After Nissen fundoplication. Types of fundoplication. Performing surgery through open access

Currently, crurorrhaphy, Nissen fundoplication, is one of the most common surgical operations performed for disorders of the functioning and anatomical structure of the LES - the lower esophageal sphincter, as well as reflux (that is, reflux) into the esophagus of food and gastric juice, which in turn leads to to irritation and inflammation.

An illness of this kind can be either congenital or acquired. Often the disease is associated with a hiatal hernia, that is, the muscular border between the abdominal and thoracic cavities. Crurorrhaphy fundoplication, developed by Rudolf Nissen, is rightfully considered one of the “standards” of surgery and is performed in the vast majority of cases.

The essence of the method developed by Nicsen

The goal of this treatment method is to increase pressure in the LES in order to prevent reflux, that is, the reflux of gastric juice and food into the esophagus. Fundoplication is performed both traditionally and laparoscopically. As a rule, preference is given to the second method. The essence of the operation is to create a five-centimeter “cuff” that will prevent reflux, as well as the further development of esophagitis - irritation and inflammation of the esophagus.

To construct the cuff, the fundus of the stomach is encircled around the esophagus. At the next stage, the legs of the diaphragm are sutured (direct crurorrhaphy), as a result of which the diameter of the food opening is reduced. After this, the posterior wall of the stomach is connected to the anterior wall, forming a sleeve encircling the abdominal esophagus. At the same time, to fix the created cuff and prevent relapse, the membrane of the anterior wall of the esophagus is captured. Ultimately, the anterior abdominal wall and the anterior wall of the stomach are secured with sutures.

During the operation, emptying improves and the number of transient relaxations during stomach distension decreases, the functional state and anatomical structure of the LES and its tone are restored.

Possible postoperative complications and side effects

Crurorrhaphy and Nissen fundoplication is a sure way to stop reflux, but does not exclude the occurrence of postoperative complications. These include:

• dysphagia or swallowing disorder (in most cases goes away within six months);
• heartburn;
• bloating;
• diarrhea;
• abdominal discomfort;
• gastric cuff ulcer;
• displacement of the fundoplication into the body of the stomach or into the chest;
• fundoplication dehiscence;
• chest pain and so on.

Most of the complications are due to incompetent patient selection, since there are a number of contraindications for which fundoplication is strictly not recommended.

Contraindications for crurorrhaphy and Nissen fundoplication

The operation is contraindicated in patients with uncoordinated motility, severe esophagitis, esophageal motility disorders, stricture and shortening of the esophagus. That is why, before direct surgical intervention, a thorough diagnosis is carried out, including examination of the gastrointestinal tract using X-rays, esophagogastroduodenoscopy, esophageal manometry and daily pH monitoring.

Crurorrhaphy fundoplication according to Nissen in our clinic in Kyiv

Our clinic in Kyiv provides the services of experienced doctors who perform crurorrhaphy and Nissen fundoplication. You can find out more about the method used, the cost of treatment depending on the stage of development of the disease and other information of interest on our website by clicking the “Check price” button or by calling the specified telephone number.

This information is intended for healthcare and pharmaceutical professionals. Patients should not use this information as medical advice or recommendations.

Repeated antireflux surgeries

A.F. Chernousov, T.V. Khorobrikh, F.P. Vetshev
Department of Faculty Surgery No. 1, Faculty of Medicine, State Educational Institution of Higher Professional Education "First Moscow State Medical University named after I.M. Sechenov" (head - Academician of the Russian Academy of Medical Sciences A.F. Chernousov)

The article analyzes the variety of causes of failures and complications of antireflux operations. Our own experience of repeated operations on 15 patients is presented. It has been shown that in order to prevent the development of complications before the first operation for reflux esophagitis and hiatal hernia (HHH), it is necessary to take into account the degree of shortening, the severity of inflammatory and sclerotic changes in the esophagus, and the functional reserve of the organ’s propulsive motility. The need for surgical treatment of this contingent of patients in specialized hospitals has also been substantiated. Key words: repeated antireflux interventions, failures of antireflux surgery.

Introduction

Antireflux surgery is currently the most common surgical intervention on the esophagus, which reflects the prevalence of reflux esophagitis (RE) and its complications among gastroenterological diseases among the population of highly developed countries. A large number of works are devoted to the issues of surgical treatment of hiatal hernia (HH) and ER, the authors of which agree on two issues: 1) the indication for surgery is severe ER that is not amenable to conservative treatment, or its complications; 2) the operation should consist of creating a reliable anti-reflux valve at the level of the esophagogastric junction.

Over the past 60 years, as a result of intensive study of this problem, the main methodological and technical approaches to antireflux operations have been developed. However, none of the existing methods completely guarantees against relapse of EC, which is detected in 11-24% of cases. At the same time, some specific complications of antireflux operations have become widely known, often requiring repeated interventions. Despite the growing interest in antireflux surgery, there are few works specifically devoted to the indications, techniques and analysis of the advantages and disadvantages of various repeated antireflux operations.

As a rule, antireflux surgery performed by an experienced, highly qualified surgeon in a specialized hospital for uncomplicated EC gives a positive result in 80-95% of cases. However, if a similar operation is performed by a less qualified surgeon, the rate of positive results is much lower and reaches only 40-50% during the first year after surgery. . In addition, even in an experienced specialist in the late postoperative period, the number of patients with relapse of EC symptoms can reach 15-20%. The continuing increase in the number of antireflux operations, many of which are performed outside of large specialized centers, inevitably leads to an increase in the number of patients with ineffective surgical treatment and relapse of the disease, which becomes a significant medical and social problem.

