|Ahead of print publication
Endoscopic management of esophageal leak post-heller myotomy for achalasia cardia in children
Anilkumar Pura Lingegowda, Ramachandra Chandrayya
Department of Pediatric Surgery, Sakra World Hospital, Bengaluru, Karnataka, India
|Date of Submission||24-Apr-2020|
|Date of Decision||20-Jul-2020|
|Date of Acceptance||20-Jul-2020|
Anilkumar Pura Lingegowda,
Flat 411, Wing 2, Sandeep Square Apartment, Gear School Road, Bhoganahalli, Bellandur Post, Bengaluru - 560 103, Karnataka
Source of Support: None, Conflict of Interest: None
A 9-year-old male child diagnosed to have achalasia cardia when he presented with a history of vomiting of undigested food particles with poor weight gain. He underwent lap Heller myotomy and Dor fundoplication. The immediate postoperative period was uneventful. After discharge, he presented with peritonitis and septic shock. On contrast-enhanced computed tomography abdomen, leak at the lower end of esophagus with intra-abdominal pus collection was identified. After intra-abdominal pus drainage and stabilizing the child, endoscopic covered stent was placed. He recovered well. Endoscopic esophageal covered stent placement is a viable and best option for a sick child with esophageal leak post-Heller myotomy.
Keywords: Endoscopy, esophageal achalasia, esophageal leak, Heller myotomy, stent
|How to cite this URL:|
Lingegowda AP, Chandrayya R. Endoscopic management of esophageal leak post-heller myotomy for achalasia cardia in children. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2021 Feb 28]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=308997
| Introduction|| |
Achalasia is a rare esophageal neurodegenerative disorder in the pediatric population. The incidence of achalasia in childhood is 0.11/100,000 children annually., Children present with progressive dysphagia, vomiting, and weight loss. Contrast study demonstrates a dilated esophagus with “bird's-beak-”like tapering. Lap Heller myotomy in children as in adults is the surgical treatment of choice., The complications of surgical management of achalasia cardia are esophageal perforation and recurrent dysphagia. Perforation rates occur from 0% to 15% in larger series but rarely require reoperation.,, Implantation of self-expandable metallic stent in patients with esophageal leak or perforation in adults is a safe and feasible alternative to operative treatment and can lower the interventional morbidity rate. We present a usage of endoscopic self-expandable metallic stent in a child with post-cardiomyotomy esophageal leak for achalasia cardia.
| Case Report|| |
A 9-year-old male child presented with a history of vomiting undigested food particles since early childhood with poor weight gain. He was evaluated with barium swallow and diagnosed to have achalasia cardia. After preoperative workup, he was subjected to lap Heller myotomy and Dor fundoplication. He had mucosal perforation while doing myotomy, which was identified and sutured securely. His immediate postoperative period was uneventful. On a postoperative day (POD) 4, upper gastrointestinal (GI) dye study done under C-Arm which showed no leak; hence, he was started on feeds which he had coped well. On POD 6, he was discharged home.
He presented to the emergency room on POD 10 with severe abdominal pain, altered sensorium, and septic shock. He was resuscitated and stabilized. He underwent contrast-enhanced computed tomography (CECT) abdomen, which revealed leak at the lower end of esophagus [Figure 1]a with intra-abdominal pus collection [Figure 1]b. CT-guided abdominal drains were placed, and further management was done in pediatric intensive care unit (PICU). Once general condition stabilized on POD 13, upper GI endoscopy performed and perforation noted above the gastroesophageal (GE) junction [Figure 2]. Self-expandable metallic covered stent (23 mm × 10 cm) [Figure 3] was placed under general anesthesia (GA) [Figure 4]a. Correct position and expansion of the stent was confirmed on X-ray [Figure 4]b. Ryle's tube feeding had been administered to him the next day for which he had coped with the treatment satisfactorily. Daily drain wash was given, and collection clearance was monitored under CT. On POD 33, CECT abdomen revealed no evidence of esophageal leak and intra-abdominal collection. On POD 34, esophageal stent was removed under GA by upper GI endoscopy. Perforation was healed completely [Figure 5]. Ryle's tube was removed; he was started on liquids on the same day and later upgraded to normal food which he had coped well. He was discharged home on POD 36. On 18-month follow-up, the child has gained a considerable weight and had taken food without any recurrence of symptoms.
|Figure 1: (a) Contrast-enhanced computed tomography showing leak at lower esophagus (oval marking). (b) Multiple air pockets and collection anterior to stomach (collection marked with white liner)|
Click here to view
|Figure 2: Endoscopic view showing perforation at lower esophagus (marked with black arrow)|
Click here to view
|Figure 4: (a) Expanded esophageal stent in situ. (b) Chest X-ray with a stent in place (white arrow)|
Click here to view
| Discussion|| |
Achalasia cardia is a rare condition in children., Lap Heller myotomy and fundoplication are well-accepted methods of treatment., Even though complications are rare but still a possibility. Esophageal perforations may occur at the time of Heller myotomy but do not seem to impact the surgical outcomes by ensuring an adequate myotomy distal to the injury, accompanied with primary suture repair of the perforation and fundoplication. Literature search did not yield much about the managing a child with late presentation of esophageal leak with sepsis.
