Upper GI Surgery JC051: I Can't Swallow: Esophageal Cancer

Question 1

Dysphagia

Answer 1

Dysfunction of clearing of food and drink through oral cavity, pharynx, esophagus into stomach at an appropriate rate and speed

1. Oropharyngeal dysphagia:
   - difficulty with initial phases of swallowing, from mouth to esophagus
2. Esophageal dysphagia:
   - sensation that foods / liquids are being obstructed in the passage from mouth to stomach

Question 2

Anatomy

Answer 2

• Tongue, Oropharynx, Upper esophageal sphincter, Upper 5% of Esophagus: Striated muscle (Voluntary)
• Mid 35-40% of Esophagus: Mixed
• Distal 50-60% of Esophagus: Smooth muscle (Involuntary)

(From GIS05 06:
- Muscular tube (~25cm long)
- Conveys food from pharynx to stomach
- behind trachea, heart; adjacent to aorta (danger of penetration)

3 parts:
1. Cervical part (skeletal)
2. Thoracic part (smooth + skeletal)
3. Abdominal part (smooth)

3 constrictions:
1. Upper esophageal constriction (level of cricoid cartilage)
2. Middle esophageal constrictions (level of aortic arch)
3. Lower esophageal constriction (level of diaphragm)

Clinical significance:
- passing instruments through esophagus into stomach
- viewing radiographs in dysphagia patients)

Question 3

Physiology of swallowing

Answer 3

Peripheral stimuli of oropharynx, larynx, esophagus
—> Sensory neurons (CN5, 7, 9, 10)
—> Cortical and Subcortical structure
—> Brainstem swallowing centre
—> Motor nuclei:

1. Oropharyngeal (Trigeminal, Facial, Ambiguus, Hypoglossal, C1-2)
   —> CN5, 7, 9, 11, 12, Ansa cervicalis motor neurons
   —> Oropharyngeal swallow response
2. Esophagus (Dorsal motor nucleus)
   —> CN10
   —> Primary peristalsis

Question 4

Phases of swallowing

Answer 4

1. Oral preparatory phase
   - Voluntary
   - **Mastication (solid)
   - **Glossopalatal seal (fluid): Soft palate closing passage between nasal and oral cavity
2. Oral propulsive
   - Mouth —> Pharynx —> Esophagus
   - **Tongue movement push food from mouth to posterior pharynx
   - **Epiglottis cover airway, ***Larynx move upwards to cover —> prevent aspiration of food into airway
3. Pharyngeal
   - Involuntary
   - Oro-pharyngeal: Relaxation of UES
4. Esophageal
   - Involuntary
   - Peristalsis

Question 5

Manometry

Answer 5

Conventional Manometry:
- test pressure
- 4-8 pressure channels
- water / solid state catheter
- spacing in esophagus 5 cm apart
- spacing in LES 1cm / radial

High Resolution Manometry:
- sensors only 1 cm apart
- 12 circumferencial sensors at each level to test pressure

Question 6

***Approach to Dysphagia

Answer 6

1. Real dysphagia?
   - ***Globus hystericus (something sticking in the throat)
2. **Oropharyngeal vs Esophageal dysphagia
   - **level of obstruction
   - ***type of food
   - pattern reported
   - Esophageal dysphagia patient may perceive location at cervical region mimicking Oropharyngeal dysphagia
3. ***Mechanical (Anatomical) vs Functional (Motility)

Question 7

***Oropharyngeal dysphagia

Answer 7

Features:
- Difficulty **initiating a swallowing, repetitive swallowing
- Nasal regurgitation (when soft palate seal not tight)
- **Coughing from aspiration, diminished cough reflex
- Drooling of saliva / food choking (when jaw cannot move properly)
- **Choking
- Dysarthria + Diplopia
- **Halitosis (bad breath, food retained in pharyngeal pouch)
- Recurrent pneumonia

