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THE USE OF A ROBOTIC THAL-HATAFUKU ESOPHAGOGASTROPLASTY FOR SEVERE ESOPHAGEAL STRICTURE, A FRESH LOOK AT AN OLD PROCEDURE
K Piening, A Awwad, D Crawford
University of Illinois, Peoria

Introduction
Severe Gastroesophageal Reflux Disease causing esophageal stricture is a well know disease process often encountered by General Surgeons. While first line treatment for stricture commonly involves repeated endoscopic dilations and potential stent placement, between ten and thirty percent of patients will experience re-stenosis regardless of the underlying cause. Once recalcitrant disease has been identified, more invasive surgical techniques are required to appropriately treat the patients. One such technique, the Thal-Hatafuku esophagogastroplasty, has historically been used on severe strictures and megaesophagus.

Case Description
A 79 year old male with a long standing history of GERD presented with dysphagia and 30 pound weight loss over the course of two years. He underwent esophagogastroduodenoscopy which revealed a near obstructing stricture at the distal esophagus; this was dilated at the time of procedure. Despite repeated endoscopic attempts at dilation, the patient remained severely symptomatic from his stricture. Therefore he was taken to the operating room for a robotic Thal-Hatafuku esophagogastroplasty. The superior stomach and distal esophagus were mobilized in the standard fashion of fundoplications. An endoscope was then advanced down the esophagus and across the level of the stricture. A gastrotomy was then created over the distal end of the endoscope and a vessel sealer then used to open the proximal cardia and distal esophagus. The luminal opening was then closed by creating an anterior fundoplication where the serosa of the fundus was sewn directly to the esophageal and gastric mucosa. Postoperatively his diet was slowly advanced with complete resolution of his symptoms.

Discussion
This patient had a severely symptomatic benign stricture that was recalcitrant to endoscopic therapy necessitating more invasive surgical intervention and the Thal-Hatafuku procedure has been historically described to treat such patients. While there have been prior reports of laparoscopic and robotic Heller myotomies, this is the first such case of a robotic Thal-Hatafuku esophagogastroplasty to the knowledge of the authors. We hope to contribute to the growing body of literature on complex foregut pathology successfully treated through robotic assisted surgery.


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