Cindy Kin, MD, MS, FACS, FASCRS

All Publications

• No thanks and not for me: A qualitative study of barriers to prehabilitation participation. Surgery Clemons, J., Zhou, Z., Hoy, S. A., Gerber, S. Q., Nambiar, A., Kwon, A., Kin, C. 2024

  Abstract

  Prehabilitation programs have been shown to improve functional status prior to surgery, postoperative recovery, and even long-term outcomes. However, these programs often lack participation, often by patients who seem to need it the most. This study aimed to identify the primary reasons for patients' declining enrollment or low adherence to a prehabilitation program.We recruited adult patients who had undergone or planned to undergo major abdominal surgery for semistructured one-on-one audio-recorded interviews. Interviews were transcribed verbatim and iteratively coded deductively and inductively. Thematic analysis was performed.We interviewed 11 patients, at which point we reached thematic saturation. The patients were on average 53 years old (range 38-75) and 27% were women and 73% were men. The pooled kappa score was 0.81, indicating concordance among the coding researchers. Seven potential barriers to prehabilitation participation and adherence were identified: poorly timed recruitment efforts, misconceptions about prehabilitation diet recommendations, competing priorities that made prehabilitation less feasible, lack of family alignment, belief that prehabilitation would not be helpful, concerns over specific prehabilitation program components, and belief that prehabilitation is helpful for others but not for themselves.Low participation and adherence limit the success and reach of many prehabilitation programs. Improved timing and content of communication by the prehabilitation team is critical for improving recruitment of patients. Flexibility and customization may reframe prehabilitation as feasible rather than a difficult chore, increasing participation and adherence. Understanding patients' concerns and readiness to adopt new health behaviors is a necessary component of any behavioral intervention.

  View details for DOI 10.1016/j.surg.2024.08.014

  View details for PubMedID 39306566

• Gastrointestinal Surgical Patient and Multidisciplinary Healthcare Provider Beliefs and Practices Around Perioperative Nutrition: A Mixed-Methods Study. The Journal of surgical research Arbaugh, C., Kimura, C., Kin, C. 2024; 302: 80-91

  Abstract

  INTRODUCTION: Nutrition is critical to gastrointestinal (GI) disease prevention and treatment, including operations, yet perioperative nutrition practices vary widely. We aimed to understand GI surgical patient and health care provider's perioperative nutrition beliefs and practices.MATERIALS AND METHODS: We used a mixed-methods approach, including a patient survey (n=19), provider survey (n=26), and semistructured interviews with a subset of providers (n=15). Providers included surgeons, gastroenterologists, medical oncologists, advanced practice providers, and dietitians. Provider interviews were transcribed, iteratively coded, and thematically analyzed. Quantitative and qualitative data were integrated.RESULTS: 94.7% of patients and 100% of providers surveyed believe that nutrition affects outcomes. Patients seek nutrition information from diverse resources (73.7% from websites or blogs, 42.1% from documentaries, and 36.8% from books or /magazines) and people (52.6% from family members, 42.1% from a significant other, partner, or spouse, and 36.8% from a dietitian or nutritionist). Providers cited a lack of quality information, misinformation, and inconsistency among health care providers as barriers to high-quality nutrition care. Both patients and providers noted that nutritional supplements have drawbacks, with 100% of patients and 96.2% of providers expressing interest in house- made plant-based protein smoothie or soup alternatives.CONCLUSIONS: This study led to the development of a multidisciplinary task force, which has collaborated on multiple interventions to improve inpatient perioperative surgical nutrition (e.g., smoothie pilot and postoperative menu revisions).

  View details for DOI 10.1016/j.jss.2024.07.030

  View details for PubMedID 39094260

• Phase II trial of organ preservation program using short-course radiation and FOLFOXIRI for rectal cancer (SHORT-FOX). Pollom, E. L., Fisher, G. A., Shelton, A., Johnson, T., Chen, C., Jackson, S., Shaheen, S., Holden, T., Bien, J., King, D., Morris, A. M., Kin, C., Dawes, A., Kirilcuk, N., Gahagan, J., Vitzthum, L., Sheth, V., Brown, E., Pratapneni, A., Chang, D. LIPPINCOTT WILLIAMS & WILKINS. 2024

  View details for Web of Science ID 001275557400852

• Society for Surgery of the Alimentary Tract State-of-the-Art Session 2022: Frailty in Surgery. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract Keller, D. S., Kimura, C. M., Kin, C. J., Chu, D. I., Smith, B. P., Dhala, A., Arrington, A. K., Clark, C. J., Winslow, E. R., Al-Refaie, W. B., Khaitan, P. G. 2024; 28 (2): 158-163

  Abstract

  Given the exponentially aging population and rising life expectancy in the United States, surgeons are facing a challenging frail population who may require surgery but may not qualify based on their general fitness. There is an urgent need for greater awareness of the importance of frailty measurement and the implementation of universal assessment of frail patients into clinical practice. Pairing risk stratification with stringent protocols for prehabilitation and minimally invasive surgery and appropriate enhanced recovery protocols could optimize and condition frail patients before, during, and immediately after surgery to mitigate postoperative complications and consequences on patient function and quality of life. In this paper, highlights from the 2022 Society for Surgery of the Alimentary Tract State-of-the-Art Session on frailty in surgery are presented. This work aims to improve the understanding of the impact of frailty on patients and the methods used to augment the outcomes for frail patients during their surgical experience.

  View details for DOI 10.1016/j.gassur.2023.10.004

  View details for PubMedID 38445937

• GITR and TIGIT immunotherapy provokes divergent multicellular responses in the tumor microenvironment of gastrointestinal cancers. Genome medicine Sathe, A., Ayala, C., Bai, X., Grimes, S. M., Lee, B., Kin, C., Shelton, A., Poultsides, G., Ji, H. P. 2023; 15 (1): 100

  Abstract

  Understanding the mechanistic effects of novel immunotherapy agents is critical to improving their successful clinical translation. These effects need to be studied in preclinical models that maintain the heterogenous tumor microenvironment (TME) and dysfunctional cell states found in a patient's tumor. We investigated immunotherapy perturbations targeting co-stimulatory molecule GITR and co-inhibitory immune checkpoint TIGIT in a patient-derived ex vivo system that maintains the TME in its near-native state. Leveraging single-cell genomics, we identified cell type-specific transcriptional reprogramming in response to immunotherapy perturbations.We generated ex vivo tumor slice cultures from fresh surgical resections of gastric and colon cancer and treated them with GITR agonist or TIGIT antagonist antibodies. We applied paired single-cell RNA and TCR sequencing to the original surgical resections, control, and treated ex vivo tumor slice cultures. We additionally confirmed target expression using multiplex immunofluorescence and validated our findings with RNA in situ hybridization.We confirmed that tumor slice cultures maintained the cell types, transcriptional cell states and proportions of the original surgical resection. The GITR agonist was limited to increasing effector gene expression only in cytotoxic CD8 T cells. Dysfunctional exhausted CD8 T cells did not respond to GITR agonist. In contrast, the TIGIT antagonist increased TCR signaling and activated both cytotoxic and dysfunctional CD8 T cells. This included cells corresponding to TCR clonotypes with features indicative of potential tumor antigen reactivity. The TIGIT antagonist also activated T follicular helper-like cells and dendritic cells, and reduced markers of immunosuppression in regulatory T cells.We identified novel cellular mechanisms of action of GITR and TIGIT immunotherapy in the patients' TME. Unlike the GITR agonist that generated a limited transcriptional response, TIGIT antagonist orchestrated a multicellular response involving CD8 T cells, T follicular helper-like cells, dendritic cells, and regulatory T cells. Our experimental strategy combining single-cell genomics with preclinical models can successfully identify mechanisms of action of novel immunotherapy agents. Understanding the cellular and transcriptional mechanisms of response or resistance will aid in prioritization of targets and their clinical translation.

  View details for DOI 10.1186/s13073-023-01259-3

  View details for PubMedID 38008725

  View details for PubMedCentralID PMC10680277

• Remote Telemonitoring with a Human Touch: a Promising Addition to Post-discharge Care for Surgical Patients. World journal of surgery Zhou, Z., Kin, C. 2023

  View details for DOI 10.1007/s00268-023-07232-w

  View details for PubMedID 37932501

• Impact of preoperative uni- or multimodal prehabilitation on postoperative morbidity: meta-analysis. BJS open Cambriel, A., Choisy, B., Hedou, J., Bonnet, M., Fellous, S., Lefevre, J. H., Voron, T., Gaudilliere, D., Kin, C., Gaudilliere, B., Verdonk, F. 2023; 7 (6)

  Abstract

  BACKGROUND: Postoperative complications occur in up to 43% of patients after surgery, resulting in increased morbidity and economic burden. Prehabilitation has the potential to increase patients' preoperative health status and thereby improve postoperative outcomes. However, reported results of prehabilitation are contradictory. The objective of this systematic review is to evaluate the effects of prehabilitation on postoperative outcomes (postoperative complications, hospital length of stay, pain at postoperative day 1) in patients undergoing elective surgery.METHODS: The authors performed a systematic review and meta-analysis of RCTs published between January 2006 and June 2023 comparing prehabilitation programmes lasting ≥14 days to 'standard of care' (SOC) and reporting postoperative complications according to the Clavien-Dindo classification. Database searches were conducted in PubMed, CINAHL, EMBASE, PsycINFO. The primary outcome examined was the effect of uni- or multimodal prehabilitation on 30-day complications. Secondary outcomes were length of ICU and hospital stay (LOS) and reported pain scores.RESULTS: Twenty-five studies (including 2090 patients randomized in a 1:1 ratio) met the inclusion criteria. Average methodological study quality was moderate. There was no difference between prehabilitation and SOC groups in regard to occurrence of postoperative complications (OR = 1.02, 95% c.i. 0.93 to 1.13; P = 0.10; I2 = 34%), total hospital LOS (-0.13 days; 95% c.i. -0.56 to 0.28; P = 0.53; I2 = 21%) or reported postoperative pain. The ICU LOS was significantly shorter in the prehabilitation group (-0.57 days; 95% c.i. -1.10 to -0.04; P = 0.03; I2 = 46%). Separate comparison of uni- and multimodal prehabilitation showed no difference for either intervention.CONCLUSION: Prehabilitation reduces ICU LOS compared with SOC in elective surgery patients but has no effect on overall complication rates or total LOS, regardless of modality. Prehabilitation programs need standardization and specific targeting of those patients most likely to benefit.

  View details for DOI 10.1093/bjsopen/zrad129

  View details for PubMedID 38108466

• Barriers and Facilitators of Surgical Prehabilitation Adherence from the Patient Perspective: a Mixed Method Study. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract Kimura, C., Liu, Y., Crowder, S. E., Arbaugh, C., Mai, U., Shankar, K., Shelton, A., Visser, B., Kin, C. 2023

  Abstract

  Adherence to prehabilitation is crucial for optimal benefit, but reasons for low adherence to home-based programs remain unexplored. Our aim was to identify and explore barriers and facilitators to prehabilitation adherence among patients undergoing abdominal surgery.Nested in a single-center randomized controlled trial on prehabilitation (Perioperative Optimization With Enhanced Recovery (POWER)), this study had an explanatory sequential design with a connect integration. Patients randomized to the intervention arm were included in the quantitative analysis, and a subset of them was invited for a semi-structured interview. The exposure was the frequency of barriers to physical activity and healthy eating, and the outcome was adherence to those components of prehabilitation. Logistic or linear regression was used as appropriate.Among 133 participants in the intervention arm, 116 (87.2%) completed the initial survey ((56.9% women, median age 61 years old (IQR 49.0; 69.4)). The most frequent barriers to exercise and healthy eating were medical issues (59%) and lack of motivation (31%), respectively. There was no significant association between the barriers to physical activity score and adherence to this component of the program (OR 0.89, 95% CI 0.78-1.02, p=0.09). Higher barriers to healthy eating scores were associated with lower Mediterranean diet scores pre- and post-intervention (coef.: -0.32, 95% CI: -0.49; -0.15, p<0.001; and coef.: -0.27, 95% CI: -0.47; -0.07, p=0.01, respectively). Interviews with 15 participants revealed that participating in prehabilitation was a motivator for healthy eating and exercising through goal setting, time-efficient workouts, and promoting self-efficacy.We identified key barriers to be addressed and facilitators to be leveraged in future prehabilitation programs.NCT04504266.

