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Rayan Nikkilä,1– 4 Elli Hirvonen,1 Janne Pitkäniemi,1,5,6 Jari V Räsänen,7 Nea K Malila,1 Antti Mäkitie2,3,8 1Finnish Cancer Registry, Institute for Statistical and Epidemiological Cancer Research, Helsinki, Finland; 2Department of Otorhinolaryngology, Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; 3Research Program in Systems Oncology, Faculty of Medicine, University of Helsinki, Helsinki, Finland; 4Päijät-Häme Joint Authority for Health and Wellbeing, Department of Oral and Maxillofacial Surgery, Lahti Central Hospital, Lahti, 15850, Finland; 5Unit of Health Sciences, Faculty of Social Sciences, Tampere University, Tampere, Finland; 6Department of Public Health, University of Helsinki, Helsinki, Finland; 7Department of General Thoracic and Oesophageal Surgery, Heart and Lung Centre, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; 8Division of Ear, Nose and Throat Diseases, Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet and Karolinska Hospital, Stockholm, SwedenCorrespondence: Antti Mäkitie, Helsinki University Hospital, Department of Otorhinolaryngology, Head and Neck Surgery, P.O.Box 263, FI-00029 HUS, Helsinki, Finland, Tel +358-50-428 6847, Email antti.makitie@helsinki.fiPurpose: The occurrence of a second primary cancer (SPC) after primary esophageal carcinoma (EC) or gastric cardia carcinoma(GCC) is well acknowledged. However, previous research on the risk of SPC among these patients has been predominantly conducted in Asian countries. Yet, notable population-dependent variation in histological types and risk profiles exists. This register-based study assesses the histology-specific risk of SPC among individuals initially diagnosed with a first primary EC or GCC.Patients and Methods: We obtained data on 7197 patients diagnosed with EC/GCC in Finland between 1980 and 2022 from the Finnish Cancer Registry. Standardized incidence ratios (SIR) of SPC were subsequently calculated relatively to the cancer risk of the general population.Results: The average and median follow-up times were 2.8 years and 10.5 months. Adenocarcinomas and squamous cell carcinomas comprised 57.8% (n = 4165) and 36.6% (n = 2631) of all cases, respectively. An increased SIR was noted among EC/GCC patients after 15– 20 years of follow-up (SIR 1.49, 95% CI: 1.01– 2.11). Among adenocarcinoma patients, an increased SIR for SPCs of the digestive organs was seen in the 40– 54-year-old group (SIR 9.86, 95% CI: 3.62– 21.45). Squamous cell carcinoma patients displayed increased SIRs for cancer of the mouth/pharynx (SIR 3.20, 95% CI: 1.17– 6.95) and respiratory organs (1.77, 1.07– 2.76).Conclusion: Healthcare professionals should be aware of the increased risk of SPCs occurring in the mouth/pharynx, respiratory and digestive organs in survivors of EC/GCC. Patients should be advised about this risk and remain alert for symptoms, even beyond the standard 5-year follow-up period.Keywords: esophageal squamous cell carcinoma, adenocarcinoma, gastric cardia carcinoma, tumor, second primary cancer

Background: No national studies comparing long-term survival after total or partial gastrectomy with splenectomy due to injury or oncologic reasons or spleen preservation exist. This study aimed to examine the 5-year overall survival (OS) of patients with gastric adenocarcinoma who underwent total or partial gastrectomy with splenectomy due to injury or oncologic reasons or spleen preservation in a population-based nationwide setting., Methods: This study included all patients undergoing total or partial gastrectomy with splenectomy or spleen preservation for gastric adenocarcinoma in Finland from 2005 to 2016, with follow-up until December 31, 2019. A total of 2196 patients with gastric cancer diagnosis and total or partial gastrectomy were identified in the registries. Of these patients, 2118 were applicable for this study. Cox proportional hazard models provided hazard ratios (HRs) with 95% CIs of 5-year OS. The results were adjusted for age, sex, year of operation, comorbidities, tumor location, pathologic stage, and neoadjuvant therapy., Results: The observed 5-year OS rates were 38.7% in patients with no or minor spleen injury, 39.7% in patients with splenectomy due to injury, and 30.8% in patients with splenectomy due to oncologic reasons (P = .032). Patients who underwent R0 gastrectomy with splenectomy due to oncologic reasons had higher 5-year mortality (the adjusted model HR, 1.26; 95% CI, 1.01-1.56) than patients who underwent spleen preservation., Conclusion: The OS was worst in patients who underwent gastrectomy with splenectomy due to oncologic reasons, highlighting the poor prognosis in patients with advanced gastric cancer. Splenectomy due to injury does not compromise the prognosis., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Reasons for structural and outcome differences in esophageal cancer surgery in Western Europe remain unclear. This questionnaire study aimed to identify differences in the organization of esophageal cancer surgical care in Western Europe. A cross-sectional international questionnaire study was conducted among upper gastrointestinal (GI) surgeons from Western Europe. One surgeon per country was selected based on scientific output and active membership in the European Society for Diseases of the Esophagus or (inter)national upper GI committee. The questionnaire consisted of 51 structured questions on the structural organization of esophageal cancer surgery, surgical training, and clinical audit processes. Between October 2021 and October 2022, 16 surgeons from 16 European countries participated in this study. In 5 countries (31%), a volume threshold was present ranging from 10 to 26 annual esophagectomies, in 7 (44%) care was centralized in designated centers, and in 4 (25%) no centralizing regulations were present. The number of centers performing esophageal cancer surgery per country differed from 4 to 400, representing 0.5-4.9 centers per million inhabitants. In 4 countries (25%), esophageal cancer surgery was part of general surgical training and 8 (50%) reported the availability of upper GI surgery fellowships. A national audit for upper GI surgery was present in 8 (50%) countries. If available, all countries use the audit to monitor the quality of care. Substantial differences exist in the organization and centralization of esophageal cancer surgical care in Western Europe. The exchange of experience in the organizational aspects of care could further improve the results of esophageal cancer surgical care in Europe., (© The Author(s) 2024. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus.)

Background: The purpose of this study was to examine the rates of 90-day anastomotic complications and other postoperative complications after total or partial gastrectomy with antecolic versus retrocolic reconstruction in a population-based setting., Methods: This population-based nationwide retrospective cohort study included all patients undergoing total or partial gastrectomy for gastric adenocarcinoma in Finland in 2005-2016, with follow-up until 31 December 2019. Logistic regression provided odds ratios (ORs) with 95% confidence intervals (CIs) of 90-day mortality. Results were adjusted for age, sex, year of the surgery, comorbidities, tumor locations, pathological stage, and neoadjuvant therapy., Results: A total of 2063 patients having gastrectomy with antecolic (n = 814) or retrocolic (n = 1249) reconstruction were identified from the registries. The anastomotic complication rate was 3.8% with antecolic reconstruction and 5.0% with retrocolic reconstruction. Antecolic reconstruction was not associated with a higher risk of anastomotic complications compared with retrocolic reconstruction in the adjusted analysis (OR 0.69, 95% CI 0.44-1.09) of the whole cohort or in the predefined subgroups. The reoperation rate was 8.2% with antecolic reconstruction and 7.7% with retrocolic reconstruction, without statistical significance. In subgroup analysis of total gastrectomy patients, the risk of major complications was lower with antecolic reconstruction compared with retrocolic reconstruction (OR 0.62, 95% CI 0.45-0.86)., Conclusions: The rate of anastomotic complications did not differ after antecolic versus retrocolic reconstruction after total or partial gastrectomy. In total gastrectomies, the risk of major complications was lower after antecolic compared with retrocolic reconstruction., (© 2024. The Author(s).)

