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Objective: The objective of this study was to test the hypothesis that bariatric surgery decreases the risk of esophageal and cardia adenocarcinoma. Background: Obesity is strongly associated with esophageal adenocarcinoma and moderately with cardia adenocarcinoma, but whether weight loss prevents these tumors is unknown. Methods: This population-based cohort study included patients with an obesity diagnosis in Sweden, Finland, or Denmark. Participants were divided into a bariatric surgery group and a nonoperated group. The incidence of esophageal and cardia adenocarcinoma (ECA) was first compared with the corresponding background population by calculating standardized incidence ratios (SIR) with 95% CIs. Second, the bariatric surgery group and the nonoperated group were compared using multivariable Cox regression, providing hazard ratios (HR) with 95% CI, adjusted for sex, age, comorbidity, calendar year, and country. Results: Among 748,932 participants with an obesity diagnosis, 91,731 underwent bariatric surgery, predominantly gastric bypass (n=70,176; 76.5%). The SIRs of ECA decreased over time after gastric bypass, from SIR= 2.2 (95% CI, 0.9--4.3) after 2 to 5 years to SIR= 0.6 (95% CI, <0.1--3.6) after 10 to 40 years. Gastric bypass patients were also at a decreased risk of ECA compared with nonoperated patients with obesity [adjusted HR= 0.6, 95% CI, 0.4--1.0 (0.98)], with decreasing point estimates over time. Gastric bypass was followed by a strongly decreased adjusted risk of esophageal adenocarcinoma (HR=0.3, 95% CI, 0.1--0.8) but not of cardia adenocarcinoma (HR=0.9, 95% CI, 0.5--1.6), when analyzed separately. There were no consistent associations between other bariatric procedures (mainly gastroplasty, gastric banding, sleeve gastrectomy, and biliopancreatic diversion) and ECA. Conclusions: Gastric bypass surgery may counteract the development of esophageal adenocarcinoma in morbidly obese individuals. [ABSTRACT FROM AUTHOR]

Objective: To examine the hypothesis that survival in esophageal cancer increases with more removed lymph nodes during esophagectomy up to a plateau, after which it levels out or even decreases with further lymphadenec-tomy. Summary of Background Data: There is uncertainty regarding the ideal extent of lymphadenectomy during esophagectomy to optimize long-term survival in esophageal cancer. Methods: This population-based cohort study included almost every patient who underwent esophagectomy for esophageal cancer in Sweden or Finland in 2000-2016 with follow-up through 2019. Degree of lymphadenectomy, divided into deciles, was analyzed in relation to all-cause 5-year mortality. Multivariable Cox regression provided hazard ratios (HR) with 95% confidence intervals (95% CI) adjusted for all established prognostic factors. Results: Among 2306 patients, the second (4–8 nodes), seventh (21–24 nodes) and eighth decile (25–30 nodes) of lymphadenectomy showed the lowest all-cause 5-year mortality compared to the first decile [hazard ratio (HR) = 0.77, 95% CI 0.61–0.97, HR = 0.76, 95% CI 0.59–0.99, and HR = 0.73, 95% CI 0.57–0.93, respectively]. In stratified analyses, the survival benefit was greatest in decile 7 for patients with pathological T-stage T3/T4 (HR = 0.56, 95% CI0.40–0.78), although it was statistically improved in all deciles except decile 10. For patients without neoadjuvant chemotherapy, survival was greatest in decile 7 (HR = 0.60, 95% CI 0.41–0.86), although survival was also statistically significantly improved in deciles 2, 6, and 8. Conclusion: Survival in esophageal cancer was not improved by extensive lymphadenectomy, but resection of a moderate number (20–30) of nodes was prognostically beneficial for patients with advanced T-stages (T3/T4) and those not receiving neoadjuvant therapy. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to estimate risks of myocardial infarction, ischemic stroke, and cardiovascular-related and all-cause mortality after Roux-en-Y gastric bypass (RYGB) for obesity compared with nonop-erated obese patients and matched nonobese population controls. Background: Few studies have assessed the influence of RYGB on fatal and non-fatal myocardial infarction and ischemic stroke, and the results vary between studies. Method: All patients aged 20 to 65 years with obesity diagnosis in the nationwide Swedish Patient Registry in 2001 to 2013 were included. These participants were divided into those who underwent RYGB within 2 years of obesity diagnosis (n = 28,204) and nonoperated (n = 40,827), and were matched for age, sex, and region with 2 nonobese population controls. Participants were followed until onset of outcome disease, death, or end of follow-up. Multivariable Cox regression provided hazard ratios (HR) with 95% confidence intervals (95% CI). Results: Compared with nonoperated patients with obesity, RYGB patients had a reduced risk of myocardial infarction [HR = 0.44 (95% CI 0.28-0.63)], similar risk of ischemic stroke [HR = 0.79 (95% CI 0.54–1.14)], and decreased risks of cardiovascular-related [HR = 0.47 (95% CI 0.35–0.65)] and all-cause mortality [HR = 0.66 (95% CI 0.54–0.81)] within the first 3 years of follow-up, but not later. Compared with nonobese population controls, RYGB patients had excess risks of ischemic stroke [HR = 1.57 (95% CI 1.08–2.29)], cardiovascular-related mortality [HR = 1.82 (95% CI 1.29–2.60)], and all-cause mortality [HR = 1.42 (95% CI 1.16–1.74)], but not of myocardial infarction [HR = 1.02 (95% CI 0.72–1.46)]. Conclusion: RYGB for obesity might not decrease the risk of ischemic stroke, but seems to decrease the risk of myocardial infarction back to population levels. [ABSTRACT FROM AUTHOR]

