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Nita AF, Chanpong A, Nikaki K, Rybak A, Thapar N, Borrelli O. Recent advances in the treatment of gastrointestinal motility disorders in children. Expert Rev Gastroenterol Hepatol 2023; 17:1285-1300. [PMID: 38096022 DOI: 10.1080/17474124.2023.2295495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 12/12/2023] [Indexed: 01/12/2024]
Abstract
INTRODUCTION Pediatric gastrointestinal motility disorders represent some of the most challenging clinical conditions with largely undefined pathogenetic pathways and therefore limited therapeutic options. Herein, we provide an overview of the recent advances in treatment options for these disorders and their clinical impact. AREAS COVERED PubMed and Medline databases were searched for relevant articles related to the treatment of achalasia, esophageal atresia, gastroparesis, PIPO and constipation published between 2017 and 2022. In this article, we review and summarize recent advances in management of gastrointestinal motility disorders in children with a particular focus on emerging therapies as well as novel diagnostic modalities that help guide their application or develop new, more targeted treatments. EXPERT OPINION Gastrointestinal motility disorders represent one of the most challenging conundrums in pediatric age and despite significant advances in investigative tools, the palette of treatment options remain limited. Overall, while pharmacological options have failed to bring a curative solution, recent advances in minimal invasive therapeutic and diagnostic techniques have emerged as potential keys to symptom and quality of life improvement, such as ENDOFLIP, POEM, cine-MRI, fecal microbiota transplantation.
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Affiliation(s)
- Andreia Florina Nita
- Department of Pediatric Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Atchariya Chanpong
- Department of Pediatric Gastroenterology, Great Ormond Street Hospital, London, UK
- Division of Gastroenterology and Hepatology, Department of Paediatrics, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
- Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, Australia
- Stem Cells and Regenerative Medicine, UCL Institute of Child Health, London, UK
| | - Kornilia Nikaki
- Department of Pediatric Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Anna Rybak
- Department of Pediatric Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Nikhil Thapar
- Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, Australia
- Stem Cells and Regenerative Medicine, UCL Institute of Child Health, London, UK
- School of Medicine, University of Queensland, Brisbane, Australia
- Woolworths Centre for Child Nutrition Research, Queensland University of Technology, Brisbane, Australia
| | - Osvaldo Borrelli
- Department of Pediatric Gastroenterology, Great Ormond Street Hospital, London, UK
- Stem Cells and Regenerative Medicine, UCL Institute of Child Health, London, UK
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Mussies C, van Lennep M, van der Lee JH, Singendonk MJ, Benninga MA, Bastiaansen BA, Fockens P, Bredenoord AJ, van Wijk MP. Protocol for an international multicenter randomized controlled trial assessing treatment success and safety of peroral endoscopic myotomy vs endoscopic balloon dilation for the treatment of achalasia in children. PLoS One 2023; 18:e0286880. [PMID: 37796851 PMCID: PMC10553306 DOI: 10.1371/journal.pone.0286880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 05/13/2023] [Indexed: 10/07/2023] Open
Abstract
INTRODUCTION Achalasia is a rare neurodegenerative esophageal motility disorder characterized by incomplete lower esophageal sphincter (LES) relaxation, increased LES tone and absence of esophageal peristalsis. Achalasia requires invasive treatment in all patients. Conventional treatment options include endoscopic balloon dilation (EBD) and laparoscopic Heller's myotomy (LHM). Recently, a less invasive endoscopic therapy has been developed; Peroral Endoscopic Myotomy (POEM). POEM integrates the theoretical advantages of both EBD and LHM (no skin incisions, less pain, short hospital stay, less blood loss and a durable myotomy). Our aim is to compare efficacy and safety of POEM vs. EBD as primary treatment for achalasia in children. METHODS AND ANALYSIS This multi-center, and center-stratified block-randomized controlled trial will assess safety and efficacy of POEM vs EBD. Primary outcome measure is the need for retreatment due to treatment failure (i.e. persisting symptoms (Eckardt score > 3) with evidence of recurrence on barium swallow and/or HRM within 12 months follow-up) as assed by a blinded end-point committee (PROBE design). DISCUSSION This RCT will be the first one to evaluate which endoscopic therapy is most effective and safe for treatment of naïve pediatric patients with achalasia.
