Preoperative Chemoprophylaxis is Safe in Major Oncology Operations and Effective at Preventing Venous Thromboembolism

BACKGROUND

We prospectively evaluated the safety and efficacy of adding preoperative chemoprophylaxis to our institution's operative venous thromboembolism (VTE) prophylaxis policy as part of a physician-led quality improvement initiative.

STUDY DESIGN

Patients undergoing major cancer surgery between August 2013 and January 2014 were screened according to service-specific eligibility criteria and targeted to receive preoperative VTE chemoprophylaxis. Bleeding, transfusion, and VTE rates were compared with rates of historical controls who had not received preoperative chemoprophylaxis.

RESULTS

The 2,058 eligible patients who underwent operation between August 2013 and January 2014 (post-intervention) were compared with a cohort of 4,960 patients operated on between January 2012 and June 2013, who did not receive preoperative VTE chemoprophylaxis (pre-intervention). In total, 71% of patients in the post-intervention group were screened for eligibility; 82% received preoperative anticoagulation. When compared with the pre-intervention group, the post-intervention group had significantly lower transfusion rates (pre- vs post-intervention, 17% vs 14%; difference 3.5%, 95% CI 1.7% to 5%, p = 0.0003) without significant difference in major bleeding (difference 0.3%, 95% CI -0.1% to 0.7%, p = 0.2). Rates of deep venous thrombosis (1.3% vs 0.2%; difference 1.1%, 95% CI 0.7% to 1.4%, p < 0.0001) and pulmonary embolus (1.0% vs 0.4%; difference 0.6%, 95% CI 0.2% to 1%, p = 0.017) were significantly lower in the post-intervention group.

CONCLUSIONS

In patients undergoing major cancer surgery, institution of a single dose of preoperative chemoprophylaxis, as part of a physician-led quality improvement initiative, did not increase bleeding or blood transfusions and was associated with a significant decrease in VTE rates.

Esophageal and esophagogastric junction cancers, version 1.2015

Esophageal cancer is the sixth most common cause of cancer deaths worldwide. Adenocarcinoma is more common in North America and Western European countries, originating mostly in the lower third of the esophagus, which often involves the esophagogastric junction (EGJ). Recent randomized trials have shown that the addition of preoperative chemoradiation or perioperative chemotherapy to surgery significantly improves survival in patients with resectable cancer. Targeted therapies with trastuzumab and ramucirumab have produced encouraging results in the treatment of advanced or metastatic EGJ adenocarcinomas. Multidisciplinary team management is essential for patients with esophageal and EGJ cancers. This portion of the NCCN Guidelines for Esophageal and EGJ Cancers discusses management of locally advanced adenocarcinoma of the esophagus and EGJ.

Serum VEGF-A and Tumor Vessel VEGFR-2 Levels Predict Survival in Caucasian but Not Asian Patients Undergoing Resection for Gastric Adenocarcinoma

BACKGROUND

Clinical trials of agents targeting the vascular endothelial growth factor A (VEGF-A) pathway in gastric adenocarcinoma (GA) suggest that these therapies may have varying efficacy in different races.

METHODS

VEGF-A in serum and/or VEGF receptor 2 (VEGFR-2) in CD31-positive tumor vessels (VEGFR-2/CD31) were measured in 118 Caucasians and 263 Asians who underwent gastric resection at two institutions and correlated with overall survival (OS). Blood was drawn before any treatment. Patients receiving neoadjuvant treatment were excluded from VEGFR-2 analysis.

RESULTS

Compared with Asians, Caucasians were older (mean age 66-73 vs 59-62 years), had more proximal tumors, and had more advanced TNM stage. In the VEGF-A cohort, Caucasians had a median VEGF-A level that was 95 % higher than that of Asians and a much higher standard deviation (88 ± 6.206 vs 45 ± 76 pg/ml, p < 0.001). The 5-year OS for patients with low versus high VEGF-A levels was 72 versus 43 % in Caucasians (p = 0.001) and 86 versus 77 % in Asians (p = 0.236). In the VEGFR-2 cohort, OS was worse in Caucasians with high VEGFR-2/CD31 levels (49 vs 73 %, p = 0.038), while there was no significant difference in OS in Asians (80 vs 90 %, p = 0.119). On multivariate analyses of significant prognostic factors (excluding treatment factors and margin status), serum VEGF-A and tumor VEGFR-2/CD31 levels were independent predictors of OS only in Caucasians.

