Long-term results of laparoscopic treatment of esophageal achalasia in children: a multicentric survey

Paediatric achalasia - what is different?

BACKGROUND

Achalasia is a rare condition characterized by disturbed oesophageal motility. Therapeutic control of symptoms is difficult to achieve, and no curative approach is available. Laparoscopic Heller myotomy (LHM) is the treatment of choice for achalasia. We describe our experience in paediatric patients with achalasia treated at a tertiary paediatric surgery center.

METHODS

A retrospective longitudinal cohort study was conducted in paediatric patients diagnosed with achalasia in a tertiary paediatric surgery center from 2005 to 2022.

RESULTS

Sixteen patients with achalasia were selected; 13 were males (81.2%) and the mean age was 11.6(±2.16) years. The most common presentation of the disease was solid dysphagia (93.8%). Timed esophagogram was performed in 15 patients (93.8%), manometry was conducted in 12 patients (75%) and all patients were submitted to upper endoscopy. All patients were submitted to LHM with Dor fundoplicature. All patients had postoperative relief of symptoms in the immediate postoperative period. The median postoperative follow-up time was 4 (0.6-11) years. Two patients (12.5%) needed endoscopic dilatation due to relapsed symptoms. Three patients (18.8%) suffered from gastroesophageal reflux disease (GERD). No patient needed re-operation for achalasia.

CONCLUSION

LHM is safe and effective in the symptomatic relief of achalasia in paediatric patients. Nonetheless, there is no proved curative treatment for achalasia. Close follow-up is essential for disease control in the long term.

Laparoscopic Heller-Dor Is a Persistently Effective Treatment for Achalasia Even in Pediatric Patients: A 25-Year Experience at a Single Tertiary Center

BACKGROUND

 Esophageal achalasia (EA) is a rare primary motility disorder in any age group, and particularly rare in the pediatric population, with a reported incidence of 0.18 per 100,000 children a year. EA in pediatric age is currently treated in the same way as in adults, but this approach is based on only a few studies on small case series. The aim of this retrospective study was to assess the long-term outcome of the laparoscopic Heller-Dor (LHD) procedure when performed in pediatric patients with EA at our university hospital.

MATERIALS AND METHODS

 We considered children and adolescents younger than 16 years old diagnosed with EA and treated with LHD between 1996 and 2022. Clinical data were prospectively collected in an ongoing database. Symptoms were recorded and their severity was calculated using the Eckardt score. Barium swallow, esophageal manometry (conventional or high-resolution), and endoscopy were performed before and after the surgical procedure.

RESULTS

 During the study period, 40 children with a median age of 14 years (interquartile range [IQR]: 11-15) underwent LHD. At a median follow-up of 10.5 years (IQR: 4.5-13.9), a good outcome was achieved in 36/40 patients (90%). Two of the four patients whose surgical procedure failed underwent complementary pneumatic dilations successfully, thus increasing the overall success rate to 95%. A previous endoscopic treatment (in five patients) did not affect the final outcome (p = 0.49). An intraoperative mucosal lesion was detected in only one patient (2.5%) and was repaired at the time without further consequences. During the follow-up, 22 patients underwent endoscopy, and 17 had pH monitoring as well: only 2 of these patients showed reflux esophagitis at endoscopy (one of them with abnormal findings on pH monitoring), amounting to a 9.1% rate of instrumentally confirmed postoperative reflux.

CONCLUSION

 LHD is a safe and persistently effective treatment for EA in pediatric age, with a success rate comparable with what is usually obtained in adults, and better than what has been reported to date in the pediatric literature. Adding a fundoplication certainly helps ensure an optimal long-term control of any gastroesophageal reflux induced by the myotomy.

Impedance planimetry (EndoFLIP) assisted laparoscopic esophagomyotomy in pediatric population

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.

