BORRELLI O.

CUCCHIARA, Salvatore

DESDRUELLE P.

ESPOSITO C.

MONTUPET P.

ROBLOT MAIGRET B.

English

Archivio della ricerca- Università di Roma La Sapienza

Laparoscopic esophagomyotomy for the treatment of achalasiain childrenA preliminary report of eight casesC. Esposito,1 S. Cucchiara,2 O. Borrelli, 2 B. Roblot-Maigret,3 P. Desruelle,3 Ph. Montupet31 Division of Pediatric Surgery, Federico II University Via Pansini 5, 80131 Naples, Italy and Magna Praecia University, Catanzoro, Italy2 Departement of Pediatrics, Federico II University Via Pansini 5, 80131 Naples, Italy3 Centre Chirurgical, Boulogne Billancourt, Frue du Laos, 75015 Paris, FranceReceived: 20 October 1998/Accepted: 19 April 1999AbstractBackground:Albeit rare in children, achalasia is a disorderwith severe symptoms that causes growth impairment. Thetreatment of choice in children is the esophagomyotomy,although there are variations in the surgical approachesavailable and differences of opinion regarding the inclusionof an adjunctive antireflux procedure. The recent advent ofthe laparoscopic approach has had a profound impact on thetreatment of achalasia in both adults and children.Methods: In this report, we describe eight patients withsevere achalasia who were treated by laparoscopic Heller’soperation associated with a fundoplication according to ei-ther Dor’s or Toupet’s technique. The patients’ ages rangedbetween 2 and 13 years. A five-port technique was used: a10-mm port placed infraumbilically for the optics and four5-mm ports. One was placed in the right abdominal quad-rant for retraction of the left hepatic lobe, one in the leftabdominal quadrant for the first operative instrument, onebelow the xyphoid appendix for the second operative in-strument, and the last one to introduce a 5-mm cannulalaterally to the umbilicus to retract the stomach below. A7–8-cm laparoscopic Heller esophagomyotomy was com-pleted, followed by an anterior Dor fundoplication in sixcases and a Toupet in two. The longitudinal division of theanterior esophageal musculature was performed with a scal-pel or scissors. The myotomy was made along the stomach,extending for$2–3 cm.Results:Mean operating time was 120 mins. Three compli-cations were recorded. There were two perforations of thegastroesophageal mucosa; the first was sutured in laparos-copy and the second required a second operation. The thirdcomplication was a case of dysphagia resolved by dis-mounting a fundoplication that was too tight. At follow-up,which lasted from 6 months to 5 years, the children were allfree of symptoms.Conclusions:Laparoscopic Heller esophagomyotomy ap-pears to be a complex and difficult operation, but it is as safeand effective as laparotomy in children with achalasia.However, complications can be numerous and severe at thebeginning of a surgeon’s experience.Key words: Esophagomyotomy — Achalasia — Children— Laparoscopy — EsophagusEsophageal achalasia is a functional disorder characterizedby impaired motility of the distal esophagus and failure ofthe lower sphincter to relax in response to swallowing. Theincidence of this pathology is about five cases per millionpeople per year, and only 5% of these are children [4, 9, 14].Pharmacological management of achalasia in children isalmost always unsuccessful, and pneumatic dilatation israrely carried out in the pediatric age group. Treatmenttherefore usually consists of surgery [3, 6, 22].The advent of minimally invasive techniques has had aprofound impact on the treatment of achalasia in adults and,recently, also in children. This report describes our prelimi-nary experience in the laparoscopic management of esoph-ageal achalasia in children. We provide an overview of thepossible complications and discuss the difficulties of thistechnique in pediatric patients.Patients and methodsBetween 1993 and 1998, eight children affected by esophageal achalasiawere treated at two different institutions and operated on by the same twosurgeons, who employed the same operative procedure. Four patients weregirls and four were boys. Their ages ranged from 2 to 13 years (median,6.3). The clinical symptoms were rumination (four cases), substernal pain(four cases), burning (four cases), nausea (three cases), vomiting (sixcases), and dysphagia for >1 year (eight cases).Preoperative diagnostic investigations included a contrast esophago-gram (eight cases), manometry (eight cases), endoscopy (eight cases), and24-h pH monitoring (four cases). In four children, pharmacological therapyCorrespondence to:C. EspositoSurg Endosc (2000) 14: 110–113DOI: 10.1007/s004640000077© Springer-Verlag New York Inc. 2000with nifedipine for 3 weeks had been unsuccessful. For all the children,treatment consisted of an esophagomyotomy according to Heller’s proce-dure via laparoscopy associated with an antireflux