Achalasia is a rare motility disorder of the esophagus characterized by impaired lower esophageal sphincter (LES) relaxation combined with abnormal esophageal peristalsis. [1] Overall, it is a rare condition with an annual incidence of 1 per 100.000 people and a prevalence of 10 per 100.000, affecting men and women equally. [2] Intermittent dysphagia, chest pain and weight loss are among the most commonly reported symptoms at the time of diagnosis. [3] The Eckardt symptom score is widely used to assess symptom severity. [4] High resolution manometry (HRM) is the gold standard examination in order to confirm the diagnosis and classify patients into achalasia subtypes according to the Chicago classification. [5] The treatment of achalasia is palliative, aiming to alleviate patients’ symptoms. [6] Standard surgical treatment, consists of Heller myotomy combined with a partial fundoplication. [7] Patients, however, may be offered alternative treatment options such as oral pharmacological or endoscopic treatment [2]. Botulinum toxin injections, pneumatic dilations, and per-oral endoscopic myotomy (POEM) are among the endoscopic procedures available [3].
GERD is recognized as a multifactorial clinical entity defined by abnormal levels of refluxed acid in the esophagus [4]. The antireflux barrier, consisting of the lower esophageal sphincter (LES), the crural diaphragm, and the phrenoesophageal ligament, facilitates swallowing while restricting reflux. Hiatal hernia is a may be identified as an anatomic cause of reflux. [8] It is classified in four subtypes based on the GEJ position in relation to the diaphragm and it is often associated with gastroesophageal reflux disease (GERD). [9] Patients with hiatal hernia may present with heartburn and regurgitation and diagnosis is usually established with UGI endoscopy combined with Computed Tomography (CT-scan) imaging. [8, 9] Patients with GERD may initially be treated conservatively and an anti-reflux procedure may be considered in selected cases. [8] Modern approach indicates surgical repair for patients with symptomatic hiatal hernias. [10]
Standard surgical treatment of both achalasia and GERD/hiatal hernia utilizes minimally invasive techniques. The laparoscopic approach has been widely applied in the surgical management of benign UGI disorders worldwide and remains the mainstay of treating benign foregut diseases. [11] On the other hand, robotic platforms have been incorporated in surgery for esophageal motility disorders during the last decade and are progressively gaining more ground due to the improved vision the articulated instruments and the higher degree of movements and manipulation of tissues. [11, 12]
The current technique in achalasia’s surgical treatment originates from the minimally invasive Heller myotomies that were first described by Cuschieri and Pellegrini [12, 13]. Subsequently, the thoracoscopic approach was abandoned because of the superiority of the laparoscopic method in terms of reduced pain and morbidity, while a landmark study conducted by Richards WO et al. established the statistically significant superiority of the addition of Dor fundoplication to prevent postoperative GERD [14, 15]. In 1991, Dallemagne also described the laparoscopic Nissen Fundoplication, which revolutionized the surgical approach to patients with GERD, and shortly after several alterations emerged by reproducing the open variants of partial fundoplication laparoscopically [16, 17].
In the present study, we present results from a case series of 34 consecutive patients who were managed surgically using the DaVinci Xi robotic system for a benign UGI disease in our department. This study aims to assess an early single-specialized unit experience with robotic-assisted surgical treatment for benign UGI diseases, emphasizing on the perioperative and postoperative outcomes.