Background. The purpose of the study was to improve the diagnosis and improving the results of surgical treatment of patients with hiatal hernia (HH) and GERD by applying the develo­ped method of surgical correction of insufficiency of physiological cardia aimed at preserving and restoring the anatomical and topographic relationships of the esophagocardial organs. Materials and methods. In the Department of Digestive Surgery of the State Institution “Institute of Gastroenterology of the National Academy of Medical Sciences of Ukraine” for the period 2017–2021 conducted a study in 78 patients with HH, including: axial HH (type I) was 60 (77.0 %) patients; paraesophageal (type II) — 9 (11.5 %) patients; mixed (type III) — 9 (11.5 %) (code for ICD-10 — K 44). To establish and confirm the diagnosis, patients underwent radiological and endoscopic examination of the esophagus, stomach, duodenum, manometry. Results. In the analysis of complaints of examined patients it can be noted that the most common clinical manifestations in patients with HH and GERD were heartburn in 73 (93.7 %), belching in 68 (87.2 %) and epigastric pain in 64 (82.0 %). The erosions of the lower third of the esophagus was found in 13 (16.7 %) patients, while according to the Los Angeles classification in 6 (7.7 %) patients had esophagitis grade A, 7 (8.9 %) patients — grade B. According to the results of the mano­metry study, the highest pressure was observed in patients with axial HH and was (13.54 ± 3.32) mm Hg, and the lowest — in patients with GERD and was (9.81 ± 3.18) mm Hg. After a comprehensive examination, 3 (3.8 %) patients after confirmation of the diagnosis of HH in combination with Barrett’s esophagus underwent two-stage treatment: the first stage performed argonoplasmic ablation of altered esophageal mucosa, the second stage — antireflux surgery. All of 78 (100 %) patients underwent antireflux surgery. Laparoscopic fundoplications were performed: the Nissen fundoplication was performed in 53 (67.9 %) patients, Toupet fundoplication in 7 (8.9 %) patients and Dor fundoplication in 5 (6.6 %) patients, cruroraphy was performed in 100.0 %. The 11 (14.1 %) patients underwent surgery according to a new method that provides reliable restoration of physiological cardia and preservation of the anatomical relationship of the diaphragm and esophageal-gastric junction and includes cruroraphy and fundoplication. Conclusions. The method of surgical treatment of insufficiency of physiological cardia in HH, proposed by us, aimed at the correction of physiological cardia is less traumatic than known, provides a reliable restoration of the anatomical relationship of the esophagogastric region.

To date, the diagnosis and treatment of extrahepatic cholestasis (EHC) at various stages of development remains one of the most pressing problems of modern biliary surgery. The purpose of the study is to determine the structural changes of the liver in patients with EHC of non-tumoral genesis according to shear wave elastometry and ultrasound in comparison with biochemical indicators of endotoxemia, inflammation and markers of fibrosis. Preoperatively, 121 patients with EHC of non-tumoral genesis were examined: standard general clinical studies, ultrasound examination of the liver and its shear wave elastometry were performed. Depending on the presence of jaundice and symptoms of hepatocyte damage, all the patients were divided into 4 groups. Serum content of medium molecular weight peptides, free hydroxyproline and glycosaminoglycans was determined. Statistical processing of the obtained data was performed using SPSS 16.0. In patients with EHC of non-tumoral genesis according to shear wave elastography, the stiffness of the liver varied depending on the increase in the intensity of jaundice. It was found that the serum bilirubin level in such patients was significantly different depending on the available jaundice and symptoms of hepatocyte damage both in comparison with the control group and between the study groups. In EHCs, structural changes in the liver depend on abnormalities in the biochemical composition of serum, which are significantly altered by prolonged extrahepatic cholestasis and manifested by severe liver failure. Thus, an increase in endotoxemia (p<0.001) was found in patients with EHC of non-tumoral genesis without jaundice and evidence of cholestasis development; indicators of liver stiffness depend on the level of bilirubinemia (r = 0.84), and in patients with hepatocyte damage also on the duration of cholestasis (r = 0.68). Bilirubin levels cannot be an indicator of long-term EHC.

