Gastro-oesophageal reflux disease is when gastric secretions escape into the oesophagus and cause heartburn and/or mass reflux (also known as volume reflux, where patients are aware of liquid rising in their oesophagus, and occasionally into their mouth).
Laryngo-pharyngeal reflux (LPR) is when gastric secretions escape up the oesophagus, all the way up to the throat and/or larynx (voice box). LPR is not always classically symptomatic – which is why it is sometimes called ‘silent reflux’ – but may result in cough or symptoms in the throat.
A hiatus hernia is when part of your stomach moves upwards into your chest. Most hiatus hernias are simple ‘sliding’ hernias, which may cause you to develop reflux. Sometimes, patients who have severe reflux or who do not wish to take long-term medication may benefit from surgery to repair the hernia and control the reflux. Mass or volume reflux is difficult to control with medication and is often better managed with surgery.
‘Giant’ paraoesophageal hernias are large hernias where at least 30% of the stomach sits above the diaphragm. In many cases, the whole stomach may sit in the hernia, as well as other organs such as the colon and (rarely) the pancreas. These hernias do not always cause heartburn, but can cause pain, retching, vomiting, breathlessness, and anaemia. Very rarely, they can cause strangulation of the stomach – an emergency condition that requires immediate medical attention.
The diaphragm is a sheet of muscle that separates the chest from the abdomen, which helps you to breathe in and out.
Congenital diaphragmatic hernias
Occasionally, the diaphragm does not fully separate the chest and abdomen, and the bowel can herniate into the chest.
This is a rare congenital (birth) defect and is usually dealt with, early in life, by paediatric surgeons. Occasionally, it does not present until adulthood, when it can become an emergency requiring urgent repair. There are two main types of congenital hernias: Bochdalek hernia (at the back of the diaphragm) and Morgagni hernia (at the front of the diaphragm).
Traumatic diaphragmatic hernias
The diaphragm can be damaged through events such as road traffic accidents or falls, usually due to broken ribs. Although this damage may initially be small and not evident at the time of the initial injury, it can enlarge over time and eventually allow the herniation, usually of bowel, into the chest – this requires urgent surgical repair.
Similarly, the diaphragm can become damaged as a rare side effect of treatments such as radiofrequency ablation (RFA) for liver metastases.
Achalasia is a rare cause of swallowing problems that occurs when the body attacks the nerves that regulate the muscle contractions of the oesophagus.??
An accurate diagnosis is very important when it comes to effectively managing achalasia. As well as comprehensive assessment and diagnosis, 米兰体育 can offer both endoscopic management – including pneumatic dilatation and peroral endoscopic myotomy (POEM) – and robotic-assisted surgery (Heller’s cardiomyotomy).?
A benign oesophageal stricture is when the oesophagus becomes narrowed. It can be caused by reflux, inflammatory conditions (such as Crohn’s), allergic conditions (such as eosinophilic oesophagitis (EoE)), and the ingestion of caustic agents. Occasionally, it can also be a side effect following surgery. Treatment involves manging the underlying condition, although you may also be advised to undergo dilation of the oesophagus.
Benign oesophageal tumours are rare. They are overgrowth of a specific cell type, usually from the supporting structures of the oesophagus. The most common are from the muscle wall of the oesophagus and are called oesophageal leiomyomas. These may be found incidentally, but when large can cause compressive effects, and may need to be excised. These are perfectly suited to the accuracy afforded by robotic-assisted surgery. Other benign oesophageal tumours do occur from fat and nerve cells, but are extremely rare, and can be managed in a similar manner.
Mediastinal cysts are rare benign growths that develop in the mediastinum (a space between your lungs). If these cysts become too large, they can cause compressive symptoms and require surgery to remove.
GISTs are rare tumours that most commonly occur in the stomach but can occur anywhere within the gastrointestinal tract. They have the potential to become cancerous if left untreated. They are often incidental findings during CT scans, but patients may experience bleeding.??
If you are found to have a GIST, your consultant will determine the best course of action according to the tumour’s size, location, and risk of becoming cancerous. For small GISTs, where the risk of it becoming cancerous is extremely small, your consultant may recommend observation (monitoring the tumour for changes) or endoscopic resection.??
For medium-sized and larger GISTs, where the risk of it becoming cancerous is more significant, surgical resection is typically recommended. At 米兰体育, these surgeries are usually carried out using robotic-assisted techniques to ensure greater precision.??
Very large GISTs may be managed in combination with oncologists, to shrink the tumour prior to resection. Targeted therapies (such as drug therapies) may be used to manage GISTs, to downstage, to reduce the risk of recurrence following surgery, or in cases where surgery is not feasible or if the tumour is recurrent or metastatic.?
Neuroendocrine tumours (NETs) – which may also be referred to as carcinoid tumours – are a type of slow-growing cancer that can develop in various parts of the gastrointestinal tract, including the stomach.??
These tumours originate from the hormone-producing cells of the body’s neuroendocrine system. Gastric NETs are classified into three types based on their characteristics and behaviour:??
