Diverticula of the Esophagus

Classification

• True diverticulum - all wall layers herniate
• False (pulsion) diverticulum - only mucosa and submucosa herniate through a muscular defect

1. Zenker's Diverticulum (Pharyngoesophageal)

Anatomy & Site

• Posterior outpouching through the Killian triangle (Killian's dehiscence) - bounded above by the oblique fibers of the inferior pharyngeal constrictor and below by the transverse fibers of the cricopharyngeus muscle
• Typically at the level of C5-C6
• Most deviate to the left of midline

Pathogenesis

• Impaired UES opening (diminished, not absent, relaxation) leads to increased hypopharyngeal pressure
• Myogenic degeneration: histologic studies show connective tissue replacement of skeletal muscle fibers and fiber degeneration
• A pulsion mechanism drives mucosa and submucosa through the area of relative mural weakness
• Sometimes called "cricopharyngeal achalasia" (though technically UES does relax)

Epidemiology

• Prevalence 0.01-0.11%; majority asymptomatic at discovery
• Median age ~70 years; male predominance
• Rare under age 30

Symptoms

• Dysphagia (most common, 80-90% of patients)
• Regurgitation of undigested food
• Halitosis
• Neck gurgling or mass
• Aspiration/cough
• ~30% have associated GERD

Complications

• Aspiration pneumonia
• Pill retention
• Ulceration, fistula, hemorrhage
• Squamous cell carcinoma (reported in 0.4% over 53 years)

Diagnosis

• Barium swallow - gold standard; shows the pouch and its size; radiologic field must include the hypopharynx
• Endoscopy - not essential; carry perforation risk due to the posterior diverticular orifice; perform with caution
• Esophageal manometry - can show UES incoordination, hypertensive UES; also locates LES for pH monitoring

Treatment

Open Transcervical Approach

• Left-sided neck incision along medial border of sternocleidomastoid
• Complete division of cricopharyngeus + myotomy of upper 3 cm of posterior esophageal wall
• Small diverticula (<2 cm) - myotomy alone
• Large diverticula - diverticulectomy (stapler, with bougie in place) or diverticulopexy (suspension to prevertebral fascia)
• Diverticula >5 cm are typically resected
• Complications (2-3%): esophageal leak, mediastinitis, stenosis, recurrent laryngeal nerve damage
• Recurrence: 5-10%
• Operative mortality <2%

Rigid Endoscopic Technique

• General anesthesia; diverticuloscope placed with one blade in esophagus, one in pouch
• Linear stapler fires across the septum, creating a common cavity
• Limitation: small diverticula (2-3 cm) don't allow proper stapler positioning

Flexible Endoscopic Technique

• Patient in left lateral decubitus; septum divided under direct vision
• Devices used: needle knife, hook knife, or argon plasma coagulation
• Endoclips placed to close the incision
• Both rigid and flexible endoscopic approaches have ~90% success rate

Z-POEM (Per-Oral Endoscopic Myotomy for Zenker's)

• Submucosal injection + mucosotomy ~3 cm proximal to the septum
• Submucosal tunnel created on both sides of the septum
• Cricopharyngeus fibers transected under direct vision; mucosotomy closed with clips
• ~90% good results; ~6% complication rate (perforation, bleeding)
• Long-term data still accumulating

2. Killian-Jamieson Diverticula

• Arise from proximal cervical esophagus below the UES (caudal to cricopharyngeus)
• Less common than Zenker's; less likely to cause dysphagia
• Usually unilateral, left-sided; bilateral in 25%; may coexist with Zenker's
• True esophageal diverticula (below UES, in striated/smooth muscle transition zone)
• Can be confused radiographically with Zenker's

3. Mid-Esophageal Diverticula

Pathogenesis

• Historically: traction diverticula from fibrous adhesions due to adjacent mediastinal lymph node inflammation (tuberculosis, histoplasmosis, sarcoidosis, anthracosis)
• Now most cases are pulsion-type associated with esophageal dysmotility (uncoordinated or high-amplitude contractions)

Presentation

• Dysphagia with or without regurgitation
• Symptoms correlate more with the underlying motility disorder than diverticulum size

Diagnosis

• Barium contrast radiography (usually)
• Manometry to evaluate underlying motility

Treatment

• Asymptomatic: observation
• Symptomatic: surgical diverticulectomy + myotomy (or endoscopic myotomy)

