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Summary Background/objective Gastric outlet obstruction can have a large impact on quality of life for patients with upper gastrointestinal cancer or benign obstruction. Partial stomach-partitioning gastrojejunostomy has previously shown promising outcomes compared to conventional gastrojejunostomy in terms of reduced delayed gastric emptying. The objective of the current study was to present outcomes of partial stomach-partitioning gastrojejunostomy in a single high-volume center for upper gastrointestinal cancer. Methods A retrospective cohort study including all consecutive patients who underwent partial stomach-partitioning gastrojejunostomy from 2013 to 2020. The primary outcome was oral intake tolerance. A subgroup analysis was performed in all patients with manifest gastric outlet obstruction comparing partial stomach-partitioning gastrojejunostomy to conventional gastrojejunostomy. Results Partial stomach-partitioning gastrojejunostomy was performed in 32 patients and laparoscopic technique was used in 19 patients (59%). The procedure improved oral intake tolerance defined by gastric outlet obstruction scoring system by 0.63 points on average (P = 0.041). No postoperative complications related to the procedure were observed. Recurrence of gastric outlet obstruction developed in six patients (19%), four patients (13%) required endoscopic reintervention but no patient required surgical reintervention. A comparison between partial stomach-partitioning gastrojejunostomy and conventional gastrojejunostomy showed no statistically significant differences regarding postoperative nutritional status, length of hospital stay, recurrence or reintervention. Conclusion The results of the study show that partial stomach-partitioning gastrojejunostomy can be an effective surgical treatment for patients suffering from gastric outlet obstruction and that the procedure can be safely performed with laparoscopic technique.

Background Population-based patient reported outcome data in oesophageal cancer are rare. The main purpose of this study was to describe health-related quality of life (HRQOL) 1 year after the diagnosis of oesophageal cancer, comparing subgroups of curatively and palliatively managed patients. Methods This is a nationwide population-based cohort study, based on the Swedish National Registry for Oesophageal and Gastric Cancer (NREV) with prospectively registered data, including HRQOL instruments from the European Organisation for Research and Treatment of Cancer including the core and disease specific questionnaires (EORTC QLQ-C30 and QLQ-OG25). Patients diagnosed with oesophageal cancer between 2009 and 2016 and with complete HRQOL data at 1 year follow-up were included. HRQOL of included patients was compared to a reference population matched by age and gender to to a previous cohort of unselected Swedish oesophageal cancer patients. Linear regression was performed to calculate mean scores with 95% confidence intervals (CI) and adjusted linear regression analysis was used to calculate mean score differences (MD) with 95% CI. Results A total of 1156 patients were included. Functions and global health/quality of life were lower in both the curative and palliative cohorts compared to the reference population. Both curatively and palliatively managed patients reported a severe symptom burden compared to the reference population. Patients who underwent surgery reported more problems with diarrhoea compared to those treated with definitive chemoradiotherapy (dCRT) (MD -14; 95% CI − 20 to − 8). Dysphagia was more common in patiens treated with dCRT compared to surgically treated patients (MD 11; 95% CI 4 to 18). Those with palliative intent due to advanced tumour stage reported more problems with dysphagia compared to those with palliative intent due to frailty (MD -18; 95% CI − 33 to − 3). Conclusions One year after diagnosis both curative and palliative intent patients reported low function scores and severe symptoms. Dysphagia, choking, and other eating related problems were more pronounced in palliatively managed patients and in the curative intent patients treated with dCRT.

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

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

Contains fulltext : 225948.pdf (Publisher’s version ) (Open Access) Delayed gastric conduit emptying (DGCE) after esophagectomy for cancer is associated with adverse outcomes and troubling symptoms. Widely accepted diagnostic criteria and a symptom grading tool for DGCE are missing. This hampers the interpretation and comparison of studies. A modified Delphi process, using repeated web-based questionnaires, combined with live interim group discussions was conducted by 33 experts within the field, from Europe, North America, and Asia. DGCE was divided into early DGCE if present within 14 days of surgery and late if present later than 14 days after surgery. The final criteria for early DGCE, accepted by 25 of 27 (93%) experts, were as follows: >500 mL diurnal nasogastric tube output measured on the morning of postoperative day 5 or later or >100% increased gastric tube width on frontal chest x-ray projection together with the presence of an air-fluid level. The final criteria for late DGCE accepted by 89% of the experts were as follows: the patient should have 'quite a bit' or 'very much' of at least two of the following symptoms; early satiety/fullness, vomiting, nausea, regurgitation or inability to meet caloric need by oral intake and delayed contrast passage on upper gastrointestinal water-soluble contrast radiogram or on timed barium swallow. A symptom grading tool for late DGCE was constructed grading each symptom as: 'not at all', 'a little', 'quite a bit', or 'very much', generating 0, 1, 2, or 3 points, respectively. For the five symptoms retained in the diagnostic criteria for late DGCE, the minimum score would be 0, and the maximum score would be 15. The final symptom grading tool for late DGCE was accepted by 27 of 31 (87%) experts. For the first time, diagnostic criteria for early and late DGCE and a symptom grading tool for late DGCE are available, based on an international expert consensus process.

Background Gastrectomy including D2 lymphadenectomy is regarded as the standard curative treatment for advanced gastric cancer in Asia. This procedure has also been adopted gradually in the West, despite lack of support from RCTs. This study sought to investigate any advantage for long‐term survival following D2 lymphadenectomy in routine gastric cancer surgery in a Western nationwide population‐based cohort. Methods All patients who had a gastrectomy for cancer in Sweden in 2006–2017 were included in the study. Prospectively determined data items were retrieved from the National Register of Oesophageal and Gastric Cancer. Extent of lymphadenectomy was categorized as D1+/D2 or the less extensive D0/D1 according to the Japanese Gastric Cancer Association classification. Overall survival was analysed and, in addition, a variety of possible confounders were introduced into the Cox proportional hazards regression model. Results A total of 1677 patients underwent gastrectomy, of whom 471 (28·1 per cent) were classified as having a D1+/D2 and 1206 (71·9 per cent) a D0/D1 procedure. D1+/D2 lymphadenectomy was not associated with higher 30‐ or 90‐day postoperative mortality. Median overall survival for D1+/D2 lymphadenectomy was 41·5 months with a 5‐year survival rate of 43·7 per cent, compared with 38·5 months and 38·5 per cent respectively for D0/D1 (P = 0·116). After adjustment for confounders, in multivariable analysis survival was significantly higher after D1+/D2 than following D0/D1 lymphadenectomy (hazard ratio 0·81, 95 per cent c.i. 0·68 to 0·95; P = 0·012). Conclusion This national registry study showed that long‐term survival after gastric cancer surgery was improved after gastrectomy involving D1+/D2 lymphadenectomy compared with D0/D1 dissection., A nationwide prospective register‐based study examined the extent of lymphadenectomy in curative gastric cancer surgery and its effects on long‐term survival. More evidence in favour of thorough lymphadenectomy

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

Oesophageal cancer management requires extensive in-hospital care. This cohort study aimed to quantify in-hospital care for esophageal cancer patients in relation to intended treatment and to analyze factors associated with risk of spending a large proportion of survival time in hospital. Methods All patients with oesophageal cancer in three nationwide registers over a ten-year period, were included. In-hospital care during the first year after diagnosis was evaluated and the proportion of survival time spent in hospital, stratified for intended treatment (curative, palliative or best supportive care) calculated. Associations of relevant factors to a greater proportion of survival time in hospital was analyzed by multivariable logistic regression. Results In-hospital care was provided for a median time of 39, 26 and 15 days the first year after diagnosis of oesophageal cancer for curative, palliative and best supportive care groups respectively. Patients receiving curatively intended treatment spent a median of 12% of their survival time in hospital during the first year after diagnosis, while palliative or best supportive care patients spent 19% and 23% respectively. Factors associated with more in-hospital care included higher age, female sex, being unmarried and chronic obstructive pulmonary disease (COPD). Conclusion The burden of in-hospital care during the first year after diagnosis of oesophageal cancer was substantial. Important clinical and socioeconomic factors were identified that predisposed to a greater proportion of survival time spent in hospital.

