Sonographic anatomy of the cervical esophagus

PURPOSE: Although conventional sonography is used widely for evaluation of the gastroesophageal junction, its use in the cervical esophagus is still limited. The aim of this study was to assess the use of sonography to demonstrate this portion of the esophagus. METHODS: The cervical esophagi in 60 cadavers and 435 healthy volunteers were examined sonographically. Among the healthy subjects 182 were scanned with a transducer operating at 7.5 MHz, 183 with a 10.0-MHz transducer, and 70 with a 12.0-MHz transducer. Sonographic layer patterns were compared among the groups. Sonographic and histologic analyses were also performed on 3 cadaveric esophageal specimens to correlate the sonographic appearances with the anatomical findings. RESULTS: Scans of the cadavers showed that the cervical esophagus lay between the trachea and vertebrae, with its origin at the midline; it gradually moved to the left as it descended toward the trunk. It moved to the right when the cadaver's head was turned to the left and the trachea was pushed gently to the left. Based on these anatomical characteristics, visualization of the cervical esophagus was optimized by scanning from both the left and the right lateral approaches, with manipulation of the trachea as needed. In scans of the 435 healthy subjects, the esophageal wall was shown as 5 layers in 423 (97.2%) and as 7 layers in the remaining 12 (2.8%). The demonstration rate of the 7-layer pattern was significantly higher for subjects scanned at 12.0 MHz than for those scanned at 10.0 and 7.5 MHz (p < 0.01). The layers demonstrated sonographically corresponded to histological structures evident on microscopy. CONCLUSIONS: The left lateral approach is essential to sonography of the cervical esophagus. However, the right wall of the esophagus is best seen from the right. In transverse scans, the cervical esophagus wall usually appears to be composed of 5 layers, although 7 layers can also appear, especially as the transducer frequency is increased.     

Transabdominal sonography of the normal gastroesophageal junction in children.

PURPOSE: Because sonography identifies abnormalities of the gastroesophageal junction, it is essential to understand the normal sonographic anatomy. The aim of this study was to determine the normal sonographic appearance of the gastroesophageal junction and its variations and to provide measurements of the abdominal esophagus in asymptomatic, healthy children. METHODS: In this prospective study, 124 healthy children (75 boys and 49 girls), aged 2 days-12 years, underwent abdominal sonography. With the patient in a supine position, the transducer was placed under the xiphoid and the ultrasound beam was directed cephalad through the window of the left lobe of the liver. The length of the abdominal esophagus was measured from the point at which it penetrated the diaphragm to the gastroesophageal junction. The thickness was measured on the anterior wall at the midpoint of the abdominal esophagus. RESULTS: The gastroesophageal junction was identified by sonography in all of the children. The mean length of the abdominal portion of the esophagus ranged from 18 mm in the newborns to 34 mm in children older than 6 years. The wall thickness ranged from 2.4 mm to 5.7 mm. CONCLUSIONS: Our results indicate that visualization of the gastroesophageal junction and measurement of the abdominal esophagus are readily achievable with real-time sonography in healthy children.     

镍钛合金人工食管替代食管后的组织反应与损伤

背景：前期实验证实镍钛合金人工食管是一种可用于替代被切除食管段,重建食管通道的食管人工代用品。目的：观察镍钛合金人工食管替代食管术后的组织反应及对邻近组织器官的损伤。方法：切除8只小型香猪一段70 mm胸段食管,将镍钛合金人工食管两端分别套入远近端正常食管腔内约10 mm,在食管与镍钛合金人工食管涤沦连接环作全层连续缝合吻合连接。术后第7天开始应用饮食调控方法调控脱管时间。分别在术后1,2,3,4个月各处死2只带管实验猪进行解剖,观察植入镍钛合金人工食管在新生食管形成过程中的组织反应和对紧密接触邻近组织器官的损伤。结果与结论：各时间段植入镍钛合金人工食管原位停留支撑,未见胸内出血、气胸、脓胸、食管穿孔、吻合口瘘等术后邻近组织器官损伤并发症。实验动物带管进食半固体食物无进食困难（Bown＇SⅡ级）。解剖所见：壁层胸膜与肺轻度膜状粘连,胸腔内无胸液,新生食管完全包裹人工食管,新生食管与邻近肺、主动脉器官组织轻度膜状粘连,未对邻近肺、主动脉及食管黏膜造成严重损伤,植入周期食管黏膜由食管残端向新生食管中间部再生延伸直到完全覆盖整条新生食管。新生食管组织学所见：镍钛合金人工食管替代食管植入周期的组织反应表现为无菌性炎症反应和异物反应,以术后1个月组织反应最为严重,随后逐渐减轻。     