Causes:
Mechanical / Obstructive causes:
- Infections
- **Thyromegaly
- **Lymphadenopathy
- Reduced muscle compliance (Myositis, Fibrosis)
- Eosinophilic esophagitis (Caucasian: treatment by steroids)
- **Head and neck malignancies
- **Surgical / Radiotherapy interventions on tumours —> stricture / cause inadequate saliva production for swallowing
- Cervical osteophytes
- Oropharyngeal malignancy / neoplasms (rare)
- ***Zenker diverticulum

Neuromuscular disturbances:
- CNS disease (**Stroke, Parkinson, CN palsy, **Bulbar palsy (e.g. MS), ALS)
- Contractile disturbance (Myasthenia gravis, Oculopharyngeal muscular dystrophy)

Question 8

***Esophageal dysphagia

Answer 8

Causes
1. Intraluminal
- **Foreign bodies, **Food bolus

2. Mediastinal (obstruct esophagus by direct invasion, compression, LN enlargement)
   - ***Tumours (e.g. lymphoma)
   - Infections (e.g. TB)
   - Cardiovascular (e.g. vascular compression)
3. Mucosal (narrow lumen though inflammation, fibrosis, neoplasm)
   - **Peptic stricture secondary to GERD (repeated esophagitis —> scarring —> stricture)
   - Esophageal rings / webs (e.g. Schatzki’s ring)
   - **Esophageal tumours
   - **Chemical injury (e.g. caustic ingestion: inflammation —> long segment stricture)
   - **Pill esophagitis (e.g. NSAIDs, Tetracyclines, KCl (Slow K), Alendronate (Bisphosphonate))
   - ***Radiation injury
   - Infectious esophagitis (e.g. Herpes virus)
   - Eosinophilic esophagitis (Caucasian: treatment by steroids)
   - Tumour / Granulation overgrowth in esophageal stenting
   (- Epiphrenic diverticulum (~Zenker but in LES))
4. Neuromuscular
   - **Achalasia
   - **Esophageal spasm
   - ***Scleroderma
5. Post-surgical

Question 9

***Esophageal dysphagia: Mechanical vs Functional

Answer 9

Mechanical:
- Gradual / Sudden onset
- Progress often (e.g. tumour progressively enlarge)
- Worse with swallowing **solid bolus, fluid better
- **Regurgitation in response to bolus
- No temperature

Functional:
- Usually Gradual onset
- Variable progression
- No difference between swallowing solid / liquid bolus (sometimes solid bolus may even stimulate swallowing)
- Bolus can usually passes with drinking liquid / **repeated swallowing
- Vary with temperature of food (*Warm food tends to swallow better)

Question 10

SpC Case study: Esophageal and Upper Gastrointestinal Surgery
Pathology based on different layers of Esophagus

Answer 10

Epithelium:
- **SCC
- **Adenocarcinoma
- Cyst
- ***Abscess

Submucosa:
- Polyp
- **Schwannoma (Made up solely of Schwann cells)
- **Neurofibroma (May include other kinds of cells, such as mast cells and the axons of nerves, mingled together with collagen bundles and other material)
- Carcinoid tumour
- ***Lipoma
- Haemangioma
(- Lymphoma?)

Muscularis propria:
- **GIST (c-kit (CD117), CD34)
- **Leiomyoma (Desmin, Smooth muscle actin) (SpC PP)
- ***Sarcoma

Question 11

***Investigations for dysphagia

Answer 11

1. VFSS (Video fluoroscopy swallowing study)
   - ***Barium swallow (Achalasia: Bird beak / Rat tail sign)
2. Upper endoscopy
   - exclude mechanical obstruction
   - ***Oesophago-gastro-duodenoscopy (OGD)
3. ***FEES (Fibreoptic endoscopic evaluation of swallowing)
4. **High resolution manometry (HRM)
   - DCI: distal contractile integral: time x length x intensity
   - DL: distal latency (time to take from swallow to contraction of distal esophagus: UES relaxation to the contractile deceleration point (CDP))
   —> report as **Pressure
   - initiated by ***Swallowing of water
5. Endoluminal functional lumen imaging probe (EndoFLIP)
   - calculated distensibility of esophagus by measuring volume, pressure
   —> report as **Diameter
   - contraction stimulated by **Secondary peristalsis
   —> additional capability over Manometry of measuring the **cross-sectional area and **intraluminal pressure of the esophagus while under distension (as if a solid bolus was present)