Undoubtedly, antireflux surgery should be considered unsuccessful after which the primary symptoms persist (heartburn, belching, pain, etc.) or new ones appear (dysphagia, pain, bloating, diarrhea, etc.). The persistence of EC symptoms or their rapid recurrence after fundoplication are described in 5-20% of patients after surgery from a laparotomic approach and in 6-30% of patients after laparoscopic fundoplication. To date, many publications have been published regarding the results of repeated operations after unsuccessful antireflux intervention. The most common symptoms of ineffective antireflux surgery are gastroesophageal reflux (30-60%) and dysphagia (10-30%), as well as a combination of reflux and dysphagia (about 20%). The world literature describes the effectiveness of the first adequately performed antireflux operation in 90-96% of cases. However, if the disease recurs, repeat surgery is often necessary. At the same time, good results are described only in 80-90% of patients who have previously undergone one operation, in 55-66% of patients who have previously undergone two operations, and only in 42% after three or more unsuccessful operations. Thus, the likelihood of achieving a good surgical outcome decreases progressively with increasing number of operations. Since the fourth reconstructive operation rarely brings a positive result, many experts consider it advisable to perform resection or extirpation of the esophagus after the third unsuccessful operation.

Accumulated clinical experience indicates that when choosing the scope of surgical intervention in patients with EC, it is important to take into account the presence and severity of its complications: the degree of shortening of the esophagus, peptic stricture of the esophagus, the results of histological examination of a biopsy of the terminal esophagus, as well as the severity of concomitant diseases. The inevitable shortening of the esophagus that occurs under conditions of chronic inflammation significantly affects surgical tactics. By shortening, the esophagus carries with it the cardiac part of the stomach into the posterior mediastinum, pulling it into a tube and contributing to the complete disruption of the pectoral valve antireflux mechanism. This not only significantly aggravates destructive changes in the esophageal wall, including the development of peptic stricture, chronic round ulcer, Barrett's esophagus, but also has a significant pathological effect on its motility. Not only the pulp mechanism of the cardia disappears: after a short compensatory increase in contractile activity (aimed at more effective self-cleaning of the mucous membrane from aggressive gastric contents), the propulsive motility of the esophagus is inhibited. Recent prospective studies in 8 large centers in Italy made it possible to intraoperatively diagnose a shortened esophagus in 20% of patients who routinely underwent antireflux surgery, which, according to the authors, is one of the leading causes of postoperative complications. In addition, the studies also made it possible to establish a direct correlation between the frequency of unsuccessful antireflux operations and body mass index - with a body mass index of more than 30, the incidence of complications reaches 31%.

Incorrect interpretation of simultaneous manometry data without taking into account the results of an X-ray examination, which allows one to assess the degree of shortening of the esophagus and the nature of the hiatal hernia (it will almost always be the cause and consequence of severe EC), can serve as the basis for diagnostic and tactical errors. In particular, severe RE is interpreted as cardiospasm or achalasia of the cardia and attempts are made to perform laparoscopic myotomy with incomplete fundoplication. Dysphagia that occurs after such interventions requires very complex correction, and sometimes extirpation of the esophagus. Partial posterior fundoplication (Toupet), according to some authors, is indicated for patients with inadequate esophageal motility. However, a recent randomized trial showed that preoperative esophageal motility disorders did not affect the incidence of postoperative dysphagia, regardless of the type of fundoplication. In addition, the rate of unsatisfactory results after incomplete fundoplication remains higher than with complete fundoplication.

According to world literature, the Nissen operation is the most frequently performed antireflux operation, however, stable control of gastroesophageal reflux does not occur in 30-76% of cases. As is known, the most common complications of the Nissen operation are “gas-bloat” syndrome, flatulence, and inability to belch. Damage to the vagus nerves during antireflux surgery can cause slow gastric emptying and cause symptoms of bloating, feelings of fullness in the stomach, nausea, and vomiting.

According to the literature, up to 30% of patients after antireflux surgery require reoperation due to the development of persistent dysphagia (Fig. 1), which cannot satisfy surgeons and requires finding ways to improve the tactics and technique of interventions. Its causes may be inhibition of relaxation of the lower esophageal sphincter by a tightened cuff, impaired migration of the cardia during the act of swallowing, or impaired motility of the esophagus due to denervation of the abdominal esophagus, as well as a “slipped” anti-reflux cuff.

Rice. 1. X-ray. Complications after Nissen fundoplication. a - dysphagia caused by an excessively tightly formed cuff; b - dysphagia caused by an excessively long fundoplication cuff. In both cases, signs of obstruction in the area of ​​the esophagogastric junction and suprastenotic expansion of the esophagus above the applied cuff are visible

Another important and quite common complication of the Nissen operation is the “telescope” phenomenon (slipped Nissen, or “sliding” Nissen) - sliding of the cardia and fundus of the stomach with the terminal esophagus relative to the cuff (Diagram 1, b). As a rule, the reason for this is the cutting of the sutures between the cuff and the esophagus. Suturing the legs of the diaphragm when shortening the esophagus and fixing an anti-reflux cuff to them also leads to “slippage”, since the esophagus, having contracted after the operation, will draw the cardia along with the straightened cuff into the posterior mediastinum. Radiologically, this appears as an “hourglass” phenomenon, when one part of the cuff is above the diaphragm and the other below (Fig. 2). The complication is accompanied by severe dysphagia, regurgitation and heartburn, which, of course, requires repeated corrective surgery. A common mistake when using endoscopic techniques is the use of the body or even the antrum of the stomach when forming an antireflux cuff (see Diagram 1, c). According to some authors, if the short gastric vessels are not divided, the surgeon is forced to use not the fundoplication of the stomach, but its anterior wall during 360° fundoplication. All this leads to torsion, severe deformation of the stomach, which, for obvious reasons, is not able to perform an antireflux function and is the main reason for the high incidence of postoperative complications in the form of dysphagia (11-54%) with this method of surgery. In particular, this is why, despite its greater technical simplicity, the Rossetti operation is rarely used.

