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Background Laparoscopic gastrectomy is increasingly used for the treatment of locally advanced gastric cancer but concerns remain whether similar results can be obtained compared to open gastrectomy, especially in Western populations. This study compared the short-term postoperative, oncological and survival outcomes following laparoscopic versus open gastrectomy based on data from the Swedish National Register for Esophageal and Gastric Cancer. Methods Patients who underwent surgery with curative intent for adenocarcinoma of the stomach or gastroesophageal junction Siewert type III from 2015 to 2020 were identified, and 622 patients with cT2-4aN0-3M0 tumors were included. The impact of surgical approach on short-term outcomes was assessed using multivariable logistic regression. Long-term survival was compared using multivariable Cox regression. Results In total, 350 patients underwent open and 272 laparoscopic gastrectomy, of which 12.9% were converted to open surgery. The groups were similar regarding distribution of clinical disease stage (27.6% stage I, 46.0% stage II, and 26.4% stage III). Neoadjuvant chemotherapy was administered to 52.7% of the patients. There was no difference in the rate of postoperative complications, but laparoscopic approach was associated with lower 90 day mortality (1.8 vs 4.9%, p = 0.043). The median number of resected lymph nodes was higher after laparoscopic surgery (32 vs 26, p p Conclusions Laparoscopic gastrectomy can be safely preformed for advanced gastric cancer and is associated with improved overall survival compared to open surgery.

Summary: The impact of body mass index (BMI) on surgical outcomes has previously been studied in relation to several oncological procedures. Regarding gastric cancer surgery, published results have been contradicting in terms of degree of technical difficulty, risk of postoperative complications and survival. In an attempt to clarify these issues, we performed a meta-analysis to evaluate the impact of obesity (defined as BMI ≥ 30 kg/m2) on outcomes after gastrectomy for gastric cancer. The meta-analysis was performed according to the PRISMA guidelines. Eligible studies were identified through search of PubMed, EMBASE, Web of Science and Cochrane Library databases. Quality assessment was performed using the Newcastle-Ottawa scale. The meta-analysis was conducted using random-effects modeling. A total of 11 studies with 13 538 patients were eligible for analysis. Obesity was associated with a significantly longer operation time (WMD = 19.38 min, 95% CI 12.72–26.04; p

Time to surgery after termination of neoadjuvant chemoradiotherapy for esophageal cancer has traditionally been 4–6 weeks. Observational studies have suggested that delay of surgery for up to three months may lead to improved tumor regression and better outcomes. NeoRes II is the first randomized trial to address this in esophageal cancer. No difference in surgical morbidity or mortality between early and delayed surgery was reported in a previous publication from the trial. A multicenter clinical trial with randomized 1:1 allocation of standard time to surgery of 4–6 weeks, or delay of surgery to 10–12 weeks, after termination of chemoradiotherapy. The primary endpoint was complete histological tumor regression in patients with adenocarcinoma. Secondary endpoints included tumor regression grade, tumor free resection margins and overall survival in all patients, and stratified by histological subtype. In total 249 patients were randomized, 204 with adenocarcinoma and 45 with squamous cell carcinoma. There was no significant difference in histological complete response between adenocarcinoma patients allocated to standard time to surgery (20.6%) compared to delayed (25.6%) surgery (P = 0.18). Tumor free resection margin was achieved in 97.4% after standard time to surgery and 97.1% after delayed surgery (P = 1.0). The median follow-up time for survival was 51 months. Delayed time to surgery was associated with a 35% higher overall mortality, hazard ratio 1.35 (95% CI:0.94–1.95), (P = 0.11). No significant difference in complete histological tumor regression or tumor free resection margins comparing standard and delayed time to surgery after chemoradiotherapy was observed. There was a non-significant trend towards inferior overall survival after delayed surgery, suggesting caution in delaying surgery for more than 6 weeks after neoadjuvant chemoradiotherapy.

OBJECTIVE: To describe the pooled learning curves of Ivor Lewis totally minimally invasive esophagectomy (TMIE) in hospitals stratified by predefined hospital- and surgeon-related factors.BACKGROUND: Ivor Lewis (TMIE is known to have a long learning curve which is associated with considerable learning associated morbidity. It is unknown whether hospital and surgeon characteristics are associated with more efficient learning.METHODS: A retrospective analysis of prospectively collected data of consecutive Ivor Lewis TMIE patients in 14 European hospitals was performed. Outcome parameters used as proxy for efficient learning were learning curve length, learning associated morbidity, and the plateau level regarding anastomotic leakage and textbook outcome. Pooled incidences were plotted for the factor-based subgroups using generalized additive models and 2-phase models. Casemix predicted outcomes were plotted and compared with observed outcomes. The investigated factors included annual volume, TMIE experience, clinic visits, courses and fellowships followed, and proctor supervision.RESULTS: This study included 2121 patients. The length of the learning curve was shorter for centers with an annual volume >50 compared to centers with an annual volume CONCLUSIONS: More efficient learning was observed in centers with higher annual volume. Visiting an expert clinic, completing a fellowship, or implementation under a proctor's supervision were not associated with more efficient learning.

Objective To examine 5-year survival in esophageal cancer after minimally invasive esophagectomy (MIE) compared to open esophagectomy (OE). Summary background data MIE is becoming an increasingly common approach in the surgical treatment of esophageal cancer. A recent meta-analysis suggested 18% lower 5-year all-cause mortality after MIE compared to OE, but the quality of the included studies was limited. Methods Population-based cohort study including almost all patients who underwent elective esophagectomy for esophageal cancer in Sweden or Finland in 2010-2016, with follow-up until 2020. Cox regression was used to provide hazard ratios (HRs) with 95% confidence intervals (CIs) of all-cause 5-year mortality (main outcome) after MIE (hybrid or total) versus OE. Adjustments were made for age, sex, comorbidity, pathological tumor stage, histological tumor type, neoadjuvant chemo(radio)therapy, country, and annual hospital volume of esophagectomy. Results Among all 1,264 patients, 470 (37.2%) underwent MIE and 794 (62.8%) underwent OE. MIE was associated with an 18% decreased risk of all-cause 5-year mortality, compared to OE (adjusted HR 0.82, 95% CI 0.67-1.00 [P = 0.048]). The HR of all-cause 5-year mortality was seemingly lower after total MIE compared to OE (adjusted HR 0.77, 95% CI 0.60-0.98) than after hybrid MIE compared to OE (adjusted HR 0.87, 95% CI 0.68-1.11). Conclusions This bi-national study indicates that MIE is associated with a higher 5-year survival than OE in patients with esophageal cancer, and that the survival benefit is greater after total MIE than hybrid MIE.