procedure. The patientsand their parents were informed of the possible need, in case of technicalproblems, to convert the laparoscopy to a laparotomy. All the operationswere performed under general anesthesia with orotracheal intubation. Anasogastric probe was placed before surgery to void the stomach.The patients were placed supine on the operating table in a reverseTrendelenburg position. The surgeon worked between the legs of the pa-tient, with the first aide on his left. A five-port technique was used, withone 10-mm port placed infraumbilically for the optics and four 5-mm ports.One was placed in the right abdominal quadrant for retraction of the lefthepatic lobe, one in the left abdominal quadrant for the first operativeinstrument, one below the xyphoid appendix for the second operative in-strument, and the last one to insert a 5-mm cannula laterally to the umbi-licus to retract the stomach below (Fig. 1).Pneumoperitoneum pressure during the operation was∼10–12 mmHg.The first phases of the operation were the same as those used to treatgastroesophageal reflux. The posterior part of the esophagus was dissectedto position a rubber sling around the esophagogastric junction in order toxercise a downward traction on it to allow a better vision of the anteriorpart of the esophagus. A 7–8-cm laparoscopic Heller esophagomyotomywas thus performed; the longitudinal division of the anterior esophagealmusculature was done with a scalpel or scissors (Fig. 2).The myotomy was always begun on the lower part of the lower esoph-ageal sphincter (LES), then extended to the stomach for$2–3 cm (Fig. 3).Fig. 1. Positioning of trocars for surgical treatment of esophageal achalasia.Fig. 2. The myotomy is begun with a scalpel on the anterior part of the esophageal wall.Fig. 3. The myotomy is extended 2 cm below the cardia with a sharp hook.Fig. 4. At the end of the procedure, it is important to verify the completeness of themyotomy and the integrity of the mucosa.Fig. 5. Following the myotomy, an anterior fundoplication according to the Dor technique isperformed.111Hemostasis of the muscle fibers was achieved via monopolar or bipolarcoagulation, or by the placement of clips. The integrity of the mucosa wascontrolled at the end of the operation by injecting air through an esophagealprobe and stretching the two muscular sides of the myotomy laterally (Fig.4). An anterior 180° hemi-fundoplication according to Dor’s technique wasused in six cases; a posterior 270° hemi-fundoplication according to Tou-pet’s method was used in two cases (Fig. 5). We always used nonabsorb-able sutures, and never used intraoperative manometry or endoscopy in ourseries.ResultsMean operating time was 120 mins (range, 90–150). Thenasogastric tube was removed on the 1st postoperative dayto start early semi-liquid feeding in all but two patients.Hospital stay ranged between 3 and 31 days (median, 4 d).We had three complications in our series. The first wasa perforation of the gastric mucosa at the level of the esoph-agogastric junction that was detected during the laparoscopyand immediately sutured with detached sutures.Two other complications occurred in the postoperativeperiod. One child presented with dysphagia 1 year aftersurgery; it was confirmed with a barium swallow test. Thedysphagia was due to the Dor fundoplication, which hadbecome extremely tight. The patient underwent a laparoto-my to dismount the Dor fundoplication and create a newfundoplication according to Hill; his hospital stay was 10days.The third complication was a tear in the esophagealmucosa at the level of the two inferior points of the Toupetfundoplication. On the 2nd postoperative day, this patientcomplained of abdominal pain, abdominal wall contraction,fever, and dyspnea. A CT scan showed a collection near thecardia. The patient underwent laparoscopy on the 3rd post-operative day. The perforation was identified and then su-tured. The patient was fed parenterally for 3 weeks. He wasdismissed after a 1-month hospital stay.All children were evaluated with a minimum follow-upof 6 months, which included a barium swallow and a mano-metric exam. At a maximum follow-up of 5 years, the chil-dren were all free of symptoms.DiscussionFor the treatment of children with esophageal achalasia, theesophagomyotomy is the technique of choice, since it givesbetter results than other treatments, relieving symptoms in∼90% of cases [1, 8, 13, 18]. The other therapeutic ap-proaches to treat esophageal achalasia in children—such aspneumatic dilation, which is frequently used in adult pa-tients—do not seem to give as good results in children;however, there is still insufficient experience with pneu-matic dilation in the pediatric population [11, 15, 16, 19].Medical treatment using pharmacological agents such asnifedipine or botulin toxin, often used