- type I, which is often multi-focal (multiple small nodules) and associated with chronic atrophic gastritis??
- type II, which is associated with Zollinger-Ellison syndrome?
- type III, which is sporadic and more aggressive?
If you are diagnosed with a gastric NET, a multidisciplinary team will determine your treatment approach according to the tumour type, size, location, and whether it has spread (metastasised). For type I and II, your consultant may recommend observation or endoscopic resection due to a lower risk of the tumour becoming cancerous. However, because type III NETs have a higher risk of becoming cancerous, a surgical approach is often required.?
In cases where NETs are metastatic or cannot be operated on, various systemic therapies can help control the disease and alleviate symptoms. At 米兰体育, the management of gastric NETs is supported by a specialised team of oncologists and surgeons, ensuring precision and comprehensive care.?
Oesophageal cancer is a malignant condition that affects the oesophagus. It often presents with difficulty or pain on swallowing.
There are two main types:
- Squamous cell carcinoma (SCC) – which develops in the cells lining the oesophagus. It is more common in smokers and those who drink spirits but can also occur in patients with achalasia and those with HPV infection.
- Adenocarcinoma (ACA) – which develops in a small percentage of patients with Barrett’s oesophagus (a change in the lining of the oesophagus that occurs in some patients as a consequence of reflux). Adenocarcinoma typically occurs in the lower to middle portion of the oesophagus.
Stomach cancer – also referred to as gastric cancer – is a malignant condition that develops in the stomach. Symptoms include indigestion, feeling full quickly, anaemia, and/or weight loss.
Stomach cancer is almost always an adenocarcinoma. Gastric lymphoma must be excluded, as it is managed by specialist haematologists.
Utilising the latest technology and state-of-the-art imaging, our consultants aim to accurately assess the size and site of your cancer – a process referred to as ‘staging’. The tests commonly carried out are:?
- diagnostic endoscopy – to visualise, map, and biopsy the oesophageal tumour?
- endoscopic ultrasound – an endoscope (a long, thin tube) with an internal ultrasound scanner is used to more closely examine the cancer, and to assess local lymph nodes?
- CT scan – to provide detailed images and assess the extent of the cancer?
- PET-CT scan?– PET is a type of nuclear imaging scan that looks for tumour cells by their activity. It is combined with a CT scan to accurately locate the areas of activity.?
- staging laparoscopy – a minimally invasive examination of the abdominal cavity for tumours that reach the junction of the oesophagus and stomach, to look for evidence of spread into the abdomen. Fluid samples are taken to look for evidence of cancerous cells in the abdomen that may not be visible.?
Other tests which are less often used include:?
- MRI scan – which is sometimes used to characterise lesions in the liver and adrenal glands, when uncertain on other scans?
- ultrasound scan (of neck) – this is only used in tumours located high up in the oesophagus, or where lymph glands are seen and may be affected. Sometimes, a sample of cells is also taken.?
The management of oesophageal and gastric cancer is highly dependent on the stage of the illness and the individual patient’s fitness:??
- Very early-stage cancer – cancer which is confined to the most superficial layer of the oesophageal wall. This may be managed by endoscopic resection and may be enough to clear the disease.?
- Locally advanced cancer – cancer that has invaded deeper into the oesophageal wall and may affect local lymph glands (nodes) but has not spread further afield. This is usually managed by a combination of therapies, such as surgery, chemotherapy, and radiation therapy, customised to your specific condition and stage of cancer. More recently, immunotherapy has also been added to the treatments available.??
- Advanced (metastatic) cancer – cancer that has spread away from the primary site of the tumour to areas that cannot be cleared with the above treatments. Patients with advanced cancer require treatment that will attack the cancer cells anywhere in the body, such as chemotherapy and/or immunotherapy.??
At 米兰体育, surgery for oesophageal and gastric cancer is delivered by robotic-assisted surgery, using the da Vinci Xi. This advanced robotic system allows your surgeon to deliver extremely accurate, minimally invasive surgery with significantly less post-operative complications and a quicker recovery.
This surgery is delivered by Professor Shaun Preston, an internationally renowned expert in radical oesophageal and gastric cancer surgery. Professor Preston established and is Director of the UK’s highest volume robotic oesophago-gastric cancer surgery unit.??
The delivery of chemotherapy, radiotherapy, and immunotherapy is closely supervised by expert clinical and medical oncologists at Cromwell Hospital.??
If your investigations result in a diagnosis or cancer, or an immediate pre-cancerous diagnosis (such as high-grade dysplasia in Barrett’s oesophagus), then your case will be discussed in the Upper GI MDT.?
At an MDT, a panel of experts will individually discuss your case, the results of any biopsies and imaging, and a plan for further investigations and/or management. The plan you receive will be specifically tailored to you and will be regularly reviewed to ensure optimum results.?
The Upper GI MDT is composed of:??
- specialist surgeon(s)?
- gastroenterologist(s)?
- oncologists (cancer specialists)?
- radiologist(s)?
- clinical nurse specialist (CNS)?
- an MDT co-ordinator??
- the MDT chair (Professor Shaun Preston)?