Question 12

Case 1:

• 35yo male
• non-smoker, non-drinker
• chest pain, regurgitation, progressive on/off dysphagia for 1 year
• require flushing with fluid
• weight loss of 20lbs

Answer 12

DDx:
- Achalasia
- Stroke (less likely)
- Distal esophageal spasm
- Reflux stricture (less likely: no symptoms of reflux)
- Ca esophagus (less likely)

1 year —> Functional obstruction
- Achalasia / Distal esophageal spasm

Weight loss 20lb (more severe):
- more likely Achalasia

Question 13

Case 2:

• 75 yo male
• Chiu Chow ancestry
• chronic smoker and drinker
• progressive dysphagia for 1 month
• weight loss
• regurgitating solid food
• cachexic
• no neck mass

Answer 13

DDx:
- Achalasia
- Stroke
- Distal esophageal spasm
- Reflux stricture
- Ca esophagus

Risk factors:
- smoking + drinking —> SCC

• rapidly progressive history
• weight loss + advanced symptoms —> most likely Ca esophagus

Question 14

1. ***Achalasia

Answer 14

Constant failed relaxation of LES (IRP >= ULN) + Failed esophageal peristalsis (No pressurisation along esophagus)

Type 1 Achalaxia:
- **no pressure at all
- **failed relaxation (high IRP)

Clinical features:
- **Dysphagia: mixed
- **Weight loss
- Cough especially when recumbent
- **Regurgitation / Food stuck
- **Chest discomfort / pain (vigorous achalasia)

Clinical scoring system for Achalasia:
- ***Eckardt score (4 categories: 0-12)
—> Weight loss
—> Dysphagia
—> Retrosternal pain
—> Regurgitation

Easily misdiagnosed as GERD (∵ similar symptoms)

Classification:
1. **Primary
2. **Secondary
- Pseudo-achalasia (Cancer of GEJ)
- Para-neoplastic syndrome
- Infiltrative disorders (amyloidosis, sarcoidosis)
- Chagas’ disease (Flagellate protozoan, Trypanosoma Cruz)

Investigations:
(1. CXR
- Absence of air fluid level in stomach)

2. Endoscopy
   - Dilated esophagus
   - Retained food residue
   - LES appear tight but can relax
   - Up to 40% “normal”
   - Possibility of malignant stricture (pseudoachalasia)
3. Barium swallow
   - Fluid level
   - Failed relaxation of LES (but is dynamic vs fixed obstruction by tumour)
4. ***High resolution manometry (HRM)
   - Gold standard
   - Chicago classification of Achalasia (Prognostic)

Treatment:
1. ***Botox injection at sphincter
- temporary effect
- reserved for poorly morbid patients who cannot withstand invasive intervention / when diagnosis is not confirmatory
- inhibit ACh release —> paralyse + relax LES

2. ***Endoscopic dilatation by balloon
   - break down circular muscle
3. Surgery: **Heller myotomy (cut away LES)
   - SE: Acid reflux —> **Dor fundoplication (a partial wrapping of the stomach around the esophagus to make a low-pressure valve)
4. PerOral endoscopic myotomy (**POEM)
   - **ESD (endoscopic submucosal dissection)
   - 1st line nowadays
   - no Dor fundoplication done —> very often ***acid reflux

End-staged Achalasia:
5. ***Esophagectomy
- Esophagus is tortuous / sigmoidal —> food can stuck along way (even if LES released surgically)

Question 15

Chicago classification of Achalasia

Answer 15

Achalasia:
- Failed relaxation of LES (IRP >= ULN)
AND
- Failed peristalsis of ***esophageal body