Accumulating evidence points to a better survival in female patients after a curative oesophageal cancer surgery. However, there is a need for more well-designed and sufficiently powered studies for limitations in previous studies. Better understanding of sex differences in the postoperative survival may be helpful for a sex-specific treatment. Methods This is a population-based cohort study including all patients in Sweden with oesophageal cancer that underwent a curative surgical treatment between 2006 and 2017. Sex difference in postoperative survival was explored with excess mortality rate ratio (EMRR) and absolute difference of excess mortality rate along the whole follow-up time, using flexible parametric model. Age at the time of surgery, Charlson comorbidity index, ASA score, tumor stage, post-operative complications, marital status, education level and hospital volume were considered as covariates in the analysis model. Stratification analysis by clinical stages, perioperative neoadjuvant treatment and post-operative complications was also performed. Results In all, there were 1301 patients resected for oesophageal adenocarcinoma and 305 patients for oesophageal squamous cell carcinoma. For both oesophageal adenocarcinoma and oesophageal squamous cell carcinoma, female patients had a lower excess mortality rate than males (adjusted EMRR: 0.77, 95% CI: 0.58–1.01, P = 0.059; 0.53, 95% CI: 0.33–0.85, P = 0.009, respectively). This sex difference was particularly strong shortly after surgery then gradually decreased over the ensuing years (Figure) and was more profound in the early clinical stages, and in patients receiving neoadjuvant treatment and without post-operative complications. Conclusion Female patients seem to have a better survival shortly after esophagectomy for patients with oesophageal adenocarcinoma and oesophageal squamous cell carcinoma, and the sex difference thereafter weakened. Our results may imply a different response to oesophageal cancer surgery between the sexes, and associated pre- and post-operative treatment, thus a sex-specific strategy may be considered in further work.

There is an unexplained male predominance in the incidence of esophageal (EAC) and non-cardia gastric adenocarcinoma (GAC) which cannot be explained by known risk factors. Differences in the exposures to sex hormones may play a part in the observed sex difference. This study aimed to test the hypothesis that androgens increase the risk of EAC, cardia GAC, and non-cardia GAC. We analysed a matched cohort based on a national Swedish database of prostate cancer patients. Methods Prostate cancer patients receiving androgen deprivation therapy (ADT) were the exposed group. Prostate cancer-free men from the general population were randomly selected and matched to the index case by birth year and county of residence, forming the unexposed control group. The participants were followed until a diagnosis of esophageal or gastric cancer, death, emigration, or end of the study period. The risk of esophageal adenocarcinoma, cardia gastric adenocarcinoma, non-cardia gastric adenocarcinoma, and esophageal squamous-cell carcinoma among ADT-exposed compared to unexposed was calculated by multivariable Cox proportional hazard regression. The hazard ratios and 95% confidence intervals were adjusted for confounders. Results There was a risk reduction of non-cardia gastric adenocarcinoma among ADT-users compared to non-users (HR 0.49 [95% CI 0.24–0.98]). No such decreased risk was found for esophageal adenocarcinoma (HR 1.17 [95% CI 0.60–2.32]), cardia gastric adenocarcinoma (HR 0.99 [95% CI 0.40–2.46]), or esophageal squamous cell carcinoma (HR 0.99 [95% CI 0.31–3.13]). Conclusion This study indicates that androgen deprivation therapy decreases the risk of non-cardia gastric adenocarcinoma, while no decreased risk was found for esophageal adenocarcinoma, cardia gastric adenocarcinoma, or esophageal squamous-cell carcinoma.

The operating surgeon’s assessment of surgical radicality following esophagectomy is reported to the Swedish National Registry for Esophageal and Gastric cancer(NREV). The variable provides means to identify risk factors for non-curative resections and study whether the surgeon’s assessment independently prognosticates survival. Methods All patients in NREV undergoing esophagectomy between 2006–2018 was grouped according to the surgeon’s assessment of radicality: Curative-, Borderline-curative- and Palliative resection. The cohort was followed until death, emigration or end of follow-up. Factors affecting group allocation was studied with multivariable logistic regression and survival with cox-regression and the Kaplan–Meier method. Results Of 1860 resected patients, esophagectomy was deemed curative in 1515(81%), borderline-curative in 179(10%), palliative in 63(3%) and missing in 103(6%). Median survival was 44.6, 20.0, 11.5 and 29.6 months respectively. Advanced stage (e.g., stage IVa), OR 7,37 (1,93–28,1 95%CI) and blood-loss >1000 mL, OR 1.90 (1,17-3,08), increased the risk of borderline-curative resection. Minimally invasive surgery and multidisciplinary treatment decision (MDT) decreased the risk of borderline-curative resection, OR 0.42 (0,23-0,77) and OR 0.41 (0,22-0,77). Adjusted for well-established prognostic factors, e.g. age, p-TNM and R1-resection, the surgeon’s assessment was an independent variable for survival; borderline-curative HR 1,38 (1,11-1,72), palliative HR 1,91 (1,38-2,63). Conclusion The surgeon’s operative assessment of radicality following esophagectomy appears to independently prognosticate survival. Advanced stage and large-volume intraoperative blood loss increases the risk while minimally invasive surgery and MDT decreases the risk for borderline-curative resection.

Background Microscopically non-radical (R1) oesophageal cancer resection has been associated with worse survival. The aim of this study was to identify risk factors for R1 resection and to investigate how this affects long-term survival. Methods The Swedish National Register for Oesophageal and Gastric Cancer was used to identify all patients who underwent oesophageal cancer resection with curative intent between 2006 and 2017. Risk factors for R1 resection were assessed by multivariable logistic regression analysis, and factors predicting 5-year survival identified by multivariable Cox regression. Results The study included 1460 patients. Surgical margins were involved microscopically in 142 patients (9.7 per cent). The circumferential resection margin was involved in 114 (7.8 per cent), the proximal margin in 53 (3.6 per cent), and the distal margin in 29 (2.0 per cent). In 30 specimens (2.1 per cent), two or all three margins were involved. Independent risk factors for R1 resection were male sex, low BMI, absence of neoadjuvant treatments, and clinical T4 disease. The 5-year survival rate for the entire cohort was 42.2 per cent, but only 18.0 per cent for those who had an R1 resection. Independent risk factors for death within 5 years of resection were male sex, age above 60 years, normal BMI, ASA fitness grade III, intermediate-level education, R1 resection (hazard ratio 1.80, 95 per cent c.i. 1.40 to 2.32), clinical T3 disease, and clinical lymph node metastasis. Conclusion R1 resection is common and predicts poor 5-year survival. Absence of neoadjuvant treatment is a risk factor for R1 resection., Data from Swedish National Register for Oesophageal and Gastric Cancer were used to study risk factors for R1 resection, and to investigate how R1 affects long-term survival. R1 resection is common and predicts poor 5- year survival. Absence of neoadjuvant treatment and advanced tumour stage are risk factors for R1 resection.

