BACKGROUND:Since 2015, multidisciplinary team (MDT) discussion is recommended for all Swedish patients diagnosed with gastric cancer. However, few studies have explored the association of MDT discussion with survival. METHODS:This study included all Swedish patients diagnosed with gastric adenocarcinoma between 2006 and 2021. Multivariable logistic regression was used to investigate the probability of receiving treatment recommendation at an MDT meeting, whereas the association between receiving an MDT treatment recommendation and overall survival was examined using Cox regression and Kaplan-Meier methods. RESULTS:Of 7813 patients, 5279 (68%) were discussed at an MDT meeting. Advanced age (80-89 years; odds ratio (OR) 0.30; 95% confidence interval (c.i.) 0.21 to 0.43) and lower performance status (Eastern Cooperative Oncology Group performance status 1; OR 0.68; 95% c.i. 0.56 to 0.81) were associated with a lower probability of receiving an MDT treatment recommendation. Clinical disease stages II and III, compared with stage I, were associated with a higher probability of an MDT discussion (OR 1.38 (95% c.i. 1.10 to 1.75) and 1.42; (95% c.i. 1.09 to 1.85), respectively), as was a later year of diagnosis (OR 1.37; 95% c.i. 1.35 to 1.40). In adjusted survival analysis with multivariable Cox regression, MDT discussion was associated with better survival (hazard ratio 0.89; 95% c.i. 0.83 to 0.95). In addition, median survival was longer in the group with than without MDT treatment recommendations (12.0 versus 5.9 months). CONCLUSION:Receiving a treatment recommendation at an MDT meeting was associated with better survival in patients with gastric adenocarcinoma. Patients with advanced disease and older age were less likely to receive an MDT treatment recommendation but, if they did, it was associated with better survival.

Objective: To establish a lymph node yield (LNY) change-point associated with improvements in overall survival (OS) and disease-free survival (DFS) in patients undergoing esophagectomy following neoadjuvant treatment for esophageal adenocarcinoma. Secondary endpoints include recurrence patterns and survival based on pathological staging. Summary Background Data: LNY has been associated with improved outcomes in esophageal cancer. The extent of lymphadenectomy following neoadjuvant treatment remains unclear. Methods: This multicenter European study included patients undergoing chemotherapy (CT) or chemoradiotherapy (CRT) followed by esophagectomy between 2018 and 2023. RA-CUSUM analysis identified change points between LNY and survival. Bootstrap resampling determined the optimal LNY, and multivariable Cox proportional hazards models analyzed LNY as continuous and categorical variables. A post hoc exploratory subgroup analysis was conducted in CT patients with optimal LNY compared with CRT irrespective of LNY. Recurrence patterns were assessed using the Fisher exact test. Results: A total of 2069 patients were included: 957 CT versus 1112 CRT. Median LNY was 32. CT data set: an optimal threshold of 25 nodes was identified (95% CI: 20–39). Categorical analysis using ≥25 nodes demonstrated 29% mortality reduction (HR: 0.714, P =0.0017). CRT data set: no significant LNY association across any endpoint. Continuous LNY showed a null effect ( P =0.633), and categorical analysis showed no benefit ( P =0.66). CT with ≥25 LNY had ∼44% lower mortality compared with CRT after adjustment for potential confounding variables (HR=0.563, P <0.001). Each positive LN increased the hazard for death by 7.3% in CT and 11.2% in CRT. Disease recurrence occurred in 32.7% of CT versus 38.3% of CRT ( P =0.001). Conclusion: On the basis of this data, there is a clear survival and recurrence benefit to performing a radical lymphadenectomy with a lymph node harvest of at least 25 nodes in patients who have received CT.

