 12-year period. In infantile achalasia, respiratory symptoms predominate and vomiting may easily be mistaken for gastroesophageal reflux (GER). Vomiting of uncurdled milk is characteristic of achalasia.

METHODS

In this retrospective study, the data were obtained from records of the Department of Pediatric Surgery IMS, BHU Varanasi, India. The patients were diagnosed by clinical examination and barium study. Any other associated anomalies were noted in these patients. The patients underwent esophagocardiomyotomy with antireflux procedure via the abdominal route.

RESULTS

In the present series, 7 patients survived. The follow-up study after operation showed remarkable relief of symptoms with satisfactory weight gain. No post-operative death occurred in the patients. Achalasia associated with alacrimia was noted in one infant who was lost to follow up. One infant was initially diagnosed as having gastric volvulus, but exploration revealed achalasia cardia.

CONCLUSIONS

Esophageal achalasia is a rare disease in children and its origin is generally indeterminable. Achalasia cardia should be emphasized in the differential diagnosis of an infant presenting with signs and symptoms of esophageal obstruction.

Laparoscopic Heller myotomy with anterior fundoplication ameliorates symptoms of achalasia in pediatric patients

BACKGROUND

This study was undertaken to define outcomes after laparoscopic Heller myotomy with anterior fundoplication in pediatric patients and compare their outcomes with those in adults.

STUDY DESIGN

A total of 337 patients have undergone laparoscopic Heller myotomy with anterior fundoplication since 1992, and were prospectively followed; 14 were pediatric patients of median age 17 years (range 11 to 19 years). Symptoms noted by pediatric patients before and after myotomy were compared with symptoms of 56 concurrently treated adults (4 treated adults for each pediatric patient) of median age 48 years. Among many symptoms, patients scored the severity and frequency of dysphagia, chest pain, regurgitation, choking, vomiting, and heartburn before and after myotomy using a Likert scale, ranging from 0 (never/not bothersome) to 10 (always/very bothersome). Followups were 38 months, 42 months+/-33.1. Data are reported as median, mean +/- SD.

RESULTS

For pediatric patients, length of stay after myotomy was 2 days, 3 days+/-2.9 versus 2 days, 2+/-2.1 for adults. Before myotomy, symptom frequency and severity were similar between groups. After myotomy, symptom frequency and severity were similar between pediatric and adult patients, except for the frequency of chest pain.

CONCLUSIONS

Achalasia can produce disabling symptoms, which were similar between pediatric and adult patients before myotomy. Laparoscopic Heller myotomy with anterior fundoplication ameliorated symptoms of achalasia in all patients, with postmyotomy symptoms similar between pediatric and adult patients. Laparoscopic Heller myotomy dramatically improved symptoms of achalasia in pediatric patients and its use is encouraged.

Le mégaœsophage de l'enfant : profil clinique et évolution à long terme

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.

Laparoscopic adrenalectomy and esophagomyotomy

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.

Complications of laparoscopic treatment of esophageal achalasia in children

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.