CONCLUSIONS

In patients with resectable GA, VEGF-A and VEGFR-2/CD31 levels are independent predictors of OS in Caucasians but not in Asians, suggesting varying importance of this pathway in GA progression among different races.

Differences in gastric cancer survival between the U.S. and China

BACKGROUND

Previous comparisons of gastric cancer between the West and the East have focused predominantly on Japan and Korea, where early gastric cancer is prevalent, and have not included the Chinese experience, which accounts for approximately half the world's gastric cancer.

METHODS

Patient characteristics, surgical procedures, pathologic information, and survival were compared among gastric cancer patients who underwent curative intent gastrectomy at two large volume cancer centers in China and the US between 1995 and 2005.

RESULTS

Median age and body mass index were significantly higher in US patients. The proportion of proximal gastric cancer was comparable. Gastric cancer patients in China had larger tumors and a later stage at presentation. The median number of positive lymph nodes was higher (5 vs 4, P < 0.02) despite a lower lymph node retrieval (16 vs 22, P < 0.001) in Chinese patients. The probability of death due to gastric cancer in Chinese patients was 1.7 fold of that in the US (P < 0.0001) after adjusting for important prognostic factors.

CONCLUSIONS

Even after adjusting for important prognostic factors Chinese gastric cancer patients have a worse outcome than US gastric cancer patients. The differences between Chinese and US gastric cancer are a potential resource for understanding the disease.

Comparing surgical infections in National Surgical Quality Improvement Project and an Institutional Database

BACKGROUND

Surgical quality improvement requires accurate tracking and benchmarking of postoperative adverse events. We track surgical site infections (SSIs) with two systems; our in-house surgical secondary events (SSE) database and the National Surgical Quality Improvement Project (NSQIP). The SSE database, a modification of the Clavien-Dindo classification, categorizes SSIs by their anatomic site, whereas NSQIP categorizes by their level. Our aim was to directly compare these different definitions.

MATERIALS AND METHODS

NSQIP and the SSE database entries for all surgeries performed in 2011 and 2012 were compared. To match NSQIP definitions, and while blinded to NSQIP results, entries in the SSE database were categorized as either incisional (superficial or deep) or organ space infections. These categorizations were compared with NSQIP records; agreement was assessed with Cohen kappa.

RESULTS

The 5028 patients in our cohort had a 6.5% SSI in the SSE database and a 4% rate in NSQIP, with an overall agreement of 95% (kappa = 0.48, P < 0.0001). The rates of categorized infections were similarly well matched; incisional rates of 4.1% and 2.7% for the SSE database and NSQIP and organ space rates of 2.6% and 1.5%. Overall agreements were 96% (kappa = 0.36, P < 0.0001) and 98% (kappa = 0.55, P < 0.0001), respectively. Over 80% of cases recorded by the SSE database but not NSQIP did not meet NSQIP criteria.

CONCLUSIONS

The SSE database is an accurate, real-time record of postoperative SSIs. Institutional databases that capture all surgical cases can be used in conjunction with NSQIP with excellent concordance.

Morbidity after Total Gastrectomy: Analysis of 238 Patients

BACKGROUND

Surgical quality improvement requires well-defined benchmarks and accurate reporting of postoperative adverse events, which have not been well defined for total gastrectomy.

STUDY DESIGN

Detailed postoperative outcomes on 238 patients who underwent total gastrectomy with curative intent, from 2003 to 2012, were reviewed by a dedicated surgeon chart reviewer to establish 90-day patterns of adverse events.

RESULTS

Of the 238 patients with stage I to III gastric adenocarcinoma who underwent curative-intent total gastrectomy, the median age was 66 years, and 68% were male. Median body mass index was 28 kg/m(2), and 68% of patients had at least 1 medical comorbidity. Forty-three percent of our patients received neoadjuvant chemotherapy, and 34% received postoperative adjuvant chemotherapy. Over the 90-day study period, 30-day mortality was 2.5% (6 of 238), and 90-day mortality was 2.9% (7 of 238). At least 1 postoperative adverse event was documented in 62% of patients, with 28% of patients experiencing a major adverse event requiring invasive intervention. The readmission rate was 20%. Anemia was the most common adverse event (20%), followed by wound complications (18%). The most common major adverse event was esophageal anastomotic leak, which required invasive intervention in 10% of patients.

