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Nehila T, Sher T, Ganam S, Sujka J, DuCoin C. Discrepancies in the Reporting of Hiatal Hernia Size: A Review. Am Surg 2025; 91:877-886. [PMID: 40114474 DOI: 10.1177/00031348251329465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2025]
Abstract
BackgroundIn the current literature there is a paucity of both standardized diagnostic criteria and accurate methods for determining hernia size. The aim of this review is to describe the most common methods for reporting hiatal hernia size.MethodsLiterature search using PubMed and Embase databases was performed. After exclusion and screening, 67 articles were analyzed and data were collected on hernia type and subtype, diagnostic method, size reporting method, and the author's definition of hernia size (measurement protocol).ResultsAuthors publishing on hiatal hernia size employed 8 different methods for diagnosing hiatal hernias and reported data using 7 distinct measurement types. Within individual diagnostic methods there was a further lack of standardization of measurement protocols.ConclusionOur review underscores the critical need for standardized reporting methods in the assessment and reporting of hiatal hernia size. Moving forward, collaboration is essential to establish and adopt standardized guidelines for reporting hiatal hernia size, ultimately improving patient care and outcomes.
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Affiliation(s)
- Timothy Nehila
- Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Theo Sher
- Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Samer Ganam
- Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
- Division of Gastrointestinal Surgery, Tampa General Hospital, Tampa, Florida, USA
| | - Joseph Sujka
- Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
- Division of Gastrointestinal Surgery, Tampa General Hospital, Tampa, Florida, USA
| | - Christopher DuCoin
- Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
- Division of Gastrointestinal Surgery, Tampa General Hospital, Tampa, Florida, USA
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Schlottmann F, Bertona S, Herbella FAM, Patti MG. Gastroesophageal reflux disease: indications for antireflux surgery, outcomes, and side effects. Expert Rev Gastroenterol Hepatol 2024; 18:693-703. [PMID: 39632344 DOI: 10.1080/17474124.2024.2438719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 10/21/2024] [Accepted: 12/03/2024] [Indexed: 12/07/2024]
Abstract
INTRODUCTION Gastroesophageal reflux disease (GERD) is a frequent digestive disorder that presents with a broad spectrum of symptoms. Global consensus on which patients should be selected for anti-reflux surgery is lacking. AREAS COVERED This evidence-based review will analyze current indications for anti-reflux surgery, outcomes of the operation, and potential side effects. EXPERT COMMENTARY Treatment of GERD has three main purposes: control symptoms, improve quality of life, and prevent potential serious complications such as bleeding, esophageal stenosis, Barrett's esophagus, and esophageal adenocarcinoma. Although medical therapy is effective in the majority of patients, some might require anti-reflux surgery in order to achieve these goals. Adequate patient selection for anti-reflux surgery is critical to obtain optimal outcomes. Most patients undergoing a fundoplication have adequate long-term symptomatic relief. However, potential side effects of anti-reflux surgery should also be discussed with patients to help manage expectations from the operation.
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Affiliation(s)
- Francisco Schlottmann
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
- Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Sofia Bertona
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | | | - Marco G Patti
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
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Santana AV, Herbella FAM, Domene CE, Volpe P, Neto WCGM, Polízio RP, Tamamoto FD, Katayama RC, Patti MG. High-resolution 3-dimensional tomography may be a useful tool for understanding the anatomy of hiatal hernias and surgical planning of patients eligible for laparoscopic or robotic antireflux surgery. Surg Endosc 2024; 38:780-786. [PMID: 38057539 DOI: 10.1007/s00464-023-10599-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 11/14/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND 3D computed tomography (CT) has been seldom used for the evaluation of hiatal hernias (HH) in surgical patients. This study aims to describe the 3D CT findings in candidates for laparoscopic or robotic antireflux surgery or HH repair and compare them with other tests. METHODS Thirty patients with HH and/or gastroesophageal reflux disease (GERD) who were candidates for surgical treatment and underwent high-resolution CT were recruited. The variables studied were distance from the esophagogastric junction (EGJ) to the hiatus; total gastric volume and herniated gastric volume, percentage of herniated volume in relation to the total gastric volume; diameters and area of the esophageal hiatus. RESULTS HH was diagnosed with CT in 21 (70%) patients. There was no correlation between the distance EGJ-hiatus and the herniated gastric volume. There was a statistically significant correlation between the distance from the EGJ to the hiatus and the area of the esophageal hiatus of the diaphragm. There was correlation between tomographic and endoscopic findings for the presence and size of HH. HH was diagnosed with manometry in 9 (50%) patients. There was no correlation between tomographic and manometric findings for the diagnosis of HH and between hiatal area and lower esophageal sphincter basal pressure. There was no correlation between any parameter and DeMeester score. CONCLUSIONS The anatomy of HH and the hiatus can be well defined by 3D CT. The EGJ-hiatus distance may be equally measured by 3D CT or upper digestive endoscopy. DeMeester score did not correlate with any anatomical parameter.
