- Cancer > GI Oncology
- Colon and Rectal Surgery Specialty
- Colorectal Surgery
- Cancer, Colon
- Colon and Rectal Surgery
Assistant Professor - Med Center Line, Surgery - General Surgery
Board Certification: Colon and Rectal Surgery, American Board of Colon and Rectal Surgery (2013)
Board Certification: General Surgery, American Board of Surgery (2011)
Board Certification, American Board of Surgery, General Surgery
Fellowship, Cleveland Clinic, OH, Colon and Rectal Surgery
Residency, Stanford Hospital and Clinics, General Surgery
MD, Columbia University, Medicine
BA, Harvard University, Government
Postdoctoral Faculty Sponsor
Graduate and Fellowship Programs
So Now My Patient Has Squamous Cell Cancer: Diagnosis, Staging, and Treatment of Squamous Cell Carcinoma of the Anal Canal and Anal Margin.
Clinics in colon and rectal surgery
2018; 31 (6): 353–60
Squamous cell carcinomas of the anal canal and the anal margin are rare malignancies that are increasing in incidence. Patients with these tumors often experience delayed treatment due to delay in diagnosis or misdiagnosis of the condition. Distinguishing between anal canal and anal margin tumors has implications for staging and treatment. Chemoradiation therapy is the mainstay of treatment for anal canal squamous cell, with abdominoperineal resection reserved for salvage treatment in cases of persistent or recurrent disease. Early anal margin squamous cell carcinoma can be treated with wide local excision, but more advanced tumors require a combination of chemoradiation therapy and surgical excision.
View details for PubMedID 30397394
TB or Not TB: Crohn's Disease, Peritoneal Tuberculosis, or Both?
Digestive diseases and sciences
View details for PubMedID 30334111
- Coordination of Care in Colorectal Cancer Patients: A Population-Based Study ELSEVIER SCIENCE INC. 2018: S141–S142
- Nonoperative Management of Appendicitis in Privately Insured Patients ELSEVIER SCIENCE INC. 2018: S156–S157
- Operative vs Nonoperative Management of Appendicitis: A Long-Term Cost-Effectiveness Analysis ELSEVIER SCIENCE INC. 2018: S157–S158
- Should Surgery Feel Like the Last Resort? Drivers of Decision Making in Inflammatory Bowel Disease ELSEVIER SCIENCE INC. 2018: S163–S164
Depression and Healthcare Utilization in Patients with Inflammatory Bowel Disease.
Journal of Crohn's & colitis
Background: Depression frequently co-occurs in patients with inflammatory bowel disease (IBD) and is a driver in health care costs and utilization.Aim: This study examined the associations between depression and total health care costs, emergency department (ED) visits, computed tomography (CT) scans during ED/inpatient visits, and IBD-related surgery among IBD patients.Methods: Our sample included 331,772 IBD patients from a national administrative claims database (Truven Health MarketScan Database). Gamma and Poisson regression analyses assessed differences related to depression controlling for key variables.Results: Approximately 16% of the IBD cohort was classified as having depression. Depression was associated with a $17,706 (95% CI [$16,892, 18,521]) increase in mean annual IBD-related health care costs and an increased incidence of ED visits (aIRR of 1.5; 95% CI [1.5, 1.6]). Among patients who had ≥1 ED/inpatient visits, depression was associated with an increased probability of receiving repeated CT scans (1-4 CT scans aOR of 1.6; 95% CI [1.5, 1.7]; ≥5 CT scans aOR 4.6; 95% CI [2.9, 7.3]) and increased odds of undergoing an IBD-related surgery (aOR of 1.2; 95% CI [1.1, 1.2]). Secondary analysis with a pediatric subsample revealed approximately 12% of this cohort was classified as having depression, and depression was associated with increased costs and incidence rates of ED visits and CT scans, but not IBD-related surgery.Conclusion: Quantifiable differences in healthcare costs and patterns of utilization exist among patients with IBD and depression. Integration of mental health services within IBD care may improve overall health outcomes and costs of care.
View details for PubMedID 30256923
Nationwide Trends in Acute and Chronic Pancreatitis Among Privately Insured Children and Non-Elderly Adults in the United States, 2007-2014.
