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Background: The presence of distinct long-term disease-specific HRQL trajectories after curative treatment for esophageal cancer and factors associated with such trajectories are unclear., Materials and Methods: This population-based and longitudinal cohort study included 425 esophageal cancer patients who underwent curative treatment, including esophagectomy, in Sweden in 2001-2005 and were followed up until 2020, that is, 15-year follow-up. The outcomes were 10 disease-specific HRQL symptoms, measured by the well-validated EORTC QLQ-OES18 questionnaire at 6 months (n = 402 patients), and 3 (n = 178), 5 (n = 141), 10 (n = 92), and 15 years (n = 52) after treatment. HRQL symptoms were examined for distinct trajectories by growth mixture models. Weighted logistic regression models provided odds ratios (OR) with 95% confidence intervals (95% CI) for nine factors in relation to HRQL trajectories: age, sex, education, proxy baseline HRQL, comorbidity, tumor histology, chemo(radio)therapy, pathological tumor stage, and postoperative complications., Results: Distinct HRQL trajectories were identified for each of the 10 disease-specific symptoms. HRQL trajectories with more symptoms tended to persist or alleviate over time, while trajectories with fewer symptoms were more stable. Eating difficulty had three trajectories: persistently less, persistently moderate, and persistently more symptoms. The OR of having a persistently more eating difficulty trajectory was decreased for adenocarcinoma histology (OR = 0.44, 95% CI 0.21-0.95), and increased for pathological tumor stage III-IV (OR = 2.19, 95% CI 0.99-4.82) and 30-day postoperative complications (OR = 2.54, 95% CI 1.26-5.12)., Conclusion: Distinct trajectories with long-term persistent or deteriorating disease-specific HRQL symptoms were identified after esophageal cancer treatment. Tumor histology, tumor stage, and postoperative complications may facilitate detection of high-risk patients for unwanted trajectories., (© 2024 The Author(s). Cancer Medicine published by John Wiley & Sons Ltd.)

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., Competing Interests: The study was funded by the Swedish Research Council (grant number 2019-00209) and Swedish Cancer Society (grant number 180684). The authors report no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Modern enhanced recovery protocols discourage drain use due to negative impacts on patient comfort, mobility, and recovery, and lack of proven clinical benefit. After oesophagectomy, however, drains are still routinely placed. This review aimed to assess the evidence for, and how best to use chest drains after oesophageal surgery., Methods: A systematic literature search was performed in Medline, Embase and Cochrane collaboration databases. Studies reporting outcomes for different types or uses of thoracic drainage, or outcomes related to drains after trans-thoracic oesophagectomy were included. Studies were collated into domains based on variations in number, position, type, removal criteria, diagnostic use and complications of drains. Methodological quality was assessed with Newcastle-Ottawa and Jadad scores., Results: Among 434 potentially relevant studies, 27 studies met the inclusion criteria and these included 2564 patients. Studies that examined the number of drains showed pain reduction with a single drain compared to multiple drains (3 studies, n = 103), and transhiatal placement compared to intercostal (6 studies, n = 425). Amylase levels may aid diagnosis of anastomotic leak (9 studies, n = 888). Narrow calibre Blake drains may effectively drain both air and fluid (2 studies, n = 163). Drain removal criteria by daily drainage volumes of up to 300 mL did not impact subsequent effusion rates (2 studies, n = 130). Complications related directly to drains were reported by 3 studies (n = 59)., Conclusion: Available evidence on the impact of thoracic drainage after oesophagectomy is limited, but has the potential to negatively affect outcomes. Further research is required to determine optimum drainage strategies., (© The Author(s) 2021. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: To assess the outcomes of patients with early esophageal cancer and high-grade dysplasia comparing esophagectomy, the historical treatment of choice, to endoscopic eradication therapy (EET)., Methods: Retrospective cohort study of consecutive patients with early esophageal cancer/high-grade dysplasia, treated between 2000 and 2018 at a tertiary center. Primary outcomes were all-cause and disease-specific mortality assessed by multivariable Cox regression and a propensity score matching sub analysis, providing hazard ratios (HR) with 95% confidence intervals (CI) adjusted for age, tumor grade (G1/2 vs. G3), tumor stage, and lymphovascular invasion. Secondary outcomes included complications, hospital stay, and overall costs., Results: Among 269 patients, 133 underwent esophagectomy and 136 received EET. Adjusted survival analysis showed no difference between groups regarding all-cause mortality (HR 1.85, 95% CI 0.73, 4.72) and disease-specific mortality (HR 1.10, 95% CI 0.26, 4.65). In-hospital and 30-day mortality was 0% in both groups. The surgical group had a significantly higher rate of complications (Clavien-Dindo ≥3 26.3% vs. endoscopic therapy 0.74%), longer in-patient stay (median 14 vs. 0 days endoscopic therapy) and higher hospital costs(£16 360 vs. £8786 per patient)., Conclusion: This series of patients treated during a transition period from surgery to EET, demonstrates a primary endoscopic approach does not compromise oncological outcomes with the benefit of fewer complications, shorter hospital stays, and lower costs compared to surgery. It should be available as the gold standard treatment for patients with early esophageal cancer. Those with adverse prognostic features may still benefit from esophagectomy., (© The Author(s) 2021. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Most patients presenting with oesophageal cancer do so with advanced disease not suitable for surgery. However, there are examples of encouraging survival following surgery in highly selected patients who respond well to chemotherapy., Methods: This was a retrospective cohort study of patients who presented with advanced but nonvisceral metastatic oesophageal cancer. Consecutive patients on a prolonged primary chemotherapy pathway who underwent surgical resection following a favourable response to chemotherapy were included. Survival and recurrence rates were analysed using Cox regression, providing hazard ratios (HRs) with 95% confidence intervals (CIs)., Results: A total of 57 patients included in the cohort operated between 2007 and 2015, the overall median survival was 44 months and the 5-year survival was 42%. Prechemotherapy cN0/cN1 (HR: 0.27, 95% CI: 0.12-0.62) conferred an independent survival advantage compared to cN2 and cN3 disease. Poor differentiation (HR: 2.46, 95% CI: 1.11-5.42), R1 resection (HR: 2.43, 95% CI: 1.14-5.19) and advanced nodal status (HR: 3.28, 95% CI: 1.44-7.47) predicted worse survival on univariable analysis. Poor differentiation (HR: 3.93, 95% CI: 1.62-9.56) was independently associated with poor survival when adjusted for other variables., Conclusion: Patients who present with advanced inoperable oesophageal cancer who have a favourable response to chemotherapy represent a limited group of patients who may benefit from surgery., (© 2021 Wiley Periodicals LLC.)

