Role of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy in the Management of Colorectal Peritoneal Metastases.

Peritoneal metastases from colon cancer are a particularly challenging disease process given the limited response to systemic chemotherapy. In patients with isolated peritoneal metastases, cytoreductive surgery with hyperthermic intraperitoneal chemotherapy offers a potential treatment option to these patients with limited peritoneal metastases as long as a complete cytoreduction is achieved. Decision about a patient's candidacy for this treatment modality should be undertaken by a multidisciplinary group at expert centers.

The Landmark Series: Appendiceal Primary Peritoneal Surface Malignancy.

Appendiceal primary peritoneal surface malignancies are rare and include a broad spectrum of pathologies ranging from indolent disease to aggressive disease. As such, the data that drive the management of appendiceal peritoneal surface malignancies is generally not based on prospective clinical trial data, but rather consists of level 1 data based on retrospective studies and high-volume institutional experiences. Complete surgical debulking typically offers the best chance for long-term survival. This review highlights the landmark articles on which management of primary appendiceal peritoneal surface malignancies are based.

The Role of Hyperthermia in the Treatment of Peritoneal Surface Malignancies.

PURPOSE OF REVIEW: Hyperthermia is used to treat peritoneal surface malignancies (PSM), particularly during hyperthermic intraperitoneal chemotherapy (HIPEC). This manuscript provides a focused update of hyperthermia in the treatment of PSM. RECENT FINDINGS: The heterogeneous response to hyperthermia in PSM can be explained by tumor and treatment conditions. PSM tumors may resist hyperthermia via metabolic and immunologic adaptation. The thermodynamics of HIPEC are complex and require computational fluid dynamics (CFD). The clinical evidence supporting the benefit of hyperthermia is largely observational. Continued research will allow clinicians to characterize and predict the individual response of PSM to hyperthermia. The application of hyperthermia in current HIPEC protocols is mostly empirical. Thus, modeling heat transfer with CFD is a necessary task if we are to achieve consistent and reproducible hyperthermia. Although observational evidence suggests a survival benefit of hyperthermia, no clinical trial has tested the individual role of hyperthermia in PSM.

Enhanced Recovery After Surgery for Noncolorectal Surgery?: A Systematic Review and Meta-analysis of Major Abdominal Surgery.

OBJECTIVE: To evaluate the impact of enhanced recovery after surgery (ERAS) protocols across noncolorectal abdominal surgical procedures. BACKGROUND: ERAS programs have been studied extensively in colorectal surgery and adopted at many centers. Several studies testing such protocols have shown promising results in improving postoperative outcomes across various surgical procedures. However, surgeons performing major abdominal procedures have been slower to adopt these ERAS protocols. METHODS: A systematic review was performed using "enhanced recovery after surgery" or "fast track" as search terms and excluded studies of colorectal procedures. Primary endpoints for the meta-analysis include length of stay (LOS) and complication rate. Secondary endpoints were time to first flatus, readmission rate, and costs. RESULTS: A total of 39 studies (6511 patients) met inclusion and exclusion criteria. Among them 14 studies were randomized trials, and the remaining 25 studies were cohort studies. Meta-analysis showed a decrease in LOS of 2.5 days (95% confidence interval, CI: 1.8-3.2, P < 0.001) and a complication rate of 0.70 (95% CI: 0.56-0.86, P = 0.001) for patient treated in ERAS programs. There was also a significant reduction in time to first flatus of 0.8 days (95% CI: 0.4-1.1, P < 0.001) and cost reduction of $5109.10 (95% CI: $4365.80-$5852.40, P < 0.001). There was no significant increase in readmission rate (OR 1.03, 95% CI: 0.84-1.26, P = 0.80) in our analysis. CONCLUSIONS: ERAS protocols decreased length of stay and cost by not increasing complications or readmission rates. This study adds to the evidence that ERAS protocols are safe to implement and are beneficial to surgical patients and the healthcare system across multiple abdominal procedures.

The first postesophagectomy chest X-ray predicts respiratory failure and the need for tracheostomy.

