Ahmer Irfan, MD

All Publications

• NET guidelines for white patients may not fit Asian patients. American journal of surgery Irfan, A., McElroy, K. E., Zheng-Pywell, R., Gillis, A., Reddy, S., Yates, C., Chen, H., Rose, J. B. 2025; 240: 116116

  Abstract

  Pancreatic neuroendocrine tumors (pNETs) are slow growing, malignant tumors that show different survival outcomes by race. Current size-based guidelines were largely developed in White patients. Our aim was to investigate tumor size and incidence of lymph node metastasis (LNM) between White and Asian pNET patients to evaluate generalizability of established guidelines.Using the National Cancer Database (NCDB), we conducted a multi-institutional analysis of patients with low grade, resected, nonfunctional, sporadic, non-metastatic pNETs. Chi-squared tests were implemented to determine correlation between PTS and LMN incidence as well as race and LMN incidence. A logistic regression model was utilized to determine correlation between LMN, tumor size, and race. Overall survival was assessed using the Kaplan-Meier method.A total of 4977 pNET patients (205 Asian and 4772 White) were included in our analysis. Asian patients presented with smaller tumors (3.0 ​cm vs 3.9 ​cm, p ​= ​0.029) but when grouped by size, there was no difference in the distribution (p ​= ​0.77). White patients demonstrated a higher incidence of lymph node metastasis at presentation compared to Asian patients (27 ​% vs 19 ​%, p ​= ​0.013), a higher likelihood of an R0 resection (95.3 ​% vs. 89.3 ​%, p ​< ​0.0001). Within both populations, tumor size (<2 ​cm, 2-3 ​cm, and ≥3 ​cm) positively correlated with incidence of LNM (11.5 ​%, 24.6 ​%, and 39.1 ​%). No difference of LNM was seen between racial cohorts at PTS <3 ​cm, however, Asian patients were less likely to exhibit LNM at PTS ≥3 ​cm (28.2 ​% and 39.5 ​%, p ​= ​0.04). Overall survival was not significantly different between racial groups (p ​= ​0.92).Size based surgical resection guidelines for pancreatic neuroendocrine tumors based on a predominantly White patient population may not be generalizable to the Asian population. Within this population, we found the risk of lymph node metastasis did not increase at similar rates with increasing primary tumor size.

  View details for DOI 10.1016/j.amjsurg.2024.116116

  View details for PubMedID 39642797

  View details for PubMedCentralID PMC11745910

• Development and Assessment of a Deceased Donor Organ Recovery Workshop for Surgical Fellows. Journal of surgical education Balaji, S., Patel, P., Muaddi, H., Coe, T. M., Ahmer, I., Gaebe, K., Luzzi, C. A., Kay, A., Rukavina, N., Selzner, M., Reichman, T. W., Shwaartz, C. 2024; 81 (12): 103273

  Abstract

  To assess the impact of a deceased donor organ procurement training workshop on the transplant fellow's confidence and proficiency in organ recovery. This pilot workshop was designed to address the current gap in the transplant fellow's training in North America.Participants' confidence and competence in deceased donor organ recovery were assessed pre- and postworkshop (immediate, 1- and 6-month) using a survey questionnaire. Participants' responses were compared using T-test and Wilcoxon tests before and after the workshop.The hepatopancreatobiliary-transplant fellows from the University of Toronto participated in the workshop.Seven fellows participated, with 57% reported very limited exposure to deceased donor operations in the past year. Fellows' confidence improved significantly immediately postworkshop (69% vs. 85%, p = <0.05), persisting at 1 month (86%, p = <0.05) and 6 months (91%, p = <0.05). Competence scores also demonstrated improvement postworkshop (88% vs. 78%, p = 0.3), remaining constant at 1 month (88%, p = 0.18), and further increasing at 6 months (92%, p = 0.19).This pilot study represents a notable step as the first workshop tailored for transplant fellows in Canada, demonstrating sustained improvement in both confidence and competence for deceased donor organ procurements. The study is limited by results from a single center and small sample size, impacting the generalizability of findings. However, the workshop addresses variability in transplant fellows' exposure and confidence levels, emphasizing the importance of structured training in organ procurement to enhance skills and readiness for real-time procedures.

  View details for DOI 10.1016/j.jsurg.2024.08.023

  View details for PubMedID 39366332

• Single-incision versus conventional multi-incision laparoscopic appendicectomy for suspected uncomplicated appendicitis. The Cochrane database of systematic reviews Irfan, A., Rao, A., Ahmed, I. 2024; 11 (11): CD009022

  Abstract

  Appendicectomy is a well-established surgical procedure to manage acute appendicitis. The operation was historically performed as an open procedure and is currently performed using minimally invasive surgical techniques. A recent development in appendicectomy technique is the introduction of single-incision laparoscopic surgery. This incorporates all working ports (either one multi-luminal port or multiple mono-luminal ports) through a single skin incision; the procedure is known as single-incision laparoscopic appendicectomy or SILA. Unanswered questions remain regarding the efficacy of this novel technique, including its effects on patient benefit and satisfaction, complications, and long-term outcomes, when compared to multi-incision conventional laparoscopy (CLA). This is an update of a review published in 2011.To assess the effects of single-incision laparoscopic appendicectomy compared with multi-incision laparoscopic appendicectomy, on benefits, complications, and short-term outcomes, in patients with acute appendicitis.We searched the Cochrane Central Register of Controlled trials (CENTRAL, the Cochrane Library 2018 Issue 2), Ovid MEDLINE (1983 to January 2024), Ovid Embase (1983 to January 2024), the WHO International Clinical Trial Register (January 2024), and Clinicaltrials.gov (January 2024). We also searched reference lists of relevant articles and reviews, conference proceedings, and ongoing trial databases. The searches were carried out on 20 January 2024.We included randomised controlled trials (RCTs) that compared the single-incision procedure SILA against CLA for patients (male and female) over the age of 10 years, diagnosed with appendicitis, or symptoms of appendicitis, and undergoing laparoscopic appendicectomy.Two review authors independently selected studies for inclusion, extracted data into a standardised form, and assessed the risk of bias in the studies. We extracted data relevant to the predetermined outcome measures. Where appropriate, we calculated a summary statistic: odds ratio (OR) with 95% confidence intervals (CIs) for dichotomous data and mean difference (MD) with 95% CI for continuous data. We used Review Manager Web for our statistical analysis.This review was first published in 2011, when there was no RCT evidence available. For this update, we identified 11 RCTs involving 1373 participants (689 in the SILA groups and 684 in the CLA groups). The participants were similar at baseline in terms of age (mean 31.7 (SILA) versus 30.9 years (CLA)) and sex (female: 53.0% (SILA) versus 50.3% (CLA)). Diagnosis of appendicitis was based on clinical assessment; none of the studies used a diagnosis confirmed by imaging as part of their inclusion criteria. The certainty of the evidence was low to moderate, and the outcomes were predominately reported in the short term. Pain scores at 24 hours after surgery may be similar between the SILA and CLA groups (mean score SILA 2.53 versus CLA 2.65; mean difference (MD) in pain score -0.12, 95% CI -0.52 to 0.28; 294 participants, 4 RCTs; low-certainty evidence). SILA probably had superior cosmetic results as indicated by patients using the Body Image questionnaire (5 to 20) (mean score SILA 14.9 versus CLA 12.4; cosmesis score MD 1.97, 95% CI 1.60 to 2.33; 266 participants, 3 RCTs; moderate-certainty evidence). The rate of visceral and vascular injury was probably similar with both techniques (SILA 0/168 versus 4/169; OR 0.20, 95% CI 0.02 to 1.79; 337 participants, 3 RCTs; moderate-certainty evidence). The conversion rate to CLA or open surgery may be higher for SILA procedures than the conversion rate from CLA to open surgery (SILA 32/574 versus CLA 7/569; OR 2.95, 95% CI 1.36 to 6.42; 1143 participants, 9 RCTs; low-certainty evidence). Use of an additional port site was probably more likely with SILA compared to CLA (SILA 28/328 versus CLA 4/336; OR 3.80, 95% CI 1.13 to 12.72; 664 participants, 5 RCTs; moderate-certainty evidence). The recovery time was probably similar for both interventions for hospital stay (mean length of stay in hospital for SILA 2.25 days versus 2.29 days for CLA patients; MD -0.13, 95% CI -0.23 to 0.03; 1241 participants, 10 RCTs; moderate-certainty evidence) and time to return to normal activities (SILA 9.28 days versus CLA 10.0 days; MD -0.59, 95% CI -1.99 to 0.81; 451 participants, 4 RCTs; moderate-certainty evidence). We have low-to-moderate confidence in our findings due to differences in the measurement of certain outcomes, and lack of blinding in the studies, which makes them prone to performance bias.There is low-to-moderate certainty evidence that single-incision laparoscopic appendicectomy is comparable to conventional laparoscopic appendicectomy in terms of complications, length of hospital stay, return to normal activities, and postoperative pain in the first 24 hours. The disadvantage of SILA may be a higher conversion rate, but SILA is probably associated with better patient cosmetic satisfaction.

