The Relationship of Anatomical Localizations of Hiatal Clamp and Oesophagogastric Junction with Body Mass Index / Relación entre las Localizaciones Anatómicas de la Pinza Hiatal y la Unión Esofagogástrica con el Índice de Masa Corporal

SUMMARY: In our study, we aimed to reveal the relationship between the anatomical localizations measured and the Body Mass Index (BMI) in patients scheduled for upper gastrointestinal endoscopy. In this study, anatomical localizations of the hiatal clamp and oesophagogastric junction in 189 female and 137 male patients who applied to the hospital with different gastrointestinal system complaints and underwent esophagogastroduodenoscopy (EGD) were investigated depending on BMI. In addition, the data were compared with the patients' complaints before EGD and the diagnoses they received after EGD. SPSS Statistics 22 (IBM Corp. Turkey) program was used for statistical analysis and p0.05). On the other hand, it was determined that the hiatal clamp distance and the distance of the oesophagogastric junction increased as the height and weight increased (p38. As a result of the study, it can be said that BMI values, hiatal clamp distance and oesophagogastric junction localizations may change in relation to height and weight.

En este estudio, buscamos revelar la relación entre las localizaciones anatómicas y el Índice de Masa Corporal (IMC) en pacientes programados para endoscopía digestiva alta. Se investigaron las localizaciones anatómicas de la pinza hiatal y la unión esofagogástrica en 189 mujeres y 137 hombres que acudieron al hospital con diferentes problemas del sistema gastrointestinal los cuales fueron sometetidos a una esofagogastro- duodenoscopia (EGD) dependiendo del IMC. Además, los datos se compararon con las quejas de los pacientes antes de la EGD y los diagnósticos que recibieron después de la EGD. Se utilizó el programa SPSS Statistics 22 (IBM Corp. Turquía) para el análisis estadístico y el valor de p0,05). Por otro lado, se determinó que la distancia de la pinza hiatal y la unión esofagogástrica aumentaba con la altura y el peso corporal (p38. Como resultado del estudio, se puede decir que los valores de IMC, la distancia de pinzamiento hiatal y las localizaciones de la unión esofagogástrica pueden cambiar en relación con la altura y el peso.

Reconstruction of the Gastro-esophageal Junction Based on Ultramill Imaging for Biomechanical Analysis.

The gastro-esophageal junction (GEJ) regulates the entry of food into the stomach and prevents reflux of acidic gastric contents into the lower esophagus. This is achieved through multiple mechanisms and the maintenance of a localized high-pressure zone. Diseases of the GEJ typically involve impairments to its muscular functions and often are accompanied by symptoms of reflux, heartburn, and dysphagia. This study aimed to develop a finite element-based model from a unique human cadaver GEJ data reconstructed from an ultramill imaging setup. A pipeline was developed to generate a mesh from an input stack of images. The anatomy of the model was compared to an existing Visible Human finite element GEJ model. Biomechanical simulations were also performed on both models using loading steps of differing levels of calcium to model different levels of contraction. It was found that the ultramill GEJ model is shorter than the Visible Human model (31 vs 48.3 mm), as well as producing lower pressure (1.35 vs 4.36 kPa). The model will be used to investigate detailed pressure development in the GEJ during swallowing under realistic loading conditions. Clinical Relevance - The modeling of the GEJ would allow further insights into pressure influencing factors and aid in the development and testing of treatments.

Histologic Study of the Esophagogastric Junction of Organ Donors Reveals Novel Glandular Structures in Normal Esophageal and Gastric Mucosae.

