Special investigations

ECG

    This is performed on all patients preoperatively. Atrial fibrillation is important as it can indicate underlying ischaemic heart disease, pericardial invasion by the tumour, unsuspected mitral stenosis or thyroid dysfunction. Previous myocardial infarctions may be evident in the form of Q waves. Ischaemic heart disease may be seen in the form of ST segment changes and T wave abnormalities. 

    Pre oesophagectomy coronary angiography and ? subsequent angioplasty remains highly controversial. Pre oesophagectomy coronary artery bypass surgery probably has no place outside the setting of unstable angina in a young patient with a small tumour.

CXR

    Oesophageal tumours are rarely seen on pain radiographs. Important check points include bony metastasis, pulmonary metastasis, the cardiothoracic ratio and cardiac silhouette. In achalasia and hiatus hernia the oessopahgus may be seen , as may a fluid level behind the heart. in addition the effects or repeated pulmonary aspiration may be seen.

    Patients exercise tolerance remains a better indicator of cardiopulmonary reserve. FEV1% however is a reasonable indicator of patients at particularly high risk of post operative pulmonary complications. Antibiotics if indicated, bronchodilators, good physiotherapy, mini trachyostomy in the setting of excessive secretions that the patient can't expectorate and effective analgesia remain key to managing patients with poor pulmonary reserve.

Blood tests

Full blood count

• Haemoglobin - Anaemia is almost to be expected in carcinoma of the oesophagus
• White cell count - May indicate latent infection
• Platelet count - A low count may indicate an underlying hematological defect, or the extent of the tumour. Obviously important in setting of post operative bleeding.

Urea and Creatinine

• Urea - Helpful in assessing the degree of dehydration secondary to reduced oral intake.
• Creatinine - Indicates underlying renal dysfunction. These patients need aggressive post operative monitoring, fluid rehydration and attention to maintenance of blood pressure.

Liver Function tests

• Albumin - An indicator of pre operative starvation / malnutrition.
• Gamma GT, AST, ALT - When raised may indicate liver metastasis, or alcoholic liver disease which should never be forgotten.
• Alkaline phospahatase - May indicate liver or bony metastasis depending on which isoenzyme is raised

Clotting

• PT, APPT, fibrinogen - Vitamin K deficiency secondary to malnutrition can occur. Correction may reduce post operative bleeding.

Oesophageal manometry

    These are not performed in the treatment of oesophageal carcinoma or perforation, but are performed in virtually all other oesophageal conditions

pH study

    These are not performed in the treatment of oesophageal carcinoma or perforation, but are performed in virtually all other oesophageal conditions

Abdominal x-ray

    This is not performed routinely preoperatively, however it can be invaluable in the management of post operative complications.

Endoscopy

    This is vital to diagnosis in gaining a histological diagnosis, assessing the intraluminal extent of tumour spread, finding the occasional synchronous tumour, and confirming the exact position from the incisors.  

Bronchoscopy

    This is mandatory especially in the treatment of middle and upper third tumours, so that bronchial (especially Left main) and tracheal invasion can be ruled out.

Endo Oesophageal ultrasound

    The exact role for Endo Oesophageal ultrasound remains unsure. It is very good at staging oesophageal tumours preoperatively, however it is less good at delineating which ones are resectable. It can provide important information on the response to preoperative chemotherapy. Tumours that result in near complete oesophageal obstruction are obviously un-assessable by this technique.

Barium studies

    The role of barium has fallen with the widespread introduction of flexible endoscopy, however they still remain important in the diagnosis and assessment of oesophageal perforation, achalasia, oesophageal dysmotility, oesophageal leaks post operatively, oesophageal diverticula, and pharyngeal pouches. A number of elderly [patient have had previous gastric surgery, but are unsure as to what was actually done, and their is no access to the operation note, a contrast barium study can be invaluable to evaluate the anatomy in theses cases.

CT Scan

    This is the main investigation other than endoscopy in the assessment of oesophageal carcinoma. Specific points on the CT scan to look for include:

• Location of tumour

• Size of tumour

• Invasion of adjacent structures eg trachea, aorta or pericardium.

• Lymph node involvement eg Coeliac or mediastinal

• Liver metastasis

    These are only performed in patients who have skeletal pain and an underlying oesophageal malignancy.

Visceral angiogram

    These are only performed in the assessment of the colonic blood supply should the colon be needed for oesophageal replacement. If the patient has had a previous bleeding duodenal ulcer that required over sewing the gastroduodenal artery, a visceral angiogram can confirm or refute this, as your gastric tube relies on this artery for its blood supply.