Clinical Focus

  • Residency

Professional Education

  • MD, University of California, Irvine (2019)
  • BS, University of California, Los Angeles (2015)

All Publications

  • Understanding the Caregiver Perspective: The Impact of Caring for Patients with Advanced Cancer. Annals of surgical oncology Sun, B. J., Lee, B. 2024

    View details for DOI 10.1245/s10434-024-14990-x

    View details for PubMedID 38285308

    View details for PubMedCentralID 8383130

  • The Role of Prophylactic and Adjuvant Hyperthermic Intraperitoneal Chemotherapy (HIPEC) in Prevention of Peritoneal Metastases in Advanced Colorectal Cancer. Journal of clinical medicine Sun, B. J., Daniel, S. K., Lee, B. 2023; 12 (20)


    Hyperthermic intraperitoneal chemotherapy (HIPEC) is a locoregional therapy that may be combined with cytoreductive surgery (CRS) to treat patients with colorectal cancer and peritoneal metastases (PM). In recent years, three randomized controlled trials (RCTs) have investigated the role of prophylactic or adjuvant HIPEC in preventing the development of PM in patients with high-risk colorectal cancer: PROPHYLOCHIP and COLOPEC evaluated adjuvant HIPEC, and HIPECT4 studied concurrent HIPEC and CRS. Although PROPHYLOCHIP and COLOPEC were negative trials, a great deal may be learned from their methodology, outcome measures, and patient selection criteria. HIPECT4 is the first RCT to show a clinical benefit of HIPEC in high-risk T4 colorectal cancer, demonstrating improved locoregional disease control with the addition of HIPEC to CRS with no increase in the rate of complications. This review critically examines the strengths and limitations of each major trial and discusses their potential impact on the practice of HIPEC. Several additional ongoing clinical trials also seek to investigate the role of HIPEC in preventing PM in advanced colorectal cancer.

    View details for DOI 10.3390/jcm12206443

    View details for PubMedID 37892582

    View details for PubMedCentralID PMC10607874

  • Results of the First Phase I PIPAC Trial in the United States: Braving the Storm. Annals of surgical oncology Sun, B. J., Lee, B. 2023

    View details for DOI 10.1245/s10434-023-14353-y

    View details for PubMedID 37770724

    View details for PubMedCentralID 7011374

  • Impact of Successful Implementation of an Enhanced Recovery After Surgery Protocol for Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy. Annals of surgical oncology Sun, B. J., Yue, T. M., Xu, N., Fowler, C., Lee, B. 2023


    Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) are complex operations for the treatment of peritoneal metastases. Enhanced recovery after surgery (ERAS) protocols are intended to standardize preoperative, intraoperative, and postoperative pathways, with the goal of improving patient care. This study describes feasibility and outcomes after implementing an ERAS protocol for CRS/HIPEC at a tertiary academic center.A single-institution experience of CRS/HIPEC was reviewed from January 2020 to March 2023. Patients were categorized according to whether they underwent CRS/HIPEC before or after ERAS initiation. Outcomes and protocol adherence were evaluated.A total of 115 CRS/HIPEC operations were included-74 before and 41 after ERAS implementation. Median age was younger in the post-ERAS group, whereas sex, comorbidities, peritoneal carcinomatosis index, operation performed, and operative time were similar between groups. The most common primary cancer sites were gynecologic (40%), appendiceal (24%), and colorectal (22%). Adherence to all postoperative ERAS components was 76%. More post-ERAS patients ambulated by postoperative day (POD) 1 (90% vs. 54%; p < 0.001), tolerated liquid diet by POD 2 (88% vs. 32%; p < 0.001), and had foley removed by POD 3 (86% vs. 43%; p < 0.001). There was a trend toward decreased length of stay in the post-ERAS cohort (7 vs. 8 days; p = 0.092), with no difference in major complications, intensive care unit admission, or 30-day readmission.Despite the heterogeneity of CRS/HIPEC operations, implementing an ERAS protocol for our patients was feasible and resulted in postoperative outcomes and adherence comparable with that of other major abdominal surgeries. This supports the potential for success in ERAS programs for CRS/HIPEC patients.

    View details for DOI 10.1245/s10434-023-14222-8

    View details for PubMedID 37684372

    View details for PubMedCentralID 10088912

  • Review of Regional Therapies for Gastric Cancer with Peritoneal Metastases. Cancers Sun, B. J., Lee, B. 2022; 14 (3)


    Gastric cancer carries a poor prognosis and is a leading cause of cancer-related mortality worldwide. Patients with gastric cancer who develop peritoneal metastases have an even more dismal prognosis, with median survival time measured in months. Since studies have demonstrated that systemic chemotherapy has poor penetration into the peritoneum, multimodal treatment with intraperitoneal chemotherapy has been proposed for the treatment of peritoneal metastases and has become the foundation for newer therapeutic techniques and clinical trials. These include heated intraperitoneal chemotherapy (HIPEC) with cytoreductive surgery (CRS), which involves the application of heated chemotherapy into the abdomen with or without tumor debulking surgery; normothermic intraperitoneal chemotherapy (NIPEC), in which non-heated chemotherapy can be delivered into the abdomen via a peritoneal port allowing for repeat dosing; and pressurized intraperitoneal aerosolized chemotherapy (PIPAC), a newer technique of pressurized and aerosolized chemotherapy delivered into the abdomen during laparoscopy. Early results with intraperitoneal chemotherapy have shown promise in increasing disease-free and overall survival in select patients. Additionally, there may be a palliative effect of these regional therapies. In this review, we explore and summarize these different intraperitoneal chemotherapy treatment regimens for gastric cancer with peritoneal metastases.