4. Epiphrenic Diverticula

• Herniation of mucosa and submucosa through the distal 10 cm of esophageal musculature
• Most commonly caused by functional LES obstruction due to motility disorders (achalasia, diffuse esophageal spasm), or mechanical obstruction (leiomyoma, stricture, web, prior surgery)
• More commonly protrude to the right
• Can enlarge over time (16% in one series over 12 years)

Symptoms

• Dysphagia, regurgitation, odynophagia, chest pain, heartburn, aspiration
• Often asymptomatic (incidentally found)

Diagnosis

• Barium radiography (primary)
• Endoscopy to exclude structural obstruction
• Esophageal manometry - essential to evaluate underlying motility disorder

Treatment

• Symptomatic: diverticulectomy + LES myotomy + partial fundoplication (to prevent reflux post-myotomy); laparoscopic transhiatal approach is established
• Botulinum toxin A injection of LES - limited utility (moderate efficacy, poor durability)

5. Esophageal Intramural Pseudodiverticulosis

• Multiple small outpouchings from dilation of excretory ducts of submucosal esophageal glands (not true diverticula)
• First described by Mendl et al. (1960)
• Presents after 6th decade with chronic dysphagia
• Associated with proximal esophageal strictures (70-90%) and manometric abnormalities (two-thirds)
• Also associated with corrosive esophageal injury
• Best diagnosed on barium studies (intramural contrast tracking in 50%)
• Diverticula can regress after stricture treatment

Summary Comparison

Oesophageal Cancers

Epidemiology

• Predominant in the 6th and 7th decades; ~70% of cases occur in males
• Highest incidence: Central Asian "esophageal cancer belt" (Iran, Central Asian republics, China), Southern/Eastern Africa, Northern Europe
• In the United States: 17th most common cancer (~21,560 new diagnoses, ~16,120 deaths/year, 2023 estimates)

Types / Histology

Other rare types

• Leiomyosarcoma
• Small cell carcinoma
• Melanoma (rare primary)
• Lymphoma (rare)

Risk Factors

Squamous Cell Carcinoma

• Tobacco and alcohol - strongest risk factors; synergistic ~3-fold increased risk with both combined
• Risk increases with amount consumed and cigarettes smoked
• Low fruit and vegetable intake; vitamin/nutrient deficiencies
• Foods containing N-nitrosamines, pickled vegetables, high-temperature liquids (hot tea in Iran, mate in South America)
• Areca (betel) nut chewing (India)
• Chronic achalasia
• Plummer-Vinson (Patterson-Kelly) syndrome (iron deficiency anemia, esophageal webs)
• Caustic (lye) ingestion
• Prior radiation therapy (for Hodgkin's lymphoma, breast cancer)
• Hereditary: Tylosis (RHBDF2 gene mutation) - markedly increased SCC risk; Fanconi anemia

Adenocarcinoma

• GERD - major risk factor; leads to Barrett's metaplasia
• Barrett's esophagus (BE) - risk of progression to cancer ~0.4-0.5% per year
• Obesity (increases reflux; note: many young EAC patients are fit without obesity)
• Tobacco use
• H. pylori infection is inversely correlated (protective for EAC)
• Hereditary: Lynch syndrome, BRCA germline mutations (modest increased risk)

Pathogenesis

ESCC

• Repeated toxin exposure + chronic inflammation → squamous dysplasia → high-grade intraepithelial neoplasia (carcinoma in situ, no basement membrane violation)
• Risk of progression from intraepithelial neoplasia to SCC: 24% at 14 years (low-grade), 50% (moderate-grade), 75% (high-grade)
• Penetration of basement membrane = invasive carcinoma
• Key genomic: TP53 mutation (most prevalent); oncogene amplification of CCND1, MYC, CDK6, EGFR, FGFR ligands

EAC

• Chronic acid exposure → columnar metaplasia (Barrett's) → dysplasia → adenocarcinoma
• Genetic accumulation: TP53 inactivation → overexpression of ERBB2 (HER2), KRAS, CCNE1
• HER2/ERBB2 amplification in ~20-25% of EAC/GEJ adenocarcinomas
• Microsatellite instability (MSI) and EBV infection can drive a subset