Background: This study aimed to examine the rate of delayed emptying and other 90-day postoperative complications after total, subtotal, and distal gastrectomies for gastric adenocarcinoma in a population-based setting., Methods: This study included all patients who underwent total, subtotal, or distal gastrectomy for gastric cancer in Finland in 2005-2016, with follow-up until December 31, 2019. Logistic regression provided the odds ratios with 95% CIs of 90-day mortality. The results were adjusted for age, sex, year of surgery, comorbidities, pathologic stage, and neoadjuvant therapy., Results: A total of 2058 patients underwent total (n = 1227), subtotal (n = 450), or distal (n = 381) gastrectomy. In the total, subtotal, and distal gastrectomy groups, the rates of 90-day delayed emptying were 1.7%, 1.3%, and 2.1% in the whole cohort and 1.6%, 1.8%, and 3.5% in the subgroup analysis of R0 resections, respectively. The resection type was not associated with the risk of delayed emptying. Subtotal gastrectomy was associated with a lower risk of major complications and reoperations, whereas distal gastrectomy was associated with a lower risk of anastomotic complications., Conclusion: The extent of resection did not affect delayed emptying, whereas fewer postoperative complications were observed after subtotal or distal gastrectomy than after total gastrectomy., Competing Interests: Declaration of competing interest The authors declare no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: There is a lack of evidence regarding anastomotic technique and postoperative complications in gastric cancer surgery. This study aimed to evaluate whether there are differences between stapled and handsewn anastomosis and anastomotic leaks., Methods: This was a population-based, retrospective, nationwide cohort study in Finland using the Finnish National Esophago-Gastric Cancer Cohort. Patients undergoing gastrectomy with available postoperative complication data were included. Logistic regression analysis was used to calculate the odds ratios with 95% CIs, adjusted for calendar period of surgery, age at surgery, sex, comorbidity, tumor stage, neoadjuvant therapy, minimally invasive surgery, type of gastrectomy, radical resection, and type of anastomosis., Results: Of the 2164 patients, 472 of all patients (21.8%) had handsewn anastomosis and 1692 of all patients (78.2%) had stapled anastomosis. In the unadjusted analysis, anastomotic leaks were significantly lower in the handsewn group (hazard ratio [HR], 0.42; 95% CI, 0.22-0.79) than the stapled group, but after adjustment for known prognostic factors, this association was no longer significant (HR, 0.57; 95% CI, 0.27-1.21). In the analysis stratified by gastrectomy type (distal or total), no differences in anastomotic leaks were observed between anastomotic techniques., Conclusion: In this population-based nationwide study, anastomotic technique (stapled or handsewn) was not associated with anastomotic leaks in any, distal or total, gastrectomy., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: To date, no large population-based studies have compared complications and short-term outcomes between neoadjuvant chemotherapy and upfront surgery in gastric cancer. More nationwide studies with standardized reporting on complications are needed to enable international comparison between studies. This study aimed to compare postoperative complications between neoadjuvant therapy and upfront surgery after gastrectomy for gastric adenocarcinoma in a population-based setting., Methods: This population-based study based on the Finnish National Esophago-Gastric Cancer Cohort included all patients 18 years of age or older undergoing gastrectomy for gastric adenocarcinoma in Finland during 2005-2016. Logistic regression provided odds ratios (ORs) with 95% confidence intervals (CIs), both crude and adjusted for key confounders. Different types of complications were graded based on the Esophagectomy Complications Consensus Group definitions, and major complications were assessed by the Clavien-Dindo scale., Results: This study analyzed 769 patients. Neoadjuvant chemotherapy did not increase major postoperative complications after gastrectomy for gastric cancer compared with upfront surgery (OR, 1.12; 95% CI 0.81-1.56). Furthermore, it did not increase pneumonia, anastomotic complications, wound complications, or other complications., Conclusions: Neoadjuvant therapy is not associated with increased postoperative complications, reoperations, or short-term mortality compared with upfront surgery in gastric adenocarcinoma., (© 2023. The Author(s).)

Background: The complication rate of modern antireflux surgery or paraesophageal hernia repair is unknown, and previous estimates have been extrapolated from institutional cohorts., Methods: A population-based retrospective cohort study of patient injury cases involving antireflux surgery and paraesophageal hernia repair from the Finnish National Patient Injury Centre (PIC) register between Jan 2010 and Dec 2020. Additionally, the baseline data of all the patients who underwent antireflux and paraesophageal hernia operations between Jan 2010 and Dec 2018 were collected from the Finnish national care register., Results: During the study period, 5734 operations were performed, and the mean age of the patients was 54.9 ± 14.7 years, with 59.3% (n = 3402) being women. Out of all operations, 341 (5.9%) were revision antireflux or paraesophageal hernia repair procedures. Antireflux surgery was the primary operation for 79.9% (n = 4384) of patients, and paraesophageal hernia repair was the primary operation for 20.1% (n = 1101) of patients. A total of 92.5% (5302) of all the operations were laparoscopic. From 2010 to 2020, 60 patient injury claims were identified, with half (50.0%) of the claims being related to paraesophageal hernia repair. One of the claims was made due to an injury that resulted in a patient's death (1.7%). The mean Comprehensive Complication Index scores were 35.9 (± 20.7) and 47.6 (± 20.8) (p = 0.033) for antireflux surgery and paraesophageal hernia repair, respectively. Eleven (18.3%) of the claims pertained to redo surgery., Conclusions: The rate of antireflux surgery has diminished and the rate of paraesophageal hernia repair has risen in Finland during the era of minimally invasive surgery. Claims to the PIC remain rare, but claims regarding paraesophageal hernia repairs and redo surgery are overrepresented. Additionally, paraesophageal hernia repair is associated with more serious complications., (© 2023. The Author(s).)

Background: The incidence of postoperative complications after gastrectomy for gastric cancer is not well known. More population-based studies using established complication classifications are needed for international comparison. The aim of this study was to evaluate the population-based incidence of postoperative complications after gastrectomy for gastric cancer., Methods: This population-based study based on the Finnish National Esophago-Gastric Cancer Cohort included all patients at least 18 years of age undergoing gastrectomy for gastric adenocarcinoma in Finland during 2005-2016. The occurrence of complications 30 and 90 days after surgery was graded based on the Esophagectomy Complications Consensus Group definitions and the severity of complications was assessed using the Clavien-Dindo scale., Results: This study included a total of 2196 patients. Postoperative complications occurred in 906 (41.3 per cent) of patients during 30 days after surgery and in 946 (43.1 per cent) during 90 days after surgery. Clavien-Dindo grade III or higher complications occurred in 375 (17.1 per cent) of patients. The most common complications 90 days after surgery by Esophagectomy Complications Consensus Group upper-level categories were gastrointestinal (n = 438; 19.9 per cent), including anastomotic leak, infectious (n = 377; 17.2 per cent) and pulmonary (n = 335; 15.3 per cent) complications. Postoperative mortality rate was occurred in 72 (3.3 per cent) patients within 30 days and in 161 (7.3 per cent) patients within 90 days after surgery. The median duration of postoperative hospital stay was 9 days (interquartile range 4-14)., Conclusions: Postoperative complications are common across all types of gastrectomy and the majority occur during the first 30 postoperative days. This study informs the patients and caregivers of the expected outcomes of gastrectomy., (© The Author(s) 2023. Published by Oxford University Press on behalf of BJS Society Ltd.)