Epidemiologic analyses of acute and chronic pancreatitis (AP and CP) provide insight into causes and strategies for prevention, and affect allocation of resources to its study and treatment. We sought to determine current and accurate incidences of AP and CP, along with the prevalence of CP, in children and adults in the United States.We collected data from the Truven MarketScan Research Databases of commercial inpatient and outpatient insurance claims in the United States from 2007 through 2014 (patients 0-64 years old). We calculated the incidences of AP and CP, and prevalence of CP, based on International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes. Children were defined as 18 years or younger and adults as 19 to 64 years old.The incidence of pediatric AP was stable from 2007 through 2014, remaining at 12.3/100,000 persons in 2014. Meanwhile the incidence for adult AP decreased from 123.7/100,000 persons in 2007 to 111.2/100,000 persons in 2014. The incidence of CP decreased over time in children (2.2/100,000 persons in 2007 to 1.9/100,000 persons in 2014) and adults (31.7/100,000 persons in 2007 to 24.7/100,000 persons in 2014). The prevalence of pediatric and adult CP was 5.8/100,000 persons and 91.9/100,000 persons, respectively in 2014. Incidences of AP and CP increased with age; we found little change in incidence during the first decade of life, but linear increases starting in the second decade.We performed a comprehensive epidemiologic analysis of privately insured non-elderly adults and children with AP and CP in the United States. Changes in gallstone formation, smoking, and alcohol consumption, along with advances in pancreatitis management, may be responsible for the stabilization and even decrease in the incidences of AP and CP.
View details for PubMedID 29660323
Frequency and Timing of Short-Term Complications Following Abdominoperineal Resection
Journal of Surgical Research
2018; 231: 69-76
View details for DOI 10.1016/j.jss.2018.05.009
Perianal Extramammary Paget's Disease: More Than Meets the Eye.
Digestive diseases and sciences
View details for PubMedID 29696480
Starting Young: Trends in Opioid Therapy Among US Adolescents and Young Adults With Inflammatory Bowel Disease in the Truven MarketScan Database Between 2007 and 2015.
Inflammatory bowel diseases
Opioids are commonly prescribed for relief in inflammatory bowel disease (IBD). Emerging evidence suggests that adolescents and young adults are a vulnerable population at particular risk of becoming chronic opioid users and experiencing adverse effects.This study evaluates trends in the prevalence and persistence of chronic opioid therapy in adolescents and young adults with IBD in the United States.A longitudinal retrospective cohort analysis was conducted with the Truven MarketScan Database from 2007 to 2015. Study subjects were 15-29 years old with ≥2 IBD diagnoses (Crohn's: 555/K50; ulcerative colitis: 556/K51). Opioid therapy was identified with prescription claims within the Truven therapeutic class 60: opioid agonists. Persistence of opioid use was evaluated by survival analysis for patients who remained in the database for at least 3 years following index chronic opioid therapy use.In a cohort containing 93,668 patients, 18.2% received chronic opioid therapy. The annual prevalence of chronic opioid therapy increased from 9.3% in 2007 to 10.8% in 2015 (P < 0.01), peaking at 12.2% in 2011. Opioid prescriptions per patient per year were stable (approximately 5). Post hoc Poisson regression analyses demonstrated that the number of opioid pills dispensed per year increased with age and was higher among males. Among the 2503 patients receiving chronic opioid therapy and followed longitudinally, 30.5% were maintained on chronic opioid therapy for 2 years, and 5.3% for all 4 years.Sustained chronic opioid use in adolescents and young adults with IBD is increasingly common, underscoring the need for screening and intervention for this vulnerable population.
View details for PubMedID 29986015
As Infliximab Use for Ulcerative Colitis Has Increased, so Has the Rate of Surgical Resection.