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Affiliation(s)
- Carlijn Mussies
- Emma Children’s Hospital—Amsterdam UMC, Location University of Amsterdam, Pediatric Gastroenterology, Amsterdam, The Netherlands
| | - Marinde van Lennep
- Emma Children’s Hospital—Amsterdam UMC, Location University of Amsterdam, Pediatric Gastroenterology, Amsterdam, The Netherlands
| | - Johanna H. van der Lee
- Emma Children’s Hospital—Amsterdam UMC, Location University of Amsterdam, Pediatric Clinical Research Office, Amsterdam, The Netherlands
- Knowledge Institute of the Dutch Association of Medical Specialists, Utrecht, The Netherlands
| | - Maartje J. Singendonk
- Emma Children’s Hospital—Amsterdam UMC, Location University of Amsterdam, Pediatric Gastroenterology, Amsterdam, The Netherlands
| | - Marc. A. Benninga
- Emma Children’s Hospital—Amsterdam UMC, Location University of Amsterdam, Pediatric Gastroenterology, Amsterdam, The Netherlands
| | - Barbara A. Bastiaansen
- Gastroenterology & Hepatology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Paul Fockens
- Gastroenterology & Hepatology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Gastroenterology & Hepatology, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Albert J. Bredenoord
- Gastroenterology & Hepatology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Michiel P. van Wijk
- Emma Children’s Hospital—Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Kumar N, Gadgade BD, Shivapur AA, Radhakrishna V, Vasudev RB. Evaluation and Management of Achalasia Cardia in Children: A Retrospective Observational Study. J Indian Assoc Pediatr Surg 2023; 28:369-374. [PMID: 37842218 PMCID: PMC10569275 DOI: 10.4103/jiaps.jiaps_175_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 01/24/2023] [Accepted: 03/06/2023] [Indexed: 10/17/2023] Open
Abstract
Background Achalasia cardia is a neuromuscular disorder of unknown etiology characterized by aperistalsis of the body of the esophagus and failure of relaxation of the lower esophageal sphincter. The diagnosis of achalasia cardia is delayed due to the rarity and the ability to mimic other common conditions in children. Hence, a study was conducted to evaluate the clinical presentation and the management of achalasia cardia in children. Materials and Methods A retrospective observational study was conducted in the department of pediatric surgery at a tertiary center. The children with achalasia cardia who presented between January 2014 and December 2021 were included. Results A total of 12 patients were treated for achalasia cardia during the study period. All children presented with recurrent episodes of vomiting, whereas dysphagia was seen in six (50%) children. Eighty-three percent of the children presented with a history of weight loss, whereas failure to thrive was seen in nine (75%) children. Five (42%) children were managed as gastroesophageal reflux disease (GERD) for more than a year before presenting to us. Three (25%) children underwent open cardiomyotomy with Thal fundoplication and the rest nine (75%) underwent laparoscopic cardiomyotomy. All are thriving well. Conclusion Achalasia is an important differential diagnosis in children with suspected GERD. The most common symptom of achalasia cardia is vomiting followed by dysphagia. Weight loss and failure to thrive are important presenting features in children with achalasia which are uncommon in adults. Cardiomyotomy without fundoplication is safe and effective to treat achalasia cardia in children without having any extra complications.
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Affiliation(s)
- Nitin Kumar
- Department of Pediatric Surgery, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
| | - Bahubali Deepak Gadgade
- Department of Pediatric Surgery, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
| | - Achyuth Ananth Shivapur
- Department of Pediatric Surgery, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
| | - Veerabhadra Radhakrishna
- Department of Pediatric Surgery, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
| | - Raghunath Bangalore Vasudev
- Department of Pediatric Surgery, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
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Durakbasa CU, Ersoy F, Pirim A, Oskayli MC. Clinical outcome of endoscopic balloon dilatations employed in benign paediatric oesophageal pathologies. J Minim Access Surg 2023; 19:62-68. [PMID: 35915522 PMCID: PMC10034793 DOI: 10.4103/jmas.jmas_79_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Background Oesophageal dilatations can be done either by bougies or balloons for differing aetiologies in children. We investigated the efficacy and safety of endoscopic balloon dilatations (EBDs) employed by a single surgeon. Patients and Methods Relevant data over 12 years were retrospectively evaluated with an ethical committee approval. Results Ninety-seven children underwent 514 EBD with a median EBD of 3 (1-50). The primary diagnoses were oesophageal atresia (OA) in 51 children, corrosive ingestion in 21, peptic strictures in 13, achalasia in 8 and congenital oesophageal stenosis in 4. The balloon size varied between 3 and 30 mm. The EBD was successfully ended in 72 patients and unsuccessful in six patients. Six children are still under EBD and 13 are lost to follow-up. The overall success rate was 92%. The age at the time of first dilatation was the youngest in OA group followed by corrosive strictures. The balloon sizes differed regarding the age of the patients with larger balloons used as the patient age increased. The sizes of the balloons used at the first and the last EBD differed among diagnostic groups. The total number of dilatations or the time interval between the first and the last EBD dilatation did not show a statistically significant difference among groups. The anatomical type of OA or the height of corrosive stricture revealed no significant difference in any of the above parameters. A transmural oesophageal perforation occurred during 2 (0.4%) EBD sessions. Conclusions EBD is an effective mean in relieving paediatric oesophageal pathologies with a variety of aetiologies and has a low complication rate.