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Affiliation(s)
- André V Santana
- Department of Surgery, Escola Paulista de Medicina, Federal University of São Paulo, São Paulo, Brazil
- Rede D'Or São Luiz Hospitals, São Paulo, Brazil
| | - Fernando A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of São Paulo, São Paulo, Brazil.
- Rede D'Or São Luiz Hospitals, São Paulo, Brazil.
- Department of Surgery, Escola Paulista de Medicina, Rua Diogo de Faria 1087 cj 301, São Paulo, SP, 04037-003, Brazil.
| | | | - Paula Volpe
- Rede D'Or São Luiz Hospitals, São Paulo, Brazil
| | | | | | | | - Rafael C Katayama
- Department of Surgery, Escola Paulista de Medicina, Federal University of São Paulo, São Paulo, Brazil
- Rede D'Or São Luiz Hospitals, São Paulo, Brazil
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Shi Z, Qi C, Chen Q, Fan X, Tian F, Huang D, Tang L, Fang J. Measurement of oesophageal hiatus surface area by multiplanar reconstruction of MDCT: relationship with lower oesophageal sphincter pressure and acid reflux. Clin Radiol 2023; 78:789-794. [PMID: 37500337 DOI: 10.1016/j.crad.2023.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 05/21/2023] [Accepted: 05/24/2023] [Indexed: 07/29/2023]
Abstract
AIM To evaluate the relationship between oesophageal hiatus surface area (OHSA) and gastro-oesophageal reflux disease (GERD). MATERIALS AND METHODS Patients who underwent 24-h pH monitoring, oesophageal high-resolution manometry, and upper abdominal contrast-enhanced multidetector computed tomography (MDCT) during 2014-2021 were enrolled. Patients with a hiatus hernia (HH) on MDCT or who had a history of gastro-oesophageal surgery were excluded. Multiplanar reconstruction (MPR) of the MDCT image was used for the measurement of OHSA. Correlations of OHSA with acid exposure time (AET) and lower oesophageal sphincter (LOS) pressure of all patients were analysed. RESULTS Seventy-eight patients were included in the study. OHSA was much less in the AET <4% group than in the AET >6% group (1.61 ± 0.42 versus 2.09 ± 0.55 cm2, p<0.001). Correlation analysis reveals that OHSA correlated positively with AET (correlation coefficient = 0.47, p<0.001). Receiver operating characteristic (ROC) curve analysis reveals that OHSA can significantly distinguish patients in different groups divided by AET (area under the ROC curve [AUC] = 0.76, 95% confidence interval [CI]: 0.63-0.90). OHSA was not related to LOS pressure (correlation coefficient = -0.268, p=0.051). There was no difference in OHSA between the low LOS pressure group and the normal LOS pressure group (1.84 ± 0.61 versus 1.74 ± 0.50 cm2, p=0.52). CONCLUSIONS OHSA significantly correlated with AET but has no relationship with LOS pressure. It may be an independent risk factor of GERD.
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Affiliation(s)
- Z Shi
- Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3 East Qingchun Rd, Hangzhou, 310016, China
| | - C Qi
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3 East Qingchun Rd, Hangzhou, 310016, China
| | - Q Chen
- Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3 East Qingchun Rd, Hangzhou, 310016, China
| | - X Fan
- Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3 East Qingchun Rd, Hangzhou, 310016, China
| | - F Tian
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3 East Qingchun Rd, Hangzhou, 310016, China
| | - D Huang
- Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3 East Qingchun Rd, Hangzhou, 310016, China
| | - L Tang
- Department of General Surgery, Shaoxing People's Hospital, 568 Zhongxing North Rd, Shaoxing, 312000, China.
| | - J Fang
- Department of General Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3 East Qingchun Rd, Hangzhou, 310016, China.
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Cocco AM, Chai V, Read M, Ward S, Johnson MA, Chong L, Gillespie C, Hii MW. Percentage of intrathoracic stomach predicts operative and post-operative morbidity, persistent reflux and PPI requirement following laparoscopic hiatus hernia repair and fundoplication. Surg Endosc 2023; 37:1994-2002. [PMID: 36278994 PMCID: PMC10017603 DOI: 10.1007/s00464-022-09701-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 10/02/2022] [Indexed: 10/31/2022]
Abstract
PURPOSE Large hiatus hernias are relatively common and can be associated with adverse symptoms and serious complications. Operative repair is indicated in this patient group for symptom management and the prevention of morbidity. This study aimed to identify predictors of poor outcomes following laparoscopic hiatus hernia repair and fundoplication (LHHRaF) to aid in counselling potential surgical candidates. METHODOLOGY A retrospective analysis was performed from a prospectively maintained, multicentre database of patients who underwent LHHRaF between 2014 and 2020. Revision procedures were excluded. Hernia size was defined as the intraoperative percentage of intrathoracic stomach, estimated by the surgeon to the nearest 10%. Predictors of outcomes were determined using a prespecified multivariate logistic regression model. RESULTS 625 patients underwent LHHRaF between 2014 and 2020 with 443 patients included. Median age was 65 years, 62.9% were female and 42.7% of patients had ≥ 50% intrathoracic stomach. In a multivariate regression model, intrathoracic stomach percentage was predictive of operative complications (P = 0.014, OR 1.05), post-operative complications (P = 0.026, OR 1.01) and higher comprehensive complication index score (P = 0.023, OR 1.04). At 12 months it was predictive of failure to improve symptomatic reflux (P = 0.008, OR 1.02) and persistent PPI requirement (P = 0.047, OR 1.02). Operative duration and blood loss were predicted by BMI (P = 0.004 and < 0.001), Type III/IV hernias (P = 0.045 and P = 0.005) and intrathoracic stomach percentage (P = 0.009 and P < 0.001). Post-operative length of stay was predicted by age (P < 0.001) and emergency presentation (P = 0.003). CONCLUSION In a multivariate regression model, intrathoracic stomach percentage was predictive of operative and post-operative morbidity, PPI use, and failure to improve reflux symptoms at 12 months.
