{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,28]],"date-time":"2026-08-28T21:12:10Z","timestamp":1787951530226,"version":"build-2784847793"},"reference-count":26,"publisher":"Oxford University Press (OUP)","issue":"10","license":[{"start":{"date-parts":[[2019,7,5]],"date-time":"2019-07-05T00:00:00Z","timestamp":1562284800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/academic.oup.com\/journals\/pages\/open_access\/funder_policies\/chorus\/standard_publication_model"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2019,12,13]]},"abstract":"<jats:title>SUMMARY<\/jats:title>\n                  <jats:p>Minimally invasive Heller myotomy is considered the gold standard surgical approach for symptomatic achalasia because it is a safe and effective procedure. Over the last years, several studies comparing the laparoscopic and robotic approach for Heller myotomy have been published. Although the robotic approach appears to have some advantages over standard laparoscopy, data on this topic are still controversial and no definite conclusions have been drawn. This metanalysis has been designed to systematically evaluate and compare the effectiveness and safety of the robot-assisted Heller myotomy as compared to the standard laparoscopic approach. According to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, a systematic search on both laparoscopic and robotic Heller myotomy was performed in all the major electronic databases (PubMed, Web of Science, Scopus, EMBASE), using the following search string: (achalasia OR Dor) AND robotic. Six articles were included in the final analysis. A metaregression analysis was performed to assess the possible effects of demographic variables (age, gender, body mass indes (BMI)) and previous abdominal surgery or endoscopic intervention on the analyzed outcomes. No statistical difference was observed in operative times (mean difference (MD) = 20.79, P = 0.19, 95% confidence interval (CI) \u221210.05,51,62), estimated blood loss (MD = \u221217.10, P = 0.13, 95% CI \u221240.48,5.08), conversion rate to open surgery (risk difference (RD) = \u22120.01, P = 0.33, 95% CI \u22120.05,0.02), length of hospital stay (MD = \u22120.73, P = 0.15, 95% CI \u22121.71,0.25) and long-term recurrence (odds ratio (OR) = 0.59, P = 0.45, 95% CI 0.15,2.33). On the contrary, the robotic approach was found to be associated with a significantly significant lower rate of intraoperative esophageal perforations (OR = 0.13, P &amp;lt; 0.001, 95% CI 0.04, 0.45). Our results suggest that the robotic approach is safer than the laparoscopic Heller myotomy, encouraging the use of robot-assisted surgery. However, our analysis is limited because of the exiguous number of comparative studies and because most of the included studies were statistically underpowered, given the small sample size. Moreover, a high degree of heterogeneity was observed in most of published studies. Taking in consideration the additional costs of robot-assisted procedures, larger Randomized Controlled Trials (RCTs) are advocated to confirm the safety and effectiveness of the robotic approach, and its advantages over standard laparoscopic surgery. In conclusion, well-designed prospective trials and RCTs with homogeneous parameters are needed to draw definitive conclusions about the best surgical approach to pursue in treating symptomatic achalasia.<\/jats:p>","DOI":"10.1093\/dote\/doz062","type":"journal-article","created":{"date-parts":[[2019,7,5]],"date-time":"2019-07-05T05:02:56Z","timestamp":1562302976000},"page":"1-8","source":"Crossref","is-referenced-by-count":54,"title":["Robotic versus laparoscopic approach to treat symptomatic achalasia: systematic review with meta-analysis"],"prefix":"10.1093","volume":"32","author":[{"given":"M","family":"Milone","sequence":"first","affiliation":[{"name":"Department of Clinical Medcine and Surgery, Federico II University, Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"M","family":"Manigrasso","sequence":"additional","affiliation":[{"name":"Department of Clinical Medcine and Surgery, Federico II University, Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"S","family":"Vertaldi","sequence":"additional","affiliation":[{"name":"Department of Clinical Medcine and Surgery, Federico II University, Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"N","family":"Velotti","sequence":"additional","affiliation":[{"name":"Department of Clinical Medcine and Surgery, Federico II University, Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"G","family":"Aprea","sequence":"additional","affiliation":[{"name":"Department of Clinical Medcine and Surgery, Federico II University, Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"F","family":"Maione","sequence":"additional","affiliation":[{"name":"Department of Clinical Medcine and Surgery, Federico II University, Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"N","family":"Gennarelli","sequence":"additional","affiliation":[{"name":"Department of Clinical Medcine and Surgery, Federico II University, Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"G","family":"De