but) Indications for Fundopling on Nissen-Rosetty and Stupid:
- Planned: Stubborn reflux disease, despite conservative treatment in the insolvency of the lower esophageal sphincter; The operation is usually laparoscopically.
- Contraindications: Symptoms of reflux due to violations of the gastric emptying or poor mobility of the esophagus.
- Alternative operations: Fundoplikation by BelSi-Brand IV, Laparoscopic operation.

b) Preoperative preparation:
- Preoperative studies: endoscopy, x-ray study Upper departments gastrointestinal tract, manometry, 24-hour pH-metry, exclusion of gallstone disease and peptic disease stomach.
- Preparation of the patient: Preoperative Stricks Pastement.

in) Specific risks informed by the patient's consent:
- Temporary dysphagia (5-10% of cases)
- Nausea / belching
- damage to the esophagus, stomach, spleen (5% of cases) and a wandering nerve
- Weakening / Cutting Cam
- Recurney (less than 5% of cases)

d) Anesthesia. General anesthesia (intubation).

e) Patient position. Lying on the back.

e) Nissenu-Rosetty's Fundoplikation Access and Stupid. For a regular operation, as a rule, abdominal access (top-medal laparotomy) is used.

g) Stages of Fundoplikation on Nissen-Rosetty and Stupid:
- Access



- Displacement of the bottom of the stomach
- crosslinking cuff from the bottom

h) Anatomical features, serious risks, operational techniques:
- The left proportion of the liver together with the left triangular ligament lies the kleon from the esophageal and gastric transition.
- The trunks of the wandering nerves lie on the front and rear surface of the esophagus.
- The bottom of the stomach lies above the cardia and has a close neighborhood with a spleen.
- Warning: Be especially careful in the area of \u200b\u200bshort gastric veins.
- Warning: Remember the added left hepatic artery, sometimes departing from the left gastric artery.
- After the start of the anesthesia, enter the thick (40 FR) of the title-gastral probe, which at the end of the operation is replaced with a conventional nasogastric probe.
- enough short cuff (2-3 cm).
- Make sure the cuff is free, without tension.

and) Specific complications. If there is damage to the esophagus, immediately earn it and close the cuff from the bottom of the stomach.

to) Postoperative care after Fundopling on Nissen-Rosetty and Stupid:
- Medical care: Remove the active drainage and nasogastric probe after 1-2 days.
- Resumption of nutrition: from the 1st month day.
- Activation: Immediately.
- Disability period: 1-2 weeks.

l) Operational technique of Fundopling on Nissen-Rosetty and stupid:
- Access
- mobilization of the left lobe of the liver
- exposure of the distal esophagus
- skeletonizing the proximal part of great curvature
- DNA displacement
- crosslinking cuff from the bottom
- Cut width confirmation

1. Access. The median laparotomy is performed on the left of the navel in the patient's position lying on the back with the re-coated top of the body. Currently, the best approach is a laparoscopic operation.

2. Mobilization of the left lobe of the liver. After opening the abdominal cavity, retractors are introduced, and the left proportion of the liver mobilizes. It is recommended to cross the triangular ligament in its lateral part between the clips of the overtakes and tie it with a stitching culture, given that bleeding can occur here. Then the left triangular bundle intersects with scissors or diathermy near hepatic veins.
The left lobe of the liver is shifted to the left and laterally, covered with wet tampons and is held in this position throughout the operation. This provides good visualization of the esophageal hole of the diaphragm.

3. The exposion of the distal esophagus. Tampon, installed for the spleen, reduces the tension of the ligament between the stomach and the spleen. The permanently disseminated over the distal esophagus department. The dissection is carefully moving to the left or right from the esophagus with careful preservation of the truder nerve, until the esophagus is naked at a distance of about 3 cm, and it can be completely circumvented. You can also cover a loop around the esophagus.

4. Skeletoning of the proximal part of great curvature. A sequential dissection is carried out with a large curvature for 3 cm by intersection of short gastric vessels. While performing this stage, the spleen is carefully protected. The vessels must be tied up and cross it separately.

5. DNA displacement stomach. After sufficient mobilization, you can wrap the dorzal 2-3 cm with a narrow cuff from the bottom of the stomach around the esophagus. The bottom cuff is captured by a climb on the right and is displayed ventral. This maneuver can be facilitated by caudal traction for the ribbon circled around the esophagus. Annesthetian introduced by anesthesiologist 40 Fr. Prevents the creation of too tight cuffs. The same goal pursues intraoperative gastroscopy.

6. Locking cuff. The cuff out of the bottom is freely closed by two or three seams of proximal than the lower duty station. The wall of the esophagus is included in the first and last seam. The bottom cuff should cover the esophagus without tension. Caudally, it lies on the mesogastric part of small curvature (that is, on the hepatic branches), which for this reason should be highlighted very economically. Suture material - silk 0.

7. Confirmation of the width of the cuff. As a result, the cuff must be quite wide in order to index and thumb The surgeon could come freely between the cuff and the esophagus (a). The part of the cuffs from the bottom adjacent to the large curvature can be fixed by two more seams in the form of hemifundoplication (b). Upon completion of the operation, the thick nasogastric probe is removed by anesthesiologist and is replaced by a standard nasogastric probe.

I Surgical Gastroenterology

surgical Gastroenterology.

* Illustrations for the article - on color plying in the log.

Laparoscopic Fundoplikation on Nissen - Golden Standard for the Treatment of Gastroesophageal Reflux in children *

Razumovsky A. Yu., Alkhasov A. B., Batayev S-X. M., Ekimovskaya E. V.

GBOU VPO RNYMU them. N. I. Pirogova Ministry of Health of Russia, Moscow; Children's urban clinical Hospital № 13. N. F. Filatova, 103001, Moscow

Laparoscopic Fundoplication Nissen - Gold Standard Treatment Of Gastroesophadle Reflux in Children

Razumosky Ay, Alhasov AB, Bataev SHM, Yekimovskaya EV

The Russian National Research Medical University Named After N. I. Pirogov

Razumovsky Alexander Yuryevich; Razumosky Aleksandr Yu.

Gastroesophageal reflux is frequent disease In children and often leads to the development of erosive reflux-esophagitis, the peptic stenosis of the esophagus, metaplasia of the mucosa of the esophagus (etc. N. Barrett-Ta). Children with resistance to conservative therapy, with complications and hernias of the diaphragm ecoming hole, surgical treatment is shown. Its effectiveness is more than 80%, the adopted standard is a laparoscopic fondoplikation on Nissen. At the same time, the main problem is recurrences after the primary operation. The probable risk of risk of relapse is the presence of hernia of the esophageal hole of the diaphragm, as well as the technique of forming a fondoplication cuff. Our clinic has developed a modification of laparoscopic fondoplikation on the Nissen, in which in the first row of the seams when creating a fondoplication cuff, the walls of the stomach are blocked through all layers. Since 2010, more than 180 patients were operated on this technique, while the frequency of recurrence has decreased by 2 times.

Keywords: gastroesophageal reflux, relapse, re-laparoscopic fondoplikation on the nisssen, hernia of the esophageal hole of the diaphragm, failure of the fondoplication cuff

Experimental and clinical gastroenterology 2015; 113 (1): 72-77

Gastroesophageal reflux is very common in children and often leads to reflux-esophagitis, peptic esophageal strictures, Barrett "s esophagus. If the conservative treatment fails a patient needs surgical treatment as well as those who suffer from complications and hiatal hernia. The most popular operation is laparoscopic Nissen fundoplication with the efficiency of more than 80%. However, the main challenge is redo fundoplications. Hiatal hernia and operation technique are considered to be the most probable risk-factors.In our study we introduce the new technique of laparoscopic Nissen procedure . IT Implies Different WAY OF THE FUNDOPOLICATION WRAP CONSTRUCTION: IN THE FUNDOPOLICATION WRAP CONSTRUCTION: IN THE FIST ROW WRAPH WALL ALL THE LAYERS OF THE STOMACH WALL INSTEAD OF THE SEROMUSCULAR ONES. SINCE 2010 More THAN 180 PATIENTS HAVE BEEN OPERATED ON WITH THE INCIDENCE OF RECURRENT REFLUX 2 TIMES LOWER .

Keywords: Recurrent Gastroesophageal Reflux, Redo Laparoscopic Nissen Fundoplication, Hiatal Hernia, Wrap Dysfunction Eksperimental "Naya I Klinicheskaya Gastroenterologiya 2015; 113 (1): 72-77

laparoscopic Fundoplikation on Nissen ... | ! Arago $ Sork Fundoplication YBBEP.

Gastroesophageal reflux (GER) is a frequent disease in children and adolescents. The basis of pathology is the failure of the lower esophageal sphincter (NPS), often with the presence of hernias of the diaphragm ecoming hole (GPO). Despite the high level of modern medicine therapy of the GER, its effect is temporary. After the abolition of drugs, the symptoms are resumed in 50% after 6 months and in 100% - after 1 year. In chronic flow, serious complications arise: erosive reflux-esophagitis (RE), peptic stenosis of the esophagus (PSP), metaplasia of the mucosa of the esophagus or the Barrett esophagus (PB). In such cases, only surgical treatment is shown. Operation also perform children with severe neurological pathology in the presence of constant vomiting and aspiration syndrome

Material and research methods

Since 2002, in DGKB No. 13. N. F. Filatova, in the separation of thoracic surgery and surgical gastroenterology, about 600 laparoscopic fondoplikations were performed. To assess the results of treatment, a retrospective study of 345 patients operated on in 2005-2013 was carried out. (396 operations). Patients with GER came to the sample after conservative therapy without effect, with hernias of the diaphragm and complicated formations (reflux-e-zoophagitis, peptic stenosis of the esophagus, Barrett's esophagus), children with secondary reflux after chemical burns esophagus with recurrent scar stenosis of the esophagus, children with an atressee of the esophagus after the imposition of esophago-esophagoano-mosen with the occasional stenosis of the anastomosis region.

