Association of Upper GI Surgery of Great Britain and Ireland (AUGIS) Delphi consensus recommendations on the adoption of robotic upper GI surgery.

BACKGROUND: The adoption of robotic platforms in upper gastrointestinal (GI) surgery is expanding rapidly. The absence of centralised guidance and governance in adoption of new surgical technologies may lead to an increased risk of patient harm. METHODS: Surgeon stakeholders participated in a Delphi consensus process following a national open-invitation in-person meeting on the adoption of robotic upper GI surgery. Consensus agreement was deemed met if >80% agreement was achieved. RESULTS: Following two rounds of Delphi voting, 25 statements were agreed on covering the training process, governance and good practice for surgeons' adoption in upper GI surgery. One statement failed to achieve consensus. CONCLUSIONS: These recommendations are intended to support surgeons, patients and health systems in the adoption of robotics in upper GI surgery.

Laparoscopic large hiatus hernia repair with mesh reinforcement versus suture cruroplasty alone: a systematic review and meta-analysis.

BACKGROUND: To compare the difference in outcomes in laparoscopic large hiatus hernia (LHH) repair using suture-based and mesh-based repair techniques. METHODS: A systematic search of articles was conducted in PubMed, Medline and Embase using the PRISMA guidelines. Studies comparing recurrences and reoperations in those patients with large hiatal hernia repair (> 30% stomach in the chest, > 5 cm hiatal defect, hiatal surface area > 10 cm2) who had mesh vs no mesh were assessed quantitatively. The impact of mesh on significant intraoperative/postoperative surgical complications was qualitatively assessed. RESULTS: Pooled data included six randomized controlled trials and thirteen observational studies with 1670 patients (824 with no mesh, 846 with mesh). There was a significant reduction in the total recurrence rate with mesh (OR 0.44, 95% CI 0.25-0.80, p = 0.007). Mesh use did not cause significant reduction in recurrences > 2 cm (OR 0.94, 95% CI 0.52-1.67, p = 0.83) or in reoperation rates (OR 0.64, 95% CI 0.39-1.07, p = 0.09). None of the specific meshes assessed were found to be superior in the reduction of recurrence or reoperation rates. Cases of mesh erosion with eventual foregut resection were noted and were associated with synthetic meshes only. CONCLUSION: Mesh reinforcement seemed protective against total recurrence in LHH although this has to be interpreted with caution given the level of heterogeneity introduced by the inclusion of observational studies in the analysis. There was no significant reduction in large recurrences (> 2 cm) or reoperation rate. If the synthetic mesh is to be used patients need to be informed of the risk of mesh erosion.

'She's not obese, she's a normal 5-year-old and she keeps up with the other kids': families' reasons for not attending a family-based obesity management programme.

AIMS: To discover the reasons behind invited families' lack of engagement with a family-based childhood obesity programme in a deprived area. METHODS: Interviews were conducted with 10 families who were invited to join the programme, but declined to engage. There were two distinct subgroups of participants: those who had no interest in attending the programme and those who showed initial interest yet did not continue attending. The two subgroups were analyzed separately using inductive thematic analysis, and then compared. RESULTS: Analysis identified eight themes overall. For both groups, when the service was perceived to be not needed ('I didn't see how that would help'), the families disengaged with it. For both groups, this perception was partly related to the perceived appearance of their children: either that they were not obese ('I didn't think my son was overweight') or that they were growing into their size. There was also a similarity in both groups that they perceived that they were already following healthy lifestyles. In addition, several of the themes arising from the families who had no initial interest were related to the impact of the letter that parents received detailing the result of their child being weighed and measured at school. This angered parents ('I was disgusted'), and there was a feeling that the approach was too generic. CONCLUSION: This study identified a number of potential reasons behind why families may decline to engage with a childhood obesity programme in a deprived area. Across all families, if the programme was perceived as not needed, they would disengage. For those who did not engage at all, the initial communication of the child's body mass index (BMI) is crucial. Recommendations include taking a more personal and tailored approach for the initial communication and shifting the focus of the programmes onto healthier lifestyles.

Routine pre- and post-neoadjuvant chemotherapy fitness testing is not indicated for oesophagogastric cancer surgery.

