Background and aim:The use of robot-assisted surgery in Norway has increased over the past decade. We report selected quality indicators for robot-assisted oesophageal and gastric resection for cancer or premalignant lesions. Material and method:A retrospective review of selected quality indicators following oesophageal and gastric resection for cancer or premalignant lesions at Oslo University Hospital between 2018 and 2024. We recorded the proportion of patients with anastomotic leakage and 90-day mortality, and assessed whether these rates were within the target levels defined by the Norwegian Registry for Gastrointestinal Surgery (NORGAST). For gastric resections, the 30-day reoperation rate was also recorded. Results:A total of 104 patients with oesophageal cancer and 96 patients with gastric cancer or premalignant lesions were included in the study. Anastomotic leakage following surgery for oesophageal and gastric cancer occurred in 17 % and 5 % of cases, respectively. Corresponding 90-day mortality rates were 3 % and 2 %. The reoperation rate after gastric resection was 11 %. All values were within the national target levels set by NORGAST. Interpretation:Target levels for the selected quality indicators were met following the introduction of robot-assisted oesophageal and gastric resection. Use of this technique appears to be safe at our centre, which has prior experience with minimally invasive surgery for oesophageal and gastric cancer.

Esophageal cancer incidence is rising globally, with at least 500,000 new cases diagnosed annually. Management options for non-metastatic disease include primary resection, neoadjuvant or perioperative therapies, or definitive non-surgical treatment, with the choice being guided by tumor staging, histology, patient fitness, and available resources. However, even with the use of advanced diagnostic modalities, preoperative clinical staging is challenging with respect to accuracy of both tumor and nodal assessment. Early-stage esophageal cancer may be managed with local therapies, such as endoscopic mucosal resection or submucosal dissection, while for more advanced tumors managed with curative intent neoadjuvant oncologic therapy is commonly recommended. However, between these two groups lies an infrequent but important subgroup of patients, clinically staged cT2N0M0 esophageal cancer. Guidelines such as the NIH's National Cancer Institute recommends either surgery alone or neoadjuvant therapy followed by surgery for AJCC Stage I cancers, and add the option of definitive chemoradiation for Stage II disease. With cT2N0 disease straddling both AJCC classifications, management guidance is lacking. This guideline will provide an evidence-based recommendation from the International Society For Disease Of The Esophagus on the management of cT2N0 esophageal cancer, of all types. The recommendations are intended to support surgeons, oncologists, and patients in decisions about the best practice preoperative oncologic management of cT2N0M0 esophageal cancer.A Working Group within the International Society for Diseases of the Esophagus (ISDE) Guidelines Committee performed a systematic review of the literature. Results of the systematic review were presented to a panel of experts and these results informed the panel discussion about the guideline. This panel used Grading of Recommendations Assessment, Development, and Evaluation approach to deliberate and formulate recommendations.The panel agreed on a conditional recommendation for the use of neoadjuvant therapy followed by surgery over primary surgical resection (PSR) for adult patients with cT2N0M0 esophageal cancer.Preoperative clinical staging of esophageal cancer is uncertain, with deficiencies in all diagnostic modalities. However, when all modern staging techniques are utilized, the ISDE recommends neoadjuvant therapy followed by surgical resection as the favored treatment of cT2N0 esophageal cancer. Certain patient groups may still be offered PSR, particularly those unable to tolerate neoadjuvant therapies, or those patients with very low risk of lymph node metastasis as suggested by histological features, small tumor size, and other features.