  View details for DOI 10.1007/s11605-023-05857-9

  View details for PubMedID 37848690

  View details for PubMedCentralID 7165160

• Impact of Preoperative Uni- or Multimodal Prehabilitation on Postoperative Morbidity: A Systematic Review and Meta-Analysis Verdonk, F., Choisy, B., Cambriel, A., Hedou, J., Bonnet, M., Lefevre, J., Voron, T., Gaudilliere, D., Kin, C., Gaudilliere, B. LIPPINCOTT WILLIAMS & WILKINS. 2023: 806-807

  View details for Web of Science ID 001058985600285

• GITR and TIGIT immunotherapy provokes divergent multi-cellular responses in the tumor microenvironment of gastrointestinal cancers. bioRxiv : the preprint server for biology Sathe, A., Ayala, C., Bai, X., Grimes, S. M., Lee, B., Kin, C., Shelton, A., Poultsides, G., Ji, H. P. 2023

  Abstract

  Understanding the cellular mechanisms of novel immunotherapy agents in the human tumor microenvironment (TME) is critical to their clinical success. We examined GITR and TIGIT immunotherapy in gastric and colon cancer patients using ex vivo slice tumor slice cultures derived from cancer surgical resections. This primary culture system maintains the original TME in a near-native state. We applied paired single-cell RNA and TCR sequencing to identify cell type specific transcriptional reprogramming. The GITR agonist was limited to increasing effector gene expression only in cytotoxic CD8 T cells. The TIGIT antagonist increased TCR signaling and activated both cytotoxic and dysfunctional CD8 T cells, including clonotypes indicative of potential tumor antigen reactivity. The TIGIT antagonist also activated T follicular helper-like cells and dendritic cells, and reduced markers of immunosuppression in regulatory T cells. Overall, we identified cellular mechanisms of action of these two immunotherapy targets in the patients' TME.

  View details for DOI 10.1101/2023.03.13.532299

  View details for PubMedID 36993756

  View details for PubMedCentralID PMC10054933

• Using AI and computer vision to analyze technical proficiency in robotic surgery. Surgical endoscopy Yang, J. H., Goodman, E. D., Dawes, A. J., Gahagan, J. V., Esquivel, M. M., Liebert, C. A., Kin, C., Yeung, S., Gurland, B. H. 2022

  Abstract

  BACKGROUND: Intraoperative skills assessment is time-consuming and subjective; an efficient and objective computer vision-based approach for feedback is desired. In this work, we aim to design and validate an interpretable automated method to evaluate technical proficiency using colorectal robotic surgery videos with artificial intelligence.METHODS: 92 curated clips of peritoneal closure were characterized by both board-certified surgeons and a computer vision AI algorithm to compare the measures of surgical skill. For human ratings, six surgeons graded clips according to the GEARS assessment tool; for AI assessment, deep learning computer vision algorithms for surgical tool detection and tracking were developed and implemented.RESULTS: For the GEARS category of efficiency, we observe a positive correlation between human expert ratings of technical efficiency and AI-determined total tool movement (r=-0.72). Additionally, we show that more proficient surgeons perform closure with significantly less tool movement compared to less proficient surgeons (p<0.001). For the GEARS category of bimanual dexterity, a positive correlation between expert ratings of bimanual dexterity and the AI model's calculated measure of bimanual movement based on simultaneous tool movement (r=0.48) was also observed. On average, we also find that higher skill clips have significantly more simultaneous movement in both hands compared to lower skill clips (p<0.001).CONCLUSIONS: In this study, measurements of technical proficiency extracted from AI algorithms are shown to correlate with those given by expert surgeons. Although we target measurements of efficiency and bimanual dexterity, this work suggests that artificial intelligence through computer vision holds promise for efficiently standardizing grading of surgical technique, which may help in surgical skills training.

  View details for DOI 10.1007/s00464-022-09781-y

  View details for PubMedID 36536082

• Is It Really Gone? Assessing Response to Neoadjuvant Therapy in Rectal Cancer. Journal of gastrointestinal cancer Kimura, C., Crowder, S. E., Kin, C. 2022

  Abstract

  PURPOSE: Non-operative management of rectal cancer is a feasible and appealing treatment option for patients who develop a complete response after neoadjuvant therapy. However, identifying patients who are complete responders is often a challenge. This review aims to present and discuss current evidence and recommendations regarding the assessment of treatment response in rectal cancer.METHODS: A review of the current literature on rectal cancer restaging was performed. Studies included in this review explored the optimal interval between the end of neoadjuvant therapy and restaging, as well as modalities of assessment and their diagnostic performance.RESULTS: The current standard for restaging rectal cancer is a multimodal assessment with the digital rectal examination, endoscopy, and T2-weighted MRI with diffusion-weighted imaging. Other diagnostic procedures under investigation are PET/MRI, radiomics, confocal laser endomicroscopy, artificial intelligence-assisted endoscopy, cell-free DNA, and prediction models incorporating one or more of the above-mentioned exams.CONCLUSION: Non-operative management of rectal cancer requires a multidisciplinary approach. Understanding of the robustness and limitations of each exam is critical to inform patient selection for that treatment strategy.

  View details for DOI 10.1007/s12029-022-00889-x

  View details for PubMedID 36417142

• Association of an Online Home-Based Prehabilitation Program With Outcomes After Colorectal Surgery. JAMA surgery Kimura, C. S., Bidwell, S., Gurland, B., Morris, A., Shelton, A., Kin, C. 2022

  Abstract

  This quality improvement study evaluates the association of an online home-based patient prehabilitation program with colorectal surgery outcomes.

  View details for DOI 10.1001/jamasurg.2022.4485

  View details for PubMedID 36322070

• Augmented reality neuronavigation for en bloc resection of spinal column lesions. World neurosurgery Tigchelaar, S. S., Medress, Z. A., Quon, J., Dang, P., Barbery, D., Bobrow, A., Kin, C., Louis, R., Desai, A. 2022

  Abstract

  Primary tumors involving the spine are relatively rare but represent surgically challenging procedures with high patient morbidity. En bloc resection of these tumors necessitates large exposures, wide tumor margins, and poses risks to functionally relevant anatomical structures. Augmented reality Neuronavigation (ARNV) represents a paradigm shift in neuronavigation, allowing on-demand visualization of 3-Dimensional navigation data in real-time directly in line with the operative field. Here, we describe the first application of ARNV to perform distal sacrococcygectomies for the en bloc removal of sacral and retrorectal lesions involving the coccyx in two patients, as well as a thoracic 9-11 laminectomy with costotransversectomy for en bloc removal of a schwannoma in a third patient. In our experience, ARNV allowed our teams to minimize the length of the incision, reduce the extent of bony resection, and enhanced visualization of critical adjacent anatomy. All tumors were resected en bloc, and the patients recovered well postoperatively, with no known complications. Pathologic analysis confirmed the en bloc removal of these lesions with negative margins. We conclude that AR is an effective strategy for the precise, en bloc removal of spinal lesions including both sacrococcygeal tumors involving the retrorectal space and thoracic schwannomas.

  View details for DOI 10.1016/j.wneu.2022.08.143

  View details for PubMedID 36096393

• Adherence to a Home-Based Prehabilitation Program for Patients Undergoing Colorectal Surgery. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract Kimura, C., Bidwell, S., Shankar, K., Shelton, E., Shelton, A., Kin, C. 2022

  View details for DOI 10.1007/s11605-022-05446-2

  View details for PubMedID 36050618

• Integrated single-cell and plasma proteomic modeling to predict surgical site complications, a prospective cohort study Tsai, A. S., Hedou, J., Einhaus, J., Rumer, K., Verdonk, F., Stanley, N., Choisy, B., Ganio, E. A., Bonham, A., Jacobsen, D., Warrington, B., Gao, X., Tingle, M., McAllister, T., Fallahzadeh, R., Feyaerts, D., Stelzer, I., Gaudilliere, D., Ando, K., Shelton, A., Morris, A., Kebebew, E., Aghaeepour, N., Kin, C., Angst, M. S., Gaudilliere, B. LIPPINCOTT WILLIAMS & WILKINS. 2022: 1204-1205

  View details for Web of Science ID 000840283001162

• Multimodal, coached telehealth prehabilitation has high compliance and improves exercise and cognitive capacity prior to surgery: a pilot study Choisy, B., Hedou, J., Verdonk, F., Gaudilliere, D., Tsai, A. S., Shankar, K., Sato, M., Einhaus, J., Ganio, E. A., Bonham, A., Warrington, B., Ahmad, S., Tingle, M., Ando, K., Bruckman, S., Angst, M. S., Kin, C., Gaudilliere, B. LIPPINCOTT WILLIAMS & WILKINS. 2022: 415

  View details for Web of Science ID 000840283000157

• Mitigating Bias in Postoperative Pain Management: a Critical Piece of the Opioid Puzzle. World journal of surgery Kimura, C., Kin, C. 2022

  View details for DOI 10.1007/s00268-022-06554-5

  View details for PubMedID 35394229

• Phase II trial of organ preservation program using short-course radiation and folfoxiri for rectal cancer (SHORT-FOX) Pollom, E. L., Shelton, A., Fisher, G. A., Bien, J., King, D., Johnson, T., Chen, C., Shaheen, S., Chong, C., Vitzthum, L., Kirilcuk, N., Morris, A. M., Kin, C., Dawes, A., Sheth, V., Sundaram, V., Brown, E., Chang, D. LIPPINCOTT WILLIAMS & WILKINS. 2022

  View details for DOI 10.1200/JCO.2022.40.4_suppl.TPS218

  View details for Web of Science ID 000770995900213

• Association of Prehabilitation With Postoperative Opioid Use in Colorectal Surgery: An Observational Cohort Study. The Journal of surgical research Lee, A., Shelton, E., Bidwell, S., Shankar, K., Ando, K., Gaudilliere, B., Shelton, A., Kin, C. 1800; 273: 226-232

  Abstract

  INTRODUCTION: Preoperative optimization programs have demonstrated positive effects on perioperative physical function and surgical outcomes. In nonsurgical populations, physical activity and healthy diet may reduce pain and pain medication requirement, but this has not been studied in surgical patients. Our aim was to determine whether a preoperative diet and exercise intervention affects postoperative pain and pain medication use.METHODS: Patients undergoing abdominal colorectal surgery were invited to participate in a web-based patient engagement program. Those enrolling in the first and third time periods received information on the standard perioperative pathway (enhanced recovery after surgery [ERAS]). Those enrolling in the second time period also received reminders on nutrition and exercise (PREHAB+ERAS). The primary outcome was postoperative inpatient opioid use. The secondary outcomes were inpatient postoperative pain scores and nonopioid pain medication use.RESULTS: The ERAS and PREHAB+ERAS groups were similar in demographic and operative characteristics. Subgroup analysis of patients who activated their accounts demonstrated that the two groups had similar average maximum daily pain scores, but the PREHAB+ERAS group (n=158) used 15.9 fewer oral morphine equivalents per postoperative inpatient day than the ERAS group (n=92), representing a 30% decrease (53mg versus 37.1mg, P=0.04). The two groups used comparable amounts of acetaminophen, gabapentin, and ketorolac. Generalized linear models demonstrated that PREHAB+ERAS, minimally invasive surgery, and older age were associated with lower inpatient opioid use.CONCLUSIONS: Access to a web-based preoperative diet and exercise program may reduce inpatient opioid use after major elective colorectal surgery. Further studies are necessary to determine whether the degree of adherence to nutrition and physical activity recommendations has a dose-dependent effect on opioid use.

