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Sugano K, Spechler SJ, El-Omar EM, McColl KEL, Takubo K, Gotoda T, Fujishiro M, Iijima K, Inoue H, Kawai T, Kinoshita Y, Miwa H, Mukaisho KI, Murakami K, Seto Y, Tajiri H, Bhatia S, Choi MG, Fitzgerald RC, Fock KM, Goh KL, Ho KY, Mahachai V, O'Donovan M, Odze R, Peek R, Rugge M, Sharma P, Sollano JD, Vieth M, Wu J, Wu MS, Zou D, Kaminishi M, Malfertheiner P. Kyoto international consensus report on anatomy, pathophysiology and clinical significance of the gastro-oesophageal junction. Gut 2022; 71:1488-1514. [PMID: 35725291 PMCID: PMC9279854 DOI: 10.1136/gutjnl-2022-327281] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/03/2022] [Indexed: 02/07/2023]
Abstract
OBJECTIVE An international meeting was organised to develop consensus on (1) the landmarks to define the gastro-oesophageal junction (GOJ), (2) the occurrence and pathophysiological significance of the cardiac gland, (3) the definition of the gastro-oesophageal junctional zone (GOJZ) and (4) the causes of inflammation, metaplasia and neoplasia occurring in the GOJZ. DESIGN Clinical questions relevant to the afore-mentioned major issues were drafted for which expert panels formulated relevant statements and textural explanations.A Delphi method using an anonymous system was employed to develop the consensus, the level of which was predefined as ≥80% of agreement. Two rounds of voting and amendments were completed before the meeting at which clinical questions and consensus were finalised. RESULTS Twenty eight clinical questions and statements were finalised after extensive amendments. Critical consensus was achieved: (1) definition for the GOJ, (2) definition of the GOJZ spanning 1 cm proximal and distal to the GOJ as defined by the end of palisade vessels was accepted based on the anatomical distribution of cardiac type gland, (3) chemical and bacterial (Helicobacter pylori) factors as the primary causes of inflammation, metaplasia and neoplasia occurring in the GOJZ, (4) a new definition of Barrett's oesophagus (BO). CONCLUSIONS This international consensus on the new definitions of BO, GOJ and the GOJZ will be instrumental in future studies aiming to resolve many issues on this important anatomic area and hopefully will lead to better classification and management of the diseases surrounding the GOJ.
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Affiliation(s)
- Kentaro Sugano
- Division of Gastroenterology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Stuart Jon Spechler
- Division of Gastroenterology, Center for Esophageal Diseases, Baylor University Medical Center, Dallas, Texas, USA
| | - Emad M El-Omar
- Microbiome Research Centre, St George & Sutherland Clinical Campuses, School of Clinical Medicine, Faculty of Medicine & Health, Sydney, New South Wales, Australia
| | - Kenneth E L McColl
- Division of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Kaiyo Takubo
- Research Team for Geriatric Pathology, Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan
| | - Takuji Gotoda
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Katsunori Iijima
- Department of Gastroenterology, Akita University Graduate School of Medicine, Akita, Japan
| | - Haruhiro Inoue
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Takashi Kawai
- Department of Gastroenterological Endoscopy, Tokyo Medical University, Tokyo, Japan
| | | | - Hiroto Miwa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo College of Medicine, Kobe, Japan
| | - Ken-ichi Mukaisho
- Education Center for Medicine and Nursing, Shiga University of Medical Science, Otsu, Japan
| | - Kazunari Murakami
- Department of Gastroenterology, Oita University Faculty of Medicine, Yuhu, Japan
| | - Yasuyuki Seto
- Department of Gastrointestinal Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hisao Tajiri
- Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | | | - Myung-Gyu Choi
- Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, The Republic of Korea
| | - Rebecca C Fitzgerald
- Medical Research Council Cancer Unit, Hutchison/Medical Research Council Research Centre, University of Cambridge, Cambridge, UK
| | - Kwong Ming Fock
- Department of Gastroenterology and Hepatology, Duke NUS School of Medicine, National University of Singapore, Singapore
| | | | - Khek Yu Ho
- Department of Medicine, National University of Singapore, Singapore
| | - Varocha Mahachai
- Center of Excellence in Digestive Diseases, Thammasat University and Science Resarch and Innovation, Bangkok, Thailand
| | - Maria O'Donovan
- Department of Histopathology, Cambridge University Hospital NHS Trust UK, Cambridge, UK
| | - Robert Odze
- Department of Pathology, Tuft University School of Medicine, Boston, Massachusetts, USA
| | - Richard Peek
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Massimo Rugge
- Department of Medicine DIMED, Surgical Pathology and Cytopathology Unit, University of Padova, Padova, Italy
| | - Prateek Sharma
- Department of Gastroenterology and Hepatology, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Jose D Sollano
- Department of Medicine, University of Santo Tomas, Manila, Philippines
| | - Michael Vieth
- Institute of Pathology, Klinikum Bayreuth, Friedrich-Alexander University Erlangen, Nurenberg, Germany
| | - Justin Wu
