GC189 I Can’t Swallow Oesophageal Cancer
Oesophageal cancer is a malignant neoplasm arising from the epithelial lining of the oesophagus, most commonly squamous cell carcinoma or adenocarcinoma, typically presenting with progressive dysphagia and weight loss.
This lecture (GC 189) by Prof. Ian Wong covers the entire clinical approach to a patient presenting with "I can't swallow" – from understanding what dysphagia means, through differential diagnosis, investigation, and landing on the most feared cause: oesophageal cancer. The deck is structured as a journey: definitions → anatomy → physiology → clinical approach → differentials (with case scenarios) → and then a deep dive into oesophageal cancer epidemiology, risk factors, staging, and surgical management (esophagectomy). [1]
Why this matters for exams: Dysphagia is a classic surgical SAQ/MCQ/minicase stem. You need to distinguish oropharyngeal from oesophageal, mechanical from functional, and know the red flags that point to malignancy. Oesophageal cancer specifically is examined on risk factors (especially the difference between SCC and adenocarcinoma), staging investigations, and principles of esophagectomy.
Learning Objectives (from the slide deck) [1]
- Definition & Classification of dysphagia
- Anatomy & Physiology of swallowing
- Approach to dysphagia
- Differential diagnosis
- Clinical history
- Specific investigations
- Case scenarios (achalasia, oesophageal cancer)
Dysphagia – from Greek "dys" (disordered) + "phago" (eat/swallow) – the function of clearing food and drink through the oral cavity, pharynx, and oesophagus into the stomach at an appropriate rate and speed. [1]
Two Categories of Dysphagia – High Yield
Oropharyngeal dysphagia: Difficulty with the initial phases of a swallow, from mouth to oesophagus.
Oesophageal dysphagia: Sensation that food and/or liquids are being obstructed in their passage from the mouth to the stomach. [1]
Why this distinction matters: They have completely different causes and investigations. Oropharyngeal = neurological/muscular problem (stroke, MG, Parkinson's, MND). Oesophageal = structural or motility problem (cancer, stricture, achalasia).
Key terminology to distinguish [3]:
- Vomiting: forceful expulsion of contents after reaching the stomach
- Reflux: backward flow from stomach (partially digested, acidic)
- Regurgitation: backward flow from oesophagus (undigested food, no acid taste)
Tongue, oropharynx, upper oesophageal sphincter (UES), upper 5% of oesophagus = striated muscle Distal 50–60% of oesophagus = smooth muscle Mid 35–40% = mixed (striated + smooth) [1]
Why this matters clinically:
- The transition from striated to smooth muscle explains why the upper oesophagus is under voluntary control (and why neurological diseases cause oropharyngeal dysphagia), while the lower oesophagus relies on involuntary peristalsis (and why motility disorders like achalasia affect the distal oesophagus).
- The oesophagus has no serosa – only adventitia. This is critical because it means tumours can spread transmurally more easily and earlier compared to stomach/colon. This is also why oesophageal cancer has worse prognosis stage-for-stage.
Four phases: [1]
- Oral preparatory – Voluntary; mastication (solids), glossopalatal seal (fluids)
- Oral propulsive – Tongue pushes bolus from mouth → pharynx → oesophagus
- Pharyngeal – Involuntary; oropharyngeal; epiglottis closes, UES relaxes
- Oesophageal – Involuntary; peristalsis carries bolus to stomach
Manometry to HRM (High-Resolution Manometry): This is the investigation that maps the pressure profile along the oesophagus in real time, essential for diagnosing motility disorders like achalasia. [1]
EndoFLIP (Endoluminal Functional Lumen Imaging Probe): Measures oesophageal distensibility – used to assess the compliance of the oesophageal wall/sphincter. Newer tool, increasingly used intraoperatively during POEM or Heller myotomy. [1]
4. Approach to Dysphagia
Key questions to ask yourself: [1]
- Is it REAL dysphagia? – Exclude globus hystericus (sensation of a lump in the throat without actual swallowing difficulty; benign, often anxiety-related)
- Oropharyngeal vs. oesophageal dysphagia?
- Mechanical (anatomical) vs. functional (motility)?