Purpose Insertion of a nutritional jejunostomy in conjunction with esophagectomy is performed with the intention to decrease the risk for postoperative malnutrition and improve recovery without adding significant catheter-related complications. However, previous research has shown no clear benefit and there is currently no consensus of practice. Methods All patients treated with esophagectomy due to cancer during the period 2006–2017 reported in the Swedish National Register for Esophageal and Gastric Cancer were included in this register-based cohort study from a national database. Patients were stratified into two groups: esophagectomy alone and esophagectomy with jejunostomy. Results A total of 847 patients (45.27%) had no jejunostomy inserted while 1024 patients (54.73%) were treated with jejunostomy. The groups were comparable, but some differences were seen in histological tumor type and tumor stage between the groups. No significant differences in length of hospital stay, postoperative surgical complications, Clavien-Dindo score, or 90-day mortality rate were seen. There was no evidence of increased risk for significant jejunostomy-related complications. Patients in the jejunostomy group with anastomotic leaks had a statistically significant lower risk for severe morbidity defined as Clavien-Dindo score ≥ IIIb (adjusted odds ratio 0.19, 95% CI: 0.04–0.94, P = 0.041) compared to patients with anastomotic leaks and no jejunostomy. Conclusion A nutritional jejunostomy is a safe method for early postoperative enteral nutrition which might decrease the risk for severe outcomes in patients with anastomotic leaks. Nutritional jejunostomy should be considered for patients undergoing curative intended surgery for esophageal and gastro-esophageal junction cancer.

Objectives The aim of this study was to investigate the sentinel lymph node biopsy (SLNB) method in patients with cancer of the oesophagus or gastro-oesophageal junction (GOJ) guided by preoperative hybrid single-photon emission tomography/computed tomography (SPECT/CT) lymphoscintigraphy. Methods Thirty-nine patients with stage T1-T3, any N-stage, M0 cancer of the oesophagus or GOJ planned for curatively intended esophagectomy underwent preoperative SPECT/CT lymphoscintigraphy following endoscopically guided submucosal injection of radiocolloid and intraoperative radio-guided SLNB using a hand-held gamma scintillation device. Results The detection rate in preoperative SPECT/CT imaging was 88%. The median number of detected SLN stations in preoperative imaging was 1 (range 0-4). At least one suspected SLN was identified in all intraoperative SLNP procedures. In six cases, no lymph nodes were identified in the SLNB. In six cases, the SLNB was false negative. The sensitivity for successful SLNB procedures was 20%, the specificity was 100% and the accuracy was 75%. Conclusions Preoperative SLN mapping using SPECT/CT yields a high number of detected SLN stations compared to previous studies using planar imaging. The accuracy of the SLNB method in patients with predominantly ≥T3-stage tumours and with a history of previous neoadjuvant treatment is poor, and the method is not recommended in these patient groups.

Background Laparoscopic gastrectomy (LG) for cancer has been introduced in institutions worldwide in an effort to minimize surgical trauma, while aiming to provide comparable oncological outcomes to conventional open gastrectomy (OG). The aim of this study was to present our results during the period of implementation of the laparoscopic technique. Materials and methods In 2012, LG for the treatment of gastric cancer was introduced at our institution. The results presented are based on a retrospective analysis of data from a cohort of all patients treated with curative intent over the period 2010-2018. Results During the study period, 206 patients underwent surgery for gastric cancer: 129 patients (62.6%) had an OG and 77 patients (37.4%) an LG. The conversion rate due to technical reasons was 2.6%. LG was associated with significantly less intraoperative blood loss [mean (mL), OG 544 versus LG 176] and shorter hospital stay than OG [mean (d), OG 12 versus LG 8], fewer severe complications (Clavien-Dindo grade ≥ IIIb) [OG 29 (22.5%) versus LG 9 (11.7%), P = 0.081], significantly lower anastomotic leak rate [OG 18 (14.0%) versus LG 1 (1.3%)] and no 90-day mortality. The percentage of R0 resections was similar between the two groups (OG 82.2% versus LG 85.7%, P = 0.507), while the mean number of resected lymph nodes was significantly higher in the laparoscopic group [OG 34 versus LG 39, P = 0.030]. Conclusions Our data suggest that similar and, in some aspects, better short-term outcomes can be achieved with LG with maintained oncological quality.

Robot-assisted minimally invasive esophagectomy (RAMIE) was introduced as a further development of the conventional minimally invasive esophagectomy, aiming to further improve the high morbidity and mortality associated with open esophagectomy. We aimed to compare the outcomes between RAMIE and open esophagectomy, which remains a popular approach for resectable esophageal cancer. Ten studies meeting our inclusion criteria were identified, including five retrospective cohort, four prospective cohort, and one randomized controlled trial. RAMIE was associated with significantly lower rates of overall pulmonary complications (odds ratio (OR): 0.38, 95% confidence interval (CI): [0.26, 0.56]), pneumonia (OR: 0.39, 95% CI: [0.26, 0.57]), atrial fibrillation (OR: 0.53, 95% CI: [0.29, 0.98]), and wound infections (OR: 0.20, 95% CI: [0.07, 0.57]) and resulted in less blood loss (weighted mean difference (WMD): −187.08 mL, 95% CI: [−283.81, −90.35]) and shorter hospital stays (WMD: −9.22 days, 95% CI: [−14.39, −4.06]) but longer operative times (WMD: 69.45 min, 95% CI: [34.39, 104.42]). No other statistically significant difference was observed regarding surgical and short-term oncological outcomes. Similar findings were observed when comparing totally robotic procedures only to OE. RAMIE is a safe and feasible procedure, resulting in decreased cardiopulmonary morbidity, wound infections, blood loss, and shorter hospital stays compared to open esophagectomy.

