We aim to compare the outcomes of patients undergoing R0 esophagectomy by a multidisciplinary team (MDT) with outcomes after surgery alone performed by surgeons working independently in a UK cancer unit. An historical control group of 77 consecutive patients diagnosed with esophageal cancer and undergoing surgery with curative intent by six general surgeons between 1991 and 1997 (54 R0 esophagectomies) were compared with a group of 67 consecutive patients managed by the MDT between 1998 and 2003 (53 R0 esophagectomies, 26 patients received multimodal therapy). The proportion of patients undergoing open and closed laparotomy and thoracotomy decreased from 21% and 5%, respectively, in control patients, to 13% and 0% in MDT patients (chi2 = 11.90, DF = 1, P = 0.001; chi2 = 5.45, DF = 1, P = 0.02 respectively). MDT patients had lower operative mortality (5.7%vs. 26%; chi2 = 8.22, DF = 1, P = 0.004) than control patients, and were more likely to survive 5 years (52%vs. 10%, chi2 = 15.05, P = 0.0001). In a multivariate analysis, MDT management (HR = 0.337, 95% CI = 0.201-0.564, P < 0.001), lymph node metastases (HR = 1.728, 95% CI = 1.070-2.792, P = 0.025), and American Society of Anesthesiologists grade (HR = 2.207, 95% CI = 1.412-3.450, P = 0.001) were independently associated with duration of survival. Multidisciplinary team management and surgical subspecialization improved outcomes after surgery significantly for patients diagnosed with esophageal cancer.

Modified D2 gastrectomy without pancreatico-splenectomy, performed by specialist surgeons, can improve survival after R0 resections without increasing operative morbidity and mortality, when compared with D1 gastrectomy performed by general surgeons.

The impressive outcomes following radical D2 gastrectomy for gastric cancer in large retrospective series from Japan [1-4] have not been reproduced in randomized comparative studies from Europe [5-8]. It is assumed widely and asserted confidently at scientific meetings that this discrepancy in outcomes after D2 gastrectomy for gastric cancer is due to the greater age, comorbidity, advanced stages of disease, and greater body mass indices (overweight with deep abdominal cavities) of Western patients when compared with patients in Japan [9,10]. Furthermore, a recent report from Japan concluded that a higher body mass index (BMI) hampered lymphadenectomy in gastric cancer patients, and was an independent predictor of cancer recurrences [11]. Obesity is becoming more prevalent, with 15% to 20% of individuals in Europe fulfilling the criteria of a BMI of greater than 30kgm Ϫ2 , and the situation is far worse in the United States of America [12-14]. Surgery and anesthesia are more hazardous in patients who are overweight, not least because of the increased incidence of cardiorespiratory comorbidity [15]. Moreover, lymphadenectomy remains a painstaking procedure when extended beyond the D1 level and is not without risk in its own right [5,6]. The aim of this study, therefore, was to examine the relationship between BMIs American Society of Anesthesiology (ASA) grades, operative times, and outcomes after modified D2 gastrectomy (preserving pancreas and spleen where possible) for gastric cancer. The setting was a large acute district general hospital in South Wales serving a population of 480000.

S urgeons' operative work-load has by tradition been assessed by weighting individual operations for complexity on the basis of the BUPA schedule of procedures.1 Each operation can be given an intermediate equivalent value (IEV), or hernia equivalent, in order to convert the case-load to a work-load.It has been suggested that a consultant surgeon in a district general hospital might perform 3-4 intermediate equivalents per operating list, which would amount to a total operative work-load of 900 intermediate equivalents per year.2 However, our own prospective audit over a period of 3 years has raised questions regarding the accuracy and correlation between the weighting given and certain common complex major operations by the BUPA schedule, 3 and the actual time taken to perform the surgery. The aim of this study, therefore, was to determine whether a relationship exists between the intermediate equivalent weighting of a surgical operation, anaesthetic preparation time, operative time, and the complexity of commonly performed general surgical operations. A clear and consistent relationship between the intermediate equivalent rating of an operation, and the actual theatre time required to complete the procedure, would allow transparent planning of operating lists with regard to available operating theatre time, and facilitate accurate audits of a work-load. MethodsThe operative work-load of 9 consultant surgeons working in a district general hospital serving a population of 480,000 was studied retrospectively. General surgical services are provided by 8 general surgeons, two vascular,

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