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

There are differences in esophageal cancer care across different counties in Sweden. According to national guidelines, all patients should be offered equal care which should be administrated by regional multidisciplinary cancer conferences (MCCs). The aim of the study was to investigate differences between the six regional MCCs in Sweden regarding clinical stageing and recommended treatment. Ten consecutive cases per participating center, 60 cases in total, were planned for inclusion. After anonymization the radiological investigations were presented, along with the original case-specific medical history, anew at the six regional MCCs. Estimation of clinical TNM and treatment allocation (curative, palliative or best supportive care) were compared between MCCs as well as with the original assessment. Interim analysis was performed in April 2022 when ten cases had been presented at five of the six regional MCCs. All available cases were assessed at five MCCs in addition to the previous original assessment (60 assessments). The mean age for the first ten cases was 74.8 years (SD ± 9.8 years). Eight out of ten cases were men. In estimations of T- and N-stage the MCCs agreed in only one out of ten cases. In half of the cases more than three different estimations of N-stage were made. For clinical M-stage there was exact agreement in three cases. In determination of recommended treatment, all five MCCs were in agreement on half of the cases. Preliminary data show striking differences, both in assessment of TNM as well as treatment recommendation at different MCCs. One patient, recommended curative treatment by one MCC could be allocated to palliative care by another. Inclusion is ongoing and further analysis of these differences are warranted to achieve more equal care for esophageal cancer patients in Sweden. MCC_fig1.jpg (could not be inserted).

The Nordic countries have similar health care systems and registries simplifying epidemiological research and the treatment of esophageal cancer is largely centralized. However, differences in treatment traditions can hamper the possibility to assess results and harmonize control arms in joint randomized trials. In setting up a Nordic multi-center randomized trial regarding the use of nasogastric tube (NG-tube) decompression, we aimed to investigate differences in perioperative routines after esophageal resection at Nordic University hospitals. All Nordic University Hospitals with an upper gastrointestinal cancer center (UGC) were contacted regarding a Nordic randomized controlled trial exploring the effects and complications associated with the use of NG-tube after esophagectomy for cancer. Those who chose to join the trial were sent a questionnaire regarding surgical volumes and practices including mean annual number of esophagectomies, surgical method/access, and routine use of pyloric drainage and jejunostomy. In addition, the current standard postoperative use of NG-tube and routine X-ray/CT evaluation, along with postoperative traditions regarding the start of liquid diet was enquired. High volume centers were defined as performing >20 procedures/year. Thirteen of 17 centers with a combined catchment area of 16 million inhabitants and an annual volume of 445 esophagectomies joined the trial network. All, but one center used a total minimally invasive- or hybrid surgical approach but otherwise, the routine use of pyloric drainage and jejunostomy varied widely without being statistically different. All 13 centers reported routine use of NG-tube and 4 employed continuous suction. The NG-tube was removed between 3 and 7 days postoperatively, but also strategies between the centers (suction on NG-tube, start of liquid diet, routine X-ray/CT evaluation) varied without being statistically significant Firm adherence to standardized operations and safety protocols are implemented in Nordic UGCs to reduce the potential consequences of complications. However, the results find the differences in perioperative care after esophagectomy apparent, highlighting the need for high-level evidence regarding these practices. A unified approach may facilitate clinical trial initiatives. There is a paucity of evidence regarding optimal NG-tube use after esophagectomy for cancer and a randomized trial (kiNETiC ISRCTN39935085) investigating this issue is underway.

The advantages of multidisciplinary treatment conferences (MDT) are advocated in staging and treatment of esophageal cancer. Improved timeliness to surgery, adherence to guidelines, increased probability of complete clinical staging and allocation to curative treatment have all been attributed to the introduction of MDTs but there are few studies published in support of MDTs positive effect on outcomes. The aim is to investigate the association between MDT and survival in esophageal cancer. All patients diagnosed with esophageal cancer in the Swedish Registry for Esophageal and Gastric Cancer between 2006-2018 were included in this retrospective cohort study. Patients were grouped according to whether or not they had been discussed at an MDT as part of their staging process. The cohort was followed until death, emigration, or end of follow-up. Factors possibly affecting group allocation was explored with multivariable logistic regression and the impact of MDT on survival was studied with Cox-regression and the Kaplan–Meier method. Of 6607 patients diagnosed with esophageal cancer, 1338 (20%) were not discussed at an MDT. Median survival was 10.7 months with MDT and 4.4 months without MDT. Age above 80, OR 0.29 (0.18-0.47 95%CI), Charlson Comorbidity Index>2, OR 0.79 (0.66-0.96) and clinical stage IVb, OR 0.66 (0.44-0-97) all decreased the probability of being presented at an MDT, whereas squamous cancer, OR 1.45 (1.18-1.77) and later year of diagnosis OR 1.33 (1.30-1.37 per year) increased the probability of an MDT. Adjusted for the well-established prognostic factors above, the MDT was still an independent predictor of survival, HR 0.63 (0.58-0.69 95%CI). The role of the MDT in the staging and treatment of patients with esophageal cancer is, in the present study, clearly associated with improved survival. Older, more comorbid patients with advanced disease are at a disadvantage since they are not consistently discussed in a multidisciplinary setting. Whether the survival benefit is due to the MDT alone or lack of ambition in what appears to be non-curable cases is yet to be determined.

