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

Abstract

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.