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1.
Dis Esophagus ; 37(6)2024 Jun 01.
Artículo en Inglés | MEDLINE | ID: mdl-38366900

RESUMEN

Esophagectomy is a complex and complication laden procedure. Despite centralization, variations in perioparative strategies reflect a paucity of evidence regarding optimal routines. The use of nasogastric (NG) tubes post esophagectomy is typically associated with significant discomfort for the patients. We hypothesize that immediate postoperative removal of the NG tube is non-inferior to current routines. All Nordic Upper Gastrointestinal Cancer centers were invited to participate in this open-label pragmatic randomized controlled trial (RCT). Inclusion criteria include resection for locally advanced esophageal cancer with gastric tube reconstruction. A pretrial survey was undertaken and was the foundation for a consensus process resulting in the Kinetic trial, an RCT allocating patients to either no use of a NG tube (intervention) or 5 days of postoperative NG tube use (control) with anastomotic leakage as primary endpoint. Secondary endpoints include pulmonary complications, overall complications, length of stay, health related quality of life. A sample size of 450 patients is planned (Kinetic trial: https://www.isrctn.com/ISRCTN39935085). Thirteen Nordic centers with a combined catchment area of 17 million inhabitants have entered the trial and ethical approval was granted in Sweden, Norway, Finland, and Denmark. All centers routinely use NG tube and all but one center use total or hybrid minimally invasive-surgical approach. Inclusion began in January 2022 and the first annual safety board assessment has deemed the trial safe and recommended continuation. We have launched the first adequately powered multi-center pragmatic controlled randomized clinical trial regarding NG tube use after esophagectomy with gastric conduit reconstruction.


Asunto(s)
Neoplasias Esofágicas , Esofagectomía , Intubación Gastrointestinal , Femenino , Humanos , Masculino , Persona de Mediana Edad , Fuga Anastomótica/etiología , Neoplasias Esofágicas/cirugía , Esofagectomía/efectos adversos , Esofagectomía/métodos , Intubación Gastrointestinal/métodos , Tiempo de Internación/estadística & datos numéricos , Cuidados Posoperatorios/métodos , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/epidemiología , Calidad de Vida , Ensayos Clínicos Controlados Aleatorios como Asunto , Países Escandinavos y Nórdicos
2.
Ann Surg ; 277(3): 429-436, 2023 03 01.
Artículo en Inglés | MEDLINE | ID: mdl-34183514

RESUMEN

OBJECTIVE: To examine the hypothesis that survival in esophageal cancer increases with more removed lymph nodes during esophagectomy up to a plateau, after which it levels out or even decreases with further lymphadenec-tomy. SUMMARY OF BACKGROUND DATA: There is uncertainty regarding the ideal extent of lymphadenectomy during esophagectomy to optimize long-term survival in esophageal cancer. METHODS: This population-based cohort study included almost every patient who underwent esophagectomy for esophageal cancer in Sweden or Finland in 2000-2016 with follow-up through 2019. Degree of lymphadenectomy, divided into deciles, was analyzed in relation to all-cause 5-year mortality. Multivariable Cox regression provided hazard ratios (HR) with 95% confidence intervals (95% CI) adjusted for all established prognostic factors. RESULTS: Among 2306 patients, the second (4-8 nodes), seventh (21-24 nodes) and eighth decile (25-30 nodes) of lymphadenectomy showed the lowest all-cause 5-year mortality compared to the first decile [hazard ratio (HR) = 0.77, 95% CI 0.61-0.97, HR = 0.76, 95% CI 0.59-0.99, and HR = 0.73, 95% CI 0.57-0.93, respectively]. In stratified analyses, the survival benefit was greatest in decile 7 for patients with pathological T-stage T3/T4 (HR = 0.56, 95% CI0.40-0.78), although it was statistically improved in all deciles except decile 10. For patients without neoadjuvant chemotherapy, survival was greatest in decile 7 (HR = 0.60, 95% CI 0.41-0.86), although survival was also statistically significantly improved in deciles 2, 6, and 8. CONCLUSION: Survival in esophageal cancer was not improved by extensive lymphadenectomy, but resection of a moderate number (20-30) of nodes was prognostically beneficial for patients with advanced T-stages (T3/T4) and those not receiving neoadjuvant therapy.