BACKGROUND: Esophagectomy is a major surgical procedure associated with high rates of morbidity. The purpose of this study was to determine if the immediate first postesophagectomy chest X-ray (pCXR) is associated with morbidity or mortality. METHODS: This was a single-institution analysis of patients undergoing esophagectomy, 2005-2015. A pCXR was routinely performed. A pCXR score was developed based on the number of objective abnormal findings. A statistical analysis was performed using patient/tumor variables and the pCXR score to derive adjusted odds ratios (ORs) on short-term outcomes. RESULTS: One hundred eighty-two patients had pCXRs. Scores ranged from 0 (normal) to 4 depending on the number of abnormalities, with a mean score of 1.6. The mean patient age was 60.7 y. Within the cohort, 92.9% had adenocarcinoma, 39.6% had T3/T4 tumors, and 48.4% were node positive. Open surgeries were performed in 51.6%, and 74.2% had chest anastomoses. The 30- and 90-d mortality rates were 2.2% and 3.9%, respectively. Increasing pCXR scores were associated with increased risk of prolonged intubation (OR: 1.67, 95% confidence interval [CI]: 1.21-2.36, P = 0.002) and tracheostomy (OR: 2.12, 95% CI: 1.08-4.16, P = 0.029). Multivariable analysis adjusting for age, comorbidities and performance status, histology, pathologic stage, surgical approach, and operative time confirmed a statistically significant association with the pCXR score and respiratory failure requiring tracheostomy (OR: 2.13, 95% CI: 1.03-4.39, P = 0.041). CONCLUSIONS: This is the first study to show an association between the first pCXR and respiratory failure, providing new evidence that the first pCXR has important implications for pulmonary care after esophagectomy.

Intraoperative clinical assessment and pressure measurements of sentinel lymph nodes in breast cancer.

BACKGROUND: Clinicians have long regarded firm enlarged axillary nodes as suspicious for metastasis, and this has been confirmed to represent increased pressure in sentinel lymph nodes (SLN) in vivo in breast cancer. We hypothesized that measuring intranodal pressure (INP) in the operating room would correlate with metastasis size and be more sensitive than clinical observation. METHODS: Intranodal pressure mmHg was measured in SLNs #1 and #2 (N = 134 and 32) in 122 patients with T1/2 cN0 and 6 controls (T0) (8 bilateral). Clinical "Level of Suspicion" (LOS) was: 0 = benign; 1 = slightly suspicious; 2 = obvious metastasis. Statistical analysis was performed to compare INP, LOS, and SLN metastasis size mm. RESULTS: Sentinel lymph nodes met size correlated with INP (r = 0.65; p < 0.001). INP was 22.0 ± 1.3 mmHg in 35 SLNs with metastases compared with 9.3 ± 0.7 mmHg in 132 without (p < 0.001). Six groups created by combining LOS 0, 1, and 2 with INP >17 or ≤17 mmHg showed a significant (p < 0.001) correlation with SLN histology; sensitivity and specificity for LOS = 2/INP >17 mmHg = 100 % at predicting metastases; LOS = 0/INP ≤17 mmHg most often correct at predicting negative nodes (sensitivity 50 %, specificity 92.9 %, positive predictive value 55 %, negative predictive value 90.7 %). INP was better than LOS at predicting positive nodes in eight patients where INP was >17 mmHg. INP and LOS correlated significantly (p < 0.001). CONCLUSIONS: Clinical suspicion of metastasis correlated well with INP particularly at predicting macrometastases. INP was slightly better at predicting micrometastases. Measurement of INP may be valuable adjunct when performing SLN biopsy when further axillary surgery is contemplated.

Does elective or emergent operative status influence outcomes in patients undergoing implantation of left ventricular assist devices?

BACKGROUND: Acuity models to predict survival after left ventricular assist device (LVAD) implantation do not include operative status as one of the calculated variables. The effect of elective versus emergent LVAD implantation on outcomes has not been examined. METHODS: Patients were stratified into 2 groups based on operative status (elective versus emergent). Variables were compared to determine whether there were differences in outcomes between elective versus emergent LVAD recipients RESULTS: Of the 130 patients, 59 underwent an elective procedure, whereas 71 had their LVAD implanted as an urgent/emergent operation. Patients in the urgent/emergent cohort had significantly worse preoperative hepatic and renal function and higher central venous pressures. Survival rates at 30 days, 6 months, 1 year, and 2 years were analogous for both cohorts. Patients in the emergent cohort had a higher incidence of postoperative right ventricular failure, with the requirement for short-term right ventricular support in 9.9% versus 1.7% (P = 0.054). The incidence of other LVAD-related complications, were similar in both groups. Emergency status did not predict postoperative mortality in univariate analysis. CONCLUSIONS: Although patients who underwent emergent LVAD implantations had worse preoperative renal and liver function and a higher incidence of postoperative right ventricular failure, they exhibited similar midterm survival and a similar incidence of other postoperative complications.

