Complications of laparoscopic treatment of esophageal achalasia in children

Complications of Laparoscopic Treatment of Esophageal Achalasia in Children By Ciro Esposito, Mario Mendoza-Sagaon, Blandine Roblot-Maigret, Giuseppe Amici, Patrice Desruelle, and Philippe Montupet Naples, Italy; Catanzaro, Italy; and Billancourt, France

Background/Purpose: The aim of this study was to evaluate the incidence and management of the complications that occurred in some children who underwent laparoscopic Heller’s esophagocardiomyotomy in the authors’ institutions. Methods: Between March 1993 and October 1998, the files of all the children with achalasia who underwent laparoscopic Heller’s esophagocardiomyotomy in a community hospital in Naples, Italy, and a private hospital in Paris, France, were reviewed. A 5-port technique was used associating Heller’s esophagocardiomyotomy to an antireflux surgical mechanism (Dor’s or Toupet’s) in all cases. Intra- and postoperative complications, as well as the postoperative outcome, were evaluated. Results: Ten laparoscopic Heller’s esophagocardiomyotomies were performed in 5 girls and 5 boys with achalasia. Age ranged between 2 and 13 years. Mean operating time

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SOPHAGEAL ACHALASIA is a rare disorder in children.1,2 For this reason, scanty information is available regarding the correct treatment of pediatric patients with this pathology. Different treatments, mainly in adolescents and adults, have been reported, such as pharmacological therapy with nifedipine and botulin toxin, pneumatic dilatation, or surgery.3 Among these, surgery appears to be the most effective treatment. Heller’s esophagocardiomyotomy, usually associated with an antireflux mechanism, is the procedure of choice. In recent years, the use of laparoscopy applied to different surgical techniques in children has been gaining popularity. Laparoscopic Heller’s esophagocardiomyotomy in children suffering from achalasia have been reported with good results.4-6 However, because of the rarity of this pathology and the consequent lack of From the Division of Pediatric Surgery, University of Naples and University of Catanzaro, Italy, and the Pediatric Surgery Unit, Hospital CCBB, Boulogne Billancourt, France. Presented at the 31st Annual Meeting of the Canadian Association of Paediatric Surgeons, Montreal, Quebec, Canada, September 23-26, 1999. Address reprint requests to Ciro Esposito, MD, PhD, Division of Pediatric Surgery, ‘‘Federico II’’ University, Naples, Via Pansini 5, 80131 Napoli, Italy. Copyright r 2000 by W.B. Saunders Company 0022-3468/00/3505-0006$03.00/0 doi:10.1053/js.2000.5942 680

was 120 minutes. Hospital stay ranged between 3 and 41 days. Complications were recorded in 3 patients: in 2 an esophageal mucosal perforation and in 1 a prolonged dysphagia. Two of these complications occurred in the last patients operated on. Follow-up varied from 6 months to 6 years. All children were free of symptoms.

Conclusions: The results show that laparoscopic Heller’s esophagocardiomyotomy in children is a feasible procedure. Assessment of mucosal integrity immediately after the myotomy must be performed. Complications can happen even if the operation is performed by expert laparoscopic surgeons. J Pediatr Surg 35:680-683. Copyright r 2000 by W.B. Saunders Company. INDEX WORDS: Esophageal achalasia, laparoscopy, Heller’s esophagocardiomyotomy.

experience of pediatric surgeons in dealing with this pathology, intra- and postoperative complications can occur.7 The purpose of this study was to evaluate the incidence and management of the complications that occurred during and after a laparoscopic Heller esophagocardiomyotomy in 10 children operated on in our 2 institutions. MATERIALS AND METHODS From March 1993 to October 1998, 5 boys and 5 girls with esophageal achalasia were operated on in 2 different institutions. The same laparoscopic Heller esophagocardiomyotomy technique was performed in all cases. Age and weight of the children ranged between 2 and 13 years and 13 to 39 kg, respectively. Symptoms included dysphagia, rumination, substernal pain, burning, nausea, and vomit. Preoperative diagnostic examinations included barium esophagogram, manometry, and endoscopy in all patients and ph-metry in six. Six children received preoperative pharmacological treatment with nifedipine for 3 weeks with poor results. None of the patients underwent pneumatic dilatation or any other pharmacological treatment before surgery.