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - Ming-Shiang Wu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Duowu Zou
- Department of Gastroenterology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | | | - Peter Malfertheiner
- Medizinixhe Klinik und Poliklinik II, Ludwig Maximillian University Klinikum, Munich, Germany,Klinik und Poliklinik für Radiologie, Ludwig Maximillian University Klinikum, Munich, Germany
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Tanaka Y, Kinoshita T, Akimoto E, Sato R, Yura M, Harada J, Yoshida M, Tomi Y. The impact of hiatal hernia on survival outcomes in patients with gastroesophageal junction adenocarcinoma. Ann Gastroenterol Surg 2021; 6:366-374. [PMID: 35634180 PMCID: PMC9130920 DOI: 10.1002/ags3.12540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 11/25/2021] [Accepted: 12/10/2021] [Indexed: 11/18/2022] Open
Abstract
Aim A hiatal hernia (HH) complicates the diagnosis and surgical treatment of gastroesophageal junction (GEJ) cancer. This study aimed to investigate the effect of HH on the survival outcomes of GEJ cancer patients. Methods This single‐center study reviewed clinical data of 78 patients with GEJ adenocarcinoma who underwent R0 resection from 2008 to 2017. The patients were divided into two groups according to whether they presented with or without HH: the HH (+) group (n = 46) and the HH (−) group (n = 32). Results Patients in the HH (+) group were older than those in the HH (−) group (69.0 vs 67.5 years, P = .018). Regarding surgical outcomes, intra‐abdominal infectious complications was more common in the HH (+) group than in the HH (−) group (23.9% vs 9.4%, respectively; P = .089), particularly abscess formation (17.4% vs 3.1%, respectively; P = .036). Neither overall survival (OS) nor relapse‐free survival (RFS) differed between the two groups. However, survival rates were significantly worse in a subset of patients with T3‐4 disease (OS: log‐rank, P = .036) (RFS: log‐rank, P = .040) in the HH (+) group. In a multivariate analysis for OS in this cohort, HH was an independent prognostic factor (hazard ratio 3.60; 95% confidence interval 1.06‐11.9, P = .032). Conclusion Hiatal hernia may adversely affect surgical and survival outcomes in patients with GEJ cancer. Thus, surgical strategy must be carefully considered in these patients.
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Affiliation(s)
- Yuya Tanaka
- Gastric Surgery Division National Cancer Center Hospital East Kashiwa Japan
| | - Takahiro Kinoshita
- Gastric Surgery Division National Cancer Center Hospital East Kashiwa Japan
| | - Eigo Akimoto
- Gastric Surgery Division National Cancer Center Hospital East Kashiwa Japan
| | - Reo Sato
- Gastric Surgery Division National Cancer Center Hospital East Kashiwa Japan
| | - Masahiro Yura
- Gastric Surgery Division National Cancer Center Hospital East Kashiwa Japan
| | - Junichiro Harada
- Gastric Surgery Division National Cancer Center Hospital East Kashiwa Japan
| | - Mitsumasa Yoshida
- Gastric Surgery Division National Cancer Center Hospital East Kashiwa Japan
| | - Yoshiaki Tomi
- Gastric Surgery Division National Cancer Center Hospital East Kashiwa Japan
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Okumura K, Hojo Y, Tomita T, Kumamoto T, Nakamura T, Kurahashi Y, Ishida Y, Hirota S, Miwa H, Shinohara H. Accuracy of Preoperative Endoscopy in Determining Tumor Location Required for Surgical Planning for Esophagogastric Junction Cancer. J Clin Med 2021; 10:jcm10153371. [PMID: 34362152 PMCID: PMC8348277 DOI: 10.3390/jcm10153371] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 07/26/2021] [Accepted: 07/28/2021] [Indexed: 12/17/2022] Open
Abstract
PURPOSE The surgical strategy for esophagogastric junction (EGJ) cancer depends on the tumor location as measured relative to the EGJ line. The purpose of this study was to clarify the accuracy of diagnostic endoscopy in different clinicopathological backgrounds. METHODS Subjects were 74 consecutive patients with abdominal esophagus to upper gastric cancer who underwent surgical resection. Image-enhanced endoscopy with narrow-band imaging (NBI) was used to determine the EGJ line, prioritizing the presence of palisade vessels, followed by the upper end of gastric folds, as a landmark. The relative positional relationship between the tumor epicenter and the EGJ line was classified into six categories, and the agreement between endoscopic and pathologic diagnoses was examined to evaluate prediction accuracy. RESULTS The concordance rate of 69 eligible cases was 87% with a kappa coefficient (K) of 0.81. The palisade vessels were observed in 62/69 patients (89.9%). Of the 37 pathological EGJ cancers centered within 2 cm above and below the EGJ line, Barrett's esophagus was found to be a significant risk factor for discordance (risk ratio, 4.40; p = 0.042); the concordance rate of 60% (K = 0.50) in the Barrett's esophagus group was lower than the rate of 91% (K = 0.84) in the non-Barrett's esophagus group. In five of six discordant cases, the EGJ line was estimated to be proximal to the actual line. CONCLUSION Diagnostic endoscopy is beneficial for estimating the location of EGJ cancer, with a risk of underestimating esophageal invasion length in patients with Barrett's esophagus.