Clinical Features

Symptoms

• Progressive dysphagia - most common (initially solids, then liquids) - usually indicates >50% luminal obstruction, hence late presentation
• Odynophagia (painful swallowing)
• Unintentional weight loss
• Regurgitation
• Chest pain or retrosternal discomfort
• Cough, hoarseness (recurrent laryngeal nerve involvement)
• Hematemesis / melena (bleeding)
• Fatigue (anemia from occult bleeding)

Signs

• Cachexia (advanced disease)
• Left supraclavicular lymphadenopathy (Virchow's node)
• Cervical lymphadenopathy
• Hepatomegaly (metastatic disease)

Diagnosis and Workup

1. Upper endoscopy + biopsy - establishes diagnosis and histology; biopsy at presentation determines histology and guides molecular testing
2. Next-generation sequencing (NGS) / molecular diagnostics - should be performed on all metastatic disease to guide targeted therapy; PD-L1 by IHC; HER2 testing
3. CT scan (chest/abdomen/pelvis) - assess metastatic disease
4. FDG-PET/CT - assess for metastatic disease, especially occult metastases
5. Endoscopic ultrasound (EUS) - most accurate for T and N staging; tumor appears hypoechoic against alternating hyperechoic/hypoechoic wall layers
6. Bronchoscopy - for mid/upper esophageal tumors to rule out tracheobronchial invasion (invasion of trachea = unresectable)
7. Laparoscopy - for GEJ tumors, to assess peritoneal involvement
8. Esophageal manometry - if motility disorder suspected
9. Circulating tumor DNA (ctDNA) - emerging tool for detecting genomic alterations and assessing minimal residual disease

Staging (AJCC 8th Edition TNM)

T Stage (Depth of invasion)

N Stage

• N0: No regional LN metastasis
• N1: 1-2 regional LNs
• N2: 3-6 regional LNs
• N3: ≥7 regional LNs

M Stage

• M0: No distant metastasis
• M1: Distant metastasis

Treatment

Screening / Surveillance

• General population screening not recommended in low-incidence countries (no proven cost-effective biomarkers)
• Periodic endoscopy recommended for high-risk patients (Barrett's esophagus with dysplasia)

Stage-Based Treatment Overview

Early-Stage Disease (Tis / T1a, selected small T1b)

• Endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) for tumors <2 cm
• EMR/ESD also used as part of staging to confirm T stage
• Ablative therapy (RFA, cryotherapy) for Barrett's eradication
• Esophagectomy if endoscopic therapy not feasible

Locally Advanced Disease (T2-T4, N+)

• pCR: 49% for SCC, 29% for EAC
• Median OS: 49.4 months (neoCRT) vs. 24 months (surgery alone)
• R0 resection: 92% vs. 69%

• 5-year OS: 47% vs. 34%; pCR 43.2%

• MAGIC trial: Epirubicin + cisplatin + 5-FU (ECF) pre/post-op → improved 5-year OS (36% vs. 23%)
• FLOT regimen (docetaxel, oxaliplatin, leucovorin, 5-FU): In the ESO-PEC trial, preoperative FLOT improved survival compared to CROSS chemoradiation for locally advanced adenocarcinoma - now a preferred regimen

• Definitive chemoradiation (without surgery) is a standard option
• Surgery reserved for patients not achieving complete response

Adjuvant Therapy (post-surgery)

• CheckMate 577 trial: Nivolumab (PD-1 inhibitor) adjuvant therapy significantly improved survival in esophageal/GEJ cancer patients who received preoperative chemoradiation + R0 resection but had residual tumor in specimen (not ypT0N0M0) - now standard of care

Metastatic Disease (Palliative Intent)

• Goal: symptom palliation + life extension
• HER2-positive (~20-25%): Trastuzumab + chemotherapy; or trastuzumab + chemotherapy + pembrolizumab (improves PFS)
• HER2-negative, PD-L1 positive: PD-1 inhibitors (e.g., nivolumab, pembrolizumab) + chemotherapy as first-line
• Checkpoint inhibitors are also second-line monotherapy for PD-L1 expressing tumors
• Systemic therapy regimens: platinum-based combinations (cisplatin/oxaliplatin + 5-FU/capecitabine)

Molecular Targets Summary

Surgical Approaches

• Esophagectomy (transthoracic/transhiatal/minimally invasive) remains the cornerstone for resectable disease
• High-volume centers and surgeons have markedly better outcomes
• Minimally invasive esophagectomy (MIE) - non-inferior to open (TIME trial) with reduced pulmonary complications

