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Fundoplication according to Nissen can be performed by abdominal or thoracic access. However, thoracic access leads to many severe postoperative complications, such as esophago-pleural or gastro-pleural fistulas, ulcers in the area of ​​fundoplication, etc. Because of these and other complications, thoracic access is rarely used. Therefore, we will describe only the abdominal approach.

Transabdominal surgery Nissen is to form a 360" cuff around the lower esophagus using the gastric fundus. The original Nissen technique, although leading to a reliable cessation of gastroesophageal reflux, can also lead to serious postoperative complications. In order to reduce the number of these complications while maintaining Due to the value of the Nissen technique as an antireflux operation, it has been modified.Complications encountered with the classical Nissen technique are the following: dysphagia, difficulty in regurgitation and vomiting, gas swelling syndrome, slippage of the fundoplication down into the body of the stomach, causing its obstruction, slippage of the fundoplication into the chest cell, divergence of the fundoplication, ulceration of the gastric cuff, etc.

Operation Nissen consists of simply wrapping the stomach around the lower esophagus. It is absolutely necessary to have sufficient experience in the successful performance of this operation and reliable criteria for selecting patients. It is important to assess the degree of pressure that the gastric fundus must exert on the esophagus, determine the appropriate height of the cuff, and accurately select the gastric segment from which it is formed. Many complications of this operation are due to the use of inadequate technique and poor selection of patients. Patients with esophageal dysmotility, uncoordinated motility, weak waves or lack of peristalsis should not undergo Nissen surgery, especially those who for these reasons have symptoms of dysphagia. Patients with severe esophagitis, stricture or shortening of the esophagus, who cannot bring the esophagus down sufficiently into the abdominal cavity, or who have residual tension on the esophagus, should not be subjected to this operation. For the correct selection of patients undergoing this operation, a complete preoperative examination, including manometry and 24-hour pH-metry, is absolutely necessary.

Operation Nissen- a technique that is most often used to treat hiatal hernia with reflux. The proposed technical modifications, developing the original method, significantly reduced the incidence of complications. We will continue to describe the Nissen operation with modifications proposed in recent years. The release of the lower esophagus and fundus is carried out in exactly the same way as in the Hill operation.

The figure shows that the lower esophagus and esophagogastric junction. The gastrophrenic ligament was severed and three short vessels were transected and ligated proximally. The patient has a nasogastric tube (18F). The esophageal opening of the diaphragm was sutured behind the esophagus with five non-absorbable sutures. Some surgeons believe that it is not necessary to ligate short vessels by performing a Nissen fundoplication. However, most surgeons believe that in order to adequately mobilize the fundus, select an appropriate segment of the stomach, and perform a 360° eversion without tension, it is absolutely necessary to ligate at least three short vessels.

Before proceeding to the fundoplication, it is necessary to make sure that esophageal opening of the diaphragm sutured correctly. This means that only the tip of the right index finger can be inserted between the esophagus into which the nasogastric tube is inserted and the edge of the esophageal opening, as shown in the figure. If the tip of the index finger cannot be passed through the esophageal opening of the diaphragm, this means that it is too narrow, and the position of the suture closest to the esophagus must be changed. If the remaining space is too large, one or two stitches should be added so that only the tip of the index finger passes through the hole. Too wide a space between the esophagus and the edge of the esophagus facilitates the displacement of the fundoplication into the chest.

On the illustration shows the moment when the fold of the fundus is wrapped on the lower esophagus. The surgeon performs winding with the index and middle fingers of the right hand. When the fundus is moved to the right edge of the esophagus, it is grasped with a Babcock forceps to complete the maneuver. If the three short vessels at the top of the stomach have been previously transected, then this maneuver can be performed correctly and without tension. The figure shows that a portion of the esophagus sufficient to form a cuff without tension has been brought down into the abdominal cavity. The abdominal esophagus should be 4-7 cm long. Only the fundus of the stomach should be used to form the cuff. The proximal body of the stomach should not be included in the cuff.

There are important functional differences between muscle fibers fundus and body of the stomach. The muscle fibers of the fundus contract and relax in sync with the lower esophageal sphincter. During swallowing, if the fundic section is screwed onto the esophagus, at the moment of relaxation of the lower esophageal sphincter, the fundic section relaxes synchronously and the food bolus passes into the stomach without difficulty. If the cuff was formed using the proximal part of the body of the stomach, this segment will not relax, preventing the advancement of the food bolus, and dysphagia will be observed in the postoperative period. DeMeester et al. demonstrated that using part of the stomach body to form a cuff around the esophagus is easy to make a mistake, as some patients have one, two, or even shorter vessels passing retroperitoneally.

Before suturing, connecting both sides of the fundus around the esophagus, the anesthesiologist should retract the nasogastric tube into the mid-esophagus and insert a Hurt or Maloney 50 F soft bougie. If the bougie is placed before tying the sutures, the cuff shaping procedure may become more difficult. The purpose of the bougie is to keep the cuff from excessive compression of the esophagus, leading to dysphagia, gas swelling syndrome, difficulty regurgitation, and vomiting. It has been shown that there is no need to have a dense fundoplication to achieve cardia sufficiency. In addition, it should be noted that during the Nissen operation there is another factor leading to compression of the abdominal esophagus. This is the air in the stomach that compresses the esophagus through the fold of the fundus.

The figure shows a Hurst 50 F bougie inserted into the stomach. Two 2-0 prolene sutures are applied, including serous, muscular and submucosal layer of the fundus folds on the left, further passing through the wall of the esophagus and including both muscle layers, then the serous layer of the fundic fold on the right. It is important that the sutures include the submucosal layer, as this is the most powerful layer of the gastrointestinal tract. To avoid serious postoperative complications, care should be taken not to perforate the gastric and esophageal mucosa. Some surgeons use small gauge bougies, 36 or 40 F, others use large bougies up to 60 F. Not all authors place sutures through the muscular wall of the esophagus, as they believe that this is not of great importance due to the low density of the muscular layer. Other authors, however, believe that these sutures on the esophagus promote fusion of the fundal cuff with it.

Two prolene seams 2-0 on the fundus cuff are tied with a Hurt 50 F bougie. It should be possible to easily insert a finger between the esophagus and the cuff. If the finger cannot be inserted or is difficult to insert, the fundoplication needs to be corrected. If a large gap is found between the fundic fold and the esophagus with a finger, then the necessary correction must also be made.

