Strengthening lower esophageal sphincter. Strengthening the Lower Esophageal Sphincter: Exercises to Combat Acid Reflux and GERD

13.07.202328.06.2023 by alexxlab

How can exercises help strengthen the lower esophageal sphincter. What are the most effective techniques for improving LES function. Why is a strong LES important for preventing acid reflux and GERD. Which lifestyle changes can support LES health.

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Understanding the Lower Esophageal Sphincter (LES) and Its Role in Digestion

The lower esophageal sphincter (LES) is a crucial component of the digestive system, acting as a barrier between the esophagus and stomach. This ring-shaped muscle plays a vital role in preventing the backflow of stomach contents into the esophagus, a condition known as acid reflux or gastroesophageal reflux disease (GERD) when chronic.

How does the LES function? When functioning properly, the LES remains closed most of the time, only opening to allow food and liquids to pass into the stomach during swallowing. After swallowing, it quickly closes again to prevent stomach acid and contents from flowing back up into the esophagus.

Why is a strong LES important? A weak or improperly functioning LES can lead to frequent acid reflux, causing symptoms such as heartburn, regurgitation, and chest pain. Over time, chronic acid reflux can damage the esophageal lining and lead to more serious complications.

Common Causes of LES Weakness and Dysfunction

Several factors can contribute to a weakened or malfunctioning lower esophageal sphincter:

Obesity and excess weight
Pregnancy
Smoking
Certain medications
Aging
Hiatal hernia
Chronic stress
Poor dietary habits

How do these factors affect the LES? Excess weight and pregnancy can put additional pressure on the abdomen, pushing stomach contents upward. Smoking and certain medications can relax the LES muscle, while aging may lead to decreased muscle tone. A hiatal hernia can alter the position of the LES, compromising its ability to function as an effective barrier.

Exercises to Strengthen the Lower Esophageal Sphincter

Can specific exercises help strengthen the LES? While the LES is not a voluntary muscle that can be directly controlled like arm or leg muscles, certain exercises and techniques may help improve its function and reduce acid reflux symptoms.

1. Diaphragmatic Breathing

Diaphragmatic breathing, also known as belly breathing, can help strengthen the diaphragm and potentially improve LES function:

Lie on your back with knees bent and feet flat on the floor
Place one hand on your chest and the other on your abdomen
Breathe in slowly through your nose, allowing your stomach to rise while your chest remains still
Exhale slowly through pursed lips, gently pressing on your abdomen
Repeat for 5-10 minutes, several times a day

2. Abdominal Hollowing

This exercise targets the transverse abdominis muscle, which can indirectly support the LES:

Lie on your back with knees bent and feet flat on the floor
Place your fingertips just inside your hip bones
Take a deep breath in, then as you exhale, gently draw your lower abdomen inward toward your spine
Hold for 5-10 seconds while breathing normally
Relax and repeat 10-15 times

3. Seated Leg Lifts

This exercise engages the core muscles, potentially improving overall abdominal strength:

Sit on a chair with your back straight and feet flat on the floor
Lift one leg a few inches off the ground, keeping your knee bent
Hold for 5-10 seconds, then lower
Repeat with the other leg
Perform 10-15 repetitions on each side

Lifestyle Changes to Support LES Health

In addition to exercises, certain lifestyle modifications can help improve LES function and reduce acid reflux symptoms:

Maintain a healthy weight
Avoid tight-fitting clothing around the abdomen
Eat smaller, more frequent meals
Avoid lying down immediately after eating
Elevate the head of your bed by 6-8 inches
Quit smoking
Limit alcohol and caffeine consumption
Avoid trigger foods (e.g., spicy, fatty, or acidic foods)

How do these changes help? Maintaining a healthy weight reduces pressure on the abdomen, while eating smaller meals and avoiding lying down after eating minimize the risk of stomach contents refluxing into the esophagus. Elevating the head of the bed uses gravity to help keep stomach acid in place during sleep.