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Affiliation(s)
- Cigdem Ulukaya Durakbasa
- Department of Pediatric Surgery, Istanbul Medeniyet University Faculty of Medicine, Goztepe Dr. Suleyman Yalcin Sehir Hospital, Istanbul, Turkey
| | - Furkan Ersoy
- Department of Pediatric Surgery, Istanbul Medeniyet University Faculty of Medicine, Goztepe Dr. Suleyman Yalcin Sehir Hospital, Istanbul, Turkey
| | - Ahmet Pirim
- Department of Pediatric Surgery, Istanbul Medeniyet University Faculty of Medicine, Goztepe Dr. Suleyman Yalcin Sehir Hospital, Istanbul, Turkey
| | - Meltem Caglar Oskayli
- Department of Pediatric Surgery, Istanbul Medeniyet University Faculty of Medicine, Goztepe Dr. Suleyman Yalcin Sehir Hospital, Istanbul, Turkey
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Nabi Z, Talukdar R, Chavan R, Basha J, Reddy DN. Outcomes of Per-Oral Endoscopic Myotomy in Children: A Systematic Review and Meta-analysis. Dysphagia 2022; 37:1468-1481. [PMID: 35092485 DOI: 10.1007/s00455-022-10409-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 01/19/2022] [Indexed: 12/16/2022]
Abstract
Per-oral endoscopic myotomy (POEM) is an established treatment modality in adult patients with achalasia cardia. There are limited data regarding the efficacy and safety of POEM in pediatric achalasia. In this systematic review and meta-analysis, we aimed to analyze the outcomes of POEM in children and adolescents with achalasia cardia. Literature search was performed in Embase, PubMed, and Cochrane database for studies evaluating the outcome of POEM in pediatric achalasia between January 2010 and March 2021. Primary objective of the study was clinical success (Eckardt ≤ 3). Secondary outcomes included technical success, procedure duration, adverse events , and gastroesophageal reflux after POEM. A total of 14 studies (419 children, 234 boys) were included in the review. The subtypes of achalasia were type I (30.6%), type II (63.8%), and type III (5.6%). Pooled rate of technical success was 97.1% (95% CI 94.5-98.5%; I2 = 0). Pooled clinical success in intention to treat and per-protocol population was 88% (95% CI 84.4-90.9%; I2 = 0) and 94.4% (95% CI 91.5-96.4%; I2 = 0), respectively. Post-POEM, pooled mean reduction in Eckardt scores was 6.71 (95% CI 6.14 7.28; p < 0.001; I2 = 81%). Pooled rate for overall adverse events was 12.9% (95% CI 7.4-21.7%; I2 64.5%), major adverse events was 4.2% (95% CI 2.4-7.4%), and erosive esophagitis was 26.3% (95% CI 17.5-37.7%; I2 51%). POEM is an effective procedure in children with achalasia. Future studies are required to determine the durability of response and comparative outcomes with other treatment modalities for achalasia.
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Affiliation(s)
- Zaheer Nabi
- Asian Institute of Gastroenterology, Hyderabad, India.
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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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Keane OA, Dantes G, Emani S, Garza JM, Heiss KF, Clifton MS. Implementation of enhanced recovery protocols reduces opioid use in pediatric laparoscopic Heller myotomy surgery. J Pediatr Surg 2022; 57:1132-1136. [PMID: 35292166 DOI: 10.1016/j.jpedsurg.2022.01.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 01/22/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Enhanced recovery protocols (ERPs) are effective means of standardizing and improving the quality of surgical care in adults. Our purpose was to retrospectively compare outcomes before and after implementation of ERPs in children undergoing laparoscopic Heller myotomy for achalasia. METHODS A pediatric-specific ERP was used for children undergoing laparoscopic Heller myotomy starting July 2017 at two pediatric surgery centers within a single metropolitan healthcare system. A retrospective review of 8 patients undergoing Heller myotomies between July 2014 and July 2017 was performed as a control. This cohort was compared to 14 patients managed post-ERP implementation (2017-2020). Outcomes of interest investigated included opioid use during admission, narcotics at discharge, time to regular diet, length of stay (LOS), and readmissions. RESULTS There was a significant decrease in opioid use both while in the hospital and at time of discharge. Mean morphine equivalent use was 4.50 mg in the pre-ERP cohort and 1.97 mg in the post-ERP cohort. Furthermore, 8 out of 14 (57%) patients in the post-ERP cohort received no opioids during the admission compared with only 2 out of 8 (25%) patients in the pre-ERP cohort. Only 1 out of 14 (7.14%) patients in the post-ERP cohort was discharged with a prescription for opioid medication while 6 out of 8 (75%) in the pre-ERP cohort were discharged with an opiate prescription. CONCLUSIONS The use of ERP in children undergoing laparoscopic Heller myotomy surgery is safe and effective and leads to a reduction in opioid use during admission and at discharge. LEVELS OF EVIDENCE Level III.