Critical Exam Trap
An oesophageal dysphagia patient may perceive the location of obstruction at the cervical region, mimicking oropharyngeal dysphagia. [1]
This is a classic discriminator. Don't assume cervical-level sensation = oropharyngeal cause. The oesophagus refers sensation poorly – a distal lesion can be felt "high up."
- Difficulty initiating a swallow, repetitive swallowing
- Nasal regurgitation
- Coughing, diminished cough reflex
- Drooling of saliva or food
- Choking
- Dysarthria & diplopia (these point to neurological aetiology)
- Halitosis
- Recurrent pneumonia (aspiration)
This table is directly from the lecture slides: [1]
| Feature | Mechanical | Functional |
|---|---|---|
| Onset | Gradual or sudden | Usually gradual |
| Progression | Often progressive | Variable |
| Type of bolus | Solid (first) | Solid or liquids (both from start) |
| Response to bolus | Often regurgitation | Usually passes with drinking liquid or repeated swallowing |
| Temperature | No effect | May vary with temperature of food |
How to Remember This
Mechanical = physical blockage → solids get stuck first (because they're bigger), then liquids as the lumen narrows. Progressive = getting worse = think CANCER or stricture.
Functional = motility problem → the oesophagus can't push, so both solids AND liquids are affected equally from the beginning. Response to temperature (e.g. cold drinks worsen spasm) is a motility clue.
The lecture lists five key investigations: [1]
- Video fluoroscopy swallowing study (VFSS) / Barium swallow
- Upper endoscopy (High definition)
- Fiberoptic endoscopic evaluation of swallowing (FEES)
- High Resolution Manometry (HRM)
- Endoluminal Functional Lumen Imaging Probe (EndoFLIP)
| Investigation | Best For | Why |
|---|---|---|
| VFSS / Barium swallow | Dynamic assessment of swallow phases; tracheoesophageal fistula; extrinsic compression; Zenker's diverticulum | Shows real-time bolus transit; can detect proximal dilatation, mucosal irregularity, "bird's beak" (achalasia), corkscrew pattern (diffuse spasm) |
| Upper endoscopy (OGD) | All oesophageal dysphagia – FIRST LINE | Direct visualisation + biopsy; essential to exclude malignancy; can also be therapeutic (dilatation, stenting) [4] |
| FEES | Oropharyngeal dysphagia; aspiration assessment | Bedside test; uses a nasendoscope passed through the nose to visualise the pharynx during swallowing |
| HRM | Motility disorders (achalasia, DES, oesophageal hypomotility) | Creates a colour pressure topography plot; Chicago classification system for motility disorders |
| EndoFLIP | Oesophageal distensibility; post-myotomy assessment | Inflatable balloon catheter measures cross-sectional area and pressure simultaneously |
For oesophageal cancer staging specifically (see Section 8 below): CT thorax/abdomen/pelvis, EUS, PET-CT, ± bronchoscopy (upper/mid third tumours). [5][6]
6. Differential Diagnoses & Case Scenarios
35/M. Non-smoker & non-drinker. Chest pain, regurgitation, progressive on-and-off dysphagia for 2 years. Required flushing with fluid. Weight loss of 20 lbs.
Answer: Achalasia
Why not the others?
- Young, non-smoker/drinker → low risk for oesophageal cancer
- On-and-off for 2 years → not the relentless progression of cancer
- Required flushing with fluid → classic for motility disorder (bolus doesn't pass with gravity alone, but liquid helps push it through)
- Both solids and liquids affected → functional
- Weight loss can occur in achalasia from chronic food avoidance
Achalasia HRM findings: Absence of EGJ (esophagogastric junction) relaxation, IRP = 18.4 mmHg (elevated), no pressurization in the oesophageal body [1]
Treatment of Achalasia:
- POEM (Peroral Endoscopic Myotomy) – highlighted on the lecture slides as the treatment [1]
- Other options: Pneumatic balloon dilatation, laparoscopic Heller myotomy + partial fundoplication
- End-stage achalasia → Esophagectomy (when the oesophagus is massively dilated/sigmoid-shaped and myotomy won't work) [1]
75/M, Chiu Chow ancestry, chronic smoker & drinker. Progressive dysphagia for 1 month. Weight loss. Regurgitating solid food. PE: Cachexic, Right SCF LN.