CONCLUSIONS

This analysis has defined comprehensive 90-day patterns in postoperative adverse events after total gastrectomy with curative intent in a Western population. This benchmark allows surgeons to measure, compare, and improve outcomes and informed consent for this surgical procedure.

Laparoscopic Versus Open Gastrectomy for Gastric Adenocarcinoma in the West: A Case-Control Study

INTRODUCTION

Data on laparoscopic gastrectomy in patients with gastric cancer in the Western hemisphere are lacking. This study aimed to compare outcomes following laparoscopic versus open gastrectomy for gastric adenocarcinoma at a Western center.

METHODS

Eighty-seven consecutive patients who underwent laparoscopic gastrectomy from November 2005 to April 2013 were compared with 87 patients undergoing open resection during the same time period. Patients were matched for age, stage, body mass index, and procedure (distal subtotal vs. total gastrectomy). Endpoints were short- and long-term perioperative outcomes.

RESULTS

Overall, 65 patients (37 %) had locally advanced disease, and 40 (23 %) had proximal tumors. The laparoscopic approach was associated with longer operative time (median 240 vs.165 min; p < 0.01), less blood loss (100 vs.150 mL; p < 0.01), higher rate of microscopic margin positivity (9 vs.1 %; p = 0.04), decreased duration of narcotic and epidural use (2 vs. 4 days, p = 0.04, and 3 vs. 4 days, p = 0.02, respectively), decreased minor complications in the early (27 vs. 16 %) and late (17 vs. 7 %) postoperative periods (p < 0.01), decreased length of stay (5 vs. 7 days; p = 0.01), and increased likelihood of receiving adjuvant therapy (82 vs. 51 %; p < 0.01). There was no difference in the number of lymph nodes retrieved (median 20 in both groups), major morbidity, or 30-day mortality.

CONCLUSIONS

Laparoscopic gastrectomy for gastric adenocarcinoma is safe and effective for select patients in the West.

Preoperative serum VEGF-A levels to predict survival for Caucasian and Asian patients undergoing resection for gastric adenocarcinoma

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Background: Clinical trials in gastric adenocarcinoma (GC) patients of vascular endothelial growth factor A (VEGF-A) targeted therapies have suggested these therapies may be more effective in Caucasians (CA) than in Asians (AS). Methods: Levels of VEGF-A in serum were measured in CA and AS treated at two institutions prior to potentially curative surgical resection for GC, and levels were correlated with overall survival (OS). Results: There were significant differences in CA (n=118) and AS (n=115) in terms of age (median 66 vs. 59), use of neoadjuvant (52% vs. 14%) and adjuvant therapy (27% vs. 18%), tumor location (58% upper/GE junction vs. 80% distal/middle), Lauren classification (57% vs. 46% intestinal), and TNM status (65% stage II or III vs. 55% stage I). CA had a median VEGF-A levels that was 95% higher than that of AS as well as a much higher standard deviation (88.1 + 6206 vs. 45.2 + 76.3 pg/ml, p<0.001). CA with proximal/nondiffuse tumors had significantly higher VEGF-A levels than those with distal/nondiffuse or diffuse tumors (median 120 vs. 71 and 50 pg/ml; p=0.016). The 5-year OS for CA with low vs. high VEGF-A levels was 72.4% vs. 43.4% (p=0.001). In AS, there was no significant difference in 5-year OS according to VEGF-A level (77.4%% vs.85.6%, p=0.236). On multivariate analysis, tumor size, location, grade, N stage, and serum VEGF-A level were independent predictors of OS in CA. Conclusions: In patients with resectable GC, higher circulating VEGF-A levels are independently associated with decreased OS in CA but AS, suggesting varying importance of this angiogenic factor in GC progression among different races.

Esophageal reinforcement with an extracellular scaffold during total gastrectomy for gastric cancer

BACKGROUND

Esophagojejunal (EJ) anastomotic leaks after total gastrectomy (TG) for malignancy lead to significant morbidity and mortality, thus affecting long-term survival. Preclinical and clinical trials have shown promise in utilizing degradable extracellular matrix (ECM) scaffolds in buttressing anastomoses. We describe our experience buttressing the EJ anastomosis after TG with a ECM scaffold.

METHODS

From February 2012 to January 2014, a total of 37 consecutive patients underwent TG buttressing of the EJ anastomosis with the degradable ECM scaffold composed of a porcine urinary bladder called MatriStem (ACell Inc.). The scaffold was circumferentially wrapped around the EJ anastomosis. The primary end point was the EJ leak rate, while the secondary end point was the EJ stricture rate.

