FAISAL GHANI SIDDIQUI MBBS; FCPS (GENERAL SURGERY); PG DIPLOMA-BIOMEDICAL ETHICS;

1. 79-YEAR OLD GENTLEMAN WITHPROGRESSIVE DYSPHAGIA………………………………………………………………………………………………………………………………………………………………………………………………………………………………. FAISAL GHANI SIDDIQUI MBBS; FCPS (GENERAL SURGERY); PG DIPLOMA-BIOMEDICAL ETHICS; MCPS-HPE; FICLS; (MHPE) HEAD, SURGICAL UNIT-I PROFESSOR OF SURGERY CHAIRMAN, DEPARTMENT OF SURGERY & DIRECTOR, DEPARTMENT OF MEDICAL EDUCATION LIAQUAT UNIVERSITY OF MEDICAL & HEALTH SCIENCES faisalghani@lumhs.edu.pk

2. CASE REPORT A 79-year-old retired teacher was admitted in the surgery ward with H/O: • Increasing difficulty in swallowing • Initially could swallow soft diet but now can tolerate fluids only • Weight loss of 5 kg in last one month On examination, he appears cachectic WHAT IS THE MOST LIKELY DIAGNOSIS?

3. DIAGNOSIS CARCINOMA ESOPHAGUS

4. WHAT IS THE THE DIFFERENTIAL DIAGNOSIS?

5. STAGES OF SWALLOWING

6. DYSPHAGIA -difficulty in the progression of bolus from the mouth to the stomach due to dysfunction of: oropharynx esophagus

7. DIFFERENTIAL DIAGNOSIS OF DYSPHAGIA

8. CARCINOMA OF THE OESOPHAGUS PATHOLOGY

9. CARCINOMA ESOPHAGUS –INCREASE IN INCIDENCE

10. 3TIMESMORE COMMON IN MALES

11. TYPES OF CARCINOMA ESOPHAGUS 25% 75 %

12. SPREAD OF CARCINOMA OESOPHAGUS ACROSS THE WALL LONGITUDINALLY THROUGH SUBMUCOSAL LYMPHATICS TO THE REGIONAL LYMPH NODES • LIVER • LUNGS • BONE

13. Carcinoma Esophagus disseminates early! Symptoms are often absent until tumour becomes advanced poor prognosis at the time of diagnosis!

14. WHY ME? RISK FACTORS

15. SMOKING • ALCOHOL • HOT BEVERAGES • CORROSIVE INJURY • ACHALASIA CARDIA • OBESITY --> REFLUX • SMOKING

16. CASE REPORT A 79-year-old man admitted in the surgery ward with H/O: • Increasing difficulty in swallowing • Initially required soft diet but now can tolerate fluids • Weight loss of 5 kg in last one month On examination, he appears cachectic HOW WILL YOU INVESTIGATE THIS PATIENT?

17. HOW TO INVESTIGATE PATIENT WITH DYSPHAGIA? 1 3 2

18. ENDOSCOPY • First-line investigation • Site/size/extent/ histology of lesion • Disadvantage: only mucosal surfaces biopsied

19. SQUAMOUS CELL CARCINOMA OF THE MID ESOPHAGUS NORMAL MUCOSA OF THE ESOPHAGUS

20. HISTOPATHOLOGY SHOWS SQUAMOUS CELL CARCINOMA WHAT NEXT?

21. HOW TO INVESTIGATE PATIENT WITH DYSPHAGIA? 1 Local tumour and regional nodes (T, N) • Endoscopic ultrasound Metastases (M) • CT / PET scan (lung; liver; bones; distant nodes) • Laparoscopy (peritoneal metastases) 3 2 • Anemia • Tests for malnutrition

22. MANAGING A PATIENT WITH SUSPICIOUS SYMPTOMS ADVANCED CURATIVE TREATMENT

23. EARLY DISEASE T1/T2, N0 LOCALLY ADVANCED DISEASE T3/T4, N1 INCURABLE DISEASE Any T, N2/N3, M0

26. IVOR-LEWIS TWO PHASE ESOPHAGECTOMY

27. IVOR-LEWIS TWO PHASE ESOPHAGECTOMY

28. MCKEOWN THREE PHASE ESOPHAGECTOMY

31. SELF-EXPANDING METAL STENT

32. CASE REPORT A 79-year-old man admitted in the surgery ward with H/O: • Increasing difficulty in swallowing • Initially required soft diet but now can tolerate fluids • Weight loss of 5 kg in last one month On examination, he appears cachectic CONCLUSION: This case report demonstrated the importance of a timely upper endoscopy. It carries major impact on primary care physicians who serve as the first tier in managing patients with ‘red flag’ features.

33. . . . IN SUMMARY • Squamous cell affects the upper two-thirds; adenocarcinoma affects the lower third • Common etiological factors are tobacco and alcohol (squamous cell), GORD and obesity (adenocarcinoma) • Dysphagia is the most common presenting symptom • Accurate pretreatment staging is essential in patients thought to be fit to undergo ‘curative’ treatment