Palliation

• Esophageal stenting (self-expanding metal stents) for malignant dysphagia
• Laser therapy / photodynamic therapy for luminal obstruction
• Radiotherapy for dysphagia palliation
• Nutritional support (feeding jejunostomy, gastrostomy)

Prognosis

• Localized (early): ~47% (esophageal SCC), 47% (EAC)
• Regional (lymph node spread): ~26%
• Distant (metastatic): ~5%
• Overall (all stages): ~20%

Recent evidence note (PubMed, 2025): Recent meta-analyses (PMID 40207218, PMID 40386769) confirm that PD-1/PD-L1 inhibitors + chemotherapy as first-line treatment for advanced gastroesophageal junction/esophageal adenocarcinoma significantly improve overall survival and progression-free survival in both HER2-negative and HER2-positive subgroups, supporting integration of immunotherapy into standard first-line regimens.

Surgeries for Oesophageal Cancer

Overview and Patient Selection

Preoperative Assessment

• Upper endoscopy - confirm tumor location and plan approach
• Bronchoscopy - for mid or upper third tumors to exclude tracheobronchial invasion
• Nutritional assessment - malnutrition is common; a feeding jejunostomy is often placed
• Pulmonary function testing - single-lung ventilation required for thoracic approaches
• Cardiopulmonary fitness - cardiac risk stratification essential
• Staging CT + PET/CT + EUS - to confirm resectability

The Esophageal Conduit

The Four Major Surgical Approaches

1. Ivor Lewis Esophagectomy (Two-field / Transthoracic)

• Incisions: Abdominal (laparotomy or laparoscopy) + Right thoracotomy (right posterolateral, 5th intercostal space) or thoracoscopy
• Patient positioning: Supine (abdominal phase) → Left lateral decubitus (thoracic phase)
• One-lung ventilation: Required (double-lumen ETT or capnothorax)
• Anastomosis: Right intrathoracic (high in the chest, above azygos vein)
• Order of operation: Abdomen first → then thorax

1. Abdominal phase: D2 lymph node dissection at celiac trunk, hepatic and left gastric artery; gastric conduit creation (3-5 cm wide, stapled from incisura to fundus); pyloroplasty; transhiatal dissection of the distal esophagus
2. Patient repositioned; right thoracotomy/thoracoscopy
3. Azygos vein divided
4. Thorough posterior mediastinal lymphadenectomy
5. Esophagus divided; gastric conduit pulled up into thorax
6. Intrathoracic esophagogastric anastomosis (end-to-side or end-to-end; stapled or hand-sewn)

• Excellent direct visualization of the thoracic esophagus
• Superior mediastinal lymphadenectomy
• Lower anastomotic leak rate than cervical anastomosis
• Less GERD post-op (anastomosis high in chest)

• If anastomotic leak occurs in the chest - more dangerous, often requires reoperation or stenting
• Requires one-lung ventilation; higher pulmonary morbidity
• Longer recovery

2. McKeown Esophagectomy (Three-incision / Three-field)

• Incisions: Right thoracotomy/thoracoscopy + Abdominal (laparotomy/laparoscopy) + Left cervical
• Patient positioning: Left lateral decubitus (thoracic) → Supine with neck extension (abdominal + cervical)
• One-lung ventilation: Required
• Anastomosis: Left cervical (neck)
• Order of operation: Right thoracic first → Abdominal → Left cervical

1. Right thoracoscopy/thoracotomy: esophageal mobilization from thoracic inlet to hiatus; mediastinal lymphadenectomy; azygos vein ligated
2. Abdominal phase: gastric conduit creation; D2 nodal dissection; pyloroplasty
3. Left cervical incision (anterior to SCM): cervical esophagus freed, divided; specimen extracted through neck; gastric conduit pulled to neck; cervical anastomosis constructed (single-layer interrupted silk or stapled posterior row)

• Mid and upper thoracic tumors near the airways (where proximal margin is at risk)
• Extensive Barrett's esophagus requiring maximal esophageal resection
• Concern for adequate proximal margin

• Maximal proximal margin - widest possible excision
• Access to all mediastinal nodal stations (two-field or three-field dissection)
• Cervical leak (if occurs) is much less morbid than intrathoracic leak
• Avoids severe post-op GERD (less residual esophageal mucosa)