Abstract Topic Esophageal Cancer: Barrett‘s Esophagus: High-Grade Dysplasia and Early Invasive Cancer Background Although endoscopic resection is reported to be safe for early stage esophagogastric cancer, uncertainty remains regarding oncological efficacy, particularly for submucosal lesions. The aim of this study was to assess the frequency of lymph node metastasis (LNM) and survival in patients operated for chemo- and radiotherapy naïve pT1 esophagogastric cancer. Methods Patients who underwent surgical resection for esophageal or gastric pT1 adenocarcinoma or squamous cell carcinoma without neoadjuvant oncologic treatment were included. Data were retrospectively extracted from registries in Denmark (2013-2021), Norway (2007-2024), Sweden (2012-2022), and Finland (2000-2016). The primary outcome was the frequency of LNM in patients operated for pT1 esophagogastric cancer. Secondary outcomes included: 5-year overall survival, number of lymph nodes harvested, and risk factors associated with LNM and mortality. Results 1647 patients with pT1 tumors were identified, of whom 949 (58%) did not receive neoadjuvant treatment. Of these 949 patients, esophagectomy had been performed in 413 (43%) and gastric resection in 536 (56%). 146 (15%) patients had LNM identified in the resected specimens: 19 (6%) with pT1a tumors and 127 (21%) with pT1b tumors. The median follow-up was 47 months (Interquartile range: 24-81) and 5-year overall survival was 81% for patients with pT1a tumors and 65% for those with pT1b tumors. Among patients with pT1b, the overall survival was 69% without LNM and 51% with LNM. Depth of tumor invasion was associated with risk of LNM. Conclusion A high proportion of patients had LNM after resection for chemo- and radiotherapy naïve pT1 esophagogastric cancer.

Background:The aim of the study was to map current practices in the management of gallstone disease at Norwegian hospitals providing acute care surgery. Material and method:A questionnaire was distributed to all surgical departments in Norway providing acute care for cholecystectomy. Results:A total of 41 hospitals met the inclusion criteria and 40 responded to the questionnaire. Institutions were categorised as low, medium or high-volume hospitals (< 50, 50-200 and > 200 cholecystectomies annually, respectively). Six, 20 and 14 hospitals were classified as low, medium and high-volume centres, respectively. Acute cholecystitis and acute biliary pancreatitis were indications for acute cholecystectomy at 31 and 16 hospitals, respectively. Intraoperative cholangiography was performed during elective cholecystectomy at six hospitals and during acute cholecystectomy at eight hospitals. Antibiotic therapy was continued after cholecystectomy for cholecystitis at 37 hospitals. The management of concomitant common bile duct stones was relatively similar across low, medium and high-volume hospitals. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) was the preferred treatment for common bile duct stones in both elective and acute cholecystectomy at 31 and 32 hospitals, respectively. Intraoperative ERCP was performed in elective and acute cases at three and six hospitals, respectively, while intraoperative transcystic stone clearance was performed in elective and acute cases at two and four hospitals, respectively. Interpretation:The management of gallstone disease at Norwegian hospitals varies in terms of indications for acute cholecystectomy, management of common bile duct stones, use of intraoperative cholangiography and antibiotic prophylaxis.

Long-term weight loss and improvement in associated medical problems are seen after metabolic bariatric surgery (MBS) as Roux-en-Y gastric bypass (RYGB). Few studies have focused on recurrent weight gain (RWG) after RYGB. Patients operated with RYGB from 2004 to 2008 were invited to 10-year follow-up consultations. The primary outcome was weight development in terms of total weight loss and RWG. Significant RWG was defined as gaining > 30 1. Significant reduction in weight and associated medical problems after RYGB. 2. Significant RWG > 30

BACKGROUND:Single-anastomosis sleeve ileal bypass is a novel metabolic bariatric surgery intended to enhance metabolic outcomes and reduce the risk of postoperative complications. Although preliminary outcome data for single-anastomosis sleeve ileal bypass are promising, evidence from adequately powered, randomized head-to-head comparisons is scarce. This trial compares the efficacy and safety of single-anastomosis sleeve ileal bypass versus sleeve gastrectomy in patients with class II obesity (body mass index = 35.0-39.9 kg/m²) with at least one obesity‑related comorbidity or class III obesity (body mass index ⩾40.0 kg/m²). METHODS:This two-center randomized clinical superiority trial enrolls patients eligible for metabolic bariatric surgery at two specialized Norwegian centers. Included patients are randomly assigned (1:1) to either single-anastomosis sleeve ileal bypass or sleeve gastrectomy with standardized perioperative treatment and care. The primary endpoint is the between-group difference in change in body mass index from baseline to 2 years after single-anastomosis sleeve ileal bypass versus sleeve gastrectomy. Secondary endpoints include additional weight loss outcomes, the prevalence of gastroesophageal reflux disease, surgical and postoperative complications, obesity-related comorbidities, nutritional status, bone mineral density, gastrointestinal symptoms, quality of life, and rates of revisional and conversion surgery. All endpoints will be evaluated at 2 and 5 years after surgery. Statistical analyses utilize linear mixed models and analysis of covariance within an intention-to-treat framework. DISCUSSION:This trial will provide high-level evidence with robust and comparative outcome data on single-anastomosis sleeve ileal bypass and sleeve gastrectomy, aiming to clarify the clinical utility of single-anastomosis sleeve ileal bypass and inform surgical practice. Findings will address gaps in medium- and long-term evidence regarding weight loss, safety, comorbidity resolution, and quality of life following single-anastomosis sleeve ileal bypass.

