Improving the diagnostic accuracy of hiatal hernia in patients undergoing bariatric surgery

Surgical correction of hiatal hernia (HH) during bariatric surgery has been found to improve patient outcomes and decrease reoperation rate. Although barium esophagram is more sensitive than endoscopy for detection of HH, accurate preoperative diagnosis remains a challenge. The aim of this study is to determine whether diagnostic accuracy improves by utilizing right anterior oblique (RAO) esophagram technique instead of the commonly used upright technique when comparing to the gold standard of intraoperative detection.

All patients undergoing bariatric surgery were prospectively evaluated for HH by barium esophagram. After the first 69 patients, the technique was changed from upright to RAO. Hiatal hernia was assessed intraoperatively by laxity of the phrenoesophageal ligament and, if present, was repaired posteriorly. Two board-certified radiologists specializing in gastrointestinal radiology, who were blinded to the intraoperative results, retrospectively reviewed the esophagrams. Consensus reads were utilized for divergent opinions. Sensitivity and specificity were calculated for each technique.

Between 2008 and 2010, a total of 388 patients underwent preoperative esophagrams (69 upright, 388 RAO). For upright esophagram, sensitivity was 50 % and specificity was 97 %. For RAO esophagram, sensitivity was 70 % and specificity was 77 %. RAO had a lower percentage of false negatives (11 vs. 21 %) than upright esophagram.

The use of RAO technique for preoperative esophagram is more sensitive for diagnosis of hiatal hernia than upright esophagram. If surgeons desire routine preoperative esophagram, RAO technique is the best.