Journal of gastrointestinal surgery
Infliximab was approved for ulcerative colitis in 2005 after randomized trials showed it reduced the risk of colectomy. Its effect on population-level surgery rates is unknown. Our aim is to assess the impact of infliximab approval for ulcerative colitis on surgical intervention.Retrospective review of a private insurance claims database (2002 to 2013) was performed of patients aged 18-64 diagnosed with ulcerative colitis and with 2 years of follow-up. Outcome measures were infliximab treatment and surgical resection. Multivariable logistic regression used independent variables of time period of diagnosis, age, gender, comorbidities, and insurance type.The cohort included 58,681 patients. Age, gender, and comorbidities were comparable across time periods. Patients diagnosed in the post-infliximab period had greater odds of undergoing infliximab treatment within the first year of diagnosis than those in the pre-infliximab era (OR = 2.88, p < 0.001). However, the odds of undergoing total colectomy or total proctocolectomy were also higher in patients diagnosed in the post-infliximab period (OR 1.5, p < 0.001).The use of infliximab for ulcerative colitis has, as expected, increased since its approval, but so has the risk of surgery. Thus, the introduction of biologic therapy has not decreased the risk for surgery for this patient population.
View details for DOI 10.1007/s11605-017-3431-0
View details for PubMedID 28484890
- Black Is the New Black: Prolapsing Primary Anorectal Melanoma. Digestive diseases and sciences 2017
Surgery for diverticulitis in the 21st century: recent evidence.
Minerva gastroenterologica e dietologica
Sigmoid diverticulitis is an increasingly common disease in Western countries. As technology has led to increased knowledge about the disease and options for treatment, management strategies have become less certain. In previous years, the rationale for early elective surgery was largely preventive, due to concern that diverticulitis recurrence would result in increased risk of sepsis or the need for a colostomy. New technology has enabled diagnosis, through computed tomography scans, predictive information through clinical and administrative databases, and less invasive treatment options, through laparoscopic techniques. While the new data have mitigated outdated beliefs regarding recurrence prevention strategies, there is little to replace previous guidelines for care. For example, we lack clear guidelines for whether and when to use percutaneous drainage, intra-peritoneal lavage, minimally invasive techniques, and fecal diversion via ostomy. Fortunately, several newly published high impact studies attempt to address these more nuanced questions. In this paper, we review available findings and potential for use of the data from recent surgical randomized controlled trials. It is important to note that controlling sepsis when present remains the most important goal of treatment.
View details for DOI 10.23736/S1121-421X.17.02389-3
View details for PubMedID 28240005
- Say What? Bannayan-Riley-Ruvalcaba Syndrome Presenting with Gastrointestinal Bleeding Due to Hamartoma-Induced Intussusception. Digestive diseases and sciences 2017
Deep Immune Profiling of an Arginine-Enriched Nutritional Intervention in Patients Undergoing Surgery.
Journal of immunology (Baltimore, Md. : 1950)
Application of high-content immune profiling technologies has enormous potential to advance medicine. Whether these technologies reveal pertinent biology when implemented in interventional clinical trials is an important question. The beneficial effects of preoperative arginine-enriched dietary supplements (AES) are highly context specific, as they reduce infection rates in elective surgery, but possibly increase morbidity in critically ill patients. This study combined single-cell mass cytometry with the multiplex analysis of relevant plasma cytokines to comprehensively profile the immune-modifying effects of this much-debated intervention in patients undergoing surgery. An elastic net algorithm applied to the high-dimensional mass cytometry dataset identified a cross-validated model consisting of 20 interrelated immune features that separated patients assigned to AES from controls. The model revealed wide-ranging effects of AES on innate and adaptive immune compartments. Notably, AES increased STAT1 and STAT3 signaling responses in lymphoid cell subsets after surgery, consistent with enhanced adaptive mechanisms that may protect against postsurgical infection. Unexpectedly, AES also increased ERK and P38 MAPK signaling responses in monocytic myeloid-derived suppressor cells, which was paired with their pronounced expansion. These results provide novel mechanistic arguments as to why AES may exert context-specific beneficial or adverse effects in patients with critical illness. This study lays out an analytical framework to distill high-dimensional datasets gathered in an interventional clinical trial into a fairly simple model that converges with known biology and provides insight into novel and clinically relevant cellular mechanisms.