  View details for DOI 10.1002/14651858.CD009022.pub3

  View details for PubMedID 39498756

  View details for PubMedCentralID PMC11536430

• An Analysis on the Effect of Income Changes in the Resection of Early-Stage Pancreatic Adenocarcinoma. The American surgeon Irfan, A., Rose, J. B., Dudeja, V., Chu, D. I., Reddy, S. 2024; 90 (11): 2885-2891

  Abstract

  The impact of socioeconomic inequalities on cancer care and outcomes has been well recognized and the underlying causes are likely multifactorial. Income is regarded as a cornerstone of socioeconomic status and has been assumed to correlate with access to care. We therefore sought to investigate whether income and changes in income would affect the rate of patients undergoing surgical resection for early-stage pancreatic cancer.Inflation-adjusted income data were obtained from the United States Census Bureau from 2010 to 2019. The cancer data were obtained from the SEER database. Counties present in both data sets were included in the analysis. Patients with stage I or II pancreatic cancer who underwent formal resection were deemed to have undergone appropriate surgical management. Patients were grouped into an early (2010-2014) and late (2015-2019) time period.The final analysis included 23968 patients from 173 counties across 11 states. The resection rate was 45.1% for the entire study and rose from 42.8% to 47.4% from the early to late time periods (P < .001). The median change in income between the two time periods was an increase by $2387. The rate of resection was not dependent on income class or income change in our study population.Our surgical care of pancreatic cancer is improving with more patients undergoing resection. In addition, there are now fewer disparities between patients of lower-income and higher-income groups with respect to receiving surgical intervention. This implies that our access to care has improved over the past decade. This is an encouraging finding with regards to reducing health care disparities.

  View details for DOI 10.1177/00031348241256058

  View details for PubMedID 38819076

• Can screen-time help? An analysis of usage of patient engagement technology following colorectal surgery. American journal of surgery Irfan, A., Smith, B., Wood, L., Hollis, R. H., Wallace, E., Rubyan, M., Reddy, S., Chu, D. I. 2024; 233: 78-83

  Abstract

  Patient engagement technologies (PETs) guide patients through the perioperative period. We aimed to investigate the levels of patient engagement with PETs through the peri-operative period and its impact on clinical outcomes.Retrospective cohort study of patients undergoing elective colorectal surgery from 2018 to 2022. Outcomes were length of stay, readmissions, and complications within 30 days of index hospitalization.359 (89.1%) patients activated the PET. Patients completed a median of 7 surveys, 2 in-hospital health-checks, and 1 post-discharge health-check. Median LOS was 3 days, 57 (14.1%) patients were readmitted, and 56 (13.9%) had a complication. Patients who completed no surveys had longer LOS than those who completed 2 or more. Patients who were readmitted and had post-operative complications completed significantly fewer surveys and post-discharge health-checks. Completion of surveys in more phases was associated with shorter LOS and lower readmission rates. Completion of more post-discharge health-checks was associated with lower complication rate.The use of PETs improves patient outcomes and experiences in the perioperative period. Patients who engage more frequently with PETs have shorter LOS with lower readmission and post-operative complication rates.

  View details for DOI 10.1016/j.amjsurg.2024.02.015

  View details for PubMedID 38383163

• Is it resectable? A survey regarding tumor classification and vascular involvement. HPB : the official journal of the International Hepato Pancreato Biliary Association Irfan, A., Feng, W., Dudeja, V., Reddy, S., Rose, J. B. 2024; 26 (5): 711-716

  Abstract

  The anatomic location of the pancreas can result in involvement of major vasculature, which may act as a contraindication to resection. Several classification systems have been developed. We sought to discover the variations in the HPB community determining PDAC resectability.The multiple-choice survey was distributed to all full members of the IHPBA. Questions were asked regarding demographics and clinical scenarios regarding tumor resectability.164 responses were submitted. Most of the respondents were male and had been in practice for over 10 years. The median age range was 40-50 years old. Most practiced in either Asia (n = 57,35.9%), North America (n = 52,32.7%), or Europe (n = 32,20.1%). Classification systems used to determine resectability were: NCCN (n = 42,26.3%), JPS (n = 35,21.9%), International consensus (n = 33,20.6%), AHPBA/SSO (n = 23,14.4%), Alliance (n = 3,1.9%), and other/no-classification (n = 23,14.5%). There was significant variation in the frequency of the most common answer within the scenarios (84.7%-33.5%). Participant concordance with their stated classification system found a median rate of 62.5%. Participant decision of tumor resectability was not dependent on their adopted classification system.When classifying PDAC resectability, there is significant variation between surgeons as to how they would classify a specific tumour, independent of the classification system they use. In addition, surgeons do not show high concordance with the definitions within that classification system.

  View details for DOI 10.1016/j.hpb.2024.02.013

  View details for PubMedID 38431512

• What would you do? A survey of HPB surgeons practice patterns. HPB : the official journal of the International Hepato Pancreato Biliary Association Irfan, A., Feng, W., McElroy, K., Dudeja, V., Reddy, S., Rose, J. B. 2024; 26 (3): 436-443

  Abstract

  The surgical decision making for pancreatic adenocarcinoma is complex. Although practice guidelines exist for many scenarios, these do not cover many common eventualities that may be encountered during these cases. We sought to identify the practice pattern variations amongst pancreatic surgeons in response to commonly experienced clinical scenarios.A multiple-choice questionnaire was distributed to all full members of the IHPBA. Participant demographics, training history, and clinical practice information were obtained. The survey provided various operative scenarios and participants were asked how they would likely proceed. Responses were collected and stored anonymously in a secure database. Statistical analysis was performed using Stata 16.0.164 responses were submitted. Most of the respondents were male and had been in practice for over 10 years. The median age range was 40-50 years old. When asked about staging laparoscopy, the majority performed it selectively. For most respondents a pathological aorto-caval nodes was a reason to abort the procedure but most would have continued in the setting of a positive hepatic artery node. When encountering a single Segment 2 liver metastasis, participants who practiced in Europe were significantly more likely to resect and proceed compared to those in Asia and North America. Participants who had undergone only a Surgical Oncology fellowship were most likely to abort. With respect to direct colonic invasion, most participants would resect the specimen en bloc. Respondents who participated in fewer that 20 PDAC operations/year were most likely to abort.Surgical decision making in PDAC surgery is complex and there is significant disagreement on the correct management. While formal guidelines cannot exist for all situations, this survey highlights the need for consensus on commonly encountered operative scenarios.