Asunto(s)
Neoplasias Esofágicas , Escisión del Ganglio Linfático , Humanos , Estudios de Cohortes , Ganglios Linfáticos/cirugía , Ganglios Linfáticos/patología , Modelos de Riesgos Proporcionales , Tasa de Supervivencia , Esofagectomía , Estadificación de Neoplasias , Pronóstico
3.
Gastric Cancer ; 26(3): 467-477, 2023 05.
Artículo en Inglés | MEDLINE | ID: mdl-36808262

RESUMEN

BACKGROUND: Laparoscopic gastrectomy is increasingly used for the treatment of locally advanced gastric cancer but concerns remain whether similar results can be obtained compared to open gastrectomy, especially in Western populations. This study compared the short-term postoperative, oncological and survival outcomes following laparoscopic versus open gastrectomy based on data from the Swedish National Register for Esophageal and Gastric Cancer. METHODS: Patients who underwent surgery with curative intent for adenocarcinoma of the stomach or gastroesophageal junction Siewert type III from 2015 to 2020 were identified, and 622 patients with cT2-4aN0-3M0 tumors were included. The impact of surgical approach on short-term outcomes was assessed using multivariable logistic regression. Long-term survival was compared using multivariable Cox regression. RESULTS: In total, 350 patients underwent open and 272 laparoscopic gastrectomy, of which 12.9% were converted to open surgery. The groups were similar regarding distribution of clinical disease stage (27.6% stage I, 46.0% stage II, and 26.4% stage III). Neoadjuvant chemotherapy was administered to 52.7% of the patients. There was no difference in the rate of postoperative complications, but laparoscopic approach was associated with lower 90 day mortality (1.8 vs 4.9%, p = 0.043). The median number of resected lymph nodes was higher after laparoscopic surgery (32 vs 26, p < 0.001), while no difference was found in the rate of tumor-free resection margins. Better overall survival was observed after laparoscopic gastrectomy (HR 0.63, p < 0.001). CONCLUSIONS: Laparoscopic gastrectomy can be safely preformed for advanced gastric cancer and is associated with improved overall survival compared to open surgery.


Asunto(s)
Neoplasias Esofágicas , Laparoscopía , Neoplasias Gástricas , Humanos , Resultado del Tratamiento , Estudios de Cohortes , Neoplasias Gástricas/patología , Neoplasias Esofágicas/patología , Suecia/epidemiología , Estudios Retrospectivos , Laparoscopía/métodos , Gastrectomía/métodos
4.
Ann Surg Oncol ; 29(9): 5609-5621, 2022 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-35752726

RESUMEN

BACKGROUND: Recent research indicates long-term survival benefits of minimally invasive esophagectomy (MIE) compared with open esophagectomy (OE) for patients with esophageal and gastroesophageal junction (GEJ) cancers, but there is a need for more population-based studies. METHODS: We conducted a prospective population-based nationwide cohort study including all patients in Sweden diagnosed with esophageal or junctional cancer who underwent a transthoracic esophagectomy with intrathoracic anastomosis. Data were collected from the Swedish National Register for Esophageal and Gastric Cancer in 2006-2019. Patients were grouped into OE and MIE including hybrid MIE (HMIE) and totally MIE (TMIE). Overall survival and short-term postoperative outcomes were compared using Cox regression and logistic regression models, respectively. All models were adjusted for age, sex, American Society of Anesthesiologists (ASA) score, clinical T and N stage, neoadjuvant therapy, year of surgery, and hospital volume. RESULTS: Among 1404 patients, 998 (71.1%) underwent OE and 406 (28.9%) underwent MIE. Compared with OE, overall survival was better following MIE (hazard ratio [HR] 0.72, 95% confidence interval [CI] 0.55-0.94), TMIE (HR 0.67, 95% CI 0.47-0.94), and possibly also after HMIE (HR 0.76, 95% CI 0.56-1.02). MIE was associated with shorter operation time, less intraoperative bleeding, higher number of resected lymph nodes, and shorter hospital stay compared with OE. MIE was also associated with fewer overall complications (odds ratio [OR] 0.70, 95% CI 0.47-1.03) as well as non-surgical complications (OR 0.64, 95% CI 0.40-1.00). CONCLUSIONS: MIE seems to offer better survival and similar or improved short-term postoperative outcomes in esophageal and GEJ cancers compared with OE in this unselected population-based cohort.


