Antireflux Videoendoscopic Operation by the Hill Method for Hiatal Hernias

The dissertation addresses the diagnosis and treatment of hiatal hernias (HH), with a focus on the antireflux operation by the Hill method in a videoendoscopic variant. The work comprises a literature review on diagnosis, conservative, surgical, and endosurgical treatment of HH, clinical observations, and a comparative analysis of short-term and long-term outcomes of surgical and endosurgical treatment by the Hill method. The aim of the study is to demonstrate the effectiveness of videoendoscopic treatment of hiatal hernias using the Hill method and to substantiate its advantages over open laparotomy surgery.

The scientific novelty of the dissertation lies in demonstrating the advantages of laparoscopic antireflux operation by the Hill method compared to traditional surgical intervention from the standpoint of short-term treatment outcomes, as well as justifying the application of the Hill technique as the most appropriate among other antireflux operations for HH. The practical significance is that laparoscopic antireflux operation by the Hill method is a safer but no less reliable method of treating hiatal hernias and can be recommended for wide application in clinical practice.

Relevance of the study. Hiatal hernia (HH) is observed, according to summary data, in approximately 10% of the population (V.G. Sakhautdinov, O.V. Galinov, 1995). This pathology is one of the most common causes of gastroesophageal reflux disease (GERD), the recurrence rate of which within a year under inadequate maintenance therapy is 90–98% (P.L. Grigoriev, E.L. Yakovenko, 1996; A.V. Kalinin, 1996; V.I. Ivashkin, L.S. Trukhmanov, 2003). The low effectiveness of conservative treatment of HH and GERD is confirmed by the development of such complications as Barrett syndrome (10–15%), esophageal ulceration (2–7%), stricture of the distal esophagus (4–20%), esophageal bleeding (2%) (A.I. Pyrogov et al., 1989; A.V. Kalinin, 1996; B.D. Starostin, 1997; K. Fuchs et al., 1997). Therefore, at present, an increasing number of gastroenterologists are inclined toward surgical treatment of HH (A.V. Vukolov, K.V. Kubyškin, 1996; K.V. Puchkov et al., 1996; K.V. Lapkin, A.V. Klimov, 1996; O.E. Luchevnic et al., 1996; V.S. Kornyak, 2001; N.I. Glushkov, K.G. Kubychev, 2002; V.I. Oskretkov et al., 2002; A.N. Vachev et al., 2005; E.M. Mokhov et al., 2005; M. Anvari et al., 1995; R. Belt et al., 1996; K. Fraitzheidss, 2000).

Antireflux operations performed via laparotomy are accompanied by a relatively high frequency of early and postoperative complications and fatal outcomes, especially in elderly and senile patients (P.I. Atanyan, 1961; B.V. Petrovsky, N.N. Kanshin, 1966; B.D. Starostin, 1997; R. Nissen, M. Rossetti, 1962; K. De Vault, 1996).

The introduction in 1991 into clinical practice (V. Dallagnese et al., 1998) of laparoscopic fundoplication by the Nissen method allowed significant improvement of short-term treatment outcomes for HH (V.A. Kubyškin et al., 1999; A.V. Fedorov et al., 2001). At the same time, antireflux operations by the Nissen method are often accompanied by dysphagia, the frequency of which varies from 6 to 44% (K.V. Puchkov et al., 2004; M. Anvari, 1996; G. Champault, 1997), and disease recurrence in the long-term period after this operation is observed in 3–15% of cases (R. Pommer, 1999; N. Soper, 1999; J. Bais, 2000).

Therefore, subsequently in the treatment of hiatal hernias, in addition to Nissen operations, antireflux interventions by the Nissen-Rosseth (Nissen-Rosseiii), Toupet (Toupet), Dor (Dor) and other authors began to be applied, which were accompanied by more favorable short-term and long-term outcomes both after "open" (A.F. Chernoousov, A.L. Shestakov, 1998; J. Dor et al., 1962; M. Linder et al., 1983) and after laparoscopic operations (E.V. Luchevnic et al., 2003; K.V. Puchkov et al., 2004; J. McKenna, 1994). At the same time, these methods of antireflux operations also could not fully satisfy surgeons due to the relatively high frequency of complications in the early postoperative period and persistent disease recurrences in the long-term period after surgery (V.V. Sumin et al., 1998; N. Floch, 1999; M. Carlson, T. Frantzides, 2001).

Among all antireflux operations for HH, the antireflux operation by the Hill method (L. Hill, 1967) is of great practical interest. In the work of L. Hill (1977), based on the analysis of experience in performing 531 antireflux operations, an extremely low recurrence rate of the disease was noted, amounting to only 0.9%. Furthermore, according to A.A. Shalimov (1975), the Hill method operation is the most effective intervention for the treatment of HH. As for laparoscopic operations by the Hill method, the literature contains only isolated reports based on a small number of observations, which does not allow the authors to draw generalizing conclusions (E.A. Shmakova, V.V. Ainschenko, 2005; R. Hinder, S. Filipi, 1995). In this connection, it is important from both scientific and practical standpoints to conduct a more in-depth study of the rational aspects of this operation.

The aim of the present work: to demonstrate the effectiveness of videoendoscopic treatment of hiatal hernias by the Hill method and to substantiate the advantages of this method over the "open" laparotomy method of performing this operation.

In accordance with the stated aim, the following tasks were formulated:

1. To study the feasibility of antireflux laparoscopic operations by the Hill method for hiatal hernias.

2. To conduct a comparative analysis of general and local complications of laparotomy and laparoscopic treatment of hiatal hernias by the Hill method.

3. To conduct a comparative analysis of long-term outcomes of laparotomy and laparoscopic treatment of hiatal hernias by the Hill method.

4. To justify the choice of the Hill method among the most commonly performed antireflux operations for hiatal hernias.

Scientific novelty.

The advantages of laparoscopic antireflux operation by the Hill method compared to traditional surgical intervention by this method have been demonstrated from the standpoint of short-term treatment outcomes.

The application of the Hill technique for hiatal hernias has been justified as the most appropriate compared to previously used techniques.

Practical significance of the study lies in the fact that laparoscopic antireflux operation by the Hill method is a safer but no less reliable, compared to laparotomy, method of treating hiatal hernias.

High effectiveness, relative simplicity, and a lower frequency of early postoperative complications in performing laparoscopic antireflux operation by the Hill method for hiatal hernias allows recommending this treatment method for wide application in clinical practice.

Main provisions presented in defense.

1. Antireflux operation by the Hill method is the most effective method of treating hiatal hernias.

2. Endoscopic antireflux operation by the Hill method does not inferior the laparotomy operation by the same technique from the standpoint of long-term outcomes, but at the same time is simpler to perform, is accompanied by fewer complications, and has a significantly easier course of the early postoperative period.

Abstraction of the work.

Materials of the dissertation were reported at the Regional Scientific Society of Surgeons of Khabarovsk and Khabarovsk Krai (2003), at the First Far Eastern Interdistrict Scientific-Practical Conference in Vladivostok (2005), and at the Scientific-Practical Conference "Current Issues of Endoscopy and Endosurgery of Children and Adolescents" in Khabarovsk (2005).

Six printed works have been published on the topic of the dissertation.

Implementation into practice.

The main provisions and developments of the study have been implemented into the practice of surgical departments of MUZ GKB No. 11 in Khabarovsk, the surgical department of MUZ GB in Komsomolsk-on-Amur, and are used in the educational process at the Department of Hospital Surgery of the Pediatric Faculty, FPK and PPS of the Far Eastern State Medical University, Russia.

Volume and structure of the dissertation