Abstract
ObjectiveTo evaluate the accuracy and reproducibility of hiatal surface area (HSA) measurement on dedicated multidetector computed tomography (MDCT) acquisition, in patients, previously subjected to laparoscopic sleeve gastrectomy (LSG), and affected by gastroesophageal reflux disease (GERD). Intraoperative HSA measurement was considered the reference standard.MethodsFifty-two candidates for laparoscopic hiatal hernia repair were prospectively included in the study. MDCT images were acquired during swallowing of oral iodinated contrast media and during strain. Measurements were performed by nine readers divided into three groups according to their experience. Results were compared with intraoperative measurements by means of Spearman correlation coefficient. Reproducibility was evaluated with intra- and interreader agreement by means of weighted Cohen’s kappa and intraclass correlation coefficient (ICC).ResultsSignificant differences between MDCT and intraoperative HSA measurements were observed for swallowing imaging for less experienced readers (p = 0.037, 0.025, 0.028 and 0.019). No other statistically significant differences were observed (p > 0.05). The correlation between HSA measured intraoperatively and on MDCT was higher for strain imaging compared to swallowing (r = 0.94—0.92 vs 0.94—0.89). The overall reproducibility of MDCT HSA measurement was excellent (ICC of 0.95; 95% CI 0,8993 to 0,9840) independently of reader’s experienceConclusionHSA can be accurately measured on MDCT images. This method is reproducible and minimally influenced by reader experience. The preoperative measurement of HSA has potential advantages for surgeons in terms of correct approach to hiatal defects in obese patient.
Highlights
Laparoscopic sleeve gastrectomy (LSG) is an effective surgical treatment of morbid obese patients, providing a considerable and durable weight loss, as well as a resolution/improvement of related comorbidities [1]
When hiatal surface area (HSA), measured on multidetector computed tomography (MDCT) and intraoperatively, was compared, significant differences were observed only for measurements performed on swallowing imaging for groups 2 and 3 for small (≤ 4 cm2; p = 0.037 and 0.025) and hiatal hernia repair (HHR)
The overall reproducibility of MDCT HSA measurement, comparing all nine readers and both strain and swallowing acquisitions, was excellent resulting in a grouped intraclass correlation coefficient (ICC) of 0.95 independently of reader’s experience
Summary
Laparoscopic sleeve gastrectomy (LSG) is an effective surgical treatment of morbid obese patients, providing a considerable and durable weight loss, as well as a resolution/improvement of related comorbidities [1]. LSG has been reported to increase the risk of “de novo” or recurrent gastroesophageal reflux disease (GERD), due to anatomical and pathophysiological changes [2]. ITM, similar to sliding hiatal hernia (HH), is characterized by a widening of the muscular hiatus and circumferential laxity of the phreno-esophageal ligament, allowing the esophagogastric junction and the upper part of the sleeve to herniate into the mediastinum [5, 6]. ITM is associated with GERD and increased incidence of severe esophagitis and Barrett esophagus [2,3,4, 7]. Whereas hiatal defect contributes to the HH’s pathogenesis, the herniated sleeve per se enlarges the hiatus, both causing impairment of the low esophageal sphincter (LES) function and predisposing to reflux. HSA measurement has been advocated as useful tool for choosing the right tailored treatment (simple or reinforced posterior cruroplasty) [11, 12]
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