Modern aspects of treatment of hiatal hernia and its main complications
Keywords:hernia, esophagus, fundoplication, gastroesophageal reflux, Barrett esophagus, esophageal stenosis
The aim. To evaluate the features and results of minimally invasive surgical treatment of patients with hiatal hernia (HH) and its main complications using modern endoscopic and laparoscopic technologies.
Materials and methods. The treatment results of 244 patients with HH and its main complications are given. 28 (11.5 %) patients had a combination of HH with Barrett’s esophagus, and 34 (13.9 %) patients had a combination of HH with esophageal stricture. In 62 patients with complications of HH, two-stage treatment tactics was used. Complete laparoscopic fundoplication was performed in 185 (75.8 %) patients, posterior partial Toupet fundoplication – in 59 (24.2 %) patients. Laparoscopic posterior crurography was performed in 198 (81.1 %) patients. In 7 (2.9 %) posterior crurography was supplemented by anterior. Teflon gaskets were used in 25 (10.3 %) patients during posterior crurography. Synthetic mesh prostheses were implanted in 14 (5.7 %) patients.
Results. In patients with esophageal stricture, the effect was observed after the second session of bougienage or hydro-dilation in 70.6 % of cases, after the third session - in the remaining cases. In Barrett's esophagus, a single session of argon plasma coagulation was radical in 100 % of patients with a lesion size less than 1 cm and in 85 % of patients with lesions of 1 cm to 2 cm in size. Recurrence of type III HH occurred more often than type I. The surgery required sufficient mediastinal dissection and mobilization for an adequate esophagus pull-through. In the surgical treatment of type IV HH, the use of composite diaphragmatic meshes was considered. The effectiveness of antireflux surgical intervention, as well as prevention of specific complications was depended on the technical features of the fundoplication cuff formation.
Conclusions. In the treatment of Barrett’s esophagus or esophageal stricture in combination with HH, the two-stage tactics is optimal: stage I – ablation or dilatation, and stage II – laparoscopic antireflux surgery. Laparoscopic fundoplication is an effective and safe method for treatment of patients with HH.
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