INTRODUCTION: Whether cardiac mucosa at the esophagogastric junction is normal or metaplastic is controversial. Studies attempting to resolve this issue have been limited by the use of superficial pinch biopsies, abnormal esophagi resected typically because of cancer, or autopsy specimens in which tissue autolysis in the stomach obscures histologic findings. METHODS: We performed histologic and immunohistochemical studies of the freshly fixed esophagus and stomach resected from 7 heart-beating, deceased organ donors with no history of esophageal or gastric disease and with minimal or no histologic evidence of esophagitis and gastritis. RESULTS: All subjects had cardiac mucosa, consisting of a mixture of mucous and oxyntic glands with surface foveolar epithelium, at the esophagogastric junction. All also had unique structures we termed compact mucous glands (CMG), which were histologically and immunohistochemically identical to the mucous glands of cardiac mucosa, under esophageal squamous epithelium and, hitherto undescribed, in uninflamed oxyntic mucosa throughout the gastric fundus. DISCUSSION: These findings support cardiac mucosa as a normal anatomic structure and do not support the hypothesis that cardiac mucosa is always metaplastic. However, they do support our novel hypothesis that in the setting of reflux esophagitis, reflux-induced damage to squamous epithelium exposes underlying CMG (which are likely more resistant to acid-peptic damage than squamous epithelium), and proliferation of these CMG as part of a wound-healing process to repair the acid-peptic damage could result in their expansion to the mucosal surface to be recognized as cardiac mucosa of a columnar-lined esophagus.

Esophagogastric junction morphology and contractile integral on high-resolution manometry in asymptomatic healthy volunteers: An international multicenter study.

BACKGROUND: Esophagogastric junction contractile integral (EGJ-CI) and EGJ morphology are high-resolution manometry (HRM) metrics that assess EGJ barrier function. Normative data standardized across world regions and HRM manufacturers are limited. METHODS: Our aim was to determine normative EGJ metrics in a large international cohort of healthy volunteers undergoing HRM (Medtronic, Laborie, and Diversatek software) acquired from 16 countries in four world regions. EGJ-CI was calculated by the same two investigators using a distal contractile integral-like measurement across the EGJ for three respiratory cycles and corrected for respiration (mm Hg cm), using manufacturer-specific software tools. EGJ morphology was designated according to Chicago Classification v3.0. Median EGJ-CI values were calculated across age, genders, HRM systems, and regions. RESULTS: Of 484 studies (28.0 years, 56.2% F, 60.7% Medtronic studies, 26.0% Laborie, and 13.2% Diversatek), EGJ morphology was type 1 in 97.1%. Median EGJ-CI was similar between Medtronic (37.0 mm Hg cm, IQR 23.6-53.7 mm Hg cm) and Diversatek (34.9 mm Hg cm, IQR 22.1-56.1 mm Hg cm, P = 0.87), but was significantly higher using Laborie equipment (56.5 mm Hg cm, IQR 35.0-75.3 mm Hg cm, P < 0.001). 5th percentile EGJ-CI values ranged from 6.9 to 12.1 mm Hg cm. EGJ-CI values were consistent across world regions, but different between manufacturers even within the same world region (P ≤ 0.001). Within Medtronic studies, EGJ-CI and basal LESP were similar in younger and older individuals (P ≥ 0.3) but higher in women (P < 0.001). CONCLUSIONS: EGJ morphology is predominantly type 1 in healthy adults. EGJ-CI varies widely in health, with significant gender influence, but is consistent within each HRM system. Manufacturer-specific normative values should be utilized for clinical HRM interpretation.

El diafragma, el hiato y la unión gastroesofágica / The diaphragm, the hiatus and the gastroesophageal junction

RESUMEN La unión del tubo esofágico con el estómago en lo que denominamos el cardias, su tránsito y relacio nes con el hiato diafragmático, las estructuras fibromembranosas que la fijan y envuelven, la existencia de un esfínter gastroesofágico anatómico y su real morfología, así como la interacción de todos estos elementos, han sido materia de controversia por décadas y aún hoy. Este artículo actualiza la descrip ción de tales estructuras.

ABSTRACT The point where the esophagus connects to the stomach, known as the cardia, its transition and re lationship with the diaphragmatic hiatus, its fibromembranous attachments, the existence of an ana tomic gastroesophageal sphincter and its real morphology, and the interaction between all these ele ments, have been subject of debate for decades that still persist. The aim of this article is to describe the updated information of such structures.

Laparoscopic fundoplication and new aspects of neural anatomy at the oesophagogastric junction.