体表超声在食管腐蚀伤后瘢痕狭窄诊断中的应用

目的　探讨常规体表超声在食管腐蚀伤后瘢痕狭窄诊断中的价值。方法　用超声检查 18例食管腐蚀伤后瘢痕狭窄患者及 2 0例正常人作为对照。结果　超声显示率为 83.3%。食管腐蚀伤后瘢痕狭窄患者的食管壁较对照组增厚 (P<0 .0 1) ,其病变段食管前后径和左右径均较对照组增大 (P<0 .0 1) ,其颈段食管的返流行程大于对照组 (P<0 .0 1) ,所有患者均伴管腔回声异常。结论　超声不但可用于该病的诊断 ,而且还可用于治疗后的随访。     

Use of sonography in the evaluation of the gastroesophageal junction

To demonstrate the gastroesophageal junction with a real-time, transabdominal sonography through the window of left lobe of liver, the normal sonographic pattern and the thickness of the wall of abdominal esophagus were determined. The detection rate of the normal pattern in 30 control subjects was 93%, the normal thickness of the wall being 3.8 ± 1.2 mm (range 2 mm to 5 mm). In 7 patients with severe acute esophageal inflammation, the thickness was 7.6 ± 2.1 mm (range 5 mm to 10 mm). In 6 patients with an invading lesion in the gastroesophageal junction due to malignancy, the thickness of the wall was more than 10 mm in each case. This preliminary study indicates that the sonographic detection of gastroesophageal junction through the liver window can be included in routine abdominal sonography. An increased thickness of the wall needs further study to find the cause of the thickening. © 1996 John Wiley & Sons, Inc.     

联合胸降主动脉节段置换的T4期食管癌根治术36例临床分析

目的总结T4期侵犯胸降主动脉的局部晚期食管癌手术的治疗经验,探讨同期行降主动脉节段切除及人造血管置换的应用方法和操作技巧。方法回顾分析我院2001年1月至2010年12月36例在食管癌手术同时行胸降主动脉部分切除置换患者的手术方法和治疗结果。所有患者均采用左后外侧切口经第6肋间进胸,由胸降主动脉左侧切开血管外膜,切断相应肋间动脉,常温下在受累主动脉上、下分别阻断,切除食管肿瘤及受累主动脉,并行人造血管置换。胃充分游离后,经食管床上提至左颈部与食管残端吻合。结果本组均顺利完成根治性肿瘤切除,无围术期死亡,无截瘫、肾脏及肠道功能衰竭等严重并发症,出现乳糜胸2例,晚期吻合口瘘1例。术后住院时间10．0～42．0d,平均（15．5±7．2）d。术后病理检查均为鳞状细胞癌,均侵犯主动脉外膜,9例（25％,9／36）有中层浸润,全组未发现内膜受侵,有区域淋巴结转移者19例（52．8％,19／36）。患者1、3、5年生存率分别为80．6％、46．2％、20．0％。结论对于侵犯胸降主动脉的局部晚期食管癌,可联合采用主动脉节段切除并人造血管重建的方法达到根治目的,提高肿瘤切除率,改善患者生活质量和远期治疗效果。     

