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Howk AA, Clifton MS, Garza JM, Durham MM. Impedance planimetry (EndoFLIP) assisted laparoscopic esophagomyotomy in pediatric population. J Pediatr Surg 2022; 57:1000-1004. [PMID: 35659759 DOI: 10.1016/j.jpedsurg.2022.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/12/2022] [Accepted: 05/05/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Functional lumen imaging probe (EndoFLIP) is a diagnostic technology that assesses esophageal cross-sectional area via impedance planimetry during controlled volumetric distention. The purpose of this study is to evaluate the utility of EndoFLIP intraoperatively during laparoscopic esophagomyotomy. METHODS We performed a retrospective cohort study reviewing all patients undergoing EndoFLIP assisted laparoscopic esophagomyotomy for achalasia between January and December 2021 (n = 10). Twenty-two patients with achalasia that underwent traditional laparoscopic esophagomyotomy between July 2014 and September 2019 served as a comparison. Primary outcome evaluated was resolution of symptoms at discharge. Secondary outcomes included change in distensibility index (DI), operative time, length of stay, time to regular diet, and reinterventions. RESULTS All patients managed with EndoFLIP assistance had resolution of dysphagia and postprandial vomiting following intervention. Mean change in DI was 5.32 mm2/mmHg with a myotomy length of 3.6 cm. Operative time was shorter in the EndoFLIP cohort (97 min versus 185 min, p = <0.001). Study patients did not undergo an antireflux operation. There was no difference in length of stay or time to soft diet between groups. All patients were discharged on postoperative day 1 tolerating a mechanical soft diet. No acid suppressive medications were prescribed during the observation period. One patient required dilation for recurrent symptoms and one required reoperation for mucosal leak. CONCLUSION EndoFLIP assisted laparoscopic esophagomyotomy results in similar short-term outcomes to traditional surgical technique. EndoFLIP allows for focused myotomy length and a shorter operative time. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Amy A Howk
- Emory-Children's Pediatric Institute, Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, United States.
| | - Matthew S Clifton
- Emory-Children's Pediatric Institute, Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Jose M Garza
- Neurogastroenterology and Motility Program, Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Megan M Durham
- Emory-Children's Pediatric Institute, 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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Flokas ME, Tomani M, Agdere L, Brown B. Triple A syndrome (Allgrove syndrome): improving outcomes with a multidisciplinary approach. PEDIATRIC HEALTH MEDICINE AND THERAPEUTICS 2019; 10:99-106. [PMID: 31695556 PMCID: PMC6718240 DOI: 10.2147/phmt.s173081] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 07/11/2019] [Indexed: 12/22/2022]
Abstract
Allgrove syndrome or triple A (3A) syndrome is a multisystem disorder which classically involves the triad of esophageal achalasia, alacrima, and adrenal insufficiency due to adrenocorticotropin hormone insensitivity. It follows an autosomal recessive pattern of inheritance and is associated with mutations in the AAAS (achalasia–addisonianism–alacrima syndrome) gene. Since its first description in 1978, the knowledge on clinical and genetic characteristics has been expanding; however, the current literature is limited to case reports and case reviews. Early recognition of the syndrome is challenging, given the rarity of the condition and high phenotypic heterogeneity even among members of kin. The coordination of care for these patients requires a multidisciplinary team of specialists, including endocrinologists, neurologists, gastroenterologists, ophthalmologists, developmental specialists, dentists, geneticists, and surgeons. In this review, we aim to summarize the current recommendations for the diagnosis, management, and follow-up of patients with 3A syndrome.
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Affiliation(s)
- Myrto Eleni Flokas
- Department of Pediatrics, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Michael Tomani
- Department of Pediatrics, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Levon Agdere
- Department of Pediatrics, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Brande Brown
- Department of Pediatrics, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
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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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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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Mashkov AE, Pykchteev DA, Sigachev AV, Bobylev AV, Mayr JM. Obstructive bronchitis and recurrent pneumonia in esophageal achalasia in a child: A CARE compliant case report. Medicine (Baltimore) 2018; 97:e11016. [PMID: 29879065 PMCID: PMC5999457 DOI: 10.1097/md.0000000000011016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 05/18/2018] [Indexed: 01/14/2023] Open
Abstract
RATIONALE Esophageal achalasia is characterized by impaired relaxation of the cardia and dilation of the intrathoracic part of the esophagus. We describe the late presentation of achalasia in an 11-year old girl. PATIENT CONCERNS She suffered from recurrent pneumonia, obstructive bronchitis, and problems with swallowing solid food. Her family noted a wet pillow in the morning. DIAGNOSES This case report describes the typical symptoms of achalasia in children in order to facilitate earlier diagnosis of this rare disease. Our patient was admitted to a pediatric hospital for treatment of severe pneumonia, low-grade fever, and pancreatitis. A computed tomography (CT) scan of the thorax showed massive dilation of the esophagus and infiltration and partial atelectasis of the right lung. An upper gastrointestinal contrast study confirmed massive dilation of the esophagus and stenosis at the level of the cardia. INTERVENTIONS We performed laparoscopic Heller myotomy combined with Dor fundoplication. Bronchoscopic lavages were conducted in the pre- and postoperative period to relief obstruction of bronchi by purulent mucus secretions. OUTCOMES A further upper gastrointestinal contrast study demonstrated patency of the cardia and fast propulsive movement of contrast agent into the stomach. At follow up 2 months after the operation, the girl had gained 3 kg of body weight, and her respiratory, gastrointestinal, and swallowing symptoms had subsided. At follow-up 12 months after the operation, no recurrent symptoms of achalasia were recorded. LESSONS Late presentation of achalasia in children can mimic respiratory and gastrointestinal diseases. Laparoscopic Heller myotomy combined with Dor fundoplication is feasible and advisable in children suffering from achalasia of the cardia.