  View details for DOI 10.1016/j.jss.2021.12.023

  View details for PubMedID 35101683

• Integrated Single-Cell and Plasma Proteomic Modeling to Predict Surgical Site Complications: A Prospective Cohort Study. Annals of surgery Rumer, K. K., Hedou, J., Tsai, A., Einhaus, J., Verdonk, F., Stanley, N., Choisy, B., Ganio, E., Bonham, A., Jacobsen, D., Warrington, B., Gao, X., Tingle, M., McAllister, T. N., Fallahzadeh, R., Feyaerts, D., Stelzer, I., Gaudilliere, D., Ando, K., Shelton, A., Morris, A., Kebebew, E., Aghaeepour, N., Kin, C., Angst, M. S., Gaudilliere, B. 1800

  Abstract

  OBJECTIVE: The aim of this study was to determine whether single-cell and plasma proteomic elements of the host's immune response to surgery accurately identify patients who develop a surgical site complication (SSC) after major abdominal surgery.SUMMARY BACKGROUND DATA: SSCs may occur in up to 25% of patients undergoing bowel resection, resulting in significant morbidity and economic burden. However, the accurate prediction of SSCs remains clinically challenging. Leveraging high-content proteomic technologies to comprehensively profile patients' immune response to surgery is a promising approach to identify predictive biological factors of SSCs.METHODS: Forty-one patients undergoing non-cancer bowel resection were prospectively enrolled. Blood samples collected before surgery and on postoperative day one (POD1) were analyzed using a combination of single-cell mass cytometry and plasma proteomics. The primary outcome was the occurrence of an SSC, including surgical site infection, anastomotic leak, or wound dehiscence within 30 days of surgery.RESULTS: A multiomic model integrating the single-cell and plasma proteomic data collected on POD1 accurately differentiated patients with (n = 11) and without (n = 30) an SSC [area under the curve (AUC) = 0.86]. Model features included coregulated proinflammatory (eg, IL-6- and MyD88- signaling responses in myeloid cells) and immunosuppressive (eg, JAK/STAT signaling responses in M-MDSCs and Tregs) events preceding an SSC. Importantly, analysis of the immunological data obtained before surgery also yielded a model accurately predicting SSCs (AUC = 0.82).CONCLUSIONS: The multiomic analysis of patients' immune response after surgery and immune state before surgery revealed systemic immune signatures preceding the development of SSCs. Our results suggest that integrating immunological data in perioperative risk assessment paradigms is a plausible strategy to guide individualized clinical care.

  View details for DOI 10.1097/SLA.0000000000005348

  View details for PubMedID 34954754

• Worse outcomes and higher costs of care in fibrostenotic Crohn's disease: a real-world propensity-matched analysis in the USA. BMJ open gastroenterology Dehghan, M., Wong, G., Neuberger, E., Kin, C., Rieder, F., Park, K. T. 1800; 8 (1)

  Abstract

  BACKGROUND: Patients with Crohn's disease (CD) may develop fibrostenotic strictures. No currently available therapies prevent or treat fibrostenotic CD (FCD), making this a critical unmet need.AIM: To compare health outcomes and resource utilisation between CD patients with and without fibrostenotic disease.METHODS: Patients aged ≥18 years with FCD and non-FCD between 30 October 2015 and 30 September 2018 were identified in the Truven MarketScan Commercial Claims and Encounters Database. We conducted 1:3 nearest neighbour propensity score matching on age, sex, malnutrition, payer type, anti-tumour necrosis factor use, and Charlson Comorbidity Index score. Primary outcomes up to 1 year from the index claim were ≥1 hospitalisation, ≥1 procedure, ≥1 surgery, and steroid dependency (>100 day supply). Associations between FCD diagnosis and outcomes were estimated with a multivariable logistic regression model. This study was exempt from institutional review board approval.RESULTS: Propensity score matching yielded 11 022 patients. Compared with non-FCD, patients with FCD had increased likelihood of hospitalisations (17.1% vs 52.4%; p<0.001), endoscopic procedures (4.4% vs 8.6%; p<0.001), IBD-related surgeries (4.7% vs 9.1%; p<0.001), steroid dependency (10.0% vs 15.7%; p<0.001), and greater mean annual costs per patient ($47 575 vs $77609; p<0.001). FCD was a significant risk factor for ≥1 hospitalisation (adjusted OR (aOR), 6.1), ≥1 procedure (aOR, 2.1), ≥1 surgery (aOR, 2.0), and steroid dependency (aOR, 1.7).CONCLUSIONS: FCD was associated with higher risk for hospitalisation, procedures, abdominal surgery, and steroid dependency. Patients with FCD had a greater mean annual cost per patient. FCD represents an ongoing unmet medical need.

  View details for DOI 10.1136/bmjgast-2021-000781

  View details for PubMedID 34930755

• Are You Really the Doctor? Physician Experiences with Gendered Microaggressions from Patients. Journal of women's health (2002) Ahmad, S. R., Ahmad, T. R., Balasubramanian, V., Facente, S., Kin, C., Girod, S. 2021

  Abstract

  Background: In contrast to physician implicit bias toward patients, bias and microaggressions from patients toward physicians have received comparatively less attention. Materials and Methods: We captured physician experiences of gendered microaggressions from patients by conducting a mixed-methods survey-based study of physicians at a single academic health care institution in May 2019. A quantitative portion assessed the frequency of gendered microaggressions (microaggression experiences [ME] score) and the association with measures of perceived impacts (job satisfaction, burnout, perceived career impacts, behavioral modifications). A one-tailed Wilcoxon rank sum test compared distributional frequencies of microaggressions by gender, and by gender and race. Chi-square tests measured the associations between gendered microaggressions and perceived impacts. Welch two-sample t-tests assessed differences in ME scores by rank and specialty. Linear regression assessed the association of ME scores and job satisfaction/burnout. A qualitative portion solicited anecdotal experiences, analyzed by inductive thematic analysis. Results: There were 297 completed surveys (response rate 27%). Female physicians experienced a significantly higher frequency of gendered microaggressions (p<0.001) compared with male physicians. Microaggressions were significantly associated with job satisfaction (chi-square 6.83, p=0.009), burnout (chi-square 8.76, p=0.003), perceived career impacts (chi-square 18.67, p<0.001), and behavioral modifications (chi-square 19.96, p<0.001). Trainees experienced more microaggressions (p=0.009) and burnout (p=0.009) than faculty. Higher ME scores predicted statistically significant increases in burnout (p<0.0001) and reduced job satisfaction (p=0.02). Twelve microaggressions themes emerged from the qualitative responses, including role questioning and assumption of inexperience. The frequency of microaggressions did not vary significantly by race; however, qualitative responses described race as a factor. Conclusions: Physicians experience gendered microaggressions from patients, which may influence job satisfaction, burnout, career perceptions, and behavior. Future research may explore the multidirectionality of microaggressions and tools for responding at the individual and institutional level.

  View details for DOI 10.1089/jwh.2021.0169

  View details for PubMedID 34747651

• Engagement and Adherence with a Web-Based Prehabilitation Program for Patients Awaiting Abdominal Colorectal Surgery. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract Shelton, E., Barreto, N. B., Bidwell, S., Folk-Tolbert, M., Shelton, A., Trickey, A. W., Kin, C. J. 2021

  Abstract

  BACKGROUND: Understanding the drivers of patient engagement and adherence is critical to developing and implementing preoperative optimization programs. The aim of this project is to determine whether existing health beliefs are associated with engagement and adherence in a home-based online prehabilitation program.METHODS: Patients undergoing abdominal colorectal operations were enrolled in an online nutrition and exercise program. We collected baseline health beliefs and mindsets, daily exercises, and weekly diet recalls. Multivariable binary logistic regression predicted engagement, multivariable ordinary least squares regression predicted diet adherence, and generalized linear models with a binomial distribution predicted engagement and exercise adherence.RESULTS: Of the 227 patients who agreed to participate, 75% activated their accounts; of those, 75% used the program. Engagement with the program was unrelated to health beliefs or mindsets. Positive diet-related health beliefs and a growth mindset were associated with positive diet behaviors and inversely associated with negative diet behaviors. Exercise-related health beliefs and mindsets were not associated with exercise adherence. Patients enrolled within 4weeks of surgery used the program more than those enrolled more than 4weeks from surgery.CONCLUSIONS: This app-based prehabilitation program demonstrated moderate acceptability, engagement, and adherence. Addressing health beliefs and mindsets may be an effective way of increasing adherence to diet recommendations. To increase adherence to exercise recommendations, further assessment of potential barriers is critical. While an online platform is a highly promising scalable strategy, more customization and user engagement are necessary to make it an effective way of delivering a preoperative health behavior change intervention.

  View details for DOI 10.1007/s11605-021-05171-2

  View details for PubMedID 34668165

• Cec and You Shall Find: Cecal Perforation in a Patient with COVID-19. Digestive diseases and sciences Baiu, I., Forgo, E., Kin, C., Weiser, T. G. 2021

  View details for DOI 10.1007/s10620-020-06810-5

  View details for PubMedID 33492532

• Measuring the human immune response to surgery: multiomics for the prediction of postoperative outcomes. Current opinion in critical care Verdonk, F., Einhaus, J., Tsai, A. S., Hedou, J., Choisy, B., Gaudilliere, D., Kin, C., Aghaeepour, N., Angst, M. S., Gaudilliere, B. 2021

  Abstract

  Postoperative complications including infections, cognitive impairment, and protracted recovery occur in one-third of the 300 million surgeries performed annually worldwide. Complications cause personal suffering along with a significant economic burden on our healthcare system. However, the accurate prediction of postoperative complications and patient-targeted interventions for their prevention remain as major clinical challenges.Although multifactorial in origin, the dysregulation of immunological mechanisms that occur in response to surgical trauma is a key determinant of postoperative complications. Prior research, primarily focusing on inflammatory plasma markers, has provided important clues regarding their pathogenesis. However, the recent advent of high-content, single-cell transcriptomic, and proteomic technologies has considerably improved our ability to characterize the immune response to surgery, thereby providing new means to understand the immunological basis of postoperative complications and to identify prognostic biological signatures.The comprehensive and single-cell characterization of the human immune response to surgery has significantly advanced our ability to predict the risk of postoperative complications. Multiomic modeling of patients' immune states holds promise for the discovery of preoperative predictive biomarkers, ultimately providing patients and surgeons with actionable information to improve surgical outcomes. Although recent studies have generated a wealth of knowledge, laying the foundation for a single-cell atlas of the human immune response to surgery, larger-scale multiomic studies are required to derive robust, scalable, and sufficiently powerful models to accurately predict the risk of postoperative complications in individual patients.

  View details for DOI 10.1097/MCC.0000000000000883

  View details for PubMedID 34545029

• Opioid use among patients with pain syndromes commonly seeking surgical consultation: A retrospective cohort. Annals of medicine and surgery (2012) Kin, C., Chou, L., Safer, D. L., Morris, A., Ding, Q., Trickey, A., Girod, S. 2021; 69: 102704

  Abstract

  Surgeons often see patients with pain to exclude organic pathology and consider surgical treatment. We examined factors associated with long-term opioid therapy among patients with foot/ankle, anorectal, and temporomandibular joint pain to aid clinical decision making.Using the IBM MarketScan® Research Database, we conducted a retrospective cohort analysis of patients aged 18-64 with a clinical encounter for foot/ankle, anorectal, or temporomandibular joint pain (January 2007-September 2015). Multivariable logistic regression was used to estimate adjusted odds ratios for factors associated with long-term opioid therapy, including age, sex, geographic region, pain condition, psychiatric diagnoses, and surgical procedures in the previous year.The majority of the cohort of 1,500,392 patients were women (61%). Within the year prior to the first clinical encounter for a pain diagnosis, 14% had an encounter for a psychiatric diagnosis, and 11% had undergone a surgical procedure. Long-term opioid therapy was received by 2.7%. After multivariable adjustment, older age (age 50-64 vs. 18-29: aOR 4.47, 95% CI 4.24-4.72, p < 0.001), region (South vs. Northeast, aOR 1.76, 95% CI 1.70-1.81, p < 0.001), recent surgical procedure (aOR 1.83, 95% CI 1.78-1.87, p < 0.001), male sex (aOR 1.14, 95% CI 1.12-1.16, p < 0.001) and recent psychiatric diagnosis (aOR 2.49, 95% CI 2.43-2.54, p < 0.001) were independently associated with long-term opioid therapy.Among patients with foot/ankle, anorectal, or temporomandibular joint pain, the risk of long-term opioid therapy significantly increased with older age, recent psychiatric diagnoses and surgical history. Surgeons should be aware of these risk factors in order to make high quality clinical decisions in consultations with these patients.

