Background: The most adequate treatment of achalasia is still a matter of debate. In numerous centers, laparoscopic Heller myotomy is the treatment of choice. However, still many patients are referred for surgery after unsuccessful endoscopic treatment. (i.e. pneumatic dilatations or botulinum toxin). The aim of this study was to typify previously treated vs. nontreated patients and to evaluate the outcome after Robotic-assisted Heller Myotomy for achalasia.
Methods: All the patients that underwent robotic-assisted surgical treatment of achalasia at our institution were analized. A retrospective review of prospectively collected perioperative data was performed. Patients were divided in 2 groups: group A; patients that underwent previous endoscopic treatment before surgery, and group B; patients that underwent surgery primarily.
Results: All the operations were completed using minimally invasive techniques. There were 47 women and 46 men, mean age was 44±18 (14-87).
Conclusion: This report shows that patients who underwent unsuccessful endoscopic treatment were mostly older female. The incidence of preoperative acid reflux and aspiration pneumonia was higher in these patients. This suggests that the delay in offering to patients a most permanent method of palliation could have played a role. Although the mean duration of the operation was longer in patients previously treated, the rate of intraoperative mucosal perforations was not different among groups. There was no difference in postoperative symptom improvement between the two groups and the operation was considered equally successful. This demonstrates that Robotic-assisted Heller myotomy is a safe and effective therapy even after unsuccessful endoscopic treatment for achalasia.

	Group A 49 pts	Group B 44 pts	p value
Age (yrs)	50±18	38±16	< 0.05
Female/ Male	63%/ 37%	37%/ 63%	< 0.05
Weight loss preop (%)	47%	56%	NS
Duration of sxs (mo)	76±83	46±62	< 0.05
Preop dysphagia	100%	100%	NS
Preop regurgitation	55%	55%	NS
Preop heartburn	37%	36%	NS
Preop Asp pneumonia	12%	0%
LES Pressure (mmHg)	29±13	33±11	NS
Positive pH study	30%	12.5%
Operative time (min)	152±41	119±46	<0.01
Perforation rate	0	0
Follow up (mo)	18±11	22±15
Good/excellent results	94%	87%	NS