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Affiliation(s)
- A M Cocco
- The Department of Surgery, The University of Melbourne, St Vincent's Hospital Melbourne, Melbourne, Australia.
- Upper GI and Hepatobiliary Surgical Unit, St Vincent's Hospital Melbourne, Melbourne, Australia.
| | - V Chai
- Upper GI and Hepatobiliary Surgical Unit, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - M Read
- The Department of Surgery, The University of Melbourne, St Vincent's Hospital Melbourne, Melbourne, Australia
- Upper GI and Hepatobiliary Surgical Unit, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - S Ward
- Upper GI and Hepatobiliary Surgical Unit, St Vincent's Hospital Melbourne, Melbourne, Australia
- Upper GI and Hepatobiliary Surgical Unit, Eastern Health, Melbourne, Australia
| | - M A Johnson
- The Department of Surgery, The University of Melbourne, St Vincent's Hospital Melbourne, Melbourne, Australia
- Upper GI and Hepatobiliary Surgical Unit, St Vincent's Hospital Melbourne, Melbourne, Australia
- Upper GI and Hepatobiliary Surgical Unit, Eastern Health, Melbourne, Australia
- Upper GI and Hepatobiliary Surgical Unit, The Royal Melbourne Hospital, Melbourne, Australia
| | - L Chong
- The Department of Surgery, The University of Melbourne, St Vincent's Hospital Melbourne, Melbourne, Australia
- Upper GI and Hepatobiliary Surgical Unit, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - C Gillespie
- Upper GI and Hepatobiliary Surgical Unit, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - M W Hii
- The Department of Surgery, The University of Melbourne, St Vincent's Hospital Melbourne, Melbourne, Australia
- Upper GI and Hepatobiliary Surgical Unit, St Vincent's Hospital Melbourne, Melbourne, Australia
- Upper GI and Hepatobiliary Surgical Unit, Eastern Health, Melbourne, Australia
- Upper GI and Hepatobiliary Surgical Unit, The Royal Melbourne Hospital, Melbourne, Australia
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The effect of age and sex on esophageal hiatal surface area among normal North American adults using multidetector computed tomography. Surg Radiol Anat 2022; 44:899-906. [PMID: 35608656 DOI: 10.1007/s00276-022-02957-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 04/27/2022] [Indexed: 10/18/2022]
Abstract
The size of the esophageal hiatus is clinically important for preserving the integrity of the lower esophageal sphincter mechanism. The purpose of this study was to systematically establish the mean hiatal surface area (HSA) for normal North American adults under physiologic conditions and assess the relationship between sex and age on HSA. Multi-Detector Computer Tomogram (MDCT) images of the esophageal hiatus in 119 healthy adult subjects (61 males and 58 females with an age range of 24-88 years) were retrospectively analyzed using the multi-planar reconstruction (MPR) technique to directly measure their hiatal length (long axis), width (short axis) and surface area at end inspiration. The mean HSA for males was 2.88 cm2, with a standard deviation of 0.74 cm2. The mean HSA for females was 2.51 cm2, with a standard deviation of 0.68 cm2. There was a statistically significant difference in HSA between males and females (p = 0.0053); however, there was no statistically significant difference between the HSA among different age groups (p = 0.8439). Similarly, significant differences between males and females were demonstrated in both the length (p = 0.0263) and width (p = 0.0311) measurements, but there was no evidence of an association of these parameters with age. For the first time, the normal size of the hiatus at end inspiration has been established noninvasively for a population of healthy adults from MDCT images.
