ROBOT-ASSISTED HELLER’S MYOTOMY IN CHILDREN: A SAFE ALTERNATIVE TO LAPAROSCOPY

Background Achalasia is a rare esophageal disorder that affects mainly young adults (1-6:100000) without gender prevalence. It is rarer in children, with a prevalence of 0,11:100000 individuals. It presents as the absence of esophageal peristalsis and an incomplete or absent relaxation of the lower esophageal sphincter. The gold standard for the treatment of achalasia is Heller’s myotomy either laparoscopic or robot-assisted. Recently the perioral endoscopic myotomy (POEM) has also been introduced in the practice, leaving the botulinum injection and endoscopic dilatations as palliatives for the cases that cannot undergo surgery. Materials and methods We present the case of a 15 years old girl, who came to our attention after a 7 months history of dysphagia, regurgitation, nocturnal cough and weight loss (almost 10 kilos) with evidence at esophago-gastroduodenoscopy (EGD) of many food residuals in the esophagus and impossibility to enter the stomach. During hospitalization, we performed an upper gastrointestinal study, esophageal manometry and another EGD under general anesthesia, which returned the diagnosis of achalasia. Since the patient could not feed properly, a peripherally inserted central venous catheter (PICC) was positioned for parenteral nutrition associated with a liquid diet, followed by PICC infection and drug-related neutropenia. Once clinically stable, the girl underwent a robot-assisted Heller’s myotomy and Dor’s anterior gastric fundoplication (DaVinci Xi Surgical System ®). Results The procedure was accomplished with the patient in a supine anti-Trendelemburg position. About 8 cm-long myotomy was performed under endoscopic control of mucosal integrity. The robotic procedure was completed in about 200 minutes. The postoperative course was unremarkable: the patient started oral food intake on the first postoperave day, well tolerated, and was discharged on the 6th postoperative day. Conclusions Treatment of esophageal achalasia is mainly mini-invasive. There are 18 pediatric cases (other than our) of robot-assisted Heller’s myotomy reported in literature up-to-date. Most of the patients (12/18) underwent a consensual anti-reflux procedure (4 Dor fundoplication; 2 Thal fundoplication; 6 Toupet partial posterior wrap). None of them were converted or presented intra- or postoperative complications. The postoperative course seems to be uneventful and the patients recover well after surgery. Robot-assisted procedure is reported to be safer than laparoscopy in term of mucosal perforation (0% reported). This may be due to the robotic high definition 3D-view, tremor filtering and motion scaling. Moreover, the higher flexibility of the instruments allow the surgeon to work more comfortably in narrow spaces. Even if the number of robot-assisted pediatric Heller’s myotomy is still limited, this procedure seems to be a valid alternative to both the laparoscopy and the POEM and surely we need further experience to confirm the current data.