  View details for DOI 10.1016/j.hpb.2023.12.003

  View details for PubMedID 38143165

• Resection Versus Observation for Small (≤2 cm) Pancreatic Neuroendocrine Tumors. The American surgeon Irfan, A., Gleason, F., Reddy, S., Heslin, M. J., Rose, J. B. 2023; 89 (11): 4675-4680

  Abstract

  We hypothesized that those patients with pancreatic neuroendocrine tumors (pNETs) ≤2 cm managed nonoperatively would have comparable disease progression to individuals undergoing an operation.Patients diagnosed with nonfunctional pNETs ≤ 2 cm who were evaluated at a single comprehensive cancer center from 2010 to 2017 were selected from a cancer registry database. Clinicopathologic variables were obtained via retrospective chart review. Primary outcomes were overall and disease specific survival. Variables were compared between the 2 groups using chi-square and independent t-test.Fifty-two individuals had tumors ≤2 cm, of whom 75% had an operation, while 25% were observed. Each treatment arm had similar distributions of gender, race, and tumor location. The most common operation was distal pancreatectomy (n = 29) followed by pancreatoduodenectomy (n = 6). Nine patients had grade III postoperative complications and 4 had grade IV under Clavien-Dindo classification. The observation group was noted to have a mean disease progression interval of 80.9 months, while those who underwent an operation had a mean disease progression interval of 94.6 months (P = .246).Overall disease progression in patients with pNETs ≤ 2 cm without evidence of metastasis at the time of presentation is not different between those who underwent operation compared to those observed.

  View details for DOI 10.1177/00031348221129501

  View details for PubMedID 36134675

• Towards identifying a learning curve for robotic abdominal wall reconstruction: a cumulative sum analysis. Hernia : the journal of hernias and abdominal wall surgery Irfan, A., Cochrun, S., He, K., Okorji, L., Parmar, A. D. 2023; 27 (3): 671-676

  Abstract

  Over the past decade, an increase has been seen in robotics used for hernia repair, specifically robotic abdominal wall reconstruction (rAWR). However, the learning curve for rAWR can be steep and presently, little is understood regarding the optimal case volume required to achieve proficiency. The aim of our study was to review skill acquisition and describe the learning curve for rAWR.A retrospective, single-surgeon case series of consecutive patients who underwent rAWR from 2018 to 2022. The primary outcome was operative time, obtained from console time identified through the MyIntutive application. A one-sided cumulative sum analysis (CUSUM) curve for the total operative time was derived based on the mean operative time of chronological procedures (207 min).185 patients underwent rAWR between 2018 and 2022. These patients were more likely to be female, Caucasian, and have undergone two previous hernia repairs. ASA complexity increased over time with ASA 3 being predominant from 2020 onwards. The median hernia length was 15.0 cm and the median width was 7 cm. Average operative time was 207.8 min and decreased over time. The CUSUM analysis identified four phases of skill acquisition with the following case volumes: Initial Learning Curve (0-20), Stabilization Phase (21-55), Second Learning Curve (56-70), 4) Skill Proficiency (> 70).In the early learning curve of rAWR, operative time decreased consistently after 70 cases, with an initial inflection after 20 cases. We identified varying stages of skill acquisition that are likely typical of a surgeon as they would progress through the learning curve of advanced robotic surgery. Future studies are needed to confirm the optimal case volume for determining the skill level for the performance of rAWR.

  View details for DOI 10.1007/s10029-023-02794-z

  View details for PubMedID 37160504

  View details for PubMedCentralID 6991252

• Understanding risk factors and microbial trends implicated in the development of Whipple-related surgical-site infections. Antimicrobial stewardship & healthcare epidemiology : ASHE Feng, W., Irfan, A., Fleece, M., Dudeja, V., Reddy, S., Hashmi, S., Rose, J. B., Lee, R. A. 2023; 3 (1): e36

  Abstract

  The purpose of this study is to understand the role of risk factors and postoperative complications seen in patients undergoing Whipple procedures in the development of surgical site infections. Our secondary goal was to evaluate whether microbial patterns differed between preoperative antibiotic classes, offering insight into the effectiveness of current practices while promoting antibiotic stewardship.We performed a retrospective cohort study comparing patients with and without SSIs.This study was conducted at a tertiary-care center in the southeastern United States.Patients who underwent a Whipple procedure between 2012 and 2021 were acquired from the National Surgical Quality Improvement Program (NSQIP) database.Patients with a bleeding disorder reported higher SSI rates (P = .04), whereas patients with a biliary stent reported lower surgical site infection (SSI) rates (P = .02) Those with postoperative complications had higher SSI rates, including delayed gastric emptying (P < .001) and pancreatic fistula (P < .001). Patients with longer operative times were 1.002 times more likely to develop SSIs (adjusted odds ratio [aOR], 1.002; 95% confidence interval [CI], 1.001-1.004; P = .006) whereas surgical indications for malignancy correlated with decreased SSIs risk (aOR, 0.578; 95% CI, 0.386-866) when adjusting for body mass index, surgical indication, and duration of surgical procedure.Optimizing preoperative management of modifiable risk factors for patients undergoing pancreatoduodenectomies and decreasing operative times may reduce SSI rates and patient and hospital burden. Further research is needed to understand whether stent placement reduces SSI risk in pancreatoduodenectomy.

  View details for DOI 10.1017/ash.2022.377

  View details for PubMedID 36960091

  View details for PubMedCentralID PMC10028940

• Proximal vs. Total Gastrectomy: Is There a Difference in Quality of Life for Patients? The American surgeon Irfan, A., Yang, T., Bowring, M., Blair, A. B., Duncan, M. 2023; 89 (3): 401-406

  Abstract

  Proximal gastrectomy (PG) has been excluded from the arsenal of western surgical oncologists for fear of bile reflux and diet intolerance. However, it is often an appropriate, less morbid operation for patients requiring resection of a proximal gastric cancer.Between 2013 and 2017, we performed 19 PG and 37 total gastrectomies (TGs), of whom 15 and 25 were alive at the time of data collection. In this single-center series, we present findings of a 10-question interview of patients who underwent proximal (n = 8) or TG (n = 16) regarding postgastrectomy food-related symptoms, based on a modified version of the validated Postgastrectomy Syndrome Assessment Scale.Out of 7 Likert scale questions, there were no statistically significant differences between the groups regarding bile reflux, early satiety, appetite, energy level, physical activity limitations, pain, or general dissatisfaction with their surgery. Patients from both groups reported eating similar amounts of their preoperative volume per meal and overall food volume for the day. Both groups reported eating a similar number of snacks and meals throughout the day. Food satisfaction scores, calculated by summation of the Likert scores, were not different.Although limited by the small population, we did not find a clinically relevant difference in food-related symptoms comparing PG and TG patients. This pilot study suggests that PG is an appropriate alternative to TG in certain populations. Anecdotal beliefs regarding potential bile reflux or diet intolerance should be reconsidered.

  View details for DOI 10.1177/00031348211029850

  View details for PubMedID 35448929

• Demographic Factors Predict Decreased Technological Knowledge in Patients with Cancer Biomedical Journal of Scientific & Technical Research Irfan, A., Lever, J. P., Fouad, M., Sleckman, B. P., Liang, M. I., Chu, D. I., Rose, J. B., Wang, T. N., Reddy, S. 2023
• The evolution of peri-operative care in the safe management of pheochromocytoma. Surgery in practice and science Irfan, A., George, J., Obiarinze, R., Porterfield, J., Barker, A., Chen, H., Lindeman, B., Fazendin, J., Reddy, S. 2022; 11: 100142

  Abstract

  The use of pre- and intra-operative vasoactive agents for improved blood pressure control has transformed the outcomes following pheochromocytoma (PC) resection. The first agent utilized was phenoxybenzamine, but selective alpha-1 antagonists (SAA) and calcium channel antagonists (CCA) have also been used with success. We sought to define the relationship between pre-operative treatment and intra-operative hemodynamics associated with each of these agents in patients with PC.A retrospective, single-institution review of patients >18 years with resected PC from 1996-2020 was performed. Pre-operative blockade was at the discretion of the treating providers. Adequacy of pre-operative blockade was determined by the attending surgeon prior to proceeding with PC resection. To determine the effectiveness of pre-operative blockade during surgery, vital signs throughout the operation were examined.The final dataset included 166 patients. Phenoxybenzamine (55%) and SAA (24%) were the most commonly used pre-operative medications but phenoxybenzamine use decreased over time. Patients who experienced a hypertensive crisis had a higher initial systolic blood pressure and were older. There was no predilection for developing a hypertensive crisis based on race, sex, tumor size or type of pre-operative medication used. Patients in the early group (2010-2015) were found to have more pronounced hemodynamic instability when compared to patients in the late group (2016-2020).Although there are no demonstrated differences between antihypertensives, the prescription pattern has evolved away from phenoxybenzamine. However, as this is transition happening, patients exhibit better hemodynamic control. We hypothesize that this is due to greater experience by the intra-operative team.