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.)

Background: Esophagectomy for esophageal cancer is associated with a substantial risk of life-threatening complications and a limited long-term survival. This study aimed to clarify the controversial questions of how age influences short-term and long-term survival., Methods: This population-based cohort study included almost all patients who underwent curatively intended esophagectomy for esophageal cancer in Sweden in 1987-2010, with follow-up through 2016. The exposure was age, analyzed both as a continuous and categorical variable. The probability of mortality was computed using a novel flexible parametric model approach. The reported probabilities are proper measures of the risk of dying, and the related odds ratios (OR) are therefore more suitable measures of association than hazard ratios. The outcomes were 90-day all-cause mortality, 5-year all-cause mortality, and 5-year disease-specific mortality. A novel flexible parametric model was used to derive the instantaneous probability of dying and the related OR along with 95% confidence intervals (CIs), adjusted for sex, education, comorbidity, tumor histology, pathological tumor stage, and resection margin status., Results: Among 1737 included patients, the median age was 65.6 years. When analyzed as a continuous variable, older age was associated with slightly higher odds of 90-day all-cause mortality (OR 1.05, 95% CI 1.02-1.07), 5-year all-cause mortality (OR 1.02, 95% CI 1.01-1.03), and 5-year disease-specific mortality (OR 1.01, 95% CI 1.01-1.02). Compared with patients aged < 70 years, those aged 70-74 years had no increased risk of any mortality outcome, while patients aged ≥ 75 years had higher odds of 90-day mortality (OR 2.85, 95% CI 1.68-4.84), 5-year all-cause mortality (OR 1.56, 95% CI 1.27-1.92), and 5-year disease-specific mortality (OR 1.38, 95% CI 1.09-1.76)., Conclusions: Patient age 75 years or older at esophagectomy for esophageal cancer appears to be an independent risk factor for higher short-term mortality and lower long-term survival.

Esophagectomy is the mainstay of curative treatment for most patients with a diagnosis of esophageal cancer. This procedure needs to be optimized to secure the best possible chance of cure for these patients. Research comparing various surgical approaches of esophagectomy generally has failed to identify any major differences in long-term prognosis. Comparisons between minimally invasive and open esophagectomy, transthoracic and transhiatal approaches, radical and moderate lymphadenectomy, and high and moderate hospital volume generally have provided only moderate alterations in long-term survival rates after adjustment for established prognostic factors. In contrast, some direct surgeon-related factors, which remain independent of known prognostic factors, seem to influence the long-term survival more strongly in esophageal cancer. Annual surgeon volume is strongly prognostic, and recent studies have suggested the existence of long surgeon proficiency gain curves for achievement of stable 5-year survival rates and possibly also a prognostic influence of surgeon age and weekday of surgery. The available literature indicates a potentially more critical role of the individual surgeon's skills than that of variations in surgical approach for optimizing the long-term survival after esophagectomy for esophageal cancer. This finding points to the value of paying more attention to how the skills of the individual esophageal cancer surgeon can best be achieved and maintained. Careful selection and evaluation of the most suitable candidates, appropriate and structured training programs, and regular peer-review assessments of experienced surgeons may be helpful in this respect.

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 I test and χ 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 [I = 12%, 95% confidence interval (CI) 0%-41%, and χ = 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.

Some investigations suggest a better prognosis in women compared to men with esophageal cancer but these differences are uncertain. The aim of our study was to clarify whether sex influences the prognosis after esophagectomy for esophageal squamous cell carcinoma and esophageal adenocarcinoma. A population-based and nationwide cohort study included almost all patients who underwent esophagectomy for esophageal cancer in Sweden in 1987-2010, with follow-up until 2016. Patients' sex was analyzed in relation to risk of mortality. Multivariable Cox regression provided hazard ratios (HR) with 95% confidence intervals (CI), adjusted for calendar period, age, education, comorbidity, tumor stage, neoadjuvant therapy, and surgeon volume. Among 1,816 participants, 1,024 (56%) had esophageal squamous cell carcinoma (355 [35%] women), and 792 (44%) had esophageal adenocarcinoma (103 [13%] women). Compared to men, women had a decreased overall all-cause mortality in esophageal squamous cell carcinoma (HR = 0.73, 95% CI 0.63-0.85). Stratified analyses showed decreased mortality limited to women aged >55 years (HR = 0.71, 95% CI 0.61-0.83), but in all tumor stages, particularly stages 0-I (HR = 0.54, 95% CI 0.37-0.79). Women also had decreased 90-day all-cause mortality, 5-year all-cause mortality, and 5-year disease-specific mortality in esophageal squamous cell carcinoma compared to men. For esophageal adenocarcinoma, no sex differences were found for any of the mortality outcomes. Thus, women who undergo esophagectomy for esophageal squamous cell carcinoma seem to have better prognosis than men, especially those with early tumor stages, whereas no sex differences in prognosis were found for esophageal adenocarcinoma., (© 2018 UICC.)

Background: Surgery proficiency gain curves must be shortened to reduce patient harm during esophagectomy learning., Objective: This study aimed to test whether surgeon volume and surgeon age influenced the length of period of surgical proficiency gain., Methods: This population-based cohort study included 1384 patients with esophageal cancer who underwent esophagectomy by any of the 36 highest-volume surgeons in Sweden between 1987 and 2010, with follow-up until 2016. Annual surgeon volume was dichotomized by the median values into 'higher-volume surgeons' (≥ 4 cases per year) and 'lower-volume surgeons' (< 4 cases per year), and surgeon age at the start of practicing esophagectomies into 'younger surgeons' (aged < 45 years) and 'older surgeons' (aged ≥ 45 years). Proficiency gain curves were constructed using risk-adjusted cumulative sum analysis for 1- to 5-year mortality (main outcome) and secondary outcomes (presented below). The results were adjusted for all established prognostic factors., Results: For 1- to 5-year mortality, the change point was at 14 cases among 'higher-volume surgeons', while 'lower-volume surgeons' had a later change point at 31 cases. The corresponding change points were at 13 cases among 'younger surgeons' and at 48 cases among 'older surgeons'. Similar patterns of differences in the proficiency gain curves were seen for the secondary outcomes of 30-day mortality and resection margin status (tumor involvement)., Conclusion: Higher-volume- and younger surgeons seem to have a substantially shorter period of proficiency gain for long-term mortality and other outcomes following surgery for esophageal cancer. This indicates a value of intensified training of younger surgeons for these complex operations.

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.