Introduction There is a known correlation between anaerobic threshold (AT) during cardiopulmonary exercise testing and development of cardiopulmonary complications in high-risk patients undergoing oesophagogastric cancer surgery. This study aimed to assess the value of routine retesting following neoadjuvant chemotherapy. Methods Patients undergoing neoadjuvant chemotherapy with subsequent oesophagogastric cancer surgery with pre- and post-neoadjuvant chemotherapy cardiopulmonary exercise data were identified from a prospectively maintained database. Measured cardiopulmonary exercise variables included AT and maximum oxygen uptake at peak exercise (VO2 peak). Anaerobic threshold values within 1 ml/kg/minute were considered static. Patients were grouped into AT ranges of less than 9 ml/kg/minute, 9-11 ml/kg/minute and greater than 11 ml/kg/minute. Outcome measures were unplanned intensive care stay, postoperative cardiovascular morbidity and mortality. Results Between May 2008 and August 2017, 42 patients from 675 total resections were identified, with a mean age of 65 years (range 49-84 years). Mean pre-neoadjuvant chemotherapy AT was 11.07 ml/kg/minute (standard deviation, SD, 3.24 ml/kg/minute, range 4.6-19.3 ml/kg/minute) while post-neoadjuvant chemotherapy AT was 11.19 ml/kg/minute (SD 3.05 ml/kg/minute, range 5.2-18.1 ml/kg/minute). Mean pre-neoadjuvant chemotherapy VO2 peak was 17.13 ml/kg/minute, while post-chemotherapy this mean fell to 16.59 ml/kg/minute. Some 44.4% of patients with a pre-chemotherapy AT less than 9 ml/kg/minute developed cardiorespiratory complications compared with 42.2% of those whose AT was greater than 9 ml/kg/minute (P = 0.914); 63.6% of patients in the post-neoadjuvant chemotherapy group with an AT less than 9 ml/kg/minute developed cardiorespiratory complications. There was no correlation between direction of change in AT and outcome. Conclusion In our patient population, neoadjuvant chemotherapy does not appear to result in a significant mean reduction in cardiorespiratory fitness. Routine pre- and post-neoadjuvant chemotherapy cardiopulmonary exercise testing is currently not indicated; however, larger studies are required to demonstrate this conclusively.

A comparison of the left thoracoabdominal and Ivor-Lewis esophagectomy.

The purpose of this study was to assess the oncological outcomes of a large multicenter series of left thoracoabdominal esophagectomies, and compare these to the more widely utilized Ivor-Lewis esophagectomy. With ethics approval and an established study protocol, anonymized data from five centers were merged into a structured database. The study exposure was operative approach (ILE or LTE). The primary outcome measure was time to death. Secondary outcome measures included time to tumor recurrence, positive surgical resection margins, lymph node yield, postoperative death, and hospital length of stay. Cox proportional hazards models provided hazard ratios (HR) with 95% confidence intervals (CI) adjusting for age, pathological tumor stage, tumor grade, lymphovascular invasion, and neoadjuvant treatment. Among 1228 patients (598 ILE; 630 LTE), most (86%) had adenocarcinoma (AC) and were male (81%). Comparing ILE and LTE for AC patients, no difference was seen in terms of time to death (HR 0.904 95%CI 0.749-1.1090) or time to recurrence (HR 0.973 95%CI 0.768-1.232). The risk of a positive resection margin was also similar (OR 1.022 95%CI 0.731-1.429). Median lymph node yield did not differ between approaches (LTE 21; ILE 21; P = 0.426). In-hospital mortality was 2.4%, significantly lower in the LTE group (LTE 1.3%; ILE 3.6%; P = 0.004). Median hospital stay was 11 days in the LTE group and 14 days in the ILE group (P < 0.0001). In conclusion, this is the largest series of left thoracoabdominal esophagectomies to be submitted for publication and the only one to compare two different transthoracic esophagectomy strategies. It demonstrates oncological equivalence between operative approaches but possible short- term advantages to the left thoracoabdominal esophagectomy.

Changing behaviours: interventions that count.

Many individuals affected by tension-type headache (TTH) choose the self-care route without seeking medical advice from their primary care doctor. As a result, community pharmacies play an important role in identifying patients with TTH, providing education and counselling on potential lifestyle trigger factors and recommending appropriate analgesics.

Surgical resection strategy and the influence of radicality on outcomes in oesophageal cancer.

