Page 67 - Read Online

Page 2 of 9 Gharagozloo et al. Mini-invasive Surg 2020;4:22 I http://dx.doi.org/10.20517/2574-1225.2019.61

Keywords: Achalasia, robotic, heller myotomy, laparoscopic, eckhardt score

INTRODUCTION
Achalasia is characterized by abnormal relaxation of the lower esophageal muscle and absence of
[1]
progressive peristalsis in the body of the esophagus . In patients with achalasia, histopathologic studies
of the lower esophagus have shown depletion of the ganglion cells and inflammation of the myenteric
[2-3]
plexus . Since the function of the lower esophageal myenteric plexus cannot be restored, presently, the
treatment of achalasia is palliative. The therapeutic options include medical therapy, botulinum toxin
injections, pneumatic dilation, and distal esophageal myotomy by laparoscopy or endoscopy.

Although laparoscopic anterior esophageal myotomy with a Dor anterior fundoplication is the most
commonly performed surgical myotomy procedure, several controversies persist, including the ideal
operative approach, anterior vs. lateral esophageal myotomy, the extent of esophageal myotomy, and the
need for the addition of an antireflux procedure.

[4]
Ellis et al. reported that, after a lateral esophageal myotomy without an antireflux procedure
performed through a left thoracotomy, there was 96% relief of dysphagia and 3.5% rate of post myotomy
gastroesophageal reflux. An anterior myotomy is thought to divide the gastroesophageal valve at its
midpoint, necessitating an antireflux procedure. However, by performing the myotomy laterally and
preserving the antireflux barrier, a fundoplication may be unnecessary. On the other hand, a lateral
[5]
myotomy by thoracoscopy has been associated with high rates of post-myotomy reflux . These results
have been attributed to the shortcomings of conventional videoendoscopic visualization and instruments.
By virtue of high definition magnified 3D visualization and precise instrument maneuverability in a small
space, it has been reasoned that a surgical robot can enable the lateral myotomy procedure to be performed
by laparoscopy. We studied our experience with robotic laparoscopic lateral Heller myotomy without an
antireflux procedure for achalasia (RLHM).

METHODS
A retrospective review was conducted of the patients with achalasia who underwent RLHM. Diagnosis of
achalasia was made by esophagogram, endoscopy, and manometry. Patients who had previously undergone
a myotomy or had a hiatal hernia were excluded from this study. Patients who had undergone a previous
myotomy underwent redo myotomy by left thoracotomy, and patients with a hiatal hernia underwent
an anterior myotomy with repair of the hiatal hernia and Dor fundoplication. All patients completed
a subjective dysphagia score questionnaire, received an Eckardt score, and underwent manometry and
pH testing preoperatively. The dysphagia score, manometry, and pH testing were repeated at 6 months
following the myotomy procedure. The validated dysphagia score instrument scores subjective severity
[6]
and frequency of dysphagia on a scale from 0 to 5 with a total possible Score of 0-10 for each individual .
The dysphagia score is presented as median and range. The Eckardt achalasia scoring instrument scores
dysphagia, regurgitation, retrosternal pain, and weight loss from 0 to 3 with a total possible score of 0-12
[7]
for each individual . In addition, the Eckardt score was tabulated at 1 and 12 months after RLHM. The
Eckhardt score is presented as mean ± SE. Failure of myotomy was defined as an Eckhardt score of ≥ 3.

The study was reviewed and determined to be exempt from institutional review board approval under 45
CFR 46.101 (b).

Surgical technique
The procedure is performed on a laparoscopic platform [Figure 1]. Preoperative upper gastrointestinal
endoscopy is performed and the gastroesophageal junction is examined by the retroflexed endoscope.