Pancreatic lymphoepithelial cyst with concurrent HIV infection: A case report and review of the literature.

Pancreatic lymphoepithelial cysts are rare, benign, non-neoplastic unilocular or multilocular cystic lesions. These circumscribed pancreatic lesions are filled with keratinous material grossly and exhibit distinct microscopic features. Pancreatic lymphoepithelial cysts are like the more common lymphoepithelial cysts of the parotid glands, which have been associated with the diffuse infiltrative lymphocytosis syndrome often seen in patients with HIV infection. However, pancreatic lymphoepithelial cysts are rare and their association with HIV infection has not been established. The presence of secondary changes in non-neoplastic cysts such as goblet cell metaplasia that was present in our case is an important feature to be included in the differential diagnosis and not to be interpreted as a mucinous neoplasm, particularly on fine-needle aspiration specimen microscopic evaluation that would impact further management. Here we describe the diagnosis and treatment of lymphoepithelial cysts in a patient who was on highly active antiretroviral therapy for HIV infection and we provide a brief literature review. Defining the clinical characteristics of lymphoepithelial cysts in patients with HIV and determining accurate preoperative diagnostic procedures will be critical for establishing effective surgical and medical approaches to treating these cysts, which differ substantially from other more serious pancreatic cystic lesions.

Local resection versus radical surgery for parathyroid carcinoma: A National Cancer Database analysis.

INTRODUCTION: Parathyroid carcinoma (PC) is rare and often diagnosed incidentally after local resection (LR) for other indications. Although recommended treatment has traditionally been radical surgery (RS), more recent guidelines suggest that LR alone may be adequate. We sought to further investigate outcomes of RS versus LR for localized PC. MATERIALS AND METHODS: PC patients from 2004 to 2015 with localized disease were identified from the National Cancer Database, then stratified by surgical therapy: LR or RS. Demographic and clinicopathologic data were compared. Cox proportional hazard models were constructed to estimate associations of variables with overall survival (OS). OS was estimated from time of diagnosis using Kaplan-Meier curves. RESULTS: A total of 555 patients were included (LR = 522, RS = 33). The groups were comparable aside from LR patients having higher rates of unknown nodal status (66.9% versus 39.4%; p = 0.003). By multivariable analysis, RS did not have a significant association with OS (hazard ratio (HR) = 0.43, 95% confidence interval (95%CI) = 0.10, 1.83; p = 0.255), nor did positive nodal status (HR = 0.66, 95%CI = 0.09, 5.03; p = 0.692) and unknown nodal status (HR = 1.30, 95%CI = 0.78, 2.17; p = 0.311). There was no difference in OS between the LR and RS groups, with median survival not reached by either group at 10 years (median follow-up = 60.4 months; p = 0.20). CONCLUSIONS: There was no difference in OS between LR and RS for localized PC. RS and nodal status may not impact survival as previously identified, and LR should remain a valid initial surgical approach. Future higher-powered studies are necessary to assess the effects of surgical approaches on morbidity and oncologic outcomes.

Validation of the Risk Analysis Index for Evaluating Frailty in Ambulatory Patients.

BACKGROUND: Frailty is a marker of dependency, disability, hospitalization, and mortality in community-dwelling older adults. However, existing tools for measuring frailty are too cumbersome for rapid point-of-care assessment. The Risk Analysis Index (RAI) of frailty is validated in surgical populations, but its performance outside surgical populations is unknown. OBJECTIVE: Validate the RAI in ambulatory patients. DESIGN, SETTING, AND PARTICIPANTS: Observational cohort study of outpatient surgical clinics within the University of Pittsburgh Medical Center Healthcare System between July 1, 2016, and December 31, 2016. Frailty was assessed using the RAI. Current Procedural Terminology codes following RAI assessment identified patients with and without minor office-based procedures (eg, joint injection, laryngoscopy). MAIN OUTCOMES AND MEASURES: All-cause 1-year mortality, assessed by stratified Cox proportional hazard models. RESULTS: Of 28,059 patients, 13,861 were matched to a minor, office-based procedure and 14,198 did not undergo any procedure. The mean (SD) age was 56.7 (17.2) years; women constituted 15,797 (56.3%) of the cohort. Median time (interquartile range 25th-75th percentile) to measure RAI was 30 (22-47) seconds. Mortality among the frail was two to five times that of patients with normal RAI scores. For example, the hazard ratio for frail ambulatory patients without a minor procedure was 3.69 (95% confidence interval [CI] = 2.51-5.41), corresponding to 30-, 180-, and 365-day mortality rates of 2.9%, 11.2%, and 17.4%, respectively, compared to 0.3%, 2.3%, and 4.0% among patients with normal RAI scores. Discrimination of mortality (overall, and censored at 30, 180, and 365 days) was excellent, ranging from c = 0.838 (95% CI = 0.773-0.902) for 30-day mortality after minor procedures to c = 0.909 (95% CI = 0.855-0.964) without a procedure. CONCLUSION: RAI is a valid, easily administered tool for point-of-care frailty assessment in ambulatory populations that may help clinicians and patients make better informed decisions about care choices-especially among patients considered high risk with a potentially limited life span. J Am Geriatr Soc 68:1818-1824, 2020.