BACKGROUND: In fundoplication, mobilization of the distal oesophagus and proximal stomach is essential to obtain a sufficient tension-free intra-abdominal oesophageal length for creation of an efficient antireflux barrier. Most surgical literature and anatomical illustrations do not describe nerve branches running from the diaphragm to the stomach. After observing small nerve branches at laparoscopic fundoplication, penetrating the left crus of the diaphragm lateral to the hiatus and apparently running into the stomach, an anatomical cadaver study was undertaken to identify the origin and target organ of these nerves. METHODS: Fifty-three human cadavers (23 men, 30 women; age range 35-103 years) were dissected with special attention to the nerves that penetrate the left crus of the diaphragm. The entire course of these nerves was documented with standardized drawings and photos. RESULTS: Small nerve branches penetrating the diaphragm lateral to the left crus of the hiatus were found in 17 (32 per cent) of the 53 cadavers. In 14 of these 17 cadavers, one or two splanchnic nerve branches were identified, and in ten of the 17 the nerve branches were found to be phrenic nerves. In seven of these 17 cadavers, two different nerve branches were found and assigned to both splanchnic and phrenic nerves. CONCLUSION: Nerves penetrating the left crus with splanchnic origin or phrenic origin have been identified. Their function remains unclear and their relationship to postfundoplication symptoms remains to be determined.

ANTECEDENTES: A la hora de realizar una fundoplicatura, la movilización del esófago distal y del estómago proximal es esencial para obtener una longitud de esófago intraabdominal suficiente y sin tensión para crear una barrera antirreflujo eficiente. La mayoría de la literatura quirúrgica y de las ilustraciones anatómicas no describen unas ramas nerviosas que discurren desde el diafragma al estómago. Tras observar pequeñas ramas nerviosas durante la realización de una fundoplicatura laparoscópica que penetran la crura izquierda del diafragma lateral al hiato y que aparentemente discurren hacia el estómago, se llevó a cabo un estudio anatómico en cadáver para identificar el origen y el órgano diana de estos nervios. MÉTODOS: Se diseccionaron 53 cadáveres humanos (23 varones, 30 mujeres, rango de edad: 35-103 años) con especial atención hacia los nervios que penetran la crura izquierda del diafragma. Se documentó el recorrido completo de estos nervios con fotos y dibujos de una forma estandarizada. RESULTADOS: En 17 (32%) de 53 cadáveres se hallaron pequeñas ramas nerviosas que penetraban el diafragma lateral a la crura izquierda del hiato. En 14 cadáveres (de los 17) se identificaron una o dos ramas nerviosas esplácnicas, y en 10 de los 17 cadáveres las ramas nerviosas que se hallaron resultaron ser nervios frénicos. En 7 de estos 17 cadáveres, se hallaron dos ramas nerviosas diferentes y se asignaron a ambos nervios, esplácnicos y frénicos. CONCLUSIÓN: Se han identificado los nervios que penetran la crura izquierda con un origen esplácnico y frénico. Sus funciones están por aclarar, así como su relación con los síntomas que aparecen tras la fundoplicatura.

Laparoscopic Collis-Nissen approach for shortened esophagus treatment in children.

BACKGROUND: Short esophagus is a disability to obtain a proper portion of abdominal esophagus, thus a lengthening technique is required. Collis approach is the best option. OBJECTIVE: To demonstrate effectiveness of laparoscopic Collis-Nissen approach in children. METHOD: Retrospective and descriptive case series performed in children with reflux and short esophagus, Collis esophagoplasty was carried out with stapler, together with fundoplication. Age, symptomatology, surgical background, oral nutrition beginning, hospital stay, complications and reflux control were recorded. RESULTS: Eight children, 4-15 years old were treated from 2005 to 2017. Three of them with slipped fundoplication background and two with esophageal atresia. The rest of the children had no background, two of them with stenosis. Symptoms; cough 8/8, abdominal pain 5/8, dysphagia 3/8. Without complications. Oral nutrition beginning at the 5th day. Up to 10 years follow-up, with complete remission of the symptomatology in 6 years. DISCUSSION: Since a true short esophagus diagnosis depends on transurgical findings, pediatric surgeons should notice this entity when practicing any antireflux procedure. Laparoscopic Collis-Nissen approach is safe and efficient in these patients.