Background: The postoperative health-related quality of life (HRQOL) outcomes in patients with gastroesophageal junction (GEJ) adenocarcinoma after gastrectomy and esophagectomy are unclear. The aim was to evaluate HRQOL outcomes 6 months after extended total gastrectomy, subtotal esophagectomy, and combined esophagogastrectomy., Methods: Patients who underwent surgery for GEJ adenocarcinoma of Siewert type 2 or 3 in 2001-2005 were identified from a nationwide Swedish prospective and population-based cohort. Three surgical strategies, i.e., gastrectomy, esophagectomy, or esophagogastrectomy, were analyzed in relationship to HRQOL measured at 6 months after surgery (main outcome). HRQOL was assessed using well-validated questionnaires for general (EORTC QLQ-C30) and esophageal cancer-specific (EORTC QLQ-OES18) symptoms. Mean score differences (MSD) and 95% confidence intervals (CI) were analyzed using ANCOVA and adjusted for age, sex, tumor stage, comorbidity, education level, hospital volume, and postoperative complications. MSDs > 10 were regarded as clinically relevant., Results: Among 176 patients with complete information on HRQOL and covariates, none of the MSDs for HRQOL among the three surgery groups were clinically and statistically significant. MSDs comparing esophagectomy and gastrectomy showed no major differences in global quality of life (MSD, +8, 95% CI, 0 to +16), physical function (MSD, +2, 95% CI, -5 to +9), pain (MSD, -3, 95% CI, -12 to +7), or reflux (MSD, +5, 95% CI, -4 to +14). Also, complication rates and 5-year survival rates were similar comparing esophagectomy and gastrectomy., Conclusions: Extended total gastrectomy, subtotal esophagectomy, and combined esophagogastrectomy seemed to yield similar 6-month postoperative HRQOL outcomes for patients with GEJ adenocarcinoma.

Purpose: Centralization of surgery improves the survival following esophagectomy for cancer, but whether university hospital setting or surgeon volume influences the reoperation rates is unknown. We aimed to clarify whether hospital status or surgeon volume are associated with a risk of reoperation after esophagectomy., Methods: Patients who underwent esophagectomy for esophageal cancer in 1987-2010 were identified from a population-based, nationwide Swedish cohort study. University hospital status and cumulative surgeon volume were analyzed in relation to risk of reoperation or death (the latter included to avoid competing risk errors) within 30 days of surgery. Multivariable logistic regression provided odds ratios (OR) with 95% confidence intervals (CI), adjusted for calendar period, age, sex, comorbidity, tumor histology, stage, neoadjuvant therapy, resection margin, surgeon volume, and hospital status., Results: Among 1820 participants, 989 (54%) underwent esophagectomy in university hospitals and 271 (15%) died or were reoperated within 30 days of surgery. Non-university hospital status was associated with an increased risk of reoperation or death compared to university hospitals (adjusted OR 1.56, 95% CI 1.13-2.13). Regarding surgeon volume, the ORs were increased in the lower volume categories, but not statistically significant (OR 1.30, 95% CI 0.89-1.89 for surgeon volume <7 and OR 1.10, 95% CI 0.75-1.63 for surgeon volume 7-16, compared to surgeon volume >16)., Conclusion: The risk of reoperation or death within 30 days of esophagectomy seems to be lower in university hospitals even after adjustment for surgeon volume and other potential confounders. These results support centralizing esophageal cancer patients to university hospitals., (Copyright © 2018 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Background: Population-based studies comparing minimally invasive esophagectomy (MIE) and open esophagectomy (OE) relative to 90-day postoperative mortality are needed., Objective: The aim of this study was to compare short-term outcomes following these two techniques for esophageal cancer., Methods: Patients undergoing MIE (n = 217) or OE (n = 1397) for esophageal cancer between 2007 and 2014 were identified from nationwide complete registries in Finland and Sweden. The primary outcome was 90-day mortality, and secondary outcomes were 30-day mortality, length of hospital stay, and 30- and 90-day readmission rate. Results were adjusted for age, sex, comorbidity, tumor histology, surgery year, and country., Results: Ninety-day mortality rates were 4.1% (n = 9 of 217) for MIE and 6.8% (n = 95 of 1397) for OE; 90-day mortality was halved after MIE [adjusted hazard ratio (HR) 0.49, 95% confidence interval (CI) 0.24-0.99]. There was no difference in 30-day mortality (adjusted HR 0.87, 95% CI 0.29-2.66). Median hospital stay was 15 days for MIE and 16 days for OE (adjusted β -0.17, standard error 0.08, p = 0.030). The 30-day readmission rates were 8.9% after MIE and 12.0% after OE (adjusted HR 0.57, 95% CI 0.34-0.94), while the 90-day readmission rates were 28.8% and 33.6%, respectively, without a statistically significant difference (adjusted HR 0.82, 95% CI 0.61-1.10)., Conclusions: This population-based study from Finland and Sweden revealed lower 90-day mortality, shorter hospital stay, and lower 30-day readmission rates after MIE compared with OE for esophageal cancer. These findings support the use of minimally invasive approaches.

It is unclear whether gastrectomy or oesophagectomy offer better outcomes for gastro-oesophageal junction (GOJ) cancer. A total of 240 patients undergoing total gastrectomy (n = 85) or oesophagectomy (n = 155) for Siewert II-III GOJ adenocarcinoma were identified from a Swedish prospective population-based nationwide cohort. The surgical approaches were compared in relation to non-radical resection margins (main outcome) using multivariable logistic regression, providing odds ratios (ORs) and 95% confidence intervals (CIs), mean number of removed lymph nodes with standard deviation (SD) using ANCOVA, assessing mean differences and 95% CIs, and 5-year mortality using Cox regression estimating hazard ratios (HRs) and 95% CIs. The models were adjusted for age, sex, comorbidity, tumour stage, and surgeon volume. The non-radical resection rate was 15% for gastrectomy and 14% for oesophagectomy, and the adjusted OR was 1.61 (95% CI 0.68-3.83). The mean number of lymph nodes removed was 14.2 (SD ± 9.6) for gastrectomy and 14.2 (SD ± 10.4) for oesophagectomy, with adjusted mean difference of 2.4 (95% CI-0.2-5.0). The 5-year mortality was 76% following gastrectomy and 75% following oesophagectomy, with adjusted HR = 1.07 (95% CI 0.78-1.47). Gastrectomy and oesophagectomy for Siewert II or III GOJ cancer seem comparable regarding tumour-free resection margins, lymph nodes removal, and 5-year survival.