Scheme 1. Complications after Nissen fundoplication. a - complete rotation of the cuff when cutting the seams; b - "slipped" Nissen; c - a cuff formed around the cardiac part of the stomach; d - retraction of the antireflux cuff into the posterior mediastinum during shortening of the esophagus

Rice. 2. X-ray. “Slipped” fundoplication cuff (“slipped” Nissen). a - the slipped cuff is located below the level of the diaphragm and compresses the cardiac part of the stomach, the esophageal-gastric junction is located above the diaphragm; b, c - with double contrast, the folds of the gastric mucosa inside the slipped cuff with the formation of a diverticulum-like deformity are clearly visible (such a diverticulum often becomes a source of gastroesophageal reflux and progressive EC)

The simplest complication for diagnosis and treatment is “missing” Nissen (“insufficient” Nissen). In this case, the excessively superficial sutures on the fundoplication cuff are torn, and the latter unfolds (see diagram 1, a).

With the introduction of the laparoscopic technique, the number of inherent complications such as a two-chamber stomach and a twisted cuff has increased several times.

Migration of the fundus of the stomach into the chest cavity can occur in the early postoperative period, even at the moment the patient recovers from anesthesia. This happens for a number of reasons, in particular due to unreasonable traction of the shortened esophagus to create a fundopliation cuff below the diaphragm (see Diagram 1, d). Some authors also believe that inadequate fixation of the fundoplication cuff to the crura of the diaphragm predisposes to further development of a hiatal hernia or to the development of a paraesophageal hernia with movement of the splenic flexure of the colon into the thoracic cavity along the fundoplication cuff.

Material and methods

From 2006 to 2011 We observed 15 patients (7 men and 8 women aged from 25 to 72 years) who underwent various operations for hiatal hernia and endometriosis, the results of which were unsatisfactory. All except one patient were initially operated on in other medical institutions. The nature of the primary operations is reflected in table. 1. In most cases, fundoplication was performed as the primary operation.

Table 1. Previous surgical interventions (n ​​= 15)*

Surgical interventions	Number of operations
Antireflux surgery: Nissen-Rosetti fundoplication (laparoscopic)
Nissen fundoplication (traditional)
Toupe fundoplication (laparoscopic)
fundoplication (laparoscopic)
antireflux surgery (method unknown)
Simultaneous surgical interventions: diaphragmcrurorrhaphy
selective proximal vagotomy
truncal vagotomy
gastrostomy
suturing esophageal perforation
suturing gastric perforation
excision of duodenal ulcer with duodenoplasty
pyloroplasty
choledochojejunostomy
cholecystoduodenostomy

* Including patients with a combination of several and repeated operations.

10 out of 15 previously operated patients noted the appearance of recurrence of symptoms or their transformation in the immediate postoperative period. In 5 patients, the period of remission “lingered” for many years (from 10 to 24 years).

Analyzing the complaints of patients before and after surgery (heartburn, belching, pain in the upper abdomen and behind the sternum), not only their almost complete recurrence in the early postoperative period was noted, but also progression and transformation in the long-term period.

The vast majority of patients were bothered by constant heartburn (9). The second most common symptom was dysphagia (7). In all patients, dysphagia was caused by compression of the “slipped” cuff in the area of ​​the esophageal opening of the diaphragm after crurorrhaphy (5) or its torsion (1) (Fig. 3, a, b). In one patient, persistent dysphagia was a consequence of cicatricial stenosis in the area of ​​the esophagogastric junction, which arose after suturing iatrogenic perforation of the esophagus during the formation of a fundoplication cuff. The string blocking sessions carried out in the clinic did not bring the desired effect due to the impossibility of performing a bougie larger than No. 26 (Figure 4, a, b). As a rule, the pain was of a burning or pressing nature. In the origin of pain in this group of patients (12), both chemical (the effect of gastric contents on the inflamed and ulcerated mucous membrane of the esophagus, the so-called heartburn to the point of pain) and mechanical factors play a role (stretching of the terminal part of the esophagus by a wave of reflux, fixation of the cuff to the legs of the diaphragm , as well as tension in the branches of the solar plexus, characteristic of shortening the esophagus). The predominance of patients with localized pain syndrome behind the sternum and in the heart region is largely due to the location of the “slipped” cuff in the posterior mediastinum due to the progression of shortening of the esophagus, as well as gastrocardial Uden-Roemheld syndrome.

Rice. 3. X-ray. Complications after Nissen fundoplication. a - a “slipped” cuff compresses the upper part of the stomach, the cardia is stretched due to impaired patency and is located above the level of the diaphragm, the esophagus is shortened, the esophagogastric junction is located 4 cm above the level of the diaphragm; b - view of the formed reconstructive gastropplication cuff

Rice. 4. X-ray. Complications after Nissen fundoplication. a - complete dysphagia after fundoplication with the formation of a scar stricture and suprastenotic expansion of the esophagus, leading to its deviation and siphon-like expansion; nasogastric feeding tube visible; b - anti-reflux cuff formed after proximal resection of the stomach and resection of the abdominal esophagus

Another common symptom indicating the ineffectiveness of the newly created valve was belching (11).

All patients underwent X-ray examination and esophagogastroduodenoscopy (EGDS). At the same time, grade I shortening of the esophagus was diagnosed in 6 patients, grade II - in 8. Signs of erosive EC were identified in 6 patients.

During the examination, in 8 patients, radiographically, the previously created antireflux cuff was located in the posterior mediastinum. In all likelihood, at the time of the first operation, these patients already had a shortened esophagus, but the surgeons did not attach due importance to this and performed traditional anti-reflux surgery.

In all cases, the fundoplication cuff did not prevent gastroesophageal reflux and was considered ineffective at the preoperative stage.