The age of patients varied from a period of no-spin to 18 years (average age of 48 ± 11 months), 14 children (4%) were operated under the age of 3 months. The boys accounted for 62% (n \u003d 215), girls - 38% (n \u003d 130) (see Table 1).

Diagnosis used an X-ray examination of the esophagus, a stomach, duodenal intestine with contrasting, fibroesophagoduodenoscopy (FEGDS), pH-metry, ultrasound of the abdominal organs, if necessary, consult a neurologist, genetics. Testimony for surgical treatment

Results of research

All 345 patients were made laparoscopic Fundoplikation on Nissen (396 operations). 43 patients were repaired again, of which 6 children are three times and 2 - four. The average duration of the operation varied from 25 to 90 minutes.

Intraoperative complications were 4% (n \u003d 15). 5 patients had a pneumothorax. Of these, everyone, with the exception of one patient, had a gpod, and damage pleural cavity It happened when the junk bag is selected from the battles. Double children, this operation was performed again due to the recurrence of the GPD. In all cases, the air from the pleural cavity was

with one-step imposition of gastrostomas for feeding.

Due to the widespread introduction of endoscopic methods in children's surgery over the past ten years, the "gold standard" treatment today is laparoscopic fondoplikation. The most common fondoplikation on the Nissen, the effectiveness of which reaches 80-90%. The main problem in the correction of GER is relapses after surgical treatment. As a rule, they arise within two years after the primary operation. The percentage of such patients varies widely - 4-34%. Since 2002 in DGKB No. 13. N. F. Filatova Fundopling on the nisssen is carried out by a laparoscopic method and is considered an optimal standard of surgical treatment in both primary and repeated operations.

resistance symptoms were resistant to conservative therapy in 100% of cases, the presence of HP 29% (n \u003d 101) complicated forms in 26% (n \u003d 91). In the group of children with PSPs, the Fundopling was performed after eliminating the stenosis of the esophagus by the method of toadening against the background of conservative antirefluxue therapy with a duration of 2-6 months. The secondary reflux amounted to 5% (n \u003d 17) after the burn of the esophagus and 15% (n \u003d 51) in children operated on earlier about the atresia of the esophagus. The method of surgical treatment was laparoscopic fondopling on the nisssen in the traditional procedure, at which the fondoplication cuff was formed by nodal serous muscular seams, the similar nodular seams were superimposed on top of the first row of the seams. Since 2010, all patients have applied a modification of this operation developed on the basis of our clinic. Its difference is as follows: when creating a fondoplication cuff in the first row, instead of the serous muscular nodal seams, the firmware of the stomach wall was drawn through, through all layers, serous-muscular seams were used in the second row. In the presence of GPO, the Fundoplication was complemented by excision of a hernial bag and a diaphragm of the esophagus of the diaphragm (Fig. 1).

deleted to the end with the help of puncture, the formulation of pleural drainage was not required.

Availability adhesive process In the field of operation led to complications in three children. Damage to the esophagus was recorded in 1 patient. Even in 1 child, during a re-operation, there has been damage to the stomach when separating the battles of the cuff from the left lobe of the liver. And in one case, a diaphragm occurred in a patient with a relapse and open Fundopli-kamation in history during the separation of adhesions. All patients, the embedding of the defect was carried out with a laparoscopic way.

Table 1.

Distribution of patients by age and floor.

Primary patients n \u003d 345 (100%) repeated patients n \u003d 43 (100%)

0 to 1 year 85 (25%) 7 (16%)

newborn 5 0

4-6 months 30 4.

7-12 months. 41 3.

1-3 years 117 (34%) 22 (51%)

4-7 years 42 (12%) 6 (14%)

children 0-3 years 202 (59%) 29 (67%)

8-11 years 31 (9%) 2 (5%)

12-18 70 (20%) 6 (14%)

11-18 80 (23%) 6 (14%)

Boys 215 (62%) 26 (60%)

Table 2.

Clinical characteristics of primary and repeated patients.

Primary patients repeated patients

n \u003d 345 (100%) n \u003d 43 (100%)

N operations \u003d 396 N operations \u003d 51

Recurry \u003d 12%

Insolvency of the NPC 157 (46%) 10 (23%)

GPO 101 (29%) 25 (58%)

SCG 46 (13%) 5 (12%)

GPO + SCG 147 (43%) 30 (70%)

РЭ 70 (20%) 9 (21%)

PSP 28 (8%) 7 (16%)

PB 7 (2%) 2 (5%)

Complicated forms 91 (26%) 15 (35%)

Complicated forms + GPD and SCG 52 (15%) 11 (26%)

GPO + SCG + RE 39 (75%) 8 (73%)

GPO + SCG + PSP 17 (33%) 5 (45%)

GPO + SCG + PB 3 (6%) 2 (18%)

PSP + RE 11 (21%) 3 (27%)

PSP + PB 2 (4%) 1 (9%)

PB + RE 2 (4%) 1 (9%)

Complicated forms\u003e 1 13 (25%) 3 (27%)

Respiratory symptoms 89 (26%) 7 (16%)

Neurological pathology 149 (43%) 17 (40%)

Genetic pathology 58, 17% 7 (16%)

Atresia of the esophagus 51 (15%) 6 (14%)

Recurry \u003d 12%

Esword burns 17 (5%) 3 (7%)

Recurry \u003d 18%

Minor bleeding during the operation was noted in 4 children. In two cases, the volume of blood losses was less than 50 ml with a source of bleeding from a damaged liver capsule (the liver had large dimensions, which greatly complicated manipulation), stopped by electrocoagulation. In 1 child there was damage to the artery of the esophageal and hepatic bundle when mobilizing the stomach and esophagus. The artery is covered, the volume of blood loss was 60 ml. In one case

the source of bleeding (100 ml) was the lower seam of the fondoplication cuff, additional seams were applied to stop bleeding.

The conversion was performed in 3 (0.9%) of patients: due to damage to the gastric artery (n \u003d 1), due to the pronounced adhesion process (n \u003d 1), due to the presence of the contents of a hernial bag with a gesture of the stomach and spleen , which were located in the mediastinum and their reduction to the laparoscopic method was impossible (n \u003d 1).

laparoscopic Fundoplikation on Nissen ... | Laparoscopic Fundoplication Nissen ...

In early postoperative period In 1 patient, the discrepancy between the edges of the wound and the loss of the alp alphabet is 5 p / o day. Performed the administration of the gland and suturing the wound. In 1 child at 6 p / o day, a clinical picture of the perforation of a hollow organ developed, with diagnostic laparoscopy, the fact of perforation of the rear wall of the stomach catheter of gastrostomy was established. Middle laparotomy is performed, stomaching. Another patient at the age of 1 month was re-operated on 5 p / o day about the perforation of the transverse colon against the background of the flow of ulcer-necrotic enterocolitis, prematurity 27 weeks, cached. Larotomy has been performed, suturing perforation.

In 2 cases, an additional trocar was installed for the decoration of the gland and the liver. In 6 patients, teflon gaskets were used during the operation to strengthen the joints of the Fundoplication Cuffs.

In 46% (n \u003d 157) the cause of the GER was the inconsistency of the lower esophageal sphincter, in 29% (n \u003d 101) - hernia of the esophageal hole of the diaphragm. In 9% (n \u003d 30) cases of the contents of a junk bag came the stomach located in the mediastinum. Of these, 1 child in the mediastinum together with the stomach also migrated the spleen (a conversion was made to reduce organs into the abdominal cavity) and in two - a semiconductor area. In all three cases, in the esophageal hole of the diaphragm there was a pronounced defect in size of more than 3.0 x 3.0 cm. Sliding hernia with a discrepancy of the legs of the diaphragm to 3-6 cm (schg) were identified intraoperative in 13% (n \u003d 46), in all Cases of the legs were covered with nodal seams.

Of the total sample, 26% (n \u003d 91) children had complicated forms. Most (77%) was diagnosed with erosive reflux-esophagitis. The peptic stenosis of the esophagus was revealed in 28 children (31%), Barrett's esophagus - in 7 (8%). Of these, more than half (57%) complications were combined with the GPD, and 13% of children identified the presence of two and more complicated forms. Every fourth child had respiratory symptoms SBR (n \u003d 89, 26%).

In half cases, in addition to the underlying disease, a concomitant pathology was revealed: in 43% (n \u003d 149) - neurological disorders, in 17% (n \u003d 58) - genetic syndromes (Down syndromes, Elessa-Danlos, Vater-Association, Sota Sindrome) . Children with an atreesia of the esophagus accounted for 15% (n \u003d 51), children after the chemical burns of the esophagus - 5% (n \u003d 17).

88% after laparoscopic fondaoplikation, a complete heraling of GER was marked. The recurrence group was 12% (43 patients, 51 operations). Most frequent cause The relapse was the discrepancy and stretching of the cuff - 77%, migration to the mediastinum and the "telescope phenomenon" amounted to 30%. In 6 patients, a combination of two above recurrent mechanisms was revealed. In these cases, the full reconstruction of the cuff or its remodeling was performed (strengthening the cuff with additional seams, stitching additional seams to the legs of the diaphragm and the esophagus).

4 children (9%) - the cuff was not changed. In two cases, the imposition of additional seams on the cuff, one child is embedded the legs of the diaphragm due to the recurrence of the HPD. Even one patient, the cuff itself was preserved, but shifted down the type of "hourglass", the renovation of the cuff was performed.

