Association of esophageal hiatus size with reflux esophagitis and type I hiatal hernia in patients with obesity

BACKGROUND Chinese surgeons often rely on intraoperative exploration of the esophageal hiatus to determine the need for concurrent type I hiatal hernia (HH) repair during laparoscopic sleeve gastrectomy. However, no standardized criteria for the esophageal hiatus size or indications for exploration exist in China. AIM To investigate normal anatomical parameter ranges of the esophageal hiatus in patients with obesity. METHODS A total of 158 patients, aged 20-49 years, was analyzed from January 2020 to June 2024. The patients were classified into the no reflux esophagitis (RE) no HH group (HHG), RE group, and type I HHG. The transverse and sagittal diameters and cross-sectional area of the esophageal hiatus were measured using multiplanar reconstruction of the computed tomography images. RESULTS Body mass index was positively correlated with area and transverse and sagittal diameters of the esophageal hiatus (r = 0.72, 0.69, and 0.54, respectively; P < 0.01). In the no RE no HHG and RE group, the esophageal hiatus size in the subgroup with obesity was greater than that in the non-obesity subgroup (area: 326.15 ± 78 mm2 vs 208.12 ± 64.44 mm2, transverse diameters: 15.97 ± 2.06 mm vs 13.37 ± 1.99 mm, sagittal diameters: 15.7 ± 2.08 mm vs 11.73 ± 2.08 mm; P < 0.01). Patients with obesity showed no significant differences in esophageal hiatus size with or without RE or HH. CONCLUSION The esophageal hiatus size increased with body mass index and was larger in patients with obesity than in those without obesity.