The Role of Diet in Supporting LES Function

Can dietary changes improve LES strength and reduce acid reflux? While no specific foods have been proven to directly strengthen the LES, certain dietary habits can help minimize symptoms and support overall digestive health:

Foods to Include:

High-fiber foods (e.g., whole grains, vegetables, fruits)
Lean proteins (e.g., chicken, fish, tofu)
Alkaline foods (e.g., bananas, melons, cauliflower)
Probiotic-rich foods (e.g., yogurt, kefir, sauerkraut)

Foods to Limit or Avoid:

Citrus fruits and juices
Tomatoes and tomato-based products
Chocolate
Mint
Spicy foods
Fatty or fried foods
Carbonated beverages
Alcohol
Caffeine

Why do these dietary changes help? High-fiber foods can help promote healthy digestion and prevent constipation, which can exacerbate reflux symptoms. Alkaline foods may help neutralize stomach acid, while probiotic-rich foods support a healthy gut microbiome. Limiting trigger foods can reduce the likelihood of acid reflux episodes.

Complementary Therapies for LES Health

In addition to exercises and lifestyle changes, some complementary therapies may help support LES function and alleviate acid reflux symptoms:

1. Acupuncture

How can acupuncture help with LES function? Some studies suggest that acupuncture may help reduce acid reflux symptoms by potentially improving LES pressure and esophageal motility. While more research is needed, some individuals report symptom relief with regular acupuncture treatments.

2. Stress Management Techniques

Why is stress management important for LES health? Chronic stress can exacerbate acid reflux symptoms and potentially weaken the LES. Techniques such as meditation, yoga, and deep breathing exercises can help reduce stress levels and may indirectly support LES function.

3. Herbal Remedies

Can herbal remedies help strengthen the LES? While scientific evidence is limited, some herbal remedies have been traditionally used to support digestive health and potentially alleviate acid reflux symptoms:

Slippery elm
Marshmallow root
Licorice root (deglycyrrhizinated)
Chamomile

It’s important to note that herbal remedies can interact with medications and may not be suitable for everyone. Always consult with a healthcare professional before starting any new supplement regimen.

When to Seek Medical Attention

While exercises and lifestyle changes can be effective in managing mild to moderate acid reflux, it’s important to recognize when professional medical attention is necessary:

Persistent symptoms despite lifestyle modifications
Difficulty swallowing or painful swallowing
Unexplained weight loss
Chest pain or pressure (which could indicate a heart problem)
Chronic cough or hoarseness
Vomiting blood or passing black stools

Why is prompt medical attention important? These symptoms may indicate more serious underlying conditions or complications of chronic GERD, such as esophagitis, strictures, or Barrett’s esophagus. Early diagnosis and treatment can help prevent long-term damage to the esophagus.

Integrating LES Strengthening into Daily Life

How can LES strengthening exercises and lifestyle changes be effectively incorporated into daily routines? Consistency is key when it comes to improving LES function and managing acid reflux symptoms. Here are some tips for making these practices a regular part of your life:

Set reminders for exercise sessions and breathing exercises
Practice diaphragmatic breathing during routine activities, such as watching TV or commuting
Keep a food diary to identify trigger foods and track symptom improvements
Gradually implement dietary changes to make them more sustainable
Involve family members or friends in lifestyle modifications for support and accountability
Use stress management techniques as part of your daily self-care routine

By consistently practicing LES strengthening exercises, making appropriate lifestyle changes, and working closely with healthcare professionals when needed, many individuals can effectively manage acid reflux symptoms and improve their overall quality of life. Remember that everyone’s experience with GERD is unique, and it may take time to find the right combination of strategies that work best for you.

Esophageal Sphincter strengthening exercises can help with heartburn/r – Silver Fern™ Brand

