Background: Minimally invasive oesophagectomy (MIO; thoracoscopy, laparoscopy, cervical anastomosis) is a complex procedure and few substantial series have been published. This study documented the morbidity, mortality and challenges of adopting MIO in a specialist unit in the UK. Conclusion: MIO can be performed with acceptable mortality and morbidity rates in an unselected series of patients. There was more morbidity related to gastric tube ischaemia than was expected.

MIO leads to a rapid restoration of HRQL.

This exploratory prospective nonrandomized study of recovery after different types of surgery for esophageal cancer showed possible small benefits to MIE. A much larger study is needed to confirm these findings.

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A 36-year-old woman developed severe group A Streptococcal pneumonia, complicated by a bronchopleural fistula, ARDS and multi-organ failure. We describe the use of selective middle lobe bronchus blockade, with a Fogarty embolectomy catheter, to localise and control the air leak. This allowed effective mechanical ventilation and oxygenation on intensive care and during right middle lobectomy. The patient made a prolonged, but full recovery.

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The point of our paper was not to focus on peri-operative mortality but more on the actual benefit one might expect from postoperative ventilation. As mentioned in the paper, there are other studies that have questioned the need for postoperative ventilation and, providing patients are, kept in a high dependency unit with full monitoring and critical care support, we do not feel that prolonged postoperative ventilation for 18 h, as suggested by Forshaw and colleagues, provides any advantage to the patient. Forshaw and colleagues suggest that these patients are kept in the recovery area until the following morning, although in many hospitals postoperative ventilation would necessitate the patient being admitted to the intensive care unit. We identify in our paper that this might well result in a significant number of patients having their oesophagectomy cancelled for lack of an intensive care bed when this was not necessary. The results from our initial study, and these have been supported by our more recent data (as shown above), demonstrate that there appears to be no benefit from prolonged ventilation providing all physiological parameters are closely monitored in a critical care environment. Although the mortality in the early part of our own series was higher than later years, we did not identify any problems that were directly related to early postoperative extubation. We wish to commend the authors for high-lighting an extremely important aspect in managing patients after oesophagectomy. However, no indication was given regarding the type of resection performed in the centres surveyed. In Exeter, we currently offer minimally invasive oesophagectomy (MIO) to all patients suitable for resection and, this procedure has specific diet-related issues which are important to high-light: COMMENT ON1. In the absence of significant postoperative discomfort and morbidity following MIO, patients were inadvertently taking large portions of hospital food when commenced on oral intake after the fifth postoperative day. This resulted in excessive gastric distension, and subsequent anastomotic leak in two patients. As a consequence, we have now introduced an enforced, structured postoperative diet with no further problems.2. The authors do not mention the route of postoperative jejunal feeding used. We use fine bore nasojejunal feeding tubes placed endoscopically during surgery. These are well tolerated, and rapidly weaned after the commencement of oral intake on postoperative day 5/6 by virtue of the rapid restoration of gastrointestinal function after MIO. This avoids the inherent morbidity associated with percutaneous jejunostomy tubes.1 Reference 1. Pearce CB, Duncan HD. Enteral feeding. Nasogastric, nasojejunal, percutaneous endoscopic gastrostomy, or jejunostomy: its indications and limitations.

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