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Esophageal Pressure and Clinical Assessments in the Gastroesophageal Reflux Disease Patients with Laryngopharyngeal Reflux Disease. J Clin Med 2021; 10:jcm10225262. [PMID: 34830544 PMCID: PMC8625685 DOI: 10.3390/jcm10225262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 10/27/2021] [Accepted: 10/31/2021] [Indexed: 11/17/2022] Open
Abstract
Laryngopharyngeal reflux disease (LPRD) might be associated with reflux symptoms, and its severity is correlated with the Reflux Symptoms Index. Diagnosis is often challenging because of a lack of accurate diagnostic tools. Although an association between LPRD and gastroesophageal reflux disease (GERD) exists, the extent to which esophageal pressure changes in patients with LPRD with GERD has been unknown. Therefore, this study surveys the clinical assessments and extent of esophageal pressure changes in LRPD patients with various GERD severities, and compares esophageal sphincter pressures between ages, genders, and body mass index (BMI). This observational study assessed patients with LPRD and GERD. High-resolution esophageal manometry was used to gather data pertaining to the area pressure on the upper esophageal sphincter (UES) and lower esophageal sphincter (LES), and the correlation between such pressure and symptom severity was determined. We compared the esophageal pressure of different UES and LES levels in the following categories: gender, age, BMI, and GERD severity. We analyzed correlations between esophageal pressure and clinical assessments among 90 patients with throat globus with laryngitis with LPRD. LPRD was measured using laryngoscopy, and GERD was measured using esophagoscopy and 24 h PH monitoring. There were no significant differences in the clinical assessments among the four grades of GERD. The LPRD patients with serious GERD had a lower UES and LES pressure. The lowest pressure and longer duration of LES and UES were also observed among patients with LPRD of grade D GERD. No significant differences in UES and LES pressures among ages, genders, or BMIs were noted.
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Karatay E, Gok MA, Javadov M. Measurement of hiatal surface area and other hiatus oesophageal diameters at computed tomography imaging in patients with gastroesophageal reflux disease and its relationship with hiatal hernia. J Minim Access Surg 2021; 17:537-541. [PMID: 34259213 PMCID: PMC8486069 DOI: 10.4103/jmas.jmas_175_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: The oesophageal hiatus is a long and oblique opening in the diaphragm where the thoracic section of the oesophagus passes into the abdomen. Enlarged hiatal surface and insufficiency are considered to be associated with gastroesophageal reflux disease (GERD) and hiatal hernia (HH). In this study, we aimed to retrospectively evaluate the relationship and the presence of GERD with HH by performing hiatal surface area (HSA) and other hiatal measurements at the thorax and abdominal computed tomography (CT) images in cases without any intra-abdominal or oesophageal surgery history. Patients and Methods: A total of 192 patients of GERD+ and 173 cases with GERD− as a control group were included in the study. In CT examinations of 365 patients included in the study, measurements and comments were made by an experienced radiologist in abdominal radiology. In CT scans, the following were evaluated for each case; HSA, hiatus anterior–posterior (A-P) diameter, hiatus transverse diameter, and HH types. The HSA measurement was made with the freehand region of interest in the picture archiving and communication system. Results: A total of 365 cases were included in this study; there was a significant difference between the median HSA, A-P diameter, and transverse diameter measurements between GERD− and GERD+ groups (P < 0.001). A statistically significant difference was found between the presence of GERD and HH types (P < 0.001). Conclusions: CT imaging helps investigate the presence of HH at GERD+ patients. In addition, pre-operative valuable data can be obtained from the detection of HH types and HSA measurements in cases with HH.
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Affiliation(s)
- Emrah Karatay
- Department of Radiology, Istanbul Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
| | - Mehmet Ali Gok
- Department of General Surgery, University of Health Sciences Derince Training and Research Hospital, Kocaeli, Turkey
| | - Mirkhalig Javadov
- Department of General Surgery, Yeditepe University Faculty of Medicine, Istanbul, Turkey
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Conte A, Morabito S, Dennis R, Murgia D. Computed tomographic comparison of esophageal hiatal size in brachycephalic and non-brachycephalic breed dogs. Vet Surg 2020; 49:1509-1516. [PMID: 32949429 DOI: 10.1111/vsu.13521] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 06/22/2020] [Accepted: 08/31/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To determine whether an anatomical difference in esophageal hiatus (EH) size exists between brachycephalic and nonbrachycephalic dogs. STUDY DESIGN Retrospective clinical study. ANIMALS Client-owned dogs (n = 87). METHODS Clinical records and images of dogs that underwent computed tomography between June 2015 and September 2018 were reviewed. For the first part of the study, EH and aortic (Ao) cross-sectional surface areas were measured in brachycephalic (group 1) and nonbrachycephalic dogs of similar body size (<15 kg) without respiratory or gastroesophageal (GE) signs (group 2) by using multiplanar reconstruction. Esophageal hiatus:aortic ratio was calculated. In the second part of the study, absolute EH measurements were also compared in weight-matched (WM) dogs (8-10 kg) from groups 1 and 2. RESULTS Mean (±SD) of EH:Ao values for group 1 (8.1 ± 2.8) were higher (P < .0001) than those for group 2 (3.7 ± 1.1). In addition, EH measurements of 20 WM dogs in group 1 were higher than those of 20 dogs in group 2 (P < .05). CONCLUSION Esophageal hiatus cross-sectional surface area (directly and indirectly measured) in brachycephalic dogs was considerably larger than that in nonbrachycephalic dogs of generally similar body size. CLINICAL SIGNIFICANCE Results of this study provide evidence to support the existence of a specific anatomical factor that could likely correlate to functional GE alterations (eg, regurgitation, gastroesophageal reflux, and sliding hiatal hernia) commonly seen in brachycephalic dogs.
