Short-term safety and efficacy of peroral endoscopic myotomy for the treatment of achalasia in children

  • Zuqiang Liu
  • Yun Wang
  • Ying Fang
  • Ying Huang
  • Hongbin Yang
  • Xiaoxia Ren
  • Meidong Xu
  • Shiyao Chen
  • Weifeng Chen
  • Yunshi Zhong
  • Yiqun Zhang
  • Wenzheng Qin
  • Jianwei Hu
  • Mingyan Cai
  • Liqing Yao
  • Quanlin LiEmail author
  • Pinghong ZhouEmail author
Original Article—Alimentary Tract



Peroral endoscopic myotomy (POEM) has shown excellent results for the treatment of achalasia in adults, but studies for children are limited. The study was aimed to analyze outcomes of peroral endoscopic myotomy (POEM) in children and compared with those in adults in a large multi-center study.


Records of consecutive patients with achalasia who underwent POEM at three tertiary centers were reviewed. A total of 130 children were included in this study. The primary outcomes of perioperative outcomes and clinical follow-up data were analyzed.


One child (0.8%) experienced technical failure. Five children (3.8%) had major adverse events, including one with pneumothorax requiring drainage, two with delayed mucosa barrier failure, one with readmission, and one with vital-sign instability. Both post-POEM Eckardt score and median LES pressure were significantly lower than their pre-POEM reference values in children (0.7 vs 7.4; 7.0 vs 27.1 mmHg; both P < 0.001). During a median follow-up time of 40 months, clinical reflux rate was 27.0% and clinical failure rates at 1, 3, and 5 years were 1.8%, 3.5%, and 4.4% for children. The technical failure, major adverse events, and postoperative clinical reflux were comparable between children and adults (all P > 0.05). Kaplan–Meier analysis showed that the risk of clinical failure was lower in children than adults (log-rank test, hazard ratio = 0.37, 95% confidence interval 0.15–0.91, P = 0.023).


POEM can be safely performed in children with achalasia, and produce a better clinical response during long-term follow-up compared with that in adults.


POEM Achalasia Children Outcome 



Peroral endoscopic myotomy


Lower esophageal sphincter


Major adverse events




Carbon dioxide


Intensive care unit


Repeat POEM



All authors have none to declare.

Author contributions

Planning and conducting the study: Quanlin Li and Pinghong Zhou; Collecting data: Zuqiang Liu, Yun Wang, Ying Fang, Ying Huang, Hongbin Yang, Xiaoxia Ren, Meidong Xu, Shiyao Chen, Weifeng Chen, Yunshi Zhong, Yiqun Zhang, Wenzheng Qin, Jianwei Hu, Mingyan Cai, Liqing Yao; Analyzing and interpreting data: Zuqiang Liu, Yun Wang; Drafting manuscript: Zuqiang Liu, Quanlin Li; Final approval of manuscript: All authors.


This study was supported by grants from the National Natural Science Foundation of China (81873552, 81470811, 81570595, and 81670483), Shanghai Rising Star Program (19QA1401190), Major Project of Shanghai Municipal Science and Technology Committee (18ZR1406700, 16411950400, 16DZ2280900), Chen Guang Program of Shanghai Municipal Education Commission (15CG04), and Outstanding Young Doctor Training Project of Shanghai Municipal Commission of Health and Family Planning (2017YQ026), Xi'an hygiene and health commission, Key disciplines and dominant specialties program (2015038), and the Project of Shanghai Municipal Commission of Health and Family Planning (SHDC12016203).

Compliance with ethical standards

Conflict of interest

None disclosed.