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Affiliation(s)
- Olivia A Keane
- Department of Surgery, Emory University School of Medicine, 1364 Clifton Road NE, Atlanta, GA 30322, United States.
| | - Goeto Dantes
- Department of Surgery, Emory University School of Medicine, 1364 Clifton Road NE, Atlanta, GA 30322, United States
| | - Srinivas Emani
- Department of Behavioral Social and Health Education Sciences, Emory University, Atlanta, GA, United States
| | - Jose M Garza
- Department of Pediatrics, Children's Healthcare of Atlanta, GI Care for Kids, Atlanta, GA, United States
| | - Kurt F Heiss
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Matthew S Clifton
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, United States
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Mohammed A, Garg R, Paranji N, Samineni AV, Thota PN, Sanaka MR. Pneumatic dilation for esophageal achalasia: patient selection and perspectives. Scand J Gastroenterol 2022:1-10. [PMID: 35114867 DOI: 10.1080/00365521.2022.2034940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 01/18/2022] [Accepted: 01/21/2022] [Indexed: 02/04/2023]
Abstract
Achalasia is an esophageal motility disorder characterized by esophageal aperistalsis and impaired relaxation of the lower esophageal sphincter. Treatment is palliative, aimed at decreasing the lower esophageal sphincter pressure. Pneumatic dilation (PD) is a safe and effective treatment for achalasia. Several other invasive and minimally invasive treatment modalities, such as Laparoscopic Heller Myotomy (LHM) and Peroral Endoscopic Myotomy (POEM), also have a comparable safety and efficacy profile to PD. The current review focuses on the indications, contraindications, techniques, and outcomes of PD in various patient populations and its comparison to LHM and POEM. This review also provides relevant information to help endoscopists identify those patients who will benefit the most from PD.
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Affiliation(s)
- Abdul Mohammed
- Department of Hospital Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Rajat Garg
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Neethi Paranji
- Department of Gastroenterology and Hepatology, MetroHealth Medical Center, Cleveland, OH, USA
| | - Aneesh V Samineni
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Prashanthi N Thota
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Madhusudhan R Sanaka
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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Evaluation of the Surgical Management of Achalasia in Children and Young Adults. J Surg Res 2022; 273:9-14. [PMID: 35007858 DOI: 10.1016/j.jss.2021.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 12/10/2021] [Accepted: 12/13/2021] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Achalasia is a rare esophageal motility disorder in children and is most often treated with the Heller myotomy. This study examines the current trends in surgical management of achalasia and evaluates the safety of the Heller myotomy in children compared to the young adult population. METHODS This is a retrospective cohort study of children and young adults aged ≤25 y undergoing a Heller myotomy for achalasia. Data were collected using the adult and pediatric National Surgical Quality Improvement Program databases from 2012 to 2018. Patient characteristics, comorbidities, and 30-d outcomes were evaluated. Operative details of interest included surgical specialty and the use of esophagogastroduodenoscopy and esophageal manometry. Outcomes included operative time, length of stay, reoperation, and other postoperative complications. RESULTS A total of 178 pediatric and 202 young adult patients were included in the study. The majority of surgeries were performed laparoscopically (85.4% pediatric and 95.0% adult). Esophageal manometry was only used in pediatric cases, and esophagogastroduodenoscopy was used in 35 (19.7%) pediatric and 41 (20.3%) adult cases. Thirty-day complications occurred in 7 (3.9%) children and 3 (1.5%) adults. The median operative time for children was 174.5 min and the median length of stay (LOS) was 2 d. The median operative time for adults was 126 min and the median LOS was 1 d (P < 0.01 for both). There was a longer LOS for cases performed by pediatric surgeons (P = 0.03). CONCLUSIONS Heller myotomy continues to be a very safe operation for achalasia with minimal short-term morbidity.
