Lelli J L, Drongowski R A, Coran A G
Department of Surgery, University of Michigan Medical School, Ann Arbor 48109-0245, USA.
J Pediatr Surg. 1997 Feb;32(2):338-41. doi: 10.1016/s0022-3468(97)90206-2.
From 1974 to 1995, 19 children with achalasia of the esophagus have been treated at our institution. Presenting symptoms included vomiting (n = 14), dysphagia (n = 13), failure to thrive (n = 6), and odynophagia (n = 1). Diagnosis was established by a barium swallow in 19, with eight also undergoing esophageal manometry. Six boys and 13 girls with an average age of 10 years (range, 1.3 to 17.6) underwent a transthoracic, modified anterior Heller esophagomyotomy (HM). Five underwent a concomitant, modified, Belsey fundoplication (BF). Follow-up ranging from 6 months to 21 years (mean, 9 years) was accomplished in all 19 patients by both office visits and telephone interviews. Early postoperative follow-up showed initial swallowing difficulty in two (14%) patients with a HM alone and in four out of five (80%) patients treated with a HM and BF. All patients (n = 5) with a HM and BF and one with a HM alone required one esophageal dilation during the first postoperative year. These initial swallowing difficulties resolved in all six patients during this first postoperative year. Late postoperative follow-up, however, indicates occasional, mild dysphagia in two out of five with an HM and BF resulting in complete relief of presenting symptoms in 17 of the 19 patients (90%). All patients rated their overall result as either excellent (68%) or good (32%) with none rating it as fair or poor. None of the 19 patients had clinical evidence of gastroesophageal reflux, although five patients had evidence of nonpathologic reflux noted during upper gastrointestinal x-ray. Recurrent vomiting, asthma, wheezing, or esophagitis symptoms have not been reported by any patients. No patients required reoperation, and there were no deaths or postoperative complications. Modified Heller esophagomyotomy is safe (0% mortality) and effective (90% relief of symptoms) in children with achalasia. A concurrent modified Belsey fundoplication results in early and late mild postoperative dysphagia that was responsive to esophageal dilation. The transthoracic, modified Heller esophagomyotomy without a fundoplication is currently our treatment of choice for achalasia in children.
1974年至1995年期间，我院共治疗了19例食管失弛缓症患儿。主要症状包括呕吐（14例）、吞咽困难（13例）、发育不良（6例）和吞咽痛（1例）。19例患儿均通过吞钡检查确诊，其中8例还接受了食管测压。19例患儿中，6例为男孩，13例为女孩，平均年龄10岁（范围1.3至17.6岁），均接受了经胸改良前Heller食管肌层切开术（HM）。5例同时接受了改良Belsey胃底折叠术（BF）。通过门诊随访和电话访谈对所有19例患者进行了6个月至21年（平均9年）的随访。术后早期随访显示，单纯接受HM的2例（14%）患者及接受HM加BF的5例患者中有4例（80%）最初存在吞咽困难。所有接受HM加BF的患者（5例）及1例单纯接受HM的患者在术后第一年均需进行1次食管扩张。这6例患者在术后第一年吞咽困难均得到缓解。然而，术后晚期随访表明，接受HM加BF的5例患者中有2例偶尔出现轻度吞咽困难，19例患者中有17例（90%）主要症状完全缓解。所有患者对总体结果的评价均为优秀（68%）或良好（32%），无患者评价为一般或差。19例患者均无胃食管反流的临床证据，尽管5例患者在上消化道X线检查时有非病理性反流的证据。所有患者均未报告反复呕吐、哮喘、喘息或食管炎症状。无患者需要再次手术，也无死亡或术后并发症发生。改良Heller食管肌层切开术对于儿童食管失弛缓症是安全的（死亡率为0%）且有效的（症状缓解率为90%）。同时进行改良Belsey胃底折叠术会导致术后早期和晚期出现轻度吞咽困难，可通过食管扩张缓解。目前，我们对于儿童食管失弛缓症的首选治疗方法是经胸改良Heller食管肌层切开术，不进行胃底折叠术。