Oesophageal cancer is a clinically challenging disease that requires a multidisciplinary approach. Extensive treatment might be associated with a considerable decline in health-related quality of life and yet still a poor prognosis. In recent decades, prognosis has gradually improved in many countries. Endoscopic procedures have increasingly been used in the treatment of premalignant and early oesophageal tumours. Neoadjuvant therapy with chemotherapy or chemoradiotherapy has supplemented surgery as standard treatment of locally advanced oesophageal cancer. Surgery has become more standardised and centralised. Several therapeutic alternatives are available for palliative treatment. This Seminar aims to provide insights into the current clinical management, ongoing controversies, and future needs in oesophageal cancer., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: Psychological distress is common among patients with oesophageal cancer. However, little is known about the course and predictors of psychological distress among patients treated with curative intent. Therefore, the aim of this study was to explore the prevalence, course and predictors of anxiety and depression in patients operated for oesophageal cancer, from prior to surgery to 12 months post-operatively., Methods: A prospective cohort of patients with oesophageal cancer (n = 218) were recruited from one high-volume specialist oesophago-gastric treatment centre (St Thomas' Hospital, London, UK). Anxiety and depression were assessed prior to surgery, 6 and 12 months post-operatively. Mixed-effects modelling was performed to investigate changes over time and to estimate the association between clinical and socio-demographic predictor variables and anxiety and depression symptoms., Results: The proportion of patients with anxiety was 33% prior to surgery, 28% at 6 months, and 37% at 12 months. Prior to surgery, 20% reported depression, 27% at 6 months, and 32% at 12-month follow-up. Anxiety symptoms remained stable over time whereas depression symptoms appeared to increase from pre-surgery to 6 months, levelling off between 6 and 12 months. Younger age, female sex, living alone and more severe self-reported dysphagia (i.e., difficulty swallowing) predicted higher anxiety symptoms. In-hospital complications, greater limitations in activity status and more severe self-reported dysphagia were predictive of higher depression., Conclusions: Many patients report psychological distress during the first year following oesophageal cancer surgery. Whether improving the experience of swallowing difficulties may also reduce distress among these patients warrants further study.

The best available surgical strategy in the treatment of resectable esophago-gastric junctional (EGJ) cancer is a controversial topic. In this review we evaluate the current literature and scientific evidence examining the surgical treatment of locally advanced EGJ cancer by comparing esophagectomy with gastrectomy, transhiatal with transthoracic esophagectomy, minimally invasive with open esophagectomy, and less extensive with more extensive lymphadenectomy. We also assess endoscopic procedures increasingly used for early EGJ cancer. The current evidence does not favor any of the techniques over the others in terms of oncological outcomes. Health-related quality of life may be better following gastrectomy compared to esophagectomy. Minimally invasive procedures might be less prone to surgical complications. Endoscopic techniques are safe and effective alternatives for early-stage EGJ cancer in the short term, but surgical treatment is the mainstay in fit patients due to the risk of lymph node metastasis. Any benefit of lymphadenectomy extending beyond local or regional nodes is uncertain. This review demonstrates the great need for well-designed clinical studies to improve the knowledge in how to optimize and standardize the surgical treatment of EGJ cancer., (Crown Copyright © 2016. Published by Elsevier Ltd. All rights reserved.)

Objective: Previous studies indicate an increased short-term and long-term mortality from major cancer surgery performed towards the end of the working week or during the weekend. We hypothesised that the prognosis after major cancer surgery is also negatively influenced by surgery conducted during holiday periods., Setting: Population-based nationwide Swedish cohort study., Participants: Patients undergoing oesophagectomy for oesophageal cancer between 1987 and 2010. Among 1820 included patients, 206 (11.3%) and 373 (20.5%) patients were operated on during narrow and wide holiday periods, respectively., Interventions: Narrow (7 weeks) and wide (14 weeks) Swedish holiday periods., Primary and Secondary Outcome Measures: 90-day all-cause, 5-year all-cause and 5-year disease-specific mortality., Results: Narrow holiday period did not increase all-cause 90-day (HR=0.84, 95% CI 0.53 to 1.33), all-cause 5-year (HR=1.01, 95% CI 0.85 to 1.21) or disease-specific 5-year mortality (HR=1.04, 95% CI 0.87 to 1.26). Similarly, wide holiday period did not increase the risk of 90-day (HR=0.79, 95% CI 0.55 to 1.13), all-cause 5-year (HR=0.96, 95% CI 0.84 to 1.1) or disease-specific 5-year mortality (HR=1.03, 95% CI 0.89 to 1.19)., Conclusions: No measurable effects of holiday periods on short-term or longer term mortality following surgery for oesophageal cancer were observed in this population-based study, indicating that an adequate surgical experience was maintained during holiday periods., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

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 from Wednesday 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.

Objectives: Later weekday of surgery for oesophageal cancer seems to increase 5-year mortality, but the mechanisms are unclear. We hypothesised that early postoperative reoperations and mortality might explain this association, since reoperation after oesophagectomy decreases long-term prognosis, and later weekday of elective surgery increases 30-day mortality., Design: This was a population-based cohort study during the study period 1987-2014., Setting: All Swedish hospitals conducting elective surgery for oesophageal cancer in Sweden., Participants: Included were 1748 patients, representing almost all (98%) patients who underwent elective surgery for oesophageal cancer in Sweden during 1987-2010, with follow-up until 2014., Primary and Secondary Outcome Measures: The risk of reoperation or mortality within 30 days of oesophageal cancer surgery was assessed in relation to weekday of surgery by calculating ORs with 95% CIs using multivariable logistic regression. ORs were adjusted for age, comorbidity, tumour stage, histology, neoadjuvant therapy and surgeon volume., Results: Surgery Wednesday to Friday did not increase the risk of reoperation or mortality compared with surgery Monday to Tuesday (OR=0.99, 95% CI 0.75 to 1.31). A decreased point estimate of reoperation (OR=0.88, 95% CI 0.64 to 1.21) was counteracted by an increased point estimate of mortality (OR=1.28, 95% CI 0.83 to 1.99). ORs did not increase from Monday to Friday when each weekday was analysed separately. There was no association between weekday of surgery and reoperation specifically for anastomotic leak, laparotomy or wound infection. Stratification for surgeon volume did not reveal any clear associations between weekday of surgery and risk of 30-day reoperation or mortality., Conclusions: Weekday of oesophageal cancer surgery does not seem to influence the risk of reoperation or mortality within 30 days of surgery, and thus cannot explain the association between weekday of surgery and long-term prognosis., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Purpose: We aimed to identify the presence and length of esophagectomy proficiency gain curves in terms of short- and long-term mortality for esophageal cancer., Patients and Methods: Patients who underwent esophagectomy for esophageal cancer between 1987 and 2010 with follow-up until 2014 were identified from a well-established, population-based, nationwide Swedish cohort study. Proficiency gain curves were created by using risk-adjusted cumulative sum analysis for 30-day, 90-day, 1-year, 3-year, and 5-year all-cause and disease-specific mortality measures. Similarly, the proficiency gain curves for lymph node harvest, resection margin status, and reoperation incidence were assessed as performance-contributing factors to the observed changes in long-term survival., Results: Esophagectomies in 1,821 patients with esophageal cancer were conducted by 139 surgeons. The change-point in proficiency gain curve for all-cause 30-day mortality was early, at 15 cases, when mortality decreased from 7.9% to 3.1% (P < .001). Later change-points, which ranged from 35 to 59 cases, were observed for 1-, 3- and 5-year mortality rates, for which all-cause mortality decreased from 34.9% to 27.7% (P = .011), from 47.4% to 41.5% (P = .049), and from 31.4% to 19.1% (P = .009), respectively. Similar change-points were observed in disease-specific mortality at 1 and 3 years. There was a continuous increase in lymph node harvest, which did not plateau. Also, change-points were observed for resection margin with tumor involvement at 17 cases, with a reduction from 20.9% to 15.2% (P = .004), and for reoperation rate at 55 cases, with a reduction from 12.6% to 5.0% (P < .001)., Conclusion: The gain of proficiency in esophagectomy for cancer is associated with measurable changes in short- and long-term mortality results. These findings indicate a need for structured national training and mentorship programs for esophageal cancer surgery., (© 2016 by American Society of Clinical Oncology.)