Relapse after curative treatment for advanced gastric cancer, and especially peritoneal recurrence, is very common and has a dismal prognosis. The aim of this review is to summarize existing evidence regarding risk factors and prophylactic treatments intending to prevent peritoneal recurrence.A structured search of relevant studies was conducted in MEDLINE, Embase, and the Cochrane Library.The main risk factors identified are advanced pathological T-stage (pT ≥ 3), regional lymph node involvement, diffuse/poorly cohesive type tumor, poorly differentiated cancer, and positive peritoneal wash cytology. Systemic chemotherapy in the perioperative or adjuvant setting improves survival for the patients but despite this peritoneal recurrence remains a common and yet an unsolved clinical problem. Different approaches of intraperitoneal chemotherapy such as hyperthermic intraperitoneal chemotherapy and early postoperative intraperitoneal chemotherapy have shown promising results as prophylactic treatments aiming to prevent peritoneal recurrence.Future studies are warranted to find safe and effective treatments to prevent peritoneal recurrence.

Surgical resection of the esophagus remains a critical component of the multimodal treatment of esophageal cancer. Anastomotic leakage (AL) is the most significant complication following esophagectomy, in terms of clinical implications. Identifying risk factors for AL is important for modifying patient management and improving surgical outcomes. This review aims to examine the role of radiological risk factors for AL after esophagectomy, and in particular, arterial calcification and celiac trunk stenosis. Eligible publications prior to 25 August 2021 were retrieved from Medline and Google Scholar using a predefined search algorithm. A total of 68 publications were identified, of which 9 original studies remained for in-depth analysis. The majority of these studies found correlations between calcifications in the aorta, celiac trunk, and right post-celiac arteries and AL following esophagectomy. Some studies suggest celiac trunk stenosis as a more appropriate surrogate. Our up-to-date review highlights the need for automated quantification of aortic calcifications, as well as the degree of celiac trunk stenosis in preoperative computed tomography in patients undergoing esophagectomy, to obtain robust and reproducible measurements that can be used for a definite correlation.

Pseudoachalasia, also known as secondary achalasia, is a clinical condition mimicking idiopathic achalasia but most commonly caused by malignant tumors of gastroesophageal junction (GEJ). Our aim was to systematically review and present all available data on demographics, clinical features, and diagnostic modalities involved in patients with pseudoachalasia. A systematic search of literature published during the period 1978-2019 was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (end-of-search date: June 25th, 2019). Two independent reviewers extracted data with regards of study design, interventions, participants, and outcomes. Thirty-five studies met our inclusion criteria and were selected in the present review. Overall, 140 patients with pseudoachalasia were identified, of whom 83 were males. Mean patient age was 60.13 years and the mean weight loss was 13.91 kg. A total of 33 (23.6%) patients were wrongly 'treated' at first for achalasia. The most common presenting symptoms were dysphagia, food regurgitation, and weight loss. The median time from symptoms' onset to hospital admission was 5 months. Most common etiology was gastric cancer (19%). Diagnostic modalities included manometry, barium esophagram, endoscopy, and computed tomography (CT). Pseudoachalasia is a serious medical condition that is difficult to be distinguished from primary achalasia. Clinical feature assessment along with the correct interpretation of diagnostic tests is nowadays essential steps to differentiate pseudoachalasia from idiopathic achalasia.

The thoracic phase of minimally invasive esophagectomy was initially performed in the lateral decubitus position (LDP); however, many experts have gradually transitioned to a prone position (PP) approach. The aim of the present systematic review and meta-analysis is to quantitatively compare the two approaches. A systematic literature search of the MEDLINE, Embase, Google Scholar, Web of Knowledge, China National Knowledge Infrastructure and ClinicalTrials.gov databases was undertaken for studies comparing outcomes between patients undergoing minimally invasive esophageal surgery in the PP versus the LDP. In total, 15 studies with 1454 patients (PP; n = 710 vs. LDP; n = 744) were included. Minimally invasive esophagectomy in the PP provides statistically significant reduction in postoperative respiratory complications (Risk ratios 0.5, 95% confidence intervals [CI] 0.34–0.76, P

Introduction Introduction of multimodality treatment as the standard of care for management of esophageal and gastroesophageal junction (GEJ) cancer over the last years has led to significant improvement in survival for patients with localized disease. Nevertheless, treatment with curative intent is not considered in the case of metastatic disease. We report a case of a locally advanced GEJ adenocarcinoma with solitary resectable synchronous metastases at the jejunum and a good response to neoadjuvant therapy followed by esophagectomy with curative intention. Case presentation This is the case of a patient with poorly differentiated adenocarcinoma of the GEJ with synchronous metastases at the jejunum. The patient underwent extensive work-up including PET-CT. The metastases at the jejunum were completely resected during an initial staging laparoscopy and there was no evidence of further metastatic disease. The patient received chemotherapy and re-staging showed remarkable tumor response. Esophagectomy with curative intent was performed. Histopathology showed complete pathologic response after chemotherapy. Although our patient had a stage IV disease at presentation, he remained metastasis-free for a significant period of time, with no evidence of any distant recurrence during a follow-up of 16 months after esophagectomy. Discussion and conclusions Synchronous metastasis to the small bowel from an esophageal carcinoma is a rare entity. Routine PET-CT in addition to conventional CT may assist in more precise staging of a patient with resectable disease. Stage IV esophageal cancer with limited and resectable metastatic disease and good tumor response to oncological therapy may be considered for treatment with potentially curative intent., Highlights • Synchronous metastasis to the small bowel from an esophageal carcinoma is a rare entity. • PET-CT in addition to conventional CT may assist in more precise staging of esophageal cancer. • Esophageal cancer with resectable metastases may be considered for treatment with curative intent.

Endoscopic sutures can be used in various clinical situations where closure or fixation is needed. Stents that migrate and dislocated probes can be fixated by endoscopic sutures. The sutures can be used to stop gastrointestinal bleeding. It is possible to close perforations, leaks and fistulas with endoscopic sutures, but as with ordinary sutures, the indication must be correct for the procedure to be successful. Endoscopic sleeve gastroplasty (ESG) can be done by a series of sutures reducing the volume of the stomach. Defects after endoscopic resections, where bleeding or perforations can be expected, can be closed with endoscopic sutures. Complications are uncommon but intraabdominal fluid collection may occur after ESG. Endoscopic sutures have the same possibilities and limitations as traditional or laparoscopic sutures. Properly used, the method is safe, but the instruments are still difficult to work with and require an experienced endoscopist who has undergone proper training.

