PPT - UCLA Head and Neck Surgery

Report
Esophagus Anatomy,
Physiology, and Diseases
Alan Chu
March 13, 2013
Anatomy


18 – 26cm from UES to LES
Esophageal wall layers
 Mucosa,




submucosa, muscularis propia, adventitia
Proximal 33% skeletal muscle, middle 35-40%
mixed, distal 50-60% smooth muscle
Smooth muscle innervated by CN X.
Auerbach plexus: peristalsis
Meissner’s plexus: afferent input

Oropharyngeal dysphagia
 Difficulty
initiating swallow followed by
choking/coughing

Esophageal dysphagia
 Anatomaic
vs neuromuscular defect
 Solid vs solid+liquid dysphagia

Dysphagia best assessed by MBSS
 Demonstrates
presence of oropharyngeal
dysfunction and aspiration
Standard upper endoscope 9mm,
transnasal endoscope 4mm
 Z line = GE junction
 In barrett’s squamocolumnar junction more
proximal than GEJ

Esophageal Motility disorder

Acalasia
 Insufficient
LES relaxation
 Dilated distal 2/3 esophagus with bird’s beak
appearance at LES on esophagram
 Upper endoscopy to r/o pseudoachalasia 2/2 to
GEJ tumor
 Tx: balloon dilation to disrupt circular muscle
fibers at LES; Heller’s myotomy via laproscopic
approach; Botox/CCB/nitrates
Esophageal Motility Disorder

Diffuse Esophageal Spasm
 Simultaneous
and repetitive contraction in esophagus
body with normal LES
 Cockscrew esophagus on esophagram
 Tx:nitrates/CCB

Nutcraker esophagus
 High-amplitude

peristalsis
Ineffective esophageal motility
 High
incidence in patients with GERD
Strictures
Dysphagia when <15mm
 Tx: dilators (Bougies, Savary dilator,
balloon dilator)
 Risk of perforation 0.5%, higher in XRT
induced strictures
 Goal >15mm

Rings or Webs

Ring
 Circumferential,
muscle or mucosa, at distal
esophagus
 Schatzki’s ring
 Eosinophilic Esophagitis (>15 eosinophils/hpf in
mucosa)

Web
 Part
of lumen, mucosal, proximal esophagus
 Plummer Vinson
GERD
Chronic symptoms 2/2 abnormal reflux of
gastric contents
 Heartburn, acid regurgitation, dysphagia,
odynophagia, belching
 Tx: lifestyle modification, H2 blockers
(60%), PPI (90%), surgery
 Atypical extraesophgeal symptoms:
asthma, chest pain, cough, laryngitis,
dental erosion

Barrett’s esophagus
Pale pink squamous mucosa replaced with
salmon pink columnar mucosa
 LSBE vs SSBE (<3cm)


Risk of esophageal adenoCA 0.5% per
year
Neoplasia

AdenoCA
 Distal
esophagus or GEJ
 Barrett’s

SCC
 Mid-esopahgus
and proximal esophagus
 Tobacco, EtOH use in AA
Diverticula
Zenker’s diverticulum
 Midesophageal diveticula
 Epiphrenic diverticula
 Intramural pseudodiverticulosis

Transnasal Esophagoscopy
Alan Chu
March 13, 2013

Transnasal esophagoscope
 3.1 – 5.1mm
 Performed without sedation
 Shorter procedure time
 66% cost of transoral esophagoscope

Conventional Transoral esophagoscope
 10 - 12mm
 Performed with
sedation
 Longer procedure time

Transnasal esophagoscope
 Smaller

biopsy size
Conventional Transoral esophagoscope
Indications

Head and Neck SCC
 Replaces

panendoscopy
Barrett’s esophagus
 Surveillence

Stricture dilation
 Balloon

of Barrett’s esophagus
dilation
Tracheoesophageal puncture
Technique
Topical anesthetic and decongestant
 Pt’s head flexed and swallows as scope
approaches cricoid level
 Z-line (squamocolumnar junction)
visualized
 Retroflex view of gastric cardia


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