ANTECEDENTES: El esófago corto es la imposibilidad de obtener una porción adecuada de esófago abdominal, por lo que se requiere alguna técnica de alargamiento. La mejor opción es el procedimiento de Collis. OBJETIVO: Demostrar la eficacia del procedimiento de Collis-Nissen por laparoscopía en niños. MÉTODO: Estudio retrospectivo, descriptivo, serie de casos, niños con reflujo y esófago corto, esofagoplastía de Collis con engrapadora y funduplicatura. Se analizaron edad, sintomatología, antecedentes quirúrgicos, tiempo quirúrgico, inicio de vía oral, tiempo de hospitalización, complicaciones y control del reflujo. RESULTADOS: De 2005 a 2017 se trataron ocho niños de 4 a 15 años. De ellos, tres con antecedente de funduplicatura deslizada y dos con antecedente de atresia esofágica. El resto sin antecedentes, dos con estenosis. Síntomas; tos 8/8, dolor abdominal 5/8, disfagia 3/8. Sin complicaciones. Inició de vía oral al quinto día. Seguimiento de hasta 10 años, con remisión total de la sintomatología en seis casos. DISCUSIÓN: Debido a que el diagnóstico de esófago corto verdadero depende de los hallazgos transoperatorios, los cirujanos pediatras deben reconocer esta condición al momento de practicar cualquier procedimiento antirreflujo. El procedimiento de Collis-Nissen laparoscópico es una opción segura y eficaz en estos pacientes.

Revisiting the infracardiac bursa using multimodal methods: topographic anatomy for surgery of the esophagogastric junction.

In embryology, the infracardiac bursa (ICB) is a well-known derivative separated from the omental bursa. During surgeries around the esophagogastric junction (EGJ), surgeons often encounter a closed space considered to be equivalent to the ICB, but the macroscopic anatomy in adults is hardly known. This study aimed to revisit the ICB using multimodal methods to show its development from the embryonic to adult stage and clarify its persistence and topographic anatomy. Histological sections of 79 embryos from Carnegie stage (CS) 16 to 23 and magnetic resonance (MR) images of 39 fetuses were examined to study the embryological development of the ICB. Horizontal sections around the EGJ obtained from three adult cadavers were examined to determine the topographic anatomy and histology of the ICB. Further, 32 laparoscopic surgical videos before (n = 16) and after (n = 16) the start of this study were reviewed to confirm its remaining rate and topographic anatomy in surgery. The ICB was formed in 1 out of 10 CS17 samples, and in 8 out of 10 CS18 samples. Further, it was observed in all CS19-23 except one CS23 sample and in 25 (64%) out of 39 fetus samples. Three-dimensional reconstructed MR images of fetuses revealed that the ICB was located at the right alongside the esophagus and the cranial side of the diaphragmatic crus. In one adult cadaver, the caudal end of the ICB arose from the level of the esophageal hiatus and the cranial end reached up to the level of the pericardium. The inner surface cells of the space consisted of the mesothelium. In laparoscopic surgery, the ICB was identified in only 11 (69%) out of 16 surgeries before. However, subsequently we were able to identify the ICB reproducibly in 15 (94%) out of 16 surgeries. Thus, the ICB is the structure commonly remaining in almost all adults as a closed space located at the right alongside the esophagus and the cranial side of the diaphragmatic crus. It may be available as a useful landmark in surgery of the EGJ.

[The large hiatal hernia should be acknowledged and respected]. / Det stora hiatusbråcket ­ kräver stor uppmärksamhet och respekt - Vanligt och ofta asymtomatiskt tillstånd som snabbt kan bli potentiellt livshotande.

A hiatal hernia is a partial or total dislocation of the stomach, sometimes together with other intraabdominal organs, through the diaphragmatic esophageal hiatus into the thoracic cavity. The condition is common and often asymptomatic. Old age and obesity are risk factors for developing hiatal hernia. Small hernias might induce gastroesophageal reflux, which usually is satisfactorily treated pharmacologically. Larger hiatal hernias are more often associated with obstructive symptoms including dysphagia, vomiting or discomfort/pain due to compression of adjacent organs/tissues. In severe cases, large hiatal hernias may become incarcerated with ischemia in herniated tissues and need of acute surgical intervention. The risk of complications in association with operation for large hiatal hernias is high, particularly in acute surgery and in elderly patients with co-morbidities.