Surgical Technique All patients were premedicated. An endotracheal tube was placed and mechanical ventilation applied. General anesthesia was maintained with halotane, whereas fentanyl was used for intraoperative analgesia and vecuronium for muscle relaxation. Electrodes for electrocardiogram and an oxymeter for continuous monitoring were placed. A nasogastric tube (12F to 14F) was used in all cases. During surgery, there was never need to use Maloney’s bougie. The patients were positioned in the same Journal of Pediatric Surgery, Vol 35, No 5 (May), 2000: pp 680-683

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fashion as for the laparoscopic antireflux surgery (supine, reverse Trendelenburg, lithotomy position). A 12-mm Hg pneumoperitoneum was created with an insufflator through a 10-mm port placed through the umbilicus according to the Hasson technique. Four more ports were placed (Fig 1) for instrumentation and retraction. The gastrohepatic ligament was divided from the lesser curve up to the diaphragm, allowing visualization of the right crus. The right and left cruses were separated from the abdominal esophagus with a blunt dissection. The phrenoesophageal ligament was divided along the anterior and left sides of the esophagus. A window was created behind the cardia, and umbilical tape was placed to retract the esophagus. A 7- to 8-cm long anterior esophagocardiomyotomy was performed. The myotomy was extended toward the stomach for at least 2 to 3 cm. The longitudinal division of the anterior esophageal musculature was performed using scissors, and a hook was attached to a bipolar electrocautery whenever possible. The integrity of the mucosa was assessed at the end of the procedure by injecting air or methylene blue through an esophageal tube. Thereafter, the 2 muscular edges of the myotomy were stretched laterally. The hiatoplasty was created with 1 stitch of nonabsorbable 2-0 suture. An anterior 180° antireflux Dor valve was performed in 7 cases, and a posterior 270° Toupet fundoplication in 3. No intraoperative manometry or endoscopy was required.

Postoperative Care After the first 24 postoperative hours the nasogastric tube was removed, and 2 hours later oral feeding was resumed. At first a liquid diet was administered, progressively followed by a solid diet over the following 48 hours.

RESULTS

Operating time varied between 90 and 150 minutes (mean, 120 minutes). No conversions were performed. Hospital stay ranged between 3 and 41 days (median, 4 days). We reported 3 complications in our series, which occurred in the first and last patients. The first was an intraoperative perforation of the mucosa at the level of

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the gastroesophageal (GE) junction while performing the myotomy. The perforation was detected during surgery and sutured laparoscopically. The second complication was a tear of the esophageal mucosa at the level of the left 2 inferior stitches of Toupet’s fundoplication. This complication was identified postoperatively through the patient’s symptoms, who presented in the postoperative 48 hours with abdominal pain, abdominal distension, fever, and dyspnea. A computerized tomography (CT) scan showed a liquid collection near the cardia. The child underwent reoperation laparoscopically on postoperative day 3. The perforation was identified by the methylene blue test and sutured. This patient received total parenteral nutrition for 3 weeks; overall hospital stay was 41 days. The third complication involved a child with severe dysphagia 1 year after the surgery. The barium upper gastrointestinal series showed a narrowed esophageal lumen at the level of the GE junction as well as a GE reflux despite Dor’s montage. The dysphagia was caused by an excessively tight wrap. This patient was lost at follow-up for 4 years, and during the fifth postoperative year he underwent reoperation using the laparotomic approach. The Dor valve was dismounted, and a Thal fundoplication was performed. The last examination of this patient took place last year, in the sixth postoperative month, when he was found to be free of symptoms. All children were evaluated postoperatively with a barium upper gastrointestinal series. An esophageal manometry was performed in 9 patients, showing a dramatic decrease in the pression of the inferior esophageal sphincter in all patients. Follow-up ranged from 6 months to 6 years. To date, all patients remain free of symptoms. DISCUSSION

Fig 1.

Position of trocars for children with esophageal achalasia.