  View details for DOI 10.1016/j.amsu.2021.102704

  View details for PubMedID 34466218

  View details for PubMedCentralID PMC8384768

• A comparison of provider perspectives on cultural competency training: A mixed methods study. American journal of surgery Liu, M. M., Miller, M. O., Merrell, S. B., Bruce, J. S., Kin, C., Morris, A. M. 2020

  Abstract

  BACKGROUND: We aimed to identify differences in training among colorectal cancer physicians and advanced practice providers with high and low cultural competency METHODS: Using explanatory sequential mixed methods, we surveyed providers and dichotomized into high and low cultural competency (CC) groups, conducted qualitative interviews, and analyzed verbatim transcripts using deductive and inductive codes to compared findings across groups using a joint display.RESULTS: Fifty-four of 92 providers (59%) responded; 10 respondents from each group (20/36 invited) completed semi-structured interviews about previous CC trainings. Low CC providers' training included explanations of cultural differences that, in practice, improved awareness and utilization of communication tools, but they also desired decision-making tools and cultural exposure. High CC providers' training included action-oriented toolkits. In practice, they admitted failures, improved communication, and attributed patient behaviors to external factors. High CC providers desired performance evaluations.CONCLUSIONS: Behaviorally-oriented CC training offered a robust foundation for culturally competent care.

  View details for DOI 10.1016/j.amjsurg.2020.11.003

  View details for PubMedID 33220937

• A Deep Immune Profiling in Inflammatory Bowel Disease Reveals Disordered Immune Cell Frequencies Before and in Response to Major Abdominal Operations Rumer, K., Stanley, N., Ganio, E., Tsai, E., Kin, C., Shelton, A. A., Morris, A. M., Angst, M., Aghaeepour, N., Gaudilliere, B. ELSEVIER SCIENCE INC. 2020: S50

  View details for Web of Science ID 000582792300069

• Fear and Trust: Driving Forces behind Patient Preferences, Needs, and Motivation for a Perioperative Optimization Program Shelton, E., Shankar, K., Lee, A., Kadmon, T., Cvitanovic, M., Kin, C. ELSEVIER SCIENCE INC. 2020: E17

  View details for Web of Science ID 000582798100034

• Not in the Same Vein: Inflammatory Bowel Disease, Malignancy, and Enterocolic Lymphocytic Phlebitis. Digestive diseases and sciences Farber, O. N., Weingarden, A., Lee, C., Braxton, D. R., Bingham, D., Scott, G., Fernandez-Becker, N., Goff, D., Shelton, A., Kin, C. 2020

  View details for DOI 10.1007/s10620-020-06425-w

  View details for PubMedID 32594463

• IMMUNE PROFILING TO PREDICT RECOVERY OUTCOMES AFTER SURGERY Tsai, E. S., Rumer, K., Wong, K., Warrington, B., Shelton, E., Ganio, E., Verdonk, F., Ando, K., Tingle, M., Folk-Tolbert, M., Shankar, K., Shelton, A., Morris, A., Kirilcuk, N., Gurland, B., Kebebew, E., Kin, C., Angst, M. S., Aghaeepour, N., Gaudilliere, B. LIPPINCOTT WILLIAMS & WILKINS. 2020: 66–67

  View details for Web of Science ID 000587668800152

• Implementation of a Synoptic Operative Report for Rectal Cancer: A Mixed-Methods Study. Diseases of the colon and rectum Bidwell, S. S., Merrell, S. B., Poles, G. n., Morris, A. M. 2020; 63 (2): 190–99

  Abstract

  The National Accreditation Program for Rectal Cancer is a collaborative effort to improve the quality of rectal cancer care, including multidisciplinary assessment, treatment planning, and documentation using synoptic radiology, pathology, and operative reports.The purpose of this study was to examine the implementation and use of a synoptic operative report for rectal cancer.This was a convergent mixed-methods implementation study of electronic medical record data, surveys, and qualitative interviews.The study was conducted at US medical centers.Colorectal surgeons were included.After development, the synoptic operative report was iteratively revised and ultimately approved by the American Society of Colon and Rectal Surgeons Executive Council and the National Accreditation Program for Rectal Cancer and then implemented into participants' institutional electronic medical record systems.Change in fidelity to documentation of 19 critical items after implementation of synoptic reports and in-depth details and perspectives about the synoptic operative report were measured.Thirty-seven surgeons from 14 institutions submitted preimplementation operative reports (n = 180); 32 of 37 surgeons submitted postimplementation reports (n = 118). The operation type, approach, and formation of a stoma were present in >70% of preimplementation reports; however, the location of the tumor, the type of reconstruction, and the distal margin were reported in <50%. Each item was present in ≥89% of postimplementation reports. Twenty eight of 37 participants completed the survey, and 21 of 37 participants completed qualitative interviews. Emergent themes included concerns for additional burden and time constraints using the synoptic report themselves, as well as errors or absent information in traditional narrative operative reports of other surgeons.The study was limited by its sample size, cross-sectional nature, specialized centers, and inclusion of colorectal surgeons only.Although fidelity to the 19 items substantially increased after implementation of the synoptic report, reactions to the synoptic report varied among surgeons. Many indicated concerns that it would hinder workflow or add extra time burden. Others felt the synoptic report could indirectly improve rectal cancer quality of care and provide useful data for quality improvement and research. More work is needed to update and improve the synoptic operative report and streamline the workflow. See Video Abstract at http://links.lww.com/DCR/B100. IMPLEMENTACIÓN DE UN INFORME OPERATIVO SINÓPTICO PARA EL CÁNCER DE RECTO: UN ESTUDIO UTILIZANDO MÉTODOS MIXTOS: El Programa Nacional de Acreditación para el Cáncer Rectal es una iniciativa de colaboración para mejorar la calidad de la atención del cáncer rectal, utilizando evaluación multidisciplinaria, planificación del tratamiento y documentación mediante radiología sinóptica, patología e informes quirúrgicos.Examinar la implementación y el uso de un informe operativo sinóptico para el cáncer de recto.Estudio de implementación de métodos mixtos convergentes de datos de registros médicos electrónicos, encuestas y entrevistas cualitativas.Centros médicos de los Estados Unidos.Cirujanos colorrectales.Después de su formulación, el informe operativo sinóptico fue revisado de forma iterativa y finalmente aprobado por el Consejo Ejecutivo de la Sociedad Americana de Cirujanos de Colon y Rectal y el Programa Nacional de Acreditación para el Cáncer Rectal. Posteriormente, se implementó en los sistemas de registros médicos electrónicos institucionales de los participantes.Cambios en la precisión de documentación de 19 ítems críticos después de la implementación de informes sinópticos; Revisión de detalles y perspectivas en a profundidad sobre el informe operativo sinóptico.Treinta y siete cirujanos de 14 instituciones presentaron informes operativos previos a la implementación (n = 180); 32/37 cirujanos presentaron informes posteriores a la implementación (n = 118). El tipo de operación, el enfoque y la formación de un estoma estuvieron presentes en > 70% de los informes previos a la implementación; sin embargo, la ubicación del tumor, el tipo de reconstrucción y el margen distal se informaron en <50%. Cada ítem estuvo presente en > 89% de los informes posteriores a la implementación. 28/37 participantes completaron la encuesta y 21/37 participantes completaron entrevistas cualitativas. Los temas emergentes incluyeron preocupaciones por la carga adicional y las limitaciones de tiempo usando el informe sinóptico en sí, y errores o información ausente en los informes operativos narrativos tradicionales de otros cirujanos.Tamaño de la muestra, estudio transversal, centros especializados, cirujanos colorrectales solamente.Aunque la fidelidad a los 19 ítems aumentó sustancialmente después de la implementación del informe sinóptico, las reacciones al informe sinóptico variaron entre los cirujanos. Muchos indicaron preocupaciones de que obstaculizaría el flujo de trabajo o agregaría una carga de tiempo adicional. Otros consideraron que el informe sinóptico podría mejorar indirectamente la calidad de la atención del cáncer de recto y proporcionar datos útiles para la mejora de la calidad y la investigación. Se necesita más trabajo para actualizar y mejorar el informe operativo sinóptico y agilizar el flujo de trabajo. Consulte Video Resumen en http://links.lww.com/DCR/B100. (Traducción-Dr. Adrian E. Ortega).

  View details for DOI 10.1097/DCR.0000000000001518

  View details for PubMedID 31914112

• Pelvic/Perineal Reconstruction: Time to Consider the Anterolateral Thigh Flap as a First-line Option? Plastic and reconstructive surgery. Global open Perrault, D. n., Kin, C. n., Wan, D. C., Kirilcuk, N. n., Shelton, A. n., Momeni, A. n. 2020; 8 (4): e2733

  Abstract

  Abdominoperineal resection (APR) and pelvic exenteration continue to be common procedures for the treatment of colorectal malignancy. The workhorse flap for reconstruction in these instances has been the vertical rectus abdominis myocutaneous flap. The associated donor site morbidity, however, cannot be ignored. Here, we provide a review of the literature and present the senior author's (A.M.) experience using the pedicled anterolateral thigh (ALT) flap for reconstruction of soft tissue defects following APR and pelvic exenteration.Patients who underwent pelvic/perineal reconstruction with pedicled ALT flaps between 2017 and 2019 were included in the study. Parameters of interest included age, gender, body mass index, comorbidities, history of radiation, extent of ablative surgery, and postoperative complication rate.A total of 23 patients (16 men and 7 women) with a median age and body mass index of 66 years (inter-quartile range [IQR]: 49-71 years) and 24.9 kg/m2 (IQR: 24.2-26.7 kg/m2) were included in the study, respectively. Thirteen (56.5%) patients presented with rectal cancer, 5 (21.7%) with anal squamous cell carcinoma (SCC), 4 (17.4%) with Crohn's disease, and 1 (4.3%) with Paget's disease. Nineteen patients (82.6%) received neoadjuvant radiation. Nine (39.1%) patients experienced 11 complications (2 major and 9 minor). The most common complication was partial perineal wound dehiscence (N = 6 [26.1%]). Stable soft tissue coverage was achieved in all but one patient.The ALT flap allows for stable soft tissue coverage following APR and pelvic exenteration without being associated with abdominal donor site morbidity. Consideration to its use as a first-line reconstructive option should be given in pelvic/perineal reconstruction.