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I don’t care how our customers get feeling better. I simply care that they get better. Whether the answer comes from us or someone else I don’t care as long it is in the best interest of our customers. We have a protocol that we find to be very effective at helping our customers. It works well. BUT we also strongly suggest strengthening the esophageal sphincter along with that protocol. ⁠
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Most don’t know that there are basic exercises that can help with reflux/heartburn issues. This is free. No product required. I strongly suggest our customers and anyone else with reflux/heartburn issues consider exercising the esophageal sphincter as part of their process for overcoming reflux and heartburn issues (especially chronic problems). And here are the links to learn these exercises:⁠
⁠
🔹https://www.youtube.com/watch?v=XUty6UI8RsE⁠
🔹https://www.youtube.com/watch?v=A6M0sSMesx4⁠
⁠
As most of our customers know, we go aggressive on our protocols for reflux and heartburn issues. One problem I occasionally see is that our Upper GI Relief, which we use for motility issues like burping/reflux/heartburn, may cause a strong burning sensation in the chest because of the high gingerol count in the Upper GI Relief. The answer to this is to strengthen the esophageal sphincter. The exercises will help make Upper GI Relief work even better. ⁠
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Once again, the whole idea is to help people have success. Can the exercises alone help with reflux and heartburn issues? The data says so. Would combining the exercises with the product protocol be even better? Yes.⁠

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How to Strengthen Your Lower Esophageal Sphincter | by Acid Reflux

4 min read

Aug 20, 2016

The low esophageal sphincter (L’ensemble des) muscle can be found between your stomach and also the windpipe (throat). It opens to permit food to pass through in the windpipe into the stomach. It shuts to help keep food and acidity from flowing up in the stomach into the windpipe. Acidity is created inside your stomach to assist break lower food for digesting. Once the lower esophageal sphincter muscle is weak, acidity flows up into the windpipe and may irritate and burn inner areas of the body.

So, have you ever discovered you have gastro esophageal reflux disease (Acid reflux)? Lots of people don’t know they have it. It affects infants in addition to grownups. Acid reflux is easily the most common characteristic of Acid reflux. Other terms for acid reflux is acidity heartburn and acidity reflux. Greater than 25 million grown-ups are afflicted by acid reflux daily.

Reasons for Gastro esophageal Reflux Disease

Some doctors think that a hernia may weaken the low esophageal sphincter muscle and cause reflux. Reflux means the return flow of the liquid. A hernia is caused once the upper stomach rises into the chest via a small opening in the diaphragm. Coughing could cause a hernia. An individual of all ages might have one. Many healthy people older than 50 possess a small one. If it’s severe, you might feel a continuing discomfort behind your breastplate. The discomfort may last for several weeks.

The Issue with Soy

Isoflavones are chemical substances. Glycitein, genistein, and daidzein are isoflavones present in soy. They mimic estrogen. Oestrogen weakens the low esophageal sphincter muscle. Soy can be found in most every food today since it is an inexpensive commodity. Should you exam the components around the packages that you simply purchase, you’ll notice that soy is within bread, peanut butter, coffee mate non-dairy creamer, salad dressing, infant formula. Their email list really is limitless. The vegetable oil in the shops in supermarkets is generally soybean oil unless of course the oil is particularly labeled for example olive, safflower, sunflower, almond, etc.

Other Meals

Certain meals and drinks can weaken the low esophageal sphincter muscle. It might be useful to prevent tobacco, alcohol, coffee (caffeinated and caffeine free), caffeine, bubbly drinks, chocolate, peppermint, refined sugar and pastries, citrus, fried meals, fat and fatty meals, soy items (unless of course fermented), and particularly avoid tomato plants and tomato items. Tomato plants are extremely acidic. Think hard before you decide to eat that scrumptious pizza.

You’ve got to be very careful about studying the components around the packages from the food that you simply purchase. Sugar is definitely dangerous towards the body, and it is in many foods. Tomato can also be in many packaged food.

Meals to come across

Natural Aloe-vera Gel Will get Two Thumbs Up

Natural Aloe-vera Gel (whole leaf) might be taken before A.M. and P.M. foods. It’s a natural fix for acidity reflux. The recommended dose is 4 oz. each day. For those who have stomach problems, it might be smart to have a tablespoon (a lesser dose). Before you have the stomach problems are cured. Otherwise, an excessive amount of Natural Aloe-vera Gel may exasperate the ulcer condition.

Natural Aloe-vera Gel jackets the throat and stomach. Natural Aloe-vera is really a healing plant. With time the low esophageal sphincter muscle should strengthen. I’d provide a great year. Annually is really a normal period for anything in your body to reverse from disease and heal.