With a re-operation, 70% of patients had either HPD, or a sliding hernia, and almost each (85%) - in combination with complicated forms. Of these, the overwhelming majority (70%) was determined by reflux-esophagitis and in half (54%) peptic stenosis of the esophagus (see Table 2). The proportion of children with an atreesia of the esophagus was 14% (n \u003d 6), with the burns of the esophagus - 7% (n \u003d 3). The proportion of neurological and genetic pathology amounted to 40% and 16%, respectively. Complications took place in 4 cases. In three children during the separation of battles in the place of the first operation there was damage to the esophagus (n \u003d 1), the stomach (n \u003d 1), the diaphragm (n \u003d 1). Defects were covered with a laparoscopic way. In one case, a pneumothorax occurred, which was bought using pleural puncture. There was no conversion.

Discussion of the results obtained

The effectiveness of the surgical treatment of the SBR in children is approaching 90%, both in foreign data and our results (88%). In the overwhelming majority of cases, patients undergo several courses of conservative therapy without effect. In the study, 100% of children have long received antiref-luxury therapy with the subsequent resumption of symptoms within 12 months after its cancellation. At the same time, each fourth child suffered by recurrent bronchitis and pneumonia, and each fifth had reflux-esophagitis or peptic stenosis of the esophagus. 7 children were confirmed by metaplasia of the mucosa of the esophagus, the so-called. Barrett's esophagus. In these cases, the only treatment option is surgical correction.

The optimal method today is recognized by laparoscopic fondoplikation in the unsense modification, which gives a significant decrease in the number of relapses 2-3 times compared to other techniques: 10% of Tupet and 15% of Thal against 5% at Nissen's Fundoplikation.

Recurrements occur, as a rule, in the first one and a half or two years after surgery and are the main problem in GER surgery in children. According to our data, the re-fundoplikation was 12%, which is comparable to the results of the leading foreign clinics. The likely risk factor is the presence of a child of the hernia of the teaching hole of the diaphragm, which was 2 times more common in our patients with relapses (58% against 29% in primary patients). Almost one and a half times was

above and share of the complications of the GER. The frequency of occurrence of PSPs and PB in patients with relapses 2 times exceeded these indicators in the group of primary patients (16% against 8% and 5% versus 2%, respectively). Risk factors also include age under 6 years old, resistant urges for vomiting and balloon dialing in the early postoperative period. In our study, children under 4 amounted to 60% (n \u003d 206), adolescents 12-18 years old - 20% (n \u003d 70), the male floor prevailed almost 2 times. A gagging factor is the presence of severe neurological pathology, which occurred in 40% of children with relapses. Among the genetic syndromes, the Down Syndrome - 4%, Vater-Association - 3% and CHARGE-syndrome - 2% were common. Among children with atresia, recurrent esophagus amounted to 12%, with the burns of the esophagus - 18%.

The most common cause of relapse, according to our data, was the failure of the Fund-Plugal Cuff (stretching, discrepancy) - 77%. The shift of the cuff into the mediastinum or slushing, the so-called. The "telescope phenomenon" met 2 times less frequently (30%). In children with neurological pathology, the bias the cuff prevails. According to the results of Lopez et al., The dislocation was observed in 80% of neurological patients.

A feature of the diagnosis of relapses is the discrepancy of clinical and instrumental data. So, according to the results of Curtis et al., In 33% (Celik et al.- 49%; Pacilli et al. - 5%) if there are symptoms - actually reflux

Conclusion

Surgical treatment of children with gastrointestinal reflux is effective method With a successful result of about 90%. The "gold standard" is a laparoscopic fondoplikation on Nissen. The operation is necessary in the resistance to conservative therapy, the presence of hernia of the esophageal hole of the diaphragm and complications (reflux-e-zophagitis, peptic stenosis of the esophagus, Barrett's esophagus). The risk group on recurrences includes children of younger, with complicated forms and gpodes. The latter, as well as the peptic stenosis of the esophagus, is likely a risk factor and occurs almost half of the re-operated ones. Heavy neurological

Literature

1. Razumovsky A. Yu., Alkhasov A. B. Surgical Treatment of Gerb in Children. MOSCOW: Geotar-Media Publ.; 2010 (in russian).

2. Lobe T. The Current Role of Laparoscopic Surgery for Gastroesophageal Reflux Disease in Infants and Children. SURG ENDOSC 2007; 21: 167-74.

3. Ummarino D., Miele E. et al. Impact of AntisecoTory Treatment On Respiratory Symptoms of Gastroesophageal Reflux Disease in Children. Diseases of the Esophagus (2012) 25, 671-677

4. Herbella F., Patti M. Gastroesophageal Refux Disease: From Pathophysiology to Treatment. WORLD J GASTROENTEROL 2010 AUGUST 14; 16 (30): 3745-3749

or the displacement of the cuff on radioscopy was absent, while 8% was significantly determined by the insolvency of the cuff, but these patients did not prevent any complaints. According to our data, in 9% of children on a repeated operation during revision, the cuff was valid, despite the fact that the clinical symptoms of reflux were expressed. With the inverse situation, when, according to X-ray or FEGDS, the cuff is shifted or untenable, but no symptoms and complaints, we adhered to expectant tactics with a control examination every 3 months.

According to a number of authors, the only circumstance affecting the outcome of the operation is the technique of applying a cuff and stitching the legs of the diaphragm. A statistically reliable reduction in recurrences was obtained by Curtis et al in the use of Teflon gaskets and horizontal mattress seams during laparoscopic fondoplikation, recurrences were 3% against 11% in the control group. To improve the results of the treatment of children with GER, we have been developed and implemented since 2010 modification of laparoscopic fondoplikation on Nissen. When forming a fondoplication cuff in the first row, instead of serous muscular, nodal seams are superimposed with flashing the walls of the stomach bottom through all layers. In the second row, serous-muscular nodal seams are used. Over 180 patients were operated on, which managed to reduce the number of relapses almost 2 times.

disorders and genetic syndromes are aggravated by the current GER. Diagnosis of recurrences should consider the frequent discrepancy of clinical symptoms with X-ray data and FEGDS. In 9% of re-operated ones with pronounced complaints, immaculately revealed unchanged wealthy fondoplication cuffs. In a situation where there are no symptoms, but there is a tool confirmation of the relapse, the expectant tactics with a regular test examination should be elected. The modification of Laparoscopic Fundoplikation on Nissen used in our clinic allows to reduce the percentage of relapses 2 times and improve the results of the treatment of children with GER.

5. Jamieson G., Watson D., Britten-Jones R. et al. Laparoscopic Nissen Fundoplication. Ann Surg 1994; 220: 137-145.

6. Pimpalwar A, Najmaldin A. Results of Laparoscopic Antireflux Procedures in NeurologyCally Impaired Children. Surg Innov 2002 9: 190

7. ISLAM S., Teitelbaum D., Buntain W. ET. Al. Esophagogastric separation for failed fundoplication in neurologically Impaired Children. Michigan Journal of Pediatric Surgery, Vol 39, NO 3 (March), 2004: PP 287-291

8. Kawaharaa H., Mitani Y., Nosea K. et al. Should Fundoplication Be Added AT The Time Of Gastrostomy Placement in Patients Who Are Neurologically Impaired? Journal of Pediatric Surgery (2010) 45, 2373-2376

jianapockonimeckaa ^ yhflonnu ^ iifl no hiiccehy ... | Laparoscopic Fundoplication Nissen.

9. Trinicka R., Johnstone N., Dalzell M. ET. Al. Reflux Aspiration in Children With Neurodisability - A Significant Problem, But Can We Measure IT? Journal of Pediatric Surgery (2012) 47, 291-298

10. Neffl., Becher R., Blackham A. et al. A Novel Antireflux Procedure: GastroPlasty With Restricted Antrum to Control Emesis (Grace). Journal of Pediatric Surgery (2012) 47,99-106

11. Novotny N, Jester A., \u200b\u200bLadd A. Preoperative Prediction of Need for Fundoplication Before Gastrostomy Tube Placement in Children. J Pediatr Surg 2009; 44: 173-7

12. Rothenberg S. The First Decade "S Experience with Laparoscopic Nissen Fundoplication in Infants and Children. Journal of Pediatric Surgery (2005) 40, 142-147

13. Celik A., Loux T., Harmon C. et. Al. Revision Nissen Fundoplication CAN BE Completed Laparoscopically With A Single-Institution Experience With 72 Children. Journal of Pediatric Surgery (2006) 41, 2081-2085

14. Kubiak R., Spitz L., Kiely E. et al. Effectiveness of Fundo-Plant in Early Infancy. J Pediatr Surg 1999; 34: 295-9.

15. Rothenberg S. Laparoscopic Nissen Procedure in Children. SURG Innov 2002 9: 146

16. Rossetti M., Hell K. Fundoplication for the Treatment of Gastroesophadle Reflux in Hiatal Hernia. WORLD J SURG 1977; 1: 439-443.

17. Tan S., Wulkan M. Minimally Invasive Surgical Techniques in Reoperative Surgery for Gastroesophadle Reflux Disease in Infants and Children. AM SURG 2002; 68: 989-92.

18. Liu D., Waxman I. What is the Optimal Laparoscopic AntiReflux Procedure for Children with Gastroesophageal Reflux Disease? Nature Clinical Practice Gastroenterology & Hepatology. January 2007 Vol 4 NO 1, PP. 14-5.

19. Khan M., SMYTHE A., Globe J. et al. Randomized Controlled Trial Of Laparoscopic Anterior Versus Posterior Fundoplication for Gastro-Oesophageal Reflux Disease. Australian and New Zeland Journal of Surgery. 2010 Jul-Aug; 80 (7-8): 500-5.

20. Kubiak R., Andrews J., Grant H. Long-Term Outcome of Laparoscopic Nissen Fundoplication Compared with Laparoscopic Thal Fundoplication in Children A Prospective, Randomized Study. Annals of Surgery, Vol 253, January 2011: 44-9.

21. Markar S., Karthikesalingam A., Wagner O. et al. Systematic Review and Meta-Analysis of Laparoscopic Nissen Fun-Doplication with or Without Division of the Short Gastric Vessels. British Journal of Surgery 2011; 98: 1056-1062.

