A Novel Technique for the Surgical Treatment of Achalasia in Children: Evaluated with Postoperative Esophageal Manometry

Introduction: The current surgical treatment for achalasia in the pediatric population is the laparoscopic Heller myotomy with or without a fundoplication. Although medical management with serial dilations and botulism toxin injections may offer short-term benefits, surgical therapy offers definitive treatment. In this article, we propose a modified surgical technique that avoids pitfalls associated with the standard procedure and evaluated our results with postoperative manometry. Methods: Charts were reviewed for all patients having undergone the proposed surgical procedure. Seven patients underwent postoperative manometry, while 12 answered a short questionnaire. Results: While manometry showed a statistically significant reduction of lower esophageal sphincter tone, from a mean preoperative lower esophageal sphincter (LES) of 56.1 mm Hg (SD=8.88, 95% CI=50.36-61.93) to mean postoperative LES tone of 11.69 mm Hg (SD=11.69, 95% CI=3.287-20.08; P<0.0001), peristalsis was not consistently affected, although a trend toward improvement was noted. Symptoms related to dysphagia were noted in 42% of patients postoperatively but were mild, while all patients showed improved feeding tolerance and weight gain. Interestingly, patients with a postoperative LES pressure <12mm Hg were more likely to have no symptoms, although this LES pressure was arbitrarily chosen and the study was not powered to detect this outcome (chi-square 3.73, df=1; P<0.053). Conclusions: The proposed surgical technique for the treatment of achalasia in children was successful at improving feeding and weight gain and attaining normal postoperative LES tone; however, underlying esophageal dysmotility persisted.