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

Abstract

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.

Evaluation and Management of Achalasia Cardia in Children

“…[ 1 ] As a result, many children miss an early diagnosis and are managed as other conditions. [ 2 3 ] Hence, a study was conducted to understand the various manifestation of achalasia cardia in children which would help us diagnose the disease early and treat it to reduce morbidity.…”

“…[ 13 ] The mean age at surgery in our study was consistent with other pediatric studies such as Erginel et al , Lee et al , Hallal et al , Corda et al , Karnak et al , Singh et al , Smits et al , Zagory et al , and Saliakellis et al as they reported mean age at surgery of 3.34 years, 13 ± 6 years, 11 years, 12 years, 8.3 years, 3.25 ± 0.4 years, 11.4 ± 3.4 years, 11.6 ± 5 years, and 10 years, respectively. [ 2 7 14 15 16 17 18 19 20 ] There was no gender predilection in adult studies while the pediatric studies showed a male preponderance. [ 2 3 7 14 15 16 17 18 19 20 ] However, our study showed a female preponderance (9:3).…”

“…[ 2 7 14 15 16 17 18 19 20 ] There was no gender predilection in adult studies while the pediatric studies showed a male preponderance. [ 2 3 7 14 15 16 17 18 19 20 ] However, our study showed a female preponderance (9:3).…”

“…The incidence of achalasia in childhood is 0.11 per one lakh children annually. [ 1 2 ] Achalasia cardia is characterized by the degeneration of the inhibitory myenteric plexus that innervates the lower esophageal sphincter (LES) and esophageal body. [ 3 ] This leads to an imbalance in the inhibitory and excitatory neurons resulting in the failure of the LES to relax with swallowing, the absence of peristalsis of the esophageal body, and increased LES resting pressures.…”

“…Achalasia in children is often misdiagnosed as gastroesophageal reflux disease (GERD). [ 2 ] Up to 50% of children are treated with antacids or prokinetics before the diagnosis of achalasia is identified. [ 7 ] Achalasia cardia was also mismanaged as anorexia nervosa and asthma.…”