title: Results of Laparoscopic Heller's Myotomy for Achalasia in Children: A Systematic Review of the Literature.
abstract: BACKGROUND
  Achalasia is a rare disorder in children who are commonly treated by laparoscopic Heller's myotomy (LHM). However, there are no large studies evaluating the results of LHM in the pediatric population, and the need of a concomitant fundoplication remains unclear. The aim of the study is to appraise the results of LHM based on a systematic literature review.
  
  
  METHODS
  MEDLINE search of the English literature was performed for "achalasia," "children," "laparoscopy," "Heller," "myotomy," and "cardiomyotomy." Frequency of postoperative symptoms was grouped to calculate the percentage of patients with symptoms improvement. Incidence of postoperative gastro-esophageal reflux (GER) and dysphagia between patients with and without fundoplication at the time of LHM was compared by Fisher's Exact Test. P < .05 was regarded as significant.
  
  
  RESULTS
  Twenty-one studies were analyzed (331 children, 1-19 years). All studies were retrospective case-series reviews. Intraoperative complications occurred in 33 patients (10%), with esophageal perforations in 31 (9%), and conversion to open procedure in 9 (2.7%). Fundoplication was performed in 271 (82%): Dor (n = 205, 76%), Toupet (n = 49, 18%), Thal (n = 13, 4.5%), and Nissen (n = 4, 1.5%). Incidence of postoperative GER and dysphagia was similar between children with and without fundoplication (P = 1). Forty-nine (15%) required re-intervention: pneumatic dilatations (n = 30, 9%), redo-surgery (n = 23, 7%), botox injection (n = 1, 0.3%), and medical therapy (n = 5, 1.5%).
  
  
  CONCLUSIONS
  LHM for achalasia is effective in 85% of children. Revision surgery is required in 7%. There is no difference in incidence of GER and dysphagia between patients with and without fundoplication. Routine use of an additional fundoplication might not be justified.
authors.affiliation: Department of Paediatric Surgery, King's College Hospital , London, United Kingdom .
authors.forename: Maurizio
authors.initials: M
authors.lastname: Pacilli
authors.affiliation: Department of Paediatric Surgery, King's College Hospital , London, United Kingdom .
authors.forename: Mark
authors.initials: M
authors.lastname: Davenport
mesh_terms: D000293:Adolescent; D019274:Botulinum Toxins, Type A / Q000627:therapeutic use; D002648:Child; D002675:Child, Preschool; D061887:Conversion to Open Surgery; D003680:Deglutition Disorders / Q000601:surgery; D004106:Dilatation; D004931:Esophageal Achalasia / Q000601:surgery*; D004939:Esophageal Perforation / Q000209:etiology; D018662:Fundoplication / Q000009:adverse effects; D005764:Gastroesophageal Reflux / Q000601:surgery; D006801:Humans; D007223:Infant; D007431:Intraoperative Complications / Q000209:etiology; D010535:Laparoscopy / Q000379:methods; D011183:Postoperative Complications / Q000209:etiology / Q000628:therapy; D012086:Reoperation; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D019274:Botulinum Toxins, Type A
keywords: Heller's myotomy; achalasia children; cardiomyotomy