Item does not contain fulltext BACKGROUND: Esophagectomy is a technically challenging procedure, associated with significant morbidity. The introduction of minimally invasive esophagectomy (MIE) has reduced postoperative morbidity. OBJECTIVE: Although the short-term effect on complications is increasingly being recognized, the impact on long-term survival remains unclear. This study aims to investigate the association between postoperative complications following MIE and long-term survival. METHODS: Data were collected from the EsoBenchmark Collaborative composed by 13 high-volume, expert centers routinely performing MIE. Patients operated between June 1, 2011 and May 31, 2016 were included. Complications were graded using the Clavien-Dindo (CD) classification. To correct for short-term effects of postoperative complications on mortality, patients who died within 90 days postoperative were excluded. Primary endpoint was 5-year overall survival. RESULTS: A total of 915 patients were included with a mean follow-up time of 30.8 months (standard deviation 17.9). Complications occurred in 542 patients (59.2%) of which 50.2% had a CD grade ≥III complication [ie, (re)intervention, organ dysfunction, or death]. The incidence of anastomotic leakage (AL) was 135 of 915 patients (14.8%) of which 84 patients were classified as a CD grade ≥III. Multivariable analysis showed a significantly deteriorated long-term survival in all patients with AL [hazard ratio (HR) 1.68, 95% confidence interval (CI) 1.25-2.24]. This inverse relation was most distinct when AL was scored as a CD grade ≥III (HR 1.83, 95% CI 1.30-2.58). For all other complications, no significant association with long-term survival was found. CONCLUSION: The occurrence and severity of AL, but not overall complications, after MIE negatively affect long-term survival of esophageal cancer patients.

Summary Anastomotic leak is a serious complication after esophagectomy. Endoscopic vacuum therapy (EVT) has become increasingly popular in treating upper gastrointestinal anastomotic leaks over the last years. We are here reporting our current complete experience with EVT as primary treatment for anastomotic leak following esophagectomy. This is a retrospective study analyzing all patients with EVT as primary treatment for anastomotic leak after esophagectomy between November 2016 and January 2020 at Karolinska University Hospital, Sweden. The primary endpoint was anastomotic fistula healing with EVT only. Twenty-three patients primarily treated with EVT after anastomotic leak following esophagectomy were included. Median duration of EVT was 17 days (range 5–56) with a median number of 3 (range 1–14) vacuum sponge changes per patient. A total number of 95 vacuum sponges were placed in the entire cohort, of which 93 (97.9%) were placed intraluminally and 2 (2.1%) extraluminally. The median changing time interval of sponges was 5 days (range 2–8). Successful fistula healing was achieved in 19 of 23 patients (82.6%), of which 17 (73.9%) fistulas healed with EVT only. There were 2 (8.7%) airway fistulas following EVT. No other adverse events occurred. Three patients (13%) died in-hospital. In conclusion EVT seems to be a safe and feasible therapy option for anastomotic leak following esophagectomy. The effect of EVT on the risk for development of airway fistulas needs to be addressed in future studies and until more data are available care should be taken regarding sponge positioning as well as extended treatment duration.

For carcinoma of the esophagus or esophagogastric junction the time to surgery (TTS) has traditionally been 4-6 weeks after completed neoadjuvant chemoradiotherapy (nCRT). However, the optimal timing is not known. A majority of previous non-randomized studies addressing this issue, have not detected any significant differences in complication rates comparing patients operated with standard TTS compared to prolonged TTS. The aim of this sub-study was to investigate if prolonged TTS after completed nCRT improves postoperative outcomes. Methods A multicenter clinical trial was performed with randomized allocation to standard TTS (4–6 weeks) or prolonged TTS (10–12 weeks). All patients received nCRT according to the CROSS regimen. Patients were enrolled between 2015–2019 from 10 University Hospitals in Sweden, Norway and Germany. The primary endpoint of this sub-study was overall postoperative complications defined as Clavien-Dindo grade II-V. Secondary endpoints included complication severity according to Clavien-Dindo grade IIIb-V, postoperative 90-day mortality and length of hospital stay. The study was registered in Clinicaltrials.gov (NCT02415101). Results In total 248 patients were randomized. There were no significant differences between standard TTS and prolonged TTS regarding overall complications Clavien-Dindo II-V (59.0% vs. 69.8%, P = 0.092) or Clavien-Dindo IIIb-V (31.6% vs. 35.0%, P = 0.603). Furthermore, there were no significant differences regarding anastomotic leak (P = 0.601), conduit necrosis (P = 0.524), chyle leak (P = 0.427), pneumonia (P = 0.548) or respiratory failure (P = 0.723). The 90-day postoperative mortality was 4.3% (5 patients) in the standard TTS, and 3.8% (4 patients) in the prolonged TTS arm (P = 1.0). Median length of hospital stay was 15 days in the standard TTS arm and 17 days in the prolonged TTS arm (P = 0.220). Conclusion The timing of surgery after completed nCRT for carcinoma of the esophagus or esophagogastric junction is not of major importance with regard to short-term postoperative outcomes.

To investigate if prolonged TTS after completed nCRT improves postoperative outcomes for esophageal and esophagogastric junction cancer.TTS has traditionally been 4-6 weeks after completed nCRT. However, the optimal timing is not known.A multicenter clinical trial was performed with randomized allocation of TTS of 4-6 or 10-12 weeks. The primary endpoint of this sub-study was overall postoperative complications defined as Clavien-Dindo grade II-V. Secondary endpoints included complication severity according to Clavien-Dindo grade IIIb-V, postoperative 90-day mortality, and length of hospital stay. The study was registered in Clinicaltrials.gov (NCT02415101).In total 249 patients were randomized. There were no significant differences between standard TTS and prolonged TTS with regard to overall incidence of complications Clavien-Dindo grade II-V (63.2% vs 72.6%, P = 0.134) or regarding Clavien-Dindo grade IIIb-V complications (31.6% vs 34.9%, P = 0.603). There were no statistically significant differences between standard and prolonged TTS regarding anastomotic leak (P = 0.596), conduit necrosis (P = 0.524), chyle leak (P = 0.427), pneumonia (P = 0.548), and respiratory failure (P = 0.723). In the standard TTS arm 5 patients (4.3%) died within 90 days of surgery, compared to 4 patients (3.8%) in the prolonged TTS arm (P = 1.0). Median length of hospital stay was 15 days in the standard TTS arm and 17 days in the prolonged TTS arm (P = 0.234).The timing of surgery after completed nCRT for carcinoma of the esophagus or esophagogastric junction, is not of major importance with regard to short-term postoperative outcomes.

