Department of Pediatric Surgery and Urology, AP-HP, Robert-Debré Children University Hospital, 48 Boulevard Sérurier, 75019, Paris, France.
Paris-Cité University, Paris, France.
Surg Endosc. 2024 Jul;38(7):3602-3608. doi: 10.1007/s00464-024-10884-x. Epub 2024 May 20.
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.
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.
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).
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.
尽管食管失弛缓症在历史上一直采用 Heller 肌切开术治疗，但目前内镜食管扩张术通常是儿童的一线治疗方法。目的是评估在 Heller 肌切开术前进行内镜扩张是否会增加儿童食管穿孔的风险。
进行了一项回顾性多中心研究，纳入了 2000 年至 2022 年期间在 10 个中心接受 Heller 肌切开术的儿童患者。根据肌切开术前是否有过扩张史，将两组进行比较。观察指标为食管穿孔（术中或继发性）和需要手术治疗的术后并发症（Clavien-Dindo III 级）。使用列联表或 Kruskal-Wallis 进行统计学比较，当合适时。统计学意义：p 值<0.05。
77 例儿童患者接受了 Heller 肌切开术（中位年龄：11.8 岁），其中 53%（n=41）的患者有过内镜扩张史。90%的患者采用腹腔镜入路，95%的患者行抗反流手术。19%的患儿（n=15）发生食管穿孔，其中 12 例为术中黏膜撕裂，3 例为术后未发现的食管穿孔相关并发症。既往内镜扩张并未增加食管穿孔的风险（22% vs 17%，OR：1.4，95%CI：0.43-4.69）。术后并发症发生率为 8%（n=6），与是否有过内镜扩张史无关。术中黏膜撕裂是术后并发症的唯一危险因素，使并发症的风险从 5%增加至 25%（OR：6.89，95%CI：1.38-31.87）。
在本队列中，既往内镜扩张并未增加儿童食管失弛缓症 Heller 肌切开术的食管穿孔或术后并发症的风险。黏膜撕裂被确定为术后并发症的危险因素。