Ginger root Is Advantageous

Consuming ginger root tea might help keep stomach acidity in check. It might take some days before you visit a difference. The recommended dose is 3 cups each day, with sterilized water. It is advisable to drink the tea without sugar, honey or fresh lemon juice. Refined sugar does not perform the body worthwhile. It and citrus ought to be prevented anyway. The tea ought to be steeped.

How you can Steep Tea

Boil sterilized water

Pour 6 oz. of steamed water on the tea bag inside a cup

Convey a saucer on the top from the cup for five-ten minutes

After you have steeped your tea, it’s a good habit to squeeze the tea bag together with your spoon facing the interior wall of the cup. Doing might steeping enhances the effectiveness of the tea.

Enjoy!

Other Strategies for Controlling Acidity Reflux

Modify eating routine:

Eat many small foods throughout the day

Eat nothing 3 hrs before you go to bed (especially spicy meals)

Avoid laying lower after consuming

Eat gradually

Eat within an upright position

Sleep within an upright position or in a 45-degree position by:

Utilizing a wedged pillow

Utilizing an adjustable chair or bed

Resting on your left side in a 45-degree position so the sphincter valve shuts

Elevating the mind from the bed by 6–8 inches with blocks

Avoid using abdominal pressure for example:

Heavy-lifting

Bending at the waist

Tight devices, clothes, etc.

Slumping in chairs

Pushing with bowel actions

Lower esophageal sphincter pressure as a prognostic criterion for the outcome of antireflux surgery

Laparoscopic fundoplication is the “gold standard” for the treatment of patients with gastroesophageal reflux disease (GERD) and hiatal hernia (HH) [1], nevertheless, the question of choosing the method of surgical support remains relevant to this day. The most common variant of the operation is the formation of a 360° cuff of the Nissen type from the bottom of the stomach: modifications of the Nissen-Rossetti, Shortfloppy Nissen. The methods differ not only in the intersection of short gastric vessels and a long fundoplication cuff, but also in the shape of the cuff. After mobilization of the posterior wall of the gastric fundus, an opportunity is created for the formation of a symmetrical cuff from the anterior and posterior walls of the gastric fundus [2, 3].

In recent years, there is no doubt that laparoscopic fundoplication should be supplemented with routine posterior crurorrhaphy, as it involves extensive mobilization of the esophageal-gastric junction and dissection of the esophageal-phrenic ligament in the posterior mediastinal cavity [3].

In addition, various techniques have been described for submesh repair that can reduce the number of GERD recurrences. However, given the numerous complications associated with mesh placement in the area of the esophagogastric junction, indications for alloplasty are extremely limited [4, 5].

In addition to the technical component, the key to successful antireflux surgery is the correct selection of patients for this procedure [3].

Esophageal manometry has been used for 50 years to diagnose esophageal motility disorders and is an indispensable method in the examination of patients with GERD before surgical treatment aimed at eliminating reflux in patients with suspected esophageal motor dysfunction [6, 7].

However, according to some authors, manometry data weakly correlate with symptoms before antireflux surgery and postoperative results [8, 9].

The aim of the work is to evaluate the dynamics of changes in the pressure of the lower esophageal sphincter (LES) in patients with GERD before surgical treatment and at various times after antireflux surgery. To compare the values of LES pressure indicators and the percentage of LES relaxation after various methods of laparoscopic fundoplication.

To reveal the correlation between symptoms of heartburn and dysphagia in the postoperative period and esophageal manometry data. To identify prognostic criteria for GERD recurrence or dysphagia in the postoperative period according to preoperative esophageal manometry.