Current management of pediatric achalasia

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

Diagnosis and surgical management of children with oesophageal achalasia: A 10-year single-centre experience in Morocco

INTRODUCTION

Achalasia is a primary oesophageal motility disorder with unknown aetiology. The aim of this study was to evaluate our 10-year experience in the diagnostic process and surgical management of oesophageal achalasia (OA) in children.

METHODS

A retrospective review of all children (age: 0-15 years) treated for achalasia at the department of paediatric surgery from 2007 to 2016 was conducted. The demographics, presenting symptoms, associated diseases, diagnostic process, outcomes and complications were analysed.

RESULTS

Fourteen patients were identified, with a mean age of 5.2 years. There were eight female and six male patients. The most common symptom was chronic vomiting, in all patients (100%), followed by weight loss in 10 (71.4%), cough in 6 (42.9%), dysphagia in 5 (35.7%) and chest pain in 3 (21.4%). The mean duration of symptoms until diagnosis was 36.3 ± 29.1 months. Three patients underwent an open Heller myotomy (HM) and 11 laparoscopic HM (LHM) including three conversions. The reasons for conversion were mucosal perforation in two cases and liver bleeding in one patient. The mean operating time and the average length of postoperative stay in the patients of LHM group were, respectively, 2.0 ± 0.7 h and 4 ± 1.5 days. The mean follow-up was 43.2 months.

CONCLUSION

: The diagnosis of OA in children is based on clinical arguments and especially on the barium oesophagram findings. Laparoscopic myotomy is the most effective surgical approach in children.

Multicenter Evaluation with Eckardt Score of Laparoscopic Management with Heller Myotomy and Dor Fundoplication for Esophageal Achalasia in a Pediatric Population in Colombia

Background: Esophageal achalasia is a rare, chronic, and progressive neurodegenerative motility disorder that is characterized by a lack of relaxation of the lower esophageal sphincter. Laparoscopic Heller myotomy (LHM) is the ideal in our population. Multiple surgical and medical treatments have been raised. However, there has been a need to expand studies and generate a clear algorithm for an ideal therapeutic algorithm. Methods: Clinical record was retrospectively analyzed of patients who underwent LHM and Dor fundoplication evaluated with Eckardt score, at four Colombian medical centers between February 2008 and December 2018. Results: There were a total of 21 patients (12 males and 9 females, ages 8 months to 16 years). The time from onset of symptoms to surgery was between 5 months and 14 years. One patient had esophageal mucosa perforation, 2 patients were converted to open surgery, and 1 patient had a postoperative fistula. All patients were discharged 3 to 9 days postoperatively, at which time they tolerated normal oral feeding. During follow-up, all the patients had an improvement in nutritional status and a greater functional recovery; 4 had reflux and 1 had reflux-like symptoms. Conclusion: LHM with Dor-type fundoplication maintains the effectiveness of open surgery with low postoperative morbidity and mortality and good functional results according to Eckardt score evaluation.

Thoracoscopic esophagomyotomy for achalasia in the pediatric population: A retrospective cohort study

BACKGROUND/PURPOSE

Achalasia is an extremely rare disease in children (0.1 per 100,000 individuals). Standard treatments for this include pneumatic dilation and esophagomyotomy. Minimally invasive esophagomyotomies have increasingly been used owing to improved postoperative pain and length of stay. We describe our experience with thoracoscopic esophagomyotomy in this population.

METHODS

This is a retrospective cohort study of all patients at our institution who underwent thoracoscopic esophagomyotomy for achalasia from 1995 to 2016. We used endoscopic guidance during all procedures. No fundoplication was performed.

RESULTS

Thirty-one patients were included in this study. Thirteen patients underwent pneumatic dilations prior to their operation with a median of 3 dilations. Two patients had a mucosal injury during the case. There were no conversions to an open procedure. Median length of stay was 2 days. After the procedure, 97% of patients had initial symptom relief. Eight patients (26%) required postoperative pneumatic dilations for recurrent symptoms; there was a greater chance of this (OR 8.5) if they had a preoperative dilation. No patients required a fundoplication for reflux postoperatively.

