W. C. Kethman1, C. Thorson1, T. Sinclair1, W. Berquist2, S. Chao1, J. K. Wall1 1Stanford University,Division Of Pediatric Surgery,Stanford, CA, USA 2Stanford University,Division Of Pediatric Gastroenterology,Stanford, CA, USA
Introduction: Achalasia is a primary esophageal motility disorder characterized by aperistalsis of the esophagus and failed relaxation of the lower esophageal sphincter that presents rarely in childhood. Traditional surgical therapy of achalasia includes graded esophageal dilation or laparoscopic myotomy with partial fundoplication. The peroral endoscopic myotomy (POEM) procedure is an emerging treatment for achalasia in adults that is recently being introduced into pediatric surgical practice, necessitating an understanding of the challenges in training and translation of this procedure from adults to children.
Methods: This is a prospective cohort study of all children referred to Stanford University Lucile Packard Children’s Hospital with manometry-confirmed achalasia who underwent a POEM procedure. Pre- and post-operative manometry, validated Eckardt scores, intra-operative functional lumen imaging, and procedural details were collected.
Results: The study has enrolled 10 subjects to-date between 7-17 years of age (M=13.4) with the majority having Type I (N=9) versus Type II (N=1) disease. The mean pre- and post-procedure esophageal diameters were 6.16 mm (SD=1.7) and 10.5 mm (SD=1.7) (p<0.005), respectively, and the mean pre- and 1-month post-procedure Eckardt scores were 7 (SD=2.5) and 2.7 (SD=1.9) (p=0.001), respectively. The mean tunnel length was 11.7 cm (SD=0.95), the mean myotomy was 7.1 cm (SD=1.4) and the mean number of endoscopic clips placed was 8.7 (SD=1.8). The mean procedure time for the entire cohort was 137 minutes (SD=64.7) and the mean procedure times for the first three cases compared to the last most recent three cases was 203 minutes (SD=49.7) and 72 minutes (SD=15) (p=0.012), respectively.
Conclusion: The POEM procedure can be completed in children with demonstrated short term post-operative improvement in symptoms. The learning curve is similar for pediatric surgeons compared to the adult experience. The adoption of advanced endoscopic techniques by pediatric surgeons will enable development of unique intraluminal approaches to congenital anomalies and childhood diseases.