Material and methods

In the clinic of faculty surgery of the Belarusian State Medical University on the basis of the 1st surgical department of the GBUZ RB GKB No. 21 in 2006-2014. 199 laparoscopic operations were performed in patients with GERD. A retrospective analysis of case histories found that the surgical intervention in all patients consisted of suturing the crura of the diaphragm behind the esophagus with the formation of a Nissen-type cuff from the bottom of the stomach in 199 patients. Of the 199 patients with a circular cuff, in 150 cases the cuff was formed from the anterior wall of the gastric fundus – the Nissen-Rossetti method, in 33 patients the gastric fundus was pre-mobilized, and the cuff length was less than 2 cm – the Shortfloppy Nissen modification. The cuff length averaged 3 cm (from 1.5 to 4.5 cm). In 16 patients with paraesophageal hernias of the esophageal opening of the diaphragm, prosthetic diaphragmatic cruroplasty was performed with a surface area of the esophageal opening of more than 4 cm ² . A rectangular mesh implant was used, which was fixed over the sutured crura of the diaphragm, followed by peritonization of the implant with a fragment of the hernial sac left on the anterior wall of the esophagus (Fig. 1).

Fig. 1. Peritonization of the mesh with a fragment of the hernial sac in paraesophageal hernias. a – placement of the grid on the stitched legs of the diaphragm; b — peritonization of the mesh with a fragment of the hernial sac.

Study patients included 101 men and 98 women. Average age – 49,5±11 years.

In the period from 6 to 60 months after the operation, a study of complaints was performed in 81 patients by filling out a questionnaire designed to identify symptoms associated with gastroesophageal reflux and undergone antireflux surgery. Heartburn intensity scale was used: 0 – no heartburn, 1 – mild heartburn no more than 1 time per week, 2 – moderate heartburn 2-3 times a week, 3 – severe heartburn every day. The following scale was used to assess the symptoms of dysphagia: 0 – no dysphagia, 1 – impaired passage of solid food, 2 – impaired passage of liquid food.

The pressure of the LES and the percentage of relaxation of the LES in response to a sip (Fig. 2) were measured before laparoscopic antireflux surgery (108 patients), 6 months after the operation (79 patients), 12 months after the operation (65 patients), after 36 one month after the operation (41 people), 60 months after the operation (21 people) using water-perfusion manometry on the Gastroscan-D device (Russia, Fryazino).

Fig. 2. The plateau of the manometric curve (1) corresponds to the resting pressure zone of the lower esophageal sphincter, relaxation of the LES (2) in response to a sip.

The device is based on a system of capillary tubes that open at certain points on the surface of the catheter. The water pump delivers water inside the capillaries at a rate of 0.5 ml/min. Each capillary is connected to an external pressure sensor that detects an increase in water pressure when the port is closed due to muscle contraction. The catheter is inserted into the esophagus transnasally to a depth of about 50 cm, the distal 4 sensors are installed in the stomach, the remaining 3 – in the esophagus at a distance of 5 cm from each other. When measuring, relative indicators are obtained: the pressure of the LES relative to the pressure in the stomach.

Patients were divided into groups depending on the method of antireflux surgery performed: Shortfloppy Nissen — 33 patients, Nissen-Rossetti — 150 patients (comparison group) and prosthetic diaphragm cruroplasty — 16 patients.

Statistical processing

Descriptive statistics for qualitative indicators were calculated as the number and percentage of patients for each indicator value. The correspondence of the type of distribution to the law of normal distribution was carried out using the Kolmogorov-Smirnov and Shapiro-Wilk criteria. Descriptive statistics for quantitative indicators were calculated as the number of observations, arithmetic mean, standard deviation, median, interquartile range, minimum and maximum. Statistical hypotheses were considered as two-sided with a significance level of 0.05. To compare the median pressure of the LES, the median percentage of relaxation of the LES in response to a sip at different times after the operation, a pairwise comparison of groups was used using the Wilcoxon test with the Bonferroni correction, with a significance level of p \u003d 0.0125. The Kruskal-Wallis method was used to compare the median pressure of the LES, the median percentage of relaxation of the LES in response to a sip after various types of laparoscopic fundoplication, then a pairwise comparison of the groups was carried out using the Mann-Whitney test with the Bonferroni correction to estimate the value of p , with a significance level of p = 0.02. The compared groups of patients were comparable in terms of demographic indicators (age, gender) and preoperative examination data. An analysis of the correlation between LES pressure and the intensity of heartburn was carried out using the Spearman rank correlation method. An ANOVA factor analysis of the ratio of LES pressure and the frequency of GERD relapses was carried out to determine the threshold value of LES pressure. Data processing was carried out using the Stat Soft program Statistica 10.0.