22. Hunter J., Trus T., Branum G., Waring J. Laparoscopic Heller Myotomy and Fundoplication for AChalasia. Ann Surg 1997; 225: 655-664.

23. Chrysos E., Tzorortzinis A., Tsiaoussis J. et al. Prospective Randomized Trial Comparing Nissen To Nissen-Rossetti Technique for Laparoscopic Fundoplication. Am j Surg 2001; 182: 215-221.

24. Rothenberg S. Laparoscopic Redo Nissen Fundoplication in Infants and Children. SURG ENDOSC (2006) 20: 1518-1520

25. Graziano K., Teitelbaum D., McLean K. et al. Recurrence After Laparoscopic and Open Nissen Fundoplication. A COMPARISON OF THE MECHANISMS OF FAILURE. SURG ENDOSC (2003) 17: 704-707

26. Pacilli M. et al. Factors Predicting Failure of Redo Nissen Fundoplication in Children. PEDIATR SURG INT (2007) 23: 499-503

27. Vecchia L., Grosfeld J., West K. et al. Reoperation After Nissen Fundoplication in Children With Gastroesophageal

Reflux. Experience with 130 Patients. Annals of Surgery (1997), Vol. 226, No. 3, 315-323.

28. Lopez M., Kalfa N., Forgoes D. et al. Laparoscopic Redo Fundoplication in Children. Failure Causes and Feasibility. Journal of Pediatric Surgery (2008) 43, 1885-1890

29. Curtis J., Wong G., Gutierrez I. et al. Pledgeted Mattress Sutures Reduce Reflux After Laparoscopic Nissen Fundoplication. Journal of Pediatric Surgery (2010) 45, 1159-1164

30. Siewert J., Isolauri J., Fessner H. Reoperation Following Failed Fundoplication. WORLD J SURG (1986) 13: 791-796

31. Gott J., Polk H. Repeat Operation for Failure of AntiReflux Procedures. SURG CLIN NORTH AM 1991; 71: 13-32.

32. LANGER J. THE FAILED FUNDOPLICATION. Seminars in Pediatric Surgery, Vol 12, NO 2 (May), 2003: PP 110-117

33. Zee D., Bax N., Ure B. Laparoscopic Refundoplication in Children. SURG ENDOSC (2000) 14: 1103-1104

34. Shah S., Jegapragasan M., Fox M. et al. A Review of Laparoscopic Nissen Fundoplication in Children Weighting Less Than 5 Kg. Journal of Pediatric Surgery (2010) 45, 1165-1168

35. Rothenberg S., Cowles R. The Effects of Laparoscopic Nissen Fundoplication on Patients with Severe Gastroesophadle Reflux Disease and Steroid-Dependent Asthma. Journal of Pediatric Surgery (2012) 47, 1101-1104

36. Bratu I., Kupper S. Pediatric Fundoplications: Too Much of a Good Thing? CLINICAL PEDIATRICS, 2010 DEC; 49 (12): 1099-102

37. Dallemagne B., Weerts J., Jehaes C. et al. LaparoScopic Nissen Fundoplication: Preliminary Report. SURG LAPA-ROSC ENDOSC 1997; 1: 138-43.

38. Peter S., Barnhart D., Ostlie D. et al. Minimal VS Extensive Esophageal Mobilization During Laparoscopic Fundoplication: A Prospective Randomized Trial. Journal of Pediatric Surgery (2011) 46, 163-168

39. Caniano D., Ginn-Pease M., King D. The Failed Antireflux Procedure: Analysis of Risk Factors and Morbidity. J PediaTr Surg 1990; 25: 1022-5.

40. DONKERVOORT S., BAIS J., Rijnhart-de J. et al. Impact of Anatomical Wrap Position On The Outcome of Nissen Fundoplication. Br j Surg 2003; 90: 854-859.

41. Ngerncham M., Barnhart D., Haricharan R. et al. Risk Factors for Recurrent Gastroesophal Reflux Disease After Fundoplication In Pediatric Patients: A Case-Control Study. Journal of Pediatric Surgery (2007) 42, 1478-1485

42. Pearl R., Robie D., EIN S. et al. Complications of Gastroesophadle Antireflux Surgery in Neurologically Impaired Versus NeurologyCally Normal Children. J Pediatr Surg. 1990 Nov; 25 (11): 1169-73.

43. Galvani C., Fisichella P., Gorodner M. et al. Symptoms Are A Poor Indicator of Reflux Status After Fundoplication for Gastroesophageal Reflux Disease: Role of Esophageal Functions Tests. Arch Surg 2003; 138: 514-518.

44. Valusek P., Peter S., Keckler S. et al. Does An Upper Gastrointestinal Study Change Operative Management for Gastroesophadle Reflux? Journal of Pediatric Surgery (2010) 45, 1169-1172

45. Takahashi T., OKAZAKI T., SHIMOTAKAHARA A. Collis-Nissen Fundoplication using A Computer-Powered Right Angle Linear Cutting Stapler in Children. PEDIATR SURG INT (2009) 25: 1021-1025

46. \u200b\u200bChen S., Jarboe M., Teitelbaum D. Effectiveness of a Transluminal Effectiveness of a Transluminal Endoscopic Fundoplication for the Treatment of Pediatric Gastroesophageal Reflux Disease. PEDIATR SURG INT (2012) 28: 229-234

Laparoscopic Fundoplikation on Nissen -

golden standard for the treatment of gastroesophageal reflux in children (p. 72-77).

Picture 1.

Laparoscopic correction of the hernia of the esophageal hole of the diaphragm and the Fundoplikation on the Nissen. A - defect defect in the diaphragm - an extended esophageal hole of the diaphragm; part of the stomach located in the mediance (1 - stomach, 2 - diaphragms, 3 - spleen, 4 - transverse colon,

5 - left lodge,

6 - extended esophageal hole of the diaphragm and hernia bag); B - the stomach is reduced to the abdominal cavity;

The feet of the diaphragm (7 - distal esophagus, 8 - the left leg of the diaphragm, 9 - the left leg of the diaphragm, is mobilized. right leg diaphragms, 10 - aorta); R - the legs of the diaphragm of the ears, the esophagus will take place with separate nodal seams to the diaphragm;

D - the esophagus is fixed to the diaphragm with nodal seams; E - The nissine cuff (11) is 1.5 cm high.

Nissen Fundoplikation is an operation performed to eliminate the process called gastroesophageal reflux (reflux - esophagitis). This is a pathology in which gastric content in spasms is thrown back into the esophagus, causing a vomit reflex and nasty smell from mouth. The essence of the Fundoplikation is to strengthen the esophageal-gastric sphincter and restore its tone.

Why GERB develops

Gastroesophageal reflux disease (or reflux esophagitis) is a fairly common pathology of the digestive system associated with weakening connective tissue sphincter muscle esophagus. In the normal state, during swallowing food, the lower esophageal sphincter reflexively relaxes, and then it is tightly compressed again. Therefore, if a person starts to perform active actions, food, already treated with gastric juice, will not throw back to the esophagus.

With GERD, this mechanism is broken, and a person may experience discomfort and burning, not only in the esophagus, but also in the throat, because sometimes food rises very high. In the people, this is called heartburn, but the usual means of water type with soda do not always help. More often required Fundopling. From an anatomical point of view, the reflux esophagitis is simply explained: the sphincter does not perform the valve function and does not close after swallowing. There may be several reasons for this:

• congenital weakness of tissues and muscles;
• hernia of the esophageal hole;
• high intra-abdominal pressure;
• mechanical injuries;
• ulceal duodenal disease;
• sclerodermia;
• amyloidosis (violation of protein metabolism);
• chronic pancreatitis;
• asthenic syndrome in cirrhosis of the liver.

The predisposing factors for the development of gastroesophageal disease are stress, smoking, obesity, long-term intake of adrenoblockers, numerous pregnancy. But usually pathologies are preceded by a whole set of factors. Those. It is impossible to say that if a person from youth smokes or is overweight, he exactly will definite GERB.

By the way! Banal overeating (one volumetric meal during the day, for example, in the evening), too, often becomes a prerequisite for the development of GERD.

How the gastroesophageal disease is manifested

The main symptom of GERB - heartburn. It accompanies a person almost after each food intake and amplifies with inclons, physotransports or afternoon rest in a horizontal position.

Also one of the signs is the acidic belt with a bitter taste. If dinner was very dense, a person can even get out. At the same time, a burning sensation remains in the throat and esophagus.

Are the listed symptoms of the testimony to the fundclication on the Nissen, the doctor defines. Sometimes heartburn and belching are just the indicators of irregular nutrition or other stomach diseases.

For the operation must be more serious reasons. But it is worth contacting the clinic even when heartburn and belching, otherwise there is a risk to run the problem.

By the way! The methodology for holding the Fundopling is the name of Rudolf Nissen - the German surgeon, which suggested to treat GERD in operational way in 1955.

If the GERB is not treated for a long time, the symptoms will increase, and it will be added to swallowing disorder, chest pain, gravity in the stomach, increased salivation. From complications of gastroesophageal disease, pneumonia, otitis, laryngitis, and even laryngeal cancer or esophagus are distinguished. Therefore, he should not hide with the treatment of the doctor and carrying out the fundclication.

Diagnosis of Reflux Ezophagita

Before you prescribe a patient to the Fundoplikation, it is carefully examined. But all the conversations begins. The doctor listens to the complaint, learns about the intensity and duration of the symptoms, collects anamnesis of life. An inspection of the oral cavity is also made. White flag In the language indirectly indicates GERD. The doctor then holds the belly palpation to determine the accompanying diseases: pancreatitis, cholecystitis, gastritis.

From instrumental examinations to identify Ezophagitis refluxs, it is necessary to conduct fibroezophagogastroduodenoscopy or simply FEGDS (FGDS). The patient through the mouth in the esophagus and the stomach is introduced a probe with a camera, which displays the image of the desired section of the digestive department to the monitor.

