Optimization of the algorithm for selecting the fundoplication method in the surgical treatment of patients with hiatal hernia

Objective — to evaluate the effectiveness of a diagnostic algorithm using multidetector computed tomography (MDCT) in selecting the fundoplication technique compared to traditional diagnostic methods. Materials and methods. A retrospective controlled randomized study was conducted from August 2022 to February 2025 aiming to reduce the risk of postoperative complications and hiatal hernia (HH) recurrence by optimizing surgical tactics. The study involved 162 patients with confirmed HH and endoscopically verified gastroesophageal reflux disease. Patients were divided into two groups: Group 1 (n=87) — the choice of fundoplication method was made empirically by the surgeon; Group 2 (n=75) — the choice of surgical method was determined using the MDCT‑based algorithm. The inclusion criteria were: age 18—75 years, confirmed diagnosis of HH, absence of severe comorbidities that could affect surgical outcomes. The risk assessment scale incorporated reflux severity, hernia type, presence of erosive esophagitis, iron deficiency anemia, and Barrett’s metaplasia. The effectiveness of surgical intervention was evaluated based on the following criteria: operative duration, frequency of postoperative complications according to the Clavien‑Dindo classification, changes in patients’ functional status assessed using the Ogilvie scale, incidence of hernia recurrence at one year postoperatively, and the need for proton pump inhibitors (PPIs) after surgery. Results. The use of the MDCT algorithm significantly influenced the selection of the fundoplication method: in Group 2, anterior partial fundoplication (Dor, 180°) was performed more frequently (68% vs. 44.8%, p=0.005), whereas full Nissen fundoplication was significantly more common in Group 1 (33.3% vs. 13.3%, p=0.005). In Group 2, the operative duration was significantly shorter 111.31±28.2 min vs. 123.13±23.23 min, p=0.004), the incidence of postoperative complications classified as Clavien‑Dindo >2 was lower (12.0% vs. 24.1%, p=0.047), functional recovery, assessed using the Ogilvie scale at 3 months (1.13±0.29 vs. 1.24±0.24, p=0.008) and at 1 year (1.04±0.26 vs. 1.18±0.27, p=0.001) was better, the one‑year hernia recurrence rate was twice lower (9.3% vs. 21.8%, p=0.031), the need for PPIs one year after surgery was also significantly lower (29.3% vs. 50.6%, p=0.006), indicating a better anti‑reflux effect. Conclusions. The application of the MDCT‑based algorithm for selecting the laparoscopic fundoplication method reduces operative duration, decreases the incidence of postoperative complications and hernia recurrence, and lowers the need for long‑term acid‑suppressive therapy, which enhances the individualization of surgical decision‑making, positively impacting long‑term treatment outcomes.