Results

Median LES pressure compared to preoperative data increased significantly 6 months after surgery from 12.9 mmHg. (interquartile range from 5 to 9 mm Hg) up to 26 mm Hg. (interquartile range from 23 to 28 mm Hg), p = 0.000003. Then there was a gradual decrease in the median LES pressure to 24 mm Hg. (interquartile range from 20 to 31 mm Hg) — 12 months after surgical treatment, p = 0.00052. After 36 months, there was a moderate decrease in the median LES pressure to 21 mm Hg. (interquartile range 16 to 29mm Hg), p = 0.0015. The lowest value of LES pressure in the postoperative period was determined after 60 months: 17 mm Hg. (interquartile range from 12 to 21 mm Hg), p = 0.003 (Fig. 3, a).

Fig. Fig. 3. Dynamics of changes in LES pressure (a) and the percentage of LES relaxation (b) in response to a sip at different times after antireflux surgery.

The median relaxation of the LES in response to a sip, on the contrary, significantly decreased 6 months after surgery compared with preoperative data from 79up to 65% (interquartile range from 68 to 94%), p = 0.000013. 12 months after the operation, the median relaxation of the LES remained at the same level – 65% (interquartile range from 49 to 77%), p = 0.9; after 36 months increased without statistical significance to 69.9% (interquartile range from 56 to 85%), p = 0.02. After 60 months, the median relaxation of the LES was 70% (interquartile range from 70 to 85%), which is significantly different from that in patients 6 months after surgical treatment, p = 0.002 and from preoperative indicators, p = 0. 00009 (Fig. 3, b).

No significant differences were found between LES pressure in the postoperative period in patients after laparoscopic fundoplication using the Nissen-Rossetti and Shortfloppy Nissen methods.

Mean LES pressure after prosthetic repair of the esophageal opening of the diaphragm was statistically significantly higher than in patients who did not use a mesh implant 6 months after surgery, p = 0.0001, 12 months after the operation, p = 0.027, 36 months after the operation, p = 0.035 and even 60 months after the operation, p = 0.0144 (Fig. 4) ).

Fig. Fig. 4. Dynamics of changes in LES pressure after various types of laparoscopic antireflux surgeries from 6 months to 5 years after surgery.

Relaxation of the LES in response to a sip after prosthetic repair of the pod was statistically significantly lower compared to methods in which the mesh was not used up to 5 years after surgical treatment, p \u003d 0. 001.

One year after the operation, the percentage of LES relaxation in response to swallowing is significantly higher in the group of patients operated on using the Shortfloppy Nissen method than in the group operated on using the Nissen-Rossetti method, p = 0.0015. The same trend persists 3 years after antireflux intervention, p = 0.014. After 5 years, the differences in these methods of surgical treatment are leveled, p = 0.4 (Fig. 5).

Fig. Fig. 5. Dynamics of changes in the percentage of relaxation of the LES in response to a sip after various types of laparoscopic antireflux operations in the period from 6 months to 5 years after the operation.

Among 81 patients participating in the survey in the postoperative period, 21 had complaints of heartburn of varying degrees of intensity (Fig. 6).

Fig. 6. Identification of symptoms of heartburn within 6 to 60 months after antireflux surgery. 0 – no heartburn; 1 – mild heartburn no more than 1 time per week; 2 – moderate heartburn 2-3 times a week; 3 – severe heartburn every day.

Only 4 patients complained of difficulty passing solid food. No problems with swallowing liquid food were found in the study group of patients. A moderate inverse correlation was found between the PNS pressure and the degree of heartburn intensity, r=(–0.48), p = 0.000004.

ANOVA factor analysis of the relationship between LES pressure and the frequency of recurrence of GERD symptoms showed that when LES pressure is below 11 mm Hg. (upper limit of 0.95 confidence interval — CI) the frequency of unsuccessful fundoplications significantly increases ( p <0.00001) (Fig. 7).

