Gastroesophageal reflux disease (GERD). Hiatal hernia (HH).

Diaphragmatic hernia: a disease that can be “ciphered”

What do we know about hiatal hernia?

To understand what a diaphragmatic hernia is, let's go back to the school anatomy course.
The diaphragm is the “fence” between the cavities, thoracic and abdominal. This is a special muscle that takes part in the breathing process. There are a number of openings in the muscle, including the esophageal opening. The very presence of the hole and the flexibility of the diaphragm are partly responsible for the occurrence of a hernia. If the section of the esophagus located below the diaphragm (partially with the stomach, less often with intestinal loops) shifts to the section located above the muscle, the patient is said to have a diaphragmatic hernia.

Cost of endoscopic removal of spinal hernia

The price of the operation depends on a number of factors:

• individually selected technique, necessary additional manipulations;
• localization of the hernia (lumbar / cervical / thoracic / sacral, foraminal / extraforaminal);
• urgency of surgical intervention (the cost of express tests is higher);
• type of anesthesia;
• length of stay in the ward (usually 1 day, but at the request of the patient it can be extended).

The exact cost of endoscopic removal of a spinal hernia can be found out after consulting a neurosurgeon, when the doctor examines MRI images, medical history and determines treatment tactics. Call or request a call back through the website so we can guide you through the price list. To determine the method and cost of treatment, you can send the neurosurgeon MRI images archived from disk (quality not lower than 1.5 Tesla), a conclusion, as well as a description of complaints through a special form on this page of the site.

Don’t forget to look at the section with promotions and special offers from the Department of Spinal Neurosurgery.

Removal of sutures, dressings, and doctor's observation after surgery are included in the cost of the operation and are not paid separately.

Causes of pathology

A hiatal hernia (HHH) can be congenital (with a shortened esophagus) or acquired.

The causes of the acquired condition are not fully known. It is assumed that the elastic tissue of the diaphragm is predisposing to the appearance of a hernia, especially if there is a family history of the disease.

The likely cause may be injury. However, the diagnosis is also made to patients who have never injured the diaphragm area.

Among the provoking factors are pregnancy, obesity and excess weight as such, chronic cough, heavy lifting, poor diet, constipation.

Symptoms of the disease

The patient may not notice a small hernia at all - it does not manifest itself in any way and does not affect the quality of life.

Most patients report the following symptoms:

• Heartburn
• Belching
• Abdominal pain (stomach area)
• Discomfort behind the sternum
• Shortness of breath and rapid heart rate
• Feeling of fullness in the epigastric region
• Dysphagia (difficulty swallowing)

Symptoms may appear during abdominal exercises, sudden bending, or wearing tight clothes that are tightly tied at the waist.

Non-food manifestations include:

• Cough with no other proven cause
• Sore throat, nasal congestion
• Damage to tooth enamel
• Anemia.

Often the doctor has to exercise deductive abilities, finding a connection between a lingering cough of unknown etiology or low hemoglobin in a blood test and a hiatal hernia that no longer manifests itself.

Diagnosis of the disease

The diagnosis of “diaphragmatic hernia of the diaphragm of the stomach” is made on the basis of an examination prescribed by a gastroenterologist. Basic methods are esophagogastroduodenoscopy (EGD), x-ray of the esophagus and stomach with a contrast agent.

An endoscopic examination can both rule out diseases of the digestive system and determine the presence of a hiatal hernia, stomach diseases, such as ulcers or reflux esophagitis (GERD), since GERD is a common complication of the hiatal hernia.

An X-ray of the esophagus confirms the suspicion of a hernia and determines its size. For sliding (ascial) hernias, the degree is determined - from 1st to 3rd.

University

Nikolay Sivets , head of the surgical department of the 6th City Clinical Hospital of Minsk, professor of the department of military field surgery of BSMU, doctor of medicine. Sciences The essence of the operation is to correct the esophageal opening of the diaphragm and form a cuff from the fundus of the stomach around the abdominal esophagus and cardia. Interventions for hiatal hernia (HHH), as a rule, are performed using laparoscopic access, which reduces trauma, shortens the period of disability and speeds up rehabilitation.

Surgical treatment of hiatal hernia in the late postoperative period is accompanied by a fairly high percentage of relapses (from 11% to 30%). Good and excellent results are in the range of 84–86%. According to a number of authors, the relapse rate after laparoscopic correction of giant hiatal hernias (with a surface area of ​​the esophageal opening of the diaphragm of more than 20 cm2) is 25–40%.

