From laparoscopic to robotic-assisted Heller myotomy for achalasia in a single high-volume visceral surgery center: postoperative outcomes and quality of life

Abstract

Background Laparoscopic (LSC) Heller myotomy (HM) is considered the standard procedure for the treatment of achalasia. Robotic platforms, established over the last years, provide important advantages to surgeons, such as binocular 3-dimensional vision and improvement of fine motor control. However, whether perioperative outcomes and long-term results of robotic-assisted laparoscopic (RAL) HM are similar or even superior to LSC technique, especially concerning long-term follow-up, is still debated. Therefore, the aim of the present study was to evaluate intra- and postoperative results as well as long-term quality of life after RAL compared to LSC surgery for achalasia in a single high-volume visceral surgery center. Methods Between August 2007 and April 2020, 43 patients undergoing minimally invasive HM for achalasia in a single high-volume Swiss visceral surgery center, were included in the present study. Intra- and postoperative outcome parameters were collected and evaluated, and a long-term follow-up was performed using the gastroesophageal-reflux disease health-related quality of life (GERD-Hr-QuoL) questionnaire. Results A total of 11 patients undergoing RAL and 32 undergoing LSC HM were analyzed. Baseline demographics and clinical characteristics were similar. A trend (p = 0.052) towards a higher number of patients with ASA III score treated with RAL was detectable. Operation time was marginally, but significantly, shorter in LSC (140 min, IQR: 136–150) than in RAL (150 min, IQR: 150–187, p = 0.047). Postoperative complications graded Clavien-Dindo ≥ 3 were only observed in one patient in each group. Length of hospital stay was similar in both groups (LSC: 11 days, IQR: 10–13 vs. RAL: 11 days, IQR: 10–14, p = 0.712). Long-term follow-up (LSC: median 89 months, vs. RAL: median 28 months, p = 0.001) showed comparable results and patients from both groups expressed similar levels of satisfaction (p = 0.181). Conclusions LSC and RAL HM show similar peri- and postoperative results and a high quality of life, even in long-term (> 24 months) follow-up. Prospective, randomized, controlled multicenter trials are needed to overcome difficulties associated to small sample sizes in a rare condition and to confirm the equality or demonstrate the superiority of robotic-assisted procedures for achalasia. Meanwhile, the choice of the treatment technique could be left to the operating surgeon’s preferences.

Robotic Heller’s cardiomyotomy for achalasia: early outcomes for a high-volume UK centre

“…Importantly, they too had no oesophageal perforations in their robotic cohort. 18 A small cohort of five patients who underwent RHCM at a London hospital also demonstrated symptom improvement in all five patients, including one patient who experienced oeosphageal mucosal injury. 38 A further Turkish cohort of six patients reported excellent postoperative patient satisfaction following RHCM, and the absence of oesophageal perforation.…”

“… 11 – 13 Laparoscopic Heller’s cardiomyotomy (LHCM) has been shown to be effective with recurrence of symptoms in 10–25% of patients, but has a reported oesophageal mucosal perforation rate of 4–20%. 14 – 18 …”

“… 21 – 23 These advantages may also aid in achieving complete muscle fibre disruption during the myotomy, which is necessary to ensure resolution of symptoms. 18 …”