Supplementary material

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  1. 1.
    Liu Z, Zhang X, Zhang W, et al. Comprehensive evaluation of the learning curve for peroral endoscopic myotomy. Clin Gastroenterol Hepatol. 2018;16(1420–1426):e2.Google Scholar
  2. 2.
    Marlais M, Fishman JR, Fell JM, et al. UK incidence of achalasia: an 11-year national epidemiological study. Arch Dis Child. 2011;96:192–4.CrossRefGoogle Scholar
  3. 3.
    Mayberry JF, Mayell MJ. Epidemiological study of achalasia in children. Gut. 1988;29:90–3.CrossRefGoogle Scholar
  4. 4.
    Sato H, Yokomichi H, Takahashi K, et al. Epidemiological analysis of achalasia in Japan using a large-scale claims database. J Gastroenterol. 2019;54:621–7.CrossRefGoogle Scholar
  5. 5.
    Chen WF, Li QL, Zhou PH, et al. Long-term outcomes of peroral endoscopic myotomy for achalasia in pediatric patients: a prospective, single-center study. Gastrointest Endosc. 2015;81:91–100.CrossRefGoogle Scholar
  6. 6.
    Sato H, Takahashi K, Mizuno KI, et al. Esophageal motility disorders: new perspectives from high-resolution manometry and histopathology. J Gastroenterol. 2018;53:484–93.CrossRefGoogle Scholar
  7. 7.
    Kahrilas PJ, Katzka D, Richter JE. Clinical practice update: the use of per-oral endoscopic myotomy in achalasia: expert review and best practice advice from the AGA institute. Gastroenterology. 2017;153:1205–11.CrossRefGoogle Scholar
  8. 8.
    Miao S, Wu J, Lu J, et al. Peroral endoscopic myotomy in children with achalasia: a relatively long-term single-center study. J Pediatr Gastroenterol Nutr. 2018;66:257–62.CrossRefGoogle Scholar
  9. 9.
    Nabi Z, Ramchandani M, Reddy DN, et al. Per Oral endoscopic myotomy in children with achalasia cardia. J Neurogastroenterol Motil. 2016;22:613–9.CrossRefGoogle Scholar
  10. 10.
    Li C, Tan Y, Wang X, et al. Peroral endoscopic myotomy for treatment of achalasia in children and adolescents. J Pediatr Surg. 2015;50:201–5.CrossRefGoogle Scholar
  11. 11.
    Caldaro T, Familiari P, Romeo EF, et al. Treatment of esophageal achalasia in children: Today and tomorrow. J Pediatr Surg. 2015;50:726–30.CrossRefGoogle Scholar
  12. 12.
    Tan Y, Zhu H, Li C, et al. Comparison of peroral endoscopic myotomy and endoscopic balloon dilation for primary treatment of pediatric achalasia. J Pediatr Surg. 2016;51:1613–8.CrossRefGoogle Scholar
  13. 13.
    Zhang XC, Li QL, Huang Y, et al. Peroral endoscopic myotomy using the posterior approach in an 11-month-old girl with achalasia, severe malnutrition, and recurrent pneumonia. Endoscopy. 2015;47(Suppl 1):E480–E482. (UCTN).PubMedGoogle Scholar
  14. 14.
    Ren Y, Tang X, Chen Y, et al. Pre-treatment Eckardt score is a simple factor for predicting one-year peroral endoscopic myotomy failure in patients with achalasia. Surg Endosc. 2017;31:3234–41.CrossRefGoogle Scholar
  15. 15.
    Li QL, Zhou PH. Perspective on peroral endoscopic myotomy for achalasia: Zhongshan experience. Gut Liver. 2015;9:152–8.CrossRefGoogle Scholar
  16. 16.
    Liu ZQ, Li QL, Chen WF, et al. The effect of prior treatment on clinical outcomes in patients with achalasia undergoing peroral endoscopic myotomy. Endoscopy. 2019;51:307–16.CrossRefGoogle Scholar
  17. 17.
    Wu QN, Xu XY, Zhang XC, et al. Submucosal fibrosis in achalasia patients is a rare cause of aborted peroral endoscopic myotomy procedures. Endoscopy. 2017;49:736–44.CrossRefGoogle Scholar
  18. 18.
    Zhang XC, Li QL, Xu MD, et al. Major perioperative adverse events of peroral endoscopic myotomy: a systematic 5-year analysis. Endoscopy. 2016;48:967–78.CrossRefGoogle Scholar
  19. 19.
