Laparoscopic adrenalectomy and esophagomyotomy

Current management of pediatric achalasia

Achalasia is a rare condition affecting esophageal motility in children. In a manner similar to the disease found in the adult population, children experience symptoms of dysphagia, regurgitation, and chest pain due to a failure of relaxation of the lower esophageal sphincter. Standard diagnostic approaches include upper endoscopy and esophageal manometry. New developments in diagnosis include high-resolution esophageal manometry and the endoscopic functional lumen imaging probe. Therapies available include endoscopic balloon dilations and botulinum toxin injections into the lower esophageal sphincter, as well as surgical interventions. The Heller myotomy was first described in 1913; since then, there have been many modifications to the procedure to improve outcomes and lower morbidity. Currently, the most commonly performed surgical procedure is the laparoscopic Heller myotomy, in which the sphincter muscle is divided using longitudinal incisions with or without a partial fundoplication procedure. In recent years, per oral endoscopic myotomy (POEM) is gaining support as a viable natural orifice therapy for achalasia. Complications of POEM occur at a relatively low rate, and outcomes following the procedure have been promising. The treatment of end-stage achalasia however, may include partial or total esophagectomy with reconstruction if possible. Future research is focused primarily on increasing the efficacy, and lowering complications, of existing therapeutic modalities.

Laparoscopic adrenalectomy in children: A 25-case series and review of the literature

BACKGROUND

Laparoscopic adrenalectomy (LA) is the gold standard and is widely performed in adults, but its use in children is relatively new. We aim to present our experience in twenty-five children with diverse adrenal pathologies and to discuss an extensive review of pediatric LA in English literature.

METHODS

Medical records of children with adrenal tumors admitted to a tertiary center and treated with LA were reviewed. Characteristics and outcome of patients were compared with results of a systematic Pubmed/Medline literature review.

RESULTS

Transperitoneal LAs were performed for 12 malignant and 14 benign adrenal masses (size range: 2-8cm) in 25 children (median age:63months). Fourteen lesions were on the right side, and there was one bilateral case. There were no conversion and no complication within 36months of follow-up. A literature review revealed 437 pediatric LAs with left side predomination (51.4%). The indication was a malignant lesion in 60.2% of the cases (sizes range: 1-10cm). The transperitoneal route was preferred in 94.2% of the procedures. Conversion and complication rates were 7.5% and 3.1%, respectively.

CONCLUSION

LA should be preferred in selected children with adrenal pathologies. The transperitoneal route seems to be the standard approach for pediatric surgeons. Preoperative planning and surgical expertise are the keys to success.

TYPE OF THE STUDY

Case series with systematic literature review.

LEVEL OF EVIDENCE

IV.

IPEG guidelines for the surgical treatment of adrenal masses in children

Laparoscopic adrenalectomy and adrenal biopsy are technically feasible in children. There are no absolute contraindications to the laparoscopic approach, but for neuroblastomas and other adrenal neoplasms, care must be taken to maintain the principles of cancer surgery. As opposed to adults, there are fewer benign indications for adrenalectomy, but in selected cases, laparoscopic resection of the adrenal is feasible. Both laparoscopic and retroperitoneoscopic approaches are recommended, with the choice being dictated by the experience of the surgeon. Recommendations throughout this guideline are based on class 3 evidence, with a single article demonstrating class 2 evidence, based on a retrospective comparison.

Esophageal motor disorders

Motor dysfunction is an important cause of oropharyngeal dysphagia and distal esophageal symptoms. Minimally invasive surgical methods of managing Zenker diverticula and achalasia, important disorders associated with these presentations, continue to take center stage in the literature. Detection and characterization of hypomotility before antireflux surgery may be less important than systematically excluding achalasia, as the vague and variable presentations of this motor disorder become appreciated. The many processes that can mimic idiopathic achalasia continue to be exposed.