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A survey of 108 patients with achalasia treated by cardiomyotomy is reported. All the operations were done by the abdominal approach and all the patients were followed up for a minimum of 4 years. Fifty-five patients had some form of hiatal reconstruction, 11 of these having a formal plastic repair as practised for oesophageal reflux problems. At 4 years after operation 71 patients (65-5 per cent) had entirely satisfactory results. Twenty-seven patients had recurrent dysphagia and 20 patients had symptoms of reflux oesophagitis. The group who had had a formal repair of the hiatus had no reflux symptoms after operation and also had better swallowing than the other groups. These results suggest that much of the dysphagia following Heller's operation is due to occult gastro-oesophageal reflux and can be avoided by a reflux-preventing procedure. Adequate hiatal repair after myotomy is strongly recommended.

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SUMMARYExperience in the management of a personal series of 837 cases of carcinoma of the oesophagus and cardia is described. It is evident from this that the subject is not a static one. Improvement is occurring and there are good reasons to expect this to continue. The aspects affected by this improvement include morbidity, mortality, the well-being of patients, and the long-term survival. Unfortunately, in the majority of cases, treatment is only palliative, but palliation is good and it relieves the patient of his main symptom-dysphagia.In view of the great benefits which good palliation provides, no treatment can be considered as satisfactory unless the relief of symptoms is of a high standard.It is maintained that too much emphasis has hitherto been placed on long-term survival, which is only possible in the minority of cases.Bearing all factors in mind a strong case can be made for the overall surgical plan in the management of growths affecting the middle and lower parts of the oesophagus. all demonstrate a similar theme. With determined effort and the experience which comes from handling these cases in large numbers, the growths can be removed with a low level of morbidity and a mortality which is not too oppressing. It is also clear that improvement is still continuing. Operative mortality varies from 5 to 30 per cent and late results range between 10 and 25 per cent of operative survivors still alive at 5 years after operation. It seems reasonable to conclude that unless the operative mortality can be brought down to approximately 10 per cent and unless morbidity is low there is a tendency for radiotherapy to be preferred to surgery.Several workers have attempted to improve longterm results by combining surgery with radiotherapy and reports of the outcome of such efforts have been appearing during the past 20 years (Cliffton and