In one patient operated on in our clinic for moderate EC, sliding cardiac hiatal hernia and grade I shortening of the esophagus, on the 7th day after laparoscopic fundoplication, a control X-ray examination revealed a diverticulum-like deformation of the cardia and fundus of the stomach (Fig. 5) . However, no signs of gastroesophageal reflux were detected even in the Trendelenburg position. It should be noted that, despite the existing experience of open antireflux interventions, the operation performed was one of the first and to date the only unsuccessful laparoscopic operation that arose at the stage of development and implementation of this technique. The patient was re-operated 5 months later, after completing a course of rehabilitation, and the repeated examination made it possible to establish a progressive shortening of the esophagus to degree II, which influenced the tactics of surgical treatment. The examination data and analysis of surgical findings during re-intervention made it possible to identify the following cause of the complication: cutting through the sutures on one side of the cuff, followed by its torsion around its axis and the formation of a diverticulum-like deformity of the fundus of the stomach. The patient underwent reconstructive valve gastropplication and extramucosal pyloroplasty using a traditional approach.

Fig 5. X-ray. Complication after fundoplication: diverticulum-like deformation of the fundus of the stomach in the area of ​​the cuff that partially unfolded when cutting the sutures after laparoscopic fundoplication

It should be noted that we have never used classical Nissen fundoplication as an anti-reflux operation, but widely use symmetrical complete fundoplication, which gives better results than the Nissen technique. EGDS, in our opinion, should not be used as an independent intervention in the treatment of EC, since this operation does not create a sufficiently reliable anti-reflux valve in the cardia area.

In this case, the fundoplication cuff is formed after mobilizing the lesser curvature, cardia, abdominal esophagus and fundus of the stomach while maintaining the smooth trunks of the vagus nerves and both Latarget nerves. Mobilization of the fundus of the stomach is performed with the obligatory ligation of two short gastric arteries in order to increase the mobility of the tissues of the fundus of the stomach for the subsequent formation of a fundoplication cuff without tension."

Gradual immersion of the esophagus into the fold between the anterior and posterior walls of the fundus of the stomach without the use of a rubber holder ensures the formation of a uniform, neat, complete symmetrical cuff that does not deform the esophagogastric junction and does not create diverticulum-like pockets and cascading deformation of the stomach. The optimal height of the cuff is 4 cm. The sutures must necessarily capture the muscular wall of the esophagus. The upper edge of the cuff is additionally fixed to it with two interrupted sutures in front and one in the back (top of the cuff) to prevent the “telescope” phenomenon, i.e., slipping of the cuff (diagram 2 ).

Scheme 2. Stages of fundoplication. Formation of a complete symmetrical cuff.

If the esophagus is shortened to degree II (the location of the esophagogastric junction is more than 4 cm above the diaphragm), its reduction is pointless, since after the operation it will inevitably shorten again. In this case, the anti-reflux cuff will either slide off to form a “noose” - the so-called telescopic effect, or will unfold when the sutures are cut. Practice has shown that it is the cuff made from stomach tissue that has the main anti-reflux effect. When formed correctly, it works equally successfully under and above the diaphragm.

Back in 1960, R. Nissen proposed using fundoplication in patients with shortened esophagus, while the author did not eliminate the hernia itself, but, on the contrary, expanded the hernial orifice. The fundoplication cuff remained in the mediastinum, and the stomach was sutured to the esophageal opening of the diaphragm. The author considered an important step to be the mandatory expansion of the diaphragmatic opening in order to avoid compression and subsequent poor emptying of the supradiaphragmatic segment of the stomach. A number of studies have found that Nissen fundoplication for a short esophagus with a cuff left above the level of the diaphragm is effective with long-term pH control in 97% of cases and is not inferior to its intra-abdominal location.

Practice has shown that crurorrhaphy does not have a significant independent antireflux function in conditions of complete destruction of the pharynx-valve function of the cardia. It is appropriate for common esophageal-aortic window, giant and paraesophageal hernias solely to prevent migration of organs from the abdominal cavity into the mediastinum.

In conditions of pronounced shortening, valve gastropplication is justified (N.N. Kanshin, 1962), which today we have modified and are successfully used again. After mobilizing the cardiac part of the stomach and expanding the hernial orifice anteriorly, the stomach is turned into a tube with transverse collecting sutures (cardiography). Next, the part of the stomach turned into a tube, which is a kind of “extension” of the esophagus, is symmetrically wrapped in the gastric wall, as with fundoplication. Then we fix the upper part of the cuff to the esophagus (Diagram 3). In this way, the esophagus is “lengthened” at the expense of the stomach and an anti-reflux valve is created.

Scheme 3. Valvular gastropplication

Results and its discussion

All patients who underwent primary operations in other medical institutions were reoperated. At the same time, as a result of the examination and analysis of surgical findings, the following technical errors were identified that were made during previous operations: fixation to the lesser curvature of the mobilized greater curvature posterior to the esophagus; suturing from the front to form a duplicate of the greater and lesser curvature of the stomach without their mobilization (2); fixation of the stomach to the legs of the diaphragm (3); suturing the legs of the diaphragm (4); fixation of the stomach to the liver, anterior abdominal wall (2); pyloroplasty (5); improperly formed cuff (8) and its complete absence (3); the “telescope” phenomenon (at 8); excessively tight cuff (3); gastrostasis (2).

In one patient with severe cicatricial stenosis of the esophagogastric junction after a previously performed Nissen fundoplication and iatrogenic perforation of the esophagus, local reconstruction was impossible (see Fig. 4, a, b). Here is a brief description of the operation.