A characteristic feature of the operation: sutures are applied to the diaphragmatic legs that have already been separated from the fibers and have undergone degeneration. As a result, the diaphragm tissue erupts, creating conditions for the migration of the applied fundoplication cuff into the posterior mediastinum with the development of recurrent pathology. An attempt to apply sutures to intact tissue, while involving a large number of diaphragmatic crura, can lead to persistent postoperative dysphagia due to excessive narrowing of the esophageal opening of the diaphragm.

Specific mechanisms and types of relapses are well known: slipping of the fundoplication cuff, or telescope syndrome, displacement of the cuff into the chest cavity above the diaphragm, cutting through the sutures of the cuff or the sutures of the legs of the diaphragm, the formation of a paraesophageal hernia. Sliding of the fundoplication cuff above the diaphragm is most often observed when the crurorrhaphic suture fails. In second place is relapse due to rupture and disintegration of the diaphragmatic pedicle. The literature describes mechanical (manifested by dysphagia) and functional (manifested by heartburn) forms of relapse.

To improve the results of surgical treatment, plasty of the esophageal opening of the diaphragm is performed using a mesh implant. Many authors believe that the use of a mesh is advisable only for large sizes of the esophageal opening of the diaphragm, atrophy of the diaphragmatic legs and in old age. The attitude towards polypropylene mesh is currently very restrained. The limited use of them in plasty of the esophageal opening of the diaphragm is explained by frequent complications (long-term dysphagia in the postoperative period, cicatricial strictures, erosion of the esophagus by the implant and migration of the implant). At the same time, the indications for placing the mesh have not been worked out.

In repeated operations for recurrent hiatal hernias, Nissen fundoplication is used in approximately 70% of cases, and Toupet fundoplication is used in 17–20% of cases. Indications for re-intervention: recurrent hiatal hernia, especially if there is recurrent development of reflux, reflux esophagitis or other manifestations of gastroesophageal reflux disease (heartburn, dysphagia, vomiting, chest pain). It has been proven that with repeated operations their effectiveness decreases, and the greater the number of previously performed interventions, the lower the effectiveness of each subsequent one. This fact requires a careful approach to determining indications for refundoplication. To accurately determine whether reoperation is feasible, it is necessary to conduct a comprehensive clinical and X-ray endoscopic examination.

Patient V., 69 years old, resident of Polotsk, was hospitalized in the surgical department of the 6th City Clinical Hospital of Minsk on May 29, 2021 with a recurrent hiatal hernia.

From the anamnesis: in 2009 she was operated on in one of the clinics in Vitebsk. An endoscopic operation involving posterior crurorrhaphy was performed with the installation of a polypropylene mesh behind the esophagus and Nissen fundoplication. A year later, a recurrence of the hiatal hernia occurred, and the patient was operated on again in the same clinic. A left-sided thoracotomy and plasty of the esophageal opening of the diaphragm by suturing it were performed. About four years after the second operation I felt satisfactory. The deterioration of the condition has been noted over the past two years. I began to experience chest pain, bitterness in my mouth, and belching.

In April 2021, the patient was consulted in the surgical department of the 6th City Clinical Hospital of Minsk. Additional examination was recommended for differential diagnosis. A comprehensive clinical, endoscopic and x-ray examination was carried out at the place of residence, as a result of which a clinical diagnosis was established: recurrent hiatal hernia. On May 29, the patient was hospitalized and operated on the next day. Reconstructive surgery was performed on the esophagus and stomach: laparotomy, hernia repair, anterior crurorrhaphy, Nissen refundoplication. The duration of the operation is 3 hours 40 minutes.

FROM THE OPERATIONAL REPORT: upper-median laparotomy with bypass of the umbilicus on the left. An audit of the abdominal organs revealed that there was a moderate adhesive process in the abdominal cavity after the previous operation. The greater omentum is soldered to the anterior abdominal wall, to the liver, and to the bed of the gallbladder. In the subhepatic space on the left, in the area of ​​the esophageal opening of the diaphragm, there is a massive adhesive process.

Upon further inspection, it was determined that there was a recurrence of the hiatal hernia. The adhesions are separated, and the hernial orifice is isolated (diameter about 5 cm). Behind the esophagus, a mesh implant is palpated, which is fixed to the legs of the diaphragm. The area of ​​the esophagogastric junction on the lower right is tightly fixed to the implant. An attempt to remove the mesh implant was accompanied by tissue trauma and moderate diffuse bleeding.

