Upper GI Flashcards
Achalasia
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)
Achalasia Ix
OGD - rule out malignancy
Manometry - incomplete relaxation of LOS with high resting pressure and abscence of peristalsis
24hr pH not essential
Achalasia Mx
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%
GORD Ix
OGD, pH and manometry
Nissens in patients with poor peristalsis (Fundo not backed by RCT evidence)
24hr pH monitoring
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
Types of reflux surgery
Nissens - Total
Toupet - posterior partial (270)
Dor - Anterior (180) - common with cardiomyotomy
Risks of Nissens
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
Dividing short gastric in Nissens
yes- allows floppy wrap - possible higher rates of early dysphagia
No- (some evidence for this) . Get higher rates of gas related problems if divided
OGD for Barretts
Record length using Prague Criteria
-Circumferential extent C
Maximum extent M
Biopsies as per Seattle protocol
-4 Quadrantic biopsies every 2 cm
Barretts Surveillance
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
Treatment low grade dysplasia in Barretss
Endoscopic treatments
RFA +yearly surveillance - Phoa et al - 1% vs 26.5% progression to HGD/cancer over 3yrs
Treatment high grade hysplasia (no flat lesiosn
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
Schatzki Ring
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
GOJ cancers
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)
Treatment
T1 Tumours EMR/ESR
T2-T4 - Periop 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
Important trials
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
Treatment of early oesophageal SCC
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
Trails for Chemorad in Oeshapgeal SCC
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
Operations for Oesphageal Cancer
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
Non-operative management
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
Non - resectable Oesophageal SCC
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
Distal Gastric cancer
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
D2 lymphadenecomty
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
H. pylori in gastric cancer
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
Follow Up for gastric cancer
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