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Affiliation(s)
- Koichi Okumura
- Division of Upper GI, Department of Gastroenterological Surgery, Hyogo College of Medicine, 1-1 Mukogawacho, Nishinomiya, Hyogo 663-8501, Japan; (K.O.); (Y.H.); (T.K.); (T.N.); (Y.K.); (Y.I.)
| | - Yudai Hojo
- Division of Upper GI, Department of Gastroenterological Surgery, Hyogo College of Medicine, 1-1 Mukogawacho, Nishinomiya, Hyogo 663-8501, Japan; (K.O.); (Y.H.); (T.K.); (T.N.); (Y.K.); (Y.I.)
| | - Toshihiko Tomita
- Division of Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, 1-1 Mukogawacho, Nishinomiya, Hyogo 663-8501, Japan; (T.T.); (H.M.)
| | - Tsutomu Kumamoto
- Division of Upper GI, Department of Gastroenterological Surgery, Hyogo College of Medicine, 1-1 Mukogawacho, Nishinomiya, Hyogo 663-8501, Japan; (K.O.); (Y.H.); (T.K.); (T.N.); (Y.K.); (Y.I.)
| | - Tatsuro Nakamura
- Division of Upper GI, Department of Gastroenterological Surgery, Hyogo College of Medicine, 1-1 Mukogawacho, Nishinomiya, Hyogo 663-8501, Japan; (K.O.); (Y.H.); (T.K.); (T.N.); (Y.K.); (Y.I.)
| | - Yasunori Kurahashi
- Division of Upper GI, Department of Gastroenterological Surgery, Hyogo College of Medicine, 1-1 Mukogawacho, Nishinomiya, Hyogo 663-8501, Japan; (K.O.); (Y.H.); (T.K.); (T.N.); (Y.K.); (Y.I.)
| | - Yoshinori Ishida
- Division of Upper GI, Department of Gastroenterological Surgery, Hyogo College of Medicine, 1-1 Mukogawacho, Nishinomiya, Hyogo 663-8501, Japan; (K.O.); (Y.H.); (T.K.); (T.N.); (Y.K.); (Y.I.)
| | - Seiichi Hirota
- Department of Surgical Pathology, Hyogo College of Medicine, 1-1 Mukogawacho, Nishinomiya, Hyogo 663-8501, Japan;
| | - Hiroto Miwa
- Division of Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, 1-1 Mukogawacho, Nishinomiya, Hyogo 663-8501, Japan; (T.T.); (H.M.)
| | - Hisashi Shinohara
- Division of Upper GI, Department of Gastroenterological Surgery, Hyogo College of Medicine, 1-1 Mukogawacho, Nishinomiya, Hyogo 663-8501, Japan; (K.O.); (Y.H.); (T.K.); (T.N.); (Y.K.); (Y.I.)
- Correspondence: ; Tel.: +81-798-45-6725
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Ishimura N, Yuki M, Yuki T, Komazawa Y, Kushiyama Y, Fujishiro H, Ishihara S, Kinoshita Y. Inter-institutional variations regarding Barrett's esophagus diagnosis. Esophagus 2019; 16:71-76. [PMID: 30056606 DOI: 10.1007/s10388-018-0631-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Accepted: 07/25/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND Barrett's esophagus (BE) is a known precursor for development of esophageal adenocarcinoma and surveillance of affected patients is necessary when cancer progression risk is considered to be high. However, the accuracy of BE diagnosis may not be homogenous among institutions with endoscopy units. We investigated inter-institutional variability by examining the accuracy of endoscopic diagnosis of BE at 4 different hospitals. METHODS The accuracy of BE diagnosis at the 4 hospitals was retrospectively reviewed by 6 expert endoscopists, who independently reviewed endoscopic images of approximately 500 consecutive patients examined at each hospital without information regarding the diagnosis by the on-site endoscopists. When the expert reviewers made different diagnosis, a final diagnosis was made by consensus. That was then compared with the diagnosis of the attending endoscopists at each hospital and their concordance was calculated separately for each endoscopy unit. In addition, the relationship between diagnostic accuracy and endoscopic experience was assessed. RESULTS The prevalence of BE diagnosis by the on-site endoscopists was not homogenous and varied widely (17.2-96.8%). In 1 hospital, over-diagnosis was the cause of dissimilarity, while under-diagnosis was the cause in two hospitals. Diagnostic accuracy by the attending endoscopists in all 4 hospitals ranged from 44.6 to 83.1% (P < 0.05). There was no significant association between diagnostic accuracy and endoscopic experience or board licensing status of the on-site endoscopists. CONCLUSION Diagnostic accuracy for BE was not homogenous among 4 hospitals, and problems related to over- and under-diagnosis should be considered.
