title: Heller Myotomy Is Superior to Balloon Dilatation or Botulinum Injection in Children with Achalasia: A Two-Center Review.
abstract: BACKGROUND
  Achalasia is an uncommon disorder in children. Currently, there is no consensus regarding the optimal treatment for achalasia. We investigate the effectiveness of symptom relief in patients who underwent endoscopic treatments versus Heller myotomy (HM).
  
  
  METHODS
  We conducted a retrospective review of all children (age 0-18 years) treated for achalasia at two pediatric hospitals from 2004 to 2014. Demographics, presenting symptoms, outcomes, and complications were analyzed.
  
  
  RESULTS
  Twenty-three patients (61% male) were identified with a mean age at diagnosis of 11.6 ± 5.0 years. About 47.8% of the cohort had no comorbidities. Common presenting symptoms included weight loss/failure to thrive (87.0%), emesis (69.6%), and dysphagia (69.6%). Mean time from symptom onset to diagnosis was 18 ± 18.9 months. Nine patients underwent laparoscopic HM as their primary treatment, whereas 14 received esophageal dilatation (ED) as their first-line therapy. Patients who underwent ED as their initial treatment were younger (9.92 versus 15.6 years, P = .047). Patients who underwent HM were more likely to attain symptom resolution compared to those managed with ED alone (P = .004). Of the 14 patients who underwent ED initially, 10 subsequently required HM due to persistent symptoms. None of the 4 patients who underwent ED alone achieved long-term symptom relief and, on the average, required an increased number of procedures compared to their HM counterparts (5.25 versus 2.47, P = .010). There was a trend toward increased intraoperative mucosal perforation in patients who underwent preoperative ED and botulinum injections.
  
  
  CONCLUSIONS
  Our data suggest that HM is superior to balloon dilatation or botulinum injection in children with achalasia. We conclude that HM should be recommended for newly diagnosed children with achalasia as a first-line therapy.
authors.affiliation: 1 Department of Surgery, Children's Hospital Los Angeles , Los Angeles, California.
authors.forename: Jessica A
authors.initials: JA
authors.lastname: Zagory
authors.affiliation: 1 Department of Surgery, Children's Hospital Los Angeles , Los Angeles, California.
authors.forename: Jamie M
authors.initials: JM
authors.lastname: Golden
authors.affiliation: 1 Department of Surgery, Children's Hospital Los Angeles , Los Angeles, California.
authors.forename: Natalie E
authors.initials: NE
authors.lastname: Demeter
authors.affiliation: 1 Department of Surgery, Children's Hospital Los Angeles , Los Angeles, California.
authors.forename: Yen
authors.initials: Y
authors.lastname: Nguyen
authors.affiliation: 1 Department of Surgery, Children's Hospital Los Angeles , Los Angeles, California.
authors.forename: Henri R
authors.initials: HR
authors.lastname: Ford
authors.affiliation: 1 Department of Surgery, Children's Hospital Los Angeles , Los Angeles, California.|2 Department of Surgery, Miller Children's Hospital, Long Beach Memorial Medical Center , Long Beach, California.
authors.forename: Nam X
authors.initials: NX
authors.lastname: Nguyen
mesh_terms: D000293:Adolescent; D001905:Botulinum Toxins / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D004106:Dilatation / Q000295:instrumentation / Q000379:methods; D004931:Esophageal Achalasia / Q000628:therapy*; D049630:Esophageal Sphincter, Lower / Q000601:surgery*; D004945:Esophagoscopy; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007267:Injections; D010535:Laparoscopy; D008297:Male; D009465:Neuromuscular Agents / Q000627:therapeutic use*; D012189:Retrospective Studies; D016896:Treatment Outcome
chemical_list: D009465:Neuromuscular Agents; D001905:Botulinum Toxins