Aman B Ali, MD, Najah A Khan, Duc T Nguyen, MD, PhD, Ray K Chihara, MD, PhD, Edward Y Chan, MD, Edward A Graviss, PhD, MPH, Min P Kim, MD. Houston Methodist Hospital
Introduction: Achalasia is an uncommon disease treated by decreasing the lower esophageal sphincter resting pressure. We compared the safety and efficacy of esophago-gastric myotomy via laparoscopic, robotic, and peroral endoscopic approaches.
Methods: We performed a retrospective review of prospectively collected data on patients with achalasia or other esophageal dysmotility disorder undergoing laparoscopic, robotically assisted, or peroral endoscopic myotomy (POEM) between 2013 to 2017. We compared patient demographics, comorbidities, procedure details, length of stay, 30-day readmission rate, and combined technical complication (mucosal injury, conversion to open and delayed perforation). We then performed multivariate analysis to determine which factors contributed to combined technical complication.
Results: There were 171 patients who underwent esophago-gastric myotomy with 161 (94.2%) having achalasia. There were 40 laparoscopic Heller myotomies with partial fundoplication, 44 robotic Heller myotomies with partial fundoplication, and 87 POEM procedures during that time. There were statistical differences among the groups with diagnosis of reflux, arrhythmia, hypertension and congestive heart failure. Laparoscopic Heller myotomy had significantly higher combined technical complications (7, 17.5%) compared to robotically-assisted Heller myotomy (0, 0%) and POEM (1, 1.1%). Multivariate analysis showed that laparoscopic Heller myotomy (OR 32.22 (2.66, 389.83), p=0.01), myocardial infarction (OR 27.94 (1.66, 471.10), p=0.02) and history of smoking (OR 8.87 (1.29, 61.15), p=0.03) were risks of developing a combined technical complication.
Conclusion: Robotically-assisted Heller myotomy and POEM are safe and efficacious treatments for achalasia with lower rates of technical complication compared to laparoscopic Heller myotomy. With the advancements in endoscopic instruments and robotic surgery, peroral endoscopic myotomy and robotic Heller myotomy should be considered in the treatment of achalasia and esophageal dysmotility disorders.
Table 1. Patient outcomes
|
Total (n=171) |
Lap (n=40) |
Robot (n=44) |
POEM (n=87) |
p-value | |
| Outcomes | |||||
| Combined end point | 8(4.7) | 7(17.6) | 0(0) | 1(1.1) | <0.001 |
|
Conversion to open |
2(1.2) | 2(5) | 0(0) | 0(0) | 0.054 |
| Mucosal injury | 7(4.1) | 6(15) | 0(0) | 1(1.1) | 0.001 |
| Delayed perforation | 1(0.6) | 1(2.5) | 0(0) | 0(0) | 0.23 |
| Readmission | 4(2.3) | 3(7.5) | 1(2.3) | 0(0) | 0.02 |
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 93685
Program Number: S083
Presentation Session: Foregut III
Presentation Type: Podium