View details for PubMedID 28794234
Gender disparities in scholarly productivity of US academic surgeons
JOURNAL OF SURGICAL RESEARCH
2016; 203 (1): 28-33
Female surgeons have faced significant challenges to promotion over the past decades, with attrition rates supporting a lack of improvement in women's position in academia. We examine gender disparities in research productivity, as measured by the number of citations, publications, and h-indices, across six decades.The online profiles of full-time faculty members of surgery departments of three academic centers were reviewed. Faculty members were grouped into six cohorts by decade, based on year of graduation from medical school. Differences between men and women across cohorts as well as by academic rank were examined.The profiles of 978 surgeons (234 women and 744 men) were reviewed. The number of female faculty members in the institutions increased significantly over time, reaching the current percentage of 35.3%. Significant differences in number of articles published were noted at the assistant and full but not at the associate, professor level. Women at these ranks had fewer publications than men. Gender differences were also found in all age cohorts except among the most recent who graduated in the 2000s. The impact of publications, as measured by h-index and number of citations, was not consistently significantly different between the genders at any age or rank.We identified a consistent gender disparity in the number of publications for female faculty members across a 60-year span. Although the youngest cohort, those who graduated in the 2000s, appeared to avoid the gender divide, our data indicate that overall women still struggle with productivity in the academic arena.
View details for DOI 10.1016/j.jss.2016.03.060
View details for Web of Science ID 000378170200005
View details for PubMedID 27338531
Complex and Reoperative Colorectal Surgery: Setting Expectations and Learning from Experience
CLINICS IN COLON AND RECTAL SURGERY
2016; 29 (2): 75-79
A range of topics are covered in this issue dedicated to complex and reoperative colorectal surgery, from radiation-induced surgical problems, to enterocutaneous fistulas and locally advanced or recurrent rectal cancer. Common themes include the importance of operative planning and patient counseling on the expected functional outcomes. Experts in the field offer their technical tips and clinical lessons to maximize outcomes and minimize complications in these challenging cases.
View details for DOI 10.1055/s-0036-1580634
View details for Web of Science ID 000375966300003
View details for PubMedID 27247530
View details for PubMedCentralID PMC4882175
- Double Rarities, Double Challenges: Extra-Mammary Paget's Disease and Anal Adenocarcinoma. Digestive diseases and sciences 2016; 61 (4): 996-999
- Double Rarities, Double Challenges: Extra-Mammary Paget's Disease and Anal Adenocarcinoma DIGESTIVE DISEASES AND SCIENCES 2016; 61 (4): 996-999
Equivocal Effect of Intraoperative Fluorescence Angiography on Colorectal Anastomotic Leaks
DISEASES OF THE COLON & RECTUM
2015; 58 (6): 582-587
Intraoperative fluorescence angiography is beneficial in several surgical settings to assess tissue perfusion. It is also used to assess bowel perfusion, but its role in improving outcomes in colorectal surgery has not been studied.The purpose of this work was to determine whether intraoperative angiography decreases colorectal anastomotic leaks.This was a case-matched retrospective study in which patients were matched 1:1 with respect to sex, age, level of anastomosis, presence of a diverting loop ileostomy, and preoperative pelvic radiation therapy.The study was conducted at an academic medical center.Patients who underwent colectomy or proctectomy with primary anastomoses were included.The intraoperative use of fluorescence angiography to assess perfusion of the colon for anastomosis was studied.Anastomotic leak within 60 days and whether angiography changed surgical management were the main outcomes measured.Case matching produced 173 pairs. The groups were also comparable with respect to BMI, smoking status, diabetes mellitus, surgical indications, and type of resection. In patients who had intraoperative angiography, 7.5% developed anastomotic leak, whereas 6.4% of those without angiography did (p value not significant). Univariate analysis revealed that preoperative pelvic radiation, more distal anastomosis, surgeon, and diverting loop ileostomy were positively associated with anastomotic leak. Multivariate analysis demonstrated that level of anastomosis and surgeon were associated with leaks. Poor perfusion of the proximal colon seen on angiography led to additional colon resection before anastomosis in 5% of patients who underwent intraoperative angiography.The retrospective study design with the use of historical control subjects, selection bias, and small sample size were limitations to this study.Intraoperative fluorescence angiography to assess the perfusion of the colon conduit for anastomosis was not associated with colorectal anastomotic leak. Perfusion is but one of multiple factors contributing to anastomotic leaks. Additional studies are necessary to determine whether this technology is beneficial for colorectal surgery.
View details for DOI 10.1097/DCR.0000000000000320
View details for Web of Science ID 000354100400011
View details for PubMedID 25944430
The Prognostic Significance of Pretreatment Hematologic Parameters in Patients Undergoing Resection for Colorectal Cancer.
