Background High-quality studies from Asia have demonstrated that robotic assisted minimally invasive esophagectomy (RAMIE) is a feasible and comparable alternative to conventional minimally invasive esophagectomy (MIE), evidence regarding its application to Western patients remains limited. This study evaluates the short-term outcomes during the initial phase of RAMIE implementation in comparison to the previous standard MIE technique in a Nordic center. Methods A retrospective single center study of prospectively registered data, comparing short-term outcomes between the final 100 patients operated with MIE and the first 100 patients operated with RAMIE. The primary outcome was the total number of lymph nodes harvested. Secondary outcomes included postoperative pneumonia, anastomotic leakage, serious complications (Clavien Dindo ≥ 3), length of operation, length of hospital stay and resection margin status. An inverse probability weighting model and regression analysis was conducted. Results 200 patients were included (RAMIE n = 100, MIE n = 100). Matched groups (RAMIE n = 96, MIE n = 97) showed no difference in total number of lymph nodes harvested (RAMIE 22.1 vs. MIE 23.7, p = 0.50). RAMIE had higher postoperative pneumonia risk (OR = 2.3, p < 0.01), longer length of operation (+33.9 min, p < 0.01) and marginally increased risk of anastomotic leakage (OR = 2.4, p = 0.05). Comparing the last 50 patients operated with RAMIE to the MIE group, there was no difference in length of operation (OR = 10.3, p = 0.43). Conclusion The short-term oncological outcomes and safety remain secure even during the initial phases of RAMIE implementation in a Nordic cohort. The perioperative outcome for some measures after RAMIE were inferior to MIE, potentially related to learning curve aspects.

ObjectivesExtent of surgical repair of spontaneous esophageal effort rupture (Boerhaave syndrome) has gradually decreased by the emergence of minimal invasive treatment based on endoscopic stent sealing of the perforation. However, for this diagnosis, use of endoscopic vacuum therapy (EVT) is still in its beginning. We present our results after 7-years with both stent and/or EVT-based treatment.Materials and methods17 consecutive patients with Boerhaave syndrome from June 2015 to May 2022 were retrospectively registered in a database. The perforation was sealed by stent and/or EVT, and gastric effluent was drained transthoracically by a chest tube or pigtail catheter. Eight out of 14 patients responded to questions on fatigue and dysphagia (Ogilvie's score).ResultsSeventeen patients aged median 67 years (range 34-88), had a primary hospital stay of 38 days (7-68). Ninety-day mortality was 6% (n = 1). Perforations were sealed with stent (n = 10), EVT (n = 3) or stent and EVT (n = 4). One patient (6%) needed laparoscopic lavage and transhiatal drainage. Eight patients (47%) were re-stented due to persistent leakage (n = 4) and stent migration (n = 4). Fifteen patients (88%) had complications, including multi-organ failure (n = 9), pleural empyema (n = 8) and esophageal stricture (n = 3). The perforations healed. After 35.5 months (range 2-62) fourteen patients were alive. Eight that responded had no dysphagia and total fatigue score comparable to an age-matched reference population.ConclusionMortality rate was low after initial stent and EVT-based treatment of Boerhaave syndrome, combined with adequate transthoracic drainage of gastric effluent. Patients required repeated minimal invasive procedures, but with no apparent negative effect on functional outcome.

Summary Anastomotic leakage (AL) is a dreaded complication following esophageal resection. No clear consensus exist for the optimal handling of this severe complication. The aim of this study was to describe the treatment outcome following AL. We conducted a retrospective cross-sectional study including all patients with AL operated with Ivor Lewis esophagectomy from 2010 to 2021 at Oslo University Hospital, Norway. 74/526 (14%) patients had AL. Patient outcomes were analyzed and categorized according to main AL treatment strategy; stent (54%), endoscopic vacuum therapy and stent (EVT + stent) (19%), nasogastric tube and antibiotics (conservative) (16%), EVT (8%) and by other endoscopic means (other) (3%). One patient had surgical debridement of the chest cavity. In 66 patients (89%), the perforation healed after median 27 (range: 4–174) days. Airway fistulation was observed in 11 patients (15%). Leak severity (ECCG) was associated with development of airway fistula (P = 0.03). The median hospital and intensive care unit stays were 30 (range: 12–285) and 9 (range: 0–60) days. The 90-days mortality among patients with AL was 5% and at follow up, 13% of all deaths were related to AL. AL closure rates were comparable across the groups, but longer in the EVT + stent group (55 days vs. 29.5 days, P = 0.04). Thirty-two percent developed a symptomatic anastomotic stricture within 12 months. Conclusion: The majority of AL can be treated endoscopically with preservation of the conduit and the anastomosis. We observed a high number of AL-associated airway fistulas.