Analysis of computed tomographic findings according to gastroesophageal flap valve grade.

BACKGROUND/AIMS: The gastroesophageal junction is an important barrier against gastroesophageal ref lux. Endoscopic grading of gastroesophageal f lap valve is simple, reproducible, and may predict reflux activity. We investigated the correlation between gastroesophageal flap valve grade and the gastroesophageal junction's structural properties using abdominal computed tomography. METHODS: A total of 138 patients with early gastric cancer who underwent both pre-treatment esophagogastroduodenoscopy and water-distended stomach two-phase computed tomography were enrolled. Endoscopic gastroesophageal f lap valve grade and abdominal computed tomography findings were analyzed to assess anatomical factors including the gastroesophageal junction and related organs. RESULTS: The angle of His increased significantly with gastroesophageal flap valve grade (grade I, 65.2˚ ± 19.6˚; grade II, 66.6˚ ± 19.8˚; grade III, 76.7˚ ± 11.9˚; grade IV, 120.0˚ ± 30.3˚; p < 0.001), as did the size of the diaphragmatic hiatus (grade I, 213.0 ± 53.8 mm2 ; grade II, 232.6 ± 71.0 mm2 ; grade III, 292.3 ± 99.2 mm2 ; grade IV, 584.4 ± 268.3; p < 0.001). The length of the abdominal esophagus decreased as gastroesophageal flap valve grade increased (grade I, 34.6 ± 5.8 mm; grade II, 32.0 ± 6.5 mm; grade III, 24.6 ± 7.8 mm; grade IV, -22.6 ± 38.2 mm; p < 0.001). There was no significant relationship between gastroesophageal flap valve grade and visceral and subcutaneous fat areas (p = 0.877 and p = 0.508, respectively). CONCLUSIONS: Endoscopic grading of the gastroesophageal flap valve is well correlated with anatomical changes around the gastroesophageal junction on abdominal computed tomography, and it can provide useful information about the anti-reflux barrier.

Anatomical and functional deficiencies of the crural diaphragm in patients with esophagitis.

BACKGROUND: Inspiratory esophagogastric junction (EGJ) pressure is lower in gastroesophageal reflux disease (GERD) and patients fail to increase EGJ pressure during the inspiratory effort. The aim of this study was to assess the EGJ activity during inspiratory maneuvers (high-resolution manometry, HRM) and the crural diaphragm (CD) thickness (endoscopic ultrasound, EUS) in GERD. METHODS: Twenty esophagitis patients (average age 45 years, 7 grade A, 13 grade B) had HRM and EUS. Forty-three controls were recruited; 30 had HRM (average age 33 years), and 13 had EUS (average age 40 years). The EGJ contractility index (EGJ-CI) (mm Hg×cm) was measured during normal respiration and two inspiratory maneuvers: without and with inspiratory loads of 12, 24, and 48 cmH2 O (TH-maneuvers). A composite metric for TH-maneuvers ("EGJ total activity") was defined as the product of the maximal EGJ pressure and the length of its aboral excursion during the maneuver (mm Hg×cm). The CD thickness (cm) was measured during expiration (12 MHz). KEY RESULTS: Expiratory lower esophageal sphincter pressure and integrated relaxation pressure were lower in GERD. The EGJ-CI and the "EGJ total activity" were lower in GERD during TH-maneuvers (48-cmH2 O load: 168.4 ± 13.8 vs 114.8 ± 9.6, P=.006). Patients failed to sustain the inspiratory CD activity across the 12 and 48-cmH2 O efforts. The CD was thinner in GERD patients (0.37 ± 0.03 vs 0.49 ± 0.04, P=.02). The CD thickness correlated with the increment in the "EGJ total activity" in GERD without a hiatal hernia (r=.702, P=.016, n=11). CONCLUSIONS & INFERENCES: There are anatomical changes and functional failure of the CD in esophagitis patients supporting the possibility of a skeletal muscle deficiency in GERD.