by pediatric gastro-enterologists in the early stages of this disease, does notseem to resolve the problem definitively [9, 14, 22].If Heller’s operation is not associated with an antirefluxprocedure, 10–20% of these children develop gastroesopha-geal reflux in the postoperative period [5, 9, 14, 17]. Clini-cal data on pediatric patients operated for achalasia via lap-aroscopy are still scanty; however, on the basis of our largeexperience in the laparoscopic treatment of children withgastroesophageal reflux, our group has also adopted thelaparoscopic approach for children affected by esophagealachalasia.On the basis of our experience, we believe that the lap-aroscopic treatment of achalasia has several advantagesover the open approach. First, the magnified view and im-proved exposure of the operative field allow a more accu-rate operation with minimal operative trauma. Other impor-tant advantages include the almost total absence of traumaon the abdominal muscle walls, the mini-invasiveness of thelaparoscopic dissection of the hiatus, and the absence ofpostsurgical ileum. These benefits lead to less postoperativediscomfort than is experienced with the open approach.The technical details acquired during our experience in-dicate that a 7–8-cm myotomy is necessary to relieve thesymptoms; for this reason, in our opinion, it is important toplace a rubber sling around the junction to allow widerexposure of the anterior part of the esophagus. It is alsoimportant to perform the myotomy over the gastroesopha-geal junction along the stomach for a distance of at$2–3cm to avoid any kind of recurrence of dysphagia after sur-gery. For this reason, a lengthy follow-up period that in-cludes manometric exams and barium swallow tests is fun-damental to detect possible long-term complications, as oc-curred in one of our patients, in whom the dysphagiaappeared 1 year after the intervention [2, 7, 20, 21].The myotomy can be performed with scalpel, scissors,or hook. However, we now prefer to avoid the use of mo-nopolar coagulation near the mucosa, because it can causenecrosis of the mucosa and secondary perforation. The mostdelicate and dangerous part of the operation is the myotomyat the level of esophagogastric junction, where the musclefibers are extremely thin. Thus, the risk of damaging thegastric mucosa is high, as was seen in one of our patients. Atany rate, with adequate laparoscopic experience, it is quiteeasy to suture the perforations and complete the interventionvia laparoscopy.As for the other two complications of our series, thetoo-tight Dor fundoplication was probably due to the factthat we had fixed the anterior gastric valve onto the twodiaphragmatic pillars, which should, instead, be avoidedsince the procedure can cause postsurgical dysphagia. In-stead, it is preferable to attach the valve to the two musculardges of the myotomy. The second complication was a per-foration of the mucosa after Toupet’s procedure, whichprobably occurred during the myotomy. Unfortunately, thisincident went undetected during the operation due to thesmall size of the perforation. However, these complicationsare probably common in both laparotomy and laparoscopicprocedures. They are related to the treatment of a rare pa-thology—esophageal achalasia in children [12, 23]. For thisreason, a sound knowledge of the anatomy of the gastro-esophageal junction and extreme caution during the dissec-tion and the myotomy are necessary to avoid severe com-plications. We believe that it is necessary to include anantireflux procedure to avoid gastroesophageal reflux aftersurgery. The choice of the type of fundoplication to performdepends upon the surgeon’s personal preference; most sur-geons prefer the Dor procedure [1, 10].The laparoscopic Heller intervention is a good proce-dure to adopt for the treatment of children with esophageal112achalasia, and the laparoscopic route can now be considereda logical and modern approach for the management of thispathology. However, we believe that laparoscopic esoph-agomyotomy is a complex and difficult operation in chil-dren. The main limitation to the laparoscopic Heller-Dorprocedure is the insufficient experience in children, due tothe rarity of this pathology. For this reason, the physician’smust be experienced in the surgical treatment of gastro-esophageal reflux to perform the esophagomyotomy suc-cessfully and reduce the risk of complications for the pa-tient.References1. 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Laparoscopic esophagomyotomy for the treatment of achalasia in children - A preliminary report of eight cases

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Laparoscopic esophagomyotomy for the treatment of achalasia in children - A preliminary report of eight cases

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