Over the last three decades, there has been a dramatic change in the nature of cancers affecting the upper digestive tract, namely the oesophagus and stomach. This had lead to some major changes in the way we now perceive and treat these diseases.

The incidence of this disease has dramatically increased over the last three decades. The reasons for this are unclear, but in the Western, developed nations it is now one of the fastest growing malignant diseases. The nature of the disease has also fundamentally changed; this used to be related to smoking, drinking and other environmental pollutants, and the kind of cancer was known as a squamous cell cancer (SCC). Now, this type of cancer has virtually disappeared, but a new, totally different form of cancer has emerged, known as adenocarcinoma (ACA). Unlike SCC, there does not appear to be a relationship with smoking, drinking or pollutants. The only established risk factor for oesophageal ACA is reflux disease. The individuals affected by oesophageal adenocarcinoma are predominantly white men, (typically affluent, middle class) in aged in their mid-50’s upwards, though worryingly, more younger patients are being seen. The incidence in women is about a fifth of that in men.

Not only has the incidence and nature of this disease transformed, but also even the location in the oesophagus where it appears has changed. The oesophagus is a long, hollow muscular tube, running from the neck, through the chest, and into the abdomen where it joins into the stomach. Cancers (SCC) used to affect the middle or upper portion of the oesophagus. Now the cancers develop almost exclusively in the lower third of the oesophagus, or at the junction of the oesophagus and stomach (the gastro-oesophageal junction, GOJ). This is the exact site of the oesophagus most affected by reflux disease.

Oesophageal cancer grows into the lumen of the oesophagus making it narrower, and causing the symptom of dysphagia (difficulty in swallowing). Unfortunately, this is often a late presentation, when it might be too late to perform potentially curative surgery. Prior to dysphagia, patients may have had long-standing reflux disease symptoms. As well as growing into the oesophagus, the cancer can grow outside the oesophagus, possibly into other tissues and organs, and also spread to the local glands, known as lymph nodes.

Before oesophageal cancer can be treated, it has to be first diagnosed, and then staged. Staging is the process by which the extent of the disease is estimated. Once symptoms of oesophageal cancer are suspected, patients must undergo an urgent endoscopy, at which time biopsies of a suspected cancer are taken. This establishes the diagnosis. Staging involves the use of several special tests including a CT scan, endoscopic ultrasound(EUS), and PET scanning. The collective information will determine what kind of treatment is offered. Early disease (no evidence of local invasion or spread to lymph glands) will mean that the disease is potentially curable through surgery alone. If there is just limited local spread (i.e. just beyond the oesophagus and the local lymph nodes) then the disease is still potentially curable, but might need chemotherapy, which is usually given before surgery. Surgery is aimed at removing the diseased oesophagus and lymph node areas (oesophagectomy), followed be reconstruction of the digestive tract using the stomach. This is very major surgery, but very recently, keyhole surgery has become a means of performing the same kind of surgery but with much less stress, risk and complications for the patient. Exeter is one of the only centres in Europe where this kind of surgery is on offer.

Minimally Invasive Oesophagectomy

If it is proven that the disease is very advanced, spreading well beyond the location of the oesophagus, then curative treatment is not an option, and palliative treatment to control symptoms is the only choice. This does not usually involve surgery, but relies on the placement of stents endoscopically to allow swallowing, and possible radiotherapy or chemotherapy to try and control the growth. In rare situations, cancers may respond sufficiently to chemotherapy to make surgery an option.

As with oesophageal cancer, the nature of this disease has also changed over the last few decades. Fortunately, its overall incidence has been decreasing. The main type of gastric cancer is also adenocarcinoma (ACA). This disease is most common worldwide in Japan, where it is linked to certain kinds of food. However, in a similar fashion to oesophageal ACA, the nature and location of this disease in the United Kingdom is changing. Most cancers used to be found at the lower (distal) end of the stomach, near where it empties food into the bowel (duodenum) after digestion, an area known as the antrum. This is the commonest location for ulcers and general inflammation (gastritis) and is also the area where the organism Helicobacter pylori, central to the formation of ulcers colonise. The diagnosis and eradication of this organism has lead to a marked decline in the incidence of gastric ulcers, and also cancers in the antrum. Cancers are however being seen in the more proximal stomach (near the junction with the oesophagus), and although they are still ACA, the link with Helicobacter pylori is not so strong. It is likely that their development is more closely linked to reflux disease. The symptoms of gastric cancer are unfortunately late features of the disease, mainly because cancers can grow on the stomach, which is a large muscular bag without causing any obvious problems, and only very mild symptoms. The symptoms are usually, abdominal pain, lethargy and fatigue (due to anaemia), nausea and vomiting, loss of appetite and dysphagia.

The stomach is a location for the growth of a number of rare, but much more benign tumours, known as GIST’s (gastro-intestinal stromal tumours).

As with oesophageal cancer, diagnosis and staging has to be performed first. This done by endoscopy, biopsies and CT scanning. Other investigations may also be required. Once staged, the disease can be classified in terms of potential cure or palliation. If curative treatment is an option, then patients undergo radical surgery, possibly combined with chemotherapy. If disease is advanced, and cure is at first not an option, then patients can undergo radical chemotherapy. In some cases, the disease may respond to this and then cure by radical surgery becomes a possibility. Once spread to lymph glands is established, realistic chances of a long-term cure become slim. Surgery however is still a good palliative option in gastric cancer, and removal of the diseased stomach and local lymph nodes (gastrectomy) provides the best long-term, symptom-free survival.

Certain types of gastric cancer, particularly if the disease is very early, or the tumour is probably benign such as a GIST, may be amenable to treatment by keyhole surgery.