Advertisement

Per Oral Endoscopic Myotomy (POEM) for pediatric achalasia: Institutional experience and outcomes

Published:February 24, 2022DOI:https://doi.org/10.1016/j.jpedsurg.2022.02.017

      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

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Pediatric Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Sadowski D.C.
        • Ackah F.
        • Jiang B.
        • Svenson L.W.
        Achalasia: incidence, prevalence and survival. A population-based study.
        Neurogastroenterol Motil. 2010; 22 (Sep): e256-e261https://doi.org/10.1111/j.1365-2982.2010.01511.x
        • van Hoeij F.B.
        • Ponds F.A.
        • Smout A.J.
        • Bredenoord A.J.
        Incidence and costs of achalasia in The Netherlands.
        Neurogastroenterol Motil. 2018; 30 (Feb)https://doi.org/10.1111/nmo.13195
        • Duffield J.A.
        • Hamer P.W.
        • Heddle R.
        • Holloway R.H.
        • Myers J.C.
        • Thompson S.K.
        Incidence of achalasia in South Australia based on esophageal manometry findings.
        Clin Gastroenterol Hepatol. 2017; 15 (Mar): 360-365https://doi.org/10.1016/j.cgh.2016.05.036
        • Zaninotto G.
        • Bennett C.
        • Boeckxstaens G.
        • et al.
        The 2018 ISDE achalasia guidelines.
        Dis Esophagus. 2018; 31 (Sep 1)https://doi.org/10.1093/dote/doy071
        • Petrosyan M.
        • Khalafallah A.M.
        • Guzzetta P.C.
        • Sandler A.D.
        • Darbari A.
        • Kane T.D.
        Surgical management of esophageal achalasia: evolution of an institutional approach to minimally invasive repair.
        J Pediatr Surg. 2016; 51 (Oct): 1619-1622https://doi.org/10.1016/j.jpedsurg.2016.05.015
        • Inoue H.
        • Minami H.
        • Kobayashi Y.
        • et al.
        Peroral endoscopic myotomy (POEM) for esophageal achalasia.
        Endoscopy. 2010; 42 (Apr): 265-271https://doi.org/10.1055/s-0029-1244080
        • Dirks R.C.
        • Kohn G.P.
        • Slater B.
        • et al.
        Is peroral endoscopic myotomy (POEM) more effective than pneumatic dilation and Heller myotomy? A systematic review and meta-analysis.
        Surg Endosc. 2021; 35 (May): 1949-1962https://doi.org/10.1007/s00464-021-08353-w
        • Zhang X.C.
        • Li Q.L.
        • Xu M.D.
        • et al.
        Major perioperative adverse events of peroral endoscopic myotomy: a systematic 5-year analysis.
        Endoscopy. 2016; 48 (Nov): 967-978https://doi.org/10.1055/s-0042-110397
        • Darisetty S.
        • Nabi Z.
        • Ramchandani M.
        • Chavan R.
        • Kotla R.
        • Nageshwar Reddy D.
        Anesthesia in per-oral endoscopic myotomy: a large tertiary care centre experience.
        Indian J Gastroenterol. 2017; 36 (Jul): 305-312https://doi.org/10.1007/s12664-017-0782-0
        • Li H.
        • Peng W.
        • Huang S.
        • et al.
        The 2 years' long-term efficacy and safety of peroral endoscopic myotomy for the treatment of achalasia: a systematic review.
        J Cardiothorac Surg. 2019; 14 (Jan 3): 1https://doi.org/10.1186/s13019-018-0811-9
        • Lee Y.
        • Brar K.
        • Doumouras A.G.
        • Hong D.
        Peroral endoscopic myotomy (POEM) for the treatment of pediatric achalasia: a systematic review and meta-analysis.
        Surg Endosc. 2019; 33 (Jun): 1710-1720https://doi.org/10.1007/s00464-019-06701-5
        • Chone A.
        • Familiari P.
        • von Rahden B.
        • et al.
        Multicenter evaluation of clinical efficacy and safety of per-oral endoscopic myotomy in children.
        J Pediatr Gastroenterol Nutr. 2019; 69 (Nov): 523-527https://doi.org/10.1097/MPG.0000000000002432
        • Liu Z.
        • Wang Y.
        • Fang Y.
        • et al.
        Short-term safety and efficacy of peroral endoscopic myotomy for the treatment of achalasia in children.
        J Gastroenterol. 2020; 55 (Feb): 159-168https://doi.org/10.1007/s00535-019-01607-4
