Alexander William Phillips

Background: Diversity, equity, and inclusion is vital for improving patient care, reducing health disparities, and driving innovation in surgery. Despite this, surgical doctors who are women or from minority groups remain under-represented in surgery. Barriers including limited exposure, entrenched stereotypes, systemic biases, and lack of diverse role models persist, whereas effective strategies remain underexplored. This review evaluates existing diversity, equity, and inclusion interventions that improve recruitment, retention, and promotion in surgery. Methods: Following PRISMA-ScR guidelines, PubMed, Embase, and the Cochrane Library were searched in November 2024 and updated in September 2025 to include all studies published up to that date. Eligible studies ranged from October 2010 to August 2025. Methodological quality was assessed using an adapted 2018 Critical Appraisal Skills Programme checklist. Data were synthesized thematically to identify recurring intervention patterns. Results: From 928 articles, 19 studies were included. Four overarching themes emerged: (1) pipeline programmes (workshops and scholarships) fostered early exposure, with some reporting > 70% participants from minority groups and doubled surgical entry of women; (2) holistic recruitment strategies overcoming rigid academic cut-offs increased interview offers to participants from minority groups (up to 8%) while maintaining academic standards, with some programmes reporting zero attrition; (3) mentorship from medical school to early career yielded 86% fellowship pursuit and > 50% faculty appointments among surgeons from minority groups; and (4) comprehensive institutional efforts, including diversity committees and faculty bias training, achieved up to 55% women and 33% people from minority groups among new hires. Mentorship, holistic reviews, career-stage scholarships, and institutional accountability emerged as impactful measures. Conclusion: This review underscores the importance of integrated diversity, equity, and inclusion strategies providing evidence-based pathways to address systemic inequities and build a more inclusive surgical workforce.

Barrett’s oesophagus is the only known precursor to oesophageal adenocarcinoma, a cancer with very poor prognosis. The main risk factors for Barrett’s oesophagus are a history of gastro-oesophageal acid reflux symptoms and obesity. Men, smokers and those with a family history are also at increased risk. Progression from Barrett’s oesophagus to cancer occurs via an intermediate stage, known as dysplasia. However, dysplasia and early cancer usually develop without any clinical signs, often in individuals whose symptoms are well controlled by acid suppressant medications; therefore, endoscopic surveillance is recommended to allow for early diagnosis and timely clinical intervention. Individuals with Barrett’s oesophagus need to be fully informed about the implications of this diagnosis and the benefits and risks of monitoring strategies. Pharmacological treatments are recommended for control of symptoms, but not for chemoprevention. Dysplasia and stage 1 oesophageal adenocarcinoma have excellent prognoses, since they can be cured with endoscopic or surgical therapies. Endoscopic resection is the most accurate staging technique for early Barrett’s-related oesophageal adenocarcinoma. Endoscopic ablation is effective and indicated to eradicate Barrett’s oesophagus in patients with dysplasia. Future research should focus on improved accuracy for dysplasia detection via new technologies and providing more robust evidence to support pathways for follow-up and treatment.

Introduction Curative treatment of gastro-oesophageal cancer encompasses surgery and peri-operative chemo(radio)therapy. Oesophagectomy carries significant morbidity and mortality with an adverse impact upon patients’ quality of life (QoL). Advancements in oncological treatment and surgical techniques have resulted in incremental prognostic gains with increasing focus on survivorship and optimising QoL. Despite enhanced recovery pathways, patients receive no assistance to improve physical functioning and QoL in the recovery period following hospital discharge. Post-operative rehabilitation has demonstrated improvement in physical fitness and psychosocial wellbeing among other cancer subtypes. There is a need to develop rehabilitative interventions that improve and restore patients’ QoL following an oesophagectomy. The aim of the FARO (Fitness AfteR Oesophagectomy) pilot trial is to determine if a pragmatic, patient-directed rehabilitation programme following oesophagectomy improves patients’ QoL. Methods The FARO study is a prospective, single-centre, parallel group, open-label, two-arm pragmatic randomised controlled external pilot trial that will run over 24 months. The trial aims to recruit 60 patients undergoing oesophageal cancer surgery. Patients will be randomized to receive standard clinical care or post-operative rehabilitation (alongside standard clinical care) in a 1:1 ratio. The rehabilitation intervention encompasses a 12-week home-based programme with weekly step-count targets, completion of resistance exercises and dietary monitoring. The primary outcome is patients’ health-related quality of life (assessed by the EORTC QLQ-C30 and OG-25 questionnaires). Secondary outcomes include cardiopulmonary fitness, functional impact of sarcopenia and biochemical nutritional markers. Outcomes are measured at baseline (at discharge from hospital post-oesophagectomy), 6 weeks, 3- and 6 months post-surgery. Discussion This external pilot trial aims to assess if a patient-directed rehabilitation programme following oesophagectomy restores and improves patients’ HR-QOL and recovery of physical functioning. Further, the trial aims to obtain adequate pilot data to plan a future definitive UK-wide trial of perioperative rehabilitation following oesophagectomy. Trial registration number: ISRCTN Registry ISCRTN73024784; Pre-results