At our hospital, the main treatment for resectable esophageal cancer (EC) has since 2013 been total minimally invasive esophagectomy (TMIE). The aim of this study was to present the short- and long-term results in patients operated with TMIE. This cross-sectional study includes all patients scheduled for TMIE from June 2013 to January 2016 at Oslo University Hospital. Data on morbidity, mortality, and survival were retrospectively collected from the patient administration system and the Norwegian Cause of Death Registry. Long-term postoperative health-related quality of life (HRQL) and level of dysphagia were assessed by patients completing the following questionaries: EORTC QLQ-OG25, QLQ-C30, and the Ogilvie grading scale. A total of 123 patients were included in this study with a median follow-up time of 58 months (1-88 months). 85% had adenocarcinoma, 15% squamous cell carcinoma. Seventeen patients (14%) had T1N0M0, 68 (55%) T2-T3N0M0, or T1-T2N1M0 and 38 (31%) had either T3N1M0 or T4anyNM0. Ninety-eight patients (80%) received neoadjuvant (radio)chemotherapy and 104 (85%) had R0 resection. Anastomotic leak rate and 90-days mortality were 14% and 2%, respectively. The 5-year overall survival was 53%. Patients with tumor free resection margins of >1 mm (R0) had a 5-year survival of 57%. Median 60 months (range 49-80) postoperatively the main symptoms reducing HRQL were anxiety, chough, insomnia, and reflux. Median Ogilvie score was 0 (0-1). In this study, we report relatively low mortality and good overall survival after TMIE for EC. Moreover, key symptoms reducing long-term HRQL were identified.

Background Despite the efforts to describe the molecular landscape of esophageal adenocarcinoma (EAC) and its precursor lesion Barrett’s esophagus (BE), discrepant findings are reported. Here, we investigated the prevalence of selected genetic ( TP53 mutations and microsatellite instability (MSI) status) and epigenetic (DNA promoter hypermethylation of APC , CDKN2A , MGMT , TIMP3 and MLH1 ) modifications in a series of 19 non-dysplastic BE and 145 EAC samples. Additional biopsies from adjacent normal tissue were also evaluated. State-of-the-art methodologies and well-defined scoring criteria were applied in all molecular analyses. Results Overall, we confirmed frequent TP53 mutations among EAC (28%) in contrast to BE, which harbored no mutations. We demonstrated that MSI and MLH1 promoter hypermethylation are rare events, both in EAC and in BE. Our findings further support that APC , CDKN2A , MGMT and TIMP3 promoter hypermethylation is frequently seen in both lesions (21–89%), as well as in a subset of adjacent normal samples (up to 12%). Conclusions Our study further enlightens the molecular background of BE and EAC. To the best of our knowledge, this is one of the largest studies addressing a targeted analysis of genetic and epigenetic modifications simultaneously across a combined series of non-dysplastic BE and EAC samples.

Abstract Background Few European centers have reported on robotic gastrectomy for malignancy. We report our early experience with curative-intent total robotic gastrectomy. Materials and methods The Intuitive Surgery Da Vinci Surgical System Xi 4 armed robot was used. Routine D2 lymphadenectomy was applied. Results Some 27 patients with adenocarcinoma (n = 18), hereditary cancer susceptibility (n = 8) and premalignancy (n = 1) were allocated to robotic gastrectomy, three were excluded due to inoperability during surgery. Median (range) age was 66 (18–87) years, 14 (58.3%) were females and body mass index was 25.5 (22.1–33.5) kg/m2. Total gastrectomy was performed in 19 (79.2%) and subtotal in five (20.8%) patients. One (4.2%) procedure was converted to laparotomy. Procedural time was 273 (195–427) minutes. Three (12.5%) patients were reoperated within 30 days, one (4.2%) died. Serious complications (Clavien Dindo IIIb or more) occurred in three (12.5%) patients. Postoperative hospital stay was 10 (6–43) days. Fourteen of 16 (87.5%) patients with adenocarcinoma/premalignancy received radical resections. The median number of harvested lymph nodes was 20 (11–34). Eleven (73.3%) patients with adenocarcinoma had T3/T4 tumors and 6 (40%) had TNM stage III or more. Conclusion Total robotic D2 gastrectomy appears feasible and safe during early introduction in a low incidence region.