Height anterior segment of the fundoplication should be 1.5-2 cm. This is the height that is achieved using two seams. High altitude can lead to symptoms of obstruction. DeMeester produces a cuff that is only 1 cm high by placing a single mattress suture over a Teflon pad.

After the formation of fundoplasty the soft bougie is removed, and the previously partially removed nasogastric tube is returned to its place. Again, as shown in the figure, the index finger is inserted between the esophagus and the cuff. Without a bougie, the index finger is easier to gradually insert inside, and the gap can skip even two fingers. If the described technique is strictly followed, postoperative symptoms of obstruction rarely develop. In some patients, however, even with all precautions in the postoperative period, swallowing may be difficult for 2-4 weeks, due to local tissue edema.

Some patients with difficulty swallowing may be longer. For this reason, it is advisable to leave the nasogastric tube for at least 1 week. Some surgeons prefer to achieve gastric decompression by means of a gastrostomy to avoid the discomfort of a weekly nasogastric tube in the esophagus (6). Gastrostomy, in addition to a very effective decompression, helps to fix the stomach to the anterior abdominal wall, preventing its displacement into the chest. With this in mind, some surgeons recommend fixing the gastric cuff to the right crus of the diaphragm (16). Others recommend fixing it to the medial arcuate ligament with multiple sutures. To improve the fixation of the fundus fold, Rossetti suggested two or three sutures, including the cuff and the anterior wall of the stomach, as shown in the inset.

Schematic section of the lower esophagus and proximal upper stomach in patients undergoing a Nissen fundoplication. This figure graphically illustrates that in addition to the pressure exerted on the esophagus by the gastric cuff, there is another compression factor that is usually not taken into account when performing a Nissen fundoplication. This factor is the air, which, rising to the zone of the gastric fold, increases the pressure on the wall of the lower esophagus through the cuff. To prevent symptoms of esophageal obstruction during a Nissen fundoplication, the pressure that this air will exert on the lower esophagus must be taken into account.

Operation Belsey produced by thoracic access. This allows the esophagus to be mobilized from the diaphragm to the aortic arch, often allowing a segment of the lower esophagus and the esophagogastric junction to be brought down into the abdominal cavity, which is not always possible with an abdominal approach. In addition, the Belsey operation includes a fundoplication at 240, which effectively contributes to the creation of an antireflux barrier.

All materials on the site are prepared by specialists in the field of surgery, anatomy and specialized disciplines.
All recommendations are indicative and are not applicable without consulting the attending physician.

A fundoplication is an operation used to eliminate gastroesophageal reflux (reflux of contents from the stomach into the esophagus). The essence of the operation is that the walls of the stomach wrap around the esophagus and thereby strengthen the esophageal-gastric sphincter.

The fundoplication operation was first performed in 1955 by the German surgeon Rudolf Nissen. The first methods had many shortcomings. Over the past years, the classical Nissen operation has been somewhat modified, and several dozens of its modifications have been proposed.

The essence of the fundoplication operation

Gastroesophageal reflux (GERD) is a fairly common pathology. Normally, food passes freely through the esophagus and enters the stomach, since the place where the esophagus passes into the stomach (lower esophageal sphincter) reflexively relaxes during the act of swallowing. After skipping a portion of food, the sphincter contracts tightly again and prevents the contents of the stomach (food mixed with gastric juice) from falling back into the esophagus.

general scheme of fundoplication

In GERD, this mechanism is disturbed for various reasons: congenital weakness of the connective tissue, hernia of the esophageal opening of the diaphragm, increased intra-abdominal pressure, relaxation of the muscles of the esophageal sphincter under the influence of certain substances and other reasons.

The sphincter does not function as a valve, the acidic contents of the stomach are thrown back into the esophagus, which causes many unpleasant symptoms and complications. The main symptom of GERD is heartburn.

Any conservative methods of treating GERD in most cases are quite effective, able to relieve symptoms for a long time. But it is necessary to note the disadvantages of conservative treatment:

• Lifestyle changes and drugs that reduce the production of hydrochloric acid can only eliminate the symptoms, but do not affect the mechanism of reflux itself and cannot prevent its progression.
• Taking acid-lowering drugs for GERD is necessary for a long time, sometimes throughout life. This can lead to the development of side effects, and is also a significant material cost.
• The need for constant restrictive measures leads to a decrease in the quality of life (a person must limit himself in certain products, sleep constantly in a certain position, do not bend over, do not wear tight clothes).
• In addition, in about 20% of cases, even compliance with all these measures remains ineffective.

Then the question arises about the operation and the elimination of the anatomical prerequisites for reflux.

Regardless of the cause of the reflux, the essence of the fundoplication operation is to create a barrier to backflow into the esophagus. To do this, the sphincter of the esophagus is strengthened with a special sleeve formed from the walls of the fundus of the stomach, the stomach itself is sutured to the diaphragm, and, if necessary, the enlarged diaphragmatic opening is sutured.

Transoral fundoplication - medical animation

Indications for fundoplication

There are no clear criteria and absolute indications for surgical treatment of GERD. Most gastroenterologists insist on conservative treatment, while surgeons, as always, are more committed to radical methods. Surgery is usually suggested in cases of:

1. Persistence of disease symptoms despite adequate long-term conservative treatment.
2. Recurrent erosive esophagitis.
3. Large sizes of diaphragmatic hernia, leading to compression of the mediastinal organs.
4. Anemia due to microbleeding from erosions or hernial sac.
5. Barrett's esophagus (precancerous condition).
6. The patient's lack of adherence to long-term medication or intolerance to proton pump inhibitors.

Examination before surgery

Fundoplication is a planned operation. Urgency is necessary in rare cases of strangulated esophageal hernia.

Before prescribing surgery, a thorough examination should be carried out. It must be confirmed that the symptoms (heartburn, belching, dysphagia, chest discomfort) are due to reflux and not to another pathology.