Sonographic findings in achalasia

PURPOSE: The aim of this study was to describe the sonographic features of achalasia. METHODS: Thirty-five patients with achalasia (17 men and 18 women; mean age, 43 years) were examined with transabdominal sonography, and the findings were compared with those in 41 volunteers without esophageal disease (21 men and 20 women; mean age, 41 years), 10 patients with gastroesophageal junction carcinoma (7 men and 3 women; mean age, 55 years), and 4 patients with peptic stricture (3 men and 1 woman; mean age, 39 years). The distal end of the esophagus was evaluated, and the thickness of the esophageal wall was measured. RESULTS: In 28 fasting patients (80%) with achalasia, sonography showed dilatation, retention of fluid, and smooth narrowing of the distal esophagus (like a bird's beak). These findings were not identified in the other patients or volunteers. In addition, in 6 of 7 achalasia patients who had no sign of esophageal dilatation in the fasting state, water retention was demonstrated after ingestion of water, bringing the total number of patients with achalasia with positive sonographic findings to 34 (97%). In patients with achalasia, the mean thickness (+/- standard deviation) of the esophageal wall at the gastroesophageal junction was 4.8 +/- 0.9 mm (range, 3.6-7.2 mm). The thickening was regular, symmetric, and localized to the gastroesophageal junction. In the volunteers, the mean thickness of the esophageal wall was 2.3 +/- 0.5 mm (range, 1.4-3.5 mm). The difference between the 2 groups was statistically significant (p < 0.001). In the patients with carcinoma, the mean wall thickness was 17.0 /+ 1.1 mm, and the thickening was irregular. In the patients with peptic stricture, the mean wall thickness was 5.1 +/- 1.1 mm (range, 3.8-8.3 mm), and the thickening was irregular and occupied a longer segment of the distal esophagus. CONCLUSIONS: In patients with achalasia, transabdominal sonography clearly shows the regular thickening of the esophageal wall, water retention, dilatation of the distal esophagus, and the bird's beak appearance. Sonography may help in differentiating achalasia from carcinoma and peptic stricture of the gastroesophageal junction, which is difficult to do with other modalities.     

The influence of transducer position on the M-mode echocardiographic measurement of the left atrial dimension

Summary. Eighty-five subjects were investigated to see if the left atrial dimension (LAD) determined by M-mode echocardiography varies with different placements of the transducer in the parasternal long-axis view. Satisfactory images from the third and fourth intercostal spaces were obtained in all subjects. A satisfactory image from the second, third and fourth intercostal spaces was obtained in 58 subjects and from the third, fourth and fifth intercostal spaces in 27 subjects. The mean LAD was significantly smaller (P<0–001) in the fourth intercostal space than in the third. The mean value obtained from the fifth intercostal space was smaller than that from the fourth. The beam pathway seen on the two-dimensional echocardiogram indicates that the transducer should preferably be placed in the third intercostal space. If the transducer is placed in a lower intercostal space the measured left atrial dimension might be underestimated.     

Sonographic demonstration of cervical esophageal web

We report a case of esophageal web demonstrated with sonography in a 45-year-old woman with dysphagia. The esophageal web was incidentally detected as a circumferential hypoechoic membrane on sonograms of the cervical esophagus.     

Doppler sonographic indices in diagnosing the nutcracker phenomenon in a hematuric adolescent

Compression of the left renal vein between the aorta and the superior mesenteric artery, known as the nutcracker phenomenon, may cause gross or microscopic hematuria, pain in the flank, proteinuria, or a combination of these symptoms. We report the case of a hematuric adolescent diagnosed with a high index of suspicion by noninvasive Doppler sonography using the diagnostic indices of Doppler sonography established for adults with hematuria. Compression of the patient's left renal vein at the aortomesenteric portion and dilatation at the hilar portion were visualized by magnetic resonance angiography, which verified the diagnosis.     

Correlation of color Doppler sonographic findings with pH measurements in gastroesophageal reflux in children