Simone","sequence":"additional","affiliation":[{"name":"Department of Clinical Medcine and Surgery, Federico II University, Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"B","family":"De Conno","sequence":"additional","affiliation":[{"name":"Department of Clinical Medcine and Surgery, Federico II University, Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"M","family":"Pesce","sequence":"additional","affiliation":[{"name":"Department of Clinical Medcine and Surgery, Federico II University, Naples, Italy"},{"name":"Division of Gastroenterology, Department of GI Physiology, University College London Hospitals, London, England, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"G","family":"Sarnelli","sequence":"additional","affiliation":[{"name":"Department of Clinical Medcine and Surgery, Federico II University, Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"G D","family":"De Palma","sequence":"additional","affiliation":[{"name":"Department of Clinical Medcine and Surgery, Federico II University, Naples, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2019,7,5]]},"reference":[{"issue":"5","key":"2019121802272744400_bib1","doi-asserted-by":"crossref","first-page":"698","DOI":"10.1016\/S1072-7515(02)01837-9","article-title":"Impact of minimally invasive surgery on the treatment of esophageal achalasia: a decade of change","volume":"196","author":"Patti","year":"2003","journal-title":"J Am Coll Surg"},{"issue":"6","key":"2019121802272744400_bib2","doi-asserted-by":"crossref","first-page":"655","DOI":"10.1097\/00000658-199706000-00003","article-title":"Laparoscopic Heller myotomy and fundoplication for achalasia","volume":"225","author":"Hunter","year":"1997","journal-title":"Ann Surg"},{"issue":"4","key":"2019121802272744400_bib3","doi-asserted-by":"crossref","first-page":"553","DOI":"10.1016\/j.surg.2005.07.025","article-title":"Computer-enhanced robotic telesurgery minimizes esophageal perforation during Heller myotomy","volume":"138","author":"Melvin","year":"2005","journal-title":"Surgery"},{"issue":"7","key":"2019121802272744400_bib4","doi-asserted-by":"crossref","first-page":"1105","DOI":"10.1007\/s00464-005-0272-9","article-title":"Laparoscopic Heller myotomy for achalasia facilitated by robotic assistance","volume":"20","author":"Galvani","year":"2006","journal-title":"Surg Endosc"},{"issue":"2","key":"2019121802272744400_bib5","doi-asserted-by":"crossref","first-page":"254","DOI":"10.1097\/SLA.0b013e3181e6239e","article-title":"Efficacy of the Da Vinci surgical system in abdominal surgery compared with that of laparoscopy: a systematic review and meta-analysis","volume":"252","author":"Maeso","year":"2010","journal-title":"Ann Surg"},{"issue":"7","key":"2019121802272744400_bib6","doi-asserted-by":"crossref","first-page":"e1000097","DOI":"10.1371\/journal.pmed.1000097","article-title":"Preferred reporting items for systematic reviews and meta-analyses: The PRISMA Statement","volume":"6","author":"Moher","year":"2009","journal-title":"PLoS Med"},{"key":"2019121802272744400_bib7","article-title":"The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomized studies in meta-analyses.","author":"Wells","year":"2011"},{"issue":"1","key":"2019121802272744400_bib8","doi-asserted-by":"crossref","first-page":"127","DOI":"10.1016\/j.ijcard.2012.06.078","article-title":"Using risk difference as opposed to odds-ratio in meta-analysis","volume":"20","author":"Messori","year":"2013","journal-title":"Int J Cardiol"},{"issue":"1","key":"2019121802272744400_bib9","doi-asserted-by":"crossref","first-page":"13","DOI":"10.1186\/1471-2288-5-13","article-title":"Estimating the mean and variance from the median, range, and the size of a sample","volume":"5","author":"Hozo","year":"2005","journal-title":"BMC Med Res Methodol"},{"issue":"1","key":"2019121802272744400_bib10","doi-asserted-by":"crossref","first-page":"7","DOI":"10.1016\/j.jclinepi.2005.06.006","article-title":"Imputing missing standard deviations in meta-analyses can provide accurate results","volume":"59","author":"Furukawa","year":"2006","journal-title":"J Clin Epidemiol"},{"issue":"7304","key":"2019121802272744400_bib11","doi-asserted-by":"crossref","first-page":"101","DOI":"10.1136\/bmj.323.7304.101","article-title":"Systematic reviews in health care: investigating and dealing with publication and other biases in meta-analysis","volume":"323","author":"Sterne","year":"2001","journal-title":"BMJ"},{"issue":"2","key":"2019121802272744400_bib12","doi-asserted-by":"crossref","first-page":"455","DOI":"10.1111\/j.0006-341X.2000.00455.x","article-title":"Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis","volume":"56","author":"Duval","year":"2000","journal-title":"Biometrics"},{"issue":"3","key":"2019121802272744400_bib13","doi-asserted-by":"crossref","first-page":"397","DOI":"10.1007\/s11701-018-0865-7","article-title":"Optimal surgical intervention for achalasia: laparoscopic or robotic approach","volume":"13","author":"Kim","year":"2019","journal-title":"J Robot Surg"},{"issue":"11","key":"2019121802272744400_bib14","doi-asserted-by":"crossref","first-page":"3162","DOI":"10.1007\/s00464-014-3576-9","article-title":"Efficacy