The normal squamocolumnar junction is circumferentially even and minimal irregularities are manifestations of gastroesophageal acid reflux.

BACKGROUND: The macroscopic appearance of the normal squamocolumnar junction (SCJ) is often described as serrated with short projections of columnar mucosa that extend into the esophagus. As studies of the normal SCJ are sparse, the aim of this study was to test the hypothesis that the normal SCJ is even and that irregularities are manifestations of acid reflux. METHOD: Fifty asymptomatic subjects and 149 patients with symptoms suggestive of gastroesophageal reflux disease underwent endoscopy and 48-h pH monitoring with a pH electrode positioned immediately above the SCJ. The shape of the SCJ was assessed according to the Z-line appearance classification and correlated with clinical characteristics and the degree of esophageal acid exposure in the most distal esophagus. RESULTS: Even SCJs without irregularities were significantly more common in asymptomatic subjects compared with patients (50% versus 10%, p < .001) and were never found in patients with erosive esophagitis. The median degree of distal esophageal acid exposure in individuals with an even SCJ was within normal limits. With increasing degree of irregularity of the SCJ, the frequency and duration of reflux episodes, the degree of distal esophageal acid exposure, and the prevalence of abnormal acid exposure increased progressively and significantly. CONCLUSION: The shape of the normal SCJ is even and also minimal irregularities are a consequence of acid reflux, likely due to the formation of small areas of metaplastic columnar mucosa.

Classification for esophagogastric junction (EGJ) complex based on physiology.

We propose a new classification for esophagogastric junction (EGJ) incorporating both physiologic and morphologic characteristics. Additionally, we contrast it with the Chicago v 3.0 EGJ classification. With Institutional Review Board (IRB) approval, prospectively maintained database was queried to identify patients who underwent high-resolution manometry (HRM) and pH-study between October 2011 and October 2015. Patients with prior foregut intervention, pH study on acid suppression, esophageal dysmotility, or lower esophageal sphincter-crural diaphragm separation of >5 cm were excluded. We classified patients into three groups-Type-A: Complete overlap of lower esophageal sphincter-crural diaphragm (single high-pressure zone); Type-B: Double high-pressure zone with pressure inversion point (PIP) at or above lower esophageal sphincter; Type-C: Double high-pressure zone with PIP below lower esophageal sphincter. A total of 214 included patients were divided into Type-A (n = 101), Type-B (n = 32), and Type-C (n = 81). Abdominal lower esophageal sphincter length (AL), lower esophageal sphincter pressure (LESP), and lower esophageal sphincter pressure integral (LESPI) were significantly lower in Type-C than both Type-A and Type-B [AL(cm): 0.2 vs. 2(P < 0.001) vs. 1.6(P <0.001); LESP(mmHg): 20.1 vs. 32.1(P < 0.001) vs. 29.2(P < 0.001); LESPI(mmHg.cm.s): 187 vs. 412(P < 0.001) vs. 343(P < 0.05)] while overall lower esophageal sphincter length(OL) and Integrated Relaxation Pressure (IRP) were significantly lower in Type-C than Type-A [OL(cm): 2.9 vs. 3.6(P < 0.001); IRP(mmHg): 8.2 vs. 9.6(P < 0.05)]. Type-C patients had significantly higher positive pH score (>14.7) than Type-A and Type-B [72% vs. 47% (P < 0.05) vs. 41% (P < 0.001)]. In Type-C morphology, there is both anatomical and physiological deterioration, weakest lower esophageal sphincter function (abdominal length, lower esophageal sphincter pressure, and lower esophageal sphincter pressure integral) and is most likely to be associated with pathological reflux. This proposed classification incorporates both physiological and morphological derangements in a graded fashion.