Importance:Pathological complete response (pCR) following neoadjuvant therapy is associated with favorable prognosis in esophageal adenocarcinoma. However, whether long-term outcomes differ by neoadjuvant modality among patients achieving pCR remains uncertain. Objective:To compare survival outcomes and recurrence patterns in patients with esophageal or gastroesophageal junction adenocarcinoma achieving pCR after perioperative 5-fluorouracil, leucovorin, oxaliplatin, and docetaxel (FLOT) chemotherapy vs the Chemoradiotherapy for Oesophageal Cancer Followed by Surgery Study protocol (CROSS). Design, Setting, and Participants:This cohort study was conducted at 14 high-volume European esophagogastric cancer centers between January 2018 and December 2024 with follow-up from surgery to death or last contact among patients with esophageal or junctional adenocarcinoma treated with neoadjuvant therapy followed by curative esophagectomy. Patients with squamous carcinoma, noncurative resection, incomplete pathological response, or 90-day mortality were excluded. Exposure:Neoadjuvant perioperative FLOT chemotherapy or CROSS chemoradiotherapy followed by curative-intent esophagectomy. Main Outcomes and Measures:The primary outcome was overall survival. Secondary outcomes included disease-free survival, recurrence patterns, and nodal stage-stratified survival. Survival was estimated using Kaplan-Meier methods and multivariable Cox proportional hazards models. Results:Among 2717 eligible patients, 297 achieved pCR and were analyzed (mean [SD] age, 64.4 [9.7] years; 256 [79.5%] men). Of these, 150 received CROSS and 147 FLOT. FLOT patients were younger and more frequently clinically node-positive at baseline, while postoperative outcomes were similar. On unadjusted analysis, FLOT was associated with better overall survival (hazard ratio [HR], 0.32; 95% CI, 0.17-0.60; P < .001) and disease-free survival (HR, 0.32; 95% CI, 0.19-0.55; P < .001). After adjustment, FLOT remained independently associated with better overall survival (HR, 0.34; 95% CI, 0.16-0.69; P = .003) and disease-free survival (HR, 0.35; 95% CI, 0.19-0.62; P < .001). Recurrence occurred in 13 of 147 patients receiving FLOT (8.8%) compared with 37 of 150 receiving CROSS (24.7%). Distant metastases predominated in the CROSS group (27 of 37 recurrences [70.3%]), whereas recurrence patterns were more heterogeneous after FLOT (locoregional, 2 of 13 recurrences [15.4%]; distant, 2 of 13 recurrences [38.5%]; both, 6 of 13 recurrences [30.8%]). The median (IQR) time to recurrence was longer after FLOT than CROSS (16.8 [12.3-21.5] vs 12.8 [7.1-26.7] months). In subgroup analyses, FLOT was associated with better survival in cN0 or 1 disease (HR, 0.32; 95% CI, 0.15-0.67; P = .002). Conclusions and Relevance:In this cohort study, perioperative FLOT in patients achieving pCR for esophageal adenocarcinoma was associated with superior survival, lower recurrence risk, and later recurrence compared with CROSS. These findings suggest the prognostic significance of pCR may vary by neoadjuvant modality and should be interpreted in the context of treatment strategy.

BACKGROUND:Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) is widely used for patients with gastric cancer and peritoneal metastases. However, the efficacy of this treatment has never been compared with that of systemic therapy. We aimed to investigate the efficacy of gastrectomy with cytoreductive surgery and HIPEC for patients with gastric cancer and limited peritoneal metastases, compared with systemic therapy alone. METHODS:In this European, multicentre, randomised, controlled, phase 3 trial (PERISCOPE II) in eight European tertiary referral hospitals, we recruited adults (aged ≥18 years) with resectable cT3 or cT4a gastric adenocarcinoma who had limited peritoneal metastases (Peritoneal Cancer Index <7) or tumour-positive peritoneal cytology, or both, in the absence of disease progression after three or more cycles of systemic therapy. Participants were randomly allocated (1:1) to the standard group (continuation of systemic therapy) or the experimental group (gastrectomy plus cytoreductive surgery and HIPEC with oxaliplatin [460 mg/m2 at 41°C] and docetaxel [50 mg/m2 at 37°C]), stratified by centre, histological subtype, and extent of peritoneal metastases. The primary endpoint was overall survival, calculated following the intention-to-treat principle. This trial is registered with ClinicalTrials.gov, NCT03348150, and was closed prematurely due to an unplanned interim analysis for futility. FINDINGS:Between Nov 6, 2017 and Aug 21, 2024, 102 participants were recruited (51 per group). Median age was 60 years (IQR 51-69); 58 (57%) participants were men, 43 (43%) were women, and 86 (85%) were White. Median follow-up was 67 months (IQR 47-73). Median overall survival in the standard group was 16·6 months (95% CI 14·1-21·9), compared with 15·7 months (11·4-25·5) in the experimental group (hazard ratio 1·10 [95% CI 0·69-1·74]; p=0·70). Ten (20%) of 51 patients in the standard group and 21 (42%) of 50 patients in the experimental group had grade 3 or worse adverse events. The most common grade 3 or worse adverse events were anaemia (four [8%] patients) and elevated liver enzymes (four [8%]) in the experimental group, and nausea (two [4%]), elevated liver enzymes (two [4%]), and electrolyte disturbances (two [4%]) in the standard group. Three (6%) of 51 patients in the standard group and 22 (44%) of 50 patients in the experimental group had serious adverse events. At 100 days after randomisation, three treatment-related deaths had occurred, all in the experimental group and attributed to acute respiratory distress syndrome (one patient), anastomotic leakage (one patient), and bleeding (one patient). INTERPRETATION:Gastrectomy with cytoreductive surgery and HIPEC provided no survival benefit in patients with gastric cancer and limited peritoneal metastases compared with systemic therapy alone. FUNDING:The Dutch Cancer Society, the Netherlands Organisation for Health Research and Development, the Dutch Ministry of Health, Henk Boot, the Bengt Ihre Research Foundation, and the Swedish Cancer Society.