Asunto(s)
Neoplasias Esofágicas , Neoplasias Gástricas , Estudios de Cohortes , Neoplasias Esofágicas/cirugía , Esofagectomía , Humanos , Procedimientos Quirúrgicos Mínimamente Invasivos , Complicaciones Posoperatorias/cirugía , Estudios Prospectivos , Sistema de Registros , Estudios Retrospectivos , Neoplasias Gástricas/cirugía , Resultado del Tratamiento
5.
Scand J Gastroenterol ; 57(9): 1018-1023, 2022 09.
Artículo en Inglés | MEDLINE | ID: mdl-35400263

RESUMEN

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


Asunto(s)
Perforación del Esófago , Perforación del Esófago/epidemiología , Perforación del Esófago/etiología , Femenino , Humanos , Incidencia , Masculino , Factores de Riesgo , Análisis de Supervivencia , Suecia/epidemiología
6.
Scand J Gastroenterol ; 56(4): 458-462, 2021 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-33590795

RESUMEN

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


Asunto(s)
Neoplasias de la Vesícula Biliar , Pólipos , Colecistectomía , Neoplasias de la Vesícula Biliar/epidemiología , Neoplasias de la Vesícula Biliar/cirugía , Humanos , Pólipos/cirugía , Estudios Retrospectivos
7.
Dis Esophagus ; 34(3)2021 Mar 08.
Artículo en Inglés | MEDLINE | ID: mdl-32960273

RESUMEN

The main curative treatment modality for esophageal cancer is resection. Patients initially deemed suitable for resection may become unsuitable, most commonly due to signs of generalized disease or having become unfit for surgery. The aim was to assess risk factors for abandoning esophagectomy and its impact on survival. All patients diagnosed with an esophageal or gastroesophageal junction cancer in the Swedish National Register for Esophageal and Gastric Cancer from 2006-2016 were included and risk factors associated with becoming ineligible for resection were analyzed in multivariable logistic regression analysis. Overall survival was explored by multivariable Cox regression models. Among 1,792 patients planned for resection, 189 (11%) became unsuitable for resection before surgery and 114 (6%) had exploratory surgery without resection. Intermediate and high educational levels were associated with an increased probability of resection (odds ratio (OR) 1.46, 95% CI 1.05-2.05, OR 1.92, 95% CI 1.28-2.87, respectively) as was marital status (married: OR 1.37, 95% CI 1.01-1.85). Clinically advanced disease (cT4: OR 0.38, 95% CI 0.16-0.87; cN3: OR 0.27, 95% CI 0.09-0.81) and neoadjuvant treatment were associated with a decreased probability of resection (OR 0.62, 95% CI 0.46-0.88). Five-year survival for non-resected patients was only 4.5% although neoadjuvant treatment was associated with improved survival (HR 0.75, 95% CI 0.56-0.99). Non-resected patients with squamous cell carcinoma had comparatively reduced survival (HR 1.64, 95% CI 1.10-2.43). High socioeconomic status was associated with an increased probability of completing the plan to resect whereas clinically advanced disease and neoadjuvant treatment were independent factors associated with increased risk of abandoning resectional intent.


Asunto(s)
Neoplasias Esofágicas , Neoplasias Gástricas , Neoplasias Esofágicas/patología , Neoplasias Esofágicas/cirugía , Esofagectomía , Humanos , Terapia Neoadyuvante , Estadificación de Neoplasias , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia , Suecia/epidemiología
8.
J Surg Oncol ; 117(8): 1687-1696, 2018 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-29806960

RESUMEN

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


Asunto(s)
Adenocarcinoma/terapia , Quimioradioterapia Adyuvante , Quimioterapia Adyuvante , Neoplasias Esofágicas/terapia , Terapia Neoadyuvante , Adenocarcinoma/mortalidad , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Australia/epidemiología , Neoplasias Esofágicas/mortalidad , Esofagectomía , Femenino , Mortalidad Hospitalaria , Humanos , Análisis por Apareamiento , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Puntaje de Propensión , Estudios Prospectivos
10.
Surg Endosc ; 30(5): 2011-5, 2016 May.
Artículo en Inglés | MEDLINE | ID: mdl-26194258