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Affiliation(s)
- Norihisa Ishimura
- Department of Gastroenterology and Hepatology, Shimane University School of Medicine, 89-1 Enya-cho, Izumo, Shimane, 693-8501, Japan.
| | - Mika Yuki
- Department of Internal Medicine, Izumo City General Medical Center, Izumo, Japan
| | - Takafumi Yuki
- Division of Gastroenterology, Matsue Red Cross Hospital, Matsue, Japan
| | - Yoshinori Komazawa
- Department of Internal Medicine, Izumo City General Medical Center, Izumo, Japan
| | | | - Hirofumi Fujishiro
- Division of Gastroenterology, Shimane Prefectural Central Hospital, Izumo, Japan
| | - Shunji Ishihara
- Department of Gastroenterology and Hepatology, Shimane University School of Medicine, 89-1 Enya-cho, Izumo, Shimane, 693-8501, Japan
| | - Yoshikazu Kinoshita
- Department of Gastroenterology and Hepatology, Shimane University School of Medicine, 89-1 Enya-cho, Izumo, Shimane, 693-8501, Japan
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Maselli R, Inoue H, Ikeda H, Onimaru M, Yoshida A, Santi EG, Sato H, Hayee B, Kudo SE. Microvasculature of the esophagus and gastroesophageal junction: Lesson learned from submucosal endoscopy. World J Gastrointest Endosc 2016; 8:690-696. [PMID: 27909548 PMCID: PMC5114457 DOI: 10.4253/wjge.v8.i19.690] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 03/06/2016] [Accepted: 10/24/2016] [Indexed: 02/05/2023] Open
Abstract
Advanced therapeutic endoscopy, in particular endoscopic mucosal resection, endoscopic submucosal dissection, per-oral endoscopic myotomy, submucosal endoscopic tumor resection opened a new era where direct esophageal visualization is possible. Combining these information with advanced diagnostic endoscopy, the esophagus is organized, from the luminal side to outside, into five layers (epithelium, lamina propria with lamina muscularis mucosa, submucosa, muscle layer, adventitia). A specific vascular system belonging to each layer is thus visible: Mucosa with the intra papillary capillary loop in the epithelium and the sub-epithelial capillary network in the lamina propria and, at the lower esophageal sphincter (LES) level with the palisade vessels; submucosa with the drainage vessels and the spindle veins at LES level; muscle layer with the perforating vessels; peri-esophageal veins in adventitia. These structures are particularly important to define endoscopic landmark for the gastro-esophageal junction, helpful in performing submucosal therapeutic endoscopy.
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Detection of palisade vessels as a landmark for Barrett's esophagus in a Western population. J Gastroenterol 2016; 51:682-90. [PMID: 26538077 DOI: 10.1007/s00535-015-1136-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 10/14/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND In Japan, palisade vessels (PV) are used to distinguish the esophagogastric junction (EGJ). Elsewhere, the EGJ is defined by the upper end of the gastric folds (GF) and PV are considered difficult to detect. This study evaluated the detection rate of PV in Western patients with Barrett's esophagus (BE) using white light imaging (WLI) and narrow band imaging (NBI), and quantified any discordance between Western and Japanese criteria for the EGJ. METHODS In 25 BE patients, the presence and location of PV and GF were determined and biopsies were obtained. High-quality images of the EGJ were collected under different conditions (insufflations-desufflation, WLI-NBI, forward-retroflex approach), resulting in eight different images per patient. The presence of PV on each still image was assessed by a panel of six Western and Japanese endoscopists with expertise in BE. RESULTS PV were observed in ≥ 1 images by a majority of the panel (≥ 4 raters) in 100 % of patients during insufflation versus 60 % during desufflation (p < 0.001). WLI and NBI detected PV in 100 and 92 %, respectively (p = 0.50). Interobserver agreement of the panel was 'moderate' (κ = 0.51). During endoscopy PV were located a median of 1 cm distal of the GF in 15 patients (63 %), with intestinal metaplasia (IM) in this discordant zone, in 27 % of patients. CONCLUSIONS PV are visible in most Western BE patients and are best inspected during insufflation. The location of the GF and PV differed in a substantial group of patients, partially with IM in this discordant zone.
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