Answer: Ca oesophagus (squamous cell carcinoma)
Why this is classic SCC oesophagus:
- Elderly male
- Chiu Chow ancestry → Southern China / high-incidence region for SCC oesophagus
- Chronic smoker AND drinker → synergistic risk factors for SCC
- Progressive dysphagia over 1 month → rapid, relentless → malignancy
- Solid food regurgitation → mechanical obstruction
- Cachexia → cancer-related wasting
- Right supraclavicular fossa lymph node (Virchow's node) → metastatic spread → advanced disease
Painless Progressive Dysphagia = Cancer Until Proven Otherwise
This is the cardinal teaching point. Any patient with progressive dysphagia (especially solid → liquid progression) must have an urgent OGD with biopsy. [3]
| Condition | Key Features | Notes from Slides |
|---|---|---|
| Diffuse oesophageal spasm | Intermittent dysphagia + chest pain; barium swallow shows "corkscrew" oesophagus | Functional; can mimic cardiac chest pain [1] |
| Pill-induced ulceration | NSAIDs, tetracyclines, potassium chloride (Slow-K), alendronate (bisphosphonate) | These pills cause direct mucosal injury → ulceration → odynophagia ± dysphagia; always take medications with adequate water and sitting upright [1] |
| Pharyngeal pouch (Zenker's diverticulum) | Posterior herniation of mucosa through Killian's triangle above cricopharyngeus; elderly males; halitosis, regurgitation of undigested food, recurrent aspiration pneumonia | Treated by diverticulotomy + cricopharyngeal myotomy [1][7] |
| GERD / Reflux stricture | Chronic heartburn → fibrotic stricture → dysphagia; lower oesophagus | Montreal definition: reflux of gastric content leads to troublesome symptoms and/or complications [1] |
GERD → Barrett's oesophagus → Dysplasia → Adenocarcinoma [1]
- Montreal definition of GERD: reflux of gastric content leads to troublesome symptoms and/or complications [1]
- The lecture specifically highlights the association between GERD + overweight and oesophageal (adeno)cancer. [1]
Why GERD leads to adenocarcinoma:
- Chronic acid/bile reflux damages the squamous epithelium of the distal oesophagus
- The body replaces it with intestinal-type columnar epithelium (intestinal metaplasia) = Barrett's oesophagus
- Barrett's → low-grade dysplasia → high-grade dysplasia → invasive adenocarcinoma
- Obesity increases intra-abdominal pressure → more reflux → more Barrett's → more adenocarcinoma
8. Oesophageal Cancer – Detailed Coverage
Worldwide: 85% of oesophageal cancers are SCC 2–3 fold higher incidence in males Highest rates: Eastern Asia, Southern & Eastern Africa Lowest rates: Western Africa, Central America
Hong Kong Cancer Registry data shows oesophageal cancer is an important local malignancy, predominantly SCC in Chinese populations. [1]
Linxian (山西林縣) study: Even chickens in this region get pharyngeal/oesophageal cancer – dramatically illustrating the environmental/dietary factors in the region. Prevalence increases steeply with age. [1]
Risk factors with attributed risk (from lecture slides): [1]
| Factor | Attributed Risk |
|---|---|
| Alcohol | 48% |
| Smoking | 44% |
| Salted fish, pickled vegetables | 29% |
| Infrequent citrus fruit | 26% |
| Infrequent green vegetables | 15% |
| Hot soup/beverage | 14% |
SCC vs Adenocarcinoma Risk Factors – Exam Discriminator
| Feature | SCC | Adenocarcinoma |
|---|---|---|
| Location | Upper/mid oesophagus (most common) | Distal oesophagus / GEJ |
| Geography | Eastern Asia, Africa | Western countries (rising incidence) |
| Risk factors | Smoking, alcohol, hot beverages, preserved foods, nutritional deficiency, achalasia, caustic injury, Plummer-Vinson syndrome | GERD, Barrett's oesophagus, obesity |
| Precursor lesion | Squamous dysplasia | Barrett's oesophagus (intestinal metaplasia) |
| Predominant in HK/China | Yes (vast majority) | Less common but rising |
| Chromoendoscopy | Lugol's iodine (SCC depletes glycogen → unstained) [5] | Not applicable |
Additional risk factors from supporting notes [7]:
- Plummer-Vinson (Paterson-Brown-Kelly) syndrome: triad of dysphagia + iron deficiency anaemia + oesophageal webs → increased risk of SCC