Medicinal mushrooms have documented effects against different diseases, including infections and inflammatory disorders. The relatedBasidiomycota Agaricus blazei Murill (AbM),Hericium erinaceus(HE), andGrifola frondosa(GF) have been shown to exert antimicrobial activity against viral agents, Gram-positive and Gram-negative bacteria, and parasites in vitro and in vivo. Since the mechanism is immunomodulatory and not antibiotical, the mushrooms should be active against multi-drug resistant microbes as well. Moreover, since theseBasidiomycotaalso have anti-inflammatory properties, they may be suited for treatment of the severe lung inflammation that often follows COVID-19 infection. An AbM-based mushroom extract (Andosan (TM)), also containing HE and GF, has been shown to significantly reduce bacteraemia and increase survival in mice with pneumococcal sepsis, and to improve symptoms and quality of life in IBD patients via an anti-inflammatory effect. Hence, such mushroom extracts could have prophylactic or therapeutic effect against the pneumonic superinfection and severe lung inflammation that often complicates COVID-19 infection. Here, we review antimicrobial and anti-inflammatory properties of AbM, HE and GF mushrooms, which could be used for the battle against COVID-19.

Background and Aims. The optimal treatment of patients with internal rectal intussusception (IRI) is unresolved. The aim was to study the short- and long-term outcome of resection rectopexy in these patients. Methods. An observational and mainly prospective study of 48 patients (44 women) with IRI who had ligament-preserving suture rectopexy by laparoscopic (n=25) or open (n=23) technique. Outcome measures were morbidity, scores for constipation and anal incontinence, patients’ report, and health-related quality of life (HRQoL). Results. From preoperatively to a median of 6 months and 76 months postoperatively, constipation scores were reduced from a mean of (95% CI) 13.20 (11.41 to 15.00) to 6.91 (5.29 to 8.54) and 6.35 (4.94 to 7.76) (P<0.0001). The number of constipated patients was reduced from 35 to eleven and eight, respectively, and none became constipated. Nine of ten symptoms of constipation improved. Corresponding scores for anal incontinence were 4.7 (2.4–7.0), 4.0 (2.4–5.7), and 4.1 (2.3–5.8), respectively. HRQoL at long-term followup compared to the general Norwegian population was reduced in four out of eight dimensions concerning physical factors. The patient-reported outcome at short- and long-term followup was improved by 85.4% and 75.0%, respectively. Conclusions. Resection rectopexy for IRI improved the outcome. HRQoL was reduced compared with the general population.

Two novel enzyme-linked immunosorbent assays (ELISAs), designed to detect complexes containing DNA, leucocyte calprotectin and S100A12 proteins, were generated for improved specificity and rapid measurement of neutrophil extracellular traps (NETs). The assays were applied on plasma and serum samples from blood donors for establishment of reference values, and from patients with multiple myeloma (MM) or rheumatoid arthritis (RA) in order to examine putatively increased values in the two different inflammatory conditions. Although NETs were hardly detectable in healthy individuals, NET levels were as expected highly and statistically significantly increased in RA patients. The detection of statistically significantly increased NET levels in MM is a novel finding.