Esophageal perforation is a rare and life-threatening condition with several treatment options. The aim was to assess the incidence, type of treatment and mortality of esophageal perforations in Sweden and to identify risk factors for 90-day mortality. All patients admitted with an esophageal perforation from 2007–2017 were identified from the National Patient Register. Mortality was assessed by linkage with the Cause of Death Registry. We analyze the incidence and the impact of age, sex, comorbidities on mortality. 879 patients with esophageal perforation were identified, giving an incidence rate of 1.09 per 100,000 person years. Median age at diagnosis was 68.8 years and 60% were men. The mortality was 26% at 90 days. Independent risk factors for death within 90 days were age (Odds Ratio (OR) OR 6.20 95% CI 2.16–17.79 at 60–74 years and OR 11.58 95% CI 4.04–33.15 at 75 years or older), peripheral vascular disease (OR 2.92 95% CI 1.44–5.92) and underlying malignant disease (OR 5.91 95% CI 3.86–9.03). 90-day mortality was 26%, old age, vascular disease and underlying malignant disease were risk factors. In patients younger than 45 years survival was lower among women than among men (at five years 73% and 93% respectively). Cause of death among young women was often drug-related or suicide.

Background Esophageal perforation is a rare and life-threatening condition with several treatment options. The aim was to assess the incidence, type of treatment and mortality of esophageal perforations in Sweden and to identify risk factors for 90-day mortality. Method All patients admitted with an esophageal perforation from 2007 to 2017 were identified from the National Patient Register. Mortality was assessed by linkage with the Cause of Death Registry. We analyze the incidence and the impact of age, sex, comorbidities on mortality. Results 879 patients with esophageal perforation were identified, giving an incidence rate of 1.09 per 100,000 person-years. The median age at diagnosis was 68.8 years and 60% were men. The mortality was 26% at 90 days. Independent risk factors for death within 90 days were age (odds ratio (OR): 6.20; 95% (confidence interval) CI: 2.16-17.79 at 60-74 years and OR: 11.58; 95% CI: 4.04-33.15 at 75 years or older), peripheral vascular disease (OR: 2.92; 95% CI: 1.44-5.92) and underlying malignant disease (OR: 5.91; 95% CI: 3.86-9.03). In patients younger than 45 years, survival was lower among women than among men (at 5 years 73 and 93%, respectively). The cause of death among young women was often drug-related or suicide. Conclusions 90-day mortality was 26%, old age, vascular disease and underlying malignant disease were risk factors.

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.

To compare circular stapler (CS) with linear stapler (LS) in a meta-analysis concerning operative time, anastomotic leaks, wound infections, strictures, and length of stay. Pubmed, Medline, and Scopus were searched for articles published since 2006. Four hundred and five articles were assessed, and 13 articles of which only one was a randomized controlled trial were included in all 49,331 patients from different regions of the world. The pooled analysis shows that operative time was shorter in LS than in CS (weighted mean difference 36.2 min; 95% CI 34.7–37.6.; p

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 lymphadenectomy. Summary 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 2,306 patients, the 2nd (4-8 nodes), 7th (21-24 nodes) and 8th decile (25-30 nodes) of lymphadenectomy showed the lowest all-cause 5-year mortality compared to the 1st decile (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% CI 0.40-0.78), 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.

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.

Gallbladder cancer is a rare but aggressive malignancy. Surgical resection is recommended for gallbladder polyps ≥10 mm. For gallbladder wall thickening, resection is recommended if malignancy cannot be excluded. The incidence of gallbladder malignancy after cholecystectomy with indications of polyps or wall thickening in the Swedish population is not known.A retrospective study was performed at Linköping University Hospital and included patients who underwent cholecystectomy 2010 - 2018. All cholecystectomies performed due to gallbladder polyps or gallbladder wall thickening without other preoperative malignant signs were identified. Preoperative radiological examinations were re-analysed by a single radiologist. Medical records and histopathology reports were analysed.In all, 102 patients were included, of whom 65 were diagnosed with gallbladder polyps and 37 with gallbladder wall thickening. In each group, one patient (1.5% and 2.7% in each group) had gallbladder malignancy ≥ pT1b.Two (3.1%) and three (8.1%) patients with gallbladder malignancy T1b were identified in each group.This study indicates that the incidence of malignancy is low without other malignant signs beyond gallbladder polyps and/or gallbladder wall thickening. We propose that these patients should be discussed at a multidisciplinary tumour board. If the polyp is 10-15 mm or if the gallbladder wall is thickened but no other malignant signs are observed, cholecystectomy can be safely performed by an experienced general surgeon at a general surgery unit. If the histopathology indicates ≥ pT1b, the patient should be referred immediately to a hepatobiliary centre for liver and lymph node resection.