Two metal brackets removed. The mesh implant was left in its original place. The parietal peritoneum was dissected in the area of ​​the hernial orifice along the left wall of the esophageal opening of the diaphragm. The stomach in the cardiac region was mobilized along the lesser curvature, two short gastrosplenic branches were crossed along the greater curvature. The abdominal part of the esophagus is isolated. The thoracic esophagus was mobilized down to 3 cm. The esophagus was displaced downward. There were no signs of the presence of a Nissen fundoplication cuff formed during the first operation. Self-destruction of the cuff occurred, apparently, due to the resorption of the suture material or cutting through the sutures.

Considering the above, an esophageal opening of the diaphragm up to 2.5 cm in diameter was formed by placing two sutures on the legs of the diaphragm in front of the esophagus. A Nissen fundoplication was performed with cuff formation using four sutures. The stomach, together with the esophagus, is fixed to the right leg of the diaphragm with one suture. On the left, the cuff is fixed to the diaphragm with one seam. Hemostasis control. Drainage tube into the subhepatic space to the plastic area, the second - above the spleen. Instruments were removed from the abdominal cavity. Layered suture of the wound with a mechanical skin suture. Bandage.

In the first days after surgery, severe dysphagia was observed. The patient could only take liquid food in small portions. On the 9th day after surgery, a control FEGDS was performed.

ENDOSCOPIC PICTURE : the esophagus is freely passable, the mucous membrane is pink, there are curdled mycotic deposits on it. The cardia closes. The cuff is formed in the area of ​​the cardia and is passable without effort for endoscopes sequentially 5.2 mm and 8.0 mm in diameter. Empty contents with copious admixture of bile. The gastric mucosa is focally hyperemic, edematous, the relief is preserved. The pylorus, bulb and cavity of the duodenum are without features.

CONCLUSION : condition after hernioplasty with fundoplication according to Nissen. Erythematous gastropathy of the 1st degree. Mycosis of the esophagus.

Over the next four days, conservative therapy was continued. Two weeks after the operation, on June 13, the patient was discharged in satisfactory condition for outpatient treatment.

Conclusions 1. In modern conditions, the use of a minimally invasive endoscopic method of surgical treatment of hiatal hernia is a promising direction in esophageal surgery.

2. To prevent recurrence of the hernia, it is necessary to observe the basic principle of surgical treatment: not only to eliminate the hernia, narrow the hernial orifice, but also to restore normal interaction between the stomach and the esophagus.

3. In case of failure of crurorrhaphy sutures, cutting of sutures or dissection of the diaphragmatic leg, the task of reoperation is to restore the usefulness of the plastic and the size of the esophageal opening of the diaphragm.

4. The use of synthetic mesh endoprostheses for surgical correction of the hernia is considered a convenient immediate solution to the problem, but in case of recurrence of the hernia, this may interfere with the quality of the reconstructive operation. Mesh implants can only be considered as an option for the surgical treatment of giant hiatal hernias. Medical Bulletin , July 18, 2017

Why is a hiatal hernia dangerous?

Typically, a diaphragmatic hernia causes gastroesophageal reflux disease, which results in the reflux of acidic stomach contents into the esophagus.

GERD must be kept under control, as the disease can have unpleasant consequences. Among them are erosive esophagitis, narrowing of the esophagus due to the formation of scar tissue and, finally, the so-called Barrett's Esophagus - a threatening precancerous condition, which is characterized by the degeneration of esophageal cells.

Hiatal hernia: treatment, drugs responsible for its success

Lifestyle change

A hernia of 1st and 2nd degree is most often treated conservatively, without surgery, subject to a certain diet (table number 5) and lifestyle.

• Avoid spicy, fatty, sour, fried foods.
• Make it a rule to eat small portions, avoiding long breaks between meals.
• Quit smoking and don't drink alcohol or soda
• Do not eat later than an hour and a half before going to bed
• Elevate the head of the bed to prevent stomach contents from refluxing during sleep.

You should also reduce heavy physical work and stressful situations as much as possible.

Drug therapy

Drugs that help improve the condition of hiatal hernia include antacids that neutralize gastric acid: Almagel and phosphalugel, Gaviscon, Maalox. They eliminate heartburn and belching.

