Hiatal surface area measurement as useful tool for preoperative decision making in the management of hiatal defect in bariatric patients

Introduction: Hiatal surface area calculation has been recently proposed as a useful marker for choosing the right treatment of enlarged esophageal hiatus complicated with hiatal hernia: simple, reinforced or tension-free cruroplasty, based on arbitrary values (lower or more than 5 cm2). In the same time, preoperative upper GI endoscopy or barium swallow cannot predict exactly the real intraoperative findings. MDCT scan of the hiatal area was shown to be useful in hiatal hernia management. Methods: We retrospectively analyzed 25 patients, candidates for laparoscopic antireflux surgery LARS as primary surgery, single or concomitant with or after bariatric surgery. Patients were analyzed before surgery and after one-year follow-up and 6 control patients were analyzed prospectively. Multiplanar multislice MDCT scan measurement of esophageal hiatus surface was done preoperatively, while intraoperative calculation of the HSA completed evaluation. Control postoperative CT-scan was done after 12 months, or when necessary. Results: Mean HSA in obese patients candidates to LARS, with known defect of hiatal area was 10.75 ± 4.54 cm2, while mean HSA after LARS (cruroplasty ± redo bariatric surgery) was 5.89 ± 3.0 cm2. Intraoperative measurement of HSA was 11.25 ± 6.2 cm2. Mean HSA in control patients (no obesity, no HH, no MRGE) was less 5 cm2 (2.94 ± 0.66), and similar in obese, non-complicated patients with previous bariatric surgery and cruroplasty (simple or reinforced). Conclusions: these are preliminary results, but multiplanar MDCT measurement of esophageal hiatus surface could be a better radiological instrument in preoperative evaluation and decision making for which kind of surgical treatment should be chosen.