PURPOSE: We conducted a prospective study of color Doppler sonography in children with suspected gastroesophageal reflux (GER). The purpose of this study was to compare the accuracy of color Doppler sonography with that of continuous 24-hour pH monitoring of the esophagus in diagnosing GER and to determine how to interpret the reflux episodes detected on color Doppler sonography in children at high risk for reflux. METHODS: Color Doppler sonography and 24-hour esophageal pH monitoring were performed in 54 children ranging in age from 2 months to 10 years (mean, 3 years). The stomach of each patient was filled for adequate gastric distention just before the color Doppler sonographic examination. We counted the number of reflux episodes over a period of 15 minutes. One day after the sonographic examination, the reflux was evaluated with esophageal pH monitoring, and the resultant reflux index (ReI) was obtained. The ReI was considered to be pathologic when it was equal to or greater than 11.99%. The number of refluxes on color Doppler sonography and the ReI were correlated for each patient. RESULTS: The 2 tests showed an 81.5% agreement in the detection of GER. When pH monitoring was taken as the reference test, color Doppler sonography had a high sensitivity (95.5%) for diagnosing GER but a very low specificity (11.0%), with a positive predictive value of 84.3% and a negative predictive value of 33.3%. There was no statistically significant correlation between the frequencies of GER detected on color Doppler sonography and the ReIs on pH monitoring (p = 0.1103). There was no correlation between the reflux grades on sonography and the ReI grades on pH monitoring (p = 0.422). CONCLUSIONS: Color Doppler sonography is highly sensitive and easier to use than pH monitoring. Although there are no definite criteria for evaluating the severity of GER on color Doppler imaging, this modality may be useful in screening children for GER.     

Endocardial visualization of esophageal-left atrial anatomic relationship by three-dimensional multidetector computed tomography "navigator imaging"

BACKGROUND: The close proximity of left atrium (LA) and esophagus during radiofrequency ablation for atrial fibrillation (AF) predisposes to thermal injury resulting in atrio-esophageal fistula. This work proposes to study the anatomic relationship between the esophagus and the LA wall using multidetector computed tomography (MDCT) three-dimensional (3D) "Navigator" reconstruction technique. METHODS: Forty-five consecutive patients (37 men, mean age 52.7+/-14.1 years) with preradiofrequency ablation MDCT scans of the thorax for AF were recruited. Length and type (continuous or interrupted) of fat pad between esophagus and LA were evaluated. The position, width, and length of the esophagus in contact (without fat pad) with the LA were determined by using "Navigator" software on the endocardial view of LA. RESULTS: The fat pad was continuous in 4% (2 of 45) and interrupted in 96% (43 of 45) patients. The mean width and length of esophageal-LA contact in 43 cases with interrupted fat pad was 24.0+/-5.8 mm (range 10.5-35.3 mm) and 41.9+/-11.6 mm (5.4-64 mm), respectively. There was an inverse relationship between the lengths of the esophageal-LA contact and the upper fat pad (r=-0.50, P=0.001). The esophagus was located to the left, right, and midline of the LA in 40, 2, and 1 patients, respectively, and the esophagus was in contact with and overrode the PV orifice in 22 and 4 patients, respectively. CONCLUSION: Direct esophageal-LA contact without the intervening fat pad was present in 96% of the cases, with 93% of esophagi lying to the left of the LA and 51% in contact with a PV orifice. Three-dimensional Navigator imaging technique has enhanced the visualization of the anatomical information of the esophagus, LA wall, and PV orifices that may be used to avoid thermal injury to the esophagus during LA ablation procedure.     

The fetal esophagus: anatomical and physiological ultrasonographic characterization using a high-resolution linear transducer.

OBJECTIVE: To study the sonographic anatomy and physiology of the human fetal esophagus during the mid-trimester of pregnancy using a high-resolution linear transducer. METHODS: This was a prospective observational study of the fetal esophagus between 19 and 25 weeks' gestation. The study was performed in 60 consecutive fetuses, after a normal anatomy scan, using a 5-13-MHz matrix array wide-band transducer. During the examination the collapsed esophagus was first visualized, and followed by a 5-min video recording in order to demonstrate luminal patency and peristaltic waves. RESULTS: Complete anatomical visualization of the esophagus was possible in 52 (86.7%) patients and at least partial visualization in 58 (96.7%) patients. Three different patterns of esophageal motility were observed: a simultaneous and short opening of the whole esophagus was found in 35 (58.3%) fetuses; a segmental, peristalsis-like movement from the pharynx, through the mediastinum, and into the stomach was found in 18 (30%) fetuses; and in one fetus reflux-like passage of solid contents from the stomach was observed. The mean time required for demonstration of esophageal patency was 96.1 (range, 10-300) s. CONCLUSIONS: Demonstration of normal anatomy and physiological activity of the fetal esophagus is feasible using appropriate transducers. The most commonly observed pattern of esophageal motility in the mid-trimester of pregnancy is the simultaneous relaxation of the upper and lower esophageal sphincters with concurrent opening of the esophageal lumen from the upper thorax to the stomach. Demonstration of a patent esophagus may be helpful in fetuses with suspected esophageal atresia.     

