Evaluation of Minimally Invasive Approaches to Achalasia in

Evaluation of Minimally Invasive Approaches to Achalasia in Children Ahmad AL - Raymoony , M. D. MBCHB, JBGS, JBPS, FRACS. Waseem Al mefleh , M. D. Queen Rania AL abdullah Hospital for Children - King Hussein Medical Center Royal Medical Services Amman – Jordan.

Queen Rania Aladullah Hospital for Children

Achalasia: Background p Failure of relaxation in the distal esophagus and esophagogastric junction p Uncommon in children, rare in infants p Primary neurogenic abnormality l l Lack of inhibitory innervation Progressive degeneration or loss of ganglion cells in the myenteric plexus

Achalasia: Diagnosis p Symptoms: l Regurgitation of undigested food l Poor growth l Aspiration symptoms l Dysphagia

Achalasia: Treatment p Goal is to relieve the functional obstruction in the distal esophagus and esophagogastric junction p Pharmacologic p Pneumatic dilatation p Botulinum Toxin p Surgical

Achalasia: Surgical Treatment p Heller esophagocardiomyotomy l l Transthoracic (7 th or 8 th interspace) Transabdominal (Myers et al, 1994) p Minimally invasive techniques l Laparoscopic vs. Thoracoscopic (Pellegrini et al, 1992) (Patti et al, 1998)

Achalasia: Study Purpose To evaluate the safety and efficacy of minimally invasive techniques for definitive treatment of achalasia in children.

Achalasia: Patients p six children between 2/2010 and 2/2015 p Age range from 5 to 14 years (mean 12 yrs) p Weight 23 to 65 Kg (mean 45 Kg) p Symptomatic from 6 months to 2 years

Achalasia: Patients p Dilated thoracic esophagus with classic “birds beak narrowing” at LES l All patients had upper endoscopy supporting the diagnosis of achalasia p All six children had at least one esophageal pneumatic dilatation l Recurrent symptoms in 6 to 8 weeks p None had botulinum injection

Laparoscopic Heller Myotomy (LH) Thorax Supine Abdomen 5 mm

Laparoscopic Heller Myotomy (LH) Nurse Surgeon Supine Head Assist p Five Trocars p Naso-Gastric Tube in esophagus p. Oseophago-cardio myotomy p Thall fundoplication Monitor

Laparoscopic Heller's

Achalasia: Surgical Results p Operative time 95 to 140 minutes l Mean for LH 125 minutes (n =6) p One patient had small esophageal perforation repaired primarily p No blood transfusions

Results (n = 6) p First 5 patients l N. G. tubes removed POD 1 l Oral fluids resumed on POD 1 l Oral feeds resumed on POD 2 l Discharged Home on POD 3 p Patient with esophageal perforation l Barium study performed on POD 4 l No leak l Feeds resumed and N. G. removed POD 5 l Discharged home POD 5

Achalasia: Follow-Up Results p Four patients are asymptomatic with only occasional difficulty swallowing p One with persistent dysphagia, but tolerating regular diet and gaining weight p One patient developed recurrent symptoms 6 months post-op l l Balloon Dilatation Asymptomatic 2 years out

Achalasia: Follow-Up GER p No children have GER on follow-up. contrast study p Follow-up endoscopy studies 6 mo. l l asymptomatic Normal lower Oseophagus

Conclusions p Heller myotomy using minimally invasive techniques is a safe and effective procedure p. From these results, we now favor laparoscopic Heller myotomy with a Thall fundoplication. p. Less invasive p. Superior cosmoses p. Short post operative satyr p. Less complication

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