Given the rarity of this pathology in children, reports in the medical literature regarding the treatment of esophageal achalasia in pediatric patients are scanty. Yet, adequate treatment is controversial, and little experience exists among pediatric surgeons. Pharmacological therapy is not well defined, because the use of nifedipine or botulin toxin have been studied mostly in adults.8,9 In our series, 6 children were treated pharmacologically with nifedipine for 3 weeks with a poor result. Esophagic pneumatic dilatation is another possible treatment. Although good results have been reported, this technique is associated with a high rate of recurrences and with gastroesophageal reflux disease (GERD).3,10 To date, surgical correction seems to be the treatment of choice. Reports of successful modified Heller esophagocardiomyotomy (HECM), with or without an antireflux procedure, have been reported in children.11,12 Moreover, technological progress has made this procedure possible also laparoscopically.6 Because of the lack of information regarding laparo-

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scopic HECM in children, little is known about the surgical complications and postoperative outcome. Therefore, aside from the review of the literature, a retrospective analysis of the surgical reports, videotapes, and clinical outcomes of all the patients we operated on was made to define all technical difficulties and surgical complications. First, we agree that the anterior esophagocardiomyotomy according to Heller is the surgical procedure of choice for the treatment of children with esophageal achalasia.13-15 We also agree, as most pediatric surgeons, that the addition of an antireflux mechanism is imperative to avoid the risk of secondary GERD, which is reported in 10% to 30% of cases according to different series.16,17 As to the technical details, the most dangerous step of the procedure is believed to be the anterior myotomy. Two major complications could occur here: (1) mucosal perforations and (2) incomplete myotomies can induce postoperative dysphagia.11,18 This is in part because of the tactile limitation that the laparoscopic instrumentation exerts. Mucosal perforations occur mainly in the GE junction because of the thinner muscular layer at this level, as happened in a patient of this series.19 If a perforation is well identified during surgery, it can be safety sutured laparoscopically. As to the second perforation, the last 2 distal stitches in the left side of Toupet’s valve may have created a little tear in the mucosa. Unfortunately, this complication occurred postoperatively because mucosal integrity had been verified intraoperatively. This patient underwent re-operation laparoscopically, and the perforation was sealed with detached stitches of nonabsorbable suture. Regarding the possibility of an incomplete myotomy, the advantage of the magnified laparoscopic view allows the surgeon to identify easily the longitudinal and circular muscular layers of the esophagus and stomach.12 In case of doubt, an intraesophageal fluorescent bougie or an endoscope can be inserted to examine the residual muscular fibers.20 In our series, we have assessed the mucosal integrity in all our patients by insufflating air into the esophagus through an intraesophagic tube. Postoperative outcome and long-term follow-up are fundamental to detect postoperative complications.10 A manometric examination and a barium upper gastrointes-

tinal series six months and 2 years following surgery, are essential to evaluate the results of the operation.21,22 We believe that these instrumental examinations always should be performed, even when the patients appear to be clinically well, to evaluate exactly the results of the laparoscopic procedure in this kind of pathology. In another patient of our series, a prolonged dysphagia appeared after 1 postoperative year because of an excessively tight Dor valve. This patient underwent reoperation 5 years after the laparoscopic Heller procedure. The first valve was dismounted, and a Thal antireflux mechanism was performed. Although some investigators have reported pneumatic dilatation as an alternative treatment in patients with postoperative dysphagia before attempting surgery again, this could be indicated mainly in case of incomplete myotomy rather than for a tight antireflux valve.22 This complication is a perfect example of the technical difficulty of the laparoscopy to verify the tightness of an anterior valve. Although the Dor, Toupet, and Nissen montages are the most accepted fundoplications performed with the conventional open HECM, further studies are necessary to evaluate which of these antireflux mechanisms could be better suitable for the laparoscopic approach.2,9,10 The laparoscopic Heller esophagocardiomyotomy is a feasible procedure in children with esophageal achalasia. One of the main limitations of this type of laparoscopic surgery is the surgeon’s experience. Although complications related to the laparoscopic approach and an antireflux mechanism can be expected, the intra- and postoperative complications of the laparoscopic Heller esophagocardiomyotomy in children may not be related to the surgeon’s laparoscopic experience. Therefore, it is highly recommended that a laparoscopic HECM be performed in children only after satisfactory training and experience with laparoscopic gastroesophageal reflux surgery. Assessment of mucosal integrity must be performed in all cases. Finally, a long-term follow-up, including manometric and barium upper gastrointestinal studies are essential to detect the postoperative complications that occasionally occur, even long after the initial treatment.

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