RESULTS

The mean ± SD age and body mass index were 59 ± 16 years and 28.1 ± 4.9 kg/m(2), respectively. Most patients were male (51 %), white (78 %), and former smokers (51 %). Over half (59 %) underwent neoadjuvant chemotherapy. A minimally invasive TG was performed in 70 % of patients. Signet ring was the most common tumor type (48 %), and most patients had midstage disease (59 %). The mean number of lymph nodes procured was 36 ± 16. Eighteen patients (49 %) experienced a complication, mostly minor. One patient (2.7 %) developed an EJ leak, while three patients (8 %) developed an EJ stricture. Median follow-up was 7 months (range 2-12 months). There was no operative or in-hospital mortality.

DISCUSSION

The use of urinary bladder matrix scaffolds may be helpful in decreasing the incidence of EJ anastomotic leak and/or stricture. A prospective phase II trial at our institution is currently under way.

Development and assessment of Memorial Sloan Kettering Cancer Center's Surgical Secondary Events grading system

BACKGROUND

Studying surgical secondary events is an evolving effort with no current established system for database design, standard reporting, or definitions. Using the Clavien-Dindo classification as a guide, in 2001 we developed a Surgical Secondary Events database based on grade of event and required intervention to begin prospectively recording and analyzing all surgical secondary events (SSE).

METHODS

Events are prospectively entered into the database by attending surgeons, house staff, and research staff. In 2008 we performed a blinded external audit of 1,498 operations that were randomly selected to examine the quality and reliability of the data.

RESULTS

Of 4,284 operations, 1,498 were audited during the third quarter of 2008. Of these operations, 79 % (N = 1,180) did not have a secondary event while 21 % (N = 318) had an identified event; 91 % of operations (1,365) were correctly entered into the SSE database. Also 97 % (129 of 133) of missed secondary events were grades I and II. There were 3 grade III (2 %) and 1 grade IV (1 %) secondary event that were missed. There were no missed grade 5 secondary events.

CONCLUSIONS

Grade III-IV events are more accurately collected than grade I-II events. Robust and accurate secondary events data can be collected by clinicians and research staff, and these data can safely be used for quality improvement projects and research.

Extended lymphadenectomy in gastric cancer is debatable

Much debate still exists regarding the appropriate extent of lymphadenectomy for gastric adenocarcinoma. In high incidence countries in Eastern Asia, more extensive (e.g. D2) lymphadenectomies are standard, and these surgeries are generally done by experienced surgeons with low morbidity (<20 %) and mortality (<1 %). In United States and Western Europe, where the incidence of gastric adenocarcinoma is much lower, the majority of patients are treated at non-referral centers with less extensive (e.g. D1 or D0) lymphadenectomy. This symposium article first reviews early studies that led to recommendations for less extensive lymphadenectomy. Two large prospective, randomized trials performed in the United Kingdom and the Netherlands in the 1990s failed to demonstrate a survival benefit of D2 over D1 lymphadenectomy, but these trials have been criticized for inadequate surgical training and high surgical morbidity (43-46 %) and high mortality rates (10-13 %) in the D2 group. We then discuss more contemporary studies that support more extensive lymphadenectomy with a minimum of 16 lymph nodes for adequate staging. The 15-year follow-up of the Netherlands trial now demonstrates an improved disease-specific survival and locoregional recurrence in the D2 group. A prospective, randomized trial from Taiwan found a survival benefit of more extensive lymphadenectomies, and another randomized trial from Japan found adding dissection of para-aortic nodes to a D2 lymphadenectomy did not improve survival. Western surgeons have increasingly accepted the importance of performing more than a D1 node dissection, and Eastern surgeons are accepting that more than a D2 node dissection does not improve survival and increases morbidity. Thus both Eastern and Western approaches are favoring D2 lymphadenectomy as a standard, and on this topic we appear to be harmonizing.

Is gastric cancer different in Korea and the United States? Impact of tumor location on prognosis

PURPOSE

To compare the characteristics and prognoses of gastric cancers by tumor location in Korean and U.S. subjects after curative-intent (R0) resection for gastric cancer (GC).

METHODS

Data were collected for all patients who had undergone R0 resection at one U.S. institution (n = 567) and one South Korean institution (n = 1,620). Patients with gastroesophageal junction tumors or neoadjuvant therapy were excluded. Patient, surgical, and pathologic variables were compared by tumor location. Factors associated with disease-specific survival (DSS) were determined via multivariate analysis.