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Moten AS, Ouyang W, Hava S, Zhao H, Caroline D, Abbas A, Dass C. In vivo measurement of esophageal hiatus surface area using MDCT: description of the methodology and clinical validation. Abdom Radiol (NY) 2020; 45:2656-2662. [PMID: 31667547 DOI: 10.1007/s00261-019-02279-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
PURPOSE Accurate estimation of esophageal hiatus surface area (HSA) prior to surgical repair of hiatal hernia is difficult. The ability to do so may assist with following progression of hiatal hernias, choosing the optimal surgical approach and post-surgical evaluation. We developed a method for measurement of HSA using multi-planar reconstruction (MPR) of multi-detector computed tomography (MDCT) scans and sought to validate our method using intra-operative HSA measurements. METHODS Patients with thoracic or abdominal CT scans who were scheduled to undergo hiatal hernia repair were identified. A radiologist performed MPR of each MDCT scan to obtain the measured HSA (mHSA). Estimated HSA (eHSA) was obtained using intra-operative measurements of crura length and distance between crural edges. The association between eHSA and the corresponding mHSA was assessed using Pearson correlation. The intra-class correlation coefficient was calculated to assess both intra-observer and inter-observer agreement for the MDCT-MPR technique. RESULTS Of 30 subjects included, 16 (53.3%) were female and the median age was 68.5 years. All patients underwent robotic-assisted laparoscopic hiatal hernia repair. The median HSA was 8.1 cm2 based on intra-operative measurements and 9.9 cm2 based on CT measurements. The correlation coefficient for eHSA and corresponding mHSA was 0.83 (p < 0.001). The intra-class correlation coefficient was 0.97 (p < 0.001) for intra-observer agreement and 0.97 (p < 0.001) for inter-observer agreement. CONCLUSION We developed a MDCT-MPR technique that measures HSA in vivo. This technique is reproducible and can be used for pre-operative planning and post-operative follow-up of patients with symptomatic hiatal hernia.
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Ouyang W, Dass C, Zhao H, Kim C, Criner G. Multiplanar MDCT measurement of esophageal hiatus surface area: association with hiatal hernia and GERD. Surg Endosc 2015; 30:2465-72. [PMID: 26304104 DOI: 10.1007/s00464-015-4499-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 08/03/2015] [Indexed: 01/11/2023]
Abstract
BACKGROUND Accurate measurement of esophageal hiatus size is clinically important, especially when antireflux surgery is planned. We present a novel method for in vivo measurement of esophageal hiatal surface area using MDCT multiplanar reconstruction. We aimed to determine whether large hiatal area is associated with hiatal hernia and gastroesophageal reflux disease. METHODS We retrospectively analyzed subjects prospectively enrolled in the COPDGene(®) project. We created two test groups, one with hiatal hernia on chest CT and one with GERD on medical treatment identified by history without hernia. Matched control groups were formed. We performed CT postprocessing to define the double-oblique plane of the esophageal hiatus, on which the hiatal surface area is manually traced. RESULTS Subjects with hernia (n = 48) had larger mean hiatus areas than matched controls (6.9 vs. 2.5 cm(2), p < 0.0001), and were more likely to have GERD (42 vs. 10 %, p < 0.0005). Subjects with mixed (type III) hernias had larger hiatuses compared to subjects with sliding (type I) hernias, who, in turn, had larger hiatuses than subjects without hernia (p < 0.0001). Hernia-negative subjects with GERD (n = 55) did not have significantly larger mean hiatal areas compared to matched controls (3.0 vs. 2.5 cm(2), p = 0.12). Twenty measurements obtained by two radiologists showed correlation of 0.93, with mean difference of 0.5 cm(2) (p = 0.20). CONCLUSIONS We devised a method to measure in vivo esophageal hiatal surface area using MDCT reconstruction and established the normal size range for the first time. This methodology has the potential to guide decision-making in antireflux surgery technique preoperatively, and assess surgical result postoperatively. The presence of hernia correlated with large hiatuses and GERD. However, hiatal area failed to identify those with GERD in the absence of hiatal hernia.
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Affiliation(s)
- Wei Ouyang
- Department of Radiology, Temple University Hospital, 3401 North Broad Street, Philadelphia, PA, 19140, USA.