Background Sleeve gastrectomy (SG) is the most common bariatric procedure worldwide. Obstructive symptoms, together with leaks, are among the most serious postoperative complications. This study aimed to investigate the incidence of symptomatic obstruction after SG in Sweden and to explore risk factors, treatment strategies, and outcome. Methods A retrospective analysis of prospectively collected data from the Scandinavian Obesity Surgery Registry (SOReg) of patients undergoing SG and developed obstruction symptoms within the first postoperative year was performed. For patients who had undergone any re-intervention, such as endoscopic dilatation or remedial surgery, medical charts were reviewed. Results From 2007 to 2018, a total of 9,726 SG were performed, and 59 (0.6%) of them developed postoperative obstruction. Intolerance of solid food was the most common symptom associated with obstruction (80%). Sixty-one percent of the patients had obstruction at the level of incisura angularis. Longer operative time, higher rate of perioperative complications, longer hospital stay, and oversewing the staple line were associated with an increased risk of obstruction. Endoscopic balloon dilatation was performed in 59% of patients (n=35) and successful in 18 patients (51%). Twenty-one patients (36%) underwent surgical conversion to Roux-en-Y gastric bypass (RYGB). After revisional surgery, 11 (52%) reported complete relief of symptoms. Conclusions Obstruction was rare (0.6%) and most often located at the incisura angularis. Obstruction was associated with longer operative time, perioperative complications, oversewing of the staple line, and longer hospital stay. Endoscopic dilatation or surgical conversion to RYGB frequently alleviates symptoms, but despite treatment, almost 50% reported residual symptoms. Graphical abstract

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.

Roux-en-Y gastric bypass (RYGB) is the most common bariatric procedure worldwide. Anastomotic stricture is a known complication of RYGB. The aim was to explore the incidence and outcomes of strictures within the Scandinavian Obesity Surgery Registry (SOReg).SOReg included prospective data from 36,362 patients undergoing bariatric surgery in the years 2007-2013. Outcomes were recorded at 30-day and at 1-year follow-up according to the standard SOReg routine. The medical charts of patients suffering from stricture after RYGB were requested and assessed.National bariatric surgery registry RESULTS: Anastomotic stricture within 1 year of surgery was confirmed in 101 patients representing an incidence of 0.3%. Risk factors for stricture were patient age above 60 years (odds ratio (OR), 6.2 95% confidence interval (CI) 2.7-14.3), circular stapled gastrojejunostomy (OR 2.7, 95% CI 1.4-5.5), postoperative anastomotic leak (OR 8.9 95%, CI 4.7-17.0), and marginal ulcer (OR 30.0, 95% CI 19.2-47.0). Seventy-five percent of the strictures were diagnosed within 70 days of surgery. Two dilatations or less was sufficient to successfully treat 50% of patients. Ten pecent of patients developed perforation during dilatation, and the risk of perforating at each dilatation was 3.8%. Perforation required surgery in six cases but there was no mortality. Strictures in SOReg may be underreported, which could explain the low incidence in the study.Most strictures present within 2 months and are successfully treated with two dilatations or less. Dilating a strictured gastrojejunostomy entails a risk of perforation (3.8%).

BACKGROUND: The optimal treatment strategy for patients with esophageal adenocarcinoma (EAC) remains undetermined. This study compared outcomes in patients undergoing neoadjuvant chemotherapy (nCT) and neoadjuvant chemoradiotherapy (nCRT) for EAC. METHODS: Patients who underwent nCT or nCRT followed by surgery for EAC were identified from a prospective database (2000-2017) and included. After propensity score matching, the impact of the treatments on postoperative complications, in-hospital mortality, pathological outcomes, and survival rates were compared. RESULTS: Of the 396 eligible patients, 262 patients were analysed following matching with 131 patients in both groups. There were no significant differences between the nCT and nCRT groups for overall complications (59% vs 57%, P = 0.802) or in-hospital mortality (2% vs 0%, P = 0.156). Patients who had nCRT had more R0 resections (93% vs 83%, P = 0.013), and higher pathological complete response rates (15% vs 5%, P < 0.001). No differences in 5-year overall survival rates (nCT vs nCRT; 44% vs 33%, P = 0.645) were found. CONCLUSION: In this study no differences between nCT and nCRT were seen in postoperative complications and in-hospital mortality in patients treated for EAC. Inspite of improved complete resection and pathological response there was no difference in the overall survival between the treatment modalities.

Closing the remaining opening in a linear stapled anastomosis, for example in laparoscopic Roux-en-Y gastric bypass (LRYGB), can be challenging.To evaluate if the novel unidirectional barbed suture (BS) is of value in LRYGB compared with polyfilament (PS) suture. We have compared operative time, early complications, and length of stay, as well as anastomotic strictures and small bowel obstruction during the first year.Retrospective study from the Scandinavian Obesity Surgery Registry (SOReg).A nationwide cohort of 25,006 primary LRYGB (2211 BS and 22,795 PS) from SOReg were studied. No preoperative differences in age or gender were noted; however, BS patients had lower Body Mass Index (BMI) (41.3 versus 42.3 kg/mTotal operative time was 11 minutes (16%) shorter using BS compared with PS (58 versus 69 minutes, P.001), although the mesenteric openings were more frequently closed among BS patients (94% versus 71%, P.001). No differences were seen in early complications; anastomotic leaks or intra-abdominal abscesses were noted in 1.8% and 1.4%, respectively, P = .17. The incidence of anastomotic strictures was similar (.13% versus .17%, P = .73) as was the incidence of surgery for small bowel obstruction (1.8% versus 1.6%, P = .69).The use of barbed suture for closing the remaining opening in the gastrojejunostomy shortened the operative time without increasing the risk of complications. BS is still uncommon in LRYGB, but its implementation could have significant impact on operative time.