Introduction: Minimally invasive techniques show improved short-term and comparable long-term outcomes compared to open techniques in the treatment of gastric cancer and improved survival has been seen with the implementation of multimodality treatment. Therefore, focus of research has shifted towards optimizing treatment regimens and improving quality of life. Materials and methods: A randomized trial was performed in thirteen hospitals in Europe. Patients were randomized between open total gastrectomy (OTG) or minimally invasive total gastrectomy (MITG) after neoadjuvant chemotherapy. This study investigated patient reported outcome measures (PROMs) on health-related quality of life (HRQoL) following OTG or MITG, using the Euro-Qol-5D (EQ-5D) and the European Organization for Research and Treatment of Cancer (EORTC) questionnaires, modules C30 and STO22. Due to multiple testing a p-value < 0.001 was deemed statistically significant. Results: Between January 2015 and June 2018, 96 patients were included in this trial. Forty-nine patients were randomized to OTG and 47 to MITG. A response compliance of 80% was achieved for all PROMs. The EQ5D overall health score one year after surgery was 85 (60–90) in the open group and 68 (50–83.8) in the minimally invasive group (P = 0.049). The median EORTC-QLQ-C30 overall health score one year postoperatively was 83,3 (66,7–83,3) in the open group and 58,3 (35,4–66,7) in the minimally invasive group (P = 0.002). This was not statistically significant. Conclusion: No differences were observed between open total gastrectomy and minimally invasive total gastrectomy regarding HRQoL data, collected using the EQ-5D, EORTC QLQ-C30 and EORTC-QLQ-STO22 questionnaires.

Aims: The role of resection remains debated in cases of metastatic gastric carcinoma (mGC). Some mGCs are technically resectable. At the population level, the real-world application of resection for mGC remains largely unclear in most Western countries. This large, population-based international investigation aimed to reveal the resection patterns and trends for mGC and the treatment-associated factors in Europe and the US. Methods: Data on cases with microscopically-confirmed primary invasive stomach carcinoma with distant metastasis were obtained from the nationwide cancer registries of the Netherlands, Belgium, Norway, Sweden, Estonia, and Slovenia and the US Surveillance, Epidemiology, and End Results-18 database. We calculated age-standardized rates of primary cancer-directed resection and assessed resection trends using linear regression. We investigated associations of treatment with patient and cancer factors using multivariable-adjusted log-binomial regression. Results: Among 133,321 patients with gastric cancer, overall, 40,215 cases with mGC diagnosed between 2003–2017 were investigated. Age-standardized resection rates significantly declined over time in the US, Belgium, Sweden, and Norway (by 5–14%). Resection rates greatly differed from 5% to 16% in 2013–2014. Cases with older ages, cardia tumors, or tumors involving adjacent structures were significantly less often operated across most countries. Sex was not significantly associated with resection. Across countries the association patterns and strengths differed largely. With multivariable adjustment, resection rates decreased significantly in all countries except Slovenia and Estonia (prevalence ratio per year = 0.90–0.98), and the decreasing trends were consistently observed in various stratifications by age and location. Conclusion: In Europe and the US, resection patterns and trends largely varied across countries for mGCs, which were mostly less often resected in the early 21st century. Various resection-associated factors were shown, with greatly varying association patterns and strengths. Our report could aid to identify discrepancies in clinical practice and highlight the great need for further clarifying the role of resection in mGCs to enhance standardization of care.

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

Background There are marked geographical variations in the proportion of patients undergoing resection for gastric cancer. This study investigated the impact of resection rate on survival. Methods All patients with potentially curable gastric cancer between 2006 and 2017 were identified from the Swedish National Register of Oesophageal and Gastric Cancer. The annual resection rate was calculated for each county per year. Resection rates in all counties for all years were grouped into tertiles and classified as low, intermediate or high. Survival was analysed using the Cox proportional hazards model. Results A total of 3465 patients were diagnosed with potentially curable gastric cancer, and 1934 (55.8 per cent) were resected. Resection rates in the low (1261 patients), intermediate (1141) and high (1063) tertiles were 0–50.0, 50.1–62.5 and 62.6–100 per cent respectively. The multivariable Cox analysis revealed better survival for patients diagnosed in counties during years with an intermediate versus low resection rate (hazard ratio (HR) 0.81, 95 per cent c.i. 0.74 to 0.90; P, There is large geographical variation in the proportion of patients undergoing curative resection of gastric cancer in Sweden. This study found that a higher proportion of patients undergoing curative resection is of survival benefit for the whole population of patients with gastric cancer. Regional variations influence outcome

The Swedish National Quality Register for Esophageal and Gastric Cancer (NREV) was introduced in 2007 and is the sole quality registry in Sweden for patients with esophageal and gastric cancer. Previously, selected variables from the registry was made available to both caregivers and the public through a downloadable annual report. We aimed to make quality indicators readily available to all interested parties; caregivers, patient groups, hospital staff, researchers, administrators and health-political decision-makers. Methods A database was compiled with registry data presented for all years since 2007 and updated every six months. Several graphical and numeric presentations were implemented. Both medical expertise and a patient representative were involved in choosing relevant quality indicator variables as well as designing the web interface. Results Registry Coverage, Quality indicators/lead times, Treatment and Outcomes were the four main focus areas. All areas contained selectable sub-variables and the user was given the choice to present data on a national or regional level. Alterations in chosen variables or selection-base resulted in real time changes in the online report. Thus, a variable national or regional report could be tailored to the users’ needs. All data could be presented as comparative diagrams, crude tables or as time-trend analysis, as exemplified by figure 1. Conclusion An interactive online platform to display population based results and time-trends for important quality indicators in the diagnosis and treatment of esophageal and gastric cancer is now available for all. The main purpose, to make anonymized data available, was achieved by OPEN-NREV. We propose that presenting data in this manner is of interest to patients, caregivers, scientists and decision makers.

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

Background Minimally invasive techniques have gradually come to take a leading position in the surgical treatment of gastrointestinal malignancies. In order to define an effective process for the implementation of similar techniques in the treatment of gastric cancer, patient caseload represents a pivotal factor for education and training, but is a prerequisite not fulfilled in most Western countries. Additionally, as opposed to the East, a variety of additional factors such as the usually advanced stage of the disease and differences in patient characteristics are prevailing and raise further obstacles. Hereby we report a strategy for a safe and effective process for the implementation of laparoscopic gastric cancer surgery in a Western tertiary referral center. Methods The present study describes the stepwise implementation of laparoscopic gastrectomy for the treatment of gastric cancer at a tertiary referral center, comprising the time period 2012–2019. This process was facilitated by a close collaboration with two high-volume centers in Japan, as well as exchanging fellowships and observerships between the Karolinska University Hospital and other European centers. From the initially strict selection of cases for laparoscopic surgery, laparoscopic gastrectomy has gradually become the preferred approach also in patients with locally advanced tumors. Results From January 1st 2010 until December 31st 2019, 249 patients were operated for gastric cancer, of whom 141 (56.6%) had an open and 108 (43.4%) a laparoscopic procedure. In the latter group, total gastrectomy was performed in 33.3% of the patients. While blood loss, operation time and length of stay decreased during the first years after implementation, these variables increased slightly during the last years of the study period, probably due to the higher proportion of advanced gastric cancer cases, as well as the higher rate of laparoscopic total gastrectomy with more extended lymphadenectomy. Conclusions Laparoscopic surgery is currently a valid therapeutic option for gastric cancer, which has expanded to also embrace total gastrectomy and locally advanced tumors. Collaboration between centers in the East and West, centralization to high-volume centers and application of enhanced recovery protocols are essential components in the implementation and further refinement of minimally invasive gastrectomy.