RESUMEN

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the most common bariatric procedures worldwide, but the importance of gastric pouch size is still under debate. We have studied how pouch size affects risk of marginal ulcer and excess body mass index loss (EBMIL%) at 6 weeks and 1 year postoperatively. METHODS: Scandinavian Obesity Surgery Registry included 14,168 LRYGB patients with linear stapled gastrojejunostomies, having complete pre- and postoperative data concerning length of stapler needed to complete the gastric pouch, incidence of marginal ulcers and weight loss. LRYGB technique in Sweden is highly standardized, and total length of stapler was used as a proxy for pouch size. RESULTS: Mean length of stapler used for the pouch was 145 mm. At 1 year, symptomatic marginal ulcers were noted in 0.9 % of the patients. The relative risk of marginal ulcer increased by 14 % (95 % confidence interval 9-20 %), for each centimeter of stapler used for the pouch. Body mass index (BMI) was reduced from 42.4 ± 5.1 to 36.1 kg/m(2) at 6 weeks and 28.9 kg/m(2) at 1 year. The total length of stapler predicted EBMIL% at 6 weeks but not at 1 year. Female gender, low preoperative BMI, young age and absence of diabetes predicted better EBMIL% at 1 year. CONCLUSION: A smaller pouch reduces the risk of marginal ulcers, but does not predict better weight loss at 1 year. Additional stapling should be avoided as each extra centimeter increases the relative risk of marginal ulcers by 14 %.


Asunto(s)
Derivación Gástrica/métodos , Obesidad Mórbida/cirugía , Úlcera Péptica/epidemiología , Complicaciones Posoperatorias/epidemiología , Sistema de Registros , Estómago/cirugía , Adulto , Factores de Edad , Índice de Masa Corporal , Estudios de Cohortes , Comorbilidad , Diabetes Mellitus/epidemiología , Femenino , Humanos , Incidencia , Laparoscopía/métodos , Masculino , Persona de Mediana Edad , Obesidad Mórbida/epidemiología , Periodo Posoperatorio , Factores Sexuales , Grapado Quirúrgico/métodos , Suecia/epidemiología , Resultado del Tratamiento
11.
Lipids Health Dis ; 14: 42, 2015 May 02.
Artículo en Inglés | MEDLINE | ID: mdl-25934644

RESUMEN

BACKGROUND: Visceral fat accumulation is associated with metabolic disease. It is therefore relevant to study factors that regulate adipose tissue distribution. Recent data shows that overeating saturated fatty acids promotes greater visceral fat storage than overeating unsaturated fatty acids. Visceral adiposity is observed in states of hypercortisolism, and the enzyme 11-ß-hydroxysteroid-dehydrogenase type 1 (11ß-hsd1) is a major regulator of cortisol activity by converting inactive cortisone to cortisol in adipose tissue. We hypothesized that tissue fatty acid composition regulates body fat distribution through local effects on the expression of 11ß-hsd1 and its corresponding gene (HSD11B1) resulting in altered cortisol activity. FINDINGS: Visceral- and subcutaneous adipose tissue biopsies were collected during Roux-en-Y gastric bypass surgery from 45 obese women (BMI; 41±4 kg/m2). The fatty acid composition of each biopsy was measured and correlated to the mRNA levels of HSD11B1. 11ß-hsd1 protein levels were determined in a subgroup (n=12) by western blot analysis. Our main finding was that tissue saturated fatty acids (e.g. palmitate) were associated with increased 11ß-hsd1 gene- and protein-expression in visceral but not subcutaneous adipose tissue. CONCLUSIONS: The present study proposes a link between HSD11B1 and saturated fatty acids in visceral, but not subcutaneous adipose tissue. Nutritional regulation of visceral fat mass through HSD11B1 is of interest for the modulation of metabolic risk and warrants further investigation.


