Dr Bernard Stacey Southampton General Hospital
Incidence of adenocarcinoma of the oesophagus is fastest rising cancer in Western world Majority present late when only palliation possible Resection implies a major procedure and many have concurrent disease
Blot WJ et al. JAMA 1991;265:1287-9
1. Lower oesophageal sphincter 2. Crural diaphragm 3. Sling fibres of the stomach
Longitudinal Circular Oesophageal wall histology distance in lower oesophagus
How??
Experimental oesophagitis Distal peristaltic contractions disappear LOS pressure by 60% Oesophagus 1-2cm shorter Oesophageal compliance by 30% Largely recovered by 4 weeks Zhang X et al. Am J Physiol Gastrointest Liver Physiol; 2005
Attached to hypopharynx and diaphragm At lower end it blends with phreno-oesophageal ligament More muscle bulk than circular muscle Can shorten oesophagus by 5-6cm
Mittal, R. K. et al. N Engl J Med 1997;336: Anatomy of the Esophagogastric Junction
The phreno- oesophageal ligament: Origin - fascia transversalis Insertion: oesophageal wall Rich in collagen and elastic fibres
The phreno-oesophageal ligament
Fatty infiltration
BMI and waist circumference correlates to in: intra-gastric pressure and G-O pressure gradient Also separation of LOS and crural diaphragm = perfect scenario for reflux
Does weight loss help reflux? Remarkably little data! Yes: Derby pts BMI >23, GORD 6/ % lost wt and symptoms improved r = 0.548, p<0.001 No: Stockholm pts; pH study confirmed reflux - no significant improvement despite mean of 10kg wt loss Maybe: Amsterdam pts BMI 43 - wt loss, no gastric distension improved - with gastric distension continued reflux
One extra oesophageal adenocarcinoma for every 5000 men over 60 treated
?
Lagergren J. NEJM 1999; 340: OesCardia Recurrent symptoms ‘Long-standing’ reflux
Normaloesophagus MildOesophagitisSevereOesophagitisBarrett’sMetaplasia 100% of adults >30yrs Adenocarcinoma High Grade Dysplasia Low Grade Dysplasia months years 0.25% years 0.08% years 0.06% days - weeks 10% 3.5% 1.2% 95% don’t present Role of chemoprevention ?
43% had Ca in resection specimen 24% progressed to Ca during 2-46 months follow up Ca incidence at 3 yrs 56% if diffuse 14% if focal HGD Veterans’ study – 7.3 yrs F/U: 4 / 79 Ca in 1 st year 12 / 75 Ca of whom 11 cured But: single pathologist
~10% of population have reflux 10-15% of these have Barrett’s change (short > long segment) These get adenocarcinoma at 0.5%/year 40% of adenocarcinomas have no history of GORD <5% of adenocarcinomas are known to have Barrett’s on presenting with symptoms of their cancer
Lagergren J. NEJM 1999; 340: OesCardia Recurrent symptoms ‘Long-standing’ reflux
Dysphagia Weight loss Nausea and vomiting Pain uncommon (unless metastases)
Stage TNM 1st seen5yr surv 1 T1 N0 M010%90% 2a T2/3 N0 M025%50% 2b T1/2 N1 M0 3 T3 N1 M045%15% Any T4 4 Any M120%0%
T1
T4
Stenting Dilatation Alcohol injection Laser Brachytherapy
Ultraflex Z-stent Wall stent Esophacoil Plastic stents
Common Food bolus Tumour overgrowth “Knuckle” of stomach Reflux Rarer Stent migration Perforation Aspiration Airway compression
Who will get the most problems?
Weight loss Length of stricture (tumour volume) Not: Age, histology, BMI r=0.63 r=0.59
14 Median
Poor Poor-mod Mod Mod-well Well
1 2a 2b 3 4
Stage:
Nil Non-malignant Other malignancy Cardio-resp
Never Ex Current
Median = 14 months Mean = 41 months 1-year survival = 42.3% (58 / 137) 5-year survival = 12.4% (17 / 137 )