Cáncer de esófago: particularidades anatómicas, estadificación y técnicas de imagen / Esophageal cancer: anatomic particularities, staging, and imaging techniques

El cáncer de esófago es un tumor de comportamiento agresivo, que suele diagnosticarse en etapas avanzadas. La ausencia de serosa permite su rápida propagación a estructuras vecinas del mediastino, y una extensa red de drenaje linfático facilita la diseminación tumoral incluso en estadios precoces. La actual clasificación TNM, armonizada con la del cáncer gástrico, proporciona nuevas definiciones en la clasificación anatómica, añade características no anatómicas del tumor e incluye los tumores de la unión esofagogástrica. La mayor precisión en la determinación del estadio clínico inicial se obtiene con la combinación de ecoendoscopia, TC, PET-TC y RM, que desempeñan un papel esencial en la elección, la planificación y la evaluación del tratamiento. En este artículo repasamos algunas particularidades que explican el comportamiento de este tumor, revisamos la estadificación TNM actual y presentamos las distintas pruebas de imagen de que disponemos en la actualidad para su evaluación, incluyendo un algoritmo de diagnóstico (AU)

Cancer of the esophagus is a tumor with aggressive behavior that is usually diagnosed in advanced stages. The absence of serosa allows it to spread quickly to neighboring mediastinal structures, and an extensive lymphatic drainage network facilitates tumor spread even in early stages. The current TNM classification, harmonized with the classification for gastric cancer, provides new definitions for the anatomic classification, adds non-anatomic characteristics of the tumor, and includes tumors of the gastroesophageal junction. Combining endoscopic ultrasound, computed tomography, positron emission tomography, and magnetic resonance imaging provides greater accuracy in determining the initial clinical stage, and these imaging techniques play an essential role in the selection, planning, and evaluation of treatment. In this article, we review some particularities that explain the behavior of this tumor and we describe the current TNM staging system; furthermore, we discuss the different imaging tests available for its evaluation and include a diagnostic algorithm (AU)

Normal and abnormal physiology, pharmacology, and anatomy of the gastroesophageal junction high-pressure zone.

The high-pressure zone of the gastroesophageal junction acts as a multifunctional valve that comprises different groups of smooth muscles located in the distal esophagus and the proximal stomach, in addition to the extrinsic crural diaphragm, composed of skeletal muscle. In this review article, we evaluate the current literature with respect to human subjects, discussing the anatomic locations and physiologic and pharmacologic processes controlling these muscles. These muscles work individually and as a group to prevent reflux of gastric contents while allowing anterograde passage of food and liquid and retrograde passage of gas. We also reviewed new findings with respect to abnormalities that are permissive of reflux of gastric contents into the esophagus, which may lead to gastroesophageal reflux disease.

The virtual esophagus: investigating esophageal functions in silico.

Esophageal and gastroesophageal junction (GEJ) diseases are highly prevalent worldwide and are a significant socioeconomic burden. Recently, applications of multiscale mathematical models of the upper gastrointestinal tract have gained attention. These in silico investigations can contribute to the development of a virtual esophagus modeling framework as part of the larger GIome and Physiome initiatives. There are also other modeling investigations that have potential screening and treatment applications. These models incorporate detailed anatomical models of the esophagus and GEJ, tissue biomechanical properties and bolus transport, sensory properties, and, potentially, bioelectrical models of the neural and myogenic pathways of esophageal and GEJ functions. A next step is to improve the integration between the different components of the virtual esophagus, encoding standards, and simulation environments to perform more realistic simulations of normal and pathophysiological functions. Ultimately, the models will be validated and will provide predictive evaluations of the effects of novel endoscopic, surgical, and pharmaceutical treatment options and will facilitate the clinical translation of these treatments.

[What is the esophagogastric junction?].

The esophagogastric junction is a muscle, not a mucosal, junction. The boundary of the esophagus is at the upper esophageal sphincter and lower esophageal sphincter (LES) at the oral and anal ends, respectively. The distal end of the LES is the esophagogastric junction. Fine palisade vessels occur in the mucosa above the LES, and the esophagogastric junction is at the distal end of this palisade zone. The esophagogastric junction is defined as the part changing into the lumen seen in radiographic, examination or in surgically resected specimens. It is extremely difficult to identify the esophagogastric junction pathologically, requiring special effort.