Introduction: Oesophageal cancer survival is reported by epidemiological studies, but knowledge on survival trends regarding different histologies and operative treatment status is lacking., Materials and Methods: Data from all patients diagnosed with oesophageal cancer in Finland in 1987-2016 was collected from national registries. 1-, 3- and 5-year survival rates were examined stratified by histology (adenocarcinoma (OAC) and squamous cell carcinoma (OSCC)) and treatment strategy (surgery, no surgery). Hazard ratios (HR) with 95% confidence intervals (CI) for death were provided by multivariable Cox regression, adjusted for confounders., Results: Of the 9102 patients, 3140 had OAC (1074 [34%] oesophagectomies), and 3778 had OSCC (870 [23%] oesophagectomies). Men were overrepresented in both OAC (77%) and OSCC (55%). The proportion of oesophagectomies decreased in both histologies. From 1987 to 1991 to 2012-2016, 5-year survival increased from 11% to 22% in OAC and from 7% to 13% in OSCC. For patients undergoing oesophagectomy, the corresponding increases were from 20% to 49% in OAC and from 11% to 54% in OSCC, and non-operated patients from 5% to 8% and from 5% to 7%, respectively. Earlier calendar period, older age and comorbidity were associated with mortality in both histologies. Female sex was a protective factor for patients operated for OSCC (HR 1.56 (95% CI 1.33-1.83), men versus women)., Conclusions: The prognosis of oesophageal cancer has improved in Finland over the last 30 years in both main histological types. The survival of patients undergoing oesophagectomy has drastically improved, while the prognosis of patients not undergoing surgery is slowly improving but remains poor., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Preoperative esophageal stenting is proposed to have a negative effect on outcomes. The aim was to compare a 5-year survival in patients undergoing esophagectomy for esophageal cancer with and without preoperative esophageal stent in a population-based nationwide cohort from Finland. The secondary outcome was 90-day mortality., Methods: This study included curatively intended esophagectomies for esophageal cancer in Finland between 1999 and 2016, with follow-up until December 31, 2019. Cox proportional hazards models provided hazard ratios (HRs) with 95% confidence intervals (CIs) of overall 5-year and 90-day mortality. Model 1 was adjusted for age, sex, year of the surgery, comorbidities, histology, pathological stage, and neoadjuvant therapy. Model 2 included also albumin level and BMI., Result: Of 1064 patients, a total of 134 patients underwent preoperative stenting and 930 did not. In both adjusted models 1 and 2, higher 5-year mortality was seen in patients with preoperative stent with HRs of 1.29 (95% CI 1.00-1.65) and 1.25 (95% CI 0.97-1.62), respectively, compared to no stenting. The adjusted HR of 90-day mortality was 2.49 (95% CI 1.27-4.87) in model 1 and 2.49 (95% CI 1.25-4.99) in model 2. When including only neoadjuvant-treated patients, those with preoperative stent had a 5-year survival of 39.2% compared to 46.4% without stent (adjusted HR 1.34, 95% CI 1.00-1.80), and a 90-day mortality rate of 8.5% and 2.5% (adjusted HR 3.99, 95% CI 1.51-10.50)., Discussion: This nationwide study reports worse 5-year and 90-day outcomes in patients with preoperative esophageal stent. Since residual confounding remains possible, observed difference could be only an association rather than the cause., (© 2023. The Author(s).)

Objective: The aim of study was to compare overall 5-year survival of esophageal cancer patients undergoing transthoracic esophagectomy with either neck or intrathoracic anastomosis, that is, McKeown and Ivor-Lewis esophagectomy., Background: No national studies comparing long-term survival after McKeown and ivor-Lewis esophagectomies in the West exist., Methods: This population-based nationwide study included all curatively intended transthoracic esophagectomies for esophageal adenocarcinoma or squamous cell carcinoma in Finland in 1987 to 2016, with follow-up until December 31, 2019. Cox proportional hazard models provided hazard ratios (HR) with 95% confidence intervals (ci) of all-cause 5-year mortality. The results were adjusted for age, sex, year of the operation, comorbidities, histology, stage, and neoadjuvant treatment. Adjusted model 2 included also tumor location and lymph node yield., Results: A total of 990 patients underwent McKeown (n = 278) or Ivor-Lewis (n = 712) esophagectomy The observed overall 5-year survival was 43.1% after McKeown, and 45.9% after Ivor-Lewis esophagectomy. McKeown esophagectomy was not associated with the overall 5-year mortality (adjusted HR 1.11, 95% CI: 0.89-1.38), compared to Ivor-Lewis esophagectomy. Additional adjustment for tumor location and lymphadenectomy further attenuated the point estimate (HR 1.06, 95% CI: 0.85-1.33). Surgical approach was not associated with 90-day mortality rate (adjusted HR 1.15, 95% CI: 0.67-1.97)., Conclusions: This population-based nationwide study suggests that overall 5-year survival or 90-day survival with McKeown and Ivor-Lewis esopha-gectomy for esophageal cancer are comparable., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: No population-based studies comparing long-term survival after transhiatal esophagectomy (THE) and transthoracic esophagectomy (TTE) exist. This study aimed to compare the 5-year survival of esophageal cancer patients undergoing THE or TTE in a population-based nationwide setting., Methods: This study included all curatively intended THE and TTE for esophageal cancer in Finland during 1987-2016, with follow-up evaluation until 31 December 2019. Cox proportional hazard models provided hazard ratios (HRs) with 95% confidence intervals (CIs) of 5-year and 90-day mortality. The results were adjusted for age, sex, year of operation, comorbidities, histology, neoadjuvant treatment, and pathologic stage., Results: A total of 1338 patients underwent THE (n = 323) or TTE (n = 1015). The observed 5-year survival rate was 39.3% after THE and 45.0% after TTE (p = 0.072). In adjusted model 1, THE was not associated with greater 5-year mortality (HR 0.99; 95% CI 0.82-1.20) than TTE. In adjusted model 2, including T stage instead of pathologic stage, the 5-year mortality hazard rates after THE (HR 0.87, 95% CI 0.72-1.05) and TTE were comparable. The 90-day mortality rate for THE was higher than for TTE (adjusted HR 0.72; 95% CI 0.45-1.14). In subgroup analyses, no differences between THE and TTE were observed in Siewert II gastroesophageal junction cancers, esophageal cancers, or pN0 tumors, nor in the comparison of THE and TTE with two-field lymphadenectomy. The sensitivity analysis, including patients with missing patient records, who underwent surgery during 1996-2016 mirrored the main analysis., Conclusions: This Finnish population-based nationwide study suggests no difference in 5-year or 90-day mortality after THE and TTE for esophageal cancer., (© 2022. The Author(s).)

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 <50. Analysis with an annual volume cut-off of 30 cases showed similar but less pronounced results. No outcomes suggesting more efficient learning were found for longer experience as consultant, visiting an expert clinic, completing a minimally invasive esophagectomy fellowship or implementation under proctor supervision., 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., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Robotic assistance in lung lobectomy has been suggested to enhance the adoption of minimally invasive techniques among surgeons. However, little is known of learning curves in different minimally invasive techniques. We studied learning curves in robotic-assisted versus video- assisted lobectomies for lung cancer., Methods: A single surgeon performed his first 75 video-assisted thoracic surgery (VATS) lobectomies from April 2007 to November 2012, and his 75 first robotic-assisted thoracic surgery (RATS) lobectomies between August 2011 and May 2018. A retrospective chart review was done. Cumulative sum (CUSUM) analysis was used to identify the learning curve., Results: No operative deaths occurred for VATS patients or RATS patients. Conversion-to-open rate was significantly lower in the RATS group (2.7% vs. 13.3%, p = 0.016). Meanwhile, 90-day mortality (1.3% vs. 5.3%, p = 0.172), postoperative complications (24% vs. 24%, p = 0.999), re- operation rates (4% vs. 5.3%, p = 0.688), operation time (170±56 min vs. 178±66 min, p = 0.663) and length of stay (8.9 ± 7.9 days vs. 8.2 ± 5.8 days, p = 0.844) were similar between the two groups. Based on CUSUM analysis, learning curves were similar for both procedures, although slightly shorter for RATS (proficiency obtained with 53 VATS cases vs. 45 RATS cases, p = 0.198)., Conclusions: Robotic-assisted thoracoscopic lung lobectomy can be implemented safely and efficiently in an expert center with earlier experience in VATS lobectomies. However, there seems to be a learning curve of its own despite the surgeon's previous experience in conventional thoracoscopic surgery., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Nuss bars are increasingly used for minimally invasive correction of pectus excavatum and are usually removed within 3 years of insertion. Previously, several complications related to pectus bar removal have been reported with only 1 case report of aortic haemorrhage. Herein, we report a case with life-threatening aortic haemorrhage during late removal of displaced double Nuss bars., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Patients with pulmonary aspergillomas occasionally undergo surgery but it is somewhat unclear who of these patients benefit from surgical treatment., Methods: We retrospectively evaluated all 22 patients that underwent surgery in Helsinki University Central Hospital between 2004 and 2017. We assessed their clinical backgrounds, anti-fungal medication, indication for surgery, complications, recurrent infections and survival., Results: Of the 22 patients, 14 male and 8 female, mean age 56, an underlying pulmonary disease was present in 20. On immunosuppressive medication were 8 (36%). Most received anti-fungal medication preoperatively (n=12) and/or postoperatively (n=17), 3 patients did not receive anti-fungal medication. Length of the medication periods were diverse. Main indication for surgery was haemoptysis. One in-hospital-death occurred, and other complications included prolonged air-leak, postoperative pneumonia, pneumothorax and pneumomediastinum. No Aspergillus empyema or pleurites occurred. Five-year survival was 54%. One in-hospital-death and one other death were the result of Aspergillus disease, other deaths were unrelated to Aspergillus . Recurrent disease occurred in four cases. Three of these patients were asthma patients with allergic bronchopulmonary aspergillosis (ABPA)., Conclusions: Overall results of surgery in this cohort were good and number of complications was low. Therapy with antifungals was diverse. Surgical treatment of aspergilloma can be life-saving for patients suffering of haemoptysis, and patients with restricted disease and well-preserved pulmonary capacity may benefit from surgery. Careful patient selection is crucial., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare., (2019 Journal of Thoracic Disease. All rights reserved.)