  View details for DOI 10.1097/GOX.0000000000002733

  View details for PubMedID 32440406

  View details for PubMedCentralID PMC7209827

• "It's Like Learning by the Seat of Your Pants": Surgeons Lack Formal Training in Opioid Prescribing. Journal of surgical education Ayakta, N. n., Sceats, L. A., Merrell, S. B., Kin, C. n. 2020

  Abstract

  To determine the training surgical residents and faculty receive on opioid prescribing, and to identify opportunities for curricula development to fill training gaps.We conducted qualitative semi-structured interviews and surveys. After applying an overarching organizational framework, we used an iterative, team-based process to develop relevant inductive codes. We then performed thematic analyses to identify and catalogue critical domains related to surgeons' education about opioid prescribing.Tertiary care academic medical center.Maximum variation purposive sampling was used to recruit general surgery residents and surgical faculty members.We interviewed 21 attending surgeons and 20 surgical residents. Surgeons reported minimal formal training on pain management and prescribing opioids. A minority of individuals described receiving opioid training in the form of continuing medical education, intern boot camp sessions, and medical school classes. Participants compensated for the lack of formal training during residency by informally learning from senior residents, consulting pain specialists, and seeking external learning resources. Increased surgical experience was correlated with increased comfort with pain management. A majority of surgeons desired formal training. The most commonly requested educational resources were opioid prescribing guidelines for common operations and recommendations for treating chronic pain patients. Residents requested that training occur early in residency to maximize the benefits received. Based on these findings, we developed a conceptual framework to explain how surgeons learn to prescribe opioids and to highlight opportunities for improvement.Although surgeons routinely prescribe opioids and desire education on opioids, a majority of them do not receive any training. Instituting formal educational programs is critical for improving opioid prescribing practices among surgeons.These programs should include standard prescribing guidelines and address management of acute postoperative pain in patients with chronic pain.

  View details for DOI 10.1016/j.jsurg.2020.07.003

  View details for PubMedID 32917541

• Elucidating the fundamental fibrotic processes driving abdominal adhesion formation. Nature communications Foster, D. S., Marshall, C. D., Gulati, G. S., Chinta, M. S., Nguyen, A. n., Salhotra, A. n., Jones, R. E., Burcham, A. n., Lerbs, T. n., Cui, L. n., King, M. E., Titan, A. L., Ransom, R. C., Manjunath, A. n., Hu, M. S., Blackshear, C. P., Mascharak, S. n., Moore, A. L., Norton, J. A., Kin, C. J., Shelton, A. A., Januszyk, M. n., Gurtner, G. C., Wernig, G. n., Longaker, M. T. 2020; 11 (1): 4061

  Abstract

  Adhesions are fibrotic scars that form between abdominal organs following surgery or infection, and may cause bowel obstruction, chronic pain, or infertility. Our understanding of adhesion biology is limited, which explains the paucity of anti-adhesion treatments. Here we present a systematic analysis of mouse and human adhesion tissues. First, we show that adhesions derive primarily from the visceral peritoneum, consistent with our clinical experience that adhesions form primarily following laparotomy rather than laparoscopy. Second, adhesions are formed by poly-clonal proliferating tissue-resident fibroblasts. Third, using single cell RNA-sequencing, we identify heterogeneity among adhesion fibroblasts, which is more pronounced at early timepoints. Fourth, JUN promotes adhesion formation and results in upregulation of PDGFRA expression. With JUN suppression, adhesion formation is diminished. Our findings support JUN as a therapeutic target to prevent adhesions. An anti-JUN therapy that could be applied intra-operatively to prevent adhesion formation could dramatically improve the lives of surgical patients.

  View details for DOI 10.1038/s41467-020-17883-1

  View details for PubMedID 32792541

• Use of Biological Medications Does Not Increase Postoperative Complications Among Patients With Ulcerative Colitis Undergoing Colectomy: A Retrospective Cohort Analysis of Privately Insured Patients. Diseases of the colon and rectum Rumer, K. K., Dehghan, M. S., Sceats, L. A., Trickey, A. W., Morris, A. M., Kin, C. n. 2020; 63 (11): 1524–33

  Abstract

  Existing studies on the effects of biological medications on surgical complications among patients with ulcerative colitis have mixed results. Because biologicals may hinder response to infections and wound healing, preoperative exposure may increase postoperative complications.The purpose of this study was to evaluate associations between biological exposure within 6 months preceding colectomy or proctocolectomy and postoperative complications among patients with ulcerative colitis.This was a retrospective cohort study with multivariate regression analysis after coarsened exact matching.A large commercial insurance claims database (2003-2016) was used.A total of 1794 patients with ulcerative colitis underwent total abdominal colectomy with end ileostomy, total proctocolectomy with end ileostomy, or total proctocolectomy with IPAA. Twenty-two percent were exposed to biologicals in the 6 months preceding surgery.Healthcare use (length of stay, unplanned reoperation/procedure, emergency department visit, or readmission) and complications (infectious, hernia or wound disruption, thromboembolic, or cardiopulmonary) within 30 postoperative days were measured.Exposure to biological medications was associated with shorter surgical hospitalization (7 vs 8 d; p <0.001) but otherwise was not associated with differences in healthcare use or postoperative complications.who underwent total proctocolectomy with IPAA had higher odds of infectious complications compared with those who underwent total abdominal colectomy with end ileostomy (adjusted OR = 2.2 (95% CI, 1.5-3.0); p < 0.001) but had lower odds of cardiopulmonary complications (adjusted OR = 0.4 (95% CI, 0.3-0.6); p < 0.001).Analysis of private insurance database claims data may not represent uninsured or government-insured patients and may be limited by coding accuracy. Matched cohorts differed in age and Charlson Comorbidity Index, which could be influential even after multivariate adjustments.Biological exposure among patients with ulcerative colitis is not associated with higher odds of postoperative complications or healthcare resource use. These data, in combination with clinical judgment and patient preferences, may aid in complex decision-making regarding operative timing, operation type, and perioperative medication management. See Video Abstract at http://links.lww.com/DCR/B370. EL USO DE MEDICAMENTOS BIOLÓGICOS NO AUMENTA LAS COMPLICACIONES POSTOPERATORIAS ENTRE PACIENTES CON COLITIS ULCERATIVA SOMETIDOS A UNA COLECTOMÍA: UN ANÁLISIS DE COHORTE RETROSPECTIVO DE PACIENTES CON SEGURO PRIVADO: Estudios existentes sobre los efectos de medicamentos biológicos, en complicaciones quirúrgicas, en pacientes con colitis ulcerativa, presentan resultados mixtos. Debido a que los productos biológicos pueden retrasar la respuesta a las infecciones y curación de heridas, su exposición preoperatoria pueden aumentar las complicaciones postoperatorias.Evaluar las asociaciones entre la exposición biológica dentro de los seis meses anteriores a la colectomía o proctocolectomía y las complicaciones postoperatorias entre los pacientes con colitis ulcerativa.Estudio de cohorte retrospectivo con análisis de regresión multivariante después de una coincidencia exacta aproximada.Una gran base de datos de reclamaciones de seguros comerciales (2003-2016).Un total de 1.794 pacientes con colitis ulcerativa, se sometieron a colectomía abdominal total con ileostomía terminal, proctocolectomía total con ileostomía terminal o proctocolectomía total con anastomosis anal y bolsa ileal. 22% estuvieron expuestos a productos biológicos, seis meses antes de la cirugía.Utilización de la atención médica (duración de la estadía, reoperación o procedimiento no planificado, visita al servicio de urgencias o reingreso) y complicaciones (infecciosas, hernias o dehiscencias de heridas, tromboembólicas o cardiopulmonares) dentro de los 30 días postoperatorios.La exposición a medicamentos biológicos se asoció con una hospitalización quirúrgica más corta (7 frente a 8 días, p <0,001), pero por lo demás, no se asoció con diferencias en la utilización de la atención médica o complicaciones postoperatorias. Los pacientes que se sometieron a proctocolectomía total con anastomosis anal y bolsa ileal, tuvieron mayores probabilidades de complicaciones infecciosas, en comparación con aquellos que se sometieron a colectomía abdominal total con ileostomía final (aOR 2.2, IC 95% [1.5-3.0], p <0.001) pero tuvieron menores probabilidades de complicaciones cardiopulmonares (aOR 0.4, IC 95% [0.3-0.6], p <0.001).El análisis de los datos de reclamaciones, de la base de datos de los seguros privados, puede no representar a pacientes no asegurados o asegurados por el gobierno, y puede estar limitado por la precisión de la codificación. Las cohortes emparejadas diferían en la edad y el índice de comorbilidad de Charlson, lo que podría influir incluso después de ajustes multivariados.La exposición biológica entre los pacientes con colitis ulcerativa, no se asocia con mayores probabilidades de complicaciones postoperatorias, o a la utilización de recursos sanitarios. Estos datos, en combinación con el juicio clínico y las preferencias del paciente, pueden ayudar en la toma de decisiones complejas con respecto al momento quirúrgico, el tipo de operación y el manejo de la medicación perioperatoria. Consulte Video Resumen en http://links.lww.com/DCR/B370. (Traducción-Dr Fidel Ruiz Healy).

  View details for DOI 10.1097/DCR.0000000000001684

  View details for PubMedID 33044293

• Diet Quality at the Initiation of Treatment for Metastatic Colorectal Cancer. JAMA network open Kin, C. n. 2020; 3 (10): e2023718

  View details for DOI 10.1001/jamanetworkopen.2020.23718

  View details for PubMedID 33125491

• Comparative Incidence of Inflammatory Bowel Disease in Different Age Groups in the United States INFLAMMATORY BOWEL DISEASES Keyashian, K., Dehghan, M., Sceats, L., Kin, C., Limketkai, B. N., Park, K. T. 2019; 25 (12): 1983–89

  View details for DOI 10.1093/ibd/izz092

  View details for Web of Science ID 000504314600024

• Drivers, Beliefs, and Barriers Surrounding Surgical Opioid Prescribing: A Qualitative Study of Surgeons' Opioid Prescribing Habits. The Journal of surgical research Sceats, L. A., Ayakta, N., Merrell, S. B., Kin, C. 2019

  Abstract

  BACKGROUND: Recent data demonstrate that surgeons overprescribe opioids and vary considerably in the amount of opioids prescribed for common procedures. Limited data exist about why and how surgeons develop certain opioid prescribing habits. We sought to identify surgeons' knowledge, attitudes, and beliefs about opioid prescribing and elicit barriers to guideline-based prescribing.METHODS: We conducted qualitative semistructured interviews accompanied by demographic surveys at an academic medical center. Surgical residents and faculty members were selected by maximum variation purposive sampling. We used thematic analysis to identify themes associated with opioid prescribing.RESULTS: Twenty surgical residents and twenty-one surgical faculty members were interviewed. Characteristics of individual surgeons, patients, health care teams, practice environments, and the complex interplay between these domains drove prescribing habits. Attending-resident communication about opioid prescribing was extremely limited. Surgeons received little training and feedback about opioid prescribing and were rarely aware of negative long-term consequences, limiting motivation to change prescribing habits. Although surgeons frequently interacted with pain management physicians to comanage patients postoperatively, few involved pain management physicians in preoperative planning. Perceived barriers to guideline-based prescribing included the following: limitations to electronic prescribing, cross-coverage problems, inadequate time for patient education, and impediments to use of nonopioid alternatives.CONCLUSIONS: Interventions to improve compliance with opioid prescribing guidelines should include surgeon education and personal feedback. Future interventions should aim to improve attending-resident communication about opioid prescribing, reduce hurdles to electronic prescribing, provide clear pain management plans for cross-covering physicians, assess alternative methods for efficient patient education, and maximize use of nonnarcotic pain medications.