    View details for DOI 10.3390/cancers14030570

    View details for PubMedID 35158837

  • Induction therapy is not associated with improved survival in large cT4N0 non-small cell lung cancers. The Annals of thoracic surgery Sun, B. J., Bhandari, P., Jeffrey Yang, C., Berry, M. F., Shrager, J. B., Backhus, L. M., Lui, N. S., Liou, D. Z. 2021


    BACKGROUND: The 8th edition staging for non-small cell lung cancer reclassified tumors >7 cm as stage IIIA (T4N0); previously, such tumors without nodal disease were considered stage IIB (T3N0). This study tested the hypothesis that induction chemotherapy for these stage IIIA patients does not improve survival compared to primary surgery.METHODS: The National Cancer Database was queried for non-small cell lung cancer patients with tumor size >7 cm who underwent surgical resection from 2010 - 2015. Patients with clinically node-positive disease or tumor invasion of major structures were excluded. Patients undergoing induction chemotherapy followed by surgery (IC) were compared to patients undergoing primary surgery (PS). Propensity-score matching was performed.RESULTS: In total, 1,610 patients with cT4N0 disease based on tumor size >7 cm and no tumor invasion underwent surgical resection: 1,346 (83.6%) comprised the PS group and 264 (16.4%) the IC group. After propensity-score matching, IC had a higher rate of pN0 (78.4% vs 66.0%, p<0.001) and less lymphovascular invasion (13.9% vs 26.3%, p<0.001), but longer postoperative stay (6 vs 5 days, p<0.001) and higher 30-day mortality (3.5% vs 0%, p=0.002). Median 5-year survival was similar between IC and PS (53.5% vs 62.2%, p=0.075), and IC was not independently associated with survival (HR 1.45, p=0.146).CONCLUSIONS: Patients with cT4N0 non-small cell lung cancer based on tumor size >7 cm and no tumor invasion of major structures have similar overall survival with either IC or PS. IC should not be routinely given for this subset of stage IIIA patients.

    View details for DOI 10.1016/j.athoracsur.2021.07.058

    View details for PubMedID 34425099

  • Palliative Intervention for Malignant Bowel Obstruction Comes at a Cost: A National Inpatient Study. The American surgeon Sun, B. J., Tennakoon, L., Spain, D. A., Lee, B. 2024: 31348241256083


    Background: Malignant bowel obstruction (MBO) due to peritoneal carcinomatosis (PC) is associated with poor outcomes. Optimal management for palliation remains unclear. This study aims to characterize nonoperative, procedural, and operative management strategies for MBO and evaluate its association with mortality and cost.Materials and Methods: ICD-10 coding identified patient admissions from the 2018 to 2019 National Inpatient Sample (NIS) for MBO with PC from gastrointestinal or ovarian primary cancers. Management was categorized as nonoperative, procedural, or surgical. Multivariate analysis was used to associate treatment with mortality and cost.Results: 356,316 patient admissions were identified, with a mean age of 63 years. Gender, race, and insurance status were similar among groups. Length of stay (LOS) was longest in the surgical group (surgical: 17 days; procedural: 14 days; nonoperative: 7 days; P = .001). In comparison to nonoperative, procedural and surgical patients had statistically higher hospital charges, post-discharge medical needs, palliative care consults, and admission to rehab centers. Mortality was 7% in nonoperative, 9% in procedural, and 8% in surgical (P = .007) groups. In adjusted analyses, older age, palliative care consult, and non-Medicare payer status were associated with higher mortality. Compared to nonoperative, procedural and surgical groups resulted in increased costs (procedural: $17K more; surgical: $30K more).Conclusions: Admissions for procedural and surgical treatment of MBO are associated with increased LOS, hospital costs, and discharge needs. Optimal management remains challenging. Clinicians must examine all options prior to recommending palliative interventions given a trend towards higher resource utilization and mortality.