Single anastomosis sleeve ileal (SASI) bypass combines sleeve gastrectomy with intestinal bipartition to promote weight loss and metabolic improvement. We conducted a systematic review and meta-analysis comparing SASI with sleeve gastrectomy (1 RCT and 4 non-randomized comparative studies (NRCTs)), one-anastomosis gastric bypass (2 RCTs, 4 NRCTs), and Roux-en-Y gastric bypass (2 NRCTs), regarding weight loss, metabolic and nutritional outcomes, and adverse effects. Certainty of evidence was assessed with GRADE for 1-year outcomes. Twenty-six studies (1603 patients) were included, mostly reporting 12-month results. Pooled single-arm analysis from 11 studies showed mean total weight loss of 35.9 kg (95

ABSTRACT Objective Candidates for metabolic bariatric surgery (MBS) often exhibit a higher prevalence of depressive symptoms compared with the general population. Studies have shown improvements in depressive symptoms and a reduction in depression prevalence during the initial years following MBS. However, reports on the long‐term maintenance of these improvements are conflicting, and factors such as preoperative predictors and gender differences remain poorly understood. Methods Data were collected from 210 subjects pre‐MBS and at 1‐ and 5‐years post‐MBS. Health care providers measured Body Mass Index (BMI). All other data were collected via self‐report (questionnaires). Pre‐MBS factors assumed associated with depressive symptoms at 5 years included BMI, body dissatisfaction, appearance orientation, resilience, and outcome expectancies. Results The sample comprised 77.6% women. Pre‐MBS there were no significant gender differences in depressive symptomatology or the likelihood of being depressed. At both one and 5 years post‐MBS, a higher proportion of men were categorized as probably depressed. From baseline to 5 years post‐MBS, depressive symptoms declined among women, whereas there was no change among men. Regardless of gender, preoperative depressive symptoms and resilience predicted postoperative depression. Among women, preoperative body dissatisfaction and expectations regarding weight change and appearance were initially associated with postoperative levels of depression. Conclusions Contrasting common findings, this study identified higher rates of post‐surgery depression in men than in women. Furthermore, the results indicate that post‐surgery depression may be bivariately associated with different factors depending on gender, although resilience predicted depressive symptoms irrespective of gender.

BACKGROUND:Robotic-assisted gastrectomy is increasingly used in the treatment of gastric cancer, but the evidence on outcomes in Western low-volume centers remains limited. We aimed to evaluate the surgical and oncological outcomes during implementation of robotic-assisted gastrectomy in a university hospital in Norway and to compare outcomes with laparoscopic-assisted gastrectomy. METHODS:All patients undergoing curative-intent resection for gastric adenocarcinoma at Oslo University Hospital with either robotic-assisted gastrectomy or laparoscopic-assisted gastrectomy from November 2018 to December 2025 were included in this retrospective cohort study. Laparoscopic-assisted gastrectomy was introduced at the center in 2015 and robotic-assisted gastrectomy in 2018. During the study period, two surgeons received training in laparoscopic-assisted gastrectomy, while robotic-assisted gastrectomy was implemented with sequential training of five surgeons. The main outcome was textbook outcome, defined as no serious complications, R0 resection, no conversion to open surgery, at least 15 lymph nodes in the specimen, and no 30-day mortality or readmission. Secondary outcomes included R0 resection, number of lymph nodes, serious complications, anastomotic leakage, procedure time and overall survival. RESULTS:During the study period, there were 136 attempted robotic-assisted gastrectomies and 134 attempted laparoscopic-assisted gastrectomies, of which 108 (79%) and 104 (78%) were completed (p = 0.72). The overall distribution of tumor location differed between the robotic-assisted gastrectomy and laparoscopic-assisted gastrectomy groups (p = 0.03). Otherwise, the groups were comparable for the assessed baseline characteristics. Textbook outcome was achieved in 54/108 (50%) robotic-assisted gastrectomy and 55/104 (53%) laparoscopic-assisted gastrectomy procedures (p = 0.67). Procedure time was 60 min (95% confidence interval: 41, 79) longer in robotic-assisted gastrectomy versus laparoscopic-assisted gastrectomy. R0 resection was observed in 94/108 (87%) patients after robotic-assisted gastrectomy and 100/104 (96%) after laparoscopic-assisted gastrectomy (p = 0.03). There was no difference in other short-term outcomes or overall survival. CONCLUSION:Robotic-assisted gastrectomy was associated with a similar textbook outcome rate compared with that of laparoscopic-assisted gastrectomy. The lower rate of R0 resections after robotic-assisted gastrectomy warrants continued audit and further evaluation.

