Vandewalle Robert J, Frye Christian C, Landman Matthew P, Croffie Joseph M, Rescorla Frederick J
Division of Pediatric Surgery, Department Of General Surgery, Indiana University School of Medicine, Indianapolis, Indiana.
Division of Gastroenterology, Department Of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana.
J Surg Res. 2018 Sep;229:345-350. doi: 10.1016/j.jss.2018.04.027. Epub 2018 May 11.
Esophageal achalasia is an uncommon condition in children. Although many interventions exist for the management of this disorder, esophageal (Heller) myotomy offers one of the most durable treatments. Our institution sought to review patients undergoing Heller myotomy concentrating on preoperative clinical factors that might predict postoperative outcomes.
All patients from January 1, 2007, to December 31, 2016, who underwent surgical treatment for achalasia at our tertiary pediatric hospital were identified and included in the study cohort. Electronic medical records for these patients were reviewed for clinical presentation variables, nonsurgical preoperative treatment, surgical approach, clinical response to surgery, need for postoperative treatment for ongoing symptoms, and high-resolution manometry (HRM) data.
Twenty-six patients were included in the study, and all underwent myotomy with partial fundoplication (median age: 14.4 y [interquartile range 11.6-15.5]). At a median follow-up of 9.75 mo (interquartile range 3.5-21 mo), 16 (61.5%) patients reported good resolution of their dysphagia symptoms with surgery alone. Two patients (7.7%) had perforation of the gastrointestinal tract requiring surgical intervention. Eight patients (30.8%) required additional treatment for achalasia, with 5 (19.2%) of these undergoing additional surgery or endoscopic treatment. Patients who had preoperative dilation did not have good resolution of their dysphagia (n = 2; P = 0.037). Two of four patients undergoing postoperative dilation had preoperative dilation. None of these patients underwent preoperative manometry. There was a statistically significant difference in the ages of patients who required postoperative intervention and those who did not (14.1 versus 15.2 y old, respectively; P = 0.043). In patients who reported improvement of gastroesophageal reflux disease/reflux type symptoms after Heller myotomy, lower esophageal residual pressure (29.1 versus 18.7 mmHg; P = 0.018) on preoperative HRM was significantly higher than in those who did not report improvement after surgery. Higher upper esophageal mean pressure (66.6 versus 47.8 mmHg; P = 0.05) also predicted good gastroesophageal reflux disease/reflux symptom response in a similar manner.
Current analysis suggests that preoperative dilation should be used cautiously and older patients may have a better response to surgery without need for postoperative treatment. In addition, preoperative HRM can aid in counseling patients in the risk of ongoing symptoms after surgery and may aid in determining if a fundoplication should be completed at the index procedure. Further research is needed to delineate these factors.
Level III.
食管失弛缓症在儿童中并不常见。尽管针对这种疾病的治疗有多种干预措施，但食管（Heller）肌切开术是最持久的治疗方法之一。我们机构试图回顾接受Heller肌切开术的患者，重点关注可能预测术后结果的术前临床因素。
确定并纳入2007年1月1日至2016年12月31日期间在我们的三级儿科医院接受贲门失弛缓症手术治疗的所有患者作为研究队列。查阅这些患者的电子病历，了解临床表现变量、术前非手术治疗、手术方式、手术临床反应、持续症状术后治疗需求以及高分辨率测压（HRM）数据。
26例患者纳入研究，均接受了肌切开术加部分胃底折叠术（中位年龄：14.4岁[四分位间距11.6 - 15.5]）。中位随访9.75个月（四分位间距3.5 - 21个月），16例（61.5%）患者报告仅手术就使吞咽困难症状得到良好缓解。2例患者（7.7%）发生胃肠道穿孔，需要手术干预。8例患者（30.8%）需要针对贲门失弛缓症进行额外治疗，其中5例（19.2%）接受了额外手术或内镜治疗。术前接受扩张治疗的患者吞咽困难症状未得到良好缓解（n = 2；P = 0.037）。4例术后接受扩张治疗的患者中有2例术前接受过扩张治疗。这些患者均未进行术前测压。需要术后干预的患者与无需术后干预的患者年龄存在统计学显著差异（分别为14.1岁和15.2岁；P = 0.043）。在Heller肌切开术后报告胃食管反流病/反流型症状改善的患者中，术前HRM显示的食管下残余压力（29.1对18.7 mmHg；P = 0.018）显著高于术后未报告症状改善的患者。较高的食管上平均压力（66.6对47.8 mmHg；P = 0.05）也以类似方式预测胃食管反流病/反流症状的良好反应。
目前的分析表明，应谨慎使用术前扩张，年龄较大的患者可能对手术反应更好，无需术后治疗。此外，术前HRM有助于向患者咨询术后持续症状的风险，并可能有助于确定在初次手术时是否应完成胃底折叠术。需要进一步研究来明确这些因素。
三级。