Background: As a result of routine low-dose computed tomographic screening, lung cancer is more frequently diagnosed at earlier, operable stages of disease. In treating local non-small-cell lung cancer, video-assisted thoracoscopic surgery (VATS), a minimally invasive surgical approach, has replaced thoracotomy as the standard of care. While short-term quality-of-life outcomes favor the use of VATS, the impact of VATS on long-term health-related quality of life (HRQoL) is unknown., Patients and Methods: We studied patients who underwent lobectomy for the treatment of non-small-cell lung cancer from January 2006 to January 2013 at a single institution (n = 456). Patients who underwent segmentectomy (n = 27), who received neoadjuvant therapy (n = 13), or who were found to have clinical stage > T2 or > N0 disease (n = 45) were excluded from analysis. At time of HRQoL assessment, 199 patients were eligible for study and were mailed the generic HRQoL instrument 15D., Results: A total of 180 patients (90.5%) replied; 92 respondents underwent VATS while 88 underwent open thoracotomy. The VATS group more often had adenocarcinoma (P = .006), and lymph node stations were sampled to a lesser extent (P = .004); additionally, hospital length of stay was shorter among patients undergoing VATS (P = .001). No other clinical or pathologic differences were observed between the 2 groups. Surprisingly, patients who underwent VATS scored significantly lower on HRQoL on the dimensions of breathing, speaking, usual activities, mental function, and vitality, and they reported a lower total 15D score, which reflects overall quality of life (P < .05)., Conclusion: In contrast to earlier short-term reports, long-term quality-of-life measures are worse among patients who underwent VATS compared to thoracotomy., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Introduction: Surgery for oesophageal and gastric cancers is associated with high morbidity, mortality and poor quality of life postoperatively. The Finnish National Esophago-Gastric Cancer Cohort has been established with the aim of identifying factors that could contribute to improved outcomes in oesophago-gastric cancer., Methods and Analysis: All patients with oesophageal and gastric cancer diagnosed in Finland between 1987 and 2015 will be identified from the Finnish national registries. The Finnish Cancer Registry and Finnish Patient Registry will be used to identify patients that fulfil the inclusion criteria for the study: (1) diagnosis of oesophageal, gastro-oesophageal junction, or gastric cancer, (2) any surgical treatment for the diagnosed cancer and (3) age of 18 or over at the time of diagnosis. Clinical variables and complication information will be retrieved in extensive data collection from the medical records of the relevant Finnish hospitals and complete follow-up for vital status from Statistics Finland. Primary endpoint is overall all-cause mortality and secondary endpoints include complications, reoperations, medication use and sick leaves. Sub-studies will be implemented within the cohort to investigate specific populations undergoing oesophageal and gastric cancer surgery. The initial estimated sample size is 1800 patients with surgically treated oesophageal cancer and 7500 patients with surgically treated gastric cancer., Ethics and Dissemination: The study has been approved by the Ethical Committee in Northern Ostrobothnia, Finland and The National Institute for Health and Welfare, Finland. Study findings will be disseminated via presentations at conferences and publications in peer-reviewed journals., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Evidence suggests that structured training programs for laparoscopic procedures can ensure a safe standard of skill acquisition prior to independent practice. Although minimally invasive esophagectomy (MIO) is technically demanding, no consensus on requirements for training for the MIO procedure exists. The aim of this study is to determine essential steps required for a structured training program in MIO using the Delphi consensus methodology. Eighteen MIO experts from 13 European hospitals were asked to participate in this study. The consensus process consisted of two structured meetings with the expert panel, and two Delphi questionnaire rounds. A list of items required for training MIO were constructed for three key domains of MIO, including (1) requisite criteria for units wishing to be trained and (2) to proctor MIO, and (3) a framework of a MIO training program. Items were rated by the experts on a scale 1-5, where 1 signified 'not important' and 5 represented 'very important.' Consensus for each domain was defined as achieving Cronbach alpha ≥0.70. Items were considered as fundamental when ≥75% of experts rated it important (4) or very important (5). Both Delphi rounds were completed by 16 (89%) of the 18 invited experts, with a median experience of 18 years with minimally invasive surgery. Consensus was achieved for all three key domains. Following two rounds of a 107-item questionnaire, 50 items were rated as essential for training MIO. A consensus among European MIO experts on essential items required for training MIO is presented. The identified items can serve as directive principles and core standards for creating a comprehensive training program for MIO.

To address uncertainty of whether pathologic stage groupings after neoadjuvant therapy (ypTNM) for esophageal cancer share prognostic implications with pathologic groupings after esophagectomy alone (pTNM), we report data-simple descriptions of patient characteristics, cancer categories, and non-risk-adjusted survival-for pathologically staged cancers after neoadjuvant therapy from the Worldwide Esophageal Cancer Collaboration (WECC). Thirty-three institutions from six continents submitted data using variables with standard definitions: demographics, comorbidities, clinical cancer categories, and all-cause mortality from first management decision. Of 7,773 pathologically staged neoadjuvant patients, 2,045 had squamous cell carcinoma, 5,686 adenocarcinoma, 31 adenosquamous carcinoma, and 11 undifferentiated carcinoma. Patients were older (61 years) men (83%) with normal (40%) or overweight (35%) body mass index, 0-1 Eastern Cooperative Oncology Group performance status (96%), and a history of smoking (69%). Cancers were ypT0 (20%), ypT1 (13%), ypT2 (18%), ypT3 (44%), ypN0 (55%), ypM0 (94%), and G2-G3 (72%); most involved the distal esophagus (80%). Non-risk-adjusted survival for yp categories was unequally depressed, more for earlier categories than later, compared with equivalent categories from prior WECC data for esophagectomy-alone patients. Thus, survival of patients with ypT0-2N0M0 cancers was intermediate and similar regardless of ypT; survival for ypN+ cancers was poor. Because prognoses for ypTNM and pTNM categories are dissimilar, prognostication should be based on separate ypTNM categories and groupings. These data will be the basis for the 8th edition cancer staging manuals following risk adjustment for patient, cancer, and treatment characteristics and should direct 9th edition data collection., (© 2016 International Society for Diseases of the Esophagus.)