Objective: To examine 5-year survival in esophageal cancer after MIE compared to 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 to 2016, with follow-up until end of 2019. 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 1264 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. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to clarify whether antireflux surgery prevents laryngeal and pharyngeal squamous cell carcinoma. Summary Background Data: Gastroesophageal reflux disease (GERD) seems to increase the risk of laryngeal and pharyngeal squamous cell carcinoma. Methods: All-Nordic (Denmark, Finland, Iceland, Norway, and Sweden) population-based cohort study of adults with documented GERD in 1980 to 2014. First, cancer risk after antireflux surgery was compared to the expected risk in the corresponding background population by calculating standardized incidence ratios (SIRs) with 95% confidence intervals (CIs). Second, cancer risk among antireflux surgery patients was compared to nonoperated GERD patients using multivariable Cox regression, providing hazard ratios (HR) with 95% CIs, adjusted for sex, age, calendar period, and diagnoses related to tobacco smoking, obesity, and alcohol overconsumption. Results: Among 814,230 GERD patients, 47,016 (5.8%) underwent antireflux surgery. The overall SIRs and HRs of the combined outcome laryngeal or pharyngeal squamous cell carcinoma (n=39) were decreased after antireflux surgery [SIR=0.62 (95% CI 0.44–0.85) and HR=0.55 (95% CI 0.38–0.80)]. The point estimates were further decreased >10 years after antireflux surgery [SIR=0.48 (95% CI 0.26–0.80) and HR=0.47 (95% CI 0.26–0.85)]. The risk estimates of laryngeal squamous cell carcinoma were particularly decreased >10 years after antireflux surgery [SIR=0.28 (95% CI 0.08–0.72) and HR=0.23 (95% CI 0.08–0.69)], whereas no such decrease over time after surgery was found for pharyngeal squamous cell carcinoma. Analyses of patients with severe GERD (reflux esophagitis or Barrett esophagus) showed similar results. Conclusion: Antireflux surgery may decrease the risk of laryngeal squamous cell carcinoma and possibly also of pharyngeal squamous cell carcinoma. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is available in the text Objective: To identify risk factors for suicide after bariatric surgery. Summary background data: Bariatric surgery reduces obesity-related mortality. However, it is for unclear reasons is associated with an increased risk of suicide. Methods: This population-based cohort study included patients having undergone bariatric surgery in 1982 to 2012 in any of the 5 Nordic countries, with follow-up through 2012. Eleven potential risk factors of suicide (sex, age, comorbidity, surgery type, surgical approach, calendar year of surgery, history of depression or anxiety, psychosis, schizophrenia, mania, or bipolar disorder, personality disorder, substance use, and number of previously documented psychiatric diagnoses) were analyzed using Cox regression. Results: Of 49,977 bariatric surgery patients, 98 (0.2%) committed suicide during follow-up. Women had a decreased risk of suicide compared to men (hazard ratio [HR] = 0.48, 95% confidence interval [CI] 0.33–0.77), although age and comorbidity did not influence this risk. Compared to gastric bypass, other types of bariatric surgery had lower risk of suicide (HR = 0.44, 95%CI 0.27–0.99). There was no difference in suicide risk between laparoscopic and open surgical approach. A history of depression or anxiety (HR = 6.87, 95%CI 3.97–11.90); mania, bipolar disorder, psychosis, or schizophrenia (HR = 2.70, 95%CI 1.14–6.37); and substance use (HR = 2.28, 95%CI 1.08–4.80), increased the risk of suicide. More of the above psychiatric diagnoses increased the risk of suicide (HR = 22.59, 95%CI 12.96–39.38 for ≥2 compared to 0 diagnoses). Conclusions: Although the risk of suicide is low, psychiatric disorders, male sex, and gastric bypass procedure seem to increase the risk of suicide after bariatric surgery, indicating a role for tailored preoperative psychiatric evaluation and postoperative surveillance. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is available in the text Objective: To test the hypothesis that higher hospital volume decreases endoscopic and surgical re-intervention rates after antireflux surgery. Background: Antireflux surgery for gastro-esophageal reflux disease is followed by varying rates of re-interventions. Whether hospital volume influences re-intervention rates is uncertain. Methods: This population-based cohort study used nationwide data from Denmark, Finland, and Sweden for patients having undergone primary antireflux surgery. Hospitals were divided into tertiles based upon annual volume, that is, 3 equal-sized groups. The outcomes were 30-day surgical re-intervention, endoscopic re-intervention, and secondary antireflux surgery. Multivariable Cox regression provided hazard ratios (HRs) with 95% confidence intervals (CIs) for risk of the first outcome occurrence. Incidence rate ratios were calculated to count all outcome occurrences. All risk estimates were adjusted for age, sex, comorbidity, type of antireflux surgery, year of surgery, and country. Results: Among 33,060 patients and a median follow-up of 12 years after antireflux surgery, the frequencies of 30-day re-intervention, endoscopic re-intervention, and secondary antireflux surgery were 1.2%, 4.6%, and 7.0%, respectively. When comparing the highest with the lowest tertiles, higher hospital volume did not decrease HRs of 30-day re-intervention (adjusted HR = 1.14, 95% CI 0.73–1.77), endoscopic re-intervention (HR = 1.21, 95% CI 0.96–1.51), or secondary antireflux surgery (HR = 1.28, 95% CI 1.05–1.54), but rather increased point estimates. The incidence rate ratios showed similar patterns. Conclusions: Higher hospital volume of primary antireflux surgery may not decrease risk of endoscopic or surgical re-intervention, suggesting that centralization will not decrease rates of postoperative complications or recurrence of gastro-esophageal reflux disease. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is available in the text Objective: We aimed to clarify the long-term risk development of EAC after antireflux surgery. Summary of Background Data: Gastroesophageal reflux disease (GERD) increases EAC risk, but whether antireflux surgery prevents EAC is uncertain. Methods: Multinational, population-based cohort study including individuals with GERD from all 5 Nordic countries in 1964–2014. First, EAC risk after antireflux surgery in the cohort was compared with the corresponding background population by calculating standardized incidence ratios (SIRs) with 95% confidence intervals (95% CIs). Second, multivariable Cox proportional hazards regression, providing hazard ratios (HRs) with 95% CIs, compared EAC risk in GERD patients with antireflux surgery with those with nonsurgical treatment. Results: Among 942,071 GERD patients, 48,863 underwent surgery and 893,208 did not. Compared to the corresponding background population, EAC risk did not decrease after antireflux surgery [SIR 4.90 (95% CI 3.62–6.47) 1–<5 years and SIR 4.57 (95% CI 3.44–5.95) ≥15 years after surgery]. Similarly, no decrease was found for patients with severe GERD (esophagitis or Barrett esophagus) after surgery [SIR 6.09 (95% CI 4.39–8.23) 1–<5 years and SIR = 5.27 (95% CI 3.73–7.23) ≥15 years]. The HRs of EAC were stable comparing the surgery group with the nonsurgery group with GERD [HR 1.71 (95% CI 1.26–2.33) 1–<5 years and HR 1.69 (95% CI 1.24–2.30) ≥15 years after treatment], or for severe GERD [HR 1.56 (95% CI 1.11–2.20) 1–<5 years and HR 1.57 (95% CI 1.08–2.26) ≥15 years after treatment]. Conclusions: Surgical treatment of GERD does not seem to reduce EAC risk. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is available in the text Objective: This population-based study aimed to compare presentation, treatment allocation and survival of potentially curable esophageal cancer patients between Sweden and the Netherlands. Summary of Background data: Identification of inter-country differences in treatment allocation and survival may be used for targeted esophageal cancer care improvement. Methods: Nationwide datasets were acquired from a Swedish cohort study and the Netherlands Cancer Registry. Patients with potentially curable (cT1-T4a/Tx, cN0/+, cM0/x) esophageal adenocarcinoma or squamous cell carcinoma (SCC) diagnosed in 2011–2015 were included. Multivariable logistic regression provided odds ratios (OR) for treatment allocation, and multivariable Cox model provided hazard ratios (HR) for overall survival, all with 95% confidence intervals (CI), adjusted for age, sex, year, tumor sub-location and stage. Results: Among 1980 Swedish and 7829 Dutch esophageal cancer patients, Swedish patients were older (71 vs 69 years, P <0.001) and had higher cT-stage (cT3: 49% vs 46%, P <0.001). After adjustment for confounders, Swedish patients were less frequently allocated to curative treatment (adenocarcinoma: OR=0.31, 95%CI 0.26–0.36; SCC: OR=0.28, 95%CI 0.22–0.36). Overall survival was lower in Swedish patients (adenocarcinoma: HR=1.36, 95%CI 1.27–1.46; SCC: HR=1.38, 95%CI 1.24–1.53), also when allocated to curative treatment (adenocarcinoma: HR=1.12, 95%CI 1.01–1.24; SCC: HR=1.34, 95%CI 1.14–1.59). Conclusion: Swedish patients with potentially curable esophageal cancer were less frequently allocated to curative treatment, and showed lower survival compared to Dutch patients. The less pronounced inter-country survival difference after curative treatment suggests that the overall survival difference could at least partly be due to relative undertreatment of Swedish patients. Shared curative treatment thresholds across Europe may help improve survival of esophageal cancer patients. [ABSTRACT FROM AUTHOR]