Background: As older gastric cancer patients are often excluded from randomized clinical trials, the most appropriate treatment strategy for these patients remains unclear. The current study aimed to gain more insight in treatment strategies and relative survival of older patients with resectable gastric cancer across Europe. Methods: Population-based cohorts from Belgium, Denmark, The Netherlands, Norway, and Sweden were combined. Patients ≥70 years with resectable gastric cancer (cT1-4a, cN0-2, cM0), diagnosed between 2004 and 2014 were included. Resection rates, administration of chemotherapy (irrespective of surgery), and relative survival within a country according to stage were determined. Results: Overall, 6698 patients were included. The percentage of operated patients was highest in Belgium and lowest in Sweden for both stage II (74% versus 56%) and stage III disease (57% versus 25%). For stage III, chemotherapy administration was highest in Belgium (44%) and lowest in Sweden (2%). Three year relative survival for stage I, II, and III disease in Belgium was 67.8% (95% CI:62.8–72.6), 41.2% (95% CI:37.3–45.2), 17.8% (95% CI:12.5–24.0), compared with 56.7% (95% CI:51.5–61.7), 31.3% (95% CI:27.6–35.2), 8.2% (95% CI:4.4–13.4) in Sweden. There were no significant differences in treatment strategies of patients with stage I disease. Conclusion: Substantial treatment differences are observed across North European countries for patients with stages II and III resectable gastric cancer aged 70 years or older. In the present comparison, treatment strategies with a higher proportion of patients undergoing surgery seemed to be associated with higher survival rates for patients with stages II or III disease.

BACKGROUND The increasing age of the population and prolonged life expectancy result in a widening of age limit criteria for a variety of surgical procedures. Oesophagectomy and total gastrectomy are complex operations associated with significant risks of post-operative complications. METHODS This is a single-centre cohort study of patients operated with curative intent due to oesophageal or gastric cancer. RESULTS From 2007 to 2017, 548 patients underwent surgery with curative intent, with 122 patients (22.3%) classified as elderly (≥75 years). There was no difference in total complication rates between the groups. The adjusted odds ratio for 90-day mortality after oesophageal resection in the elderly group was 3.65 (95% confidence interval (CI): 1.33-10.03) and after gastrectomy was 1.62 (95% CI: 0.55-4.79). The adjusted hazard ratio for 1-year mortality after oesophagectomy was 2.29 (95% CI: 1.25-4.19), and after gastrectomy the adjusted hazard ratio was 1.48 (95% CI: 0.75-2.92). In the event of a complication with Clavien-Dindo score IIIb or higher, there was a statistically significant increase of 90-day mortality to over 50% among elderly patients both after oesophagectomy and gastrectomy (50.0% versus 19.8%; P = 0.005 and 57.1% versus 17.4%; P = 0.012, respectively). CONCLUSION There is a statistically significant increase in 90-day mortality after oesophageal and gastric cancer surgery in elderly compared with younger patients. Post-operative complications with high Clavien-Dindo score in patients undergoing oesophagectomy or gastrectomy, with age ≥75 years, are a dramatic risk factor for post-operative death.

BACKGROUND Tubularized stomach is a common substitute used after oesophageal resection. The risk for gastric conduit ischemia, as well as the mechanisms and dynamics for the occurrence of deficient tissue perfusion during the critical construction of a gastric tube, is poorly understood. METHODS Twenty-nine patients that underwent oesophagectomy were studied with transmural pulse oximetry of different parts of the stomach, and at predefined preparatory steps during the construction of the gastric conduit. RESULTS After ligation of the left gastric artery (LGA), a reduction to 83.5% in tissue saturation was observed. Three patients (10.3%) had a sustained saturation despite ligation at this point. During final preparation of the gastric tube, and after stapling of the minor curvature, saturation fell to 76.5%. Saturation increased significantly to 80.0% 2 h after the stapling, just before construction of the anastomosis (P = 0.021). There was no association between the level of oxygen saturation and the risk of anastomotic dehiscence. CONCLUSION During gastric tube construction for oesophageal replacement, conduit perfusion, measured as oxygen saturation with pulse oximetry, decreases significantly. The main cause of this reduction seems to be ligation of the LGA and the final stapling of the gastric tube. Future studies are needed to establish the clinical implications of this finding.

Background Post-esophagectomy hiatal hernia (PEHH) is a known, but relatively uncommon, complication after esophagectomies. The incidence of PEHH seems to be increasing since the introduction of minimally invasive esophagectomy. This systematic review and meta-analysis aimed to determine the pooled incidence of PEHH after esophagectomy, and to evaluate if minimally invasive technique is associated with increased risk for PEHH compared to open esophagectomy. Methods A systematic search of PubMed, Medline via Ovid and Web of Science was performed. Retrospective and prospective studies in English language describing the incidence or risk factors for PEHH were included. Weighted incidence of PEHH after all types of esophagectomy, and after open or minimally invasive technique was calculated. Results A total of 7943 esophagectomy patients were included in the analysis. In total, 310 patients (3.9%) were diagnosed with PEHH. The estimated weighted incidence rate for PEHH after open esophagectomy was 0.024 (95% confidence interval: 0.012–0.045) compared to 0.065 (95% confidence interval: 0.040–0.106) after minimally invasive esophagectomy. Odds ratio for PEHH after minimally invasive esophagectomy compared to open esophagectomy was 2.76 (95% confidence interval: 1.49–5.11). Conclusion The risk for post-esophagectomy hiatal hernia was significantly higher after minimally invasive esophagectomy compared to open technique. Heterogeneity and retrospective designs of the included studies were important limitations of the analysis. Future studies should investigate preventive measures to reduce PEHH after minimally invasive esophagectomy.