BACKGROUND: The optimal surgical approach to tumours of the oesophagus and oesophagogastric junction remains controversial. The principal randomized trial comparing transhiatal (THO) and transthoracic (TTO) oesophagectomy showed no survival difference, but suggested that some subgroups of patients may benefit from the more extended lymphadenectomy typically conducted with TTO. METHODS: This was a cohort study based on two prospectively created databases. Short- and long-term outcomes for patients undergoing THO and TTO were compared. The primary outcome measure was overall survival, with secondary outcomes including time to recurrence and patterns of disease relapse. A Cox proportional hazards model provided hazard ratios (HRs) and 95 per cent confidence intervals (c.i.), with adjustments for age, tumour stage, tumour grade, response to chemotherapy and lymphovascular invasion. RESULTS: Of 664 included patients (263 THO, 401 TTO), the distributions of age, sex and histological subtype were similar between the groups. In-hospital mortality (1·1 versus 3·2 per cent for THO and TTO respectively; P = 0·110) and in-hospital stay (14 versus 17 days respectively; P < 0·001) favoured THO. In the adjusted model, there was no difference in overall survival (HR 1·07, 95 per cent c.i. 0·84 to 1·36) or time to tumour recurrence (HR 0·99, 0·76 to 1·29) between the two operations. Local tumour recurrence patterns were similar (22·8 versus 24·4 per cent for THO and TTO respectively). No subgroup could be identified of patients who had benefited from more radical surgery on the basis of tumour location or stage. CONCLUSION: There was no difference in survival or tumour recurrence for TTO and THO.

Gastric tube necrosis following minimally invasive oesophagectomy is a learning curve issue.

INTRODUCTION: Gastric tube necrosis following oesophagectomy is thought to have an increased association with a minimally invasive technique. Some suggest gastric ischaemic preconditioning may reduce ischaemic complications. We discuss our series of 155 consecutive minimally invasive oesophagectomies (MIOs), including a number of cases of gastric tube ischaemia, of which 4 (2.6%) developed conduit necrosis. METHODS: Data were collected prospectively of MIOs carried out by a single surgeon between 2005 and 2011. Cases of gastric tube necrosis were identified. RESULTS: Overall, 155 patients were identified. The inpatient mortality rate was 2.6%. Gastric tube necrosis occurred in four patients (2.6%). An ultrasonic dissector injury to the gastroepiploic arcade had occurred in two cases. In another case, the gastric tube was strangulated in the hiatus. In the remaining case, no clear mechanical cause was identified. All 4 cases occurred within the first 73 cases. The gastric tube necrosis rate of the first 50 cases versus cases 51-155 was 4% and 2% respectively (p=0.5948). The anastomotic leak rate in these two cohorts was 18% and 7% respectively (p=0.0457). There was a significant reduction in overall gastric tube complications from 22% to 10% following the learning curve of the initial 50 cases (p=0.0447). CONCLUSIONS: In our series, gastric tube necrosis appears to be a learning curve issue. Prophylactic measures such as ischaemic preconditioning become less relevant as the operating surgeon's experience increases. Instead, meticulous attention to preserving the gastroepiploic arcade, avoidance of tension in the tube and careful positioning of the gastric conduit through an adequately sized hiatus are key factors.

Cardiopulmonary exercise testing as a predictor of complications in oesophagogastric cancer surgery.

INTRODUCTION: An anaerobic threshold (AT) of <11 ml/min/kg can identify patients at high risk of cardiopulmonary complications after major surgery. The aim of this study was to assess the value of cardiopulmonary exercise testing (CPET) in predicting cardiopulmonary complications in high risk patients undergoing oesophagogastric cancer resection. METHODS: Between March 2008 and October 2010, 108 patients (83 men, 25 women) with a median age of 66 years (range: 38-84 years) underwent CPET before potentially curative resections for oesophagogastric cancers. Measured CPET variables included AT and maximum oxygen uptake at peak exercise (VO2 peak). Outcome measures were length of high dependency unit stay, length of hospital stay, unplanned intensive care unit (ICU) admission, and postoperative morbidity and mortality. RESULTS: The mean AT and VO2 peak were 10.8 ml/min/kg (standard deviation [SD]: 2.8 ml/min/kg, range: 4.6-19.3 ml/min/kg) and 15.2 ml/min/kg (SD: 5.3 ml/min/kg, range: 5.4-33.3 ml/min/kg) respectively; 57 patients (55%) had an AT of <11 ml/min/kg and 26 (12%) had an AT of <9 ml/min/kg. Postoperative complications occurred in 57 patients (29 cardiopulmonary [28%] and 28 non-cardiopulmonary [27%]). Four patients (4%) died in hospital and 21 (20%) required an unplanned ICU admission. Cardiopulmonary complications occurred in 42% of patients with an AT of <9 ml/min/kg compared with 29% of patients with an AT of ≥9 ml/min/kg but <11 ml/min/kg and 20% of patients with an AT of ≥11 ml/min/kg (p = 0.04). There was a trend that those with an AT of <11 ml/min/kg and a low VO2 peak had a higher rate of unplanned ICU admission. CONCLUSIONS: This study has shown a correlation between AT and the development of cardiopulmonary complications although the discriminatory ability was low.

