H. Worth Boyce

Endoscopic definitions of esophagogastric junction regional anatomy

Precise endoscopic definitions of the anatomic features of the esophagogastric junction region are essential before accurate diagnosis and local treatments of pathologic disorders will be optimum. In spite of much confusion regarding the endoscopic and radiographic anatomy, there have been few reports on definitions of this area of endoscopic anatomy. Unfortunately, the incorrect uses of the terms esophagogastric (muscular) junction (EGJ) and squamocolumnar (mucosal) junction (SCJ) as synonyms have created considerable misunderstanding in both written and oral medical communication. EGJ is best used as the correct term for the static, mural muscular junction between esophagus and stomach, whereas the SCJ is specific for the circumferential margin of contact between the two types of mucosa, esophageal squamous and gastric columnar. The normal SCJ may vary in contour, but its level of location relative to the EGJ, i.e., proximal margin of the gastric folds, is constant in the normal esophagus (Fig. 1). The purpose of this presentation is to review definitions derived from observations (and obvious interpretational bias) developed over 38 years of endoscopic examinations of the EGJ and SCJ.1-5 Some redundancy in narrative descriptions is necessary, but hopefully this repetition may assist in a better understanding of these endoscopic definitions.

The Plasma and Red Cell Vitamin B Levels of Chronic Hemodialysis Patients: A Longitudinal Study

Plasma B12, folate, B6 and thiamine, and red blood cell folate, thiamine and niacin levels were monitored for a period of 6 months in 15 clinically stable, chronic hemodialysis patients who were not supplemented with the water-soluble vitamins. Microbiological assays were used to determine the blood levels of the water-soluble vitamins. Over the period of 6 months, none of the patients had plasma or red cell vitamin levels below the normal range. No appreciable changes were observed in the plasma and red blood cell vitamin levels before and after dialysis in 5 patients. This study showed that chronic hemodialysis patients are able to maintain normal plasma and red cell levels of some water-soluble vitamins without daily supplementation.

Dilation of Difficult Benign Esophageal Strictures

A large experience with management of a variety of esophageal strictures has taught me that all strictures are not created equal! My observations suggested the need to classify strictures as a guide to therapy. Technique, equipment, and goal for diameter of lumen restoration were altered to suit the etiology and pathology of the stricture. I determine the goal for dilation by using the patient’s dietary habits and nutritional needs as factors in the treatment plan. The plan for difficult esophageal strictures should not be simply scheduling the dilation.

Preoperative intervention does not affect esophageal muscle histology or patient outcomes in patients undergoing laparoscopic Heller myotomy

Botox injection and pneumatic dilation are common therapies for achalasia. We sought to determine the impact of these preoperative therapies on esophageal muscle histology and outcomes after laparoscopic Heller myotomy. A total of 73 consecutive patients had esophageal muscle biopsies taken from the gastroesophageal junction at the time of myotomy between November 1998 and November 2001. Muscle fibrosis was graded by a senior pathologist who was blinded to preoperative treatments and postoperative outcomes. Patients graded their dysphagia and heartburn symptoms before and after myotomy and graded their outcomes at follow-up. Patients were grouped according to the preoperative endoscopic treatment (dilation, Botox, both, or neither) and the groups were compared. Preoperative therapy did not correlate with esophageal fibrosis or postoperative outcomes, and the degree of esophageal muscle fibrosis was not predictive of outcome. Symptom scores improved significantly for dysphagia (4.5 ± 0.9 vs. 1.6 ± 1.6) and heartburn (2.3 ± 1.8 vs. 1.5 ± 1.4) irrespective of preoperative therapy or fibrosis. Overall, excellent or good outcomes were obtained in 92% of patients at follow-up of 15.7 months ± 14.4. Successful outcomes are highly probable after laparoscopic Heller myotomy regardless of preoperative interventions. The amount of fibrosis in the esophageal muscle is not related to preoperative intervention and is not predictive of outcomes.