• Three separate incisions/positions
• Highest rate of recurrent laryngeal nerve (RLN) injury (vocal cord palsy 2-14%)
• Higher anastomotic leak rate at the cervical site than intrathoracic
• Longer operative time

3. Transhiatal Esophagectomy (THE)

• Incisions: Abdominal (laparotomy/laparoscopy) + Left cervical only - no thoracotomy
• Patient positioning: Supine throughout
• One-lung ventilation: Not required
• Anastomosis: Left cervical
• Key feature: Mediastinal esophageal dissection performed bluntly via the diaphragmatic hiatus (surgeon's hand passed into mediastinum) and from the neck downward

1. Abdominal phase: same as Ivor Lewis; gastric conduit creation; pyloroplasty; hiatus dilated; surgeon's hand inserted transhiatally into posterior mediastinum to bluntly free the thoracic esophagus
2. Left cervical incision: cervical esophagus dissected downward; esophagus divided in neck; specimen pulled down through hiatus into abdomen
3. Gastric conduit passed through posterior mediastinum to neck; cervical anastomosis

• Lower esophageal early-stage disease (T1-T2)
• Barrett's esophagus with high-grade dysplasia (lymph node dissection less critical)
• Patients with poor pulmonary function who cannot tolerate one-lung ventilation

• Least invasive - no thoracotomy, no one-lung ventilation
• Shortest operative time
• Lower pulmonary morbidity
• Cervical anastomotic leaks less dangerous (drain to skin rather than into pleural cavity)
• Excellent functional outcomes and quality of life

• Limited lymphadenectomy (cannot access mediastinal nodes as thoroughly)
• Higher anastomotic leak rate (cervical)
• Higher rate of RLN injury
• Intraoperative cardiac dysrhythmias during blunt mediastinal dissection (up to 65% - usually atrial, mostly tolerated)
• Rare but serious: hemorrhage (<2%), airway injury (<1%) from blind mediastinal dissection
• Many consider it to have lower oncologic yield for advanced tumors

4. Left Thoracoabdominal Esophagectomy

• Incisions: Single left thoracoabdominal incision (chest + abdomen through the same incision extended across the costal margin)
• Patient positioning: Supine with chest bumped 45 degrees
• One-lung ventilation: Yes
• Anastomosis: Left chest
• Best for: Cardia and GEJ tumors, re-do cases, patients where prior abdominal surgeries make separate abdominal access difficult

• Excellent exposure to distal esophagus, GEJ, and proximal stomach
• Single incision (no repositioning)

• Limited access to the upper mediastinum and proximal esophagus
• High risk of post-op GERD due to low position of intrathoracic anastomosis
• Restricted use compared to the other three approaches

Comparison Summary

Minimally Invasive Esophagectomy (MIE)

• TIME Trial (2012): MIE (thoracoscopic + laparoscopic) vs. open Ivor Lewis - MIE had significantly fewer pulmonary complications (9% vs. 29%) with equivalent oncologic outcomes (R0 resection, lymph node yield)
• ECOG E2202 trial (16 institutions): 30-day MIE mortality 2%
• University of Pittsburgh series (222 patients): median ICU stay 1 day, median hospital stay 7 days, 30-day mortality 1.4%
• High-volume experienced centers report mortality as low as 0.9%

• Fewer pulmonary complications
• Shorter ICU and hospital stay
• Less blood loss
• Faster recovery
• Equivalent oncologic outcomes (lymph node yield, R0 rate, survival) to open

Lymph Node Dissection

• Two-field dissection: Abdominal + mediastinal nodes (standard for most cases)
• Three-field dissection: Abdominal + mediastinal + bilateral cervical nodes - performed for upper thoracic SCC or tumors at/above the carina; associated with higher morbidity but improved staging and potentially improved survival in SCC
• Transthoracic approaches provide better access to relevant mediastinal nodes than transhiatal approaches
• A minimum of 15-20 lymph nodes recommended for adequate staging

Resection Classification (AJCC)

Complications

Intraoperative

• Cardiac dysrhythmias: up to 65% (mainly during transhiatal blunt dissection; mostly atrial, well-tolerated)
• Hemorrhage: <2% (transhiatal); may require emergency thoracotomy
• Airway injury (trachea/bronchi): <1% - detected by smell of inhaled anesthetic; management by advancing ETT past injury, possible primary repair

Perioperative Morbidity (30-50% of patients have at least one serious complication)

