Introduction
Achalasia is a primary motility disorder of the esophagus that is treated most effectively
with operative myotomy. Excellent outcomes with laparoscopic myotomy and fundoplication
are well known. Heller myotomy utilizing a computer-enhanced (robotic) laparoscopic
platform allows for a more precise dissection by utilizing the superior optics of
a 3-dimensional camera and greater degrees of freedom provided by robotic instrumentation.
How this affects outcome and quality of life is unknown.
Methods
We assessed patients’ health perceptions using a standardized, validated, health-related,
disease-specific quality-of-life metric. Sixty-one consecutive patients undergoing
laparoscopic or robotic myotomy over a 6-year period were evaluated prospectively.
All operations were performed using intraoperative manometric and endoscopic guidance
and all except 5 patients had a fundoplication. The effects of the operation on health-related
quality of life were evaluated with the Short Form (SF-36) Health Status Questionnaire
and a disease-specific gastroesophageal reflux disease activity (GERD) activity index
(GRACI) preoperatively and postoperatively. All patients completed the questionnaire
at both time points. Patient scores were compared using 2-way repeated measures analyses
of variance followed by the Tukey test. Operative time, estimated blood loss, duration
of stay, intraoperative complication, and postoperative complications were analyzed.
Results
Thirty-seven patients had laparoscopic and 24 patients had robotic Heller myotomy.
There was an increase in SF-36 overall evaluation of health postoperatively compared
with preoperatively in both groups (P < .05). The robotic myotomy patients had better SF-36 Role Functioning (emotional)
and General Health Perceptions (P < .05) compared with the laparoscopic group. The GRACI showed an equivalent improvement
in severity of symptoms in both groups (P < .05). Operative time was 287 ± 9 minutes for laparoscopic cases and 355 ± 23 minutes
for robotic cases. Estimated blood loss and duration of stay were not different between
groups. There were 3 operative esophageal perforations (8%) during laparoscopic myotomy
and all were repaired immediately. There were no perforations or operative complications
in the robotic group. Neither group had any additional complications.
Conclusions
Minimally invasive operative myotomy improves functional status and overall evaluation
of health in patients with achalasia. Robotic myotomy had no intraoperative esophageal
perforations compared with an 8% intraoperative rate during laparoscopic myotomy.
Heller myotomy with partial fundoplication using a robotic platform appears to be
a more precise and safer operation than laparoscopic myotomy with improved quality-of-life
indices postoperatively compared with laparoscopic myotomy with fewer complications;
this suggests that, in skilled hands, the robotic platform may be safer, with improved
quality-of-life outcomes.
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Article info
Publication history
Accepted:
August 18,
2007
Identification
Copyright
© 2007 Mosby, Inc. Published by Elsevier Inc. All rights reserved.
