Upper GI

Question 1

Achalasia

Answer 1

Failure of relaxation of the lower oesophageal sphincter and absence of peristalsis

Due to loss of inhibitory ganglion cells in Auerbach’s plexus

Associated with increased risk of SCC (140fold)

Question 2

Achalasia Ix

Answer 2

OGD - rule out malignancy
Manometry - incomplete relaxation of LOS with high resting pressure and abscence of peristalsis

24hr pH not essential

Question 3

Achalasia Mx

Answer 3

Lap Hellers Myotomy with anterior For Fundoplication -85-95% successful

Controlled division of muscles of lower 6cm of Oesphagus and 2cm of stoma - Fundo prevents reflux which occurs in 20%

Non-surgical
Endscopic ballon dilation - 70-80% initial success with 5% risk of perf .
Approx 50% need repeat tx within 1yr
BSG initial diameter of 30mm with second session 2-28days later of 35mm

Botox injections - sort term relief and 70% have reoccurrence at 1yr

Medications
Ca channel blockers and nitrates - only effective in 10%

Question 4

GORD Ix

Answer 4

OGD, pH and manometry
Nissens in patients with poor peristalsis (Fundo not backed by RCT evidence)

Question 5

24hr pH monitoring

Answer 5

Total acid reflux time as percentage of total recording (<5% is normal)

Others - episodes >5mins, number of episodes, upright and supine time and longest episode

Computer generates a DeMesester score - (normal <14.72)

Symptoms correlation is important - symptom index (episodes related to recorded reflux) - >50% is positive

Question 6

Types of reflux surgery

Answer 6

Nissens - Total
Toupet - posterior partial (270)
Dor - Anterior (180) - common with cardiomyotomy

Question 7

Risks of Nissens

Answer 7

Swallowing difficult for 2 weeks - advise sloppy food
Bloating, inability to belch and flatulence
2% risk of conversion to open
Reparation (up to 15%
Reoccurrence of reflux

Question 8

Dividing short gastric in Nissens

Answer 8

yes- allows floppy wrap - possible higher rates of early dysphagia

No- (some evidence for this) . Get higher rates of gas related problems if divided

Question 9

OGD for Barretts

Answer 9

Record length using Prague Criteria
-Circumferential extent C
Maximum extent M

Biopsies as per Seattle protocol
-4 Quadrantic biopsies every 2 cm

Question 10

Barretts Surveillance

Answer 10

BSG guidlines

No dysplasia >3cm OGD every 2-3yrs

Low Grade dysplasia - repeat in 6months - Needs to be confirmed on at least 2 sets of biopsies

Question 11

Treatment low grade dysplasia in Barretss

Answer 11

Endoscopic treatments
RFA +yearly surveillance - Phoa et al - 1% vs 26.5% progression to HGD/cancer over 3yrs

Question 12

Treatment high grade hysplasia (no flat lesiosn

Answer 12

Discuss at UGI MDT
EUS +/1 FNA in selective case to exclude advanced stage

Endoscopic resection/ablative Tx of which RFA is best safety profile

Endoscopic follow up is recommended after such Tx with biopsies at previous extent

Question 13

Schatzki Ring

Answer 13

Benign ring-like stricture at lower oesophagus (squamous-columnar junction)

Postientally related to GORD

Tx by maximal acid suppression and balloon dilatation to fracture ring (16-20mm

Question 14

GOJ cancers

Answer 14

Siewert classification
Type 1 1-5cm above gastric cardia
type 2 (true) 1cm above to 2cm below
Type 3 2-5cm below

Staging - Ct C/A/P, PET and EUA (diagnostic lap for 2/3)

Question 15

Treatment

Answer 15

T1 Tumours EMR/ESR
T2-T4 - Period Chemo - FLOT 4 trial then ILO

Median survival at 50months with FLOT and 35months with ECF/ECX

ILO - Laparotomy for abdominal approach then Right throacic approach with anastomosis high in chest

Pathology report
R status, T and N status
Lymph node yields
High >25
Intermediate 15-25
Low<15

Question 16

Important trials

Answer 16

MRC OEO2 trial
MRC OEO5 trial
MAGIC trial
USA INTI0116
Cross trial - 386 patients SCC or adenosine T3N0-1 - ChemoRad vs survey alone. 49.4months vs 24months
FLOT4 - important - FLOT vs ECF or ECX 50 vs 35 months
Dutch D1D2 trial. - D2 lymphadenectomy associated with lower locorlgional recurrence

Question 17

Treatment of early oesophageal SCC

Answer 17

CIN/high grade dysplasia and most T1 tumours - EMR or ESD

Need to exam resected specimen - if low risk of LN and complete margins then consider definative

LN Rush - depth of invasion, LV invasion, Low differentiation grade, Ulceration, Large size.

Consider surgery if High risk of LN or incomplete or Chemo-rad for organ preservation

Question 18

Trails for Chemorad in Oeshapgeal SCC

Answer 18

CROSS trial
Weekly Carboplatin-paclitaxel combined with 41.4Gray over 23 fractions then oesphagectomy.

5yr survival exceeded 60%

Better outcome vs surgery and definitive chemo radio

With residual disease post Neoadjuvent then adjuvant with Nivolumab - Checkmate 577 trial

Question 19

Operations for Oesphageal Cancer

Answer 19

Distal cancer - Ivor Lewis - Abdo + Right chest

Mid to Upper tumours - McKeown - adds cervical access for anastomosis at cervical oesophagus - en bloc two field lmyhadenectomy

Court study from Sweden and Finland indicated improved long term survival with minimally invasive

Question 20

Non-operative management

Answer 20

Definitive Chemoradiotherpy

5-FU or carboplatin-paxlitaxel with 50.4Gry radiotherapy

Needs close monitoring to see if residual disease or reoccurrence needing salvage surgery

Similar survival rates - can avoid laryngectomy

Question 21

Non - resectable Oesophageal SCC

Answer 21

Refer to oncology
1st Line Chemo - Platinum and fluropyrimidine regime
If cannot tolerate the dose reduced oxaliplatin-capecitabine

If tumour high PD-L1 expression Pembrolizumab with chemo (Combined positive score >10)

Nivolumab with chemo in PD-L1 toumr proportion score 1% or more

Nivolumab with ipilimumab possible but carries higher risk of early progress

Question 22

Distal Gastric cancer

Answer 22

T1s tumours may be resectable using EMR/ESD according to Japanese Gastric Cancer association guidelines (limited size, no ulceration, low grade histology

Otherwise Dital gastrectomy with D2 lymphadenectomy + Billroth 2 or Roux en Y gastrojej recon

FLOT 4 Trial showed advantages of the MAGIC regimen - now standard of care

Question 23

D2 lymphadenecomty

Answer 23

Perigastric node - Station 1-6
Nodes along Left gastric, common hepatic, celiac and splenic arteries (7-12a)

Adequacy of lymphadenecomt is assessed by retrieving at least 16 notes but too extensive if >30

Question 24

H. pylori in gastric cancer

Answer 24

Well recognised risk factor
Causes Chronic gastritis and progession to intestinal metaplasia and dysplasia

Needs eradication in ESM or post surgery - risk of metachronous cancers

Question 25

Follow Up for gastric cancer

Answer 25

Focuses on detecting recurrence, managing complications and addressing nutritional deficiency

Regular reviews inc tumour marks CEA and Ca 19 9
CT every 6-12months for 2yrs then annually

Supplementation of iron, Vit B12, calcium and Vitamin D