J. Gould1, R. Rentea1, S. St. Peter1 1Children’s Mercy Hospital- University Of Missouri Kansas City,Pediatric Surgery,Kansas City, MO, USA
Introduction: Achalasia is a rare neurodegenerative disorder of the esophagus characterized by dysmotility. Surgical repair consists of esophagomyotomy, often in conjunction with a reflux-reducing procedure. Given the rarity of this surgery in the pediatric population, we sought to determine which surgical techniques and studies are being performed for the surgical treatment of pediatric achalasia.
Methods: Data of surgeon workup and technique preferences treating esophageal achalasia were collected as part of a comprehensive online-based survey sent to members of the International Pediatric Endosurgery Group (IPEG).
Results: The survey was completed by 191 surgeons. Of the 191 surgeons polled, 141 perform esophagomyotomies for achalasia.The number of procedures performed per surgeon were; 1-2 (15%); 3-5 (34%); 6-10 (28%); 11-20 (15%); >20 (8%). The majority of responders approach the operation laparoscopically (90%) while robotic and open approaches were used with equal frequencies at 5% each. None of the surgeons employed peroral endoscopic myotomy. Work up prior to esophageal myotomy most frequently consisted of a diagnostic esophagram (94%) or manometry (73%). Only 60% required an EGD and few requested T cruzi studies.
No preference between circumferential, isolated anterior, or anterior and lateral division of the phrenoesophageal ligament for mobilization of the esophagus was demonstrated. Placement of anchoring sutures between the crus and esophagus after myotomy were performed equally. There was a predominant preference for hook cautery (68%) over harmonic shears (21%), ligasure (13%) and other devices (8%) for muscle division. Intraoperatively 57% had endoscopy and 50% had post operative esophagram prior to initiation of enteral feeding. Fundoplication accomplished by the Thal/Dor approach was performed most frequently (81%) followed by the Toupe (13%) and Nissen (3%). Five percent of patients did not obtain any type of fundoplication to prevent post operative GERD. Diet restrictons were provided in 76% of post-operative patients.
Conclusion: Given the relative infrequency of achalasia in the pediatric population, no established treatment protocol exists. Most existing recommendations are based on those established in the adult population. We have identified current practices as a first step in developing more standard, and ultimately more effective, treatment pathways.