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Affiliation(s)
| | | | | | - Andrei Viktorovich Bobylev
- Department of Paediatric Surgery, University Basel Children‘s Hospital, Spitalstrasse, Basel, Switzerland
| | - Johannes Michael Mayr
- Department of Paediatric Surgery, University Basel Children‘s Hospital, Spitalstrasse, Basel, Switzerland
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Saliakellis E, Thapar N, Roebuck D, Cristofori F, Cross K, Kiely E, Curry J, Lindley K, Borrelli O. Long-term outcomes of Heller's myotomy and balloon dilatation in childhood achalasia. Eur J Pediatr 2017; 176:899-907. [PMID: 28536813 DOI: 10.1007/s00431-017-2924-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Revised: 04/24/2017] [Accepted: 05/02/2017] [Indexed: 02/08/2023]
Abstract
UNLABELLED Achalasia is a rare esophageal motility disorder: its optimal treatment in children is still a matter of debate. Records of children treated for achalasia, over an 18-year period, were reviewed.Forty-eight children (median age at diagnosis 10 years; range 3-17 years) were identified. Twenty-eight patients were initially treated with Heller's myotomy (HM) and 20 with balloon dilatation (BD). At last follow-up (median 3 years; range 1-5.5 years), 43.8% (21/48) of children were symptom free. The number of asymptomatic children was significantly higher among those treated initially with HM compared to BD (HM 15/28, 53.6% BD 6/20, 30%, p < 0.05). All children who underwent BD required HM due to symptom recurrence. The median (range) total number of procedures was significantly higher in the BD group (BD 3 (1-7); HM 1 (1-5); p < 0.05) with a shorter time to the second intervention (BD 14 months, 95%CI 4-24; HM 58 months, 95%CI 38-79; p < 0.05). Of 108 procedures, esophageal perforation occurred in two children after HM (two out of 48 HM procedures in total, 4%) and one child after BD (1/60, 1.7%). CONCLUSION Less than half of children with achalasia are symptom free after initial treatment with either BD or HM. HM, however, when performed as first procedure, provided longer symptom-free period and reduced need for subsequent intervention. What is Known: • Balloon dilatation (BD) and Heller's myotomy (HM) are safe and effective treatment options for achalasia. • Controversy, however, exists regarding the most effective initial therapeutic approach. What is New: • HM with or without fundoplication may represent the initial therapeutic approach of choice. • Initial BD may negatively affect the outcome of a subsequent HM.
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Affiliation(s)
- Efstratios Saliakellis
- Neurogastroenterology and Motility Unit, Department of Gastroenterology,, Great Ormond Street Hospital NHS Foundation Trust, London, UK.
| | - Nikhil Thapar
- Neurogastroenterology and Motility Unit, Department of Gastroenterology,, Great Ormond Street Hospital NHS Foundation Trust, London, UK.,Stem Cells and Regenerative Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Derek Roebuck
- Interventional Radiology Division, Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Fernanda Cristofori
- Neurogastroenterology and Motility Unit, Department of Gastroenterology,, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Kate Cross
- Specialist Neonatal and Paediatric Surgery (SNAPS) Department, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Edward Kiely
- Specialist Neonatal and Paediatric Surgery (SNAPS) Department, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Joseph Curry
- Specialist Neonatal and Paediatric Surgery (SNAPS) Department, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Keith Lindley
- Neurogastroenterology and Motility Unit, Department of Gastroenterology,, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Osvaldo Borrelli
- Neurogastroenterology and Motility Unit, Department of Gastroenterology,, Great Ormond Street Hospital NHS Foundation Trust, London, UK
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Abstract
Achalasia is a rare neurogenic motility disorder of the esophagus, occurring in approximately 0.11 cases per 100,000 children. The combination of problems (aperistalsis, hypertensive lower esophageal sphincter (LES), and lack of receptive LES relaxation) results in patients having symptoms of progressive dysphagia, weight loss, and regurgitation. Treatment modalities have evolved over the past few decades from balloon dilation and botulinum toxin injection to laparoscopic Heller myotomy and endoscopic myotomy. Most data on achalasia management is extrapolated to children from adult experience. This article describes understanding of the pathogenesis and discusses newer therapeutic techniques as well as controversies in management.
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Affiliation(s)
- Saleem Islam
- Division of Pediatric Surgery, University of Florida College of Medicine, 1600 SW Archer Rd, PO Box 100119, Gainesville, Florida 32610.