***Major disorders of peristalsis: Entities not seen in normal subjects
1. IRP (Integrated relaxation pressure): Pressure at LES in response to swallow
- If IRP >= ULN: Failed relaxation
AND
- Failed peristalsis
—> Achalasia

2. If IRP >= ULN and not type 1-3 Achalasia:
   - Look for other causes of obstruction: Mechanical obstruction
3. IRP normal
   - Short DL: **Distal esophageal spasm
   - High DCI: **Jackhammer esophagus (high amplitude abnormal contractions)
   - Failed peristalsis: ***Absent contractility

***Minor disorders of peristalsis: Impaired clearance (also see in normal subjects)
- Ineffective motility (IEM)
- fragmented peristalsis

Question 16

2. Diffuse esophageal spasm (DES)

Answer 16

IRP normal, ***Short DL
- Almost simultaneous contraction of esophagus with Swallowing (不協調收縮)

Barium swallow / Endoscopy:
- ***Spiral appearance of Esophagus (“Corkscrew” deformity)

S/S:
- Dysphagia
- ***Chest pain
- Seldom significant weight loss

Question 17

3. Pills induced ulceration

Answer 17

1. ***NSAIDs
2. ***Tetracyclines
3. KCl (Slow K)
4. ***Alendronate (Bisphosphonate)

Question 18

4. Pharyngeal pouch / Zenker’s diverticulum

Answer 18

• False diverticulum
• A sac which can trap food

Etiology:
- Uncoordinated swallowing, Impaired relaxation, Spasm of the **cricopharyngeus muscle (UES)
—> ↑ pressure within distal pharynx
—> its wall herniates through point of least resistance (known as **Killian’s triangle, located superior to cricopharyngeus and inferior to thyropharyngeus)

S/S:
- **Halitosis
- **Regurgitation of food stored within sac

Treatment:
- **Resection of diverticulum + **Incise Cricopharyngeus (UES) (Myotomy: use muscle to patch the defect)

Question 19

5. Gastroesophageal reflux disease (GERD)

Answer 19

***Montreal definition: Reflux of gastric content leads to troublesome symptoms / complications

Etiology:
1. **Hiatus hernia —> Tortuosity + Mechanical obstruction + Volvulus of herniated stomach
- Type 1: Sliding
- Type 2: Rolling (GEJ still intraabdominal, not cause reflux, but more obstructive symptoms / even strangulation)
- Type 3: Mixed
2. **Lax LES
3. **Transient LES relaxation (TLESR)
4. **Poor esophageal clearance
5. Acid pockets
6. ***Increased intra-abdominal pressure (obesity, tight garment)

Clinical features:
1. Heartburn
- substernal discomfort
- radiation of pain towards mouth
- precipitated by meals and recumbency
- ameliorated with antacid
2. Regurgitation

Diagnosis:
1. **Chinese GERDQ (7 items)
2. **PPI test
3. ***Endoscopy
4. Manometry + 24 hour pH monitoring

Esophagitis:
- Graded by ***Los Angeles classification: Grade A-D

Complications:
- **Peptic stricture
- **Barrett’s esophagus (pre-malignant)

Treatment:
1. **Lifestyle modification
- Stop smoking, alcohol, chocolate, high fat diet, coffee, tea, cola, acid juices, peppermint, reduce size of meal
- Lose weight
- Avoid tight clothing
- Elevate head of bed
2. **Antacid
3. **H-2 antagonists
- Cimetidine, ranitidine, famotidine
4. Mucosa protectant
- Sucralfate
5. **PPI
- Omeprazole, lansoprazole, esomeprazole, rabeprazole

Indication for surgery:
1. **Compliance issue, preferred not to have life long medication / SE
- PPI responders (good prognostic factor)
2. **Refractory GERD
- PPI non-responders (10-30%)
3. **Regurgitation symptoms: usually not relieved by PPI (PPI only treat acid-related symptoms: esophagitis, heartburn but not reflux mechanism)
4. **Hiatal hernia (Anatomical defect to correct)

Surgery:
Complete vs Partial fundoplication
- **Nissen fundoplication (complete)
- **Toupet fundoplication (partial)