    View details for DOI 10.1177/00031348241256083

    View details for PubMedID 38782409

  • Factors Predicting Readmission and Mortality in Patients Admitted for Malignant Bowel Obstruction. The American surgeon Xu, N., Sun, B. J., Yue, T. M., Lee, B. 2024: 31348241250045


    Malignant bowel obstruction (MBO) is a common complication of patients with advanced malignancies and has poor prognosis. Currently, there are limited guidelines for MBO management or predicting outcomes for these patients.To identify patient factors associated with readmission and mortality after hospital admission for MBO.A 5-year retrospective review was performed from 2017 to 2022 at a single tertiary institution to evaluate patients admitted for MBO. All patients had advanced cancer of gastrointestinal or gynecologic primary. Patient demographics, socioeconomic factors, tumor characteristics, and inpatient outcomes were collected. Multivariable analyses were performed to determine variables predicting hospital readmission for recurrent MBO and 90-day mortality.210 patients were included. Mean age was 61 years, 28% were male, and 19% did not primarily speak English. 35% of patients lived over 50 miles from the hospital. On multivariable analysis, non-English speaking patients exhibited increased risk of readmission for MBO (OR = 2.82, P = .039). Older age was associated with decreased risk for MBO readmission (OR = .96, P = .007). Ascites was associated with increased mortality (OR = 2.17, P = .043). Earlier palliative care (PC) consultation predicted decreased readmission (OR = .24, P < .001) yet increased mortality at 90 days (OR = 3.20, P = .003).Patient age, primary language, and PC consult were predictors for MBO readmission, which may impact 90-day mortality. Given the palliative nature of MBO, modifiable factors such as PC consultation and multidisciplinary goals of care discussions should be prioritized in order to reduce readmissions and focus on quality of life (QOL) for this patient population.

    View details for DOI 10.1177/00031348241250045

    View details for PubMedID 38676624

  • Surgical Palliation for Malignant Bowel Obstruction in Preventing Hospital Readmission: Experience of a Tertiary Care Center. Annals of surgical oncology Sun, B. J., Yue, T. M., Xu, N., Ayala, C. I., Lee, B. 2024

    View details for DOI 10.1245/s10434-024-15318-5

    View details for PubMedID 38668918

  • ASO Author Reflections: Integrating Multimodal Pain Management Protocols into ERAS for Patients Undergoing CRS-HIPEC. Annals of surgical oncology Yue, T., Sun, B., Lee, B. 2024

    View details for DOI 10.1245/s10434-024-15178-z

    View details for PubMedID 38483646

  • Improved Postoperative Pain Management Outcomes After Implementation of Enhanced Recovery After Surgery (ERAS) Protocol for Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (CRS-HIPEC). Annals of surgical oncology Yue, T. M., Sun, B. J., Xu, N., Ohkuma, R., Fowler, C., Lee, B. 2024


    Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) for patients with peritoneal carcinomatosis is promising but has potential for significant morbidity and prolonged hospitalization. Enhanced Recovery After Surgery (ERAS) is a standardized protocol designed to optimize perioperative care. This study describes trends in epidural and opioid use after implementing ERAS for CRS-HIPEC at a tertiary academic center.A retrospective analysis of patients undergoing CRS-HIPEC from January 2020 to September 2023 was conducted. ERAS was implemented in February 2022. Medication and outcomes data were compared before and after ERAS initiation. All opioids were converted to morphine milligram equivalents (MMEs).A total of 136 patients underwent CRS-HIPEC: 73 (54%) pre- and 63 (46%) post-ERAS. Epidural usage increased from 63% pre-ERAS to 87% post-ERAS (p = 0.001). Compared with those without epidurals, patients with epidurals had decreased total 7-day oral and intravenous (IV) opioid requirements (45 MME vs. 316 MME; p < 0.001). There was no difference in 7-day opioid totals between pre- and post-ERAS groups. After ERAS, more patients achieved early ambulation (83% vs. 53%; p < 0.001), early diet initiation (81% vs. 25%; p < 0.001), and early return of bowel function (86% vs. 67%; p = 0.012).ERAS implementation for CRS-HIPEC was associated with increased epidural use, decreased oral and IV opioid use, and earlier bowel function return. Our study demonstrates that epidural analgesia provides adequate pain control while significantly decreasing oral and IV opioid use, which may promote gastrointestinal recovery postoperatively. These findings support the implementation of an ERAS protocol for effective pain management in patients undergoing CRS-HIPEC.

    View details for DOI 10.1245/s10434-024-15120-3

    View details for PubMedID 38466484

    View details for PubMedCentralID 3087875

  • Single cell pharmacogenic pipeline identifies novel opportunities in uterine leiomyosarcoma Daniel, S. K., Foster, D., Nosrati, F., Korah, M., Fallah, M., Sun, B. J., Loftus, T., Hu, D., Dua, M., Visser, B., Poultsides, G., Kirane, A., Longaker, M., Ganjoo, K., Lee, B., Delitto, D. SPRINGER. 2024: S42
  • Initial Multivisceral Resection for Retroperitoneal Liposarcoma Does Not Predict Improved Outcomes After Recurrence Sun, B. J., Yue, T. M., Nobuhara, C. K., Castro, S., Agolia, J. P., Lee, B. SPRINGER. 2024: S42
  • Timing of Palliative Care Consultation in Malignant Bowel Obstruction Management Decreases Hospital Readmission Sun, B., Yue, T., Xu, N., Einkauf, K. B., Lee, B. LIPPINCOTT WILLIAMS & WILKINS. 2023: S213-S214
  • Patient-Reported Resource Needs of Young Adult Surgical Oncology Patients with Advanced Cancer Diagnoses: A Qualitative Analysis Sun, B., Pang, E. M., Lee, B. LIPPINCOTT WILLIAMS & WILKINS. 2023: S260
  • PIPAC for Gastrointestinal Malignancies. Journal of clinical medicine Daniel, S. K., Sun, B. J., Lee, B. 2023; 12 (21)