American journal of clinical oncology
The prognostic value of several hematologic parameters, including platelet, lymphocyte, and neutrophil counts, has been studied in a variety of solid tumors. In this study, we examined the significance of inflammatory markers and their prognostic implications in patients with colorectal cancer (CRC).Patients with stage I-III CRC who underwent surgical resection at the Stanford Cancer Institute between 2005 and 2009 were included. Patients were excluded if they did not have preoperative complete blood counts performed within 1 month of surgical resection, underwent preoperative chemotherapy or radiation, had metastatic disease at diagnosis, or had another previous malignancy. We included 129 eligible patients with available preoperative complete blood counts in the final analysis.A preoperative neutrophil-to-lymphocyte ratio of>3.3 was significantly associated with worse disease-free (DFS) and overall survival (OS) (P=0.009, 0.003), as was a preoperative lymphocyte-to-monocyte ratio of ≤2.6 (P=0.01, 0.002). Preoperative lymphopenia (P=0.002) was associated with worse OS but not DFS (P=0.09). In addition, preoperative thrombocytosis was associated with worse DFS (P=0.006) and OS (P=0.010). Preoperative leukocytosis was associated with worse OS (P=0.048) but not DFS (P=0.49). Preoperative hemoglobin was neither associated with OS (P=0.24) or DFS (P=0.15).Pretreatment lymphopenia, thrombocytosis, a decreased lymphocyte-to-monocyte ratio, and an elevated neutrophil-to-lymphocyte ratio independently predict for worse OS in patients with CRC.
View details for PubMedID 25756348
- Study shows insufficient decrease in wound complications with sutured versus stapled skin closure in gastrointestinal operations. Evidence-based medicine 2014; 19 (3): 100-?
- Perioperative Outcomes of Major Noncardiac Surgery in Adults with Congenital Heart Disease ANESTHESIOLOGY 2013; 119 (4): 762-769
Perioperative outcomes of major noncardiac surgery in adults with congenital heart disease.
2013; 119 (4): 762-769
An increasing number of patients with congenital heart disease are surviving to adulthood. Consensus guidelines and expert opinion suggest that noncardiac surgery is a high-risk event, but few data describe perioperative outcomes in this population.By using the Nationwide Inpatient Sample database (years 2002 through 2009), the authors compared patients with adult congenital heart disease (ACHD) who underwent noncardiac surgery with a non-ACHD comparison cohort matched on age, sex, race, year, elective or urgent or emergency procedure, van Walraven comborbidity score, and primary procedure code. Mortality and morbidity were compared between the two cohorts.A study cohort consisting of 10,004 ACHD patients was compared with a matched comparison cohort of 37,581 patients. Inpatient mortality was greater in the ACHD cohort (407 of 10,004 [4.1%] vs. 1,355 of 37,581 [3.6%]; unadjusted odds ratio, 1.13; P = 0.031; adjusted odds ratio, 1.29; P < 0.001). The composite endpoint of perioperative morbidity was also more commonly observed in the ACHD cohort (2,145 of 10.004 [21.4%] vs. 6,003 of 37,581 [16.0%]; odds ratio, 1.44; P < 0.001). ACHD patients comprised an increasing proportion of all noncardiac surgical admissions over the study period (P value for trend is <0.001), and noncardiac surgery represented an increasing proportion of all ACHD admissions (P value for trend is <0.001).Compared with a matched control cohort, ACHD patients undergoing noncardiac surgery experienced increased perioperative morbidity and mortality. Within the limitations of a retrospective analysis of a large administrative dataset, this finding demonstrates that this is a vulnerable population and suggests that better efforts are needed to understand and improve the perioperative care they receive.
View details for DOI 10.1097/ALN.0b013e3182a56de3
View details for PubMedID 23907357
Colorectal cancer diagnostics: biomarkers, cell-free DNA, circulating tumor cells and defining heterogeneous populations by single-cell analysis.