To address uncertainty of whether clinical stage groupings (cTNM) for esophageal cancer share prognostic implications with pathologic groupings after esophagectomy alone (pTNM), we report data-simple descriptions of patient characteristics, cancer categories, and non-risk-adjusted survival-for clinically staged patients from the Worldwide Esophageal Cancer Collaboration (WECC). Thirty-three institutions from six continents submitted data using variables with standard definitions: demographics, comorbidities, clinical cancer categories, and all-cause mortality from first management decision. Of 22,123 clinically staged patients, 8,156 had squamous cell carcinoma, 13,814 adenocarcinoma, 116 adenosquamous carcinoma, and 37 undifferentiated carcinoma. Patients were older (62 years) men (80%) with normal body mass index (18.5-25 mg/kg 2 , 47%), little weight loss (2.4 ± 7.8 kg), 0-1 ECOG performance status (67%), and history of smoking (67%). Cancers were cT1 (12%), cT2 (22%), cT3 (56%), cN0 (44%), cM0 (95%), and cG2-G3 (89%); most involved the distal esophagus (73%). Non-risk-adjusted survival for squamous cell carcinoma was not distinctive for early cT or cN; for adenocarcinoma, it was distinctive for early versus advanced cT and for cN0 versus cN+. Patients with early cancers had worse survival and those with advanced cancers better survival than expected from equivalent pathologic categories based on prior WECC pathologic data. Thus, clinical and pathologic categories do not share prognostic implications. This makes clinically based treatment decisions difficult and pre-treatment prognostication inaccurate. These data will be the basis for the 8th edition cancer staging manuals following risk adjustment for patient characteristics, cancer categories, and treatment characteristics and should direct 9th edition data collection., (© 2016 International Society for Diseases of the Esophagus.)

We report data-simple descriptions of patient characteristics, cancer categories, and non-risk-adjusted survival-for patients with pathologically staged cancer of the esophagus and esophagogastric junction after resection or ablation with no preoperative therapy from the Worldwide Esophageal Cancer Collaboration (WECC). Thirty-three institutions from six continents submitted de-identified data using standard definitions: demographics, comorbidities, clinical cancer categories, and all-cause mortality from first management decision. Of 13,300 patients, 5,631 had squamous cell carcinoma, 7,558 adenocarcinoma, 85 adenosquamous carcinoma, and 26 undifferentiated carcinoma. Patients were older (62 years) men (80%) with normal body mass index (51%), little weight loss (1.8 kg), 0-2 ECOG performance status (83%), and a history of smoking (70%). Cancers were pT1 (24%), pT2 (15%), pT3 (50%), pN0 (52%), pM0 (93%), and pG2-G3 (78%); most involved distal esophagus (71%). Non-risk-adjusted survival for both squamous cell carcinoma and adenocarcinoma was monotonic and distinctive across pTNM. Survival was more distinctive for adenocarcinoma than squamous cell carcinoma when pT was ordered by pN. Survival for pTis-1 adenocarcinoma was better than for squamous cell carcinoma, although monotonic and distinctive for both. WECC pathologic staging data is improved over that of the 7th edition, with more patients studied and patient and cancer variables collected. These data will be the basis for the 8th edition cancer staging manuals following risk adjustment for patient, cancer, and treatment characteristics, and should direct 9th edition data collection. However, the role of pure pathologic staging as the principal point of reference for esophageal cancer staging is waning., (© 2016 International Society for Diseases of the Esophagus.)

Endoscopically superimposed Amplatzer (St. Jude Medical, St. Paul, Minnesota, United States) septal occluder plug was successfully used in the treatment of septic right main bronchus fistula having developed after extrapleural pneumonectomy and heated chemotherapy in two patients with malignant pleural mesothelioma. In the first case the method was curative and in the other Amplatzer served as temporary bridging allowing rehabilitation from empyema and sepsis. After 4.5 and 4.2 years both patients are alive with no sign of relapse of mesothelioma or infection., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: No randomized studies exist comparing pneumonectomy (PN) and sleeve lobectomy (SL). We evaluated surgical results and long-term quality of life in patients operated on for central non-small cell lung cancer (NSCLC) using either SL or PN., Methods: A total of 641 NSCLC patients underwent surgery 2000-2010. SL was performed in 40 (6.2%) and PN in 67 (10.5%). In 2011, all surviving patients were sent a 15D Quality of Life Questionnaire which 83% replied. Propensity-score-matching analysis was utilized to compare the groups., Results: Thirty-two bronchial (18 right/14 left), seven vasculobronchial (3 right/4 left), one right wedge SL, and 18 right and 22 left PN were performed. Preoperatively, the Charlson Comorbidity Index (CCI) score, forced expiratory volume in 1 s (FEV1) and diffusion capacity did not differ between groups. The perioperative complication rate and pattern were similar, but SL group had less major complications (P<0.027). One perioperative death (2.5%) occurred in SL group and four (6%) in PN. The 90-day mortality rate was 5% (n=2) for SL and 7.5% (n=5) for PN. In the follow-up total cancer recurrence did not differ (P=0.187). Quality of life measured by 15D showed no significant difference in separate dimensions or total score, except tendency to favor SL in moving or breathing. The 5-year survival did not differ between groups (P=0.458), but no deaths were observed in SL group after 5 years., Conclusions: Due to less major operative complications and better long-term survival, we would advocate using SL when feasible, but in patients tolerating PN it should be considered if SL seems not to be oncologically sufficiently radical.

Background: This study aimed at defining the mortality and the nature of fatal complications that arise out of esophageal ulcer for one clearly defined geographical area., Methods: In this national, population-based study, the occurrence of fatal esophageal ulcer or ulcer requiring hospital treatment between January 1987 and December 2000 was assessed by the use of Finland's administrative databases. Medical records provided etiology of fatal ulcer and agonal symptoms., Results: Due to an esophageal ulcer, 2,242 patients received treatment in Finnish hospitals, at an annual frequency of 3.2/100,000. Ulcer with hemorrhage (53.5%), perforation (38.4%), or aspiration pneumonia (2.3%) was the cause of death in 86 patients for an annual mortality of 0.12/100,000. Based on the number of ulcers treated, 3.8% cases ended fatally. Gastroesophageal reflux disease (GERD) seemed to be the etiologic factor for ulcer in 68 (79.0%) patients. The most common agonal symptoms were hematemesis (41.8%), abdominal pain (25.6%), melaena (22.1%), and dyspnea (17.4%). Twenty (23.3%) patients were found dead at home., Conclusion: The rarity of the disease, related disorders, and the diversity of symptoms make the complicated esophageal ulcer a diagnostic challenge. Effective monitored treatment for severe GERD may be an important step to prevent fatal outcome.

Background: Retrospective evaluation of the long-term health-related quality of life (HRQoL) among survivors after non-small-cell lung cancer (NSCLC) surgery., Patients and Methods: A total of 586 patients underwent surgery for NSCLC in Helsinki University Central Hospital between January 2000 and June 2009. Two validated quality-of-life questionnaires, the 15D and the EORTC QLQ-C30 with its lung cancer-specific module, QLQ-LC13, were sent to the 276 patients alive in June 2011. Response rate was 83.3%. Results of the 15D were compared with those of an age- and gender-standardized general population., Results: Median follow-up was 5 years. Compared with a general population, our patients had a significantly lower 15D total score, representing their total HRQoL and scores for dimensions of mobility, breathing, usual activities, depression, distress, and vitality. The patients, however, scored significantly higher on vision, hearing, and mental function., Conclusions: NSCLC survivors may suffer postoperatively from permanently reduced long-term HRQoL compared to an age- and gender-matched general population. This is essential patient information as more patients are surviving longer., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Trees can improve air quality by capturing particles in their foliage. We determined the particle capture efficiencies of coniferous Pinus sylvestris and three broadleaved species: Betula pendula, Betula pubescens and Tilia vulgaris in a wind tunnel using NaCl particles. The importance of leaf surface structure, physiology and moderate soil drought on the particle capture efficiencies of the trees were determined. The results confirm earlier findings of more efficient particle capture by conifers compared to broadleaved plants. The particle capture efficiency of P. sylvestris (0.21%) was significantly higher than those of B. pubescens, T. vulgaris and B. pendula (0.083%, 0.047%, 0.043%, respectively). The small leaf size of P. sylvestris was the major characteristic that increased particle capture. Among the broadleaved species, low leaf wettability, low stomatal density and leaf hairiness increased particle capture. Moderate soil drought tended to increase particle capture efficiency of P. sylvestris., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Aim: To identify linear peptide homing to non-small cell lung cancer (NSCLC) tumor cells using ex vivo phage display method., Materials and Methods: Twenty-six clinical patient samples were used to identify linear homing peptide, which was exposed to NSCLC cell cultures and control cell lines to determine cell binding affinity and cell localization. Also, ex vivo biodistribution was analyzed using tumor-bearing mice., Results: The panning yielded peptide enrichment with a core motif (A)/SRXPXXX. Based on this, an amino acid sequence, ARRPKLD, was selected for characterization and named Thx-peptide. The in vitro binding properties of Thx-peptide demonstrated selectivity toward NSCLC. Internalization assays showed that Thx-Alexa and fluorescein conjugates were located in a subset of perinuclearly located lysosomes of tumor cells. Thx-peptide appeared with fluorescein-labeled peptide and peptide-DTPA-chelator complex in adenocarcinoma xenografts in mice., Conclusion: Thx shows promise for targeted imaging and drug delivery.