        • Nabi Z.
        • Ramchandani M.
        • Chavan R.
        • et al.
        Outcome of peroral endoscopic myotomy in children with achalasia.
        Surg Endosc. 2019; 33 (Nov): 3656-3664https://doi.org/10.1007/s00464-018-06654-1
        • Werner Y.B.
        • Hakanson B.
        • Martinek J.
        • et al.
        Endoscopic or surgical myotomy in patients with idiopathic achalasia.
        N Engl J Med. 2019; 381 (Dec 5): 2219-2229https://doi.org/10.1056/NEJMoa1905380
        • Pachl M.J.
        • Rex D.
        • Decoppi P.
        • et al.
        Paediatric laparoscopic Heller's cardiomyotomy: a single centre series.
        J Pediatr Surg. 2014; 49 (Febdiscussion 292): 289-292https://doi.org/10.1016/j.jpedsurg.2013.11.042
        • Nabi Z.
        • Ramchandani M.
        • Darisetty S.
        • Kotla R.
        • Reddy D.N.
        Impact of prior treatment on long-term outcome of peroral endoscopic myotomy in pediatric achalasia.
        J Pediatr Surg. 2020; 55 (Aug): 1552-1555https://doi.org/10.1016/j.jpedsurg.2019.07.010
        • Weche M.
        • Saad A.R.
        • Richter J.E.
        • Jacobs J.J.
        • Velanovich V.
        Revisional procedures for recurrent symptoms after heller myotomy and per-oral endoscopic myotomy.
        J Laparoendosc Adv Surg Tech A. 2020; 30 (Feb): 110-116https://doi.org/10.1089/lap.2019.0277
        • El Zein M.
        • Kumbhari V.
        • Ngamruengphong S.
        • et al.
        Learning curve for peroral endoscopic myotomy.
        Endosc Int Open. 2016; 4 (May): E577-E582https://doi.org/10.1055/s-0042-104113
        • Liu Z.
        • Zhang X.
        • Zhang W.
        • et al.
        Comprehensive evaluation of the learning curve for peroral endoscopic myotomy.
        Clin Gastroenterol Hepatol. 2018; 16 (Sepe2): 1420-1426https://doi.org/10.1016/j.cgh.2017.11.048
        • Wood L.S.
        • Chandler J.M.
        • Portelli K.E.
        • Taylor J.S.
        • Kethman W.C.
        • Wall J.K.
        Treating children with achalasia using per-oral endoscopic myotomy (POEM): twenty-one cases in review.
        J Pediatr Surg. 2020; 55 (Jun): 1006-1012https://doi.org/10.1016/j.jpedsurg.2020.02.028
        • Kurian A.A.
        • Dunst C.M.
        • Sharata A.
        • Bhayani N.H.
        • Reavis K.M.
        • Swanstrom L.L.
        Peroral endoscopic esophageal myotomy: defining the learning curve.
        Gastrointest Endosc. 2013; 77 (May): 719-725https://doi.org/10.1016/j.gie.2012.12.006
        • Bechara R.
        • Onimaru M.
        • Ikeda H.
        • Inoue H.
        Per-oral endoscopic myotomy, 1000 cases later: pearls, pitfalls, and practical considerations.
        Gastrointest Endosc. 2016; 84 (Aug): 330-338https://doi.org/10.1016/j.gie.2016.03.1469
        • Patel K.S.
        • Calixte R.
        • Modayil R.J.
        • Friedel D.
        • Brathwaite C.E.
        • Stavropoulos S.N.
        The light at the end of the tunnel: a single-operator learning curve analysis for per oral endoscopic myotomy.
        Gastrointest Endosc. 2015; 81 (May): 1181-1187https://doi.org/10.1016/j.gie.2014.10.002
        • McKay S.C.
        • Dunst C.M.
        • Sharata A.M.
        • et al.
        POEM: clinical outcomes beyond 5 years.
        Surg Endosc. 2021; (Jan 4)https://doi.org/10.1007/s00464-020-08031-3
        • Duggan E.M.
        • Nurko S.
        • Smithers C.J.
        • Rodriguez L.
        • Fox V.L.
        • Fishman S.J.
        Thoracoscopic esophagomyotomy for achalasia in the pediatric population: a retrospective cohort study.
        J Pediatr Surg. 2019; 54 (Mar): 572-576https://doi.org/10.1016/j.jpedsurg.2018.07.013
        • Goneidy A.
        • Cory-Wright J.
        • Zhu L.
        • Malakounides G.
        Surgical management of esophageal achalasia in pediatrics: a systematic review.
        Eur J Pediatr Surg. 2020; 30 (Feb): 13-20https://doi.org/10.1055/s-0039-1697958