Laparoscopic esophagomyotomy for the treatment of achalasia in children - A preliminary report of eight cases

Background: Albeit rare in children, achalasia is a disorder with severe sy mptoms that causes growth impairment. The treatment of choice in children i s the esophagomyotomy, although there are variations in the surgical approa ches available and differences of opinion regarding the inclusion of an adj unctive antireflux procedure. The recent advent of the laparoscopic approac h has had a profound impact on the treatment of achalasia in both adults an d children. Methods: In this report, we describe eight patients with severe achalasia w ho were treated by laparoscopic Heller's operation associated with a fundop lication according to either Dor's or Toupet's technique. The patients' age s ranged between 2 and 13 years. A five-port technique was used: a 10-mm po rt placed infraumbilically for the optics and four 5-mm ports. One was plac ed in the right abdominal quadrant for retraction of the left hepatic lobe, one in the left abdominal quadrant for the first operative instrument, one below the xyphoid appendix for the second operative instrument, and the la st one to introduce a 5-mm cannula laterally to the umbilicus to retract th e stomach below, A 7-8-cm laparoscopic Heller esophagomyotomy was completed , followed by an anterior Dor fundoplication in six cases and a Toupet in t wo. The longitudinal division of the anterior esophageal musculature was pe rformed with a scalpel or scissors. The myotomy was made along the stomach, extending for greater than or equal to 2-3 cm. Results: Mean operating time was 120 mine, Three complications were recorde d. There were two perforations of the gastroesophageal mucosa; the first wa s sutured in laparoscopy and the second required a second operation. The th ird complication was a case of dysphagia resolved by dismounting a fundopli cation that was too tight. At follow-up, which lasted from 6 months to 5 ye ars, the children were all free of symptoms. Conclusions: Laparoscopic Heller esophagomyotomy appears to be a complex an d difficult operation, but it is as safe and effective as laparotomy in chi ldren with achalasia, However, complications can be numerous and severe at the beginning of a surgeon's experience.