In some cases, the Fundopling additionally requires x-ray study by a contrasting method. The patient drinks a glass of water with a barium dissolved in it. It gives a dairy-white color that will discern in the picture, as the liquid throws out of the stomach in the esophagus.

If the patient has contraindications to the fondoplikation in the form of some pathologies, the operation is postponed. Either it is also searched for an alternative way to treat this pathology of the esophagus. So, the fondoplikation is not carried out at the oncology, severe course Diabetes, comprehensive failure internal organs and exacerbation of chronic diseases.

How the Fundoplikation is held

The essence of the Fundoplikation with GERB is the creation of a cuff around the lower esophageal department. This is a kind of strengthening of tissues that will function as a valve. The safest and most convenient method for the patient is a laparoscopic fondoplikation on the Nissen.

It does not require an open section, so blood loss and infection risks are minimized. With the help of manipulators (tools), the doctor makes the necessary actions, watching its work through the monitor.

To date, it remains relevant and open fondoplikation at GERD. The incision is made at the top of the abdominal wall. The doctor shifts the liver to the side so as not to damage it during manipulations. A special tool is inserted into the esophagus to expand the lumen - buck. Then the front or rear wall of the gastric bottom turns around around the lower section of the esophagus, thus forming a cuff.

By the way! In addition to the Nissen operation, it is also sometimes used, the fondoplikation of stupid, dorah or in black stuffed. They differ in the volume of the cuff (360, 270 or 180 degrees) and on the mobilized area of \u200b\u200bthe gastric day.

If this is a classic operation performed with reflux esophagite, then the intervention ends. If the reading to the fondoplication was hernia, additionally, the absorption and stitching of the pathological opening is eliminated.

Rehabilitation Features after Fundoplishing

10 days that the patient spends in the hospital after surgery for GERD, it is peace, a strict diet, dropper and injection. But there are certain rules that need to be abide by at least 4-5 weeks, so as not to load the stomach and do not provoke it to unnatural processes.

Fundoplikation forecasts for Nissen

Gastroenterologue-therapists and gastroenterological surgeons were divided into two camps. The first believe that the NISSEN technique for GERB is imperfect, because in 30% of cases, symptoms do not leave, and in 60-70% of cases the patient suffers from postoperative complications. The latter are most often associated with scaling or reversal of the cuff. And, given that the role of the cuff is performed by one of the parts of the gastric bottom, the patient begins to experience not only pain, but also problems with food.

Surgeons are confident that competently conducted Fundopling on the method of Nissen is capable of saving a person from GERD. And successful operations of this confirmation. But still, deciding to such interference, it is necessary to prepare carefully to him, not to take some diseases from doctors or health problems, as well as clearly follow the recommendations for rehabilitation.

This information is intended for health care professionals and pharmaceuticals. Patients should not use this information as medical councils or recommendations.

Repeated antirefluxic operations

A.F. Cherniusov, T.V. Horobry, F.P. Neschev
Department of Faculty Surgery No. 1 of the Medical Faculty of GOU VPO "First MGMU. I.M. Sechenov" (Head of Academician RAMN A.F. Chernousov)

The article analyzes the diversity of the causes of failures and complications of antirefluux operations. Presents your own experience of repeated operations of 15 patients. It is shown that in order to prevent the development of complications before the first operation on reflux-esophagitis and hernia, the burdensile hole (GPO) should be taken into account, the degree of shortening, the severity of inflammatory and sclerotic changes in the esophagus, a functional reserve of passive motorbers of the organ. The need for surgical treatment of this contingent of patients in specialized hospitals is also substantiated. Keywords: repeated antireflury interventions, failures of antirefluxus surgery.

Introduction

The antirefluux surgery is currently the most frequent operational intervention in the esophagus, reflecting the prevalence of reflux-esophagitis (RE) and its complications in a number of gastroenterological diseases among the population of highly developed countries. Issues of surgical treatment of the hernia of the esophageal hole of the diaphragm (GPO) and RF are devoted to a large number of works, the authors of which converge in views on two issues: 1) the testimony for the operation is a heavy RE, not conservative treatment, or its complications; 2) The operation should be to create a reliable antireflux valve at the level of the esophageal and gastric transition.

Over the past 60 years, the main methodological and technical approaches to antirefluux operations have been developed as a result of intensive study of this problem. However, none of the existing techniques fully guarantees from recycling RE, which is detected in 11-24% of observations. At the same time, some specific complications of antirefluux operations, which often require repeated interventions become widely known. Despite the increasing interest in antirefluxus surgery, work specifically devoted to the testimony, technology and analysis of the advantages and disadvantages of various repeated antirefluux operations, little.

As a rule, an antirefluux surgery conducted by an experimental highly qualified surgeon in a specialized hospital with an uncomplicated RE gives a positive result in 80-95% of observations. However, if a similar operation performs a less qualified surgeon, the number of positive results is significantly lower and reaches only 40-50% during the first year after the operation. . In addition, even in an experienced specialist in a distant postoperative period, the number of patients with recurrent symptoms of RE can reach 15-20%. The continued increase in the number of antireflury operations, many of which are performed outside large specialized centers, inevitably leads to an increase in the number of patients with inefficiently conducted surgical treatment and recurrence of the disease, which becomes a significant medical and social problem.

Undoubtedly, an unsuccessful antireflux operation should be recognized, after which the primary symptoms (heartburn, belching, pain, etc.) are preserved or new (dysphagia, pain, owl of belly, diarrhea, etc.). The preservation of the symptoms of RE or their rapid recurrence after the Fundoplikation is described in 5-20% of patients after a laparotomous access operation and in 6-30% of patients after laparoscopic fondoplikation. To date, many publications related to the results of repeated operations after unsuccessful antireflury intervention. The most frequent symptoms of ineffective antirefluux surgery are gastroesophageal reflux (30-60%) and dysphagia (10-30%), as well as a combination of reflux and dysphagia (about 20%). In world literature, the effectiveness of the first adequately performed antirefluxic operation in 90-96% of observations is described. However, when recurring the disease, a re-operation is often necessary. In this case, good results are described only in 80-90% of patients who have previously overlooking one operation, in 55-66% of patients who have previously overlooking two operations, and only in 42% - after three or more unsuccessful operations. Thus, the probability of achieving a good result of surgical intervention is progressively reduced with an increase in the number of operations. Since the fourth reconstructive operation rarely brings a positive result Many specialists consider it appropriate after the third unsuccessful operation to perform resection or extirpation of the esophagus.

Accumulated clinical experience It indicates that when choosing the volume of operational intervention in patients with RE, it is important to take into account the presence and severity of its complications: the degree of budding of the esophagus, the peptic stricture of the esophagus, the results of the histological research of the biopsy of the terminal esophagus department, as well as the severity of concomitant diseases. What is happening in the conditions of chronic inflammation, the inevitable shortening of the esophagus significantly affects the surgical tactics. Procherating, the esophagus fonds in the rear media cardiac division of the stomach, pulling it into the tube and contributing to a complete disruption of the zombie-valve antireflux mechanism. This not only significantly weights destructive changes in the wall of the esophagus, including the development of peptic stricture, chronic round ulcers, Barrett's esophagus, but also has a significant pathological effect on his motility. Not only the chemical mechanism of the cardia disappears: after a short compensatory increase in the contractile activity (aimed at more efficient self-purification of the mucous membrane from aggressive gastric content) is oppressed by passionating motility of the esophagus. Recently held prospective studies in 8 major centers of Italy allowed intraoperatively diagnose the shortened esophagus in 20% of patients who routinely performed an anti-reflower operation, which, according to the authors, is one of the leading causes of the emergence. postoperative complications. In addition, the studies were also allowed to establish a direct correlation bond between the frequency of unsuccessful antirefluux operations and the body mass index - under the body mass index, more than 30, the incidence of complications reaches 31%.

Incorrect interpretation of data of a simultaneous pressure gauge without taking into account the results of a radiological study, which makes it possible to estimate the degree of shortening the esophagus and the nature of the HPD (it will almost always be the cause and consequence of severe RV), can serve as a basis for diagnostic and tactical errors. In particular, heavy RF is interpreted as cardiospasm or Ahalazia Cardia and are trying to perform laparoscopic myotomy with incomplete fundclication. The dysfagia occurs after such interventions requires a very complex correction, and sometimes extirpation of the esophagus. Partial rear Fundoplikation (toupet), according to a number of authors, is shown in patients with inadequate motility of the esophagus. However, the recently conducted randomized study showed that the disruption of the motility of the esophagus detected before the operation does not affect the incidence of postoperative dysfagia regardless of the type of fondopling. In addition, the frequency of unsatisfactory results after incomplete fundoplishing remains above, rather than with complete Fundoplikation.

According to the world literature, the NISSEN operation is the most frequently performed antirefluux surgery, but the resistant containment of gastrointestinal reflux does not occur in 30-76% of observations. As you know, the most frequent complications of the Nissen operation are "Gas-Bloat" -Cunder, meteorism, the impossibility of belching. Damage to the wandering nerves during an antirefluxus operation can cause a slowdown in the gastric emptying and determine the symptoms of the abdomen, feelings of overflow in the stomach, nausea, vomiting.

According to the literature, up to 30% of patients after the transferred antirefluux surgery need a re-operation due to the development of the dysfagia resistant (Fig. 1), which cannot satisfy the surgeons and requires the search for ways to improve tactics and techniques to perform interventions. The reasons for it may be the oppression of the relaxation of the lower esophageal sphincter with a pulled cuff, a violation of the cardi migration at the act of swallowing or a violation of the motility of the esophagus due to the denervation of the abdominal esophagus department, as well as the "slipping" antireflux cuff.

