Fizz-computed tomography as a novel modality of objective esophageal hiatal assessment

Background: Traditional investigations of esophageal hiatal assessment for reflux disease and hiatal hernia (HH), such as endoscopy and barium swallow are subjective. High resolution manometry (HRM) limits hiatal hernia assessment to vertical length. We report a novel use of 3D volumetric Computed Tomography with effervescent oral contrast (Fizz-CT) as a means of preoperative HH diagnosis. Methods: A pilot series of 12 consecutive patients who underwent preoperative Fizz-CT assessment, as well as a combination of traditional investigations for HH (five primary, seven revisional HH). Results: The median age was 70years (IQR 57.5-76.8years) and median BMI 28.62 kg/m2 (IQR 24.9-34.1 kg/m2). Seven patients (58%) had a recurrent HH and five patients (42%) had a primary hiatus hernia. Fizz-CT was able to diagnose the HH in all cases. The median oesophageal hiatal surface area (HSA) was 9.46cm2 (IQR 4.66-13.79cm2). The median HH sac volume was 36.3cm3 (IQR 26.0-80.3cm3). All patients had a least one other investigation that has been traditionally used to diagnose HH. Seven of the 12 patients subsequently underwent laparoscopic HH repair surgery with intraoperative findings further confirming the radiological diagnosis of hiatus hernia. Conclusion: Fizz-CT imaging is a novel and accurate means of objective esophageal hiatal assessment in both primary and revisional HH patients. Vertical and radial measures of hiatal defects as well as hernia volumetry can be obtained. In post-surgical patients the relationship between the esophago-gastric junction and an infra- or supra-diaphragmatic fundoplication can also be assessed.