Background: ([18F])fluorodeoxyglycose-Positron Emission Tomography/Computer Tomography (([18F])FDG-PET/CT) is commonly used in staging of locally advanced esophageal cancer. Its predictive value for response to neoadjuvant therapy and survival after multimodality therapy is controversial., Methods: Sixty-six consecutive patients with locally advanced adenocarcinoma of the esophagus or esophagogastric junction underwent surgery after neoadjuvant chemotherapy. Staging was done prospectively with ([18F])FDG-PET/CT, before and after completion of neoadjuvant therapy. Pre- and post-therapy maximal standardized uptake values for the primary tumor (SUV1 and SUV2) were determined, and their relative change (SUV∆%) calculated. Percentage change in SUV1 was compared with histopathologic response (HPR, complete or subtotal histologic remission), disease-free- (DFS) and overall survival (OS)., Results: Resection with negative margins was achieved in 60 patients. HPR rate was 14 of 66 (21.2%). Median follow-up was 16 months (range 4-72). For all patients, OS probability at three years was 59% and DFS 50%. In receiver operating characteristics (ROC) analysis, HPR was optimally predicted by a > 67% change in baseline maximal SUV (sensitivity 79% and specificity 75%). In univariate survival analysis (Cox regression proportional hazards), HPR associated with improved DFS (HR 0.208, p = 0.033) but not OS (HR 0.030, p = 0.101), SUV % > 67% associated with improved OS (HR 0.249, p = 0.027) and DFS (HR 0.383, p = 0.040). In a multivariate model (adjusted by age, sex, and ASA score), neither HPR nor SUV∆% > 67% was predictive of improved OS and DFS. However, SUV∆% as a continuous variable was an independent predictor of OS (HR 0.966, p < 0.0001) or DFS (HR 0.973, p < 0.0001)., Conclusion: Our results support previous results showing that ([18F])FDG-PET/CT can distinguish a group of patients with worse prognosis after neoadjuvant chemotherapy in adenocarcinoma of the esophagus or esophagogastric junction. This information could offer a new independent preoperative marker of prognosis.

Objective: Fundoplication is widely used to treat gastroesophageal reflux disease (GERD). Whether it diminishes the development of esophageal adenocarcinoma (EAC) is, however, controversial. Our aim was to define, at the national level in Finland, frequency and predisposing factors for post-fundoplication EAC., Methods: For this population-based study from 1980 to 2006, Finland's administrative databases provided preliminary data. Analyses of EAC patient records (N = 1035) led us to include those with preceding antireflux surgery. Conservatively treated patients were not analyzed. The EAC incidence in patients with antireflux surgery was compared with that in the general population (1987-2006) by means of standardized incidence ratio (SIR)., Results: A total of 53 (5.1%) EAC patients had undergone antireflux surgery. Of these patients with male predominance (74%), preoperatively 41 (77%) had developed endoscopic esophagitis, 40 (75%) hiatal hernia, 24 (45%) Barrett's esophagus (BE), nine (17%) ulcer in the esophagus or gastroesophageal junction, and three (6%) stricture. Postoperatively, histologically confirmed BE was present in 42 (79%). Antireflux surgery had preceded EAC at a mean interval of 10.1 years (range 0.5-25.6 years). This interval was significantly (p=0.02) shorter in patients with long-term functioning fundoplication (n = 15; 30%) at EAC diagnosis (6.4 years, range 0.5-15.2 years) than in those (n = 22, 44%) with failure (11.2 years, range 4.0-24.3 years). Overall, the SIR for EAC after antireflux surgery (1987-2006) was 9.21., Conclusions: Intention-to-treat GERD with antireflux surgery does not prevent EAC. It often develops more than 5 years postoperatively, also in the patients with a good antireflux barrier. Only one-third of the patients had, however, a functioning fundoplication. Preoperative BE and endoscopic esophagitis may be risk factors. Prospective, long-term, randomized studies in experienced centers may reveal the definite effect of antireflux surgery on EAC development., (Copyright © 2011 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

Background: Patients undergoing surgery for non-small cell lung cancer (NSCLC) are often elderly with co-morbid conditions and decreased performance status. Thus, the morbidity of lung resection via thoracotomy may be unacceptable for some patients. This is the reason why video-assisted thoracoscopic surgery (VATS) instead of open thoracotomy has gained more use and acceptance, especially in patients with stage I disease. The aim of this study was to evaluate the difference between VATS and open thoracotomy in treatment outcomes of stage I NSCLC patients., Methods: A total of 328 stage I NSCLC patients underwent lobectomy, bilobectomy or segmentectomy between January 2000 and February 2010. VATS was implemented in 116 patients, of which 16 were converted to thoracotomy. Muscle-sparing anterolateral thoracotomy was performed in 212. Propensity-matched groups were analyzed based on preoperative variables and stage., Results: VATS was associated with lower postoperative morbidity in both overall (p = 0.020) and propensity-matched analysis (p = 0.026) and shorter hospitalization (both p < 0.001). Patients selected for VATS were older (p = 0.001) with a significantly higher Charlson comorbidity index (p = 0.007) and poorer diffusion capacity (p < 0.001). The conversion rate was 14%. Between the two groups, no significant difference was observable in two-year overall and progression-free survival., Conclusions: Despite the VATS lobectomy and segmentectomy patients' being older, with more comorbid condition and poorer pulmonary function, the incidence of major complications was lower and hospitalization shorter than for open thoracotomy patients. For stage I NSCLC, VATS should be considered the primary surgical approach.

Background: The role of fundoplication in the prevention of esophageal adenocarcinoma is controversial. Development of cancer is associated with proliferation and anti-apoptosis, for which little data exist regarding their response to fundoplication., Methods: Ki-67 and Bcl-2 expression was assessed in the esophagogastric junction (EGJ) and the distal and proximal esophagus of 20 patients with gastroesophageal reflux disease (GERD) treated by fundoplication and in 7 controls. Endoscopy was performed preoperatively and 6 (20 patients) and 48 months (16 patients) postoperatively., Results: There were positive correlations between Ki-67 and Bcl-2 levels in the EGJ (p > 0.001) and in the distal (p = 0.001) and proximal esophagus (p = 0.013). Compared to the preoperative level, Ki-67 expression was elevated in the distal (p = 0.012) and proximal (p = 0.007) esophagus at 48 months. In addition, compared to control values, Ki-67 expression was lower at the 6-month follow-up in the EGJ (p = 0.037) and the proximal esophagus (p = 0.003), and higher at the 48-month follow-up in the distal esophagus (p = 0.002). Compared to control values, Bcl-2 was lower at 6 months in the EGJ (p = 0.038)., Conclusions: Proliferative activity after fundoplication increased in the long term in the distal esophagus despite a normal fundic wrap and healing of GERD., (Copyright © 2011 S. Karger AG, Basel.)

