Hiatal Hernia

Background. The objective: to compare the effectiveness and safety of known laparoscopic antireflux interventions in the treatment of hiatal hernia and to detect the causes for their failure in a retrospective study. Materials and methods. In a retrospective comparative study, the long-term results of using the main methods of laparoscopic plastic surgery for hiatal hernias of various types and degrees were analyzed. Seventy-four (56.5 %) patients who underwent Nissen fundoplication were included in group 1. Group 2 consisted of 37 (28.2 %) people who underwent Toupet fundoplication and group 3 included 20 (15.3 %) patients who underwent Dor fundoplication. The study includes patients operated in the clinic of the institute over a 7-year period, with the possibility of clinical evaluation of long-term results and the exclusion of factors affecting the results of plastic surgery. All patients underwent X-ray and endoscopic examinations of the esophagus, stomach, duodenum, as well as manometry. Results. When analyzing the complaints of patients from groups 1–3 in the postoperative period, it can be noted that the most statistically significant indicators were dysphagia, regurgitation, cough, heartburn, bloating, stomach heaviness, pain behind the sternum (p < 0.05, exact F test). During endoscopic examination, reflux esophagitis was detected in 16 (21.6 %) patients of group 1, in 7 (18.9 %) of group 2, and in 2 (10.0 %) patients of group 3. Erosions of the lower third of the esophagus were found in 14 (18.9 %) patients from group 1, in 6 (16.2 %) from group 2, and in 2 (10.0 %) patients from group 3. Esophageal stricture was detected in 1 (1.4 %) patient from group 1 in the postoperative period during endoscopic examination. Signs of a “second entrance” to the stomach were found in 16 (13.5 %) patients of group 1, in 5 (13.5 %) of group 2, and in 2 (10.0 %) of group 3. Dislocation of the fundoplication cuff was noted in 1 (1.3 %) patient of group 1, resulting in deformation of the esophagogastric junction and pain syndrome. Pylorospasm was found in 8 (8.8 %) patients from group 1, in 3 (2.9 %) from group 2 and in 1 (5.0 %) patient from group 3. During the X-ray examination, recurrent hiatal hernia was detected: in group 1 — in 10 (13.5 %) cases, in group 2 — in 5 (13.5 %), in group 3 — in 2 (10.0 %). When assessing the quality of life of patients after surgical interventions, it was found that in group 1, the average score on the Gastroesophageal Reflux Disease — Health-Related Quality of Life (GERD-HRQL) questionnaire was (11.0 ± 5.5 (3–35) points, in group 2 — (19.0 ± 8.0 (3–35)), in group 3 — (16.0 ± 7.3 (3–35)) points, which was quite high in all groups. The distribution of satisfaction with the condition in group 1 was as follows: satisfied — 34 (45.9 %) patients, partially satisfied — 24 (32.4 %), unsatisfied — 16 (21.6 %). The distribution of satisfaction with the condition in group 2 was as follows: satisfied — 16 (43.2 %) patients, partially satisfied — 14 (37.8 %), unsatisfied — 7 (19.0 %). The distribution of satisfaction with the condition in group 3 was as follows: satisfied — 9 (45.0 %) patients, partially satisfied — 8 (40.0 %), unsatisfied — 3 (15.0 %). In the distant postoperative period, complications (pylorospasm, dysphagia, dyspeptic disorders, reflux esophagitis, esophageal strictures) occurred in 40 (54.1 %) patients of group 1, in 14 (37.8 %) of group 2, and in 6 (30.0 %) of group 3. There were no significant differences in the frequency of postoperative complications between groups (54.1 vs. 37.8 %, p > 0.05, exact F test; 54.1 vs. 30.0 %, p > 0.05, exact F test; 37.8 vs. 30.0 %, p > 0.05, exact F test). Conclusions. 1. The number of patients who are unsatisfied with the results of surgery according to GERD-HRQL questionnaire, was 21.6 % ((11.0 ± 5.5) points) after Nissen fundoplication, 19.0 % ((19.0 ± 8.0) points) after Toupet fundoplication, and 15.0 % ((16.0 ± 7.3) points) after Dor fundoplication. 2. Failures of the known methods of antireflux laparoscopic interventions for hiatal hernia are associated with the destruction of the components of the physiological cardia and occurred in 40 (54.1 %) patients of group 1 (pylorospasm, dysphagia, dyspeptic disorders, reflux esophagitis, esophageal strictures), in 14 (37.8 %) in group 2 and in 6 (30.0 %) in the third group. 3. Nissen fundoplication in the postoperative period was significantly more often accompanied by dysphagia and pylorospasm compared to Toupet and Dor fundoplications (p < 0.05).