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Peng D, Tan Y, Li C, Lv L, Zhu H, Liang C, Li R, Liu D. Peroral Endoscopic Myotomy for Pediatric Achalasia: A Retrospective Analysis of 21 Cases With a Minimum Follow-Up of 5 Years. Front Pediatr 2022; 10:845103. [PMID: 35444970 PMCID: PMC9013798 DOI: 10.3389/fped.2022.845103] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 03/01/2022] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) has shown promising short-term safety and efficacy in pediatric patients, while long-term outcomes are largely unknown. This study aimed to assess the clinical effects of POEM for pediatric achalasia who had a follow-up of at least 5 years. METHODS Pediatric patients from a single center who underwent a POEM between October 2011 and November 2016 were, respectively, collected and analyzed for long-term clinical outcomes. Patients were contacted to evaluate their current symptoms and encouraged repeat endoscopy and manometry. The clinical success, procedure-related parameters, adverse events, gastroesophageal reflux disease after POEM, and quality of life were evaluated. RESULTS A total of twenty-four patients who underwent POEM in our center were studied, with a mean age of 14.42 ± 2.65. Two of the 24 patients (8.3%) had previous treatment. The mean of the procedure time was 58.67 ± 19.10 min, 8.3% (2/24) of patients experienced perioperative adverse events. The current symptom scores were obtained from 21 patients at a mean follow-up of 92.57 months, the remainder were lost to follow-up after a mean of 38 months. Eckardt scores were significantly improved from preoperative baseline (preoperative 7.67 ± 1.62 vs. current 0.86 ± 1.28, P < 0.001). Long-term overall success was achieved in 95.8% of patients and none required retreatment for symptoms. 12.5% of patients were suffered from clinical reflux. 76.2% of patients expressed satisfaction with POEM. No severe adverse events were observed during the operation and the 5-years follow-up. CONCLUSION POEM resulted in successful symptomatic mitigation in a majority of pediatric patients after 5 years. A multi-center large-scale, prospective study is necessary for a confirmed conclusion.
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Affiliation(s)
- Dongzi Peng
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, China.,Research Center of Digestive Disease, Central South University, Changsha, China
| | - Yuyong Tan
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, China.,Research Center of Digestive Disease, Central South University, Changsha, China
| | - Chenjie Li
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, China.,Research Center of Digestive Disease, Central South University, Changsha, China
| | - Liang Lv
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, China.,Research Center of Digestive Disease, Central South University, Changsha, China
| | - Hongyi Zhu
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, China.,Research Center of Digestive Disease, Central South University, Changsha, China
| | - Chengbai Liang
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, China.,Research Center of Digestive Disease, Central South University, Changsha, China
| | - Rong Li
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, China.,Research Center of Digestive Disease, Central South University, Changsha, China
| | - Deliang Liu
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Changsha, China.,Research Center of Digestive Disease, Central South University, Changsha, China
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Nabi Z, Ramchandani M, Basha J, Goud R, Darisetty S, Reddy DN. POEM Is a Durable Treatment in Children and Adolescents With Achalasia Cardia. Front Pediatr 2022; 10:812201. [PMID: 35281245 PMCID: PMC8913929 DOI: 10.3389/fped.2022.812201] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 01/14/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND AND AIM Per-oral endoscopic myotomy (POEM) is emerging as an effective treatment for pediatric achalasia. There are limited data on the long-term efficacy of POEM in children and adolescents with achalasia. In this study, we aim to evaluate the outcomes of POEM at ≥4 years follow-up. METHOD The data of consecutive children who underwent POEM (September 2013-July 2021) and completed at least 4 years follow-up were analyzed retrospectively. The primary outcome was clinical success (Eckardt ≤ 3) at ≥4 years follow-up. The secondary outcomes included the prevalence of gastroesophageal reflux disease (GERD) and predictors of recurrent symptoms (Eckardt ≥2) after POEM. RESULTS A total of 69 children underwent POEM for achalasia during the study period. Of these, 41 (59.4%) children completed ≥4 years [mean 68.5 months (range 48-94)] follow-up, and 38 were included in the final analysis. The subtypes of achalasia included type I (28.9%), type II (60.5%), and type III (2.6%). There was a history of prior treatment in 11 children (28.9%). Clinical success was recorded in 36 (94.7%) patients who successfully underwent POEM. Recurrent symptoms (Eckardt ≥ 2) were noticed in 12 (31.6%) children at ≥4 years. On multivariate analysis, there were no identifiable factors which predicted recurrent symptoms after POEM. Symptomatic GERD and erosive esophagitis were detected in 13.8% (4/29) and 57.1% (8/14) of the children, respectively. CONCLUSION POEM is a durable treatment modality for achalasia in the pediatric population irrespective of the sub-type of achalasia and history of prior treatment.
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Affiliation(s)
- Zaheer Nabi
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Mohan Ramchandani
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Jahangeer Basha
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Rajesh Goud
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Santosh Darisetty
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
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Miller J, Khlevner J, Rodriguez L. Upper Gastrointestinal Functional and Motility Disorders in Children. Pediatr Clin North Am 2021; 68:1237-1253. [PMID: 34736587 DOI: 10.1016/j.pcl.2021.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Children with disorders affecting the sensory and motor functions of the esophagus will present primarily with swallowing dysfunction, dysphagia, and chest pain, and those with disorders affecting the normal function of the stomach will present with symptoms like abdominal pain, nausea, and vomiting. Recent advances in the mechanisms of disease and technology have increased our understanding of gastrointestinal physiology and that knowledge has been applied to develop new diagnostic studies and therapeutic interventions. We present an overview of the clinical presentation, diagnosis, and treatment of common primary and secondary functional and motility disorders affecting the upper gastrointestinal tract in children.
