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Tempora mutanter, et nos mutamer in illis.—Harrison, 1577
The prognosis for patients with carcinoma of the oesophagus is funereal. 5855 people died from the condition in England in 1997, the one-year survival rate for all cases being 27% and the five-year survival only 9%1,2. These poor results are in large part due to late presentation of the disease, but perioperative mortality and long-term survival rates after oesophagectomy are evidently worse in Britain than in other developed countries3,4.
Just one-third of patients with oesophageal cancer are candidates for resection; in the remainder, only symptomatic relief can be offered, perhaps by intubation or palliative radiotherapy5. Despite the small numbers requiring surgery, published results3,4 suggest that some oesophageal resections are being undertaken by the ‘occasional oesophagectomist’. In-hospital mortality, due to inappropriate patient selection or technically inadequate surgery, is then generally higher than that recorded in specialist centres6. The existing strategy in National Health Service hospitals to treat the patient as close to home as possible may therefore be inapposite. Surgical outcomes are now an issue in the UK7. High-profile cases before the General Medical Council, and the Bristol Enquiry, have alerted the press and the public to the fact that results of surgery can be unsatisfactory, partly because of the shortcomings of individual surgeons and partly because of the inability of their employers to monitor results. Questions about the current organization of oesophageal cancer surgery in the UK are therefore timely.
McKeown of Darlington set the standard in the closing decades of the last century. His results in a district general hospital encouraged single-handed oesophageal surgeons to match his success rate by careful case selection and scrupulous operative technique8. This approach has been attractive both to patients, who have not had to travel to undergo oesophageal resection, and to surgeons, who have welcomed the surgical challenge, perhaps in an otherwise anodyne professional life9. In practised hands, the process has been successful. Single-handed oesophageal surgeons can achieve satisfactory surgical outcomes with careful patient selection and the help of an enthusiastic intensive-care team10.
Drawbacks to McKeown's model have taken time to surface. National datasets have never existed, and data collected locally (if collected at all) are not easily compared. The absence of a reliable national audit, open to inspection, currently allows the maladroit oesophagectomist to continue undetected. Centralization of the surgical treatment of oesophageal cancer may thus be necessary to ensure that treatment in the UK is comparable with best practice worldwide. Palliative treatment might be organized locally, perhaps by gastroenterologists and oncologists without surgical input.
Single-handed upper gastrointestinal surgeons must, in the best interests of their patients and themselves, become part of a regional team—possibly with sessions in a specialist centre. If sessions in a central unit are unavailable, a ‘virtual’ oesophageal cancer resection centre, with electronic linkage, should be considered. Electronic linkage of a weekly multidisciplinary meeting, with regular interchange of histology and radiology reporting, would not be difficult to organize. It is a sad reflection on the NHS, fifty-four years after its establishment, that such systems do not yet exist. Audit of outcomes in all general hospitals by the local hospital clinical governance committee, and by the National Cancer Guidance Organization, could result in closure of any unit with an in-hospital mortality of over 10%.
This conclusion is bruising to the sensibilities of the single-handed specialist surgeon, but oesophageal cancer has an incidence in England and Wales of only 23.2 per 100 000 per annum. Most patients will not be suitable for surgery, so for long periods none of those presenting to a general hospital will require resection, and the single-handed specialist oesophageal surgeon will be working in other spheres of surgery. The accreditation of such a surgeon might, in the future, be challenged either by professional contemporaries or by the courts.
An interim strategy of specialization and an eventual strategy of centralization could destabilize the chosen oesophageal resection centres as well as the units from which oesophageal surgery had been withdrawn. Surgical capacity in any chosen centre will require expansion, to prevent a rise in waiting time for resection. Replacement of one specialty by another might be appropriate in those units where oesophageal surgery is discontinued. Finance could be a difficult issue, if funds must be transferred from one institution to another. Management of this change in the function of many district general hospitals would require tact and discretion, but the upheaval would be a small price to pay for an end to the existing situation whereby even neighbouring hospitals are unable to compare results effectively. Anarchy would be replaced by national cohesion. In time, regional oesophageal cancer resection centres may emerge, with satellite units at some distance from them. The best of McKeown could be preserved, provided that individual units and surgeons met national criteria. Clinical governance must ensure closure of underperforming units before public disrepute does so.
Cancer outcomes in the UK can be improved by reorganization of existing resources. Surgeons are now conscious that patients will not accept second best. An inevitable corollary is that travel may be necessary for optimal treatment. The tentative solution proposed here, to the issues surrounding the provision of a reliable oesophageal cancer resection service, does not represent a threat to any specialist in the field provided his or her results withstand local and national review.