Anastomotic leak at the gastrojejunostomy in Roux-en-Y gastric bypass is a rare, but serious, complication. Little has been published on leaks at other sites.To assess incidence, risk factors, treatment, and outcome of small bowel leaks at the enteroenteral anastomosis (EA) and undiagnosed iatrogenic small bowel perforations in primary Roux-en-Y gastric bypass.Nationwide cohort, Sweden.All leaks within 30 days in 41,342 patients (age 40.8 [standard deviation 11.1] yr, females 68%, and body mass index 42.4 [standard deviation 5.4] kg/mThe incidence of small bowel leaks was .3%. Iatrogenic perforations were diagnosed earlier than EA leaks, 3.6 versus 6.5 days after surgery (P = .02). EA leaks were seen in 75 patients (.2%), with surgery at a low-volume center (125 cases/yr, OR 2.1 [1.0-4.1]) and prolonged operative time (≥90 min, OR 3.5 [1.1-11.0]) as risk factors. The risk of iatrogenic small bowel perforations, .1%, was tripled by prolonged operative time (OR 3.4 [1.2-9.4]). Surgical reintervention was required in 97% of leaks, repairing the defect and draining the abdominal cavity in most cases. A third of the patients required intensive care, of which 5% developed multiorgan failure and 1% died.Small bowel leaks, seen in .3%, were associated to prolonged operative time, and surgery at a low-volume center for EA leaks. Surgical reintervention was common, while mortality was low.

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.

Energy restriction reduces liver fat, improves hepatic insulin resistance and lipid metabolism. However, temporal data in which these metabolic improvements occur and their interplay is incomplete. By performing repeated MRI scans and blood analysis at day 0, 3, 7, 14 and 28 the temporal changes in liver fat and related metabolic factors were assessed at five times during a low-calorie diet (LCD, 800–1100 kcal/day) in ten obese non-diabetic women (BMI 41.7 ± 2.6 kg/m2) whereof 6 had NAFLD. Mean weight loss was 7.4 ± 1.2 kg (0.7 kg/day) and liver fat decreased by 51 ± 16%, resulting in only three subjects having NAFLD at day 28. Marked alteration of insulin, NEFA, ALT and 3-hydroxybuturate was evident 3 days after commencing LCD, whereas liver fat showed a moderate but a linear reduction across the 28 days. Other circulating-liver fat markers (e.g. triglycerides, adiponectin, stearoyl-CoA desaturase-1 index, fibroblast growth factor 21) demonstrated modest and variable changes. Marked elevations of NEFA, 3-hydroxybuturate and ALT concentrations occurred until day 14, likely reflecting increased tissue lipolysis, fat oxidation and upregulated hepatic fatty acid oxidation. In summary, these results suggest linear reduction in liver fat, time-specific changes in metabolic markers and insulin resistance in response to energy restriction.

Leak at the gastrojejunostomy (GJ) after Roux-en-Y gastric bypass is a rare but life-threatening complication.To assess incidence, risk factors, treatment, and outcome of leaks at the GJ after Roux-en-Y gastric bypass in a nationwide cohort.Sweden.Leaks at GJ within 30 days postoperatively in 40,844 patients (age 41 yr, females 76%, and body mass index of 42.4 kg/mLeak at the GJ was registered in 262 (.6%) patients, with 44% diagnosed within the first 3 postoperative days. Risk factors were male sex (OR 1.5 [1.1-1.9]), age ≥49 years (OR 1.9 [1.3-2.7]), diabetes (OR 1.4 [1.1-1.9]), conversion to open surgery (OR 3.9 [2.2-6.9]), and operative time ≥90 minutes (OR 2.6 [1.8-3.8]). In most patients, the leak resulted in a severe complication. Reoperative surgery was done in 85%, with the placement of a feeding gastrostomy in 24%. Stents were used at some time point in 31% of leaks. Of all patients with leaks, 25% required intensive care, 4% developed multiorgan failure, and 1% died. Median duration of stay for patients with leaks was 22 days, versus 2 days for others (P.001).GJ leaks occurred in .6% of patients. Risk factors were male sex, age ≥49 years, diabetes, operative time ≥90 minutes, and conversion to open surgery. Surgical reintervention was common. Mortality was 1%.