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8
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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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9
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Zagory JA, Golden JM, Demeter NE, Nguyen Y, Ford HR, Nguyen NX. Heller Myotomy Is Superior to Balloon Dilatation or Botulinum Injection in Children with Achalasia: A Two-Center Review. J Laparoendosc Adv Surg Tech A 2016; 26:483-7. [PMID: 27135255 DOI: 10.1089/lap.2015.0435] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Achalasia is an uncommon disorder in children. Currently, there is no consensus regarding the optimal treatment for achalasia. We investigate the effectiveness of symptom relief in patients who underwent endoscopic treatments versus Heller myotomy (HM). METHODS We conducted a retrospective review of all children (age 0-18 years) treated for achalasia at two pediatric hospitals from 2004 to 2014. Demographics, presenting symptoms, outcomes, and complications were analyzed. RESULTS Twenty-three patients (61% male) were identified with a mean age at diagnosis of 11.6 ± 5.0 years. About 47.8% of the cohort had no comorbidities. Common presenting symptoms included weight loss/failure to thrive (87.0%), emesis (69.6%), and dysphagia (69.6%). Mean time from symptom onset to diagnosis was 18 ± 18.9 months. Nine patients underwent laparoscopic HM as their primary treatment, whereas 14 received esophageal dilatation (ED) as their first-line therapy. Patients who underwent ED as their initial treatment were younger (9.92 versus 15.6 years, P = .047). Patients who underwent HM were more likely to attain symptom resolution compared to those managed with ED alone (P = .004). Of the 14 patients who underwent ED initially, 10 subsequently required HM due to persistent symptoms. None of the 4 patients who underwent ED alone achieved long-term symptom relief and, on the average, required an increased number of procedures compared to their HM counterparts (5.25 versus 2.47, P = .010). There was a trend toward increased intraoperative mucosal perforation in patients who underwent preoperative ED and botulinum injections. CONCLUSION Our data suggest that HM is superior to balloon dilatation or botulinum injection in children with achalasia. We conclude that HM should be recommended for newly diagnosed children with achalasia as a first-line therapy.
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Affiliation(s)
- Jessica A Zagory
- 1 Department of Surgery, Children's Hospital Los Angeles , Los Angeles, California
| | - Jamie M Golden
- 1 Department of Surgery, Children's Hospital Los Angeles , Los Angeles, California
| | - Natalie E Demeter
- 1 Department of Surgery, Children's Hospital Los Angeles , Los Angeles, California
| | - Yen Nguyen
- 1 Department of Surgery, Children's Hospital Los Angeles , Los Angeles, California
| | - Henri R Ford
- 1 Department of Surgery, Children's Hospital Los Angeles , Los Angeles, California
| | - Nam X Nguyen
- 1 Department of Surgery, Children's Hospital Los Angeles , Los Angeles, California.,2 Department of Surgery, Miller Children's Hospital, Long Beach Memorial Medical Center , Long Beach, California
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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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Abstract
A laparoscopic Heller myotomy with partial fundoplication is considered today in most centers in the United States and abroad the treatment of choice for patients with esophageal achalasia. Even though the operation has initially a very high success rate, dysphagia eventually recurs in some patients. In these cases, it is important to perform a careful work-up to identify the cause of the failure and to design a tailored treatment plan by either endoscopic means or revisional surgery. The best results are obtained by a team approach, in Centers where radiologists, gastroenterologists, and surgeons have experience in the diagnosis and treatment of this disease.
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12
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Tang X, Gong W, Deng Z, Zhou J, Ren Y, Zhang Q, Chen Z, Jiang B. Usefulness of peroral endoscopic myotomy for treating achalasia in children: experience from a single center. Pediatr Surg Int 2015; 31:633-8. [PMID: 25957132 DOI: 10.1007/s00383-015-3717-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/28/2015] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Achalasia is a rare esophageal motility disorder in the pediatric population. Peroral endoscopic myotomy (POEM) has been demonstrated to be effective and safe for the treatment of achalasia as a novel endoscopic technique, but data involving its utility in pediatric patients are limited. We aimed to assess the safety and efficacy of POEM for pediatric patients with achalasia. MATERIALS AND METHODS Between July 2012 and August 2014, five consecutive pediatric patients (2 female and 3 male, with a median age of 15 years) with achalasia underwent POEM in our center. Diagnosis was based on symptoms, manometry, radiology and endoscopy. Preoperative and postoperative symptoms scores, and manometry outcomes were recorded and analyzed. RESULTS Procedure was performed successfully in all patients, and the median time required for the procedure was 50 min (range 40-90 min). There were no mortalities and no serious intraoperative and postoperative complications. The median length of myotomy was 8 cm (range 6-11 cm). During a median follow-up period of 18 months, treatment success (Eckardt score ≤3) was achieved in all patients. There was a significant improvement of symptoms relief, dysphagia score and lower esophageal sphincter pressure decrease after POEM. No patient developed gastroesophageal reflux disease. CONCLUSION Our study suggests that POEM is a safe and effective technique for treating pediatric achalasia. Further studies with long-term follow-up in large-volume pediatric patients are warranted to clearly define the durability of the procedure.