  View details for DOI 10.1016/j.sipas.2022.100142

  View details for PubMedID 39845156

  View details for PubMedCentralID PMC11749965

• Inflammatory myofibroblastic tumor: A multi-institutional study from the Pediatric Surgical Oncology Research Collaborative. International journal of cancer Rich, B. S., Fishbein, J., Lautz, T., Rubalcava, N. S., Kartal, T., Newman, E., Wok, P. E., Romao, R. L., Whitlock, R., Naik-Mathuria, B., Polites, S. F., Løfberg, K., Lascano, D., Kim, E., Davidson, J., Bütter, A., Kastenberg, Z. J., Short, S. S., Meyers, R. L., Mastropolo, R., Malek, M. M., Weller, J., Irfan, A., Rhee, D. S., Utria, A. F., Rothstein, D. H., Riehle, K., Commander, S. J., Tracy, E., Becktell, K., Hallis, B., Lal, D., Li, O., Dal-Soglio, D. B., Piché, N., Quevedo, O. G., Murphy, A. J., Davidoff, A. M., Barber, J. C., Watters, E., Dasgupta, R., Glick, R. D. 2022; 151 (7): 1059-1067

  Abstract

  Inflammatory myofibroblastic tumor (IMT) is a mesenchymal neoplasm of intermediate malignancy. We describe the largest cohort of IMT patients to date, aiming to further characterize this rare, poorly understood tumor. This is a multi-institutional review of IMT patients ≤39 years, from 2000 to 2018, at 18 hospitals in the Pediatric Surgical Oncology Research Collaborative. One hundred and eighty-two patients were identified with median age of 11 years. Thirty-three percent of tumors were thoracic in origin. Presenting signs/symptoms included pain (29%), respiratory symptoms (25%) and constitutional symptoms (20%). Median tumor size was 3.9 cm. Anaplastic lymphoma kinase (ALK) overexpression was identified in 53% of patients. Seven percent of patients had distant disease at diagnosis. Ninety-one percent of patients underwent resection: 14% received neoadjuvant treatment and 22% adjuvant treatment. Twelve percent of patients received an ALK inhibitor. Sixty-six percent of surgical patients had complete resection, with 20% positive microscopic margins and 14% gross residual disease. Approximately 40% had en bloc resection of involved organs. Median follow-up time was 36 months. Overall 5-year survival was 95% and 5-year event-free survival was 80%. Predictors of recurrence included respiratory symptoms, tumor size and distant disease. Gross or microscopic margins were not associated with recurrence, suggesting that aggressive attempts at resection may not be warranted.

  View details for DOI 10.1002/ijc.34132

  View details for PubMedID 35604778

• Does race affect the long-term survival benefit of systemic therapy in pancreatic adenocarcinoma? American journal of surgery Irfan, A., Fang, H. A., Awad, S., Alkashah, A., Vickers, S. M., Gbolahan, O., Williams, G. R., Nien-Tsu Wang, T., Dudeja, V., Rose, J. B., Reddy, S. 2022; 224 (3): 955-958

  Abstract

  Systemic therapy is a key management component of pancreatic ductal adenocarcinoma(PDAC). Racial disparities exist in PDAC, often linked to socioeconomic variables. We investigated the impact of race in PDAC patients who had undergone systemic therapy and surgical resection.A retrospective analysis was performed for all patients who underwent surgical resection for PDAC from 2010 to 2018.234 patients (78.2% White; 21.8% Black) were included. Black patients presented at a younger age with larger tumors. White patients benefited from systemic therapy with longer overall survival (35vs20 months, p = 0.002). This survival advantage was not present in Black patients (21vs15 months, p = 0.15). Black patients receiving systemic therapy had similar survival as White patients who did not (p = 0.81).Black PDAC patients present at younger ages and with larger initial tumors. In our population, White patients had a longer overall survival after both surgical and systemic therapy. These findings may indicate differences in tumor biology. Further prospective studies are needed.

  View details for DOI 10.1016/j.amjsurg.2022.04.004

  View details for PubMedID 35430088

• Effect of implementing an enhanced recovery protocol for pediatric colorectal surgery on complication rate, length of stay, and opioid use in children. Journal of pediatric surgery George, J. A., Salazar, A. J., Irfan, A., Prichett, L., Nasr, I. W., Garcia, A. V., Boss, E. F., Jelin, E. B. 2022; 57 (7): 1349-1353

  Abstract

  Introduction In the past two decades, Enhanced Recovery After Surgery (ERAS) pathways for adults have improved efficiency of care and decreased length of stay (LOS) without increasing postoperative complications. The effects of enhanced recovery pathways for children are less well known. In this retrospective cohort study, we evaluated the effects of an enhanced recovery protocol (ERP) implementation in children undergoing colorectal surgery. Methods We introduced a colorectal ERP in 2017. Children and young adults (ages 2-22 years) were divided into pre-intervention (2014-2016) and post-intervention groups (2017-2019) for analysis. We abstracted data, including demographics, primary surgery, LOS, postoperative pain scores, and postoperative complications. Results A total of 432 patients were included. Of those,148 (34%) were pre-ERP implementation and 284 (66%) were post-ERP implementation. Post-ERP patients experienced significantly shorter LOS (5.7 vs. 8.3 days, p<0.01); required less intraoperative local anesthetic (9.5% vs. 38.5%, p<0.01) because 55% of patients received an epidural and 18% received an abdominal plane block; and used less postoperative opioid (62.5% vs. 98.7%, p<0.01) than did pre-ERAS patients. After protocol implementation, average pain scores were lower on postoperative day 1 (3.6 vs. 4.5, p<0.05) and across the hospitalization (3.0 vs. 4.0, p<0.01). Conclusion Enhanced recovery pathways decrease LOS, opioid use, and postoperative pain scores for children undergoing colorectal surgery and should be considered for this patient population.

  View details for DOI 10.1016/j.jpedsurg.2022.01.004

  View details for PubMedID 35153077

• Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study LANCET GLOBAL HEALTH Knight, S. R., Chu, K., Lapitan, M., Dare, A. J., Pius, R., Shaw, C. A., Drake, T. M., Norman, L., Ademuyiwa, A. O., Adisa, A. O., Aguilera, M., Al-Saqqa, S. W., Al-Slaibi, I., Bhangu, A., Biccard, B. M., Brocklehurst, P., Costas-Chavarri, A., Elhadi, M., Fairfield, C. J., Fitzgerald, J., Ghosh, D., Glasbey, J., Henegouwen, M., Ingabire, J., Kingham, T., Lawani, I., Lieske, B., Lilford, R., Martin, J., Mclean, K. A., Moore, R., Morton, D., Nepogodiev, D., Ntirenganya, F., Pata, F., Pinkney, T., Qureshi, A., Ramos-De la Medina, A., Riad, A., Salem, H., Simoes, J., Spence, R., Smart, N., Tabiri, S., Thomas, H., West, M., Whitaker, J., Weiser, T. G., Harrison, E. M., GlobalSurg Collaborative, NIHR Global Hlth Res Unit Global S 2022; 10 (7): E1003-E1011

  Abstract

  Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide.A multimethods analysis was performed as part of the GlobalSurg 3 study-a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital.Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58-5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23-0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer.Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised.National Institute for Health and Care Research.

