A cautionary tale

This patient attended for dilatation of his biopsy confirmed peptic oesophageal stricture. Clip has been speeded up somewhat.
WHAT WOULD YOU ORGANISE NEXT?

■ A clinic appointment

To ask pt about the swallowing? Hmm, somethings missing!

■ Another dilatation in 2 weeks time

Stricture not very tight and the dilatation should last longer

■ an early follow up OGD for biopsies

The mid-oesophageal stricture is peptic but what of the mucosa below?

explanation

The background to this case is a recent audit which we did in Leeds on missed upper GI neoplasia.  We have had several instances of oesophageal cancers being missed when the endoscopist focused too much on the 'task in hand'.  For example, we have had several SCC's missed when the endoscopist was carrying out a Barrett's surveillance endoscopy.  

This is another example of a missed (intramucosal) adenocarcinoma, glimpsed about 10 seconds into the clip in the 3 O'clock position. With mid-oesophageal peptic strictures there is often a stretch of Barrett's below which of course must be assessed and sampled at the earliest convenience. 

Of course, one can argue that when the job is to do something therapeutic, such as placing a PEG or removing a large polyp,  it is 'permissible' to miss a cancer elsewhere. After all, the objective is not to undertake a careful diagnostic examination but to 'do a job'! 

I'm a strong believer that 'diagnostic' examinations and 'therapeutic' examinations must be clearly separated when you are looking at 'missed lesions. There is a distinct 'therapeutic window' during all endoscopic procedures done without a general anaesthetic. In the upper GI tract, it's up to 20-30 minutes and in the colon I think that it's up to 45-60 minutes. Your patient will not thank you for wasting the valuable minutes of your therapeutic window on carrying out a full diagnostic examination.  Of course, after your therapeutic procedure you should consider if an early diagnostic gastroscopy or colonoscopy is needed.  

But carrying out a full assessment of the squamous portion of the oesophagus at the time of a Barrett's surveillance examination doesn't add much to the procedure. Similarly, when a mid-oesophageal peptic stricture is found, one should realise that the reason that the peptic stricture is in the middle of the oesophagus and not the gastro-oesophageal junction, is probably that there is a a Barrett's segment below the stricture.  It doesn't add much time to the procedure and that IMca could have been spotted earlier!