内镜超声检查对食管隆起性病变的诊断价值

目的 探讨超声内镜对食管隆起性病变的诊断价值。方法 对161例食管隆起性病变患者行内镜超声检查。结果 发现黏膜下肿瘤92例，其中肌原性肿瘤86例，脂肪瘤4例，囊肿2例，息肉14例，静脉瘤（静脉曲张）34例；外压性改变21例，其中胸主动脉外压18例，纵隔肿瘤3例。结论 内镜超声检查能较清楚地显示食管壁的5层结构，比较准确地判断隆起性病变与食管壁的关系，对食管隆起性病变的诊断、鉴别诊断和指导治疗均有很大价值。     

系统性硬皮病累及食管的X线表现与早期诊断

目的探讨系统性硬皮病（PSS）累及食管的X线表现与早期诊断。方法采用食道气钡双重造影,同时行立位及卧位多体位观察,并对其X线征象进行分析。结果PSS食道受累患者排空时间、管腔直径及黏膜均有不同程度异常。结论食道气钡双重造影是观察食管功能的有效检查手段,对早期诊断PSS具有极高价值。     

Movement of the Feline Esophagus Associated with Respiration and Peristalsis. AN EVALUATION USING TANTALUM MARKERS

The outer, lateral esophageal walls in the distal half of the esophagus in each of five cats were labeled with small tantalum wires. About 8 wk later, esophageal motion associated with respiration and peristalsis, induced by injecting barium boli (5 ml each) into the proximal esophagus, was recorded on cine and serial biplane roentgenograms while recording intraluminal esophageal pressures simultaneously by manometry. Esophageal motion was also evaluated without a manometric tube in place. The coordinates for each marker were digitized and a computer was used to plot marker position against time. During respiration, the markers passively made a shallow, 2-10 mm excursion on the longitudinal esophageal axis. This movement was synchronous with thoracic and diaphragmatic movement and changes in intraluminal esophageal pressure. Immediately after the onset of peristalsis, the markers made a pronounced oral movement of 10 mm or more above their mean respiratory position, as if to engulf the bolus. Markers in opposing esophageal walls approximated one another and commenced an aboral movement as the bolus tail, which was essentially co-incident with onset of the manometric pressure complex, passed the marker sites. The markers returned to their respective rest positions essentially coincident with passage of the pressure complex peak and then moved below their respective rest positions. The aboral excursion occurred predominantly after the bolus had emptied into the stomach. The magnitude and duration of oral excursion was significantly greater for the distal than for the more proximal markers; conversely, the magnitude and duration of aboral excursion was greater for the proximal than for the more distal markers. During the peristaltic sequence, the labeled portion of the esophagus shortened from 26 to 46% of its resting length. No evidence of esophageal torque was shown. These findings suggest that both the longitudinal and circular esophageal musculature play an active and important role during peristaltic transport of a bolus through the esophagus.     

Neuromodulation of thoracic intraspinal visceroreceptive transmission by electrical stimulation of spinal dorsal column and somatic afferents in rats.