Laparotomy and enterolysis of the upper abdominal cavity were performed. The stomach is of normal size, deformed in the cardiac region, the esophagogastric junction and the upper third of the stomach are practically not differentiated (the area of ​​perforation and the application of a fundoplication cuff). The tissues in this area are swollen, infiltrated, and previously applied ligatures are visible. With technical difficulties, after partial sagittal diaphragmotomy, the legs of the diaphragm, previously sutured with interrupted sutures, were identified; threads removed; in the posterior mediastinum, the lower thoracic section of the esophagus is identified, expanded to 6 cm with hypertrophied walls. The esophageal-gastric junction, rigid, stenotic with rough scars for 2 cm, was gradually mobilized. Distally, the upper third of the stomach was deformed due to the previously formed fundoplication cuff. The latter with technical difficulties was dealt with. The lesser curvature of the stomach was mobilized up to the angle, the greater curvature was mobilized with ligation of three short gastric and posterior gastric arteries. The tissues of the upper third of the stomach in the area of ​​the straightened cuff are atonic, the wall is thinned, infiltrated - unsuitable for the formation of an anti-reflux cuff, a circular stricture is not subject to transverse plasty. Under these conditions, proximal gastrectomy, resection of the abdominal esophagus, and pyloroplasty were performed. In this case, an esophageal-gastric anastomosis was formed with the anterior wall of the gastric stump, followed by the formation of an anti-reflux cuff using the tissues of the gastric stump on a thick gastric tube. The left corner of the sutures of the gastric stump is additionally sutured to the esophagus.

Of the 15 patients who underwent repeated interventions in our clinic, there were no unsatisfactory results (Table 2). Only 2 patients in the early postoperative period were diagnosed with dysphagia (mainly when swallowing solid food), caused by hyperfunction of the reconstructive gastric plication cuff. It should be noted that both patients had a history of undergoing two operations on the cardia. The balloon dilatation sessions (1-2 sessions) under X-ray television control made it possible to eliminate the clinical and radiological manifestations of dysphagia without destroying the newly created anti-reflux valve in the form of a cuff.

Table 2. Nature of repeated antireflux operations

* Including simultaneous operations.

Good immediate functional results with the disappearance of clinical symptoms were obtained in the vast majority of reoperated patients. Long-term results were studied in all 15 patients and monitored for periods from 6 months to 4 years. The study was carried out both using traditional approaches and using assessment of the quality of life of operated patients, which is a mandatory attribute of international research in recent years, complies with the principles of evidence-based medicine and allows for a more adequate assessment of long-term results. The results obtained were assessed based on direct examination, comprehensive examination, and also on the basis of questionnaire data. All patients underwent a routine follow-up examination on an outpatient basis. The examination plan included x-ray examination of the esophagus and stomach, endoscopy. Also, in the long-term period, we did not encounter the symptoms described in the literature, which often (10-33%) occur after antireflux operations: dysphagia, bloating, early satiety, nausea, pain in the epigastric region, inability to belch and vomit, diarrhea.

Quality of life was assessed using a modified specific questionnaire - the Gastrointestinal Quality of Life Index (GIQL1). When comparing the obtained quality of life indicators, a significant increase in the quality of life index after reconstructive surgery was revealed on all scales of the questionnaire (p<0,05). Гастроэнтерологическая симптоматика у исследуемых больных претерпела обратное развитие наряду с улучшением показателей качества жизни. У больных отмечено увеличение индекса качества жизни с 42 баллов (до операции) до 70 баллов (после операции) при максимальном показателе 84 балла. Наиболее значительно увеличение индекса качества жизни отмечено после операции по шкале симптомов - на 47%. Также отмечено увеличение показателей по шкале субъективного восприятия своего здоровья и влияния проведенного лечения.

X-ray examination did not reveal any problems with swallowing or the passage of contrast material through the esophagus in any patient. In 3 patients, the stomach was located in the abdominal cavity; in the remaining 12 patients, the formed antireflux cuff was located at or above the level of the diaphragm. At the same time, no gastroesophageal reflux of the contrast agent was detected during polypositional examination, including the Trendelenburg position.

The results obtained once again demonstrate the long-standing assertion that the main anti-reflux effect is exerted by the cuff made from gastric tissue, and when it is formed correctly, it “works” equally successfully both under and above the diaphragm.

EGD revealed no signs of esophagitis in any patient.

Thus, patients undergoing surgical treatment can usually eat any food of their choice, lie horizontally and bend over without experiencing clinical manifestations of gastroesophageal reflux, and, equally important, they do not need to take constant medications.

Unsuccessful outcomes of primary antireflux operations are observed in 6-30% of cases. We identify the following groups of reasons for these failures: 1) the desire to necessarily eliminate the hiatal hernia, and not the gastroesophageal reflux - hence the vicious operations of fixing the stomach to the diaphragm, abdominal wall, etc., causing persistent pain, dysphagia, painful hiccups and belching. This also includes isolated interventions on the esophageal opening of the diaphragm; 2) vicious palliative operations to speed up evacuation and “reduce” reflux, such as distal gastrectomy or pyloroplasty, as well as dissection of the ligament of Treitz; 3) technical errors, consisting of attempts to form a fundoplication cuff without proper mobilization of the esophagus, cardia and fundus of the stomach, and, as a result, various variants of an incorrectly formed cuff or its complete absence during revision during repeated operations; 4) complications characteristic of fundoplication, such as paraesophageal hernia, the “telescope” phenomenon, compression of the esophagus with a too tight cuff, gastrostasis due to pinching or intersection of the vagus nerves, gastric ulcer; 5) various functional disorders of swallowing and digestion in the absence of characteristic anatomical changes according to the examination data - they reflect an unjustified expansion of indications for primary operations for hiatal hernia.