Fig. 1. Radiograph. Complications after Nissen's Fundoplikation. a - dysphagia due to an excessive tightly formed cuff; B - Dysphagia caused by an excessive long-long fondoplication cuff. In both cases, signs of violation of the passability in the field of esophageal and gastric transition and the suprastetic expansion of the esophagus are above the superimposed cuff

Another important and fairly frequent complication of the Nissen operation is the telescope phenomenon (Slipped Nissen, or "sliding" nissen) is the cracking of the cardiac department and the gastric bottom with the terminal separation department relative to the cuff (scheme 1, b). As a rule, the reason for this is the rubbering of seams between the cuff and the esophagus. Surfing the legs of the diaphragm during the shortening of the esophagus and fixing them to the antirefluxus cuffs also lead to the "slipping", since the esophagus, shrinking after the operation, draws the cardia along with the cuff into the rear media. X-ray it looks like a phenomenon of "hourglass", when one piece of the cuff is above the diaphragm, and the other is below (Fig. 2). The complication is accompanied by severe dysfagia, regurgitation and heartburn, which, of course, requires a re-corrective operation. A frequent error when using endoscopic equipment is the use of the body or even the anthral stomach unit during the formation of an antirefluxular cuff (see scheme 1, B). According to a number of authors, if short gastric vessels are not crossed, the surgeon is forced to use at 360 ° fondoplikation not the bottom of the stomach, and its anterior wall. All this leads to a twist, pronounced strain of the stomach, which, for obvious reasons, is not able to perform an anti-reflower function and is the main cause of a high frequency of postoperative complications in the form of dysfagia (11-54%) with the operation of the operation. In particular, that is why, with greater technical simplicity, the Rossetti operation is rarely applied.

Scheme 1. Complications after Nissen Fundoplishing. a - a complete turn of the cuff during the rubber of seams; b - "slipped" nissen; B - a cuff shaped around the cardiac ventilator; g - pulling an antireflux cuff into the rear media in the shortening of the esophagus

Fig. 2. Radiograph. "Slipping" Fundoplication Cuff ("Slipped" Nissen). A - the sling cuff is located below the diaphragm level and squeezes the cardiac diversity of the stomach, the esophageal and gastric transition is above the diaphragm; B, B - with double contrasting, the folds of the stomach mucosa inside the sludgeing cuffs with the formation of a die-acting deformation (such a diverticulus often becomes a source of gastroofic reflux and progressive RV)

The simplest for diagnosis and treatment is the complication of "Missing" Nissen ("Insufficient" Nissen). In this case, overlooking the superficial seams on the fondoplication cuffs are died, and the latter unfolds (see schema 1, a).

With the introduction of a laparoscopic technique, several times the number of such complications inherent in it, like a two-chamber stomach and twisted cuffs, increased several times.

The migration of the genust in the chest cavity can occur in the early postoperative period, even at the time of the exit of the patient from anesthesia. This occurs for a number of reasons, in particular due to the unreasonable traction of a shortened esophagus to create a fondoplication cuff below the diaphragm (see scheme 1, g). Some authors also believe that the inadequate fixation of the fondoplication cuff to the legs of the diaphragm predisposes to the further development of the GPD or the development of parasezophageal HPD with the movement of the sealer of the colon along the fondoplication cuff.

Material and methods

From 2006 to 2011 We observed 15 patients (7 men and 8 women aged from 25 to 72 years) who have undergone various operations about HPD and RE, the result of which was unsatisfactory. All with the exception of one patient were primary operated in other hospitals. The nature of primary operations is reflected in Table. 1. In most cases, fondoplikation was performed as the primary operation.

Table 1. Early transferred surgical interventions (n \u200b\u200b\u003d 15) *

* Including patients with a combination of several and repeated operations.

10 of 15 previously operated patients noted the emergence of recurrence of symptoms or their transformation in the near postoperative period. In 5 patients, the remission period "dragged" for many years (from 10 to 24 years).

Analyzing patient complaints before and after surgery (heartburn, belching, pain in the upper half of the abdomen and behind the sternum), not only their almost complete recurrence in the early postoperative period, but also progression and transformation in the remote period.

The absolute majority of patients were disturbed by a permanent heartburn (9). The second in the frequency of the symptom was dysphagia (7). In all patients, dysphagia was due to the compression of the "slut" cuff in the field of the esophageal hole of the diaphragm after the rapid (5) or its twist (1) (Fig. 3, a, b). In one patient, persistent dysphagia was a consequence of scarsing stenosis in the field of esophageal-gastric transition arising from the embedding of the nutritional perforation of the esophagus during the formation of a fondoplication cuff. The blocking sessions carried out in the clinic did not bring the proper effect due to the inability to carry out the buck more than 26 (Fig. 4, a, b). As a rule, the pain wore a burning or pressure. In the origin of pain in this group of patients (12) play a role as chemical (the impact of gastric content on the inflamed and ulcerated mucous membrane of the esophagus, the so-called heartburn to pain) and mechanical factors (stretching the terminal separation of the reflux wave of reflux, fixation of the cuffs to the legs of the diaphragm , as well as the tension of the branches of the solar plexus characteristic of the shortening of the esophagus). The predominance of patients with the localization of pain syndrome behind the sternum and in the region of the heart is largely due to the location of the "slipping" cuff in the rear mediastinum due to the progression of the shortening of the esophagus, as well as with the gastroindial syndrome of Uden-Remecheld.

Fig. 3. Radiograph. Complications after Nissen's Fundoplikation. A - "Slipping" cuff groales the upper part of the body of the stomach, cardia is stretched due to impaired passability and is located above the level of the diaphragm, the esophagus is shortened, the esophageal and gastric transition is located 4 cm above the diaphragm level; B - type of formed reconstructive gastroplication cuff

Fig. 4. Radiograph. Complications after Nissen's Fundoplikation. a - complete dysfagia after the Fundoplishing with the formation of scar stricture and the suprasteotic expansion of the esophagus, which led to its deviation and siphono-like expansion; A nastogastric probe is visible; B - antirefluxus cuff formed after proximal resection of the stomach and resection of the abdominal esophagus department

Another frequent symptom indicating the ineffectiveness of the newly created valve was the belching (11).

All patients conducted x-ray research and esophagastroduodenoscopy (EGDS). At the same time, the shortening of the esophagus of the I degree was diagnosed in 6 patients, II degree - in 8. Signs of erosive RE were identified in 6 patients.

During the examination, in 8 patients, the radiologically, the previously created antirefluxus cuff was in the region of the rear media. In all likelihood, at the time of the first operation, these patients had to shorten the esophagus, but the surgeons did not give it due value and performed traditional antireflury intervention.

In all observations, the Fundoplication Cuff did not provide obstacles to the gastroofing reflux and was recognized as ineffective at the preoperative stage.

In one patient, operated in our clinic about the Middle severity, the sliding cardiac gender and the shortening of the esophagus of the I degree, on the 7th day after laparoscopic fondoplikation during the control x-ray study, the diverticopod-like deformation of the cardiac department and the dance of the stomach was revealed (Fig. 5) . At the same time, the signs of gastroesophageal reflux were found not even in the position of Trendelenburg. It should be noted that, despite the existing experience of open antireflux interventions, the operation was one of the first and uniquely unsuccessful laparoscopic operation, which arose at the stage of mastering and implementing this technique. The patient was re-operated after 5 months, after passing the rehabilitation course, and the re-examination made it possible to establish the progressive shortening of the esophagus to the II degree, which influenced the tactics of operational treatment. Survection data and analysis of operating finds during re-intervention allowed us to identify the following reason for the complication: rubbering of seams with one side of the cuff, followed by its twist around the axis and the formation of the divertic-like deformation of the bottom of the stomach. The patient produced a reconstructive valve gastroplation, extra-made piloroplastic traditional access.

Fig 5. Radiograph. Complication after Fundoplishing: Diverticopod-like deformation of the bottom of the stomach in the region of partially unfolded with the cutting of cuffs of the cuffs after laparoscopic fondoplication

It should be noted that as an antirefluxic operation, we never used the classical Fundopling by Nissen, and we widely use symmetric full futures, giving the best results than the Nissen method. EGDS, in our opinion, should not be used as an independent intervention in the treatment of RE, since this operation does not create a sufficiently reliable antirefluxus valve in the cardia.

At the same time, the fondoplication cuff is formed after mobilizing the small curvature, cardia, the abdominal dial of the esophagus and the bottom of the stomach with the preservation of smooth trunks of the wandering nerves and both nerves of Latail. The mobilization of the gastric bottom is carried out with the mandatory ligation of two short gastric arteries in order to increase the mobility of the tissue of the gastric bottom for the subsequent formation of the fondoplication cuff without tension. "

The gradual immersion of the esophagus into the fold between the front and rear walls of the dna stomach without using rubber holding ensures the formation of a uniform neat complete symmetrical cuff, which does not deform the esophageal and gastric transition and does not create divertic-like pockets and cascading stomach deformation. The optimal cuff altitude is 4 cm. In the seams there must be a museum of the esophagus. The top edge of the cuffs additionally fix the two nodal seams in front and one behind (the tip of the cuff) for the prevention of the telescope's phenomenon, i.e. casing casing (circuit 2 ).

Scheme 2. Stages of the Fundopling. Forming a complete symmetrical cuff.

In shortening the esophagus of the II degree (the location of the vane and gastric transition is more than 4 cm above the diaphragm), it is meaningless, because after the operation it will inevitably decrease again. At the same time, the antirefluxular cuff will or slip with the formation of "removing" - the so-called telescopic effect, or will unfold when the seams are rubbering. Practice has shown that the main anti-reflower effect is valid from the tissues of the stomach. With its proper formation, it is equally successfully working under the diaphragm.