Objective: We aimed to develop prediction models for estimating the long-term survival in patients who have undergone surgery for esophageal cancer. Background: Few prediction models have been developed for the long-term survival in esophageal cancer patients. Methods: This nationwide Swedish population-based cohort study included 1542 patients who survived for ≥90 days after esophageal cancer surgery between 1987 and 2010, with follow-up until 2016. Risk prediction models for 1-, 3-, and 5-year all-cause mortality and 3- and 5-year disease-specific mortality were developed using logistic regression. Candidate predictors were established and readily identifiable prognostic factors. The performance of the models was assessed by the area under receiver-operating characteristic curve (AUC) with interquartile range (IQR) using bootstrap cross-validation and risk calibration. Results: Predictors included in all models were age, sex, pathological tumor stage, tumor histology, and resection margin status. The models also included various additional predictors depending on the outcome, that is, education level, neoadjuvant therapy, reoperation (within 30 d of primary surgery) and comorbidity (Charlson comorbidity index). The AUC statistics after cross-validation were 0.71 (IQR 0.69–0.74) for 1-year, 0.77 (IQR 0.75–0.80) for 3-year, and 0.78 (IQR 0.76–0.81) for 5-year all-cause mortality. The corresponding values were 0.76 (IQR 0.74–0.79) for 3-year and 0.77 (IQR 0.71–0.83) for 5-year disease-specific mortality. All models showed good agreement between the observed and predicted risks. Conclusions: These models showed good performance for predicting long-term survival after esophageal cancer surgery and may thus be useful for patients in planning their lives and to guide the postoperative treatment and follow-up. [ABSTRACT FROM AUTHOR]