- Tylosis (palmoplantar keratoderma): autosomal dominant; very high lifetime risk of SCC
Why do we stage? Staging determines prognosis and guides treatment selection – whether a patient gets curative surgery, neoadjuvant therapy, or palliation only. [2]
TNM Staging (AJCC/UICC 8th Edition) [6]:
| Stage | Criteria |
|---|---|
| T | |
| Tis | High-grade dysplasia (within basement membrane) |
| T1a | Invades lamina propria or muscularis mucosae |
| T1b | Invades submucosa |
| T2 | Invades muscularis propria |
| T3 | Invades adventitia (NOT serosa – oesophagus has no serosa) |
| T4a | Invades pleura, pericardium, azygous vein, diaphragm, peritoneum (resectable) |
| T4b | Invades aorta, vertebral body, airway (UNRESECTABLE) |
| N | |
| N0 | No regional nodal metastasis |
| N1 | 1–2 regional LN |
| N2 | 3–6 regional LN |
| N3 | ≥7 regional LN |
| M | |
| M0 | No distant metastasis |
| M1 | Distant metastasis |
T4b = Unresectable – Critical Exam Point
If the tumour invades the aorta, vertebral body, or airway → T4b = unresectable. These patients go to palliative treatment. T4a structures (pleura, pericardium, azygous, diaphragm) are technically resectable. [6]
Staging Investigations:
- CT thorax/abdomen/pelvis (CT TAP) – standard for detecting distant metastases
- EUS (Endoscopic Ultrasound) – best for T-staging (depth of invasion) and locoregional N-staging
- PET-CT – detects distant metastases and occult nodal disease
- Bronchoscopy – indicated for upper/mid-third tumours (proximity to trachea/bronchi → assess for airway invasion/tracheoesophageal fistula) [5]
- Staging laparoscopy – for GEJ/lower oesophageal tumours to exclude peritoneal disease
The lecture shows a management protocol flowchart. The principles are:
| Clinical Stage | Management |
|---|---|
| Early cancer (Tis–T1aN0M0) | Endoscopic treatment (EMR/ESD) for selected cases |
| Superficial cancer (T1–2, N0, M0) | Oesophagectomy without neoadjuvant |
| Resectable locoregional/locally advanced (T3–4aN0M0 or T1–4aN1–3M0) | Neoadjuvant chemo/RT → Oesophagectomy ± adjuvant |
| Unresectable (T4b or M1) | Palliative chemo/RT, endoscopic stenting, nutritional support |
Neoadjuvant regimen [6]: Platinum-based (cisplatin) + antimetabolite (5-FU) ± taxane (paclitaxel) + radiotherapy
Why neoadjuvant before surgery?
- Downstages the tumour → increases chance of R0 resection (negative margins)
- Treats micrometastatic disease early
- CROSS trial demonstrated survival benefit for neoadjuvant chemoRT + surgery vs surgery alone
The lecture dedicates multiple slides to the components of esophagectomy. This is a complex operation with many variables: [1]
| Parameter | Options |
|---|---|
| Approach | Transabdominal, Transhiatal, Transthoracic |
| Phase | II (Ivor Lewis / Lewis-Tanner): abdominal + thoracic; III (McKeown): abdominal + thoracic + cervical |
| Field of LN dissection | II-field (thorax + abdomen); III-field (II + neck) |
| Conduit | Stomach (most common), Colon, Jejunum |
| Route of conduit | Orthotopic (posterior mediastinum – shortest), Retrosternal, Subcutaneous |
| Anastomosis | Stapled (linear, circular) or Handsewn |
| Surgical approach | Open, VATS (video-assisted thoracoscopic), Total MIE (minimally invasive esophagectomy), Robotic |
| Patient position | Supine, Left lateral, Prone |
Esophagectomy Details – Exam Relevance
You don't need to know every detail of the surgical approach for written exams, but you MUST understand:
- Why stomach is the preferred conduit – robust blood supply (from right gastroepiploic artery after mobilisation), reaches the neck, single anastomosis
- Why the oesophagus cannot simply be joined back together – no mesentery, limited blood supply, under tension → anastomotic leak
- The concept of clear resection margin (R0) – microscopic tumour-free margin is essential for curative intent
- Two-field vs three-field lymphadenectomy – more extensive dissection may improve staging accuracy and survival but increases morbidity
Key Procedures Explained:
- Ivor Lewis (2-phase): Laparotomy (mobilise stomach) → right thoracotomy (resect oesophagus, intrathoracic anastomosis). Best for mid/lower oesophageal tumours.