Background: The selection for surgery is multifaceted for patients diagnosed with esophageal cancer. Since it is uncertain how comorbidity should influence the selection, this study addressed comorbidities in relation to risk of severe complications following esophageal cancer surgery., Methods: This population-based cohort study was based on prospectively included patients who underwent surgical resection for an esophageal or gastro-esophageal junctional cancer in Sweden during 2001-2005. The participation rate was 90%. Associations between pre-defined comorbidities and pre-defined post-operative complications occurring within 30 days of surgery were analyzed using multivariable logistic regression. The resulting odds ratios (ORs) and 95% confidence intervals (CIs) were adjusted for age, sex, tumor stage, tumor histology, neoadjuvant therapy, type of surgery, annual hospital volume, other comorbidities, and other complications., Results: Among 609 included patients, those with cardiac disease (n = 92) experienced an increased risk of pre-defined complications in general (adjusted OR 1.81, 95% CI 1.13-2.90), while patients with hypertension (n = 137), pulmonary disorders (n = 79), diabetes (n = 67), and obesity (n = 66) did not. Patients with a Charlson comorbidity index score ≥2 had substantially increased risks of pre-defined complications (adjusted OR 2.44, 95% CI 1.60-3.72)., Conclusion: Cardiac disease and a Charlson comorbidity index score ≥2 seem to increase the risk of severe and early post-operative complications in patients with esophageal cancer, while hypertension, pulmonary disorders, diabetes, and obesity do not. These findings should be considered in the clinical decision-making for improved selection of patients for surgery.

Background: Postoperative mortality is traditionally defined as death within 30 days of surgery. We hypothesised that the declining 30-day mortality after oesophageal cancer resection is, at least partly, explained by a shift towards increased 90-day mortality., Methods: This population-based cohort study included 95 % of all patients who underwent surgical resection for oesophageal cancer in Sweden in 1987-2010. Cox proportional-hazards regression models were used to calculate hazard ratios (HRs) with 95 % confidence intervals (CIs) of 30-day and 31-90 days postoperative mortality in three calendar periods (1987-1994, 1995-2002, and 2003-2010). Adjustments were made for age, sex, comorbidity, tumour stage, tumour histology, surgical radicality, neoadjuvant therapy, and hospital volume of oesophagectomy., Results: Among 1,822 patients, the 30-day postoperative mortality decreased from 9.3 % in 1987-1994 to 3.0 % in 2003-2010, while the corresponding 31-90 days mortality decreased from 8.4 to 4.6 %. The adjusted HR of 30-day mortality in the earliest period was markedly increased compared to the latest period (HR 3.26; 95 % CI 1.96-5.45), whereas the corresponding HR of 31-90 days mortality was weaker (HR 2.16; 95 % CI 1.34-3.46). Among patients who died within 90 days of surgery, the proportion of 31-90 days mortality increased from 47 to 61 % during the study period., Conclusions: This population-based study indicates a shift of postoperative mortality following surgery for oesophageal cancer from 30 days to 31-90 days with more recent calendar periods. Reporting of 90-day mortality rates might replace 30-day mortality rates in assessing early postoperative mortality in oesophageal cancer patients.

Background: Little is known about how early postoperative complications after oesophagectomy for cancer influence healthcare utilisation in the long-term. We hypothesised that these complications also increase healthcare utilisation long after the recovery period., Methods: This was a prospective, nationwide Swedish population-based cohort study of patients who underwent curatively intended oesophagectomy for cancer in 2001-2005 and survived at least 1 year postoperatively (n = 390). Total days of in-hospitalisation, number of hospitalisations and number of visits to the outpatient clinic within 5 years of surgery were analysed using quasi-Poisson models with adjustment for patient, tumour and treatment characteristics and are expressed as incidence rate ratios (IRR) and 95% confidence intervals (CI)., Results: There was an increased in-hospitalisation period 1-5 years after surgery in patients with more than 1 complication (IRR 1.5, 95% CI 1.0-2.4). The IRR for the number of hospitalisations by number of complications was 1.1 (95% CI 0.7-1.6), and 1.2 (95% CI 0.9-1.6) for number of outpatient visits in patients with more than 1 complication. The IRR for in-hospitalisation period 1-5 years following oesophagectomy was 1.8 (95% CI 1.0-3.0) for patients with anastomotic insufficiency and 1.5 (95% CI 0.9-2.5) for patients with cardiovascular or cerebrovascular complications. We found no association with number of hospitalisations (IRR 1.2, 95% CI 0.7-2.0) or number of outpatient visits (IRR 1.3, 95% CI 0.9-1.7) after anastomotic insufficiency, or after cardiovascular or cerebrovascular complications (IRR 1.2, 95% CI 0.7-1.9) and (IRR 1.1, 95% CI 0.8-1.5) respectively., Conclusion: This study showed an increased total in-hospitalisation period 1-5 years after oesophagectomy for cancer in patients with postoperative complications, particularly following anastomotic insufficiency.