    The peritoneum is a common site of metastases for gastrointestinal tumors that predicts a poor outcome. In addition to decreased survival, peritoneal metastases (PMs) can significantly impact quality of life from the resulting ascites and bowel obstructions. The peritoneum has been a target for regional therapies due to the unique properties of the blood-peritoneum barrier. Cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) have become accepted treatments for limited-volume peritoneal disease in appendiceal, ovarian, and colorectal malignancies, but there are limitations. Pressurized intraperitoneal aerosolized chemotherapy (PIPAC) improves drug distribution and tissue penetration, allowing for a minimally invasive application for patients who are not CRS/HIPEC candidates based on high disease burden. PIPAC is an emerging treatment that may convert the patient to resectable disease, and may increase survival without major morbidity, as indicated by many small studies. In this review, we discuss the rationale and benefits of PIPAC, as well as sentinel papers describing its application for gastric, colorectal, appendiceal, and pancreatobiliary PMs. While no PIPAC device has yet met FDA approval, we discuss next steps needed to incorporate PIPAC into neoadjuvant/adjuvant treatment paradigms, as well as palliative settings. Data on active clinical trials using PIPAC are provided.

    View details for DOI 10.3390/jcm12216799

    View details for PubMedID 37959264

    View details for PubMedCentralID PMC10650315

  • Results of the First Phase I PIPAC Trial in the United States: Braving the Storm ANNALS OF SURGICAL ONCOLOGY Sun, B. J., Lee, B. 2023
  • ASO Author Reflections: The Potential of ERAS in Standardizing Care for Patients Undergoing CRS-HIPEC. Annals of surgical oncology Sun, B. J., Lee, B. 2023

    View details for DOI 10.1245/s10434-023-14300-x

    View details for PubMedID 37707666

  • Detection of Circulating Tumor DNA Predicts Recurrence in Soft Tissue Sarcomas Sun, B. J., Li, A., Alobuia, W., Hur, D., Daniel, S. K., Kirane, A. R., Poultsides, G., Lee, B. SPRINGER. 2023: S16
  • Outcomes of Procedural-Based Palliation for Malignant Bowel Obstruction Sun, B. J., Xu, N., Yue, T. M., Einkauf, K. B., Lee, B. SPRINGER. 2023: S103
  • Efficacy of Surgical Management of Malignant Bowel Obstruction on Preventing Hospital Readmission - Experience of a Tertiary Care Center Sun, B. J., Ayala, C. I., Einkauf, K. B., Xu, N., Yue, T. M., Lee, B. SPRINGER. 2023: S110
  • A National Assessment of Disparities Between Rural-Urban Patients with Surgically Managed Advanced Appendiceal Cancer Li, A. Y., Sun, B. J., Tran, T. B., Lee, B., Eng, O. S. SPRINGER. 2023: S225
  • Facial Fractures Have Similar Outcomes When Managed by Either Otolaryngology or Plastic Surgery: Encounters From a Single Level I Trauma Center. Craniomaxillofacial trauma & reconstruction Christian, A., Sun, B. J., Khoshab, N., Grigorian, A., Cantwell, C. Y., Melucci, S. A., Hu, A. C., Kuza, C. M., Lekawa, M. E., Nahmias, J. 2022; 15 (2): 111-121


    Retrospective cohort.Traumatic facial fractures (FFs) often require specialty consultation with Plastic Surgery (PS) or Otolaryngology (ENT); however, referral patterns are often non-standardized and institution specific. Therefore, we sought to compare management patterns and outcomes between PS and ENT, hypothesizing no difference in operative rates, complications, or mortality.We performed a retrospective analysis of patients with FFs at a single Level I trauma center from 2014 to 2017. Patients were compared by consulting service: PS vs. ENT. Chi-square and Mann-Whitney-U tests were performed.Of the 755 patients with FFs, 378 were consulted by PS and 377 by ENT. There was no difference in demographic data (P > 0.05). Patients managed by ENT received a longer mean course of antibiotics (9.4 vs 7.0 days, P = 0.008) and had a lower rate of open reduction internal fixation (ORIF) (9.8% vs. 15.3%, P = 0.017), compared to PS patients. No difference was observed in overall operative rate (15.1% vs. 19.8%), use of computed tomography (CT) imaging (99% vs. 99%), time to surgery (65 vs. 55 hours, P = 0.198), length of stay (LOS) (4 vs. 4 days), 30-day complication rate (10.6% vs. 7.1%), or mortality (4.5% vs. 2.6%) (all P > 0.05).Our study demonstrated similar baseline characteristics, operative rates, complications, and mortality between FFs patients who had consultation by ENT and PS. This supports the practice of allowing both ENT and PS to care for trauma FFs patients, as there appears to be similar standardized care and outcomes. Future studies are needed to evaluate the generalizability of our findings.