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Affiliation(s)
- Xiaowei Tang
- Department of Gastroenterology, Nanfang Hospital, Southern Medical University, No. 1838, Guangzhou North Ave, Guangzhou, 510515, China
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Rai GS, Sarawagi R, Sharma S, Apte A. An infant with nasal regurgitation since birth and failure to thrive. J Clin Diagn Res 2015; 9:TD03-4. [PMID: 26023621 DOI: 10.7860/jcdr/2015/12711.5819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2014] [Accepted: 03/19/2015] [Indexed: 11/24/2022]
Abstract
The condition achalasia cardia is rare in paediatric age group, especially in infants. An 11-month-old female infant presented with complaints of oronasal regurgitation since birth and failure to thrive. Upper GI contrast study was conducted which demonstrated massive dilatation of lower 2/3(rd) of oesophagus with abrupt narrowing at lower oesophageal sphincter and positive 'bird beak sign'. On the basis of radiological findings infantile achalasia cardia was diagnosed and patient underwent modified Heller's Oesophagocardiomyotomy with anti reflux procedure. Post operatively the symptoms subsided and weight gain was noted after six month follow up. Although functional infant regurgitation and Gastro-oesophageal reflux (GER) is common in infancy, uncommon causes like achalasia cardia should also be considered as a differential when symptoms are persisting.
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Affiliation(s)
- Garjesh Singh Rai
- Associate Professor, Department of Radiodiagnosis, Peoples College of Medical Science and Research Centre Bhopal, India
| | - Radha Sarawagi
- Professor, Department of Radiodiagnosis, Peoples College of Medical Science and Research Centre Bhopal, India
| | - Sakshi Sharma
- Professor, Department of Radiodiagnosis, Peoples College of Medical Science and Research Centre Bhopal, India
| | - Ashwin Apte
- Professor, Department of Radiodiagnosis, Peoples College of Medical Science and Research Centre Bhopal, India
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14
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Abstract
Surgery has changed dramatically over the last several decades. The emergence of MIS has allowed pediatric surgeons to manage critically ill neonates, children, and adolescents with improved outcomes in pain, postoperative course, cosmesis, and return to normal activity. Procedures that were once thought to be too difficult to attempt or even contraindicated in pediatric patients in many instances are now the standard of care. New and emerging techniques, such as single-incision laparoscopy, endoscopy-assisted surgery, robotic surgery, and techniques yet to be developed, all hold and reveal the potential for even further advancement in the management of these patients. The future of MIS in pediatrics is exciting; as long as our primary focus remains centered on developing techniques that limit morbidity and maximize positive outcomes for young patients and their families, the possibilities are both promising and infinite.
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Affiliation(s)
- Hope T Jackson
- Department of Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Timothy D Kane
- Department of Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC, USA; Surgical Residency Training Program, Division of Pediatric Surgery, Department of Surgery, Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Medical Center, 111 Michigan Avenue, Northwest, Washington, DC 20010-2970, USA.
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15
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Paediatric laparoscopic Heller's cardiomyotomy: a single centre series. J Pediatr Surg 2014; 49:289-92; discussion 292. [PMID: 24528969 DOI: 10.1016/j.jpedsurg.2013.11.042] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Accepted: 11/10/2013] [Indexed: 01/18/2023]
Abstract
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.
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Abstract
Peroral endoscopic myotomy (POEM) is a new endoscopic technique for the treatment of esophageal achalasia, with excellent results in adults. Three children with classic-type achalasia (mean age 9.6 years) underwent POEM in a single center. Mean basal lower esophageal sphincter pressure and Eckard score were 34.6 mmHg and 5.3, respectively. Mean length of myotomy was 10 cm. On average, POEM was completed in 60.6 minutes. No patients experienced postoperative complications or gastroesophageal reflux disease. In the 2 patients who completed a 12-month follow-up, complete symptoms relief was documented (Eckard score 0), as well as a significant drop of the basal lower esophageal sphincter pressure.
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Esposito C, Riccipetitoni G, Chiarenza SF, Roberti A, Vella C, Alicchio F, Fava G, Escolino M, De Pascale T, Settimi A. Long-term results of laparoscopic treatment of esophageal achalasia in children: a multicentric survey. J Laparoendosc Adv Surg Tech A 2013; 23:955-9. [PMID: 24073839 DOI: 10.1089/lap.2013.0308] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND This report describes three Italian centers' experience in the treatment of children with esophageal achalasia. PATIENTS AND METHODS Between June 2000 and June 2012, 31 children (13 girls and 18 boys, with a median age of 8.4 years) affected by esophageal achalasia were treated in three different institutions with an esophagomyotomy according to Heller's procedure via laparoscopy associated with a Dor antireflux procedure. Between 2000 and 2005 (for 14 patients) we used mono- or bipolar coagulation to perform myotomy; after 2005 (for 17 patients) we used the new hemostatic devices to perform it. RESULTS Median length of surgery was 120 minutes. Median hospital stay was 4 days. We recorded eight complications in our series: 3 patients (9.6%) had a mucosal perforation, and 5 children (16.1%) presented dysphagia after surgery. When comparing the data before and after 2005, it seems that the new hemostatic devices statistically shortened the length of surgery (P<.01, Student's t test). CONCLUSIONS On the basis of our experience, laparoscopic Heller's myotomy associated with an antireflux procedure is a safe and effective method for the treatment of achalasia in the pediatric population. Intraoperative complications were <10%, and they occurred mostly at the beginning of our experience. Residual dysphagia occurred in about 16% of cases. The use of the new hemostatic devices seems to reduce the length of surgery and intraoperative bleeding. Considering the rarity of this pathology, we believe that patients with achalasia have to be treated only at centers with a strong experience in the treatment of this pathology.