Expert review of molecular diagnostics
2013; 13 (6): 581-599
Reliable biomarkers are needed to guide treatment of colorectal cancer, as well as for surveillance to detect recurrence and monitor therapeutic response. In this review, the authors discuss the use of various biomarkers in addition to serum carcinoembryonic antigen, the current surveillance method for metastatic recurrence after resection. The clinical relevance of mutations including microsatellite instability, KRAS, BRAF and SMAD4 is addressed. The role of circulating tumor cells and cell-free DNA with regards to their implementation into clinical use is discussed, as well as how single-cell analysis may fit into a monitoring program. The detection and characterization of circulating tumor cells and cell-free DNA in colorectal cancer patients will not only improve the understanding of the development of metastasis, but may also supplant the use of other biomarkers.
View details for DOI 10.1586/14737159.2013.811896
View details for PubMedID 23895128
Predictors of postoperative urinary retention after colorectal surgery.
Diseases of the colon & rectum
2013; 56 (6): 738-746
: National quality initiatives have mandated the earlier removal of urinary catheters after surgery to decrease urinary tract infection rates. A potential unintended consequence is an increased postoperative urinary retention rate.: The aim of this study was to determine the incidence and risk factors for postoperative urinary retention after colorectal surgery.: This was a prospective observational study.: A colorectal unit within a single institution was the setting for this study.: Adults undergoing elective colorectal operations were included.: Urinary catheters were removed on postoperative day 1 for patients undergoing abdominal operations, and on day 3 for patients undergoing pelvic operations. Postvoid residual and retention volumes were measured.: The primary outcomes measured were urinary retention and urinary tract infection.: The overall urinary retention rate was 22.4% (22.8% in the abdominal group, 21.9% in the pelvic group) and was associated with longer operative time and increased perioperative fluid administration. Mean operative time for those with retention was 2.8 hours and, for those without retention, the mean operative time 2.2 hours (abdominal group 2 hours vs 1.4 hours, pelvic group 3.9 hours vs 3.1 hours, p ≤ 0.02). Patients with retention received a mean of 2.7L during the operation, whereas patients without retention received 1.8L (abdominal group 1.9L vs 1.4L, pelvic group 3.6L vs 2.2L, p < 0.01). In the abdominal group, patients with and without retention also received different fluid volumes on postoperative days 1 (2.2L vs 1.7L, p = 0.004) and 2 (1.6L vs 1L, p = 0.05). Laparoscopic abdominal group had a 40% retention rate in comparison with 12% in the open abdominal group (p = 0.004). Age, sex, preoperative radiation therapy, preoperative prostatism, preoperative diagnosis, and level of anastomosis were not associated with retention. The urinary tract infection rate was 4.9%.: The lack of documentation of preoperative urinary function was a limitation of this study.: The practice of earlier urinary catheter removal must be balanced with operative time and fluid volume to avoid high urinary retention rates. Also important is increased vigilance for the early detection of retention.
View details for DOI 10.1097/DCR.0b013e318280aad5
View details for PubMedID 23652748
Accidental Puncture or Laceration in Colorectal Surgery: A Quality Indicator or a Complexity Measure?
Meeting of the American-Society-of-Colon-and-Rectal-Surgeons (ASCRS)
LIPPINCOTT WILLIAMS & WILKINS. 2013: 219–25
Accidental puncture or laceration during a surgical procedure is a patient safety indicator that is publicly reported and will factor into the Centers for Medicare and Medicaid's pay-for-performance plan. Accidental puncture or laceration includes serosal tear, enterotomy, and injury to the ureter, bladder, spleen, or blood vessels.This study aimed to identify risk factors and assess surgical outcomes related to accidental puncture or laceration.This is a retrospective study.This study was conducted in a single-hospital department of colorectal surgery.Inpatients undergoing colorectal surgery in which an accidental puncture or laceration did or did not occur were selected.The primary outcomes measured were surgical complications, length of stay, and readmission.Of 2897 operations, 269 had accidental puncture or laceration (9.2%) including serosal tear (47%), enterotomy (38%), and extraintestinal injuries (15%). Accidental puncture or laceration cases had more diagnoses of enterocutaneous fistula (11% vs 2%, p < 0.001), reoperative cases (91% vs 61%, p < 0.001), open surgery (96% vs 77%, p < 0.001), longer operative times (186 vs 146 minutes, p = 0.001), and increased length of stay (10 vs 7 days, p = 0.002). Patients with serosal tears had entirely similar outcomes to those without an injury, whereas patients with enterotomies had increased operative times and length of stay, and patients with extraintestinal injuries had higher rates of reoperation and sepsis (p < 0.05 for all).This study was limited by the loss of sensitivity due to grouping extraintestinal injuries.Accidental puncture or laceration is more likely to occur in complex colorectal operations. The clinical consequences range from none to significant depending on the specific type of injury. To make accidental puncture or laceration a more meaningful quality indicator, we advocate that groups who use the measure eliminate the injuries that have no bearing on surgical outcome and that risk adjustment for operative complexity is performed.