Investigations required for suspected esophageal reflux:

• Fibroendoscopy of the esophagus and stomach. Allows:
  1. Confirm the presence of esophagitis.
  2. Non-closure of the cardia.
  3. See stricture or dilatation of the esophagus.
  4. rule out the tumor.
  5. Suspect a hernia of the esophagus and roughly estimate its size.
• Daily pH-metry of the esophagus. Using this method, the reflux of acidic contents into the esophagus is confirmed. The method is valuable in cases where endoscopic pathology is not detected, and the symptoms of the disease are present.
• Manomeria of the esophagus. Allows you to exclude:
  1. Achalasia of the cardia (lack of reflex relaxation of the sphincter when swallowing).
  2. Assess the peristalsis of the esophagus, which is important for choosing the surgical technique (complete or incomplete fundoplication).
• X-ray of the esophagus and stomach in a head-down position. It is carried out with esophageal-diaphragmatic hernia to clarify its location and size.

Once the diagnosis of esophageal reflux has been confirmed and prior consent for surgery has been obtained, a standard pre-operative examination must be completed at least 10 days prior to surgery:

Fundoplication Contraindications

• Acute infectious and exacerbations of chronic diseases.
• Decompensated cardiac, renal, hepatic insufficiency.
• Oncological diseases.
• Severe course of diabetes.
• Severe condition and advanced age.

If there are no contraindications and all examinations are carried out, the day of the operation is scheduled. Three to five days before the operation, foods rich in fiber, black bread, milk, and muffins are excluded. This is necessary to reduce gas formation in the postoperative period. On the eve of the operation, a light dinner is allowed; on the morning of the operation, you can not eat.

Types of fundoplication

The Nissen fundoplication remains the gold standard for antireflux surgery. Currently, there are many of its modifications. As a rule, each surgeon uses his favorite method. Distinguish:

1. Open fundoplication. Access can be:

• Thoracic- the incision is made along the intercostal space on the left. Currently, it is used very rarely.
• Abdominal. An upper median laparotomy is performed, the left lobe of the liver is moved aside and the necessary manipulations are carried out.

2. Laparoscopic fundoplication. An increasingly popular method due to low trauma to the body.

In addition to different types of access, fundoplications differ in the volume of the cuff formed around the esophagus (360, 270, 180 degrees), as well as in the mobilized part of the fundus of the stomach (anterior, posterior).

left: open fundoplication, right: laparoscopic fundoplication

The most popular types of fundoplications:

• Full 360 degree posterior fundoplication.
• Anterior partial 270° Belsi fundoplication.
• Posterior 270-degree Tupe fundoplication.
• 180 degree Dohr fundoplication.

Stages of open access operation

The fundoplication operation is performed under general anesthesia.

• An incision is made in the anterior abdominal wall in the upper abdomen.
• The left lobe of the liver is shifted to the side.
• The lower segment of the esophagus and the fundus of the stomach are mobilized.
• A bougie is inserted into the esophagus to form a given lumen.
• The anterior or posterior wall of the gastric fundus (depending on the chosen method) is wrapped around the lower part of the esophagus. A cuff up to 2 cm long is formed.
• The walls of the stomach are sutured with the capture of the wall of the esophagus with non-absorbable threads.

These are the steps of the classical fundoplication. But others can be added to them. So, in the presence of a hernia of the esophageal opening of the diaphragm, the hernial protrusion is brought down into the abdominal cavity and the dilated diaphragmatic opening is sutured.

With incomplete fundoplication, the walls of the stomach also wrap around the esophagus, but not on the entire circumference of the esophagus, but partially. In this case, the walls of the stomach are not sutured, but are sutured to the side walls of the esophagus.

Laparoscopic fundoplication

Laparoscopic fundoplication was first proposed in 1991. This operation revived interest in surgical antireflux treatment (before that, fundoplication was not so popular).

laparoscopic fundoplication

The essence of laparoscopic fundoplication is the same: the formation of a sleeve around the lower end of the esophagus. The operation is performed without an incision, only a few (usually 4-5) punctures are made in the abdominal wall, through which the laparoscope and special instruments are inserted.

Advantages of laparoscopic fundoplication:

1. Less traumatic.
2. Less pain syndrome.
3. Reduction of the postoperative period.
4. Fast recovery. According to the reviews of patients who underwent laparoscopic fundoplication, all symptoms (heartburn, belching, dysphagia) disappear the very next day after the operation.

However, it is necessary to note some features of laparoscopic surgery, which can be attributed to cons:

• Laparoscopic fundoplasty takes longer (on average 30 minutes longer than open fundoplasty).
• After laparoscopic surgery, the risk of thromboembolic complications is higher.
• Laparoscopic fundoplication requires special equipment, highly qualified surgeon, which somewhat reduces its availability. Such operations are usually paid.

Nissen fundoplication - operation video

Postoperative period

1. On the first day after the operation, a nasogastric tube is left in the esophagus, an infusion of fluid and saline solutions is performed. Some clinics practice early (after 6 hours) drinking.
2. Antibiotics are prescribed to prevent infection, painkillers.
3. The next day, it is recommended to get up, you can drink liquid.
4. On the second day, an X-ray contrast study of the patency of the esophagus and the functioning of the valve is performed.
5. On the third day, liquid food (vegetable broth) is allowed.
6. Gradually, the diet expands, you can take pureed, then soft food in small portions.
7. The transition to a normal diet occurs within 4-6 weeks.

Since a fundoplication essentially creates a “one-way” valve, after such an operation the patient is unable to vomit, and he will also not have an effective burp (air accumulated in the stomach will not be able to exit through the esophagus). Patients are warned about this in advance.

For this reason, patients who have undergone fundoplication are not recommended to consume large amounts of carbonated drinks.

Possible complications after fundoplication surgery

The percentage of relapses and complications remains quite high - up to 20%.

Possible Complications during surgery and early postoperative period:

• Bleeding.
• Pneumothorax.
• Infectious complications with the development of peritonitis, mediastinitis.
• Spleen injury.
• Perforation of the stomach or esophagus.
• Obstruction of the esophagus due to a violation of technique (cuff too tight).
• Failure of the sutures.

All of these complications require early reoperation.

There may be symptoms of dysphagia (difficulty swallowing) due to postoperative edema. These symptoms may persist for up to 4 weeks and do not require special treatment.

