Minimally invasive techniques of Heller myotomy have become increasingly popular in the pediatric age group. The anatomical approach (thoracoscopic or laparoscopic) lacks any evidence based series and there is likely to never be any randomized trial answering the question of an optimal age or approach for management of the child with achalasia. In part this is because of the low incidence of pediatric and adult cases (0.6 cases/ 100,000/yr). Thus, case reports may have merit for future concensus guidelines and potential clinical pathways.

This case involves an 11 year-old boy with 10 months of increasing dysphagia and regurgitation. Esophagogram demonstrated the classic birds' beak associated with achalasia, and significant proximal esophageal dilatation culminating in poor emptying. Motility studies confirmed the absence of peristalsis in the distal esophagus and incomplete relaxation of the lower esophageal sphincter associated with achalasia. The child symptoms were refractory to consecutive botox injections and balloon dilatation. He was ultimately referred for surgical consultation, and Heller myotomy with anterior fundopolication was recommended. The child's parents understood the risks and benefits of the procedure and they agreed to laparoscopic Heller myotomy.

Heller myotomy and anterior Fundoplication. The procedure was undertaken using 5 abdominal trocars, ranging in size from 5mm to 12mm positioned at the umbilicus, bilateral subcostal midclavicular lines, right anterior auxillary line at the subcostal margin, and subxiphoid. A subxiphoid camera approach facilitated exposure for the entire procedure. Salient features of this procedure included: division of the gastrohepatic omentum, clear exposure of the phrenoesophageal membranes, division of the gastroesophageal fat pad, delivery of 8 to 10 cm of intrathoracic esophagus into the abdomen, myotomy of the transverse muscle layer of the esophagus for a distance of 8 cm along the of the distal esophagus, division of proximal stomach muscle fibers beyond the Z-line, endoscopic confirmation of the extent of the procedure, anterior fundoplication, reapproximation of the crura, and post operative esophagogram.

Esophagogram done within 24 hrs of operation documented significantly less narrowing and no evidence of perforation. The child had remarkable early resolution of dysphagia and resumption of solid foods within 8 days. Esophagogram at one month post procedure documented continued patency of the distal esophagus consistent with his ability to tolerate a regular diet.