1. Dr Bernard Stacey Southampton General Hospital

2.  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

3. Blot WJ et al. JAMA 1991;265:1287-9

8. 1. Lower oesophageal sphincter 2. Crural diaphragm 3. Sling fibres of the stomach

9. Longitudinal Circular Oesophageal wall histology  distance in lower oesophagus

12. How??

14.  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

15. 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

21. Mittal, R. K. et al. N Engl J Med 1997;336:924-932 Anatomy of the Esophagogastric Junction

22. The phreno- oesophageal ligament: Origin - fascia transversalis Insertion: oesophageal wall Rich in collagen and elastic fibres

23. The phreno-oesophageal ligament

24. Fatty infiltration

26.  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

27. 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

29. One extra oesophageal adenocarcinoma for every 5000 men over 60 treated

32. ?

38.  Lagergren J. NEJM 1999; 340: 825-31 OesCardia Recurrent symptoms7.72.0 ‘Long-standing’ reflux43.54.4

42. Normaloesophagus MildOesophagitisSevereOesophagitisBarrett’sMetaplasia 100% of adults >30yrs Adenocarcinoma High Grade Dysplasia Low Grade Dysplasia months years 0.25% 2 - 5 years 0.08% 0 - 3 years 0.06% days - weeks 10% 3.5% 1.2% 95% don’t present Role of chemoprevention ?

43.  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

44.  ~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

45.  Lagergren J. NEJM 1999; 340: 825-31 OesCardia Recurrent symptoms7.72.0 ‘Long-standing’ reflux43.54.4

47.  Dysphagia  Weight loss  Nausea and vomiting  Pain uncommon (unless metastases)

49. 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%

52. T1

55. T4

62.  Stenting  Dilatation  Alcohol injection  Laser  Brachytherapy

63. Ultraflex Z-stent Wall stent Esophacoil Plastic stents

64.  Common  Food bolus  Tumour overgrowth  “Knuckle” of stomach  Reflux  Rarer  Stent migration  Perforation  Aspiration  Airway compression

65. Who will get the most problems?

66.  Weight loss  Length of stricture (tumour volume) Not:  Age, histology, BMI r=0.63 r=0.59

71. 1990 - 1996

72. 14 Median

74. Poor Poor-mod Mod Mod-well Well

75. 1 2a 2b 3 4

76. Stage:

77. Nil Non-malignant Other malignancy Cardio-resp

78. Never Ex Current

80.  Median = 14 months  Mean = 41 months  1-year survival = 42.3% (58 / 137)  5-year survival = 12.4% (17 / 137 )