  View details for DOI 10.1016/S2214-109X(22)00168-1

  View details for Web of Science ID 000835720300001

  View details for PubMedID 35623378

  View details for PubMedCentralID PMC9210173

• Medial Patellofemoral Ligament Repair with Suture Tape Augmentation: A Case Series With Five-Year Follow Up. Surgical technology international Hopper, G. P., Irfan, A., Wilson, W. T., Mackay, G. M. 2022; 40: 363-367

  Abstract

  The medial patellofemoral ligament (MPFL) is the main restraining force against lateral patellar displacement in the first 20 degrees of knee flexion and is often disrupted following patellar subluxation or dislocation. MPFL reconstruction is commonly performed to restore patellar stability but requires autograft harvest with associated donor site morbidity. The aim of this study was to assess the five-year outcomes of MPFL repair performed with suture tape augmentation.All patients who underwent isolated MPFL repair for recurrent patellar instability between 2011 and 2017 were included. Patients requiring any additional surgery, such as osteotomy, were excluded. Patient-reported outcomes were measured at two-year follow up using the Knee Injury and Osteoarthritis Outcome (KOOS) Score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Visual Analogue Pain Scale (VAS-pain), Veterans RAND 12-Item Health Survey (VR-12), Marx Activity Scale, and an overall satisfaction questionnaire. At the end of the study period, any complications or secondary surgeries were determined.Eighteen patients underwent MPFL repair with one lost to follow up. There was a significant improvement in all subscales of the KOOS scoring systems, the WOMAC functional score, and the VR-12 physical score. A significant decrease was seen in the VAS-pain score. A non-significant decrease was seen in the Marx activity scale from pre-injury. The majority of patients reported satisfaction with reduction in pain and return to sporting activities. There were no complications with no further instability episodes.This is the first study that describes the five-year follow-up results of patients treated with MPFL repair and suture tape augmentation. Our results show that this technique is an alternative treatment to traditional MPFL reconstruction with comparable outcomes and avoidance of autograft harvest.

  View details for DOI 10.52198/22.STI.40.OS1558

  View details for PubMedID 35415831

• Does health literacy impact technological comfort in cancer patients? American journal of surgery Irfan, A., Lever, J. M., Fouad, M. N., Sleckman, B. P., Smith, H., Chu, D. I., Rose, J. B., Wang, T. N., Reddy, S. 2022; 223 (4): 722-728

  Abstract

  As healthcare systems are adapting due to COVID-19, there has been an increased need for telehealth in the outpatient setting. Not all patients have been comfortable with this transition. We sought to determine the relationship between health literacy and technological comfort in our cancer patients.We conducted a survey of patients that presented to the oncology clinics at a single-center over a 2-month period. Patients were given a voluntary, anonymous, survey during their visit containing questions regarding demographics, health literacy and technological comfort.344 surveys were returned (response-rate 64.3%). The median patient age was 61 years, 70% of responders were female and the most common race was White (67.3%). Increasing patient age, male gender, Black and Native-American race, decreased health literacy and lack of home broadband were associated with lower technological comfort score.In our cohort, patients with lower health literacy scores, older and male patients, or who have poor internet access showed a lower level of technological comfort. At risk patients can be identified and provided additional support in their use of telehealth services.

  View details for DOI 10.1016/j.amjsurg.2021.08.006

  View details for PubMedID 34384588

  View details for PubMedCentralID PMC9549521

• The Fate of Resectable Pancreatic Adenocarcinoma After Neoadjuvant Chemotherapy. Pancreas Irfan, A., Rose, J. B., Wang, T. N., Vickers, S. M., Dudeja, V., Gbolahan, O., Reddy, S. 2022; 51 (1): 100-105

  Abstract

  Pancreatic cancer continues to be a major cause of cancer-related mortality. There has been a greater implementation of up-front chemotherapy for pancreatic adenocarcinoma patients. Although there are many theoretical benefits to neoadjuvant chemotherapy, its clinical impact is uncertain. We sought to understand the outcomes of patients with resectable and borderline-resectable pancreatic adenocarcinoma who underwent neoadjuvant chemotherapy.Patients were collected in a secure database from September 2018 to May 2020. Patients were excluded if they presented with locally advanced or metastatic disease, inability to complete chemotherapy, or if they were not a surgical candidate.Sixty-six patients with resectable disease underwent chemotherapy. Folinic acid/5-fluorouracil/irinotecan/oxaliplatin was used in 41 patients (62.1%) and gemcitabine-based regimens in 28 patients (42.4%, greater than 100% as some patients underwent both regimens). After restaging, 47 patients (71.2%) were thought to have resectable disease. Of these patients, 36 have been successfully resected to date. Metastatic disease was found in 12 patients (18.2%) and 6 patients (9.1%) had locally advanced disease.Most patients with resectable pancreatic cancer are resected after neoadjuvant chemotherapy, but a subset will develop local or distant progression. Further studies will be needed to determine which patients will progress locally and may benefit from an up-front surgical approach.

  View details for DOI 10.1097/MPA.0000000000001972

  View details for PubMedID 35195602

• Presence of Lymph Node Metastasis Has a Greater Impact on Survival in Black Patients with Pancreatic Cancer: An Effect of Tumor Biology or a Disparity in Treatment? Fang, H., Irfan, A., Vickers, S. M., Williams, G. R., Wang, T. N., Dudeja, V., Rose, B., Reddy, S. ELSEVIER SCIENCE INC. 2021: S142

  View details for Web of Science ID 000718303100260

• Advanced prehospital resuscitative care: Can we identify trauma patients who might benefit? The journal of trauma and acute care surgery Irfan, A., Juneja, K., Abraham, P., Smedley, W. A., Stephens, S. W., Griffin, R. L., Ward, W., Hallmark, R., Qasim, Z., Carroll, S. L., Reiff, D., Holcomb, J. B., Jansen, J. O. 2021; 91 (3): 514-520

  Abstract

  Uncontrolled truncal hemorrhage remains the most common cause of potentially preventable death after injury. The notion of earlier hemorrhage control and blood product resuscitation is therefore attractive. Some systems have successfully implemented prehospital advanced resuscitative care (ARC) teams. Early identification of patients is key and is reliant on rapid decision making and communication. The purpose of this simulation study was to explore the feasibility of early identification of patients who might benefit from ARC in a typical US setting.We conducted a prospective observational/simulation study at a level I trauma center and two associated emergency medical service (EMS) agencies over a 9-month period. The participating EMS agencies were asked to identify actual patients who might benefit from the activation of a hypothetical trauma center-based ARC team. This decision was then communicated in real time to the study team.Sixty-three patients were determined to require activation. The number of activations per month ranged from 2 to 15. The highest incidence of calls occurred between 4 pm to midnight. Of the 63 patients, 33 were transported to the trauma center. The most common presentation was with penetrating trauma. The median age was 27 years (interquartile range, 24-45 years), 75% were male, and the median Injury Severity Score was 11 (interquartile range, 7-20). Based on injury patterns, treatment received, and outcomes, it was determined that 6 (18%) of 33 patients might have benefited from ARC. Three of the patients died en-route to or soon after arrival at the trauma center.The prehospital identification of patients who might benefit from ARC is possible but faces challenges. Identifying strategies to adapt existing processes may allow better utilization of the existing infrastructure and should be a focus of future efforts.Prognostic/Epidemiologic, level III.