Late Complications

1. Stricture (narrowing of the esophagus) due to the growth of scar tissue.
2. Esophageal slippage from the formed cuff, relapse of reflux.
3. Slipping the cuff over the stomach can lead to dysphagia and obstruction.
4. Formation of diaphragmatic hernia.
5. Postoperative hernia of the anterior abdominal wall.
6. Dysphagia, flatulence.
7. Atony of the stomach due to damage to the branch of the vagus nerve.
8. Reflux esophagitis recurrence.

The percentage of postoperative complications and relapses depends mainly on the skills of the operating surgeon. Therefore, it is advisable to perform the operation in a reliable clinic with a good reputation by a surgeon with sufficient experience in performing such operations.

The open access operation is possible free of charge under the CHI policy. The cost of paid laparoscopic fundoplication will be 50-100 thousand rubles.

Video: patient's life after fundoplication, lecture

At the moment, cruroraphy fundoplication according to Nissen is one of the most common surgical operations performed for functional disorders and disorders of the anatomical structure of the LES - 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.

A disease of this kind can be both congenital and acquired. Often the disease is associated with a hernia of the esophageal opening of the diaphragm, that is, the muscular border between the abdominal and chest cavities. Cruroraphy 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 Nixen

The objective of this method of treatment is to increase pressure in the LES in order to prevent reflux, that is, 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 esophagus is encircled by the fundus of the stomach. At the next stage, the legs of the diaphragm are sutured (directly crororaphy), as a result of which the diameter of the food opening decreases. After that, 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 recurrence, the sheath of the anterior wall of the esophagus is captured. Ultimately, the anterior abdominal wall and the anterior wall of the stomach are fixed with sutures.

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

Possible postoperative complications and side effects

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

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

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

Contraindications for Nissen fundoplication cruroraphy

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 an examination of the gastrointestinal tract using X-rays, esophagogastroduodenoscopy, esophageal manometry and daily pH monitoring.

Cruroraphy fundoplication according to Nissen in our clinic in Kyiv

Our clinic in Kyiv provides services of experienced doctors who perform Nissen fundoplication cruroraphy. 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 phone 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 of the Medical Faculty of the 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. The own experience of repeated operations in 15 patients is presented. It has been shown that to prevent the development of complications before the first operation for reflux esophagitis and hiatal hernia (HH), 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 propulsive motility of the organ. The need for surgical treatment of this group of patients in specialized hospitals is also 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 in a number of 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 RE, the authors of which agree on two issues: 1) an indication for surgery is a severe RE that is not amenable to conservative treatment, or its complications; 2) the operation should be to create a reliable antireflux valve at the level of the esophageal-gastric 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 the recurrence of RE, which is detected in 11-24% of cases. At the same time, some specific complications of antireflux operations, which often require repeated interventions, have become widely known. Despite the growing interest in antireflux surgery, there is little work specifically devoted to the indications, technique 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 with uncomplicated RE gives a positive result in 80-95% of cases. However, if such an operation is performed by a less qualified surgeon, the number of positive results is much lower and reaches only 40-50% during the first year after the operation. . In addition, even in an experienced specialist in the late postoperative period, the number of patients with recurrence of EC symptoms can reach 15-20%. The continuing increase in the number of antireflux surgeries, many of which are performed outside large specialized centers, inevitably leads to an increase in the number of patients with ineffective surgical treatment and disease recurrence, which becomes a significant medical and social problem.

Undoubtedly, an antireflux operation should be recognized as unsuccessful, after which the primary symptoms persist (heartburn, belching, pain, etc.) or new ones appear (dysphagia, pain, bloating, diarrhea, etc.). The persistence of RE symptoms or their early recurrence after fundoplication has been described in 5-20% of patients after laparotomic access and in 6-30% of patients after laparoscopic fundoplication. To date, many publications have been published regarding the results of reoperations 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 surgery in 90-96% of cases. However, if the disease recurs, a second operation 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 probability of achieving a good surgical outcome progressively decreases with an increase in the number of operations. Since the fourth reconstructive operation rarely brings a positive result, many experts consider it expedient to perform resection or extirpation of the esophagus after the third unsuccessful operation.

Accumulated clinical experience suggests that when choosing the scope of surgical intervention in patients with RE, 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 biopsy of the terminal esophagus, as well as the severity of concomitant diseases. The inevitable shortening of the esophagus that occurs in conditions of chronic inflammation significantly affects the surgical tactics. Shortening, the esophagus drags the cardial section of the stomach into the posterior mediastinum, pulling it into the tube and contributing to the complete disruption of the pulp-valve antireflux mechanism. This not only significantly aggravates destructive changes in the esophageal wall, including the development of peptic stricture, chronic round ulcers, and 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-purification of the mucosa from aggressive gastric contents), the propulsive motility of the esophagus is inhibited. Recent prospective studies in 8 large centers in Italy have made it possible to diagnose shortened esophagus intraoperatively in 20% of patients who underwent routine 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%.

Misinterpretation of the data of one-stage manometry without taking into account the results of an X-ray examination, which allows to assess the degree of shortening of the esophagus and the nature of HH (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. The dysphagia that occurs after such interventions requires a very complex correction, and sometimes even 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 esophageal motility disorders detected before surgery do not affect the incidence of postoperative dysphagia, regardless of the type of fundoplication. In addition, the frequency of unsatisfactory results after an incomplete fundoplication remains higher than with a complete fundoplication.

According to the world literature, the Nissen operation is the most frequently performed antireflux operation, however, persistent containment of gastroesophageal reflux does not occur in 30-76% of cases. As you know, the most common complications of the Nissen operation are "gas-bloat" syndrome, flatulence, inability to belch. Damage to the vagus nerves during antireflux surgery can 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 undergoing antireflux surgery need 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 performing interventions. The reasons for it may be inhibition of the relaxation of the lower esophageal sphincter by a constricted cuff, a violation of the migration of the cardia during the act of swallowing or a violation of the motility of the esophagus due to denervation of the abdominal esophagus, as well as a slipped antireflux cuff.

