Gastroesophageal Reflux Disease in Patients with Visceroptosis (Clinical Picture, Diagnosis, Treatment)

The dissertation is devoted to the study of the clinical features, diagnosis and surgical treatment of gastroesophageal reflux disease in patients with visceroptosis. It examines the prevalence of GERD in visceroptosis, the role of chronic colonic stasis in its development, and disturbances of lower esophageal sphincter function. The work presents the results of a comprehensive examination using endoscopic, radiological, radioisotope, secretory and manometric methods, as well as morphological investigation. Algorithms for early diagnosis and indications for surgical correction of GERD in patients with visceroptosis have been developed, including various types of fundoplication and combined surgical interventions. The immediate and long-term results of operative treatment in this category of patients have been evaluated.

The study was carried out at the Department of Hospital Surgery of the Faculty of General Medicine of the Medical Institute of Yakutsk State University and is of practical significance for improving the diagnosis and surgical care of patients with visceroptosis complicated by gastroesophageal reflux disease.

Relevance of the problem: At present, gastroesophageal reflux disease (GERD) is one of the most widespread diseases in gastroenterology [31, 39, 42, 62, 83, 84, 100–102, 106, 110, 111, 129, 157, 165]. However, certain issues concerning etiopathogenesis, pathogenetic conservative and surgical treatment of GERD remain controversial and unresolved. The mechanism maintaining the tone of the lower esophageal sphincter (LES) has not been fully elucidated [107, 120, 121]. Some authors [44, 58, 114, 140, 157] believe that the cause of LES dysfunction is a defect of neuromuscular control. Others [129] hold the view that LES insufficiency is associated with a disturbance of the cholinergic component of the autonomic nervous system. The mechanisms of individual mucosal resistance (pre-epithelial, epithelial and post-epithelial protective factors), which, in the opinion of certain researchers [42], influence the severity of inflammatory changes in the esophagus, remain unclear, and the pathogenesis of Barrett's esophagus continues to be the subject of discussion [39, 44, 64, 80, 82, 113, 123, 136].

The failures of conservative therapy for reflux esophagitis are caused by a large number of patients suffering from regurgitation of not only acidic but also alkaline contents [137, 155, 163]. The shortcomings of treatment include: the "rebound effect" during administration of H2-blockers, the need for continuous intake of maintenance doses of drugs, recurrence of the disease in 70% of cases upon discontinuation of treatment [37, 44, 116, 132–135, 138, 148, 152], as well as uncorrected disturbances of transit along the gastrointestinal tract. With the accumulation of experience in conservative therapy it became evident that in 20–30% of patients it provides only a temporary effect and is unable to prevent the development of complications.

The issues of predicting disease recurrence and treating the complicated course of GERD have been insufficiently studied and remain unresolved [1, 30, 42, 80, 84, 85, 123, 137], and the currently applied methods of surgical treatment of GERD do not always lead to recovery of patients with this pathology.

According to a number of authors [34, 69, 74], GERD in visceroptosis occurs in 60–90% of cases. In their opinion, the diversity of clinical variants of visceroptosis manifestation, leading to a disturbance of chyme transit along the gastrointestinal tract, causes its reflux into the overlying sections, with the development of chronic inflammation in them [34, 74]. Meanwhile, the causes of development and the features of the course of GERD in visceroptosis remain insufficiently studied.

In this connection, an in-depth study and the search for new methods of diagnosis and treatment of this pathology in visceroptosis appear to be necessary.

Aim of the work: Improvement of the results of surgical treatment of gastroesophageal reflux disease in patients with visceroptosis.

Research objectives:

1. To investigate the features of the course of gastroesophageal reflux disease depending on the degree of HTC in patients with visceroptosis;

2. To determine the level of gastric acidity in patients with GERD combined with visceroptosis;

3. To develop an algorithm for the early diagnosis of GERD in patients with visceroptosis;

4. To determine and substantiate the indications for surgical treatment of GERD in patients with visceroptosis.

Scientific novelty: as a result of a comprehensive study and surgical treatment of patients with visceroptosis complicated by chronic colonic stasis, for the first time:

1. The features of the clinical picture of GERD in patients with visceroptosis have been considered;

2. The acid-producing function of the stomach in patients with GERD combined with visceroptosis has been studied on an extensive clinical material;

3. An algorithm for the early diagnosis of GERD has been developed;

4. Indications for surgical treatment of GERD in patients with visceroptosis have been developed.

Propositions submitted for defense:

1. One of the causes of the development of gastroesophageal reflux disease in patients with visceroptosis is chronic colonic stasis in the sub- and decompensated degree;

2. The principal mechanism of the development of gastroesophageal reflux disease in patients with visceroptosis complicated by chronic colonic stasis syndrome is transient relaxation of the lower esophageal sphincter;

3. Gastroesophageal reflux disease in patients with visceroptosis constitutes an indication for surgical correction of the lower esophageal sphincter regardless of the degree of reflux esophagitis.

Practical significance: The use of functional research methods for the diagnosis of insufficiency of the cardiac sphincter enables the detection of GERD at early stages of disease development. Algorithms for the diagnosis and surgical treatment of GERD in visceroptosis have been introduced into the practice of public health. The indications for surgical treatment of GERD before the development of its complications have been substantiated, which has significantly increased the effectiveness of treatment of this category of patients.

The work was carried out at the Department of Hospital Surgery of the Faculty of General Medicine of the Medical Institute of Yakutsk State University.

I consider it my duty to express my deep gratitude and appreciation to my untimely departed teacher, scientific supervisor, Head of the Department of Hospital Surgery of the Medical Institute of Yakutsk State University, Director of the Yakut Scientific Center of the Russian Academy of Medical Sciences and the Government of the Republic of Sakha (Yakutia), Doctor of Medical Sciences, Professor Alkiviad Isidorovich Ivanov.

I consider it my duty to express my deep gratitude to my teacher, scientific supervisor, Head of the Department of Hospital Surgery of the Medical Institute of Yakutsk State University, Doctor of Medical Sciences Aleksandr Vasilyevich Tobokhov for the opportunity to carry out the present work and for his invaluable assistance and support during its preparation. I express my gratitude to the staff of the Department of Hospital Surgery of the Medical Institute of Yakutsk State University and to the team of Surgical Unit No. 2 of the Republican Hospital No. 1 – National Center of Medicine, who participated in the development and clinical implementation of methods for the early diagnosis and surgical treatment of gastroesophageal reflux disease in the comprehensive surgical correction of visceroptosis.