Question 20

6. ***Esophageal cancer

Answer 20

• High incidence in China / Asia (Hebei, Henan, ***Chewchow)
• ***Male predominant
• 10th mortality rank in HK

Symptoms (from SpC Interactive tutorial: Esophageal cancer):
1. **Dysphagia
2. **Regurgitation
3. **Loss of weight
4. **Retrosternal pain
5. Odynophagia
6. **Hoarseness of voice (RLN palsy)
7. **Cough + Chest infection (Aspiration, Tracheo-esophageal fistula)

Risk factors:
1. **Alcohol (Aldehyde dehydrogenase deficiency in Han Chinese —> Heterozygous flusher —> High risk of cancer)
2. **Smoking
3. **Salted fish, **pickled vegetables (Nitrosamine, Nitrite)
4. Infrequent citrus fruit
5. Infrequent green vegetables
6. ***Hot soup, beverage
(7. Micronutrient deficiencies (e.g. Selenium)
8. Mouldy food, fungi-toxins (e.g. Aflatoxin)
9. HPV
10. Genetics)

SCC:
- Above
- History of **H/N cancer —> **Field change effect (H/N region contact with same carcinogen as esophagus) —> screen for synchronous (within 6 months) / metachronous cancer (>=6 months from each other)
- **Caustic injury to esophagus —> chronic inflammation
- **History of radiotherapy
(- Achalasia
- Lye corrosive stricture
- **Paterson-Brown Kelly syndrome (aka Plummer-Vinson syndrome) (esophageal + laryngeal web, **Fe deficiency anaemia, dysphagia, glossitis, cheilosis —> female predominant, young —> ↑ risk of CA esophageal + hypopharynx)
- Tylosis (Howel-Evans syndrome))

Adenocarcinoma:
- **Barrett’s esophagus (Columnar epithelium migrate proximally to above GEJ)
- **Reflux symptoms
- **Overweight
- **History of radiotherapy

Question 21

Adenocarcinoma of Esophagus

Answer 21

Epidemiology:
- ↑ Incidence —> ∵ ↑ GERD + Overweight

Pathogenesis:
Obesity
—> GERD
—> Barrett’s esophagus (***Metaplasia) (Screening)
—> Low grade dysplasia (Surveillance)
—> High grade dysplasia (Surveillance)
—> Cancer

Non-dysplastic Barrett: <1% malignant transformation per year

Diagnosis:
1. **Endoscopic
2. **Histological: Intestinal metaplasia (Goblet cells)

**Prague criteria:
- measure **Circumferential (C) + ***Maximum extent of metaplasia (M)

Treatment:
- Low grade dysplasia: Local ablative (Radiofrequency ablation, **Endoscopic mucosal resection (EMR))
- High grade dysplasia: **Endoscopic resection (distinguish between sampling error vs true invasive tumour)

Question 22

Management of Esophageal cancer

Answer 22

Staging investigations:
1. **Endoscopy
2. **Endoscopic USG
3. **CT
4. **PET-CT
5. Pathological examination

Localised Tis / T1a (i.e. early):
- ***Endoscopic therapies (ESD, EMR, Ablative therapy)
—> if diffuse: may develop stricture after EMR —> may do upfront esophagectomy instead

T1b / T2N0:
- ***Upfront esophagectomy

T1b-T4a, N0-N+:
- **Neoadjuvant Chemotherapy / Neoadjuvant Chemoradiation
—> **Esophagectomy (Curative with R0 resection)
- if too frail for surgery —> Definitive Chemoradiotherapy —> ***Salvage surgery (for residual / recurrent disease)

Cervical esophageal tumour (close to larynx, vocal apparatus):
- **Pharyngo-laryngo-esophagectomy
or
- **Definitive chemoradiotherapy —> Laryngeal-preserving esophagectomy

T4b / M1 (i.e. Inoperable, Metastasis):
- **Chemotherapy, **Radiotherapy, Palliative (stenting to maintain patency of esophagus)

