All the weighting criteria are public and they can be consulted on this website. At merco. Accept More information. What is Merco? Our values Transparency Our methodology is public. KPMG verifies the results. Independence The presence in the ranking is free. Our income comes exclusively from the sale of confidential reports. The criterion utilized for endoscopically defining this anatomical transition is the Z-line or ora serrata , which corresponds to the abrupt change in color of the esophageal mucosa, going from whitish or pink to reddish.
This transition appears as a jagged transversal line and corresponds histologically to the transition from nonkeratinized squamous epithelium to simple columnar epithelium Macea, ; Tolentino et al. The Z-line is situation in the plane of the esophageal hiatus of the diaphragm according to endoscopists, at the so-called diaphragmatic pinch , or up to 2 cm above this, in the thoracic esophagus Akiba; Tolentino et al.
Since endoscopists consider the cardia to be the most proximal region of the stomach, they take the Z-line to be the boundary between the esophagus and the cardia Figure 1.
However, because the Z-line does not correspond to the anatomical transition between the esophagus and the stomach in adults, the endoscopic concept for the cardia is not valid.
In this view, the cardia is defined as the region of the stomach around the endoscope, which has an extent of 3 to 4 cm Falavigna et al. The surgical controversy. The terms cardia and lower esophageal sphincter are used without distinction by many surgeons Rodrigues et al. Although anatomically there is no sphincter in the esophagus, unlike what indubitably exists in the pylorus Williams et al.
The upper sphincter ranges in length from 3 to 4 cm, and its pressure is, approximately, mmHg. The lower sphincter ranges in length from 2 to 4 cm and its maximum pressure is between 10 and 45 mmHg Felix, Thus, it needs to be made clear that the lower esophageal sphincter is not an anatomical structure, but rather a functional structure. It is situated in the distal esophagus, and not at the esophageal-gastric transition, as many people imagine.
Because surgeons view the cardia as the sphincter, they often inappropriately utilize the terms "cardiomyotomy" and "cardioplasty" to describe the surgical techniques that are used for treating, respectively, achalasia and gastroesophageal reflux disease.
This procedure is certainly myotomy, i. In the understanding taken by surgeons, the term would mean modeling of the lower sphincter but, because the cardia and sphincter are not synonymous, the term therefore remains inappropriate. The oncological controversy. Because of the ambiguous localization of the adenocarcinomas that affect the esophagogastric transition, Siewert et al.
Although Siewert et al. Thus, from a strictly oncological point of view, the cardia would be the region that included the most distal 5 cm of the esophagus and the most proximal 5 cm of the stomach, a concept that is completely mistaken.
The confusion becomes even greater when considering the staging system put forward by the Union Internationale Contre le Cancer International Union Against Cancer and the American Joint Committee on Cancer, which is the one most utilized around the world. This system brings the nomenclature "tumor of the cardia" in its classification and gives the guidance that this should be considered in the same way as tumors of the stomach and staged as such Greene et al.
The concept of the cardia is not the same for anatomists, histologists, surgeons, oncologists and endoscopists. Because of the lack of a common definition for the cardia, terminological confusion ensues, thereby creating complications for scientific communication. Akiba, T. In: Vinhaes, J. Rio de Janeiro: Guanabara-Koogan, Anatomy of the esophagus.
In: Nyhus, L. Mastery of surgery. Boston, Little, Brown and Company; Influence of site classification on cancer incidence rates: an analysis of gastric cardia carcinomas.
Cancer Inst. Columnar mucosa and intestinal metaplasia of the esophagus: fifty years of controversy. Surg, 3 : , In: DiDio, L. Sao Paulo: Atheneu; Rio de Janeiro, Elsevier, Chil, 2 : , The esophagus and stomach. In: Fawcett, D. Bloom and Fawcett, a textbook of histology. Rio de Janeiro, Guanabara-Koogan, Sistema digestivo II- Tubo digestivo.
In Gartner, L. I st ed. JCC Cancer staging handbook. New York, Springer-Verlag, The lower end of the esophagus. Thorax, , In: Kierszenbaum A, editor. Esophagogastric junction. In: Oppenheimer E, editor. The Ciba collection of medical illustrations. A compilation of paintings on the normal and pathologic anatomy of the digestive system.
Upper digestive tract. Part 1. Digestive system. New Jersey, Ciba-Geigy Corporation, a. Histology of esophagus. A compilation ofpaintings on the normal and pathologic anatomy of the digestive system. Part I. New Jersey, Ciba-Geigy Corporation, b. Accessed in Nov In: Porto, C. Rio de Janeiro, Guanabara Koogan, Gastroesophageal reflux and hiatalhernia.
In: Zinner, M. Maingot's abdominal operation. Esofagite de Refluxo. In: Raia, A. Sao Paulo, Sarvier, In: Glassen, M.
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