  View details for DOI 10.1097/TA.0000000000003277

  View details for PubMedID 33990533

• Perioperative Outcomes of Robotic Pancreaticoduodenectomy: a Propensity-Matched Analysis to Open and Laparoscopic Pancreaticoduodenectomy. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract van Oosten, A. F., Ding, D., Habib, J. R., Irfan, A., Schmocker, R. K., Sereni, E., Kinny-Köster, B., Wright, M., Groot, V. P., Molenaar, I. Q., Cameron, J. L., Makary, M., Burkhart, R. A., Burns, W. R., Wolfgang, C. L., He, J. 2021; 25 (7): 1795-1804

  Abstract

  Robotic pancreaticoduodenectomy is slowly gaining acceptance within pancreatic surgery. Advantages have been demonstrated for robotic surgery in other fields, but robust data for pancreaticoduodenectomy is limited. The aim of this study was to compare the short-term outcomes of robotic pancreaticoduodenectomy (RPD) to open pancreaticoduodenectomy (OPD) and laparoscopic pancreaticoduodenectomy (LPD).Patients who underwent a pancreaticoduodenectomy between January 2011 and July 2019 at the Johns Hopkins Hospital were included in this retrospective propensity-matched analysis. The RPD cohort was matched to patients who underwent OPD in a 1:2 fashion and LPD in a 1:1 fashion. Short-term outcomes were analyzed for all three cohorts.In total, 1644 patients were included, of which 96 (5.8%) underwent RPD, 131 (8.0%) LPD, and 1417 (86.2%) OPD. RPD was associated with a decreased incidence of delayed gastric emptying (9.4%) compared to OPD (23.5%; P = 0.006). The median estimated blood loss was significantly less in the RPD cohort (RPD vs OPD, 150 vs 487 mL; P < 0.001, RPD vs LPD, 125 vs 300 mL; P < 0.001). Compared to OPD, the robotic approach was associated with a shorter median length of stay (median 8 vs 9 days; P = 0.014) and a decrease in wound complications (4.2% vs 16.7%; P = 0.002). The incidence of other postoperative complications was comparable between RPD and OPD, and RPD and LPD.In the hands of experienced surgeons, RPD may have a modest yet statistically significant reduction in estimated blood loss, postoperative length of stay, wound complications, and delayed gastric emptying comparing to OPD in similar patients.

  View details for DOI 10.1007/s11605-020-04869-z

  View details for PubMedID 33201457

  View details for PubMedCentralID 1421271

• A Criterion Based Rehabilitation Protocol for ACL Repair with Internal Brace Augmentation. International journal of sports physical therapy Irfan, A., Kerr, S., Hopper, G., Wilson, W., Wilson, L., Mackay, G. 2021; 16 (3): 870-878

  Abstract

  The anterior cruciate ligament (ACL) is one of the main stabilizing structures of the knee and its rupture is a common injury in young active adults. ACL reconstruction has been the preferred operative management of an ACL rupture for several decades; however, success rates are variable. Recently, interest in arthroscopic primary repair of the ligament has increased. The repair is augmented with an Internal Brace (IB), which is an ultra-high strength suture tape that bridges the ligament. This technique protects the ligament during the healing and the ligament is encouraged to heal naturally, whilst not requiring any external braces. It acts as a stabiliser to permit early mobilization and optimise rehabilitation. As understanding of rehabilitation has progressed, there has been an increased focus on early weight-bearing and achieving full range of movement. While detailed criterion-based rehabilitation protocols exist for ACL reconstruction, this is not the case for ACL repair. The purpose of this commentary is to present a novel criterion-based rehabilitation protocol following ACL repair surgery augmented with an IB.V.

  View details for DOI 10.26603/001c.22217

  View details for PubMedID 34123539

  View details for PubMedCentralID PMC8169034

• Fetal interventions for congenital renal anomalies. Translational pediatrics Irfan, A., O'Hare, E., Jelin, E. 2021; 10 (5): 1506-1517

  Abstract

  Congenital abnormalities of the kidney and urinary tract (CAKUT) represent 20% of prenatally diagnosed congenital abnormalities. Although the majority of these abnormalities do not require intervention either pre or postnatally, there is a subset of patients whose disease is so severe that it may warrant intervention prior to delivery to prevent morbidity and mortality. These cases consist of patients with moderate lower urinary tract obstruction (LUTO) in which vesicocentesis, shunting or cystoscopy are options and patients with early pregnancy renal anhydramnios (EPRA) in whom amnioinfusion therapy may be an option. The main causes of EPRA are congenital bilateral renal agenesis (CoBRA), cystic kidney disease (CKD) and severe LUTO. Untreated, EPRA is universally fatal secondary to anhydramnios induced pulmonary hypoplasia. The evidence regarding therapy for LUTO is limited and the stopped early PLUTO (Percutaneous Shunting in Lower Urinary Tract Obstruction) trial was unable to provide definitive answers about patient selection. Evidence for EPRA therapy is also scant. Serial amnioinfusions have shown promise in cases of EPRA due to CoBRA or renal failure and this treatment modality forms the basis of the ongoing NIH funded RAFT (Renal Anhydramnios Fetal Therapy) trial. At present, there is consensus that treatment for EPRA should only occur in the setting of a clinical trial.

  View details for DOI 10.21037/tp-2020-fs-05

  View details for PubMedID 34189109

  View details for PubMedCentralID PMC8192995

• Comparing 30-day outcomes between early versus delayed repair of anorectal malformations with perineal or rectovestibular fistulas: An analysis of the ACS NSQIP-Pediatric database. Journal of pediatric surgery Irfan, A., Hu, A., Martin, L. Y., Jelin, E. B., Garcia, A. V., Jancelewicz, T., Boss, E., Nasr, I. W., Rhee, D. S. 2021; 56 (5): 979-983

  Abstract

  Anorectal malformations (ARMs) have a wide spectrum of presentation ranging from mild defects with perineal fistulas to more severe defects requiring complex management. A primary repair of ARMs with perineal or rectovestibular fistulas has been shown to have good outcomes. However, the timing of the reconstruction is still debated. The aim of this study is to investigate the safety of early versus delayed repair.This study was performed using data from the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) from 2012 to 2017. Patients who underwent repair of anorectal malformation with perineal or vestibular fistula were included in the study. Patients with associated diagnosis for Hirschsprung disease, cloaca, rectal prolapse or stenosis, bladder exstrophy, and tracheoesophageal fistula were excluded. 30-day postoperative outcomes included wound and nonwound complications, readmissions, and reoperations. Outcomes were compared by early (≤7 days of age) versus delayed repair (6 weeks to 8 months).A total of 291 patients were included, with 66 in the early and 231 in the delayed group. Patients in the early group were more likely to be male (68.2% vs 31.8%; p < 0.01) and have cardiac risk factors (71.2% vs 49.4%, p < 0.01). The mean operative time was significantly shorter in the early group (90.1 vs 129.6 min; p < 0.01). 30-day complications were not statistically significant between the two groups (p = 0.76). After multivariate analysis, timing of repair did not affect 30-day complications (p = 0.15).Our study shows that early repair of low anorectal malformations with a perineal or vestibular fistula appears to be associated with no increase in risk of postoperative complications as compared to delayed repair. At present, the decision remains dependent on the surgeon's experience and judgment.Level III. Retrospective comparative study.