LEAK AT GASTROJEJUNOSTOMY AFTER ROUX-EN-Y GASTRIC BYPASS-40,844 PATIENTS FROM THE SCANDINAVIAN OBESITY SURGERY REGISTRY (SOREG)

Background Roux-en-Y gastric bypass (RYGB) is the most common bariatric procedure worldwide. There are few studies investigating how early return to solid food affects complications. Objective The aim of this study was to explore how oral intake was resumed in RYGB patients and how the postoperative food regimen affects outcomes, such as complications and length of stay. Setting Retrospective nationwide registry study. Methods The Scandinavian Obesity Surgery Registry included prospective data from RYGB patients operated in 2009 to 2014. A questionnaire assessed the postoperative reintroduction of solid food applied at each bariatric center. The postoperative regimen was established in 23,589 patients. Outcomes were recorded at 30-day follow-up according to the standard Scandinavian Obesity Surgery Registry routine. Results Nine percent of patients (n = 2074) returned to solid food within the first week after surgery. Most commonly solid food was resumed in week 4 (37%, n = 8659). Median length of stay was 2 days for all. Of all, 2.8% suffered from a severe complication (>Clavien-Dindo 3a). After adjusting for the annual volume of procedures at hospitals, there was no correlation that the timing of solid food affected complication rates. The odds ratio for a severe complication was significantly lower for intermediate- (odds ratio .64 95% confidence interval .48–.85) or high- (odds ratio .52 95% confidence interval .42–.66) volume centers. The rate of leaks and small bowel obstructions were evenly distributed between the different postoperative food regimens. Conclusion Early return to solid food after RYGB did not affect the risk of severe complications. Patients operated at centers with an annual volume of >100 procedures have a lower risk of severe complications.

Background Although laparoscopic Roux-en-Y gastric bypass (LRYGB) is a common bariatric procedure worldwide, no consensus on the optimal technique for the gastrojejunostomy (GJ) has been reached. Circular stapling (CS) immediately results in a GJ of standardized width, whereas linear stapling (LS) requires a technically challenging closure of the stapler defect. The aim was to study differences in outcomes between CS and LS. Setting Nationwide Swedish cohort. Methods The Scandinavian Obesity Registry (SOReg) included prospective data from 34,284 primary LRYGB patients operated on in 2007–2013. We studied operative time, length of hospital stay, postoperative complications, and percent excess body mass index loss (%EBMIL) after 1 year. Outcomes were assessed through multivariate analysis adjusting for gender, age, preoperative body mass index (BMI), and diabetes. Results Preoperatively the groups were similar (40.9 yr, BMI 42.4 kg/m 2 , 76% female). For CS and LS, operative time and hospital stay were 114 and 73 minutes ( P P Conclusion CS was found to be associated with disadvantages regarding operative time, hospital stay, and postoperative complications compared with LS.

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the most common bariatric procedures worldwide, but the importance of gastric pouch size is still under debate. We have studied how pouch size affects risk of marginal ulcer and excess body mass index loss (EBMIL%) at 6 weeks and 1 year postoperatively. Scandinavian Obesity Surgery Registry included 14,168 LRYGB patients with linear stapled gastrojejunostomies, having complete pre- and postoperative data concerning length of stapler needed to complete the gastric pouch, incidence of marginal ulcers and weight loss. LRYGB technique in Sweden is highly standardized, and total length of stapler was used as a proxy for pouch size. Mean length of stapler used for the pouch was 145 mm. At 1 year, symptomatic marginal ulcers were noted in 0.9 % of the patients. The relative risk of marginal ulcer increased by 14 % (95 % confidence interval 9–20 %), for each centimeter of stapler used for the pouch. Body mass index (BMI) was reduced from 42.4 ± 5.1 to 36.1 kg/m2 at 6 weeks and 28.9 kg/m2 at 1 year. The total length of stapler predicted EBMIL% at 6 weeks but not at 1 year. Female gender, low preoperative BMI, young age and absence of diabetes predicted better EBMIL% at 1 year. A smaller pouch reduces the risk of marginal ulcers, but does not predict better weight loss at 1 year. Additional stapling should be avoided as each extra centimeter increases the relative risk of marginal ulcers by 14 %.

It is evident that morbidly obese patients have a low health-related quality-of-life (HRQoL), and this low HRQoL has become a common reason for them to seek bariatric surgery. Several HRQoL studies demonstrate a dramatic postoperative improvement, but most of these have had a short follow-up period. An observational, cross-sectional study for HRQoL was conducted to study 486 patients (average age of 50.7 ± 10.0 years, with 84 % of them being female) operated with gastric bypass (GBP) in the period 1993 to 2003 at the University Hospitals of Orebro and Uppsala. Mean follow-up after gastric bypass was 11.5 ± 2.7 years (range 7–17). Two HRQoL instruments were used, SF-36 and the Obesity-related Problems scale (OP). The study group was compared with two control groups, both matched for age and gender, one from the general population and one containing morbidly obese patients evaluated and awaiting bariatric surgery. The study group scored better in the SF-36 domains (all four physical domains and the vitality subscore) and OP scale compared to obese controls, but their HRQoL scores were lower than those of the general population. HRQoL was better among younger patients and in the following subgroups: men, patients with satisfactory weight loss, satisfied with the procedure, free from co-morbidities and gastrointestinal symptoms, employment, good oral status and those not hospitalised or regularly followed up for non-bariatric reasons. Long-term follow-up after GBP for morbid obesity showed better scores in most aspects of HRQoL compared to obese controls but did not achieve the levels of the general population. Patients with better medical outcome after gastric bypass operation had better HRQoL.

