From
Live Event Content
Update Course 2023 - Updates in Pediatric Achalasia Management
hosted by Dr. Whit Holcomb
Part of
Achalasia 8 items
Chapter 1 of 5 · Fundamentals
Achalasia types
Introduction and Achalasia Classification
Expert statements on this page
No expert statements were drawn from this page.
Host summaries · secondary, not cited in answers
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Achalasia types 1, 2, and 3 all have high LES pressure and require the same treatment (myotomy), but type 2 responds best to surgery while type 3 responds worst
Type 3 achalasia is the most rare (11% in their series) and patients may have symptoms down the road that may or may not be related to myotomy
The ECAR score consists of four components: weight loss, dysphagia, chest pain, and regurgitation, used for both diagnosis and clinical follow-up
At their institution, they have observed cases where Dor fundoplication twisted the esophagus as children grew, requiring takedown of the wrap to resolve symptoms
Approximately 50% of their pediatric achalasia patients had some intervention (dilation or Botox) before definitive surgery
Botox injection causes significant scar tissue formation, while prior dilations cause minimal fibrosis
Biopsies of all pediatric POEM patients at one year show a reflux rate of approximately 5%, compared to 50% in adults
Symptoms within one year after myotomy suggest incomplete myotomy, while later recurrence may represent true recurrent achalasia related to growth
Their standard myotomy length is approximately 6-7 centimeters total: 4-5 centimeters proximal and 2 centimeters onto the stomach
Manometry in post-operative achalasia patients often continues to show achalasia findings and is not routinely used for follow-up at their institution
Endoflip measures esophageal distensibility index and diameter, with accepted adult standards that are extrapolated to pediatric patients
Their institution began performing POEM in 2015 after taking a course with Lee Swanstrom in Portland in 2013
The first 2-3 POEM cases were difficult and had the option to convert to Heller myotomy if needed; no conversions have been necessary since 2018
Their current POEM volume is approximately 15 cases per year
POEM offers 360 degrees of myotomy options compared to approximately 180 degrees with laparoscopic Heller myotomy
POEM does not require hiatal dissection, reducing reflux concerns, and allows choosing different planes for redo procedures
In their series of 73 POEM procedures, the re-intervention rate is approximately 15%, similar to their prior Heller myotomy experience
Only two centers in the United States perform POEM in pediatric patients, with one center (Children's National) being the primary active program
Re-intervention is defined as needing balloon dilation within one year post-operatively
Of 5 redo POEM procedures performed, 3 were in patients with type 3 achalasia, and these patients presented with recurrent symptoms within one year
In their series, 11% of patients had type 3 achalasia (higher than most literature), and 62% had type 2
Type 2 achalasia patients have no peristalsis, so opening the LES allows them to swallow effectively
Type 1 achalasia patients have spastic esophagus after LES opening and may have more persistent symptoms
Many patients are referred specifically requesting POEM after doing their own research, not wanting to hear about Heller myotomy
The same endoscopic pyloromyotomy technique used in POEM has been successfully applied to treat gastroparesis in 3 patients
A 2015 IPEC survey showed 95% of pediatric surgeons would perform fundoplication with Heller myotomy
In adult literature, when Heller myotomy is performed, good evidence shows fundoplication is not necessary
The learning curve for POEM is approximately 20 cases, with mastery at about 60 cases according to adult literature