Asunto(s)
11-beta-Hidroxiesteroide Deshidrogenasa de Tipo 1/metabolismo , Ácidos Grasos/análisis , Grasa Intraabdominal/química , Adulto , Western Blotting , Femenino , Expresión Génica , Humanos , Grasa Intraabdominal/enzimología
12.
Surg Obes Relat Dis ; 20(4): 362-366, 2024 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-38114384

RESUMEN

BACKGROUND: Roux-en-Y gastric bypass (RYGB) is one of the most common bariatric procedures. Internal herniation may lead to small bowel ischemia requiring small bowel resection, resulting in short bowel syndrome. OBJECTIVE: To determine the incidence of extensive small bowel resection in patients operated with RYGB. We also aimed to look for early clinical warning signs among patients requiring extensive small bowel resection. SETTING: Cohort from national quality registers. METHODS: All patients having undergone RYGB between January 2007 to June 2019 were analyzed in the Scandinavian Obesity Surgery Registry (SOReg). We identified patients with small bowel obstruction (SBO) for whom small bowel resection was necessary. Additionally, we assessed clinical signs in these patients. RESULTS: The study included 57,255 patients having undergone RYGB. Closure of the mesenteric openings was performed in 78%. Surgery for SBO was required in 3659 (6%) of patients, and small bowel resection in 188 (.3%). Extensive small bowel resection, resulting in less than 1.5 meters of remaining small bowel, was required in 7 patients (.01%). All patients with extensive small bowel resection presented with abdominal pain and had confirmed internal herniation as the cause of the small bowel resection, and 2 of 7 patients died. Closure of mesenteric defects was not associated with a reduction in overall small bowel resection rates (P = .89) CONCLUSION: Surgery for SBO after RYGB was common (6%). The risk of extensive small bowel resection leading to short bowel was low (.01%). Patients with abdominal pain after RYGB should be assessed for internal hernia, as it can be devastating.


Asunto(s)
Derivación Gástrica , Hernia Abdominal , Obstrucción Intestinal , Laparoscopía , Obesidad Mórbida , Humanos , Derivación Gástrica/efectos adversos , Derivación Gástrica/métodos , Estudios de Cohortes , Suecia/epidemiología , Estudios Retrospectivos , Laparoscopía/métodos , Hernia Abdominal/epidemiología , Hernia Abdominal/etiología , Hernia Abdominal/cirugía , Obstrucción Intestinal/epidemiología , Obstrucción Intestinal/etiología , Obstrucción Intestinal/cirugía , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/cirugía , Dolor Abdominal/epidemiología , Dolor Abdominal/etiología , Obesidad Mórbida/complicaciones
13.
Paediatr Int Child Health ; 43(1-3): 19-22, 2023.
Artículo en Inglés | MEDLINE | ID: mdl-38018156

RESUMEN

ABBREVIATION: AEF: aorto-oesophageal fistula;BB: button battery;CTA: computed tomography angiography;ER: emergency room;GI: gastro-intestinal;SBT: Sengstaken-Blakemore tube.


Asunto(s)
Fístula Esofágica , Niño , Humanos , Lactante , Fístula Esofágica/complicaciones , Hemorragia Gastrointestinal , Tomografía Computarizada por Rayos X/efectos adversos
14.
Front Oncol ; 12: 917961, 2022.
Artículo en Inglés | MEDLINE | ID: mdl-35912196

RESUMEN

Background: The globally dominant treatment with curative intent for locally advanced esophageal squamous cell carcinoma (ESCC) is neoadjuvant chemoradiotherapy (nCRT) with subsequent esophagectomy. This multimodal treatment leads to around 60% overall 5-year survival, yet with impaired post-surgical quality of life. Observational studies indicate that curatively intended chemoradiotherapy, so-called definitive chemoradiotherapy (dCRT) followed by surveillance of the primary tumor site and regional lymph node stations and surgery only when needed to ensure local tumor control, may lead to similar survival as nCRT with surgery, but with considerably less impairment of quality of life. This trial aims to demonstrate that dCRT, with selectively performed salvage esophagectomy only when needed to achieve locoregional tumor control, is non-inferior regarding overall survival, and superior regarding health-related quality of life (HRQOL), compared to nCRT followed by mandatory surgery, in patients with operable, locally advanced ESCC. Methods: This is a pragmatic open-label, randomized controlled phase III, multicenter trial with non-inferiority design with regard to the primary endpoint overall survival and a superiority hypothesis for the experimental intervention dCRT with regard to the main secondary endpoint global HRQOL one year after randomization. The control intervention is nCRT followed by preplanned surgery and the experimental intervention is dCRT followed by surveillance and salvage esophagectomy only when needed to secure local tumor control. A target sample size of 1200 randomized patients is planned in order to reach 462 events (deaths) during follow-up. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT04460352.

