Management of oesophageal cancer

EDITOR, - With regard to future approaches to the management of oesophageal cancer,1 we suggest an initiative that could be immediately implemented and would improve survival - namely, consideration of the operator's experience.2 We have analysed data on admissions to hospital for oesophageal resection for carcinoma of the oesophagus or cardia in the West Midlands region in the three years April 1990 to April 1993 (table). As in Matthews et al's study,2 “frequent” operators were defined as those who performed six or more resections a year. Operative mortality was 8.9% for frequent operators and 16.9% for all other operators. There was no difference in the mean age of the patients between these two groups. In Matthews et al's original series prognostic factors were similar in each group and lower operative mortality accounted for the improved five year survival of patients operated on by frequent operators.2

The difference is due to the operators' experience rather than the experience of the unit in which they work (anaesthetic management, postoperative intensive care). When we restricted the analysis to hospitals with at least one frequent operator there was still a lower operative mortality among patients operated on by frequent operators (23/257, 8.9%) than among those operated on by all other operators (10/57, 17.5%).

Operative skill presents a challenge both to purchasers of health care, who could move contracts to units with frequent operators, and to the professional audit process in these units. Both purchasing and audit have been introduced since Matthews et al's paper was published: can they effect a change that previous systems did not deliver?