Question 23

Esophagectomy techniques

Answer 23

Phase:
- 1 Phase (1 incision in abdomen): Esophagogastrectomy (longer jejunum anastomose with lower esophagus, when stomach have tumour and cannot be used as conduit)
- 2 Phase (Transhiatal, Lewis-Tanner / Ivor-Lewis (Transthoracic))
- 3 Phase (***Mckeown (Transthoracic))

Transthoracic vs Transhiatal:
- Transthoracic: collapse lungs for adequate view of esophagus
- Transhiatal: no need to collapse lungs, can maintain ventilation, but suboptimal view + poorer quality of LN dissection —> mediastinal part of esophagus dissected bluntly

Ivor-Lewis vs Mckeown:
- Ivor-Lewis: dissect esophagus in chest, **2 incisions, stomach pulled up to **chest for anastomosis
- Mckeown: dissect esophagus in chest, **3 incisions, stomach pulled up to **neck for anastomosis (for proximally located tumour)

Field of LN dissection:
- Phase II: Thorax + Abdomen
- Phase III: Thorax + Abdomen + Neck

Conduit:
- **Stomach (rely on Right Epiploic Arcade to supply whole stomach, Short gastric vessels cut, rely on submucosal plexus to diffuse blood from **Right Epiploic Arcade + **Right gastric artery)
- **Colon
- ***Jejunum (tumour only involve cervical esophagus —> no need gastric pull-up —> free jejunal flap instead)

Route:
- **Orthotopic (natural route of esophagus)
- **Retrosternal (conduit run behind sternum, used when suspected residual tumour at posterior mediastinum, adjuvant radiotherapy can then be used to clear residual tumour)
- ***Subcutaneous (in front of sternum)

Anastomosis:
- Stapled (Linear, Circular)
- Handsewn

Approach:
- Open
- VATS (Video assisted thoracoscopic surgery)
- Total MIE (Laparoscopy)
- Robotic (tackle narrow cavity e.g. lung apex for LN dissection)

Position:
- Supine
- Left lateral (tackle through right chest)
- Prone (lung fall anteriorly —> make room for tackling posterior mediastinum)

Question 24

SpC Interactive tutorial: Benign esophageal diseases
Esophageal perforation: Boerhaave’s syndrome

Answer 24

***Causes:
1. Iatrogenic (endoscopy, dilatation, intubation)
2. Intrinsic (carcinoma, peptic esophagitis)
3. Traumatic (FBI, post surgical, caustic injury, blunt / penetrating trauma)
4. Spontaneous (Boerhaave’s syndrome / Emetogenic)

Boerhaave’s syndrome:
- ***Retching against a closed glottis (also laughing, childbirth, trauma, heavy lifting)

Classical triad:
1. **Vomiting
2. **Excruciating chest pain
3. ***Subcutaneous emphysema

Symptoms:
- Chest pain
- N+V / Haemetemesis
- SOB

Signs:
- Sepsis
- Surgical emphysema
- Hydropneumothorax

Investigation:
1. CXR
- **Hydropneumothorax
- **Mediastinal air
2. **Endoscopy
- Site and size of perforation
3. **Water-soluble contrast study (NO barium)
- Site and size of perforation
4. CT scan
- Collections, mediastinal air, effusion, pneumothorax

Treatment:
1. **Resuscitation + **Antibiotics
2. Conservative
- in stable patient with very localized leak - selective
- hole can heal itself
3. **Drainage (what kills is dirty stuff)
4. **Surgical repair (usually for early diagnosis)
- close if possible (sometimes tissue can be unhealthy / edematous —> high risk of anastomotic leak)
5. Esophagectomy (rarely done, ?cancer)
6. Endoscopic stenting
7. Outcome depends on timely diagnosis + treatment

Question 25

Caustic ingestion

Answer 25

Degree of esophageal injury depends on:
1. Specific caustic agent
- Alkaline: **Liquefaction necrosis —> easy penetration into deeper layers of esophagus
- Acid: **Coagulation necrosis —> limit penetration
2. Quantity + Concentration
3. Duration of contact time
4. Physical form

