O3279: Per Oral Endoscopic Myotomy (POEM) for Pediatric Achalasia: Children's National Hospital Experience and Outcomes

Background: The surgical treatment of achalasia is considered the most effective management strategy, regardless of whether it is performed using a laparoscopic or endoscopic approach. There has been a growing global experience with endoscopic approaches for pediatric achalasia. This study aims to present our institutional experience with per-oral endoscopic myotomy (POEM) as the initial or revisional therapy for achalasia.

Methods: A retrospective analysis was conducted on all patients with esophageal achalasia who received surgical treatment at a tertiary children's hospital in the United States between 2015 and 2023. Data were analyzed, including patient demographics, operative techniques, pre-and post-operative Eckardt scores, complications, outcomes, and follow-up.

Results: During the study period, 72 children underwent 77 operations for achalasia, including POEM and laparoscopic Heller myotomy (LHM). Operations included 67 POEMs (53 primary POEM, 9 POEM after failed LHM, and 4 POEM after failed POEM); and 1 POEM after failed open Heller myotomy (OHM).
Additionally, 10 LHM, including 5 primary LHM; 3 attempted POEM converted to LHM; 1 attempted POEM after failed LHM converted to redo LHM; and 1 LHM after failed POEM. In the POEM group (n=64), achalasia Chicago types at diagnosis were 14 type I (21.9%); 40 type II (62.5%); 8 type III (12.5%), and two unknown (3.1%). Twenty-eight children (43.8%) had prior treatment of achalasia before POEM [Pneumatic Balloon Dilatation (PBD) and/or Botox injection (BTI)].
The prior operative intervention occurred in 14 patients (21.9%), 9 LHM, 1 OHM, and 4 POEM. Age at operation was 2-18 years (years mean + SD age: 11.2 + 4.4 years).
Weight at operation 11.8-100.7 kg (mean + SD kg; 39.2 + 19.4 kg). The range of baseline Eckardt score was 4-10 (mean + SD: 6.8 + 1.7).
Operative time was 45-359 minutes (mean + SD minutes: 112 + 57.2 minutes). Intraoperative complications occurred in 24 cases (35.8%) but did not require reoperation during the index admission, including:
mucosotomy, pneumothoraces, pneumomediastinum, pneumoperitoneum. There were no open conversion or deaths. Post-operative complications included: 8 recurrent dysphagia (11.9%); 0 esophageal leak (0%); GERD 4 (6.2%); 3 failed POEM (4%).
The median length of stay was mean 1.8 days (+ SD 1 day). Follow-up ranged 1-99 months (mean 27.4:median 23). Seven patients required a single PBD post-POEM (10.9%), and three patients required a repeat myotomy after POEM (1LHM: 2 POEM; 3.7%) for a 14.6% reintervention rate. Subsequent normalization of Eckardt scores ( < 3) and symptomatic relief was achieved in all patients (100%).

Conclusion: Based on our experience, utilizing POEM as the primary treatment for pediatric achalasia or as a secondary intervention after a previous myotomy or POEM procedure is safe and effective. Long-term follow-up assessments will be performed to monitor patients for the recurrence of symptoms, adequate physical growth, and reflux symptoms.