and durability of robotic Heller myotomy for achalasia: patient symptoms and satisfaction at long-term follow-up","volume":"28","author":"Perry","year":"2014","journal-title":"Surg Endosc"},{"key":"2019121802272744400_bib15","doi-asserted-by":"crossref","first-page":"213","DOI":"10.1007\/s11701-011-0294-3","article-title":"Robotic-assisted Heller myotomy versus laparoscopic Heller myotomy for the treatment of esophageal achalasia: a case-control study","volume":"6","author":"S\u00e1nchez","year":"2012","journal-title":"J Robot Surg"},{"issue":"4","key":"2019121802272744400_bib16","doi-asserted-by":"crossref","first-page":"1047","DOI":"10.1007\/s00464-011-1994-5","article-title":"How does the robot affect outcomes? A retrospective review of open, laparoscopic, and robotic Heller myotomy for achalasia","volume":"26","author":"Shaligram","year":"2012","journal-title":"Surg Endosc"},{"issue":"4","key":"2019121802272744400_bib17","doi-asserted-by":"crossref","first-page":"613","DOI":"10.1016\/j.surg.2007.08.003","article-title":"Robotic Heller myotomy: a safe operation with higher postoperative quality-of-life indices","volume":"142","author":"Huffmanm","year":"2007","journal-title":"Surgery"},{"issue":"8","key":"2019121802272744400_bib18","doi-asserted-by":"crossref","first-page":"1020","DOI":"10.1016\/j.gassur.2005.06.026","article-title":"Robotic-assisted Heller myotomy versus laparoscopic Heller myotomy for the treatment of esophageal achalasia: multicenter study","volume":"9","author":"Horgan","year":"2005","journal-title":"J Gastrointest Surg"},{"key":"2019121802272744400_bib19","doi-asserted-by":"crossref","first-page":"789","DOI":"10.1016\/0016-5085(81)90142-6","article-title":"A prospective randomized study comparing forceful dilatation and esophagomyotomy in patients with achalasia of the esophagus","volume":"80","author":"Csendes","year":"1981","journal-title":"Gastroenterology"},{"key":"2019121802272744400_bib20","first-page":"152","article-title":"Laparoscopic cardiomyotomy for achalasia","volume":"36","author":"Shimi","year":"1991","journal-title":"J R Coll Surg Edinb"},{"issue":"4","key":"2019121802272744400_bib21","doi-asserted-by":"crossref","first-page":"587","DOI":"10.1097\/00000658-199910000-00014","article-title":"Minimally invasive surgery for achalasia: an 8-year experience with 168 patients","volume":"230","author":"Patti","year":"1999","journal-title":"Ann Surg"},{"issue":"8","key":"2019121802272744400_bib22","doi-asserted-by":"crossref","first-page":"892","DOI":"10.1001\/archsurg.136.8.892","article-title":"Laparoscopic Heller myotomy improves esophageal emptying and the symptoms of achalasia","volume":"136","author":"Finley","year":"2001","journal-title":"Arch Surg"},{"issue":"3","key":"2019121802272744400_bib23","doi-asserted-by":"crossref","first-page":"282","DOI":"10.1016\/S1091-255X(00)80077-3","article-title":"Treatment of esophageal achalasia with laparoscopic Heller myotomy and dor partial anterior fundoplication: prospective evaluation of 100 consecutive patients","volume":"4","author":"Zaninotto","year":"2000","journal-title":"J Gastrointest Surg"},{"issue":"19","key":"2019121802272744400_bib24","doi-asserted-by":"crossref","first-page":"1807","DOI":"10.1056\/NEJMoa1010502","article-title":"Pneumatic dilation versus laparoscopic Heller's myotomy for idiopathic achalasia","volume":"364","author":"Boeckxstaens","year":"2011","journal-title":"N Engl J Med"},{"issue":"4","key":"2019121802272744400_bib25","doi-asserted-by":"crossref","first-page":"587","DOI":"10.1097\/00000658-199910000-00014","article-title":"Minimally invasive surgery for achalasia: an 8-year experience with 168 patients","volume":"230","author":"Patti","year":"1999","journal-title":"Ann Surg"},{"issue":"9","key":"2019121802272744400_bib26","doi-asserted-by":"crossref","first-page":"827","DOI":"10.1001\/archsurg.140.9.827","article-title":"Laparoscopic Heller myotomy with Toupet fundoplication: outcome predictors in 121 consecutive patients","volume":"140","author":"Khajanchee","year":"2005","journal-title":"Arch Surg"}],"container-title":["Diseases of the Esophagus"],"original-title":[],"language":"en","link":[{"URL":"http:\/\/academic.oup.com\/dote\/article-pdf\/32\/10\/1\/31558762\/doz062.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"http:\/\/academic.oup.com\/dote\/article-pdf\/32\/10\/1\/31558762\/doz062.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2019,12,18]],"date-time":"2019-12-18T02:27:56Z","timestamp":1576636076000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/dote\/article\/32\/10\/1\/5528452"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2019,7,5]]},"references-count":26,"journal-issue":{"issue":"10","published-online":{"date-parts":[[2019,7,5]]},"published-print":{"date-parts":[[2019,12,13]]}},"URL":"https:\/\/doi.org\/10.1093\/dote\/doz062","relation":{},"ISSN":["1120-8694","1442-2050"],"issn-type":[{"value":"1120-8694","type":"print"},{"value":"1442-2050","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2019,10]]},"published":{"date-parts":[[2019,7,5]]}}}