Association of Preoperative Patient Frailty and Operative Stress With Postoperative Mortality.

Importance: Patients with frailty have higher risk for postoperative mortality and complications; however, most research has focused on small groups of high-risk procedures. The associations among frailty, operative stress, and mortality are poorly understood. Objective: To assess the association between frailty and mortality at varying levels of operative stress as measured by the Operative Stress Score, a novel measure created for this study. Design, Setting, and Participants: This retrospective cohort study included veterans in the Veterans Administration Surgical Quality Improvement Program from April 1, 2010, through March 31, 2014, who underwent a noncardiac surgical procedure at Veterans Health Administration Hospitals and had information available on vital status (whether the patient was alive or deceased) at 1 year postoperatively. A Delphi consensus method was used to stratify surgical procedures into 5 categories of physiologic stress. Exposures: Frailty as measured by the Risk Analysis Index and operative stress as measured by the Operative Stress Score. Main Outcomes and Measures: Postoperative mortality at 30, 90, and 180 days. Results: Of 432 828 unique patients (401 453 males [92.8%]; mean (SD) age, 61.0 [12.9] years), 36 579 (8.5%) were frail and 9113 (2.1%) were very frail. The 30-day mortality rate among patients who were frail and underwent the lowest-stress surgical procedures (eg, cystoscopy) was 1.55% (95% CI, 1.20%-1.97%) and among patients with frailty who underwent the moderate-stress surgical procedures (eg, laparoscopic cholecystectomy) was 5.13% (95% CI, 4.79%-5.48%); these rates exceeded the 1% mortality rate often used to define high-risk surgery. Among patients who were very frail, 30-day mortality rates were higher after the lowest-stress surgical procedures (10.34%; 95% CI, 7.73%-13.48%) and after the moderate-stress surgical procedures (18.74%; 95% CI, 17.72%-19.80%). For patients who were frail and very frail, mortality continued to increase at 90 and 180 days, reaching 43.00% (95% CI, 41.69%-44.32%) for very frail patients at 180 days after moderate-stress surgical procedures. Conclusions and Relevance: We developed a novel operative stress score to quantify physiologic stress for surgical procedures. Patients who were frail and very frail had high rates of postoperative mortality across all levels of the Operative Stress Score. These findings suggest that frailty screening should be applied universally because low- and moderate-stress procedures may be high risk among patients who are frail.

Pancreaticoduodenectomy and placement of operative enteral access: Better or worse?

BACKGROUND: It is unclear whether placement of operative enteral access (OEA) during pancreaticoduodenectomy (PD) correlates with decreased morbidity. METHODS: A retrospective chart review of patients undergoing PD with and without OEA placement between January 2016 and May 2018 was undertaken. Outcomes included length of stay (LOS), 30- and 90-day readmission, initiation of total parenteral nutrition (TPN), postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), and surgical site infection (SSI). RESULTS: 69 patients were evaluated; there was a trend toward decreased LOS for patients without OEA (9 vs. 7.5 days, p = 0.07). There were no significant differences in initiation of TPN (9.1% vs 19.4%, p = 0.311), POPF (21.2% vs 11.1%, p = 0.999), DGE (24.2% vs 22.2%, p = 0.999), organ/space SSI (12.1% vs 8.3%, p = 0.702). CONCLUSION: OEA placement at the time of PD is not necessarily associated with improved perioperative morbidity and outcomes, suggesting that OEA may not be necessary and should be considered on a case by case basis. SUMMARY: It is unclear whether placement of operative enteral access (OEA) during pancreaticoduodenectomy (PD) correlates with decreased morbidity. A retrospective review of patients undergoing PD with and without OEA placement between January 2016 and May 2018 was performed, demonstrating that there were no overall significant differences in postoperative complications and outcomes.