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

Another important and fairly common complication of the Nissen operation is the "telescope" phenomenon (slipped Nissen, or "sliding" Nissen) - slippage of the cardiac section and fundus of the stomach with the terminal section of the esophagus relative to the cuff (Scheme 1, b). As a rule, the reason for this is the eruption of the sutures between the cuff and the esophagus. Suturing the legs of the diaphragm during shortening of the esophagus and fixing an antireflux cuff to them also lead to slippage, since the esophagus, having contracted after the operation, will draw the cardia along with the expanded cuff into the posterior mediastinum. Radiographically, this looks like an "hourglass" phenomenon, where one part of the cuff is above the diaphragm and the other is 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 technique is to use the body or even the antrum of the stomach when forming an antireflux cuff (see Scheme 1, c). According to a number of authors, if the short gastric vessels are not crossed, the surgeon is forced to use not the fundus of the stomach, but its anterior wall during 360° fundoplication. All this leads to torsion, a pronounced 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, with greater technical simplicity, the Rossetti operation is rarely used.

Scheme 1. Complications after Nissen fundoplication. a - full reversal of the cuff when cutting the seams; b - "slipped" Nissen; c - a cuff formed around the cardial part of the stomach; d - retraction of the antireflux cuff into the posterior mediastinum with 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 cardial section of the stomach, the esophageal-gastric junction is above the diaphragm; b, c - with double contrasting, the folds of the gastric mucosa are clearly visible inside the slipped cuff with the formation of a diverticulum-like deformity (such a diverticulum often becomes a source of gastroesophageal reflux and progressive RE)

The simplest complication for diagnosis and treatment is "missing" Nissen ("insufficient" Nissen). At the same time, the overly 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 complications inherent in it, 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 time of the patient's recovery from anesthesia. This happens for a number of reasons, in particular, due to unreasonable traction of the shortened esophagus to create a fundoplication cuff below the diaphragm (see Scheme 1, d). Some authors also believe that inadequate fixation of the fundoplication cuff to the crura of the diaphragm predisposes to the further development of HH or to the development of paraesophageal HH with movement of the splenic flexure of the colon along the fundoplication cuff into the chest cavity.

Material and methods

From 2006 to 2011 we observed 15 patients (7 men and 8 women aged 25 to 72 years) who underwent various operations for HH and RE, the result of which was unsatisfactory. All except one patient were initially operated in other medical institutions. The nature of primary operations is reflected in Table. 1. In most cases, a 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: diaphragmocrorrhaphy
selective proximal vagotomy
stem vagotomy
gastrostomy
esophageal perforation closure
suturing of gastric perforation
duodenal ulcer excision 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 "was delayed" 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 worried about 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 the result of cicatricial stenosis in the area of ​​the esophageal-gastric junction, which arose after suturing the iatrogenic perforation of the esophagus during the formation of the fundoplication cuff. The string blocking sessions performed in the clinic did not bring the desired effect due to the impossibility of holding a bougie over No. 26 (Fig. 4, a, b). As a rule, the pain wore a burning or pressing character. In the origin of pain in this group of patients (12), both chemical (effect of gastric contents on the inflamed and ulcerated mucous membrane of the esophagus, the so-called heartburn to pain) and mechanical factors (stretching of the terminal esophagus by a reflux wave, fixation of the cuff to the crura of the diaphragm) play a role. , as well as the tension of the branches of the solar plexus, characteristic of the shortening of the esophagus). The predominance of patients with localization of pain syndrome behind the sternum and in the region of the heart is largely due to the location of the "slipped" cuff in the posterior mediastinum due to the progression of the shortening of the esophagus, as well as the gastrocardial Houdin-Remheld syndrome.

Rice. 3. X-ray. Complications after Nissen fundoplication. a - the "slipped" cuff compresses the upper body 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 esophageal-gastric junction is located 4 cm above the level of the diaphragm; b - view of the formed reconstructive gastroplication cuff

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

Belching was another common symptom indicating the ineffectiveness of the newly created valve (11).

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

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

In all cases, the fundoplication cuff did not prevent gastroesophageal reflux and was found to be ineffective even at the preoperative stage.

In one patient operated in our clinic for moderate RE, sliding cardiac HH and shortening of the 1st degree esophagus, on the 7th day after laparoscopic fundoplication, a control X-ray examination revealed a diverticulum-like deformity of the cardia and fundus of the stomach (Fig. 5) . At the same time, no signs of gastroesophageal reflux were detected even in the Trendelenburg position. It should be noted that, despite the experience of open antireflux interventions, the operation was one of the first and the only unsuccessful laparoscopic operation to date, which arose at the stage of development and implementation of this technique. The patient was re-operated 5 months later, after undergoing a course of rehabilitation, and the re-examination made it possible to establish a progressive shortening of the esophagus to degree II, which affected the tactics of surgical treatment. Examination data and analysis of surgical findings during repeated intervention revealed the following cause of the complication: eruption of sutures on one side of the cuff, followed by its torsion around the axis and the formation of a diverticulum-like deformity of the gastric fundus. The patient underwent reconstructive valvular gastric plication, extramucosal pyloroplasty by traditional access.

Fig 5. X-ray. Complication after fundoplication: diverticulum-like deformity of the fundus of the stomach in the area of ​​the cuff partially unfolded during suture eruption after laparoscopic fundoplication

It should be noted that we have never used the classical Nissen fundoplication as an antireflux operation, but widely use the 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 RE, since this operation does not create a sufficiently reliable antireflux valve in the cardia.

At the same time, the fundoplication cuff is formed after mobilization of the lesser curvature, cardia, abdominal esophagus and fundus of the stomach, while maintaining even trunks of the vagus nerves and both Latarjet 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 gastric fundus without the use of a rubber holder ensures the formation of a uniform, accurate, complete, symmetrical cuff that does not deform the esophageal-gastric junction and does not create diverticulum-like pockets and cascade deformation of the stomach. The optimal height of the cuff is 4 cm. The muscle wall of the esophagus must be captured in the sutures. The upper edge of the cuff is additionally fixed to it with two interrupted sutures in front and one behind (the top of the cuff) to prevent the “telescope” phenomenon, i.e. slipping of the cuff (Scheme 2 ).

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

With a shortening of the esophagus of the II degree (the location of the esophageal-gastric junction more than 4 cm above the diaphragm), its reduction is meaningless, since after the operation it will inevitably decrease again. In this case, the antireflux cuff will either slip off with the formation of a "noose" - the so-called telescopic effect, or turn around when the sutures are cut. Practice has shown that the main anti-reflux effect is exerted by the cuff from the tissues of the stomach. With its proper formation, it works equally well under and above the diaphragm.

