Background: Albeit rare in children, achalasia is a disorder
with severe symptoms that causes growth impairment. The
treatment of choice in children is the esophagomyotomy,
although there are variations in the surgical approaches
available and differences of opinion regarding the inclusion
of an adjunctive antireflux procedure. The recent advent of
the laparoscopic approach has had a profound impact on the
treatment of achalasia in both adults and children.
Methods: In this report, we describe eight patients with
severe achalasia who were treated by laparoscopic Heller’s
operation associated with a fundoplication according to either
Dor’s or Toupet’s technique. The patients’ ages ranged
between 2 and 13 years. A five-port technique was used: a
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 left hepatic lobe, one in the left
abdominal quadrant for the first operative instrument, one
below the xyphoid appendix for the second operative instrument,
and the last one to introduce a 5-mm cannula
laterally to the umbilicus to retract the stomach below. A
7–8-cm laparoscopic Heller esophagomyotomy was completed,
followed by an anterior Dor fundoplication in six
cases and a Toupet in two. The longitudinal division of the
anterior esophageal musculature was performed with a scalpel
or scissors. The myotomy was made along the stomach,
extending for $2–3 cm.
Results: Mean operating time was 120 mins. Three complications
were recorded. There were two perforations of the
gastroesophageal mucosa; the first was sutured in laparoscopy
and the second required a second operation. The third
complication was a case of dysphagia resolved by dismounting
a fundoplication that was too tight. At follow-up,
which lasted from 6 months to 5 years, the children were all
free of symptoms.
Conclusions: Laparoscopic Heller esophagomyotomy appears
to be a complex and difficult operation, but it is as safe
and effective as laparotomy in children with achalasia.
However, complications can be numerous and severe at the
beginning of a surgeon’s experience
