SU28.5-9 | Upper Gastrointestinal Surgery — Assignment

CLINICAL SCENARIO

A 64-year-old man is referred to the upper GI clinic with a three-month history of difficulty swallowing. He first noticed food 'sticking' when he ate meat, and over the weeks the problem has progressed so that he now struggles with soft food and is beginning to find liquids difficult. He has lost 8 kg in weight. He has suffered heartburn and acid reflux for over twenty years, for which he occasionally takes antacids, and he has smoked 20 cigarettes a day for forty years. On examination he is thin, with no palpable abdominal mass, but you note a firm node in the left supraclavicular fossa. Upper GI endoscopy reveals an ulcerated, partly stricturing lesion in the lower third of the oesophagus arising from a segment of salmon-pink columnar mucosa; biopsies are taken.

1. Interpreting the dysphagia and reaching a diagnosis

Analyse the pattern of this patient's dysphagia and state your working diagnosis. Explain how the pattern, the site of the lesion, the columnar (salmon-pink) mucosa and the long history of reflux fit together.

Guidance: Use the rule that progressive solids-then-liquids dysphagia with weight loss suggests a mechanical/malignant cause, whereas solids-and-liquids together from the outset suggests a motility disorder. Link chronic GERD → Barrett's metaplasia → adenocarcinoma in the lower oesophagus.

2. Applied anatomy and physiology relevant to the lesion

Describe the applied anatomy and physiology of the oesophagus that are relevant here: the three constrictions, the divisions (cervical/thoracic/abdominal), the relationship of histological type to site, and the role of the lower oesophageal sphincter and reflux in disease.

Guidance: Explain why lower-third tumours tend to be adenocarcinoma (Barrett's) and upper/middle-third tumours squamous cell carcinoma; note the lymphatic drainage and how it underlies nodal spread.

3. Significance of the supraclavicular node and assessment of spread

Explain the significance of the left supraclavicular node in this patient and outline how you would assess for local and distant spread.

Guidance: Discuss the implications of a Virchow's node, and how lymphatic and haematogenous spread of oesophageal cancer determine resectability and prognosis.

4. Investigation and staging

Outline the investigations you would request to confirm the diagnosis and stage the disease, and justify each. State what each test contributes to the management decision.

Guidance: Cover histological confirmation (endoscopic biopsy — already taken), and staging (CT chest/abdomen, endoscopic ultrasound for T and N stage, PET where available), plus assessment of nutrition and fitness for treatment.

5. Principles of management

Discuss the principles of management for benign versus malignant oesophageal disease, then apply them to this patient. Distinguish curative from palliative intent and explain how the stage and the patient's fitness drive the choice.

Guidance: Contrast the management of GERD/Barrett's (lifestyle, acid suppression, surveillance) with that of oesophageal carcinoma (potentially curative resection ± neoadjuvant chemoradiotherapy for localised disease; palliation with stenting, chemoradiotherapy or nutritional support for advanced disease). Address nutritional support throughout.

6. Prevention, counselling and the missed opportunity

Reflect on how this cancer might have been detected earlier and how you would counsel the patient and address modifiable risk factors.

Guidance: Discuss Barrett's surveillance, the alarm features that should prompt early endoscopy, smoking cessation and the principle that new progressive dysphagia over forty warrants prompt upper GI endoscopy.