A stenosing tumour in the throat region is a common indication for percutaneous endoscopic gastrostomy (PEG), which may be used for enteral nutrition in palliative cases or placed prior to curative treatment (surgery, radiotherapy and/or chemotherapy) and removed when the patient has recovered and has a reliable and adequate oral intake. Major complications related to PEG are rare, but their treatment poses a challenge. We are presenting a case of the transmission of metastasis to the gastrostomy site in a patient with pharynx cancer after percutaneous endoscopic gastrostomy.

Summary The main curative treatment modality for esophageal cancer is resection. Patients initially deemed suitable for resection may become unsuitable, most commonly due to signs of generalized disease or having become unfit for surgery. The aim was to assess risk factors for abandoning esophagectomy and its impact on survival. All patients diagnosed with an esophageal or gastroesophageal junction cancer in the Swedish National Register for Esophageal and Gastric Cancer from 2006–2016 were included and risk factors associated with becoming ineligible for resection were analyzed in multivariable logistic regression analysis. Overall survival was explored by multivariable Cox regression models. Among 1,792 patients planned for resection, 189 (11%) became unsuitable for resection before surgery and 114 (6%) had exploratory surgery without resection. Intermediate and high educational levels were associated with an increased probability of resection (odds ratio (OR) 1.46, 95% CI 1.05–2.05, OR 1.92, 95% CI 1.28–2.87, respectively) as was marital status (married: OR 1.37, 95% CI 1.01–1.85). Clinically advanced disease (cT4: OR 0.38, 95% CI 0.16–0.87; cN3: OR 0.27, 95% CI 0.09–0.81) and neoadjuvant treatment were associated with a decreased probability of resection (OR 0.62, 95% CI 0.46–0.88). Five-year survival for non-resected patients was only 4.5% although neoadjuvant treatment was associated with improved survival (HR 0.75, 95% CI 0.56–0.99). Non-resected patients with squamous cell carcinoma had comparatively reduced survival (HR 1.64, 95% CI 1.10–2.43). High socioeconomic status was associated with an increased probability of completing the plan to resect whereas clinically advanced disease and neoadjuvant treatment were independent factors associated with increased risk of abandoning resectional intent.

Purpose In order to further understand genetically predisposing factors of gastric cancer, a retrospective study on 107 patients with gastric cancer was conducted. The family history of cancer cases was registered, in search of associations between gastric cancer and other cancer types. Materials and methods Within Stockholm County in Sweden, all patients previously diagnosed with gastric cancer and still alive were invited to participate in the study. Patients were asked to complete a questionnaire about their gastric cancer diagnosis and if any cancers had occurred in their family. A blood sample for DNA extraction was collected. The proportions of different cancer types in the relatives of the patients were compared to the general Swedish population in 1970 and 2010. Results Among first- and second-degree relatives to the index patients with gastric cancer, the frequency of uterine cancer as well as gastric cancer was significantly overrepresented compared to the general population in Sweden. The frequency of breast cancer was significantly lower. Conclusions There seems to be an increased risk of both gastric cancer and uterine cancer in the families of gastric cancer survivors, indicating a possible hereditary connection between these two cancer types.

BackgroundObesity is considered a chronic disease with an increasing prevalence worldwide during the last decades. Laparoscopic sleeve gastrectomy is the most commonly performed bariatric procedure, due to its relative safety and long-term efficacy. The use of bougie to ensure correct size of the gastric tube is part of the standard operation, usually placed by the anesthesiologist and with a very low rate of complications. We report the first case, to our knowledge, of a cervical esophageal perforation caused by the use of bougie during laparoscopic sleeve gastrectomy.Case presentationThe complication occurred in a previously healthy 42-year old female patient who underwent laparoscopic sleeve gastrectomy for class 1 obesity (BMI 31 kg/m2) and was diagnosed the first post-operative day. She was subsequently treated with an emergency thoracoscopy and evacuation of a mediastinal fluid collection, with additional neck incision for primary closure of the esophageal defect which was reinforced with a sternocleidomastoid muscle flap. The post-operative course was uneventful.ConclusionsWe made a literature review to better understand the options considering the diagnosis and treatment in case of very proximal iatrogenic esophageal perforations. The risks related to the use of bougie during surgery should not be underestimated, and its insertion must be done with extreme caution. Esophageal perforation is still a challenging, life threatening complication where prompt diagnosis and adequate treatment are essential.

Only around one-quarter of patients with cancer of the oesophagus and the gastro-oesophageal junction (GOJ) undergo surgical resection. This population-based study investigated the rates of treatment with curative intent and resection, and their association with survival.Patients diagnosed with oesophageal and GOJ cancer between 2006 and 2015 in Sweden were identified from the National Register for Oesophageal and Gastric Cancer (NREV). The NREV was cross-linked with several national registries to obtain information on additional exposures. The annual proportion of patients undergoing treatment with curative intent and surgical resection in each county was calculated, and the counties divided into groups with low, intermediate and high rates. Treatment with curative intent was defined as definitive chemoradiation therapy or surgery, with or without neoadjuvant oncological treatment. Overall survival was analysed using a multilevel model based on county of residence at the time of diagnosis.Some 5959 patients were included, of whom 1503 (25·2 per cent) underwent surgery. Median overall survival after diagnosis was 7·7, 8·8 and 11·1 months respectively in counties with low, intermediate and high rates of treatment with curative intent. Corresponding survival times for the surgical resection groups were 7·4, 9·3 and 11·0 months. In the multivariable analysis, a higher rate of treatment with curative intent (time ratio 1·17, 95 per cent c.i. 1·05 to 1·30; P 0·001) and a higher resection rate (time ratio 1·24, 1·12 to 1·37; P 0·001) were associated with improved survival after adjustment for relevant confounders.Patients diagnosed in counties with higher rates of treatment with curative intent and higher rates of surgery had better survival.En los pacientes con cáncer en el esófago y de la unión gastroesofágica (gastroesophageal junction, GOJ), solamente en una cuarta parte se practica una resección quirúrgica. Este estudio de base poblacional analizó las tasas de tratamiento con intención curativa y de resección y su asociación con la supervivencia. MÉTODOS: A partir del Registro Nacional Sueco de Cáncer de Esófago y Estómago (National Register for Oesophageal and Gastric Cancer, NREV), se identificaron los pacientes diagnosticados de cáncer de esófago y de la GOJ entre 2006-2015. El NREV se cruzó con otros registros nacionales para obtener información adicional. Se calculó la proporción anual de pacientes tratados con intención curativa o mediante resección quirúrgica en cada una de las áreas territoriales de los condados y se categorizaron en baja, intermedia y alta. El tratamiento con intención curativa se definió como la quimiorradioterapia definitiva (definitive chemoradiation therapy, dCRT) o la cirugía, con o sin tratamiento oncológico neoadyuvante. Se analizó la supervivencia global con un modelo multinivel basado en el condado de residencia en el momento del diagnóstico.Se incluyeron 5.959 pacientes, de los que 1.503 (25,2%) fueron tratados quirúrgicamente. La mediana de supervivencia global después del tratamiento con intención curativa fue de 7,7, 8,8 y 11,1 meses para los condados de volumen bajo, intermedio y alto. Para el grupo de cirugía fue de 7,4, 9,3 y 11,0 meses, respectivamente. En el análisis multivariable, una mayor tasa de tratamiento con intención curativa y una mayor tasa de resección se asociaron con una mejor supervivencia (tiempo ganado 1,17; i.c. del 95% 1,05-1,30, P0,001 y tiempo ganado 1,24; i.c. del 95% 1,12-1,37, P0,001) después del ajuste para los factores principales de confusión. CONCLUSIÓN: Los pacientes diagnosticados en condados con tasas altas de tratamiento con intención curativa y de cirugía tuvieron una mejor supervivencia.