16.
Obes Surg ; 31(11): 4701-4707, 2021 11.
Artículo en Inglés | MEDLINE | ID: mdl-34392476

RESUMEN

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


Asunto(s)
Derivación Gástrica , Obesidad Mórbida , Estudios de Cohortes , Gastrectomía/efectos adversos , Humanos , Obesidad Mórbida/cirugía , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/cirugía , Prevalencia , Sistema de Registros , Estudios Retrospectivos , Resultado del Tratamiento
17.
Surg Obes Relat Dis ; 16(8): 1005-1010, 2020 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-32471726

RESUMEN

BACKGROUND: Anastomotic leak at the gastrojejunostomy in Roux-en-Y gastric bypass is a rare, but serious, complication. Little has been published on leaks at other sites. OBJECTIVES: To assess incidence, risk factors, treatment, and outcome of small bowel leaks at the enteroenteral anastomosis (EA) and undiagnosed iatrogenic small bowel perforations in primary Roux-en-Y gastric bypass. SETTING: Nationwide cohort, Sweden. METHODS: All leaks within 30 days in 41,342 patients (age 40.8 [standard deviation 11.1] yr, females 68%, and body mass index 42.4 [standard deviation 5.4] kg/m2) between 2007 and 2014 in the Scandinavian Obesity Surgery Registry were assessed. Register data and outcomes were verified by reviewing patient charts. Logistic regression estimated odds ratios (OR) and 95% confidence intervals for significant risk factors. RESULTS: The incidence of small bowel leaks was .3%. Iatrogenic perforations were diagnosed earlier than EA leaks, 3.6 versus 6.5 days after surgery (P = .02). EA leaks were seen in 75 patients (.2%), with surgery at a low-volume center (<125 cases/yr, OR 2.1 [1.0-4.1]) and prolonged operative time (≥90 min, OR 3.5 [1.1-11.0]) as risk factors. The risk of iatrogenic small bowel perforations, .1%, was tripled by prolonged operative time (OR 3.4 [1.2-9.4]). Surgical reintervention was required in 97% of leaks, repairing the defect and draining the abdominal cavity in most cases. A third of the patients required intensive care, of which 5% developed multiorgan failure and 1% died. CONCLUSION: Small bowel leaks, seen in .3%, were associated to prolonged operative time, and surgery at a low-volume center for EA leaks. Surgical reintervention was common, while mortality was low.


Asunto(s)
Derivación Gástrica , Laparoscopía , Obesidad Mórbida , Adulto , Anastomosis en-Y de Roux , Fuga Anastomótica/epidemiología , Fuga Anastomótica/etiología , Fuga Anastomótica/cirugía , Estudios de Cohortes , Femenino , Derivación Gástrica/efectos adversos , Humanos , Incidencia , Obesidad Mórbida/cirugía , Sistema de Registros , Suecia/epidemiología
18.
Obes Surg ; 29(6): 1946-1953, 2019 06.
Artículo en Inglés | MEDLINE | ID: mdl-30864104

RESUMEN

To compare circular stapler (CS) with linear stapler (LS) in a meta-analysis concerning operative time, anastomotic leaks, wound infections, strictures, and length of stay. Pubmed, Medline, and Scopus were searched for articles published since 2006. Four hundred and five articles were assessed, and 13 articles of which only one was a randomized controlled trial were included in all 49,331 patients from different regions of the world. The pooled analysis shows that operative time was shorter in LS than in CS (weighted mean difference 36.2 min; 95% CI 34.7-37.6.; p < 0.0001). No difference was seen concerning leaks or strictures. The relative risk (RR) of leakage after LS was 80% of the risk after CS; however, the 95% confidence interval (CI) showed overlap (0.58-1.11). The RR of anastomotic stricture after LS was 74% of the risk after CS; however, 95% CI (0.52-1.05) showed overlap. Wound infections were less common after LS than after CS; RR was 27% (95% CI 0.21-0.33). Length of stay (LOS) was 0.65 days shorter after LS than after CS (95% CI 0.51-0.78). LS compared with CS results in shorter operative time, less wound infections, and shorter length of stay, but no difference was seen concerning risks of leaks or strictures.