A number of authors emphasize the unnecessary and harmful nature of fixing the stomach and fundoplication cuff in the abdominal cavity. Others continue to promote this method. Crurorrhaphy has been suggested as a preventive measure for paraesophageal hernia formation as an adjunct to fundoplication, although some authors argue that gastropexy alone is effective for this purpose. We have learned from our own experience that the esophagus and fundoplication cuff must move freely in relation to the diaphragm. Contractions of the longitudinal muscles of the esophagus are able to “tear” it from any fixed cuff, which usually leads to the appearance of various severe deformities and relapse of EC. We consider crurorrhaphy indicated for primary operations in cases of cardiofundal or paraesophageal hernia, especially when there is a common esophageal-aortic window in the diaphragm. With repeated antireflux operations, it is also justified in the case of the development of a paraesophageal hernia as a complication of fundoplication.

Complete fundoplication gives good and excellent long-term results in 84-95% of cases. In our series, in half of the observations, we encountered the fact that during primary operations in other medical institutions, attempts were made to form a cuff with gross technical errors, which led to a wide variety of gastric deformations, and most often to aggravation of the symptoms of the disease (Fig. 6, a, b).

Rice. 6. X-ray. Complications after Nissen fundoplication. a - perforation of the fundus of the stomach during the formation of a fundoplication cuff with the formation of an external gastric fistula; b - reconstructive gastropplication

According to the literature, repeated antireflux operations give worse results compared to primary ones. Methods of repeated antireflux operations are varied. As with primary interventions, the well-known methods Nissen, Toupet, Collis are offered. Both laparotomy, laparoscopy and thoracotomy are used as surgical approaches. We believe that for repeated operations for hiatal hernia and ER, the method of choice should be upper midline laparotomy with access correction using Segal dilators. This access allows you to thoroughly study the existing anatomical relationships and make the right decision about the nature of the reconstructive operation. It should be noted that laparoscopic operations for ER should be performed by a surgeon with significant experience in such open operations and who knows all the details of the intervention. This especially applies to patients with II degree shortening of the esophagus and a long history of severe EC. Such patients experience certain difficulties in mobilizing the esophagus and the cardiac part of the stomach, elongated in the form of a tube, due to severe periesophagitis. It is in such a situation that intraoperative perforation of the esophagus is possible.

In our opinion, in most cases, fundoplication in patients with EC should be combined with selective proximal vagotomy to reduce acidic gastric secretion and reduce the aggressive effect of gastric juice on the esophageal mucosa. Truncal vagotomy during repeated interventions is justified in conditions of severe scarring in the lesser omentum and around the cardia, when it is impossible to identify and preserve the Latarget nerves.

We consider it inappropriate to perform partial resection of the esophagus with replacement of part of it with the stomach or intestinal segment, as proposed by other authors, in the development of such complications of EC as an extended cicatricial peptic stricture or Barrett's esophagus with high-grade dysplasia. It must be borne in mind that partial resection of the esophagus in this case is always dangerous with relapse of EC, since it is very difficult, and most likely impossible, to create a reliable universal anti-reflux valve in the abdominal or thoracic cavity at the level of the esophageal anastomosis. Therefore, the most radical operation proposed in cases of multiple unsuccessful operations and with extended peptic strictures deserves attention - extirpation of the esophagus using a cervico-abdominal approach with simultaneous gastric esophagoplasty. We consider this operation to be the method of choice in the most difficult situations.

Particular attention should be paid to patients who, according to examination data, are cured of EC, but the result of the operation cannot be called satisfactory due to poor health and a negative assessment of their health. In our series there were 2 similar patients who had undergone several antireflux surgeries in their anamnesis. Analyzing the clinical picture of the disease and data from special research methods, we came to the conclusion that in many of these patients the symptoms of the disease are largely due to latent depression and synesthopathy, and in some cases it is more advisable to refuse reconstructive surgery in favor of conservative treatment with mandatory consultation with a neuropsychiatrist. Up to 28% of patients who have undergone antireflux surgery have various gastroenterological symptoms. Moreover, 35% of them, upon examination, do not have any disorders or changes in the gastrointestinal tract, and symptoms resolve over time without any intervention. In this regard, we are much more strict in determining the indications for both primary and repeated operations for hiatal hernia and renal hernia.

Conclusion

Thus, the variety of reasons for failures and complications of antireflux operations, the technical complexity of repeated interventions and the problematic nature of their good results determine the advisability of concentrating patients with hiatal hernia and endometrial cancer in specialized hospitals and dictate the need for further clinical research in this area.

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Fundoplication is a surgical procedure used to treat gastroesophageal reflux disease. The essence of the surgical intervention is to restore the cardiac sphincter of the stomach, which prevents the reflux of hydrochloric acid into the esophagus. This is done by suturing the stomach around the esophageal opening of the diaphragm. In this case, the stomach must be fixed at a certain angle.

Surgery for reflux esophagitis is performed only in severe cases when there are pronounced changes in the esophageal mucosa. As a rule, this disease can be managed conservatively. The first signs of GERD are symptoms such as heartburn and belching that occur almost immediately after eating. With regular contact of hydrochloric acid with the esophagus, inflammation of the mucous membrane occurs, which leads to cellular metaplasia and the formation of carcinoma.

The surgical technique is the gold standard for the treatment of gastroesophageal reflux disease (GERD). Among surgeons and gastroenterologists, it is believed that a correctly performed operation leads to the elimination of symptoms of the disease for more than 10 years, which saves the patient from constant use of proton pump inhibitors. The surgical technique has its own indications and contraindications, as well as pros and cons.

Indications and contraindications

Surgery is always associated with a certain proportion of postoperative complications, so the decision to operate is made by a council that includes a surgeon and a gastroenterologist. Nissen fundoplication is performed in the following cases:

1. Presence of GERD proven by instrumental methods.
2. Ineffectiveness of proton pump inhibitors that have been used for a long time.
3. Constantly occurring, chronic inflammation of the esophagus.
4. Treatment of hiatal hernia (HH).
5. Metaplasia of the esophageal epithelium - Barrett's esophagus.