Symptoms:
1. Dysphagia
2. Sore throat
3. Drooling of saliva
4. Burn to mouth + lips
5. SOB
6. Signs of perforation, sepsis

Complications:
1. **Laryngeal edema, Pneumonitis
2. **Esophageal, gastric perforation, adjacent organs
3. ***Metabolic acidosis / alkalosis
4. Stricture (as early as 2 weeks)
5. Cancer risk

Treatment:
1. Resuscitation (ABCs)
- Airway assessment
2. ***Role out perforation
3. Upper endoscopy
- Assessment of oropharynx, esophagus, stomach
- Nasogastric tube insertion (endoscopic guided)
4. Supportive

Late sequalae:
1. **Pharyngeal / Airway injury
- swallowing problem
- breathing problem
- speech problem
2. **Esophageal stricture
- commonly refractory to endoscopic dilation
- occur as early as 2 weeks or years later
3. ***Esophageal cancer
4. Gastric / Colonic reconstruction
- after 6 months
- +/- esophagectomy
- +/- hypopharyngeal reconstruction

Question 26

SpC Interactive tutorial: Esophageal cancer
Early diagnosis of Esophageal cancer

Answer 26

1. Balloon / Sponge cytology (Obsolete)
2. Chromoendoscopy
   - ***Lugol’s iodine
   —> Spray iodine onto esophageal mucosa —> dysplastic mucosa absorb glycogen —> not stained black (normal mucosa have glycogen will be stained black)
   —> Risk of aspiration + messy

• ***Narrow band imaging
  —> Capillaries (Intraepithelial papillary capillary loop) on mucosal surface displayed in brown + veins in submucosa displayed in cyan
  —> Thicker / more tortuous vessels —> deeper level of cancer

Question 27

Endoscopic management of Esophageal cancer

Answer 27

Endoscopy:
—> EMR / ESD / Just biopsy
—> Clinical + Histopathological evaluation
—> Determine of radicality (if margin not cleared after EMR / ESD)
—> Follow-up observation / Additional surgery, Chemo, RT

EMR / ESD:
- Absolute indications: dysplastic epithelium / laminar propria mucosae not exceeding 2/3 of circumference (∵ low risk of nodal metastasis)
- Relative indications: in-between
- Investigational indications (i.e. Not indications of submucosal dissection): SM2 / deeper lesions (∵ high risk of nodal metastasis)

EMR vs ESD:
- ESD better than EMR but EMR easier to do
- ESD require more training

Question 28

***Investigations of Esophageal cancer

Answer 28

Staging of Esophageal cancer: TNM
1. ***Barium swallow
- Stenosis
- Proximal dilatation
- Sinuses
- Shouldering
- Level

2. ***Upper endoscopy
   - Distance from incisor
   - Obstruction
   - Biopsy
   - Cytology
   - Feeding tube insertion
3. Bronchoscopy
   - Tumour infiltration of airway
   - Obstruction
   - ***Tracheo-esophageal fistula
4. ***Endoscopic USG
   - Best to stage T + regional N stage
   - >80% accurate
   - EUS + FNA
5. CT
   - Wall thickening
   - Aortic infiltration
   - Airway infiltration
   - Level
   - Distant metastasis
6. ***PET-CT
   - For distant metastasis

Question 29

Barrett’s esophagus

Answer 29

Definition:
- Presence of an abnormal segment of ***metaplastic columnar epithelium in the esophagus and biopsies of which showed intestinal metaplasia

Histology (3 types):
1. Cardiac
2. Fundic
3. Intestinal metaplasia

Definition of GEJ:
- ***Top of gastric fold
(Japan: palisade vessels present at distal end of esophagus)

(GEJ vs Z-line:
- Z-line: Squamocolumnar junction, transition between squamous mucosa and columnar mucosa, 3-11mm above GEJ)

(ACG clinical guideline 2015:
- Extension of salmon-coloured mucosa into the tubular esophagus extending >=1cm proximal to the GEJ with biopsy confirmation of intestinal metaplasia (IM)

