Dr Bernard StaceySouthampton 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??

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;336:924-932

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 andcrural diaphragm

= perfect scenario for reflux

Does weight loss help reflux?

•Remarkably little data!

•Yes: Derby 1999

23 pts BMI >23, GORD 6/12

- 80% lost wt and symptoms improved

r = 0.548, p<0.001

•No: Stockholm 1996

20 pts; pH study confirmed reflux

- no significant improvement despite mean of 10kg wt loss

•Maybe: Amsterdam 2002

42 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: 825-31

Oes CardiaRecurrent symptoms 7.7

2.0‘Long-standing’ reflux 43.5

4.4

NormalNormaloesophagusoesophagus

Mild Mild OesophagitisOesophagitis

Severe Severe OesophagitisOesophagitis

Barrett’sBarrett’sMetaplasiaMetaplasia

100% of adults >30yrs100% of adults >30yrs

AdenocarcinomaAdenocarcinomaHigh GradeHigh GradeDysplasiaDysplasia

Low GradeLow GradeDysplasiaDysplasia

monthsmonths months months

yearsyears

0.25%0.25%

2 - 5 years2 - 5 years

0.08%0.08%

0 - 3 years0 - 3 years

0.06%0.06%

days - weeksdays - weeks

10%10% 3.5%3.5% 1.2%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 1st 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: 825-31

Oes CardiaRecurrent symptoms 7.7

2.0‘Long-standing’ reflux 43.5

4.4

DysphagiaWeight lossNausea and vomitingPain uncommon (unless metastases)

02468

101214

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-90

>90

Stage TNM 1st seen 5yr surv

1 T1 N0 M0 10% 90%2a T2/3 N0 M0 25%

50%2b T1/2 N1 M03 T3 N1 M0 45% 15%

Any T44 Any M1 20% 0%

T1

T4

StentingDilatationAlcohol injectionLaserBrachytherapy

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,

BMI0

2

4

6

8

10

12

0 20 40 60 80 100 120 140

-5

0

5

10

15

20

25

30

35

40

0 20 40 60 80 100 120 140

r=0.63

r=0.59

0

10

20

30

40

50

60

70

Pre-stent 1 month 3 months

0

10

20

30

40

50

60

70

Pre-stent 1 month 3 months

0

10

20

30

40

50

60

70

80

90

Pre-stent 1 month 3 months

1990 - 1996

0

1

2

3

4

5

6

7

8

0 20 40 60 80 100 120 14014

Median

0

10

20

30

40

50

60

70

80

90

0 20 40 60 80 100 120 140 160

0

20

40

60

80

100

120

140

160

Poor Poor-mod Mod Mod-well Well

0

20

40

60

80

100

120

140

160

1 2a 2b 3 4

6%

34%

59%

1%

1 2 3 4Stage:

0

20

40

60

80

100

120

140

160

Nil Non-malignant Other malignancy Cardio-resp

0

20

40

60

80

100

120

140

160

Never Ex Current

34%

34%

32%

Never

Ex

Current

Median = 14 months

Mean = 41 months

1-year survival = 42.3% (58 / 137)

5-year survival = 12.4% (17 / 137 )