OBJECTIVE:To establish a lymph node yield (LNY) change-point associated with improvements in overall survival (OS) and disease-free survival (DFS) in patients undergoing esophagectomy following neoadjuvant treatment for esophageal adenocarcinoma. Secondary endpoints include recurrence patterns and survival based on pathological staging. SUMMARY BACKGROUND DATA:LNY has been associated with improved outcomes in esophageal cancer. The extent of lymphadenectomy following neoadjuvant treatment remains unclear. METHODS:This multicenter European study included patients undergoing chemotherapy (CT) or chemoradiotherapy (CRT) followed by esophagectomy between 2018 and 2023. RA-CUSUM analysis identified change points between LNY and survival. Bootstrap resampling determined the optimal LNY, and multivariable Cox proportional hazards models analyzed LNY as continuous and categorical variables. A post hoc exploratory subgroup analysis was conducted in CT patients with optimal LNY compared with CRT irrespective of LNY. Recurrence patterns were assessed using the Fisher exact test. RESULTS:A total of 2069 patients were included: 957 CT versus 1112 CRT. Median LNY was 32. CT data set: an optimal threshold of 25 nodes was identified (95% CI: 20-39). Categorical analysis using ≥25 nodes demonstrated 29% mortality reduction (HR: 0.714, P=0.0017). CRT data set: no significant LNY association across any endpoint. Continuous LNY showed a null effect (P=0.633), and categorical analysis showed no benefit (P=0.66). CT with ≥25 LNY had ∼44% lower mortality compared with CRT after adjustment for potential confounding variables (HR=0.563, P<0.001). Each positive LN increased the hazard for death by 7.3% in CT and 11.2% in CRT. Disease recurrence occurred in 32.7% of CT versus 38.3% of CRT (P=0.001). CONCLUSION:On the basis of this data, there is a clear survival and recurrence benefit to performing a radical lymphadenectomy with a lymph node harvest of at least 25 nodes in patients who have received CT.