It is generally recognized that in patients with an intact stomach diagnosed with esophageal cancer, gastric tubulization and pull-up shall always be the preferred technique for reconstruction after an esophageal resection. However, in cases with extensive gastroesophageal junction (GEJ) cancer with aboral spread and after previous gastric surgery, alternative methods for reconstruction have to be pursued. Moreover, in benign cases as well as in those with early neoplastic lesions of the esophagus and the GEJ that are associated with long survival, it is basically unclear which conduit should be recommended. The aim of this study is to determine the long-term functional outcomes of different conduits used for esophageal replacement, based on a comprehensive literature review. Eligible were all clinical studies reporting outcomes after esophagectomy, which contained information on at least three years of follow-up after the operation in patients who were older than 18 years of age at the time of the operation. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic web-based search using MEDLINE, the Cochrane Library, and EMBASE databases was performed, reviewing medical literature published between January 2006 and December 2015. The scientific quality of the data was generally low, which allowed us to incorporate only 16 full text articles for the final analyses. After a gastric pull-up, the proportion of patients who suffered from dysphagia varied substantially but seemed to decrease over time with a mild dysphagia remaining during long-term follow-up. When reflux-related symptoms and complications were addressed, roughly two third of patients experienced mild to moderate reflux symptoms a long time after the resection. Following an isoperistaltic colonic graft, the functional long-term outcomes regarding swallowing difficulties were sparsely reported, while three studies reported reflux/regurgitation symptoms in the range of 5% to 16%, one of which reported the symptom severity as being mild. Only one report was available after the use of a long jejunal segment, which contained only six patients, who scored the severity of dysphagia and reflux as mild. Very few if any data were available on a structured assessment of dumping and disturbed bowel functions. Few high-quality data are available on the long-term functional outcomes after esophageal replacement irrespective of the use of a gastric tube, the right or left colon or a long jejunal segment. No firm conclusions regarding the advantages of one graft over the other can presently be drawn.

Background: Esophagectomy remains the gold standard in the curative intent treatment of resectable esophageal cancer. However, this procedure is complex and associated with high risk of complications. In an effort to reduce the postoperative morbidity associated with open esophagectomy various minimally invasive techniques have been introduced and developed during the recent years. The aim of the current study was to present our 4.5-year experience of the gradual implementation of various minimally invasive esophagectomy (MIE) techniques in our tertiary referral center Methods: From May 2012 a transitional period from conventional open esophagectomy to MIE was initiated. This period was preceded by fellowships and visits to expert centers abroad. Thereafter, a gradual implementation and refinement of the new techniques followed. Technique related data were collected prospectively. Results: Between January 1 st 2011 and December 31 st 2016 a total of 249 patients underwent an esophagectomy in our unit. Seventy-six cases were performed through a conventional open esophagectomy and 173 by some type of MIE. An increasing utilization of MIE over this time period was seen and finally reached 100% of treatment intentions, during the last 2 years. Ten cases (5.7%) where converted to open approach. A decrease in leak rate, operating time, peroperative bleeding and hospital stay as well as an increasing number of harvested lymph nodes was observed during the implementation period. Conclusions: The transition from conventional open esophagectomy to MIE was successful at our center. The implementation was overall safe with good postoperative outcomes, although changes in results required technical modifications over time.

Aim The incidence of esophageal malignancies is higher in cirrhotic patients due to the fact that cirrhosis and esophageal cancer share common risk factors. Our goal was to define the impact of cirrhosis on postoperative outcomes following esophagectomy for esophageal cancer. Methods This study was performed according to the PRISMA guidelines. Eligible studies were identified through search of PubMed, Scopus, and Cochrane (end-of-search date: March 8th, 2019). A meta-analysis was conducted using random effects modeling. Results We included 12 observational studies reporting on a total of 1938 patients who underwent surgery for esophageal cancer. Cirrhotic patients were more likely to develop postoperative pulmonary complications (OR: 2.60; 95% CI: 1.53–4.42), ascites (OR: 37.77; 95% CI: 10.95–130.28) and anastomotic leak/fistula within 30 days (OR: 2.81; 95% CI: 1.05–7.49) after esophageal cancer surgery. Cirrhotic patients had higher 30-day (OR: 3.04; 95% CI: 1.71–5.39) mortality rate. Liver disease did not appear to influence 90-day (OR: 2.84; 95% CI: 0.94–8.93) or late mortality rates (at a mean of 24 months of postoperative follow up) (OR: 1.70; 95% CI: 0.53–5.51). Esophagectomy for carcinoma in Child-Turcotte-Pugh class A cirrhotic patients was associated with significantly lower 30-day mortality rates compared to class B patients (OR: 0.14; 95% CI: 0.04–0.54). Conclusions Cirrhotic patients have higher odds of developing pulmonary complications, ascites, and anastomotic leak during the first postoperative month. Although, 30-day mortality was higher among cirrhotic patients after esophagectomy, liver disease does not seem to influence long-term prognosis.

Aim The objective of the present pilot study was to address the feasibility and practical use of SenseWear Armband Mini® (SWA) as a possible valid method offering longitudinal, comprehensive and complete assessment of energy balance in oesophageal cancer patients submitted to modern multimodality therapy. Background and methods Assessment of malnutrition and its consequences are pivotal in the curative management of patients with oesophageal cancer. Twenty patients were recruited at diagnosis of oesophageal cancer, all amenable for curative treatment. The baseline measurement took place before start of neoadjuvant treatment and at three additional measurement periods: after the completion of neoadjuvant treatment, and at three and six months postoperatively. The patients carried the SWA for three consecutive days at each measurement period, allowing the measurement of free-living total energy expenditure (TEE) and physical activity level (PAL). Alongside, a three-day food diary was recorded, permitted the calculation of energy and protein intake. The body weigth was measured at all four occasions. Results Body weight steadily decreased during the preoperative phase. However, the greatest weight loss was observed during the first 3 months after surgery (mean=5.6 kg), where after it stabilised. The median energy intake of 1982 kcal (range: 910-3455) at baseline increased to 2210 kcal (range: 1718-3355, p=0.009) after the completion of the neoadjuvant treatment. At 3 months after oesophagectomy energy intake decreased to 1749 kcal (range: 1024-2707, p=0.101) and regained baseline levels first at 6 months postoperatively. The same trend was observed regarding protein intake. The TEE was 2262 kcal (range: 1595-3150) at baseline with no change after preoperative oncological treatment. A significant reduction in energy expenditure to 1975 kcal (range 1396-2336, p=0.005) was recorded at 3 months post oesophagectomy, which remained unchanged at six months after surgery. Conclusion There are significant obstacles in recording complete, comprehensive and repetitive data on energy balance during the entire course of modern multimodality treatment of oesophageal cancer patients. With the objective to achieve and maintain positive energy balance focus must be on the patients’ energy intake already at the time of diagnosis, throughout the neoadjuvant therapy phase but particularly during the first 3 postoperative months.