RESULTS

In the Korean cohort, significantly more upper third GC (UTG) patients had undifferentiated, diffuse type, and advanced stage cancers compared to lower third GC (LTG) and middle third GC (MTG) patients. In the U.S. cohort, however, T stage was relatively evenly distributed among UTG, MTG, and LTG patients. The independent predictors of DSS in the Korean cohort were T stage, tumor size, retrieved and positive lymph node counts, and age, but in the U.S. cohort, the only independent predictors were T stage and positive lymph node count. Tumor size significantly affected DSS of Korean UTG patients but not U.S. UTG patients.

CONCLUSIONS

There were significant differences in tumor characteristics by tumor location within and between both national cohorts. On the basis of these findings, further study to investigate the biological difference between the two countries is needed.

Imaging and management of a small cell lung cancer metastasis/adrenal adenoma collision tumor: a case report and review of the literature

Objective

We report a case of an adrenal collision tumor composed of a small cell lung carcinoma metastasis and a benign adrenal adenoma identified preoperatively on FDG-PET, CT and MRI and confirmed pathologically.

Methods

The patient’s history, preoperative imaging characteristics, postoperative course, and histopathology are described. A review of the literature addressing adrenal collision tumors is provided.

Results

A 47-year-old female was found to have a left upper lobe lung mass and an adrenal lesion on imaging. FDG-PET, CT and MRI of the adrenal suggested a metastatic lesion adjacent to an adrenal adenoma. CT-guided biopsy of the adrenal gland was consistent with a small cell lung cancer metastasis. The patient underwent systemic chemotherapy and had complete resolution of the left upper lobe mass. Post-treatment FDG-PET demonstrated a persistently enlarged adrenal gland with decreased but persistent FDG uptake. The patient underwent adrenalectomy and pathologic examination demonstrated a small cell lung cancer/adenoma collision tumor.

Conclusions

This case and a review of the literature demonstrate that FDG, CT and MR imaging can all characterize the separate components of collision tumors within the adrenal gland.

Evaluation of PET response to neoadjuvant therapy for patients with gastric and GEJ adenocarcinoma

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Background: The implications of response to neoadjuvant treatment as measured by PET remain poorly defined for patients with gastric and gastro-esophageal junction (GEJ) adenocarcinoma. Our aims are to determine if changes in PET avidity correlate with histologic response, and to determine the best predictor(s) of disease-free survival (DFS) and overall survival (OS). Methods: We reviewed a prospective database to identify patients with gastric and GEJ adenocarcinoma who were evaluated with PET imaging prior to andfollowing neoadjuvant treatment. Spearman correlation and Cox proportional hazards were utilized. Results: Since 2002, 216 patients of median age 63 years met our criteria. At last follow-up (median 22 months, range: 0 - 119), 118 patients recurred or died. The median DFS and OS for expired patients were 7.5 months (range: 0-62) and 14 months (range: 0 - 69), respectively. Between baseline and follow-up PET imaging (median 63 days, range: 15 - 454), 170 patients were treated with chemotherapy and 46 patients with chemoradiotherapy. The median change in SUV was 43% (range: -300 - 100.0%) and the median histologic tumor response was 50% (range: 0 - 100%). No association was identified with the use of chemoradiation (as compared to chemotherapy alone) and change in SUV (p=0.8). We identified a significant relationship between change in SUV and histologic response (r=0.32, p<0.01). Furthermore, the change in SUV was related to both DFS and OS on univariate analysis, as was tumor response and pathologic stage (Table). On multivariate analysis only pathologic stage, and specifically the presence of lymph node metastases, was related to DFS (p<0.01) or OS (p<0.01). Conclusions: Following neoadjuvant therapy for gastric and GEJ adenocarcinoma, PET response is prognostic, although pathologic nodal status is the best predictor of outcome. [Table: see text]

Stage-stratified prognosis of signet ring cell histology in patients undergoing curative resection for gastric adenocarcinoma

BACKGROUND

The prognosis of signet ring cell (SRC) gastric adenocarcinoma is regarded as poor, although studies addressing outcomes in relation to non-SRC tumors are conflicting. Our objective was to compare the survival of SRC tumors with stage-matched intestinal-type tumors in a cohort of Western patients.