    View details for DOI 10.1177/19433875211020615

    View details for PubMedID 35633765

    View details for PubMedCentralID PMC9133515

  • Improving tracheostomy delivery for trauma and surgical critical care patients: timely trach initiative. BMJ open quality McShane, E. K., Sun, B. J., Maggio, P. M., Spain, D. A., Forrester, J. D. 2022; 11 (2)


    BACKGROUND: Tracheostomy is recommended within 7days of intubation for patients with severe traumatic brain injury (TBI) or requiring prolonged mechanical ventilation. A quality improvement project aimed to decrease time to tracheostomy to ≤7days after intubation for eligible patients requiring tracheostomy in the surgical intensive care unit (SICU).LOCAL PROBLEM: From January 2017 to June 2018, approximately 85% of tracheostomies were performed >7days after intubation. The tracheostomy was placed a median of 10 days after intubation (range: 1-57).METHODS: Quality improvement principles were applied at an American College of Surgeons-verified level I trauma centre to introduce and analyse interventions to improve tracheostomy timing. Using the electronic health record, we analysed changes in tracheostomy timing, hospital length of stay (LOS), ventilator-associated pneumonia and peristomal bleeding rates for three subgroups: patients with TBI, trauma patients and all SICU patients.INTERVENTIONS: In July 2018, an educational roll-out for SICU residents and staff was launched to inform them of potential benefits of early tracheostomy and potential complications, which they should discuss when counselling patient decision-makers. In July 2019, an early tracheostomy workflow targeting patients with head injury was published in an institutional Trauma Guide app.RESULTS: Median time from intubation to tracheostomy decreased for all patients from 14 days (range: 4-57) to 8days (range: 1-32, p≤0.001), and median hospital LOS decreased from 38 days to 24 days (p<0.001, r=0.35). Median time to tracheostomy decreased significantly for trauma patients after publication of the algorithm (10 days (range: 3-21days) to 6days (range: 1-15days), p=0.03). Among patients with TBI, family meetings were held earlier for patients who underwent early versus late tracheostomy (p=0.008).CONCLUSIONS: We recommend regular educational meetings, enhanced by digitally published guidelines and strategic communication as effective ways to improve tracheostomy timing. These interventions standardised practice and may benefit other institutions.

    View details for DOI 10.1136/bmjoq-2021-001589

    View details for PubMedID 35551095

  • Moderate to severe leukocytosis with vasopressor use is associated with increased mortality in trauma patients. Journal of the Intensive Care Society Hasjim, B. J., Grigorian, A., Stopenski, S., Swentek, L., Sun, B., Livingston, J. K., Williams, B., Nastanski, F., Nahmias, J. 2022; 23 (2): 117-123


    Leukocytosis is a rise in white blood cell (WBC) count and clinical outcomes of moderate to severe leukocytosis in trauma patients have not been described. We hypothesized that trauma patients with severe leukocytosis (SL; ≥40.0 × 109 leukocytes/L) have higher rates of in-hospital complications and mortality than those with moderate leukocytosis (ML; 25.0-39 × 109 leukocytes/L).We performed a retrospective analysis (2010-2017) on trauma patients developing ML or SL at a single Level-I trauma center. A multivariable logistic regression analysis for risk factors were performed.From 15,807 trauma admissions, 332 (2.1%) had ML or SL. Of these, 308 (92.8%) were ML and 24 (7.2%) were SL. Patients with ML and SL reached their peak WBC count in 1 and 10 days after admission respectively (p < 0.001). SL patients suffered higher rates of in-hospital complications (p < 0.05) and mortality compared to those without ML or SL (14.5% vs. 3.3%, p < 0.001). Between ML and SL, mortality rates rose with leukocytosis severity (13.3% vs. 29.2%, p = 0.03). Among all patients with ML or SL, vasopressor use was the strongest independent risk factor for mortality (OR 12.61, p < 0.001).Clinicians should be weary of the increased mortality rates and in-hospital complications in SL patients. Among patients with ML or SL, vasopressor use, rather than SL, was the strongest predictor of mortality. Patients with ML had a quicker time course to peak leukocytosis compared to SL, suggesting these two entities to be distinct in etiology and outcome, warranting future research.

    View details for DOI 10.1177/1751143720975316

    View details for PubMedID 35615240

    View details for PubMedCentralID PMC9125442

  • Prevention of Creutzfeldt-Jakob Disease in Patients Undergoing Surgery. JAMA network open Sun, B. J., Forrester, J. D. 2022; 5 (3): e221561

    View details for DOI 10.1001/jamanetworkopen.2022.1561

    View details for PubMedID 35262721

  • Facial Fractures Have Similar Outcomes When Managed by Either Otolaryngology or Plastic Surgery: Encounters From a Single Level I Trauma Center CRANIOMAXILLOFACIAL TRAUMA & RECONSTRUCTION Christian, A., Sun, B. J., Khoshab, N., Grigorian, A., Cantwell, C. Y., Melucci, S. A., Hu, A. C., Kuza, C. M., Lekawa, M. E., Nahmias, J. 2021
  • Concomitant Sternal Fractures: Harbinger of Worse Pulmonary Complications and Mortality in Patients With Rib Fractures. The American surgeon Choi, J. n., Mulaney, B. n., Sun, B. n., Trimble, R. n., Tennakoon, L. n., Spain, D. A., Forrester, J. D. 2021: 3134821991978