We had three options for managing this particular complication:
- Option 1 – drain the pus + intravenous antibiotics + nasogastric/nasojejunal feeds – would have taken long time.
- Option 2 – drain the pus + primary repair (redo laparoscopic repair ± feeding jejunostomy) – too risky because of child critical condition.
- Option 3 – drain the pus + endoscopic intervention – we opted.
In view of his critical condition, we opted for draining the pus and endoscopic intervention. Endoscopic intervention for esophageal leak is well known in adults. The methods of intervention include (1) placing the covered esophageal stent and (2) closing the perforation using over-the-scope clip.
We extrapolated this technique used in adults in our case. We have preferred stent over clip as it was more time tested in adults. Under GA, upper GI scope is done and 23 mm × 10 cm covered esophageal expandable metallic stent placed under C-arm guidance. We calculated the length of the stent based on the guide wire placed in the esophagus under C-Arm, to cover from just distal to the GE junction to proximally well above the perforation. Selecting the size of the stent and placing appropriately is a very crucial step to prevent migration of the stent. Stent was removed 3 weeks later after confirming no further leak on CECT abdomen. Fistula was healed completely. The child recovered well, and he had coped with the normal food. On 18-month follow-up, the child is doing well and putting on good weight. There was no recurrence of dysphagia symptoms.
| Conclusion|| |
Esophageal perforations may occur at the time of Heller myotomy but do not seem to impact the surgical outcomes. In a child with late presentation of esophageal leak with associated sepsis, endoscopic esophageal covered metallic stent placement is a viable and best option. It decreases the morbidity related to leak and enhances early recovery. Institutional studies are required to validate our statement.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the parents have given their consent for their child's images and other clinical information to be reported in the journal. The parents understand that their child's name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Walzer N, Hirano I. Achalasia. Gastroenterol Clin North Am 2008;37:807-25,
Lee CW, Kays DW, Chen MK, Islam S. Outcomes of treatment of childhood achalasia. J Pediatr Surg 2010;45:1173-7.
Rosemurgy AS, Morton CA, Rosas M, Albrink M, Ross SB. A single institution's experience with more than 500 laparoscopic Heller myotomies for achalasia. J Am Coll Surg 2010;210:637-45, 645-7.
Salvador R, Costantini M, Cavallin F, Zanatta L, Finotti E, Longo C, et al
. Laparoscopic Heller myotomy can be used as primary therapy for esophageal achalasia regardless of age. J Gastrointest Surg 2014;18:106-11.
Pastor AC, Mills J, Marcon MA, Himidan S, Kim PC. A single center 26-year experience with treatment of esophageal achalasia: Is there an optimal method? J Pediatr Surg 2009;44:1349-54.
Corda L, Pacilli M, Clarke S, Fell JM, Rawat D, Haddad M. Laparoscopic oesophageal cardiomyotomy without fundoplication in children with achalasia: A 10-year experience: a retrospective review of the results of laparoscopic oesophageal cardiomyotomy without an anti-reflux procedure in children with achalasia. Surg Endosc 2010;24:40-4.
Askegard-Giesmann JR, Grams JM, Hanna AM, Iqbal CW, Teh S, Moir CR. Minimally invasive Heller's myotomy in children: safe and effective. J Pediatr Surg 2009;44:909-11.
Leers JM, Vivaldi C, Schafer H, Bludau M, Brabender J, Lurje G, et al
. Endoscopic therapy for esophageal perforation or anastomotic leak with a selfexpandable metallic stent. Surg Endosc 2009;23:2258-62.
Salvador R, Spadotto L, Capovilla G, Voltarel G, Pesenti E, Longo C, et al.
Mucosal Perforation during Laparoscopic Heller Myotomy has no influence on final treatment outcome. J Gastrointest Surg 2016;20:1923-30.
Yılmaz B, Unlu O, Roach EC, Can G, Efe C, Korkmaz U, et al
. Endoscopic clips for the closure of acute iatrogenic perforations: Where do we stand? Dig Endosc 2015;27:641-8.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]