Asunto(s)
Derivación Gástrica/métodos , Yeyunostomía/métodos , Obesidad Mórbida/cirugía , Grapado Quirúrgico/métodos , Fuga Anastomótica/epidemiología , Fuga Anastomótica/cirugía , Constricción Patológica/epidemiología , Constricción Patológica/cirugía , Derivación Gástrica/efectos adversos , Humanos , Yeyunostomía/efectos adversos , Laparoscopía/efectos adversos , Laparoscopía/métodos , Tiempo de Internación/estadística & datos numéricos , Obesidad Mórbida/epidemiología , Tempo Operativo , Complicaciones Posoperatorias/epidemiología , Ensayos Clínicos Controlados Aleatorios como Asunto/estadística & datos numéricos , Grapado Quirúrgico/efectos adversos
19.
Obes Surg ; 29(1): 172-177, 2019 01.
Artículo en Inglés | MEDLINE | ID: mdl-30206785

RESUMEN

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


Asunto(s)
Anastomosis Quirúrgica/efectos adversos , Anastomosis Quirúrgica/estadística & datos numéricos , Constricción Patológica/epidemiología , Derivación Gástrica/efectos adversos , Derivación Gástrica/estadística & datos numéricos , Obesidad Mórbida/epidemiología , Obesidad Mórbida/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Fuga Anastomótica/epidemiología , Fuga Anastomótica/etiología , Estudios de Cohortes , Constricción Patológica/etiología , Femenino , Derivación Gástrica/métodos , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Estudios Prospectivos , Sistema de Registros , Países Escandinavos y Nórdicos/epidemiología , Factores de Tiempo
20.
Surg Obes Relat Dis ; 15(7): 1075-1079, 2019 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-31201112

RESUMEN

BACKGROUND: Leak at the gastrojejunostomy (GJ) after Roux-en-Y gastric bypass is a rare but life-threatening complication. OBJECTIVES: To assess incidence, risk factors, treatment, and outcome of leaks at the GJ after Roux-en-Y gastric bypass in a nationwide cohort. SETTING: Sweden. METHODS: Leaks at GJ within 30 days postoperatively in 40,844 patients (age 41 yr, females 76%, and body mass index of 42.4 kg/m2) between 2007 and 2014 in the Scandinavian Obesity Surgery Registry were assessed. Register data and outcomes were verified by reviewing patient charts. Logistic regression was done to estimate odds ratios (ORs) for significant risk factors. RESULTS: Leak at the GJ was registered in 262 (.6%) patients, with 44% diagnosed within the first 3 postoperative days. Risk factors were male sex (OR 1.5 [1.1-1.9]), age ≥49 years (OR 1.9 [1.3-2.7]), diabetes (OR 1.4 [1.1-1.9]), conversion to open surgery (OR 3.9 [2.2-6.9]), and operative time ≥90 minutes (OR 2.6 [1.8-3.8]). In most patients, the leak resulted in a severe complication. Reoperative surgery was done in 85%, with the placement of a feeding gastrostomy in 24%. Stents were used at some time point in 31% of leaks. Of all patients with leaks, 25% required intensive care, 4% developed multiorgan failure, and 1% died. Median duration of stay for patients with leaks was 22 days, versus 2 days for others (P < .001). CONCLUSION: GJ leaks occurred in .6% of patients. Risk factors were male sex, age ≥49 years, diabetes, operative time ≥90 minutes, and conversion to open surgery. Surgical reintervention was common. Mortality was 1%.


Asunto(s)
Anastomosis en-Y de Roux/efectos adversos , Fuga Anastomótica/epidemiología , Fuga Anastomótica/cirugía , Derivación Gástrica/efectos adversos , Obesidad Mórbida/cirugía , Adulto , Índice de Masa Corporal , Estudios de Cohortes , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Tempo Operativo , Reoperación , Factores de Riesgo , Suecia
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