Surgery for non-small cell lung cancer (NSCLC) is associated with a significant negative impact on health-related quality of life (HRQoL), but only a few published studies evaluate the long-term HRQoL and its association with preoperative pulmonary function tests (PFTs). We conducted a prospective study, with 53 patients undergoing lobectomy (n=49) or bilobectomy (n=4) for NSCLC, between May 2002 and September 2005. The 15D HRQoL instrument was administered preoperatively, and 3, 12, and 24 months postoperatively. Preoperative PFTs were recorded. We also compared the preoperative HRQoL results to an age-standardized general population. The two-year survival was 81%, 43/53 patients. Sustained impairment of HRQoL was noted two years after the surgery. No correlation emerged between preoperative PFTs and postoperative HRQoL. No differences were observed between stages I-II and stage III patients. Thus, lobectomy and bilobectomy are associated with significant sustained decrease especially in breathing, sleeping, usual activities, mental function, vitality and sexual activity, and in the overall HRQoL. These findings maybe used as preoperative patient information to emphasize the long-term consequences of lung cancer surgery., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

In open or video-assisted thoracic surgery, injury to one to four intercostal sensory nerves is a well-recognized complication. This nerve damage is a well-defined cause for chronic postoperative pain. In this discussion, the motor innervation of the rectus abdominis muscle with the T7 to T12 intercostal nerves has been neglected. Paralysis of rectus abdominis might pose significant burden on patients, delay recovery, and thus warrants exploration.

Objectives: Data on mortality from paraesophageal hernia are scarce. This study focused on mortality associated with its natural history or conservative treatment., Methods: For this population-based retrospective study, Finland's administrative databases provided preliminary data. Among 333 patients who died from benign esophageal diseases or hiatal hernias, analysis of medical records led us to include 32., Results: From 1987 through 2001 in Finnish hospitals, 563 patients underwent surgical intervention and 67 underwent conservative treatment for paraesophageal hernia. This hernia caused death (mortality, 0.6/1,000,000 of the adult population; 95% confidence interval, 0-1.8/1,000,000) in 32 patients, 29 (91%) with concomitant diseases. The overall mortality rate for the 563 having surgical treatment was 2.7% (15 patients). Three died after elective repair. Of 67 patients hospitalized for symptomatic paraesophageal hernia and treated conservatively, 11 (16.4%) died in the hospital within a mean of 42 months (range, 2-96 months) from onset of symptoms. Four (13%) deaths might have been prevented by elective surgical intervention. Of the 32 deceased patients, 4 (12.5%) had type II, 16 (50%) had type III, and 9 (28.1%) had type IV hiatal hernias. In 3 (9.4%) patients type remained unknown. Death resulted from incarceration in 24 (75%), complications of surgical intervention in 6 (18.8%), and bleeding ulcer in 2 (6.2%)., Conclusions: Overall, most deaths were related to type III or IV hernias in aged patients with concomitant diseases, with those with severe symptoms requiring hospitalization at significant risk. Except for those at high surgical risk, we recommend repair of the paraesophageal hernia, at least in symptomatic patients.

Background: Cigarette smoke is strongly associated with NSCLC, but the carcinogenesis of NSCLC is poorly understood., Methods: To discover the role of oxidative stress and anti-oxidative defense in NSCLC, we measured NADPH oxidase (NOX) activity, myeloperoxidase activity, 8-OHdG, and glutathione content from lung specimens. These came from 32 patients: 22 NSCLC patients and ten controls without cancer., Results: In NSCLC patients, NOX activity was significantly higher both in the malignant (p = 0.001) and non-malignant (p = 0.044) samples from NSCLC patients, than in the control specimens. Myeloperoxidase activity was lower (p = 0.001) and glutathione content (p = 0.009) higher in malignant tissue. No significant difference was observable in 8-OHdG content between patient groups., Conclusions: Increase in NOX activity in the malignant tissues was independent of smoking history and myeloperoxidase activity, suggesting its independent role in NSCLC pathogenesis.

Background: Oxidative stress has a role in the pathogenesis of gastroesophageal reflux disease (GERD)., Aim: To investigate the redox balance in proximal esophagus before and 6 and 48 months after antireflux surgery., Methods: In 20 GERD patients and 9 controls oxidative stress by myeloperoxidase activity (MPO activity) and antioxidative capacity of esophageal mucosa by superoxide dismutase activity (SOD), and glutathione content (GSH) was measured from proximal esophageal samples., Results: In proximal esophagus of GERD patients compared to controls', antioxidative capacity appearing as GSH level was significantly decreased (P < 0.001) at all time points and as SOD levels preoperatively (P < 0.001) and 4 years postoperatively (P = 0.01). MPO activity of patients was significantly lower than controls' preoperatively, and 6 months and 4 years postoperatively (P < 0.05). MPO activity remained lower than that of the distal esophagus at 6 months and 4 years (P < 0.01 for both)., Conclusions: In GERD patients, proximal esophageal mucosal antioxidative defense is defective before and after antireflux surgery. Antireflux surgery seems not to change the level of oxidative stress in proximal esophagus, suggesting that defective mucosal antioxidative capacity plays a role in development of oxidative damage to the esophageal mucosa in GERD.

Purpose: The most common marker of oxidative DNA damage is 8-hydroxydeoxyguanosine (8-OHdG), which is linked with several malignancies. In the present study we investigated whether DNA damage linked to oxidative stress (as 8-OHdG) is present in Barrett's mucosa with or without associated adenocarcinoma or high-grade dysplasia and in normal controls' squamous mucosa., Experimental Design: We measured 8-OHdG in 51 patients (13 Barrett's metaplasia, six Barrett's oesophagus with high-grade dysplasia, 18 adenocarcinoma of the distal oesophagus/oesophagogastric junction and 14 normal controls). The amount of DNA damage was determined by high-performance liquid chromatography in oesophagus samples obtained either from endoscopy or as samples from surgery. The median 8-OHdG concentration was expressed as the ratio of 8-OHdG per 10(5) deoxyguanosine., Results: Analysis revealed that 8-OHdG was present in both Barrett's metaplasia with and without dysplasia as well as in adenocarcinoma of the oesophagus/oesophagogastric junction. Although the study group was small the amount of 8-OHdG was significantly increased in the distal oesophagus both in Barrett's epithelium 1.26 (0.08-29.47) and in high-grade dysplasia 1.35 (1.04-1.65) as well as in adenocarcinoma of oesophagus/oesophagogastric junction 1.08 (0.59-1.94) compared to controls 0.06 (0-4.08) (p=0.002, p=0.012, p=0.001, respectively). Barrett's patients had no significant difference in 8-OHdG levels between their distal and proximal oesophageal samples., Conclusions: Our results show the presence of oxidative DNA damage in the distal oesophagus of patients with Barrett's oesophagus and adenocarcinoma of the oesophagus/oesophagogastric junction. This may have a connection to carcinogenesis in Barrett's oesophagus.

Background: Pneumonectomy is associated with high morbidity and mortality. After pneumonectomy, data on health-related quality of life (HRQoL) or its correlation with dyspnea and lung function are scarce. Our main aim was to evaluate long-term HRQoL after pneumonectomy., Methods: In a retrospective one-center cross-sectional study, we investigated 31 of 98 patients who underwent pneumonectomy between January 1997 and October 2003 due to primary lung cancer. Pre- or postoperative chemotherapy or radiotherapy was applied according to hospital protocol. In June 2004, all patients alive received the generic HRQoL instrument (15D), as well as the Baseline Dyspnea Index (BDI). Results of the 15D were compared with those for an age- and gender-standardized general population. In April 2005, 20 patients participated in follow-up spirometric pulmonary function tests., Results: The 15D total score and its various dimensions were significantly lower after pneumonectomy than in the general population. Females both in 15D score and in the BDI had more dyspnea (p<0.05). No difference appeared between right and left pneumonectomy patients, except for more prominent dyspnea in women with right-sided pneumonectomy., Conclusions: Pneumonectomy had a negative impact on patients' HRQoL. The use of a broad HRQoL instrument like the 15D, which covers multiple dimensions of HRQoL, yields a more accurate evaluation than did a single-dimension HRQoL instrument. Possibilities for sleeve-resection should be considered thoroughly before any pneumonectomy., Summary: Quality of life (QoL) after pneumonectomy, as measured with a generic QoL instrument, the 15D, was compared in an age- and gender-standardized population. QoL after pneumonectomy was significantly lower, especially in women after right-sided pneumonectomy.

