BeyHealth Quarterly Journal (BHQJ) BHQJ 2018: 001:1 (May 2018) - Page 24

Case Review Stomach & Oesophageal Cancer in Nigeria Abuchi Okaro MS FRCS FWACS Mr Abuchi Okaro is Consultant Laparoscopic Upper GI & Bariatric Surgeon at Maidstone & Tunbridge Wells NHS Trust, Kent, UK. G astric and Oesophageal (Upper GI) cancers remain a major health challenge worldwide. Combined, these cancers are responsible for approximately 1,407,378 (10%) cancer deaths per annum. Nigeria has a reported 101.3 cancer cases per 100,000 (UK 272.9 cancers per 100,000). Despite such reported low cancer rates, we know that due to its large population size and low levels of socioeconomic development, Nigeria and other low and middle-income countries in sub-Saharan Africa and beyond, together carry a substantial and disproportionate burden of cancer, all in all accounting for over half (57%) of the world’s total. In the 21st century, the diagnosis and management of Upper GI cancers is a multi- disciplinary task, promoting accurate diagnosis and appropriate staging of disease. Treatment modalities typically involve a combination of chemotherapy, radiotherapy and surgery. The challenge, however, remains detection of the disease at an early stage. It is a well-known fact that by the time symptoms are reported in the majority of patients, Upper GI cancers are usually at an advanced stage and not infrequently metastasised incurably to distant organs like the liver and lungs. The negative impact of such spread on outcomes observed in this scenario is remarkably profound. Regions of the world with a high incidence of such cancers, like Japan and China, have invested considerably in targeted screening programs aimed entirely at early detection usually at the asymptomatic, initial period of the disease, during which patients are usually without symptoms. 1 The incidence of gastric and oesophageal cancer in Nigeria remains unclear. There have been retrospective studies reporting this incidence to be low. However, as with other forms of cancer in this part of the world, a lack of cancer reporting registries, major deficiencies in access to adequate endoscopy, the absence of high-quality histopathological services and low levels of community awareness, means we do not really know the true situation regarding Case Study 1 It was a weekday morning on the day that I received a call from the hospital manager about a 42-year-old man who had called up just a few moments before. He was complaining of a single episode of transient dysphagia (difficulty swallowing) while having dinner the evening before. During a telephone consultation, I was able to understand that his symptom was accompanied by some transient pain at the time. He recalls drinking several mouthfuls of water appeared to aid in its rapid resolution and left him feeling as he described it with ‘a wound-like feeling’ in his upper abdomen (epigastric region) whenever he attempted to swallow after the episode was over. He admitted that he was yet to try anything solid since the event of the evening before but was remarked that he was tolerating fluids ‘OK’. There was no prior history of anything significant aside from a history of infrequent reflux disease. My immediate thoughts went towards a possible hiatus hernia as the likely underlying problem. I recommended a clinic review, possibly an early endoscopy along with acid suppression therapy. Later that day, he came to see me in clinic. He was a fit and well-looking gentleman, currently working as a high-ranking executive of an international organization There was nothing further in the history of note. He was in full agreement with the plan for an endoscopy and we proceeded later that day to do the needful. To my shock and surprise, I discovered a 1cm malignant ulcer in the cardia of the stomach, just beyond the gastro-oesophageal junction. I placed him on high dose acid suppression and a soft diet, pending pathology results. The histopathological analysis returned and revealed moderately differentiated adenocarcinoma of local origin. Staging CT scan of the chest, abdomen and pelvis showed only mild thickening at the cardia. The upper GI MDT case review agreed that a decision to proceed straight to surgery was an appropriate treatment option. Consent was given for the procedure to proceed and we performed a laparoscopically-assisted vagus nerve-sparing proximal gastrectomy and Merendino Reconstruction (Interpositional Jejunum–oesophagojej and Gastro-Jej anastomosis) 4 . He made an uneventful post-surgical recovery, leaving the hospital 4 days later on a liquid diet for 2 weeks. The postoperative histology revealed a yPT1N1Mx adenocarcinoma of the stomach with 1 out of 15 LN involved and a focus of microvascular invasion. The Upper GI MDT recommended 4 cycles of Adjuvant FLOT chemotherapy. He is currently going through this and appears to be coping well. 24 | MAY 2018 | Issue 1