A hiatal hernia is a condition in which the stomach partially protrudes into the esophageal opening of the diaphragm. Clinically, the hiatal hernia manifests itself as reflux esophagitis, however, this disease cannot be treated with conservative treatment. The only treatment available is fundoplication.

The operation cannot be performed in the following cases:

1. The patient has decompensated pathology of the liver and kidneys.
2. Efficacy of proton pump inhibitors.
3. Senile age.
4. Neuromuscular pathology of the esophagus, due to which GERD developed.

Technique

There are two types of surgical access for fundoplication:

1. Laparotomy, which is an incision along the midline of the abdomen in the upper part.
2. Laparoscopic fundoplication is a minimally invasive surgical technique that involves the use of a special endoscopic camera. Up to 5 punctures are made on the anterior abdominal wall, measuring up to 1.0 cm. The advantage is that the patient recovers much faster after surgery than after a laparotomy. The disadvantage is the presence of a qualified surgeon who knows how endoscopic fundoplication is performed.

The technique of performing the operation, regardless of the type of access, is as follows:

• release of the lower part of the esophagus and the fundus of the stomach, followed by mobilization;
• depending on the type of technique, the anterior and posterior parts of the fundus of the stomach are wrapped around the esophagus 360°;
• the lower esophageal sphincter should be located in the abdominal cavity;
• suturing the wall of the stomach and esophagus;
• crurorrhaphy – plastic surgery of a hernia defect of the esophageal opening of the diaphragm;
• suturing a postoperative wound.

Advantages

The advantage of the surgical method is that if the operation is successfully performed, the patient with GERD is cured. Also, in some cases when proton pump inhibitors are not effective or are contraindicated, surgery is the option.

Flaws

Complications that occur after surgery include:

1. Relapse of the disease.
2. Difficulty swallowing and passing food through the esophagus.
3. Movement of the cardiac part of the stomach relative to the formed cuff. The cause of this complication is the cutting of sutures between the cuff formed from the stomach and the esophagus. Clinically, slippage manifests itself as a disturbance in the passage of food, a feeling of a lump in the esophagus and pain behind the sternum, heartburn, and regurgitation of food. X-ray of the esophagus has the appearance of an hourglass. Such patients require repeated surgical intervention.
4. Movement of the fundus of the stomach into the chest cavity with the formation of a two-chamber stomach.
5. Cuff torsion.
6. Movement of part of the large intestine into the chest cavity.

Other fundoplication techniques

In addition to the Nissen operation, there are many modifications of it. Some methods are more effective and are successfully used, while others have long been abandoned. List of different fundoplication options:

• According to Tupa;
• According to the Douro;
• According to Chernousov;
• According to Rosetti;
• Endoscopic method.

Toupet fundoplication

Modification of the Nissen operation. Surgery can also be performed through a laparotomy or laparoscopic approach. During the operation, a cuff is formed from the fundus of the stomach around the esophagus, which does not completely cover it. The passage of the vagus nerve remains free. Toupet fundoplication has the advantages of reducing the incidence of postoperative dysphagia. The disadvantage is the insufficient antireflux function of the technique.

The indication for partial fundoplication is the presence of neuromuscular pathology of the esophagus.

Dorou fundoplication

At the moment, this surgical technique is not used due to the lack of antireflux function. During the operation, a cuff is formed around the esophagus from the anterior wall of the fundus of the stomach. It is placed in front of the esophagus and sutured to the right wall, also suturing the esophageal-diaphragmatic ligament. Previously, Dor fundoplication was performed when there was a violation of the innervation of the esophagus.

According to Chernousov

An addition to the circular cuff formed from the fundus of the stomach is a proximal selective vagotomy. Only the branches of the vagus nerve that go to the body and fundus of the stomach are crossed, which leads to a lack of parasympathetic innervation of these sections and a decrease in the production of hydrochloric acid by the parietal cells of the stomach.

The Chernousov operation prevents the development of complications such as sliding of parts of the stomach into the chest, the formation of a two-chamber stomach, and torsion of the cuff. Moreover, the operation makes it possible to achieve high antireflux effectiveness even in older patients.

Surgical treatment can be performed through laparoscopic or laparotomy approaches.

According to Rosetti

This is a modification of the Nissen operation during which the anterior wall of the stomach is passed along the posterior wall of the esophagus. The advantage is that the short arteries of the stomach are not crossed. This leads to a reduction in complications in the long-term postoperative period.

Complications

Plastic surgery of the fundus of the stomach is considered a fairly extensive surgical intervention, so some complications may develop during this manipulation. Most often, their appearance is associated with improper preoperative preparation, insufficient qualifications of the operating doctor, or due to unforeseen circumstances. The most common complications:

• Dysphagia (impaired swallowing). May be permanent or temporary (postoperative swelling);
• Odynophagia – pain when swallowing;
• Recurrence of GERD;
• Formation of diaphragmatic hernias;
• Quick satiety when eating;
• Excessive bloating;
• Stool disorder.

Mild dysphagia and bloating can be corrected with proper diet and medications. Compared to other types of surgery, laparoscopic fundoplasty is the least invasive and therefore less likely than others to lead to severe complications.

The four most commonly performed types of fundoplication. A - anterior 270° fundoplication through the left Belsey thoracotomy approach. B — 360° Nissen fundoplication. Requires mobilization of the fundus of the stomach. C — posterior 270° Toupet fundoplication. D — 180° Dor fundoplication, which does not require mobilization of the fundus of the stomach.

Nissen fundoplication technique. An upper-middle procedure is performed or five laparoscopic ports are installed.

