4th Edition

Chapter 7: An actuary with a leak

A 63-year-old actuary presented with painful dysphagia.

  • 1. What are the common causes of dysphagia?

    Correct answer:
    Dysphagia can be divided into oesophageal dysphagia and oropharyngeal dysphagia.
    Oesophageal dysphagia:

    • Achalasia
    • Oesophageal spasm
    • Stricture
    • Radiotherapy
    • Foreign body
    • Scleroderma
    • Gastro-oesophageal reflux disease (GORD)
    • Cancer (oesophagus or extrinsic from lung/mediastinal tumours)
    Oropharyngeal dysphagia:
    • Neurological disorders (multiple sclerosis, muscular dystrophy, Parkinson’s disease, CVA, spinal cord injury)
    • Pharyngeal diverticulum
    • Tumours of oropharynx (and their treatment)

  • 2. What do the endoscopy and CT scan show?

    Correct answer:
    Endoscopy revealed a mid-oesophageal adenocarcinoma and staging investigations confirmed T3N0M0 disease.

  • 3. What is the relationship between the site of the oesophageal cancer, its histological subtype and risk factors?

    Correct answer:
    Upper two-third of oesophageal cancers are usually squamous cell tumours that represent about 25% of all oesophageal cancers and are associated with smoking and alcohol.
    Tumours of the lower one-third of the oesophagus are more common and are usually adenocarcinomas. They are associated with gastro-oesophageal reflux (GORD) and Barrett’s oesophagus.

He received neoadjuvant chemoradiotherapy followed by total oesophagectomy and gastric pull-up. This is a two-stage Ivor Lewis approach with laparotomy and mobilization of the stomach followed by a right thoracotomy with resection of the tumour and oesophago-gastric anastomosis.

Two weeks post-operatively he developed shortness of breath and a fever.

  • 4. What post-operative complication does the chest X-ray, CT scan and Gastrografin swallow show?

    Correct answer:
    Post-operative anastomotic leak following Ivor Lewis oesophagectomy and gastric pull up, causing large right pleural effusion.

In addition to anastomotic leaks, common post-operative surgical complications of oesophagectomy include infection, strictures and less commonly fistulas.

He had a further thoracotomy and surgical repair of the anastomotic leak and recovered remarkably well.

  • 5. What are the options for fertility conservation?

    Correct answer:

    • *Egg harvesting (at present ovum storage remains an unreliable method for routine usage and requires ovarian stimulation prior to egg harvesting, which introduces a delay prior to starting chemotherapy and is relatively contraindicated in breast cancer)
    • *Ovarian strip cryopreservation (experimental strategy that attempts to harvest ova without ovarian hyperstimulation and the delay that it entails)
    • *Ovarian suppression (use of gonadotropin-releasing hormone (GnRH) suppression during chemotherapy has been used in an attempt to reduce oocyte damage)
    • Storage of fertilized ova (storage of embryos is the most reliable method of conserving fertility in women)
    • Egg donation (donor eggs fertilized by chosen sperm and implanted into the uterus)
    • Embryo donation (donor embryos implanted into the uterus)
    *currently viewed as experimental

  • 6. What are the three most common psychological effects in breast cancer survivors?

    Correct answer:

    • The Lazarus syndrome (difficulty returning to normal mundane life)
    • The Damocles syndrome (fear of cancer recurrence and terror of even trivial symptoms)
    • The Survivor syndrome (guilt about surviving cancer where others have died)

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