METHODS

Review of a prospectively maintained database identified 569 patients undergoing curative resection (R0) from 1990 to 2009. Patients were divided into three histologic groups on the basis of the Lauren classification: SRC (n = 210), intestinal well- or moderately differentiated (WMD, n = 242) disease, and intestinal poorly differentiated (PD, n = 117) disease. Patient demographics, clinicopathologic features, and postoperative outcomes were determined. Stage-stratified disease-specific mortality was calculated and multivariate analysis performed.

RESULTS

When compared with WMD and PD tumors, SRC tumors were associated with younger age (63 years SRC vs. 71 years WMD and 72 years PD, p < 0.0001) and with female sex (58 % SRC vs. 40 % WMD and 40 % PD, p = 0.0003). Median follow-up was 115 months. Patients with stage Ia SRC lesions had a better 5-year disease-specific mortality compared with stage-matched intestinal-type tumors (0 % SRC vs. 8 % WMD and 24 % PD, p = 0.001). In contrast, SRC patients with stage III disease fared significantly worse (78 % SRC vs. 54 % WMD and 72 % PD, p = 0.001). On multivariate analysis, the risk of death from gastric cancer comparing all three groups was lowest for SRC in stage I and highest for SRC in stage III disease (stage III hazard ratio: SRC 1 vs. 0.47 WMD and 0.85 PD).

CONCLUSIONS

When compared with intestinal-type tumors, SRC tumors at early stages are not necessarily associated with poor outcomes.

Gastric cancer, version 2.2013: featured updates to the NCCN Guidelines

The NCCN Clinical Practice Guidelines in Oncology for Gastric Cancer provide evidence- and consensus-based recommendations for a multidisciplinary approach for the management of patients with gastric cancer. For patients with resectable locoregional cancer, the guidelines recommend gastrectomy with a D1+ or a modified D2 lymph node dissection (performed by experienced surgeons in high-volume centers). Postoperative chemoradiation is the preferred option after complete gastric resection for patients with T3-T4 tumors and node-positive T1-T2 tumors. Postoperative chemotherapy is included as an option after a modified D2 lymph node dissection for this group of patients. Trastuzumab with chemotherapy is recommended as first-line therapy for patients with HER2-positive advanced or metastatic cancer, confirmed by immunohistochemistry and, if needed, by fluorescence in situ hybridization for IHC 2+.

Internal hernia after gastrectomy for cancer with Roux-Y reconstruction

BACKGROUND

The incidence of internal hernia (IH) after gastrectomy for cancer with Roux-Y reconstruction has not been well-defined. This study aimed to define the true incidence of IH after gastrectomy for cancer with Roux-Y reconstruction; to describe the presentation, timing, and management of this complication; and to identify factors associated with IH.

METHODS

Clinical and follow-up information were reviewed for all patients who underwent open or laparoscopic gastrectomy with Roux-Y reconstruction for cancer at a single institution from January 2005 through April 2012.

RESULTS

A total of 298 patients underwent gastrectomy for cancer with Roux-Y reconstruction. At a median follow-up of 22.4 months, we identified 16 patients (5%) who underwent subsequent reoperation for IH. No patient who had closure of mesenteric defects developed IH. IH occurred in 1 of 99 patients after open subtotal gastrectomy (1%), 10 of 165 after open total gastrectomy (6%), 1 of 16 after laparoscopic subtotal gastrectomy (6%), and 4 of 18 after laparoscopic total gastrectomy (22%; P < .03). On univariate analysis, younger age, lower body mass index, no previous abdominal surgery, laparoscopic approach, and total gastrectomy were associated with IH. IH tended to occur early after laparoscopic gastrectomy (median, 7 months) and late after open gastrectomy (median, 24 months).

CONCLUSION

IH after gastrectomy with Roux-Y reconstruction is likely underreported. A high degree of suspicion for IH should be maintained in patients presenting with emesis or abdominal pain after gastrectomy with Roux-Y reconstruction, especially after laparoscopic or total gastrectomy. Closure of mesenteric defects after laparoscopic and total gastrectomy should be considered when technically feasible.

Surgical management of adrenal metastases

In the presence of a history of cancer, adrenal masses are commonly, but not exclusively, metastases. Depending upon the status of the patient's ongoing cancer therapy, overall tumor burden, and performance score, adrenalectomy is a viable treatment option. Herein we review the prevalence, diagnostic evaluation, and selection for surgical treatment of adrenal metastases. Additional attention is paid to recent data supporting the safety and oncologic efficacy of laparoscopic adrenalectomy.