Background Surgical resection with adequate lymphadenectomy is regarded the only curative option for gastric cancer. Regarding minimally invasive techniques, mainly Asian studies showed comparable oncological and short-term postoperative outcomes. The incidence of gastric cancer is lower in the Western population and patients often present with more advanced stages of disease. Therefore, the reproducibility of these Asian results in the Western population remains to be investigated. Methods A randomized trial was performed in thirteen hospitals in Europe. Patients with an indication for total gastrectomy who received neoadjuvant chemotherapy were eligible for inclusion and randomized between open total gastrectomy (OTG) or minimally invasive total gastrectomy (MITG). Primary outcome was oncological safety, measured as the number of resected lymph nodes and radicality. Secondary outcomes were postoperative complications, recovery and 1-year survival. Results Between January 2015 and June 2018, 96 patients were included in this trial. Forty-nine patients were randomized to OTG and 47 to MITG. The mean number of resected lymph nodes was 43.4 ± 17.3 in OTG and 41.7 ± 16.1 in MITG (p = 0.612). Forty-eight patients in the OTG group had a R0 resection and 44 patients in the MITG group (p = 0.617). One-year survival was 90.4% in OTG and 85.5% in MITG (p = 0.701). No significant differences were found regarding postoperative complications and recovery. Conclusion These findings provide evidence that MITG after neoadjuvant therapy is not inferior regarding oncological quality of resection in comparison to OTG in Western patients with resectable gastric cancer. In addition, no differences in postoperative complications and recovery were seen.

Background: Resection is the cornerstone of curative treatment for many nonmetastatic gastric cancers (GCs), but the population treatment patterns remains largely unknown. This large international population-based study aimed at investigating the treatment patterns and trends for nonmetastatic GC in Europe and the United States and at exploring factors associated with resection. Methods: Data of patients with microscopically confirmed primary invasive GC without distant metastasis from the national cancer registries of the Netherlands, Belgium, Sweden, Norway, Slovenia, and Estonia and the US Surveillance, Epidemiology, and End Results (SEER)-18 Program were retrieved. Age-standardized treatment rates were computed and trends were evaluated using linear regression. Associations of resection with patient and tumor characteristics were analyzed using multivariable-adjusted log-binomial regression. Analysis was performed in each country respectively without pooling. Results: Together 65 707 nonmetastatic GC patients diagnosed in 2003-2016 were analyzed. Age-standardized resection rates significantly decreased over years in all countries (by 4-24%). In 2013-2014, rates varied greatly from 54 to 75%. Patients with increasing ages, cardia cancers, or cancers invading adjacent structure were significantly less frequently resected. Resection was further associated with sex, performance status, comorbidities, tumor histology, tumor size, hospital type, and hospital volume. Association patterns and strengths varied across countries. After multivariable adjustment, resection rates remained decreasing (prevalence ratio = 0.97-0.995 per year), with decreasing trends consistently seen in various subgroups. Conclusions: Nonmetastatic GCs were less frequently resected in Europe and the United States in the early 21st century. Resection rates varied greatly across countries and appeared not to be optimal. Various factors associated with resection were revealed. Our findings can help to identify differences and possibly modifiable places in clinical practice and provide important novel references for designing effective population-based GC management strategies. ∙ In Europe and the United States, nonmetastatic gastric cancers were less frequently resected in the early 21st century. ∙ Resection rates varied greatly across countries and appeared not optimal. ∙ Various factors associated with resection were revealed. ∙ Our findings identify differences and possibly modifiable places in clinical practice and provide important novel references for designing effective population-based management strategies.

Background: Benchmarking on an international level might lead to improved outcomes at a national level. The aim of this study was to compare treatment and surgical outcome data from the Swedish National Register for Oesophageal and Gastric Cancer (NREV) and the Dutch Upper Gastrointestinal Cancer Audit (DUCA).Methods: All patients with primary oesophageal or gastric cancer who underwent a resection and were registered in NREV or DUCA between 2012 and 2014 were included. Differences in 30-day mortality were analysed using case mix-adjusted multivariable logistic regression.Results: In total, 4439 patients underwent oesophagectomy (2509 patients) or gastrectomy (1930 patients). Estimated resection rates were comparable. Swedish patients were older but had less advanced disease and less co-morbidity than Dutch patients. Neoadjuvant treatment rates were lower in Sweden than in the Netherlands, both for patients who underwent oesophagectomy (68·6 versus 90·0 per cent respectively; P < 0·001) and for those having gastrectomy (38·3 versus 56·6 per cent; P < 0·001). In Sweden, transthoracic oesophagectomy was performed in 94·7 per cent of patients, whereas in the Netherlands, a transhiatal approach was undertaken in 35·8 per cent. Higher annual procedural volumes per hospital were observed in the Netherlands. Adjusted 30-day and/or in-hospital mortality after gastrectomy was statistically significantly lower in Sweden than in the Netherlands (odds ratio 0·53, 95 per cent c.i. 0·29 to 0·95).Conclusion: For oesophageal and gastric cancer, there are differences in patient, tumour and treatment characteristics between Sweden and the Netherlands. Postoperative mortality in patients with gastric cancer was lower in Sweden. (Less)

Background In the randomized Asian REGATTA trial, no survival benefit was shown for additional gastrectomy over chemotherapy alone in patients with advanced gastric cancer with a single incurable factor, thereby discouraging surgery for these patients. The purpose of this study was to evaluate treatment strategies for patients with metastatic gastric cancer in daily practice in five European countries, along with relative survival in each country. Methods Nationwide population-based data from Belgium, Denmark, the Netherlands, Norway and Sweden were combined. Patients with primary metastatic gastric cancer diagnosed between 2006 and 2014 were included. The proportion of gastric resections performed and the administration of chemotherapy (irrespective of surgery) within each country were determined. Relative survival according to country was calculated. Results Overall, 15 057 patients with gastric cancer were included. The proportion of gastric resections varied from 8·1 per cent in the Netherlands and Denmark to 18·3 per cent in Belgium. Administration of chemotherapy was 39·2 per cent in the Netherlands, compared with 63·2 per cent in Belgium. The 6-month relative survival rate was between 39·0 (95 per cent c.i. 37·8 to 40·2) per cent in the Netherlands and 54·1 (52·1 to 56·9) per cent in Belgium. Conclusion There is variation in the use of gastrectomy and chemotherapy in patients with metastatic gastric cancer, and subsequent differences in survival.

