Introduction

The most common among surgical antireflux methods for the treatment of hiatal hernias (HH) are Nissen, Toupet, or Dor surgery. Among the disadvantages of these interventions, the greatest importance is the destruction of the physiological cardia, which is accompanied by the recurrence of HH, dysphagia, gas-bloat syndrome and heartburn recovery. Despite the advances in HH surgery, the performance of antireflux operations remains debatable.

Aims & Methods

To improve methods of diagnosis and treatment of complications of insufficiency of the physiological cardia in HH.In 2017-2022, 78 patients with HH were diagnosed and treated surgically in the digestive surgery department of the institute.
The type and degree of HH were determined during X-ray examination. An endoscopic examination was performed to determine the condition of the mucous membrane of the esophagus and the degree of violations of the physiological cardia. Endoscopic balloon manometry was used to study pressure in the lower esophageal sphincter (LES) and monitor the effectiveness of antireflux surgery.

Results

Axial HH (I type) was diagnosed during X-ray examination – in 60 (77.0%); paraesophageal (II type) – in 9 (11.5%); mixed (III type) – in 9 (11.5%) patients. Depending on the amount of penetration of organs into the chest cavity, HH of the 1st degree was established – in 42 (53.8%), 2nd degree – in 27 (34.6%) and 3rd degree – in 9 (11.5%) patients.
Changes in the mucous membrane of the esophagus – in 40 (51.3%) patients with type I and III HH: non-erosive reflux esophagitis – in 9 (11.5%), erosive reflux esophagitis – in 16 (20.5%), esophageal ulcer – in 6 (7.7%), peptic stricture of the esophagus on the background of esophagitis – in 3 (3.8%), Barrett's esophagus - in 6 (7.7%) patients.
During endoscopic balloon manometry, the pressure in the LES is reduced: axial HH – (11.39±2.44) mmHg, paraesophageal – (13.54±3.32) mmHg, mixed – (8.06±3, 64) mm Hg (the norm is 14-21 mm Hg). The first stage of treatment for patients with reflux esophagitis was conservative therapy, for peptic stricture of the esophagus – endoscopic balloon hydrodilatation, for Barrett's esophagus – argon plasma ablation. As a second stage, 78 patients underwent standard laparoscopic antireflux operations according to Nissen – in 32 (41.1%), Toupet – in 7 (8.9%), Dor – in 5 (6.4%), and in 34 (43.6%) patients, according to the proposed method, which preserves the connections of the diaphragm, esophagus, and stomach, and performing cardiocrurorrhaphy, fundocruroesophagorraphy, cardiogastroplication with gastrodiaphragmopexy restores the antireflux function of the physiological cardia.In the long term, from 6 months to 4 years, significantly more complications were diagnosed after standard antireflux operations compared to the proposed method - gas bloat-syndrome (X²=4.65, p=0.031) pylorospasm (X²=4.03, p=0.045), dysphagia (X²=4.30, p=0.038) and recurrence of HH – 11 (25.0%) vs 3 (8.8%) cases (p<0.05).

Conclusion

The proposed two-stage method of surgical treatment of patients with HH is highly effective. The application of the proposed method ensures the elimination of pathological changes in the mucous membrane of the esophagus, the restoration of the physiological cardia, the preservation of the anatomical relationships of the diaphragm and the zone of the esophageal-gastric transition. In the postoperative period, the proposed method reduces the frequency of recurrence of HH, occurrence of gas bloat-syndrome, pylorospasm, and dysphagia.

Introduction

Vedolizumab (VED) and ustekinumab (UST) are valid options for ulcerative colitis (UC) and Crohn’s disease (CD) patients who fail anti-tumour necrosis factor (TNF) therapy. However, there are conflicting data on which drug should be preferred as second-line.

Aims & Methods

UC and CD patients who received VED or UST after anti-TNF failure or intolerance were included, and treatment groups were compared. The primary outcome of clinical remission (CR) was evaluated at 6 and 12 months of therapy, as were the secondary outcomes of corticosteroid-free CR and biochemical remission (BR). Endoscopic remission (ER) was evaluated at 12 months. Predictors of these outcomes were assessed using Cox regression.

Results

A total of 72 patients were included, 21 with UC (14 UST | 7 VED) and 51 with CD (35 UST | 16 VED). There were no significant differences in the various remission rates between both treatment groups, in UC and CD. In CD, multivariate analysis revealed baseline Harvey-Bradshaw index (HBI) as an independent predictor of failed CR (p<0.001, HR 1.42, IC 95% 1.18-1.71) and corticosteroid-free CR (p<0.001, HR 1.43, IC 95% 1.19-1.72) at 12 months. Anti-TNF discontinuation due to primary or secondary failure (vs. adverse event) was an independent predictor of BR at 12 months (p=0.028, HR 2.33, IC 95% 1.09-4.98). Interestingly, subanalysis of 16 patients who advanced to a third-line therapy with the opposite drug revealed a tendency for lower CR rates with VED (40.0%), when compared to UST (72.73%), albeit not statistically significant (p=0.299).

Conclusion

In this study, clinical, biochemical and endoscopic remission rates in UC and DC were not significantly different between patients treated with VED or UST as second-line therapy. HBI and reason for anti-TNF withdrawal were independent predictors of failed CR and BR, respectively. There may be a tendency for larger differences in CR when comparing VED and UST as third-line agents, with better results for the latter.

References

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2. Onali S, Pugliese D, Caprioli FA, Orlando A, Biancone L, Nardone OM, et al. An Objective Comparison of Vedolizumab and Ustekinumab Effectiveness in Crohn’s Disease Patients’ Failure to TNF-Alpha Inhibitors. Am J Gastroenterol. 2022 Aug;117(8):1279–87.

3. Hyun HK, Zhang HS, Yu J, Kang EA, Park J, Park SJ, et al. Comparative effectiveness of second-line biological therapies for ulcerative colitis and Crohn’s disease in patients with prior failure of anti-tumour necrosis factor treatment. BMC Gastroenterol. 2022 Dec;22(1):143.

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