title: Robotic Heller myotomy: a safe operation with higher postoperative quality-of-life indices.
abstract: BACKGROUND
  Achalasia is a primary motility disorder of the esophagus that is treated most effectively with operative myotomy. Excellent outcomes with laparoscopic myotomy and fundoplication are well known. Heller myotomy utilizing a computer-enhanced (robotic) laparoscopic platform allows for a more precise dissection by utilizing the superior optics of a 3-dimensional camera and greater degrees of freedom provided by robotic instrumentation. How this affects outcome and quality of life is unknown.
  
  
  METHODS
  We assessed patients' health perceptions using a standardized, validated, health-related, disease-specific quality-of-life metric. Sixty-one consecutive patients undergoing laparoscopic or robotic myotomy over a 6-year period were evaluated prospectively. All operations were performed using intraoperative manometric and endoscopic guidance and all except 5 patients had a fundoplication. The effects of the operation on health-related quality of life were evaluated with the Short Form (SF-36) Health Status Questionnaire and a disease-specific gastroesophageal reflux disease activity (GERD) activity index (GRACI) preoperatively and postoperatively. All patients completed the questionnaire at both time points. Patient scores were compared using 2-way repeated measures analyses of variance followed by the Tukey test. Operative time, estimated blood loss, duration of stay, intraoperative complication, and postoperative complications were analyzed.
  
  
  RESULTS
  Thirty-seven patients had laparoscopic and 24 patients had robotic Heller myotomy. There was an increase in SF-36 overall evaluation of health postoperatively compared with preoperatively in both groups (P < .05). The robotic myotomy patients had better SF-36 Role Functioning (emotional) and General Health Perceptions (P < .05) compared with the laparoscopic group. The GRACI showed an equivalent improvement in severity of symptoms in both groups (P < .05). Operative time was 287 +/- 9 minutes for laparoscopic cases and 355 +/- 23 minutes for robotic cases. Estimated blood loss and duration of stay were not different between groups. There were 3 operative esophageal perforations (8%) during laparoscopic myotomy and all were repaired immediately. There were no perforations or operative complications in the robotic group. Neither group had any additional complications.
  
  
  CONCLUSIONS
  Minimally invasive operative myotomy improves functional status and overall evaluation of health in patients with achalasia. Robotic myotomy had no intraoperative esophageal perforations compared with an 8% intraoperative rate during laparoscopic myotomy. Heller myotomy with partial fundoplication using a robotic platform appears to be a more precise and safer operation than laparoscopic myotomy with improved quality-of-life indices postoperatively compared with laparoscopic myotomy with fewer complications; this suggests that, in skilled hands, the robotic platform may be safer, with improved quality-of-life outcomes.
authors.affiliation: Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio 45267, USA. lynn.huffman@uc.edu
authors.forename: L C
authors.initials: LC
authors.lastname: Huffmanm
authors.forename: P K
authors.initials: PK
authors.lastname: Pandalai
authors.forename: B J
authors.initials: BJ
authors.lastname: Boulton
authors.forename: L
authors.initials: L
authors.lastname: James
authors.forename: S L
authors.initials: SL
authors.lastname: Starnes
authors.forename: M F
authors.initials: MF
authors.lastname: Reed
authors.forename: J A
authors.initials: JA
authors.lastname: Howington
authors.forename: M S
authors.initials: MS
authors.lastname: Nussbaum
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D013505:Digestive System Surgical Procedures / Q000009:adverse effects / Q000379:methods*; D004931:Esophageal Achalasia / Q000523:psychology* / Q000601:surgery*; D004939:Esophageal Perforation / Q000209:etiology; D005260:Female; D018662:Fundoplication / Q000009:adverse effects / Q000379:methods*; D006304:Health Status; D006801:Humans; D007431:Intraoperative Complications; D010535:Laparoscopy / Q000009:adverse effects; D008297:Male; D008875:Middle Aged; D017060:Patient Satisfaction; D011788:Quality of Life; D012371:Robotics; D025321:Surgery, Computer-Assisted; D011795:Surveys and Questionnaires