ESOPHAGEAL CANCER AND GERD. Prof Salman Guraya FRCS, Masters MedEd

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1 ESOPHAGEAL CANCER AND GERD Prof Salman Guraya FRCS, Masters MedEd

2 Learning objectives Esophagus anatomy and physiology Esophageal cancer Causes, presentations of esophageal cancer Diagnosis and management Pathophysiology of GERD Management strategies for GERD

3 Esophagus anatomy 25 cm long and 2 cm wide tube from mouth to stomach Upper and lower esophageal sphincters open involuntarily for traffic of food 4 layers as other parts of GIT Cervical, thoracic and abdominal parts

4 Esophagus Esophagus is lined by stratified squamous epithelium At its junction with stomach, this changes to simple columnar epithelium Normal esophageal ph is almost 7.0 LES protects against acid reflux

5 Esophageal cancer Common in years Men are affected 3 times more than women SCC is the most common type of esophageal cancer SCC commonly affects middle of esophagus Adenocarcinoma affects lower part of esophagus SCC caused by smoking and alcohol Adenocarcinoma caused by GERD

6 Predisposing factors Smoking Alcohol GERD Barrett s esophagus Obesity Achalasia Tylosis Plummer-Vinson syndrome Human papilloma virus Corrosive esophagitis Vitamin D deficiency (GIT, Breast, Thyroid, Prostate, lung)

7 Cancers caused by smoking Esophageal/pharyngeal Tracheobronchial Lung Pancreatic Urinary bladder Kidney

8 Presenting features Dysphagia, first for solids and then liquids Weight loss Bleeding Epigastric or retrosternal pain Hoarseness Persistent cough Bone pain due to metastases

9 Signs of esophageal cancer Typically normal exam unless mets Lymphadenopathy (cervical, SC, mediastinal) Hepatomegaly (mets) Cachexia, emaciation, lethargic Stigma of weight loss and dehydration

10 Diagnosis o o o o o o o o Labs EGD (Localization and Bx) EUS, most sensitive for staging CT abdomen and chest Positron emission tomography (PET) scan Bronchoscopy (tracheo-bronchial invasion) Laparoscopy and thoracoscopy Barium swallow, now rarely used

11 EGD and EUS

12 CT and PET Scans

13 TNM classification T1S T1 T1a T1b T2 T3 T4 N0 N1 N2 M0 and M1 Carcinoma in situ Lamina propria or submucosa Muscularis mucosa Submucosa Muscularis propria Adventitia Adjacent structures No regional nodal mets 1-2 regional nodal mets 3-6 regional mets No mets and positive mets

14 Staging classification Stages T N M Stage I T1 and T2 N0 M0 Stage II T3 N1 M0 Stage III T4 N2 M0 Stage IV Any T Any N M1

15 Management According to cancer staging Improve nutrition, electrolyte and hydration by TPN Stage I; endoscopic mucosal resection or submucosal dissection Stage II and III; chemoradiation and then surgery Stage IV; chemoradiation and palliative care

16 Endoscopic resections

17 Surgical modalities Transthoracic esophagectomy (TTE) Transhiatal esophagectomy (THE) Minimally invasive esophagectomy Robotic assisted esophagectomy

18 TTE

19 THE

20 Colonic interposition after esophagectomy

21 Robotic assisted esophagectomy

22 Palliation

23 GERD Impaired acid neutralization by saliva O 3 Impaired esophageal motility Incompetent LES Hiatal hernia Delayed gastric emptying LES=lower esophageal sphincter

24 What causes GERD Obesity, if BMI >30 kg/m 2 Smoking Diet Pregnancy Hiatus hernia Medicines; Aspirin and NSAIDs, Ca channel blockers, diazepam, antocholinergic drugs Incompetent LES

25 H pylori. peptic ulcer and gastritis

27 Presenting features Heartburn Retrosternal pain Chest pain Easily confused with angina pain Weight loss and loss of appetite Affects daily life

28 Phenotypic classification of GERD GERD NERD 60-70% Erosive Esophagitis 20-30% Barrett s Esophagus 6-10% Fass et al. Alim Pharm Ther 2005

29 Complications of GERD Esophageal stricture

30 Complications of GERD Barrett's esophagus - Associated with prolonged acid reflux

31 Complications of GERD severe dysphagia weight loss bleeding hematemesis mass in the upper abdomen anemia

32 My patient A 31-year old man complains of heartburn since 6 months. His medical history is unremarkable. He has no dysphagia, odynophagia, anemia or weight loss. He feels symptoms several times a week, usually during stressful days at his job. What should be done at this point?

33 Initial management of heartburn Antacids and lifestyle changes H 2 -receptor antagonists Standard proton pump inhibitors (once a day) High-dose proton pump inhibitors (twice a day) Endoscopy and/or ph testing followed by therapy based on results

34 You place him on H 2 -receptor antagonists, antacids and recommend lifestyle changes. BUT he returns a month later with no change in his symptoms You put him on once daily PPIs and request for an EGD He comes back with a normal EGD and he is still symptomatic

35 Next management strategies Increase proton pump inhibitors to twice a day Endoscopic treatment Surgical treatment Perform ph study Esophageal manometry

36 Esophageal ph monitoring Indicated to determine; - Effectiveness of medications for GERD - Whether chest pain is due to GERD or non GERD origin - If reflux is causing acid aspiration and chronic cough

37 Bravo wireless capsule

38 High resolution esophageal manometry

39 Further treatment Will depend upon tests results If no improvement with conservative steps, think of surgery consultation. Surgical indications: Failure of medical therapy Atypical symptoms from the start Complications of GERD

40 Anti reflux surgery; Nissen s fundoplication

Esophageal cancer is a disease of old men Smoking, alcohol GERD are major causes EUS, EGD and PET scan are key diagnostic tools Stage I treated by endoscopic

41 Esophageal cancer is a disease of old men Smoking, alcohol GERD are major causes EUS, EGD and PET scan are key diagnostic tools Stage I treated by endoscopic resection, II and III by chemotherapy and surgery Stage IV palliation only GERD can be managed by medicines and lifestyle changes Non responsive or complicated GERD needs surgery

Hiatal Hernias and Barrett s esophagus. Dr Sajida Ahad Mercy General Surgery

Hiatal Hernias and Barrett s esophagus Dr Sajida Ahad Mercy General Surgery Objectives Identify the use of different diagnostic modalities for hiatal hernias List the different types of hiatal hernias