Upper GI

Question 1

Oesophageal cancer RFs

Answer 1

• smoking
• alcohol
• GORD
• Barrett’s oesophagus
• achalasia
• Plummer-Vinson syndrome
• squamous cell carcinoma is also linked to diets rich in nitrosamines
• rare: coeliac disease, scleroderma

Question 2

Oesophageal cancer diagnosis

Answer 2

• Upper GI endoscopy is the first line test
• Contrast swallow may be of benefit in classifying benign motility disorders but has no place in the assessment of tumours
• Staging is initially undertaken with CT scanning of the chest, abdomen and pelvis. If overt metastatic disease is identified using this modality then further complex imaging is unnecessary
• If CT does not show metastatic disease, then local stage may be more accurately assessed by use of endoscopic ultrasound.
• Staging laparoscopy is performed to detect occult peritoneal disease. PET CT is performed in those with negative laparoscopy. Thoracoscopy is not routinely performed.

Question 3

Oesophageal cancer management

Answer 3

• Operable disease is best managed by surgical resection.
• The most standard procedure is an Ivor- Lewis type oesophagectomy. This procedure involves the mobilisation of the stomach and division of the oesophageal hiatus. The abdomen is closed and a right sided thoracotomy performed. The stomach is brought into the chest and the oesophagus mobilised further. An intrathoracic oesophagogastric anastomosis is constructed. Alternative surgical strategies include a transhiatal resection (for distal lesions), a left thoraco-abdominal resection (difficult access due to thoracic aorta) and a total oesophagectomy (McKeown) with a cervical oesophagogastric anastomosis.
• The biggest surgical challenge is that of anastomotic leak, with an intrathoracic anastomosis this will result in mediastinitis. With high mortality. The McKeown technique has an intrinsically lower systemic insult in the event of anastomotic leakage.
• In addition to surgical resection many patients will be treated with adjuvant chemotherapy.