Key Facts

Upper GI surgery addresses pathology of the oesophagus, stomach, and proximal duodenum. Oesophagogastric cancer surgery is centralised to high-volume centres in the UK. Emergency upper GI surgery includes management of peptic ulcer complications and oesophageal perforation.

Epidemiology

Oesophageal cancer is the 14th most common cancer in the UK (~9,200 cases/year). Gastric cancer accounts for ~6,500 cases/year. The incidence of oesophageal adenocarcinoma has risen dramatically over 40 years, linked to rising obesity and GORD. Squamous cell carcinoma is more common worldwide and is associated with smoking and alcohol.

Aetiology

• Oesophageal adenocarcinoma: Barrett's oesophagus, GORD, obesity, smoking
• Oesophageal SCC: Smoking, alcohol, achalasia, caustic injury, Plummer-Vinson syndrome
• Gastric cancer: H. pylori (Group 1 carcinogen), smoking, dietary nitrates, pernicious anaemia, family history (CDH1 mutation)
• Peptic ulcer disease: H. pylori, NSAIDs

Pathophysiology

Oesophageal cancer spreads early due to the absence of a serosal layer, allowing submucosal and lymphatic dissemination. The rich lymphatic drainage facilitates nodal metastasis. Barrett's oesophagus represents intestinal metaplasia of the oesophageal squamous epithelium, progressing through dysplasia to adenocarcinoma (metaplasia-dysplasia-carcinoma sequence).

Oesophageal Cancer

• Progressive dysphagia (solids → liquids)
• Weight loss, anorexia
• Odynophagia, retrosternal pain
• Hoarseness (recurrent laryngeal nerve involvement)
• Aspiration pneumonia

Gastric Cancer

• Vague epigastric pain, early satiety, weight loss
• Iron-deficiency anaemia
• Virchow's node (left supraclavicular), Sister Mary Joseph nodule (umbilical), Krukenberg tumour (ovarian)

Peptic Ulcer Complications

• Haemorrhage: haematemesis, melaena
• Perforation: sudden severe epigastric pain, peritonitis, pneumoperitoneum
• Gastric outlet obstruction: projectile vomiting, succussion splash

Red Flags

• Dysphagia in anyone >55 years — urgent 2WW referral (NICE NG12)
• Upper GI bleeding with haemodynamic instability — emergency endoscopy
• Pneumoperitoneum — emergency laparotomy
• Iron-deficiency anaemia with weight loss — investigate for GI malignancy

Bedside

• Observations: NEWS2, fluid balance
• Nutritional screening: MUST score — malnutrition is common

Bloods

• FBC: Anaemia (iron deficiency suggests chronic GI blood loss)
• LFTs: Liver metastases, biliary obstruction
• Albumin: Nutritional status, prognostic marker
• CEA, CA19-9, CA72-4: Tumour markers (not diagnostic but useful for monitoring)
• Group and save/crossmatch: Pre-operative or if bleeding

Imaging

• OGD: First-line for suspected upper GI cancer — biopsy for histology
• CT thorax/abdomen/pelvis: Staging for oesophagogastric cancer
• PET-CT: Detect occult metastases, guide treatment decisions
• Endoscopic ultrasound (EUS): T and N staging of oesophageal/gastric cancer
• Staging laparoscopy: Mandatory before oesophagogastric resection to exclude peritoneal disease

Special Tests

• High-resolution manometry: For dysmotility/achalasia
• 24-hour pH/impedance: For refractory GORD assessment pre-fundoplication
• H. pylori testing: Urea breath test, stool antigen, CLO test at OGD

Non-pharmacological

• MDT discussion: All oesophagogastric cancers must be discussed at specialist MDT
• Nutritional optimisation: Pre-operative dietitian input, consider supplementary feeding or jejunostomy
• Prehabilitation: Exercise programme pre-surgery to optimise fitness
• Smoking and alcohol cessation: Reduce surgical risk

Pharmacological

• Neoadjuvant chemotherapy: FLOT regimen (5-FU, leucovorin, oxaliplatin, docetaxel) — OE05 and FLOT4 trials
• Perioperative chemotherapy: Standard for resectable gastric cancer (MAGIC trial — ECF regimen)
• Palliative chemotherapy: For metastatic disease — improves survival and quality of life
• PPI therapy: Omeprazole 20-40mg OD for GORD, Barrett's surveillance
• H. pylori eradication: Triple therapy — amoxicillin 1g BD + clarithromycin 500mg BD + PPI for 7 days

Surgical/Interventional

• Oesophagectomy: Ivor Lewis (2-stage), McKeown (3-stage), transhiatal — choice depends on tumour location
• Gastrectomy: Total or subtotal depending on tumour location; D2 lymphadenectomy standard
• Laparoscopic Nissen fundoplication: For refractory GORD with confirmed reflux on pH studies
• Endoscopic treatments: EMR/ESD for early mucosal cancers; RFA for dysplastic Barrett's
• Oesophageal stenting: Palliative — for malignant dysphagia in inoperable disease

Referral Criteria

• Dysphagia — urgent 2WW to gastroenterology/upper GI surgery
• Confirmed OG cancer — specialist OG cancer MDT centre
• GI bleeding unresponsive to endoscopy — surgical review

• Oesophageal cancer 5-year survival: 15-20% overall; 40-50% after curative resection
• Gastric cancer 5-year survival: 20% overall; 45-55% after curative resection
• Oesophagectomy operative mortality: 2-5% in high-volume centres
• Anastomotic leak rate post-oesophagectomy: 5-15% — associated with 20-35% mortality if it occurs
• Barrett's oesophagus: annual risk of progression to adenocarcinoma 0.3-0.5% per year

TNM Staging — Oesophageal Cancer (Simplified)

Landmark Trials in OG Cancer