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Complications after Heller myotomy in children: a national multicenter study on the impact of prior endoscopic dilatation and identification of risk factors

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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.

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Authors and Affiliations

  1. Department of Pediatric Surgery and Urology, AP-HP, Robert-Debré Children University Hospital, 48 Boulevard Sérurier, 75019, Paris, France

    Louise Montalva, Elie Farha, Liza Ali & Arnaud Bonnard

  2. Paris-Cité University, Paris, France

    Louise Montalva, Liza Ali & Arnaud Bonnard

  3. Department of Pediatric Surgery, Armand Trousseau University Hospital, Paris, France

    Erik Hervieux

  4. Department of Pediatric Surgery, AP-HP, Necker-Enfants Malades, Paris, France

    Véronique Rousseau

  5. Department of Pediatric Surgery, Angers University Hospital, Angers, France

    Françoise Schmitt

  6. Department of Pediatric Surgery, Hôtel-Dieu University Hospital, Nantes, France

    Audrey Guinot

  7. Department of Pediatric Surgery, Strasbourg University Hospital, Strasbourg, France

    Nizar Sassi

  8. Department of Pediatric Surgery, Limoges University Hospital, Limoges, France

    Céline Grosos

  9. Department of Pediatric Surgery, Rennes University Hospital, University of Rennes, Rennes, France

    Alexis P. Arnaud

  10. Department of Pediatric Surgery, University Hospital, Saint-Etienne, France

    Aurélien Scalabre

  11. Department of Pediatric Surgery, Hospices Civils de Lyon, Hôpital Femme Mère Enfant University Hospital, Bron, France

    Remi Dubois

Authors
  1. Louise Montalva
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Consortia

The French Society of Pediatric Surgery (SFCP)

Contributions

Conception or design of the study: Louise Montalva, Elie Farha, Erik Hervieux, Arnaud Bonnard. Acquisition of the data: Louise Montalva, Elie Farha, Erik Hervieux, Véronique Rousseau, Françoise Schmitt, Audrey Guinot, Nizar Sassi, Céline Grosos, Alexis P. Arnaud, Aurélien. Scalabre, Remi Dubois, Analysis of the data: Louise Montalva, Liza Ali, Arnaud Bonnard, Alexis P. Arnaud. Drafting the manuscript: Louise Montalva, Elie Farha. Critical revision of the manuscript: Erik Hervieux, Véronique Rousseau, Françoise Schmitt, Audrey Guinot, Nizar Sassi, Céline Grosos, Alexis P. Arnaud, Aurélien Scalabre, Remi Dubois, Arnaud Bonnard

Corresponding author

Correspondence to Louise Montalva.

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Disclosures

Drs. Louise Montalva, Elie Farha, Erik Hervieux, Liza Ali, Véronique Rousseau, Françoise Schmitt, Audrey Guinot, Nizar Sassi, Céline Grosos, Alexis P. Arnaud, Aurélien Scalabre, Remi Dubois, and Arnaud Bonnard have no conflicts of interest or financial ties to disclose.

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Montalva, L., Farha, E., Hervieux, E. et al. Complications after Heller myotomy in children: a national multicenter study on the impact of prior endoscopic dilatation and identification of risk factors. Surg Endosc (2024). https://doi.org/10.1007/s00464-024-10884-x

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