- McKeown (3-phase): Laparotomy → right thoracotomy → left cervical incision (cervical anastomosis). Used when a cervical anastomosis is needed for adequate proximal margin or for upper oesophageal tumours. Cervical anastomotic leak is safer than intrathoracic leak (drains externally rather than into mediastinum).
From supporting material [5][6]:
| Complication | Why It Happens |
|---|---|
| Anastomotic leak | Most feared; can cause mediastinitis (intrathoracic) or cervical abscess |
| Pneumonia / aspiration | Loss of normal swallow mechanism; recurrent laryngeal nerve injury |
| Recurrent laryngeal nerve palsy | From dissection in the neck or mediastinum → hoarseness, aspiration |
| Chylothorax | Thoracic duct injury during dissection |
| Conduit necrosis | Compromise of gastric tube blood supply → catastrophic complication |
| Stricture at anastomosis | Late; requires endoscopic dilatation |
| Reflux | Loss of LES; lifestyle modification + PPI |
| Dumping syndrome | Rapid gastric emptying into small bowel (vagotomy effect) |
Prevention of respiratory complications [5]:
- Pre-operative: respiratory muscle exercise, smoking cessation
- Intra-operative: avoid prolonged operation, avoid excessive fluid
- Post-operative: deep breathing exercises, chest physiotherapy, pain control (epidural/PCA), early mobilisation
For patients with T4b or M1 disease:
- Endoscopic stenting (self-expanding metallic stent – SEMS) → maintains lumen patency for oral feeding
- Not suitable for very long tumours or cervical oesophageal tumours (discomfort)
- Complications: perforation, stent migration, tumour ingrowth
- Stents across GEJ → higher reflux risk → consider RT instead [5]
- Endoluminal laser / photodynamic therapy → tumour debulking
- Radiotherapy → SCC is radiosensitive; adenocarcinoma less so
- Chemotherapy → cisplatin + 5-FU
- Nutritional support → fluid diet, NG tube, PEG/PEJ [6][8]
| Type | Location | Behaviour | Surgical Approach |
|---|---|---|---|
| I | 1–5 cm proximal to endoscopic GEJ | Arises from Barrett's; behaves like distal oesophageal cancer | Transthoracic oesophagectomy + proximal gastrectomy + 2-field LN dissection |
| II | 1 cm proximal to 2 cm distal to GEJ | Mixed | Case-dependent |
| III | 2–5 cm distal to GEJ | Arises from gastric mucosa; behaves like gastric cancer | Extended total gastrectomy + distal oesophageal resection + D2 LN clearance |
9. Related Conditions Mentioned in the Lecture
Common culprits:
- NSAIDs
- Tetracyclines
- Potassium chloride (Slow-K)
- Alendronate (Bisphosphonate)
Why these drugs? They are either caustic/acidic or create a hyperosmolar environment that damages the mucosa. Patients should take these with a full glass of water and remain upright for at least 30 minutes.
- Posterior herniation through Killian's triangle (area of least resistance above cricopharyngeus muscle)
- More common in elderly males (> 70)
- Presents with: regurgitation of undigested food, halitosis, dysphagia, recurrent aspiration pneumonia
- Treatment: diverticulotomy + cricopharyngeal myotomy (surgical or endoscopic)
- Associated with Plummer-Vinson syndrome [7]
Common Exam Traps
-
SCC vs Adenocarcinoma: In Hong Kong/Chinese patients, oesophageal cancer is overwhelmingly SCC. Adenocarcinoma is associated with GERD/Barrett's and is more common in Western populations. If the stem mentions "chronic heartburn" + "salmon-pink mucosa" → Barrett's → adenocarcinoma.