Abstract Topic Esophageal Cancer: Surgical Treatment of Esophageal Cancer – early outcomes and complications Background Esophagectomy is a cornerstone in the treatment of esophageal cancer. Although postoperative chyle leak (PCL) is uncommon, it is clinically important due to its associated morbidity and often challenging management. This study aimed to investigate risk factors for PCL and associations with survival in a nationwide cohort. Methods All patients with esophageal cancer, registered in the Swedish National Registry for Esophageal and Gastric Cancer (NREV) between 2006 and 2025, were included. The study represents an updated analysis of PCL in NREV, including an expanded cohort with extended follow-up. Directed acyclic graphs (DAGs) were used to identify confounders and guide covariate selection. Missing data for key variables were handled with multiple imputation. Variables associated with PCL were analyzed with adjusted multivariable logistic regression, and estimates were pooled according to Rubin’s rules. Overall and adjusted survival were assessed with the Kaplan–Meier method and Cox proportional hazards regression. Results A total of 3,182 patients with esophageal cancer undergoing esophagectomy were included. PCL occurred in 97 patients (3.0%), of whom 57 (58.8%) required interventional radiology or surgical management. Patients with PCL had a longer median hospital stay compared with those without PCL (23 vs. 14 days, p <0.001). In multivariable logistic regression, overweight patients (BMI >25) and patients with obesity (BMI >30) had a significantly lower risk of PCL (OR 0.60 [95% CI 0.37–0.98]; OR 0.43 [95% CI 0.21–0.88], respectively). Neoadjuvant chemo- or chemoradiotherapy was associated with an increased risk of PCL (OR 2.92 [95% CI 1.47–5.81]). There was no significant association between PCL and overall survival. Conclusion PCL is a clinically important complication after esophagectomy, prolonging hospitalization and often requiring reintervention. Overweight patients and patients with obesity appear to have a lower risk of PCL, possibly due to a reduced risk of accidental thoracic duct injury in an adipose mediastinum. Neoadjuvant treatment was associated with an increased risk of PCL. In contemporary clinical practice, PCL does not appear to compromise long-term survival. Further studies on preventive strategies and perioperative management are warranted.

OBJECTIVE:To determine the impact of severity of esophageal anastomotic leak (AL), standardized by ECCG grading, on long-term survival within a contemporary multicenter cohort. SUMMARY BACKGROUND DATA:Historical evidence suggesting AL is associated with increased recurrence and poor survival is limited by heterogeneous definitions and outdated management. This study utilizes the standardized ECCG definition to evaluate the prognostic significance of AL severity under modern perioperative protocols and endoscopic rescue strategies. METHODS:An international multicenter cohort across 17 high-volume European centers. Adult patients with esophageal or junctional cancer treated with neoadjuvant CROSS or FLOT, followed by esophagectomy were included (2018-2023). RESULTS:Out of 2905 patients, 425 (14.6%) developed an AL. AL was associated with a nearly two-fold increase in pulmonary complications (46.8% vs. 26.7%; P<0.001). AL requiring surgical reintervention (type III) was associated with an increased 30- and 90-days mortality rate (7.3% vs. 2.7% and 12.3% vs. 4%, P<0.001) and a significant reduction in median overall survival versus the no leak group (33.9 vs. 69.3; months P<0.001). After multivariable adjustment, type III AL was associated with a greater likelihood of death (HR 1.51; 95% CI: 1.04-2.18; P=0.029). A lower rate of adjuvant therapy administration (33.9% vs. 43.3%; P=0.004) was observe for AL patients. No significant survival deficits were observed for leaks treated conservatively or with no-surgical intervention. CONCLUSIONS:AL requiring surgical reintervention was associated with impaired survival. This relationship identifies a high-risk clinical profile and represents a critical target for future research into strategies for clinical stabilization and risk mitigation.

Conventional Swedish snus is used by millions in Scandinavia and increasingly worldwide, yet its cardiovascular effects remain poorly characterized. The emergence of nicotine pouches-commonly referred to as 'white snus' in Sweden-that deliver comparable nicotine without tobacco constituents adds complexity to a heterogeneous landscape and raises questions about whether cardiovascular risk follows nicotine exposure regardless of product type. We explore epidemiological and mechanistic evidence on snus and cardiovascular disease, the contributions of nicotine versus tobacco-specific nitrosamines (TSNAs) to risks, and identify knowledge gaps, with focus on novel nicotine products and the research opportunity offered by the Swedish Tobacco Cohort (SWETOC). Epidemiological evidence suggests elevated cardiovascular disease (CVD) mortality among snus users, with the most consistent signals for fatal myocardial infarction and heart failure. Associations with incident atherosclerotic events are more heterogeneous. Mechanistic evidence points to nicotine-mediated pathways, including sympathetic activation, endothelial dysfunction and increased arterial stiffness, whereas evidence for TSNA-driven CVD risk remains sparse, and declining TSNA levels in modern Swedish snus make that path less likely and harder to study. Nicotine pouches deliver comparable or higher systemic nicotine than conventional snus but lack long-term cardiovascular outcome data. Real-world cessation data from Denmark suggest structured programmes can achieve 6-month abstinence rates of approximately 53% among non-smoking nicotine users. The evidence supports nicotine as the primary driver of snus-associated CVD risk, with important implications for the cardiovascular safety of novel nicotine products. Evidence is needed to inform public health guidance, clinical advice and regulatory decisions. SWETOC represents a unique infrastructure to generate this evidence.