Background: It is unclear how the extent of surgical lymph node clearance influences prognosis after surgery for esophageal cancer., Methods: This nationwide, population-based cohort study included 1044 esophageal cancer patients who had undergone esophagectomy between 1987 and 2010 in Sweden, with follow-up until 2012. The independent role of lymph node removal in relation to survival was analyzed using Cox proportional hazards regression, providing hazard ratios (HRs) with 95% confidence intervals (CIs), adjusted for age, sex, comorbidity, tumor (T) stage, neo-adjuvant treatment, surgeon volume, and calendar period. Statistical tests were two-sided, except tests for trend., Results: Analyzed as a linear variable, a higher number of lymph nodes removed did not influence the overall five-year mortality (adjusted HR = 1.00, 95% CI = 0.99 to 1.01). Patients in the third (7-15 nodes) and fourth (16-114 nodes) quartiles of removed nodes did not demonstrate any decreased overall five-year mortality compared with those in the lowest two quartiles (<7 nodes) (HR = 1.13, 95% CI = 0.95 to 1.35 and HR = 1.17, 95% CI = 0.94 to 1.46, respectively). In early T stages (Tis-T1) the hazard ratios indicated a worse survival with more lymphadenectomy using the median as cutoff (HR = 1.53, 95% CI = 1.13 to 2.06). Increased lymph node removal did not decrease mortality in any specific T stage. A greater number of metastatic nodes and a higher positive-to-negative node ratio were associated with strongly increased mortality. All results were similar when disease-specific mortality was analyzed., Conclusion: This population-based study indicates that more extensive lymph node clearance during surgery for esophageal cancer may not improve survival. These results challenge current clinical guidelines, and further research is needed to change clinical practice., (© The Author 2015. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.)

Objective: The aim of this study was to establish the proportion of patients reporting emotional problems following oesophagectomy for cancer and identify the risk characteristics for emotional problems., Methods: A Swedish population-based cohort study of patients with surgically treated oesophageal cancer was used. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 was used to assess tension, worry, irritation and depressed mood at 6 months and 5 years after surgery. Potential risk characteristics were retrieved from medical notes and data linkages to Swedish health registries. Multivariable logistic regression analyses were performed to examine risk characteristics for poor emotional recovery., Results: Of 401 patients included at 6 months, 49% reported problems with tension, 61% worry, 62% irritation and 63% depressed mood. Of the 140 (35%) patients who completed the 5-year follow-up, 39% reported problems with tension and about half of the patients reported problems with worry, irritation, and depressed mood (49, 45 and 52%, respectively). Squamous cell carcinoma was identified as a risk characteristic for tension (OR 2.15, 95% CI 1.30-3.55), worry (OR 2.02, 95% CI 1.19-3.40) and depressed mood (OR 1.71, 95% CI 1.01-2.90) at 6 months compared with adenocarcinoma. Compared with higher education, lower education was associated with tension (upper secondary schooling: OR 1.97, 95% CI 1.02-3.79 and 9-year compulsory: OR 2.46, 95% CI 1.28-4.74), while non-cohabitating patients were less likely to report problems with worry at 6 months (OR 0.53, 95% CI 0.34-0.84) compared with cohabitating patients., Conclusions: A substantial proportion of patients reports emotional problems following oesophagectomy, and risk characteristics include squamous cell carcinoma histology and low educational level., (Copyright © 2014 John Wiley & Sons, Ltd.)

Background: Centralisation of healthcare, especially for advanced cancer surgery, has been a matter of debate. Clear short-term mortality benefits have been described for oesophageal cancer surgery conducted at high-volume hospitals and by high-volume surgeons., Objective: To clarify the association between hospital volume, surgeon volume and hospital type in relation to long-term survival after oesophagectomy for cancer, by a meta-analysis., Design: The systematic literature search included PubMed, Web of Science, Cochrane library, EMBASE and Science Citation Index, for the period 1990-2013. Eligible articles were those which reported survival (time to death) as HRs after oesophagectomy for cancer by hospital volume, surgeon volume or hospital type. Fully adjusted HRs for the longest follow-up were the main outcomes. Results were pooled by a meta-analysis, and reported as HRs and 95% CIs., Results: Sixteen studies from seven countries met the inclusion criteria. These studies reported hospital volume (N=13), surgeon volume (N=4) or hospital type (N=4). A survival benefit was found for high-volume hospitals (HR=0.82, 95% CI 0.75 to 0.90), and possibly also, for high-volume surgeons (HR=0.87, 95% CI 0.74 to 1.02) compared with their low-volume counterparts. No association with survival remained for hospital volume after adjustment for surgeon volume (HR=1.01, 95% CI 0.97 to 1.06; N=2), while a survival benefit was found in favour of high-volume surgeons after adjustment for hospital volume (HR=0.91, 95% CI 0.85 to 0.98; N=2)., Conclusions: This meta-analysis demonstrated better long-term survival (even after excluding early deaths) after oesophagectomy with high-volume surgery, and surgeon volume might be more important than hospital volume. These findings support centralisation with fewer surgeons working at large centres., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Accurate selection of patients for radical treatment of esophageal cancer is essential to avoid early recurrence and death (ERD) after surgery. We sought to evaluate a large series of consecutive resections to assess factors that may be associated with this poor outcome., Methods: This was a cohort study including 680 patients operated for esophageal cancer between 2000 and 2010. The poor outcome group comprised 100 patients with tumor recurrence and death within 1 year of surgery. The comparison group comprised 267 long-term survivors, defined as those surviving more than 3 years from surgery. Pathological characteristics associated with poor outcome were analyzed using logistic regression to determine odds ratios (OR) and 95% confidence intervals (CI)., Results: On the adjusted model T stage and N stage predicted poor survival, with the greatest risk being patients with locally advanced tumors and three or more involved lymph nodes (OR 10.6, 95% CI 2.8-40.0). Poor differentiation (OR 2.8, 95% CI 1.4-5.5), chemotherapy response (OR 3.6, 95% CI 1.2-10.6), and involved resection margins (OR 2.7, 95% CI 1.2-6.0) were all significant independent prognostic markers in the multivariable model. There was a trend toward worse survival with lymphovascular invasion (OR 2.0, 95% CI 0.9-4.2) and low albumin (OR 1.9, 95% CI 0.8-4.4) but not of statistical significance in the adjusted model., Conclusions: Esophageal cancer patients with poorly differentiated tumors and three or more involved lymph nodes have a particularly high risk of ERD after surgery. Accurate risk stratification of patients may identify a group who would be better served by alternative oncological treatment strategies., (© 2013 Wiley Periodicals, Inc.)