CONCLUSIONS

Thoracoscopic esophagomyotomy is a safe and effective procedure for achalasia in the pediatric population. It should be considered as an alternative to the laparoscopic approach for these patients.

LEVEL OF EVIDENCE

IV.

Long-term outcomes of Heller's myotomy and balloon dilatation in childhood achalasia

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.

Achalasia

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.

Results of Laparoscopic Heller's Myotomy for Achalasia in Children: A Systematic Review of the Literature

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.

Comparison of peroral endoscopic myotomy and endoscopic balloon dilation for primary treatment of pediatric achalasia

BACKGROUND

Both peroral endoscopic myotomy (POEM) and endoscopic balloon dilation (EBD) are effective method for pediatric achalasia, however little is known about the comparison between them. Herein we compare the safety and efficacy of them for primary treatment of pediatric achalasia.

METHODS

We retrospectively reviewed the medical records of pediatric patients who received POEM or EBD for their primary therapy of achalasia at our hospital from January 2007 to June 2015, they were divided into the POEM group and EBD group. Demographics, and data about safety and efficacy were retrospectively collected and compared between the two groups.

RESULTS

A total of 21 patients (Female/male: 11/10, aged 6~17year-old) were enrolled, 12 of them received POEM, while the other 9 received EBD. As for the short-term efficacy, the treatment success (Eckardt score≤3) rate of POEM and EBD 3, 6 and 12months after the primary treatment were comparable (100% vs 100%, 100% vs 88.9%, 100% vs 66.7%, P>0.05). As for the medium to long-term efficacy, the treatment success rate of POEM 24 and 36months after the primary treatment was higher than that of EBD (100% vs 44.4%, 100% vs 33.3%, P<0.05). Two cases in the POEM group suffered from esophagitis, and there was no significant difference between POEM and EBD (P>0.05). No severe complications were observed during operation and periodical follow-up.

CONCLUSIONS

Short-term efficacy of POEM and EBD for primary treatment of pediatric achalasia was comparable, however POEM could result in a better intermediate and long-term efficacy. Large scale, randomized study is necessary for a confirmed conclusion.

Surgical management of esophageal achalasia: Evolution of an institutional approach to minimally invasive repair

BACKGROUND

Surgical management of esophageal achalasia (EA) in children has transitioned over the past 2 decades to predominantly involve laparoscopic Heller myotomy (LHM) or minimally invasive surgery (MIS). More recently, peroral endoscopic myotomy (POEM) has been utilized to treat achalasia in children. Since the overall experience with surgical management of EA is contingent upon disease incidence and surgeon experience, the aim of this study is to report a single institutional contemporary experience for outcomes of surgical treatment of EA by LHM and POEM, with regards to other comparable series in children.

METHODS

An IRB approved retrospective review of all patients with EA who underwent treatment by a surgical approach at a tertiary US children's hospital from 2006 to 2015. Data including demographics, operative approach, Eckardt scores pre- and postoperatively, complications, outcomes, and follow-up were analyzed.

RESULTS

A total of 33 patients underwent 35 operative procedures to treat achalasia. Of these operations; 25 patients underwent laparoscopic Heller myotomy (LHM) with Dor fundoplication; 4 patients underwent LHM alone; 2 patients underwent LHM with Thal fundoplication; 2 patients underwent primary POEM; 2 patients who had had LHM with Dor fundoplication underwent redo LHM with takedown of Dor fundoplication. Intraoperative complications included 2 mucosal perforations (6%), 1 aspiration, 1 pneumothorax (1 POEM patient). Follow ranged from 8months to 7years (8-84months). There were no deaths and no conversions to open operations. Five patients required intervention after surgical treatment of achalasia for recurrent dysphagia including 3 who underwent between 1 and 3 pneumatic dilations; and 2 who had redo LHM with takedown of Dor fundoplication with all patients achieving complete resolution of symptoms.

