SAGES Magazine

THE SOUTH AFRICAN GASTROENTEROLOGY REVIEW 2021 | VOLUME 19 | ISSUE 2 | 6 REVIEW been shown to have an impact on mortality reduction with a 33% reduction. 17 Endoscopic therapy for early oesophageal squamous neoplasia includes excisional and ablative methods. The excisional methods provide a histological diagnosis and include endoscopic mucosal resection, multiband mucosectomy and oesophageal submucosal dissection. These methods are technically more difficult than ablative methods and have a higher risk of adverse events including bleeding, perforation and stricture formation. However, as they provide a tissue specimen, they are the only way to distinguish between mucosal and sub mucosal invasion. The ablative methods involve tissue destruction and include Argon Plasma Coagulation and Radio Frequency Ablation. To setup an early detection and treatment program, there are several essential components required: a way of identifying the precursor lesion, a primary screening method, endoscopic localization and the ability to stage. In Kenya, screening for oesophageal cancer was incorporated into the National Cancer Screening guidelines. 18 The overall screening recommendations include a one-time endoscopy at 40 years of age for individuals living in high-risk areas. For first degree relatives of patients with biopsy proven OC, a one-time screening endoscopy at age 40 or ten years younger than the age of the confirmed relative whichever is the earlier. In addition, patients who have had caustic acid ingestion should be screened 10 years from the injury via endoscopy. Patients treated for head and neck squamous cell carcinoma should be screened annually for ten years. There is emerging research and clinical data that shows that minimally invasive screening options can be used and with good sensitivity and specificity. The cytosponge device has been demonstrated to be a potential useful screening tool for barretts oesophagus. 19 The cytosponge device is useful for screening larger numbers and during the challenging times of the pandemic it can be used in the outpatient setting without having to get an upper endoscopy done which would need access to an endoscopy unit. There is still limited data on its use in oesophageal squamous cell carcinoma even though there have been some good reports on its feasibility in the African setup. 20 Surgical Management: Surgical resection offers an opportunity for complete cure in combination with chemotherapy and radiotherapy depending on the stage. 21 Assessment for suitability for surgery is institutional dependent. Proper evaluation of the patient is a critical component to selecting patients for surgery. This includes performance status assessment for the patient. A modified way of doing this is what we call the eye-ball test which is done by the surgeon during the initial clinic visits. Another practical way of doing this is the stairs stress test which involves the patient being made to go up and down Figure 2. a flight of stairs and assessing whether they can accomplish this without getting out of breath. CT scan is the mainstay of accurately staging the disease. In those deemed surgical candidates a thorough discussion is mandatory so that they are aware of the magnitudes of the surgery and stages of the surgical care pathway. This makes it more likely they will be compliant with post-operative instructions and rehabilitation. At one high volume oesophageal center in east Africa, they have developed a list of indications for surgery which have evolved over time. 22 The current indications include absence of metastatic disease, albumin greater than 30g/l, Body mass index greater than 18.5, tumor length less than 10 centimeters, SEMS stent in place less than 8 weeks and age under 70 years. A small case series showed that the outcomes were equivalent in patients with HIV compared to those without. 22 Stents have a possible unique use as a bridge to surgery in the African context. Patient with poor nutrition and low BMI usually are not very good candidates. However, SEMS stents can be deployed, and the patient allowed to have 4 to 6 weeks of nutritional support through regular diet and supplements. At the follow up visits, improvements in the BMI usually mean that the patient can now be considered as an operative candidate. The stents have to be in less than two months to avoid having a dense fibroblastic reaction around the stent area which would make dissection much harder. There is a role for further research in this area to provide additional data on stents as a bridge to surgery especially in the African setup where patients present with advanced disease and profound nutritional deficits brought about by dysphagia. Oesophagectomy is associated with significant morbidity and mortality rates. 23 Complications can be both peri-operative and operative. Reducing these complications is one of the targets for all sites carrying out this surgery. One of the strategies to do this is establishing high volume centers and increasing exposure of the surgeons through training and exchange programs. These centers must have Intensive Care Units and experienced critical care health personnel and access to interventional endoscopy and radiology. Across the continent there is also need to provide access to chemotherapy and radiation therapy. Neoadjuvant therapy if available would be ideal. At Tenwek Hospital which manages a high volume of disease, provision of surgery has been centralized to generate sufficient volume to build up expertise and minimize morbidity and mortality. Palliative care for Oesophageal Cancer In Africa the vast majority of OSCC patients are beyond curative therapy or long-term survival as they present with late-stage disease and comorbidities. This results in an average survival that is measured in months not years. The main concern of these patients with end stage disease is their quality of life and the best way to improve this is palliative care focussing on prompt relieve of dysphagia, and psychosocial support. 10 Nutritional support is a key component of care and is best achieved by restoring oesophageal luminal patency. Although gastrostomy and jejunal feeding tubes can be placed surgically or endoscopically they do not relieve dysphagia or address the risk of aspiration and their value in very advanced stage disease should be considered in terms of the overall palliative care plan. There are multiple therapies available to alleviate dysphagia including oesophageal dilatation, argon plasma coagulation, laser therapy, oesophageal stent placement, external beam radiotherapy (EBRT), brachytherapy (intraluminal radiotherapy), and photodynamic therapy. 24 Dilation should be reserved for very proximal esophageal tumors that are not stentable as dysphagia relief is short-