Back in 1960, R. Nissen proposed to apply the Fundopling in patients with the shortening of the esophagus, while the author did not eliminate the hernia itself, but, on the contrary, expanding the hernia. The fondoplication cuff remained in the mediastinum, while the stomach was laid to the esophageal hole of the diaphragm. An important step by the author considered the mandatory expansion of the diaphragmal opening to avoid compression and subsequent poor emptying of the propadiaphragmal segment of the stomach. A number of studies have found that Nissen's Fundoplishing with a short esophagus with the leaving of the cuff over the diaphragm level is effective with long-term pH control in 97% of observations and is not inferior to the intra-abdominal location.

Practice has shown that the crude does not carry a significant independent antirefluxus function under conditions of complete destruction of the romance valve cardia. It is advisable to the general esophageal-aortic "window", giant and parasepal hernias solely to prevent migration to the mediastinum of the abdominal organs.

In terms of pronounced shortening, the valve gastroplation is justified (N.N. Kanshin, 1962), which today we are modified and has been successfully applied again. After mobilizing the cardiac ventilation and expansion of the hernial gate of the stomach, turn into a tube with transverse seerful seams (cardiography). Next, a part of the stomach transformed into the tube, which is a kind of "rebel" of the esophagus, symmetrically envelop the gastric wall, as for the fondoplikation. Then the upper part of the cuff is fixed to the esophage (scheme 3). Thus, the "extension" of the esophagus occurs due to the stomach and the creation of an antirefluxic valve.

Scheme 3. Valve gastroplication

Results and its discussion

All patients who have undergone primary operations in other medical institutions were operated on again. At the same time, as a result of a survey and analysis of operating finds, they identified the following technical errors made during previous operations: fixation to a small curvature of mobilized large curvature from behind the esophagus; crosslinking in front with the formation of duplication of large and small crumples of the stomach without their mobilization (2); fixation of the stomach to the legs of the diaphragm (3); suturing the legs of the diaphragm (4); fixation of the stomach to the liver, front abdominal wall (2); Pyloroplasty (5); incorrectly formed cuff (8) and its complete absence (3); The phenomenon of "telescope" (in 8); Neighten dense cuff (3); Gastrostaz (2).

To one patient with a pronounced scar stenosis of the esophageal and gastric transition after a previously made Nissen's fondation and the nutritional perforation of the esophagus, the implementation of the local reconstruction was impossible (see Fig. 4, a, b). We bring a brief description of the operation of the operation.

Larotomy, enterolysis of the upper floor of the abdominal cavity. The stomach of ordinary sizes is deformed in the cardiac department, the esophageal-gastric transition and the upper third of the stomach is practically not differentiated (the area of \u200b\u200bperforation and overlapping a fondoplication cuff). Fabrics in this area of \u200b\u200bedema, infiltrated, previously imposed ligatures are visible. With technical difficulties after partial sagittal diaphragotomy identified the legs of the diaphragm, which were previously stitched with nodal seams; Threads are removed; In the rear mediastum, the Nizhnegroindian esophagus department is highlighted, extended to 6 cm with hypertrophied walls. The esophageal-gastric transition, rigid, stenzated with rude scars for 2 cm. A distal than the upper third of the stomach is deformed due to a previously formed fondoplication cuff. The latter with technical difficulties is stripped. The small curvature of the stomach to the angle is mobilized, large curvature with the ligation of three short gastric and rear gastric artery. The tissue of the upper third of the stomach in the area of \u200b\u200bthe straighted cuff is atonic, the wall is thinned, infiltrated - are unsuitable for the formation of an anti-reflower cuff, circular stricture is not subject to transverse plastic. Under these conditions, proximal resection of the stomach, resection of the abdominal department of the esophagus, pyloroplasty was performed. At the same time, esophageal-gastric anastomosis was formed with the front wall of the stomach cult, followed by the formation of an anti-reflower cuff due to the tissues of the stomach culture on a thick gastric probe. The left corner of the seams of the stomach crust is additionally laid to the esophage.

Of the 15 patients who have undergone repeated interventions in our clinic, there were no unsatisfactory results (Table 2). Only 2 patients in the early postoperative period were diagnosed with dysfagia (mainly in the swallowing of solid food), due to hyperfunction of the reconstructive gastroplation cuff. It should be noted that both patients in history have moved two operations on the region of the cardia. Conducted sessions of balloon dilatation (1-2 sessions) under the control of X-ray-television allowed to eliminate clinical and radiological manifestations of dysphagia, without destroying the newly created antirefluux valve in the form of a cuff.

Table 2. The nature of repeated antirefluux operations

* Including the simultaneous operations.

Good direct functional results with the disappearance of clinical symptoms are obtained from the absolute majority of re-operated patients. Remote results are studied in all 15 patients and traced in time from 6 months to 4 years. The study was carried out both using traditional approaches and using the assessment of the quality of life of the operated patients, which is a mandatory attribute of international studies of recent years, complies with the principles of evidence-based medicine and allows you to more adequately evaluate remote results. The results were evaluated on the basis of a direct inspection, a comprehensive examination, as well as on the basis of the survey data. A planned control examination was held to all sick outpatient patients. The survey plan included X-ray examination of the esophagus and stomach, EGDS. Also in the remote period did not come across the symptoms described in the literature, often (10-33%) arising from the antirefluxic operations: dysphagia, bloating, earlier saturation, nausea, soreness in the epigastric area, inability to belch and vomiting, diarrhea.

Assessment of the quality of life was carried out using a modified specific questionnaire - a gastrointestinal quality index of life (Gastrointestinal Quality of Life Index, GIQL1). When comparing the obtained quality indicators of life, a reliable increase in the quality of life index after the reconstructive operation on all questionnaire scales was identified (P<0,05). Гастроэнтерологическая симптоматика у исследуемых больных претерпела обратное развитие наряду с улучшением показателей качества жизни. У больных отмечено увеличение индекса качества жизни с 42 баллов (до операции) до 70 баллов (после операции) при максимальном показателе 84 балла. Наиболее значительно увеличение индекса качества жизни отмечено после операции по шкале симптомов - на 47%. Также отмечено увеличение показателей по шкале субъективного восприятия своего здоровья и влияния проведенного лечения.

With a radiological study, no patient has disrupted swallowing and passing a contrast substance on the esophagus. In 3 patients, the stomach was located in the abdominal cavity, in the remaining 12 patients, the formed antirefluux cuff was on or above the level of the diaphragm. At the same time, the gastroesophageal reflux of a contrast agent in a polyposition study, including in the Trendelenburg position, was not detected.

The results obtained once again demonstrate a long-standing statement that the main antirefluux effect is precisely the cuff from the tissues of the stomach, and in its proper formation it is equally successfully "works" both under and above the diaphragm.

In the EGDS of the gaping or insufficiency of the cardia signs of esophagitis, no patient was detected.

Thus, patients who have been surgical treatment can usually take any food in their choice, to be in a horizontal position and lean, without experiencing clinical manifestations of gastroesophageal reflux, and, not less important, they do not have the need for a constant reception of drug drugs.

Unsuccessful outcomes of primary antirefluux operations are observed in 6-30% of cases. We allocate the following groups of the reasons for these failures: 1) The desire to necessarily eliminate the GPD, and not a gastroofic and esophageal reflux - hence the vicious operations of fixing the stomach to the diaphragm, the abdominal wall, etc., causing persistent pain syndrome, dysfagia, painful and belch. This also includes isolated interventions on the esophageal hole of the diaphragm; 2) vicious palliative operations to accelerate the evacuation and "reduction" of reflux, such as distal resection of the stomach or pyloroplasty, as well as dissection of the conjunction; 3) technical errors in attempts to form a fondoplikational cuff without due to mobilization of the esophagus, cardia and the bottom of the stomach, and, as a result, a variety of options for an incorrectly formed cuff or its complete absence during revision during repeated operations; 4) the complications characteristic of the Fundopling, such as parasephageal hernia, the telescope phenomenon, the compression of the esophagus is too dense cuff, gastrostaz due to the infringement or intersection of the wandering nerves, the stomach ulcer; 5) various functional disorders of swallowing and digestion in the absence of characteristic anatomical changes according to the survey data - they reflect the unjustified expansion of the testimony to primary operations during the GPD.

A number of authors emphasize the unnecessariness and harmfulness of the stomach fixation and the fondoplication cuff in the abdominal cavity. Others continue to promote this method. Cropraphia is offered as the prevention of the formation of parasezophageal hernia as a supplement to the Fundopling, although some authors argue that only gastropka is effective for this purpose. We were convinced of our own experience in the fact that the esophagus and the fondoplication cuff should be freely moved relative to the diaphragm. Reducing the longitudinal musculature of the esophagus in the state of "snatch" it from any fixed cuff, which usually leads to the appearance of various pronounced deformations and recycling of the RE. Crowraphia is considered to be shown in primary operations in cases of cardioofundal or parasezophageal hernia, especially when there is a common esophageal-aortic window in a diaphragm. With repeated antirefluux operations, it is also justified in the case of the development of parasezophageal hernia as complications of the Fundopling.

A full-fledged fondoplikation gives a good and excellent remote results in 84-95% of observations. In our series in half of the observations, we met that with primary operations in other medical institutions, attempts were made to form a cuff with rude technical errors, which led to the most diverse stomach deformations, and most often to the aggravation of the symptoms of the disease (Fig. 6, and, b).

Fig. 6. Radiograph. Complications after Nissen's Fundoplikation. a - perforation of the bottom of the stomach during the formation of a fondoplication cuff with the formation of an outer gastric fistula; b - reconstructive gastroplation

According to literature, repeated antirefluux operations give the worst results compared to primary. Methods of repeated antirefluux operations are diverse. As with primary interventions, well-known Nissen, Tupet, Collis methods are offered. As operating access, both laparotomy, laparoscopy and thoracotomy are used. We believe that when repeated operations over the GPD and RE, the method of choice should have upper median laparotomy with the correction of the extenders of the cigala. This access allows you to thoroughly explore the established anatomical relationships and take the right decision on the nature of the reconstructive operation. It should be noted that laparoscopic operations at RV should perform a surgeon with significant experiences of such open operations and owning all parts of the intervention. This is especially true of patients with shortening the esophagus of the II degree and a long history of heavy RE. There are certain difficulties of mobilizing the esophagus and stretched in the form of a tube cardiac part of the stomach in the form of a tube of the cardiac part of the stomach due to expressed periodsophagitis. It is in such a situation that an intraoperative perforation of the esophagus is possible.