Background: After antireflux surgery, highly variable rates of recurrent gastroesophageal reflux disease (GERD) have been reported. Objective: To identify the occurrence and risk factors of recurrent GERD requiring surgical reintervention or medication. Methods: The Hospital Episode Statistics database was used to identify adults in England receiving primary antireflux surgery for GERD in 2000 to 2012 with follow-up through 2014, and the outcome was surgical reintervention. In a subset of participants, the Clinical Practice Research Datalink was additionally used to assess proton pump inhibitor therapy for at least 6 months (medical reintervention). Risk factors were assessed using multivariable Cox regression providing adjusted hazard ratios (HRs) with 95% confidence intervals (95% CIs). Results: Among 22,377 patients who underwent primary antireflux surgery in the Hospital Episode Statistics dataset, 811 (3.6%) had surgical reintervention, with risk factors being age 41 to 60 years (HR ¼ 1.22, 95% CI 1.03-- 1.44), female sex (HR ¼ 1.5; 95% CI 1.3--1.74), white ethnicity (HR ¼ 1.71, 95% CI 1.06--2.77), and low hospital annual volume of antireflux surgery (HR ¼ 1.32, 95% CI 1.04--1.67). Among 2005 patients who underwent primary antireflux surgery in the Clinical Practice Research Datalink dataset, 189 (9.4%) had surgical reintervention and 1192 (59.5%) used proton pump inhibitor therapy, with risk factors for the combined outcome being age >60 years (HR ¼ 2.38, 95% CI 1.81--3.13) and preoperative psychiatric morbidity (HR ¼ 1.58, 95% CI 1.25--1.99). Conclusion: At least 3.6% of patients may require surgical reintervention and 59.5% medical therapy following antireflux surgery in England. The influence of patient characteristics and hospital volume highlights the need for patient selection and surgical experience in successful antireflux surgery [ABSTRACT FROM AUTHOR]

Objective: Evaluate the existing literature comparing long-term survival after minimally invasive esophagectomy (MIE) and open esophagectomy (OE), and conduct a meta-analysis based on relevant studies. Background: It is unknown whether the choice between MIE and OE influences the long-term survival in esophageal cancer. Methods: A systematic electronic search for articles was performed in Medline, Embase, Web of Science, and Cochrane Library for studies comparing long-term survival after MIE and OE. Additionally, an extensive hand-search was conducted. The I² test and χ² test were used to test for statistical heterogeneity. Publication bias and small-study effects were assessed using Egger test. A random-effects meta-analysis was performed for all-cause 5-year (main outcome) and 3-year mortality, and disease-specific 5-year and 3-year mortality. Meta-regression was performed for the 5-year mortality outcomes with adjustment for the covariates age, physical status, tumor stage, and neoadjuvant or adjuvant therapy. The results were presented as hazard ratios (HRs) with 95% confidence intervals (CIs). Results: The review identified 55 relevant studies. Among all 14,592 patients, 7358 (50.4%) underwent MIE and 7234 (49.6%) underwent OE. The statistical heterogeneity was limited [I² = 12%, 95% confidence interval (CI) 0%-41%, and χ² = 0.26] and the funnel plot was symmetrical both according to visual and statistical testing (Egger test = 0.32). Pooled analysis revealed 18% lower 5-year all-cause mortality after MIE compared with OE (HR 0.82, 95% CI 0.76-0.88). The meta-regression indicated no confounding. Conclusions: The long-term survival after MIE compares well with OE and may even be better. Thus, MIE can be recommended as a standard surgical approach for esophageal cancer. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is available in the text Objective: To compare key outcomes after transcatheter arterial embolization (TAE) with conventional surgery for peptic ulcer bleeding when endoscopic intervention fails to achieve hemostasis. Background: Mortality in peptic ulcer bleeding remains high, especially in patients who require surgical treatment. Methods: A population-based cohort study in Stockholm, Sweden, in 2000 to 2014, assessing the main outcome all-cause mortality and the secondary outcomes re-bleeding, re-intervention, length of hospitalization, and complications, was conducted. Data were taken from well-maintained registries and medical records. Multivariable Cox-regression provided hazard ratios (HRs) with 95% confidence intervals (CIs) adjusted for age, sex, ulcer history, comorbidity, and calendar period were considered. Results: Included were 282 patients, 97 in the TAE group and 185 in the surgery group. Compared with the surgery group, the overall hazard of death was 34% decreased in the TAE group (adjusted HR 0.66, 95% CI 0.46–0.96). The corresponding HRs for mortality within 30 days, 90 days, 1 year, and 5 years were 0.70 (95% CI 0.37–1.35), 0.69 (95% CI 0.38–1.26), 0.88 (95% CI 0.53–1.47), and 0.67 (95% CI 0.45–1.00), respectively. The risk of re-bleeding was higher after TAE compared with surgery (HR 2.48, 95% CI 1.33–4.62). The median length of hospital stay was shorter in the TAE group—8 versus 16 days—acceleration factor 0.59 (95% CI 0.45–0.77) and the risk of complications was lower (8.3% vs 32.2%; P < 0.0001). Conclusions: This study indicates that TAE compares favorably with surgery regarding prognosis after refractory peptic ulcer bleeding, and the shorter length of hospital stay and fewer complications outweigh a higher risk of re-bleeding. TAE could be recommended as first-line treatment for these patients. [ABSTRACT FROM AUTHOR]