View details for DOI 10.1097/DCR.0b013e3182765c43
View details for Web of Science ID 000313550100015
View details for PubMedID 23303151
Assessment of the Clinical Usefulness of Imaging Modalities in Identifying Postoperative Upper Gastrointestinal Tract Leaks Requiring Reoperation
SURGICAL LAPAROSCOPY ENDOSCOPY & PERCUTANEOUS TECHNIQUES
2012; 22 (4): 328-332
To assess the usefulness of imaging modalities in the diagnosis and determination of whether postoperative upper gastrointestinal tract leak (UGITL) requires operative intervention.: Patients with suspected UGITL who underwent reoperation ≤ 30 days after the primary operation with intraoperative confirmation of leaks were identified. Data of those patients who had undergone computerized tomography (CT) or upper gastrointestinal contrast study (UGIS) before reoperation were reviewed. The usefulness and impact of imaging studies obtained before reoperation were evaluated.Thirty patients with confirmed UGITL were identified, 24 of whom had undergone imaging studies before reoperation. Fourteen CTs (63.7%) and 4 UGIS (67%) were positive or highly indicative of UGITL. The interval between the primary operation and the reoperation and the morbidity rates after the reoperation were similar between patients with and those without imaging studies before the reoperation (5.6 ± 4.8 vs. 6.8 ± 4.2 d, P=0.55; 91.6% vs. 100%, P=0.29, respectively). False-negative imaging results caused postponement of reoperation by ≥ 24 hours in 4 patients whose outcome was similar to those with true-positive results.CTs and UGIS are supportive tools when deciding whether to reoperate for postoperative UGITL. However, a negative imaging study for UGITL does not exclude it definitively, and therefore should not replace clinical evaluations.
View details for DOI 10.1097/SLE.0b013e3182517e3a
View details for Web of Science ID 000307671400030
View details for PubMedID 22874681
The impact of hepatic portoenterostomy on liver transplantation for the treatment of biliary atresia: Early failure adversely affects outcome
2012; 16 (4): 373-378
The most common indication for pediatric LTx is biliary atresia with failed HPE, yet the effect of previous HPE on the outcome after LTx has not been well characterized. We retrospectively reviewed a single-center experience with 134 consecutive pediatric liver transplants for the treatment of biliary atresia from 1 May 1995 to 28 April 2008. Of 134 patients, 22 underwent LTx without prior HPE (NPE), while 112 patients underwent HPE first. HPE patients were grouped into EF, defined as need for LTx within the first year of life, and LF, defined as need for LTx beyond the first year of life. NPE and EF groups differed significantly from the LF group in age, weight, PELD, and ICU status (p < 0.05) with NPE having the highest PELD and ICU status. Patients who underwent salvage LTx after EF following HPE had a significantly higher incidence of post-operative bacteremia and septicemia (p < 0.05), and subsequently lower survival rates. One-year patient survival and graft survival were as follows: NPE 100%, EF 81%, and LF 96% (p < 0.05); and NPE 96%, EF 79%, and LF 96% (p < 0.05). Further investigation into the optimal treatment of biliary atresia should focus on identifying patients at high risk of EF who may benefit from proceeding directly to LTx given the increased risk of post-LTx bacteremia, sepsis, and death after failed HPE.