Fig. 7. Factor analysis diagram reflecting the threshold level of LES pressure, at which the frequency of GERD relapses significantly increases.

To date, according to the literature, the frequency of successful antireflux operations is about 90% [10, 11].

Therefore, there remains a small group of patients who did not receive the expected effect from surgical intervention, or the effect turned out to be short-lived. Recurrence of reflux symptoms or the appearance of persistent dysphagia in the postoperative period are signs of unsuccessful fundoplication [12].

There is still debate about what exactly causes persistent dysphagia after laparoscopic fundoplication. Some authors consider dysphagia a problem associated mainly with crurorrhaphy, but not with the fundoplication cuff [13].

In all groups, a statistically significant increase in LES pressure was observed after antireflux surgery, which remained stable above preoperative values up to 5 years after surgical treatment. The absence of differences in LES pressure in the “Shortfloppy Nissen” and “Nissen-Rossetti” groups corresponds to the data of foreign authors on the absence of the effect of the length of the fundoplication cuff on LES tone [3, 14, 15].

The absence of tension on the side of the fixed posterior gastric wall and the cuff length of less than 2 cm seem to explain the higher percentage of cardia relaxation in response to swallowing in the Shortfloppy Nissen group. In our study, the intersection of short gastric vessels did not affect the number of patients with dysphagia from 6 to 60 months after surgery, which is consistent with foreign studies [14].

In the group of patients operated on using a mesh implant to strengthen the crura of the diaphragm, LES pressure was statistically significantly higher, and the percentage of cardia relaxation, on the contrary, was significantly lower up to 5 years after surgical treatment. It is important to note that in this study, 90% of cases of dysphagia in the postoperative period were observed in patients after prosthetic diaphragm cruroplasty.

According to some foreign sources, the severity of esophagitis correlates with LES pressure, in patients with high-grade esophagitis and Barrett’s metaplasia, LES pressure is below 10 mmHg. [16].

The contraction of the muscle fibers of the diaphragm is the key mechanism that provides the tone of the LES [17], therefore, the plasty of the subcutaneous tissue is no less important stage of the operation than the qualitative formation of the fundoplication cuff.

Most authors agree that HOD alloplasty, although fraught with possible complications [18—22], is necessary in case of a large hernial defect in the diaphragm.

In our opinion, not only the size of the hernia ring, but also the tone of the diaphragmatic crura can serve as a predictive criterion for unsuccessful antireflux intervention.

Conclusions

Any antireflux operation leads to a persistent increase in LES pressure and a decrease in the degree of relaxation of the LES in response to a sip up to 5 years after surgery. The use of mesh to strengthen the crura of the diaphragm statistically significantly increases LES pressure compared to cruroraphy alone, and this does not lead to a statistically significant increase in dysphagia symptoms in the postoperative period.

Based on the obtained significant differences in the frequency of GERD relapses depending on the pressure of the LES with the use of ANOVA factor analysis, the obtained moderate inverse correlation between the pressure of the LES and the intensity of heartburn in the postoperative period, we believe that LES pressure below 11 mm Hg is possible. considered as a prognostic criterion for unsuccessful fundoplication.

Surgical treatment of gastroesophageal reflux disease

SURGICAL TREATMENT

GASTROESOPHAGEAL REFLUX DISEASE

90 002 The currently available ideas about the pathogenesis of gastroesophageal reflux imply two fundamentally different concepts for its treatment of GERD: pharmacological and surgical.

The advantages of drug therapy for gastroesophageal reflux disease are safety, acceptable side effects, and good results in most cases.

However, in the persistent course of the disease, accompanied by severe clinical symptoms or severe changes in the mucosa of the esophagus (erosive esophagitis, Barrett’s esophagus, peptic strictures), long-term or even lifelong use of antisecretory drugs is required. However, the use of proton pump inhibitors (PPIs), like any other pharmacological drugs, has certain negative effects. Long-term use of PPIs has been shown to increase the risk of cardiovascular complications and osteoporosis (with possible pathological fractures) in clinical studies. Intensive antisecretory pharmacotherapy significantly increases the incidence of upper gastrointestinal and respiratory tract infections.