The use of self-expanding plastic stents in the management of oesophageal leaks and spontaneous oesophageal perforations.

Leakage after oesophageal anastomosis or perforation remains a challenge for the surgeon. Traditional management has been operative repair or intensive conservative management. Both treatments are associated with prolonged hospitalisation and high morbidity and mortality rates. Self-expanding metallic stents have played an important role in the palliation of malignant oesophageal strictures and the treatment of tracheoesophageal fistulae. However, self-expanding metal stents in benign oesophageal disease are associated with complications such as bleeding, food bolus impaction, stent migration, and difficulty in retrieval. The Polyflex stent is the only commercially available self-expanding plastic stent which has been used in the management of malignant oesophageal strictures with good results. This review will consider the literature concerning the use of self-expanding plastic stents in the treatment of oesophageal anastomotic leakage and spontaneous perforations of the oesophagus.

Prevalence and outcome of litigation claims in England after laparoscopic cholecystectomy.

BACKGROUND: Approximately, 50,000 cholecystectomies are performed annually in the United Kingdom resulting in a number of negligence claims referred to the NHS Litigation Authority (NHSLA). The aim of this study was to assess the prevalence and outcomes of claims reported to the NHSLA after laparoscopic cholecystectomy performed in England between 1995 and 2008. METHODS: Data were requested from the NHSLA on all claims related to laparoscopic cholecystectomy which occurred in England between 1995 and 2008. RESULTS: A review of the data provided by the NHSLA data identified over 300 claims in this time period. Of the claims identified, 244 have been completed. Common bile duct injury (41%), bile leak (12%), bowel injury (9%), haemorrhage (9%) and fatality (9%) were the most frequent types of claim. Common bile duct injury resulted in the highest proportion of successful claims (86%) and the largest sums paid to the claimant (average £65,000). DISCUSSION: Common bile duct injury is the most common claim to the NHSLA after laparoscopic cholecystectomy and results in the highest proportion of successful claims and the largest sums paid to the claimant.

Proposed follow up programme after curative resection for lower third oesophageal cancer.

The incidence of oesophageal adenocarcinoma has risen throughout the Western world over the last three decades. The prognosis remains poor as many patients are elderly and present with advanced disease. Those patients who are suitable for resection remain at high risk of disease recurrence. It is important that cancer patients take part in a follow up protocol to detect disease recurrence, offer psychological support, manage nutritional disorders and facilitate audit of surgical outcomes. Despite the recognition that regular postoperative follow up plays a key role in ongoing care of cancer patients, there is little consensus on the nature of the process. This paper reviews the published literature to determine the optimal timing and type of patient follow up for those after curative oesophageal resection.

Presentation and survival of operable esophageal cancer in patients 55 years of age and below.

BACKGROUND: The increased incidence of esophageal cancer, especially in the younger age group, should encourage early diagnosis. The perceived rarity and poor prognostic outcome of esophageal cancer in this group is based on retrospective studies. The goal of this study was to review the presentation and survival of young patients with esophageal cancer. METHODS: This study was conducted from 2000 to 2007 in a specialized esophagogastric center. All patients who had esophageal cancer operations were included. Variables collected included ages, duration of symptoms, presenting symptoms, tumor characteristics, and follow-up data. RESULTS: In total, 365 esophagectomies were performed for cancer, of which 76 patients were younger than aged 55 years (20.8%) and 289 were older than aged 55 years. In patients younger than aged 55 years, 15 patients had symptoms for 6 months or more, 54 had dysphagia, 35 had weight loss compared with 220 and 175 respectively of patients older than aged 55 years. On histopathology, 48 had T3 tumors (63.2%), 17 had T2 (22.4%), and 10 had T1 (13.2%) for patients younger than aged 55 years compared with 141 had T3 (48.7%), 85 had T2 (29.4%), and 55 had T1 (19%) for patients older than aged 55 years. These differences in tumor stage at presentation between groups were significant (p < 0.05 with 3DF). In-hospital mortality was 0 for the group younger than aged 55 years and 5 for those older than aged 55 years. Average follow-up was 35 (minimum, 15) months. Thirty patients had locoregional recurrence in the first group and 110 in the latter group. Survival at 1 year after surgery was 79.6%, at 2 years 65.1%, and at 5 years 42.3% compared with 78.4, 60.6, and 45.9%, respectively, for the group older than aged 55 years, but this was not significant using log-rank (p = 0.99). CONCLUSIONS: A significant proportion (20.8%) of patients presenting with operable esophageal cancer was younger than aged 55 years. Almost two-thirds of those presenting younger than aged 55 years had T3 stage tumors, which was significantly different than those older than aged 55 years. Despite more advanced tumor stage at presentation, the prognosis of esophageal cancer for patients younger than aged 55 years is similar to those older than aged 55 years (log-rank = 0.99).