  View details for DOI 10.1016/j.jss.2019.10.039

  View details for PubMedID 31767277

• Oncologic and Perioperative Outcomes of Laparoscopic, Open, and Robotic Approaches for Rectal Cancer Resection: A Multicenter, Propensity Score-Weighted Cohort Study. Diseases of the colon and rectum Kethman, W. C., Harris, A. H., Morris, A. M., Shelton, A., Kirilcuk, N., Kin, C. 2019

  Abstract

  BACKGROUND: Minimally invasive approaches have been shown to reduce surgical site complications without compromising oncologic outcomes.OBJECTIVE: The primary aim of this study is to evaluate the rates of successful oncologic resection and postoperative outcomes among laparoscopic, open, and robotic approaches to rectal cancer resection.DESIGN: This is a multicenter, quasiexperimental cohort study using propensity score weighting.SETTINGS: Interventions were performed in hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program.PATIENTS: Adult patients who underwent rectal cancer resection in 2016 were included.MAIN OUTCOME MEASURES: The primary outcome was a composite variable indicating successful oncologic resection, defined as negative distal and radial margins with at least 12 lymph nodes evaluated.RESULTS: Among 1028 rectal cancer resections, 206 (20%) were approached laparoscopically, 192 (18.7%) were approached robotically, and 630 (61.3%) were open. After propensity score weighting, there were no significant sociodemographic or preoperative clinical differences among subcohorts. Compared to the laparoscopic approach, open and robotic approaches were associated with a decreased likelihood of successful oncologic resection (ORadj = 0.64; 95% CI, 0.43-0.94 and ORadj = 0.60; 95% CI, 0.37-0.97), and the open approach was associated with an increased likelihood of surgical site complications (ORadj = 2.53; 95% CI, 1.61-3.959). Compared to the laparoscopic approach, the open approach was associated with longer length of stay (6.8 vs 8.6 days, p = 0.002).LIMITATIONS: This was an observational cohort study using a preexisting clinical data set. Despite adjusted propensity score methodology, unmeasured confounding may contribute to our findings.CONCLUSIONS: Resections that were approached laparoscopically were more likely to achieve oncologic success. Minimally invasive approaches did not lengthen operative times and provided benefits of reduced surgical site complications and decreased postoperative length of stay. Further studies are needed to clarify clinical outcomes and factors that influence the choice of approach. See Video Abstract at http://links.lww.com/DCR/B70.

  View details for DOI 10.1097/DCR.0000000000001534

  View details for PubMedID 31764247

• Surgery, Stomas, and Anxiety and Depression in Inflammatory Bowel Disease: A Retrospective Cohort Analysis of Privately Insured Patients. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland Sceats, L. A., Dehghan, M. S., Rumer, K. K., Trickey, A., Morris, A. M., Kin, C. 2019

  Abstract

  AIM: Inflammatory bowel disease (IBD) patients are diagnosed with anxiety/depression at higher rates than the general population. We aimed to determine the frequency of anxiety/depression among IBD patients and temporal association with abdominal surgery and stoma formation.METHODS: We conducted a retrospective cohort study in adult IBD patients using difference-in-differences methodology using a large commercial claims database (2003-2016). Outcomes were anxiety/depression diagnoses before and after major abdominal surgery or stoma formation.RESULTS: We identified 10,481 IBD patients who underwent major abdominal surgery, 18.8% of whom underwent stoma formation, and 41,924 nonsurgical age- and sex-matched IBD controls who were assigned random index dates. Rates of anxiety and depression increased among all cohorts (p<0.001). Surgical patients had higher odds of anxiety (one surgery: adjusted odds ratio 6.90, 95% confidence interval [6.11-7.79], p<0.001; 2+ surgeries: 7.53 [5.99-9.46], p<0.001) and depression (one surgery: 6.15, [5.57-6.80], p<0.001; 2+ surgeries: 6.88 [5.66-8.36], p<0.001) than nonsurgical controls. Undergoing multiple surgeries was associated with a significant increase in depression from pre- to post-time periods (1.43, [1.18-1.73, p<0.001). Amongst surgical patients, stoma formation was independently associated with anxiety (1.40, [1.17-1.68], p<0.001) and depression (1.23, [1.05-1.45], p=0.01). New ostomates experienced a greater increase in postoperative anxiety (1.24, [1.05-1.47], p=0.01) and depression (1.19, [1.03-1.45], p=0.01) than other surgical patients.CONCLUSIONS: IBD patients who undergo surgery have higher rates of anxiety and depression than nonsurgical patients. Rates of anxiety and depression increase following surgery. Stoma formation represents an additional risk factor. These findings suggest the need for perioperative psychosocial support services.

  View details for DOI 10.1111/codi.14905

  View details for PubMedID 31713994

• Long-Term Outcomes after Nonoperative Management of Perforated Appendicitis: A Retrospective Cohort Analysis Sceats, L. A., Kin, C. J., Spain, D. A. ELSEVIER SCIENCE INC. 2019: S157

  View details for Web of Science ID 000492740900292

• Open vs Laparoscopic vs Robotic Surgery for Rectal Cancer: A Cost-Effectiveness Analysis Chandler, J. M., Conway, A. A., Huckels, J., Pooni, R. K., Zarnett, L. J., Lee, K., Kin, C. J., Salomon, J. A., Owens, D. K. ELSEVIER SCIENCE INC. 2019: S67

  View details for Web of Science ID 000492740900109

• Effect of a Multimodal Prehabilitation Program Prior to Colorectal Surgery on Postoperative Pain and Pain Medication Use Lee, A., Shelton, E., Bidwell, S., Shelton, A., Gurland, B., Morris, A. M., Kin, C. J. ELSEVIER SCIENCE INC. 2019: S58–S59

  View details for Web of Science ID 000492740900092

• Surgical Decision-Making for Rectal Prolapse: One Size Does Not Fit All. Postgraduate medicine Lee, A., Kin, C., Syan, R., Morris, A., Gurland, B. 2019

  Abstract

  Background: Surgery remains the only known treatment option for rectal prolapse. Although over 100 abdominal and perineal procedures are available, there is no consensus as to which intervention is best suited for an individual. This retrospective cohort study describes the patient- and disease-related factors involved in making surgical recommendations around rectal prolapse in a single surgeon experience. Methods: 91 consecutive patients ≥18 years old diagnosed with external and/or high grade internal rectal prolapse were assessed and were prospectively entered into an IRB approved registry. Information on patient symptoms, comorbidities, exam findings, surgeon judgement and patient preference was collected. Treatment recommendations (abdominal, perineal, or no operation) were analyzed and compared. Results: Surgical intervention was recommended to 93% of patients. Of those, 66% were recommended robotic abdominal procedures: 75%, robotic ventral mesh rectopexies; 16%, resection rectopexies; and 9%, suture rectopexies. On univariate analysis, patients with older age, higher ASA scores, presence of cardiopulmonary morbidity, pain as a primary rectal prolapse symptom, rectal prolapse always descended, and surgeon concern for frailty and general anesthesia were associated with recommendations for perineal operations (p<0.05 for all). However, on multivariate analysis, only age and concern over prolonged anesthesia remained correlated with recommendation for perineal surgery. Of patients >80 years of age, 15% were recommended an abdominal approach. Conclusions: With multiple options available for treatment of rectal prolapse, treatment recommendations remain surgeon-dependent and may be influenced by many factors. In our practice, robotic ventral mesh rectopexy was the most commonly recommended operation and was offered to carefully selected patients of advanced age. Although robotic surgery and ventral mesh rectopexy may not be accessible to all patients and surgeons, this represents a single surgeon's practice bias. This study reinforces the importance of perineal procedures for higher-risk individuals.

  View details for DOI 10.1080/00325481.2019.1669330

  View details for PubMedID 31525304

• Fragility of Life: Recurrent Intestinal Perforation Due to Vascular Ehlers-Danlos Syndrome DIGESTIVE DISEASES AND SCIENCES Sceats, L. A., Sukerkar, P. A., Raghavan, S. S., Shandiz, A., Shelton, A., Kin, C. 2019; 64 (8): 2120–23

  View details for DOI 10.1007/s10620-019-5467-3

  View details for Web of Science ID 000477029000012

• Questioning the Higher Abscess Rate and Overall Cost of Care Associated With Nonoperative Management of Uncomplicated Acute Appendicitis Reply JAMA SURGERY Sceats, L. A., Kin, C., Staudenmayer, K. L. 2019; 154 (8): 784–85

  View details for DOI 10.1001/jamasurg.2019.1162

  View details for Web of Science ID 000484369400029

• Trends in the Inclusion of Black and Female Surgeons in Invited Visiting Professorships. JAMA surgery Tabata, M. M., Rosenthal, E. L., Arbaugh, C. J., Kin, C., Kim, E., Graham, L. A., Hawn, M. T. 2019

  View details for DOI 10.1001/jamasurg.2019.2137

  View details for PubMedID 31290945

• Operative Versus Nonoperative Management of Appendicitis: A Long-Term Cost Effectiveness Analysis. MDM policy & practice Sceats, L. A., Ku, S., Coughran, A., Barnes, B., Grimm, E., Muffly, M., Spain, D. A., Kin, C., Owens, D. K., Goldhaber-Fiebert, J. D. 2019; 4 (2): 2381468319866448

  Abstract

  Background. Recent clinical trials suggest that nonoperative management (NOM) of patients with acute, uncomplicated appendicitis is an acceptable alternative to surgery. However, limited data exist comparing the long-term cost-effectiveness of nonoperative treatment strategies. Design. We constructed a Markov model comparing the cost-effectiveness of three treatment strategies for uncomplicated appendicitis: 1) laparoscopic appendectomy, 2) inpatient NOM, and 3) outpatient NOM. The model assessed lifetime costs and outcomes from a third-party payer perspective. The preferred strategy was the one yielding the greatest utility without exceeding a $50,000 willingness-to-pay threshold. Results. Outpatient NOM cost $233,700 over a lifetime; laparoscopic appendectomy cost $2500 more while inpatient NOM cost $7300 more. Outpatient NOM generated 24.9270 quality-adjusted life-years (QALYs), while laparoscopic appendectomy and inpatient NOM yielded 0.0709 and 0.0005 additional QALYs, respectively. Laparoscopic appendectomy was cost-effective compared with outpatient NOM (incremental cost-effectiveness ratio $32,300 per QALY gained); inpatient NOM was dominated by laparoscopic appendectomy. In one-way sensitivity analyses, the preferred strategy changed when varying perioperative mortality, probability of appendiceal malignancy or recurrent appendicitis after NOM, probability of a complicated recurrence, and appendectomy cost. A two-way sensitivity analysis showed that the rates of NOM failure and appendicitis recurrence described in randomized trials exceeded the values required for NOM to be preferred. Limitations. There are limited NOM data to generate long-term model probabilities. Health state utilities were often drawn from single studies and may significantly influence model outcomes. Conclusion. Laparoscopic appendectomy is a cost-effective treatment for acute uncomplicated appendicitis over a lifetime time horizon. Inpatient NOM was never the preferred strategy in the scenarios considered here. These results emphasize the importance of considering long-term costs and outcomes when evaluating NOM.

  View details for DOI 10.1177/2381468319866448

  View details for PubMedID 31453362

• TB or Not TB: Crohn's Disease, Peritoneal Tuberculosis, or Both? DIGESTIVE DISEASES AND SCIENCES Miller, M., Kim-Nhien Vu, Zemek, A., Shelton, A., Kin, C. 2019; 64 (6): 1432–35

  View details for DOI 10.1007/s10620-018-5334-7

  View details for Web of Science ID 000468153200007

• Questioning the Higher Abscess Rate and Overall Cost of Care Associated With Nonoperative Management of Uncomplicated Acute Appendicitis-Reply. JAMA surgery Sceats, L. A., Kin, C., Staudenmayer, K. L. 2019

  View details for PubMedID 31090887

• Sex Differences in Treatment Strategies Among Patients With Ulcerative Colitis: A Retrospective Cohort Analysis of Privately Insured Patients DISEASES OF THE COLON & RECTUM Sceats, L. A., Morris, A. M., Bundorf, M., Park, K. T., Kin, C. 2019; 62 (5): 586–94

  View details for DOI 10.1097/DCR.0000000000001342

  View details for Web of Science ID 000469491700017

• Nonoperative Management of Uncomplicated Appendicitis Among Privately Insured Patients JAMA SURGERY Sceats, L. A., Trickey, A. W., Morris, A. M., Kin, C., Staudenmayer, K. L. 2019; 154 (2): 141–49

  View details for DOI 10.1001/jamasurg.2018.4282

  View details for Web of Science ID 000459484600012

• Effects of Colorectal Surgery Classification on Reported Postoperative Surgical Site Infections. The Journal of surgical research Kethman, W. C., Shelton, E. A., Kin, C., Morris, A. M., Shelton, A. A. 2019; 236: 340–44

  Abstract

  BACKGROUND: Current procedural terminology (CPT) for colon and rectal surgery lacks procedural granularity and misclassification rates are unknown. However, they are used in performance measurement, for example, in surgical site infection (SSI). The objective of this study was to determine whether American College of Surgeons National Surgical Quality Improvement Program (NSQIP) abstraction methods accurately classify types of colorectal operations and, by extension, reported SSI rates.MATERIALS AND METHODS: This was a retrospective study conducted at a single tertiary care center. The colectomy- and proctectomy-targeted NSQIP database from January 2011 to July 2016 was used to perform a semiautomated reclassification (SAR) of all colectomy and proctectomy cases performed by colorectal surgeons. The primary outcome was the difference in perioperative SSI rates by case classification method.RESULTS: Thousand sixty-three patients underwent a colectomy or proctectomy during the study period with a mean age of 55.7 (SD=16.7) years. Use of the NSQIP classification scheme resulted in 849 colectomy and 214 proctectomy cases. Use of the SAR method resulted in 650 colectomy cases and 413 proctectomy cases (P<0.001), a 23.4% reclassification of colectomy cases. The group of cases classified as colectomy by SAR had a lower rate of deep/organ space infections than those classified as colectomy by NSQIP (4.5% versus 7.1%, P=0.034).CONCLUSIONS: These findings highlight the challenges of CPT code-based patient classification and subsequent outcomes analysis. Expanding the CPT system to more accurately represent colorectal operations would allow for more representative reported outcomes, thus enabling benchmarking and quality improvement.

