Diagnosis of Sliding Hiatal Hernia in Patients With Morbid Obesity: A Comparison of High-resolution Esophageal Manometry and Upper Gastrointestinal Series

Evidence regarding the diagnostic value of non-to-minimally invasive investigations for identifying sliding hiatal hernia (HH) in patients with morbid obesity is limited. Herein, we aimed to evaluate the diagnostic performance of preoperative high-resolution esophageal manometry (HREM) compared with that of upper gastrointestinal (UGI) series in this patient population. In this retrospective comparative-paired design study at a university hospital, we analyzed data from 149 consecutive patients with morbid obesity who underwent bariatric surgery (BS) between 2020 and 2024. All patients underwent preoperative workup, including HREM, UGI series, and esophagogastroduodenoscopy. Diagnostic performance was evaluated and compared between the diagnostic tests using intraoperative HH diagnosis as a reference standard. After excluding 12 patients, BS confirmed sliding HHs in 26 of 137 patients (19.0%). HREM showed a superior predictive capacity for identifying intraoperative HH than UGI series, showing area under the receiver operating characteristic curves of 0.93 (95% confidence interval [CI], 0.87-0.99; P < 0.01) and 0.63 (95% CI, 0.53-0.73; P < 0.01), respectively. Furthermore, HREM demonstrated significantly higher sensitivity (92.31% vs 42.31%), specificity (93.70% vs 83.78%), positive likelihood ratio (14.64; 95% CI, 7.09-30.24 vs 2.61; 95% CI, 1.41-4.83), and diagnostic accuracy (93.43% vs 75.91%) than UGI series (all P < 0.05). HREM identified a major esophageal motility disorder in 3/137 (2.2%) patients, which guided specific treatment before undergoing BS. No serious procedure-related complications occurred. HREM has high diagnostic performance in detecting sliding HH; thus, HREM should be considered as an important part of the preoperative work-up for patients with morbid obesity.