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Affiliation(s)
- Ciro Esposito
- 1 Department of Pediatrics, "Federico II" University of Naples , Naples, Italy
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Torab FC, Hamchou M, Ionescu G, Al-Salem AH. Familial achalasia in children. Pediatr Surg Int 2012; 28:1229-33. [PMID: 23076455 DOI: 10.1007/s00383-012-3186-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/01/2012] [Indexed: 12/22/2022]
Abstract
Achalasia is rare in the pediatric age group and in most cases it is idiopathic with no family history. Familial achalasia is very rare. This report describes two families with achalasia: in one, six children were affected while in the other a brother and a sister had Allgrove's syndrome (triple-A syndrome consisting of achalasia, adrenal insufficiency, and alacrima). Familial achalasia suggests that it is hereditary and may be transmitted as an autosomal recessive trait. The management of achalasia in children is still controversial. With the recent advances in minimal invasive surgery, laparoscopic Heller's myotomy is the procedure of choice in the management of achalasia in children.
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Affiliation(s)
- Fawaz Chikh Torab
- Division of Pediatric Surgery, Department of Surgery, Tawam Hospital, Al-Ain, Abu Dhabi, United Arab Emirates.
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Velhote MCP, Tannuri U, Andrade WDC, Maksoud Filho JG, Apezzato MLDP, Tannuri ACA. [Videosurgery in infancy and childhood: state of the art. Experience with 1408 procedures in the Instituto da Criança "Pedro de Alcântara"]. Rev Col Bras Cir 2012; 39:425-35. [PMID: 23174797 DOI: 10.1590/s0100-69912012000500016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2012] [Accepted: 07/27/2012] [Indexed: 11/22/2022] Open
Abstract
The videosurgery in Pediatric Surgery has a large field of applications unfortunately still underexplored. There are few services that routinely use this techinic , and Brazilian articles published are scarce. The Institute of Children's Hospital of the Faculty of Medicine, University of São Paulo, has been using for fifteen years the videosurgery which is now the first choice of treatment, among other diseases as gastroesophageal reflux, the cholecystolithiasis, the nonpalpable undescended testicles and megaesophagus. In this article we report our experience in laparoscopic pediatric surgery, acquired with 1408 surgical procedures, to present this useful method, and beneficial to a large number of situations and still underused in Pediatric Surgery.
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Esophageal achalasia 2011: pneumatic dilatation or laparoscopic myotomy? J Gastrointest Surg 2012; 16:870-3. [PMID: 21969248 DOI: 10.1007/s11605-011-1694-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Accepted: 09/13/2011] [Indexed: 01/31/2023]
Abstract
This article reviews the changes that have taken place in the treatment of patients with achalasia in the last 20 years. It compares and contrasts treatment preferences in the USA with those of Canada and Europe. It provides a critical analysis of the recent randomized trial between laparoscopic Heller myotomy and pneumatic dilatation that was carried out in several European centers. It supports the use of laparoscopic Heller myotomy as the preferred treatment for the average patient with this disease in the USA.
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Kobayashi M, Mizuno M, Sasaki A, Arisue A, Akiyama S, Wakabayashi G. Single-port laparoscopic Heller myotomy and Dor fundoplication: initial experience with a new approach for the treatment of pediatric achalasia. J Pediatr Surg 2011; 46:2200-3. [PMID: 22075359 DOI: 10.1016/j.jpedsurg.2011.07.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2011] [Revised: 07/27/2011] [Accepted: 07/27/2011] [Indexed: 01/17/2023]
Abstract
PURPOSE The aim of this report was to evaluate the safety and feasibility of single-port laparoscopic Heller myotomy and Dor fundoplication (SPLHD) as treatment of pediatric esophageal achalasia. METHODS A 9-year-old boy with a significant history of achalasia underwent SPLHD. The single-port was inserted using an umbilical incision. The falciform ligament and left liver lobe were raised using an elevating suture, providing good visualization of the operative field at the cardia. The Heller myotomy was planned to be 4 cm long, extending 1 cm onto the gastric wall. RESULTS The SPLHD was successfully accomplished without the need for any skin incisions or additional ports. Oral intake was resumed on the first postoperative day, and the length of hospital stay was 8 days. The patient had complete resolution of dysphagia and regurgitation. No complications were noted, and the patient had an excellent cosmetic result. CONCLUSIONS The SPLHD is a safe and feasible procedure for symptomatic pediatric achalasia when performed by a surgeon experienced in laparoscopic and esophageal surgery.
