Esophageal Achalasia: From Laparoscopic to Robotic Heller Myotomy and Dor Fundoplication

Abstract

Objective: Laparoscopic Heller myotomy and Dor fundoplication has become the gold standard in treating esophageal achalasia and robotic surgical platform represents its natural evolution. The objective of our study was to assess durable long-term clinical outcomes in our cohort.Methods and Procedures: Between June 1, 1999 and June 30, 2019, 111 patients underwent minimally invasive treatment for achalasia (96 laparoscopically and 15 robotically). Fifty-two were males. Mean age was 49 years (20 -96). Esophageal manometry confirmed the diagnosis. Fifty patients underwent pH monitoring study, with pathologic reflux in 18. Preoperative esophageal dilation was performed in 76 patients and 21 patients received botulin injection. Dysphagia was universally present, and mean duration was 96 months (5 -480).Results: Median operative time was 144 minutes (90 -200). One patient required conversion to open approach. Four mucosal perforations occurred in the laparoscopic group and were repaired intraoperatively. Seven patients underwent completion esophageal myotomy and added Dor fundoplication. Upper gastrointestinal series was performed before discharge. Median hospital stay was 39 hours (24 -312). Median follow up was 157 months (6 -240), and dysphagia was resolved in 94% of patients. Seven patients required postoperative esophageal dilation.Conclusions: Minimally invasive Heller myotomy and Dor fundoplication are feasible. The operation is challenging, but excellent results hinge on the operative techniques and experience. The high dexterity, three-dimensional view, and the ergonomic movements of robotic surgery allow application of all the technical elements, achieving the best durable outcome for the patient. Robotic surgery is the natural evolution of minimally invasive treatment of esophageal achalasia.

The impact of robotic surgery on the treatment of benign esophageal and gastric disease. Early experience of a specialized unit

“…[14] Early cases series on robotic Heller myotomies report excellent post-operative symptom relief, noninferior to that of the established laparoscopic approach with acceptable intraoperative and postoperative complication rate. [15][16][17][18][19][20][21][22][23] In fact, Kim et al presented superior average length of myotomy and improved symptom control with the robotic approach, while Raja et al demonstrated superior long-term symptom relief and decreased reintervention rate when comparing robotic to laparoscopic myotomy. [16,23] A number of studies report reduced incidence of intraoperative complication rate, mainly mucosal tears while using the robotic platform [15,18,20,22].…”

“…[15][16][17][18][19][20][21][22][23] In fact, Kim et al presented superior average length of myotomy and improved symptom control with the robotic approach, while Raja et al demonstrated superior long-term symptom relief and decreased reintervention rate when comparing robotic to laparoscopic myotomy. [16,23] A number of studies report reduced incidence of intraoperative complication rate, mainly mucosal tears while using the robotic platform [15,18,20,22]. According to the authors of these studies, this is mainly attributed to the more precise three-dimensional vision combined with more elegant tissue manipulation of the robotic platform.…”

“…According to the authors of these studies, this is mainly attributed to the more precise three-dimensional vision combined with more elegant tissue manipulation of the robotic platform. [15,18,20,22] Ali et al based on a large-scale retrospective analysis presented superior technical complication rate with the robotic platform, comparable only to that of POEM. [19] A population-based analysis revealed that even in high-volume centers, average length of stay is shorter with the robotic approach although average cost Is elevated.…”

Nasogastric tube after laparoscopic Heller-Dor myotomy: do you really need it?

“…The use of NGT for achalasia surgery is still controversial. Many authors routinely place NGT after this surgery, others insert it before, but they say nothing about its removal [54][55][56]. However, it is not clear if other authors use it [57][58][59][60][61][62][63].…”

Dietary and Nutritional Support in Gastrointestinal Diseases of the Upper Gastrointestinal Tract (I): Esophagus

“…The patient was diagnosed with achalasia and underwent Heller myotomy after prehabilitation with fluid and electrolyte replacement and parenteral nutrition. The decision making regarding treatment must be individualized, and the participation of a multidisciplinary team is always advisable [45][46][47][48]55]. While patients are waiting for an expeditious solution to their disease, some dietary measures should be adopted.…”