[Gastroesophageal reflux after laparoscopic hiatal hernia repair in patients with axial hiatal hernia]. / Prichiny patologicheskogo gastroezofageal'nogo reflyuksa posle videolaparoskopicheskoi korrektsii zamykatel'noi funktsii kardii u bol'nykh aksial'noi gryzhei pishchevodnogo otverstiya diafragmy.

OBJECTIVE: To find out significance of the main locking mechanisms of lower esophageal sphincter in the relapse of GERD in patients with axial hiatal hernia after previous antireflux laparoscopic surgery. MATERIAL AND METHODS: There were 103 patients with GERD and axial hiatal hernia who underwent original circular laparoscopic esophagofundoplication with correction of hiatal opening dimensions by crural and hiatal repair. Depending on generalized DeMeester index (within the normal range or its excess), all patients were divided into two groups - without relapse (group 1, n=88) and with recurrent GERD (group 2, n=15). Both groups were comparable by the main characteristics and postoperative follow-up period (mean - 6 years). Antireflux function was investigated by X-ray examination and endoscopy, manometry of the esophageal-gastric passage, intra-esophageal 24-hour pH-monitoring. Processing and graphical presentation of data was carried out using Statistica v.10.0 Rus software (StatSoft, USA) and Microsoft Office Excel 2013 (USA). RESULTS: Abnormal gastroesophageal reflux was detected in 14.56±3.48% of patients after laparoscopic anti-reflux surgery. Recurrent hiatal hernia occurred in 20±10.33% of these patients, malfunction of lower esophageal sphincter - in 80±10.33%. Failure of cardia was caused by shortening of its length by 30.43% and decrease of tone by 6.78% with significantly (61.09%) increased tone of the stomach. Failure of cardia was manifested by increase of generalized DeMeester index in the lower third of the esophagus by 3.2 times, acidic gastroesophageal refluxes, reflux index and index reflux values. Preserved esophageal motility combined with shortening of time of esophageal clearance in patient's lying position was associated with reduced incidence of reflux-esophagitis by 77.26% even in case of recurrent GERD. CONCLUSION: Abnormal reflux after antireflux laparoscopic surgery due to GERD with axial hiatal hernia is caused by recurrent hiatal hernia in every fifth patient while the main reason is failure of LES cuff with increased intragastric pressure.

High resolution manometry and new classification of esophageal motility disorders.

AIM: To present application of Chicago classification criteria of esophageal motility disorders defined in high resolution manometry in clinical practice. MATERIALS AND METHODS: High-resolution manometry is the most exact hi-tech diagnostic method for esophageal motor function disorders according to Chicago classification v3.0. Uniqueness of the method consists in capacity to define integrated quantitative and qualitative metrics of esophageal contractile function and to establish their specific disorders e.g.: change of intrabolus pressure at disorders of esophagogastric junction (EGj) outflow, hypercontractile esophagus, fragmented contractions and weak or failed peristalsis, distal esophageal spasm. Assessment of the type of achalasia subtypes has significant impact on the patients' treatment choice. According to anatomical location of the lower esophageal sphincter and crural diaphragm several morphological types of gastro-esophageal junction are defined that determine severity of gastroesophageal reflux disease. Multiple rapid swallow responses during esophageal high-resolution manometry reflect esophageal body peristaltic reserve and is a predictor of postoperative complications. Differential diagnosis of belching type became possible at combined application of high-resolution manometry and impedance measurement. CONCLUSION: High-resolution manometry is a fundamental diagnostic test of esophageal motor function disorders. Clinical application of this method significantly expands diagnostic potential and allows to carry out personalized treatment that increases treatment quality.

[Possibilities of pH impedance and high-resolution manometry in managing patients with refractory gastroesophageal reflux disease]. / Vozmozhnosti rN-impedansometrii i manometrii vysokogo razresheniia pri vedenii patsientov s refrakternoi gastroézofageal'noi refliuksnoi bolezn'iu.

Gastroesophageal reflux disease (GERD) is a common condition that has a substantial impact on quality of life in patients and is a leading risk factor for esophageal adenocarcinoma. Now therapy with proton pump inhibitors (PPIs) is a basic method in the treatment of patients with GERD; however, one third of the patients do not respond to the therapy used. The causes of refractory GERD are a fairly large group of heterogeneous factors contributing to the inefficacy of PPIs in adequate dosage. Among these factors, there is low compliance by patients to the prescribed treatment regimen; nocturnal acid breakthrough; СУР2С19 gene polymorphism; chiasm syndrome with functional diseases of the gastrointestinal tract; non-acidic refluxes in a patient; thoracic esophageal motility disorders; the increased number and duration of transient lower esophageal sphincter relaxation periods; hiatus hernia; and misdiagnosis. 24-hour pH impedance and high-resolution esophageal manometry are now the most informative diagnostic techniques in patients who fail to respond to PPI therapy. These techniques allow one to timely recognize the causes of refractory GERD, to make a differential diagnosis with other nosological entities, and to timely correct therapy for each individual patient.