Specific Features of Surgical Treatment of Gastroesophageal Reflux Disease in Patients with Excess Body Weight

The dissertation is devoted to the study of specific features of the surgical treatment of gastroesophageal reflux disease (GERD) in patients with excess body weight. It examines the prevalence and pathogenetic relationships between GERD and obesity, the particularities of the clinical picture and diagnosis of the disease in this category of patients, as well as the limitations of conservative therapy that justify the priority of the surgical approach. On the basis of clinical material, an optimal diagnostic complex has been developed and a new antireflux laparoscopic operation has been proposed, employing an original explant and mesh devices for hiatal repair, protected by RF patents. An analysis of the immediate and long-term results of surgical treatment has been carried out, demonstrating a reduction in the frequency of postoperative complications and recurrences in patients with excess body weight.

The practical significance of the work is related to the implementation of the developed recommendations for the examination and surgical treatment of GERD in patients with an elevated body mass index into the clinical practice of abdominal surgery departments, which has been confirmed by the medical, social, and economic effectiveness of the proposed method.

RELEVANCE OF THE PROBLEM.

At present, gastroesophageal reflux disease (GERD) is one of the most widespread diseases in gastroenterology. The reasons for its increasing prevalence are commonly attributed to changes in the dietary patterns of the population, which, together with the growing prevalence of obesity, lead to an increase in morbidity (Kubyshkin V.A., Kornyak B.S., 2000).

The complexity of the problem of treating gastroesophageal reflux disease lies not so much in the need to eliminate the existing inflammatory changes in the esophageal mucosa as in the need to address the underlying disease that caused these changes.

Considering that conservative therapy, even with the use of modern pharmacological agents, provides only a temporary effect according to most authors, it becomes evident that surgical treatment becomes the principal approach. The common etiological factors and pathogenetic mechanisms of gastroesophageal reflux disease and obesity contribute to a higher frequency of excess body weight among patients with GERD than in the general population. Every second patient with excess body weight or obesity presents signs of gastroesophageal reflux disease. The leading place in its pathogenesis is occupied by impairment of the antireflux barrier function, which may arise from a primary decrease in the tone of the lower esophageal sphincter (LES), its structural changes (for example, in the presence of a concomitant hiatal hernia or excess body weight), and an increased number of transient relaxations. As a result of excess body weight, the frequency of GERD symptoms rises and the risk of cholelithiasis and other forms of gastrointestinal pathology associated with the metabolic syndrome increases (Gallingеr Yu.I., Timoshin A.D. et al., 1999). Patients with an elevated body mass index and complaints of heartburn and belching constitute a risk group for the development of GERD. The identification of patients with excess body weight and obesity is justified because, firstly, the presence of excess weight itself is a predisposing factor for the development of GERD. Secondly, the course of the disease in such patients is, as a rule, more severe, which leads to inadequate prediction of disease recurrence and to the treatment of complicated forms of gastroesophageal reflux disease, while the currently used methods of surgical treatment of GERD do not always result in the cure of patients with this pathology, making the problem of surgical treatment highly topical. Therefore, any attempt to develop new methods of treatment and prevention of this severe pathology appears highly relevant.

Despite the advantages of laparoscopic surgery for gastroesophageal reflux disease, several issues remain unresolved: assessment of operative trauma, the cost-effectiveness of the performed operation, the rationale for choosing the method of surgical treatment in patients with excess body weight, and the selection of patients. In the light of recent implementations, these tasks acquire particular relevance. However, attempts to solve this complex problem by applying various modified interventions do not always yield the desired result and therefore have not found wide acceptance.

Thus, at present, the issues of laparoscopic surgery for gastroesophageal reflux disease in patients with excess body weight require further elaboration both from the tactical and technical perspectives in order to improve the results of surgical treatment. The present work continues research in this direction.

Aim of the study

To develop methods of surgical treatment of patients with gastroesophageal reflux disease and excess body weight that demonstrate high clinical efficacy and the lowest rate of complications and recurrences.

