Outcomes of surgical treatment for physiological cardia insufficiency in hiatal hernias andgastroesophageal reflux disease
Authors: Babii O.M. , Shevchenko B.F. , Prolom N.V. , Zeleniuk O.V. , Tarabarov S.O. , Ushchina S.V. 
Published: February 2023

Background. The purpose was to determine the effectiveness of the developed method of surgical treatment for insufficiency of the physiological cardia in hiatal hernias (HH) and gastroesophageal reflux disease (GERD). Materials and methods. From January 2013 to September 2021, 141 patients were treated laparoscopically for HH and GERD at the clinic of the Institute of Gastroenterology of the National Academy of Medical Sciences of Ukraine, 44 (31.2%) men and 97 (68.8%) women aged 21–70 (36.5±4.2) years. To evaluate the immediate and long-term results in the follow-up period lasting from 11 months to 3 years, a randomized comparative study was conducted between groupI— 45 patients after classical antireflux operations and group II— 34 patients after surgery to restore the physiological cardia. X-ray examination of the esophagus and stomach was performed to diagnose HH. Endoscopic examination was used to evaluate the condition of the mucous membrane of the esophagogastroduodenal zone. Results. In 141 patients, the following types of laparoscopic surgical interventions were performed: Nissen fundoplication— in 84 (59.6%), Toupet fundoplication— in 12 (8.5%), Dor fundoplication— in 11 (7.8%), restoration of the physiological cardia according to the proposed method, namely, medial cruroplication, anterior cardiogastroplication with gastrodiaphragmopexy,— in 34 (24.1%) cases. Crurorrhaphy was carried out in 100.0% of patients: posterior— in 64 (45.4%), anterior and posterior (combined)— in 27 (20.1%), medial cardiocrurorrhaphy and lateral cardiofundocrurorrhaphy according to the proposed method— in 34 (19.1%). Alloplasty of the esophageal hiatus was performed in 16 (11.3%) cases. By the frequency of intraoperative and early postoperative complications, a significant difference was detected in favor of group II (5 (11.1%) vs. 1 (2.9%), p<0.05, and 14 (31.1%) vs. 2 (5.8%), p<0.05, respectively, Fisher’s exact test). Depending on the frequency of anatomical (5.8 vs. 17.7%, p=0.003, χ2 test), functional (5.8 vs. 13.3%, p=0.045, χ2 test) and a combination of anatomical and functional (11.1 vs. 2.9%, p=0.003, χ2 test) relapses, a significant difference is revealed in favor of group II. In terms of the frequency of pylorospasm and dysphagia, a significant difference was detected in favor of groupII (2.9 vs. 17.7%, p=0.009, and 2.9 vs. 28.9%, p=0.007, respectively, Fisher’s exact test). Conclusions. The analysis of the immediate results of using the proposed method of surgical treatment for the restoration of the physiological cardia has shown that it ensures the elimination of pathological changes in HH, in comparison with classical antireflux methods, reduces the frequency of intraoperative (2.9 vs. 11.1%) and early postoperative (5.8 vs. 31.1%) complications. In the long-term period after surgical treatment of HH with the proposed method, the frequency of HH recurrence is reliably reduced compared to the outcomes when using classical antireflux methods, particularly the frequency of anatomical (5.8 vs. 17.7%, p=0.003, χ2 test) and functional (5.8 vs. 13.3%, p=0.045, χ2 test) relapses.