    Sternal and rib fractures are common concomitant injuries. However, the impact of concurrent sternal fractures on clinical outcomes of patients with rib fractures is unclear. We aimed to unveil the pulmonary morbidity and mortality impact of concomitant sternal fractures among patients with rib fractures.We identified adult patients admitted with traumatic rib fractures with vs. without concomitant sternal fractures using the 2012-2014 National Inpatient Sample (NIS). After 2:1 propensity score matching and adjustment for residual imbalances, we compared risk of pulmonary morbidity and mortality between patients with vs. without concomitant sternal fractures. Subgroup analysis in patients with flail chest assessed whether sternal fractures modify the association between undergoing surgical stabilization of rib fractures (SSRF) and pulmonary morbidity or mortality.Of 475 710 encounters of adults admitted with rib fractures, 24 594 (5%) had concomitant sternal fractures. After 2:1 propensity score matching, patients with concomitant sternal fractures had 70% higher risk (95% CI: 50-90% higher, P < 0.001) of undergoing tracheostomy, 40% higher risk (30-50% higher, P <.001) of undergoing intubation, and 20% higher risk of respiratory failure (10-30% higher, P <.001) and mortality (10-40% higher, P =.007). Subgroup analysis of 8600 patients with flail chest showed concomitant sternal fractures did not impact the association between undergoing SSRF and any pulmonary morbidity or mortality.Concomitant sternal fractures are associated with increased risk for pulmonary morbidity and mortality among patients with rib fractures. However, our findings are limited by a binary definition of sternal fractures, which encompasses heterogeneous injury patterns with likely variable clinical relevance.

    View details for DOI 10.1177/0003134821991978

    View details for PubMedID 33522281

  • Systematic Review and Meta-Analysis of Hardware Failure in Surgical Stabilization of Rib Fractures: Who, What, When, Where, and Why? The Journal of surgical research Choi, J., Kaghazchi, A., Sun, B., Woodward, A., Forrester, J. D. 2021; 268: 190-198


    Surgical stabilization of rib fractures (SSRF) is increasingly used to reduce pulmonary complications and death among patients with rib fractures. However, the five Ws of hardware failure -who, what, when, where, and why- remains unclear. We aimed to synthesize available evidence on the five Ws and outline future research agenda for mitigating hardware failure.Experimental and observational studies published between 2009 and 2020 evaluating adults undergoing SSRF for traumatic rib fractures underwent evidence synthesis. We performed random effects meta-analysis of cohort/consecutive case studies. We calculated pooled prevalence of SSRF hardware failures using Freeman-Tukey double arcsine transformation and assessed study heterogeneity using DerSimonian-Laird estimation. We performed meta-regression with rib fracture acuity (acute or chronic) and hardware type (metal plate or not metal plate) as moderators.Twenty-nine studies underwent qualitative synthesis and 24 studies (2404 SSRF patients) underwent quantitative synthesis. Pooled prevalence of hardware failure was 4(3-7)%. Meta-regression showed fracture acuity was a significant moderator (P = 0.002) of hardware failure but hardware type was not (P = 0.23). Approximately 60% of patients underwent hardware removal after hardware failure. Mechanical failures were the most common type of hardware failure, followed by hardware infections, pain/discomfort, and non-union. Timing of hardware failure after surgery was highly variable, but 87% of failures occurred after initial hospitalization. Mechanical failures was attributed to technical shortcomings (i.e. short plate length) or excessive force on the thoracic cavity.SSRF hardware failure is an uncommon complication. Not all hardware failures are consequential, but insufficient individual patient data precluded characterizing where and why hardware failures occur. Minimizing SSRF hardware failure requires concerted research agenda to expand on the paucity of existing evidence.

    View details for DOI 10.1016/j.jss.2021.06.054

    View details for PubMedID 34333416

  • Modified percutaneous tracheostomy in patients with COVID-19. Trauma surgery & acute care open Sun, B. J., Wolff, C. J., Bechtold, H. M., Free, D., Lorenzo, J., Minot, P. R., Maggio, P. G., Spain, D. A., Weiser, T. G., Forrester, J. D. 2020; 5 (1): e000625


    Patients hospitalized with COVID-19 are at risk of developing hypoxic respiratory failure and often require prolonged mechanical ventilation. Indication and timing to perform tracheostomy is controversial in patients with COVID-19.This was a single-institution retrospective review of tracheostomies performed on patients admitted for COVID-19 between April 8, 2020 and August 1, 2020 using a modified percutaneous tracheostomy technique to minimize hypoxia and aerosolization.Twelve tracheostomies were performed for COVID-related respiratory failure. Median patient age was 54 years (range: 36-76) and 9 (75%) were male. Median time to tracheostomy was 17 days (range: 10-27), and 5 (42%) patients had failed attempts at extubation prior to tracheostomy. There were no intraprocedural complications, including hypoxia. Post-tracheostomy bleeding was noted in two patients. Eight (67%) patients have been discharged at the time of this study, and there were four patient deaths unrelated to tracheostomy placement. No healthcare worker transmissions resulted from participating in the tracheostomy procedure.A modified percutaneous tracheostomy is feasible and can be safely performed in patients infected with COVID-19.Level V, case series.