Objective: To evaluate how antireflux surgery influences the risk of esophageal cancer in patients with gastroesophageal reflux disease (GERD) and Barrett esophagus. Background: GERD is a major risk factor for esophageal adenocarcinoma, and the United Kingdom has the highest incidence of esophageal adenocarcinoma globally. Methods: Hospital Episode Statistics database was used to identify all patients in England aged over 18 years diagnosed with GERD with or without Barrett Esophagus from 2000 to 2012, with antireflux surgery being the exposure investigated. The Clinical Practice Research Datalink (CPRD) was used to provide a sensitivity analysis comparing proton pump inhibitor therapy and antireflux surgery. Hazard ratios (HR) with 95% confidence intervals (CI) were calculated using Cox proportional hazards model with inverse probability weights based on the probability of having surgery to adjust for selection bias and confounding factors. Results: (i) Hospital Episode Statistics analysis; among 838,755 included patients with GERD and 28,372 with Barrett esophagus, 22,231 and 737 underwent antireflux surgery, respectively. In GERD patients, antireflux surgery reduced the risk of esophageal cancer (HR = 0.64; 95% CI 0.52–0.78). In Barrett esophagus patients, the corresponding HR was (HR = 0.47; 95% CI 0.12–1.90). (ii) CPRD analysis; antireflux surgery was associated with decreased point estimates of esophageal adenocarcinoma in patients with GERD (0% vs. 0.2%; P = 0.16) and Barrett esophagus (HR = 0.75; 95% CI 0.21–2.63), but these were not statistically significant. Conclusion: Antireflux surgery may be associated with a reduced risk of esophageal cancer risk, however it remains primarily an operation for symptomatic relief. [ABSTRACT FROM AUTHOR]

Objective: It was hypothesized that patient survival improves with increasing surgeon age up to an age where it then decreases. Background: Experience, physical and psychological abilities required for esophagectomy may change with increasing surgeon age. Methods: This population-based cohort study included all patients having undergone esophagectomy for esophageal cancer in Sweden in 1987 to 2010, with follow-up until 2016. Risk-adjusted cumulative sum (RA-CUSUM) analysis was performed to estimate the relation between surgeon age and 90-day mortality, all-cause, and disease-specific 5-year mortality. Change-points in surgeon age identified by the RA-CUSUM were then analyzed in relation to mortality using multivariable Cox regression, providing hazard ratios (HRs) with 95% confidence intervals (CIs), adjusted for age, sex, comorbidity, tumor stage, tumor histology, neoadjuvant therapy, surgeon volume, and calendar year. Results: Among 139 surgeons performing 1761 esophagectomies, RA-CUSUM analysis of 90-day mortality showed change-points at 43 years (downward deflection) and at 56 years (upward deflection). Both all-cause and disease-specific 5-year mortality had corresponding change-points at 52 years and 56 years. Compared with surgeon age 52 to 55 years, surgeon age ≤51 years was associated with increased 90-day mortality (HR = 1.71, 95% CI 1.01-2.90) and 5-year all-cause mortality (HR = 1.21, 95% CI 1.02-1.43), and surgeon age ≥56 years showed increased 90-day mortality (HR = 2.38, 95% CI 1.38-4.13), 5-year all-cause mortality (HR = 1.29, 95% CI 1.08-1.55), and disease-specific 5-year mortality (HR = 1.18, 95% CI 1.01-1.42). Conclusions: Surgeon age ≤51 and ≥56 years may increase short- and long-term mortality after esophagectomy for cancer. [ABSTRACT FROM AUTHOR]