Esophagectomy is one of the highest risk surgical procedures and complications are common. While patient safety remains the primary focus, the impact on healthcare staff-the so-called 'second victims'-is often overlooked. Evidence suggests that a large proportion of surgeons experience emotional, professional, and social consequences following adverse outcomes. Our aims were to explore the effect of complications on personal and professional wellbeing and to identify systems and support required to help surgeons. An online survey, containing questions on surgeon demographics, the impact of surgical complications on personal and professional wellbeing, and current support systems available, was distributed globally to practicing esophageal cancer surgeons. A total of 100 responses were analysed from 30 countries. The median number of esophagectomies performed was 18 (IQR 0-90; n = 100)/annually. The complications with the most significant impact included patient mortality, gastric conduit necrosis and tracheobronchial injury. About 73% of surgeons reported changes in personal relationships and 66% experienced workplace pressures. Support was mainly obtained from colleagues (67%) or family (30%), however, 29% sought no support. 55% felt they received adequate support. About 58% felt under-supported by their particular institution. Complications after esophagectomy significantly affect surgeons' emotional wellbeing and clinical practice. While peer support was valued, many felt under-supported institutionally. These findings highlight the need for structured support systems to protect surgeon wellbeing and maintain safe surgical standards.

BACKGROUND:Esophagectomy is associated with pulmonary complications. This study evaluated if thoracoscopic minimally invasive esophagectomy (MIE) mitigates these risks by comparing pulmonary findings on postoperative computed tomography (CT) between open esophagectomy and MIE. METHOD:Postoperative (day 5) thoracic CT from 40 patients (20 open and 20 MIE) who had undergone esophagectomy with epidural analgesia and right-sided thoracic drainage were reviewed. On an axial view, the areas of atelectasis and pleural effusion were measured at 1 and 5 cm above the right diaphragmatic dome and at the level of the carina. In addition, the total distribution of atelectasis and pleural effusion was estimated on an ordinal scale (0-5), with ≥3 considered clinically important. RESULTS:The groups were well-matched in terms of age, sex, and smoking status. There were no differences in the areas of atelectasis or pleural effusion for open surgery compared with MIE. The groups did not differ in the proportion of patients with clinically important atelectasis (right: 30% vs. 25%, left: 65% vs. 65%) or pleural effusion (right: 15% vs. 15%, left: 65% vs. 45%). More pleural effusion and atelectasis at the 1-cm level was present on the left side at day 5 in both open and MIE patients. CONCLUSION:Despite major differences in surgical trauma and ventilation strategies between open and MIE, CT evaluation at day 5 was surprisingly similar. Less right-sided pleural effusion demonstrates the effect of surgical drains. We believe that the defined levels of measurement used in this study, performed at clear anatomical landmarks, can be of value in future studies.

Background In recent years, several studies have shown that permanent hypoparathyroidism has a negative impact on health-related quality of life. However, these results could have been affected by short-term follow-up, selection bias and confounding factors. The aim of this study was to investigate health-related quality of life in patients with and without permanent hypoparathyroidism after total thyroidectomy for benign thyroid disease, using a strict definition of permanent hypoparathyroidism and long-term follow-up data. Methods All patients who underwent total thyroidectomy for benign thyroid disease in a region of Sweden between 1 January 2005 and 31 December 2015 were assessed for eligibility. Eligible patients were invited to participate in the study through a letter on 26 August 2021. The 36-item Short Form Health Survey version 2 was used to compare health-related quality of life in patients with and without permanent hypoparathyroidism. Results Of 1636 patients, 1483 patients were invited to participate in the study. In total, 716 (48.3%) patients answered the Short Form Health Survey questionnaire and were included in the study cohort. Mean(s.d.) follow-up was 10.9(3.2) years. Patients with and without permanent hypoparathyroidism did not differ in baseline characteristics, with the exception that patients with permanent hypoparathyroidism were younger. There were no evident differences in health-related quality of life between the two groups, encompassing all health domains and summary component scores (P > 0.05). Conclusion No difference in health-related quality of life was found between patients with and without permanent hypoparathyroidism after total thyroidectomy on long-term follow-up. These results challenge previous findings and highlight the need for comprehensive, long-term studies to better understand the impact of this condition on health-related quality of life.