Abstract Low-grade dysplasia (LGD) and superficial esophageal cancer (high grade dysplasia, T1a and superficial T1b) can be endoscopically treated according to most international guidelines, including the European Society of Gastrointestinal Endoscopy from 2017. The aim was to assess the level of dysphagia and health-related quality of life (HRQOL) in patients who underwent endoscopic treatment. Methods From 2014–2018 all patients with LGD and superficial esophageal cancer were included. The patients underwent endoscopic mucosal resection (EMR) and/or radiofrequency ablation (RFA). In June 2019 the patients were contacted per mail for assessment of the level of dysphagia and HRQOL, using the Ogilvie score and the European Organisation for Research and Treatment of Cancer (EORTC) core-questionnaire QLQ-C30 together with the disease-specific module QLQ-OG25. Results 59 out of the 86 patients alive (69%) completed the questionnaires after a median follow-up of 28 months (8–65 months). 24% of the patients answering the questionnaires underwent EMR, 31% RFA and 44% both EMR and RFA. There was no significant difference (p > 0.05) regarding the level of dysphagia, weight loss, global QoL and emotional status, neither with respect to a non-cancerous reference population nor between the treatment groups. For the other variables in QLQ-C30 and QLQ-OG25, the patients experienced significant lower HRQOL. 12% had minor problems eating solid food (Ogilvie score 1), of whom all underwent EMR. Conclusion The majority of patients endoscopically treated for LGD and superficial esophageal cancer experienced no dysphagia after a median follow-up of 28 months. The patients experienced significant lower HRQOL when being compared to an age-matched non-cancerous reference population. There was no difference regarding the level of dysphagia, weight loss, global QoL and emotional status.

Hereditary ventricular polyposis in the form of gastric adenocarcinoma and proximal polyposis of the stomach (GAPPS) is a rare condition characterised by a typical distribution of polyps in the stomach and risk of gastric cancer at a young age. Prophylactic gastrectomy may be indicated. The condition is not thought to be associated with increased risk of colon cancer, but the evidence base is limited.

Background and aims: Gastrointestinal (GI) symptoms, malabsorption, reduced food intake and weight loss are common sequela of gastrectomy. This can result in malnutrition with a subsequent prolonged recovery, reduced physical functioning and deteriorated quality of life (QoL). Few studies have investigated the relationship between GI-symptoms, QoL and malnutrition in long-term survivors of gastric cancer. Therefore, we assess nutritional status, GI-symptoms and QoL 2-5 years after gastrectomy for malignancy. Methods: A cross-sectional, pilot study was carried out in patients who underwent total or subtotal gastrectomy at Oslo University Hospital between 2012 and 2016, who had not experienced disease recurrence. Subjects above 85 years were excluded. The nutritional status of the patients fell into three groups by a score of subjective global assessment (SGA)-A, B, and C. Muscle mass was measured by body composition by bioelectrical impedance analysis and muscle strength was measured by handgrip strength (HGS). Dietary intake was assessed by repeated 24-h dietary recalls. GI-symptoms and QoL were assessed using GI-Symptom Rating Scale (GSRS) and the SF-36 questionnaire. Results: 21 patients were included. Mean (SD) weight loss was 12.8% (11.6) from preoperative status to follow up. Percentage weight loss was larger after total gastrectomy compared with subtotal gastrectomy (17.9% (12.3) vs. 6.6% (7.1) (p = 0.03)). A low mean intake of energy and protein was reported compared to dietary recommendations for the general Nordic population and intake in a national dietary survey. All of the patients were classified as pre-sarcopenic, and 5% as sarcopenic. Persistent weight loss >10% was observed in 45% of the subjects and these were in risk of malnutrition. Subjects with malnutrition had higher GSRS score for the abdominal pain syndrome (p = 0.042) and lower SF-36 scores for bodily pain (p = 0.01) and vitality (p = 0.02) compared with those without malnutrition. Conclusions: A high prevalence of weight loss, and pre-sarcopenia was observed. Malnutrition as assessed by SGA was associated with more GI-Symptoms and reduced QoL scores. Further studies with larger number of participants are needed to verify our findings. (C) 2020 The Author(s). Published by Elsevier Ltd on behalf of European Society for Clinical Nutrition and Metabolism.

Medicinal mushrooms have documented effects against different diseases, including infections and inflammatory disorders. The related Basidiomycota Agaricus blazei Murill (AbM), Hericium erinaceus (HE), and Grifola frondosa (GF) have been shown to exert antimicrobial activity against viral agents, Gram‐positive and Gram‐negative bacteria, and parasites in vitro and in vivo. Since the mechanism is immunomodulatory and not antibiotical, the mushrooms should be active against multi‐drug resistant microbes as well. Moreover, since these Basidiomycota also have anti‐inflammatory properties, they may be suited for treatment of the severe lung inflammation that often follows COVID‐19 infection. An AbM‐based mushroom extract (Andosan™), also containing HE and GF, has been shown to significantly reduce bacteraemia and increase survival in mice with pneumococcal sepsis, and to improve symptoms and quality of life in IBD patients via an anti‐inflammatory effect. Hence, such mushroom extracts could have prophylactic or therapeutic effect against the pneumonic superinfection and severe lung inflammation that often complicates COVID‐19 infection. Here, we review antimicrobial and anti‐inflammatory properties of AbM, HE and GF mushrooms, which could be used for the battle against COVID‐19.