Summary Background Assessment of malnutrition and its consequences are important aspects of curative management of patients with oesophageal cancer. The objective of the present study was to assess total energy expenditure using SenseWear Armband Mini® (SWA) as well as energy and protein intake in oesophageal cancer patients submitted to modern multimodality therapy. Material and methods Twenty patients were recruited at the time of diagnosis of oesophageal cancer. All patients were amenable for curative intended treatment. Baseline measurement was conducted before start of neoadjuvant treatment and three additional measurements were performed: after the completion of neoadjuvant treatment, at three, and six months postoperatively. The patients carried the SWA for three consecutive days at each measurement period, allowing the measurement of the free-living total energy expenditure and physical activity level. Alongside, a three-day complete food diary was recorded for calculation of energy and protein intake. Body weight was measured at all four occasions and weight six months prior to baseline was reported by the patients. Results Body weight steadily and significantly decreased during the preoperative phase (p = 0.005 and p = 0.007 at 6 months before baseline and after neoadjuvant treatment, respectively). However, the greatest weight loss was observed at 3 months after surgery (mean = 5.6 kg, p ≤ 0.001), where after it stabilised. Mean energy intake per day was 2033 (1730–2336) kcal at baseline, and increased to 2236 (2012–2461) kcal (p = 0.012) after completion of neoadjuvant treatment. At 3 months after oesophagectomy the daily energy intake decreased to 1759 (1459–2059) kcal (p = 0.155) compared to baseline and regained baseline levels first at 6 months postoperatively. The same trend was observed regarding protein intake. The mean total daily energy expenditure was 2259 (2077–2440) kcal at baseline with no change after the neoadjuvant oncological treatment. A significant reduction in energy expenditure to 1929 (1754–2105) kcal (p = 0.004) compared to baseline was recorded at 3 months post oesophagectomy, which remained unchanged at six months after surgery. Conclusion With the objective to achieve and maintain energy balance, focus must be on the patients' energy intake already at the time of diagnosis, with regular follow up throughout the neoadjuvant therapy phase and during the first 3 postoperative months.

Background: The impact of cardiorespiratory comorbidity on operative outcomes after esophagectomy remains controversial. This study investigated the effect of cardiorespiratory comorbidity on postoperative complications for patients treated for esophageal or gastroesophageal junction cancer. Patients and Methods: A European multicenter cohort study from five high-volume esophageal cancer centers including patients treated between 2010 and 2017 was conducted. The effect of cardiorespiratory comorbidity and respiratory function upon postoperative outcomes was assessed. Results: In total 1590 patients from five centers were included; 274 (17.2%) had respiratory comorbidity, and 468 (29.4%) had cardiac comorbidity. Respiratory comorbidity was associated with increased risk of overall postoperative complications, anastomotic leak, pulmonary complications, pneumonia, increased Clavien–Dindo score, and critical care and hospital length of stay. After neoadjuvant chemoradiotherapy, respiratory comorbidity was associated with increased risk of anastomotic leak [odds ratio (OR) 1.83, 95% confidence interval (CI) 1.11–3.04], pneumonia (OR 1.65, 95% CI 1.10–2.47), and any pulmonary complication (OR 1.52, 95% CI 1.04–2.22), an effect which was not observed following neoadjuvant chemotherapy or surgery alone. Cardiac comorbidity was associated with increased risk of cardiovascular and pulmonary complications, respiratory failure, and Clavien–Dindo score ≥ IIIa. Among all patients, forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) ratio > 70% was associated with reduced risk of overall postoperative complications, cardiovascular complications, atrial fibrillation, pulmonary complications, and pneumonia. Conclusions: The results of this study suggest that cardiorespiratory comorbidity and impaired pulmonary function are associated with increased risk of postoperative complications after esophagectomy performed in high-volume European centers. Given the observed interaction with neoadjuvant approach, these data indicate a potentially modifiable index of perioperative risk.

Objective: Curative gastric cancer surgery entails removal of the primary tumor with adequate margins including regional lymph nodes. European randomized controlled trials with recruitment in the 1990’s reported increased morbidity and mortality for D2 compared to D1. Here, we examined the extent of lymphadenectomy during gastric cancer surgery and the associated risk for postoperative complications and mortality using the strengths of a population-based study. Methods: A prospective nationwide study conducted within the National Register of Esophageal and Gastric Cancer. All patients in Sweden from 2006 to 2013 who underwent gastric cancer resections with curative intent were included. Patients were categorized into D0, D1, or D1+/D2, and analyzed regarding postoperative morbidity and mortality using multivariable logistic regression. Results: In total, 349 (31.7%) patients had a D0, 494 (44.9%) D1, and 258 (23.4%) D1+/D2 lymphadenectomy. The 30-d postoperative complication rates were 25.5%, 25.1% and 32.2% (D0, D1 and D1+/D2, respectively), and 90-d mortality rates were 8.3%, 4.3% and 5.8%. After adjustment for confounders, in multivariable analysis, there were no significant differences in risk for postoperative complications between the lymphadenectomy groups. For 90-d mortality, there was a lower risk for D1 vs. D0. Conclusions: The majority of gastric cancer resections in Sweden have included only a limited lymphadenectomy (D0 and D1). More extensive lymphadenectomy (D1+/D2) seemed to have no impact on postoperative morbidity or mortality. (Less)

