Robotic lateral heller myotomy without fundoplication for achalasia

Abstract

Aim: Laparoscopic anterior esophageal myotomy with a Dor anterior fundoplication is the most commonly performed surgical myotomy procedure. A lateral esophageal myotomy without an antireflux procedure performed through a left thoracotomy has been associated with the lowest rate of postoperative gastroesophageal reflux and the highest rate for relief of dysphagia. The surgical robot allows for the lateral myotomy procedure to be performed by laparoscopy rather than thoracotomy. We studied our experience with Robotic Lateral Heller Myotomy Without Fundoplication (RLHM) for achalasia.

Methods: A retrospective review was conducted of the patients with achalasia who underwent RLHM. All patients completed a subjective dysphagia score questionnaire, received an Eckardt Score, and underwent manometry and pH testing preoperatively, as well as at 6 and 12 months following the myotomy procedure.

Results: Forty-eight patients underwent RLHM. The median operating room time was 85 min (range 60-132 min). There was no conversion to a laparotomy. Median hospitalization was 2 days (range 2-3 days). There were no mucosal perforations, complications, or deaths. Following RLHM, the Lower Esophageal pressure decreased from 35 mmHg (range 18-120 mmHg) to 13.2 mmHg (range 9.8-16.6 mmHg) (P < 0.0001). The length of the Lower Esophageal high-pressure xone decreased from 5.5 cm (range 4-9 cm) to 2.2 cm (range 1.5-2.8 cm) (P < 0.0001). Two patients (2/48) (4.2%) had pathologic gastroesophageal reflux. The median acid exposure in all patients was 0.4% (range 0%-17.8%), and the median Demeester score was 7.5 (range 2-125). The Eckardt score decreased from 6.3 ± 1.8 to 0.8 ± 1.8 at 1 month (P < 0.0001), and 0.8 ± 1.1 at 12 months (P < 0.0001).

Conclusion: RLHM is associated with excellent relief of dysphagia and a low incidence of new gastroesophageal reflux.

Keywords

Achalasia / robotic / heller myotomy / laparoscopic / eckhardt score

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