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Affiliation(s)
- Jonathan Miller
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, 3959 Braodway CHN7, New York, NY 10032, USA
| | - Julie Khlevner
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, 3959 Braodway CHN7, New York, NY 10032, USA
| | - Leonel Rodriguez
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Yale New Haven Children's Hospital, Yale University School of Medicine, 333 Cedar Street, LMP 4093, New Haven, CT 06510, USA.
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Achalasia in Children-Clinical Presentation, Diagnosis, Long-Term Treatment Outcomes, and Quality of Life. J Clin Med 2021; 10:jcm10173917. [PMID: 34501361 PMCID: PMC8432175 DOI: 10.3390/jcm10173917] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 08/24/2021] [Accepted: 08/25/2021] [Indexed: 12/12/2022] Open
Abstract
Background: In spite of the introduction of peroral endoscopic myotomy (POEM), Heller myotomy (HM) remains the mainstay of treatment and the role of pneumatic dilatation (PD) is being debated. The aim of this study was to present a single-center experience in the diagnostic approach and treatment of esophageal achalasia (EA), including the long-term assessment of the QoL. Methods: Data collection was based on the retrospective analysis of clinical notes and prospective interviews with patients and their parents. Results: The study group consisted of 60 patients with EA (F: 26, M: 34), with a median age of 12.0 (1–17) years at diagnosis. The time from the first symptoms until the diagnosis was 1.0 year (0.5–2.0) and the most common were: regurgitation (91.3%), dysphagia (84.8%), and chest pain (47.8%). The diagnostic approach showed a high sensitivity for barium X-ray follow through, esophageal manometry, and endoscopy. Overall, a long-term good outcome of HM was achieved in 27 out of 37 patients (73%) and it was negatively affected by the time between the first symptoms and the diagnosis. Out of the 16 patients who underwent PD before HM, a good outcome was achieved in 14 patients (87.5%), compared to 13 out of 21 patients (62%) who only underwent HM (p = 0.22). Concomitant fundoplication was routinely performed, and 18% required post-operative endoscopic dilatation. At the end of the 12.1 (0.7–26.6)-year follow up, most patients had a good QoL, which significantly corresponded with the treatment outcomes. Conclusions: Patients suspected of EA should undergo a thorough clinical evaluation including a manometry, a barium X-ray, and an endoscopy. HM is a safe and effective treatment for achalasia and the outcome is not worsened by a preceding endoscopic PD. In most patients, HM alleviates symptoms, although an impaired QoL is common in long-term follow ups.
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Multicenter Evaluation of Clinical Efficacy and Safety of Per-oral Endoscopic Myotomy in Children. J Pediatr Gastroenterol Nutr 2019; 69:523-527. [PMID: 31259787 DOI: 10.1097/mpg.0000000000002432] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Per-oral endoscopic myotomy (POEM) is a recommended treatment modality for achalasia, but there is little published data for its use in children. The objective of the present study was to evaluate whether POEM is clinically effective and safe for children. METHODS International multicenter retrospective study conducted in 14 tertiary centers that included consecutive children who underwent POEM between January 2012 and August 2018. Outcomes, such as clinical response were assessed whenever available. Adverse events and factors associated with clinical failure were also investigated. RESULTS A total of 117 patients (mean ± SD age: 14.2 ± 3.7 years) underwent POEM for achalasia (type I, n = 36; type II n=66; type III, n=8). Among these, 30 (26%) were pretreated (botulinum injection and/or pneumatic dilatation). Mean ± SD baseline Eckardt score was 7.5 ± 2.0. Clinical success was achieved in 90.6% of cases (95%CI [83.8%;95.2%]) in the intention-to-treat analysis. The mean ± SD Eckardt score post-POEM was 0.9 ± 1.2 (P < 0.001). The mean duration of follow-up time 545 days (range: 100-1612). A total of 7 adverse events occurred (4 mucosotomies, 2 subcutaneous emphysema, 1 esopleural fistula). Gastroesophageal reflux symptoms were seen in 17 patients (15%); missing data for 10 patients (9%). There was a trend towards more frequent clinical failure in achalasia associated with genetic disorders (40% vs 8%, P = 0.069). CONCLUSIONS POEM in pediatric patients appears to be effective and safe, although there was a trend towards more frequent clinical failure achalasia associated with genetic disorders. Further studies are needed to assess the long-term outcomes, especially the consequences of GERD.