View details for DOI 10.1111/j.1399-3046.2012.01677.x
View details for Web of Science ID 000303998800021
View details for PubMedID 22463739
Utility of liver allograft biopsy obtained at procurement
2008; 14 (5): 639-646
Extended-donor criteria (EDC) liver allografts potentiate the role of procurement biopsy in organ utilization. To expedite allocation, histologic evaluation is routinely performed upon frozen-section (FS) specimens by local pathologists. This descriptive study compares FS reports by local pathologists with permanent-section (PS) evaluation by dedicated hepatopathologists, identifies histologic characteristics underrepresented by FS evaluation, and evaluates the efficacy of a biopsy decision analysis based on organ visualization. Fifty-two liver transplants using EDC allografts evaluated by FS with PS were studied. Pathologic worksheets created by an organ procurement organization were applied in 34 FS. PS analysis included 7 staining procedures for 8 histologic criteria. PS from 56 additional allografts determined not to require donor biopsy were also analyzed. A high correlation was observed between FS and PS. Underestimation of steatosis by FS was associated with allograft dysfunction. Surgical assessment of cholestasis, congestion, and steatosis was accurate whereas inflammation, necrosis, and fibrosis were underestimated in allografts suffering parenchymal injury. In conclusion, the correlation between FS and PS is high, and significant discrepancies are rare. Biopsy is not a prerequisite for EDC utilization but is suggested in hepatitis C, hypernatremia, donation after cardiac death, or multiple EDC indications. Implementation of a universal FS worksheet could standardize histologic reporting and facilitate data collection, allocation, and research.
View details for DOI 10.1002/lt.21419
View details for Web of Science ID 000255581800010
View details for PubMedID 18324657
Extended-donor criteria liver allografts
SEMINARS IN LIVER DISEASE
2006; 26 (3): 221-233
Extended-donor criteria liver allografts do not meet traditional criteria for transplantation. Although these organs offer immediate expansion of the donor pool, transplantation of extended-donor criteria liver allografts increases potential short- and long-term risk to the recipient. This risk may manifest as impaired allograft function or donor-transmitted disease. Guidelines defining this category of donor, level of acceptable risk, principles of consent, and post-transplantation surveillance have not been defined. This article reviews the utilization, ethical considerations, and outcomes of extended-donor criteria liver allografts.
View details for DOI 10.1055/s-2006-947292
View details for Web of Science ID 000239388500004
View details for PubMedID 16850371
Utilization of extended donor criteria liver allografts maximizes donor use and patient access to liver transplantation
125th Annual Meeting of the American-Surgical-Association
LIPPINCOTT WILLIAMS & WILKINS. 2005: 556–65
The objective of this study was to evaluate the effect of systematic utilization of extended donor criteria liver allografts (EDC), including living donor allografts (LDLT), on patient access to liver transplantation (LTX).Utilization of liver allografts that do not meet traditional donor criteria (EDC) offer immediate expansion of the donor pool. EDC are typically allocated by transplant center rather than regional wait-list priority (RA). This single-institution series compares outcomes of EDC and RA allocation to determine the impact of EDC utilization on donor use and patient access to LTX.The authors conducted a retrospective analysis of 99 EDC recipients (49 deceased donor, 50 LDLT) and 116 RA recipients from April 2001 through April 2004. Deceased-donor EDC included: age >65 years, donation after cardiac death, positive viral serology (hepatitis C, hepatitis B core antibody, human T-cell lymphotrophic), split-liver, hypernatremia, prior carcinoma, steatosis, and behavioral high-risk donors. Outcome variables included patient and graft survival, hospitalization, initial graft function, and complication categorized as: biliary, vascular, wound, and other.EDC recipients were more frequently diagnosed with hepatitis C virus or hepatocellular carcinoma and had a lower model for end-stage liver disease (MELD) score at LTX (P < 0.01). Wait-time, technical complications, and hospitalization were comparable. Log-rank analysis of Kaplan-Meier survival estimates demonstrated no difference in patient or graft survival; however, deaths among deceased-donor EDC recipients were frequently the result of patient comorbidities, whereas LDLT and RA deaths resulted from graft failure (P < 0.01). EDC increased patient access to LTX by 77% and reduced pre-LTX mortality by over 50% compared with regional data (P < 0.01).Systematic EDC utilization maximizes donor use, increases access to LTX, and significantly reduces wait-list mortality by providing satisfactory outcomes to select recipients.
View details for DOI 10.1097/01.sla.0000183973.49899.b1
View details for Web of Science ID 000232357200011
View details for PubMedID 16192816