Peter J. Lamb

The role of lymphadenectomy in esophageal cancer.

Objective:To address the role of lymphadenectomy in the treatment of esophageal cancer. Background:The role of lymphadenectomy in esophageal cancer surgery is controversial, and there is a lack of uniformity as to what the term means. Methods:The published data was reviewed to evaluate the evidence base for, and the terminology associated with, lymphadenectomy for esophageal cancer. Results:Recommendations are given for a standardization of terminology for radical and nonradical lymphadenectomy procedures. Although there is no doubt that the presence of lymph node metastases worsens prognosis for a patient, there is a lack of high-level evidence to support lymphadenectomy. Logically, the best procedure, from a staging and perhaps theoretical oncologic point of view, is a 3-field lymphadenectomy but it is not clear which patients, if any, are most likely to benefit. Conclusions:Well-designed randomized controlled trials are required to test, in a scientific manner, which of these procedures we should be offering our patients.

Long‐term outcomes of revisional surgery following laparoscopic fundoplication

A small proportion of patients who have laparoscopic antireflux procedures require revisional surgery. This study investigated long‐term clinical outcomes.

The Anatomy and Physiology of the Oesophagus

The oesophagus is a muscular tube connecting the pharynx to the stomach and measuring 25–30 cm in the adult. Its primary function is as a conduit for the passage of swallowed food and fluid, which it propels by antegrade peristaltic contraction. It also serves to prevent the reflux of gastric contents whilst allowing regurgitation, vomiting and belching to take place. It is aided in these functions by the upper and lower oesophageal sphincters sited at its proximal and distal ends. Any impairment of oesophageal function can lead to the debilitating symptoms of dysphagia, gastro-oesophageal reflux or oesophageal pain. The apparently simple basic structure of the oesophagus belies both its physiological importance and the dangers associated with surgical intervention. As a consequence of its location deep within the thorax and abdomen, a close anatomical relationship to major structures throughout its course and a marginal blood supply, the surgical exposure, resection and reconstruction of the oesophagus are complex. Despite advances in perioperative care, oesophagectomy is still associated with the highest mortality of any routinely performed elective surgical procedure [1]. In order to understand the pathophysiology of oesophageal disease and the rationale for its medical and surgical management a basic knowledge of oesophageal anatomy and physiology is essential. The embryological development of the oesophagus, its anatomical structure and relationships, the physiology of its major functions and the effect that surgery has on them will all be considered in this chapter.

Long‐term outcomes following laparoscopic anterior and Nissen fundoplication

Limited evidence exists to which operation gives best long‐term outcomes for gastro‐oesophageal reflux disease. This study aimed to assess long‐term symptomatic outcome and satisfaction following laparoscopic anterior (LA) or Nissen fundoplication in a specialist upper gastrointestinal unit.

Authors' reply: Long-term outcomes of revisional surgery following laparoscopic fundoplication (Br J Surg 2009; 96: 391–397)

failure of the repairs and the reverse is true2. We agree with authors that subjective assessment is important and the response to surgery therefore highlighted. Nevertheless, objective tests will provide complete assessment of the proposed technique. The authors noted that the pattern of failure appeared to be related to the type of original fundoplication. Stewart et al. has pointed out that the level of experience of the surgeon in a particular operation was more important than the procedure performed3. A. Hussain, T. Singhal, T. Ansari, B. Aravind and S. El-Hasani Minimal Access Unit, General Surgery Department, Princess Royal University Hospital, Farnborough Common, Orpington, Kent, BR6 8ND, UK DOI: 10.1002/bjs.6766