Effect of baclofen on the acid pocket at the gastroesophageal junction.

Previous studies established that a pocket of highly acidic gastric juice is present postprandially at the gastroesophageal junction in man. The GABA-B agonist baclofen inhibits postprandial reflux events through its effects on the lower esophageal sphincter (LES). The aim of the current study was to investigate whether baclofen would affect the location and the extent of the postprandial acid pocket in healthy volunteers. Twelve healthy volunteers underwent acid pocket studies on two different occasions, at least 1 week apart. LES position was determined preprandially with pull-through manometry. Dual pH electrode and manometry probe stepwise pull-through (1 cm/minute, LES-10 to +5 cm) was performed at 30-minute intervals for 150 minutes, with administration of placebo or baclofen 40 mg after the first and ingestion of a liquid meal after the second pull-through. After placebo, a significant drop in intragastric gastric pH was present at the gastroesophageal junction after the meal, reflecting the acid pocket, and this was associated with a drop in LES pressure. Baclofen did not affect the presence of the acid pocket, but prevented the postprandial drop in LES pressure, and the extent of the acid pocket above the upper margin of the manometrically located LES was significantly decreased by baclofen (1.6 ± 0.7 vs. 0.3 ± 0.4 cm at 60 minutes, 2.2 ± 0.6 vs. 0.2 ± 0.6 at 90 minutes, and 1.5 ± 0.5 vs. 0.7 ± 0.7 cm at 120 minutes, all P < 0.05). Baclofen does not alter the intragastric acid pocket, but limits its extension into the distal esophagus, probably through an increase in postprandial LES pressure.

The eminent anatomists who discovered the upper oesophageal sphincter.

OBJECTIVE: To discover the anatomist who first identified the upper oesophageal sphincter. METHOD: The authors searched dozens of antique anatomy textbooks kept in the old section of the 'Vincenzo Pinali' Medical Library of Padua University, looking for descriptions of the upper oesophageal sphincter. RESULTS: The oesophageal sphincter was drawn correctly only in 1601, by Julius Casserius, in the book De vocis auditusque organis historia anatomica… (which translates as 'An Anatomical History on the Organs of Voice and Hearing …'), and was properly described by Antonio Maria Valsalva in 1704 in the book De aure humana tractatus… ('Treatise on the Human Ear …'). CONCLUSION: Anatomists Casserius and Valsalva can be considered the discoverers of the 'oesophageal sphincter'.

Dextranomer hyaluronic acid copolymer effects on gastroesophageal junction.

OBJECTIVE: The outcomes of fundoplication for gastroesophageal reflux disease are suboptimal in many children, and alternatives are clearly needed. Dextranomer hyaluronic acid (DxHA) copolymer, an agent with proven efficacy in vesicoureteral reflux, was studied with respect to its effects on the gastroesophageal junction (GEJ). METHODS: Twelve New Zealand white rabbits underwent measurement of lower esophageal sphincter pressure followed by laparotomy and injection into the muscular layer of the GEJ (controls, 1.0 mL saline; low-dose DxHA [0.5 mL]; high-dose DxHA [1.0 mL]). After a 12-week survival period, the animals underwent manometry, sacrifice, and necropsy. Organs were examined histologically by pathologists blinded to the injection delivered. RESULTS: All animals survived. Weight gain was equal in the 3 groups. There was no significant difference in mean lower esophageal sphincter pressure from baseline in any group (control 2.3 mmHg [95% confidence interval, CI -3.3 to 7.9]; low-dose group 3.2 mmHg [95% CI -0.8 to 7.2]; high-dose group -4.0 mmHg [95% CI -18.95 to 10.95]). Histologically, DxHA injection produced an intramural implant, with a foreign body giant cell reaction, and fibroblastic infiltration with collagen deposition. High-dose injection did not consistently result in a qualitative increase in the magnitude of the reaction. There was no mucosal injury or luminal stenosis. CONCLUSIONS: In this first study evaluating the effects of DxHA injection at the GEJ, a histologic bulking effect was observed without obvious functional complications. The agent may have a role in the treatment of gastroesophageal reflux disease.