Stomach pain and flatulence are well relieved by antispasmodics: enterospasmil and meteospasmil.

Proton pump blockers: omez, nexium, nolpaza, dexilant reduce gastric secretion, protecting the stomach and esophagus from the aggressive effects of acid if the disease is complicated by high acidity.

Surgery

If conservative treatment does not help, in cases of such serious complications as strangulation, and with a high degree of hiatal hernia, the patient is offered surgery.

Our current progressive surgical treatment method is fundoplication performed laparoscopically. The operation completely eliminates the symptoms of diaphragmatic hernia in 80-90% of cases.

It is important to know

The first is to correctly diagnose a hiatal hernia and treatment without surgery is the second stage. It is important to get tested for the following symptoms:

• regular heartburn;
• chest discomfort;
• difficulty swallowing;
• sour taste;
• discomfort after eating;
• labored breathing;
• pain in the esophagus.

Non-surgical methods

Treatment of hiatal hernia without surgery is indicated for all patients with any form of the disease, when there are no signs of complications.

Principles of conservative therapy for hiatal hernia:

• correction of diet;
• drug therapy;
• Exercise therapy (physical therapy);
• physiotherapeutic procedures;
• elimination of negative factors in the form of bad habits;
• use of folk remedies.

Drug treatment of hiatal hernia without surgery

The following drugs are used to treat hernia:

1. Antacids . Neutralizes acid, prevents hyperacid gastritis and inflammation of the esophagus. Representatives: Phosphalugel , Maalox , Almagel .
2. Histamine receptor blockers . Reduce acid secretion. Representatives: Ranitidine , Famotidine , Roxatidine .
3. Prokinetics . Restore motor function. Representatives – Motilium , Domrid .
4. Bile acids . Reduce the harmful effects of acid thrown into the stomach. Representatives: Ursofalk , Urokhol .
5. Proton pump inhibitors . They reduce acid production; unlike histamine receptor blockers, they have a smaller list of adverse reactions. Representatives – Omeprazole , Controloc .

Treatment regimens used:

• prescribing one drug for a long period of time to normalize the acidity of gastric juice;
• prescribing several medications from different groups to eliminate signs of reflux;
• a short-term course of treatment with one or more drugs when severe symptoms appear.

Physiotherapy

The prescription of physiotherapeutic procedures is rational in case of concomitant diseases of the stomach and intestines. They contribute to the overall health of the body, elimination of the inflammatory process, pain relief, muscle relaxation, which generally has a positive effect on the patient’s well-being.

The following physiotherapy procedures are prescribed for hernia with reflux:

• medicinal electrophoresis with the use of antispasmodic drugs;
• paraffin therapy to eliminate spasms and improve metabolic processes;
• medicinal baths for general calming and removal of toxins from the body;
• ultrasound therapy to increase the body's resistance and heal damaged mucous membranes of the stomach and esophagus.

Exercises for hiatal hernia

To relax and form a natural muscle corset in case of a hernia, physical therapy is required. When there is a hiatal hernia, exercise therapy is prescribed to strengthen the anterior abdominal wall and improve blood circulation in the affected area. The complex should be selected together with a doctor, because some techniques can be dangerous for this disease.

Esophageal hernia: exercises

• The most effective exercises for hiatal hernia are as follows.
• Exercise No. 1 : lying down, perform torso turns left and right.
• Exercise No. 2 : while kneeling, slowly bend forward.
• Exercise No. 3 : lying on your right side, stick your stomach out as you inhale, and pull in as you exhale.

Therapeutic exercises for hiatal hernia and reflux are performed regularly. Exercises should be given at least half an hour a day, dividing the complex into several approaches of 5-10 minutes. They must be performed in the first half of the day on an empty stomach or 2 hours after eating. Every movement should be smooth and slow.

Breathing exercises for esophageal hernia can also achieve good effects.

Diet for hiatal hernia

Treatment of a hiatal hernia without surgery is not complete without following a diet. It is necessary to adhere to certain rules to reduce the load on the gastrointestinal tract.

When a person overeats, intrauterine pressure increases, the defect begins to compress the surrounding tissues, which manifests itself as discomfort. For the same reason, the diet should exclude foods that increase gas formation.

A ban on certain foods helps normalize the acidity of gastric juice, which is important for concomitant reflux.