Objective: Preoperative weight loss might increase the risk of postoperative morbidity and mortality after esophagectomy for cancer. We hypothesized that patients with esophageal cancer with >10% weight loss during the 3 months before their diagnosis would be at an increased risk of postoperative complications, have a longer length of stay, and have worse overall survival., Methods: In the present hospital-based cohort study, all patients who had undergone surgery for esophageal cancer in 1990 to 2010 at the Erasmus University Medical Center Rotterdam were included. Weight loss was defined as "no, or limited" (≤10%) or "severe" (>10%). Logistic regression analysis was used to estimate the relative risk of complications, expressed as odds ratios (ORs) with 95% confidence intervals (CIs). Hazard ratios were calculated to assess the length of hospital stay and survival. The risk estimates were adjusted for potential confounding factors., Results: Of 922 included patients, 155 (17%) had experienced severe weight loss. These patients had no increased risk of early surgical, early nonsurgical, or late surgical complications (OR, 0.83 and 95% CI, 0.54-1.24; OR, 0.90 and 95% CI, 0.63-1.30; OR, 1.14 and 95% CI, 0.79-1.66, respectively) and had no increased length of stay (hazard ratio, 1.09; 95% CI, 0.89-1.35). Preoperative weight loss was followed by increased 5-year mortality (hazard ratio, 1.34; 95% CI, 1.02-1.74)., Conclusions: A >10% preoperative weight loss was followed by decreased 5-year survival after esophageal cancer surgery but no increased risk of postoperative complications., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: This study assessed the associations between hospital volume, resection rate and survival of oesophageal and gastric cancer patients in England., Design: 62,811 patients diagnosed with oesophageal or gastric cancer between 2004 and 2008 were identified from a national population-based cancer registration and Hospital Episode Statistics-linked dataset. Cox regression analyses were used to assess all-cause mortality according to hospital volume and resection rate, adjusting for case-mix variables (sex, age, socioeconomic deprivation, comorbidity and type of cancer). HRs and 95% CIs, according to hospital volume, were evaluated for three predefined periods following surgery: <30, 30-365, and >365 days. Analysis of mortality in relation to resection rate was performed among all patients and among the 13 189 (21%) resected patients., Results: Increasing hospital volume was associated with lower mortality (p trend=0.0001; HR 0.87, 95% CI 0.79 to 0.95 for hospitals resecting 80+ and compared with <20 patients a year). In relative terms, the association between increasing hospital volume and lower mortality was particularly strong in the first 30 days following surgery (p trend<0.0001; HR 0.52, (0.39 to 0.70)), but a clinically relevant association remained beyond 1 year (p trend=0.0011; HR 0.82, (0.72 to 0.95)). Increasing resection rates were associated with lower mortality among all patients (p trend<0.0001; HR 0.86, (0.84 to 0.89) for the highest, compared with the lowest resection quintile)., Conclusions: With evidence of lower short-term and longer-term mortality for patients resected in high-volume hospitals, this study supports further centralisation of oesophageal and gastric cancer surgical services in England.

Purpose: The influence of hospital and surgeon volume on survival after esophageal cancer surgery deserves clarification, particularly the prognosis after the early postoperative period. The interaction between hospital and surgeon volume, and the influence of known prognostic factors need to be taken into account., Methods: A nationwide Swedish population-based cohort study of 1,335 patients with esophageal cancer who underwent esophageal resection in 1987 to 2005, with follow-up for survival until February 2011, was conducted. The associations between annual hospital volume, annual surgeon volume, and cumulative surgeon volume and risk of mortality were calculated with multivariable parametric survival analysis, providing hazard ratios (HRs) with 95% CIs. HRs were mutually adjusted for the surgery volume variables and further adjusted for the prognostic factors age, sex, comorbidity, calendar period, tumor stage, tumor histology, and neoadjuvant therapy., Results: There was no independent association between annual hospital volume and overall survival, and hospital volume was not associated with short-term mortality after adjustment for hospital clustering effects. A combination of higher annual and cumulative surgeon volume reduced the mortality occurring at least 3 months after surgery (P trend < .01); the HR was 0.78 (95% CI, 0.65 to 0.92) comparing surgeons with both annual and cumulative volume above the median with those below the median. These results remained when hospital and surgeon clustering were taken into account., Conclusion: Because surgeon volume rather than hospital volume independently influences the prognosis after esophageal cancer surgery, centralization of this surgery to fewer surgeons seems warranted.

Background: Results are conflicting and no population-based studies are available regarding the postoperative mortality after intrathoracic anastomotic leakage. The current study addressed the unselected and independent fatality rate of intrathoracic esophageal anastomotic leaks after resection for cancer., Methods: A prospective, nationwide study was conducted in Sweden in April 2001 through December 2005. Details concerning patient and tumor characteristics, surgical procedures, postoperative anastomotic leakage, and mortality were collected prospectively. Logistic regression was performed to estimate odds ratios (ORs) and 95% confidence intervals (95% CIs), adjusted for age, tumor stage, comorbidity, and hospital volume., Results: Among 559 resected patients with an intrathoracic anastomosis, 44 patients (7.9%) sustained an anastomotic leak within 30 days of surgery. Of these, 8 patients (18.2%) died within 90 days of surgery, compared with 32 of the 515 patients without leakage (6.2%) (P = .003). The adjusted OR of postoperative death following intrathoracic anastomotic leakage was increased 3-fold compared with those without such a complication (OR 3.0, 95% CI 1.2-7.2)., Conclusion: Intrathoracic anastomotic leakage after esophageal resection for cancer remains a major risk factor for short-term postoperative death in an unselected, population-based setting.

Oesophageal cancer is an aggressive disease with a poor prognosis. Oesophagectomy is an established, potentially curative treatment, for patients with resectable oesophageal cancer. The anatomical location of the oesophagus explains why this type of operation is one of the most demanding and traumatic surgical procedures undertaken in general surgery. Unfortunately, the risk for severe post-operative complications is high and the chance for cure remains low. It is, however, encouraging that the post-operative morbidity has been decreasing and the survival has been improving during recent years. Several factors might have contributed to this improvement, including the centralization of oesophageal cancer surgery to high volume centres. This review focuses on the impact of hospital and surgeon volume on various outcomes after oesophagectomy for oesophageal cancer. Most available research indicates that, as far as post-operative complications, early post-operative mortality and health economics after oesophagectomy are concerned, high surgery volume is to be recommended, while the few studies evaluating long-term survival and health-related quality of life adjusted for tumour stage found no evidence of a role for volume. In conclusion, the available literature supports the centralization of oesophagectomy for cancer to dedicated centres with a multidisciplinary approach and a good track record of valid clinical research., (© 2010 The Authors. ANZ Journal of Surgery © 2010 Royal Australasian College of Surgeons.)