| | - Chandra Dass
- Department of Radiology, Temple University Hospital, 3401 North Broad Street, Philadelphia, PA, 19140, USA
| | - Huaqing Zhao
- Clinical Research Center, Temple University School of Medicine, Philadelphia, PA, USA
| | - Cynthia Kim
- Department of Pulmonary and Critical Care Medicine, Temple University Hospital, Philadelphia, PA, USA
| | - Gerard Criner
- Department of Pulmonary and Critical Care Medicine, Temple University Hospital, Philadelphia, PA, USA
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Abstract
STUDY DESIGN Retrospective analysis. OBJECTIVE The main objectives of this study were to analyze and compare cervical sagittal parameters, including the T1 slope, in a population of 45 patients with degenerative cervical spondylolisthesis (DCS) and to compare these patients with a control group of asymptomatic population. SUMMARY OF BACKGROUND DATA Sagittal balance in the cervical spine is as important as the pelvic incidence and is related to the concept of T1 slope. Compared with degenerative lumbar spondylolisthesis, there are few studies evaluating DCS, and characteristic changes of the cervical sagittal parameters (including T1 slope) in patients with DCS are not well studied. METHODS We identified 45 patients with DCS (5.8%) from a database of 767 patients, using cervical radiograph in a standing position. All had radiograph and computed tomographic scan at the same time. Cervical sagittal parameters were analyzed on computed tomographic scan in a standardized supine position. The following cervical sagittal parameters were measured: T1 slope, neck tilt, thoracic inlet angle, and cervical lordosis (C2-C7 angle). The DCS group was compared with a control group of 45 asymptomatic age- and sex-matched adults to the DCS group, who were studied in a recently published study. RESULTS Of our initial group of 767 patients, 45 with anterolisthesis (5.8%) were included for this study. The T1 slope was significantly greater for DCS (26.06° ± 7.3°) compared with the control group (22.32° ± 7.0°). No significant difference of the neck tilt, thoracic inlet angle, and C2-C7 angle was seen between the DSC group and the control group. Therefore, the T1 slope of the DSC group was significantly greater than that of the control group (P < 0.005). CONCLUSION The DCS group was characterized by a greater T1 slope than the control group; therefore, we suggest that a high T1 slope may be a predisposing factor in developing DCS. LEVEL OF EVIDENCE 3.
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Santonicola A, Angrisani L, Cutolo P, Formisano G, Iovino P. The effect of laparoscopic sleeve gastrectomy with or without hiatal hernia repair on gastroesophageal reflux disease in obese patients. Surg Obes Relat Dis 2014; 10:250-255. [PMID: 24355324 DOI: 10.1016/j.soard.2013.09.006] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Revised: 07/29/2013] [Accepted: 09/14/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND Obesity is an independent risk factor for gastroesophageal reflux disease (GERD), which is often associated with the presence of a hiatal hernia (HH). Despite increasing popularity of laparoscopic sleeve gastrectomy (LSG) in bariatric surgery, its effect on GERD is still unclear. The objective of this study was to evaluate the effect of LSG with or without hiatal hernia repair (HHR) on GERD in obese patients. METHODS Seventy-eight patients with HH underwent LSG with concomitant HHR (LSG+HHR group). Their data were compared with that of 102 patients without HH, who underwent only LSG (LSG-group). All patients underwent a standardized questionnaire, a double-contrast barium swallow, and an upper-gastrointestinal endoscopy before the surgical procedure and at least 6 months later. RESULTS At baseline, the prevalence of GERD symptoms and their frequency-intensity scores did not differ between groups. At follow up, there was a significant decrease in the prevalence of typical GERD symptoms only in the LSG-group (P = .003). LSG+HHR patients showed a significantly higher heartburn frequency-intensity score compared with LSG patients (P = .009). CONCLUSION This finding confirms that LSG has a beneficial effect on relieving GERD symptoms, although the underlying mechanisms are still unclear; conversely, the procedure of HHR did not produce any improvement in GERD symptoms.
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Affiliation(s)
- Antonella Santonicola
- Clinical and Experimental Medicine Department, Federico II University of Naples, Naples, Italy
| | - Luigi Angrisani
- General and Endoscopic Surgery Unit, San Giovanni Bosco Hospital, Naples, Italy
| | - Pierpaolo Cutolo
- General and Endoscopic Surgery Unit, San Giovanni Bosco Hospital, Naples, Italy
| | - Giampaolo Formisano
- General and Endoscopic Surgery Unit, San Giovanni Bosco Hospital, Naples, Italy
| | - Paola Iovino
- Medicine and Surgery Department, University of Salerno, Salerno, Italy.
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Franzén T, Tibbling L. Is the severity of gastroesophageal reflux dependent on hiatus hernia size? World J Gastroenterol 2014; 20:1582-1584. [PMID: 24587634 PMCID: PMC3925867 DOI: 10.3748/wjg.v20.i6.1582] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 10/22/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine if the severity of gastroesophageal reflux disease is dependent on the size of a hiatus hernia.
METHODS: Seventy-five patients with either a small (n = 25), medium (n = 25) or large (n = 25) hiatus hernia (assessed by high resolution esophageal manometry) were investigated using 24-h esophageal monitoring and a self-assessed symptom questionnaire. The questionnaire comprised the following items, each graded from 0 to 3 according to severity: heartburn; pharyngeal burning sensation; acid regurgitation; and chest pain.
RESULTS: The percentage total reflux time was significantly longer in the group with hernia of 5 cm or more compared with the group with a hernia of < 3 cm (P < 0.002), and the group with a hernia of 3 to < 5 cm (P < 0.04). Pharyngeal burning sensation, heartburn and acid regurgitation were more common with large hernias than small hernias, but the frequency of chest pain was similar in all three hernia groups.
CONCLUSION: Patients with a large hiatus hernia are more prone to have pathological gastroesophageal reflux and to have more acid symptoms than patients with a small hiatus hernia. However, it is unlikely that patients with an absence of acid symptoms will have pathological reflux regardless of hernia size.