Background Bile acid (BA) synthesis is regulated by BA signalling in the liver and by fibroblast growth factor 19 (FGF19), synthesized and released from the intestine. In morbid obesity, faecal excretion and hepatic synthesis of BAs and cholesterol are strongly induced and caloric restriction reduces their faecal excretion considerably. We hypothesized that the high intestinal food mass in morbidly obese subjects promotes faecal excretion of BAs and cholesterol, thereby creating a shortage of both BAs and cholesterol in the liver. Methods Ten morbidly obese women (BMI 42 ± 2.6 kg m−2) were monitored on days 0, 3, 7, 14 and 28 after beginning a low-calorie diet (800–1100 kcal day−1). Serum was collected and liver size and fat content determined. Synthesis of BAs and cholesterol was evaluated from serum markers, and the serum levels of lipoproteins, BAs, proprotein convertase subtilisin/kexin type 9 (PCSK9), insulin, glucose and FGF19 were monitored. Fifty-four nonobese women (BMI

Bariatric surgery has gained wide acceptance as treatment for severe obesity and is associated with decreased overall mortality. The aims of this study were to evaluate the prevalence of anemia long term after Roux-en-Y gastric bypass (RYGB) and to search for factors predicting anemia. All 745 patients who underwent RYGB between 1993 and 2003 at either Orebro or Uppsala University Hospital and who were living in Sweden were invited to participate by providing a fasting blood sample and completing a questionnaire about their health status. Full blood count, serum iron, transferrin, vitamin B12, and folic acid were determined. Follow-up was completed in 431 patients (58 %) with mean age 51.3 ± 10 years. Of all patients, 27 % had anemia postoperatively and related deficiencies; iron, folic acid, and vitamin B12 were seen in 20, 12, and 2 %, respectively. There was no correlation between anemia and sex, follow-up time, 25-OH vitamin D level, and preoperative or postoperative BMI. An inverse correlation was found between anemia and regular medical checkups concerning gastric bypass surgery. Twenty-seven percent of patients had anemia more than 10 years after RYGB. Anemia does not seem to progress with time and was less common in patients with regular medical checkups. Thus, improved long-term follow-up is needed.

Background MIE is becoming more common and is considered safe. There are few studies supporting laparoscopy in favor of laparotomy for the abdominal part of a three-field esophagectomy and long term survival data are scarce. The objective was to compare open esophagectomy (OE), with hybdrid thoracoscopic-laparotomic esophagectomy (HMIE) and minimally invasive esophagectomy (MIE) with regard to surgical outcomes, postoperative complications and survival. Methods A prospective database of esophageal resection for cancer at a single centre identified 243 OE, 688 HMIE and 80 MIE procedures. Propensity scores were used to match 80 patients in each group adjusting for age, gender, weight, clinical stage, neoadjuvant treatment, and year of surgery. Results Respiratory complications were more common after OE (49%) than after MIE (31%, P = 0.02). Median operative time was longer for MIE (330 minutes) versus HMIE or OE (both 300 minutes, P Conclusion Compared with OE and HMIE, MIE was associated with shorter length of stay and fewer respiratory complications, but longer operative time. Thus, there may be additional benefit for MIE without comprising oncological outcomes. Disclosure All authors have declared no conflicts of interest.

The primary aim of this study was to evaluate the prevalence of vitamin D deficiency and secondary hyperparathyroidism after Roux-en-Y gastric bypass. Secondly, we have tried to assess predictors for vitamin D deficiency.Five hundred thirty-seven patients who underwent primary Roux-en-Y gastric bypass surgery between 1993 and 2003 at the Örebro University Hospital and Uppsala University Hospital were eligible for the study. Patients were asked to provide a blood sample between November 2009 and June 2010 and to complete a questionnaire about their postoperative health status. Serum values of 25-OH vitamin D, parathyroid hormone (PTH), alkaline phosphatase (ALP) and calcium were determined.Follow-up was completed in 293 patients, of which 83 % were female, with an age of 49 ± 9.9 years after a median time of 11 ± 2.8 years. Vitamin D, PTH and albumin-corrected calcium values were 42 ± 20.4 nmol/L, 89.1 ± 52.7 ng/L and 2.3 ± 0.1 mmol/L, respectively. Of all patients, 65 % were vitamin D deficient, i.e. 25-OH vitamin D50 nmol/L, and 69 % had PTH above the upper normal reference range, i.e.73 ng/L. Vitamin D was inversely correlated with PTH levels (p 0.001) and positively correlated with calcium (p = 0.016). Vitamin D did not correlate with ALP. The only factor found to predict vitamin D deficiency was high preoperative body mass index (BMI) (p = 0.008), whereas gender, age, time after surgery and BMI at follow-up did not.Vitamin D deficiency and secondary hyperparathyroidism after Roux-en-Y gastric bypass (RYGB) were confirmed in our study because 65 % of patients had vitamin D deficiency, and 69 % had increased PTH levels more than 10 years after surgery. These data are alarming and highlight the need for improved long-term follow-up. Vitamin D deficiency does not seem to progress with time after surgery, possibly due to weight loss. Only preoperative BMI, cutoff point 43 kg/m(2), was a predictor of vitamin D deficiency at follow-up. Improved long-term follow-up of patients that undergo RYGB is needed.