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Affiliation(s)
- Megumi Kobayashi
- Department of Surgery, Iwate Medical University School of Medicine, Morioka 020-8505, Japan.
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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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Logan MS, Vossoughi F, Watson CM, Amarnath R, Camps JI. A novel technique for the surgical treatment of achalasia in children: evaluated with postoperative esophageal manometry. J Laparoendosc Adv Surg Tech A 2009; 19:589-93. [PMID: 19575636 DOI: 10.1089/lap.2009.0122] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The current surgical treatment for achalasia in the pediatric population is the laparoscopic Heller myotomy with or without a fundoplication. Although medical management with serial dilations and botulism toxin injections may offer short-term benefits, surgical therapy offers definitive treatment. In this article, we propose a modified surgical technique that avoids pitfalls associated with the standard procedure and evaluated our results with postoperative manometry. METHODS Charts were reviewed for all patients having undergone the proposed surgical procedure. Seven patients underwent postoperative manometry, while 12 answered a short questionnaire. RESULTS While manometry showed a statistically significant reduction of lower esophageal sphincter tone, from a mean preoperative lower esophageal sphincter (LES) of 56.1 mm Hg (SD = 8.88, 95% CI = 50.36-61.93) to mean postoperative LES tone of 11.69 mm Hg (SD = 11.69, 95% CI = 3.287-20.08; P < 0.0001), peristalsis was not consistently affected, although a trend toward improvement was noted. Symptoms related to dysphagia were noted in 42% of patients postoperatively but were mild, while all patients showed improved feeding tolerance and weight gain. Interestingly, patients with a postoperative LES pressure <12 mm Hg were more likely to have no symptoms, although this LES pressure was arbitrarily chosen and the study was not powered to detect this outcome (chi-square = 3.73, df = 1; P < 0.053). CONCLUSIONS The proposed surgical technique for the treatment of achalasia in children was successful at improving feeding and weight gain and attaining normal postoperative LES tone; however, underlying esophageal dysmotility persisted.
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Affiliation(s)
- Melissa S Logan
- Department of Surgery, The University of Virginia, Charlottesville, VA, USA
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25
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Corda L, Pacilli M, Clarke S, Fell JM, Rawat D, Haddad M. Laparoscopic oesophageal cardiomyotomy without fundoplication in children with achalasia: a 10-year experience: a retrospective review of the results of laparoscopic oesophageal cardiomyotomy without an anti-reflux procedure in children with achalasia. Surg Endosc 2009; 24:40-4. [PMID: 19495877 DOI: 10.1007/s00464-009-0513-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2008] [Revised: 04/09/2009] [Accepted: 04/20/2009] [Indexed: 01/01/2023]
Abstract
BACKGROUND Oesophageal achalasia is a rare disorder in childhood. Common treatments in adults include oesophageal cardiomyotomy (laparoscopic or open) with fundoplication. We aimed to assess the results of laparoscopic oesophageal cardiomyotomy without fundoplication for treatment of achalasia in children. METHODS We reviewed the results of laparoscopic oesophageal cardiomyotomy between January 1998 and June 2008. Patients below the age of 18 years, who had undergone laparoscopic oesophageal cardiomyotomy without an anti-reflux procedure by a single surgeon, were identified. Data were collected from patient notes. Results are reported as median (range). RESULTS There were 20 patients (13 males and 7 females). Median age at surgery was 12 years (5-15 years) and weight was 38 kg (15-53 kg). Median duration of symptoms before surgery was 2.4 years (1.5-5 years). Duration of surgery was 96 min (60-160 min). Four patients (20%) required conversion to the open technique. In the remaining 16 children, fluids were started at a median of 7 h (6-8 h) post-operatively, and solid feeds were commenced at 22 h (20-24 h). Median length of hospital stay was 3 days (1-5 days). Median length of follow-up was 60 months (8-114 months). None of the patients had evidence of gastro-oesophageal reflux post-operatively. Five patients (25%) continued to experience dysphagia, with one of them also experiencing vomiting. Two patients were found to have oesophageal stricture and three patients were found to have oesophageal dysmotility. The remaining patients are asymptomatic. CONCLUSIONS These results suggest that laparoscopic oesophageal cardiomyotomy is a valid treatment in children with achalasia. In our experience, an adjunctive anti-reflux procedure is not required, as there was no evidence of post-operative gastro-oesophageal reflux in all patients. Oesophageal stricture and dysmotility account for residual post-operative symptoms.