Purpose Prognosis of oesophageal cancer is primarily based upon the TNM stage of the disease. However, even in those with similar TNM staging, survival can be varied. Additional histopathological factors including venous invasion (VI), lymphatic invasion (LI) and perineural invasion (PNI) have been identified as prognostic markers yet are not part of TNM classification. The aim of this study is to determine the prognostic importance of these factors and overall survival in patients with oesophageal or junctional cancer who underwent transthoracic oesophagectomy as the unimodality treatment. Methods Data from patients who underwent transthoracic oesophagectomy for adenocarcinoma without neoadjuvant treatment were reviewed. Patients were treated with radical resection, with a curative intent using a transthoracic Ivor Lewis or three staged McKeown approach. Results A total of 172 patients were included. Survival was poorer when VI, LI and PNI were present (ppp<0.001). Conclusion Histological factors of VI, LI and PNI are markers of aggressive disease and may have a role in prognostication and decision-making prior to treatment. The presence of LI as an independent marker of upstaging could be a potential indication for the use of neoadjuvant treatment in patients with early clinical disease.

There are few data evaluating the extent of downstaging in patients with oesophageal adenocarcinoma and oesophageal squamous cell carcinoma and the difference in outcomes for a similar pathological stage in neoadjuvant-naive patients. The aim of this study was to characterize the prognostic value of downstaging extent in patients receiving neoadjuvant therapy for oesophageal cancer. Oesophageal adenocarcinoma and oesophageal squamous cell carcinoma patients receiving either neoadjuvant chemotherapy or neoadjuvant chemoradiotherapy between 2004 and 2017 were identified from the National Cancer Database. The extent of downstaging was defined as the extent of migration between groups (for example stage IVa to IIIb = one stage). Cox multivariable regression was used to produce adjusted models for downstaging extent. Of 13 594 patients, 11 355 with oesophageal adenocarcinoma and 2239 with oesophageal squamous cell carcinoma were included. In oesophageal adenocarcinoma, patients with downstaged disease by three or more stages (hazards ratio (HR) 0.40, 95 per cent c.i. 0.36 to 0.44, P < 0.001), two stages (HR 0.43, 95 per cent c.i. 0.39 to 0.48, P < 0.001), or one stage (HR 0.57, 95 per cent c.i. 0.52 to 0.62, P < 0.001) had significantly longer survival than those with upstaged disease in adjusted analyses. In oesophageal squamous cell carcinoma, patients with downstaged disease by three or more stages had significantly longer survival than those with less downstaged disease, no change, or upstaged disease. Patients with downstaged disease by three or more stages (HR 0.55, 95 per cent c.i. 0.43 to 0.71, P < 0.001), two stages (HR 0.58, 95 per cent c.i. 0.46 to 0.73, P < 0.001), or one stage (HR 0.69, 95 per cent c.i. 0.55 to 0.86, P = 0.001) had significantly longer survival than those with upstaged disease in adjusted analyses. The extent of downstaging is an important prognosticator, whereas the optimal neoadjuvant therapy remains controversial. Identifying biomarkers associated with response to neoadjuvant regimens may permit individualized treatment.

Background: Treatment for locally advanced oesophagogastric adenocarcinoma involves neoadjuvant chemotherapy which has a negative impact on patient fitness. Using ‘prehabilitation’ to increase activity levels and fitness may affect physiology, postoperative outcomes and improve patient wellbeing and quality of life. The aims of the trial were to address the feasibility and acceptability of recruiting participants to a home-based prehabilitation programme and provide data to allow design of future studies. Methods: We recruited patients to a single-arm feasibility trial of home-based exercise prehabilitation. Eligible patients were aged ≥18years, had operable oesophageal or gastric adenocarcinoma and were receiving neoadjuvant chemotherapy at our tertiary referral hospital. All participants commenced a home-based exercise programme utilising pedometers and step counting to target daily aerobic exercise sessions alongside daily strengthening exercises. A weekly telephone consultation directed the exercise programme and facilitated weekly data collection. The primary (feasibility) outcomes for the trial were (a) recruitment rate, (b) completion rate, (c) engagement with the programme (use of pedometers, recording step counts, telephone consultations) and (d) compliance with exercise sessions, exercise intensity and strengthening exercises. Results: There were 42 patients recruited, and the recruitment rate was 72.4% (42/58). 92.3% (36/39) of patients completed the exercise programme. There was 98.7% (IQR 93.2–100.0%) compliance with wearing a pedometer and recording data, and 100.0% (IQR 93.1–100.0%) compliance with a weekly telephone consultation. Exercise sessions and strengthening exercises were completed 70.2% (IQR 53.1–88.9%) and 69.4% (IQR 52.1–84.3%) of the time, respectively. Appropriate exercise intensity was recorded 96% (IQR 85.4–99.4%) of the time. There were no adverse events. Participants were enrolled in the exercise programme for a median of 91 days (IQR 84 to 105 days). Conclusions: The results of this trial support the feasibility and acceptability of recruiting participants to an appropriately powered randomised controlled trial of prehabilitation. Trial registration: Clinicaltrials.gov NCT04194463. Registered on 11th December 2019—retrospectively registered.