Background:Oesophagectomy, a corner stone in curative treatment of oesophageal cancer, is a complex procedure with high complication rates. Postoperative gastric tube decompression is debated and some centres are abandoning routine nasogastric (NG) tube use. We hypothesised that postoperative NG tube removal is non-inferior to five days of NG tube decompression, with regard to the risk of anastomotic leak. Methods:In this open-label, non-inferiority randomised controlled trial across 12 hospitals in Sweden, Norway, Denmark and Finland, participants treated for oesophageal or gastroesophageal junctional cancer with oesophagectomy were randomly assigned (1:1) to no postoperative NG tube or five days of NG tube decompression. Anastomotic leak was the primary outcome and secondary outcomes included pneumonia and length of hospital stay. Analyses were performed on the intention to treat and per protocol populations and non-inferiority for anastomotic leak was defined as a risk difference below 9%. ISRCTN.com registration ISRCTN39935085. Findings:Between January 1st 2022 and March 27th 2024, 448 patients were randomly assigned, 217 to no postoperative NG tube and 231 to five days NG tube treatment. The mean age was 67.5 (standard deviation (SD) 9.8) years and 367 (81.9%) were males. Non-inferiority with regard to anastomotic leak for no NG tube decompression could not be shown with 48 patients (22.1% (95% confidence interval (CI) 16.8%, 28.2%)) having anastomotic leak compared to 35 (15.2% (95% CI 10.8%, 20.4%)) with five days of NG tube decompression, a risk difference of -7.0% (95% CI -14.4%, 0.00%), pnon-inferiority 0.30. In a Supplementary analysis, patients had a lower risk of anastomotic leak if postoperative NG decompression was used. Rate of other complications, e.g., pneumonia, were similar between groups. In a per-protocol analysis, the risk difference was -11.3% to the advantage of NG tube (95% CI, -19.1, -0.3%). Interpretation:We could not establish safety (increased risk of anastomotic leak) and therefore do not support omission of NG tube after oesophagectomy. Funding:This trial was funded by the Swedish Cancer Society and the Nordic Cancer Union.

INTRODUCTION:Oesophageal resection carries significant morbidity and mortality. Artificial intelligence (AI) advances in medical research enable enhanced predictions, flexibility, and interpretability, especially for complex interactions and nonlinear relationships. MATERIAL AND METHODS:We used a register-based case-control design nested within prospectively collected data from the Swedish National Quality Register for Oesophageal and Gastric Cancer (NREV) to perform traditional logistic regression (LR) and machine learning (ML) with explainable AI (XAI) to predict 90-day mortality and anastomotic leakage in 1846 patients who underwent oesophageal resection between November 2005 and February 2018. RESULTS:The 90-day mortality was 6.0 % and anastomotic leakage was 12.4 %. XAI models yielded an area under the curve (AUC) of 0.95 for 90-day mortality, compared to 0.88 for LR. For anastomotic leakage, the AUC was 0.84 with XAI versus 0.74 with LR. LR identified significant odds ratios for 90-day mortality associated with age, ASA 2-3, BMI, and anastomotic leakage. ML models identified the same variables plus year of surgery as significant. For anastomotic leakage, LR was significant only for ASA 3, whereas ML found all examined variables to be significant predictors. XAI showed age and perioperative bleeding as important survival factors, while high BMI and age were significant risk factors for anastomotic leakage. All factors demonstrated nonlinear associations. XAI also visualises individual risk assessments for each procedure. CONCLUSIONS:By applying XAI, we advance surgical understanding of anastomotic leakage and mortality after oesophagectomy. Our data contain significant nonlinear relationships that cannot be visualised LR. With XAI, we extract personalised risk assessments, bringing oesophageal surgery closer to personalised medicine.