To achieve this aim, the following tasks were set:

1. To study, on the basis of clinical material, the prevalence of gastroesophageal reflux disease in patients with excess body weight.

2. To develop an optimal diagnostic complex for patients with gastroesophageal reflux disease and excess body weight that allows determining the indications for surgical treatment.

3. To develop and introduce into clinical practice new methods of surgical intervention for gastroesophageal reflux disease in persons with excess body weight.

4. To study the clinical results of surgical treatment of gastroesophageal reflux disease using the proposed method in the immediate and long-term periods.

Scientific novelty

The prevalence of gastroesophageal reflux disease in patients with excess body weight has been studied, and the immediate and long-term results of antireflux operations have been evaluated. For the first time, a method of surgical treatment of hiatal hernias has been developed and introduced into clinical practice; its essence consists in placing and fixing around the esophagus an explant that closes the enlarged esophageal hiatus in the form of a circle 8 cm in diameter with a central opening 3 cm in diameter (RF Patent No. 2281703). The advantages of the proposed operative technique in reducing the risk of postoperative complications and the frequency of GERD recurrences in patients with excess body weight have been identified and substantiated. For the first time, devices for the surgical treatment of hiatal hernias have been developed, characterized in that they are made of polypropylene and polytetrafluoroethylene meshes (RF Patent No. 47646, RF Patent No. 52697), which reduce the occurrence of complications associated with narrowing of the esophageal hiatus and prevent disease recurrence. It has been proved that laparoscopic operations in the treatment of patients with gastroesophageal reflux disease and excess body weight are the operations of choice and allow simultaneous correction of combined abdominal pathology to be successfully performed without extending the access.

Practical significance of the work

Recommendations have been formulated regarding the comprehensive method of examination and surgical treatment of GERD in patients with excess body weight. The results of surgical treatment have been improved through the introduction of the developed method into the surgery of gastroesophageal reflux disease in patients with excess body weight, which has a certain medical, social, and economic effectiveness. The suggested method of antireflux operation and the devices for this operation are characterized by a high degree of physiological compatibility compared with the known antireflux operations and lack a number of their inherent shortcomings; along with a good antireflux effect, this allows the method to be recommended for wide application in clinical practice.

Statements submitted for defense:

1. The need for new tactical approaches to the management of patients with excess body weight in the treatment of gastroesophageal reflux disease.

2. The proposed method of treatment is the method of choice in performing operations in patients with concomitant excess body weight, contributing to improved treatment outcomes in patients with GERD and to a reduction in the risk of intra- and postoperative complications and recurrences.

Implementation of the results

The subject of the work is part of the research plan of the Bashkir State Medical University. The present work resulted from the introduction of minimally invasive technologies into the practice of the abdominal surgery departments of the BSMU clinic and the Nondepartmental Clinical Hospital at the Ufa Railway Station. The main provisions and practical recommendations of the dissertation have been implemented in the practice of the surgical departments of the BSMU clinic, the Nondepartmental Clinical Hospital at the Ufa Railway Station, and City Clinical Hospitals No. 21 and No. 18.

Approval of the research results

The main provisions of the work were reported at: the BSMU problem committee "Main Surgical Diseases" (Ufa, 2006), the 9th All-Russian Congress of Endoscopic Surgeons "Laparoscopic Technologies in the Correction of Hiatal Hernias" (Moscow, 2006), the Association of Surgeons of the Republic of Bashkortostan (Ufa, 2006), the Republican Conference of Young Scientists "New Technologies in Medicine" (Ufa, 2005), and the Republican Conference of Scientists "Scientific Breakthrough" (Ufa, 2004).

Publications on the topic of the dissertation

On the topic of the work, 10 articles have been published in foreign, central, and local press, and 4 patents have been developed and obtained.

Structure of the dissertation

The work is presented on 117 pages of typewritten text and consists of an introduction, four chapters, a conclusion, practical recommendations, findings, and a bibliography. The dissertation is illustrated with 19 figures and contains 11 tables. The work cites data from 142 domestic and 48 foreign authors.