Andrei Barbulescu,1 Viktor Oskarsson,2 Mats Lindblad,3,4 Rickard Ljung,1 Hannah L Brooke1 1Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden; 2Unit of Nutritional Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden; 3Division of Surgery, Department of Clinical Science Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; 4Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden Objective: Oral metronidazole used in combined regimens for Helicobacter pylori eradication has been associated with an increased risk of acute pancreatitis; however, it is less clear whether a similar association exists for single-regimen metronidazole. We, therefore, examined the association of single and combined regimens of oral metronidazole with risk of acute pancreatitis.Methods: In this population-based case-control study, all individuals in Sweden (aged 40–84 years) hospitalized with acute pancreatitis between January 2006 and December 2008 were identified from a national hospital register (n=5,996). Controls, matched for calendar year, age, and sex, were randomly sampled from a national population register (n=60,681). Data on oral metronidazole and covariates were extracted from national health and prescription registers. Odds ratios (ORs) of acute pancreatitis, according to timing of the latest metronidazole prescription before hospitalization, were estimated using logistic regression models. Confounding by indication was examined by contrasting the main results with the association when amoxicillin was used as exposure. The robustness of results was examined by calculating incidence rate ratios using a self-controlled case series approach.Results: After adjustment for potential confounders, there was a substantially increased risk of acute pancreatitis within 30 days of oral metronidazole exposure, both for single (OR: 4.06; 95% confidence interval [CI]: 1.90–8.64) and combined (OR: 11.80; 95% CI: 6.86–20.28) regimens, compared to nonexposure. In contrast, the adjusted OR was 1.79 (95% CI: 1.25–2.54) for current use of amoxicillin compared to nonexposure. These results were supported by the self-controlled cases series analysis (incidence rate ratio: 3.30; 95% CI: 2.69–4.06, for single and combined regimens of oral metronidazole pooled). There was no strong association between oral metronidazole and acute pancreatitis more than 30 days after exposure.Conclusion: There was an increased risk of acute pancreatitis within 30 days of exposure to single and combined regimens of oral metronidazole. While reverse causality and confounding by indication cannot be entirely excluded, they are unlikely to fully explain the association. These results warrant an increased awareness among physicians. Keywords: case–control studies, Helicobacter infections, drug therapy, metronidazole, adverse effects, pancreatitis, epidemiology, Sweden

Enhanced recovery after surgery (ERAS) programs provide a format for multidisciplinary care and has been shown to predictably improve short term outcomes associated with surgical procedures. Esophagectomy has historically been associated with significant levels of morbidity and mortality and as a result routine application and audit of ERAS guidelines specifically designed for esophageal resection has significant potential to improve outcomes associated with this complex procedure. A team of international experts in the surgical management of esophageal cancer was assembled and the existing literature was identified and reviewed prior to the production of the guidelines. Well established procedure specific components of ERAS were reviewed and updated with changes relevant to esophagectomy. Procedure specific, operative and technical sections were produced utilizing the best current level of evidence. All sections were rated regarding the level of evidence and overall recommendation according to the evaluation (GRADE) system. Thirty-nine sections were ultimately produced and assessed for quality of evidence and recommendations. Some sections were completely new to ERAS programs due to the fact that esophagectomy is the first guideline with a thoracic component to the procedure. The current ERAS society guidelines should be reviewed and applied in all centers looking to improve outcomes and quality associated with esophageal resection.

SUMMARY The optimal time interval from neoadjuvant therapy to surgery in the treatment of esophageal cancer is not known. The aim of this study was to investigate if a prolonged interval between completed neoadjuvant chemoradiotherapy and surgery was associated with improved histological response rates and survival in a population-based national register cohort. The population-based cohort study included patients treated with neoadjuvant chemoradiotherapy and esophagectomy due to cancer in the esophagus or gastroesophageal junction. Patients were divided into two groups based on the median time from completed neoadjuvant treatment to surgery. The primary outcome was complete histological response. Secondary outcomes were lymph node tumor response, postoperative complications, R0 resection rate, 90-day mortality, and overall survival. In total, 643 patients were included, 344 (54%) patients underwent surgery within 49 days, and 299 (47%) after 50 days or longer. The groups were similar concerning baseline characteristics except for a higher clinical tumor stage (P = 0.009) in the prolonged time to surgery group. There were no significant differences in complete histological response, R0 resection rate, postoperative complications, 90-day mortality, or overall survival. Adjusted odds ratio for ypT0 in the prolonged time to surgery group was 0.99 (95% confidence interval: 0.64–1.53). Complete histological response in the primary tumor (ypT0) was associated with significantly higher overall survival: adjusted hazard ratio: 0.55 (95% CI 0.41–0.76). If lymph node metastases were present in these patients, the survival was, however, significantly lower: adjusted hazard ratio for ypT0N1: 2.30 (95% CI 1.21–4.35). In this prospectively collected, nationwide cohort study of esophageal and junctional type 1 and 2 cancer patients, there were no associations between time to surgery and histological complete response, postoperative outcomes, or overall survival. The results suggest that it is safe for patients to postpone surgery at least 7 to 10 weeks after completed chemoradiotherapy, but no evidence was seen in favor of recommending a prolonged time to surgery after neoadjuvant chemoradiotherapy for esophageal cancer. A definitive answer to this question requires a randomized controlled trial of standard vs. prolonged time to surgery.

Aim To identify potential risk factors for a microscopically non-radical esophageal cancer resection (R1) and investigate how such a resection affects long-term survival. Background & Methods Esophageal cancer resections that are considered R1 have been associated with worse survival. The Swedish National Register for Esophageal and Gastric Cancer includes information on all esophageal cancer resections in Sweden. All patients having undergone esophageal resection with curative intent 2006-2017 were included. Risk factors for R1 resection were assessed through logistic regression. Factors predicting five-year survival were assessed through Cox-regression, adjusted for T-stage, N-stage, age and R-status. Results The study included 1,504 patients. The margins were microscopically involved in 146 patients (10%). Of these the circumferential margin was involved in 115 (8%). The proximal margin was involved in 55 patients (4%) and the distal in 30 (2%). In 54 (4%) specimens two margins were involved. Independent risk factors for R1-resection were absence of neoadjuvant treatment and clinical T3 stage or higher. The 5-year survival for the entire cohort was 41%, but only 19% for those with an R1 resection. Independent risk factors for death within 5-year from resection were regional lymph node metastasis (Hazard Ratio (HR) 2.6 (95% CI 2.2-3.1), histopathological stage T3 or higher (HR 1.2 95% CI 1.1-1.5), age above 60 years and R1-resection (HR 1.6 95% CI 1.4-2.0) Conclusion Involved margin in the resected specimen is an independent risk factor predicting worse 5-year survival. Besides striving for adequate surgical margins, the rate of R1-resections could be decreased through neoadjuvant treatment in fit patients.

