Robot-assisted Heller’s myotomy for achalasia in children

Abstract

Background: Achalasia is rare in children. Surgical options include open, laparoscopic and robotic approaches. However, Heller's myotomy remains the treatment of choice. This report describes our experience with robot-assisted Heller's myotomy in children and presents a review of the literature. Methods: Included in this study are children who underwent robot-assisted Heller's myotomy for esophageal achalasia via the Da Vinci surgical system between 2004 and 2015 at King Saud University Medical City, Riyadh, Saudi Arabia. The medical records of these patients were reviewed for demographic data, presenting symptoms, diagnostic modalities, operative procedures, complications, outcomes and follow-ups. Results: Six patients were identified. The age of the patients at surgery ranged between 2 and 12 years (mean 7.1 years). The most common presenting symptoms were dysphagia, vomiting and nocturnal cough. Contrast swallow and upper gastrointestinal endoscopy established a diagnosis of esophageal achalasia in all of the patients. Four patients underwent esophageal dilatation 2-5 times before the definitive procedure. All patients underwent successful robot-assisted Heller's myotomy with concomitant partial posterior fundoplication. The postoperative course was uneventful. Five patients had a complete resolution of the symptoms and one patient improved. The follow-up assessments have been consistent and have ranged from 0.5 to 11 years (mean 4.4 years). Conclusion: Robotic-assisted Heller's myotomy for esophageal achalasia in children is safe and effective and is a suitable alternative to open and laparoscopic approaches.

Robotic Heller myotomy

“…The left crus is then identified and dissected out. The method of esophageal exposure is consistent with prior literature description [17,[24][25][26] . Figure 1.…”

“…The rate of esophageal mucosal perforation is of primary consideration throughout the literature. There are no noted mucosal perforations in any of the case reports and only 1 perforation noted in the retrospective reviews [14,15,21,22,24,25,27,32] . In a review of the progression of the role of myotomy, Allaix and Patti [33] highlight two separate studies that show rates of mucosal perforation in LHM being 16% and 8%, while the RHM groups had a 0% perforation rate in both studies.…”

“…When considering the operative surgical goal for achalasia, RHM is effective in achieving symptomatic relief without producing significant morbidity. Each case report indicates short-term post-operative relief of dysphagia symptoms [22,24,25,32] . Two larger studies of greater than 50 patients reported a 92.4% and 100% rate of relief for dysphagia symptoms following operation with 80% of patients needing no further intervention [13,27] .…”

Paediatric robotic surgery and urology: where are we?

“…Case reports and small series have been published that describe a range of other general paediatric surgery procedures such as diaphragmatic hernia repair [2,25], Heller's cardiomyotomy for achalasia [26,27], duodenojejunostomy for SMA syndrome [28], duodenal atresia repair [3], and anorectal pull-through for anorectal malformations [15]. Currently these case studies are mostly demonstrating feasibility rather than equivalence/superior outcomes.…”

Paediatric robotic surgery

“…There are also case reports and series that document a diverse array of successful robotic general and gynaecological surgery such as robotic-assisted diaphragmatic hernia repair, 39,40 Heller's cardiomyotomy for achalasia, 41,42 duodenojejunostomy for SMA syndrome, 43 repair of duodenal atresia, 44 anorectal pull-through for anorectal malformations, 38 ovarian cystectomies and salpingo/oophorectomies. 45 Further study is needed to assess whether these procedures are indeed effective and whether they confer any benefit above traditional minimally invasive surgery (MIS).…”