Use of computed tomography volumetric measurements to predict operative techniques in paraesophageal hernia repair
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Despite advances in diagnostic imaging capabilities, little information exists concerning the impact of physical dimensions of a paraesophageal hernia (PEH) on intraoperative decision making. The authors hypothesized that computerized volumetric analysis and multidimensional visualization to measure hiatal defect area (HDA) and intrathoracic hernia sac volume (HSV) would correlate to operative findings and required surgical techniques performed.
Using volumetric analysis software (Aquarius iNtuition, TeraRecon, Inc), HDA and HSV were measured in PEH patients with preoperative computerized tomography (CT) scans, and used to predict the likelihood of intraoperative variables. Multidimensional rotation of images enabled visualization of the entire hiatal defect in a plane mimicking the surgeon’s view during repair. The intrathoracic hernia sac was outlined producing volume measurements based on a summation of exact dimensions.
A total of 213 PEHR patients had preoperative CT imaging, with 14.1% performed emergently. Primary cruroplasty was performed in 89.2%, salvage gastropexy in 10.3%, and diaphragmatic relaxing incisions in 4.2%. Median HDA was 25.7 cm2 (IQR17.8–35.6 cm2); median HSV was 365.0 cm3 (IQR150.0–611.0 cm3). Incremental 5 cm2 increase in HDA was associated with greater likelihood of presenting emergently (OR 1.27; 95%CI 1.124–1.428, p = 0.0001), incarceration (OR 1.27; 1.074–1.499, p = 0.005), gastric volvulus (OR 1.13; 1.021–1.248, p = 0.02), and requiring either relaxing incision (OR 1.43; 1.203–1.709, p < 0.0001) or salvage gastropexy (OR 1.13; 1.001–1.274, p = 0.04). Similarly, HSV increases of 100 cm3 were associated with 23% greater likelihood of emergent repair (CI 1.121–1.353, p < 0.0001), and were more likely to require a relaxing incision (OR 1.18; 1.043–1.339, p = 0.009) or salvage gastropexy (1.19; 1.083–1.312, p = 0.0003).
Utilization of CT volumetric measurements is a valuable adjunct in preoperative planning, allowing the surgeon to anticipate complexity of repair and operative approach, as incremental increases in HSV by 100 cm3 and HDA by 5 cm2 are more likely to require complex techniques or bailout procedures and/or present emergently.
KeywordsLaparoscopic paraesophageal hernia repair CT measurements Paraesophageal hernia size Predictive analytics
This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.
Compliance with ethical standards
Dr. Heniford is on the speaker’s bureau for Allergan and on the advisory committee for W.L. Gore. Dr. Augenstein has speaker’s fees for W.L. Gore, Allergan and is a consultant for Acelity and Intuitive. Dr. Colavita has speaker’s fees for Allergan. The remainder of the authors, Drs. Kao, Ross, Otero, Maloney, and Prasad have no conflicts of interest or financial ties to disclose.
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