Esophageal cancer is a global burden, and multiple international societies exist to address the issue in international collaboration. This study aims to analyze the characteristics of esophageal cancer and robot-assisted minimally invasive esophagectomy (RAMIE) across geographic areas. We performed a retrospective analysis of the Upper GI International Robotic Association (UGIRA) international database from January 2016 to April 2024. Forty centers worldwide that were known to perform RAMIE were involved in establishing this consortium. The patient characteristics, surgical techniques, and short-term outcomes of RAMIE were compared by each regional area (Europe, Asia, North America, and South America). A total of 3,916 RAMIE cases were registered in the UGIRA database (2,643 in Europe, 1,130 in Asia, 111 in North America, and 32 in South America). The median age was 66 years, and 80.5% of patients were male. Notably, Asia had a high prevalence of squamous cell carcinoma (91.2%) and predominant use of the McKeown approach (94.9%). BMI was lower in Asia, whereas comorbidities were more common in Western countries across all types. The use of neoadjuvant chemotherapy and radiation was lower in Asia (48.2% and 20.8 %, respectively). Postoperative complications also differed by region; pneumonia was most common in Europe and South America, cardiopulmonary complications in North America, and recurrent nerve injury in Asia. In conclusion, regional differences were observed in baseline characteristics, treatment approaches, and complication patterns in patients treated by RAMIE for esophageal cancer. Recognizing these variations is essential for fostering mutual understanding and advancing the field through international collaboration.

BACKGROUND AND AIMS:Shared decision-making (SDM) is increasingly emphasized in clinical guidelines. For uncomplicated gallstone disease, both surgical and conservative strategies are considered safe, making patient preferences central to treatment selection. This study assessed the extent of patient involvement in decision-making regarding treatment for uncomplicated gallstone disease. METHODS:In this prospective pilot study conducted at a surgical outpatient clinic in Norway, all referred patients with uncomplicated gallstone disease were invited to participate. Video-recorded consultations were independently evaluated by two expert raters. Surgeons, patients, and experts completed the MAPPIN-SDM questionnaire. The MAPPIN-SDM score is calculated as the mean of 11 items (0-4), with higher scores indicating greater SDM. RESULTS:Of 34 eligible patients, 26 were included; 68% were women, and the mean age was 47.8 years (SD = 16.1). The overall mean MAPPIN-SDM score was 2.6 (SD = 0.48). Patients (mean = 3.5, SD = 0.48) and surgeons (mean = 2.9, SD = 0.56) rated the level of SDM higher than external observers (mean = 1.55, SD = 0.65; p < 0.001). Fourteen patients (54%) ultimately underwent surgery. Their average MAPPIN-SDM score was significantly higher than that of managed conservatively (2.89 versus 2.28, p < 0.001). CONCLUSION:This study demonstrates a moderate level of SDM in consultations for uncomplicated gallstone disease but reveals considerable discrepancies between patient/surgeon perceptions and observer assessments. Higher SDM scores were associated with the choice of surgery. These findings highlight the need for targeted strategies to improve the quality and consistency of SDM in the management of uncomplicated gallstone disease.

