Abstract
Background
The surgical treatment of achalasia by both laparoscopic and endoscopic approaches
has been recognized as the definitive management in children. Despite reported low
volumes in many centers, there has been an increasing worldwide experience with endoscopic
approaches to pediatric achalasia. The aim of this study is to report our institutional
experience with per oral endoscopic myotomy (POEM) as first-line or revisional therapy
for achalasia.
Methods
An IRB approved retrospective review of all patients who underwent operative procedures
for achalasia, specifically with the POEM technique, from July 2015 to September 2021.
Data including demographics, intra-operative details, pre and post operative Eckardt
scores, complications, outcomes, and follow-up were obtained.
Results
During the study period, a total of 43 children underwent 46 operations for achalasia
including POEM and laparoscopic Heller myotomy (LHM). Operations included 37 POEMS
(33 primary POEMS; 3 POEMS after failed LHM; and 1 POEM after failed POEM). Additionally,
9 LHM operations including, 4 primary LHM; 3 attempted POEMS converted to LHM; 1 attempted
POEM after failed LHM converted to redo LHM; and 1 LHM after failed POEM. In the POEM
group (n = 37), based on the high resolution esophageal manometry findings Chicago Classification
types at diagnosis were as follows: 9 patients were type I (24.3%); 25 patients were
type II (67.6%); 2 patients were type III (5.9%) and 1 patient was unknown type (2.7%).
Sixteen children (43.2%) had prior endoscopic treatment of achalasia prior to POEM
[Pneumatic Balloon Dilatation (PBD), and/or Botox injection (BTI)],), while prior
operative intervention occurred in 4 patients (10.8%), 3 LHM and 1 POEM. Age at operation
was 2–18 years (mean ± SD age: 11.6 ± 4.5 years). Weight at operation 11.8–100.7 kg
(mean ± SD kg; 39 ± 19.9 kg). Range of baseline Eckardt score was 4–10 (mean ± SD:
6.73 ± 1.5). Operative time was 64–359 min (mean ± SD minutes: 138.1 ± 62.2 min).
Intraoperative complications occurred in 16 patients (43.2%) but did not require reoperation
during index admission including: 4 mucosotomy (11.8%); 9 pneumothoraces (24.3%);
2 pneumomediastinum (5.4%); 10 pneumoperitoneum (27%); 0 sub-mucosal tunnel bleeding
(0%); 0 open conversion/death (0%). Post operative complications included: 5 recurrent
dysphagia (13.5%); 0 esophageal leak (0%); 3 GERD (8.1%); 1 failed POEM (2.7%). Median
length of stay was 2 days (mean ± SD days: 2.4 ± 0.9 day). Follow-up ranged from 1
to 74 months (median 15 months), mean follow-up 22.6 months ± 20 months. Post POEM
Eckardt score was 0.6 ± 0.9. Five patients required a single PBD post POEM (13.5%)
and 1 patient required a repeat myotomy (LHM) after POEM (2.7%) for a 16.2% reintervention
rate. Subsequent normalization of Eckardt scores (≤ 3) and symptomatic relief was
achieved in all patients (100%).
Conclusions
POEM as first-line therapy for pediatric achalasia, or as a secondary procedure after
failed prior myotomy or POEM, in our experience is safe and effective. We have shown
equivalent results to our own prior experience with LHM. Long-term follow-up will
be performed to monitor for recurrent symptoms, adequate physical growth, and general
development.
Level of evidence
II.
Keywords
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Article info
Publication history
Published online: February 24, 2022
Accepted:
February 21,
2022
Received in revised form:
January 24,
2022
Received:
October 11,
2021
Identification
Copyright
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