  View details for DOI 10.1016/j.jpedsurg.2020.09.002

  View details for PubMedID 33023749

• Posterior cruciate ligament repair with suture tape augmentation: a case series with minimum 2-year follow-up. Journal of experimental orthopaedics Hopper, G. P., Irfan, A., Jenkins, J. M., Wilson, W. T., Mackay, G. M. 2021; 8 (1): 28

  Abstract

  The posterior cruciate ligament (PCL) is an important stabilizer of the knee and can be damaged in up to 20% of ligamentous injuries. Numerous techniques for surgical treatment have been described in the literature with none shown to be clearly superior. The aim of this study was to assess the 2-year outcomes of PCL repair with suture tape augmentation.Seventeen patients undergoing PCL repair with suture tape augmentation were prospectively followed up for a minimum of two years. One patient was lost to follow-up leaving sixteen patients in the final analysis (94.1%). Indications for this procedure were acute Grade III PCL ruptures, symptomatic chronic tears and PCL tears as part of a multi-ligament injury. Exclusion criteria were patients with retracted PCL remnants or poor tissue quality. Patient-reported outcomes were measured using the Knee Injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Visual Analogue Pain Scale (VAS-pain), Veterans RAND 12 Item Health Survey (VR-12) and Marx Activity Scale. Patients with any postoperative complications were identified. Mean differences between the outcomes pre-operatively and at two years postoperatively were evaluated using paired t-tests with significance set at p < 0.05.The mean KOOS at 2 years was 87.0, 75.5, 93.0, 69.6 and 54.2 for pain, symptoms, ADL, sport/recreation and QOL respectively. These improved significantly from 60.2, 49.8, 65.0, 33.0 and 34.2 preoperatively (p < 0.05). The mean WOMAC scores at 2 years were 91.0, 78.3 and 93.0 for pain, stiffness and function respectively. These improved significantly from 63.0, 51.7 and 65.0 preoperatively (p < 0.01). The VAS score improved from 3.0 to 0.8 (p < 0.01) and the VR-12 score improved from 34.9 to 50.9 at 2 years (p < 0.001). However, the Marx activity scale decreased from 8.7 pre-injury to 6.3 at 2 years (N.S.). One patient (6.3%) suffered a re-rupture.PCL repair with suture tape augmentation demonstrates satisfactory patient reported outcome measures at minimum 2-year follow-up. These figures compare favorably with success rates described in the literature for PCL reconstruction techniques. Therefore, PCL repair with suture tape augmentation is an effective treatment option in selected patients.IV.

  View details for DOI 10.1186/s40634-021-00337-y

  View details for PubMedID 33860391

  View details for PubMedCentralID PMC8050190

• Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries LANCET Knight, S. R., Shaw, C. A., Pius, R., Drake, T. M., Norman, L., Ademuyiwa, A. O., Adisa, A. O., Aguilera-Arevalo, M., Al-Saqqa, S. W., Al-Slaibi, I. S., Bhangu, A., Biccard, B. M., Brocklehurst, P., Costas-Chavarri, A., Chu, K. M., Dare, A. J., Elhadi, M., Fairfield, C. J., Fitzgerald, J., Ghosh, D. N., Glasbey, J., Henegouwen, M., Ingabire, J., Kingham, T., Lapitan, M. M., Lawani, I., Lieske, B., Lilford, R. J., Martin, J., Mclean, K. A., Moore, R. L., Morton, D., Nepogodiev, D., Ntirenganya, F., Pata, F., Pinkney, T. D., Qureshi, A. U., Ramos-De la Medina, A., Riad, A. M., Salem, H., Simoes, J., Spence, R. T., Smart, N. J., Tabiri, S., Thomas, H. S., Weiser, T. G., West, M. A., Whitaker, J., Harrison, E. M., GlobalSurg Collaborative, Global Surg Writing Grp 2021; 397 (10272): 387–97

  Abstract

  80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality.This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494.Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70-8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39-8·80) and upper-middle-income countries (2·06, 1·11-3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26-11·59) and upper-middle-income countries (3·89, 2·08-7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications.Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications.National Institute for Health Research Global Health Research Unit.

  View details for DOI 10.1016/S0140-6736(21)00001-5

  View details for Web of Science ID 000614227700026

  View details for PubMedID 33485461

  View details for PubMedCentralID PMC7846817

• Hazards of Fatigue - Learning from Aviation The Bulletin of the Royal College of Surgeons Irfan, A., Ahmed, I., Malik, M. 2021
• The impact of post-operative opioid guidelines on prescribing behaviors in the pediatric population. Pediatric surgery international Irfan, A., Martin, L. Y., Canner, J., Etra, J., Gonzalez Salazar, A. J., Overton, H. N., Jelin, E. B. 2020; 36 (11): 1339-1343

  Abstract

  Opioid misuse continues to be a major source of morbidity and mortality in the US, in both the adult and pediatric populations. Post-operative opioid prescriptions are often the first exposure children have to opioids and increases their risk of chronic use. There is significant variation in the number of opioids following identical procedures and measures have been taken within the adult population to limit this. However, specific post-operative opioid prescription guidelines are not present in the pediatric population.Seven common pediatric surgery procedures were selected for inclusion. The recommended number of opioid doses following each procedure was determined by a multi-disciplinary expert panel. All surgery residents were sent an initial survey to determine the number of opioids they would prescribe for each procedure. They were then shown the guidelines and the survey repeated to determine changes in response.35 and 27 general surgery residents took part in and pre- and post-educational surveys respectively. In all procedures, there was a decrease in the mean number of post-operative opioids prescribed. In addition, there was an increase in the number of residents who prescribed within the guidelines and a decrease in the number who overprescribed post-operative opioids.Pediatric postoperative opioid prescribing guidelines derived from expert opinion increase resident compliance with appropriate dosing; this has the potential to decrease the classic problem of general surgery residents accustomed to treating adults overprescribing opioids to children. These results are promising, and we aim to expand on this work and incorporate these guidelines into our clinical practice.III/IV.

  View details for DOI 10.1007/s00383-020-04739-4

  View details for PubMedID 32915274

  View details for PubMedCentralID PMC7554093

• Recurrent Tracheitis Due to Acquired Esophageal Atresia. Clinical pediatrics Irfan, A., Rhee, D., Alaish, S. M. 2020; 59 (9-10): 947-950

  View details for DOI 10.1177/0009922820920010

  View details for PubMedID 32425072

• Epidemiology of Irritable Hip in Western Scotland: A Follow-Up Study. Cureus Irfan, A., Rose, A., Roberts, B., Foster, S., Huntley, J. S. 2020; 12 (8): e10036

  Abstract

  Background A 'limping child' commonly presents to the emergency department (ED). In the absence of trauma, many are diagnosed with irritable hip (IH). The aetiology of IH is not well understood and there may be geographical and seasonal variations. We previously established one year (2016) epidemiological data of IH presenting to the Royal Hospital for Children (RHCG) ED in Glasgow, Scotland. The sentinel findings in that year were (i) an age distribution shift to younger (peak at two years of age), (ii) no marked association with social class, and (iii) a spring preponderance. We sought to strengthen or refute these findings by repeating our study to obtain comparative data for 2017. Methods We performed a retrospective analysis of all children discharged from the RHCG ED from January to December 2017. Relevant discharge codes were determined, and patient records screened. Patients without a discharge code had their presenting complaint and medical record screened. These data were compared to that of the previously published study from the same ED (2016). Results Several findings were consistent with the conclusions of the 2016 study. The incidence was similar with 362 and 354 cases diagnosed in 2017 and 2016 respectively. The boy-girl ratio was consistent across both data-sets, 2:1 and 1.9:1 respectively. The mean age of presentation was similar (3.3 vs 3.5 years) across both years, with the same medians (three years) and peaks (two years). There was no overt difference in incidence or correlation to social deprivation. However, in 2016, a spring preponderance was seen whereas there was an autumn preponderance in 2017. Pooling data from the two cohorts, 93% (n=668) of patients were managed exclusively by ED physicians, with 70% (n=504) not requiring any further follow-up. The majority of patients who required follow-up were seen in ED clinics (169/212, 79.7%). No patient initially diagnosed as IH was found to have septic arthritis (SA). Conclusion In this follow-up study, we again found (i) a younger age profile than other studies, and (ii) no overt association with social deprivation. The major difference between the previous (2016) and current (2017) study was the apparent seasonal peaks: spring (2016), and autumn (2017). This difference does not negate the 'antecedent infection' hypothesis, but any aetiological proposal should be capable of accounting for this discrepancy. Additionally, our studies highlight that the majority of these patients can be managed in the ED alone.