BACKGROUND AND AIMS:Textbook outcome (TO) and textbook oncological outcome (TOO) are two multidimensional quality measures designed to evaluate and benchmark the surgical and oncological outcomes following esophagectomy. Most studies on TO and TOO originate from high-volume tertiary centers, whereas less is known about the outcome from low- to medium-sized centers. METHODS:Retrospective national cohort study of patients operated for esophageal cancer with Ivor Lewis or McKeown esophagectomy between 07/2021 and 06/2025. The primary outcome was the fraction of patients achieving TO defined as no 30-days mortality, no Clavien-Dindo complications ≥ III, length of hospital stay < 21 days, R0 resection, no re-admissions within 30 days, ≥ 15 lymph nodes harvested and no intraoperative complications. The main secondary outcome was the proportion of patients achieving TOO, defined as achievement of TO and completed neoadjuvant (radio)chemotherapy. Patients were grouped according to type of resection. RESULTS:A total of 317 patients were included. 97 (31%) of all patients achieved TO and 83 (27%) TOO, with no difference between the two surgical techniques (p = 0.40 and p = 0.94, respectively); 30-day mortality was 1%. No predictive variables of TO were identified, specifically no association was found with the annual procedural center volume, type of resection or the use of robotic-assisted technique. CONCLUSIONS:Less than one in three patients achieved TO or TOO. Neither the annual procedure volume of the individual treatment centers nor the type of resection predicted TO. The lack of a consensus-based definition of TO and TOO makes comparisons across patient series challenging.

Introduction: Accumulation of fat in omental visceral adipose tissue (OVAT) is strongly linked to metabolic diseases. Our recent findings show a distinct and more accessible chromatin landscape of the visceral depot compared to its subcutaneous counterpart. Based on integrated analysis of chromatin accessibility and transcriptomics, we identified previously unrecognised genes linked with obesity. Here, we performed in-depth analyses of one of the candidates, HOOK1, and tested for depot-specific gene expression, correlation with clinical traits and regulatory mechanisms including DNA methylation. METHODS:We utilised intra-individually paired adipose tissue samples of human OVAT and subcutaneous adipose tissue (SAT) from our in-house cohort (N = 78). Gene expression was measured using real-time quantitative PCR and pyrosequencing was used to determine DNA methylation levels. Data were analysed for differential gene expression and DNA methylation differences between SAT and OVAT, along with correlation analyses with clinical variables related to obesity. Results were validated in adipose tissue samples from 1,618 donors of the Leipzig Obesity Biobank. RESULTS:We observed consistently higher HOOK1 gene expression in OVAT compared to SAT and successfully confirmed this effect direction in several validation cohorts. We further identified that HOOK1 gene expression correlated with body mass index and hip circumference. We discovered a relationship between DNA methylation of the HOOK1 promoter with clinical variables important for liver function. CONCLUSION:Our data show that HOOK1 gene expression is adipose tissue depot-specific. We observed that gene expression and DNA methylation are correlated to clinical variables of obesity, suggesting that HOOK1 may play a role in obesity and its sequelae. .

Obesity is a major health challenge and fat accumulation in visceral depots is more strongly associated with metabolic comorbidities than deposition in subcutaneous depots. Epitranscriptomic regulation of gene expression by N6-methyladenosine (m6A) influences various aspects of RNA metabolism, however the m6A methylome in human adipose tissue and its relationship with fat distribution has not yet been investigated in detail. In this study, we performed epitranscriptomic mapping of m6A in intra-individually paired samples of subcutaneous (SAT) and omental visceral adipose tissue (OVAT) from women with normal weight (BMI ≤25, n = 3) and obesity (BMI ≥35, n = 10) using meRIP-seq (discovery cohort). We further investigated differential m6A methylation for specific target genes in a larger cohort of individuals with obesity (n = 72, validation cohort) using meRIP-qPCR. meRIP-seq was performed for primary adipocytes from a subset of the patients (n = 4) to account for cell type specific differences. We here provide the first global map of m6A in human adipose tissue in paired samples of SAT and OVAT. We show an overall high overlap in m6A sites between individuals and depots, but also distinct depot-specific differences. We identify 339 target genes showing depot-specific m6A methylation. Depot-specific methylation was validated for selected sites in SEMA3A, SNAP47 and PPP1R9A in a larger validation cohort. We additionally identify differentially methylated targets between lean individuals and individuals with obesity, including TSC22D1, FMNL2 and IL1R1. By combining data from primary adipocytes with data from corresponding bulk adipose tissue, we identified a higher number of genes containing m6A in non-adipocyte cells in OVAT compared to SAT. Mechanistically, we show for selected targets that m6A affects RNA lifetime in pre-adipocyte cell culture models. Importantly, m6A methylation in selected targets correlates with clinically important variables related to obesity, fat distribution and glucose metabolism. We identify a catalogue of novel targets showing adipose tissue depot specific m6A methylation, with potential as biomarkers in metabolic disease. Our findings underscore the regulatory role of m6A in obesity and provide valuable insights for future research. The datasets generated represent a significant resource for further insight in adipose tissue biology and its implications for metabolic health.