Background Roux-en-Y gastric bypass surgery (RYGB) as treatment of morbid obesity results in substantial weight loss. Most published long-term studies have included few patients at the last follow-up point. The aim of the present study was to explore long-term results in a large cohort of patients 7–17 years after gastric bypass. Methods All 539 patients who had undergone primary RYGB from 1993 to 2003 at Uppsala and Orebro University Hospitals received a questionnaire regarding their postoperative status. Blood samples were obtained and the medical charts studied. Results Of the 539 patients, 384 responded (71.2% response rate, mean age 37.9 yr, body mass index 44.5 kg/m 2 at surgery, 317 women, and 67 men). At a mean follow-up of 11.4 years (range 7–17), the body mass index had decreased to 32.5 kg/m 2 , corresponding to an excess body mass index loss of 63.3%. Similar weight loss was observed, regardless of the length of follow-up. Orally treated diabetes resolved in 72% and sleep apnea and hyperlipidemia were improved. Revisional bariatric surgery had been performed in 2.1% and abdominoplasty in 40.2%. The gastrointestinal symptoms were considered tolerable. The overall result was satisfactory for 79% of the patients and 92% would recommend Roux-en-Y gastric bypass to a friend. Attendance to the annual checkups was 37%. Vitamin B 12 supplements were taken by 72% and multivitamins by 24%. Conclusion At 11 years, substantial weight loss was maintained and revisional surgery was rare. Surprisingly few patients were compliant with the recommendation of lifelong supplements and yearly evaluations; however, patient satisfaction was high.

Background Multimodality treatment of patients with esophageal adenocarcinoma (EAC) improve survival, but the optimal treatment strategy remains undetermined. The aim of this study was to compare outcomes in patients undergoing neoadjuvant chemotherapy (nCT) and neoadjuvant chemoradiotherapy (nCRT) for EAC. Methods Patients who underwent nCT or nCRT followed by surgery for EAC were identified from a prospective database (2000–2017) and included in this study. After propensity score matching, we compared the impact of the treatments on postoperative complications, in-hospital mortality, pathological outcomes and survival rates. Results Of the 396 eligible patients, 262 patients were analysed following propensity score matching. This resulted in 131 patients in the nCT group versus 131 patients in the nCRT group. There were no significant differences between the nCT and nCRT groups for overall complications (59% vs 57%, P = 0.802) or in-hospital mortality (2% vs 0%, P = 0.156). Patients who had nCRT had more R0 resections (93% vs. 83%, P = 0.013), and a higher pathological complete response rate (15% vs. 5%, P Conclusion In this study no differences between nCT and nCRT were seen in postoperative complications and in-hospital mortality in patients treated for EAC. Inspite of improved complete resection and pathological response there was no difference in the overall survival between the treatment modalities. Disclosure All authors have declared no conflicts of interest.

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Increased Bile Acid And Cholesterol Syntheses And PCSK9 In Morbid Obesity Are Rapidly Normalized Following Acute Caloric Restriction

Weight loss before laparoscopic Roux-en-Y gastric bypass (LRYGB) is desirable, because it can reduce liver volume and thereby facilitate the procedure. The optimal duration of a low-calorie diet (LCD) has not been established. The objective of this study was to assess changes in liver volume and body composition during 4 weeks of LCD.Ten women (aged 43±8.9 years, 114±12.1 kg, and body mass index 42±2.6 kg/m(2)) were examined on days 0, 3, 7, 14, and 28 after commencing the LCD. At each evaluation, body composition was assessed through bioelectric impedance analysis, and liver volume and intrahepatic fat content were assessed by magnetic resonance imaging. Serum and urine samples were obtained. Questionnaires regarding quality of life and LCD-related symptoms were administered.In total, mean weight decreased by 7.4±1.2 kg (range 5.7-9.1 kg), and 71% of the weight loss consisted of fat mass according to bioelectric impedance analysis. From day 0 to day 3, the weight loss (2.0 kg) consisted mainly of water. Liver volume decreased by 18%±6.2%, from 2.1 to 1.7 liters (P.01), during the first 2 weeks with no further change thereafter. A continuous 51%±16% decrease was seen in intrahepatic fat content. Systolic blood pressure, insulin, and lipids improved, while liver enzymes, glucose levels, and quality of life were unaffected.A significant decrease in liver volume (18%) occurred during the first 2 weeks of LCD treatment, and intrahepatic fat gradually decreased throughout the study period. A preoperative 2-week LCD treatment seems sufficient in similar patients.