Key complication management:

• Anastomotic leak: 57% managed non-operatively; options include endoscopic stenting (if small/contained), primary repair, muscle flap reinforcement, esophageal diversion. Early leaks (<5 days) or those with conduit necrosis often need surgery
• Chylothorax: NPO + TPN for low output; thoracic duct embolization (IR) or surgical ligation for high output
• Anastomotic stricture: Endoscopic dilation (up to 3 dilations needed in 6.6% of patients)
• Atrial fibrillation: Electrolyte correction, antiarrhythmics; always prompt workup for anastomotic leak

Mortality and Volume-Outcome Relationship

Post-Esophagectomy Quality of Life

• Most patients report good satisfaction with life after gastric conduit replacement
• Long-term issues: dysphagia (from stricture), early satiety, loss of appetite, reflux
• Post-op GERD is more common with intrathoracic anastomoses (Ivor Lewis, left thoracoabdominal) vs. cervical anastomoses
• SF-36 scores in patients operated for high-grade dysplasia/early cancer generally equal healthy controls at ~46 months post-op
• Patients who had esophagectomy report more reflux and eating problems vs. endoscopic therapy patients; endoscopy patients report higher fear of cancer recurrence

Recent evidence (PubMed 2024): A meta-analysis (PMID 38869981) comparing mediastinoscopy-assisted vs. thoracoscope-assisted esophagectomy found comparable perioperative outcomes and long-term survival, supporting both as valid minimally invasive options depending on institutional expertise.

Courvoisier's Law

The Statement

"In the presence of jaundice, a palpable, non-tender, distended gallbladder is unlikely to be due to gallstones, and is more likely caused by malignant (neoplastic) obstruction of the common bile duct."

The Diagram

Pathophysiological Basis

Causes of a Positive Courvoisier Sign (Palpable Gallbladder + Jaundice)

1. Carcinoma of the head of the pancreas - most common cause
2. Periampullary carcinoma (carcinoma of the ampulla of Vater)
3. Cholangiocarcinoma (distal bile duct)
4. Carcinoma of the gallbladder (rare)
5. Duodenal carcinoma with bile duct involvement
6. Metastatic nodes at the porta hepatis compressing the CBD
7. Mirizzi syndrome (less common - stone in the cystic duct/Hartmann's pouch externally compressing the CBD; but the gallbladder may still be palpable in this case)
8. High insertion of the cystic duct (anatomical variant - a Courvoisier's gallbladder with high cystic duct insertion is a commonly encountered anatomy in such presentations)

Clinical Significance

• The triad of painless jaundice + palpable non-tender gallbladder + weight loss is highly suspicious for carcinoma of the head of the pancreas until proven otherwise
• The Courvoisier sign is uncommon even in pancreatic cancer (reported in <30% of cases); its absence does not exclude malignancy
• Important caveat: The sign can occasionally be falsely positive - a patient with stones in the gallbladder can still have a palpable gallbladder if the CBD is obstructed by malignancy simultaneously. As noted by Sleisenger & Fordtran: "Deep jaundice without pain, particularly with a palpable gallbladder (Courvoisier sign), suggests neoplastic obstruction of the bile duct, even when the patient has stones in the gallbladder."
• The absence of a palpable gallbladder does not exclude malignancy (the sign has low sensitivity)

Investigations to Follow

1. LFTs - raised bilirubin + ALP disproportionately (obstructive pattern); ALP rises faster and precedes bilirubin rise
2. Ultrasound abdomen - first-line; confirms dilated intrahepatic and extrahepatic bile ducts; identifies the level of obstruction; may show pancreatic mass
3. Contrast-enhanced CT scan (CECT) - preferred test if pancreatic head tumour suspected; assesses resectability (vascular encasement, metastases)
4. MRCP / MRI - excellent for biliary anatomy and soft tissue characterisation
5. EUS - superior for visualising the distal CBD and pancreatic head; can guide FNA biopsy
6. ERCP - if cholangitis present, diagnostic uncertainty, or biliary decompression needed (brush cytology, biopsy, stenting); not routine pre-operatively in resectable disease (higher infective complications post-surgery)
7. CA 19-9 - tumour marker; raised in pancreatic cancer (not specific or sensitive alone)
8. Prothrombin time - check; prolonged obstructive jaundice causes vitamin K malabsorption; correct with Vitamin K before any procedure

Summary