BSG guideline 2014:
- Any portion of normal distal squamous epithelial lining has been replaced by metaplastic columnar epithelium, which is clearly visible endoscopically (>=1cm) above the GEJ and confirmed histopathologically from esophageal biopsies)

Question 30

***Classification of Adenocarcinoma of Esophagus

Answer 30

1. ***Siewert classification
   - Typing based on Epi-centre of tumour + Tumour must involve GEJ
   —> Type 1: Esophageal
   —> Type 2: True cardia
   —> Type 3: Subcardia
2. Nishi classification (only used in Japan)

Question 31

***Treatment of Esophageal cancer

Answer 31

Curative:
1. ***Surgery
- Lewis-Tanner / Ivor Lewis operation (2 phase: abdominal + thoracic phase)
- Mckeown (3 phase: abdominal + thoracic + neck phase)

2. ***Endoscopic ablation / resection
   - EMR / ESD
   - RFA
   - Photodynamic therapy
   - Cryotherapy
   - Argon plasma coagulation
3. **Chemotherapy + RT
   - **Combined with surgery
   - Spatial + synergistic actions
   - Radiosensitisers
4. Systemic therapy
   - Chemo
   - Targeted
   - Immunotherapy

Palliative:
1. Surgery
- **Resection
- **Bypass

2. Endoscopic
   - **Dilatation
   - **Laser therapy
   - Esophageal prosthesis (Self-expanding metallic stents)
   - Alcohol injection
   - Brachytherapy
3. Chemo, RT

Question 32

RFA

Answer 32

• Targeted epithelium: ~500um

Advantage:
- Ablation depth ~500-1000um (less deep than EMR / ESD)
- Post-RFA: give PPI (prevent mucosa grow back to columnar mucosa —> instead grow back to normal squamous mucosa)

Disadvantage:
- ***No histology information (∵ cells already burnt)

Question 33

Important structures in Esophageal surgery

Answer 33

Esophagus: Posterior mediastinal structure

1. **Left + Right RLN
   - Left RLN: hook around ligamentum arteriosum in sub-aortic arch —> goes up in tracheo-esophageal groove
   - Right RLN: hook around right subclavian artery at lung apex
   - **Cancer has propensity to spread along RLN
   —> nodal metastasis along RLN
   —> hoarseness: poor prognostic sign
   —> indicate infiltration to nerve / LN metastasis compressing on nerve
2. LN
   - Paratracheal + Supraclavicular area
   - usually only involve level 4/6 LN
   - if involve level 2 LN —> also screen for ***second primary cancer (synchronous cancer)
3. ***Trachea (in front of esophagus)
4. ***Bronchus
5. ***Pericardium, Aorta

Question 34

***Complications of Esophagectomy

Answer 34

Medical complications:
1. **Cardiac
- AF
2. **Pulmonary
- Atelectasis
- Consolidation
- Sputum retention
- Pneumonia

Surgical complications:
Early:
1. **RLN injury (hoarseness, aspiration risk)
2. **Anastomotic leak (highest leakage rate in GI surgery)
3. **Tracheo-bronchial injury
4. **Ischaemic conduit
5. ***Chylothorax

Late:
6. Gastric outlet obstruction, stasis
7. ***Hiatal herniation of bowel

Question 35

Reasons for difficult treatment in Esophageal cancer

Answer 35

1. ***Late presentation / disease stage
   - early disease have no symptoms (no dysphagia)
2. ***Early spread of disease
   - mucosal / submucosal lesion can already spread via nodal metastasis (compared to malignancy in other GI tract)
3. ***Deep seated organ anatomically with important surrounding structures
4. Elderly population with co-morbid diseases

Question 36

(Field change effect / Field cancerisation (from web))

Answer 36

1. H+N cancer
2. Esophageal cancer
3. Stomach cancer
4. Lung cancer
5. Breast cancer
6. Colorectal cancer
7. Bladder cancer
8. Skin cancer