Objective: Positive peritoneal cytology is traditionally viewed as representative of metastatic disease and a poor prognostic factor. The objective of this multi-center study was to define the prognostic role of peritoneal cytology in curative gastrectomy, evaluate international variation in cytology sampling, and assess the impact on positive peritoneal cytology yields. Methods: This was a multi-center international retrospective cohort study of 16 tertiary gastric cancer centers. Adult patients who underwent peritoneal lavage cytology at staging laparoscopy and subsequent gastrectomy between 2009 and 2023 were included. The primary outcome measure was overall survival at five years. Multivariable Cox regression provided hazard ratios (HRs) with 95 % CIs, adjusted for relevant confounding factors. Results: 837 patients with no radiological or macroscopic M1 disease were included, with a mean age of 66 (IQR 58-73) and 71 % were male. Non-distal gastric cancer was most common (47 %), with 59 % and 43 % of tumors staged pT3/4 and pN2/3, respectively. 66 patients (7.9 %) had positive cytology. Positive cytology was not associated with overall survival in multivariable analysis, controlled for stage and neoadjuvant treatment (HR=1.0; 95 %CI 0.51-2.0). Higher T and N stages were associated with positive cytology (p < 0.001). The proportion of patients with positive cytology was variable, depending on how many quadrants were sampled. Conclusion: Positive peritoneal cytology with otherwise M0 disease was not associated with decreased survival after curative intent gastrectomy in this study, meaning prospective study is needed. The technique of performing peritoneal washings influenced cytology yield and thus must be standardized in a much-needed prospective evaluation of peritoneal cytology. Synopsis: The POPEC multicenter international retrospective cohort study included 837 patients receiving curative gastrectomy. This study showed the technique of performing peritoneal washings influenced cytology yield, however positive peritoneal cytology was not associated with decreased survival. Therefore, positive peritoneal cytology should not be considered an absolute contradiction to curatively intended gastrectomy.

Background Omentectomy has traditionally been performed in gastric cancer surgery, but omental preservation has become increasingly common. It is unclear whether omentectomy leads to additional survival benefit compared with omental preservation. This nationwide population-based cohort study aimed to assess survival and surgical outcomes comparing omental preservation to omentectomy in curative-intent gastrectomy. Methods Patients were identified from the Swedish National Registry for Oesophageal and Gastric Cancer with inclusion between 2006 and 2022. The primary endpoint was overall survival assessed by a multivariable Cox proportional hazards model, adjusted for age, sex, American Society of Anesthesiologists physical status score, clinical T and N stage, type of gastrectomy, surgical approach, extent of lymphadenectomy, neoadjuvant chemotherapy, surgery year and regional cancer centre. Secondary endpoints were surgical outcomes including tumour-free resection margins, lymph node yield and postoperative complications. Results A total of 1615 patients were included, 517 (32.0%) underwent gastrectomy with omental preservation, and 1098 (68.0%) underwent gastrectomy with omentectomy. Overall survival after omental preservation was similar compared with omentectomy in the multivariable Cox model (HR 1.00, 95% c.i. 0.83 to 1.20; P = 0.967). Omental preservation also had similar surgical outcomes including lymph node yield and postoperative morbidity rate, compared with omentectomy. Conclusions Omental preservation was similar to omentectomy in terms of overall survival and surgical outcomes. The results suggest that omentectomy can safely be omitted in curative-intent gastrectomy for gastric cancer.