  View details for PubMedID 30694775

• Shared Decision Making in Appendicitis Treatment: Optimized, Standardized, or Usual Communication. JAMA network open Sceats, L. n., Kin, C. n., Morris, A. M. 2019; 2 (6): e194999

  View details for DOI 10.1001/jamanetworkopen.2019.4999

  View details for PubMedID 31173112

• Fragility of Life: Recurrent Intestinal Perforation Due to Vascular Ehlers-Danlos Syndrome. Digestive diseases and sciences Sceats, L. A., Sukerkar, P. A., Raghavan, S. S., Esmaeili Shandiz, A. n., Shelton, A. n., Kin, C. n. 2019

  View details for PubMedID 30656563

• Sex Differences in Treatment Strategies Among Patients With Ulcerative Colitis: A Retrospective Cohort Analysis of Privately Insured Patients. Diseases of the colon and rectum Sceats, L. A., Morris, A. M., Bundorf, M. K., Park, K. T., Kin, C. n. 2019

  Abstract

  Sex-based treatment disparities occur in many diseases. Women undergo fewer procedural interventions, and their care is less consistent with guideline-based therapy. There is limited research exploring sex-based differences in ulcerative colitis treatment. We hypothesized that women are less likely to be treated with strategies consistent with long-term disease remission, including surgery and maintenance medications.The aim of this study was to determine if patient sex is associated with choice of treatment strategy for ulcerative colitis.This is a retrospective cohort analysis.Data were gathered from a large commercial insurance claims database (Truven MarketScan) from 2007 to 2015.We identified a cohort of 38,851 patients newly diagnosed with ulcerative colitis, aged 12 to 64 years with at least 1 year of follow-up.The primary outcomes measured were the differences between male and female patients in 1) rates and types of index ulcerative colitis operations, 2) rates and types of ulcerative colitis medication prescriptions, and 3) rates of opioid prescriptions.Men were more likely to undergo surgical treatment for ulcerative colitis (2.94% vs 1.97%, p < 0.001, OR 1.51, p < 0.001). The type of index operation performed did not vary by sex. Men were more likely to undergo treatment with maintenance medications, including biologic (12.4% vs 10.2%, p < 0.001, OR 1.22, p < 0.001), immunomodulatory (16.3% vs 14.9%, p < 0.001, OR 1.08, p = 0.006), and 5-aminosalicylate medications (67.0% vs 63.2%, p < 0.001, OR 1.18, p < 0.001). Women were more likely to undergo treatment with rescue therapies and symptomatic control with corticosteroids (55.5% vs 54.0%, p = 0.002, OR 1.07, p = 0.002) and opioids (50.2% vs 45.9%, p < 0.001, OR 1.17, p < 0.001).Claims data lack clinical characteristics acting as confounders.Men with ulcerative colitis were more likely to undergo treatment consistent with long-term remission or cure, including maintenance medications and definitive surgery. Women were more likely to undergo treatment consistent with short-term symptom management. Further studies to explore underlying mechanisms of sex-related differences in ulcerative colitis treatment strategies and disease trajectories are warranted. See Video Abstract at http://links.lww.com/DCR/Axxx.

  View details for PubMedID 30762599

• Comparative Incidence of Inflammatory Bowel Disease in Different Age Groups in the United States. Inflammatory bowel diseases Keyashian, K. n., Dehghan, M. n., Sceats, L. n., Kin, C. n., Limketkai, B. N., Park, K. T. 2019

  Abstract

  Data on the incidence of inflammatory bowel disease (IBD) by age group are available in countries outside of the United States or localized populations within the United States. We aimed to estimate the incidence rates (IRs) of IBD by age group using a US multiregional data set.We used the Optum Research Database to identify incident IBD patients with a disease-free interval of 1.5 years between 2005 and 2015. Overall and age-specific IRs were calculated for 4 different age groups: pediatric (0-17 years), young adult (18-25 years), adult (26-59 years), elderly (>60 years). Time trends of incidence were evaluated in each age group. Perianal phenotype (in Crohn's disease [CD]) was also compared.The mean IR for the cohort (n = 60,247) from 2005 to 2015 was 37.5/100,000. The IR was highest in adult and elderly cohorts (36.4 and 36.7/100,000 respectively). In the adult and elderly groups, the IR for UC was higher than that for CD, whereas the opposite was true in the pediatric and young adult groups. The IR increased over the 10-year study period for all age groups (time trends P < 0.001). The elderly group had less perianal disease than the adult group (20.8 vs 22.3%, respectively; P < 0.05).In one of the most comprehensive evaluations of the incidence of IBD in the United States, we found an incidence rate similar to those of other national populations. We also confirmed differences of specific IBD phenotypes based on age groups, with lower rates of perianal disease in the elderly.

  View details for PubMedID 31095681

• Caring for Caregivers - Resident Physician Health and Wellbeing. Journal of surgical education Baiu, I. n., Titan, A. n., Kin, C. n., Spain, D. A. 2019

  Abstract

  There is a national epidemic of physician burnout and serious concerns exist regarding the well-being of future physicians. This project seeks to address resident physician health, by creating a sense of support and community during training, as a method to target one of the many facets of burnout.We created a program that allows residents who fall ill to receive a health package, delivered to work or home, consisting of essential medications, vitamins, nutrition, and hydration. The recipients were asked to answer a short survey regarding their experience.Stanford Health Care, Department of Surgery, Division of General Surgery, Palo Alto California.Eighteen packages have been delivered since the start of the project. One hundred percent of residents agree that this program fulfills an otherwise unmet need in residency. Similarly, all felt that the supplies they received helped them recover faster. The majority (83%) of the packages were requested by colleagues of the ill residents.We present an innovative project aimed at improving resident physician health, fostering a feeling of support, and helping to reduce resident burnout. This is the first report of a program of this kind and we hope that it incentivizes a broader discussion and implementation of similar initiatives in other residency programs across the country.

  View details for DOI 10.1016/j.jsurg.2019.08.007

  View details for PubMedID 31494061

• Patient Decision-Making in Severe Inflammatory Bowel Disease: The Need for Improved Communication of Treatment Options and Preferences. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland Lai, C. n., Sceats, L. n., Qiu, W. n., Park, K. T., Morris, A. M., Kin, C. n. 2019

  Abstract

  Patients with inflammatory bowel disease and their physicians must navigate ever-increasing options for treatment. The aim of this study was to elucidate the key drivers of treatment decision-making in inflammatory bowel disease.We conducted qualitative semi-structured in-person interviews of 20 adult patients undergoing treatment for inflammatory bowel disease at an academic medical centre who either recently initiated biologic therapy or underwent an operation or surgical evaluation. Interviews were audio-recorded, transcribed verbatim, iteratively coded, and discussed to consensus by five researchers. We used thematic analysis to explore factors influencing decision-making.Four major themes emerged as key drivers of treatment decision-making: perceived clinical state and disease severity, the patient-physician relationship, knowledge, attitudes, and beliefs about treatment options, and social isolation and stigma. Patients described experiencing a clinical turning point as the impetus for proceeding with a previously undesired treatment such as infusion medication or surgery. Patients reported delays in care or diagnosis, inadequate communication with their physicians, and lack of control over their disease management. Patients often stated that they considered surgery to be the treatment of last resort, which further compounded the complexity of making treatment decisions.Patients described multiple barriers to making informed and collaborative decisions about treatment, especially when considering surgical options. Our study reveals a need for more comprehensive communication between the patient and their physician about the range of medical and surgical treatment options. We recommend a patient-centred approach toward the decision-making process that accounts for patient decision-making preferences, causes of social stress, and clinical status. This article is protected by copyright. All rights reserved.

  View details for DOI 10.1111/codi.14759

  View details for PubMedID 31295766

• Nonoperative Management of Uncomplicated Appendicitis Among Privately Insured Patients. JAMA surgery Sceats, L. A., Trickey, A. W., Morris, A. M., Kin, C., Staudenmayer, K. L. 2018

  Abstract

  Importance: Health care professionals have shown significant interest in nonoperative management for uncomplicated appendicitis, but long-term population-level data are lacking.Objective: To compare the outcomes of nonoperatively managed appendicitis against appendectomy.Design, Setting, and Participants: This national retrospective cohort study used claims data from a private insurance database to compare patients admitted with uncomplicated appendicitis from January 1, 2008, through December 31, 2014, undergoing appendectomy vs nonoperative management. Coarsened exact matching was applied before multivariate analysis to reduce imbalance between groups. Data were analyzed from February 12 through May 1, 2018.Exposures: Appendectomy (control arm) or nonoperative management (treatment arm).Main Outcomes and Measures: Short-term primary clinical outcomes included emergency department visits, hospital readmission, abdominal abscess, and Clostridium difficile infections. Long-term primary clinical outcomes were small-bowel obstructions, incisional hernias, and appendiceal cancers. Nonoperative management failure was defined by hospital readmission with appendicitis diagnosis and an appendicitis-associated operation or procedure. Secondary outcomes included number of follow-up visits, length and cost of index hospitalization, and total cost of appendicitis-associated care. Covariates included age, sex, region, insurance plan type, admission year, and Charlson comorbidity index.Results: Of 58 329 patients with uncomplicated appendicitis (52.7% men; mean [SD] age, 31.9 [16.5] years), 55 709 (95.5%) underwent appendectomy and 2620 (4.5%) underwent nonoperative management. Patients in the nonoperative management group were more likely to have appendicitis-associated readmissions (adjusted odds ratio, 2.13; 95% CI, 1.63-2.77; P<.001) and to develop an abscess (adjusted odds ratio, 1.42; 95% CI, 1.05-1.92; P=.02). Patients in the nonoperative management group required more follow-up visits in the year after index admission (unadjusted mean [SD], 1.6 [6.3] vs 0.3 [1.4] visits; adjusted +1.11 visits; P<.001) and had lower index hospitalization cost (unadjusted mean [SD], $11 502 [$9287] vs $13 551 [$10 160]; adjusted -$2117, P<.001), but total cost of appendicitis care was higher when follow-up care was considered (unadjusted, $14 934 [$31 122] vs $14 186 [$10 889]; adjusted +$785; P=.003). During a mean (SD) of 3.2 (1.7) years of follow-up, failure of nonoperative management occurred in 101 patients (3.9%); median time to recurrence was 42 days (interquartile range, 8-125 days). Among the patients who experienced treatment failure, 44 did so within 30 days.Conclusions and Relevance: According to results of this study, nonoperative management failure rates were lower than previously reported. Nonoperative management was associated with higher rates of abscess, readmission, and higher overall cost of care. These data suggest that nonoperative management may not be the preferred first-line therapy for all patients with uncomplicated appendicitis.