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.

Hypothesis: The improved survival after esophageal cancer surgery in Sweden during recent years may be attributable to the increased centralization of such surgery., Design: Population-based study., Setting: All Swedish residents undergoing esophageal cancer surgery from January 1, 1987, through December 31, 2000, were identified from the inpatient and cancer registers and were followed up until October 18, 2004, through nationwide registers. Hospital, tumor, and patient characteristics and preoperative oncological treatment were assessed through the registers and histopathological records., Patients: Among 4904 patients with esophageal cancer, 1199 patients (24.4%) who underwent resection constituted the study cohort. Main Outcome Measure Survival rates and hazard ratios (HRs) relative to hospital volume. Low-volume hospitals (LVHs) conducted fewer than 10 esophagectomies annually, while high-volume hospitals (HVHs) conducted 10 or more. Hazard ratios were adjusted for several potential confounders., Results: Thirty-day survival was 96% at HVHs and 91% at LVHs (P = .09). Survival rates 1, 3, and 5 years after surgery at HVHs were nonsignificantly higher (58%, 35%, and 27%, respectively) compared with those at LVHs (55%, 30%, and 24%, respectively). The adjusted HR was nonsignificantly 10% decreased at HVHs (HR, 0.90; 95% confidence interval, 0.79-1.04). In an analysis restricted to 764 patients (64%) without preoperative oncological treatment (in which the tumor stage was also adjusted for), survival was similar at HVHs and at LVHs (HR, 0.99; 95% confidence interval, 0.84-1.18)., Conclusions: This study revealed no effect of hospital volume on long-term survival after esophageal cancer surgery. Tumor biology apparently has a greater effect on the chances of long-term survival than hospital volume.

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]

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]

Purpose Centralization of surgery improves the survival following esophagectomy for cancer, but whether university hospital setting or surgeon volume influences the reoperation rates is unknown. We aimed to clarify whether hospital status or surgeon volume are associated with a risk of reoperation after esophagectomy. Methods Patients who underwent esophagectomy for esophageal cancer in 1987–2010 were identified from a population-based, nationwide Swedish cohort study. University hospital status and cumulative surgeon volume were analyzed in relation to risk of reoperation or death (the latter included to avoid competing risk errors) within 30 days of surgery. Multivariable logistic regression provided odds ratios (OR) with 95% confidence intervals (CI), adjusted for calendar period, age, sex, comorbidity, tumor histology, stage, neoadjuvant therapy, resection margin, surgeon volume, and hospital status. Results Among 1820 participants, 989 (54%) underwent esophagectomy in university hospitals and 271 (15%) died or were reoperated within 30 days of surgery. Non-university hospital status was associated with an increased risk of reoperation or death compared to university hospitals (adjusted OR 1.56, 95% CI 1.13–2.13). Regarding surgeon volume, the ORs were increased in the lower volume categories, but not statistically significant (OR 1.30, 95% CI 0.89–1.89 for surgeon volume <7 and OR 1.10, 95% CI 0.75–1.63 for surgeon volume 7–16, compared to surgeon volume >16). Conclusion The risk of reoperation or death within 30 days of esophagectomy seems to be lower in university hospitals even after adjustment for surgeon volume and other potential confounders. These results support centralizing esophageal cancer patients to university hospitals. [ABSTRACT FROM AUTHOR]

Background: It is unclear how the extent of surgical lymph node clearance influences prognosis after surgery for esophageal cancer. Methods: This nationwide, population-based cohort study included 1044 esophageal cancer patients who had undergone esophagectomy between 1987 and 2010 in Sweden, with follow-up until 2012. The independent role of lymph node removal in relation to survival was analyzed using Cox proportional hazards regression, providing hazard ratios (HRs) with 95% confidence intervals (CIs), adjusted for age, sex, comorbidity, tumor (T) stage, neo-adjuvant treatment, surgeon volume, and calendar period. Statistical tests were two-sided, except tests for trend. Results: Analyzed as a linear variable, a higher number of lymph nodes removed did not influence the overall five-year mortality (adjusted HR = 1.00, 95% CI = 0.99 to 1.01). Patients in the third (7-15 nodes) and fourth (16-114 nodes) quartiles of removed nodes did not demonstrate any decreased overall five-year mortality compared with those in the lowest two quartiles (<7 nodes) (HR = 1.13, 95% CI = 0.95 to 1.35 and HR = 1.17, 95% CI = 0.94 to 1.46, respectively). In early T stages (Tis-T1) the hazard ratios indicated a worse survival with more lymphadenectomy using the median as cutoff (HR = 1.53, 95% CI = 1.13 to 2.06). Increased lymph node removal did not decrease mortality in any specific T stage. A greater number of metastatic nodes and a higher positive-to-negative node ratio were associated with strongly increased mortality. All results were similar when disease-specific mortality was analyzed. Conclusion: This population-based study indicates that more extensive lymph node clearance during surgery for esophageal cancer may not improve survival. These results challenge current clinical guidelines, and further research is needed to change clinical practice. [ABSTRACT FROM AUTHOR]

Esophagectomy remains the standard treatment for resectable esophageal cancer, but the cure rate is low. Neoadjuvant therapy has been tried in attempts to prolong survival and reduce tumor recurrence. The aim of this study was to assess the surgical outcomes with and without neoadjuvant treatment for resectable esophageal cancer in a population-based setting. All 1,155 patients treated with esophagectomy for esophageal cancer in Sweden in 1987 through 2000 with or without neoadjuvant therapy were identified and followed up in nationwide registers up to 18 October 2004. Tumor characteristics and response to neoadjuvant treatment were obtained from histopathological reports. Hazard ratios (HRs) with 95% confidence intervals (CIs) adjusted for potential confounding factors were calculated by a Cox proportional hazards regression model. Overall survival was similar in the groups with and without neoadjuvant therapy (adjusted HR 0.99, 95% CI 0.86–1.16). The 3-year survival rates were 34.6% and 32.0%, respectively. Survival was better among the 27.6% of the neoadjuvant group with a complete histopathological response (HR 0.71, 95% CI 0.53–0.94) compared with the surgery only group. Patients without complete response to neoadjuvant therapy had seemingly poorer survival (HR 1.10, 95% CI 0.94–1.29). Surgical outcomes with and without neoadjuvant therapy were equivalent. Only patients with a complete histopathological response after neoadjuvant treatment had better survival. [ABSTRACT FROM AUTHOR]