Back in 1960, R. Nissen suggested using fundoplication in patients with shortening of the 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 obligatory 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 the Nissen fundoplication with a short esophagus leaving the cuff 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 cruroraphy does not have a significant independent anti-reflux function in conditions of complete destruction of the pulp-valve function of the cardia. It is appropriate for a common esophago-aortic "window", giant and paraesophageal hernias solely to prevent migration of organs from the abdominal cavity into the mediastinum.

In conditions of pronounced shortening, valvular gastroplication is justified (N.N. Kanshin, 1962), which today we have modified and is successfully used again. After mobilization of the cardial part of the stomach and expansion of the hernial orifice anteriorly, the stomach is turned into a tube with transverse collecting sutures (cardiography). Further, the part of the stomach turned into a tube, which is a kind of "extension" of the esophagus, is symmetrically wrapped around the gastric wall, as in a fundoplication. Then we fix the upper part of the cuff to the esophagus (Scheme 3). Thus, the esophagus is "lengthened" at the expense of the stomach and an anti-reflux valve is created.

Scheme 3. Valvular gastroplication

Results and its discussion

All patients who underwent primary operations in other medical institutions were operated on again. At the same time, as a result of the examination and analysis of surgical findings, they revealed the following technical errors made during previous operations: fixation to the lesser curvature of the mobilized greater curvature behind the esophagus; stitching in front with the formation of a duplication 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 of the legs of the diaphragm (4); fixation of the stomach to the liver, anterior abdominal wall (2); pyloroplasty (5); incorrectly formed cuff (8) and its complete absence (3); the "telescope" phenomenon (8); excessively dense cuff (3); gastrostasis (2).

One patient with severe cicatricial stenosis of the esophagogastric junction after a previously performed Nissen fundoplication and iatrogenic perforation of the esophagus was unable to perform local reconstruction (see Fig. 4, a, b). We give a brief description of the course of the operation.

Performed laparotomy, enterolysis of the upper floor of the abdominal cavity. The stomach is of normal size, deformed in the cardial region, the esophageal-gastric junction and the upper third of the stomach are practically not differentiated (the area of ​​perforation and the application of the fundoplication cuff). The tissues in this area are edematous, infiltrated, previously applied ligatures are visible. With technical difficulties after partial sagittal diaphragmotomy, the crura of the diaphragm, previously sutured with interrupted sutures, was identified; threads removed; in the posterior mediastinum, the lower thoracic esophagus was isolated, expanded to 6 cm with hypertrophied walls. The esophageal-gastric junction was gradually mobilized, rigid, stenotic with rough scars for 2 cm. Distally, the upper third of the stomach was deformed due to the previously formed fundoplication cuff. The latter with technical difficulties straightened out. Mobilized lesser curvature of the stomach to the angle, greater curvature with ligation of three short gastric and posterior gastric arteries. The tissues of the upper third of the stomach in the area of ​​the expanded cuff are atonic, the wall is thinned, infiltrated - unsuitable for the formation of an antireflux cuff, a circular stricture is not subject to transverse plasty. Under these conditions, proximal resection of the stomach, resection of the abdominal esophagus, and pyloroplasty were performed. At the same time, an esophageal-gastric anastomosis was formed with the anterior wall of the stomach stump, followed by the formation of an antireflux cuff due to the tissues of the stomach stump on a thick gastric tube. The left corner of the sutures of the stomach 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), due to hyperfunction of the reconstructive gastroplication cuff. It should be noted that both patients had a history of two operations on the area of ​​the cardia. The sessions of balloon dilatation (1-2 sessions) under the control of X-ray television made it possible to eliminate the clinical and radiological manifestations of dysphagia without destroying the newly created antireflux valve in the form of a cuff.

Table 2. The nature of repeated antireflux operations

* Including simultaneous operations.

Good immediate functional results with the disappearance of clinical symptoms were obtained in the absolute majority of reoperated patients. Long-term results were studied in all 15 patients and were followed up from 6 months to 4 years. The study was carried out both using traditional approaches and using an assessment of the quality of life of operated patients, which is a mandatory attribute of international studies in recent years, complies with the principles of evidence-based medicine and allows a more adequate assessment of long-term results. The results obtained were evaluated on the basis of a direct examination, a comprehensive examination, and also on the basis of questionnaire data. All patients underwent a scheduled 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.

The quality of life was assessed using a modified specific questionnaire - the gastrointestinal quality of life index (GIQL1). When comparing the obtained indicators of quality of life, 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.

An x-ray examination did not reveal any violation of swallowing and the passage of a contrast agent through the esophagus in any patient. In 3 patients, the stomach was located in the abdominal cavity, in the remaining 12 patients, the antireflux cuff was formed at or above the level of the diaphragm. At the same time, gastroesophageal reflux of the contrast agent was not detected during polypositional examination, including in the Trendelenburg position.

The results obtained once again demonstrate the long-standing assertion that the cuff from the stomach tissues has the main antireflux effect, and when it is properly formed, it equally successfully "works" both under and above the diaphragm.

EGDS showed no gaping or insufficiency of the cardia with signs of esophagitis in any of the patients.

Thus, surgically treated patients can usually eat any food of their choice, be in a horizontal position and bend over without experiencing clinical manifestations of gastroesophageal reflux, and, last but not least, they do not need constant medication.

Unsuccessful outcomes of primary antireflux operations are observed in 6-30% of cases. We distinguish the following groups of reasons for these failures: 1) the desire to eliminate HH, and not 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 surgeries to expedite evacuation and "decrease" reflux, such as distal gastric resection or pyloroplasty, and dissection of the ligament of Treitz; 3) technical errors, consisting in 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 typical for fundoplication, such as paraesophageal hernia, "telescope" phenomenon, compression of the esophagus by too tight cuff, gastrostasis due to infringement or intersection of the vagus nerves, stomach ulcer; 5) various functional disorders of swallowing and digestion in the absence of characteristic anatomical changes according to the examination - they reflect an unjustified expansion of indications for primary operations in HH.

