R. J. Vandewalle1, C. C. Frye1, M. P. Landman1, J. M. Croffie2, F. J. Rescorla1 1Indiana University School Of Medicine,Department Of General Surgery, Division Of Pediatric Surgery,Indianapolis, IN, USA 2Indiana University School Of Medicine,Department Of Pediatrics, Division Of Gastroenterology,Indianapolis, IN, USA
Introduction:
Esophageal achalasia is an uncommon condition in children. While many interventions exist for the management of this disorder, esophageal (Heller) myotomy offers one of the most durable treatments. We reviewed patients undergoing Heller myotomy to ascertain pre-operative clinical factors that might predict post-operative outcomes.
Methods:
All patients from 1/1/2007 to 12/31/2016 who underwent surgical treatment for achalasia at a tertiary pediatric hospital were identified and included in the study cohort. Medical records for these patients were reviewed for clinical presentation variables, pre-operative high resolution manometry (HRM) data, non-surgical pre-operative treatment, surgical approach, response to surgery, and need for post-operative treatment for ongoing symptoms.
Results:
Twenty-six patients were included in the study and all underwent myotomy with partial fundoplication [median age: 14.4 years (IQR 11.6-15.5). Twenty patients had HRM data available for review. At a median follow up of 9.75 months (IQR 3.5-21), 16 (61.5%) patients self-reported complete/near-complete resolution of their dysphagia symptoms with surgery alone. Eight patients (30.8%) required additional treatment for achalasia, with 5 (19.2%) undergoing additional operative/endoscopic interventions. Patients who had pre-operative dilation did not have self-reported complete/near-complete resolution of their dysphagia (n=2; p=0.037). There was a statistically significant association for patients with pre-operative dilation undergoing post-operative dilation (p=0.0010). None of these patients underwent pre-operative manometry. There was a statistically significant difference in the ages of patients who required post-operative treatment to improve dysphagia and those that did not (14.1 vs. 15.2 years old; p=0.043), respectively. When comparing patients who reported good response of GERD/reflux type symptoms to surgical intervention, there was a statistically significant difference in pre-operative HRM lower esophageal residual pressure (29.1 vs. 18.7mmHg; p=0.018) and upper esophageal mean pressure (66.6 vs. 47.8mmHg; p=0.050) and those that did not, respectively. 3 patients who underwent reversal of their fundoplication for ongoing dysphagia had available HRM data. There was a significant difference in distal contractile integral (4374.2 vs. 1573.5mmgHg-cm-sec; p= 0.030), upper esophageal sphincter mean residual pressure (14.3 vs. 3.8mmHg; p=0.025), and effective contractions (10% vs. 0%; p=0.010) between those that had their fundoplication reversed and those that did not, respectively.
Conclusion:
Current analysis suggests that pre-operative dilation may either indicate a higher likelihood of disease difficult to treat surgically or make achalasia difficult to treat itself. Older patients appear to have a better response to surgery. Additionally, pre-operative HRM may aid in determining if fundoplication should be completed at the time of myotomy. Further research is needed to delineate these factors.