Overall Complications Following Robotic Heller Myotomy Are Lower Compared With Laparoscopy

Robotic versus laparoscopic heller myotomy for esophageal achalasia: an updated systematic review and meta-analysis

BACKGROUND

The surgical treatment for esophageal achalasia has evolved over the years, with laparoscopic Heller myotomy (LHM) and partial fundoplication becoming widely used worldwide. More recently, an increased interest in the robotic Heller myotomy (RHM) has arisen.

PURPOSE

Compare short-term and functional outcomes of RHM vs. LHM.

METHODS

Systematic review and meta-analysis. PubMed, MEDLINE, Scopus, Web of Science, Cochrane Central Library, and ClinicalTrials.gov were queried. Primary outcome was esophageal perforation (EP). Risk ratio (RR), standardized mean difference (SMD), and 95% confidence intervals (95% CI) were effect size and relative inference measures. PROSPERO Registration Number: CRD42024512644.

RESULTS

Fourteen observational studies (12962 patients) were included. Of those, 2503 (19.3%) underwent RHM. The patient age ranged from 34 to 66 years and 51.7% were males. EP occurred in 259 patients (1.99%). The cumulative incidence of EP was 1.67% for RHM and 2.07% for LHM. Compared to LHM, RHM was associated with a reduced risk of EP (RR: 0.31; 95% CI 0.16-0.59). No differences were found in term of dysphagia requiring reoperation or additional endoscopic procedures (RR: 0.47; 95% CI 0.20-1.09) and postoperative Eckardt score (SMD: -0.42; 95% CI -0.94, 0.11). Blood loss, conversion to open, operative time, and hospital length of stay were comparable.

CONCLUSIONS

RHM may be associated with a reduced risk of EP compared to LHM. However, because of selection bias, diverse surgeon expertise, variations in surgical technique, and prior endoscopic procedures these findings should not be viewed as conclusive while the superiority of one approach over the other remains to be established.

Robotics vs Laparoscopy in Foregut Surgery: Systematic Review and Meta-Analysis Analyzing Hiatal Hernia Repair and Heller Myotomy

BACKGROUND

Laparoscopic surgery remains the mainstay of treating foregut pathologies. Several studies have shown improved outcomes with the robotic approach. A systematic review and meta-analysis comparing outcomes of robotic and laparoscopic hiatal hernia repairs (HHR) and Heller myotomy (HM) repairs is needed.

STUDY DESIGN

PubMed, EMBASE, and SCOPUS databases were searched for studies published between January 2010 and November 2022. The risk of bias was assessed using the Cochrane Risk of Bias in Non-Randomized Studies of Interventions tool. Assessed outcomes included intra- and postoperative outcomes. We pooled the dichotomous data using the Mantel-Haenszel random-effects model to report odds ratio (OR) and 95% CIs and continuous data to report mean difference and 95% CIs.

RESULTS

Twenty-two comparative studies enrolling 196,339 patients were included. Thirteen (13,426 robotic and 168,335 laparoscopic patients) studies assessed HHR outcomes, whereas 9 (2,384 robotic and 12,225 laparoscopic patients) assessed HM outcomes. Robotic HHR had a nonsignificantly shorter length of hospital stay (LOS) (mean difference -0.41, 95% CI -0.87 to -0.05), fewer conversions to open (OR 0.22, 95% CI 0.03 to 1.49), and lower morbidity rates (OR 0.76, 95% CI 0.47 to 1.23). Robotic HM led to significantly fewer esophageal perforations (OR 0.36, 95% CI 0.15 to 0.83), reinterventions (OR 0.18, 95% CI 0.07 to 0.47) a nonsignificantly shorter LOS (mean difference -0.31, 95% CI -0.62 to 0.00). Both robotic HM and HHR had significantly longer operative times.

CONCLUSIONS

Laparoscopic and robotic HHR and HM repairs have similar safety profiles and perioperative outcomes. Randomized controlled trials are warranted to compare the 2 methods, given the low-to-moderate quality of included studies.

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

INTRODUCTION

Heller's cardiomyotomy (HCM) is the gold standard treatment for achalasia. Laparoscopic HCM has been shown to be effective with low rates of symptom recurrence, though oesophageal mucosal perforation rates remain high. The aim of this prospective case series is to assess the short-term complication rates and perioperative outcomes for the first cohort of patients undergoing robotic-assisted HCM for achalasia in a single high-volume UK centre.

METHODS

Data were collected from a prospective cohort of patients who underwent robotic HCM at a single high-volume UK centre. Outcomes were assessed using the Eckhard score, which was calculated after their routine postoperative clinic appointments.

RESULTS

Thirteen patients underwent robotic HCM during the study period; this is the second largest reported case series in the European literature. There were no intraoperative oesophageal perforations. Six patients were discharged as day cases, six patients were discharged on the first postoperative day and one patient's hospital stay was two nights. There was a single perioperative complication of urinary retention. All patients reported improvement of symptoms following their operation, and all had a postoperative Eckhard score of less than 3, indicating their achalasia was in remission.

CONCLUSIONS

This cohort has demonstrated that robotic HCM has an exceptional safety profile and results in high levels of symptom resolution, even early in the learning curve. The robotic approach may be superior to laparoscopy as it allows more precise identification and dissection of the oesophageal muscle fibres, which likely reduces the risk of inadvertent mucosal damage or incomplete myotomy.