A number of authors emphasize the uselessness and harmfulness of fixing the stomach and fundoplication cuff in the abdominal cavity. Others continue to promote this method. Cruroraphy has been suggested as a prophylaxis for paraesophageal hernia formation as an adjunct to fundoplication, although some authors argue that only gastropexy is effective for this purpose. We have seen 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 out of any fixed cuff, which usually leads to the appearance of various pronounced deformities and recurrence of RE. Crurorrhaphy is considered 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 paraesophageal hernia as a complication of fundoplication.

A complete fundoplication gives good and excellent long-term results in 84-95% of cases. In our series, in half of the observations, we met with the fact that during primary operations in other medical institutions, attempts were made to form a cuff with gross technical errors that led to the most diverse deformities of the stomach, 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 the fundoplication cuff with the formation of an external gastric fistula; b - reconstructive gastroplication

According to the literature, repeated antireflux operations give worse results compared to primary ones. Methods of repeated antireflux operations are various. As with primary interventions, the well-known Nissen, Toupet, Collis methods are offered. As a surgical access, both laparotomy, laparoscopy, and thoracotomy are used. We believe that in case of repeated operations for HH and RE, the method of choice should be the upper midline laparotomy with access correction by 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 surgery for RE should be performed by a surgeon who has significant experience in such open surgery and knows all the details of the intervention. This is especially true for patients with II degree shortening of the esophagus and a long history of severe RE. In such patients, there are certain difficulties in mobilizing the esophagus and the cardial part of the stomach elongated in the form of a tube due to severe periesophagitis. It is in this 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 gastric acid secretion and reduce the aggressive effect of gastric juice on the esophageal mucosa. Stem vagotomy during repeated interventions is justified in conditions of a pronounced cicatricial process in the lesser omentum and around the cardia, when it is impossible to identify and preserve Latarjet's nerves.

We consider it inappropriate in the development of such complications of EC as an extended cicatricial peptic stricture or Barrett's esophagus with high-grade dysplasia, performing a partial resection of the esophagus with replacement of its part with a stomach or a segment of the intestine, as suggested by other authors. It should be borne in mind that partial resection of the esophagus in this case is always dangerous for RE recurrence, since it is very difficult, and most likely impossible, to create a reliable universal antireflux 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, extirpation of the esophagus by cervical-abdominal access with simultaneous gastric esophagoplasty, deserves attention. We consider this operation the method of choice in the most difficult situations.

Particular attention should be paid to patients who, according to the examination, were 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 several antireflux surgeries in their history. Analyzing the clinical picture of the disease and the data of 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 expedient to abandon reconstructive surgery in favor of conservative treatment with a mandatory consultation of a psychoneurologist. Up to 28% of patients undergoing antireflux intervention have various gastroenterological symptoms. At the same time, 35% of them do not have any disorders or changes in the gastrointestinal tract during the examination, and the 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 HH and RE.

Conclusion

Thus, the variety of causes of failures and complications of antireflux operations, the technical complexity of repeated interventions and the problematic nature of their good results determine the expediency of concentrating patients with HH and RE in specialized hospitals and dictate the need for further clinical research in this area.

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Fundoplication according to Nissen(English) Nissen fundoplication) is an anti-reflux operation, which consists in wrapping the bottom of the stomach around the esophagus, creating a cuff that prevents gastric contents from being thrown into the esophagus. For the first time, an antireflux operation - fundoplication was carried out by Rudolf Nissen in 1955, who proposed to form a sleeve from the upper part of the fundus of the stomach, which consisted of a 360-degree plication of a 5-cm cuff around the lower part of the esophagus (Vasnev O.S.). During the fundoplication, not only the anatomical structure is restored, but also the functional state of the lower esophageal sphincter: the tone is restored, the number of transient relaxations during stretching of the stomach decreases, and its emptying improves.

Fig.1. General scheme of fundoplication according to Nissen

Nissen fundoplication can be performed either laparoscopically or openly. The Nissen fundoplication, including its modifications, is currently considered the "gold standard" of antireflux surgery.

The Nissen fundoplication is the most common surgical procedure for the treatment of GERD. It can be performed laparoscopically by an experienced surgeon. The purpose of the operation is to increase pressure in the lower esophageal sphincter to prevent reflux. When performed by an experienced surgeon (who has performed at least 30–50 laparoscopic procedures), its success approaches that of a well-planned and carefully administered therapeutic treatment with proton pump inhibitors. Side effects or complications associated with surgery occur in 5-20% of cases. The most common is dysphagia, or difficulty swallowing. It is usually temporary and resolves in 3-6 months. Another problem that some patients have is their inability to burp or vomit. This is because the operation creates a physical barrier to any type of backflow of any stomach contents. The consequence of the impossibility of effective belching is the "gas-bloat" syndrome - bloating and discomfort in the abdomen (J. Richter et al. Gastroesophageal reflux disease (GERD) in questions and answers).

When choosing a long-term treatment strategy for patients who have achieved the effect of the use of proton pump inhibitors, surgical treatment is inappropriate. No surgical operation can be performed with "zero" mortality. There is always a certain risk of complications. One of the important steps in antireflux surgery is the restoration of normal anatomical relationships in the area of ​​the transition of the esophagus into the stomach. In this case, the lower esophageal sphincter should be below the diaphragm under the influence of high intra-abdominal pressure. Restoration of the legs of the diaphragm and valvuloplasty are carried out. If the operation is performed correctly, the recurrence of hiatal hernia is prevented for a long time, at least 10 years. Before the operation, the mandatory diagnostic measures carried out before the operation include endoscopy, 24-hour pH monitoring, esophageal manometry, preferably X-ray examination (Lundell L.).

The main postulate of the approach to antireflux surgery today is a thorough preoperative diagnosis. Before performing antireflux surgery, it is necessary to confirm that the patient's symptoms are caused by exposure to pathological acid or alkaline reflux on the mucosa of the esophagus and there is no neuromuscular disease of the esophagus and cardia. The study of the function of the esophagus includes esophagogastroduodenoscopy, x-ray examination of the upper gastrointestinal tract, (ideally -), esophageal manometry (Vasnev O.S.).

Disadvantages of the Nissen fundoplication

Nissen fundoplication is the most commonly performed antireflux operation, however, persistent containment of gastroesophageal reflux does not occur in 30-76% of cases. Up to 30% of patients after undergoing antireflux surgery need a second operation due to the development of persistent dysphagia. The reasons for it can be inhibition of relaxation of the lower esophageal sphincter by a constricted cuff, impaired migration of the cardial part of the stomach during swallowing or impaired esophageal motility due to denervation of the abdominal esophagus, as well as a slipped antireflux cuff (A.F. Chernousov and others).