The effect of economic deprivation on oesophageal and gastric cancer in a UK cancer network.

AIMS: The National Health Service (NHS) Cancer Plan aims to eliminate economic inequalities in healthcare provision and cancer outcomes. This study examined the influence of economic status upon the incidence, access to treatment and survival from oesophageal and gastric cancer in a single UK cancer network. METHODOLOGY: A total of 3619 patients diagnosed with either oesophageal or gastric cancer in a London Cancer Network (population = 1.48 million) were identified from the Thames Cancer Registry (1993-2002). Patients were ranked into economic quintiles using the income domain of the Multiple Index of Deprivation. Statistical analysis was performed using a chi(2) test. Survival analysis was performed using a Cox's proportional hazards model. RESULTS: Between 1993-1995 and 2000-2002, the incidence of oesophageal cancer in the most affluent males rose by 51% compared with a 2% rise in the least affluent males. The incidence of gastric cancer in most affluent males between 1993-1995 and 2000-2002 fell by 32% compared with a 7% fall in the least affluent males. These changes were less marked in females. Economic deprivation had no effect on the proportion of patients undergoing either resectional surgery or chemotherapy; the least affluent oesophageal cancer patients with a higher incidence of squamous cell carcinoma received significantly more radiotherapy. Economic deprivation had no effect upon survival for either oesophageal or gastric cancer. CONCLUSIONS: There has been an increase in oesophageal cancer and a decrease in gastric cancer incidence among more affluent males in the last 10 years. Economic status did not appear to influence access to treatment or survival.

Endoscopic transanal resection of rectal adenomas using the urological resectoscope.

OBJECTIVE: Large sessile rectal adenomas are often difficult to excise and several different techniques have been described. This study evaluates the results of adenoma excision by endoscopic transanal resection using the urological resectoscope by a single surgeon in a UK district general hospital. METHOD: Between January 1989 and November 2004, data on all patients treated by endoscopic transanal resection of benign rectal tumours using a urological resectoscope (ETAR) were prospectively collected and analysed. RESULTS: Forty patients (50% male, median age 72 years) underwent a total of 81 endoscopic transanal resections. The tumour characteristics were: size > 2 cm (83%), location in lower 2/3 of rectum (83%) and extensive circumferential carpet-like appearances (13%). Fifty percent of the patients required only one procedure to achieve clearance. Mean operative time was 26 min (range 10-65 min). Seventy-eight percent of the patients were discharged home within 24 h. Postoperative morbidity was 8% and in-hospital mortality was zero. Histology revealed severe dysplasia in 48% of the tumours and five patients were incidentally found to have foci of rectal adenocarcinoma. With a median follow-up of 47 months (range 2-162 months), local recurrences occurred in 13% (n = 5) of patients. All, except one, were treated successfully with further endoscopic transanal resections. CONCLUSION: ETAR is simple and safe for managing rectal adenomas.

Transhiatal oesophagectomy: techniques, tips and outcomes.

AIM: To demonstrate our technique and valuable tips for transhiatal oesophagectomies. METHOD: 215 patients underwent transhiatal oesophagectomies in our unit between 2000 and 2006. RESULTS: In-hospital mortality was 0.9%. Anastomotic leak in 12 patients (5.6%). Chyle leak was seen in five patients and recurrent nerve neuropraxia in six patients. Iatrogenic splenectomy rate was 6%. The median operative time was 151 minutes (range 93-276 minutes). Overall median length of hospital stay was 15 days (range 8-95 days). The median survival for all patients undergoing transhiatal oesophagectomy for invasive malignancy was 42.9 months and the one-year and five-year survival were 81% and 48% respectively. CONCLUSION: This is a safe and oncologically sound procedure. We feel that the tips can be helpful for anyone performing this procedure.

Anastomotic strictures and delayed gastric emptying after esophagectomy: incidence, risk factors and management.