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Koch OO, Spaun G, Antoniou SA, Rabl C, Köhler G, Emmanuel K, Öfner D, Pointner R. Endoscopic grading of the gastroesophageal flap valve is correlated with reflux activity and can predict the size of the esophageal hiatus in patients with gastroesophageal reflux disease. Surg Endosc 2013; 27:4590-5. [PMID: 23846367 DOI: 10.1007/s00464-013-3071-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2013] [Accepted: 06/13/2013] [Indexed: 12/23/2022]
Abstract
BACKGROUND Endoscopic grading of the gastroesophageal flap valve (GEFV) is simple, reproducible, and suggested to be a good predictor of reflux activity. This study aimed to investigate the potential correlation between grading of the GEFV and quality of life (QoL), gastroesophageal reflux disease (GERD) symptoms, esophageal manometry, multichannel intraluminal impedance monitoring (MII) data, and size of the hiatal defect. METHODS The study included 43 patients with documented chronic GERD who underwent upper gastrointestinal endoscopy, esophageal manometry, and ambulatory MII monitoring before laparoscopic fundoplication. The GEFV was graded 1-4 using Hill's classification. QoL was evaluated using the Gastrointestinal Quality-of-Life Index (GIQLI), and gastrointestinal symptoms were documented using a standardized questionnaire. The size of the esophageal hiatus was measured during surgery by calculating the hiatal surface area (HSA). Analysis of the correlation between QoL, GERD symptoms, esophageal manometry, MII data, HSA size, and GEFV grading was performed. Statistical significance was set at a p value of 0.05. RESULTS A significant positive correlation was found between increased GEFV grade and DeMeester score, total number of acid reflux events, number of reflux events in the supine position, and number of reflux events in the upright position. Additionally, a significant positive correlation was found between HSA size and GEFV grading. No significant influence from intensity of GERD symptoms, QoL, and the GEFV grading was found. The mean LES pressures were reduced with increased GEFV grade, but not significantly. CONCLUSIONS The GEFV plays a major role in the pathophysiology of GERD. The results underscore the importance of reconstructing a valve in patients with GERD and an altered geometry of the gastroesophageal junction when they receive a laparoscopic or endoscopic intervention.
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Affiliation(s)
- Oliver Owen Koch
- Department of General and Visceral Surgery, Sisters of Charity Hospital, 4010, Linz, Austria,
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Antoniou SA, Koch OO, Antoniou GA, Asche KU, Kaindlstorfer A, Granderath FA, Pointner R. Similar symptom patterns in gastroesophageal reflux patients with and without hiatal hernia. Dis Esophagus 2013; 26:538-43. [PMID: 22642514 DOI: 10.1111/j.1442-2050.2012.01368.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Gastroesophageal reflux disease is a common clinical entity in Western societies. Its association with hiatal hernia has been well documented; however, the comparative clinical profile of patients in the presence or absence of hiatal hernia remains mostly unknown. The aim of the present study was to delineate and compare symptom, impedance, and manometric patterns of patients with and without hiatal hernia. A cumulative number of 120 patients with reflux disease were enrolled in the study. Quality of life score, demographic, symptom, manometric, and impedance data were prospectively collected. Data comparison was undertaken between patients with and without hiatal hernia. A P-value < 0.05 was considered statistically significant. Patients with hiatal hernia tended to be older than patients without hernia (52.3 vs. 48.6 years, P < 0.05), whereas quality of life scores were slightly better for the former (97.0 vs. 88.2, P= 0.005). Regurgitation occurred more frequently in patients without hiatal hernia (78.3% vs. 93.9%, P < 0.05). Otherwise, no differences were found with regard to esophageal and extraesophageal symptoms. However, lower esophageal sphincter pressures (7.7 vs. 10.0 mmHg, P= 0.007) and more frequent reflux episodes (upright, 170 vs. 134, P= 0.01; supine, 41 vs. 24, P < 0.03) were documented for patients with hiatal hernia on manometric and impedance studies. Distinct functional characteristics in patients with and without hiatal hernia may suggest a tailored therapeutic management for these diverse patient groups.
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Affiliation(s)
- S A Antoniou
- Department of General Surgery, Hospital Zell am See, Zell am See, Austria.