Objectives: The population impact of modern treatment on complicated gastroesophageal reflux disease (GERD) is not well understood. Our aim was to determine the current mortality from GERD in Finland and compare this with the use of health resources., Methods: In this population-based retrospective study, Finland's administrative databases provided figures on the nationwide use of antireflux medication, rate of antireflux surgery, and mortality from GERD. Any deceased person included had classic symptoms as well as objective findings of GERD., Results: After analysis of the medical records of 306 patients, 213 were included. Annual mortality from GERD increased (P < 0.001) from 0.18/100,000 in 1987 to 0.46/100,000 in 2000. During that time, use of H2-blockers and proton pump inhibitors and the annual rate of antireflux surgery increased significantly (P < 0.001). Mortality from antireflux surgery, including fundoplication and gastric and esophageal resection, remained around 1.9/1,000 operations. Of the 213 patients whose cause of death was considered to be GERD, 180 (85%) had received medical treatment, including 4 patients whose death was related to either diagnostic or therapeutic endoscopy. Early complications of antireflux surgery caused 24 (11%) deaths; 9 (4%) were late failures of antireflux surgery. Causes of death in the medical group were hemorrhagic esophagitis (82, 47%), aspiration pneumonia (41, 23%), ulcer perforation (25, 14%), rupture with esophagitis (15, 9%), and stricture (13, 7%)., Conclusions: Regardless of the increased use of health resources, mortality from GERD, especially with medical treatment, rose. Surgery for GERD was also associated with early mortality and usually could not prevent the fatal outcome.

Background and Aim: Oxidative stress to esophageal mucosa plays a key role in the pathogenesis of gastroesophageal reflux disease (GERD), Barrett's esophagus, and adenocarcinoma. We investigated whether successful antireflux surgery eliminates oxidative stress., Methods: Oxidative stress of esophageal mucosa was measured in 20 GERD patients, before antireflux surgery and 6 and 48 months after it, and compared with normal controls' mucosa (N = 9). Preoperatively, 12 of the 20 had erosive esophagitis or Barrett's metaplasia. Postoperatively, healing of GERD was verified with endoscopy and 24-h pH monitoring. We measured oxidative stress by myeloperoxidase activity (MPA), superoxide dismutase activity, and glutathione content (GSH) in distal esophagus samples from endoscopy., Results: No patient had reflux symptoms after surgery, and pH measurements had normalized. MPA in the distal esophagus decreased (p < 0.05) after successful antireflux surgery, but remained higher than that of controls both 6 months and 4 yr postoperatively (p < 0.05). At all time-points, MPA was higher in patients with preoperatively detected erosive reflux disease (ERD) as compared to non-erosive reflux disease (NERD) (p < 0.01, p < 0.05, and p < 0.05, respectively). GSH values decreased with time only in NERD. At all time-points, GSH levels in distal esophagus were lower than control levels., Conclusions: Antireflux surgery can heal macroscopic esophagitis but cannot fully reverse the oxidative stress (as reflected by MPA and GSH) upon the distal esophageal mucosa.

Gastropericardial fistula, purulent pericarditis, and cardiac tamponade developed 7 years after laparoscopic Nissen fundoplication. The patient was successfully managed through a thoracotomy by open drainage of the pericardium, excision and closure of the fistula, and an omentum flap.

In adenocarcinoma of the esophagus and esophagogastric junction for prognostication and treatment allocation, one prerequisite is accurate pretreatment staging. This staging, we hypothesized, would be improved by the use of positron emission tomography (PET). After 55 patients suitable for radical esophageal resection were staged with PET, spiral computed tomography (CT), and endoscopic ultrasonography (EUS), results were compared with histopathology and with survival. Accuracy in detecting locoregional lymph node metastasis did not differ significantly between EUS (72%), PET (60%), and CT (58%). Adding PET to standard staging failed to improve the accuracy of N staging (P=0.250). In M staging, accuracy between CT (75%) and PET (76%) did not differ. The accuracy of combined studies of CT and PET and of EUS, CT, and PET were 87% (P=0.016 versus CT) and 91% (P=0.031 versus EUS and CT), respectively. Of the 55 patients, 19 (35%) had metastatic lesions. By combined use of CT and EUS and by combined use of CT, EUS, and PET, 8 and 14 (P=0.031), respectively, could be detected. In nodal disease without distant metastases, PET did not improve the prediction of survival. However, positive PET for distant metastasis by either positive EUS or CT predicts well the poor survival of these patients. The staging value of PET by itself in adenocarcinoma of the esophagus is limited because of low accuracy for nodal and the lack of specificity for distant disease prognosis. Adding PET to standard staging does, however, improve detection of stage IV disease and its associated poor survival.

Background: Exact preoperative staging of esophageal cancer is essential for accurate prognosis and selection of appropriate treatment modalities., Methods: Forty-two patients with adenocarcinoma of the esophagus or the esophagogastric junction suitable for radical esophageal resection were staged with positron emission tomography (PET), spiral computed tomography (CT), and endoscopic ultrasonography (EUS)., Results: Diagnostic sensitivity for the primary tumor was 83% for PET and 67% for CT; for local peritumoral lymph node metastasis, it was 37% for PET and 89% for EUS; and for distant metastasis, it was 47% for PET and 33% for CT. Diagnostic specificity for local lymph node metastasis was 100% with PET and 54% with EUS, and for distant metastasis, it was 89% for PET and 96% for CT. Accuracy for locoregional lymph node metastasis was 63% for PET, 66% for CT, and 75% for EUS, and for distant metastasis, it was 74% with PET and 74% with CT. Of the 10 patients who were considered inoperable during surgery, PET identified 7 and CT 4. The false-negative diagnoses of stage IV disease in PET were peritoneal carcinomatosis in two patients, abdominal para-aortic cancer growth in one, metastatic lymph nodes by the celiac artery in four, and metastases in the pancreas in one. PET showed false-positive lymph nodes at the jugulum in three patients., Conclusions: The diagnostic value of PET in the staging of adenocarcinoma of the esophagus and the esophagogastric junction is limited because of low accuracy in staging of paratumoral and distant lymph nodes. PET does, however, seem to detect organ metastases better than CT.

Objective: To assess the impact of surgical treatment on health-related quality of life (QoL) and its various dimensions in four common gastrointestinal diseases, to compare it with that of the general population, and to assess the relationship between the patient's and the surgeon's satisfaction., Design: Prospective, observational study., Setting: Tertiary care centre, Finland., Patients: 131 patients, of whom 77 had cholecystectomy, 20 fundoplication, 20 incisional herniorrhaphy, 12 large bowel resection, and 2 construction of a stoma only because of unresectable colorectal cancer., Interventions: Routine operative treatment of four gastrointestinal diseases., Main Outcome Measures: QoL measured by a generic 15-dimensional instrument., Results: The health-related QoL improved postoperatively in the entire group. Discomfort, symptoms, and vitality were all reduced at 2 months, whereas bowel movements, eating, and usual activities had been restored at 12 months. The health related QoL was comparable with that of the general population at 12 months except for breathing and sleeping. The pattern of recovery varied among diagnostic subgroups, being most improved in patients operated on for biliary disease, those aged 60 years or younger, women and otherwise previously healthy patients. There was a close agreement between the patient's and the surgeon's opinion of outcome., Conclusions: Gastrointestinal surgery improves quality of life. Separating a generic health-related QoL measure into dimensions allows a more appropriate estimation of quality of life than a single index score. Because some dimensions were made worse soon after operation and some were restored slowly, a minimum 12-month follow-up may be needed to assess the effect of gastrointestinal surgery on health- related QoL.