EFFICACY OF THE TRANSTHORACIC MODIFIED HELLER MYOTOMY IN CHILDREN WITH ACHALASIA - A 21-YEAR EXPERIENCE

From 1974 to 1995, 19 children with achalasia of the esophagus have be en treated at our institution. Presenting symptoms included vomiting ( n = 14), dysphagia (n = 13), failure to thrive (n = 6), and odynophagi a (n = 1). Diagnosis was established by a barium swallow in 19, with e ight also undergoing esophageal manometry. Six boys and 13 girls with an average age of 10 years (range, 1.3 to 17.6) underwent a transthora cic, modified anterior Heller esophagomyotomy (HM). Five underwent a c oncomitant, modified, Belsy fundoplication (BF). Follow-up ranging fro m 6 months to 21 years (mean, 9 years) was accomplished in all 19 pati ents by both office visits and telephone interviews. Early postoperati ve follow-up showed initial swallowing difficulty in two (14%) patient s with a HM alone and in four out of five (80%) patients treated with a HM and BF. All patients (n = 5) with a HM and BF and one with a HM a lone required one esophageal dilation during the first postoperative y ear. These initial swallowing difficulties resolved in all six patient s during this first postoperative year. Late postoperative follow-up, however, indicates occasional, mild dysphagia in two out of five with an HM and BF resulting in complete relief of presenting symptoms in 17 of the 19 patients (90%). All patients rated their overall result as either excellent (68%) or good (32%) with none rating it as fair or po or. None of the 19 patients had clinical evidence of gastroesophageal reflux, although five patients had evidence of nonpathologic reflux no ted during upper gastrointestinal x-ray. Recurrent vomiting, asthma, w heezing, or esophagitis symptoms have not been reported by any patient s. No patients required reoperation, and there were no deaths or posto perative complications. Modified Heller esophagomyotomy is safe (0% mo rtality) and effective (90% relief of symptoms) in children with achal asia. A concurrent modified Belsey fundoplication results in early and late mild postoperative dysphagia that was responsive to esophageal d ilation. The transthoracic, modified Heller esophagomyotomy without a fundoplication is currently our treatment of choice for achalasia in c hildren. Copyright (C) 1997 by W.S Saunders Company.