Section: вступunclassified

Causes of failures of known methods of antireflux laparoscopic interventions for hiatal hernias

Shevchenkо

Prolom

Babii

et al. 2023

“…При цілеспрямованому обстеженні ГСОД виявляють в 1-9 %, а в літньому віці -у 50 % спостережень [1,2]. ГСОД становить 98 % усіх гриж діафрагми, а у 50 % випадків не викликає ніяких клінічних проявів і не діагностується [5,6].…”

Section: вступunclassified

“…У виникненні рефлюксу зі шлунка в стравохід відіграє велику роль ціла низка факторів: неспроможність НСС, тимчасові епізоди розслаблення НСС; недостатність стравохідного кліренсу, патологічні зміни з боку шлунка, які підсилюють вираженість фізіологічного рефлюксу. Більше ніж у 85 % випадків епізоди зниження внутрішньостравохідної кислотності менше за 4 не супроводжуються якими-небудь відчуттями [3][4][5].…”

Section: вступunclassified

“…Медикаментозна терапія забезпечує хороший ефект у 90-95 % випадків, але після прийому препаратів рецидив захворювання спостерігається у 80-100 % випадків, тому що не усуває основні причини захворювання -ГСОД і недостатність фізіологічної кардії [9]. Це, у свою чергу, призводить до хронічного перебігу захворювання: у 2-7 % хворих призводить до виразки стравоходу, у 4-20 % -до пептичної стриктури стравоходу, у 7 % хворих -до розвитку стравоходу Барретта [5,6].…”

Section: вступunclassified

See 1 more Smart Citation

Diagnosis and surgical correction of insufficiency of physiological cardia in hiatal hernia

Shevchenkо

Prolom

Babii

et al. 2022

Background. The purpose of the study was to improve the diagnosis and improving the results of surgical treatment of patients with hiatal hernia (HH) and GERD by applying the developed method of surgical correction of insufficiency of physiological cardia aimed at preserving and restoring the anatomical and topographic relationships of the esophagocardial organs. Materials and methods. In the Department of Digestive Surgery of the State Institution “Institute of Gastroenterology of the National Academy of Medical Sciences of Ukraine” for the period 2017–2021 conducted a study in 78 patients with HH, including: axial HH (type I) was 60 (77.0 %) patients; paraesophageal (type II) — 9 (11.5 %) patients; mixed (type III) — 9 (11.5 %) (code for ICD-10 — K 44). To establish and confirm the diagnosis, patients underwent radiological and endoscopic examination of the esophagus, stomach, duodenum, manometry. Results. In the analysis of complaints of examined patients it can be noted that the most common clinical manifestations in patients with HH and GERD were heartburn in 73 (93.7 %), belching in 68 (87.2 %) and epigastric pain in 64 (82.0 %). The erosions of the lower third of the esophagus was found in 13 (16.7 %) patients, while according to the Los Angeles classification in 6 (7.7 %) patients had esophagitis grade A, 7 (8.9 %) patients — grade B. According to the results of the manometry study, the highest pressure was observed in patients with axial HH and was (13.54 ± 3.32) mm Hg, and the lowest — in patients with GERD and was (9.81 ± 3.18) mm Hg. After a comprehensive examination, 3 (3.8 %) patients after confirmation of the diagnosis of HH in combination with Barrett’s esophagus underwent two-stage treatment: the first stage performed argonoplasmic ablation of altered esophageal mucosa, the second stage — antireflux surgery. All of 78 (100 %) patients underwent antireflux surgery. Laparoscopic fundoplications were performed: the Nissen fundoplication was performed in 53 (67.9 %) patients, Toupet fundoplication in 7 (8.9 %) patients and Dor fundoplication in 5 (6.6 %) patients, cruroraphy was performed in 100.0 %. The 11 (14.1 %) patients underwent surgery according to a new method that provides reliable restoration of physiological cardia and preservation of the anatomical relationship of the diaphragm and esophageal-gastric junction and includes cruroraphy and fundoplication. Conclusions. The method of surgical treatment of insufficiency of physiological cardia in HH, proposed by us, aimed at the correction of physiological cardia is less traumatic than known, provides a reliable restoration of the anatomical relationship of the esophagogastric region.

1

Shevchenkо¹,

Prolom²,

Babii³

et al. 2021

The physiological incompetent cardia is a condition that is accompanied by reflux of gastric contents into the esophagus — gastroesophageal reflux disease, migration of a part of the stomach into the chest cavity — hiatal hernia. The main task of the surgical treatment of hiatal hernia is the correction of anatomical and physiological disorders: elimination of a hernia, correction of the antireflux function of the lower esophageal sphincter, and provision of the free antegrade passage of food. There is a large number of operations (more than 60 proposed methods) that are used in the surgical treatment of hiatal hernias, as well as gastroesophageal reflux disease. The article presents a method of surgical correction of the physiological incompetent cardia, ensures reliable restoration of the physiological cardia and preservation of the anatomical relationship of the diaphragm and the zone of the esophageal-gastric junction. It includes cruraphy and fundoplication. Cruraphy is performed with U-shaped sutures, which are placed on the right and left walls of the esophagus at the level of the cardia, with the crura of diaphragm fixed in them, corrugated sutures, which are applied to the medial pedicle of the diaphragm, reduce the esophageal opening of the diaphragm to the outer diameter of the esophagus and perpendicular to the axis of the esophagus as U-shaped sutures perform cardiogastric plication of the anterior wall of the stomach, followed by gastro-diaphragmopexy. The proposed method was used to treat 11 patients, the postoperative condition of the patients was satisfactory, without signs of postoperative dysphagic disorders. In all cases, good immediate and long-term results were obtained for a period of 6 months to 1 year. The use of the proposed method allows avoiding postoperative dysphagia and recurrence of the disease.