1. 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.

2. Queen Rania Aladullah Hospital for Children

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

4. Achalasia: Diagnosis Symptoms: Regurgitation of undigested food
Poor growth
Aspiration symptoms
Dysphagia

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

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

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

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

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

10. Laparoscopic Heller Myotomy (LH)
Thorax
Supine
Abdomen
5 mm

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

12. Laparoscopic Heller's

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

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

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

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

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

20. THANK YOU