CONCLUSIONS

Esophageal achalasia in children occurs at a much lower incidence than in adults as documented by published series describing the surgical treatment in children. We believe the MIS surgical approach remains the standard of care for this condition in children and describe the surgical outcomes and complications for LHM, as well as, the introduction of the POEM technique in our center for treating achalasia. Our institutional experience described herein represents the largest in the "MIS era" with excellent results. We will refer to alterations in our practice that have included the use of flexible endoscopy in 100% of LHM cases and use of the endoscopic functional lumen imaging probe (EndoFLIP) in both LHM and POEM cases which we believe enables adequate Heller myotomy.

Heller Myotomy Is Superior to Balloon Dilatation or Botulinum Injection in Children with Achalasia: A Two-Center Review

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.

Early myotomy and fundoplication in achalasia in childhood: a single-centre experience for 22 years

Introduction The aim of this study was to review a single institution's experience with surgical interventions in children with achalasia and to determine treatment strategies for this rare disorder. Patients and methods This study is a retrospective analysis of 22 cases of childhood achalasia from 1991 to 2013. The patients were evaluated in terms of age, symptoms, interventions, intraoperative complications, and recurrent dysphagia. Results There were 13 boys and nine girls (7 months to 17 years old). The clinical symptoms were vomiting (68%), dysphagia (36%), wheezing (18%), coughing (13%), and weight-loss (13%). The mean duration of symptoms was 2.4 years (1 month to 6 years). A barium contrast X-ray study was performed in all of the patients. Oesophageal manometry was performed in eight patients. Six patients underwent multiple oesophageal dilatations (ED) as a first intervention. A Heller myotomy (HM) and fundoplication were performed in all the patients except two patients who recovered with dilatation. In the long term, one patient had a stricture due to the operation and had to undergo a reoperation. Of the Heller myotomy patients, one had a recurrent stricture that responded to dilatation. No other complications were present. All the patients are now asymptomatic. Conclusion Early diagnosis and prompt surgical treatment is important to prevent growth impairment in childhood achalasia cases. A Heller myotomy followed by a partial anti-reflux procedure is an effective treatment for achalasia in children. Based on our experience, it is superior to oesophageal dilatation therapy.

Laparoscopic esophagomyotomy for achalasia in children: A review

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.

Usefulness of peroral endoscopic myotomy for treating achalasia in children: experience from a single center

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.

Peroral endoscopic myotomy for treatment of achalasia in children and adolescents

BACKGROUND

Peroral endoscopic myotomy (POEM) is a novel endoscopic technique for treatment of achalasia (AC) and has shown exciting results in adults. However, little is known about the safety and efficacy of POEM in children and adolescents. Herein we report our preliminary results of POEM for children and adolescents with AC.

METHODS

POEM was performed in 9 consecutive patients with AC, whose age ranged from 10 to 17years. After submucosal injection, a submucosal tunnel was created. Endoscopic myotomy of muscle bundles was then achieved under direct vision. The mucosal entry was closed by several clips. A validated clinical symptom score (Eckardt score), LES pressure, esophageal diameters and procedure-related complications were used to evaluate the outcomes.

RESULTS

All 9 patients underwent POEM successfully. Mean operation time was 56.7minutes. Mean myotomy length was 8.3cm. Among them, 4 patients underwent circular myotomy and 5 underwent full-thickness myotomy. Symptoms remitted in all of the cases during a follow-up of 3-30months, Eckardt score was significantly reduced (preoperation vs postoperation, 7.0±1.9 vs 0.8±0.8, P<0.05). Mean LES pressure decreased from 26.8mm Hg to 9.1mm Hg. Mean diameter of esophagus was dramatically decreased (preoperation vs postoperation, 50.6±4.9mm vs 29.6±3.7mm, P<0.05). No serious complications related to POEM were encountered.

CONCLUSIONS

Our initial experience suggests that POEM is a safe and effective method for treatment of achalasia in children and adolescents. Further evaluation and long-term data are mandatory for a more confirmed conclusion.