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Affiliation(s)
- Larisa Corda
- Department of Paediatric Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
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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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Approach to the child who has persistent dysphagia after surgical treatment for esophageal achalasia. J Pediatr Gastroenterol Nutr 2008; 47:92-7. [PMID: 18607275 DOI: 10.1097/mpg.0b013e318148b673] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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Upadhyaya VD, Gangopadhyaya AN, Gupta DK, Sharma SP, Kumar V, Gopal SC. Esophageal achalasia of unknown etiology in infants. World J Pediatr 2008; 4:63-5. [PMID: 18402256 DOI: 10.1007/s12519-008-0013-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Robert M, Poncet G, Mion F, Boulez J. Results of laparoscopic Heller myotomy without anti-reflux procedure in achalasia. Monocentric prospective study of 106 cases. Surg Endosc 2007; 22:866-74. [PMID: 17943360 DOI: 10.1007/s00464-007-9600-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2007] [Revised: 07/31/2007] [Accepted: 08/13/2007] [Indexed: 12/12/2022]
Abstract
BACKGROUND Heller myotomy (HM) combined with an anti-reflux procedure has been shown to be effective for the treatment of achalasia, as postoperative gastro-esophageal reflux (GER) is observed in about 10% of the cases. Laparoscopy has brought an undeniable benefit in providing excellent visualisation of the gastro-esophageal junction (GEJ) without lateral and posterior dissection. Respecting the anatomical fixation of the GEJ seems to permit the performing of HM without an anti-reflux procedure, the need for which is therefore debatable. The purpose of this study was to analyse the results of this controversial procedure. METHODS A monocentric prospective study was carried out on 106 patients who underwent HM without an anti-reflux procedure. The postoperative assessment consisted of a manometry and a 24-hour pH study two months after surgery, and a yearly clinical examination for a minimum of five years. The data capture was done using a statistical analysis. RESULTS There was no mortality, one conversion to an open procedure, and four mucosal perforations. Postoperative morbidity was 2%. The average follow-up period was 55 months (range, 2 to 166), with 10 patients lost to follow-up. Good functional results were observed in 91.4% of patients at one year, and 78.6% at five years. Two months after surgery, a 9.4% prevalence of GER was detected in the pH study, and the lower esophageal sphincter pressure had significantly decreased. After a long term follow-up we observed an 11.3% global rate of GER. No repeat surgery was necessary to control postoperative GER. CONCLUSIONS Laparoscopic HM without anti-reflux procedure gives good functional results provided the anatomical fixation of the GOJ is respected.
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Affiliation(s)
- M Robert
- Department of Digestive Surgery, Edouard Herriot Hospital, Pavillon D, Pr Boulez unit, Place d'Arsonval, Lyon, France.
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Paidas C, Cowgill SM, Boyle R, Al-Saadi S, Villadolid D, Rosemurgy AS. Laparoscopic Heller myotomy with anterior fundoplication ameliorates symptoms of achalasia in pediatric patients. J Am Coll Surg 2007; 204:977-83; discussion 983-6. [PMID: 17481524 DOI: 10.1016/j.jamcollsurg.2006.12.046] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2006] [Accepted: 12/15/2006] [Indexed: 12/30/2022]
Abstract
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.
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Affiliation(s)
- Charles Paidas
- Division of Pediatric Surgery, Department of Surgery, University of South Florida College of Medicine, Tampa General Hospital, Tampa, FL 33606, USA
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Garzi A, Valla JS, Molinaro F, Amato G, Messina M. Minimally invasive surgery for achalasia: combined experience of two European centers. J Pediatr Gastroenterol Nutr 2007; 44:587-91. [PMID: 17460491 DOI: 10.1097/mpg.0b013e318032062f] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The present report summarizes 12 cases with achalasia treated with laparoscopic Heller myotomy and anterior fundoplication according to the method of Thal and Dor. PATIENTS AND METHODS From 1997 to 2005 at 2 institutions in Europe, 12 patients (7 male and 5 female, ages ranging from 3.5 to 7 years) were treated for esophageal achalasia (EA) with laparoscopic Heller myotomy and anterior fundoplication according to Thal and Dor. In 1 case a perforation of the esophageal mucosa occurred, which was promptly treated during surgery. Follow-up ranged from 18 to 60 months and included clinical examination and barium radiography of the upper digestive tract. RESULTS Postoperatively, 10 patients showed a normal weight curve and complete resolution of symptoms. All patients showed complete regression of digestive and respiratory symptoms from the first examination, with a normal oral meal intake and an improvement of weight and height parameters. One case required repeat intervention after 2 years because of persisting pain; in this case surgery revealed an insufficient myotomy. CONCLUSIONS Modified extramucosal Heller cardiomyotomy associated with 180 degree anterior antireflux plastic surgery (according to Thal and Dor's procedures) is a useful and safe procedure in the treatment of EA in pediatric patients. Our data, which are supported by long-term follow-up, also stress the relevance of anterior fundoplication in preventing postoperative gastroesophageal reflux.
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Affiliation(s)
- Alfredo Garzi
- Section of Pediatric Surgery, Department of Pediatrics, Obstetrics and Reproductive Medicine, University of Siena, Italy
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Endoskopie im Kindesalter. Monatsschr Kinderheilkd 2007. [DOI: 10.1007/s00112-007-1492-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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González López M, Maese Heredia R, Sierra Salinas C, del Río Mapelli L, Barco Gálvez A. Disfagia persistente en una niña de 9 años. An Pediatr (Barc) 2004; 60:175-6. [PMID: 14757023 DOI: 10.1016/s1695-4033(04)78240-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- M González López
- Unidad de Gastroenterología, Hepatología y Nutrición Pediátrica, Hospital Materno-Infantil de Málaga, Spain.