Objective: To assess whether weekday of surgery influences long-term survival in esophageal cancer. Background: Increased 30-day mortality rates have been reported in patients undergoing elective surgery later compared with earlier in the week. Methods: This population-based cohort study included 98% of all esophageal cancer patients who underwent elective surgery in Sweden in 1987 to 2010, with follow-up until 2014. The association between weekday of surgery and 5-year all-cause and disease-specific mortality was analyzed using a multivariable Cox proportional hazards model, providing hazard ratios (HRs) with 95% confidence intervals (CIs), adjusted for age, comorbidity, tumor stage, histology, neoadjuvant therapy, and surgeon volume. Results: Among 1748 included patients, surgery conducted fromWednesday to Friday entailed 13% increased all-cause 5-year mortality compared with surgery conducted from Monday to Tuesday (HR=1.13, 95% CI, 1.01-1.26). The corresponding association was strong for early tumor stages (0-I) (HR = 1.59, 95% CI, 1.17-2.16), moderate for intermediate tumor stage (II) (HR = 1.28, 95% CI, 1.07-1.53), and absent in advanced tumor stages (III-IV) (HR = 0.93, 95% CI, 0.79-1.09). The increase in 5-year mortality for each later weekday (discrete variable) was 7% for all tumor stages (HR = 1.07, 95% CI, 1.02-1.12), 24% for early tumor stages (HR = 1.24, 95% CI, 1.09-1.41), 13% for intermediate stage (HR = 1.13, 95% CI, 1.05-1.22), whereas no increase was found for advanced stages (HR = 0.98, 95% CI, 0.92-1.05). The disease-specific 5-year mortality was similar to the all-cause mortality. Conclusions: The increased 5-year mortality of potentially curable esophageal cancer after surgery later in the week suggests that this surgery is better carried out earlier in the week. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to assess risk factors for developing marginal ulcer (MU) after gastric bypass (GBP) surgery for obesity. Background: MU is a common and potentially serious complication of GBP surgery, little is known about its etiology. Methods: This population-based cohort study of GBP in 2006-2011 evaluated MU in relation to diabetes, hyperlipidemia, hypertension, chronic obstructive pulmonary disease (COPD), ulcer history, use of proton pump inhibitors (PPIs), aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and selective serotonin reuptake inhibitors (SSRIs). Multivariable Cox proportional hazard regression models estimated hazard ratios (HRs) and 95% confidence intervals (CIs), adjusted for confounding. Results: Among 20,294 GBP patients, diabetes and peptic ulcer history entailed statistically significantly increased risk of MU (HR=1.26, 95% CI 1.03-1.55 and HR = 2.70, 95% CI 1.81-4.03), although hyperlipidemia, hypertension, and COPD did not. PPI users had an increased HR of MU (HR = 1.37, 95% CI 1.17-1.60). Aspirin and NSAID consumption less than or equal to median entailed decreased HRs of MU (HR = 0.56, 95% CI 0.37- 0.86 and HR = 0.30, 95% CI 0.24-0.38), although aspirin and NSAID users more than median had an increased risk and no association with MU, respectively (HR = 1.90, 95% CI 1.41-2.58 and HR = 0.90, 95% CI 0.76-1.87). The use of SSRI less than or equal to median had a decreased risk of MU (HR = 0.50, 95% CI 0.37-0.67), although use more than median entailed increased HR (HR = 1.26, 95% CI 1.01-1.56). Conclusions: Diabetes and peptic ulcer history seem to be risk factors forMU, but not hyperlipidemia, hypertension, or COPD. Limited doses of aspirin, NSAIDs, and SSRIs might not increase the risk, although higher doses of aspirin do. The association with PPI could be due to confounding by indication. [ABSTRACT FROM AUTHOR]

Objective: To investigate the preventive effect of antireflux surgery against esophageal adenocarcinoma (EAC) compared with medical treatment of gastroesophageal reflux disease (GERD) and to the background population. Background: GERD is causally associated with EAC. Effective symptomatic treatment can be achieved with medication and antireflux surgery; however the possible preventive effect on EAC development remains unclear. Methods: This systematic review identified 10 studies comparing EAC risk after antireflux surgery with nonoperated GERD patients, including 7 studies of patients with Barrett's esophagus, and 2 studies comparing EAC risk after antireflux surgery to the background population. A fixed-effects Poisson meta-analysis was conducted to calculate pooled incidence rate ratios (IRR) and 95% confidence intervals (CIs). Results: The pooled IRR in patients after antireflux surgery was 0.76 (95% CI 0.42-1.39) compared with medically treated GERD patients. In patients with Barrett's esophagus, the corresponding IRR was 0.46 (95% CI 0.20-1.08), and 0.26 (95% CI 0.09-0.79) when restricted to publications after 2000. There was no difference in EAC risk between antireflux surgery and medical treatment in GERD patients without known Barrett's esophagus (IRR 0.98, 95% CI 0.72-1.33). The EAC risk remained elevated in patients after antireflux surgery compared with the background population (IRR 10.78, 95% CI 8.48-13.71). Although the clinical heterogeneity of the included studies was high, the statistical heterogeneity was low. Conclusions: Antireflux surgery may prevent EAC better than medical therapy in patients with Barrett's esophagus. The EAC risk after antireflux surgery does not seem to revert to that of the background population. [ABSTRACT FROM AUTHOR]

The article presents the discussion on follow-up of many participants of old age and mortality from other causes than esophageal squamous cell carcinoma using a competing risk regression.