Since the 1980s, medicinal effects have been documented in scientific studies with the related Basidiomycota mushrooms Agaricus blazei Murill (AbM), Hericium erinaceus (HE) and Grifola frondosa (GF) from Brazilian and Eastern traditional medicine. Special focus has been on their antitumor effects, but the mushrooms' anti-inflammatory and antiallergic properties have also been investigated. The antitumor mechanisms were either direct tumor attack, e.g., apoptosis and metastatic suppression, or indirect defense, e.g., inhibited tumor neovascularization and T helper cell (Th) 1 immune response. The anti-inflammatory mechanisms were a reduction in proinflammatory cytokines, oxidative stress and changed gut microbiota, and the antiallergic mechanism was amelioration of a skewed Th1/Th2 balance. Since a predominant Th2 milieu is also found in cancer, which quite often is caused by a local chronic inflammation, the three conditions-tumor, inflammation and allergy-seem to be linked. Further mechanisms for HE were increased nerve and beneficial gut microbiota growth, and oxidative stress regulation. The medicinal mushrooms AbM, HE and GF appear to be safe, and can, in fact, increase longevity in animal models, possibly due to reduced tumorigenesis and oxidation. This article reviews preclinical and clinical findings with these mushrooms and the mechanisms behind them.

Background: Over the past two decades, hybrid and total minimally invasive esophagectomy for esophageal cancer (EC) has increasingly been implemented with the aim to improve morbidity, functional result and ultimately the prognosis in these patients. However, more results are warranted and in this single-center study we report long-time outcome in a cohort of cancer patients treated with hybrid esophagectomy (HE). Material and methods: Hundred and nine patients with EC operated with HE from November 2007 to June 2013 were included. Clinical, pathological and survival data were retrieved from the patient administration system and the Norwegian Cause of Death Registry. Patients alive were asked to fill out the Ogilvie dysphagia score, EORTC QLQ-C30 and EORTC QLQ-OG25. Survival was analyzed by Kaplan-Meier's method and prognostic factors by uni- and multivariable Cox regression analyses. Results: Median overall follow-up time was 55 months (range 2-135) after R0-2 resection (n = 109) and 76 months (5-135) for R0 resection (n = 100). Five-year overall survival rate was 49% and 53%, respectively. Anastomotic leakage rate and 90-days mortality were 5% and 2%, respectively. Six patients (6%) had later surgery for metastases to mediastinum, hepatoduodenal ligament, brain, lung, liver or bladder median 26 months (4-51) after HE. Forty-one out of 51 patients alive (80%) filled out questionnaires after median 65.5 months (63-123) follow-up. All patients could eat normal food without (n = 37) or with (n = 4) problems. Nearly, half of the patients reported problems with reflux, one-third experienced fatigue and anxiety while one out of four had weight loss and episodes of dyspnea. Conclusions: In this patient series, HE offered low postoperative mortality and good overall long-term survival. Most survivors maintained good quality of life more than five years post treatment. There was a low rate of serious postoperative complications.

