HIGH-RESOLUTION 3-DIMENSION TOMOGRAPHY MAY BE AN USEFUL TOOL FOR THE UNDERSTANDING OF THE ANATOMY OF HIATAL HERNIAS AND SURGICAL PLANNING OF PATIENTS ELIGIBLE FOR LAPAROSCOPIC / ROBOTIC ANTIREFLUX SURGERY
Andre V. Santana*1, Fernando A. Herbella1, carlos e. domene2, Paula Volpe2, William C. Neto2, Rodrigo P. Polízio2, Fernando D. Tamamoto2, Marco G. Patti3
1Universidade Federal de Sao Paulo Escola Paulista de Medicina, Sao Paulo, São Paulo, Brazil; 2Hospital e Maternidade Sao Luiz Unidade Itaim, Sao Paulo, SP, Brazil; 3University of Virginia, Charlottesville, VA
BACKGROUND: Hiatal Hernias (HH) may be diagnosed by different tests: barium esophagram, endoscopy, and manometry. Although these tests are frequently used in combination and evaluate HH through different perspectives and based on different parameters, they fail to show the complex anatomy of HH and the interaction with the esophageal hiatus. Modern Computed Tomography (CT) software allows 3D reconstruction of unique organs or structures. This technology has been seldom used for the evaluation of HH in surgical patients.
AIM: This study aims to describe the 3D CT findings in candidates for laparoscopic or robotic antireflux surgery or HH repair and compare with other tests.
METHODS: 30 patients (17 females, age 49±17) underwent CT, with oral contrast, specific protocol, and 3D image reconstruction. 5 (17%) had recurrent HH. All patients underwent endoscopy, 18 (60%) had an esophageal manometry, and 17 (57%) pH monitoring. The variables studied were: distance from the esophagogastric junction (EGJ) - hiatus, total gastric volume, herniated volume, % of herniated volume, diameters and area of the hiatus (figures 1 and 2).
RESULTS: 21 (70%) patients had HH by CT as compared to 20 (67%) by endoscopy (positive correlation p<0.001) and 9 (50%) by manometry (no correlation p=0.1). The EGJ-hiatus distance was 2.2±1.7cm (positive correlation with endoscopy p<0.01). The size of HH was 3,1±1,1cm by CT and 2,8±1,5cm by endoscopy. The gastric volume was 636±203cm3. Herniated gastric volume was 64±181cm3. The % of herniated stomach was 9%±21%. The diameters of the hiatus were 2.1±0.8cm anteroposterior; 2.0±1.0cm lateral; hiatal area 15±16cm2. In patients with HH, hiatal area was 19±17cm2 compared to 7±2cm2 in patients without HH. EGJ-hiatus distance direct correlated with the area of hiatus (p=0.02) but not with herniated gastric volume (p=0.2). There was no correlation between hiatal area and lower esophageal sphincter resting pressure by manometry (p=0.08). DeMeester score did not correlate with herniated gastric volume (p=0.6), EGJ-hiatus distance (p=0.6), total gastric volume (p=0.9) or hiatal area (p=0.6).
CONCLUSIONS: The anatomy of HH and the hiatus can be well defined by 3D CT. Our results showed that the EGJ-hiatus distance may be equally measured by 3D CT or upper digestive endoscopy, but this parameter does not correlate with herniated volume since HH may present mushroom-shaped. Although HH size by endoscopy is generally associated to gastroesophageal reflux disease, we could not correlate DeMeester score with any anatomical parameter. Future studies may indicate if 3D CT may play a role in surgical technique decision such as the need for mesh hiatoplasty. The understanding of the interface between HH and the esophageal hiatus anatomy may help comprehend the pathophysiology of HH and gastroesophageal reflux disease.
Figure 1. Type I HH. Distance of EGJ to hiatus of 3.2 cm in sagittal CT slice (A). Anteroposterior diameter of the hiatus of 2.4cm in a sagittal CT section (B). Side-to-side diameter of the hiatus of 1.50cm in axial CT section (C). Gastric reconstruction in 3D, with demonstration of the herniated stomach (D).
Figure 2. Axial CT section showing the entire stomach (red) in an intrathoracic position (A). CT sagittal section showing the entire stomach (red arrows) above the diaphragm, with a large hiatal defect, with an anteroposterior diameter of 4 cm (B). 3D image reconstruction, showing 100% of the herniated volume, associated with gastric volvulus (C).
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