Oesophageal carcinoma in the horn of Africa Ten year cumulative experience in two hospitals in Djibouti

Abstract

INTRODUCTION: In this paper we report on our experience of diagnosis, treatment and follow up of cases of cancer of the oesophagus treated in Balbala Cheiko Hospital and in the Djibouty Military Hospital. Oesophageal cancer, mainly squamous cellular type, is the prevalent cancer of the gastrointestinal tract (GIT) observed in our two Hospitals. Djibouti is a small pacific country located in the Horn of Africa in the tropics, bordered by Somaliland in the south, Ethiopia in the southwest, Eritrea in the north and the Red Sea and the Gulf of Aden in the east. Yemen lies across the Gulf of Aden. Djibouti is the principal maritime port for Ethiopia. The country was formerly French Somaliland and it became independent from France in June 1977. It is a multi-ethnic nation with a population of just over 900,000.

MATERIAL AND METHODS: From January 2011 to April 2021, we observed 159 patients diagnosed with cancer of the oesophagus: 89 females representing 56 % and 70 males representing 44 %. An Oesophageal Cancer Card (see Annex 1) was completed for each patient. 107 patients (67.30%) reported regularly (twice a week) chewing of khat (see Annex 2) and 68 patients (42,76%) regularly smoked more than 20 cigarettes and drank more than three very hot cups of coffee or tea per day. All patients underwent an oesophagoscopy with biopsy. Squamous Cell Carcinoma (OSCC) was confirmed by histology in all cases, 89 of them being females (64%) which is surprisingly different from data reported in the literature which reports a general prevalence of males. 60 patients (37.7 % of the total) underwent surgery. The Ivor-Lewis operation was the most frequent type of surgery and was done in 44 patients (66.6%).

RESULTS: Our ten years experience involved two hospitals serving a large area. Cancer of the oesophagus (OC) was the prevalent gastrointestinal cancer we observed, second only to female breast cancer. There are no facilities in the country for radiotherapy. It is very difficult to report on long term survival because most of patients live in rural areas which are very difficult to reach and they rarely return for medical check-ups. The best survival recorded was a 48 year old Afar male who was still alive 6 years after an Ivor-Lewis operation was performed for squamous carcinoma on 3 April 2014 and checked on September 2020. A further 6 patients (2 males and 4 females, 3 with adenocarcinoma and 3 with squamous cell carcinoma) recently checked are still alive and come in regularly for check-up.

CONCLUSIONS:Oesophageal cancer is one of the most frequent cancers found in the Horn of Africa and our experience in Djibouti confirms the data of the literature 16,28,29. A peculiarity in our study is the high prevalence in the female population. Our recommendation is to set-up an oesophageal cancer unit (OCU) with a team of specialists: gastroenterologist, surgical oncologist, anaesthesiologists, pathologists, nutritionalists and trained nurses who could ensure, not only hospital support, but also the active post operative follow up of patients. The implementation of a National Cancer Register would be mandatory.