  View details for DOI 10.7759/cureus.10036

  View details for PubMedID 32983727

  View details for PubMedCentralID PMC7515813

• Virtual and Augmented Reality in Surgical Specialties. Past, Present and Future. Journal of the College of Physicians and Surgeons--Pakistan : JCPSP Irfan, A. 2020; 30 (4): 455

  View details for DOI 10.29271/jcpsp.2020.04.455

  View details for PubMedID 32513376

• The Relationship Between Tumor Glucose Metabolism and Host Systemic Inflammatory Responses in Patients with Cancer: A Systematic Review. Journal of nuclear medicine : official publication, Society of Nuclear Medicine Dolan, R. D., McLees, N. G., Irfan, A., McSorley, S. T., Horgan, P. G., Colville, D., McMillan, D. C. 2019; 60 (4): 467-471

  Abstract

  One of the most important and long recognized characteristics of tumor cells is their dysregulated cellular energetics with anaerobic driven glucose uptake. In patients with cancer, the prognostic value of the systemic inflammatory response has been well established, and the recent combination of PET and CT scanning combines the assessment of tumor physiologic activity with detailed anatomic localization. The aim of this study was to perform a systematic review of the assessment of the relationship between both the tumor and the host inflammatory responses using PET/CT. Methods: An extensive literature review using targeted subject headings was performed in the U.S. National Library of Medicine, the Excerpta Medica database, and the Cochrane Database of Systematic Reviews on March 31, 2018. On completion of the online search, the title and abstracts of each identified study were examined for relevance. Studies with duplicate datasets, not available in English, and that did not have full text availability were excluded. Full texts of relevant articles were obtained and were then examined to identify any further relevant articles. Results: Twelve studies containing 2,588 patients were included in the final analysis. All of the included studies used the 18F-FDG tracer in PET/CT imaging and had biochemical assessment of the systemic inflammatory response. Most studies showed a direct relationship between the tumor and bone marrow glucose uptake and host systemic inflammatory responses as measured by C-reactive protein (n = 2), albumin (n = 2), white cell count (n = 3), neutrophils (n = 2), and platelets (n = 2). Most of the studies (n = 8) also showed a direct relationship between tumor and bone marrow glucose uptake and poor outcomes. Conclusion: This review suggests a direct relationship between the tumor and bone marrow glucose uptake and host systemic inflammation. This may suggest new approaches for more optimal therapeutic targeting and monitoring strategies in patients with cancer.

  View details for DOI 10.2967/jnumed.118.216697

  View details for PubMedID 30166353

• "Irritable Hip": Diagnosis in the Emergency Department. A Descriptive Study Over One Year. Cureus Irfan, A., Starr, R. J., Foster, S., Smith, I. D., Huntley, J. S. 2018; 10 (10): e3481

  Abstract

  Background A 'limping child' commonly presents to the emergency department (ED), often without a history of trauma. It is important that serious underlying pathology is ruled out before a diagnosis of benign irritable hip (IH). The aetiology of IH is not well understood and there may be geographical and seasonal variation. The aim of this study was to determine the basic epidemiology of IH in the Glasgow Population. Methods A retrospective analysis was carried out of all children discharged from the Glasgow Children's Emergency Department from January to December 2016. Relevant discharge codes were determined and patient records screened. Any patient who did not have a discharge code had their presenting complaint and medical record screened. Results A total of 354 patients were diagnosed with IH, of which 319 and 189 were in the Greater Glasgow and Clyde and City of Glasgow catchment areas, respectively. The majority of these patients (n = 254) were diagnosed clinically. The incidence of IH was 177.7 per 100,000 children with a boy:girl ratio of 1.9:1 (209:110). The mean age of presentation was 3.5 years and the recurrence rate was 5.9% (n = 18). There was an increased incidence in spring (n = 111), especially in March (n = 42) and April (n = 40). There was no incidence variation or influence discernible by social deprivation. Conclusion In this population, IH has: (i) an atypical age profile (age distribution shift to younger), (ii) no marked association with social deprivation (in contrast to other studies), and (iii) a 'spring preponderance'. We suggest that most cases can safely be managed in the ED without recourse to further investigations or speciality referral.

  View details for DOI 10.7759/cureus.3481

  View details for PubMedID 30613443

  View details for PubMedCentralID PMC6314824

• What is the best treatment for a child with an acute tear of the anterior cruciate ligament? Journal of paediatrics and child health Smith, I. D., Irfan, A., Huntley, J. S., Spencer, S. J. 2018; 54 (9): 1037-1041

  Abstract

  With the heightened popularity of childhood sporting activity, the number of paediatric anterior cruciate ligament (ACL) ruptures has increased. Management of these injuries presents a particular challenge due to the open femoral and tibial growth plates. Physeal damage has the potential to cause angular deformity or length discrepancy. This review was conducted to determine the best way to treat this injury. A primary search of Ovid MEDLINE (1 October 2017) used the terms: (ACL or anterior cruciate ligament) and (young or child or children or pediatric or immature or pre-pubescent). Titles/Abstracts of 369 articles were screened for relevance. A total of 217 were excluded, leaving 152 articles for full-paper retrieval. Of these, 9 articles remained with one further article identified during cross-referencing; 10 papers (1 level 2 and 9 level 3) were included for analysis. Comparative studies investigating surgical (140 knees) versus conservative (110 knees) treatment provide evidence in favour of the former, in reducing instability and meniscal tears and improving return to previous activity. Of the papers analysed (163 reconstructions), there was only one case of growth arrest (0.6%) and no cases of length discrepancy. In those studies investigating early (218 patients) versus delayed (140 patients) reconstruction, medial meniscal tears and chondral injuries occurred more frequently in the delayed group. To conclude, for children, there is level 2/3 evidence that early operative ACL reconstruction offers the best chance of a return to pre-injury sporting activity and minimises the risks of further structural damage. Iatrogenic growth disturbance remains a rare but worrying complication.

  View details for DOI 10.1111/jpc.14129

  View details for PubMedID 30178593

• Clinical Applications of Stem Cells in Liver Cirrhosis Liver, Lung and Heart Regeneration Irfan, A., Ahmed, I. 2017
• Hepatic Arterial Mapping by CT Angiography, Cone Beam CT and Digital Subtraction Angiography Journal of Liver Research, Disorders and Therapy Irfan, A., Weir, G. 2016
• Could Stem Cell Therapy be the Cure in Liver Cirrhosis? Journal of clinical and experimental hepatology Irfan, A., Ahmed, I. 2015; 5 (2): 142-6

  Abstract

  Over the past five decades, liver cirrhosis has become an increasingly prevalent disease and one that will often require considerable medical intervention. However, current treatment options have demonstrated severe problems that have prompted research to provide a suitable alternative. These treatments are scarcely available, very expensive and present at a huge cost to the patient's quality of life. The introduction of stem cell therapy into liver disease has been heralded as the future of personalized medicine and may be the alternative that the healthcare system desperately seeks. To truly determine the scientific basis surrounding this excitement, a literature search was carried out in January 2013 to determine all the data that was present in this topic area. All articles also underwent full cross-referencing to ensure no data was missed. 11 clinical trials were found to meet this criteria and trials were included in both English and non-English languages. The sporadic nature of the data across the trials, with various methods and stem cell types, made comparisons difficult. The basic trends from the data were positive and the majority deemed the use of stem cells safe and feasible in patients presenting with cirrhotic liver disease. However, there is a clear requirement for more research, not only to determine the most efficacious technique and stem cell type but also to further understand stem cells to enhance progress. There may also be a requirement for a framework that future stem cell trials can be based on, which would allow future data to be comparative and allow valid conclusions to be drawn which may propel this therapy into standard clinical practice.

  View details for DOI 10.1016/j.jceh.2014.03.042

  View details for PubMedID 26155042

  View details for PubMedCentralID PMC4491605

• Stem Cells: The Future of Personalized Medicine Medical Equipment Insights Irfan, A., Ahmed, I. 2014
• Hepatocellular Carcinoma: Could Stem Cell Therapy Ever be a Viable Solution? El Mednifico Journal Irfan, A., Ahmed, I. 2014