    View details for DOI 10.1136/tsaco-2020-000625

    View details for PubMedID 34192161

    View details for PubMedCentralID PMC7736959

  • Surgical technique for atrial-esophageal fistula repair after catheter ablation: An underrecognized complication. JTCVS techniques Guenthart, B. A., Sun, B., De Biasi, A., Fischbein, M. P., Liou, D. Z. 2020; 4: 169-172

    View details for DOI 10.1016/j.xjtc.2020.07.022

    View details for PubMedID 34318000

    View details for PubMedCentralID PMC8303005

  • Is there a role for artistic training in surgery? A multi-institutional assessment of general surgeons and plastic surgeons. Journal of plastic, reconstructive & aesthetic surgery : JPRAS Hu, A. C., Sun, B. J., Ng, W. K. 2020

    View details for DOI 10.1016/j.bjps.2020.10.047

    View details for PubMedID 33172825

  • Modified percutaneous tracheostomy in patients with COVID-19 Trauma Surg Acute Care Open Sun, B. J., Wolff, C. J., Bechtold, H. M., Free, D., Lorenzo, J., Minot, P. R., Maggio, P. G., Spain, D. A., Weiser, T. G., Forrester, J. D. 2020; 5 (1)
  • Recurrent Small Bowel Obstruction with Intraluminal Structures. The journal of trauma and acute care surgery Sun, B. J., Kopecky, K. E., Garcia, P. n., Spain, D. A. 2020

    View details for DOI 10.1097/TA.0000000000002956

    View details for PubMedID 33003015

  • The quality of systematic reviews addressing peripheral nerve repair and reconstruction JOURNAL OF PLASTIC RECONSTRUCTIVE AND AESTHETIC SURGERY Sun, B. J., Tijerina, J. D., Agbim, U. N., Lee, G. K., Nazerali, R. S. 2019; 72 (3): 447–56
  • The quality of systematic reviews addressing peripheral nerve repair and reconstruction. Journal of plastic, reconstructive & aesthetic surgery : JPRAS Sun, B. J., Tijerina, J. D., Agbim, U. N., Lee, G. K., Nazerali, R. S. 2018


    While systematic reviews are regarded as the strongest level of medical evidence, inconsistency in the quality and rigor of systematic reviews raises concerns about their use as a tool in guiding quality delivery in evidence-based clinical practice. The objective of this present study was to assess methodological soundness of systematic reviews with a particular focus on peripheral nerve repair and reconstruction. We performed a comprehensive search using PubMed and Scopus to identify all systematic reviews published on peripheral nerve reconstruction in 9 high-impact surgical journals. Two authors independently performed literature searches, screened abstracts, and extracted data. Discrepancies were resolved by discussion and consensus. The quality of systematic reviews was assessed using AMSTAR criteria. Initial search retrieved 184 articles. After screening duplicates, titles, abstracts, and conducting full text reviews, 26 studies met inclusion criteria. Of those, 18 (65%) were published by Plastic Surgery, 7 (27%) by Orthopedic Surgery, and 1 (4%) by Occupational Therapy. The total number of systematic reviews published on peripheral nerves each year has shown an increasing trend from 2004 through 2015. The overall median AMSTAR score was 5, reflecting a "fair" quality. There was no evidence of AMSTAR score improvement over time. Although the number of systematic reviews published on peripheral nerve repair has risen over the last decade, their quality has not exhibited the same increase. This highlights the necessity to increase familiarity with and conform to methodological quality criteria in order to improve the integrity of evidence-based medicine in peripheral nerve repair and reconstruction.

    View details for PubMedID 30655242

  • Defining Quality in Hand Surgery From the Patient'sPerspective: A Qualitative Analysis. The Journal of hand surgery Eppler, S. L., Kakar, S., Sheikholeslami, N., Sun, B., Pennell, H., Kamal, R. N. 2018


    PURPOSE: Quality measures are used to evaluate health care delivery. They are traditionally developed from the physician and health system viewpoint. This approach can lead to quality measures that promote care that may be misaligned with patient values and preferences. We completed an exploratory, qualitative study to identify how patients with hand problems define high-quality care. Our purpose was to develop a better understanding of the surgery and recovery experience of hand surgery patients, specifically focusing on knowledge gaps, experience, and the surgical process.METHODS: A steering committee (n= 10) of patients who had previously undergone hand surgery reviewed and revised an open-ended survey. Ninety-nine patients who had undergone hand surgery at 2 tertiary care institutions completed the open-ended, structured questionnaire during their 6- to 8-week postoperative clinic visit. Two reviewers completed a thematic analysis to generate subcodes and codes to identify themes in high-quality care from the patient's perspective.RESULTS: We identified 4 themes of high-quality care: (1) Being prepared and informed for the process of surgery, (2) Regaining hand function without pain or complication, (3) Patients and caregivers negotiating the physical and psychological challenges of recovery, and (4) Financial and logistical burdens of undergoing hand surgery.CONCLUSIONS: Multiple areas that patients identify as representing high-quality care are not reflected in current quality measures for hand surgery. The patient-derived themes of high-quality care can inform future patient-centered quality measure development.CLINICAL RELEVANCE: Efforts to improve health care delivery may have the greatest impact by addressing areas of care that are most valued by patients. Such areas include patient education, system navigation, the recovery process, and cost.