The left lobe of the liver is retracted. Isolation of the esophagus begins with division of the esophagophrenic ligament, usually above the hepatic branch of the anterior vagus nerve. This allows access to the legs of the diaphragm. The dissection continues posteriorly along the left and right legs until they join behind the esophagus. Then the short gastric vessels are crossed, and in order to gain access to the base of the left leg of the diaphragm, the stomach is retracted downwards from the diaphragm. Penrose is installed behind the esophagus under visual control. The gastroesophageal junction is retracted inferiorly and all adhesions are divided to mobilize 2-3 cm of the esophagus into the abdominal cavity. The crura of the diaphragm are then sutured back behind the esophagus using separate interrupted sutures. After closing the diaphragm, the fundus of the stomach is moved behind the esophagus from left to right. A thick probe (56-60F) is placed transorally into the stomach, after which the condition of the sutures on the diaphragm is monitored. Two or three separate sutures with non-absorbable sutures are then placed to close the walls of the stomach, usually involving the wall of the esophagus. It is important that the probe ensures the consolidated position of the fundoplication cuff. In general, the fundoplication cuff should not exceed 2 cm. Creating a short, loose fundoplication cuff during Nissen fundoplication is important to prevent dysphagia.

The postoperative period includes a short hospital stay, where the patient adheres to a gentle diet (soft and liquid food) to facilitate evacuation. The diet is maintained for 3-6 weeks after.

Nissen fundoplication results

After laparoscopic Nissen fundoplication, 90-95% of patients actually do not suffer from heartburn. In 85% of patients with extraesophageal symptoms, positive dynamics are observed, but complete resolution of symptoms occurs only in approximately 50%. Patients with dyspepsia are sometimes treated with antisecretory drugs, but postoperative reflux is rare. Quality of life improves after Nissen fundoplication.

Unfavorable outcome of Nissen fundoplication

All prevention procedures are subject to the risk of adverse outcome, either functionally or structurally. Several adverse outcomes have been described. Symptoms of reflux return when the fundoplication cuff sutures rupture. The cuff may also slip from the esophagus and wrap around the stomach, causing dysphagia, bloating, and recurrence of GERD. Another complication is recurrent hiatal hernia, in which the intact fundoplication cuff moves above the diaphragm through the newly formed esophageal hiatus, resulting in heartburn and dysphagia. If, when creating a fundoplication cuff, the greater curvature of the stomach is mistakenly used rather than its fundus, a two-chamber stomach with a tortuous valve structure may be formed. These patients experience severe

Nissen fundoplica. The most popular method of surgical intervention to date remains the one proposed by Nissen in 1961. The essence of the method is to wrap the abdominal esophagus with the anterior and posterior walls of the fundus of the stomach to form a circular cuff covering the esophagus at 360°.

This way formation Fundoplication cuff is effective in eliminating the symptoms of GERD, since the circular cuff has good anti-reflux properties. The disadvantages of this method of fundoplication include the risk of complications such as compression of the vagus nerve trunks by the cuff, cascade deformation of the stomach, axial torsion of the stomach and esophagus, hyperfunction of the cuff (persistent dysphagia in the postoperative period).

Toupet fundoplication

Andre Toupet, like Nissen, proposed isolating the esophagus, placing sutures on the legs of the diaphragm, but not completely enveloping the esophagus, but by displacing the fundus of the stomach posteriorly with the creation of a fundoplication cuff at 1/2 the circumference of the esophagus (180°), leaving its anterior-right surface free ( localization of the left vagus nerve).

Most Popular Toupet fundoplication, described by P. Boutelier and G. Jansson. Later, a technique for forming a fold length along a circumference of up to 270° was presented.

Advantages of partial fundoplication Compared with the formation of a circular cuff (Nissen), the occurrence of persistent dysphagia after surgery is extremely rare, and there is no discomfort associated with excessive accumulation of gases in the stomach and the inability to belch normally (gas-bloat syndrome). Disadvantages of Toupet fundoplication: worse anti-reflux properties compared to a circular cuff.

Partial fundoplication It is advisable to perform it in patients with neuromuscular diseases of the esophagus (achalasia of the esophagus, scleroderma with damage to the esophagus), who have a high risk of recurrent dysphagia due to the absence of peristaltic contractions in the body of the esophagus.

Fundoplica by Dor

At fundoplication according to Dor, the anterior wall of the fundus of the stomach is placed in front of the abdominal esophagus and fixed to its right wall, while the esophageal-diaphragmatic ligament is necessarily captured in the first suture.

Such a fundoplication cuff has the worst antireflux properties and is most often used after seromyotomy for achalasia cardia. In recent years, this method of antireflux surgery has been abandoned.

Fundoplication according to Chernousov

Fundoplication according to Chernousov

Optimal way can be called an antireflux operation with the formation of a symmetrical circular cuff with selective proximal vagotomy, proposed by A.F. Chernousov.

In the technique of this method prevention of such complications as compression of the vagus nerve trunks by the fundoplication cuff, torsion and cascade deformation of the stomach, and displacement of the cuff is included. The fundoplication cuff with this method of operation, like any circular cuff, has excellent anti-reflux properties, but does not have the disadvantages of asymmetric fundoplication.

Must be reflected age aspect this problem. The effectiveness and feasibility of surgical treatment of GERD in the elderly is often questioned. However, a retrospective analysis of three-year observations of patients with complicated forms of GERD over 80 years of age after laparoscopic fundoplication revealed 96% success with restoration of a high level of quality of life for patients. The high effectiveness and safety of surgical treatment of GERD in the elderly, comparable to that in the young, is confirmed by other authors.

Successfully completed antireflux The operation relieves the patient of GERD from the need for observation by a gastroenterologist and taking antisecretory drugs and prokinetics.

At present, sufficient experience has already been gained in implementing fundoplication in patients with GERD, including laparoscopic access, and most researchers come to the conclusion that if antireflux surgery is performed in patients with symptoms of heartburn and regurgitation by an experienced, highly qualified surgeon, then positive results after surgery are achieved in 80-90% of cases.

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