-
Dysphagia localisation trap: Patient feels food sticking at the neck → examiner expects you to consider oesophageal causes, not just oropharyngeal, because oesophageal dysphagia can be perceived cervically.
-
Achalasia vs Cancer: Both cause progressive dysphagia and weight loss. Key discriminators:
- Achalasia: younger, non-progressive or on-and-off, both solids AND liquids, longer duration
- Cancer: older, progressive (solid → liquid), rapid, alarm features (cachexia, LN, bleeding)
-
T4a vs T4b: T4a is resectable, T4b is not. Know which structures fall into each category.
-
Staging investigations: CT TAP + EUS is the standard answer for "how would you stage oesophageal cancer?" PET-CT is for distant metastases. The 2016 SAQ Q6 specifically asks for "two investigations most useful to stage the disease."
-
Neoadjuvant = BEFORE surgery: For locally advanced but resectable disease (T3+ or N+). Don't confuse with adjuvant (after surgery).
Past Paper Questions
Stem: "A 60-year-old man with a history of chronic acid regurgitation and heartburn presented with dysphagia. Endoscopy showed a circumferential mass lesion of the lower oesophagus and gastro-oesophageal junction. It straddled the gastro-oesophageal junction and had gone up the oesophagus for about 3 cm. Within this segment of the oesophagus, the mucosa appeared salmon-pink in colour."
-
(a) Most likely diagnosis? (2 marks)
- Adenocarcinoma of the oesophagus / GEJ arising from Barrett's oesophagus
- "Salmon-pink" mucosa = Barrett's oesophagus (intestinal metaplasia). Chronic GERD → Barrett's → dysplasia → adenocarcinoma.
-
(b) Five predisposing factors (5 marks)
- Chronic GERD / acid reflux
- Barrett's oesophagus
- Obesity / overweight
- Smoking
- Male sex
- (Also acceptable: high-fat diet, Helicobacter pylori negative status [paradoxically protective for SCC but associated with increased GERD])
-
(c) Two investigations most useful to stage the disease (2 marks)
- CT thorax/abdomen/pelvis (distant metastases, lymphadenopathy)
- EUS (Endoscopic Ultrasound) (T-stage and locoregional N-stage)
- (PET-CT also acceptable)
-
(d) Standard treatment if lesion confined to oesophagus only (1 mark)
- Oesophagectomy (± neoadjuvant chemoRT depending on T/N stage)
Stem: "Oesophageal cancer – what is the COMMONEST presentation of loco-regional symptom?"
Answer: C. Dysphagia
Dysphagia is the most common presenting symptom of oesophageal cancer. Weight loss is the second most common. Discriminator: Q15 asks about lung cancer → answer is B. Cough.
Q19 stem: "A 45-year-old taxi driver with a long history of epigastric pain presented with vomiting. The vomitus was mainly undigested food. He is a regular user of NSAIDs due to chronic pain. On examination, the upper abdomen was distended but the lower part was scaphoid."
Answer: I. Peptic ulcer disease (causing gastric outlet obstruction – GOO)
While not directly about oesophageal cancer, "H. Oesophageal cancer" is a listed option. The discriminator here is that undigested food vomiting + scaphoid lower abdomen + NSAID use → pyloric/duodenal stenosis from chronic peptic ulcer, not oesophageal cancer (which would cause regurgitation, not true vomiting with abdominal distension pattern).
Stem: "A 55-year-old heavy smoker with newly diagnosed small-cell lung cancer developed SVC obstruction... Which drug is MOST APPROPRIATE to relieve current symptoms?"
