GORD And Oseophageal Cancer

Question 1

What is the los angeles classification of reflux?

Answer 1

Grades reflux oseopahgitis based on severity of the endoscopic findings of mucosal breaks in the distal oseopahgus.

Grade A - breaks ≤5mm
Grade B - breaks >5mm
Grade C - breaks extending between tops of ≥2 mucosal folds, but <75% of circumference
Grade D - circumferential breaks ≥75%

Question 2

What are the diffrential diaganosis fo GORD?

Answer 2

Malignancy
Peptic ulceration
Oseophageal motility disorders

Cardiac or billary disease

Question 3

What are the red flags symptoms for suspected upper GI maliganancy that require urgent endoscopy?

Answer 3

Patients with dysphagia

Any pt >55yrs with weight loss and upper abdominal pain, dyspepsia or reflux

Question 4

What investigations should be performed if PPI managament failed for GORD?

Answer 4

OGD

24hr pH monitoring is gold standard (DeeMeester score)- when medical managemnt failed and surgery being consider for GORD. Alongside oseophgeal manometry to exlude oseophageal dysmotility

Question 5

What are the indications for surgical management for GORD?

Answer 5

Failure to respond to medical therapy
Patient preference to avoid ife-long medication
Pts with complications of GORD (recurrent pneumonia)

Question 6

What is the main sugical intervention for GORD?

Answer 6

Fundoplication - fundus wrapped around oseophageal sphincter - different types e.g. Nissens, partial anterior)

Question 7

What are the mmain side effects of anti-reflux surgery?

Answer 7

Dysphagia
Bloating
Inability to vomit

Most settle after 6 weeks

Question 8

What some of the newer surgical techniques for GORD?

Answer 8

Stretta - radio-freq energy delivered endocopically to casue thickening of the LOS

Linx - string of magnetic beads inserted around LOS wich tightens LOS.

Question 9

What are the main complications of GORD?

Answer 9

Aspiration pneumonia
Barretts oesophgus
Oseopheal stricture
Oseophgeal cancer

Question 10

What are the two main types of oseophageal cancers?

Answer 10

SCC

Adenocarcinoma

Question 11

What is classifications of each type of oseophageal cancer?

Answer 11

SCC - morecommon in developing world, typically occuring in the middle and upper thirds of oseophagus. Associated more with smoking and excessive alcohol consumption.

Adenocarcinoma- more common in developed world, typically in lower third of the oseophagus. Arises from baretts oseophgus. Associated risk factors - GORD, obesity and high fat intake

Question 12

What are the clincial features of oseophageal cancer?

Answer 12

Often present late as symptoms less well defiend.

Progressive Dysphagia - red flag
Weight loss
Odynophagia and hoarseness

Examntion:
Cachexia, weight loss
signs of dehydration
Supraclavicular lymphadenopathy or any signs of metastaic disease

Question 13

What is the investigation of choice in oseophageal cancers?

Answer 13

OGD with biopsy sent for histology

Question 14

What further investigations are required for osophageal cancers?

Answer 14

CT chest-abdo-pelvis and PET CT scan

Endoscopic ultrasound - penetration of oseophegal wall and biopsy suspicious mediatinal lymph nodes

Staging laproscopy - intra-peritoneal meataseses

Palpable cervical lymph nodes - fine needle aspiration (FNA)

Hoarseness or haemoptysis - bronchoscopy

Question 15

What is the management for advanced oseophageal cancers?

Answer 15

Palliative care

Question 16

What are the curative managemnt options for oseophageal cancers?

Answer 16

Depends on tumour type, tumour site and pateint factors

SCC- chemo-radiotheapry

Adenocainoma - neoadjuvant chemo or chem-radio followed by oseophageal resection - major undertaking - 6-9 months to recover post-op quality of life.

Question 17

What are some of the surgical procedures performed for oseophageal cancer?

Answer 17

Right thoracotomy with laparotomy (termed an Ivor-Lewis procedure)
Right thoracotomy with abdominal and neck incision (termed a McKeown procedure)
Left thoracotomy with or without neck incision
Left thoraco-abdominal incision (one large incision starting above the umbilicus and extending round the back to below the left shoulder blade)

For a small number of patients with very early cancers or high grade Barrett’s oesophagus, an option is Endoscopic Mucosal Resection (EMR), which is the removal of just the mucosal layer of the oesophagus.

Question 18

What are the main complications post op of oseophageal cancer patients?

Answer 18

Anastomotic leak
Pneumonia
Death
Re operation

Question 19

What post-op nutrition can be used in oseophageal cancer surgeries?

Answer 19

Feeding jejunostomy

Most pts wil need to eat 5-6 small meals per day to meet their nutritial requirements

Question 20

What are the pallative care options for osephageal cancers?

Answer 20

Oseophageal stent - dysphagia

Radio and chemothearpy

Nutritional support - thickend fluid and nutritional supplements

If dyspahgia to severe the radiologically inserted gastrostomy (RIG) may need to be inserted

Question 21

What is the median survial rate of pallitive care patients with oseopahgeal cancer?

Answer 21

4 months

Question 22

What is the investgation and management of barretts oesophagus?

Answer 22

OGD with biposy as it is a histological diagnosis

High dose PPI and lifestyle advice

Regular endoscopy in confimed baretts oseophagus

Question 23

What is the endoscopic survalliance?

Answer 23

No dysplasia - every 2 to 5 years

Low grade dysplasia - every 6 months

High grade dysplasia - every 3 months - sutible for endoscopic ablation with mucosal resection (EMR) or radiofreqency ablation, endoscopic submucosal dissection (ESD)