Adipose tissue influences cardiometabolic health through its endocrine activity and its role in regulating inflammation, lipid metabolism, and cardiovascular function. The expression of cardiac-associated genes within adipose tissue may reflect or contribute to cardiometabolic risk, yet this relationship remains poorly understood. This study investigates the expression profiles of the cardiac function associated genes GJA1, DES, DSP and SMOC2 in human adipose tissue, and analyses their associations with cardiometabolic traits. Additionally, we explore epigenomic mechanisms that may underlie their differential gene expression. Expression profiling and functional enrichment analyses were conducted to identify depot-specific cardiac gene expression patterns. Quantitative PCR validated gene expression in paired subcutaneous (SAT) and omental visceral adipose tissue (OVAT) samples from 78 individuals with obesity. Gene expression was further validated in three independent cohorts (N = 1,548 total). Associations with clinical traits were assessed using Spearman correlations and multivariate linear regression, adjusted for age, sex, and BMI. Integration with transcriptomic and proteomic datasets publicly available from the Adipose Tissue Knowledge Portal was performed to strengthen clinical relevance. Epigenomic profiling using genome-wide ChIP-seq for histone marks (H3K4me3, H3K4me1, H3K27ac, H3K27me3) was conducted in paired SAT and OVAT samples from five individuals. DES, DSP, GJA1, and SMOC2 were significantly upregulated in OVAT compared to SAT. DES, DSP, and SMOC2 showed consistent expression patterns across all cohorts, while GJA1 exhibited context-dependent regulation. Gene expression in SAT was negatively correlated with cardiometabolic traits, including blood pressure, insulin resistance, and liver function markers. These associations were confirmed by regression analysis and supported by publicly available multi-omics data. Epigenetic analyses revealed OVAT-specific enrichment of active histone marks and reduced repressive marks, supporting higher differential transcriptional activity in OVAT. Depot-specific gene expression of DES, DSP, and SMOC2 in adipose tissue is robustly linked to cardiometabolic traits and supported by distinct epigenetic landscapes in OVAT vs SAT, highlighting their potential as novel biomarkers for cardiometabolic health.

The association between body mass index (BMI) and cancers of the esophagus and the stomach remains complex and requires further exploration. This study aimed to investigate this association, including early-onset (< 50 years) cancer and cancer related mortality. A nationwide registry-based cohort study was performed by linking data from multiple national registries in Norway. The cohort included 1,723,692 individuals, with 22,473 gastroesophageal cancer cases identified over 55,701,169 person-years of follow-up. In men, a 5 kg/m2 increase in BMI was associated with an increased risk of esophageal (HR 1.34, 95%CI 1.22-1.48) and cardia adenocarcinoma (HR 1.36, 95% CI, 1.22-1.50). This finding extended to individuals with high BMI in early life (16-29 years) for esophageal adenocarcinoma. The highest risk per 5 kg/m2 increase in BMI was observed for early-onset esophageal (HR 2.49, 95%CI 1.23-5.02) and cardia adenocarcinoma (HR 2.26, 95%CI 1.19-4.27). Among women, increased BMI was associated with a higher risk of both esophageal (HR 1.28, 95%CI 1.13-1.44) and gastric adenocarcinoma (HR 1.04, 95%CI 1.01-1.07). Women with elevated BMI in early life also demonstrated increased risk for these cancers. In both sexes, a 5 kg/m2 increase in BMI was inversely associated with squamous cell carcinoma of the esophagus. No association was observed between BMI and risk of cancer-related mortality. This study highlights an elevated risk of gastroesophageal adenocarcinomas with increasing BMI, with notable sex, age, and site-specific variations. The findings also point to a heightened risk of early-onset esophageal and cardia adenocarcinoma in men with high BMI.