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

Low socioeconomic status and poor education elevate the risk of developing esophageal- and junctional cancer. High education level also increases survival after curative surgery. The present study aimed to investigate associations, if any, between patient education-level and treatment allocation after diagnosis of esophageal- and junctional cancer and its subsequent impact on survival.A nation-wide cohort study was undertaken. Data from a Swedish national quality register for esophageal cancer (NREV) was linked to the National Cancer Register, National Patient Register, Prescribed Drug Register, Cause of Death Register and educational data from Statistics Sweden. The effect of education level (low; ≤9 years, intermediate; 10-12 years and high12 years) on the probability of allocation to curative treatment was analyzed with logistic regression. The Kaplan-Meier-method and Cox proportional hazard models were used to assess the effect of education on survival.A total of 4112 patients were included. In a multivariate logistic regression model, high education level was associated with greater probability of allocation to curative treatment (adjusted OR: 1.48, 95% CI: 1.08-2.03, p = 0,014) as was adherence to a multidisciplinary treatment-conference (adjusted OR: 3.13, 95% CI: 2.40-4.08, p 0,001). High education level was associated with improved survival in the patients allocated to curative treatment (HR: 0.82, 95% CI: 0.69-0.99, p = 0,036).In this nation-wide cohort of esophageal- and junctional cancer patients, including data regarding many confounders, high education level was associated with greater probability of being offered curative treatment and improved survival.

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

// Huan Song 1 , Jianwei Zhu 1 , Donghao Lu 1 , Fang Fang 1 , Weimin Ye 1 , Lars Lundell 2 , Jan Johansson 3 , Mats Lindblad 2 and Magnus Nilsson 2 1 Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden 2 Division of Surgery, CLINTEC, Department of Surgical Gastroenterology, Karolinska Institute at Karolinska University Hospital, Stockholm, Sweden 3 Department of Surgery, Skane University Hospital, Lund, Sweden Correspondence to: Huan Song, email: huan.song@ki.se Keywords: psychiatric morbidity, prognosis, surgery, gastric cancer, esophageal cancer Received: March 14, 2017 Accepted: May 20, 2017 Published: June 02, 2017 ABSTRACT Background: Due to the lack of detailed clinical information, existed evidence regarding a link between psychiatric factors and adverse cancer prognosis was inclusive. Results: We identified 1,340 patients (48.8%) with perioperative psychiatric morbidity. Preoperative psychiatric morbidity was significantly associated with both general and surgical complications within 30 days (RR = 1.3, 95% confidence interval [CI] 1.1–1.5), and the risk of death within 90 days (RR = 1.6; 95% CI 1.1–2.2) after surgery. The hazards for mortality beyond 90 days was approximately 2-fold increased among patients with perioperative psychiatric morbidity (HR = 2.0, 95% CI 1.7–2.3 for overall mortality). Materials and Methods: Based on the Swedish National Registry for Esophageal and Gastric cancer (NREV), we constructed a nationwide prospective cohort containing 2,745 surgically treated patients in 2006–2012. Perioperative psychiatric morbidity was defined as a clinical diagnosis of psychiatric disorder, from two years before to two years after surgery. Using propensity scores, we applied inverse probability of treatment weights (IPTW)-weighted Poisson regression model to evaluate relative risk (RR) of short-term surgical outcomes in relation to perioperative psychiatric morbidity. Further, IPTW-weighted Cox proportional hazards model was used to estimate hazard ratios (HRs) for mortality that occurred after 90 days of surgery. Conclusions: Perioperative psychiatric morbidity could worsen both short-term and long-term surgical outcomes among patients with gastric or esophageal cancer.

The presence of Enterobacteriaceae producing extended spectrum beta-lactamases (ESBL) or transferable AmpC beta-lactamases (pAmpC) is increasingly being reported in humans, food-producing animals and food world-wide. However, the occurrence and impact of these so-called extended spectrum cephalosporinase (ESC)-producing Enterobacteriaceae in aquatic environments are poorly documented. This study investigated the occurrence, concentrations and characteristics of ESC-producing E. coli (ESC-Ec) in samples of surface water collected at five Swedish water treatment plants that normally have relatively high prevalence and concentration of E. coli in surface water. ESC-Ec was found in 27 of 98 surface water samples analysed. All but two positive samples were collected at two of the water treatment plants studied. The ESC-Ec concentration, 1-3cfu/100mL, represented approximately 4% of the total amount of E. coli in the respective surface water sample. In total, 74% of the isolates were multi-resistant, but no isolate was resistant to carbapenems. Six types of ESBL/pAmpC genes were found in the 27 E. coli isolates obtained from the positive samples, of which four (blaCTX-M-15, blaCMY-2, blaCTX-M-1 and blaCTX-M-14) were found during the whole sampling period, in samples taken at more than one water treatment plant. In addition, the genes were situated on various types of plasmids and most E. coli isolates were not closely related with regard to MLST types. The combinations of ESBL/pAmpC genes, plasmids and E. coli isolates were generally similar to those found previously in healthy and sick individuals in Sweden. In conclusion, the occurrence of ESC-Ec in Swedish surface water shows that resistant bacteria of clinical concern are present in aquatic environments even in a low-prevalence country such as Sweden.

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

Endoscopic surveillance of Barrett’s esophagus (BE) is probably not cost-effective. A sub-population with BE at increased risk of high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC) who could be targeted for cost-effective surveillance was sought. The outcome for BE surveillance from 2003 to 2012 in a structured program was reviewed. Incidence rates and incidence rate ratios for developing HGD or EAC were calculated. Risk stratification identified individuals who could be considered for exclusion from surveillance. A health-state transition Markov cohort model evaluated the cost-effectiveness of focusing on higher-risk individuals. During 2067 person-years of follow-up of 640 patients, 17 individuals progressed to HGD or EAC (annual IR 0.8%). Individuals with columnar-lined esophagus (CLE) ≥2 cm had an annual IR of 1.2% and >8-fold increased relative risk of HGD or EAC, compared to CLE

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

SUMMARY The Swedish National Register for Esophageal and Gastric cancer was launched in 2006 and contains data with adequate national coverage and of high internal validity on patients diagnosed with these tumors. The aim of this study was to describe the evolution of esophageal and gastric cancer care as reflected in a population-based clinical registry. The study population was 12,242 patients (6,926 with esophageal and gastroesophageal junction (GEJ) cancers and 5,316 with gastric cancers) diagnosed between 2007 and 2016. Treatment strategies, short- and long-term mortality, gender aspects, and centralization were investigated. Neoadjuvant oncological treatment became increasingly prevalent during the study period. Resection rates for both esophageal/GEJ and gastric cancers decreased from 29.4% to 26.0% (P = 0.022) and from 38.8% to 33.3% (P = 0.002), respectively. A marked reduction in the number of hospitals performing esophageal and gastric cancer surgery was noted. In gastric cancer patients, an improvement in 30-day mortality from 4.2% to 1.6% (P = 0.005) was evident. Overall 5-year survival after esophageal resection was 38.9%, being higher among women compared to men (47.5 vs. 36.6%; P