Answer: A. Dexamethasone
Relevance: SVC obstruction is an oncological emergency that can be caused by oesophageal or lung cancer spreading to mediastinal nodes. IV dexamethasone 4 mg Q6h is first-line to reduce oedema while awaiting definitive RT/chemo. [13]
- GC 068 (Indigestion and Heartburn): Provides the GERD → Barrett's → adenocarcinoma pathway in detail. Alarm features for dyspepsia overlap with oesophageal cancer red flags (age ≥ 45, dysphagia, weight loss, anaemia). [7][14]
- GC 185 (Surgical Nutrition): Enteral feeding (NG, PEG, PEJ) is critical for oesophageal cancer patients who cannot swallow. Always choose enteral over parenteral if GI tract is functional. [8]
- GC 202 (Surgical Oncology): Surgery cures cancer by removing tumour + adequate margin + regional lymph nodes. Outcome measured by hospital mortality rate and 30-day operative mortality rate. [15]
- GC 187 (Head & Neck Cancer) and GC 216 (Dysphonia/Laryngeal Cancer): Smoking and alcohol are shared risk factors. Recurrent laryngeal nerve palsy causes hoarseness – important complication of oesophageal cancer and esophagectomy.
- Interactive Tutorial (Esophageal Cancer): The four learning issues are: (1) demographics/epidemiology/pathology differences between Chinese and Western patients; (2) purpose and methods of staging; (3) treatment options by stage; (4) determinants of immediate and late outcome after resection. [2]
High Yield Summary
- Dysphagia = difficulty swallowing. Classify as oropharyngeal vs oesophageal, then mechanical vs functional.
- Mechanical dysphagia: solid > liquid, progressive → CANCER until proven otherwise. Functional: solid AND liquid from start, on-and-off, passes with repeated swallowing.
- Oesophageal cancer in HK/China: predominantly SCC; risk factors = smoking (44%), alcohol (48%), salted fish/pickled vegetables, hot beverages, nutritional deficiency.
- Adenocarcinoma: GERD → Barrett's → dysplasia → cancer; associated with obesity; rising in Western world.
- Staging: CT TAP + EUS ± PET-CT ± bronchoscopy. Know T4a (resectable) vs T4b (unresectable: aorta, vertebral body, airway).
- Treatment: Early → endoscopic (EMR/ESD); Resectable → neoadjuvant chemoRT + esophagectomy; Unresectable/metastatic → palliative chemo/RT + stenting + nutritional support.
- Esophagectomy: know Ivor Lewis (2-phase) vs McKeown (3-phase); conduit = stomach; complications = anastomotic leak, pneumonia, RLN palsy, chylothorax.
- Achalasia: on-and-off dysphagia, both solids and liquids, HRM shows absent EGJ relaxation → POEM.
- Pill-induced ulcers: NSAIDs, tetracyclines, Slow-K, alendronate.
- Zenker's diverticulum: elderly male, halitosis, regurgitation of undigested food, aspiration pneumonia.
Active Recall - Lecture Notes
[1] Lecture slides: GC 189. I can't swallow oesophageal cancer.pdf [2] Lecture slides: Interactive Tutorial Questions 1 - 4.pdf (Esophageal Cancer tutorial) [3] Senior notes: Maksim Surgery Notes.pdf (Section 3.2 Dysphagia) [4] Senior notes: Block A - Introduction to GI_Hepatology investigations (LFT, Endoscopy).pdf (OGD indications) [5] Senior notes: MBBS Final MB (Surgery) (Felix PY Lai).pdf (Oesophageal cancer investigations and management) [6] Senior notes: Ryan Ho GI.pdf (Oesophageal cancer staging and management) [7] Senior notes: Block A - Indigestion and 'heartburn'_ nausea and vomiting; gastric motility problems; benign esophageal lesions.pdf [8] Senior notes: Ryan Ho Fluids and Nutrition.pdf (Enteral feeding) [9] Past papers: 2016 Fourth Summative SAQ.pdf (Q6) [10] Past papers: 2019 Fourth Summative MCQ.pdf (Q16) [11] Past papers: 2023 Fourth Summative MCQ.pdf (Q17-20) [12] Past papers: 2020 Fourth Summative Assessment MCQ paper.pdf (Q73) [13] Senior notes: Maksim Medicine Notes.pdf (SVC obstruction management) [14] Senior notes: Block A - Upper abdominal pain_ peptic ulcer; pancreatitis and gallstone.pdf (Alarming features) [15] Lecture slides: GC 202. Surgery may cure your cancer Surgical oncology - Notes.pdf
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