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Frozen ultrasound image as a prompt for stop before you block

Our analysis of pre-operative variables has not demonstrated threshold values that can be used in isolation to classify low or high risk of complications after oesophagectomy for an individual [1]. In our experience, the combination of both fitness and oncological assessment is necessary for multidisciplinary team (MDT) planning, and the strongest association with survival is the cancer itself rather than the cardiopulmonary fitness of the patient. Cardiopulmonary exercise testing (CPET) is increasingly available in centres throughout the UK, with 60% of clinics using CPET for high-risk surgical patients within their pre-operative assessment service [2]. When we introduced CPET to the oesophagogastric group, we designed a pathway that included early involvement of the peri-operative anaesthetic consultant in the pre-operative assessment clinic before discussion of individuals at the oesophagogastric MDT meeting. This review takes place after assessment and CPET; it reports a summary to the MDT detailing clinical history, CPET measurements, risk factors and an individualised, considered clinical opinion. Analysis of the CPET and preoperative measurements presented in our paper allows us to use these results when individualising risk prediction, knowing that there is still a high incidence of complications despite the oesophagogastric surgical cohort having good physiological reserve (median peak oxygen uptake 18.8 ml.kg 1 min , median anaerobic threshold 14.0 ml.kg 1 min ). Quantification of cardiopulmonary reserve allows mean fitness comparison among the operable population, identifying individuals with relatively physiological reserve. This aids targeted treatment(s), including cardiopulmonary optimisation, drug titration, bronchodilator use, anaemia management, guides critical care provision and informs patients’ decisions and expectations about treatment options and recovery when poor reserve is identified. Chemotherapy has a recognised impact upon CPET measurements [3, 4]. A mean reduction of 2.1–2.4 ml.kg 1 min 1 in anaerobic threshold occurs after neoadjuvant chemotherapy. This may be prognostically important for patients with a limited physiological reserve (e.g. with an anaerobic threshold ~ 8.0 ml.kg 1 min ) and usefully informs the shared decision still further. Multidisciplinary team discussion considers these factors alongside tumour staging and oncological strategies. We have found that holistic assessment of patients early in their cancer pathway has become a valued aspect of their treatment, particularly for those presenting with the highest perioperative risks.