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Abstract
Purpose of the review Gastroesophageal reflux disease (GERD) is frequently implicated as a cause for respiratory disease. However, there is growing evidence that upper gastrointestinal dysmotility may play a significantly larger role in genesis of respiratory symptoms and development of underlying pulmonary pathology. This paper will discuss the differential diagnosis for esophageal and gastric dysmotility in aerodigestive patients and will review the key diagnostic and therapeutic interventions for this dysmotility. Recent findings Previous studies have shown an association between GERD and pulmonary pathology in children with aerodigestive disorders. Recent publications have demonstrated the presence of esophageal and gastric dysfunction, using fluoroscopic and nuclear medicine studies, in aerodigestive patients who commonly present to pulmonary and otolaryngology clinics. High-resolution impedance manometry (HRIM) has revolutionized our understanding of esophageal dysmotility and its role in pathogenesis of aspiration and esophageal dysfunction and subsequent respiratory compromise. Summary Esophageal and gastric dysmotility have a profound effect on development of respiratory symptoms and pulmonary sequalae in aerodigestive patients. However, our understanding of the pathophysiology is in its infancy. Prospective studies in are needed to address key clinical questions such as: What degree of dysmotility initiates respiratory compromise? What diagnostic tests and therapeutic options best predict aerodigestive outcomes?
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Abstract
OBJECTIVES Pediatric achalasia is a rare neurodegenerative disorder of the esophagus that requires treatment. Different diagnostic and treatment modalities are available, but there are no data that show how children can best be diagnosed and treated. We aimed to identify current practices regarding the diagnostic and therapeutic approach toward children with achalasia. METHODS Information on the current practice regarding the management of pediatric achalasia was collected by an online-based survey sent to members of the European and North American Societies for Pediatric Gastroenterology Hepatology and Nutrition involved in pediatric achalasia care. RESULTS The survey was completed by 38 centers from 24 countries. Within these centers, 108 children were diagnosed with achalasia in the last year (median 2, range 0-15). Achalasia was primarily managed by a pediatric gastroenterologist (76%) and involved a multidisciplinary team in 84% of centers, also including a surgeon (87%), radiologist (61%), dietician (37%), speech pathologist (8%), and psychologist (5%). Medical history taking and physical examination were considered most important to establish the diagnosis (50%), followed by (a combination of) manometry (45%) or contrast swallow (21%). Treatment of first choice was Heller myotomy (58%), followed by pneumatic dilation (46%) and peroral endoscopic myotomy (29%). CONCLUSION This study shows a great heterogeneity in the management of pediatric achalasia amongst different centers worldwide. These findings stress the need for well-designed intervention trials in children with achalasia. Given the rarity of this disease, we recommend that achalasia care should be managed in centers with access to appropriate diagnostic and treatment modalities.
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Patel PA, Minhas K, Ang J, Stuart S, De Coppi P, Gnannt R. Non-vascular interventional radiology in the paediatric alimentary tract. Eur J Radiol 2019; 112:72-81. [PMID: 30777223 DOI: 10.1016/j.ejrad.2018.12.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 12/03/2018] [Accepted: 12/12/2018] [Indexed: 11/17/2022]
Abstract
Paediatric interventional radiology is an evolving speciality which is able to offer numerous minimally invasive treatments for gastrointestinal tract pathologies. Here we describe interventions performed by paediatric interventional radiologists on the alimentary tract from the mouth to the rectum. The interventions include sclerotherapy, stricture management by dilation, stenting and adjunctive therapies such as Mitomycin C administration and enteral access for feeding, motility assessment and administration of enemas.
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Affiliation(s)
- Premal A Patel
- Interventional Radiology, Radiology Department, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JH, United Kingdom.