Abstract Superficial esophageal cancer (HGD = high grade dysplasia, T1a and T1b with no evidence of spread) accounts for about 20 % of all esophageal cancers. Traditionally, radical esophagectomy, with a significant degree of comorbidity has been the mainstay of treatment. Now most international guidelines, including the ESGE (European Society of Gastrointestinal Endoscopy) recommends endoscopic treatment as the first choice of treatment. The aim of this abstract was to present our data from 2014-2018. Methods From 2014 to 2018 (and ongoing) we have registered all patients endoscopically treated for LGD (low grade dysplasia) and superficial esophageal cancer, including some cases with T1b. The patient material, including treatment modality, histology, time of follow-up, the need for surgery and its outcome were registered. The majority of follow-ups took place at our hospital. Data was also retrieved from cases of late follow-up at other hospitals. Results 86 patients were endoscopically treated. The histology revealed LGD (24%), HGD (50%) and adenocarcinoma (21%). 15% were treated for a T1a tumor, 7% for T1b. 29% underwent endoscopic mucosal resection (EMR), 29% radiofrequency ablation (RFA) and 40% had both. The endoscopic treatment resulted in complete resolution of dysplasia in 64%, downstaging in 11%, whilst progression occurred in 11%. Five patients were operated for initial T1b or progression into T1b. The operation specimen showed no residual tumor in 3/5 patients. There were no serious complications. 90-days mortality was 1%. Conclusion Endoscopic treatment is a safe and efficient treatment option for superficial esophageal cancer. Few patients needed surgery and there was few and exclusively mild complications. This treatment modality will spare many patients for esophageal surgery with its associated high level of comorbidity.

Background Dysplasia and superficial esophageal cancer should initially be treated endoscopically. Little is known about post-procedural health-related quality of life (HRQL). The aim of this study was to present our results with endoscopic treatment and post-procedural HRQL. Materials and methods From June 2014 to December 2018, all patients treated with endoscopic mucosal resection (EMR) and/or radiofrequency ablation (RFA) for low-grade dysplasia (LGD), high-grade dysplasia (HGD), T1a and a minority of patients with T1b at Oslo University Hospital were prospectively included. In June 2019, all patients alive were scored according to the Ogilvie dysphagia score as well as the QLQ-C30 and QLQ-OG25 for assessment of HRQL. Results Eighty-six patients were treated out of whom 22 (26%) had LGD, 44 (51%) HGD, 13 (15%) T1a, and six patients (7%) T1b. Histology revealed adenocarcinoma in 18 (21%) and squamous cell carcinoma in one (1%), respectively. The mean follow-up was 22.9 months. Tumor regression or downstaging was archived in 78% of the patients with LGD, 66% of patients with HGD and in 89% of patients with T1a/b. Five patients (6%) had esophagectomy. There were few and no serious complications. The 90-days mortality was 1%. Fifty-two patients (88%) experienced no dysphagia (Ogilvie score 0). There was no difference in 11 out of the 15 variables in QLQ-C30 when compared to a non-cancerous reference population. Conclusions Endoscopic treatment is safe and efficient for treatment of dysplasia and superficial esophageal cancer. The two-years post-procedural level of HRQL and dysphagia was satisfactory.

04.05.2020: Klinisk oversikt - Arvelig ventrikkelpolypose i form av gastrisk adenokarsinom og proksimal ventrikkelpolypose (gastric adenocarcinoma and proximal polyposis of the stomach, GAPPS) er en sjelden tilstand karakterisert av typisk fordeling av polypper i magesekken og risiko for magesekkreft i ung alder.

Abstract Objectives: Iatrogenic perforations are the most common cause of esophageal perforation. We present our experience mainly based on a non-operative treatment approach as well as long-term outcome in these patients. Materials and methods: Twenty-one patients were treated for iatrogenic esophageal perforation at Oslo University Hospital, Ullevål from February 2007 to March 2014. The etiology of perforation was dilation of benign stricture in eight patients, either dilation, stenting or stent removal in four with malignant stenosis, during diagnostic endoscopy in four, removal of foreign body in two and by other causes in three patients, respectively. After median 82 months, 10 patients alive (47.6%) were sent questionnaires about dysphagia, HRQoL and fatigue. Results: Median age at time of treatment was 66 years. Median in-hospital stay and mortality were 10.5 days and 4.8%, respectively. Initial treatment in 15 patients (71.4%) was non-surgical of whom one needed delayed debridement for pleural empyema. Initial treatment in six patients (28.6%) was surgical of whom three needed delayed stenting. Altogether 14 patients (66.7%) were stented. Eight (57.1%) had restenting. Median number of stents used was 1 (1–4). The stents were removed after median 36 days. The perforations healed after 2.5 months. After median 82 months, the patients reported reduced HRQoL. There was no significant difference regarding level of dysphagia and fatigue. Conclusions: We report satisfactorily short-term and long-term results of iatrogenic esophageal perforations. Mortality was low and HRQoL was deteriorated. Dysphagia and fatigue were comparable to a reference population.