Robotic and Per-oral Endoscopic Myotomy Have Fewer Technical Complications Compared to Laparoscopic Heller Myotomy

Background: Achalasia is an uncommon disease treated by decreasing the lower esophageal sphincter resting pressure. This study compared the safety and efficacy of esophago-gastric myotomy via laparoscopic, robotic, and per-oral endoscopic approaches.

Methods: A retrospective review of data on patients with achalasia or other esophageal dysmotility disorder undergoing laparoscopic, robotically assisted, or per-oral endoscopic myotomy (POEM) procedures between 2013 and 2017 was performed. Patient demographics, comorbidities, procedure details, length of stay, 30-day readmission rate, and combined technical complication (full-thickness injury, conversion to open, and delayed perforation) were compared. Multiple logistic regression analysis was performed 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 performed during the study period. Baseline statistical differences were found among the groups in regard to gastroesophageal reflux symptoms, 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; 95% CI 2.66, 389.83; p = 0.01), myocardial infarction (OR 27.94; 95% CI 1.66, 471.10; p = 0.02), and history of smoking (OR 8.87; 95% CI 1.29, 61.15; p = 0.03) were risks for developing combined technical complications.

Conclusion: Robotically assisted Heller myotomy and POEM are safe and efficacious treatments for achalasia with lower rates of technical complications compared to laparoscopic Heller myotomy. With the advancements in endoscopic instruments and robotic surgery, POEM and robotically assisted Heller myotomy should be considered in the treatment of achalasia and esophageal dysmotility disorders.