Rice. 3. X-ray. Complications after fundoplication according to Nissen. a - dysphagia due to an overly tightly formed cuff; b - dysphagia caused by an excessively long fundoplication cuff. In both cases, there are signs of impaired patency in the area of ​​the esophageal-gastric junction and suprastenotic expansion of the esophagus above the applied cuff (Chernousov A.F. et al.)

Another important and rather frequent complication of the Nissen fundoplication operation is the slippage of the cardiac section and fundus of the stomach with the terminal section of the esophagus relative to the cuff (Fig. 4b). As a rule, the reason for this is the eruption of the sutures between the cuff and the esophagus. Suturing the legs of the diaphragm during shortening of the esophagus and fixing an antireflux cuff to them also lead to “slipping”, since the esophagus, having contracted after the operation, will draw the cardia along with the expanded cuff into the posterior mediastinum. Radiographically, this looks like an "hourglass" phenomenon, where one part of the cuff is above the diaphragm and the other is below (Fig. 5). The complication is accompanied by severe dysphagia, regurgitation and heartburn, which, of course, requires repeated corrective surgery. A common mistake when using endoscopic technique is to use the body or even the antrum of the stomach when forming an antireflux cuff (see Fig. 4c). If the short gastric vessels are not crossed, the surgeon is forced to use not the fundus of the stomach, but its anterior wall during 360° fundoplication. All this leads to torsion, a pronounced 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.

Rice. Fig. 4. Complications after the Nissen fundoplication: a - complete reversal of the cuff during suture eruption; b - slippage of the cardiac section and fundus of the stomach with the terminal section of the esophagus relative to the cuff; c - a cuff formed around the cardial part of the stomach; d - retraction of the antireflux cuff into the posterior mediastinum with shortening of the esophagus (Chernousov A.F. et al.)

Rice. 5. X-ray. "Sliding" fundoplication cuff: a - the slipped cuff is located below the level of the diaphragm and compresses the cardial part of the stomach, the esophageal-gastric junction is above the diaphragm; b, c - with double contrasting, the folds of the gastric mucosa are clearly visible inside the slipped cuff with the formation of a diverticulum-like deformity (such a diverticulum often becomes a source of gastroesophageal reflux and progressive reflux esophagitis) (Chernousov A.F. et al.)

The simplest complication for diagnosis and treatment is "insufficient" Nissen. At the same time, the overly superficial sutures on the fundoplication cuff are torn, and the latter unfolds (see Fig. 4, a). With the introduction of the laparoscopic technique, the number of complications inherent in it, 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 time of the patient's recovery from anesthesia. This happens for a number of reasons, in particular, due to unreasonable traction of the shortened esophagus to create a fundoplication cuff below the diaphragm (Fig. 4d). Inadequate fixation of the fundoplication cuff to the crura of the diaphragm predisposes to the further development of a hernia of the esophageal opening of the diaphragm or to the development of a paraesophageal hernia of the esophageal opening of the diaphragm with the movement of the splenic flexure of the colon along the fundoplication cuff into the chest cavity (A.F. Chernousov and others).

The position of gastroenterologists-therapists regarding the treatment of GERD using the Nissen fundoplication

Despite the fact that gastroenterologists around the world say that it is not advisable to treat GERD surgically with a Nissen fundoplication, gastroenterologist surgeons continue to perform such operations. Postoperative complications occur in 60% of cases.

Postoperative lesions of the esophagus:

• impossibility of belching, regurgitation, vomiting
• postoperative achalasia of the cardia type II
• chest pain.

Stomach lesions:

• syndrome of accumulation of gas and bloating of the upper abdomen
• postoperative gastroparesis
• postoperative dumping syndrome.

Intestinal lesions:

• bacterial overgrowth syndrome
• swelling of the lower abdomen.

In 30% of cases, repeated operations are required. With the Nissen fundoplication, there is a low effectiveness of relief of symptoms. In most cases, surgery does not relieve long-term medication. Therefore, the first choice therapy is proton pump inhibitors, and surgery is only in extreme cases after a joint consultation of a gastroenterologist and a surgeon, and only in specialized departments with experienced surgeons (E.K. Baranskaya).

Prof. E.K. Baranskaya talks about the complications of the Nissen fundoplication operation (Conference Esophagus-2014)

The position of gastroenterologists-surgeons regarding antireflux surgery, including Nissen fundoplication

A large number of antireflux operations are not effective. An antireflux operation should be recognized as unsuccessful, after which the primary symptoms persist (heartburn, belching, pain, etc.) or new ones appear (dysphagia, pain, bloating, diarrhea, etc.). The persistence of symptoms of reflux esophagitis or their rapid recurrence after fundoplication has been described in 5-20% of patients after laparotomic access, and in 6-30% of patients after laparoscopic fundoplication. 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 variety of causes of failures and complications of antireflux operations, the technical complexity of repeated interventions and the problematic nature of their good results determine the expediency of concentrating patients with HH and reflux esophagitis in specialized hospitals and dictate the need for further clinical research in this area (Chernousov A.F. et al.).

Professional medical papers concerning the problems of the Nissen fundoplication

• Lundell L. Surgical treatment of GERD // Experimental and Clinical Gastroenterology. Special issue. - 2004. - No. 5. - p. 42–45.


• Vasnev OS Ups and downs of antireflux surgery // Experimental and Clinical Gastroenterology. 2010. No. 6. S. 48–51.


• Chernousov A.F., Khorobrykh T.V., Vetshev F.P. Repeated antireflux operations // Bulletin of Surgical Gastroenterology. 2011. No. 3. S. 4-15 ..


• Volchkova I.S. Indicators of daily pH-metry for various types of fundoplications. Bulletin of Experimental and Clinical Surgery. 2012. Vol. V. No. 1. pp. 168–170.


• Maksimova K.I. Results of endoscopic treatment of hiatal hernias // International Journal of Experimental Education. 2017. No. 3. S. 39–41.

On the site in the literature catalog there is a section "Surgery of the esophagus", which contains a large number of professional medical works on this topic.