Objective: The objective of this study was to test the hypothesis that bariatric surgery decreases the risk of esophageal and cardia adenocarcinoma., Background: Obesity is strongly associated with esophageal adenocarcinoma and moderately with cardia adenocarcinoma, but whether weight loss prevents these tumors is unknown., Methods: This population-based cohort study included patients with an obesity diagnosis in Sweden, Finland, or Denmark. Participants were divided into a bariatric surgery group and a nonoperated group. The incidence of esophageal and cardia adenocarcinoma (ECA) was first compared with the corresponding background population by calculating standardized incidence ratios (SIR) with 95% CIs. Second, the bariatric surgery group and the nonoperated group were compared using multivariable Cox regression, providing hazard ratios (HR) with 95% CI, adjusted for sex, age, comorbidity, calendar year, and country., Results: Among 748,932 participants with an obesity diagnosis, 91,731 underwent bariatric surgery, predominantly gastric bypass (n=70,176; 76.5%). The SIRs of ECA decreased over time after gastric bypass, from SIR=2.2 (95% CI, 0.9-4.3) after 2 to 5 years to SIR=0.6 (95% CI, <0.1-3.6) after 10 to 40 years. Gastric bypass patients were also at a decreased risk of ECA compared with nonoperated patients with obesity [adjusted HR=0.6, 95% CI, 0.4-1.0 (0.98)], with decreasing point estimates over time. Gastric bypass was followed by a strongly decreased adjusted risk of esophageal adenocarcinoma (HR=0.3, 95% CI, 0.1-0.8) but not of cardia adenocarcinoma (HR=0.9, 95% CI, 0.5-1.6), when analyzed separately. There were no consistent associations between other bariatric procedures (mainly gastroplasty, gastric banding, sleeve gastrectomy, and biliopancreatic diversion) and ECA., Conclusions: Gastric bypass surgery may counteract the development of esophageal adenocarcinoma in morbidly obese individuals., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: We aimed to develop prediction models for estimating the long-term survival in patients who have undergone surgery for esophageal cancer., Background: Few prediction models have been developed for the long-term survival in esophageal cancer patients., Methods: This nationwide Swedish population-based cohort study included 1542 patients who survived for ≥90 days after esophageal cancer surgery between 1987 and 2010, with follow-up until 2016. Risk prediction models for 1-, 3-, and 5-year all-cause mortality and 3- and 5-year disease-specific mortality were developed using logistic regression. Candidate predictors were established and readily identifiable prognostic factors. The performance of the models was assessed by the area under receiver-operating characteristic curve (AUC) with interquartile range (IQR) using bootstrap cross-validation and risk calibration., Results: Predictors included in all models were age, sex, pathological tumor stage, tumor histology, and resection margin status. The models also included various additional predictors depending on the outcome, that is, education level, neoadjuvant therapy, reoperation (within 30 d of primary surgery) and comorbidity (Charlson comorbidity index). The AUC statistics after cross-validation were 0.71 (IQR 0.69-0.74) for 1-year, 0.77 (IQR 0.75-0.80) for 3-year, and 0.78 (IQR 0.76-0.81) for 5-year all-cause mortality. The corresponding values were 0.76 (IQR 0.74-0.79) for 3-year and 0.77 (IQR 0.71-0.83) for 5-year disease-specific mortality. All models showed good agreement between the observed and predicted risks., Conclusions: These models showed good performance for predicting long-term survival after esophageal cancer surgery and may thus be useful for patients in planning their lives and to guide the postoperative treatment and follow-up., Competing Interests: The authors report no conflicts of interest., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The purpose was to determine whether obesity surgery is associated with a long-term increased risk of colorectal cancer., Background: Long-term cancer risk after obesity surgery is not well characterized. Preliminary epidemiological observations and human tissue biomarker studies recently suggested an increased risk of colorectal cancer after obesity surgery., Methods: A nationwide retrospective register-based cohort study in Sweden was conducted in 1980-2009. The long-term risk of colorectal cancer in patients who underwent obesity surgery, and in an obese no surgery cohort, was compared with that of the age-, sex- and calendar year-matched general background population between 1980 and 2009. Obese individuals were stratified into an obesity surgery cohort and an obese no surgery cohort. The standardized incidence ratio (SIR), with 95% confidence interval (CI), was calculated., Results: Of 77,111 obese patients, 15,095 constituted the obesity surgery cohort and 62,016 constituted the obese no surgery cohort. In the obesity surgery cohort, we observed 70 patients with colorectal cancer, rendering an overall SIR of 1.60 (95% CI 1.25-2.02). The SIR for colorectal cancer increased with length of time after surgery, with a SIR of 2.00 (95% CI 1.48-2.64) after 10 years or more. In contrast, the overall SIR in the obese no surgery cohort (containing 373 colorectal cancers) was 1.26 (95% CI 1.14-1.40) and remained stable with increasing follow-up time., Conclusions: Obesity surgery seems to be associated with an increased risk of colorectal cancer over time. These findings would prompt evaluation of colonoscopy surveillance for the increasingly large population who undergo obesity surgery.

Objectives: Gastroesophageal reflux is the main risk factor for esophageal adenocarcinoma, but there is no strong support for any cancer-protective effect after antireflux surgery. We hypothesized that recurrent reflux or high exposure to other established risk factors, that is, obesity and tobacco smoking, are overrepresented among patients who despite antireflux surgery develop esophageal adenocarcinoma., Design: A population-based case-control study was nested within an antireflux surgery cohort from the Swedish Patient Register between 1965 and 2006. Cases were patients who developed esophageal adenocarcinoma more than 5 years after antireflux surgery, whereas randomly selected controls were matched to the cases regarding age, sex, and calendar year of the antireflux surgery. Study exposures among cases and controls were collected through review of medical records. Data on cancer were assessed through the Swedish Cancer Register. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using multivariable conditional logistic regression, adjusted for recurrent reflux, body mass index (BMI), tobacco smoking, and type of antireflux surgery., Results: From 14,102 patients in the total antireflux surgery cohort, 55 cases and 240 controls were included. Patients who developed esophageal adenocarcinoma were 3 times more likely to have recurrent reflux after their antireflux surgery, compared with those who had not (OR: 3.1, 95% CI: 1.5-6.3). There were no statistically significant differences in risk when comparing BMI of 30 kg/m or more with BMI of less than 25 kg/m (OR: 1.6, CI: 0.8-3.5), ever smokers with never smokers (OR: 1.4, 95% CI: 0.7-2.8), or total fundoplication with partial fundoplication (OR: 0.6, 95% CI: 0.3-1.3)., Conclusions: Recurrence of reflux might explain the lack of protective effect of antireflux surgery regarding risk of developing esophageal adenocarcinoma.