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Mattioli G, Esposito C, Pini Prato A, Doldo P, Castagnetti M, Barabino A, Gandullia P, Staiano AM, Settimi A, Cucchiara S, Montobbio G, Jasonni V. Results of the laparoscopic Heller-Dor procedure for pediatric esophageal achalasia. Surg Endosc 2003; 17:1650-2. [PMID: 12915969 DOI: 10.1007/s00464-002-9257-0] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2002] [Accepted: 03/27/2003] [Indexed: 10/26/2022]
Abstract
BACKGROUND Esophageal achalasia is not a frequent disorder in children and different treatments have been proposed during past decades. This study reviews the results of the laparoscopic Heller-Dor procedure performed in pediatric patients in two different surgical units. METHODS We included the patients aged <14 years with a minimum follow-up of 6 months operated on in the period 1994-2001. A single longitudinal anterior esophageal myotomy (Heller) and a 180 degrees anterior gastropexy (Dor) were laparoscopically performed. The patients were checked to detect intra- or postoperative complications and recurrence. RESULTS Twenty children were operated on. Mean follow-up was 45 months (range 6-102). Postoperative clinical score was Visick 1 in 15 cases and Visick 2 in five. CONCLUSIONS As complication and recurrence rates are very low we consider modified Heller myotomy and Dor gastropexy through a laparoscopic approach our first choice to treat esophageal achalasia in the pediatric population.
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Affiliation(s)
- G Mattioli
- Pediatric Surgery, Gaslini Research Institute, University of Genova, Largo G. Gaslini, 5, 16100 Genova, Italy.
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Patti MG, Fisichella PM, Perretta S, Galvani C, Gorodner MV, Robinson T, Way LW. Impact of minimally invasive surgery on the treatment of esophageal achalasia: a decade of change. J Am Coll Surg 2003; 196:698-703; discussion 703-5. [PMID: 12742198 DOI: 10.1016/s1072-7515(02)01837-9] [Citation(s) in RCA: 114] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Twenty years ago an average of 1.5 Heller myotomies were performed per year in our hospital, mostly for patients whose dysphagia did not improve following balloon dilatation or whose esophagus had been perforated during a balloon dilatation. Ten years ago we started using minimally invasive surgery to treat this disease. STUDY DESIGN This study measures the impact of minimally invasive surgery with regard to the following: the number of patients referred for treatment; the number of patients who came to surgery without previous treatment; and the results of surgical treatment. Between 1991 and 2001, 149 patients had minimally invasive surgery for achalasia: 25 patients (17%) had thoracoscopic Heller myotomy and 124 (84%) had laparoscopic Heller myotomy and Dor fundoplication. Of the 149 patients, 79 patients (53%) had previous treatment (56 patients [71%], balloon dilatation; 7 patients [9%], botulinum toxin injection; 16 patients [20%], both) and 70 patients (43%) had none of these treatments. Mean postoperative followup was 59 +/- 36 months. Patients were divided into two groups: group A, operated on between 1991 and 1995; and group B, operated on between 1996 and 2001. RESULTS In the past decade, the number of patients referred for surgery has increased substantially--group A, 48; group B, 101; an increasing proportion of patients were referred for surgery without previous treatment--group A, 38%; group B, 51%; and the outcomes of the operation progressively improved--group A, 87%; group B, 95%. CONCLUSIONS These data show that the high success rate of laparoscopic Heller myotomy for achalasia has brought a shift in practice; surgery has become the preferred treatment of most gastroenterologists and other referring physicians. This has followed documentation that laparoscopic treatment outperforms balloon dilatation and botulinum toxin injection.
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Affiliation(s)
- Marco G Patti
- Department of Surgery, University of California, San Francisco, CA 94143, USA
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36
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Abstract
Reoperative esophageal surgery can be a very challenging endeavor. Preoperative evaluation, planning and preparation are essential to optimize results. A general reoperative approach and the range of reconstructive options are outlined. Management of specific problems is discussed including stricture, recurrent gastroesophageal reflux, recurrent tracheoesophageal fistula, esophageal interposition, and recurrent achalasia.
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Affiliation(s)
- Craig W Lillehei
- Department of Surgery, Children's Hospital Boston, 300 Longwood Avenue, Boston, MA 02115, USA
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37
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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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38
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Abstract
Refinements continue in the measurement, display, and interpretation of pressure events that serve as signatures of esophageal motor disorders, and esophageal manometry retains its position as the diagnostic gold standard. The focus of attention remains with achalasia, not because of pathophysiologic developments or changing prevalence, but in response to the growing interest in minimally invasive surgery and its success. Some controversy remains regarding the role of preoperative motility assessments in patients undergoing antireflux surgery, as peristaltic features do not solely predict outcome. The disconnect between motor dysfunction and symptoms continues to promote careful consideration of sensory dysfunction as a component of esophageal motor disorders.
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Affiliation(s)
- Chandra Prakash
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri 63110, USA
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