Complications of surgical treatment of hiatal hernia and tactics of its elimination: An observational non-randomized study

Abstract

Background. An introduction of minimally invasive technologies contributes to annual increase in the number of surgical interventions for hiatal hernia. However, the rate of major complications (pain syndrome, dysphagia and recurrence of gastroesophageal reflux) inevitably reaches 32%. 19% of the patients need re-surgery, 60‒70% of them fail to recover, and 45% undergo surgical interventions for the third time.Aim. To specify the major complications of surgical treatment for hiatal hernia and to substantiate the optimal techniques of reconstructive interventions for its elimination.Methods. An observational non-randomized study involved 78 patients diagnosed with hiatal hernia without obstruction or gangrene. Patients were categorized into three groups depending on the performed surgical intervention — primary or reconstructive. Group 1 included 31 patients who underwent surgical treatment by means of traditional tactics and techniques (Nissen, Dor procedures); Group 2 enrolled 35 patients after incomplete selective proximal vagotomy with fundoplication according to Chernousov; Group 3 consisted of 12 patients who underwent reconstructive re-surgey for complications of surgical treatment of hiatal hernia. Surgical interventions were performed in five city and district general surgical hospitals of Belgorod Oblast, Russia. The hospitals were considered equally equipped and had surgeons of similar qualification. Patients were included in the study from 2015 to 2023, the follow-up of each patient lasted from 3 months to 8 years. The results of surgical treatment were evaluated by a questionnaire survey. Presence and severity of the major complications of surgical treatment for hiatal hernia were assessed according to the Dakkak scale and Gastro Esophageal Reflux Disease (GERD) questionnaire, evaluating patient outcomes as excellent, good, satisfactory, and unsatisfactory. Statistical data processing was carried out by means of Microsoft Excel 2019 (Microsoft, USA). A statistical level with p ≤ 0.05 was considered statistically significant.Results. The major complications of surgical interventions for hiatal hernia include recurrence of gastroesophageal reflux, pain syndrome and dysphagia, which made up 54.8, 48.4 and 61.3% in Group 1, respectively. In total, the shares of all types of complications exceed 100%, as three patients were recorded with all three complications, 12 patients — with two types of complications, and 15 patients had one complication. The results evaluating the patient’s condition were expressed as good in 19.4% of patients, satisfactory — in 22.6%, and unsatisfactory — in 58.0%. In Group 2, the results evaluating the patient’s condition appeared only good (22.9%) and excellent (77.1%). The reconstructive interventions in Group 3 included: elimination of cruroraphia; incomplete selective proximal vagotomy with modified gastroesophageal refundoplication and fundoplication according to Chernousov; formation of the esophageal hiatus in the diaphragm adequate to the parameters of the fundoplication cuff. The results evaluating the patient’s condition appeared only good (22.2%) and excellent (77.8%).Conclusion. The major complications of surgical treatment for hiatal hernia include pain syndrome, dysphagia and recurrence of gastroesophageal reflux and can be eliminated by the reconstructive interventions composed of the following techniques: elimination of cruroraphia, removal of the cuff, incomplete selective proximal vagotomy, refundoplication by the modified method according to Chernousov, formation of the esophageal hiatus in the diaphragm with adequate parameters of the fundoplication cuff.

Keywords

• gastroesophageal reflux
• hiatal hernia
• refundoplication
• dysphagia
• pain syndrome
• lower esophageal sphincter
• complications