Tu1149 PERORAL ENDOSCOPIC MYOTOMY FOR THE TREATMENT OF ACHALASIA IN CHILDREN: EXPERIENCE OF A SINGLE CENTER WITH LONG TERM FOLLOW-UP

Abstract

Oesophageal achalasia is very rare in children. Peroral Endoscopic Myotomy (POEM) is now widely used for the treatment of achalasia in adults. POEM has been also occasionally performed for the management of paediatric achalasia. We report on a large series of children with achalasia, treated with POEM in a single center, and with a long-term follow-up. From January 2012 to June 2017, 26 children (46.2% male, median age 10.9, SD ± 4.5, range 2-17 years) with achalasia underwent POEM. Eckardt score (ECKs) was used for symptoms evaluation before the procedure and during the follow-up. Two children had already undergone pneumatic dilation. Two children were affected from Down syndrome and two children were affected from Allgrove syndrome. Twenty children underwent high resolution manometry [HRM] (25% type I, 70% type II, 5% type III of achalasia). The other six patients underwent standard manometry. POEM was successfully completed in 25 cases; one procedure was interrupted during submucosal tunnel dissection because of massive fibrosis of the EGJ, probably caused by the previous 4 pneumatic dilations. Mean symptoms duration before POEM was 18.2 months [SD ± 14.9]. Mean preoperative 4sIRP was 33.2 mmHg [SD ± 12.2]. Mean preoperative ECKs was 7.2 [SD ± 2.2]. Perioperative details are summarized in the table 1. Complications occurred in one patient who experienced a oesophageal leak, managed conservatively. All patient underwent an EGD 24 hours after procedure, before starting oral feeding. Small ulcerations of the EGJ were seen in 16% of patients, but patients were regularly fed. One patient had ab-ingestis pneumonia after POEM. No other complications occurred. After a mean follow-up of 30.6 months [SD ± 15.0], all the treated patients had an ECKs < 3 and normal growth curve by age. At 6 or 12 month after POEM, 17 patients (68%) underwent HRM and 24 hours pH-monitoring. The mean 4IRP was 8.5 mmHg [SD ± 4.7]. Pathologic oesophageal acid exposure has been detected in four children (16%); two of them had a grade A esophagitis at EGD. POEM is a minimally-invasive procedure for the treatment of achalasia in paediatric patients. Our results confirm the long term efficacy of POEM in children, in absence of severe complications. Gastroesophageal reflux has been detected in a small percentage of treated patients.Tabled 1Procedural outcomes and follow-upProcedure time, mean min (±SD)56.2 (12.6)Myotomy length, mean cm (±SD)10 (2.6)Gastric myotomy length, mean cm (±SD)3 (0.9)Pneumoperitoneum (%)4Cervical emphysema (%)4Superficial ulcerations or blanching, (%)16Feeding time, mean days (±SD)1.8 (1)Hospitalization, mean days (±SD)3.7 (1.7)ECKs at 6-month follow-up, mean(±SD)0.3 (0.6)4sirp at 6-month follow-up, mean (±SD)8.7 (3.8)GER (altered esophageal acid exposure) (%)16Mean follow-up, months (±SD)30.2 (15.4)Clinical success (ECKs ≤3) at last follow-up (%)100 Open table in a new tab