Clinical studies have shown that neuromodulation therapies, such as spinal cord stimulation (SCS) and transcutaneous electrical nerve stimulation (TENS), reduce symptoms of chronic neuropathic and visceral pain. The neural mechanisms underlying SCS and TENS therapy are poorly understood. The present study was designed to compare the effects of SCS and TENS on spinal neuronal responses to noxious stimuli applied to the heart and esophagus. Direct stimulation of an intercostal nerve (ICNS) was used to simulate the effects of TENS. Extracellular potentials of left thoracic (T3) spinal neurons were recorded in pentobarbital anesthetized, paralyzed, and ventilated male rats. SCS (50 Hz, 0.2 ms, 3-5 minutes) at a clinical relevant intensity (90% of motor threshold) was applied on the C1-C2 or C8-T1 ipsilateral spinal segments. Intercostal nerve stimulation (ICNS) at T3 spinal level was performed using the same parameters as SCS. Intrapericardial injection of bradykinin (IB, 10 microg/mL, 0.2 mL, 1 minute) was used as the noxious cardiac stimulus. Noxious thoracic esophageal distension (ED, 0.4 mL, 20 seconds) was produced by water inflation of a latex balloon. C1-C2 SCS suppressed excitatory responses of 16/22 T3 spinal neurons to IB and 25/30 neurons to ED. C8-T1 SCS suppressed excitatory responses of 10/15 spinal neurons to IB and 17/23 neurons to ED. ICNS suppressed excitatory responses of 9/12 spinal neurons to IB and 17/22 neurons to ED. These data showed that SCS and ICNS modulated excitatory responses of T3 spinal neurons to noxious stimulation of the heart and esophagus. PERSPECTIVE: Neuromodulation of noxious cardiac and esophageal inputs onto thoracic spinal neurons by spinal cord and intercostal nerves stimulation observed in the present study may help account for therapeutic effects on thoracic visceral pain by activating the spinal dorsal column or somatic afferents.     

Doppler sonography of the inferior mesenteric artery: a preliminary study.

The purposes of this study were to look for the inferior mesenteric artery in patients undergoing abdominal sonography, to determine in what percentage of patients it is visible, and to characterize Doppler flow patterns of the inferior mesenteric artery in fasting patients without intestinal vascular disease. The inferior mesenteric artery was sought in 100 consecutive fasting adults (mean age, 54 years; 63 women, 37 men), as follows: the infrarenal aorta was scanned in a transverse plane; the origin of the inferior mesenteric artery was identified on the left anterolateral surface of the aorta; the inferior mesenteric artery was then traced caudally along the left side of the aorta. The inferior mesenteric artery and the superior mesenteric artery were studied with Doppler sonography in 50 different subjects without clinical or Doppler sonographic evidence of abdominal vascular disease (mean age, 44.9 years; 17 men, 33 women). Pulsed Doppler samples were taken within the inferior mesenteric artery in sagittal planes. The resistive index was calculated from the superior mesenteric artery and the inferior mesenteric artery. The inferior mesenteric artery was detected in all but eight patients (92%). In seven patients obesity prevented visualization. The eighth patient had undergone abdominal surgery on the previous day, limiting the sonographic examination. The diastolic flow in the inferior mesenteric artery was less than that in the superior mesenteric artery in all patients. The resistive index was 0.959 +/- 0.045 in the inferior mesenteric artery and 0.856 +/- 0.046 in the superior mesenteric artery (P < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)     

腔内隔绝术治疗主动脉夹层及胸主动脉瘤

目的探讨腔内隔绝术治疗DeBakeyⅢ型主动脉夹层及胸主动脉瘤的手术时机及操作技巧。方法10例DeBakeyⅢ型主动脉夹层及胸主动脉瘤(DeBakeyⅢ型主动脉夹层9例、胸主动脉瘤1例)患者行腔内隔绝术,术前行CTA或MRA及主动脉造影检查,判断主动脉夹层裂口位置与数量及胸主动脉瘤范围、左锁骨下动脉开口左侧胸主动脉直径、近端裂口至左锁骨下动脉开口的距离、真腔直径以及腹主动脉主要分支血管的血供来源,选支架规格及输送路径,然后在全麻下行右股动脉切开,透视引导下置入支架释放系统,定位准确后释放覆膜支架,完成腔内隔绝术。1例因破裂口位于左颈总动脉与左锁骨下动脉之间而先行右颈总动脉-左颈总动脉-左锁骨下动脉转流术。结果10例患者腔内隔绝术均获得成功。近端裂口距左锁骨下动脉开口距离平均3.5cm,出现Ⅱ型内漏1例。随访1~24个月,术后无截瘫发生,胸背部疼痛症状消失。1例胸主动脉瘤破裂伴食道瘘患者术后1个月死于感染。结论腔内隔绝术治疗DeBakeyⅢ型主动脉夹层和胸主动脉瘤是一种创伤小、疗效确切的方法。但远期效果仍有待进一步观察。