Letter to the editor : stercoral perforation of the sigmoid colon possibly associated with anticholinergic drugs or opiates

Gastric banding (GB) and vertical banded gastroplasty (VBG) may result in unsatisfactory weight loss or intolerable side effects. Such outcomes are potential indications for additional bariatric surgery, and Roux-en-Y gastric bypass is frequently used at such revisions (rRYGB). The present study examined long-term results of rRYGB.In total, 175 patients who had undergone rRYGB between 1993 and 2003 at 2 university hospitals received a questionnaire regarding their current status. The questionnaire was returned by 131 patients (75% follow-up rate, 66 VBG and 65 GB patients). Blood samples were obtained and medical charts studied. The reason for conversion was mainly unsatisfactory weight loss among the VBG patients and intolerable side effects among GB patients.The 131 patients (112 women), mean age 41.8 years at rRYGB, were evaluated at mean 11.9 years (range 7-17) after rRYGB. Mean body mass index of those with prior unsatisfactory weight loss was reduced from 40.1 kg/m(2) (range 28.7-52.2) to 32.6 kg/m(2) (range 19.1-50.2) (P.01). Only 2 patients (2%) underwent additional bariatric surgery after rRYGB. The overall result was satisfactory for 74% of the patients. Only 21% of the patients adhered to the recommendation of lifelong multivitamin supplements while 76% took vitamin B12. Anemia was present in 18%.rRYGB results in sustained weight loss and satisfied patients when VBG or GB have failed. Subsequent bariatric surgery was rare but micronutrient deficiencies were frequent.

The aim of this study was to explore changes in liver volume and intrahepatic fat in morbidly obese patients during 4 weeks of low-calorie diet (LCD) before surgery and to investigate if these changes would facilitate the following laparoscopic gastric bypass. Fifteen female patients (121.3 kg, BMI 42.9) were treated preoperatively in an open study with LCD (800–1,100 kcal/day) during 4 weeks. Liver volume and fat content were assessed by magnetic resonance imaging and spectroscopy before and after the LCD treatment. Liver appearance and the complexity of the surgery were scored at the operation. Eighteen control patients (114.4 kg, BMI 40.8), without LCD were scored similarly. Average weight loss in the LCD group was 7.5 kg, giving a mean weight of 113.9 kg at surgery. Liver volume decreased by 12% (p

Background and Aims: Unsatisfactory weight loss after gastric bypass or sleeve gastrectomy in super-obese patients (body mass index > 50) is a growing concern. Biliopancreatic diversion with duodenal switch results in greater weight loss, but is technically challenging to perform, especially as a laparoscopic procedure (Lap-DS). The aim of this study was to compare perioperative outcomes of Lap-DS and the corresponding open procedure (O-DS) in Sweden. Material and Methods: The data source was a nationwide cohort from the Scandinavian Obesity Surgery Registry and 317 biliopancreatic diversion with duodenal switch patients (mean body mass index = 56.7 ± 6.6 kg/m2, 38.4 ± 10.2 years, and 57% females) were analyzed. Follow-up at 30 days was complete in 98% of patients. Results: The 53 Lap-DS patients were younger than the 264 patients undergoing O-DS (35.0 vs 39.1 years, p = 0.01). Operative time was 163 ± 38 min for lap-DS and 150 ± 31 min for O-DS, p = 0.01, with less bleeding in Lap-DS (94 vs 216 mL, p Conclusion: Lap-DS can be performed by dedicated bariatric surgeons as a single-stage procedure. The use of laparoscopic approach halved the length of stay, without increasing the risk for complications significantly. Any difference in long-term weight result is pending.

Background: Visceral fat accumulation is associated with metabolic disease. It is therefore relevant to study factors that regulate adipose tissue distribution. Recent data shows that overeating saturated fatty acids promotes greater visceral fat storage than overeating unsaturated fatty acids. Visceral adiposity is observed in states of hypercortisolism, and the enzyme 11-beta-hydroxysteroid-dehydrogenase type 1 (11 beta-hsd1) is a major regulator of cortisol activity by converting inactive cortisone to cortisol in adipose tissue. We hypothesized that tissue fatty acid composition regulates body fat distribution through local effects on the expression of 11 beta-hsd1 and its corresponding gene (HSD11B1) resulting in altered cortisol activity. Findings: Visceral- and subcutaneous adipose tissue biopsies were collected during Roux-en-Y gastric bypass surgery from 45 obese women (BMI; 41 +/- 4 kg/m(2)). The fatty acid composition of each biopsy was measured and correlated to the mRNA levels of HSD11B1. 11 beta-hsd1 protein levels were determined in a subgroup (n = 12) by western blot analysis. Our main finding was that tissue saturated fatty acids (e.g. palmitate) were associated with increased 11 beta-hsd1 gene- and protein-expression in visceral but not subcutaneous adipose tissue. Conclusions: The present study proposes a link between HSD11B1 and saturated fatty acids in visceral, but not subcutaneous adipose tissue. Nutritional regulation of visceral fat mass through HSD11B1 is of interest for the modulation of metabolic risk and warrants further investigation.