PPT - UCLA Head and Neck Surgery
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Transcript PPT - UCLA Head and Neck Surgery
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