    View details for PubMedID 30031599

  • The Quality of Systematic Reviews in Head and Neck Microsurgery A Perspective from Plastic Surgery and Otolaryngology Sun, B. J., Tijerina, J., Nazerali, R. S., Lee, G. K. LIPPINCOTT WILLIAMS & WILKINS. 2018: S267–S273


    In recent years, there has been a push to publish higher level of evidence studies in medicine, particularly in plastic surgery. Well-conducted systematic reviews are considered the strongest level of evidence in medicine, recently becoming the key process indicators for quality delivery. A varying quality of systematic reviews, however, has led to concerns of their validity in clinical decision-making. We perform a quality analysis of systematic reviews published in head and neck microsurgery by the surgical specialties of plastic surgery and otolaryngology.An evaluation of systematic reviews published on microsurgery in 13 high-impact surgical journals was conducted by searching PubMed and Scopus. Two authors independently performed searches, screened for eligibility, and extracted data from included articles. Discrepancies were resolved by discussion and consensus. Assessment of Multiple Systematic Reviews (AMSTAR) criteria were used to assess methodological quality.The initial database search retrieved 166 articles. After removing duplicates, screening titles and abstracts, 26 articles remained for full text review. Seven did not focus on head and neck microsurgery and were further excluded, leaving 19 systematic reviews for final analysis. Of those, 10 systematic reviews were published by otolaryngology, and 9 were published by plastic surgery. Median AMSTAR score was 8 for otolaryngology, 7 for plastic surgery, and 8 overall, reflecting "fair to good" quality. The number of systematic reviews on head and neck microsurgery markedly increased over time. Of note, both the AMSTAR score and the number of systematic reviews published by plastic surgery have steadily increased from 2014 to 2016, whereas those published by otolaryngology have remained relatively stable since 2010.Our review shows a trend toward publishing more systematic reviews. The increasing quantity and quality of systematic reviews published by plastic surgeons indicates recognition in the need for higher levels of evidence in plastic surgery, as well as growing interest and advances in microsurgery. Given these trends, familiarity with quality assessment guidelines, such as AMSTAR, will remain important in providing a basis for building relevant value-based quality measures.

    View details for DOI 10.1097/SAP.0000000000001384

    View details for Web of Science ID 000473114300008

    View details for PubMedID 29489536

  • Complications After Two-Stage Expander Implant Breast Reconstruction Requiring Reoperation: A Critical Analysis of Outcomes. Annals of plastic surgery Sue, G. R., Sun, B. J., Lee, G. K. 2018; 80 (5S Suppl 5): S292–S294


    Two-stage expander implant breast reconstruction is commonly performed after mastectomy. Salvage and long-term outcomes after development of complications have not been well described. We examined a single surgeon's experience to study the rate of reoperation secondary to complications after first-stage expander placement and to evaluate their outcomes. Better understanding of salvage techniques may help guide future management.We performed a retrospective analysis of consecutive patients who underwent placement of a tissue expander (TE) for breast reconstruction between December 2006 and August 2015 with the senior author. Patient demographics including age, body mass index, medical comorbidities, history of smoking, and history of radiation to the breast were collected. Surgical factors including timing of reconstruction (immediate vs delayed) and location of TE (total submuscular vs with acellular dermal matrix) were recorded. Complications were analyzed, as were patients who underwent reoperation in the setting of developing a complication.We analyzed 282 patients who underwent 453 implant-based breast reconstructions. Of these, 39 patients and 45 breasts required a reoperation after development of a postoperative complication. Return to the operating room was associated with higher body mass index (29 vs 24, P < 0.001), higher TE initial fill volume (299 mL vs 169 mL, P < 0.001), and preoperative radiation (31% vs 13%, P = 0.001). Complications resulting in reoperation included infection (60%), mastectomy skin necrosis (27%), and TE extrusion through thin mastectomy skin (11%). The affected TE was removed and exchanged in 17 patients (38%), autologous flap reconstruction occurred in 16 patients (36%), and TE was explanted without replacement in 12 patients (27%).Infectious complications including cellulitis and abscess formation accounted for most cases requiring reoperation after TE placement for breast reconstruction. More than a quarter of patients who underwent a reoperation ultimately lost their implants. Patients undergoing two-stage expander implant breast reconstruction should be appropriately counseled regarding the possibility of requiring a reoperation in the setting of developing a complication.

    View details for DOI 10.1097/SAP.0000000000001382

    View details for PubMedID 29489547