There are few data comparing health-related quality of life (HRQoL) after neoadjuvant chemotherapy alone (nCT) compared with neoadjuvant chemoradiotherapy (nCRT) in patients with oesophageal cancer.In the NeoRes trial, patients were assigned randomly in a 1 : 1 ratio to receive either cisplatin 100 mg/mOf 181 patients randomized, 165 were included in the analysis of HRQoL. In a direct comparison between the allocated treatments, odynophagia after completion of neoadjuvant therapy but before surgery (P = 0·047) and troublesome coughing at 3 years' follow-up (P = 0·011) were more pronounced in the nCRT arm. In the longitudinal analyses within each treatment arm, a large deterioration in HRQoL was noted at 1 year. Some recovery was seen in both arms over time but, after 3 and 5 years, patients in the nCRT arm reported more symptoms compared with baseline than patients in the nCT arm.HRQoL after multimodal treatment for cancer of the oesophagus or gastro-oesophageal junction was impaired and more pronounced in patients who underwent nCRT, with only partial recovery over time.Se dispone de poca información sobre la calidad de vida relacionada con la salud (health-related quality of life, HRQOL) en pacientes con cáncer de esófago después de quimioterapia neoadyuvante sola en comparación con quimiorradioterapia neoadyuvante. MÉTODOS: En el ensayo NeoRes, los pacientes fueron asignados de forma aleatoria 1:1 a tratamiento con cisplatino 100 mg/mDe 181 pacientes aleatorizados, 165 fueron incluidos en el análisis de la HRQOL. En la comparación directa entre los tratamientos asignados, la odinofagia tras terminar nCRT pero antes de la cirugía (P = 0,047) y la tos molesta a los 3 años de seguimiento (P = 0,011), fueron más acentuadas en el brazo de nCRT. En el análisis longitudinal dentro de cada rama de tratamiento hubo un fuerte deterioro en la HRQOL al año. Se observó cierta recuperación en ambas ramas con el tiempo, pero a los 3 y 5 años de seguimiento, los pacientes de la rama de nCRT describieron más síntomas en comparación con la situación de inicio que los pacientes de la rama de nCT. CONCLUSIÓN: La HRQOL después del tratamiento multimodal del cáncer de esófago o de la unión gastroesofágica se ve afectada, siendo dicha afectación más pronunciada en pacientes que recibieron nCRT, recuperándose solo parcialmente con el tiempo.

Sweden is investigating an outbreak of monophasic Salmonella Typhimurium. Eighty-two nationally-distributed cases have been confirmed, with date of symptom onset between 28 August and 29 October. Cases were 51 years of age on average (range: 0–89) and the majority of cases were female (62%). A case–control study was conducted and suggested small tomatoes as source of the outbreak (adjusted odds ratio (OR): 10.8, 95% confidence interval (CI): 4.15-112.68, p value Salmonella strain and the source of the outbreak are rarely encountered in Europe. Results from investigation at the producer are pending.

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

Purpose Drug-induced pancreatitis is receiving increased medical and epidemiological attention. However, as no study has examined the role of polypharmacy per se in the development of acute pancreatitis, we examined the association between polypharmacy and risk of acute pancreatitis. Methods A nationwide case–control study was conducted between 2006 and 2008 of Swedish people aged 40–84 years. The Swedish Patient Register was used to identify 6161 cases of first-episode acute pancreatitis. The Swedish Register of the Total Population was used to randomly select 61 637 controls from the general population using frequency-based density sampling, matched for age, sex, and calendar year. The Swedish Prescribed Drug Register was used to assess polypharmacy, defined as the number of unique drugs prescribed during the last 6 months before the index date (i.e. the date of acute pancreatitis for cases and a random date for controls). Odds ratios (ORs), with 95% confidence intervals (CIs), of acute pancreatitis were estimated by unconditional logistic regression, adjusted for matching variables and potential confounding factors. Results The number of prescribed drugs was associated with a dose-dependent increase in the risk of acute pancreatitis. In the multivariable-adjusted model, compared to those without any prescriptions, the OR was 1.69 (95%CI: 1.55–1.86) for persons with 1–2 drugs, 2.40 (2.20–2.62) for 3–5 drugs, 3.17 (2.88–3.48) for 6–9 drugs, and 4.57 (4.12–5.06) for 10 or more drugs. Conclusion This population-based case–control study shows a dose-dependent association between increasing polypharmacy and risk of acute pancreatitis. These findings provide further insights into drug-induced pancreatitis. Copyright © 2016 John Wiley & Sons, Ltd.

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

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

In the original publication of the article, the co-author name “Christoph Reiβfelder” was incorrectly published.

Background Primary antireflux surgery has high success rates but 5 to 20% of patients undergoing antireflux operations can experience recurrent reflux and dysphagia, requiring reoperation. Different surgical approaches after failed fundoplication have been described in the literature. The aim of this study was to evaluate resection of the gastroesophageal junction with jejunal interposition (Merendino procedure) as a rescue procedure after failed fundoplication. Methods All patients who underwent a Merendino procedure at the Karolinska University Hospital between 2004 and 2012 after a failed antireflux fundoplication were identified. Data regarding previous surgical history, preoperative workup, postoperative complications, subsequent investigations and re-interventions were collected retrospectively. The follow-up also included questionnaires regarding quality of life, gastrointestinal function and the dumping syndrome. Results Twelve patients had a Merendino reconstruction. Ten patients had undergone at least two previous fundoplications, of which one patient had four such procedures. The main indication for surgery was epigastric and radiating back pain, with or without dysphagia. Postoperative complications occurred in 8/12 patients (67%). During a median follow-up of 35 months (range 20–61), four (25%) patients had an additional redo procedure with conversion to a Roux-en-Y esophagojejunostomy within 12 months, mainly due to obstructive symptoms that could not be managed conservatively or with endoscopic techniques. Questionnaires scores were generally poor in all dimensions. Conclusions In our experience, the Merendino procedure seems to be an unsuitable surgical option for patients who require an alternative surgical reconstruction due to a failed fundoplication. However, the small number of patients included in this study as well as the small number of participants who completed the postoperative workout limits this study.

Dysphagia is the most significant symptom in patients with esophageal cancer. There are different therapeutic interventions designed to relieve dysphagia, but few studies have addressed the effects of neoadjuvant therapy. The aim of this study is to compare the effects on dysphagia of neoadjuvant chemotherapy (nCT) versus neoadjuvant chemoradiotherapy (nCRT) and further to study the association between dysphagia response and histological response. Patient reported swallowing function was a secondary endpoint in the NeoRes trial, in which patients were randomized between neoadjuvant chemotherapy or neoadjuvant chemoradiotherapy. Patients completed dysphagia questionnaires before the start and after neoadjuvant therapy, using the European Organization for Research and Treatment of Cancer (EORTC) esophageal cancer modules QLQ-OES24/OG25. Chirieac tumor regression grade (TRG) was used to assess the histological response. Out of 181 patients were randomized, of whom 87% completed the dysphagia questionnaires before and 73% after neoadjuvant treatment. Patient characteristics were similar between the treatment arms. Among patients reporting dysphagia at baseline, neoadjuvant therapy improved dysphagia in both arms. The mean dysphagia score after neoadjuvant treatment was significantly lower after nCT compared to after nCRT (P = 0.022). The reported dysphagia did not differ between those with a complete histological response (TRG 1) and those without any response at all (TRG 4) (P = 0. 583).