Eosinophilic esophagitis (EoE) is a chronic allergen-driven disease in which eosinophilic infiltration of the esophagus results in fibrosis, causing symptoms of esophageal dysfunction. The natural history of EoE frequently results in progressive deterioration of patients’ quality of life. In selected cases, progressive manifestations of disease cannot be managed with the conventional treatment options, and patients therefore suffer from poor quality of life. We present the case of a 27-year-old male patient whose therapy for long-standing EoE did not prevent his clinical deterioration, which in turn gradually led to worsening quality of life owing to the degree and extent of esophageal fibrosis-associated remodeling. The patient eventually underwent a combined thoracoscopic/laparoscopic esophagectomy as a last resort aimed at alleviating the severe esophageal dysfunction and poor quality of life that he experienced. The patient underwent a minimally invasive esophagectomy and recovered quickly, gaining weight as early as 4 weeks after surgery. The patient returned 5 months later complaining of dysphagia regarding solid food. Gastroscopy showed a mild anastomotic stenosis that was dilated to 18 mm. During follow-up, the patient gained 15 kg compared with his lowest body weight prior to surgery and has remained symptom free 2.5 years after his surgery. Surgery can be considered as a last-resort option for managing the refractory manifestations of EoE and its complications.

Neoadjuvant chemoradiotherapy (nCRT) improves long-term survival for patients with esophageal cancer. On the other hand, there are indications that nCRT may increase the risk for postoperative morbidity. The aims of this study were to estimate the radiation exposure to the site of anastomosis on the gastric fundus and to assess whether nCRT affected the incidence or severity of cervical anastomotic complications. A retrospective cohort of patients with cancer of the esophagus or gastroesophageal junction, who were reconstructed with cervical anastomosis. The planned radiation dose to the site of the cervical anastomosis on the gastric fundus was estimated for each patient. The analysis of the dose plans showed that 20 out of 22 (93 %) available patients received radiotherapy toward the planned site of the anastomosis in the region of the gastric fundus with doses ranging from 6 to 40 Gy. In the nCRT group, 12 out of 28 patients (43 %) had anastomotic complications compared to 16 out of 42 (38 %) in the non-RT group (p = 0.69). In the nCRT group, 39 % had anastomotic complications that led to a Clavien-Dindo grade of IVa or higher compared to 17 % in the non-RT group (p = 0.03). The OR for Clavien-Dindo grade IVa or worse was 6.0 (95 % CI 1.52–23.50). This small retrospective study suggests that nCRT exposes the future anastomotic site to doses of radiation that may impair healing of the subsequent cervical anastomosis. Our data further suggest that nCRT may increase the severity of cervical anastomotic complications, and this hypothesis needs to be tested in a large prospective study.

Background In current best practise, curatively intended treatment for oesophageal cancer usually consists of neoadjuvant chemo-radiotherapy (nCRT) or perioperative chemotherapy, and oesophagectomy. Sentinel Lymph Node Biopsy (SLNB) has the potential to identify patients without lymph node metastases and thus improve the staging accuracy and influence treatment. The impact of neoadjuvant treatment on the lymphatic drainage of oesophageal cancers and subsequently the SLNB procedure in this tumour type has previously not been well studied. Purpose To evaluate changes in lymphatic drainage patterns of the tumour in patients with cancer of the oesophagus or gastro-oesophageal junction (GOJ) using Sentinel Lymph Node (SLN) hybrid SPECT/CT lymphoscintigraphy before and after nCRT. Methods Patients with clinical stage T2-T3, any N-stage, M0 cancer of the oesophagus or GOJ underwent endoscopically guided peri−/intratumoral injection of radio-colloid followed by hybrid SPECT/CT lymphoscintigraphy prior to, and once again following, nCRT. SPECT/CT images were evaluated to number and location of SLNs and compared between the two examinations. Results Ten patients were included in this pilot trial. SPECT/CT lymphoscintigraphy was performed in twenty procedures. The same Sentinel Lymph Node station before and after nCRT was observed in one single patient. In two patients, no SLN was detected before nCRT. In three patients no SLN was detected following nCRT. In four patients, the SLN stations were not the same station at baseline compared to follow-up examination. Conclusions The reproducibility SLN detection in patients with cancer of the oesophagus/GOJ following nCRT was very poor. nCRT appears to alter lymphatic drainage patterns and thus may affect detection of SLNs and potentially also the accuracy of an SLNB in these patients. On the basis of these initial results, we abort further patient recruitment in our institution. Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR). Identifier ACTRN12618001433291. Date registered: 27/08/2018. Retrospectively registered.

Esophagectomy is an extensive procedure with severe postoperative effects. It can be assumed that the greater the trauma, the longer the nutritional recovery. This retrospective observational single-center cohort study compared weight development after esophagectomy with open and minimally invasive techniques. Three groups were compared in this study, one representing the first 41 patients who underwent the minimally invasive McKeown esophagectomy (MIMK). The second group included the first 84 consecutive patients operated with the minimally invasive Ivor-Lewis esophagectomy (MIIL). The third group comprised 100 consecutive patients operated with open thoracoabdominal Ivor-Lewis esophagectomy (IL). Virtually all patients submitted to a minimally invasive esophagectomy (MIE) and the majority with an IL had a jejunal catheter inserted during operation for postoperative enteral feeding. All together 225 patients were included in this study. The mean weight loss during the first year was 13.1% (±4.1), 11.2% (±6.1), and 9.6% (±7.5) in the IL, MIIL, and MIMK group, respectively (P = 0.85 and P = 0.95, respectively). The median duration of postoperative enteral nutrition support varied substantially within the groups and was 23.5 days in the IL group (range: 0-2033 days), 54.5 days in those having an MIIL (range: 0-308 days; P ≤ 0.001) and 57.0 days among patients in the MIMK group (range: 0-538 days; P ≤ 0.022). There was no difference in the risk of losing at least 10% of the preoperative weight at 3 or 6 months postoperatively between the groups. However, in patients who suffered severe complications (Clavien-Dindo score ≥ IIIb) after MIIL, there was a nonsignificant trend toward a lower risk of a 10% or greater weight loss, 3 months postoperatively. In conclusion, the greater surgical trauma associated with the traditional open esophagectomy was not followed by more severe weight loss, or other signs of poorer nutritional recovery, when compared to minimal invasive surgical techniques.