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Predicting Intraoperative Hiatal Hernia Size: Endoscopy or Video Esophogram?
James Tatum*1, Kamran Samakar2, Wendy J. Mack3, Kais Rona2, Jessica Reynolds2, Michael Bowdish1, Nikolai Bildzukewicz2, John Lipham2
1Department of Cardiothoracic Surgery, University of Southern California, Los Angeles, CA; 2Upper GI and Minimally Invasive Surgery, University of Southern California, Los Angeles, CA; 3Preventive Medicine, University of Southern California, Los Angeles, CA
Objective: To analyze the relationship between preoperative hiatal hernia size measurements as assessed by endoscopy and/or video esophagography (VEG) to intraoperative hernia size in a population of patients with hiatal hernias.
Methods: Between May 2009 and June 2015, 168 patients underwent surgery for placement of a magnetic sphincter augmentation device for gastroesophogeal reflux disease and intraoperative measurement (IOM) of hiatal hernia size. Preoperative work up included endoscopy, VEG or both with measurements of hiatal hernia size by each modality. Mean age was 51.7 +/- 8.35, 57% were male. 43.1% (72) were normal BMI, 42.5% (71) were overweight, 14.4% (24) were obese. DeMeester scores were broken up into quartiles with 25.9% (37) <22.6, 25.2% (36) 22.6-32.8, 25.2% (36) 32.9-52.5, 23.8% (34) >52.5. Preoperative hiatal hernia size measurements ranged from 0-5cm on endoscopy, from 0-7cm on VEG. IOM ranged from 0-6cm.
Results: Endoscopy (N = 158) underestimated difference between VEG and IOM by 0.12cm standard deviation +/- 1.36 (p= 0.27). VEG (N = 146) underestimated IOM by 0.4cm +/-1.42 (p=0.0009) (See Table). Linear regression was used to examine association of size method differences with patient characteristics: age, gender, BMI by category, duration of reflux, degree of esophagitis, presence of Barrett’s esophagitis, Hill grade, DeMeester score by quartile, % of time with reflux on pH monitoring, size of IOM hernia and the presence or absence of Shatzki ring. Significant relationships were found for VEG-IOM difference by quartiles of the DeMeester score, with the higher two DeMeester quartiles of 32.9-52.5 and >52.5 with a mean differences of -0.81 (p=0.003) and -0.80 (p=0.004), respectively. Significant relationships were found for discrepancy between endoscopy and IOM for both Age ((Beta -0.013, Standard Error 0.006 (p=0.041)), and operative hernia size was also significant for VEG-IOM difference ((Beta -0.601 Standard Error 0.062 (p=<0.0001)).
Conclusion: In patients being evaluated preoperatively for anti-reflux surgery with endoscopy or VEG who subsequently have IOM of the hernia during laparoscopy, VEG significantly underestimates IOM, whereas endoscopy measurements are not significantly different than IOM. Patient with higher DeMeester scores have greater discrepancy between VEG and IOM. Patients who are older and who are found to have larger IOM have more discrepancy between endoscopy and IOM. In a patient with a hiatal hernia ranging in size from 0-6cm, preoperative endoscopic measurement or hiatal hernia size is more accurate than preoperative video esophagographic measurement.
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Hiatal Hernia Size Estimates
| Method | N1 | Mean (SD) | IQR2 | Range | p-value3 | | Endoscopy vs IOM | 158 | | | | | | Endoscopy | | 0.94 (1.12) | 0, 2 | 0, 5 | | | IOM | | 1.06 (1.39) | 0, 2 | 0, 6 | | | Difference (Endoscopy minus IOM) | | -0.12 (1.36) | -1.0, 0 | -4.5, 4 | 0.27 | | VEG vs IOM | 146 | | | | | | VEG | | 0.80 (1.14) | 0, 1 | 0, 7 | | | IOM | | 1.12 (1.49) | 0, 2 | 0, 6 | | | Difference (VEG minus IOM) | | -0.40 (1.42) | -1.0, 0 | -4.5, 3 | 0.0009 |
1 n = number of subjects with both endoscopy/IOM or VEG/IOM measurements 2 IQR = Interquartile range =25th, 75th percentiles 3 p-value for difference in hernia size estimates, by pairet t-test IOM = Intraoperative Measurement VEG = Video Esophography
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