Nutrition rules for hiatus hernia:

• eating well-chopped food, chewing thoroughly;
• exclusion of heavy foods that cause flatulence and constipation;
• dinner should be no later than three hours before bedtime;
• after eating, resting in a horizontal position is excluded;
• food should be at normal temperature, neither hot nor cold.

Products dangerous for hiatal hernia:

• highly carbonated water;
• fatty, smoked;
• sweet, too spicy;
• sour, salty;
• strong tea, coffee;
• alcoholic, low-alcohol drinks.

Folk recipes

Traditional medicine can be used to improve general well-being and eliminate some symptoms. Properly selected medicinal plants and products will help get rid of heartburn, indigestion and many other unpleasant symptoms.

To prevent dyspepsia, including zaporozhno, prepare a tincture of dried fruits , rhubarb , and hay leaves . Dry orange peels, carrot , pumpkin and potato juice .

To get rid of bloating, you can prepare a decoction of yarrow , fennel and St. John's wort . Cranberry juice , a mixture of honey and aloe will be effective against belching .

1. Gooseberry decoction . You need to pour boiling water over the plant and leave for several hours. Take half a glass of the finished product after meals.
2. A decoction from a collection of plants . Mix flax seeds, coltsfoot leaves, yarrow and mint, add water, and boil over low heat. The prepared solution is taken up to three times a day, half a glass.
3. Propolis tincture with milk . Mix milk with a few drops of tincture. The remedy is taken after meals.
4. Olive oil with kefir . A tablespoon of oil is added to kefir. The product is used for constipation and flatulence.

List of used literature

1. Chikinev Yu.V., Drobyazgin E.A. POST-TRAUMATIC DIAPHRAGMAL HERNIA (DIAGNOSTICS AND TREATMENT). Acta Biomedica Scientifica. 2017;2(6):163-166.
2. Voitsekhovsky V.V., Anikin S.V., Goborov N.D., Yanovoy V.V., Bregadze Yu.E., Glushchenko V.V., Khatkeev V.I. A case of diagnosis of post-traumatic diaphragmatic hernia occurring under a mask pleurisy. Bulletin of physiology and pathology of respiration. 2017;
3. Grishin, I. N. Hiatal hernia and reflux gastroesophageal disease: monograph. / I.N. Grishin, A.V. Vorobey, N.N. Chur. - M.: Higher School, 2015. - 224 p.
4. Long-term results of endosurgical treatment of paraesophaneal hiatal hernias, E. I. Senderovich, E. E. Grishina, B. M. Garifullin, E. F. Gimaev, N. M. Kazakov, R. K. Ibragimov

Frequently asked questions about hiatal hernia

What are the signs of a diaphragmatic hernia?

The disease may not manifest itself in any way, have a number of characteristic signs: belching, heartburn, stomach pain, or be disguised as cough, shortness of breath, palpitations. Therefore, the diagnosis is established not by a set of symptoms, but on the basis of an X-ray examination or fibrogastroscopy.

What can hurt with a diaphragm hernia?

The patient may experience chest pain, discomfort in the stomach, or, in the case of GERD, a sore throat.

How is a hiatal hernia treated?

A mild degree involves conservative treatment using the drugs described above and lifestyle correction: changing diet, eliminating bad habits. If these measures do not lead to relief of the patient’s condition, surgical intervention is indicated.

METHODS OF TREATMENT OF HERNIA IN MEDICAL PLAZA MC

Medical Plaza MC practices removal of the hiatal hernia using laparoscopy. This technique is positioned as the safest, most gentle and optimal in terms of cost. Surgical intervention is performed using several small 3-4 incisions, the size of each of which does not exceed 1 centimeter, and includes two subsequent stages:

• isolation of the hernia followed by suturing to a size that meets anatomical standards;
• correction of reflux, as well as elimination of the conditions necessary for the re-development of the pathology.

The mandatory conditions provided to patients in our medical center are:

• taking maximum measures aimed at relieving pain;
• prices corresponding to the quality of services provided;
• providing the patient with the opportunity to return to their normal lifestyle within a few days;
• absence of scars in the area of ​​surgical intervention;
• short period of hospitalization, not exceeding three days;
• application of modern hernia removal techniques using expert equipment;
• providing the opportunity to undergo dispensary observation by leading specialists.

We offer our patients the opportunity to fully recover in a short period of time. We recommend contacting a specialist in a timely manner in order to eliminate possible negative consequences and complications.