  View details for PubMedID 30427983

• Female trainees believe that having children will negatively impact their careers: results of a quantitative survey of trainees at an academic medical center. BMC medical education Kin, C., Yang, R., Desai, P., Mueller, C., Girod, S. 2018; 18 (1): 260

  Abstract

  BACKGROUND: Medical training occurs during peak childbearing years. However, the intense workload, long work hours, and limited financial compensation are potential barriers to having children during this time. Here, we aimed to identify gender-based differences in beliefs and experiences of having children during graduate medical education. We hypothesized that both genders face significant challenges, but women are more likely to experience stressors related to work-family conflicts.METHODS: We administered an anonymous web-based survey to all trainees at an academic medical center. Primary outcomes were gender differences in beliefs and experiences of having children during training. Multivariate logistic regression was performed using independent variables of gender, specialty type (surgical vs. medical), and parental status.RESULTS: In total, 56% of trainees responded (60% women, 40% men; n=435). Women were more often concerned about the negative impact of having children and taking maternity leave on their professional reputation and career. The majority of women expressed concern about the potential negative impact of the physical demands of their jobs on pregnancy. Among parents, women were more likely than men to be the primary caregivers on weeknights and require weekday childcare from a non-parent.CONCLUSIONS: Women face greater work-related conflicts in their beliefs and experiences of having a family during graduate medical education. Trainees should be aware of these potential challenges when making life and career decisions. We recommend that institutions employ solutions to accommodate the needs and wellbeing of trainees with families while optimizing training and workload equity for all trainees.

  View details for PubMedID 30424762

• 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 Kin, C. 2018; 31 (6): 353–60

  Abstract

  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 Miller, M., Vu, K., Zemek, A., Shelton, A., Kin, C. 2018

  View details for PubMedID 30334111

• Operative vs Nonoperative Management of Appendicitis: A Long-Term Cost-Effectiveness Analysis Sceats, L. A., Coughran, A., Barnes, B., Grimm, E. L., Muffly, M., Spain, D. A., Kin, C. J., Owens, D. K., Fiebert, J. ELSEVIER SCIENCE INC. 2018: S157–S158

  View details for DOI 10.1016/j.jamcollsurg.2018.07.334

  View details for Web of Science ID 000447760600305

• Coordination of Care in Colorectal Cancer Patients: A Population-Based Study Miller, M. O., Trickey, A. W., Kin, C. J., Hawley, S. T., Abrahamse, P., Morris, A. M. ELSEVIER SCIENCE INC. 2018: S141–S142

  View details for DOI 10.1016/j.jamcollsurg.2018.07.300

  View details for Web of Science ID 000447760600271

• Should Surgery Feel Like the Last Resort? Drivers of Decision Making in Inflammatory Bowel Disease Lai, C., Sceats, L. A., Qiu, W., Park, K. T., Morris, A. M., Kin, C. J. ELSEVIER SCIENCE INC. 2018: S163–S164

  View details for DOI 10.1016/j.jamcollsurg.2018.07.347

  View details for Web of Science ID 000447760600318

• Nonoperative Management of Appendicitis in Privately Insured Patients Sceats, L. A., Trickey, A. W., Morris, A. M., Kin, C. J., Staudenmayer, K. D. ELSEVIER SCIENCE INC. 2018: S156–S157

  View details for DOI 10.1016/j.jamcollsurg.2018.07.332

  View details for Web of Science ID 000447760600303

• Depression and Healthcare Utilization in Patients with Inflammatory Bowel Disease. Journal of Crohn's & colitis Wong, J. J., Sceats, L., Dehghan, M., Wren, A. A., Sellers, Z. M., Limketkai, B. N., Bensen, R., Kin, C., Park, K. T. 2018

  Abstract

  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

• Frequency and Timing of Short-Term Complications Following Abdominoperineal Resection Journal of Surgical Research Tooley, J. E., Sceats, L. A., Bohl, D. D., Read, B., Kin, C. 2018; 231: 69-76

  View details for DOI 10.1016/j.jss.2018.05.009

• Frequency and timing of short-term complications following abdominoperineal resection. The Journal of surgical research Tooley, J. E., Sceats, L. A., Bohl, D. D., Read, B. n., Kin, C. n. 2018; 231: 69–76

  Abstract

  Abdominoperineal resection (APR) is primarily used for rectal cancer and is associated with a high rate of complications. Though the majority of APRs are performed as open procedures, laparoscopic APRs have become more popular. The differences in short-term complications between open and laparoscopic APR are poorly characterized.We conducted a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database to determine the frequency and timing of onset of 30-d postoperative complications after APR and identify differences between open and laparoscopic APR.A total of 7681 patients undergoing laparoscopic or open APR between 2011 and 2015 were identified. The total complication rate for APR was high (45.4%). APRs were commonly complicated by blood transfusion (20.1%), surgical site infection (19.3%), and readmission (12.3%). Laparoscopic APR was associated with a 14% lower total complication rate compared to open APR (36.0% versus 50.1%, P < 0.001). This was primarily driven by a decreased rate of transfusion (10.7% versus 24.9%, P < 0.001) and surgical site infection (15.5% versus 21.2%, P < 0.001). Laparoscopic APR had shorter length of stay and decreased reoperation rate but similar rates of readmission and death. Cardiopulmonary complications occurred earlier in the postoperative period after APR, whereas infectious complications occurred later.Short-term complications following APR are common and occur more frequently in patients who undergo open APR. This, along with factors such as risk of positive pathologic margins, surgeon skill set, and patient characteristics, should contribute to the decision-making process when planning rectal cancer surgery.

  View details for PubMedID 30278971

• 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 Wren, A. A., Bensen, R. n., Sceats, L. n., Dehghan, M. n., Yu, H. n., Wong, J. J., MacIsaac, D. n., Sellers, Z. M., Kin, C. n., Park, K. T. 2018

  Abstract

  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

• Nationwide Trends in Acute and Chronic Pancreatitis Among Privately Insured Children and Non-Elderly Adults in the United States, 2007-2014. Gastroenterology Sellers, Z. M., MacIsaac, D. n., Yu, H. n., Dehghan, M. n., Zhang, K. Y., Bensen, R. n., Wong, J. J., Kin, C. n., Park, K. T. 2018

  Abstract

  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

• Perianal Extramammary Paget's Disease: More Than Meets the Eye. Digestive diseases and sciences Choi, J. n., Zemek, A. n., Lee, G. K., Kin, C. n. 2018

  View details for PubMedID 29696480

• As Infliximab Use for Ulcerative Colitis Has Increased, so Has the Rate of Surgical Resection. Journal of gastrointestinal surgery Kin, C., Kate Bundorf, M. 2017

  Abstract

  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 Jensen, C., Kin, C. 2017

  View details for DOI 10.1007/s10620-017-4527-9

  View details for PubMedID 28289926

• Surgery for diverticulitis in the 21st century: recent evidence. Minerva gastroenterologica e dietologica Morris, A. M., Kin, C. 2017

  Abstract

  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 Kethman, W., Rao, A., Devereaux, K., Ouellet, E., Kin, C. 2017

  View details for DOI 10.1007/s10620-016-4443-4

  View details for PubMedID 28168574

• Deep Immune Profiling of an Arginine-Enriched Nutritional Intervention in Patients Undergoing Surgery. Journal of immunology (Baltimore, Md. : 1950) Aghaeepour, N. n., Kin, C. n., Ganio, E. A., Jensen, K. P., Gaudilliere, D. K., Tingle, M. n., Tsai, A. n., Lancero, H. L., Choisy, B. n., McNeil, L. S., Okada, R. n., Shelton, A. A., Nolan, G. P., Angst, M. S., Gaudilliere, B. L. 2017

  Abstract

  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 Mueller, C. M., Gaudilliere, D. K., Kin, C., Menorca, R., Girod, S. 2016; 203 (1): 28-33

  Abstract

  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. Clinics in colon and rectal surgery Kin, C. 2016; 29 (2): 73-4

  View details for DOI 10.1055/s-0036-1580635

  View details for PubMedID 27247529

  View details for PubMedCentralID PMC4882176

• Complex and Reoperative Colorectal Surgery: Setting Expectations and Learning from Experience CLINICS IN COLON AND RECTAL SURGERY Kin, C. 2016; 29 (2): 75-79

  Abstract

  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 Gholami, S., Wood, L. S., Bingham, D., Kin, C. 2016; 61 (4): 996-999

  View details for DOI 10.1007/s10620-015-3819-1

  View details for PubMedID 26233548

• Double Rarities, Double Challenges: Extra-Mammary Paget's Disease and Anal Adenocarcinoma DIGESTIVE DISEASES AND SCIENCES Gholami, S., Wood, L. S., Bingham, D., Kin, C. 2016; 61 (4): 996-999

  View details for DOI 10.1007/s10620-015-3819-1

  View details for Web of Science ID 000372301900012

• Equivocal Effect of Intraoperative Fluorescence Angiography on Colorectal Anastomotic Leaks DISEASES OF THE COLON & RECTUM Kin, C., Vo, H., Welton, L., Welton, M. 2015; 58 (6): 582-587

  Abstract

  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 Kozak, M. M., von Eyben, R., Pai, J. S., Anderson, E. M., Welton, M. L., Shelton, A. A., Kin, C., Koong, A. C., Chang, D. T. 2015: -?

  Abstract

  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 Vo, H., Kin, C. 2014; 19 (3): 100-?

  View details for DOI 10.1136/eb-2013-101626

  View details for PubMedID 24361753

• Perioperative Outcomes of Major Noncardiac Surgery in Adults with Congenital Heart Disease ANESTHESIOLOGY Maxwell, B. G., Wong, J. K., Kin, C., Lobato, R. L. 2013; 119 (4): 762-769

  View details for DOI 10.1097/ALN.0b013e3182a56de3

  View details for Web of Science ID 000324475400013

• Perioperative outcomes of major noncardiac surgery in adults with congenital heart disease. Anesthesiology Maxwell, B. G., Wong, J. K., Kin, C., Lobato, R. L. 2013; 119 (4): 762-769

  Abstract

  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 Kin, C., Kidess, E., Poultsides, G. A., Visser, B. C., Jeffrey, S. S. 2013; 13 (6): 581-599

  Abstract

  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 Kin, C., Rhoads, K. F., Jalali, M., Shelton, A. A., Welton, M. L. 2013; 56 (6): 738-746

  Abstract

  : 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) Kin, C., Snyder, K., Kiran, R. P., Remzi, F. H., Vogel, J. D. LIPPINCOTT WILLIAMS & WILKINS. 2013: 219–25

  Abstract

  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 Khoury, W., Kin, C., Ben Yehuda, A., Weinbroum, A. A. 2012; 22 (4): 328-332

  Abstract

  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 PEDIATRIC TRANSPLANTATION Alexopoulos, S. P., Merrill, M., Kin, C., Matsuoka, L., Dorey, F., Concepcion, W., Esquivel, C., Bonham, A. 2012; 16 (4): 373-378

  Abstract

  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 LIVER TRANSPLANTATION Lo, I. J., Lelkowitch, J. H., Feirt, N., Alkofer, B., Kin, C., Samstein, B., Guarrera, J. V., Renz, J. F. 2008; 14 (5): 639-646

  Abstract

  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 Alkofer, B., Samstein, B., Guarrera, J. V., Kin, C., Jan, D., Bellemare, S., Kinkhabwala, M., Brown, R., Emond, J. C., Renz, J. F. 2006; 26 (3): 221-233

  Abstract

  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 Renz, J. F., Kin, C., Kinkhabwala, M., Jan, D., Varadarajan, R., Goldstein, M., Brown, R., Emond, J. C. LIPPINCOTT WILLIAMS & WILKINS. 2005: 556–65

  Abstract

  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