    Jones R, Junghard O, Dent J, et al. Development of the GerdQ, a tool for the diagnosis and management of gastro-oesophageal reflux disease in primary care. Aliment Pharmacol Ther. 2009;30:1030–8.CrossRefGoogle Scholar
  20. 20.
    Li QL, Wu QN, Zhang XC, et al. Outcomes of per-oral endoscopic myotomy for treatment of esophageal achalasia with a median follow-up of 49 months. Gastrointest Endosc. 2018;87(1405–1412):e3.Google Scholar
  21. 21.
    Hassall E, Israel D, Shepherd R, et al. Omeprazole for treatment of chronic erosive esophagitis in children: a multicenter study of efficacy, safety, tolerability and dose requirements International Pediatric Omeprazole Study Group. J Pediatr. 2000;137:800–7.CrossRefGoogle Scholar
  22. 22.
    Poddar U. Gastroesophageal reflux disease (GERD) in children. Paediatr Int Child Health. 2019;39:7–12.CrossRefGoogle Scholar
  23. 23.
    Nikaki K, Woodland P, Sifrim D. Adult and paediatric GERD: diagnosis, phenotypes and avoidance of excess treatments. Nat Rev Gastroenterol Hepatol. 2016;13:529–42.CrossRefGoogle Scholar
  24. 24.
    Hurwitz M, Bahar RJ, Ament ME, et al. Evaluation of the use of botulinum toxin in children with achalasia. J Pediatr Gastroenterol Nutr. 2000;30:509–14.CrossRefGoogle Scholar
  25. 25.
    Ip KS, Cameron DJ, Catto-Smith AG, et al. Botulinum toxin for achalasia in children. J Gastroenterol Hepatol. 2000;15:1100–4.CrossRefGoogle Scholar
  26. 26.
    Anselmino M, Perdikis G, Hinder RA, et al. Heller myotomy is superior to dilatation for the treatment of early achalasia. Arch Surg. 1997;132:233–40.CrossRefGoogle Scholar
  27. 27.
    Askegard-Giesmann JR, Grams JM, Hanna AM, et al. Minimally invasive Heller's myotomy in children: safe and effective. J Pediatr Surg. 2009;44:909–11.CrossRefGoogle Scholar
  28. 28.
    Corda L, Pacilli M, Clarke S, et al. 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.CrossRefGoogle Scholar
  29. 29.
    Maselli R, Inoue H, Misawa M, et al. Peroral endoscopic myotomy (POEM) in a 3-year-old girl with severe growth retardation, achalasia, and Down syndrome. Endoscopy. 2012;44(Suppl 2):E285–E287287.PubMedGoogle Scholar
  30. 30.
    Bechara R, Onimaru M, Ikeda H, et al. Per-oral endoscopic myotomy, 1000 cases later: pearls, pitfalls, and practical considerations. Gastrointest Endosc. 2016;84:330–8.CrossRefGoogle Scholar
  31. 31.
    Nabi Z, Ramchandani M, Chavan R, et al. Peroral endoscopic myotomy in treatment-naive achalasia patients versus prior treatment failure cases. Endoscopy. 2018;50:358–70.CrossRefGoogle Scholar
  32. 32.
    Ngamruengphong S, Inoue H, Ujiki MB, et al. Efficacy and safety of peroral endoscopic myotomy for treatment of achalasia after failed heller myotomy. Clin Gastroenterol Hepatol. 2017;15(1531–1537):e3.Google Scholar
  33. 33.
    Sherman RE, Anderson SA, Dal Pan GJ, et al. Real-world evidence—What Is It and What can it tell us? N Engl J Med. 2016;375:2293–7.CrossRefGoogle Scholar

Copyright information

© Japanese Society of Gastroenterology 2019

Authors and Affiliations

  • Zuqiang Liu
    • 1
  • Yun Wang
    • 1
  • Ying Fang
    • 2
  • Ying Huang
    • 3
  • Hongbin Yang
    • 2
  • Xiaoxia Ren
    • 2
  • Meidong Xu
    • 1
  • Shiyao Chen
    • 1
  • Weifeng Chen
    • 1
  • Yunshi Zhong
    • 1
  • Yiqun Zhang
    • 1
  • Wenzheng Qin
    • 1
  • Jianwei Hu
    • 1
  • Mingyan Cai
    • 1
  • Liqing Yao
    • 1
  • Quanlin Li
    • 1
    Email author
  • Pinghong Zhou
    • 1
    Email author
  1. 1.Endoscopy Center and Endoscopy Research Institute, Zhongshan HospitalFudan UniversityShanghaiPeople’s Republic of China
  2. 2.Department of GastroenterologyThe Children’s Hospital of Xi’an CityXi’anChina
  3. 3.Department of Gastroenterology, Children’s HospitalFudan UniversityShanghaiChina

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