Nonoperative management after neoadjuvant therapy for rectal cancer: A single institution experience over 5 years.

BACKGROUND: Nonoperative or "watch and wait" strategies have emerged as a potential option for patients with rectal cancer that obtain a complete clinic response (cCR) after neoadjuvant therapy. We sought to evaluate our patients that experienced a cCR and their outcomes after non-operative management. METHODS: We performed a retrospective review of patients at our center with rectal cancer from 2012 to 2016. We then identified patients that had a documented "complete clinical response" of their tumors after different neoadjuvant treatments and underwent non-operative management. Patients were followed on a surveillance schedule that included physical exam, endoscopy and imaging. RESULTS: A total of 29 patients elected to undergo nonoperative management with a mean patient age of 67 years old. All patients were treated with neoadjuvant long course chemoradiotherapy. Seven patients were treated with initial induction chemotherapy followed by chemoradiation and 11 received consolidation chemotherapy. During a median follow-up of 27.6 months, there were 6 (21%) recurrences (1 = local, 1 = local and distant, 4 distant). Of the 6 total recurrences, 5 patients were candidates for salvage surgical resection. CONCLUSION: Neoadjuvant treatment strategies may facilitate durable rates of cCR. Continued responses after these treatments could possibly enable more patients to undergo nonoperative management. We believe nonoperative management can be offered to patients seeking rectal preservation, but more research is required to select the appropriate patients. For those patients experiencing recurrence, the majority of patients can be salvaged surgically.

Ablative Therapies for Locally Advanced Pancreatic Cancer.

The vast majority of patients who present with pancreatic adenocarcinoma have locally advanced or metastatic disease at the time of presentation without possibility of cure. Although in recent years there have been some new promising chemotherapy regimens that improve overall survival by a few months, the prognosis remains dismal. There is, however, a subset of patients who experience durable stable disease or partial responses after initial courses of chemotherapy with locally advanced disease. In these select patients, there remains interest in local ablative therapy with or without resection as a means for local control, palliation of symptoms, and possible improved survival. This review describes the techniques, complications, and expected benefits of several ablative techniques as a treatment modality for locally advanced pancreatic cancer.

Association of Frailty With Failure to Rescue After Low-Risk and High-Risk Inpatient Surgery.

Importance: Failure to rescue (FTR), or death after a potentially preventable complication, is a nationally endorsed, publicly reported quality measure. However, little is known about the impact of frailty on FTR, in particular after low-risk surgical procedures. Objective: To assess the association of frailty with FTR in patients undergoing inpatient surgery. Design, Setting, and Participants: This study assessed a cohort of 984 550 patients undergoing inpatient general, vascular, thoracic, cardiac, and orthopedic surgery in the National Surgical Quality Improvement Program between January 1, 2005, and December 31, 2012. Frailty was assessed using the Risk Analysis Index (RAI), and patients were stratified into 5 groups (RAI score, ≤10, 11-20, 21-30, 31-40, and >40). Procedures were categorized as low mortality risk (≤1%) or high mortality risk (>1%). The association between RAI scores, the number of postoperative complications (0, 1, 2, or 3 or more), and FTR was evaluated using hierarchical modeling. Main Outcomes and Measures: The number of postoperative complications and inpatient FTR. Results: A total of 984 550 patients were included, with a mean (SD) age of 58.2 (17.1) years; women were 549 281 (55.8%) of the cohort. For patients with RAI scores of 10 or less, major complication rates after low-risk surgery were 3.2%; rates of those with RAI scores of 11 to 20, 21 to 30, 31 to 40, and more than 40 were 8.6%, 13.5%, 23.8%, and 36.4%, respectively. After high-risk surgery, these rates were 13.5% for those with scores of 10 or less, 23.7% for those with scores of 11 to 20, 31.1% for those with scores of 21 to 30, 42.5% for those with scores of 31 to 40, and 54.4% for those with scores of more than 40. Stratifying by the number of complications, significant increases in FTR were observed across RAI categories after both low-risk and high-risk procedures. After a low-risk procedure, odds of FTR after 1 major complication for patients with RAI scores of 11 to 20 increased 5-fold over those with RAI scores of 10 or less (odds ratio [OR], 5.3; 95% CI, 3.9-7.1). Odds ratios were 8.1 (95% CI, 5.6-11.7) for patients with RAI scores of 21 to 30; 22.3 (95% CI, 13.9-35.6) for patients with scores of 31 to 40; and 43.9 (95% CI, 19-101.1) for patients with scores of more than 40. For patients undergoing a high-risk procedure, the corresponding ORs were likewise consistently elevated (RAI score 11-20: OR, 2.5; 95% CI, 2.3-2.7; vs RAI score 21-30: 5.1; 95% CI, 4.6-5.5; vs RAI score 31-40: 8.9; 95% CI, 8.1-9.9; vs RAI score >40: 18.4; 95% CI, 15.7-21.4). Conclusions and Relevance: Frailty has a dose-response association with complications and FTR, which is apparent after low-risk and high-risk inpatient surgery. Systematic assessment of frailty in preoperative patients may help refine estimates of surgical risk that could identify patients who might benefit from perioperative interventions designed to enhance physiologic reserve and potentially mitigate aspects of procedural risk, and would provide a framework for shared decision-making regarding the value of a given surgical procedure.

