Complications After Heller Myotomy in Children: a National Multicenter Study on the Impact of Prior Endoscopic Dilatation and Identification of Risk Factors

Overview

Journal Surg Endosc

Publisher Springer

Specialties Gastroenterology
General Surgery
Radiology

Date 2024 May 20

PMID 38769183

Authors

Louise Montalva

Elie Farha

Erik Hervieux

Liza Ali

Veronique Rousseau

Francoise Schmitt

Audrey Guinot

Nizar Sassi

Celine Grosos

Alexis P Arnaud

Aurelien Scalabre

Remi Dubois

Arnaud Bonnard

Affiliations

Soon will be listed here.

Abstract

Background: Although esophageal achalasia has been historically treated by Heller myotomy, endoscopic esophageal dilatations are nowadays often the first-line treatment in children. The aim was to assess whether performing an endoscopic dilatation before a Heller myotomy is associated with higher risks of esophageal perforation in children.

Methods: A retrospective multicentric study was performed, including children that underwent a Heller myotomy (2000-2022, 10 centers). Two groups were compared based on the history of previous dilatation before myotomy. Outcomes esophageal perforation (intra-operative or secondary) and post-operative complications requiring surgery (Clavien-Dindo III). Statistics Comparisons using contingency tables or Kruskal-Wallis when appropriate. Statistical significance: p-value < 0.05.

Results: A Heller myotomy was performed in 77 children (median age: 11.8 years), with prior endoscopic dilatation in 53% (n = 41). A laparoscopic approach was used in 90%, with associated fundoplication in 95%. Esophageal perforation occurred in 19% of children (n = 15), including 12 patients with intra-operative mucosal tear and 3 with post-operative complications related to an unnoticed esophageal perforation. Previous endoscopic dilatation did not increase the risk of esophageal perforation (22% vs 17%, OR: 1.4, 95%CI: 0.43-4.69). Post-operative complications occurred in 8% (n = 6), with similar rates regardless of prior endoscopic dilatation. Intra-operative mucosal tear was the only risk factor for post-operative complications, increasing the risk of complications from 5 to 25% (OR: 6.89, 95%CI: 1.38-31.87).

Conclusions: Prior endoscopic dilatations did not increase the risk of esophageal perforation or postoperative complications of Heller myotomy in this cohort of children with achalasia. Mucosal tear was identified as a risk factor for post-operative complications.

References

Savarino E, Bhatia S, Roman S, Sifrim D, Tack J, Thompson S . Achalasia. Nat Rev Dis Primers. 2022; 8(1):28. DOI: 10.1038/s41572-022-00356-8. View

Islam S . Achalasia. Semin Pediatr Surg. 2017; 26(2):116-120. DOI: 10.1053/j.sempedsurg.2017.02.001. View

Payne W . Heller's contribution to the surgical treatment of achalasia of the esophagus. 1914. Ann Thorac Surg. 1989; 48(6):876-81. DOI: 10.1016/0003-4975(89)90695-4. View

Goneidy A, Cory-Wright J, Zhu L, Malakounides G . Surgical Management of Esophageal Achalasia in Pediatrics: A Systematic Review. Eur J Pediatr Surg. 2019; 30(1):13-20. DOI: 10.1055/s-0039-1697958. View

Esposito C, Amici G, Desruelle P, Montupet P . Complications of laparoscopic treatment of esophageal achalasia in children. J Pediatr Surg. 2000; 35(5):680-3. DOI: 10.1053/jpsu.2000.5942. View

Nakayama D, Shorter N, Boyle J, WATKINS J, ONEILL Jr J . Pneumatic dilatation and operative treatment of achalasia in children. J Pediatr Surg. 1987; 22(7):619-22. DOI: 10.1016/s0022-3468(87)80112-4. View

Hung Y, Westfal M, Chang D, Kelleher C . Heller myotomy is the optimal index procedure for esophageal achalasia in adolescents and young adults. Surg Endosc. 2018; 33(10):3355-3360. DOI: 10.1007/s00464-018-06625-6. View

Tashiro J, Petrosyan M, Kane T . Current management of pediatric achalasia. Transl Gastroenterol Hepatol. 2021; 6:33. PMC: 8343414. DOI: 10.21037/tgh-20-215. View

A Mencin A, Sethi A, Barakat M, Lerner D . Peroral Endoscopic Myotomy (POEM) in Children: A State of the Art Review. J Pediatr Gastroenterol Nutr. 2022; 75(3):231-236. DOI: 10.1097/MPG.0000000000003503. View

10.

van Lennep M, van Wijk M, Omari T, Benninga M, Singendonk M . Clinical management of pediatric achalasia. Expert Rev Gastroenterol Hepatol. 2018; 12(4):391-404. DOI: 10.1080/17474124.2018.1441023. View

11.

Tsuboi K, Omura N, Yano F, Hoshino M, Yamamoto S, Akimoto S . Effect of preoperative balloon dilation on treatment outcomes of laparoscopic Heller-Dor surgery for achalasia: a propensity score matched study. Surg Today. 2018; 48(12):1068-1075. DOI: 10.1007/s00595-018-1695-y. View

12.

Tsuboi K, Omura N, Yano F, Hoshino M, Yamamoto S, Akimoto S . Identification of risk factors for mucosal injury during laparoscopic Heller myotomy for achalasia. Surg Endosc. 2015; 30(2):706-714. DOI: 10.1007/s00464-015-4264-0. View

13.

Morino M, Rebecchi F, Festa V, Garrone C . Preoperative pneumatic dilatation represents a risk factor for laparoscopic Heller myotomy. Surg Endosc. 1997; 11(4):359-61. DOI: 10.1007/s004649900363. View

14.

Souma Y, Nakajima K, Taniguchi E, Takahashi T, Kurokawa Y, Yamasaki M . Mucosal perforation during laparoscopic surgery for achalasia: impact of preoperative pneumatic balloon dilation. Surg Endosc. 2016; 31(3):1427-1435. DOI: 10.1007/s00464-016-5133-1. View

15.

Eckardt V, Aignherr C, Bernhard G . Predictors of outcome in patients with achalasia treated by pneumatic dilation. Gastroenterology. 1992; 103(6):1732-8. DOI: 10.1016/0016-5085(92)91428-7. View

16.

Clavien P, Barkun J, De Oliveira M, Vauthey J, Dindo D, Schulick R . The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009; 250(2):187-96. DOI: 10.1097/SLA.0b013e3181b13ca2. View

17.

Westermann C, Weller J, Patel P, Rhee D, Garcia A . Evaluation of the Surgical Management of Achalasia in Children and Young Adults. J Surg Res. 2022; 273:9-14. DOI: 10.1016/j.jss.2021.12.004. View

18.

T Adikibi B, MacKinlay G, Munro F, Khan L, Gillett P . Intraoperative upper GI endoscopy ensures an adequate laparoscopic Heller's myotomy. J Laparoendosc Adv Surg Tech A. 2009; 19(5):687-9. DOI: 10.1089/lap.2008.0156. View

19.

Stefanidis D, Richardson W, Farrell T, Kohn G, Augenstein V, Fanelli R . SAGES guidelines for the surgical treatment of esophageal achalasia. Surg Endosc. 2011; 26(2):296-311. DOI: 10.1007/s00464-011-2017-2. View

20.

Ballouhey Q, Dib N, Binet A, Carcauzon-Couvrat V, Clermidi P, Longis B . How robotic-assisted surgery can decrease the risk of mucosal tear during Heller myotomy procedure?. J Robot Surg. 2016; 11(2):255-258. DOI: 10.1007/s11701-016-0658-9. View