| | - Kishore Minhas
- Interventional Radiology, Radiology Department, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JH, United Kingdom
| | - Jestine Ang
- Interventional Radiology, Radiology Department, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JH, United Kingdom
| | - Sam Stuart
- Interventional Radiology, Radiology Department, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JH, United Kingdom
| | - Paolo De Coppi
- Specialist Neonatal and Paediatric Surgery Department, Great Ormond Street Hospital, Great Ormond Street, London, WC1N 3JH, United Kingdom
| | - Ralph Gnannt
- Bilddiagnostik, Paediatric Interventional Radiology, University Children's Hospital, Steinwiesstrasse 75, CH-8032, Zürich, Switzerland
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Clinical factors and high-resolution manometry predicting response to surgery for achalasia in children. J Surg Res 2018; 229:345-350. [PMID: 29937012 DOI: 10.1016/j.jss.2018.04.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 04/05/2018] [Accepted: 04/13/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND Esophageal achalasia is an uncommon condition in children. Although many interventions exist for the management of this disorder, esophageal (Heller) myotomy offers one of the most durable treatments. Our institution sought to review patients undergoing Heller myotomy concentrating on preoperative clinical factors that might predict postoperative outcomes. MATERIALS AND METHODS All patients from January 1, 2007, to December 31, 2016, who underwent surgical treatment for achalasia at our tertiary pediatric hospital were identified and included in the study cohort. Electronic medical records for these patients were reviewed for clinical presentation variables, nonsurgical preoperative treatment, surgical approach, clinical response to surgery, need for postoperative treatment for ongoing symptoms, and high-resolution manometry (HRM) data. RESULTS Twenty-six patients were included in the study, and all underwent myotomy with partial fundoplication (median age: 14.4 y [interquartile range 11.6-15.5]). At a median follow-up of 9.75 mo (interquartile range 3.5-21 mo), 16 (61.5%) patients reported good resolution of their dysphagia symptoms with surgery alone. Two patients (7.7%) had perforation of the gastrointestinal tract requiring surgical intervention. Eight patients (30.8%) required additional treatment for achalasia, with 5 (19.2%) of these undergoing additional surgery or endoscopic treatment. Patients who had preoperative dilation did not have good resolution of their dysphagia (n = 2; P = 0.037). Two of four patients undergoing postoperative dilation had preoperative dilation. None of these patients underwent preoperative manometry. There was a statistically significant difference in the ages of patients who required postoperative intervention and those who did not (14.1 versus 15.2 y old, respectively; P = 0.043). In patients who reported improvement of gastroesophageal reflux disease/reflux type symptoms after Heller myotomy, lower esophageal residual pressure (29.1 versus 18.7 mmHg; P = 0.018) on preoperative HRM was significantly higher than in those who did not report improvement after surgery. Higher upper esophageal mean pressure (66.6 versus 47.8 mmHg; P = 0.05) also predicted good gastroesophageal reflux disease/reflux symptom response in a similar manner. CONCLUSIONS Current analysis suggests that preoperative dilation should be used cautiously and older patients may have a better response to surgery without need for postoperative treatment. In addition, preoperative HRM can aid in counseling patients in the risk of ongoing symptoms after surgery and may aid in determining if a fundoplication should be completed at the index procedure. Further research is needed to delineate these factors. LEVEL OF EVIDENCE Level III.
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van Lennep M, van Wijk MP, Omari TIM, Benninga MA, Singendonk MMJ. Clinical management of pediatric achalasia. Expert Rev Gastroenterol Hepatol 2018; 12:391-404. [PMID: 29439587 DOI: 10.1080/17474124.2018.1441023] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Achalasia is a rare esophageal motility disorder. Much of the literature is based on the adult population. In adults, guidance of therapeutic approach by manometric findings has led to improvement in patient outcome. Promising results have been achieved with novel therapies such as PerOral Endoscopic Myotomy (POEM). Areas covered: In this review, we provide an overview of the novel diagnostic and therapeutic tools for achalasia management and in what way they will relate to the future management of pediatric achalasia. We performed a PubMed and EMBASE search of English literature on achalasia using the keywords 'children', 'achalasia', 'pneumatic dilation', 'myotomy' and 'POEM'. Cohort studies < 10 cases and studies describing patients ≥ 20 years were excluded. Data regarding patient characteristics, treatment outcome and adverse events were extracted and presented descriptively, or pooled when possible. Expert commentary: Available data report that pneumatic dilation and laparoscopic Heller's myotomy are effective in children, with certain studies suggesting lower success rates in pneumatic dilation. POEM is increasingly used in the pediatric setting with promising short-term results. Gastro-esophageal reflux disease (GERD) may occur post-achalasia intervention due to disruption of the LES and therefore requires diligent follow-up, especially in children treated with POEM.
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Affiliation(s)
- Marinde van Lennep
- a Department of Pediatric Gastroenterology and Nutrition , Emma Children's Hospital/Academic Medical Center , Amsterdam , The Netherlands
| | - Michiel P van Wijk
- b Department of Pediatric Gastroenterology , VU University Medical Center , Amsterdam , The Netherlands
| | - Taher I M Omari
- c College of Medicine and Public Health , Flinders University , Adelaide , Australia.,d Center for Neuroscience , Flinders University , Adelaide , Australia
| | - Marc A Benninga
- a Department of Pediatric Gastroenterology and Nutrition , Emma Children's Hospital/Academic Medical Center , Amsterdam , The Netherlands
| | - Maartje M J Singendonk
- a Department of Pediatric Gastroenterology and Nutrition , Emma Children's Hospital/Academic Medical Center , Amsterdam , The Netherlands
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