Novel Calculator to Estimate Overall Survival Benefit from Neoadjuvant Chemoradiation in Patients with Esophageal Adenocarcinoma.

BACKGROUND: Our group reported that patients with clinically node-negative esophageal adenocarcinoma do not derive overall survival (OS) benefit from neoadjuvant chemoradiation (nCRT) compared with clinically node-positive patients. The aim of this study was to develop a calculator that could more easily identify which patients derive OS benefit from nCRT. STUDY DESIGN: Using the National Cancer Data Base (2006 to 2012), patients with clinical status T1b to T4a, N-/+, M0 adenocarcinoma of the esophagus who underwent resection were selected. Of this cohort, 80% were randomly selected to develop and test the prediction model using Cox regression. The remaining 20% were used to internally validate the model, and performance was evaluated using receiver operating characteristic curves and area under the curves. RESULTS: A total of 8,974 patients met study criteria. Using the model testing cohort (7,179 patients), variables that were independently associated with OS in multivariable analysis were included in the model. These variables included Charlson-Deyo comorbidity score, tumor grade, clinical T and N status, and nCRT before surgery. Factors associated with increased risk of death were higher grade and higher T or N status. Receipt of nCRT was associated with improved OS. After validation, model performance showed an area under the curve of 0.630 and 0.682 for 1-year and 3-year OS, respectively. CONCLUSIONS: A novel OS calculator was developed for esophageal adenocarcinoma that reasonably predicts which patients are expected to derive OS benefit from nCRT. This tool can be helpful in determining OS benefit from nCRT to assist with treatment decision making.

Laparoscopic Intragastric Surgery With Endoscopic Assistance: A 2 Gastrostomy Approach With Multiple Applications.

PURPOSE: Laparoscopic intragastric resection is a surgical modality with acceptable oncologic outcomes for gastrointestinal stromal tumors and leiomyomas, particularly for masses located near the gastroesophageal junction (GEJ). We describe our technique of 2 gastrostomy laparoscopic, intragastric resection with endoscopic assistance. METHODS: We detail our technique and report a unique application of this versatile approach. RESULTS: Between December 2015 and July 2016, 4 patients underwent our combined technique of intragastric surgery. Complete resection was performed in the 2 patients who had gastrointestinal stromal tumors and 1 patient with a leiomyoma without complications. One patient had the unique diagnosis of gastritis cystica profunda. This mass could not be resected, but an effective Tru-cut core needle biopsy was obtained, and the mass was able to be diagnosed and decompressed. CONCLUSIONS: Our technique of 2 gastrostomy laparoscopic intragastric surgery is feasible and offers an effective oncologic approach for resection of tumors near the GEJ.

Pathogenesis, prevention, diagnosis and treatment of breast cancer.

Breast cancer is the most common cancer affecting women worldwide. Prediction models stratify a woman's risk for developing cancer and can guide screening recommendations based on the presence of known and quantifiable hormonal, environmental, personal, or genetic risk factors. Mammography remains the mainstay breast cancer screening and detection but magnetic resonance imaging and ultrasound have become useful diagnostic adjuncts in select patient populations. The management of breast cancer has seen much refinement with increased specialization and collaboration with multidisciplinary teams that include surgeons, oncologists, radiation oncologists, nurses, geneticist, reconstructive surgeons and patients. Evidence supports a less invasive surgical approach to the staging and management of the axilla in select patients. In the era of patient/tumor specific management, the advent of molecular and genomic profiling is a paradigm shift in the treatment of a biologically heterogenous disease.