In most cases, in most cases, the fundclication in patients with RE should be combined with selective proximal wagotomy to reduce acidic secretion and reduce the aggressive effect of gastric juice on the esophageal mucosa. The trunk wagotomy during re-interventions is justified in the conditions of a pronounced scarsing process in a small seal and around the cardia, when it is impossible to identify and save the nerves of Latarezh.

We consider it inappropriate with the development of such complications of RV, as an extended scar peptic stricture or a barrett's esophagus with a high-degree dysplasia, performing partial resection of the esophagus with a substitution of its part of the stomach or segment of the intestine, as other authors offer it. It should be borne in mind that partial resection of the esophagus in this case is always dangerous by the Recurrent of RE, as it is very difficult to create a reliable universal antireflux valve in the abdominal or thoracic cavity at the level of esophageal anastomosis, and most likely it is impossible. Therefore, the attention proposed in cases of multiple unsuccessful operations and at extended peptic strictures is the most radical operation - the extirpation of the esophagus with shadan-abdominal access with single-stage esophagoplastic stomach. We consider this operation by choosing in the most difficult situations.

Particular attention should be paid to patients who are heal from RE, but the result of the operation they cannot be called satisfactory due to poor well-being and negative assessment of their health. In our series there were 2 such patients who, as a history, several antirefluux operations were conducted. Analyzing the clinical picture of the disease and data of special research methods, we concluded that many such patients have symptoms of the disease are largely due to hidden depression and syntopathy and in some cases it is more expedient to abandon the reconstructive operation in favor of conservative treatment with mandatory consultation of the psychoneurologist. Up to 28% of patients who have undergone antireflury intervention have various gastroenterological symptoms. At the same time, in 35% of them, during the examination there are no disorders or changes from the gastrointestinal tract, and symptoms are permitted over time without any intervention. In this regard, we define the testimony and to primary, and to re-operations with HPD and RE.

Conclusion

Thus, the diversity of the causes of failures and complications of antirefluux operations, the technical complexity of repeated interventions and the problematic of their good results determine the feasibility of the concentration of patients with HPD and RE in specialized hospitals and dictate the need for further clinical studies in this area.

Bibliography

1. Alekseenko A.V., Senutovich R.V., Stolyar V.F. Operation A.A. Shalimova with sliding hernias of the esophageal hole of the diaphragm // Wedge, surgery. 1988. No. 10. P. 45-47.

2. Allahverdyan A ,.s. Analysis of failures and errors of antireflury operations // Ann. Hir. 2005. №2. P. 8-15.

3. Verez, PS, Krylov N.N., Shpachecho F.A., Studying the quality of life of patients after surgical treatment // Surgery. 2000. №1. P. 64-67.

4. Greats A.F., Kolkin Y.G. Surgery of the hernia of the esophageal hole of the diaphragm // Wedge. Hir. 1980. №2. P. 23-25.

5. Earthman A.G., Bugaev A.I., Kulagin V.I. Side esophago-fundoplikation with sliding hernias of the esophageal hole of the diaphragm // WHO, SURGERGY. 1989. T. 142. №4. P. 11-14.

6. Roots B. S. Gastroesophageal reflux disease. Diagnosis and surgical treatment: author. dis. ... Dr. Honey. science M., 2001.

7. Kubashkin V.A., Kornak B. S. Gastroesophageal Reflux disease. M., 1999.

8. Lutsev O.E., Gallamov E.A., Tolstoy M.P., Finogenov V.V. History and current state of the problem of gastroesof-geal reflux disease // Endoscope, surgery. №4. 2005. P. 54-59.

9. Matveev N.L., Protasov A.V., Krivtsov G.A., Lelikov A.S. Surgical treatment of gastroesophageal reflux // Endoscope, surgery. 2000. №3. P. 21-25.

10. Oskretkov V.I., Tankov V.A. The results of surgical correction of the circliament circusia // Surgery. 1997. №8. Pp. 43-46.

11. Solovyov GM, Lukovsky, i.e., Slutko A.M. and others. Gastroesophageal reflux disease - the disease of the XXI century (surgical treatment strategy) // Breast and cardiovascular surgery. 2000. №1. P. 62-65.

12. Utkin V.V., Demchenko Yu.M., Ambalov T.A., Lepins M.A. Surgical treatment of the hernia of the esophageal hole of the diaphragm // Vestn. Surgery them. Grekova. 1983. T. 130. №6. P. 30-32.

13. Cherniusov A. F., Polyelytsev A.A., Anufriev A.M., Korchak A.M. The combination of the sliding hernia of the esophageal hole of the diaphragm with gastroduodenal ulcers // Surgery. 1981. №6. P. 59-63.

14. Cherniusov A.F., Bogopolsky P.M., Warsono Chiptovardoyo. Diagnosis and treatment of peptic stricture of the esophagus // Breast surgery. 1989. №4. P. 63-65.

15. Cherniusov A.F., Bogopolsky P.M., Koyava T.O. Repeated antirefluxic operations // Breast and cardiovascular surgery. 1991. №8. P. 56-60.

16. Cherniusov A.F., Bogopolsky P.M., Kurbanov F.S. Surgery of the esophagus: manual for doctors. M: Medicine, 2000.

17. Cherniusov A.F., Korchak A.M., Stepankin S.I., Efendiyev V.M. Repeated operations after the Fundoplikation on Nissen // Surgery. 1985. №9. P. 5-10.

18. Cherniusov A.F., Khorobrykh T.V., Veschev F.P. Reflux-esophagitis in patients with a short esophagus. Surgery. 2008. №8. P. 24-31.

19. Cherniusov A.F., Shestakov A.L., Tamazyan G.S. Reflux Ezophagitis. M.: Publis, 1999.

20. The numbers of V.I. Ezophagomanometry with hernias of the esophageal hole and diverticulas: dis the disk .... Cand. honey. science M., 1967.

21. Alexander NS, Hendlerr.s. Laparoscopic Reoperation ON Failed Antireflux Procedures: Report of Two Patients // Surg. EapaRoScop. Endoscop. 1996. N6. P. 147-149.

22. Alexiou C, Beggs D., Salama T.D. et al. A TAILORED SURGICAL APPROACH FOR GASTRO-OESOPHAGEAL REFLUX DISEASE: THE NOTTINGHAM EXPERIENCE // EUR. J. Cardiothorac. Surg. 2000. V. 17. P. 389-395.

23. AWARD Z.T., ANDERSON P.I., SATO K. ET AL. EapaRoScopic Reoperative Antireflux Surgery // Surg. Endosc. 2001. V. 15. P. 1401-1407.

To date fundoplikation on Nissen (Nissen) is performed in the open method and using laparoscopic technology. This is one of the most common transactions currently produced during the hernia of the esophageal hole of the diaphragm.

The essence of this surgical intervention is to create a cuff by turnover of the 460 degree stomach, which prevents gastroesophageal reflux, and, consequently, the development of esophagitis. The operation is usually carried out from abdominal access, performing upper median laparotomy.

After the proximal part of the stomach is reduced from the chest cavity in the abdominal, all over the abdominal department of the esophagus. Then the latter neatly take on a special holding, dissect the hepatic gastric ligament and mobilize the back surface of the upper third of the stomach.

The next step is carried out to crosslink the legs of the diaphragm, due to which the diameter of the esophageal hole is reduced. After that, individual serous muscular seams combine the front and rear walls of the upper part of the stomach, as if forming a coupling that occurs around the abdominal esophagus. At the same time, to avoid scoring the formed cuff in the distal direction (the development of the so-called telescope syndrome) in these seams also capture the muscular shell of the front wall of the esophagus, which warns the recurrence of the disease. At the end of this intervention, the front wall of the stomach is fixed to the front abdominal wall of individual seams, passing the thread through the rear plate of the vagina's left straight muscle of the abdomen.

It should be noted that with a long existence of a sliding chital hernia and the peptic esophagitis arising on its background of peptic esophagitis in approximately 5-10% of cases, there is a secondary shortening of the esophagus, which causes the occurrence of significant difficulties in the process of performing the operation, namely, when moving the proximal part of the stomach down, in Abdominal cavity.

In such situations, the nisssen intervention is carried out not from the laparotomy, but from the left transducer access, leaving part of the stomach in the pleural cavity.

However, this approach is conjugate with a number of complications, ranging from the loss of natural reflexion reflex due to the fact that the cuff here is an absolute valve in the cardia region, as it is not created around the esophagus, which in a similar situation is completely in the chest, but around the stomach, to serious troubles for the formation of esophageal-pleural or gastrointestinal fistula and ulcers in the zone of the Fundoplikation, etc.

In general, for the successful implementation of the Fundopling on the Nissen, it is necessary to observe certain criteria for the selection of patients and in terms of preoperative preparation to carry out the 24-hour pH-metry and pressure gauge.

It is necessary to estimate the degree of pressure in advance, which the bottom of the stomach should have to have the esophagus, set the optimal height of the cuff and accurately outline the segment of the stomach, from which it will be formed.

In no case should not be subject to this intervention of persons who suffer from impaired motility, dyskinesia of the esophagus, with weak waves or the complete absence of peristaltic. It is also not recommended for a nonsense patient with heavy esophagitis, shortening and stricture of the esophagus, when the esophagus cannot be omitted for a sufficient length into the abdominal cavity or when the residual tension of the esophagus takes place.