Defining the Position of the Right Wall of the Esophageal Hiatus to Identify the Circumferential Distribution of Small Lesions of the Lower Esophagus

Abstract

Background: The reliability of methods to identify the circumferential position of small lower esophageal lesions remains unknown. We prospectively investigated a new method for distinctively presenting lesion positions as times on a clock face. Methods: Eighty-seven patients were consecutively examined by endoscopy. After observing the esophagus, an endoscope was inserted into the stomach and fixed, setting the greater curvature folds at the upper gastric corpus horizontal on the endoscope monitor display. The scope was retrogressed into the lower esophagus. At this point, the right wall at the hiatus may be at the 3 o'clock position (R-line). The scope was then retrogressed from the gastric angle to the cardia along the center of the lesser curvature in the retroflexed view to obtain the LC-line (the center of the lesser curvature at the cardia). The LC-line in the esophageal hiatus in the frontal view was then identified. The angle between the R-and LC-lines (R-LC) was measured. Results: Seventy-seven patients were examined after excluding 7 with >2-cm hernias and 3 with esophageal stenosis. R-LC angles ranged between −38° and +35°. The mean R-LC angle was −0.3° ± 15.9° and its 95% confidence interval was [−4.0°, 3.3°] within [−15°, + 15°]. When indicating lesion locations as times on a clock face, there may be an error of ±30 min (±15°); therefore, R-and LC-lines were demonstrated to be identical using an equivalence test. Conclusions: Using this method, the circumferential position of small lower esophageal lesions may be reliably represented as a clock face.

Orientation of Lower Esophageal Sphincter Pressure Using Three-Dimensional High-Resolution Manometry in Patients with Achalasia: A Pilot Study

“…Furthermore, the directional relationships between the orientations of the LES high-and low-pressure zones revealed that the low-pressure zones of the LES were located on the opposite side of the highpressure zones in many patients of this study. According to reports describing the circumferential distribution of mucosal breaks in patients with reflux esophagitis, mucosal breaks were most frequently observed from the lesser curvature side to the anterior wall side or from the lesser curvature side to the posterior wall side of the EGJ [14][15][16] . In addition, studies of the circumferential distribution of Barrett's mucosa also showed that Barrett's mucosa was most frequently observed on the lesser curvature side of the EGJ 17,18 .…”

Evaluation of the circumferential location of mild reflux esophagitis (Grade A and B) in the lower esophagus

“…In our method to evaluate the circumferential location of small lower esophageal lesions, 4 the 3 o'clock direction in the endoscopic view was clarified to fall on the right lateral wall of the lower esophagus (along the extension of the center line of the lesser curvature of the stomach) with sufficient clinical accuracy. This method showed mucosal breaks in the single lesion group from the right lateral to posterior wall and 50% of solitary lesions were distributed in the 3 o'clock direction (Table 2 , Fig.…”

“…The endoscope was then inserted into the stomach, immediately fixed in a position where the fold of the greater curvature in the upper body of the stomach appeared horizontal (3 o'clock direction) on the monitor screen, and then gradually withdrawn to the lower esophagus while recording images. During this procedure, the 3 o'clock direction was the direction of the right lateral wall of the lower esophagus to the hiatus, that is, the lesser curvature of the stomach 4 . When the endoscope was withdrawn from the stomach to the esophagus, the scope was inserted again into the stomach from the esophagus to confirm the horizontal position of the folds of the greater curvature on the monitor.…”

“…During this procedure, the 3 o'clock direction was the direction of the right lateral wall of the lower esophagus to the hiatus, that is, the lesser curvature of the stomach. 4 When the endoscope was withdrawn from the stomach to the esophagus, the scope was inserted again into the stomach from the esophagus to confirm the horizontal position of the folds of the greater curvature on the monitor.…”

“…We developed a method to manipulate the endoscope by orienting it in the 3 o'clock direction (right lateral wall) from the esophageal hiatus to the lower esophagus along the extension of the center line of the lesser curvature of the stomach. 4 Therefore, the circumferential locations of small lesions may be easily detected with sufficient clinical accuracy.…”