Evaluation of minimally invasive approaches to achalasia in children

Background: Achalasia is an uncommon disease in children, but when present can result in severe disabling symptoms often requiring surgical interventi on. This report describes the authors' experience with thoracoscopic (TH) a nd later laparoscopic Heller (LH) myotomy for definitive treatment of this disease. Methods: Nine patients with achalasia were referred for surgical therapy. A ges ranged from 5 to 17 years and weight from 23 to 78 kg. All had undergon e at least one dilatation with recurrence of symptoms. The first 4 were tre ated by TH and the last five by LH. The 5 LH procedures also included a par tial fundoplication. Results: All procedures were completed successfully using minimally invasiv e techniques. Operating times averaged 95 minutes for TM and 62 minutes for LH. One patient undergoing TH had a small esophageal perforation repaired primarily. The other 3 TH patients were started on clear liquids within 1 d ay and discharged on day 2. One patient had recurrent symptoms at 6 months and underwent a LH for an incomplete TH. All 5 LH patients were discharged on postoperative day 1. One had an esophageal perforation 4 days after oper ation requiring laparoscopic repair. Seven of 9 patients are asymptomatic. Studies of pH levels in 2 asymptomatic TH patients show mild gastroesophage al reflux (GER). Conclusions: Minimally invasive Heller myotomy is a safe and effective proc edure in children. TH results in a slightly longer operating time and hospi tal stay and, without a partial fundoplication, also may be associated with a higher incidence of silent GER. From these results, we prefer LH with a Dor fundoplication for treatment of achalasia in children. J Pediatr Surg 3 6:808-810. Copyright (C) 2001 by W.B. Saunders Company.