Objective: Obesity increases the risk of several cancers, but it is uncertain whether weight reduction is followed by any decreased risk. To address this topic, we selected a group of patients representing a substantial weight loss starting at a defined time, ie, patients submitted to obesity surgery. We hypothesized that risk of obesity-related cancer decreases with time after obesity surgery., Summary Background Data: A nationwide, population-based cohort study of obesity surgery in 1980-2006 as registered in the Swedish Patient Register. New cancers were identified through the Swedish Cancer Register. Cohort members' observed total number of overall obesity-related cancers and groups of obesity-related cancer (breast, prostate, colorectal, endometrial, kidney) were divided by the expected numbers, representing the baseline risk, thus calculating standardized incidence ratios (SIRs) with 95% confidence intervals (CIs). Time trends of SIR after obesity surgery were the main outcome measure., Results: Among a total of 13,123 obesity surgery patients, contributing with 125,049 person-years of follow-up, 296 new cases of obesity-related cancer were identified. There was no overall decrease in SIR of obesity-related cancer with increased time after obesity surgery (P for trend 0.40). Similarly, no statistically significant trends with follow-up time were found for cancer of the breast (P = 0.60), prostate (P = 0.34), endometrium (P = 0.83), or kidney (P = 0.42), while the risk of colorectal cancer increased with time (P for trend 0.01) after obesity surgery., Conclusions: The weight reduction following obesity surgery might not be entailed by a decreased risk of obesity-related cancer with increasing follow-up time as compared with the baseline risk.

Objective: To evaluate the impact of surgeon volume on the risk of technical surgical complications after esophageal cancer resection., Summary Background Data: Severe postoperative complications occur in about half of esophagectomized patients. Of these, technical complications might be particular targets for improvement. Population-based studies of the influence of surgeon volume on technical complications are sparse., Methods: A prospective, nationwide, population-based study was conducted in Sweden in 2001 through 2005. Details concerning patient and tumor characteristics, surgical procedures, and predefined complications were collected prospectively from the Swedish Esophageal and Cardia Cancer register. The surgeon volume cut-offs of <2, 2 to 6, and >6 operations per annum were predefined on the basis of previous research. Multivariable logistic regression was performed to estimate odds ratios (ORs) and 95% confidence intervals (CIs)., Results: Among 615 patients undergoing esophageal resection for cancer, 154 (25.0%) patients sustained at least 1 technical surgical complication. No association was found between high-volume surgery and decreased risk of such complications. Compared with high-volume surgeons, medium-volume surgeons had an adjusted OR of 0.80 (95% CI: 0.45-1.42) and low-volume surgeons had an OR of 0.99 (95% CI: 0.49-1.98) for occurrence of any technical surgical complication. Differences were found between individual HVSs regarding crude risk of anastomotic leakage (P < 0.042) and secondary surgical complications (P < 0.001)., Conclusions: Surgeon volume seems to be a poor proxy for skill in esophageal cancer surgery. Other factors might be of more importance, as indicated by variations in outcome between individual experienced surgeons.

Objective: To evaluate the diagnostic accuracy of esophageal and cardia adenocarcinoma in the Swedish Cancer Register., Summary Background Data: Based on cancer registers, a rising incidence of esophageal and cardia adenocarcinoma has been reported in several populations, but possible influence of differences in tumor classification has not been evaluated., Methods: In a nationwide study in 1995 through 1997, all Swedish patients, born in Sweden and younger than 80 years with esophageal or cardia adenocarcinoma and half of all patients with esophageal squamous cell carcinoma, were prospectively, uniformly, and thoroughly classified. This study classification was compared with the tumor classification in the Swedish Cancer Register, which is based on routine clinical practice., Results: The overall completeness of the Cancer Register was high (98.3%), whereas the site-specific completeness of the Register was 63% for esophageal adenocarcinoma, 74% for cardia adenocarcinoma, and 91% for esophageal squamous cell carcinoma. The incidence of esophageal adenocarcinomas was 16% higher in the study classification compared with that of the Register during the study period, whereas the incidence of cardia adenocarcinoma was 2% lower in the study classification., Conclusions: There is a diagnostic mismatch between esophageal and cardia adenocarcinoma in the clinical setting and, therefore, also in Cancer Registers. In etiologic and therapeutic research, this problem needs consideration, since these tumors have distinct risk factor profiles and could be subjected to different treatment strategies. The increasing incidence rate of esophageal adenocarcinoma in Sweden is unlikely to be explained by such differences in tumor classification, however.

Objective: To identify risk factors for complications after resection for esophageal or cardia cancer., Summary Background Data: Knowledge of risk factors for complications after esophageal resection for cancer is sparse, and prospective population-based studies are lacking., Methods: A prospective, nationwide, population-based study was conducted in Sweden in April 2, 2001 through December 31, 2003. Details about tumor characteristics and stage, surgical procedures, and complications were collected prospectively from the Swedish Esophageal and Cardia Cancer register. Medical records and specific charts from surgical procedures, histopathology reports, and intensive care units were continuously scrutinized. Multivariable logistic regression analyses were used to estimate relative risks and their 95% confidence intervals., Results: Among 275 patients undergoing surgical resection for esophageal or cardia cancer, 122 (44%) had at least one predefined complication. Operation by low-volume surgeons (<5 operations annually) were followed by more anastomotic leakages than those by surgeons with higher volume (odds ratio, 7.86; 95% confidence interval, 2.13-29.00). Hand-sewn and stapled anastomoses did not differ regarding risk of anastomotic leakage. Among cardia cancer patients, transthoracic approach resulted in more respiratory complications compared with transhiatal (abdominal only) approach (odds ratio, 4.78; 95% confidence interval, 1.66-13.76). Older age, adjuvant oncologic therapy, and higher preoperative bleeding volume nonsignificantly increased the risks of complications, while no influence of sex or tumor stage was found., Conclusions: High-volume esophageal surgeons seem to lower the risk of anastomotic leakage. More large-scale studies are warranted to establish the roles of the other potentially important risk factors suggested in our study.