BACKGROUND:There are differences in oesophageal cancer care across Sweden. According to national guidelines, all patients should be offered equal care, planned and administrated by regional multidisciplinary team meetings. The aim of the study was to investigate differences between regional multidisciplinary team meetings in Sweden regarding clinical staging and treatment recommendations for oesophageal cancer patients. METHODS:All six Swedish regional multidisciplinary teams were each invited to retrospectively include ten consecutive oesophageal cancer cases. After anonymization, radiological investigations were presented, along with the original case-specific medical history, anew at the participating regional multidisciplinary team meetings. Estimation of clinical tumour node metastasis (TNM) classification and treatment recommendation (curative, palliative or best supportive care) were compared between multidisciplinary team meetings as well as with original assessments. RESULTS:Five multidisciplinary teams participated and contributed a total of 50 cases presented to each multidisciplinary team. In estimations of cT-stage, the multidisciplinary teams were in total agreement in only eight of 50 cases (16%). For cN-stage, total agreement was seen in 17 of 50 cases (34%) and for cM-stage there was agreement in 34 cases (68%). For cT-stage, the overall summarized κ value was 0.57. For N-stage and M-stage the κ values were 0.66 and 0.78 respectively. Differences in appraisal were not associated with usage of positron emission tomography-computed tomography. In 15 of 50 cases (30%) the multidisciplinary teams disagreed on curative or palliative treatment. CONCLUSION:The study shows differences in assessment of clinical TNM classification and treatment recommendations made at regional multidisciplinary team meetings. Increased interrater agreement on clinical TNM classification and management plans are essential to achieve more equal care for oesophageal cancer patients in Sweden.

BACKGROUND:Blood transfusion has been associated with decreased long-term survival in cancer patients, possibly due to various immunological factors. We aimed to evaluate if perioperative transfusions decrease survival in patients who undergo resection for esophageal or gastric cancer and to identify factors associated with such events. METHODS:A population-based cohort study was conducted based on the Swedish National Registry for Esophageal and Gastric Cancer, which prospectively collects clinical data of patients with these tumors. Almost all patients (96 %) resected for esophageal or gastric cancer in Sweden between 2017 and 2022 were included. Survival data were acquired from the Swedish Cause of Death Registry. Multivariable Cox regression was used to calculate hazard ratios (HR) with 95 % confidence intervals (CI), adjusted for age, fitness, neoadjuvant therapy, surgical access, and pathological TNM stage. RESULTS:Of all 1365 patients, 227 (17 %) received perioperative transfusions. Transfusion was associated with an increased risk of all-cause mortality within 3 years of surgery (adjusted HR 1.50, 95 % CI 1.17-1.91). To exclude the influence of surgery-related postoperative complications, a sensitivity analysis was performed excluding patients who died within 30 days of resection and the negative impact of transfusions on 3-year mortality remained (adjusted HR 1.30, 95 % CI 1.01-1.68). Increasing age, open surgery, esophagectomy, perioperative bleeding, and nodal tumor involvement were all associated with an increased likelihood of receiving transfusions. CONCLUSION:Perioperative blood transfusions might have a negative impact on 3-year survival in patients who undergo surgery for esophageal or gastric cancer.

Abstract Introduction Esophagectomy can be complicated by postoperative chyle leak (PCL). PCL is rare and can be challenging to manage. Predisposing factors and the impact of PCL on survival are not fully understood. This study aimed to investigate risk factors for PCL in a national cohort and its associations with outcomes and survival. Method All patients with esophageal cancer in the Swedish Registry for Esophageal and Gastric Cancer (NREV) who underwent esophagectomy between 2006 and 2018 with information on PCL were included in the study. Risk-factors and protective-factors of PCL were explored with multivariable logistic regression and 90-day mortality was described. Survival was studied with Cox-regression and the Kaplan-Meier method. Result The study included 1540 patients. 51 patients (3.3%) had PCL of which 32 (62.7%) were managed operatively. Median time-in-hospital increased with 14 days from 15 to 29 days in patients with PCL compared to patients without. In multivariable logistic regression, overweight (BMI>25) and obese (BMI>30) patients were less likely to suffer from PCL, OR 0.41 (0.19-0.88 95%CI) and OR 0.28 (0.08-0.97) respectively. In patients with PCL, 90-day mortality was increased three-fold, 15.7% vs 5.0%, and median survival was reduced by six months (28.8 vs 34.8 months) compared to patients without PCL. PCL was not associated with adjusted long-term survival, HR 1.12 (0.75-1.66 95%CI). Discussion This study finds a reduced risk of PCL in obese esophageal cancer patients by unknown mechanisms that should be further explored. Although short-term mortality is clearly affected by PCL, the complication does not seem to impact long-term survival.