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Long-term outcomes of Heller’s myotomy and balloon dilatation in childhood achalasia

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Abstract

Achalasia is a rare esophageal motility disorder: its optimal treatment in children is still a matter of debate. Records of children treated for achalasia, over an 18-year period, were reviewed.

Forty-eight children (median age at diagnosis 10 years; range 3–17 years) were identified. Twenty-eight patients were initially treated with Heller’s myotomy (HM) and 20 with balloon dilatation (BD). At last follow-up (median 3 years; range 1–5.5 years), 43.8% (21/48) of children were symptom free. The number of asymptomatic children was significantly higher among those treated initially with HM compared to BD (HM 15/28, 53.6% BD 6/20, 30%, p < 0.05). All children who underwent BD required HM due to symptom recurrence. The median (range) total number of procedures was significantly higher in the BD group (BD 3 (1–7); HM 1 (1–5); p < 0.05) with a shorter time to the second intervention (BD 14 months, 95%CI 4–24; HM 58 months, 95%CI 38–79; p < 0.05). Of 108 procedures, esophageal perforation occurred in two children after HM (two out of 48 HM procedures in total, 4%) and one child after BD (1/60, 1.7%).

Conclusion: Less than half of children with achalasia are symptom free after initial treatment with either BD or HM. HM, however, when performed as first procedure, provided longer symptom-free period and reduced need for subsequent intervention.

What is Known:

• Balloon dilatation (BD) and Heller’s myotomy (HM) are safe and effective treatment options for achalasia.

• Controversy, however, exists regarding the most effective initial therapeutic approach.

What is New:

• HM with or without fundoplication may represent the initial therapeutic approach of choice.

• Initial BD may negatively affect the outcome of a subsequent HM.

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Abbreviations

BD:

Balloon dilatation

CI:

Confidence interval

DAS:

Discharged to adult services

EBTI:

Endoscopical botulinum toxin injection

EGD:

Esophagogastroduodenoscopy

EGJ:

Esophagogastric junction

F/U:

Follow-up

GER:

Gastro-esophageal reflux

GT:

Gastric transposition

HM:

Heller’s myotomy

HR:

Hazard ratio

LES:

Lower oesophageal sphincter

SD:

Standard deviation

Tx:

Treatment

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Authors and Affiliations

  1. Neurogastroenterology and Motility Unit, Department of Gastroenterology,, Great Ormond Street Hospital NHS Foundation Trust, London, UK

    Efstratios Saliakellis, Nikhil Thapar, Fernanda Cristofori, Keith Lindley & Osvaldo Borrelli

  2. Stem Cells and Regenerative Medicine, UCL Great Ormond Street Institute of Child Health, London, UK

    Nikhil Thapar

  3. Interventional Radiology Division, Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK

    Derek Roebuck

  4. Specialist Neonatal and Paediatric Surgery (SNAPS) Department, Great Ormond Street Hospital NHS Foundation Trust, London, UK

    Kate Cross, Edward Kiely & Joseph Curry

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  1. Efstratios Saliakellis
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Contributions

Efstratios Saliakellis contributed in designing the study; collected and organized the data for statistical analyses; analyzed and interpreted the statistical results and created the manuscript.

Nikhil Thapar contributed in designing the study and performed critical revision of the manuscript.

Derek Roebuck contributed in designing the study and performed critical revision of the manuscript.

Fernanda Cristofori contributed in designing the study, collected the data and critically reviewed the manuscript.

Kate Cross contributed in designing the study and performed critical revision of the manuscript.

Edward Kiely contributed in designing the study and performed critical revision of the manuscript.

Joseph Curry contributed in designing the study and performed critical revision of the manuscript.

Keith Lindley contributed in designing the study and performed critical revision of the manuscript.

Osvaldo Borrelli contributed in designing the study; analysed and interpreted the statistical results and created the manuscript.

Corresponding author

Correspondence to Efstratios Saliakellis.

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Funding

There was no funding received for this study.

Conflict of interest

The authors declare that they no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors. The present study was a retrospective review of case notes conducted in accordance with the ethical standards of the institutional (Great Ormond Street Hospital and Institute of Child Health, University College London) and national (NHS England) research committees (Institutional Review Board of Great Ormond Street Hospital; Registration number 13GA09).

Additional information

Communicated by Peter de Winter

Revisions received: 8 April 2017 / 24 April 2017

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Saliakellis, E., Thapar, N., Roebuck, D. et al. Long-term outcomes of Heller’s myotomy and balloon dilatation in childhood achalasia. Eur J Pediatr 176, 899–907 (2017). https://doi.org/10.1007/s00431-017-2924-x

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