The aim of this study was to report the incidence, risk factors, and management of gastric conduit dysfunction after esophagectomy in 177 patients over a 3-year period in a single center. Patients with anastomotic strictures or delayed gastric emptying (DGE) were identified from a prospective database. Anastomotic strictures occurred in 48 patients (27%). Eighty-three percent of early anastomotic strictures (<1 year) were benign, and all late strictures (>1 year) were malignant. Dilatation was effective in 98% of benign and 64% of malignant strictures. DGE occurred in 21 patients (12%), and was associated with both anastomotic leak (P = 0.001) and anastomotic stricture (P = 0.001). 4/8 patients with late DGE (>3 months postesophagectomy) were tumor-related. Pyloric dilatation was effective in 92% of early and 63% of late DGE. Pyloric stents were inserted in 3 patients with tumor-related DGE. After esophagectomy, early anastomotic strictures (within 1 year) and early delayed gastric emptying (within 3 months) are usually benign and respond to dilatation. However, patients presenting later with tumor-related obstruction are unlikely to respond to anastomotic or pyloric dilatation and should be stented.

Self-expanding metallic stents in the treatment of benign colorectal anastomotic strictures: a word of caution.

A 66-year-old man underwent an anterior resection for carcinoma at the rectosigmoid junction. Three months later, a tight stricture developed proximal to the anastomosis. This was treated with a self-expanding metallic stent. Over the next few months, the stent fractured and a fistula developed between the site of anastomic stricture and the distal ileum; the stent had to be removed. This, to our knowledge, is the first report of a coloenteric fistula developing after insertion of a metallic stent to treat a benign postoperative anastomotic stricture.

Comparison of short-and long-term outcomes following either insertion of self-expanding metallic stents or emergency surgery in malignant large bowel obstruction.

BACKGROUND: Self-expanding metallic stents (SEMS) are now regarded as a safe and effective treatment for an acute obstructing colorectal cancer. SEMS insertion is an invasive procedure that could potentially worsen prognosis. This study assessed the short-and long-term outcomes in patients stented for acute large bowel obstruction and in patients who underwent primary emergency surgery. METHODS: We retrospectively identified 19 patients who underwent SEMS insertion and 23 patients who had primary emergency surgery for left-sided large bowel obstruction as the first presentation of colorectal cancer. RESULTS: There were no significant differences between the 19 patients in the SEMS group and the 23 patients in the primary emergency surgery group in terms of demographics and tumour location and stage. Stent insertion was successful in 16 patients (84%). One patient died from a stent-related perforation and another had a stoma fashioned for stent migration. Stents were a definitive procedure in 2 patients with advanced disease and acted as a "bridge to surgery" in the remaining 12 patients. Compared to the primary surgery group, there was a trend towards a higher primary anastomosis rate in the SEMS group (p=0.08); there were no significant differences in length of hospital stay, 30-day mortality or complication rates between the groups. Long-term prognosis (estimated 3-year survival) did not differ significantly between the groups (p=0.54); this persisted when only curative resections were considered (p=0.80). CONCLUSIONS: Preoperative stent insertion is a safe and effective treatment for large bowel obstruction, and may result in a higher primary anastomosis rate. Stent insertion does not seem to have a deleterious effect on prognosis.

Training in oesophageal surgery--the gold standard: a prospective study.

INTRODUCTION: Competency in complex oesophagogastric surgery, within the current climate of changes to medical training and reduced hours, requires repeated, focused, hands-on training. We describe the training methods for oesophagectomy in our institution. METHODS: All oesophageal resections under the care of one consultant surgeon are regarded as training cases. When trainees start they are shown the first resection; subsequently, the trainees then perform every case with the consultant scrubbed. Consultant input consists of retraction and tips in difficult situations. All data were collected on a prospective database. RESULTS: Two hundred and seventy patients (215 males, median age=64 years) underwent primary oesophagectomy under the consultant, between January 2000 and May 2007. Fifteen resections (6%) were performed solely by the consultant. ASA grading was: I=15, II=154, III=95, IV=5, and unrecorded=1. In-hospital mortality and clinically apparent leak rate was 1.9% (5 deaths) and 6.2% (n=17), respectively. Reoperation was required in 15 patients (5.5%). The median length of hospital stay was 14 days (range=8-95 days). Median lymph node yield was 13 (range=0-64). CONCLUSIONS: Trainees under supervision can competently perform an oesophagectomy without compromising patient care. An early hands-on approach leads to a rapid ascent of the learning curve and is essential in today's climate of limited training opportunity.