The normal anatomy around the oesophagogastric junction: An endoscopic view

Where the oesophagus ends and the stomach begins has been a bone of contention for decades between the histologist, physiologist, gastroenterologist, radiologist and surgeon. The oesophagogastric junction (OGJ) is an important anatomical region because of its essential functions in relation to swallowing and as a site of structural defects, inflammation, metaplasia and neoplasia. The location of the diaphragmatic hiatus in relation to the distal oesophagus, the level of the squamocolumnar mucosal junction (SCJ), the location of the distal margin of the mucosal palisade veins and the proximal margin of the gastric mucosal folds are features that permit an accurate endoscopic diagnosis of hiatal hernia and reflux sequelae, including even a minimal extent for Barretts oesophagus. The physiological OGJ region can be considered to be between the rosette of the lower oesophageal sphincter (LOS) and the angle of His. The most reliable benchmarks for the precise mural OGJ that can be identified during endoscopy are the levels of the cephalad margins of the linear gastric mucosal folds, viewed with the lumen deflated as much as possible, that are juxtaposed to the level of the caudad extent of the oesophageal mucosal palisade veins.

Endoscopic lumen restoration for obstructive aphagia: outcomes of a 25-year experience

BACKGROUND After chemoradiation therapy for head/neck cancer, some patients develop strictures that progress to complete pharyngoesophageal occlusion. Total lumen occlusion is less often due to other conditions. Enteral access (enterostomy tube) and good nutritional status tend to minimize the significance of dysphagia and therefore may mask recognition of impending complete lumen occlusion. OBJECTIVE Review outcomes of a 25-year experience with endoscopic lumen restoration (ELR) in 30 patients. DESIGN Retrospective, case review study. SETTING Two tertiary-care referral centers. PATIENTS This study involved 30 consecutive patients referred for obstructive aphagia due to complete lumen occlusion, primarily after chemoradiation therapy for head/neck cancer. INTERVENTION Antegrade and retrograde endoscopy with tri-plane fluoroscopy for penetrating the occluded segment, serial retrograde and antegrade dilations, plus swallowing rehabilitation therapy. MAIN OUTCOME MEASUREMENTS Restoration of lumen patency, swallowing function, and removal of enteral feeding tube. RESULTS ELR was successful in 30 patients in 31 of 33 attempts (93%). Return to soft to regular diet was achieved in 15 of 30 patients (50%), and fluids to pureed food with partial percutaneous endoscopic gastrostomy nutrition was achieved in 5 of 30 patients (17%). Ten of 30 patients (33%) were considered unsafe for oral feeding because of oropharyngeal neuromotor deficits. Complications occurred in 5 of 30 patients (17%), with no prolonged sequelae, deaths, or surgery, but two stents were placed for anastomotic fistulas. The median duration of follow-up was 22.75 months. LIMITATIONS Retrospective, case review study. CONCLUSION ELR by using tri-plane fluoroscopic guidance with antegrade and retrograde endoscopy and serial dilations allows lumen restoration and swallowing to some degree in a majority of patients. Engagement of a core team of specialists can provide optimal restoration of swallowing function.

Approaches to Management of Cancer of the Esophagus

While at best the prognosis is grim, inoperability of the tumor should not be a signal to abandon the patient. It has now been demonstrated that radiotherapy, in combination with a number of new peroral techniques of esophageal dilation and prosthesis placement, not only provides symptomatic relief but spares the patient exposure to the substantial morbidity and mortality of surgery.

Dietary Management of Gastrointestinal Disorders

Transit, digestion and absorption of food represent a complex interplay of mechanisms by which the body alters food into suitable form to permit its utilization. Conversely, food may alter the body by its effects on the gastrointestinal tract. In the daily exercise to maintain adequate nutrition and satiation, man constantly is exposing himself to a variety of nutritious and non-nutritious chemical agents. Gastrointestinal dieto-therapy is designed to direct the patient to a proper diet to promote health and prevent injury. This may consist of the avoidance of foods that in certain persons may cause illness, or alternatively, dietotherapy may be used as a guide to certain eating habits that likely will improve intestinal function.