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

Background. The objective: to compare the effectiveness and safety of known laparoscopic antireflux interventions in the treatment of hiatal hernia and to detect the causes for their failure in a retrospective study. Materials and methods. In a retrospective comparative study, the long-term results of using the main methods of laparoscopic plastic surgery for hiatal hernias of various types and degrees were analyzed. Seventy-four (56.5 %) patients who underwent Nissen fundoplication were included in group 1. Group 2 consisted of 37 (28.2 %) people who underwent Toupet fundoplication and group 3 included 20 (15.3 %) patients who underwent Dor fundoplication. The study includes patients operated in the clinic of the institute over a 7-year period, with the possibility of clinical evaluation of long-term results and the exclusion of factors affec­ting the results of plastic surgery. All patients underwent X-ray and endoscopic examinations of the esophagus, stomach, duodenum, as well as manometry. Results. When analyzing the complaints of patients from groups 1–3 in the postoperative period, it can be noted that the most statistically significant indicators were dysphagia, regurgitation, cough, heartburn, bloating, sto­mach heaviness, pain behind the sternum (p < 0.05, exact F test). During endoscopic examination, reflux esophagitis was detected in 16 (21.6 %) patients of group 1, in 7 (18.9 %) of group 2, and in 2 (10.0 %) patients of group 3. Erosions of the lower third of the esophagus were found in 14 (18.9 %) patients from group 1, in 6 (16.2 %) from group 2, and in 2 (10.0 %) patients from group 3. Esophageal stricture was detected in 1 (1.4 %) patient from group 1 in the postoperative period during endoscopic examination. Signs of a “second entrance” to the stomach were found in 16 (13.5 %) patients of group 1, in 5 (13.5 %) of group 2, and in 2 (10.0 %) of group 3. Dislocation of the fundoplication cuff was noted in 1 (1.3 %) patient of group 1, resulting in deformation of the esophagogastric junction and pain syndrome. Pylorospasm was found in 8 (8.8 %) patients from group 1, in 3 (2.9 %) from group 2 and in 1 (5.0 %) patient from group 3. During the X-ray examination, recurrent hiatal hernia was detected: in group 1 — in 10 (13.5 %) cases, in group 2 — in 5 (13.5 %), in group 3 — in 2 (10.0 %). When assessing the quality of life of patients after surgical interventions, it was found that in group 1, the average score on the Gastroesophageal Reflux Disease — Health-Related Quality of Life (GERD-HRQL) questionnaire was (11.0 ± 5.5 (3–35) points, in group 2 — (19.0 ± 8.0 (3–35)), in group 3 — (16.0 ± 7.3 (3–35)) points, which was quite high in all groups. The distribution of satisfaction with the condition in group 1 was as follows: satisfied — 34 (45.9 %) patients, partially satisfied — 24 (32.4 %), unsatisfied — 16 (21.6 %). The distribution of satisfaction with the condition in group 2 was as follows: satisfied — 16 (43.2 %) patients, partially satisfied — 14 (37.8 %), unsatisfied — 7 (19.0 %). The distribution of satisfaction with the condition in group 3 was as follows: satisfied — 9 (45.0 %) patients, partially satisfied — 8 (40.0 %), unsatisfied — 3 (15.0 %). In the distant postoperative period, complications (pylorospasm, dysphagia, dyspeptic disorders, reflux esophagitis, esophageal strictures) occurred in 40 (54.1 %) patients of group 1, in 14 (37.8 %) of group 2, and in 6 (30.0 %) of group 3. There were no significant differences in the frequency of postoperative complications between groups (54.1 vs. 37.8 %, p > 0.05, exact F test; 54.1 vs. 30.0 %, p > 0.05, exact F test; 37.8 vs. 30.0 %, p > 0.05, exact F test). Conclusions. 1. The number of patients who are unsatisfied with the results of surgery according to GERD-HRQL questionnaire, was 21.6 % ((11.0 ± 5.5) points) after Nissen fundoplication, 19.0 % ((19.0 ± 8.0) points) after Toupet fundoplication, and 15.0 % ((16.0 ± 7.3) points) after Dor fundoplication. 2. Failures of the known methods of antireflux laparoscopic interventions for hiatal hernia are associated with the destruction of the components of the physiological cardia and occurred in 40 (54.1 %) patients of group 1 (pylorospasm, dysphagia, dyspeptic disorders, reflux esophagitis, esophageal strictures), in 14 (37.8 %) in group 2 and in 6 (30.0 %) in the third group. 3. Nissen fundoplication in the postoperative period was significantly more often accompanied by dysphagia and pylorospasm compared to Toupet and Dor fundoplications (p < 0.05).

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