Achalasia is a rare disorder of the esophagus in children. From 1971 to 1999, 20 children with achalasia of the esophagus have been treated at our institution including two patients who were referred to us after esophagomyotomy. There were 13 boys and 7 girls (average age, 8.2 years; range 2 to 15 years). Presenting symptoms were vomiting (n = 18), dysphagia (n = 11), loss of weight (n = 5), recurrent respiratory infections (n = 3), cough (n = 2) and noisy respiration (n = 1). Barium swallow established diagnosis in all patients. Esophagoscopy was used as a supportive investigation in some patients (n = 10). Nineteen patients underwent Heller-Zaiger operation (modified Heller esophagomyotomy) either by transabdominal (n = 16) or transthoracic approach (n = 3) with (n = 6) or without concomitant antireflux procedure. The postoperative period was uneventful in all patients. Follow-up ranged from 2 months to 16 years. Decreased or absent peristalsis persisted in initial control esophagograms in all patients. Gastroesophageal reflux was encountered in only one patient. Complete relief of symptoms was noted in 14 patients. Mild to moderate dysphagia was encountered in 5 patients and all of them were evaluated by endoscopy and upper gastrointestinal series. Dysphagia resolved spontaneously in one child and following two dilations in another child. One child has moderate dysphagia after a short follow-up period. Esophageal stenosis was seen in the remaining two and subsequently treated by esophagocardioplasty (Heyrowsky and Wendel operations). Achalasia should be considered in the differential diagnosis in any children with persistent dysphagia, recurrent respiratory tract infections and vomiting, including children treated for clinically suspected gastroesophageal reflux. The obvious mode of treatment is surgical myotomy in children. Modified Heller esophagomyotomy is the procedure of choice, which can be performed either by an abdominal or a thoracic approach. The need to carry out a concomitant antireflux procedure remains controversial. The most frequent postoperative problem is persistent dysphagia. It may be self-limited in some cases and disappear during follow-up. Resistant stenosis following esophagocardiomyotomy can be treated by esophagocardioplasty procedures such as Heyrowsky and Wendel operations.

The mechanism of deterioration of ipsilateral and contralateral testes during unilateral maldescent remains controversial. Proposing that alterations in tissue perfusion may play a role in ipsilateral and contralateral testicular deteriorations, an experimental study has been planned to evaluate the status of parameters of tissue hypoxia in ipsilateral and contralateral testes following surgically induced maldescent, in rats which preoperatively underwent placebo or chemical sympathectomy. 60 male albino rats were used for the experiment. At the age of 21 days each 30 rats that were treated by placebo or chemical sympathectomy agent were divided into 3 groups undergoing sham operation, abdominal fixation of one testis or abdominal fixation of both testes. At the age of 3 months the rats underwent bilateral orchidectomies and lactic acid (LA) and hypoxanthine (HX) levels were measured in testicular tissues. Maldescent of the testis resulted in a marked increase of LA and HX values in the ipsilateral testis compared to controls, and also resulted in increased levels of LA and HX in the contralateral testis. Although the levels of LA and HX were lower compared to ipsilateral undescended counterparts the levels in contralateral testis were significantly elevated compared to the contralateral testes of rats undergoing sham operation following placebo treatment. Bilateral maldescent resulted in similar elevations of LA and HX in both of the testes. Administration of 6-hydroxydopamine did not result in decreased levels of LA and HX values in the ipsilateral testis following unilateral testicular undescendence. However the LA levels in the contralateral descended testis did not reveal a significant difference compared to the contralateral testis of rats undergoing sham operation. The present experimental design reveals that abdominal fixation of the testis results in tissue hypoxia not only in the ipsilateral but also in the contralateral testis. Chemical sympathectomy has some protective effects on contralateral testicular hypoxia during unilateral maldescent. Tissue hypoxia during maldescent may result from relative inadequacy of testicular blood flow to overcome the increased metabolic demands under hyperthermic conditions.

Although deteriorating effects of unilateral spermatic cord torsion are generally accepted, the mechanism remains controversial. An experimental study was performed to evaluate the necessity of testicular and spermatogenetic material for contralateral testicular deterioration following unilateral spermatic cord torsion in rats. The animals were allocated to four groups: control, spermatic cord torsion, subepididymal orchiectomy, and spermatic cord torsion 14 days after subepididymal orchiectomy. The testes were removed on the 14th days and mean seminiferous tubular diameters and mean testicular biopsy scores were determined. Although contralateral testicular deterioration was more pronounced in the presence of testicular tissue, the absence of testicular tissue and/or spermatogenetic material did not prevent its occurrence. This is highly suggestive that autoimmune mechanism does not play a role in contralateral testicular damage following unilateral spermatic cord torsion.

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