Angela M Kao, MD, Javier Otero, MD, Sean R Maloney, MD, Tanushree Prasad, MA, Vedra A Augenstein, MD, B. Todd Heniford, MD, Paul D Colavita, MD. Carolinas Medical Center
Background:Despite advances in diagnostic imaging capabilities, little information exists concerning the impact of physical dimensions of a paraesophageal hernia (PEH) on intraoperative decision-making and postoperative outcomes. Computerized volumetric analysis allows for accurate anatomic representation, which could possibly optimize preoperative planning and patient counseling. The present study utilizes advanced imaging and multidimensional visualization to measure hiatal defect area (HDA) and intrathoracic hernia sac volume (HSV) and compares these measurements to operative findings and surgical techniques performed.
Methods:Using volumetric analysis software (Aquarius iNtuition, TeraRecon, Inc), HDA and HSV were measured in all PEH patients with preoperative computerized tomography(CT) scans, and used to predict the likelihood of intraoperative variables, including emergent case status, presence of gastric volvulus, need for a diaphragmatic relaxing incision, and salvage gastropexy. Multi-dimensional rotation of CT images allowed for visualization of the entire hiatal defect in a plane mimicking the surgeon’s view during repair. The intrathoracic hernia sac was manually outlined on multiple sequential axial images, which produced volume measurements based on a summation of exact dimensions. While prior estimations of hernia volumes have limitations when calculated from hernia width, length, and depth, volumetric analysis reduces this margin of error.
Results:A total of 203 patients underwent surgical repair of PEH and had preoperative CT scans for review. 182 (89.7%) had primary cruroplasty, while 10.3% had salvage gastropexy. 4.4% had diaphragmatic relaxing incisions, and 13.3% were emergent. Median HDA was 25.7cm2(IQR17.8-35.6cm2);median HSV was 365.0cm3(IQR150.0-611.0cm3). Incremental increase in HDA by 5cm2 was associated with 26.7% greater likelihood of presenting emergently (95%CI 1.124-1.428,p=0.0001), incarceration (OR 1.27;1.074-1.499,p=0.005), or gastric volvulus (1.13;1.021-1.248,p=0.02). Each additional 5cm2 in HDA increased odds of relaxing incision by 43.4%(1.203-1.709, p<0.0001), and salvage gastropexy by 12.9%(1.001-1.274, p=0.048). Similarly, HSV increases of 100cm3 were associated with 23% greater likelihood of emergent repair(1.121-1.353,p<0.0001), and were more likely to require a relaxing incision(1.18;1.043-1.339,p=0.008) or salvage gastropexy (1.19;1.083-1.312,p=0.0003).
Conclusions: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 100cm3 and HDA by 5cm2 are more likely to present emergently and require complex techniques or bailout procedures. Future directions for volumetric analysis include use of HDA and HSV measurements in predictive models for operative intervention based on preoperative imaging, as well as postoperative hernia or symptom recurrence.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 95205
Program Number: S046
Presentation Session: Foregut II – Physiology
Presentation Type: Podium