Per Oral Endoscopic Myotomy (POEM) for Pediatric Achalasia | 43 children | 46 surgeries | for achalasia including POEM (n=37) and laparoscopic Heller myotomy (LHM) (n=9) | 33 primary POEMS | 3 POEMS after failed LHM | 1 POEM after failed POEM | 4 primary LHM | 3 attempted POEMS converted to LHM | 1 attempted POEM after failed LHM converted to redo LHM | 1 LHM after failed POEM | Retrospective study | July 2015 - September 2021 | 16 children had endoscopic treatment prior to POEM | Pneumatic Balloon Dilatation (PBD) and/or Botox injection | Baseline Eckardt score: 4-10 (6.73 ± 1.5) | Intra-op complications in 16 patients. | 0 requiring reoperation during index admission | Post-op complications: | 5 recurrent dysphagia | 3 GERD | 1 failed POEM | Mean follow-up 22.6 months ± 20 months. | Post POEM Eckardt score 0.6 ± 0.9 | 5 PBD post POEM | 1 repeat LHM post POEM | Symptomatic relief achieved in all patients (100%) | Conclusion: For pediatric achalasia, POEM is safe and effective as primary therapy or secondary procedure after failed prior myotomy or POEM. | https://doi.org/10.1016/j.jpedsurg.2022.02.017 | @EmTombash | Source: Petrosyan M et.al. | The Department of General and Thoracic Surgery, Children's National Hospital, Washington DC, United States | @StayCurrentMD | Cincinnati Children's | Journal of Pediatric Surgery
Per Oral Endoscopic Myotomy (POEM) for Pediatric Achalasia
Infographic · Feb 2023 · 2 min read
In brief
In brief
Institutional experience with POEM as primary or revisional therapy for pediatric achalasia in 37 patients showed 83.8% success without reintervention, with mean Eckardt scores improving from 6.73 to 0.6. While 43% experienced intraoperative complications (mostly pneumothorax/pneumoperitoneum), none required reoperation, and only 16% needed subsequent intervention over median 15-month follow-up.
- POEM achieved 100% symptomatic relief in 37 pediatric achalasia cases with mean Eckardt score dropping from 6.73 to 0.6 postoperatively.
- Intraoperative complications (43.2%) including pneumothorax and mucosotomy did not require reoperation and resolved without intervention.
- Reintervention rate was 16.2% (5 balloon dilations, 1 conversion to LHM) with all patients ultimately achieving symptom control.
- POEM is effective as both primary therapy and salvage procedure after failed laparoscopic Heller myotomy in children.
- Type II achalasia (67.6%) was most common; POEM demonstrated safety across all Chicago Classification subtypes in pediatric patients.
Written by the GCMD Library team from the infographic.
A teal and white infographic divided into sections with icons including a calendar, clock, healthcare worker illustration, and child illustrations. Data is presented in colored text boxes with bullet points. The layout flows from top to bottom with study details, patient demographics, treatment outcomes, and conclusions. A yellow conclusion box appears in the bottom right corner.
Mikael Petrosyan, Shikib Mostammand, Adil A. Shah, Anil Darbari, Timothy D. Kane
Background: The surgical treatment of achalasia by both laparoscopic and endoscopic approaches has been recognized as the definitive management in children. Despite reported low volumes in many centers, there has been an increasing worldwide experience with endoscopic approaches to pediatric achalasia. The aim of this study is to report our institutional experience with per oral endoscopic myotomy (POEM) as first-line or revisional therapy for achalasia.
Methods: An IRB approved retrospective review of all patients who underwent operative procedures for achalasia, specifically with the POEM technique, from July 2015 to September 2021. Data including demographics, intra-operative details, pre and post operative Eckardt scores, complications, outcomes, and follow-up were obtained.
Results: During the study period, a total of 43 children underwent 46 operations for achalasia including POEM and laparoscopic Heller myotomy (LHM). Operations included 37 POEMS (33 primary POEMS; 3 POEMS after failed LHM; and 1 POEM after failed POEM). Additionally, 9 LHM operations including, 4 primary LHM; 3 attempted POEMS converted to LHM; 1 attempted POEM after failed LHM converted to redo LHM; and 1 LHM after failed POEM. In the POEM group (n = 37), based on the high resolution esophageal manometry findings Chicago Classification types at diagnosis were as follows: 9 patients were type I (24.3%); 25 patients were type II (67.6%); 2 patients were type III (5.9%) and 1 patient was unknown type (2.7%). Sixteen children (43.2%) had prior endoscopic treatment of achalasia prior to POEM [Pneumatic Balloon Dilatation (PBD), and/or Botox injection (BTI)],), while prior operative intervention occurred in 4 patients (10.8%), 3 LHM and 1 POEM. Age at operation was 2–18 years (mean ± SD age: 11.6 ± 4.5 years). Weight at operation 11.8–100.7 kg (mean ± SD kg; 39 ± 19.9 kg). Range of baseline Eckardt score was 4–10 (mean ± SD: 6.73 ± 1.5). Operative time was 64–359 min (mean ± SD minutes: 138.1 ± 62.2 min). Intraoperative complications occurred in 16 patients (43.2%) but did not require reoperation during index admission including: 4 mucosotomy (11.8%); 9 pneumothoraces (24.3%); 2 pneumomediastinum (5.4%); 10 pneumoperitoneum (27%); 0 sub-mucosal tunnel bleeding (0%); 0 open conversion/death (0%). Post operative complications included: 5 recurrent dysphagia (13.5%); 0 esophageal leak (0%); 3 GERD (8.1%); 1 failed POEM (2.7%). Median length of stay was 2 days (mean ± SD days: 2.4 ± 0.9 day). Follow-up ranged from 1 to 74 months (median 15 months), mean follow-up 22.6 months ± 20 months. Post POEM Eckardt score was 0.6 ± 0.9. Five patients required a single PBD post POEM (13.5%) and 1 patient required a repeat myotomy (LHM) after POEM (2.7%) for a 16.2% reintervention rate. Subsequent normalization of Eckardt scores (≤ 3) and symptomatic relief was achieved in all patients (100%).
Conclusions: POEM as first-line therapy for pediatric achalasia, or as a secondary procedure after failed prior myotomy or POEM, in our experience is safe and effective. We have shown equivalent results to our own prior experience with LHM. Long-term follow-up will be performed to monitor for recurrent symptoms, adequate physical growth, and general development.