A decade of experience with minimally invasive anti-reflux operations: robot vs. LESS

BACKGROUND

The increasing use of robotic systems for anti-reflux operations prompted this study to evaluate and compare the efficacy of robotic and Laparo-Endoscopic Single-Site (LESS) approaches.

METHODS

From 2012, 228 robotic fundoplication and 518 LESS fundoplication patients were prospectively followed, analyzing perioperative metrics. Data are presented as median (mean ± SD); significance at p ≤ 0.05.

RESULTS

Patients undergoing a robotic vs. LESS fundoplication were 67 (64 ± 13.7) vs. 61 (59 ± 15.1) years-old with BMIs of 25 (25 ± 3.2) vs. 26 (25 ± 3.9) kg/m2 (p = 0.001 and 1.00, respectively). 72% of patients who underwent the robotic approach had a previous abdominal operation(s) vs 44% who underwent the LESS approach (p = 0.0001). 38% vs. 8% had a re-operative fundoplication (p = 0.0001), 59% vs. 45% had a type IV hiatal hernia (p = 0.0004). Operative duration was 160 (176 ± 76.7) vs. 130 (135 ± 50.5) min (p = 0.0001). There were 0 (robotic) vs. 5 (LESS) conversions to a different approach (p = 0.33). 5 Patients vs. 3 patients experienced postoperative complications (p = 0.06), and length of stay (LOS) was 1 (2 ± 2.6) vs. 1 (1 ± 3.2) days (p = 0.0001). Patient symptomatic dysphagia preoperatively for the robotic vs. LESS approach was scored as 2 (2.4 ± 1.9) vs. 1 (1.9 ± 1.6). Postoperatively, symptomatic dysphagia was scored as 1 (1.5 ± 1.6) vs. 1 (1.7 ± 1.7). The change in these scores was - 1 (- 1 ± 2.2) vs. 0 (- 0.5 ± 2.2) (p = 0.004).

CONCLUSION

Despite longer operative times and LOS in older patients, the robotic approach is efficient in undertaking very difficult operations, including patients with type IV or recurrent hiatal hernias. Furthermore, preoperative anti-reflux operations were more likely to be undertaken with the robotic approach than the LESS approach. The patient's postoperative symptomatic dysphagia improved relatively more than after the LESS approach. The vast majority of patients who underwent the LESS approach enjoyed improved cosmesis, thus, making LESS a stronger candidate for more routine operations. Despite patient selection bias, the robotic and LESS approaches to anti-reflux operations are safe, efficacious, and should be situationally utilized.

Robotic-assisted versus laparoscopic redo antireflux surgery in children: A cost-effectiveness study

INTRODUCTION

Robotic-assisted redo fundoplication has some advantages compared to the laparoscopic approach in adults, although to date there are no studies in children.

METHODS

A retrospective case-control study was performed among consecutive children who underwent redo antireflux surgery between 2004 and 2020, divided into two groups: LAF group (laparoscopic redo-fundoplication) and RAF group (robotic-assisted redo-fundoplication). Demographics, clinical, intraoperative, postoperative and economic data were compared.

RESULTS

A total of 24 patients were included (10 LAF group; 14 RAF group) without demographic or clinical differences. The RAF group presented lower intraoperative blood loss (52 ± 19 vs. 145 ± 69 mL; p < 0.021), shorter surgery time (135 ± 39 vs. 179 ± 68 min; p = 0.009) and shorter length of hospital stay (median 3 days [2-4] vs. 5 days [3-7]; p = 0.002). The RAF group presented a higher rate of symptom improvement (85.7% vs. 60%; p = 0.192) and lower overall associated economic costs (25 800$ vs. 45 500$; p = 0.012).

CONCLUSION

Robotic-assisted redo antireflux surgery may offer several benefits over the laparoscopic approach. Prospective studies are still needed.

A systematic review of robot-assisted anti-reflux surgery to examine reporting standards

Robot-assisted anti-reflux surgery (RA-ARS) is increasingly being used to treat refractory gastro-oesophageal reflux disease. The IDEAL (Idea, Development, Exploration, Assessment, Long-term follow up) Collaboration's framework aims to improve the evaluation of surgical innovation, but the extent to which the evolution of RA-ARS has followed this model is unclear. This study aims to evaluate the standard to which RA-ARS has been reported during its evolution, in relation to the IDEAL framework. A systematic review from inception to June 2020 was undertaken to identify all primary English language studies pertaining to RA-ARS. Studies of paraoesophageal or giant hernias were excluded. Data extraction was informed by IDEAL guidelines and summarised by narrative synthesis. Twenty-three studies were included: two case reports, five case series, ten cohort studies and six randomised controlled trials. The majority were single-centre studies comparing RA-ARS and laparoscopic Nissen fundoplication. Eleven (48%) studies reported patient selection criteria, with high variability between studies. Few studies reported conflicts of interest (30%), funding arrangements (26%), or surgeons' prior robotic experience (13%). Outcome reporting was heterogeneous; 157 distinct outcomes were identified. No single outcome was reported in all studies.The under-reporting of important aspects of study design and high degree of outcome heterogeneity impedes the ability to draw meaningful conclusions from the body of evidence. There is a need for further well-designed prospective studies and randomised trials, alongside agreement about outcome selection, measurement and reporting for future RA-ARS studies.