Clinical and functional outcome following robotic myotomy with partial fundoplication in patients with achalasia

Introduction The minimal invasive myotomy with partial fundoplication for symptomatic patients with achalasia is the gold-standard. It has been established as a safe and effective procedure in the past decades. With the rise of robotic-assisted surgery in recent years, studies comparing both procedures have shown similar short-term results with a lower rate of intraoperative esophageal perforations in patients treated robotically. However, due to a lack of long-term results providing clinical and functional outcomes, our aim was to investigate a collective undergoing robotic-assisted surgery providing pre- and postoperative established symptom score und high-resolution manometry.

Methods All patients underwent clinical, endoscopic, radiological und manometric investigation to verify the diagnosis of achalasia. High-resolution manometry was performed preoperatively und 6 months following surgery and was categorized according to the current Chicago-Classification (v3.0). Furthermore, we used the Eckhardt Score to evaluate symptomatic outcome. All patients underwent robotic-assisted myotomy with partial anterior fundoplication using the DaVinci Xi surgical system (Intuitive, Sunnyvale, California, USA).

Results We analyzed 35 consecutive robotic procedures for achalasia between September 2017 and September 2019. Included were 18 male and 17 female patients with median age of 48 years. All patients showed a significant improvement of symptoms subjectively with a significant decrease of the Eckhard score from 8 preoperatively to 3 postoperatively. The postoperative lower esophageal resting pressure (LESP) and residual pressure (4s-IRP) was significantly reduced in all patients (median LESP 40,6 mmHg vs.11,9 mmHg; median 4s-IRP 29,6 mmHg vs 10 mmHg). There was no event of intraoperative esophageal perforation or conversion to open surgery.

Conclusion Our data support the feasibility and effective robotic approach for the surgical treatment of achalasia. Although, our data are based on a short-term follow up, our results are non-inferior to the reported laparoscopic approach. Further investigations in larger prospective multicenter studies are needed to verify a potential superiority of the robotic approach.