A serious shortcoming of the drug treatment of GERD should be considered the absence in the arsenal of modern pharmacology of agents that prevent the damaging effect of the contents of the duodenum (bile, pancreatic enzymes, etc.) on the mucosa of the esophagus. Suppression of hydrochloric acid secretion by PPIs reduces, but does not completely eliminate, the likelihood of developing Barrett’s esophagus and adenocarcinoma (glandular cancer) of the esophagus. The same reasons prevent effective medical therapy of peptic strictures of the esophagus in GERD.

An important problem in the conservative treatment of GERD is its economic component. The need for regular courses of pharmacological therapy, periodic clinical and instrumental monitoring of its effectiveness, require significant material and time costs for both the patients themselves and healthcare institutions.

The advantage of surgical treatment of GERD in comparison with pharmacological therapy is the ability to effectively eliminate the key pathogenetic factor of the disease – the failure of the barrier function of the gastroesophageal junction.

The most common cause of LES valvular insufficiency is hiatal hernia (Fig. 1, 2, 3, 4).

Moving the stomach and abdominal esophagus to a natural position, narrowing the hiatal opening to physiological dimensions, recreating the acute angle of His, in most cases normalizes the closing function of the gastroesophageal anastomosis and creates conditions for restoring the contractile activity of the esophagus (Fig. 5, 6, 7 , 8).

Anti-reflux surgery can eliminate functional disorders of the lower esophageal sphincter, which play an important role in the development of GERD and its complications. Strengthening the gastroesophageal junction with a fundus cuff allows you to create an additional zone of high pressure between the esophagus and stomach, preventing reflux.

Efficiency and good long-term results of surgical correction of duodenogastroesophageal reflux allow us to consider this treatment option as the method of choice in patients with a course of the disease resistant to pharmacological therapy, severe forms of esophagitis, peptic strictures and cylinder cell metaplasia of the esophageal mucosa.

Despite the long history, accumulated rich experience and obvious achievements of antireflux surgery, there are no generally accepted indications for surgical treatment of certain GERD variants. The choice of treatment strategy for gastroesophageal regurgitation and its complications in most cases is determined by individual ideas and experience of individual researchers, clinics or scientific communities.

The American Scientific Society of Gastroenterological and Endoscopic Surgeons (SAGES) guidelines for the treatment of gastroesophageal reflux disease (2010) consider all esophageal (and extraesophageal) complications as indications for surgical treatment. Similar ideas are enshrined in the Agreement on “Standards for the diagnosis and treatment of acid-dependent and Helicobacter pylori-associated diseases” adopted at the XIII Congress of the Scientific Society of Gastroenterologists of Russia (NOGR) in Moscow (2014).

To date, there are no generally accepted ideas for choosing the method of surgical correction of gastroesophageal reflux. For less than a century of history of this area of surgery, a large number of original reconstructions and modifications of well-known interventions have been proposed, with their own advantages and disadvantages.

The best control of gastroesophageal reflux can be achieved by “hard” circular fundoplications according to the methods of R. Nissen, M. Rossetti (Fig. 9, 10, 11, 12),

These operations are the most justified in the surgical correction of severe clinical manifestations of the disease or its complications, in the first place – cylinder cell metaplasia of the esophageal mucosa. However, their routine implementation is associated with a high risk of dysphagia in esophageal motility disorders.

Partial (90-270°) reconstructions by A. Watson, J. Dor, A. Toupet and other, less common surgical techniques are deprived of this drawback. In most cases, partial fundoplications make it possible to create a sufficiently effective barrier mechanism in the zone of the gastroesophageal junction, which eliminates the symptoms of the disease (Fig. 13, 14, 15, 16, 17, 18).

The advantages of full and partial fundoplications are largely combined in the “soft” circular reconstruction by P. Donahue, better known in the literature as the “short floppy Nissen” operation (Fig. 19, 20).

Currently, this procedure is rightly considered the “gold standard” of the surgical treatment of GERD, as it allows to achieve a good result in patients with various types of contractile activity of the esophagus. However, like all soft reconstructions, the P. Donahue technique is inferior to the operations of R.