Observational Study
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jan 28, 2019; 25(4): 498-508
Published online Jan 28, 2019. doi: 10.3748/wjg.v25.i4.498
Endoscopic identification of endoluminal esophageal landmarks for radial and longitudinal orientation and lesion location
Fabian Emura, Rene Gomez-Esquivel, Carlos Rodriguez-Reyes, Petros Benias, Javier Preciado, Michael Wallace, Luis Giraldo-Cadavid
Fabian Emura, Division of Gastroenterology, Universidad de La Sabana, Bogotá DC 140013, Colombia
Fabian Emura, Advanced Gastrointestinal Endoscopy, EmuraCenter LatinoAmerica, Bogotá DC 110121, Colombia
Fabian Emura, Emura Foundation for the Promotion of Cancer Research, Bogotá DC 110121, Colombia
Fabian Emura, Unidad de Endoscopia Digestiva, Clínica Pediátrica Colsanitas, Bogotá DC 110121, Colombia
Rene Gomez-Esquivel, Division of Digestive Diseases and Nutrition, Morsani College of Medicine, University of South Florida, Tampa, FL 33612, United States
Carlos Rodriguez-Reyes, Division of Gastroenterology, Universidad de La Sabana, Bogotá DC 53753, Colombia
Petros Benias, Division of Gastroenterology, North Shore-Long Island Jewish Medical Center. New York, NY 11030, United States
Javier Preciado, Unidad de Exploraciones Digestivas, Clinica Universitaria Colombia, Bogotá DC 110121, Colombia
Michael Wallace, Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL 32224, United States
Luis Giraldo-Cadavid, Department of Internal Medicine. Universidad de La Sabana, Bogotá DC 140013, Colombia
Luis Giraldo-Cadavid, Division of Interventional Pulmonology, Fundacion Neumologica Colombiana, Bogota DC, 110131, Colombia
Supported by (in part) a grant in aid from the Emura Foundation for the Promotion of Cancer Research, No. 01221.
Conflict-of-interest statement: There are no conflicts of interest to report.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Fabian Emura MD, PhD, FASGE, Director, EmuraCenter LatinoAmerica, Calle 134 No. 7-83. Consultorio 341. Edificio Altos del Bosque, Bogotá DC 110121, Colombia. fabian.emura@unisabana.edu.co
Telephone: +57-1-6271493
Received: September 30, 2018
Peer-review started: September 30, 2018
First decision: November 15, 2018
Revised: December 3, 2018
Accepted: December 19, 2018
Article in press: December 20, 2018
Published online: January 28, 2019
Processing time: 118 Days and 16.6 Hours
Abstract
AIM

To characterize esophageal endoluminal landmarks to permit radial and longitudinal esophageal orientation and accurate lesion location.

METHODS

Distance from the incisors and radial orientation were estimated for the main left bronchus and the left atrium landmarks in 207 consecutive patients using white light examination. A sub-study was also performed using white light followed by endoscopic ultrasound (EUS) in 25 consecutive patients to confirm the findings. The scope orientation throughout the exam was maintained at the natural axis, where the left esophageal quadrant corresponds to the area between 6 and 9 o’clock. When an anatomical landmark was identified, it was recorded with a photograph and its quadrant orientation and distance from the incisors were determined. The reference points to obtain the distances and radial orientation were as follows: the midpoint of the left main bronchus and the most intense pulsatile zone of the left atrium. With the video processor system set to moderate insufflation, measurements were obtained at the end of the patients’ air expiration.

RESULTS

The left main bronchus and left atrium esophageal landmarks were identified using white light in 99% and 100% of subjects at a mean distance of 25.8 cm (SD 2.3), and 31.4 cm (SD 2.4) from the incisors, respectively. The left main bronchus landmark was found to be a tubular, concave, non-pulsatile, esophageal external compression, occupying approximately 1/4 of the circumference. The left atrium landmark was identified as a round, convex, pulsatile, esophageal external compression, occupying approximately 1/4 of the circumference. Both landmarks were identified using white light on the anterior esophageal quadrant. In the sub-study, the left main bronchus was identified in 24 (92%) patients at 25.4 cm (SD 2.1) and 26.7 cm (SD 1.9) from the incisors, by white light and EUS, respectively. The left atrium was recognized in all patients at 30.5 cm (SD 1.9), and 31.6 cm (SD 2.3) from the incisors, by both white light and EUS, respectively. EUS confirmed that the landmarks corresponded to these two structures, respectively, and that they were located on the anterior esophageal wall. The Bland-Altman plot demonstrated high agreement between the white light and EUS measurements.

CONCLUSION

This study provides an endoscopic characterization of esophageal landmarks corresponding to the left main bronchus and left atrium, to permit radial and longitudinal orientation and accurate lesion location.

Keywords: Esophagus; Natural landmark; Radial orientation; Longitudinal orientation; Four-quadrants; Left main bronchus; Left atrium

Core tip: Although accurate photo documentation of endoscopic landmarks and a careful description of the location of an esophageal lesion are included in endoscopy quality guidelines, clinical practice lacks these essentials. This study characterized two esophageal landmarks to permit radial and longitudinal orientation and accurate lesion location. The left main bronchus and left atrium landmarks were identified in 99% and 100% of patients on the anterior esophageal quadrant and at a mean distance of 25.8 cm and 31.4 cm from the incisors, respectively. The endoscopic ultrasound sub-study confirmed these findings and the anterior orientation of the landmarks.