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Comparison of results from a randomized trial 1 year after laparoscopic Nissen and Toupet fundoplications. Surg Endosc 2013; 27:2383-90. [PMID: 23361260 DOI: 10.1007/s00464-013-2803-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Accepted: 01/03/2013] [Indexed: 12/30/2022]
Abstract
BACKGROUND The fundoplication of choice for the surgical treatment of gastroesophageal reflux disease (GERD) still is debated. Multichannel intraluminal impedance monitoring (MII) has not been used to compare objective data, and comparative subjective data on laparoscopic Nissen and Toupet fundoplications are scarce. METHODS This study randomly allocated 125 patients with documented chronic GERD to either laparoscopic floppy Nissen fundoplication (LNF; n = 62) or laparoscopic Toupet fundoplication (LTF; n = 63). The Gastrointestinal Quality of Life Index (GIQLI), symptom grading, esophageal manometry, and MII data were documented preoperatively and 1 year after surgery. The pre- and postprocedure data were compared. Statistical significance was set at a p value lower than 0.01 (NCT01321294). RESULTS Both procedures resulted in significantly improved GIQLI and GERD symptoms. Preoperative dysphagia improved in both groups, but the improvement reached significance only in the LTF group. The ability to belch was shown to be significantly more decreased after LNF than after LTF. Gas-bloat and "atypical" extraesophageal symptoms also were decreased after surgery (p < 0.01). However, bowel symptoms were virtually unchanged in both groups. Both procedures resulted in significantly improved lower esophageal sphincter pressures. The improvement was greater in the LNF group than in the LTF group (p < 0.01). The DeMeester score and the numbers of total, acid, proximal, upright, and recumbent reflux episodes decreased in both groups after surgery (p < 0.01). No significant difference between the procedures in terms of MII data was found. Six patients (4.8 %) had to undergo reoperation because of intrathoracic slipping of the wrap. All the patients had undergone LNF. CONCLUSIONS Both procedures proved to be equally effective in improving quality of life and GERD symptoms. However, the reoperation and dysphagia rates were lower and the ability to belch was higher after LTF than after LNF.
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Predictability of hiatal hernia/defect size: is there a correlation between pre- and intraoperative findings? Hernia 2013; 18:883-8. [PMID: 23292367 DOI: 10.1007/s10029-012-1033-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2012] [Accepted: 12/27/2012] [Indexed: 01/27/2023]
Abstract
PURPOSE Closure of the esophageal hiatus is an important step during laparoscopic antireflux surgery and hiatal hernia surgery. The aim of this study was to investigate the correlation between the preoperatively determined hiatal hernia size and the intraoperative size of the esophageal hiatus. METHODS One hundred patients with documented chronic gastroesophageal reflux disease underwent laparoscopic fundoplication. All patients had been subjected to barium studies before surgery, specifically to measure the presence and size of hiatal hernia. The size of the esophageal hiatus was measured during surgery by calculating the hiatal surface area (HSA). HSA size >5 cm(2) was defined as large hiatal defect. Patients were grouped according to radiologic criteria: no visible hernia (n = 42), hernia size between 2 and 5 cm (n = 52), and >5 cm (n = 6). A retrospective correlation analysis between hiatal hernia size and intraoperative HSA size was undertaken. RESULTS The mean radiologically predicted size of hiatal hernias was 1.81 cm (range 0-6.20 cm), while the interoperative measurement was 3.86 cm(2) (range 1.51-12.38 cm(2)). No correlation (p < 0.05) was found between HSA and hiatal hernia size for all patients, and in the single radiologic groups, 11.9 % (5/42) of the patients who had no hernia on preoperative X-ray study had a large hiatal defect, and 66.6 % (4/6) patients with giant hiatal hernia had a HSA size <5 cm(2). CONCLUSIONS The study clearly demonstrates that a surgeon cannot rely on preoperative findings from the barium swallow examination, because the sensitivity of a preoperative swallow is very poor.
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Subjective and objective data on esophageal manometry and impedance pH monitoring 1 year after endoscopic full-thickness plication for the treatment of GERD by using multiple plication implants. Gastrointest Endosc 2013; 77:7-14. [PMID: 23021166 DOI: 10.1016/j.gie.2012.07.033] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Accepted: 07/19/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND Subjective and especially objective data after endoluminal full-thickness gastroplication are scarce. OBJECTIVE To evaluate symptoms and reflux activity 12 months after gastroplication by using multichannel intraluminal impedance monitoring. DESIGN Open-label, prospective, single-center study. SETTING Tertiary referral hospital in Zell am See, Austria. PATIENTS Subjects without hiatal hernias with documented GERD and persistent or recurrent symptoms despite treatment with a proton pump inhibitor. INTERVENTIONS A total of 36 patients underwent endoscopic full-thickness gastroplication with 1 or more Plicator implants. MAIN OUTCOME MEASUREMENTS Mean Gastrointestinal Quality of Life Index and reflux-specific symptom scores significantly improved on follow-up (P < .01). Atypical reflux, gas/bloating, and bowel dysfunction-specific symptom scores as well as belching and dysphagia scores improved. Twenty-two patients returned for esophageal manometry and multichannel intraluminal impedance testing 1 year after surgery. DeMeester scores decreased from 20 to 10 (P < .029). The median numbers of total, acid, proximal, upright, and recumbent reflux episodes were all significantly reduced (P < .05). Manometric data were virtually unchanged. The percentage of patients taking proton pump inhibitors on daily basis after the procedure was 11.5%. There was only 1 postprocedure incident (bleeding) that required intervention. Three of 36 patients (8.3%) were considered treatment failures because of persistent symptoms and were assigned to undergo laparoscopic fundoplication. LIMITATIONS No randomized comparison with a sham procedure or laparoscopic fundoplication; follow-up interval. CONCLUSIONS Endoscopic plication is safe and improves objective and subjective parameters at 1-year follow-up, without side effects seen after laparoscopic fundoplication. Further studies on the clinical merit of this procedure in specific patient populations are warranted.
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