Thoracoscopic esophagomyotomy for achalasia in a child.

Longitudinal esophageal myotomy is effective in tions, each affording only short-term relief of dys­ relieving dysphagia in over 90% of patients with phagia. Becau se the child swims competitively , she achalasia (1-8) , but enthusiasm for this approach and the famil y were concerned about the effect s of has been limited because of the need for thoracot­ a posterolateral thoracotomy on her arm and shoul­ omy. In addition, because pharmacologic agents der mobil ity and strength and were reluctant to con­ have been largely ineffective, most children are of­ side r surgery . fered pneumatic dilatation, although it is potentiall y Using a four-trocar technique, a modified Helle r hazardou s and associated with a high rate of recur­ eso phagomyotomy was performed under combined rence (8-12). Older reports listed recurrence rates thoracoscopic and esophagoscopic control. Trocars for pneumatic dilatation at 20-25% (13). However, were placed in a diamond configuration more the results of a more recent prospective trial of widely sep ar ated than in an adult to minimize pneumatic dilatation were so poor that the authors "swo rd fighting." The 11 -mm camera port was have abandoned the procedure in patients less than placed in the mid-axillary line in the fourth inter­ 18 years of age (12). We report the first successful cost al space . Three 5-mm ports were placed to com­ esophagea l myotomy in a child using a minimally plete the diamond pattern: one in the mid-clavicular invasive, thoracoscopic technique that obviates line in the six th intercostal space; one in the poste­ thoracot om y, pre ser ves chest wall musculature, rior axillary line in the seventh intercostal space; and requi res only brief hospitalization. and the third in the mid-axillary line in the ninth intercos ta l space . Esophagoscopy during the proce­ dure allowed ide ntifica tio n of the gastroesoph ageal CASE REPORT (OE) junction and assessment of the adequacy of the esophagogastr ic myotom y (14). The myotomy A 13-year-old (40 kg) competitive swimmer was was ca rried I ern below the endoscopically defined referred for the evaluation of long-standing dyspha­ OE j unction (Fig. 2). Postoperati vely , she required gia and gastroesophageal reflux. She was initiall y ches t tub e drainage for 48 h a nd resumed a regular diagnosed and treated for severe reflux esoph agitis, diet witho ut dysph agia on the seco nd postop erati ve halitosis , and possible bulimia due to recurrent day. She was discharged home on the third postop­ postprandi al regurgitation of undigested food. Fol­ erative day on prophylactic H2 blockers (because of lOW-Up barium swallow revealed a markedly dilated the potential for gas troesophageal reflu x) and re­ esophag us with tapering of the distal esophagus mains sy mptom-free 12 months postoperativ ely. A demon str ating the "bird beak" sign consistent with follow-up barium swallow demonstrates a norm al the diagnosis of acha lasia (Fig. 1A). Esophageal eso phag us without ob struction or gastroesophageal manometry revealed hypertension of the lower reflux (Fig. IB). esophageal sphincter with a pressure of 33 mg Hg and abse nt relaxation with swallowing and absent (effec tive) peri staltic contractions in the body of the DISCUSSION eso phagus . She und erwent five pneumatic dilataNumerou s studies have demonstrated that the most definitive treatment of achalasia for the relief Address corresponde nce and reprint requests to Dr. Nabil N. of dysph agia is es ophagogastric extramucosal my­ Jac ir , Division of Pediatri c Surgery, The Floating Hospital , New En gland Medical Center, 750 Washington Street , NEMC 281, otomy, as fir st descri bed by Heller (15). Pharmaco­ Bosto n , MA 02111, U.S .A. logic agents have been largely ineffective (11). Even